|Year : 2015 | Volume
| Issue : 4 | Page : 520-524
Breast self-examination practices in Nigerian women attending a tertiary outpatient clinic
AM Ogunbode1, AA Fatiregun2, OO Ogunbode3
1 Department of Family Medicine, University College Hospital, University of Ibadan, Ibadan, Nigeria
2 Department of Epidemiology, Medical Statistics and Environmental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Web Publication||10-Mar-2016|
A M Ogunbode
Department of Family Medicine, University College Hospital, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
BACKGROUND: The morbidity and mortality caused by breast cancer can be decreased by early detection with breast self-examination (BSE). The objective of this study was to determine the prevalence and the factors determining the practice of BSE. MATERIALS AND METHODS: The study was conducted on 140 women aged above 18 years who presented consecutively in a General Outpatient's clinic in a tertiary hospital in Nigeria. This was the baseline study from an intervention study which looked at the effect of demonstration of BSE on improving Clinical Breast Examination (CBE) among two groups of respondents. Structured questionnaires were validated and administered by an interviewer and the data were analyzed using Statistical Package for Social Sciences (SPSS) version 12. RESULTS: The overall self-reported prevalence of BSE practice was 62.1% among the respondents. Older women (16, 76.2%), married women (63, 65.6%) and women with tertiary education (51, 68.9%) had the highest prevalence of BSE practice. Prevalence rate was highest for civil servant (25, 78.1%), P = 0.04. The practice of BSE was higher among women with a previous history of breast disease (15, 68.2%) and in respondents with a family history of breast disease (7, 63.6%), Only 11 (12.6%) performed BSE as per guidelines, which was once in a month. CONCLUSION: The prevalence of BSE was found to be high, especially in those with tertiary education and in those with a past personal or family history of breast disease. In resource-constrained countries, BSE is a screening tool that can be employed to help reduce the breast cancer burden because routine mammography screening is not yet feasible. Women need to be informed about the when and how to perform BSE.
Keywords: Breast self-examination, cancer screening, family history, Nigerian women, outpatient clinic
|How to cite this article:|
Ogunbode A M, Fatiregun A A, Ogunbode O O. Breast self-examination practices in Nigerian women attending a tertiary outpatient clinic. Indian J Cancer 2015;52:520-4
|How to cite this URL:|
Ogunbode A M, Fatiregun A A, Ogunbode O O. Breast self-examination practices in Nigerian women attending a tertiary outpatient clinic. Indian J Cancer [serial online] 2015 [cited 2019 Dec 14];52:520-4. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/520/178376
| » Introduction|| |
About 10 million people are diagnosed with cancer and more than 6 million die of cancer every year. Cancer is becoming an increasing burden both economically and to the health system as a whole. Breast cancer is a serious public health issue worldwide. The incidence rate of breast cancer in Nigeria has steadily increased from 15.3 per 100,000 in 1976 to 33.6 per 100,000 in 1992. The breast, an external organ, is readily accessible for breast self-examination; however, clinical diagnoses still result in high morbidity and mortality. There are three levels of prevention  of cancer. Primary prevention, which includes preventive measures done at the family and community level, involves health education about lifestyle modification issues, and legislation, and targets the healthy population. Secondary prevention comprises cancer registration, which could be hospital-based or population-based; early detection of cases through screening, as well as treatment. Tertiary prevention deals with rehabilitation of impairment, disability, and handicap.
Screening is identification of individuals within an asymptomatic population who have, or are likely to develop a specified disease at a time when intervention may result in the improvement of the progress of the disease. Screening for early detection of disease refers to the application of a test to people who are as yet asymptomatic for the purpose of classifying them with respect to their likelihood of having a particular disease. There are several methods of cancer screening, either mass screening by comprehensive cancer detection examination, mass screening at single sites, or the selective screening method.
Early detection and treatment of breast cancer can be facilitated by using screening methods that are effective in reducing breast cancer mortality. Breast cancer, a life-threatening disease, meets the criteria for screening. Possible screening methods include the following: Detection of breast cancer susceptibility genes [Breast Cancer types 1 and 2 (BRCA1 and BRCA2)], mammography, clinical breast examination (CBE), and breast self-examination (BSE).
It is important to encourage women to be breast aware in order to detect any changes in their body, especially since 80% of the breasts cancer survivors in the study by Loh and Chew in 2011, self-detected their breast lumps. There is a need to feel for changes, look for changes, and not just lumps because breast cancer can occur without lumps. Women need to be 'breast aware', and this can be done through routine screening. Being breast aware means being able to recognize symptoms of breast cancer through routine practice of practicable screening. Breast awareness can also be defined as a woman becoming familiar with her own breasts and how they will change throughout her lifetime. However, breast awareness and BSE are not the same.
BSE is a process whereby women examine their breasts regularly to detect any abnormal swelling or lumps. BSE carried out once monthly between the 7th and 10th day after the menstrual cycle goes a long way in detecting breast cancer at the early stages of growth. If the woman is menopausal, she is taught to examine her breasts on a fixed date every month. The BSE technique involves palpation of the breasts for lumps with the tips/pads of the fingers, rather than the flat of the hand. The woman would be in the erect position, either sitting or standing and while lying down. BSE is routine in developed countries, but is not so well-established in developing countries. The purpose of a BSE is to learn the topography of the breasts, which in turn will allow the woman to notice changes in the future in order to detect breast masses or lumps.
On the basis of the classifications of breast self-examination frequency, the variable of BSE frequency is reduced to three categories: a) Infrequent self-examination (performed hardly ever or not at all, once a year, or three to four times per year), b) appropriate self-examination (performed monthly or fortnightly), and c) excessive self-examination (performed weekly, daily, or more than once a day). It was found out that higher levels of anxiety about breast cancer were associated with higher rather than lower BSE frequency. Concerns have been raised that anxiety experienced as a result of increased breast cancer risk may cause women to avoid screening. Studies indicate that women with a family history of breast cancer tend to perceive heightened personal susceptibility to breast cancer and in fact deter women from practicing BSE.
Several studies have been performed to determine the prevalence of BSE practice and the influencing factors.,, Higher levels of education, employment in professional jobs, higher income, marital status, age, social support, knowledge and preventive attitudes, history of breast diseases, family history of breast cancer, seeing a physician regularly, ethnic background, and area of residence have all been found to be significant determinants of adherence to BSE practices.,
Despite the advent of modern screening methods, such as mammography, most cancers of the breast are self-detected; this fact was the inspiration for the concept of self-administered physical breast examination called BSE. BSE is a non-invasive method for early detection of breast disease and an inexpensive, easily taught screening method for women in resource-constrained countries like Nigeria.
Unlike CBE and mammography, which require hospital visits, specialized equipment, and clinical expertise, BSE can be performed by women themselves. A number of studies have reinforced the validity of BSE in detecting early breast cancer and in reducing the morbidity and mortality from breast disease. Other studies have shown that BSE may reduce breast cancer mortality.
The practice of BSE is routine in developed countries, but it is not well-established in developing countries where breast health education is not actively being pursued. There is also a dearth of knowledge regarding factors that influence the practice of BSE in Nigeria; as a result, this study was conducted to determine the prevalence of BSE and the factors influencing the practice of BSE in women who are treated in the General Outpatient's Clinic (GOPC) of a tertiary institution in Nigeria.
| » Materials and Methods|| |
The setting for this study was the GOPC of a Nigerian tertiary hospital in Ibadan. Ibadan is the largest city in West Africa and has a population of 3.6 million. It consists of people from various walks of life, with various occupations such as traders, civil servants, professionals, students, artisans, and farmers. Ibadan is also known as a student-town because of the many educational institutions such as the Universities, the Polytechnics, and many primary and secondary schools in the city.
University College Hospital (U.C.H.) was founded in 1957, as Nigeria's first Teaching Hospital. It has 1,000 beds and is a referral center for the clinics and hospitals in the surrounding environment. The GOPC, located within the U.C.H., provides primary and secondary levels of care and is the gateway for all patients coming into the hospital for the first time.
This was the baseline study of an intervention study, which looked at the effect of demonstration of BSE on improving CBE among two groups of respondents. The study was performed among 140 women aged 18 years and older who presented consecutively and were being treated for the first time in this GOPC in Ibadan, Nigeria, for a two-month-period, from August through September 2008. The exclusion criteria for this study included being too ill to participate in the study, having medical or surgical emergencies, being pregnant, and having breast cancer.
The minimum sample size for this study had been previously calculated based on the Cohen's sample size formula for effect size and the expression of medium effect size. The following assumptions were made that Z1 = alpha, at a confidence interval of 0.05-1.96 and Z2 = beta, at a confidence interval of 0.02-0.84. The minimum sample size for the study was calculated to be 126 and an attrition rate of 10% was used which brought the total sample size to 140.
The researchers obtained approval from the Head of Department and ethical approval from the Institutions Review Committee, the University College Hospital/University of Ibadan review committee (Clinical trial registration number-NHREC/05/01/2008a). Informed Consent was also obtained from all the respondents.
The respondents were interviewed using a structured questionnaire that sought information on demographic data, self-reported BSE and factors influencing the practice of BSE, which included socio-demographic factors such as levels of education, marital status, age, and history, which comprised any history of breast diseases and family history of breast cancer. Face validation of the questionnaires was done by senior colleagues to eliminate ambiguity. If any breast pathology was reported or detected, the respondents were referred to general surgeons within the hospital. Those who were infertile and had galactorrhea were referred to the Obstetrics and Gynecology clinic of U.C.H., Ibadan.
The data collected from the respondents were coded serially and entered into a computer using the software program Statistical Package for Social Sciences (SPSS) for data analysis, version 12. Descriptive statistics, such as means and proportions, were used to analyse the data. Pearson's Chi-square test was used to assess the relationship between self-reported BSE practice and socio-demographic variables. The level of significance for all statistical tests was set at alpha = 0.05. Socio-demographic factors that may influence the technique of BSE were evaluated. Variables considered for this analysis included education, age, and marital status.
| » Results|| |
One hundred and forty women were interviewed in the GOPC, U.C.H., Ibadan, Nigeria. The mean age of the respondents in the study was 35.8 ± 11.9 years. The overall self-reported prevalence of BSE was 62.1%.
[Table 1] shows the frequency of BSE practice among respondents]. Of the 87 women who reportedly performed BSE, 27 (31.0%) performed BSE irregularly (with no time pattern). Twenty-six (29.8%) women performed BSE excessively (once a day or once a week), and only 11 (12.6%) women performed BSE appropriately (once or twice a month). Only eight (9.2%) of the 87 women who reportedly performed BSE used a calendar to remind them of the next BSE. The menstrual cycle did not affect the timing of BSE practice. Most of the women, 74 (85.1%) of those who practiced BSE, did so at any period during their menstrual cycles.
[Table 2] shows the association among socio-demographic characteristics and the practice of BSE among respondents].
|Table 2: Association among socio--demographic characteristics and the practice of BSE|
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The prevalence of BSE was observed to increase with age, though this was not statistically significant (P = 0.51). The prevalence of BSE was highest in women who were married or who had a tertiary education: 63 (65.6%) of the married women practiced BSE, and of the women who had a tertiary education practiced BSE 51 (68.9%). The occupation-specific prevalence of BSE was greatest among civil servants: (25, 78.1%, P = 0.04). There was a statistically significant association between civil servants and the practice of BSE. The highest prevalence of BSE was among Christian women 65.9% (60/91), P = 0.15 and among Yoruba women 62.7% (74/118), P = 0.1.
The practice of BSE was higher among women with a previous history of breast disease (15, 68.2%, P = 0.32) and in respondents with a family history of breast disease (7, 63.6%, P = 0.6) [Table 3] shows the association between previous personal history, family history and the practice of BSE].
|Table 3: Association between previous personal and family history and the practice of BSE|
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| » Discussion|| |
The self-reported prevalence of BSE in this study was found to be 62.1%. This is comparable to a report from Enugu, Nigeria, where only 62% of the women who were interviewed actually practiced BSE. In another study, the prevalence of BSE practice was 54.8%. The prevalence determined in this present study is much higher than other reports that found only 5.5% of the respondents practiced BSE and that only 18.1% of the respondents had ever checked their breasts., This difference in prevalence of BSE practice may be due to the different socioeconomic classes of women in the different studies.
In this study, 26 (29.8%) of the respondents performed BSE excessively, while only 11 (12.6%) did BSE appropriately. Majority of the nursing students (84.3%) in a study by Bassey et al., 2011, had practised BSE before. However, most 87.5% of the respondents, who had not carried out BSE said they did not know the right technique. Among black women in the United States of America, a similar proportion has been found: 89% of respondents indicated practicing BSE during the past year, 74% in the past 6 months and 39% indicated performing BSE monthly. Another study reported that 45 (47.9%) of the respondents examine their breasts monthly. In a study done among secondary school teachers, most of those who practiced BSE (63.7%) did so irregularly and at any period during their menstrual cycles.
In this study, the age range of the respondents was 18 years and older, and the mean age was 35.8 years. This was similar to a study on BSE in which the mean age of the women was 40 years. The highest prevalence of BSE practice in this study occurred in women over 50 years of age. The majority of the women in this study were married; this is comparable to two other studies on BSE in which most of the respondents (90.6% and 73.7%) were married., Half of the respondents in this study who practiced BSE had a tertiary education. This is similar to the study performed by Kayode et al., 2005, in which 224 respondents (65.7%) had a university degree. However, our study results were different from that of Balogun and Owoaje (2005) in which majority 104 (37.0%) women had a secondary education, whereas in this study, we observed that the majority of respondents 51 (68.9%) had tertiary education. The majority of respondents were married or cohabiting (81%) and had gained qualifications at a secondary educational level or above (67%) in the study done by Brain et al.
Most of the respondents (78.1%) who practiced BSE in this study were civil servants; this could be because in the environment that we practice in, majority of the clients that present to the clinic are civil servants, followed by traders and then students. Other respondents included housewives and the unemployed. Several other studies have targeted various groups in the past., One study used occupation as the stratifying factor. The following groups were included: teachers, students, housewives, civil servants and nurses. The majority of respondents in this study who practiced BSE were Christians. This was similar to the study reported by Okobia et al., in which a majority of the participants were Christians and only 45 participants (4.7%) were Muslims. Of those practising BSE in this study, the high number of Yoruba respondents (62.7%) was the result of carrying out the study in a Yoruba-speaking part of Nigeria where most of the respondents lived.
In resource-constrained countries like Nigeria, BSE is a screening tool that can be employed to help reduce the breast cancer burden. Health workers should teach women the appropriate times to practice BSE. (The majority of the women in this study practiced BSE at any time of their menstrual cycle, only a few women practiced BSE appropriately.) The limitations in this study included the fact that this was a hospital based study, hence the health seeking behavior of the population may hinder generalization of the findings. In addition, recall bias may have influenced the data collected on BSE practice and some of the influencing factors. However, this bias was minimised by assessing the prevalence of BSE over a 2-month-period to shorten the period of recall. Also, this study did not measure body mass index, which has been associated with a lower sensitivity for CBE screening.
Even though the practice of BSE was higher among women with a previous history of breast disease and in women with a family history of breast disease, these factors were not found to be significantly associated with the practice of BSE. The reason for these results may be due to the difficulty in eliciting a family history in this environment because of a lack of records, social taboos, and fear of stigmatization.
None of the modalities for screening of breast cancer should be regarded as the best. BSE has limitations though it is needed as it does not reduce breast cancer mortality. Increased breast cancer awareness among women should be encouraged as it helps women reduce morbidity, but unfortunately, not mortality. Making women aware of the potential benefits and harm of the various screening procedures and educating them about signs of breast cancer may help to save their lives.
In conclusion, we found a high prevalence of BSE, especially in those with tertiary education and those with past personal or family history of breast disease. A study in Malaysia, reported in 2009, also suggested that since education helped to reduce the mortality and morbidity in breast cancer, there was the need to offer education and self-management principles to women. The role of education to increase awareness for reducing health disparity must be emphasized in clinical care. The implication of this study is that education of women in developing countries like Nigeria needs to be further encouraged.
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[Table 1], [Table 2], [Table 3]
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