Abstract

This study was undertaken to determine the knowledge of breast cancer, practice of breast self-examination (BSE) and formulate BSE enhancement strategies among female undergraduates in higher institutions in Imo State. To guide the study, eleven specific objectives with corresponding research questions were formulated, while eight null hypotheses were postulated. The study utilized descriptive survey design. The population of the study was consisted of 18,790 regular female undergraduates in higher institutions in Imo State and health experts in universities and colleges of education in Southeast, Nigeria. A sample of 1,089 female undergraduates representing 5.8 per cent of the female undergraduates’ population and 20 health experts in the field of Health and Physical Education and Public Health Education, participated in the study. A two-stage sampling procedure was employed to select the female undergraduates’ sample, while purposive sampling technique was employed to select the experts’ sample for the study. Data for the study were collected using three instruments. These were: a 34-item Knowledge of Breast Cancer and Practice of Beast Self-Examination Questionnaire (KBCPBSEQ), 9-item Knowledge of Breast Cancer and Practice of BSE Focus Group Discussion Guide (KBCPBSEFGDG) and a Part one and Part two item BSE Enhancement Strategies Questionnaire (BSEESQ). The KBCPBSEQ designed in a multiple choice and yes or no question format was used to generate quantitative data on female undergraduates’ bio data, knowledge of breast cancer and practice of BSE. The KBCPBSEFGDG was used to generate qualitative data on knowledge of breast cancer and practice of BSE, to complement the quantitative data. The BSEESQ was used to evaluate the researcher’s formulated BSE enhancement strategies for female undergraduates. Each of the three instruments used was validated by five experts. Split-half technique using Spearman Brown Formula and Cronbach’s alpha were used to establish the reliability of the KBCPBSEQ and BSEESQ respectively. Reliability coefficient of .73 and .87 were obtained for Section B and Section C of the KBCPBSEQ, respectively, while .73 and .95 were obtained for part one and part two of the BSEESQ respectively. 1,072 copies of duly completed and returned KBCPBSEQ, representing 98 per cent response rate, were used for data analysis. The verbal and non-verbal responses of the female undergraduates during the KBCPBSEFGDs were interpreted and analyzed qualitatively, while all the completed and returned 20 copies of the BSEESQ were used for data analysis. The data collected were analyzed by using descriptive statistics of mean percentage scores, percentages and mean for the purpose of answering the research questions, while the eight null hypotheses were tested using t-Test, ANOVA and Chi-square (χ²) statistics, at .05 level of significance. The result of the study revealed that: female undergraduates had moderate level of knowledge regarding concept of breast cancer (KCBC: 52.15%) and breast cancer risk factors (KBCRF: 53.57%), high level of knowledge regarding breast cancer signs and symptoms (KBCSS: 67.07%) and very low level of knowledge regarding breast cancer preventive measures (KBCPM: 8.5%). The result further revealed that overall, a low proportion (40.5%) of female undergraduates practised BSE, while specifically, a low proportion of female undergraduates practised BSE monthly (33.4%) and examined their breasts between the 7^th and10^th day of their menstrual cycle (39.9%). The result also revealed that there was no significant difference (p > 0.05) in the level of KCBC; KBCSS and KBCPM, while there was significant difference (p < 0.05) in the level of KBCRF according to age. There was no significant difference in the level of KCBC; KBCRF; KBCSS and KBCPM according to marital status. There was significant difference in the level of KCBC, while there was no significant difference in the level of KBCRF; KBCSS and KBCPM according to family history of breast cancer. There was significant difference in the level of KCBC and KBCRF, while there was no significant difference in the level of KBCSS and KBCPM according to religious denomination. There was no significant difference in the female undergraduates’ practice of BSE according to age, marital status, family history of breast cancer and religious denomination. Also, the result revealed that the BSE enhancement strategies formulated based on the findings were deemed very appropriate. The results were exhaustively discussed and recommendations were made. Among the recommendations made was that Higher institutions, Government, Non-Governmental Organizations, Center for Women and Gender Studies, Churches, Communities, Female Organizations, Health educators and health professionals in Imo State should adopt and use the Breast Self-Examination enhancement strategies formed in the course of this study, to mount intervention progarammes at the different settings were female undergraduates could be reached. This will help to raise to very high level, the knowledge of breast cancer and enhance the practice of BSE among female undergraduates, in Imo State.

CHAPTER ONE

Introduction

Background of the Study

Breast cancer remains a major health problem all over the world, affecting women in both the developing and developed countries. The incidence of breast cancer is even growing in regions of the world (such as Asia and Africa) that had a low incidence of the disease in the past. Based on studies 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 (Shirazi, Champeau, & Talebi, 2006). According to Jayadevan, Jayakumary, Manda and Merlin (2010), the incidence of breast cancer is increasing in most countries of Asia and Africa. Isara and Ojedokun (2011) observed that breast cancer is a public health problem that is increasing throughout the world especially in developing countries, including Nigeria.

Breast cancer is the leading type of cancer in women. It is and still remains one of the cancers affecting all age groups of women worldwide. Lesccynska, Krajewska and Leszczynski (2004) stated that globally, breast cancer is the most common malignant neoplasm among women. Continuing, they stated that globally, over one million new cases of breast cancer among females are detected each year. According to American Cancer Society (ACS) (2009), National Cancer Institute estimated that one in eight women born today will be diagnosed with breast cancer at some time in her life. This is a dramatic increase from the rate in 1977, when the rate was one in fourteen women (George, 2000).

Breast cancer is a significant cause of cancer deaths among women all over the world, including women in Nigeria. Adebamowo and Ajayi (2000) stated that breast cancer is the second principal cause of cancer deaths among women in the world as well as in Nigeria. Continuing they reported that the prevalence rate of breast cancer according to a study in Nigeria was 116 per 100,000 and 27,840 cases occurred in 1999. The report further stated that Nigerian women usually present with advanced stages of the disease at which time little or no benefit can be derived in the form of therapy. Sasco (2001) reported that in Nigeria, over 100,000 women develop breast cancer annually with majority of patients arriving medical centres at a late stage, thus resulting in a high mortality rate. Muanya (2014) stated that according to National Cancer Control Programme report, breast cancer incidence in Nigeria has gone up at least four times over the decade and in 2010, it accounted for 40 per cent of women cancers.

Breast cancer incidence is growing faster in age groups (between 36 and 44 years) that had a low incidence of the disease. The incidence of breast cancer among younger women (16- 35years) seems to be increasing also. Vorobiof, Sitas and Vorobiof (2001) reported that there has been an alarming increase in the incidence of breast cancer among young women since, 1998. Over the years, people had the belief that breast cancer is an older woman’s disease, therefore, the primary focus has been on prevention, detection and treatment of breast cancer for women who are 50 years and older. However recent reports have shown that in Nigerian Communities, the disease can strike well at a younger age. A report in Nigeria showed that the peak age of incidence was 42.6years and 12 per cent of cases occurred before the age of 30years (Adebamowo & Ajayi, 2000). Banjo (2004) reported that in Nigeria the youngest age of breast cancer incidence recorded was 16 years from Lagos. Salaudeen, Akande and Musa (2009) stated that in Nigeria, studies from various ethnic populations have reported the demographic profile of breast cancer especially from the Western and Northern parts of the country. According these authors, a review of breast biopsies in the Lagos University Teaching Hospital showed 34 per cent of all breast biopsies done over a 10-year period to be malignant. A report from Zaria described the mean age at presentation of breast cancer as 42 years with 30 per cent occurring in women less than 25 years of age. At University College Hospital, Ibadan, 74 percent of breast cancer patients were pre-menopausal. A ten year review of breast cancer in Eastern Nigeria, which Imo State is part of, revealed that patients with breast cancer constituted 30 per cent of all patients with breast disease and that 69% of these patients were pre-menopausal (Anyanwu, 2000). According to Isara and Ojedokun (2011) more young Nigerian women are being exposed to breast cancer risk factors (apart from genetic or family) such as alcohol, tobacco, obesity, late age at first pregnancy (> 30 years) due to education and late marriages. They may also be exposed to breast cancer due to inadequate knowledge of breast cancer risk factors and other breast cancer issues.

Breast cancer is a deadly disease, which is better prevented than cured. Knowledge of breast cancer issues can help women to prevent the disease. According to Smyke (1993) one-third of cancers could be prevented if women are armed with the right knowledge. Obionu (2001) observed that breast cancer was seen more among women who lack the knowledge of breast cancer concept, risk factors, signs and symptoms, and preventive measures, while Çeber, Soyer, Ciceklioglu and Cimat (2006) stated that a significant number of women present with advanced stages of breast cancer due to lack of information, knowledge and awareness on breast cancer risk factors, symptoms and preventive measures. Supporting the above statement, Muhammad (2007) stated that lack of knowledge of breast cancer issues predispose women to breast cancer.

Knowledge can be conceived as familiarity with something or someone defined by Rambo (1984) as an understanding of a subject matter. Such a subject matter could be breast cancer as is the case in the present study. Agbazue (1990) opined that one of man’s greatest enemies is ignorance, but agrees that knowledge will give one the necessary power, and put one in the appropriate frame of mind to practice healthy lifestyles and avoid diseases.

Omoregbu (1998) defined knowledge as the fact of understanding events, issues or objects that are acquired either through learning or experiences. The role of knowledge and information in the process of performing certain practices conducive for improved health has gained increased recognition. Knowledge can be empowering in that it enables one to make informed decision regarding health. One’s knowledge about health and disease prepares the way for meaningful healthy lifestyle (Ademuwagun, Ajala, Oke, Moronkola and Jegede, 2003). In this study, knowledge is defined, as the level of information female undergraduates in higher institutions have on concept of breast cancer, breast cancer risk factors, signs and symptoms and preventive measures.

Higher institutions are tertiary schools that train secondary school leavers to become qualified specialists and scientific and pedagogical personnel for various branches of the economy, science and culture. Catherine and Angus (2012) defined higher institutions as universities or similar educational establishments that offer education to students, especially to degree level. A higher institution can admit only male or female undergraduates or both male and female undergraduates. Higher institutions include universities, colleges and polytechnics. In this present study, higher institutions are conceptualized as post secondary institutions in Imo State that offer education to undergraduates.

Undergraduates are students at a college or university, who have not received a first degree and especially a bachelor’s degree. Ezugwu (2010) defined undergraduates as students who are doing a university course for first degree, while Catherine and Angus (2012) defined it as a university student who has not yet taken a first degree. Ugwu (2012) conceptualized an undergraduate as a person studying towards obtaining first degree in a tertiary institution. Undergraduates could be male, female or both male and female students. In the present study, undergraduates were conceptualized as female students in universities and colleges in Imo State, studying for their bachelor’s or first degree.

Female undergraduates’ knowledge of breast cancer is a prerequisite for them to implement desirable behavioral practices towards its prevention. Knowledge of breast cancer including its concept, risk factors, signs and symptoms, and preventive measures is seen as a factor in breast cancer morbidity and mortality prevention in women (Muhammad, 2007). Therefore, female undergraduates should possess adequate knowledge of concept of breast cancer, breast cancer risk factors, signs and symptoms, and preventive measures, in other to prevent the disease fatality.

Breast cancer can be conceptualized as a malignant growth in the breast. This disease, which is more common in women than men, has been variously defined. Martini (2001) defined breast cancer as a malignant, metastasizing cancer of the mammary gland. According to Lewis (2005), breast cancer is a space occupying destructive mass that grows and progresses at its own rate, independent of the body’s control. Furthermore, Lewis (2005) defined it as a disease that starts in the cells of the breast and can metastasize (spread) to the draining lymph nodes of the region, usually in the armpit. Once the region has been affected, it may result in swelling or even an ulcer and infection. Ogbuji (2011) defined breast cancer as a malignant, fast spreading disease, which originates from the tissues of the breast. The author further described it as an abnormal uncontrollable multiplication of the cells of the breast. Since it is apparent that cancer in the breast not only causes the cells in the breast to multiply uncontrollably, but can also spread to cells in other parts and organs of the body the definition of breast cancer by Lewis (2005), which has it that breast cancer, is a disease that starts in the cells of the breast and can metastasize (spread) to the draining lymph nodes of the region, usually in the armpits, was adopted to lend credence to the present study. Knowledge of factors that can predispose women to breast cancer is very necessary, for them to be able to prevent the disease. Female undergraduates should therefore, possess adequate knowledge of factors that can predispose them to breast cancer.

A wide range of factors have been pointed to as potential causes of breast cancer, but no definitive single cause has been identified. Risk factors that have been identified as contributing factors in the development of breast cancer include age (45years and above), gender (female), race (white race), family history, age at first pregnancy (30years and above), not having any children, early menarche, late menopause, alcohol intake, diets high in saturated fats, genetic mutation and having a personal history of breast cancer (having breast cancer in one breast) (ACS, 2007; Saurabh, Prateek & Jegadeesh, 2013). By being aware of the risk factors and knowing that they may fall into a high-risk category, female undergraduates would be more vigilant when it comes to changes to their breasts, as these changes could be signs and symptoms of breast cancer. Numerous signs and symptoms of breast cancer have been identified. According to Lewis (2005) the first and most common sign of breast cancer is often a painless lump or thickening in the breast. However, he stated that there are other symptoms of breast cancer, which may not appear until the cancer is more advanced. Chlebowski and Kuller (2009) expressed the view that breast cancer in its early stage usually does not cause symptoms. However, they stated that as the cancer grows, the symptoms may include lump in the breast or in the armpit that is hard, has uneven edges and usually does not hurt; change in size and shape of the breast, redness and dimpling of the nipple, with puckering skin, the nipple may discharge fluid that is clear or bloody, green or yellow pus-like. Mittra (2010) observed that the warning signs of breast cancer include nipple inversion and change in nipple direction, discharge and change in symmetry of the breast, redness, lump, dimpling of skin and unexplained weight loss. Knowledge of these signs and symptoms of breast cancer could lead to early detection of breast cancer and its fatality prevention. To prevent the fatality of breast cancer, one has to know its preventive measures.

Preventive measures of breast cancer are key to decreasing the mortality from the disease. According to Zakeeya (2005), two forms of preventive measures of breast cancer exist, and include: primary preventive and secondary preventive measures of breast cancer. Mckenzie, Pinger and Kotcki (2008) stated that primary prevention of breast cancer is the preventive measure that forestalls the onset of breast cancer during the pre-pathogenesis period. There are several primary prevention options aimed at altering the occurrence of breast cancer, although none has been proven to guarantee complete freedom from the risk of the disease occurring.

Primary prevention of breast cancer are: avoiding high intake of alcohol and fatty foods, avoidance of smoking and overweight, regular exercise, eating less of red meat, eating enough fruits and vegetables daily and breastfeeding of children (Chlebowski, Aiello and McTiernan, 2002). Mincey and Perez (2004) stated that individual women who have a substantially elevated risk of breast cancer development may consider surgical options for the primary prevention of breast cancer. Zakeeya (2005) reported that although not an option chosen by many, available data regarding risk reduction with surgical prophylaxis indicate that bilateral mastectomy reduces the risk of breast cancer development by approximately 90 per cent. Primary prevention of breast cancer also includes, educating women on breast cancer risk factors and influencing behavioural changes (Zakeeya, 2005).

Secondary prevention of breast cancer are preventive measures that lead to early detection or diagnosis for prompt treatment of breast cancer to prevent more severe pathogenesis (Mckenzie et al, 2008). Secondary prevention of breast cancer includes screening. At present, screening is the only feasible means of prevention of breast cancer (Zakeeya, 2005). Screening is the periodic evaluation of a population to detect previously unrecognized disease. Screening strategies are aimed at early detection with a view to early intervention (Madanat & Merrill, 2002). The primary objective of screening is the detection of breast cancer in its early stages in order to treat it and thus deter its progression. The secondary objective of screening is to reduce the costs of treating the disease by avoiding the more vigorous interventions required during its later stages (Edelman & Mandle, 1994). Screening helps to detect the early pathogenic state of breast cancer. With early detection, the cancer is often localized and responds better to treatment. Preventive measures can positively affect both cost control and mortality rates.

The implementation of the preventive measures through regular screening has been acknowledged as the main tool in the fight against breast cancer worldwide. Globally, Mammography, which involves the use of x-rays to examine breast tissues, Clinical Breast Examination (CBE) by health care professionals, and Breast Self-Examination (BSE) by women themselves, are the recommended screening tests for early detection of breast cancer (ACS, 2003; Mason & White, 2008). Clinical Breast Examinations are recommended every three years for women aged 20-40 and yearly thereafter. A baseline mammogram is recommended for women between 35 and 39 years of age, with subsequent mammography every one to two years for women between 40 and 49 years, and yearly after age 50, while BSE is recommended monthly for women aged 20 and above (Kelsey, 2011).

Breast Self-Examination has been defined by various scholars in different ways; however, there is a common focus. BSE involves regular monthly systematic examination of the breasts and axillary area, both visually and by palpation, for any signs of abnormality. It is a cost-free health practice under women’s control, which can be practiced by both young and old women (Glenn & Moor, 1990). Baxter (2001) defined BSE as a screening method used in an attempt to detect early breast cancer. According to Kayode, Akande and Osagbemi (2005), BSE is a process whereby women examine their breast regularly to detect any abnormal swelling or lumps in order to seek prompt medical attention. It is a relatively simple, convenient, non-invasive, minimal-risk, and inexpensive method of early breast self-examination for detection recommended for women (Kelsey, 2011). Sambanje and Mafuyadze (2012) defined it as a process whereby women become familiar with both the appearance and feel of their breasts which often helps them detect any changes early. Women should begin the practice of this routine in their 20s to learn the look and feel of their healthy breast so that they may report any changes in their breasts to a health expert immediately (Kelsey, 2011). However, due to the rising incidence, frequency and late presentation of breast cancer in young women, female undergraduates and other young women should begin the practice of BSE earlier than 20 years. So, BSE in this study is defined as female undergraduates’ monthly examination of their breasts to check for abnormal changes. This should be practiced regularly.

Practice can be defined as the action of applying a principle or scheme. According to Oyedele (2000) practice is any customary action or proceeding regarded as individual’s habit, while to Rapoport (2003), practice is a way of carrying out or performance of an act habitually or constantly. Sally (2004) defined practice as an established way of doing things especially, one that developed through experiences and knowledge, while Catherine and Angus (2012) defined practice as the actual application or use of a plan or method, as opposed to the theories. It is to perform (an activity) or exercise (a skill) repeatedly or regularly in order to acquire, maintain or improve proficiency in it. Continuing, the authors explained that it is to carry out or perform an activity or custom, habitually or regularly. In the present study, “Practice”, is conceptualized as the performing of BSE among female undergraduates in higher institutions in Imo State.

The practice of BSE involves the woman herself looking at and palpating (feeling) each breast for possible lumps, distortions or swelling (Baxter, 2001). According to Phumla (2011) women can perform BSE in the privacy of their bedroom or bathroom while standing in front of a mirror, lying down and in the shower. Continuing, the author stated that BSE should begin by a woman looking at her breast in the mirror, first with her arms on her hip and then arms rose up. Next, she should palpate or feel her breast while lying down, using the flat surfaces (finger pads) of the three middle fingers of her right hand to feel her left breast and then those of left hand to feel her right breast, in a circular and vertical motion. Finally, she should feel her breast in the shower with the same hand movement used while lying down. According to ACS (2012), BSEs should be done monthly, and because breast tissues change at different times of the month, these BSEs should be done at the same time of the month. Zakeeya (2005) stated that for pre-menopausal women, the ideal time is day 7 to day 10 of the menstrual cycle as breasts are least tender at that time, while post-menopausal women should perform BSE at the same time of the month, every month.

During BSE the signs and symptoms of breast cancer should be looked out for. According to Zakeeya (2005), what should be looked for during BSE are: a lump or swelling at the breast or armpit, dimpling or irritation of the skin of the breast, orange peel appearance of the skin of the breast, inversion or retraction of the nipple, eczema of the nipple, enlargement of one breast, enlargement of one arm, discharge from the nipple, skin ulcer, redness or scaliness of the nipple. Agreeing to the above statement, Phumla (2011) stated that dimpling, puckering, or bulging of the skin; a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out); redness, soreness, rash, or swelling and any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood) observed during BSE, should be brought to the attention of a doctor.

Regular BSE is a cost-effective, non-invasive, convenient, private and simple method. It is a more conservative detection method that requires no specific equipment. Despite these benefits, studies (Champion & Miller, 1992; Millar, 1997; Ashton, Karnilwics & Fooks, 2001; Luszczynska, 2004) have reported low performance of BSE among women. According to Kelsey (2011), most women are aware that BSE is a positive health behaviour that is recommended by officials, yet many women, including young women do not conduct BSEs and those who practice it do not do it on a regular basis. This may be true of female undergraduates in higher institutions in Imo State where this study is focused. Many researchers (Luszczynska, 2004; Lannin & Ponn, 2005; Kelsey, 2011) have called for well defined intervention programmes aimed at increasing BSE behaviour in women. Strategies can form intervention programmes. Thus, identifying BSE enhancement strategies can aid in designing effective intervention programmes for promoting BSE among women. Identified BSE enhancement strategies can prompt women to perform BSE regularly. Therefore, BSE enhancement strategies for female undergraduates should be determined.

Enhancement means to improve on an activity or performance. It means to improve something either in quality, amount or strength. Enhancement may also mean making greater, as in value, beauty, or effectiveness. According to Catherine and Angus (2010), enhancement means to improve the quality, value, or extent of something. In this study, enhancement is defined as strategies to improve female undergraduates’ practice of BSE. Strategy is a carefully devised plan of action to achieve a goal, or the art of developing or carrying out such a plan. Lorimer (1995) described strategy as an instance of the application of skills in achieving a purpose. Catherine and Angus (2010) defined strategy as a plan designed to achieve a particular long term aim. According to Fred (2012) strategy is a term that refers to a complex web of thoughts, ideas, insights, experiences, goals, expertise, memories, perceptions, and expectations that provides general guidance for specific actions in pursuit of particular ends. Continuing, he described strategy as a general framework that provides guidance for actions to be taken and, at the same time, is shaped by the actions taken. This means that the necessary precondition for formulating strategy is a clear understanding of the ends to be obtained. Strategy is an adaptive, evolving view of what is required to obtain the ends in view. In the present study, “strategies” is referred to as methods, plans and activities for improving BSE practice among female undergraduates.

There are many socio-demographic factors that may influence female undergraduates’ knowledge of breast cancer and practice of BSE. Nalan (2009) identified cultural and religious beliefs as factors that influence BSE practice, while Mehrnoosh, Muhamad, Posliza, Irmi and Salmiah (2011); Irurhe, Olomoyeye, Arogundade, Bassey and Onajole (2011), and Al-Naggar, Al- Naggar, Bobryshev, Chen and Assabri (2011) reported that age, level of education and family history of breast cancer, influence women’s breast cancer knowledge and BSE practice. Al-Nagger, Bobryshev and AL-Jashamy (2012) observed that race, marital status, residency, family history of breast cancer and age, significantly influence the practice of BSE among women. However, the present study is concerned with socio-demographic factors of age, marital status, family history, and religious denomination.

Age has been identified as a factor that can influence a woman’s knowledge of breast cancer and practice of BSE. Age determines growth, development and maturity. Milaat (2000) reported that higher knowledge of breast cancer was associated with older age. According to Ejifugha (2003), age brings about maturity and maturity puts one in a position to rationalize, concretize, accept or reject concept, information, habit, attitude and practice. It is believed that the more one adds years to life, the more knowledge one acquires. Karayurt, Ozmen and Cetinkaya (2008) in their study found a significant relationship between BSE practice and age. In a study done among young women in Australia, it was found that younger women did not feel at all any risk of developing breast cancer and as such did not feel the need to undertake any early detection behaviours, such as BSE (Johnson & Dickson-Swifta, 2008). Following from this, the present study sought to determine if there was any difference in female undergraduates’ knowledge of breast cancer and practice of BSE in the study area according to age.

Similarly, marital status is one important factor which can influence the ability of females to acquire health knowledge and engage in positive health behaviours. Dundar, Ozmen, Ozturk, Haspolat, Akyildiz, Coban and Cakirogiu, (2006); Ravichandran, Al-Hamadan and Mohamed (2011) and Dubia, Ganasegeran, Alabsi, Manaf, Ijaz and Kassim (2012) reported that married women are more likely to know more about breast cancer and practice BSE regularly. These may be due to the fact that married women are exposed to health care facilities and health care professionals during follow up at pregnancy and delivery. Frequent visit to health facilities and contact with health professionals in the cause of reproductive issues expose married women more to health knowledge and issues than single women. There are married, as well as single female undergraduates in higher institutions in Imo state. This explains the present study’s interest in examining the difference in female undergraduates’ knowledge of breast cancer and practice of BSE according to marital status.

Furthermore, family history of breast cancer has been reported as a very strong factor, which has some degree of influence on knowledge of breast cancer and practice of BSE. Baum, Saunders and Meredith (1994) reported that experiencing the illness of a close family member has resulted in many overly concerned young women seeking information on breast cancer and performing breast cancer screening, including BSE. Some studies reported a positive association between a maternal relative with breast cancer and consciousness about doing BSE (Leslie, Deiriggi, Gross, Durant & Smith, 2003; Choi, 2005). Choi (2005) stated that the perception of susceptibility and severity could produce motivation sufficient to change behaviour, while Kelsey (2011) opined that women who perceive themselves as susceptible to breast cancer and believe the disease is serious are more likely to be motivated to take action against the health threat. Sambanje and Mafuyadze (2012) in their study reported that women who reported family history of breast cancer were more knowledgeable of breast cancer risk factors than those who did not. Their study found that women whose relatives suffered from breast cancer wanted to learn about breast cancer and BSE. Women who have family history of breast cancer may decide to practice BSE as a coping strategy for dealing with the stress of perceived risk of mammary cancer. However, no study to the best knowledge of the researcher seems to have examined the difference in the level of knowledge of breast cancer and practice of BSE among female undergraduates according to family history of breast cancer in Imo state. Therefore, the present study has the focus to determine this.

In the same vein, religious denomination is also one of the factors that can influence female undergraduates’ knowledge of breast cancer and BSE. Women, can because of their religion, believe that breast cancer is not their portion and as such, do not seek information on breast cancer and practice of BSE. To these women, breast cancer and other chronic and fatal illnesses are viewed as God’s wrath and therefore do not concern them, since they are holy and righteous people. In some religious organizations, the church is often used as a venue for delivering of health information and services (Stillman, Bone, Rand, Levine & Becker, 1993; Weinrich, Howford, Boyd, Creanga, Cover, Johnson, Frank-Strouborg & Weinrich, 1998). When this is done, it can influence the level of knowledge of female undergraduates of those churches on breast cancer, if it is included in the health awareness programmes of those churches. Some researchers indicated that the association of the breast with sex and extreme modesty by some religions influence a woman’s conception of breast examination (Facione & Giancarlo, 1998; Kwok, Sullivan & Cant, 2006). Rea-Jeng, Lian-Hua, Yeu-Sheng, Ue-Lin, Chiun-Sheng and Herng-Dar (2010) observed that some women refuse to practice BSE to escape discovering breast cancer symptoms, which may take them to male doctor’s gaze and disrobing or uncovering their breasts to male doctors. For instance, Pentecostal churches like Faith Tabernacle do not allow their members to go to hospital or their females’ private bodies to be seen or touched by males other than their husbands. Phumla (2011) stated that religion and the church play an important role in the lives of many Africans. Female undergraduates in Imo state belong to different religious denominations, hence, the need to examine if there is any difference in the level of knowledge of breast cancer and practice of BSE according to religious denominations.

Female undergraduates in higher institutions in Imo State could be at risk for breast cancer. Even if undergraduate-aged (16-35 years) females in Imo State are not at immediate risk for breast cancer, these women are essential target population because of the cumulative effects lifestyle choices and preventive health behaviour practices can have throughout their lifespan. Hence, these lifestyle choices, in turn, can significantly impact their risk of eventually developing breast cancer. Again, there have been reports of an alarming increase in the incidence of breast cancer among young females since 1998 (Vorobiof et al 2001). Even more alarming than the reported increase in the incidence of breast cancer is the fact that young women have the lowest survival rates because they present themselves for treatment late. The presentation with advanced stages of breast cancer by young women in Nigeria may be due to lack of information, knowledge and awareness on breast cancer risk factors, signs and symptoms, preventive measures, and lack of BSE practice. The incidence rate from breast cancer in women of young age group has been gradually increasing and yet they do not have access to free mammography. BSE therefore is potentially an easily available and accessible method for them. Female undergraduates are young women, and the undergraduate period is a time that provides teaching and learning opportunities for shaping health behaviour into adulthood. Therefore, female undergraduates suit the present study.

Having very high level of Knowledge about breast cancer as early as possible will go a long way to encourage positive behaviour towards BSE, create a ‘breast-awareness’ consciousness and can lead to seeking regular professional breast examination and screenings later in life. Jones, Denhan and Springston (2005) stated two main underlying reasons why young women, such as undergraduate females should know of breast cancer issues. They cited the first reason involving the fact that breast cancer in young women is often a more aggressive form than in older women. Since younger women generally do not undergo annual mammography screening, they should appreciate the potential advantages of performing breast self-examination. The second point rests on the notion that the higher institutions environment provides a teachable moment. Most researchers agree that the undergraduate years could potentially be an effective time for health behaviour intervention strategies (Jones et al, 2005). Thus, the underlying basis of this research study is the notion that determining knowledge of breast cancer, practice of BSE and BSE enhancement strategies of female undergraduates could help health professionals in Imo State, create interventions that are better suited specifically for this populations, which, in turn, could ultimately result in enhancing their health behaviour and altering their breast cancer risks.

Female undergraduates’ knowledge of breast cancer can influence their health behaviour and practice of BSE. Therefore, this study anchored on behaviour change models and theory to explain knowledge of breast cancer and practice of BSE of female undergraduates. Health-behaviour theories and models assist researchers by organizing their inquiry into why people do or do not engage in specific health behaviours. They are valuable during selection of strategies for an intervention. Theories and models also help to explain behaviours and to suggest ways to achieve behaviour change. The behaviour change models and theory to be applied in this study include; the Health Belief Model, Powe’s Fatalism Model and Protection Motivation Theory.

Health Belief Model (HBM) was originally proposed by social psychologists; Hochbaum, Rosenstock and Kegels, in 1958, while working in the United States Public Services. The model is a value-expectancy model that has been used both to explain change and maintenance of health-related behaviours and as a guiding framework for health behaviour interventions. It explains why people would or would not use available preventive services. It stipulates that health related behaviour is influenced by a person’s perception of the threat posed by a health problem and the value associated with his or her action to reduce that threat. It is relevant to the present study because how female undergraduates perceive breast cancer and BSE can influence their knowledge of breast cancer and practice of BSE.

Powe’s Fatalism Model is another model adopted for this study. The model which was propounded by Powe in 1995, examines the interrelationship among possible barriers and their influence on outcomes. Among barriers listed in the model are cancer fatalism, cancer perceptions, cancer knowledge, risk perception, demographics, personal experience with the disease and the availability of educational material and information. Outcomes, on the other hand, are the individual’s participation in age appropriate cancer screening and health promotion activities. This model is relevant to the present study because the barriers listed can influence female undergraduates’ knowledge of breast cancer and practice of BSE.

Protection motivation theory (PMT) also adopted in this study was originally propounded by Rogers in 1975. It describes adaptive and maladaptive coping with a health threat as a result of the appraisal process. The appraisal of the health threat and the appraisal of the coping responses result in the intention to perform adaptive responses. The PMT can be used in influencing and predicting various behaviours. It can be used in enhancing healthy lifestyles and diagnostic health behaviours such as BSE, among female undergraduates. PMT is relevant to the present study because it suggests factors that will guide the selection of appropriate BSE enhancement strategies, for female undergraduates to practice BSE and forestall late detection of breast cancer. The proper application of these models and theory in this study provided basis for selecting strategies that will improve the knowledge of breast cancer and enhance BSE practice of female undergraduates in Imo State.

Imo State is one of the Eastern States in Nigeria. A ten year review of breast cancer in Eastern Nigeria revealed that patient with breast cancer constituted 30 per cent of all patients with breast disease and that 69 per cent of these patients were pre-menopausal (Anyanwu, 2000). Female undergraduates in higher institutions in Imo State are pre-menopausal women and could be at risk of breast cancer. Imo state has three higher institutions (Imo State University, Owerri; Federal University of Technology, Owerri and Alvan Ikoku Federal College of Education, Owerri) where many females enroll for their undergraduate studies. Most of these females at this stage in life in Imo State are exposed to increasing access to health compromising substance-experiences such as alcohol, tobacco, drugs, birth control pills and refined and junk foods and other wrong diets, which could be risk factors to breast cancer. These situations made the location to qualify for the study.

The recent breast cancer and breast awareness programmes that have flooded various media outlets in our country resonates as a great reminder of the tremendous significance breast cancer has come to claim in the lives of so many Nigerian women. Perhaps unlike any time in previous years, public health professionals are forced to acknowledge the remarkable impact that basic knowledge can potentially have on health beliefs, health behaviours, and, in turn, health status. Such occurrences have also been grave reminders to health professionals that the earlier in life an individual adopt positive health behaviours, the better the likelihood he or she will go on to live a healthy life in the long-term. Investigating the knowledge of breast cancer, practice of BSE, and BSE enhancement strategies among female undergraduates seems a likely step in the journey towards breast cancer incidence and mortality reduction.

Statement of the Problem

Breast cancer which affects mostly females is a disease that its fatality can be forestalled when detected early. This is because early-stage detection can prompt effective treatment of breast cancer before its progression. It can curb the greatest challenge of late presentation and improve the chances of survival from the disease. However, early-stage detection of breast cancer requires females to know about breast cancer and practice BSE.

Breast cancer was previously known to be a disease of adult females (45 years and above). But recently, this has become a myth, because the incidence of the disease in young female age groups such as 16 to 35 years abound. In fact, reports have it now that breast cancer incidence is growing faster in young females who used to have a low incidence of the disease, and that these young females have the lowest survival rates because they detect and present themselves for treatment late. Female undergraduates belong to the age group of young females that now suffer from breast cancer. Therefore, they should know about breast cancer and practice BSE. The knowledge of breast cancer can help them while growing up, to prevent breast cancer early. The practice of BSE can help them to detect breast cancer and present for breast cancer treatment early, when something meaningful can be done about it.

Despite the fact that female undergraduates could be affected by breast cancer, and the need for them to know about breast cancer and practice BSE, few research studies have ascertained their knowledge of breast cancer and practice of BSE. While numerous research studies have investigated breast cancer-related knowledge and BSE practice of older adult women—those who are age 45 and above, studies that have presented female undergraduates (16-35 years) are few in Nigeria and virtually nonexistent, to the best knowledge of the researcher, in Imo State. Thus, Imo state, still lack documented data on the knowledge of breast cancer and practice of breast self-examination among female undergraduates. This situation therefore poses a question of: what is the knowledge of breast cancer and practice of BSE among female undergraduates in higher institutions in Imo State? These were the task of the present study. Again, no study to the best knowledge of the researcher, has ever determined the BSE enhancement strategies for female undergraduates. Furthermore, this creates a question of: what BSE enhancement strategies can be proffered for female undergraduates in higher institutions in Imo State, if they are found wanting in the practice of BSE? By addressing this topic among female undergraduates in higher institutions in Imo State, this research study is attempting to fill this void.

Purpose of the Study

The purpose of the study was to ascertain the knowledge of breast cancer, practice of breast self-examination and BSE enhancement strategies among female undergraduates of higher institutions in Imo State. The specific purposes of the study were to determine the:

1. level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State;

2. proportion of female undergraduates in higher institutions in Imo State that practice BSE;

3. level of knowledge of breast cancer among female undergraduates in Imo State according to age;

4. level of knowledge of breast cancer among female undergraduates in Imo State according to marital status;

5. level of knowledge of breast cancer among female undergraduates in Imo State according to family history of breast cancer;

6. level of knowledge of breast cancer among female undergraduates in Imo State according to religious denomination;

7. proportion of female undergraduates in higher institutions in Imo State that practice BSE according to age;

8. proportion of female undergraduates in higher institutions in Imo State that practice BSE according to marital status;

9. proportion of female undergraduates in higher institutions in Imo State that practice BSE according to family history of breast cancer;

10. proportion of female undergraduates in higher institutions in Imo State that practice BSE according to religious denomination; and

11. breast self-examination enhancement strategies to be formulated for female undergraduates of higher institutions in Imo State.

Research Questions

The following research questions were formulated to guide the study:

1. What is the level of knowledge of breast cancer among female undergraduates of higher institutions in Imo State?

2. What proportion of female undergraduates in higher institutions in Imo State practice BSE?

3. What is the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to age?

5. What is the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to marital status?
6. What is the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to family history of breast cancer?

7. What is the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to religious denomination?
8. What proportion of female undergraduates in higher institutions in Imo State practice BSE according to age
9. What proportion of female undergraduates in higher institutions in Imo State practice BSE according to marital status?
10. What proportion of female undergraduates in higher institutions in Imo State practice BSE according to family history of breast cancer?
11. What proportion of female undergraduates in higher institutions in Imo State practice BSE according to religious denomination?
12. What are the BSE enhancement strategies to be formulated for female undergraduates in higher institutions in Imo State?

Research Hypotheses

The following hypotheses were postulated for this study and tested at .05 level of significance:

1. There is no significant difference in the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to age.

2. There is no significant difference in the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to marital status.

3. There is no significant difference in the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to family history of breast cancer.

5. There is no significant difference in the level of knowledge of breast cancer among female undergraduates in higher institutions in Imo State according to religious denomination.
6. There is no significant difference in the proportion of female undergraduates in higher institutions in Imo State that practice BSE according to age?
7. There is no significant difference in the proportion of female undergraduates in higher institutions in Imo State that practice BSE according to marital status.
8. There is no significant difference in the proportion of female undergraduates in higher institutions in Imo State that practice BSE according to family history of breast cancer.
9. There is no significant difference in the proportion of female undergraduates in higher institutions in Imo State that practice BSE according to religious denomination.

Significance of the Study

The data generated from the study of knowledge of breast cancer, practice of breast self-examination and BSE enhancement strategies of female undergraduates of higher institutions in Imo State will form a base line survey to develop future intervention programmes on breast cancer and BSE. The results of this study provided useful data that may be used by health institutions in Imo State and other states in Nigeria to formulate health education programmes focusing on breast cancer and BSE that target female undergraduate students. The findings will add to the pool of available data in the fields of health education and provide future researchers the background for further research work. The data generated on the female undergraduates’ level of knowledge of breast cancer may be beneficial to public health educators, school health educators, health care professionals and health organizations, since it may make them see the need to carry out breast cancer education-based programmes at the different settings where female undergraduates could be reached, to optimize their level of knowledge on concept of breast cancer, breast cancer risk factors, signs and symptoms and preventive measures.

The result of the study on the proportion of female undergraduates that practise BSE may encourage health professionals and Non Governmental Organizations to organize school, community and church sensitization campaign that will enlighten female undergraduates on the need to practice BSE regularly and correctly. The data may make health educators to see the need to organize breast self-examination trainings for female undergraduates to teach them the various techniques, steps and importance of BSE.

Data generated on the level of knowledge of breast cancer according to age may make health programme planners to design breast cancer education intervention programmes that target female undergraduates of all age groups. The data generated on the level of knowledge of breast cancer according to marital status may make health professionals, breast cancer organizations and health developers see the need to target both single and married female undergraduates for special education on concept of breast cancer, breast cancer risk factors, signs and symptoms and preventive measures.

The data generated on the level of knowledge of breast cancer according to family history of breast cancer may be useful to health care professionals, since it may make them see the need to give breast cancer education to female undergraduate family members of both breast cancer and non breast cancer patients when they visit health facilities. Data generated on the level of knowledge of breast cancer according to religious denomination may be useful to health educators and breast cancer organizations, since it may spur them to carry out faith based breast cancer education programmes that target female undergraduates. The finding may also be useful to heads of religious groups, since it may spur them to sponsor and organize breast cancer education and awareness programmes for their female undergraduates during their church youth, sisters and single programmes.

The study generated data on the proportion of female undergraduates that practised BSE according to age. This finding may enable health professionals, health organizations and health programme developers to design age specific breast cancer and BSE intervention programmes for female undergraduates and it may also make them see the need to include young female undergraduates in their breast self-examination educational programmes for women. The study generated data on the proportion of female undergraduates that practised BSE according to marital status. This finding will be useful to health educators, health programme planners and health care professionals, since it may encourage them to include, capture and target both single and married female undergraduates in their breast self-examination trainings, talks, counseling, seminar, and sensitization programmes.

The study generated data on the proportion of female undergraduates that practised BSE according to family history of breast cancer. This finding will be beneficial to health educators, NGOs and health planners as it may spur them to use breast cancer patients and survivors to mentor female undergraduates on the importance and techniques of breast self-examination. The study generated data on the proportion of female undergraduates that practised BSE according to religious denomination. This finding will be of help to religious denominations, health educators and breast cancer organizations, since it may reveal to them, the need to organize faith based BSE education and training programmes for female undergraduates that attend Orthodox, Pentecostal and Spiritual churches, to sensitize them on the need and how to practice BSE.

The study generated data on the researcher’s formulated BSE enhancement strategies for female undergraduates. This finding may be of immense significance to government, NGOs, center for women and gender studies, health professionals, school authorities, church communities and female organizations, as it may help them to modify, emphasize, strengthen and select the best and more effective health education programmes and breast awareness campaign pertaining to BSE. It may guide health programme developers in developing intervention programmes that will optimize female undergraduates’ practice of BSE, when adopted. The results may be valuable in developing educational programmes that can increase level of knowledge of breast cancer, as well as the practice of BSE, to support health promotion among female undergraduates.

The study gave support to the Health Belief Model, Powe’s Fatalism Model and Protection Motivation Theory. The Health Belief Model stipulates that health related behaviour is influenced by a person’s perception of the threat posed by a health problem and the value associated with his or her action to reduce that threat. The model is significant to this study because according to it, female undergraduates who perceive themselves as susceptible to breast cancer and believe the disease is serious are more likely to be motivated to learn about breast cancer and take action against breast cancer. Also, female undergraduates who believe that performing BSE has more benefits than barriers are more likely to take part in regularly practicing BSE.

Powe’s Fatalism Model examines the interrelationship among possible barriers and their influence on outcomes. Among barriers listed in the model are cancer fatalism, cancer perceptions, cancer knowledge, risk perception, personal experience with the disease and the availability of educational material and information. Outcomes, on the other hand, are the individual’s participation in age appropriate cancer screening and health promotion activities. This model is significant to this study because, female undergraduates’ knowledge of breast cancer and practice of BSE can be influenced by availability of educational materials and information on breast cancer and BSE, their socio-demographic factors and perception of breast cancer. Protection Motivation Theory describes adaptive and maladaptive coping with a health threat as a result of the appraisal processes. Protection Motivation is the result of the threat appraisal and the coping appraisal. This theory is significant to this study in that female undergraduates’ estimation of the chance of contracting breast cancer and their estimates of the seriousness of breast cancer can make them believe that practicing BSE, will prevent them from breast cancer and that they can practice BSE successfully. Finally, the HBM, Powe’s Fatalism Model and PMT are very significant to this study, in that their propositions guided this study, in formulating BSE enhancement strategies for female undergraduates.

Scope of the Study

The study was delimited to Imo State. It was delimited only to female undergraduates on regular programmes in higher institutions in Imo State which are Imo State University, Owerri; Federal University of Technology, Owerri and Alvan Ikoku Federal University of Education, Owerri. The study covered only level of knowledge regarding concept of breast cancer concept, breast cancer risk factors, signs and symptoms and preventive measures.

The study explored time of BSE practice, signs and symptoms looked out for during BSE and the BSE techniques, since they determine regular and correct BSE practice, and BSE enhancement strategies for female undergraduates in higher institutions in Imo State. The study also examined the following independent variables: age, marital status, family history of breast cancer and religious denomination as they relate to knowledge of breast cancer and practice of BSE.