_____________________________________________________________________________________________________ (Past name: British Journal of Medicine and Medical Research, Past ISSN: 2231-0614, NLM ID: 101570965)
How Level of Education Relates to Knowledge,
Attitude and Practices Regarding Breast Cancer and
Its Screening Methods
Ayesha Rizwan
1, Zikria Saleem
1and Saleha Sadeeqa
2*1
Punjab University College of Pharmacy, Lahore, Pakistan. 2
Institute of Pharmacy, Lahore College for Women University, Lahore, Pakistan.
Authors’ contributions
This work was carried out in collaboration between all authors. Author AR managed the literature searches, collected data, performed the statistical analysis and wrote the first draft of the manuscript. Author ZS designed the study and wrote the protocol and author SS managed the analyses, reviewed the manuscript and performed final editing. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/JAMMR/2017/37722 Editor(s): (1)Edward J. Pavlik, University of Kentucky Medical Center, Division of Gynecological Oncology, USA.
(2)Alex Xiucheng Fan, Department of Biochemistry and Molecular Biology, University of Florida, USA. Reviewers: (1) José Carlos Souza, Mato Grosso do Sul State University, Brazil. (2)Wenyin Shi, Thomas Jefferson University, USA. Complete Peer review History:http://www.sciencedomain.org/review-history/22039
Received 26th October 2017 Accepted 20th November 2017 Published 24th November 2017
ABSTRACT
Context: Breast cancer is the most frequently diagnosed cancer among women worldwide. Breast
cancer is a major contributor towards cancer related morbidity and mortality in Pakistani women.
Aims: The study aimed to examine how level of education relates to the knowledge, attitude and
practices regarding breast cancer and its screening methods amongst women.
Settings and Design: A cross-sectional survey was conducted in Lahore, Pakistan.
Methods and Materials: 504 randomly selected women participated in study, data was collected
using a structured self-administered and interview administered questionnaire.
Statistical Analysis Used: Descriptive statistics were applied for demographic data. For
association of demographics with the mean scores of knowledge, attitude and practices, chi- square test was performed. P value < 0.05 was considered as significant.
Results: Results showed a direct relation between the level of education and the knowledge of
women. Mean knowledge score was 34.5% in the group having no formal education. The groups
having primary, matriculation, college level and university level education had mean knowledge scores of 43.7%, 51.6%, 65.8% and 66.6% respectively. Attitudes and practices were independent of the level of education. However, participants from class 1 (no formal education) had better attitude towards Breast Self Exam than any other class. All the groups had almost equal practice scores relating to BSE, although, the overall practices score was low (36.5%).
Conclusion: It was concluded that overall knowledge about breast cancer was relatively weak in
all participants, being lowest in people with less education.
Keywords: Knowledge; attitude; practices; breast cancer; screening.
1. INTRODUCTION
Breast cancer is the most frequently diagnosed cancer among women worldwide, and is the most common cancer overall only second to lung cancer [1]. There is a higher incidence rate of breast cancer in Western European countries as compared to that of Eastern Asian or African countries [2]. However, there is a significantly higher survival rate of the patients diagnosed with the disease in Western European countries compared to that of Asian or African counties[3]. This is attributed to better screening and treatment facilities in developed world.
There are several contributing risk factors to the disease. Well established risk factors include; older age, family history of the disease, exposure to radiation, use of oral contraceptive pills, first child birth at a age greater than 30 years and irregular menstrual cycles among others [4]. A survey of the U.S. population showed that 47% of the total reported cases indicated a strong connection to these established risk factors [5].
Studies have shown a huge gap between the acceptance of the importance of BSE (Breast Self Exam) education and the actual awareness of the procedures and methods of BSE in the masses. This problem is particularly true for Asian and African countries [6-8]. The lack of knowledge, however, did not always present as the reason for the lack of BSE practice. Studies among the nurses of Lagos, Nigeria; school teachers of Buraidah, Saudia Arabia and lady health workers of Tehran, Iran suggested that regardless of women being educated in the field of science, they had little knowledge of the breast cancer screening methods [9-11]. Religious misconceptions, social pressures, cultural barriers, lack of facilities and misguided beliefs contribute towards lack of breast cancer screening efforts and delayed help seeking attitudes of a lot of ethnic groups in different
countries, and especially in Asia [12-17]. Older women, who are at a greater risk of developing the disease [18], are also unfortunately, among the groups who are least aware of the identifying symptoms.
Limited statistical data is available for the incidence rate of the disease in Pakistan. A 1995-1997 survey shows that breast cancer is not only the most commonly reported cancer in Pakistani females but, Pakistani females also show a significantly higher incidence rate of the disease compared to any other Asian country except for Israel [19]. The average reported age of the disease occurrence is also about 10 years younger in the Asian (and hence Pakistani) population compared to any other in the world [20,21].
Breast Self Exam and other screening methods are directly related to early detection which leads to better survival rate [22,23]. Role of education in minimizing the mortality rate of the disease cannot be stressed enough. Other studies conducting in Pakistan on similar topics suggest poor knowledge and even worse practices regarding Breast Self Exam[24,25]. There are no such studies specific to the population of Lahore. The effect of different demographic features on the knowledge and practices has also not been explored yet. Since level of education directly influences what people learn, know and understand about disease and its treatments, it is of value to study the influence it have.
Once it is established that level of education indeed has an effect on the
knowledge, attitude and practices of the people regarding breast cancer and its practices, more disease specific health awareness programs can be added to the curriculum. Further, special education and awareness programs can be arranged for the illiterate or the less
2. SUBJECTS AND METHODS
A community based descriptive cross-sectional study was carried out to assess the knowledge, attitude and practices regarding breast cancer and its screening methods in women of Lahore, Pakistan. The study was completed over a period of 5 months from February, 2016 to June, 2016. Effect of the level of education on the knowledge, attitude and practices of 550 women selected by non-probability convenient sampling, between the ages of 18 and 60 with no prior history of breast cancer was assessed using a self administered and interview administered questionnaire (in English and Urdu). The participants signed an informed consent before taking part in the study.
The participants were divided in five groups based on the level of their education; those with no formal education (class 1), with primary level education (class 2), with matriculation (grade 10) level education (Class 3), with college level education (class 4) and with university level education (class 5).
The questionnaire collected information regarding the demographic characteristics, knowledge about breast cancer, its risk factors, knowledge about breast self exam, practices regarding the frequency of Breast Self Exam (BSE) and attitude towards the prevention of the disease.
The score for knowledge, attitude and practices was calculated by giving 1 for a ‘yes’ answer and a 0 for both a ‘no’ and a ‘don’t know’ answer. The Likert scale score was assigned as 5 for ‘strongly agree’, 4 for ‘agree’, 3 for ‘neither agree nor disagree’, 2 for ‘disagree’ and 1 for ‘strongly disagree’. The total score for knowledge, attitude and practices was then calculated for each participant and an average knowledge, attitude and practice score was calculated for all participants.
Data was analyzed using SPSS version 22.0. Descriptive statistics were applied for the analysis of demographic data and for association of demographics with the mean scores of knowledge, attitude and practices; chi- square test was performed. Chi- square probability value < 0.05 was considered as significant.
3. RESULTS
The questionnaire was given to 550 women, of which 504 returned it with all questions answered, giving a response rate of 91.6%.
3.1 Socio-demographic Characteristics of Study Participants
Socio-demographic characteristics of study participants are depicted in Table 1.Mean age of the participants was 31.5 years with the age ranging from 18 years to 60 years. 53% of the women were never married, while 47% were at least married once. 6.9% of the women belonged to the socio-economic class, with the monthly household income less than PKR 10,000, 17.5% with income between PKR 10,000- 30,000, 29.8% with income PKR 30,000- 60,000, and 45.8% with income greater than PKR 60,000. 13.7% women had no formal education (class-1) while 4% had a primary education (class-2). 6% have had matriculation (class-3), 14.3% a college degree (class-4) and 62.1% had at least an undergrad degree (class-5). Breast cancer family history was found in 25.2% of the women.
Table 1. Frequency distribution of the demographic characteristics of the
participants
Variable Frequency (%)
Age
Mean 31.5
Range 18-60
Marital status
Ever married 237 (47)
Never married 267 (53)
House income
Less than PKR 10,000 35 (6.9) PKR 10,000-30,000 88 (17.5) PKR 30,000-60,000 150 (29.8) More than PKR 60,000 231 (45.8)
Level of education
No formal education (class1)
69 (13.7)
Primary education (class2) 20 (4) Matriculation (class3) 30 (6) College (class4) 72 (14.3) University (class5) 313 (62.1)
Family history of disease
Yes 127 (25.2)
No 377 (74.8)
3.2 Knowledge about Breast Cancer
class 2 knew what breast cancer was and that it can be treated but 0%, 25%, 20%, 63.9% and 69.6% from classes 1,2,3,4 and 5 knew that a Breast Self Exam can decrease the mortality rate by early diagnosis. Very few people knew how to perform a BSE with only 3% from class 1, 40% from class 2, 13% from class 3, 61.6% from class 4 and 60.1% from class 5. 3% women from class 1 knew what a mammogram was, 25% from class 2, 13.3% from class3, 54% from class4 and 50.8% from class 5 (Fig. 1).
3.3 Knowledge about Breast Cancer Risk Factors
Knowledge of breast cancer risk factors is depicted in Fig. 2. Breast feeding children decreased the risk of breast cancer was most commonly known among all other risk factors with 84% from class 1, 70% from class 2, 83.3%
from class 3, 82% from class 4 and 76.4% from class 4 knowing about it. Use of oral contraceptives being a risk factor was known in 22%, 35%, 43.3%, 68% and 62.3% of the people from classes 1, 2, 3, 4 and 5 respectively. Age andsun radiations as risk factors were also comparatively well-known specially in class 5 with 26% and 16% from class 1, 40% and 35% from class 2, 73% and 50% from class 3, 16.7% and 50% from class 4 and 85.6% and 82.4% from class 5 knowing about them. Age of start of menstrual cycle and age at the birth of the first child as risk factors were only known in about 50% or less people in all classes. Obesity as a risk factor was also not well known, with only 40% participants from class 1, 45% from class 2, 43% from class 3, 46% from class 4 and 51.4% from class 5 knowing about it. The overall knowledge score difference between all 5 classes was significant (P=0.000).
Fig. 1. Knowledge of participants about breast cancer
Fig. 2. Knowledge of participants about breast cancer risk factors 0%
20% 40% 60% 80% 100% 120%
knowledge of breast cancer
knowledge of treatment
knowledge of screening
knowledge of BSE decreasing
mortality
knowledge of how to perform
BSE
knowledge of mammogram
no formal education (class1)
primary education (class2)
matriculation education (class3)
college education (class4)
university education (class5)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
age sun radiations obesity age of start of mentrual cycle
oral contraceptives
age at the birth of first
child
breast feeding
no formal education (class1)
primary education (class2)
matriculation education (class3)
college education (class4)
Table 2. Comparing Knowledge, Attitude and Practice scores of different classes
Variable Class 1 (%) Class 2 (%) Class 3 (%) Class 4 (%) Class 5 (%)
P value
Knowledge score
34.5 43.7 51.58 65.79 66.63 0.000
Attitude score 91.9 80.25 86.7 87.9 88.8 0.000
Practice score 35.9 38.6 33.6 38.6 35.6 0.486
Table 3. Mean percentage score of knowledge, attitude and practices of the
participants
Variable Mean
Knowledge score 52.44
Attitude score 87.11
Practice score 36.46
Table 4. Attitude and practices of the women regarding breast cancer screening
Variable Percent
people People who performed a BSE
every month
Class 1 0
Class 2 15
Class 3 6.7
Class 4 22.2
Class 5 16
Women who ever performed a BSE
Class 1 2.9
Class 2 40
Class 3 26.7
Class 4 47.2
Class 5 48.6
Women who said they will perform regular BSE if they knew how
Class 1 91
Class 2 93
Class 3 95.3
Class 4 97.2
Class 5 97.5
Women who ever had a mammogram
Class 1 1.4
Class 2 15
Class 3 6.7
Class 4 11.1
Class 5 12.1
3.4 Attitude and Practices towards Breast Cancer Screening
Attitudes and practices towards breast cancer are depicted in Table 4. The attitude scores for
classes 1, 2, 3, 4 and 5 were found to be 91.9%, 80.25%, 86.7%, 87.9% and 88.8% respectively. On the other hand the practice scores were 35.9%, 38.6%, 33.6%, 38.6% and 35.6% for the five classes. Less than half of the participants had ever performed a Breast Self Exam from all five classes, with 2.9% from class 1, 40% from class 2, 26.7% from class 3, 47.2% from class 4 and 48.6% from class 5. Of these, very few people performed monthly breast self exams with 0% from class 1, 15% from class 2, 6.7% from class 3, 22.2% from class 4 and 16% from class 5. Only 1.4% of the participants in class 1 ever had a mammogram, 15% from class 2, 6.7% from class 3, 11.1% from class 4 and 12.1% from class 5. 91%, 93%, 95.3%, 97.2% and 97.5% women from classes 1, 2, 3, 4 and 5 were willing to perform monthly BSE if they were taught properly. There was a significant difference between the attitude scores of all 5 classes (p=0.000) whereas, there difference of practice score was not significant (p=0.486).
4. DISCUSSION
The majority of the participants had some form of a formal education and about half of the total belonged to the group having monthly household income of more than PKR 60,000. The mean knowledge about breast cancer screening and its risk factors was insufficient in all the participants. Previous studies have shown similar lack of knowledge in Asian women [26,27]. However, there was a statistically significant difference in the knowledge of the women in all four groups with the amount of knowledge they had about breast cancer, its screening and risk factors increasing as the level of education increased. Similar cases have been reported for most Asian and African countries [11,28-30].
showed a general increasing trend with increase in the level of education. Age of the start of the menstrual cycle and age at the time of the birth of first child were the risk factors women knew the least about. Increasing age, sun radiation and absence of breast feeding increasing the chances of getting breast cancer were most commonly known [31-33]. The attitude and practices regarding breast cancer seemed to be independent of the level of education and were low, in line with previous findings [9]. The attitude scores of the five groups were significantly different but there was no general trend towards increasing or decreasing monthly income [17,34, 35]. Participants who were educated on how to perform a BSE from all 5 classes had strong intentions of practicing it on regular basis from then onwards.
Like educational level, family income also affects knowledge about breast cancer and its screening methods [21].
The strengths of present study were to explore the idea of breast self exam (BSE) and awareness regarding the risk factors of breast cancer. The time constrain though limited the counselling among all participants. Further studies can be done to overcome this limitation on a bigger sample size.
5. CONCLUSION
The study concludes that there is a lack of awareness about breast cancer screening methods and risk factors in women of Lahore, particularly for women with low levels of education. The study also showed that the women who did know about the risks of breast cancer and screening decreasing mortality rates made little or no effort to learn to perform the screening tests. After being reminded and being taught the screening procedures most women did show the willingness and intent to perform regular breast self exams. The study hence highlights not only the importance of education in health awareness, but also emphasizes the importance of practical teaching and constant reminders through media led education campaigns, medical seminars, and specific counseling.
CONSENT
As per international standard or university standard, patient’s written consent has been collected and preserved by the authors.
ETHICAL APPROVAL
Study was approved from Punjab University College of Pharmacy, Lahore, Pakistan. Informed consent was sought from all participants and confidentiality of information was assured.
COMPETING INTERESTS
Authors have declared that no competing interests exist.
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