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Knowledge, attitude, and practice of self-breast examination among female
university students at Presbyterian University College, Ghana

http://www.usa-journals.com/wp-
content/uploads/2013/10/Sarfo_Vol111.pdf
Effects of breast self examination training program on knowledge, attitude

practice of a group of working women
http://www.nci.cu.edu.eg/Journal/00_06_05.pdf
KNOWLEDGE, ATTITUDE AND PRACTICE OF BREAST SELF-EXAMINATION

AMONG UNDERGRADUATE HEALTH SCIENCE FEMALE STUDENTS
http://publichealthmy.org/ejournal/ojs2/index.php/ijphcs/article/view/487/
405
Knowledge, attitudes, and practice of breast self-examination among female

health workers in Isfahan, Iran
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ethnic Kashmiri females
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Breast Cancer Screening Knowledge in a Turkish Population Education is

Necessary
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Knowledge and practice of breast self-examination among sample of women in
Shatra/Dhi-Qar/Iraq
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Knowledge and Beliefs of Breast Self-Examination and Breast Cancer among
Market Women in Ibadan, South West, Nigeria
Kelechi Elizabeth Oladimeji , Joyce M. Tsoka-Gwegweni , Franklin C.
Igbodekwe, Mary Twomey, Christopher Akolo, Hadiza Sabuwa Balarabe,
Olayinka Atilola, Oluwole Jegede, Olanrewaju Oladimeji
Published: November 25, 2015https://doi.org/10.1371/journal.pone.0140904
Abstract
Background
In most resource constrained settings like Nigeria, breast self-examination self-
breast examination (BSE) is culturally acceptable, religious friendly and
attracts no cost. Women's knowledge and beliefs about breast cancer and its
management may contribute significantly to medical help-seeking behaviours.
This study aimed to assess knowledge and beliefs of BSE among market
women.
Methods
A descriptive cross-sectional study was conducted among 603 market women
in Ibadan, Nigeria. Data was collected using semi-structured interviews and
analyzed using descriptive and analytic statistical methods.
Results
The mean age of the respondents was 34.6±9.3 years with 40% of the women
aged between 30-39years. The proportion of married women was 339 (68.5%)
with 425 (70.8%) respondents reporting that they do not know how to perform
BSE. However, 372 (61.7%) women strongly agreed that BSE is a method of
screening for breast cancer. Highest proportion 219 (36.3%) reported that the
best time for a woman to perform BSE was ‘anytime’. Most of the respondents
believed breast cancer is a dangerous disease that kills fast and requires a lot
of money for treatment.
Conclusion
More efforts are needed in creating awareness and advocacy campaigns in the
grassroots in order to detect early breast cancer and enhance prevention
strategies that would reduce the burden of breast cancer in Nigeria.
Figures
Citation: Oladimeji KE, Tsoka-Gwegweni JM, Igbodekwe FC, Twomey M, Akolo
C, Balarabe HS, et al. (2015) Knowledge and Beliefs of Breast Self-Examination
and Breast Cancer among Market Women in Ibadan, South West, Nigeria. PLoS
ONE 10(11): e0140904. https://doi.org/10.1371/journal.pone.0140904
Editor: Seema Singh, University of South Alabama Mitchell Cancer Institute,
UNITED STATES
Received: March 2, 2015; Accepted: October 1, 2015; Published: November
25, 2015
Copyright: © 2015 Oladimeji et al. This is an open access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited
Data Availability: Due to ethical restrictions related to patient privacy, data
will be available by contacting Ms Kelechi Elizabeth Oladimeji
via oladimejikelechi@yahoo.com; keoladimeji@cchrad.org.
Funding: This study was supported by Center for Community Health Care,
Research and Development, Nigeria (CCHARD), www.cchrad.org. Ms. Kelechi
Elizabeth Oladimeji is currently a Public Health doctorate Scholar in College of
Health Science, Howard College Campus, University of KwaZulu-Natal,
Durban, South Africa. Kelechi is also a co-lead at the Center for Community
Health Care, Research and Development, Nigeria (cchrad.org). The funders had
no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared that no competing interests
exist.
Introduction
Breast cancer is a global health concern and a leading cause of morbidity and
mortality among all the cancers that affect women [1]. In 2008, it was
estimated that the prevalence of breast cancer in women aged 15 years and
over in Sub-Saharan Africa is 23.5 per 100,000 women [2]. Breast cancer has
been identified as a major public health problem in both developed and
developing nations because of its high incidence-prevalence, the over-burdened
health system and direct medical expenditure [3]. Global statistics shows that
the annual incidence of breast cancer is increasing and this is occurring more
rapidly in countries with a low incidence rate of breast cancer [4–5]. Findings
from Elima Jedy-Agba et al. in 2012 [6] documented that the incidence of
breast cancer in Nigeria has risen significantly with incidence in 2009–2010 at
54.3 per 100 000, thereby representing a hundred percent increase in the last
decade. Some cases have been reported among women aged below 30 years in
Nigeria [7]. This is supported by the literature showing a rise in breast cancer
incidence rates in Sub-Saharan Africa [8].
The high incidence of breast cancer necessitates the need for early detection
because this would increase the treatment options available to affected women
and thereby improve survival rates [9]. Some studies have shown that in most
of the developing nations and resource constraint settings, breast cancer is
diagnosed in advanced stages of the disease when compared with developed
nations and thus has a poor outcome and high fatality rate [1, 10–17].
Screening for early detection and diagnosis of diseases and health conditions is
an important public health principle [18]. Breast self-examination (BSE) is a
check-up that a woman does by herself at home to look for changes or
problems affecting the breast tissue. BSE is still recommended as a general
approach to increasing breast health awareness and thus potentially allow for
early detection of any anomalies because it is free, painless and easy to
practice [19]. The American Cancer Society [20] also recommends that women,
starting from the age of 20 years should be educated on the pros and cons of
performing a monthly BSE. For women to present early to hospital they need to
be "breast aware"; they must be able to recognize symptoms of breast cancer
[21].
There are reports suggesting that factors related to women's knowledge and
beliefs about breast cancer and its management may contribute significantly to
medical help-seeking behaviours [21–22]. Recent studies in Senegal, Angola
and Nigeria [23–29] revealed a low level of awareness and knowledge on breast
cancer risk factors and its early warning signs. Lack of understanding of the
risk factors associated with breast cancer discourages people from seeking
early intervention or even to admit that symptoms they may be experiencing
are related to breast cancer. As such there is need for a study to assess
knowledge and beliefs about breast examination BSE and risk factors among
women in our communities. This study therefore aimed to assess the
knowledge and beliefs of breast self-examination and breast cancer among
market women in densely populated markets in Ibadan, Oyo State, Nigeria.
Methods
Ethics
Ethical approval was given by the Oyo state, Ministry of Health Ethics
Committee in August, 2012. Participant information was anonymized and de-
identified prior to analysis. Informed consent was obtained from the
participants aged 15 and above. The named ethics committees approved the
consent procedure in addition to the study protocol.
A cross-sectional study was conducted between July to October 2012, in order
to assess knowledge and beliefs on BSE among women selling in a few major
markets in Ibadan, Oyo State, Nigeria. Major markets were purposefully
selected and subsequently consented participants were interviewed from each
of the market. Ibadan is the largest indigenous city south of the Sahara and is
the capital of Oyo state, Nigeria. It has a population of about 2.6 million people
[30]. The study population comprised of 603 women selling at Oja-Oba, Agbeni,
Bode, Oje and other markets in Ibadan. These markets are the major markets
in Ibadan. These women constitute eighty-percent of all traders selling in the
selected markets. They sold mainly food items such as meat, pepper,
vegetables, provisions, raw rice and other food stuffs.
Sample size calculation
1. Estimate of the expected proportion (p) of knowledge of breast self-
examination among market women = 0.5
2. Desired level of absolute precision (d) = 0.05
3. Estimated design effect (DEFF) = 1.5
1. 4. Assuming 4% will declining to participate in the study

Minimum sample size = 576.24 + 23.05 = 599 participants
Data was collected using interviewer administered semi structured
questionnaires on socio-demographic characteristics, knowledge, attitude and
belief of participants after obtaining written informed consent. Data was
entered and analysed using statistical package for social sciences (SPSS)
version 20. Descriptive and Chi-square statistics was employed in analysing
the data.
Results
Socio-demographic profile of participants
A total of 603 market women were recruited. Table 1 shows the socio
demographic profile of the respondents. There was a fair distribution of the
women recruited at the various markets.The mean age of the respondents was
34.6±9.3 years. The highest proportion was aged between 30–39 years. The
majority of the participants were married 497/603 (82.4%).
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Table 1. Socio-demographic profile of study participants (n = 603).
https://doi.org/10.1371/journal.pone.0140904.t001
Knowledge about how to perform BSE
More than three-quarters of the participants responded to knowledge on how to
perform BSE.The majority of participants 425 (70.8%) reported that they did
not know how to perform BSE, while only 29.2% reported that they do.
Knowledge about how to perform BSE was slightly higher in participants who
came from Oja-oba- market (37.6%) followed by those from Agbeni, Bode and
other markets with level of knowledge all above 25% except in participants
from Oje market. Very few participants were recruited in the ages below 20,
and 50 years or above. Therefore the latter will not be considered further in
this discussion, only ages 20–49 years will be reported. The percentage of
participants who reported that they knew how to perform BSE increased with
age in participants up to 49 years; with age group 40–49 years (40.4%) being
the highest, followed by 30–39 years (32.0%) then 20–29 years. Married
participants had a higher knowledge of how to perform BSE than single
participants. Knowledge of BSE was correlated with educational level (Table 2),
and there were 8.0% of the women with no formal education who reported they
did not know while about close to 7% of the study women who had post-
secondary education reported to have knowledge. There was a statistically
significant relationship between educational level and knowledge on how to
perform BSE (p<0.0001),(Table 2).
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Table 2. Knowledge about how to perform BSE by socio-demographics of
study responders.
SBE: self-breast examination
Knowledge about when to perform BSE
In total 271 participants responded to the question of when is the right time to
perform BSE. Only 8.1% of these knew correctly that ‘mid-cycle’ was the right
time to perform BSE.The highest proportion 219 (80.8%), reported incorrectly
that the right time for a woman to perform BSE was ‘anytime’. Although below
10%, a large number of women who knew when to perform BSE came from
Oja-oba market (8.3%) compared to the other three markets. However, these
differences were not statistically significant. Knowledge about when to perform
BSE decreased with increasing age showing a slightly higher level of knowledge
in the 20–29 year olds than in the 30–39 and 40–49 year age groups(p<0.00).
Compared to married, a double percentage of single women knew when to
perform BSE. The level of knowledge about when to perform BSE was higher
among post-secondary education (15.1%) while among other groups it was less
than 10%. These differences were not statistically significant (Table 3).
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Table 3. Knowledge about when to perform BSE by socio-demographics of
study responders.
About two-third (61.7%) of the study population strongly agreed that BSE is a
screening method for breast cancer. About 28.5% agreed that fear of detecting
breast cancer would make them not practice BSE, while more than 50%
strongly disagreed with this statement. The majority of the women strongly
disagreed that SBE should be done ‘only if you feel abnormal around your
breast’. There was similar responses of participants who strongly agreed or
disagreed about postures for SBE (Table 4).When asked about their beliefs on
breast cancer, there were varying responses (Fig 1). Many of the respondents
had a fair knowledge on the effects of the burden of breast cancer and that the
hospital was the place they would refer someone for diagnosis and treatment
options (Fig 2).
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Fig 1. Venn diagram showing beliefs of market women about breast
cancer.
https://doi.org/10.1371/journal.pone.0140904.g001
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Fig 2. Graph showing the likely referring points of care by the market
women.
https://doi.org/10.1371/journal.pone.0140904.g002
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Table 4. Distribution of the study respondents according to their
knowledge, attitude and beliefs about breast self-examination (n = 603).
Discussion
The present confirm findings from studies conducted in Nigeria over the past
years, on BSE and breast cancer among women in the south-east [31], south
[29, 32], south-west [33–35] and north [36] of the country. All these studies
showed that knowledge on BSE as a screening method for breast cancer and
on the right time to carry out BSE was very poor. The only contrast in the
present study is that knowledge about postures involved in preforming BSE
was good.
Important knowledge deficits can have a detrimental impact on the education
of women on screening practices and attitudes of women in the adoption of
early detection practices [21]. A correlation may exist between level of
education and breast cancer knowledge [37] educational level and marital
status as predictors of (CBE) and (BSE) [28,38]. Two studies in Nigeria
indicated that education and employment in professional jobs significantly
influenced knowledge of breast cancer [21,39]. Our study revealed significant
differences between the respondents’ market area, age up to 49 years, marital
status and educational level and their knowledge on SBE.
Assessment of the participants’ knowledge, attitude and beliefs showed that
majority of the respondents reported that the right time to perform self-breast
examination was ‘anytime’ and majority also disagreed that BSE should be
done only when they feel abnormal around the breast. Some of the respondents
reported that they would not practice BSE because they are afraid of detecting
any evidence suggestive of breast cancer. In addition, findings from the study
reveal that most of the study population have heard of breast cancer as a
disease and self-breast examination as a screening method but there is still
inadequate knowledge and understanding of the disease and its screening
method. These findings are similar to the study among market women in
Abakaliki (south-east Nigeria) by [33], women in south-west Nigeria by [28,33–
34], women in Federal Capital Territory of Nigeria by Banning and Ahmed [40].
There is a great need for more awareness campaigns, advocacy to improve the
knowledge of self-breast examination directed towards women of low socio-
economic status and people at the grassroots levels in the country. This will
ensure early detection and intervention to prevent mortality due to breast
cancer.
We conclude that knowledge about how and the time to perform BSE among
Nigerian women working in the markets in Ibadan, south west Nigeria is very
poor, particularly among women who are single, young with a low level of
education after controlling for confounders. Similarly, few participants had
strong negative beliefs towards breast cancer. Any interventions aimed at
improving the knowledge about BSE and breast cancer screening should target
these groups. Such interventions should be evaluated to ensure their success
in improving women’s health.
The quantitative nature of our study limits the extent to which the information
reflects the nuanced views of respondents. A qualitative interview would have
allowed a deeper understanding of the perspectives of the respondents.
Supporting Information
S1 Questionnaire. BSE_SEMI_STRUCTURE QUESTIONNAIRE
https://doi.org/10.1371/journal.pone.0140904.s001
(PDF)
Acknowledgments
We acknowledge the efforts of the research assistants and all those market
women who gave consent to participate despite their busy time for buying and
selling.
Author Contributions
Conceived and designed the experiments: KEO OO FCI. Performed the
experiments: KEO OO FCI JMT MT CA HSB OA OJ. Analyzed the data: KEO
OO JMT OA OJ. Contributed reagents/materials/analysis tools: KEO OO FCI
JMT MT CA HSB OA. Wrote the paper: KEO OO FCI JMT MT CA HSB OA OJ.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140904
Knowledge, attitude and practice about breast cancer and breast self-
examination among women seeking out-patient care in a teaching hospital in
central India
Rao Siddharth, D Gupta, R Narang, P Singh

Department of Surgery, Mahatma Gandhi Institute of Medical Sciences,
Sevagram, Wardha, Maharashtra, India
Date of Web 6-Jan-

Publication 2017
Correspondence Address:
Rao Siddharth
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences,
Sevagram, Wardha, Maharashtra
India
Source of Support: None, Conflict of Interest: None
Abstract
Background: Breast cancer (BC) continues to be a major cause of morbidity

and mortality throughout the world. Early detection of BC and early treatment
increases the chance of survival. According to Breast Health Global Initiative
guidelines for low and middle income countries, diagnosing BCs early by
promoting breast self-awareness; clinical breast examination (CBE) and
resource adapted mammographic screening will reduce BC mortality. There is a
paucity of data on the knowledge and awareness of BC and self-breast
examination in India. We designed this hospital based cross sectional
descriptive study to evaluate the current status of knowledge, awareness and
practices related to BC and breast self-examination in the female rural
population attending a teaching hospital. Materials and Methods: We did a
random sampling to identify and enroll 360 women and their female relatives.
We excluded a participant from the study if she had already undergone a
screening mammography or had had a BC. The data was collected by a self-
administered questionnaire in vernacular language. Results: Our study
population included 360 women with a mean age of 45.81 (±10.9) years. Only 5
(1.38%) females had a family history of BC. A whopping 81% of women did not
have any knowledge about BC. All the women thought that CBE by doctors was
the only way for screening BC. Conclusions: We concluded that with the
results of this study, it is imperative to increase awareness about BC and its
detection methods in the community through health education campaigns. We
should have major policy changes to increase future screening programs and
health education programs which would have an overall positive impact on
reducing the disease burden.
Keywords: Breast cancer, early detection, self-breast examination
How to cite this article:

Siddharth R, Gupta D, Narang R, Singh P. Knowledge, attitude and practice
about breast cancer and breast self-examination among women seeking out-
patient care in a teaching hospital in central India. Indian J Cancer
2016;53:226-9
How to cite this URL:

Siddharth R, Gupta D, Narang R, Singh P. Knowledge, attitude and practice
about breast cancer and breast self-examination among women seeking out-
patient care in a teaching hospital in central India. Indian J Cancer [serial
online] 2016 [cited 2018 Mar 12];53:226-9. Available
from: http://www.indianjcancer.com/text.asp?2016/53/2/226/197710
» Introduction
Breast cancer (BC) continues to be a major cause of morbidity and mortality

throughout the world. BC is the most common cancer comprising 18% of all
female cancers and with over 1 million newly diagnosed cases annually across
the globe.[1] Incidence of BC in India varies from 7.2 to 33.4/100,000 (annual
age adjusted rate). BC accounts for about one-fourth of all cancers in Indian
women and about half of all cancer-related deaths. Only a lesser than 8% are
detected in Stage 1 and 23-58% in Stage 2 and 3. 5 year survival rates are 90%
in Stage 1 and only 22% in Stage 4.[2] Early breast cancer constitutes only 30%
of the BC cases seen at different cancer centers in India, whereas it constitutes
60-70% of cases in the developed world.[3] It is not surprising that the majority
of BC patients in India are treated at locally advanced or metastatic stage. In
India the incidence/mortality ratio is 0.48 compared with 0.25 in North
America.[3] Late diagnosis is attributed to lack of awareness and non-existent
BC screening programs in India.
Early detection of BC and early treatment increases the chance of survival.

Breast self-examination (BSE), clinical breast examination (CBE),
Mammography are different methods for screening of EBC.[4] Of the three
modalities of BC screening – BSE, CBE and mammography – BSE fulfills the
first two criteria, but early results of two randomized trials conducted in Russia
and China suggest that it would not be effective in reducing mortality from
BC.[5] CBE is also relatively simple and inexpensive, but its effectiveness in
reducing mortality from BC has not been directly tested in a randomized trial.
The American cancer society (ACS) recommends CBE and mammography in
early detection of BC. According to ACS recommendations women should start
BSE in her early 20's, should know the normal feel of her breasts and promptly
report any changes to her health-care providers.[6] But ACS does not advocate
BSE as one of the tools, which increase survival rates in BC.[7],[8] According to
Breast Health Global Initiative guidelines for low and middle income countries,
diagnosing BCs early by promoting breast self-awareness; CBE and resource
adapted mammographic screening will reduce BC mortality. In theory 95% of
survival rate can be achieved by early detection of BC.[9] It has been observed
that women can detect 95% of BCs and 65% of early minimal BCs by
themselves. It was estimated that BSE may reduce the mortality by as much as
18% and that this figure may increase with women who are particularly
competent. Though theoretically BSE remains the tool for abating mortality
with BC in low and middle income countries; in real life its application is low.
Studies conducted among different groups of women in United States, showed
that monthly BSE rates ranged from 29%-63%.[10]
There is a dearth of large scale breast screening programs in India. BSE is

advocated, but data on what proportion exercised is not available.[9] Nearly all
Indian BCs are clinically detected; almost none are detected by
screening.[11] There is a paucity of data on the knowledge and awareness of BC
and breast self examination (BSE) in India. We designed this hospital based
study to evaluate the current status of knowledge, awareness and practices
related to BC and BSE in the female rural population attending a teaching
hospital. We also wanted to explore if any associations exists between
demographic variables, knowledge of BC and the practice of BSE.
» Materials and Methods

Setting
We did this study in the out-patient department (OPD) of a 780-bed teaching

hospital located in central India.
Ethics statement
We obtained approval from the institutional ethics board for conducting this
study. We also took an informed consent form all study patients.
Study design
We did a cross-sectional descriptive study among consecutive women and their

female relatives attending the OPD of our hospital. All patients, seeking out-
patient care in our hospital are electronically registered in the registration OPD
and are asked to visit a general OPD, managed by the Community Medicine
department. The interns, supervised by faculty triage these patients to the
different departments of the hospital, based on their initial history and key
physical examination findings. We did a random sampling to identify and enroll
360 women and their female relatives. We took their informed consent for
collecting this information and ensured that their privacy, confidentiality and
rights are respected. We excluded a participant from the study if she had
already undergone a screening mammography or had a BC.
The data was collected by a self-administered questionnaire in vernacular

language. The questionnaire was adapted from Champion's Health belief model
for BC after due permission.[12] The questionnaire was translated into
vernacular language from English and then was back-translated and piloted.
The structured questionnaire had three parts: Part one, for demographic
information such as age, place of residence, monthly income of the family,
academic level, age of menarche, marital status, parity and lactation history,
menarche- first child interval, exposure to tobacco and other addiction, family
history of BC and; Part two, regarding awareness of BC which includes
questions concerning knowledge and attitude – if the participant has heard of
BC, source from which they have heard about BC, symptoms of BC, risk
factors and methods of detection (SBE and screening mammography). Part
three of the questionnaire was regarding BSE which includes questions on the
awareness of BSE, whether the participant had ever done BSE, frequency and
few questions on how to do BSE. The questionnaire was distributed by study
investigator to all the participants. Each correct answer was assigned one mark
whereas incorrect answer and non-response was given zero.
Statistical analysis
We transferred the paper based data into Microsoft excel. We described

continuous variables by mean and standard deviation if they are normally
distributed and by medians and interquartile range if they are skewed. We
used the Students t-test to compare means, Chi-square test to compare
proportions and a log rank test to compare medians. We described the
precision of estimates by 95% confidence intervals. P < 0.05 was considered
statistically significant. Data was analyzed using Stata software (version 11,
Stata Corporation, Texas, USA).
» Observation and Results
Our study population included 360 women with a mean age of 45.81 (±10.9)
years. About 31% of women had not received any formal education and another
21% were educated only until primary level. All women were married and their
mean ages of menarche were 13.83 (±1.05) years and were in their second
decade at the time of birth of their first child (19.29 ± 3.84 years). Most of the
women (92%) had breast fed their children and had no addictions (95%). Only
5 (1.38%) females had a family history of BC [Table 1] and [Table 2].
Table 1: Demographic characteristics of study population
Click here to view

Table 2: Regarding awareness of breast cancer
Click here to view
A whopping 81% of women did not have any knowledge about BC. Remaining
68 participants had heard or had some knowledge of BC either from friends
and relatives (16.94%) or television and radio (0.56%) or from doctors (0.56%).
All the women thought that CBE by doctors was the only way for screening BC.
It was seen that the proportion of women who were aware increased as the
literacy status increased and this was statistically significant (P > 0.005).
Similarly, those who belonged to higher socio-economic status (SES) were more
aware about BC as compared to those belonging to a lower SES and this
difference was also statistically significant [Table 3].
Table 3: Assessment of knowledge and practice of BSE
Click here to view
It was but a surprising revelation that none of the study participants had
knowledge about BSE or had previously done BSE.
» Discussion
From our study, we found that more than three fourths of the study population
(81.11%) was unaware about BC. Those who were aware were more educated
and belonged to higher socioeconomic strata. None of the study participants
had any knowledge about BSE or were performing BSE. All the women in the
study thought that BC could only be detected by CBE by doctors. Somdatta
and Baridalyne [3] found that only half of the study population was aware of BC
and the awareness increased with increasing literacy and increasing SES. This
was comparable to our study. It has been shown that women of low SES have a
low incidence of BC compared to women of higher SES, but they experience a
higher mortality rate, due to higher late stage diagnosis.
The same study also highlighted that half of their study population also
thought that BC can only be detected by clinical examination by doctors. Only
11% women were aware of BSE and only two of them have ever done BSE.
However, none of them do it on a regular basis.[3] Barriers identified that
contribute to low screening rates for BC among underserved women suggest
that there are both personal and health-care factors that influence
participation in screening. Personal barriers include lack of awareness or
knowledge about cancer screening, embarrassment in participating in actual
screening procedures, low trust in prevention and fear of cancer. Additional
personal barriers that prevent underserved women from participating in
screening include procrastination, social and cultural beliefs and perceptions of
discrimination in the health care system.[13]
Knowledge and awareness of early detection measures of BC such as BSE is

nonexistent.[14],[15] It is established and recommended that screening by
mammography substantially reduces mortality from BC, especially in women
over the age of 50 years. However, this technique is expensive and is not
available easily and hence is difficult to implement in India where resources are
constraint. A cohort study in Finland and a case-control study in
Canada [16] suggested BSE to be beneficial (reduction in BC mortality) at all
ages.[17] Recently, there is a debate on the role of regular self-examination of
the breast in preventing BC mortality. However, the teaching of BSE can help
women to be alert to any abnormal changes in their breasts and seek medical
advice immediately. Positive health-care behavior can go a long way in
increasing health awareness amongst the population and also health seeking
behavior.[18],[19],[20]
We acknowledge certain limitations of this study. We do not have information

about women who refused to participate in the study or who were not available
at the time of study. If the women who were not included in the study were
different from those who were interviewed in some characteristics like age, the
results of the study may have been different.
» Conclusion
This study has shown that among women attending our hospital the knowledge
about BC, its signs and symptoms or detection procedures is very poor. BC is
one of the leading causes of death globally. BSE helps detect BC at an early
stage and decreases both morbidity and mortality. The data on awareness and
practice of BSE in India is sparse. It is imperative to increase the awareness
about BC and its detection methods in the community through health
education campaigns. Educating health-care workers and nurses to impart
training about BSE is also crucially important in this regard. We should have
major policy changes to increase future screening programs and health
education programs, which would have an overall positive impact on reducing
the disease burden.
» References
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http://www.indianjcancer.com/article.asp?issn=0019-
509X;year=2016;volume=53;issue=2;spage=226;epage=229;aulast=Siddharth
Awareness of breast cancer and breast self-examination among female
undergraduate students in a higher teachers training college in Cameroon
Carlson-Babila Sama1,2,&, Bonaventure Dzekem2,3, Jules Kehbila2,4, Cyril
Jabea Ekabe2,4, Brice Vofo2,5, Naomi Liteba Abua2, Therence Nwana
Dingana2,6, Fru Angwafo III7
1Bambalang Sub-Divisional Hospital, Northwest Region, Cameroon, 2Galactic

Corps Research Group (GCRG), Cameroon and Faculty of Health Sciences,
University of Buea, Cameroon, 3Clinical Research Education, Networking and
Consultancy (CRENC), Douala, Cameroon and Health Services Partner
Cameroon, 4Grace Community Health and Development Association
(GRACHADA), Kumba, Cameroon, 5Ntam Medicalised Health Centre, Kumba,
Cameroon, 6Catholic General Hospital, Njinikom, Northwest Region,
Cameroon, 7Gynaeco-Obstetric and Paediatric Hospital and Department of
Surgery, University Teaching Hospital, Yaoundé, Cameroon
&Corresponding author
Carlson-Babila Sama, Bambalang Sub-Divisional Hospital, Northwest Region,
Cameroon
Abstract
Introduction: the incidence of breast cancer (BCa) in Cameroon is on the rise
and accounts for a leading cause of mortality. An understanding of the
knowledge and practices on breast cancer and breast self-examination (BSE)
among teachers are important first steps which will guide the designing of
interventions aimed at raising awareness across the general population.
Methods: we conducted a cross-sectional study in April 2016 involving 345

consenting female undergraduate students in the Higher Teachers Training
College, Bambili, Cameroon. Data was collected using a pretested self-
administered questionnaire and analysed using descriptive methods.
Results: the mean age of the respondents was 22.5±3.2years and a vast
majority (n = 304, 88.1%) had heard about BCa primarily from the
television/radio (n=196, 64.5%). Overall, less than a quarter (n=65, 21.4%) of
respondents who had heard about BCa had sufficient knowledge on its risk
factors and signs/symptoms. A plurality (53.3%) thought BCa can be prevented
via vaccination while over a third (38.7%) opined that BCa can be treated
spiritually. Less than half (47%) of respondents who had heard about BCa had
heard about BSE amongst which only 55 (38.5%) had ever practiced it.
Conclusion: though most students are aware of the existence of breast cancer,
their overall knowledge on its risk factors and clinical presentation is
insufficient with a concomitant low practice of BSE. These highlighted gaps
warrants intensification of sensitization campaigns and educational
programmes in order to raise knowledge levels and enhance prevention
strategies that would aid in reducing the burden of breast cancer in Cameroon.
Introduction
Worldwide, breast cancer is the second most frequent cancer and the fifth
cause of cancer-related mortality [1]. It is the most common cancer to affect
women and it is second only to lung cancer as the principal cause of cancer-
related deaths among women [1-3]. In low- and middle-income countries
(LMICs), it remains a significant public health challenge as incidence rates
have been shown to increase yearly by as much as 5% with over 1 million
projected new cases annually by 2020 [2-5]. The emergence of breast disease
and subsequent development of cancer appears to be more aggressive in young
women compared to its progression in older women [6,7]. In 2008, the
prevalence of breast cancer in women ≥15 years in sub-Saharan Africa was
estimated at 23.5 per 100,000 women and approximately 35,427 women died
from the disease (crude mortality rate of 12.8 per 100.000 women) [8,9]. In
Cameroon, the incidence of breast cancer is higher than the worlds average;
estimated at 2625 per 100,000 women with a resultant high mortality [3,5].
The high morbidity and mortality due to breast cancer can be in-part reduced if
the lesion is detected early enough [2]. In this regard, women need to be "breast
aware" by being able to identify the risk factors and symptoms of breast cancer
as well as risk reduction strategies.
Though still clouded in controversy, breast self-examination (BSE) still has an
important role to play in the early detection of breast cancer in resource-
constraint settings where routine clinical breast examination and
mammography may not be feasible. In such settings, BSE is recommended
because it is free, private, painless, easy, safe, and requires no specific
equipment. It has also been shown to improve breast health awareness and
thus potentially allow for early detection of breast anomalies [10-13]. The
American Cancer Society also recommends that women from the age of 20
years onwards should be educated on the benefits of performing BSE monthly
[14]. It had been demonstrated that factors related to women´s awareness,
knowledge and perceptions about breast cancer may contribute significantly to
medical help-seeking behaviours [15-17]. Thus, considering the potential
pivotal role played by teachers in information dissemination, this study sought
to assess the awareness, knowledge and perceptions of breast cancer and
practice of breast self-examination among female undergraduate students in a
higher institution of teaching as this will be essential in informing policy for
targeted interventions through the provision of guided educational training
programs.
Methods
Study design, setting and participants: we conducted a descriptive cross-
sectional study on the 11th of April 2016 at the Higher Teachers Training
College (HTTC) Bambili, University of Bamenda in the Northwest Region of
Cameroon. Bambili is a centre of attraction for a youthful multi-ethnic
population who either move there for studies or to explore the diverse economic
activities triggered by the presence of the university. The undergraduate
program in HTTC is a three year course and annually, this college graduates
about 500 trained teachers. The target population was first cycle female
undergraduate students. To consider equal chances of participation, the
students were informed about a free and voluntary participation in a breast
cancer survey 1 week earlier via oral message during lecture hours. On the
said day of the survey, students were consecutively approached in their
respective lecture halls for inclusion.
Study procedures and data collection: a structured and self-administered

questionnaire was developed by the researchers after an extensive review of
literature [10-12,18]. The validity of its contents was established through
consultation with experts and was pretested on 41 first cycle students from
HTTC who were eventually restrained from participating in the final study.
Other than concerns about some ambiguous words which were simplified in
the revised version, all pilot students reported they easily understood the
questionnaire. It had three sections: socio-demographic characteristics,
knowledge about breast cancer, and a section on BSE. Data collection
facilitators (1 student per academic level) underwent a 2-hour training one day
prior to the census. Coding of questionnaires rather than using names was
done in order to ensure confidentiality. Consenting participants were handed
printed copies of the questionnaire and allowed time to fill their responses and
return them anonymously to the facilitators. The completeness of returned
questionnaires was visually checked on a daily basis by the principal
investigators. The study was approved by the ethics committee of the regional
delegation of public health for the Northwest Region and all recruited students
signed a consent form.
Scoring of knowledge: each of the questions on knowledge of risk factors and

clinical presentation (signs/symptoms) of breast cancer was equitably scored.
Categorical responses (Yes/No/Don't know) were applied for the question
items. We assigned one point (1) to a correct answer and zero (0) for don't know
or an incorrect answer. The overall knowledge score was calculated by
summing scores of all knowledge questions (16 on risk factors and 12 on
signs/symptoms) yielding a possible range of overall scores from 0 to 28.
Scores were divided into two categories: insufficient knowledge (< 50% of
correct answers) and sufficient knowledge (≥ 50% of correct answers).
Statistical analysis: data from the questionnaires were entered and analysed
using statistical package for the social sciences (SPSS Inc., Chicago, IL) version
20.0. We summarised continuous variables as means and standard deviations
(SD), and categorical variables as count and percentages.
Results
Socio-demographic characteristics : of the 420 questionnaires distributed,
391 (93.1%) were returned amongst which 345 were properly filled, thus
subjected to analysis. The participants were between 17 and 34 years (mean =
22.5 ± 3.2) of age. Half (49.9%) of them were in the age range 21-25 years. A
vast majority (90.7%) were Christians while almost two-thirds (64.6%) of the
respondents were in their first year of studies. Sixty-two (18%) were married
(Table 1).
Awareness, knowledge and attitudes on breast cancer: of the 345

participants, 41 (11.9%) reported to have never heard about breast cancer.
Television/radio (n =196, 64.5%) and health personnel (n =190, 62.5%) were
the main sources of knowledge for the 304 (88.1%) participants who had heard
about breast cancer (Figure 1). Further analysis will include only the 304
participants who knew what breast cancer was. Of these, 18 (5.9%) had a
family history of breast cancer and about one fifth (21.1%) of these female
students responded “No” to the question item “will you allow a male doctor to
examine your breast” Table 2summarizes the perceptions towards breast
cancer among the 304 participants. Exposure to radiation (n =179, 58.9%),
hormone replacement therapy (n = 177, 58.2%), smoking (n = 177, 58.2%),
alcohol consumption (n = 142, 46.7%) and high fat diet (n = 138, 45.4%) were
the most frequently indexed risk factors for breast cancer. Meanwhile, late
menopause (n = 28, 9.2%), early age at first menstruation (n = 25, 8.2%) and
not having a child (n = 24, 7.9%) were the least recognized risk factors.
Witchcraft was implicated as a potential cause of breast cancer by a third (n
=106, 34.9%) of the respondents. The most common symptom of breast cancer
identified was lump in the breast (n =248, 81.6%) while over 77% (n =235) of
the respondents did not know that lump under the armpit could be a sign of
breast cancer.
The mean knowledge score on risk factors was 5.2 ± 2.7 (range: 0-14). Only 32
(10.5%) of respondents had sufficient knowledge of risk factors of breast
cancer. The mean score for knowledge on signs/symptoms of breast cancer
was 5.4 ± 3.1 ranging from 0 to 12. One hundred and eleven (36.5%) had
sufficient knowledge on the signs/symptoms of breast cancer. The overall
knowledge score ranged from 0-23 with a mean score of 10.7 ± 4.8. Overall,
less than a quarter (n = 65, 21.4%) of participants had sufficient knowledge on
breast cancer. With respect to their attitudes if diagnosed with breast cancer,
almost half (n =145, 47.7%) said they will go to a prayer house, 58 (19.1%) will
use traditional medicine and only 105 (34.5%) will agree to perform
mastectomy if necessary (Table 3). Of the 304 participants who had heard
about breast cancer, 287 (94.4%) agreed that breast cancer could be prevented
amongst which breast examination was the commonest mode of prevention
cited (n =237, 82.6%). Over half (n =153, 53.3%), 104 (36.2%) also thought
breast cancer could be prevented by vaccination and physical exercise
respectively (Table 4). A minority (n =35, 11.5%) did not know that breast
cancer could be treated. Of those who knew (n =269, 88.5%), 248 (92.2%) and
104 (38.7%) said it could be treated medically and spiritually respectively
(Table 4).
Awareness and practice of breast self-examination: less than half (n =143,

47%) of those who knew about breast cancer had heard about breast self-
examination (BSE). Majority (n = 47, 32.9%) did not know how often BSE
should be performed while only a quarter (n =37, 25.9%) correctly stated that it
should be performed monthly (Table 5). As little as 10 (7%) participants knew
that the appropriate time to perform a BSE was few days after menstruation.
Despite a substantial proportion (n =88, 61.5%) of students who had never
performed BSE, most (n =133, 93%) recognised the importance of BSE for their
health. Reasons for not performing BSE are summarised in Figure 2. Of the 95
participants that responded to the question item on the appropriate age to
commence BSE, only 3 (3.2%) correctly stated that 20 years was the
appropriate age to commence BSE.
Discussion
Our findings have shown considerable awareness about the existence of breast
cancer, but insufficient knowledge and misperceptions on its risk factors and
causes as well as infrequent practice of breast self-examination. In this study,
88.1% of participants had heard about breast cancer. This is higher than the
81.2% and 64% observed in a group of Malaysian [19] and Iranian [20] women
respectively. It is however much lower than the 100% among female medical
students in Harar, Ethiopia [6], 98.7% among female students in the University
of Ibadan, Nigeria [21] and 95% among female university students in Ghana
[22]. The lower rate of awareness on the existence of breast cancer in our study
with respect to these studies may be due to the fact that breast cancer is part
of a medical curriculum while it has been adopted in the curricula in the other
two universities in a bid to raise awareness. Though about 9 in 10 of our
participants knew about breast cancer, our findings reveal a poor
understanding and misperceptions on its risk factors, signs/symptoms,
prevention and treatment. More than two-thirds of the respondents did not
identify gender, increasing age, race/ethnicity, and positive family history, first
child at late age, early menarche, late menopause, positive personal history,
and nulliparity as potential risk factors of breast cancer. Knowledge gaps about
risk factors has also been reported elsewhere among the general population
[19,23], university students in Angola [24], female medical students in Saudi
Arabia [25], nurses in Pakistan [26] and female teachers in Malaysia [27] and
Kuwait [28]. With regards to misperceptions, 17.8% and 34.9% of participants
cited wearing of tight brassieres and witchcraft respectively as risk factors of
breast cancer. This is in line with a community survey in semi-urban
Cameroon [11], studies on rural women [29] and market women [16] in
Ibadan, Nigeria and female medical students in Ethiopia [6] that suggests
women still attribute the occurrence of breast cancer to a mystical origin.
Among others, they considered it “a spiritual attack”, “God's curse”, and
“attack from the enemy”. This observation was not that different from reports
in a more developed setting; female teachers in Saudi Arabia attributed the
occurrence of breast cancer to God and belief in the evil eye [30] while 96.8% of
Arab-speaking women in Qatar attributed its occurrence to fate/destiny and
less than one-fifth to Gods' punishment and bad luck [31]. As observed
elsewhere [6,18,28,32] the commonest symptom of breast cancer identified by
our respondents was breast lump. However, knowledge about other
signs/symptoms was unsatisfactory. Thus, the need for further health
education on the risk factors and clinical presentation of breast cancer is
desirable.
Most (94.4%) of our participants perceived that breast cancer could be

prevented which is similar to the 95% reported by Suh et al [11]. Though
breast examination was mentioned by the majority (82.6%) as a preventive
method, a plurality (53.3%) of them incorrectly mentioned vaccination against
breast cancer as a preventive method. Interestingly, 12.9% of these
respondents also identified sucking of the breast by a male partner as a
method of preventing breast cancer. This idea may have emanated, in part,
from a recent social media circular within the study setting which suggested
girls should make their breast more available to a male partner as regular
sucking will help in reducing their risk of developing breast cancer. This calls
for urgent actions by authorities to foster awareness on breast cancer in
university milieus as such an act has not been proven to prevent breast cancer,
and may also promote sexual immorality; thus increasing the risk of acquiring
sexually transmitted infections including HIV/AIDS as well as unwanted
pregnancies. Though a small proportion, it however remains disturbing that
11.5% of our respondents agreed that breast cancer cannot be treated. This
observation concurs to that of Oluwatosin et al [33] in the Akinyele locality in
rural Nigeria where the women had even attributed a local name for breast
cancer; “jejere” which means “that which devours”. Oladimeji and colleagues
[16] also noted that 30% of women in their study considered breast cancer a
fast killer. These may be an indication that the myth suggesting that "breast
cancer equals death" is still deeply rooted across communities. These wrong
assumptions may partly account for some of the reasons why patients present
late to hospitals with advanced disease states. Other than seldom mass
campaigns for breast health awareness and screening organized by the
ministry of public health, there is no national screening program for breast
cancer in Cameroon. Introduction of such a program will greatly aid in
increasing awareness, eliminate mythical concerns as well as lead to early
detection of breast anomalies, hence better prognosis. In a 20-year
retrospective analysis of the profiles of 531 breast cancer patients followed up
at the Yaoundé General Hospital, Cameroon, Ngowa and collaborators [34]
noted that there was a mean delay of 10.35 months with some taking up to 52
months between the apparition of the first signs of breast cancer and
presentation for first medical evaluation. As a consequence of this late
presentation, none of the patients presented with carcinoma in situ. More than
half of them had solicited traditional treatment and visited spiritual houses at
first intention before their first medical evaluation. Lack of awareness on breast
cancer, ignorance, cultural beliefs and the fear of mastectomy as a treatment
modality in hospitals were major setbacks to early presentation. These
observations equally concurred to findings in this study with regards to the
attitudes of our participants if they developed breast cancer.
Early detection of breast cancer plays a pivotal role in reducing related

mortalities. Until circumstances are favourable for routine mammographic
screening in resource-limited settings, emphasis should be oriented towards
encouraging women to regularly practice BSE. Freeman and collaborators [35]
had reiterated the need for young girls to be properly taught BSE as this will
greatly influence their practice as they grow older. Though controversies still
exists over its effectiveness in reducing mortality [36], the technique remains
an important tool for early detection especially in low- and middle-income
countries where access to diagnostic and curative facilities may be problematic
[4,10,12,37]. In this study, only 38.5% of the participants had ever performed
a BSE. It is comparable to the 41% reported by Nde et al [10] among female
undergraduate students in the University of Buea, Cameroon, the 42.6%
among female undergraduate students in Kirkuk University, Iraq [38], the
37.3% among health extension workers in Ethiopia [12] and 29% in Senegal
[39]. Similarly, though close to three-quarters of female undergraduate
students in the Ahmadu Bello University, Zaria, Nigeria had heard about BSE,
only about one in five had ever practiced it [40]. Our findings suggests the need
to increase awareness of BSE as a screening tool as it renders women more
“breast aware” and thus potentially allow for early detection of breast cancer.
In so doing, various breast-conserving procedures including lumpectomy,
segmentectomy, and quadrantectomy may be warranted in patients with early
stage cancers rather than the generally feared mastectomy. Raising awareness
on the possibilities of breast reconstruction surgery is also warranted as this
may improve medical help seeking attitudes of sufferers.
Limitations: other than the lack of a statistical sample estimate, our findings
are confined to a group of young educated women which does not necessarily
reflect the situation among women in rural areas, thus a potential limitation.
Furthermore, this study was conducted in a single department in the
university, thus, may not portray the full picture of awareness/perceptions of
breast cancer and practice of BSE among female students in the entire
university and other state/private universities within the country. Also, the
students were not assessed on their ability to correctly perform BSE.
Conclusion
Female undergraduate students in the Higher Teachers Training College
Bambili have insufficient knowledge on breast cancer with poor practice of
BSE. Massive health education campaigns designed to enlighten not only
female university students in this setting, but also the public at large on the
potential causes, risk factors, signs/symptoms, prevention and treatment of
breast cancer should be promoted. The unique role of mass media, particularly
television/radio to reach a large audience at the same time should be fully
explored in order to provide comprehensive information about breast cancer.
These breast awareness campaigns should also seek to dispel spirituality and
myths regarding the occurrence of breast cancer. Taking into consideration the
invaluable role that can be played by BSE in such a resource-disadvantaged
setting with a concomitant high burden of breast cancer, there is an urgent
need for focused strategies to implement and re-enforce existing cancer
awareness and the potential benefits breast self-examination.
What is known about this topic
 Generally, Cameroonian female students have poor knowledge on breast
cancer and infrequently practice breast-self-examination.
What this study adds
 Narrows awareness, knowledge levels and practice to a group of
undergraduate teachers;
 Breast lump is the most commonly known symptom of breast cancer:
important knowledge deficits on signs/symptoms and treatment of breast
cancer were noted;
 These students have poor attitudes, misperceptions and myths regarding
breast cancer; many will avert mastectomy, majority will seek
spiritual/traditional healing.
Competing interests
The authors declare no competing interest.
Authors’ contributions
Carlson-Babila Sama, Bonaventure Dzekem, Naomi Liteba Abua and Fru
Angwafo III contributed to study conception, design, data collection and
analysis and drafting of initial manuscript. J Jules Kehbila, Cyril Jabea Ekabe
and Therence Nwana Dingana provided keen reviews to the drafted
manuscript. All authors read and approved the final version prior to
submission.
Tables and figures

Table 1: socio-demographic characteristics of the included 345 female
undergraduates from HTTC, University of Bamenda, Cameroon, April 2016
Table 2: frequency distribution of knowledge and misperceptions towards

breast cancer in 304 female undergraduates from HTTC, University of
Bamenda, Cameroon, April 2016
Table 3: perceived attitudes regarding development of breast cancer of 304

female undergraduates from HTTC, University of Bamenda, Cameroon, April
2016
Table 4: perceptions about prevention and treatment options of breast cancer

among female undergraduates from HTTC, University of Bamenda, Cameroon,
April 2016
Table 5: knowledge, practice and perceived importance of breast self-

examination among female undergraduates from HTTC, University of Bamenda,
Cameroon, April 2016
Figure 1: distribution of participants according to sources of knowledge about

breast cancer
Figure 2: reasons for not performing breast-self examination
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Practicing breast self-examination among women attending primary health care
in Kuwait
Author links open overlay panelSaadoon F.Al-AzmyaAliAlkhabbazbHadeel
A.AlmutawacAli E.IsmaieldeGamalMakboulfgMedhat K.El-Shazlyhg
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Open Access funded by Alexandria University Faculty of Medicine
Under a Creative Commons license
Abstract
Background
Despite the benefits associated with breast self-examination (BSE), few women
perform it and many do not even know how to perform it.
Objectives
The purpose of this study was to identify the proportion of women practicing
BSE, factors that could affect its performance and explore women’s awareness
about its practice steps.
Methods
The study design can be differentiated into two components. The first was a
cross-sectional survey to determine the prevalence of BSE. Recruitment efforts
resulted in 510 women. BSE was practiced by 109. The second component of
the study was a case-control study to identify factors associated with BSE,
whereas practicing subjects (control) were compared with a randomly selected
similar number of non-practicing females (cases).
Results
The prevalence of BSE was 21%. Most of the socio-demographic variables have
no significant effect on the practice of BSE. Practicing women had sufficient
level of knowledge about BSE, clinical breast examination, and mammography.
They believed significantly that bloody discharge from the nipple, presence of
masses in the breasts, abnormal arm swelling, nipple retraction and
discoloration of the breast were signs and symptoms of breast cancer. About
35% of practicing women in the current study performed correctly ⩽6 steps out
of 12 steps.
Conclusion
Only 21% of women attending PHC had ever practiced BSE. Even a high
proportion of them were not aware of the correct steps of the procedure. Health
education programs are essential to encourage and improve women’s practice
of BSE.
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KEYWORDS
Breast self
Examination
Warning signs
Steps
1. Introduction
Breast cancer (BC) is the most common cancer type and cause of death among
women in many countries. Meanwhile, the early discovery of breast lumps
through breast self-examination (BSE) is important for the prevention and early
detection of this disease.1–3
Early detection of BC by population-based screening programs would be a
potentially useful approach for controlling the disease and reducing
mortality.4 Periodical mammograms, clinical breast examinations (CBE), and
monthly BSE, are crucial to detect BC at an early stage.3,5,6
In some countries, although the early detection of BC can increase the survival
rate, there has not been any systematic approach to increase the awareness of
BC. Therefore, many women miss early detection and treatment opportunities
due to lack of information, knowledge, and awareness of BC, as well as cancer
screening practices.5,7,8 In other countries, the cost of screening mammography
is considered to be high and policy makers are considering implementing
screening programs based on CBE rather than mammography.9
CBE is a simple, very low cost, non-invasive adjuvant screening method for the
detection of early BC in women. Its purpose is important in the case of a
prompt reporting of breast symptoms which are important early detection
messages for women of all ages, and to make women familiar with both the
appearance and the feel of their breasts as early as possible.4–6
Although opinions conflict about the value of BSE, there is no uniform
agreement for breast screening.10,11 BSE is an important screening measure for
detecting BC. There is evidence that women who correctly practice BSE
monthly are more likely to detect a lump in the early stage of its development,
and early diagnosis has been reported to influence early treatment, to yield a
better survival rate.12
Despite the benefits associated with BSE, few women regularly perform it and
many do not even know how to perform it. There is also evidence that women
are more likely to perform BSE effectively when taught by physicians or a
nurse.1,4 The purpose of this study was to identify women’s socio-demographic
and personal factors that could affect the practice of BSE as well as to explore
their BSE practice steps.
2. Methods
The study design can be differentiated into two phases that were conducted
from January to March 2012 in Bader Alnefesy primary health care (PHC)
clinic. The first phase was a cross-sectional survey to determine the prevalence
of practicing BSE among women attending primary care for maternity and child
care. Subjects were asked to participate in the study and fill a self-
administered questionnaire located on a table in the waiting hall. Recruitment
efforts resulted in 520 filled and returned back questionnaires. Among them,
109 females stated that they practiced BSE.
The second phase was a case-control study to investigate factors that could be
associated with non-practicing of BSE, whereas all females practicing BSE
(control group, n = 109) were compared with an equal number of females who
declared that they had never practiced BSE chosen randomly from the same
clinic (case group, n = 109). Participants were considered eligible as cases if
they had never performed BSE. Participants were considered eligible as control
if they mentioned that they had ever practiced BSE.
2.1. Data collection
Predesigned questionnaire was used to collect the information from women
who agreed to participate in the study. In order to maintain confidentiality,
questionnaires were made anonymous. The questionnaire was derived from
other published studies dealing with the same topic as well as from our own
experience.2–4,10 It included personal data, menstrual and child bearing history.
The subjects were also asked about their beliefs regarding a list of some
warning symptoms and signs of BC. The questionnaire also investigated the
knowledge and awareness of women regarding BSE, BC, CBE, and
mammography. In the last section, they were asked about 12 specific
procedures or steps used in performing BSE. A correct answer was assigned
one point, whereas a wrong or missed answer was given zero. Knowledge score
was changed into percentage score. The studied women were divided according
to their answers into two levels; insufficient level (<50% of all corrected
answers) and sufficient level (⩾50% of correct answers). The time needed for
completing the questionnaire was approximately 15 min.
2.2. Data analysis
The Statistical Package for Social Sciences (SPSS-17) was used for data
processing. Simple descriptive statistics were used (mean ± standard deviation
for quantitative variables, and frequency with percentage distribution for
categorized variables). A Chi-square test was used to detect association
between the studied variable and the practicing of BSE. A 5% level is chosen as
a level of significance in all statistical significance tests.
3. Results
A total number of 520 women who attended primary care for maternity and
child care, participated in this study. Only a fifth of the study participants (109
subjects) mentioned that they had practiced BSE accounting for 12%.
Table 1 presents personal, menstrual and child bearing history of the
participants. No significant differences were observed between practicing and
non-practicing women regarding the level of education, duration of marriage,
number of their living children, menopausal status, and the history of abortion
or use of contraceptives. On the other hand, practicing women seemed older
than non-practicing ones where 91.6% of them compared to 67.9% of non-
practicing ones were aged 30 years or more (mean age = 34.1 ± 5.6 and 32.3 ±
6.3, respectively, p = 0.03). Moreover, 92.7% of practicing females had regular
menstruation compared to 80.7% of those non-practicing, p = 0.01. Also a
history of breastfeeding as well as a family history of BC were encountered in a
significantly higher proportion among practicing women than others (p = 0.01).
Table 1. Personal characteristics and practicing breast self-examination.
Characteristics BSE practice P value
No Yes
No % No. %
Age (years)
<30 35 32.1 20 18.3 0.03*
30– 59 54.1 64 58.7

No Yes
No % No. %
40+ 15 13.8 25 22.9
Education
Less than intermediate 18 16.5 15 13.8 0.79
Secondary 38 34.9 42 38.5
University 53 48.6 52 47.7
Duration of marriage (years)
1–5 33 30.3 30 27.5 0.22
6–10 36 33.0 28 25.7
11–15 24 22.0 23 21.1
16–20 16 14.7 28 25.7
Number of living children
1 16 14.7 8 7.3 0.22
1–2 23 21.1 25 22.9
⩾3 70 64.2 76 69.7
Regularity of menstruation
No 21 19.3 8 7.3 0.01*
Yes 88 80.7 101 92.7
Menopause
No Yes
No % No. %
No 106 97.2 105 96.3 0.70
Yes 3 2.8 4 3.7
History of abortion
No 68 62.4 65 59.6 0.68
Yes 41 37.6 44 40.4
Breast feeding
No 72 66.1 52 47.7 0.01*
Yes 37 33.9 57 52.3
Use of contraceptive method
None 40 36.7 32 29.4 0.500
Pills 47 43.1 51 46.8
Others 22 20.2 26 23.9
Family history of breast cancer
No 97 89.0 81 74.3 0.01*
Yes 12 11.0 28 25.7
Total 109 100.0 109 100.0
*
Significant at 5%.
Table 2 presents participants’ beliefs regarding some warning signs and
symptoms. In comparison with non-practicing women, practicing females
believed that bloody discharge from the nipple (77.1% vs. 61.5%), presence of
masses in the breasts (96.3%vs. 89.0%), abnormal arm swelling (56.9% vs.
39.4%), nipple retraction (55.0%vs. 41.3%) and discoloration of the breast
(79.8%vs.56.0%, respectively) were signs and symptoms of BC. These
differences were statistically significant.
Table 2. Proportion of participants with correct beliefs regarding breast cancer
symptoms and signs.
Symptoms and signs BSE practice P value
No Yes
No. % No. %
Bloody discharge from nipple 67 61.5 84 77.1 0.01*
Asymmetric sagging in breast 66 60.6 76 69.7 0.17
Breast mass 97 89.0 105 96.3 0.04*
Breast pain 72 66.1 70 64.2 0.78
Enlargement of neighboring lymph nodes 94 86.2 99 90.8 0.29
Breast skin retraction 49 45.0 51 46.8 0.79
Abnormal arm swelling 43 39.4 62 56.9 0.01*
Nipple retraction 45 41.3 60 55.0 0.04*
Discoloration of breast 61 56.0 87 79.8 <0.001*
Abnormal enlargement of breast 83 76.1 90 82.6 0.24
Ovarian pain 64 58.7 53 48.6 0.14
*
Significant at 5%.
Table 3 displays that a significantly higher proportion of practicing women
compared to non-practicing group had sufficient level of awareness about BC
(67.0% vs. 37.6%), CBE (40.4% vs. 10.1%), mammography (38.5% vs. 5.5%)
and practicing mammography (15.6% vs. 1.8%).
Table 3. Participants’ awareness and practicing breast self-examination.
Variables BSE practice P value
No Yes
No. % No. %
Awareness about breast cancer
Insufficient 68 62.4 36 33.0 <0.000*
Sufficient 41 37.6 73 67.0
Awareness about clinical breast examination
No 98 89.9 65 59.6 <0.000*
Yes 11 10.1 44 40.4
Awareness about mammography
No 103 94.5 67 61.5 <0.000*
Yes 6 5.5 42 38.5
Subjection to mammography
No 107 98.2 92 84.4 <0.000*
Yes 2 1.8 17 15.6
Total 109 100.0 109 100.0
*
Significant at 5%.
Women who stated that they have ever practiced BSE were asked about
specific steps of the procedure. Table 4 displays the proportion of females who
answered correctly regarding the recommended BSE steps. The most frequently
endorsed steps were squeezing the nipple of each breast to look for discharge
(79.8%), use of right hand to examine the left breast and left hand to examine
the right breast (76.1%), when examining the breast, feeling for lumps, hard
knots, or thickening (75.2%), examining one breast at a time (72.5%), when
looking at a breast in the mirror looking for swelling, dimpling of skin, or
changes in the nipple (68.8%), looking at both the breasts in the mirror with
arms raised over the head (67.0%), examining the breasts at the end of the
menstrual period (65.1%), examining the breasts in a circular, clockwise
motion moving from outside in (55.0%), looking at the breasts in the mirror
with arms at the sides (54.1%), examining the breasts while lying down, place
the hand above the head before examining the breasts on that side (52.3%).
The least frequently endorsed steps were examining the breast while lying
down, to place a towel or pillow under the shoulder before examining the breast
on that side and looking at the breast in the mirror with hands on the thigh.
Table 4. Percentage of practicing participants performing correct steps of breast
self-examination.
Breast self-examination steps No. %

(109)
Examining breasts at end of the menstrual period 71 65.1
Looking at breasts in mirror with arms at sides 59 54.1
Looking at breasts in mirror with arms raised over head 73 67.0
Looking at breasts in mirror with hands on thigh 29 26.6
When looking at breast in mirror, looking for swelling, 75 68.8

dimpling of skin, or changes in nipple
Examining breasts while lying down, place a towel or pillow 40 36.7

under shoulder before examining breast on that side
Examining breasts while lying down, place hand above head 57 52.3
before examining breasts on that side
Breast self-examination steps No. %
(109)
Use right hand to examine left breast and left hand to 83 76.1
examine right breast
Examining one breast at a time 79 72.5
Examining breasts in a circular, clockwise motion moving 60 55.0

from outside in
When examining breast, feel for lumps, hard knots, or 82 75.2

thickening
Squeezing the nipple of each breast to look for discharge 87 79.8
Overall, the majority of subjects knew most of the recommended steps. About
35% of practicing women in the current study performed correctly ⩽6 steps out
of 12 steps as shown in Table 5.
Table 5. Frequency of correct steps among practicing women.
No of correct steps Frequency % Cumulative (%)
0 19 17.4 17.4
1 4 3.7 21.1
3 3 2.8 23.9
4 6 5.5 29.4
5 3 2.8 32.1
6 3 2.8 34.9
7 5 4.6 39.4
8 19 17.4 56.9
9 19 17.4 74.3
No of correct steps Frequency % Cumulative (%)
10 11 10.1 84.4
11 17 15.6 100.0
Total 109 100.0
4. Discussion
In the present study BSE is performed in 21% of the 520 adult females
attending PHC centers and who participated in the study. This rate is similar to
that reported in a previous study conducted on Kuwaiti female teachers,13 and
higher than another one conducted on university students in
Yemen.14 However, this rate is much lower than in many other countries
(55.4% in young Malaysian women, and 43.9% in Turkish female teachers, and
52% among Turkish midwives).15–17
The relationships between socio-demographic variables and practicing BSE are
contradictory. Previous researches suggested that the difference in practicing
BSE was related to socio-economic status.18–20 The current study did not show
a significant relationship between the practice of BSE and the level of
education, duration of marriage, number of siblings, menopause status, history
of abortion or the use of contraceptives. There are disparate findings
concerning factors that impact BSE.A study conducted by Okobia et al. in
Nigeria revealed that women with regular menstruation perform BSE on
regular basis than others.21 Other studies found a significant relationship
between BSE practice and women’s age, education level and family history of
breast problems.2,22–24 Similarly, the current study showed a significant
association between BSE practices and women’s age, regularity of
menstruation, positive family history of BC and breastfeeding. On the other
hand, Budden reported an association between BSE practices and the age,
level of education, personal history of breast problems.25 Furthermore, a study
of Malaysian teachers identified that there was no association between socio-
demographic characteristics such as age, and family history of BC and BSE
behavior.26
In the current study practicing women believed that bloody discharge from
nipple, breast mass, abnormal arm swelling, nipple retraction and discoloration
of the breast are warning signs for BC in a significant higher proportion than
non-practicing women. Contrary to that other researchers established that the
warning signs of breast cancer (e.g., painless lump, nipple retraction, bloody
discharge from the nipple) were not well known among their participant
women.12,18
Although “enlargement of neighboring lymph nodes” was the most frequently
identified symptom of BC in our respondents, the study results indicate that
women had inadequate knowledge about other BC symptoms. For instance,
only a few women knew that breast skin retraction and abnormal enlargement
of the breast are warning signs of BC. This is consistent with other studies
from developing countries and in women from minority ethnic groups.21,27
Breast pain was encountered as a warning sign by about two-thirds of
practicing and non-practicing women, whereas a study from the UK indicated
that 70% of women were well aware of a “painless lump” and were able to
identify these symptoms in their BSE.28 However, although regional and
religious differences might contribute to such variations, the role of well-
designed breast health awareness campaigns for women should not be
neglected. Various studies have shown that theoretical education on the
awareness of early BC signs was effective even in illiterate and less educated
women.29,30
Although there is controversy surrounding the efficacy of BSE in countries
where mammography and CBE are readily available,31 studies concluded that
BSE, mammography, and CBE were inadequate in terms of their practice and
availability.12,18 However, despite continuous debate about the efficacy of
BSE,32 it seems that BSE, not as a public health policy but as a preventive
measure, remains a method of choice for early BC detection in developing
countries. Resource constraints in low and middle income regions can limit the
application of established guidelines for breast health care in the developing
countries.33
The current study observed that practicing women had sufficient knowledge
about BSE and BC, were more aware about CBE and mammography as well as
more on practicing mammography than non-practicing females. Variables such
as BC knowledge, awareness of BC screening methods, and regular visits with
a physician influenced BSE behavior.34 Of interest, in developed countries,
there are higher rates of regular BSE. Thus, the contexts in which women live
likely affect those factors which impact the extent to which BSE is
practiced.35,36
Regarding awareness of the practicing women of correct practicing steps, the
findings of the current study showed that about one third of practicing women
performed six or less steps correctly out of 12 steps and only 15.6% performed
11 steps, and none performed all the steps correctly. This goes in accordance
with a finding reported by Somdatta and Baridalyne37 the corresponding figure
in the United States was 75%8 in contrast, only 30.3% of the women from
Saudi Arabia have heard about BSE.4 In Iran only 61% of the respondents
knew about BSE.18 Although the role of regular BSE in the prevention of BC
mortality has been debated, it can nevertheless be used to enhance breast
health awareness among women.25 In fact, regular BSE has been suggested as
a part of the overall breast health promotion concept.12
These data suggest that while many women perceive that the procedures they
follow in performing BSE are correct, most women are not correctly performing
the BSE technique, leaving out some or most of the critical steps. In agreement
with that, women with higher self-efficacy scores were more likely to perform
BSE. This finding was supported by previous research.3,12,31 The findings also
showed that a lack of skill in the performance of BSE was associated with
limited to no BSE activity. Therefore, educational interventions that foster BSE
skills and efficacy would likely contribute to higher rates of its performance.
Finally, women who lack confidence in their ability to perform BSE correctly or
who have not been instructed on how to do BSE appeared to perform BSE less
frequently and to have less competence in performing the technique. Therefore,
training social workers, school teachers and others who are regarded as
trusted agents of the community could be beneficial for BSE practice. PHC
professionals could play an important role in conveying correct information
regarding BSE.18,21
An apparent limitation of our study is the one PHC center selection of the
target population, which could reflect selection bias. Furthermore, selection of
married women only limited some aspects pertaining to the beliefs of the
participants. Therefore, the possibility of having missed certain issues of
greater concern cannot be ruled out.
5. Conclusion
In conclusion, only 21% of women attending PHC had ever practiced BSE. Even
a high proportion of them were not aware of the correct steps of the procedure.
Not much difference was seen between practicing and non-practicing females
regarding socio-demographic variables. It appears that the best way to save
women’s lives is to increase their awareness of the potential harms of BC, raise
their awareness level about early warning signs, risk factors and early
detection procedures for this disease. Health education programs should be
initiated to improve women’s practice of BSE. Health education programs are
essential to encourage and improve women’s practice of BSE.
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N.A. Alharbi, M.S. Alshammari, B.M. Almutairi, G. Makboul, M. El-
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among Kuwaiti female school teachers
Alexandria J Med, 48 (1) (2012), pp. 75-82
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R.A. Al-Naggar, D.H. Al-Naggar, Y.V. Bobryshev, R. Chen, A. AssabriPractice
and barriers toward breast self-examination among young Malaysian
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Asian Pac J Cancer Prev, 12 (5) (2011), pp. 1173-1178
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B.A. AhmedAwareness and practice of breast cancer and breast-self
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N. NurBreast cancer knowledge and screening behaviors of the female
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Women Health, 50 (1) (2010), pp. 37-52
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G. Ertem, A. KoçerBreast self-examination among nurses and midwives in
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Indian J Cancer, 46 (3) (2009), pp. 208-213
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A. Montazeri, M. Vahdaninia, I. Harirchi, A.M. Harirchi, A. Sajadian, F. khalegh
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Available online 24 September 2012
Peer review under responsibility of Alexandria University Faculty of Medicine.
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The Knowledge and attitude of breast self examination and mammography

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Practicing breast self-examination among women attending primary health care

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Knowledge, Attitude And Practice Of Breast Self-Examination Among
Female Medical Students In The University Of Lagos
I NK, O OA, A RA, B RB, O AT
Keywords
attitude, breast cancer, breast self-examination, knowledge, practice
Citation
I NK, O OA, A RA, B RB, O AT. Knowledge, Attitude And Practice Of Breast Self-
Examination Among Female Medical Students In The University Of Lagos. The
Internet Journal of Health. 2009 Volume 12 Number 1.
Abstract
Background: Breast cancer is the leading cause of cancer mortality in women

worldwide. The incidence of breast cancer is rising more rapidly in population
groups that enjoyed a low incidence of the disease.Objective: The purpose of
this study was to investigate the knowledge, attitude and practice of breast
self-examination (BSE) among female medical students in University of
Lagos.Method: The study was designed as a cross sectional survey of female
students in the college of medicine. The aim was to assess level of their
knowledge about breast cancer, attitude and their practice of BSE. A self-
administered questionnaire prepared by the author was employed. Consent
was obtained and assurance of confidentiality of responses was given to each
respondent. Results: Majority of the respondents, 40.7% were from the age
group 21-22 drawn from first to sixth year medical students.97.3% had heard
of breast cancer and breast self-examination.54.8% of the respondents heard of
breast cancer from television/ radio. Most of the respondents, 85.8% knew how
to perform breast self-examination correctly. Only 65.4% of the respondents
thought that breast self-examination was necessary. 43.5% of the respondents
said that the last time they performed breast self-examination less than a year
ago. Majority of the respondents, 69.6% preferred to perform breast self-
examination in the morning while 47.7% of the respondents preferred to carry
out breast self-examination in front of the mirror.Conclusion: There was a high
level of awareness of breast cancer and breast self-examination among the
respondents. Their attitude towards breast cancer and breast self-examination
was fair though the practice was poor.
Introduction
Cancers in all forms are responsible for about 12 per cent of deaths throughout
the world (Park, 2002). Globally, breast cancer is the most common malignant
neoplasm among women (Leszczynskaet al., 2004; WHO, 2006). Breast cancer
causes 376,000 deaths a year worldwide; about 900,000 women are diagnosed
every year with the disease (WHO, 1997).
Although the incidence of breast cancer in developing countries is relatively low
(Koet al., 2003), about 50% of all cases of breast cancer are diagnosed in these
countries (Haji-Mahmoodiet al., 2002; Sadler et al., 2001). Based on a study
during 1975–1990, Asia and Africa have experienced a more rapid rise in the
annual incidence rate of breast cancer than that of North America and Europe
(Shiraziet al., 2006).
Although mammography remains the best single diagnostic tool in the
detection of breast cancer it is not routinely performed in Nigeria due to low
level of awareness, ignorance, illiteracy, cost, high technology equipment and
ex¬pertise required. False negative for mammography is higher in the younger
age group, and this is likely to happen in Nigeria where cases below the age of
30 have been widely reported (Anyanwu, 2000; Wu and Yu, 2003; Banjo,
2004).
There is also evidence that most of the early breast tumours are self-discovered
and that the majority of early self-discoveries are by breast self-examination
(BSE) performers (Okobiaet al., 2006).
Cavdaret al (2007) reported that most female physi¬cians and nurses (65% and
70% respectively) believed that BSE was unnecessary; therefore the need to
evaluate breast cancer awareness, attitude and practice among female
students who are going to be our future health personnel.
Method
The study was designed as a cross sectional survey of female students in the
college of medicine. The aim was to assess level of their knowledge about breast
cancer, attitude and their practice of breast self-examination (BSE).
Participants
The study was conducted in June, 2010 at College of Medicine of the University
of Lagos, Nigeria. Consent was obtained and assurance of confidentiality of
responses was given to each respondent.
A self-administered questionnaire prepared by the author was employed.
Questions were partly drawn using information on breast cancer from the
literature. Additional questions were adapted, after modification, from
questionnaires used in similar studies conducted earlier in the country. The
questionnaire was in three parts. The first part was to elicit socio-demographic
data on age, ethnicity, and marital status of each participant. Questions
relating to knowledge of breast cancer were asked in the second part.
Participants’ awareness of breast cancer and early detection methods were also
assessed in this section. The third part of the questionnaire assessed practice
of BSE among participants.
Analysis
The data were evaluated by descriptive statistics and chi-square using Epi-info
2004 series. The differences between the three vari¬ables were considered
significant if the p-value was less than 0.05.
Results
The total number of questionnaires given out was five hundred (500) but four
hundred and ninety-nine were recovered. The respondents were drawn from
first (17.8%), second (34.3%), third (23%), fourth (3.5%), fifth (7.4%) and sixth
(13.9%) year female medical students.
Figure 1
Table 1: Demographic profile of respondents
Table 1 above shows the demographic profile of the respondents. Majority of
the respondents, 40.7% were from the age group 21-22. Most of the
respondents, 58.9% were Yoruba, 29.4% were Igbo, 2% were Hausa and 9.7%
were from other tribes. 95.4% of the respondents were single while 4.6% were
married.
Most of the respondents, 85.1% were Christians, 14.7% were Muslims while
0.2% were of other religions. Only 8.8% had a family history of breast cancer,
most of which was an aunt (53.6%).
Figure 2
Table 2: Respondent’s knowledge of breast cancer and breast self-examination
Table 2 above shows the level of breast cancer and breast self-examination
awareness of the respondents. Most of the respondents, 97.3% had heard of
breast cancer and breast self-examination. 80.9% of the respondents knew it is
common in our environment, 98.6% knew it can be detected early and 98.2%
knew that early detection increases chances of survival. 23% of the
respondents heard of breast cancer at home, 24.5% heard of it at school,
54.8% of the respondents heard of breast cancer from television/ radio and
30.8% heard of it from newspapers.
Only 53.6% knew that both male and female are required to perform breast
self-examination, with 54.5% of the respondents having the view that breast
self-examination should start at less than 19 years while 45.5% were of the
opinion that it should start at over 19 years of age.
The respondents also felt that breast self-examination should be performed
daily (23.8%), some weekly (22.5%), some monthly (50.8%) and some yearly
(2.9%). Most of the respondents, 85.8% knew how to perform breast self-
examination correctly.
Figure 3
Table 3: Attitude of respondents to breast self-examination
Table 3 above shows the respondents’ attitude to breast self-examination.
65.4% of the respondents thought that breast self-examination was necessary
while 83.1% of the respondents have carried out breast self-examination. Of
those that have carried out breast self-examination before, 87.4% did it to
examine their breasts regularly while 6.8% did it because they have a family
history of breast cancer.
Of those that have never performed breast self-examination, 46.7% did not
because they do not have any symptom, 26.7% felt it was not important, 22.6%
did not know how to do it, 20% felt they can never have cancer, 10% of the
respondents felt they were violating themselves by touching their breast and
did not believe in the efficacy of the test and 3.3% of the respondents were
scared of being diagnosed with breast cancer.
Figure 4
Table 4: Respondents’ practice of breast self-examination
Table 4 above shows the respondents’ practice of breast self-examination. Most
of the respondents, 80.2% said they perform breast self-examination regularly.
56.1% of the respondents started performing breast self-examination at less
than 19 years while 43.9% started performing at over 19 years of age. 20.9% of
the respondents said that the last time they performed breast self-examination
was less than a week ago, 28% last carried it out less than three to six months
ago while 43.5% last carried theirs out less than a year ago.
Majority of the respondents, 69.6% preferred to perform breast self-
examination in the morning followed by evening with 23.3%. 47.7% of the
respondents also preferred to carry out breast self-examination in front of the
mirror, 36.5% preferred lying on the bed while 13.3% preferred performing it in
the bathroom.
Most of the respondents, 93.2% indicated interest in knowing more about
breast self-examination.
Discussion
The age of the respondents ranged from 15 years to 26 years and above with
the mean age group as 21 years. This age pattern is consistent with the present
9-3-4 educational system in Nigeria. The study was appropriate in this age
group as most of them were young adults who should find out more
information on breast cancer and breast self-examination before they reach the
age of common occurrence of the disease and as future doctors, would be able
to educate and advice their patients effectively.
Most of the respondents surveyed had heard of breast cancer (97.3%) and
85.8% claimed they knew how (BSE) is done; the level of breast cancer
awareness of the respondents may have been due to their area of study and
level of education. In a similar study, it was found that the women who had
tertiary education were more knowledgeable about breast self-examination
while those who had primary education were the least knowledgeable (Balogun
and Owoaje, 2005).
Their primary source of information was the television/radio. This finding is
consistent with the study conducted by the Family Planning Association of
Hong Kong (1996) which revealed that the promotion activities by the media,
billboards and advertisements effectively exposed the public to breast cancer
information. Similar observation was reported in an Eastern state of Nigeria
(Nwagbo and Akpala, 1996). The least reported primary source of information
on breast cancer in the study was the home of the respondents (23%). This is
one of the gaps existing in family life education as parents and care givers have
no time to discuss pertinent health issues with their children. It might also be
due to the fact that some of the parents have no information or knowledge on
some of these topics and as such have little or nothing to discuss (Saludeenet
al., 2009).
A little more than half (65.4%) of the respondents believed that it is necessary
to perform breast self-examination. This showed that the level of concern about
screening for breast cancer is still low among the respondents considering their
status as medical students and a lot much more would be expected from them
as future doctors.
83.1% of the respondents claimed to have carried out breast self-examination
before; this demonstrates that some attention is being given by the young
adults in this study to check their breast for early onset of lump and other
symptoms of breast cancer, though not regularly as nearly half (43.5%) of the
respondents had not examined their breasts in nearly one year. This may
partly be because of the assumption that they are free from breast pathology.
As a result of this ignorance, little emphasis may be placed on regular BSE by
such respondents (Kayodeet al., 2005).
Recommendation
There is need for further study to address the knowledge gaps on breast cancer
and breast self-examination so that positive attitudes can be developed by the
young adults towards breast self-examination, to assist in early breast cancer
detection as well as reducing late breast cancer presentation.
References
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Breast Self-examination: Knowledge, Attitude, and Practice among Female

Dental Students in Hyderabad City, India
Dolar Doshi, B Srikanth Reddy, Suhas Kulkarni, and P Karunakar1
Author information ► Copyright and License information ►
This article has been cited by other articles in PMC.
Abstract
Go to:
INTRODUCTION
Breast cancer is a global health issue and a leading cause of death among
women internationally.[1–3] In India, it accounts for the second most common
cancer in women. Around 80,000 cases are estimated to occur annually. The
age-standardized incidence rate of breast cancer among Indian women is 22.9
and the mortality rate is 11.19.[4] In the present scenario, roughly 1 in 26
women are expected to be diagnosed with breast cancer in their lifetime.[5]
Breast cancer is distinguished from other types of cancer by the fact that it
occurs in a visible organ and be detected and treated at an early stage.[6]. The
5-year survival rate reached to 85% with early detection whereas later detection
decreased the survival rate to 56%.[7] The low survival rates in less developed
countries can be attributed to the lack of early detection as well as inadequate
diagnosis and treatment facilities.
Recommended preventive techniques to reduce breast cancer mortality and
morbidity include breast self-examination (BSE), clinical breast examination
(CBE), and mammography.[8] CBE and mammography require hospital visit
and specialized equipment and expertise whereas BSE is an inexpensive tool
that can be carried out by women themselves.[9] BSE benefits women in two
ways: women become familiar with both the appearance and the feel of their
breast and detect any changes in their breasts as early as possible.[10] In the
literature, it is stated that 90% of the times breast cancer is first noticed by the
person herself.[11] Also, several studies have shown that barriers to diagnosis
and treatment can be addressed by increasing women's awareness of breast
cancer.[12,13]
Even though BSE is a simple, quick, and cost-free procedure, the practice of
BSE is low and varies in different countries; like in England, a study by
Philip et al.[14] reported that only 54% of the study population practised BSE.
Furthermore, in Nigeria, the practice of BSE ranged from 19% to 43.2%,[9,15]
and in India, it varied from 0 to 52%.[16,17] Several reasons like lack of time,
lack of self-confidence in their ability to perform the technique correctly, fear of
possible discovery of a lump, and embarrassment associated with manipulation
of the breast have been cited as reasons for not practising BSE.[18,19]
With this background, the present study was designed to determine the
knowledge, attitude, and practice (KAP) regarding BSE in a cohort of Indian
female dental students.
Go to:
MATERIALS AND METHODS
A cross-sectional descriptive study was conducted on dental students at
Panineeya Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India,
among female dental students regarding their knowledge, attitude and practice
of BSE.
Participation was on voluntary basis. Anonymity and confidentiality of the
responses was assured. Ethical committee clearance from the institutional data
review board was obtained.
Data were collected by a self-administered pretested close-ended questionnaire.
The questionnaire comprised 35 items (15 items on knowledge, 13 items on
attitude, and 7 items on practice). For knowledge items, categorical responses
(true/false/don’t know) were applied, for attitude items, 5-point Likert scale
(strongly agree/agree/neutral/not agree/strongly disagree) was used, and for
practice, similar ordinals (never/seldom/neutral, frequent/always) was
applied.
For positive knowledge, item score “2” was used for correct responses, “1” for
don’t know, and “0” for incorrect response. For a positive attitude item, a score
of “4,” “3,” “2,” “1,” and “0” was used for strongly disagree, agree, neutral,
disagree, and strongly disagree respectively. For practice, an item score of “0,”
“1,” “2,” “3,” and “4” was given for never, seldom, neutral, frequently, and
always, respectively. Overall, the score was reversed for all the negative items.
Data were analyzed using SPSS software (version 12). Categorical variables
were described using frequency distribution and percentages. Continuous
variables were expressed by means and standard deviations. Multiple group
analysis was done by ANOVA and Newman–Keuls multiple post-hoc tests. Chi-
square test was used for analysis of categorical variables. Correlation was
analyzed using Pearson's correlation coefficient. The total scores for KAP were
categorized into good or poor based on 70% cut-off point out of the total
expected score for each. p-value of <0.05 was considered statistically
significant.
Go to:
RESULTS
This study involved a cohort of 216 female dental students, out of whom, 203
completed the questionnaire (response rate, 93.98%). The reliability of the
questionnaire was 0.8. The age range of the study population was 17–22 years
with a mean age of 19.6 ± 1.38 years.
Overall, the total mean knowledge score was 14.22 ± 8.04 with the fourth year
students having the maximum mean score (19.98 ± 3.68). The knowledge on
“need to observe any unusual change in the shape and size of breast” had the
highest mean score for all the students (1.51 ± 0.84), and also accounted for
the highest knowledge in the first year (1.23 ± 0.94), second year (1.69 ± 0.71),
and fourth year (1.90 ± 0.43). Among the third year students, majority
identified “lump is the early sign for cancer” (1.27 ± 0.88), whereas among the
fourth year students, “use of finger pulps to examine any lumps or thickening
of the skin” had the highest mean knowledge score. On the whole, when the
lowest mean knowledge score was considered, it was noted that “BSE must be
done between day 7 until day 10 after menses” had the least mean score of
0.43 ± 0.78, which was also the lowest among second year and third year
students (0.40 ± 0.78 and 0.30 ± 0.68, respectively). For the first year students,
the lowest score was observed for “BSE can be done using vertical strip and
circular technique” (0.33 ± 0.73), and for fourth year students, it was for
“palpate in the right breast while left-sided lying when doing the BSE.”
Though the attitude score was the best among all (mean attitude score was
26.45 ± 5.97), it was strikingly low among fourth year students who had the
maximum knowledge score. The highest overall attitude score was seen for
second year students (27.79 ± 6.01). All the participants felt that “all women
should do BSE” which had the highest overall mean score of 3.19 ± 0.91 and
also for individual years (first year, 3.11 ± 0.9; second year, 3.29 ± 0.76; third
year, 2.76 ± 1.15; fourth year, 3.52 ± 0.74). Likewise, “doing BSE is wasting
time” had the least overall mean score (0.85 ± 0.78) and also the least mean
score for all the years.
For the practice score, the overall mean score was 12.64 ± 5.92 with the
highest mean score noted for third year students, 13.94 ± 5.31. The highest
practice score for all individual years and overall was for “if notice any breast
abnormality, directly go to public health care” (overall mean score, 2.59 ± 1.39).
The least score was recorded for “avoid learning the correct method of BSE”
(0.87 ± 1.12). The practice score was comparatively low in second and fourth
year students with a higher/better knowledge score [Table 1].
Table 1
Mean scores for knowledge, attitude and practice of breast self-examination
among various years
When mean percent scores were considered, the highest mean percent for
knowledge was among fourth year students (66.69 ± 12.26) and this difference
was statistically significant when compared to other years (P = 0.000). The
mean percent of attitude score was maximum for second year students, 53.44
± 11.55. However, on comparison, no significant difference was noted among
various years (P = 0.21). Similarly, even the mean percent of practice score did
not reveal any significant difference among various years (mean Percent, 45.13
± 21.16; P = 0.52; Table 2).
Table 2
Comparison of mean percent scores among various years with respect to
knowledge, attitude, and practice scores
On the whole, when good score (i.e., a score of 70% or more of the total) was
regarded, a good knowledge and practice score was observed among fourth year
students (50% and 19.1%, respectively); for attitude, it was seen among second
year students (9.7%). Majority of the population had poor KAP scores. Good
knowledge and attitude toward BSE only had a statistically significant
difference [Table 3].
Table 3
Comparison of the knowledge, attitude, and practice between the years of study
KAP scores upon correlation revealed a significant correlation between
knowledge and attitude scores only (P < 0.05; Table 4).
Table 4
Correlation between knowledge, attitude, and practice scores
Go to:
DISCUSSION
With the incidence of breast cancer rising, and also absence of any established
national breast screening in India, it becomes important to assess the
knowledge and practice of BSE in various age groups. The present study
involved female dental students (aged 17–24 years) as it can motivate them and
instill in them preventive health behavior of practising BSE regularly. Besides,
being a part of a health-care-providing team, they can disseminate information
to patients as well as family and friends.
Due to the lack of an international standardized questionnaire on KAP of BSE,
we employed the questionnaire utilized in the study by Rosmawati;[20]
nevertheless, the questionnaire was pretested on this group and the reliability
was found to be good (0.8).
The overall knowledge of BSE in this population was rather very poor. This
finding was consistent with the study done by Yadav and Jaroli[17] among
Indian college-going students in Rajasthan wherein 28% examined their
breasts rarely or never. This poor knowledge reflects on the fact that adequate
public education is essential to facilitate early detection of breast cancer.
When the attitude toward BSE was analyzed, it was noted that the majority of
the population felt that “all women should do BSE” (mean, 3.19 ± 0.91)
suggesting the importance of self-examination in early diagnosis of breast
cancer. Though only 20.6% of the population had a good attitude score, the
overall mean percent scores for attitude component was the highest indicating
that there is an urge among this group to inculcate positive health behavior.
Moreover, the finding of this study reveals that the present study population is
more enthusiastic to gain information and interested in doing BSE, which
contrasts with the findings of previous studies wherein unpleasantness and
fear were potential barriers for practising BSE.[21,22]
The practising of BSE in this group of Indian dental students was also quite
alarmingly low (mean score, 12.64 ± 5.92). The mean percent of population
practising BSE was 45.13 ± 21.16. Though only 53% of them had a good BSE
practice score, this was a much better finding as compared to teenagers (3.4%)
and 17–30 year olds (14.8%) in Europe.[20] Also, contrasting results were
noted when comparisons were made with various populations like 28.3% of
Pakistani[23] females practised BSE and 32.1% of Nigerian females performed
BSE.[15] Among the health-care providers, around 90.3% performed BSE in
Sao Paulo,[24] and in Turkey,[25] 28% of the nurses and 32% of physicians did
not practise BSE. Likewise, in a study by Haji-Mahmoodi et al,.[26] it was
determined that most health-care practitioners (63–72%) did not practice BSE.
Our study revealed a positive correlation between knowledge and practice
(correlation coefficient, 0.2129; P < 0.05) illustrating the desire among this
population to acquire correct knowledge regarding BSE. Also, this finding
brings to light that if awareness and health education programs are conducted,
it might result in negative behaviors changing to positive healthy practices.
The present study points out to a number of conclusions. Though, this study
was carried out on a health-care-providing team of dental students, the
knowledge and practice of BSE was quite low. The study also highlights the
need for educational programs to create awareness regarding regular breast
cancer screening behavior. In this present population, most of them obtained
information in the dental school; therefore, it is vital to update them with
important health issues that are not often a part of their course.
Our study also has several limitations. The sample of the study population
includes female dental students; hence, the results of the study cannot be
generalized to a larger population in India. Likewise, the survey was conducted
on a health-care-providing team; hence, the study group might be better
informed. Even though the questionnaire utilized in the study was pretested, it
may limit the comparability of our results with other studies. Furthermore, the
data were collected by self-report, which may be a source of bias. Also, since
this study was limited to only female dental students of a dental school, the
sample size is relatively small and may not be representative of all females of
that age group; hence, it is recommended to conduct further studies using
larger samples at various institutions in India.
Go to:
Footnotes
Source of Support: Nil.
Conflict of Interest: None declared.
Go to:
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401738/

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Knowledge, attitude, and practice of self-breast examination among female

university students at Presbyterian University College, Ghana

Effects of breast self examination training program on knowledge, attitude

KNOWLEDGE, ATTITUDE AND PRACTICE OF BREAST SELF-EXAMINATION

Knowledge, attitudes, and practice of breast self-examination among female

Breast self-examination: assessing its knowledge attitude and practice among

Breast Cancer Screening Knowledge in a Turkish Population Education is

1. 4. Assuming 4% will declining to participate in the study

Rao Siddharth, D Gupta, R Narang, P Singh

Date of Web 6-Jan-

Background: Breast cancer (BC) continues to be a major cause of morbidity

Keywords: Breast cancer, early detection, self-breast examination

How to cite this article:

How to cite this URL:

Breast cancer (BC) continues to be a major cause of morbidity and mortality

Early detection of BC and early treatment increases the chance of survival.

There is a dearth of large scale breast screening programs in India. BSE is

» Materials and Methods

We did this study in the out-patient department (OPD) of a 780-bed teaching

We did a cross-sectional descriptive study among consecutive women and their

The data was collected by a self-administered questionnaire in vernacular

We transferred the paper based data into Microsoft excel. We described

» Observation and Results

Table 1: Demographic characteristics of study population

Click here to view

Click here to view

Table 3: Assessment of knowledge and practice of BSE

Click here to view

Knowledge and awareness of early detection measures of BC such as BSE is

We acknowledge certain limitations of this study. We do not have information

1. Stuckey A. Breast cancer: epidemiology and risk factors. Clin Obstet

3. Somdatta P, Baridalyne N. Awareness of breast cancer in women of an

5. Mittra I, Baum M, Thornton H, Houghton J. Is clinical breast examination

6. Tang TS, Solomon LJ, McCracken LM. Cultural barriers to mammography,

8. Lee EH. Breast self-examination performance among Korean nurses. J

10. Tavafian SS, Hasani L, Aghamolaei T, Zare S, Gregory D. Prediction of

19. Galukande M, Kiguli-Malwadde E. Rethinking breast cancer screening

20. Agarwal G, Ramakant P. Breast Cancer Care in India: The Current

1Bambalang Sub-Divisional Hospital, Northwest Region, Cameroon, 2Galactic

Methods: we conducted a cross-sectional study in April 2016 involving 345

Study procedures and data collection: a structured and self-administered

Scoring of knowledge: each of the questions on knowledge of risk factors and

Awareness, knowledge and attitudes on breast cancer: of the 345

Awareness and practice of breast self-examination: less than half (n =143,

Most (94.4%) of our participants perceived that breast cancer could be

Early detection of breast cancer plays a pivotal role in reducing related

Tables and figures

Table 2: frequency distribution of knowledge and misperceptions towards

Table 3: perceived attitudes regarding development of breast cancer of 304

Table 4: perceptions about prevention and treatment options of breast cancer

Table 5: knowledge, practice and perceived importance of breast self-

Figure 1: distribution of participants according to sources of knowledge about

Figure 2: reasons for not performing breast-self examination

2. World Health Organisation. Breast cancer: prevention and control.

3. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M et al.

4. Anderson B, Shyyan R, Eniu A, Smith R, Yip C, Bese N. Breast cancer in

5. IARC. Globocan 2012: estimated cancer incidence, mortality and

6. Ameer K, Abdulie S, Pal S, Arebo K, Kassa G. Breast Cancer Awareness

7. Anders C, Hsu D, Broadwater G, Acharya C, Foekens J. Young age at

8. Bray F, Ren J-S, Masuyer E, Ferlay J. Global estimates of cancer

9. IARC. Globocan 2008: Cancer Incidence, Mortality and Prevalence

10. Nde F, Assob J, Kwenti T, Njunda A, Tainenbe T. Knowledge,

11. Suh M, Atashili J, Fuh E, Eta V. Breast Self-Examination and