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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 361-369

Predictors of practice of breast self-examination: A study among female undergraduates of Ebonyi State University, Abakaliki, Nigeria


Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki, Nigeria

Date of Acceptance20-Dec-2018
Date of Web Publication6-Mar-2019

Correspondence Address:
Dr. E N Ossai
Department of Community Medicine, College of Health Sciences, Ebonyi State University, Abakaliki
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_482_18

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   Abstract 


Background: Breast cancer is the most common female cancer in both developed and developing countries. This study was designed to determine the predictors of practice of breast self-examination among female undergraduate students of Ebonyi State University, Abakaliki, Nigeria. Methodology: This was a descriptive cross-sectional study. A three-stage sampling design was used to select 365 female students of the university. Data were collected using a pretested self-administered questionnaire. Completion of one academic year qualified students for inclusion. Good knowledge of breast self-examination was determined by proportion of respondents who scored 50% and above of 15 variables used to assess knowledge. Results: The mean age of the students was 22.1 ± 2.5 years. Majority (76.4%) were aware of breast self-examination and health workers; 37.0% were the major source of information. A minor proportion (5.8%) have had their close relatives diagnosed with breast cancer. Majority (55.3%) had good knowledge of breast self-examination. Majority (63.6%) have ever-practiced breast self-examination; however, only 15.9% of the respondents examined their breasts on a monthly basis. Predictors of ever-practiced breast self-examination included having good knowledge of breast self-examination (adjusted odds ratios [AOR] =6.4, 95% CI: 3.9–10.4), having a close relative diagnosed with breast cancer (AOR = 4.0, 95% CI: 1.1–15.1), and mother of respondent being self-employed (AOR = 0.5, 95% CI: 0.5–1.5). Conclusions: Awareness of breast self-examination and practice were high among the respondents; however, only a minor proportion practiced breast self-examination every month. Having good knowledge of breast self-examination was associated with its practice. Having a close relative diagnosed with breast cancer encouraged the respondents to prevent the occurrence of breast cancer, thus enabling the practice of breast self-examination. Moreover, the practitioners of breast self-examination taught and encouraged others to examine their breasts. There is a need to increase knowledge of breast self-examination through public health education using the media.

Keywords: Breast self-examination, Ebonyi state, knowledge, Nigeria, practice, undergraduates


How to cite this article:
Ossai E N, Azuogu B N, Ogaranya I O, Ogenyi A I, Enemor D O, Nwafor M A. Predictors of practice of breast self-examination: A study among female undergraduates of Ebonyi State University, Abakaliki, Nigeria. Niger J Clin Pract 2019;22:361-9

How to cite this URL:
Ossai E N, Azuogu B N, Ogaranya I O, Ogenyi A I, Enemor D O, Nwafor M A. Predictors of practice of breast self-examination: A study among female undergraduates of Ebonyi State University, Abakaliki, Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 May 21];22:361-9. Available from: http://www.njcponline.com/text.asp?2019/22/3/361/253463




   Background Top


The World Health Organization has identified cancers of the breast and cervix as major cancer killers for women above 30 years in low- and middle-income countries.[1] For instance, in the year 2015, breast cancer accounted for about 15% of all cancer deaths among women globally.[2] The majority of these deaths take place in developing countries.[3] There is evidence that breast cancer rates are increasing in all regions of the world.[2] Unfortunately, in low- and middle-income countries where resources are limited, most of the cases present at the late stages,[1] including Nigeria.[4] Despite the fact that several risk factors have been linked with breast cancer, in majority of women diagnosed with the disease, there is no identifiable risk factor.[5],[6] This necessitates the need for early detection of the disease as it has been found to improve breast cancer outcome and survival.[7] This is because breast cancer cases when detected early could increase the proportion of cases that could response favorably to curative treatment, thus reducing the risk of death.[8]

The early detection methods for breast cancer include screening and early diagnosis and treatment. The World Health Organization has recognized mammography, clinical breast examination, and breast self-examination as screening tools for breast cancer.[2] Even though there are promising results from clinical breast examination, mammography remains the only effective screening method for detecting breast cancer. However, its relevance in resource-poor settings is doubtful.[2] Interestingly, breast self-examination unlike the other two methods can be performed independently by the woman and as such does not require visits to the health facility, no form of clinical expertise, or basic infrastructure. Thus, breast self-examination could be of relevance in the early detection of breast cancer in resource-poor settings where routine clinical breast examination and mammography may not be feasible.

It has been demonstrated that factors related to the awareness of women, their knowledge, and perception about breast cancer may contribute immensely to medical help-seeking behavior.[9],[10],[11] Furthermore, irrespective of the fact that there is no evidence in support of breast self-examination as a screening tool for breast cancer,[1],[12],[13],[14],[15] the practice of breast self-examination has been known to motivate women to take care of their own health invariably increasing their awareness.[1] Moreover, the use of mammography even among female health workers in Nigeria is very low,[16] and even at that, there is a limitation to its use because of cost.[17]

The World Health Organization is of the opinion that there will be a 70% increase in incidence of breast cancer by 2030 in developing countries including Nigeria.[18] Perhaps to optimize caution, the American Cancer Society encourages women to be familiar with the normal structure and texture of their breasts, thus making it possible for someone to visit a health-care provider whenever changes are observed.[12] Based on these observations, the main reason for regular breast self-examination should be for women to be able to know when changes take place in their breasts.[19] In effect, it has been postulated that the regular practice of breast self-examination promotes health.[20]

There is evidence that majority of cases of breast cancer are detected by the women themselves,[21],[22] thus revealing that there is a positive association between the practice of breast self-examination and detection of breast cancer.[23] Consequently, the practice of breast self-examination is regarded as a cost-effective method for the detection of breast cancer in resource-poor countries.[24] Thus, a woman who performs breast self-examination regularly is more likely to seek medical attention when the need arises including mammography and clinical breast examination if such services are available.[25],[26] Moreover, a woman who correctly practices breast self-examination has a higher chance of detecting a lump at the early stage, hence increasing the chances of survival.[27] This study was designed to determine the predictors of practice of breast self-examination among female undergraduate students of Ebonyi State University, Abakaliki, Nigeria.


   Methodology Top


Study setting

Ebonyi state was created on the first day of October 1996 out of the present Enugu and Abia states in southeast Nigeria. The Abakaliki campus of the then Enugu State University of Technology was upgraded to Ebonyi State University College by the State Edict of 1998 and it remained affiliated to its parent university until 1999 when it became a full-fledged university. The university has eight faculties.

Study design

This was a descriptive cross-sectional study.

Study participants

The study population were female undergraduate students of Ebonyi State University, Abakaliki, Nigeria. For inclusion in the study, the student must have stayed more than one full academic year in the university.

Study instrument

The study instrument was a pretested, semi-structured questionnaire, which was developed by the researchers. The questionnaire was self-administered. It elicited questions on the sociodemographic characteristics, source of information, and knowledge and practice of breast self-examination among the respondents.

Sample size determination

The minimum sample size for the study was determined by the formula used for single proportions.[28] A sample size of 365 students was used in the study based on a type 1 error (α) of 0.05, a tolerable margin of error of 0.05 and the proportion of 63.8% that had ever-practiced breast self-examination in a previous study.[29]

Sampling technique

A three-stage sampling technique was employed in the study. In the first stage, a simple random sampling technique of balloting was used to select four out of the eight faculties in the university. The Faculty of Medicine of the University was excluded from the study. In the second stage, a simple random sampling technique of balloting was used to select three departments in each of the four selected faculties. In the third stage, a systematic random sampling technique was used to select the respondents based on the number of eligible students in the department on the day of data collection. The number of female undergraduates present on each day of data collection in the 12 departments selected for the study was recorded and this served as the sampling frame. By dividing this number by 30, a sampling interval was obtained for each of the selected departments. The index student in each of the departments was selected by a simple random sampling technique of balloting. The respondents were allocated equally to the 12 departments of the university selected for the study. All first-year female students of the university were excluded from the study.

Data analysis

Data entry and analysis were done using IBM Statistical Package for Social Sciences statistical software version 22. Frequency tables and cross-tabulations were generated. Chi-square test of statistical significance and multivariate analysis using binary logistic regression were used in the analysis, and the level of statistical significance was determined by a P value of less than 0.05. In determining the predictors of practice of breast self-examination, variables that had a P value of less than 0.2 on bivariate analysis were entered into the logistic regression model. The results were reported using adjusted odds ratios (AOR) and 95% confidence interval. Good knowledge of breast self-examination was determined by the proportion of the respondents who correctly answered 50% of the 15 variables used to assess knowledge of breast self-examination.


   Results Top


[Table 1] shows the sociodemographic characteristics of the respondents. The mean age of the respondents was 22.1 ± 2.5 years. Majority of the respondents (71.8%) were in the age group of 20–24 years. In addition, majority of the respondents (94.2%) were not married. Majority of the fathers (55.9%) and mothers (56.4%) of the respondents were self-employed.
Table 1: Sociodemographic characteristics of respondents

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[Table 2] shows the perception of breast cancer by the respondents. A minor proportion of the respondents (5.8%) have had a close relative diagnosed with breast cancer. Only a minor proportion of the respondents (2.7%) perceived breast cancer to be due to abnormal growth of cells. Majority of the respondents (81.4%) were of the opinion that their menstrual cycle were regular.
Table 2: Respondents perception of cause of breast cancer

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[Table 3] shows the source of information of breast self-examination by the respondents. Majority of the respondents (76.4%) were aware of breast self-examination. The major source of information on breast self-examination for the respondents was health workers (37.0%) closely followed by television (27.9%).
Table 3: Respondents source of information on breast self-examination

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[Table 4] shows the knowledge of breast self-examination by the respondents. Majority of the respondents (81.1%) were aware of the age at which breast self-examination should begin. Majority (70.1%) were of the correct opinion that lump detection in the breast may be an early sign of breast cancer. Majority of the respondents (52.6%) answered correctly that during breast self-examination, unusual change in the shape and size of the breast is observed. Similarly, only a minor proportion of the respondents (45.5%) were aware that retraction of the nipple is observed during breast self-examination. A higher proportion of the respondents (55.3%) had good knowledge of breast self-examination.
Table 4: Knowledge of breast self-examination by respondents

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[Table 5] shows the practice of breast self-examination by respondents. Majority, 63.6% have ever done breast self-examination. Of this proportion, 25% performed breast self-examination every month. A minor proportion, 24.6% have had their breasts examined by a health worker while 10.3% have noticed abnormalities in their breasts. Majority, 67.2% discussed the importance of breast self-examination with their friends.
Table 5: Practice of breast self-examination by respondents

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[Table 6] shows the practice of breast self-examination by the respondents. Majority of the respondents (63.6%) have done breast self-examination before; however, only a minor proportion of them (25.0%) do breast self-examination every month. Majority of the respondents (53.9%) have been taught breast self-examination by a health worker, whereas only a minor proportion (24.6%) have had their breasts examined by a health worker. Moreover, only a minor proportion of the respondents (10.3%) have noticed an abnormality. Majority of the respondents who have ever done breast self-examination (74.6%) have encouraged friends and relatives to do breast self-examination and have also discussed the importance of breast self-examination with friends (67.2%).
Table 6: Predictors of practice of breast self-examination

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[Table 6] shows the practice of breast self-examination by the respondents. The respondents who had good knowledge of breast self-examination were six times more likely to have ever-practiced breast self-examination when compared with those who had poor knowledge (AOR 6.4; 95% CI: 3.9–10.4). Moreover, the respondents who have relatives diagnosed with breast cancer were four times more likely to practice breast self-examination when compared with those who do not have relatives diagnosed with breast cancer (AOR 4.0; 95% CI: 1.1–15.1). The respondents whose mothers were self-employed were twice less likely to perform breast self-examination when compared with those whose mothers were on salaried employment (AOR 0.5, 95% CI: 0.3–9.2).


   Discussion Top


Majority of the respondents (76.4%) were aware of breast self-examination. This may be expected, bearing in mind the level of education of the respondents as they were all undergraduates in a Nigerian university. It is instructive to note that similar studies among female undergraduates in Nigeria also recorded a high level of awareness of breast self-examination.[29],[30],[31],[32],[33],[34] It has been acknowledged that the breast cancer rates have been increasing in all regions of the world,[2] and bearing in mind the perception of breast cancer as a dangerous disease,[9],[35] this could have aroused increased awareness of the disease among the people.

Health workers were the major source of information on breast self-examination among the respondents. This is commendable considering the level of development in the country. This is similar to the result from another Nigerian university,[32] and among rural women in Nigeria.[36] However in a study among Malaysian female undergraduates, health workers were the least source of information on breast self-examination, whereas the internet was the major source of information.[37] In other studies, the mass media was the major source of information on breast self-examination.[19],[29],[30],[38],[39]

This finding emphasizes the good role of health workers as educators in matters related to health in Nigeria. It is important to note that health education is a component of primary health care and this is the foundation of the health-care system in Nigeria.[40] This good role of health workers as educators was further demonstrated by the proportion of the respondents (53.9%), who were taught how to examine their breasts by health workers in this study. Remarkably, this proportion is higher than those who had their breasts examined by health workers in this study (24.6%) and also among female undergraduates in Cameroon (19.9%).[19] This brings to the fore the good role of health workers in educating women on breast self-examination.[41] The continuous relevance of breast self-examination in resource-poor countries was demonstrated by the results of a study among female health workers in a teaching hospital in Nigeria in which a higher proportion of the participants performed breast self-examination when compared with those who had clinical breast examination.[42] Similar result was also obtained at the community level in India.[43]

Majority of the respondents (55.3%) had good knowledge of breast self-examination. This could be attributed to the high level of awareness of breast self-examination among the respondents. This proportion that had good knowledge of breast self-examination was higher than that obtained from similar studies in Nigeria [29],[34] and in Ethiopia.[38]

Majority of the respondents (63.6%) have ever-practiced breast self-examination. This is similar to that obtained from another study among undergraduates in Nigeria.[29] Among those who have ever-practiced breast self-examination, only a minor proportion (25%) examined their breasts on a monthly basis. This pattern of result has been consistent from similar studies in Nigeria.[29],[31],[32],[34],[44] This observation makes it necessary for increased public health education to enable more people to sustain the practice of self-examination. The importance of this is highlighted from the results of the study in which an approximate 1/10 of the respondents who have ever-practiced breast self-examination have noticed an abnormality of the breast. Surprisingly, half of the respondents who have noticed abnormalities never sought medical attention. Based on this finding, the need for continued public enlightenment on breast self-examination remains relevant. Interestingly, the practice of breast self-examination enabled the practitioners to become educators of the program as majority of them encouraged friends/relatives to practice breast self-examination and also discussed the importance of breast self-examination with others. This points to the several gains associated with the practice of breast self-examination in resource-poor countries.

From the results of this study, the respondents who had a good knowledge of breast self-examination were six times more likely to have ever performed breast self-examination when compared with those who had poor knowledge. This is similar to the results of others studies.[19],[38],[45],[46],[47],[48] Lack of knowledge has been identified as a major barrier to the practice of breast self-examination by women.[19],[46],[49] This observation is further supported by the finding that educating the people on breast self-examination could remove the barriers to the practice of examining the breast.[50] Since breast self-examination is closely related to breast cancer, there is also a relationship between knowledge of breast cancer and practice of breast self-examination. Thus, insufficient knowledge about breast cancer is about twice higher in women who never-practiced breast self-examination.[51] In addition, the good knowledge of risk factors of breast cancer is also associated with the practice of breast self-examination.[32] In effect, it has been concluded that lack of knowledge of breast self-examination among the populace negatively affects prevention and early diagnosis of breast cancer,[51] thus pointing on the need for increased public health education on the relevance of breast self-examination using the mass media. It may also be necessary to involve the survivors of breast cancer in the promotion of the practice of breast self-examination in resource-poor countries, especially those who identified the breast lumps themselves.

Moreover, respondents who had a close relative diagnosed with breast cancer were four times more likely to perform breast self-examination when compared with those who did not have such a relative. It has been found that family history of breast cancer positively affect the practice of breast self-examination.[30],[38],[39],[51] Perhaps while the increasing rates of breast cancer in all the regions of the world have increased, the awareness of breast self-examination, among the populace including the respondents in this study, having a close relative diagnosed with breast cancer may have evoked a sense of responsibility toward the prevention and early diagnosis of the disease, thus necessitating the practice of breast self-examination by such individuals. It has been observed that the perception of young women about breast cancer is affected by what they pass through when they see their relatives who suffered the disease.[52] It is needless for all the people to have relatives who have had breast cancer so as to evoke this response, but much of it could be communicated to the people using appropriate health education strategies.

It has also been found that those who had poor knowledge of breast cancer were about twice higher among those who had no family history of breast cancer.[52] It has been demonstrated that factors related to women's awareness, knowledge, and perception about breast cancer may contribute significantly to medical help-seeking behavior.[9],[10],[11] Thus, in resource-poor countries, the practice of breast self-examination remains the most practical tool to increase such awareness and knowledge of breast cancer, hence its continued relevance in such settings. This may have informed the call for urgent educational interventions aimed at encouraging women to engage in regular breast self-examination in some developing countries.[53],[54]

The respondents whose mothers were self-employed were twice less likely to perform breast self-examination when compared with those whose mothers were on salaried employment. This could be a reflection of family background and relationship of mothers and daughters. It could be that the mothers who were on salaried employment are more aware of breast cancer and its effects and have positively influenced their daughters toward taking such precautionary measures as practice of breast self-examination.

The importance of practice of breast self-examination in resource-poor countries cannot be over emphasized. Based on this, future research on the practice of breast self-examination in such settings may need to focus on community studies with involvement of middle-aged women who are more at risk of breast cancer. There may also be the need to include qualitative data collection methods to assess the views of the women on the cause of breast cancer, its risk factors, and practice of breast self-examination. This is because understanding the cause of breast cancer may enhance the good in the practice of breast self-examination.


   Conclusions Top


Awareness of breast self-examination and practice were high among the respondents; however, only a minor proportion practiced breast self-examination every month. Having good knowledge of breast self-examination was associated with its practice. Having a close relative diagnosed with breast cancer encouraged the respondents to prevent the occurrence of breast cancer, thus enabling the practice of breast self-examination. In addition, the practitioners of breast self-examination taught and encouraged others to examine their breasts. There is a need to increase knowledge of breast self-examination through public health education using the media.

Declarations

Ethical approval and consent to participate

The research was reviewed and accepted by the Research and Ethics Committee of Ebonyi State University, Abakaliki, Nigeria. The students were required to sign a written informed consent form before participating in the study, and the nature of the study, its relevance, and the level of their participation were made known to them. Respondents were assured that participation in the study was voluntary and there would be no victimization of any student who did not want to be part of the study or who decided to withdraw after giving consent.

Financial support and sponsorship

The researchers funded the research.

Conflict of interest

There are no conflicts of interest.

Authors' contributions

ENO conceptualized the study, did the literature search, participated in the design, wrote the study protocol and coordinated the research, performed the statistical analysis, and drafted the manuscript. BNA participated in literature search, design, and revision of draft. IOO participated in design, literature search, supervised data collection, and revision of draft. AIO participated in the design, literature search, and acquisition of data. OOE participated in the design, literature search, and acquisition of data. MAN participated in the design, literature search, and acquisition of data. All authors read and approved the final draft.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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