ABSTRACT

The purpose of the study was to compare the level of knowledge, attitude and practice of breast self-examination among nurses in Effia Nkwanta Regional

Hospital of the Sekondi-Takoradi Metropolis in the Western Region of Ghana. Five research questions were formulated to guide the study.

The descriptive design was used to conduct the study. The accessible population consisted of 229 nurses working at the regional hospital in the Sekondi-Takoradi Metropolis where the sample population were selected. A sample size of 130 nurses was considered representative enough for the study. The purposive sampling method was first used to select the category to be used for the study. The nurses who were chosen for the study have had not less than 3 years standing experiences. The instrument for the data collection was a researcher-developed questionnaire.

It was observed that virtually all respondents had heard about breast cancer. In a similar manner, almost all respondents were aware that breast cancer can be easily detected. It was recommended that Emphasis should be laid on BSE in undergraduate and postgraduate courses, especially for nurses, as they are mostly involved in patient care and education.

CHAPTER ONE

INTRODUCTION

Background to the Study

Breast cancer is one of the leading causes of mortality among women worldwide. The World Health Organization (WHO, 1997) estimates that over twelve million women die annually from the disease worldwide and the disease is showing increasing incidence among young women (American Cancer

Association, 2004).

Carcinoma of the breast is one of the leading causes of death in women aged 30 years and above. It reduces the life expectancy of the population at risks especially those between 31-50 years. Breast cancer is becoming more common worldwide (American Cancer Association, 2004). The incidence of breast cancer is rising more rapidly in population (developed nations) that enjoyed a low incidence of the disease. Breast cancer has become the commonest malignancy (excluding skin cancers) in women worldwide. It has unfavourable prognosis in women aged 40 years or younger (Haris, Lippman, Veronesi & Willet, 1992).  Breast cancer incidence rates have been increasing since the 1980s, though the rate of increase has slowed in the 1990s. Mortality rates have increased by 2.3% per year from 1990-2000, with an even larger increase in deaths among women less than 50 years of age (American Cancer Association, 2004).

Caucasians especially of North America descent seem to have been reported to have the highest incidence of breast cancer (Parkin, Muir, Whelan, Gao, Ferlay, & Powell, 1992). However, reports from other parts of the world indicate an increasing incidence as the women presumably adapt “Western” lifestyles. In multi-ethnic societies, the incidence of mortality differs among the various races creating the impression of certain constitutional or genetic factors. The black woman presents late for treatment with a bigger mass and seems afflicted with more aggressive tumors (Parkin et al., 1992). There are a lot of epidemiological variations in the occurrences of breast cancer in the developed and developing countries. The peak age of incidence of the disease in Nigeria and Ghana is at least a decade earlier compared to the Caucasians (Parkin et al.,

1992). Breast cancer is rare in men, the ratio is 1:100 compared to women (Donegan, Redlich, & Lang, 1998).

Among Nigerian women, breast cancer is the most common cancer and the second leading cause of death (Adebamowo & Ajayi, 2000).  A report from Zaria described the mean age at presentation of cancer as 42 years with 30% occurring in women less than 25 years of age (Solanke, 1996). A ten- year review of breast cancer in Eastern Nigeria revealed that patients with breast cancer constitute 30% of all patients’ with disease and that 69% of all patients were premenopausal (Solanke, 1996). There is a lot of concern as to what to do for a woman once breast cancer is detected. In a country like Nigeria, where the coverage of the population with health facilities is in a disequilibrium state, and where radiotherapy is available in only a few centres, there is the need to address cancer prevention strategies as they plan to check communicable and nutritional disease (Solanke, 1996). Mammography as a screening technique for breast cancer appears to have a more limited role in younger women with a sensitivity of only 76% (Baines, 1992). More so, this facility is not readily available in developing countries and the cost of mammography for screening breast cancer is beyond the reach of most women in developing countries including Nigeria and Ghana.

In Ghana, breast cancer accounts for 15.4% of all malignancies and appears to be on the increase (Baddoe & Baako, 2000). In 1996, 12.8 % of all admissions for malignant neoplasms to the Korle-Bu Teaching Hospital (KBTH) were for breast cancer. There have been many public education programmes about breast cancer within the last few years. Some non-governmental organizations like Mammo Care Ghana, Reach for Recovery and the Cancer Society of Ghana have been formed to create breast cancer awareness in the general public (Biritwum, Gulaid & Amaning, 2000). Yet, 50% or more of Ghanaians with breast cancer report to hospital with advanced disease. On the average, patients report 8 months or more after first noticing a change in their breasts. Many of the patients referred to KBTH are seen at the surgical out-patient clinic (Asumanu, Vowotor & Naaeder, 2000)

The two main hospitals equipped to treat cancer that is Korlebu and Komfo Anokye  and another further north in Ghana’s second city of Kumasi – are seeing between 5,000 and 7,000 new cancer patients a year (Kelland, 2012).

Medical advances have shown that one-third of all cancers are preventable and a further one-third, if diagnosed sufficiently early, is potentially curable (Asumanu, et al., 2000). This observation demands that cancer control should be of increasing priority in the health care programmes of developing countries (Stillman, 1997).

One potentially important strategy in reducing breast cancer mortality is the use of screening to achieve earlier detection of cancer (Stillman, 1997). An excellent prognosis is directly associated with the stage at which the tumour is detected. The main methods of screening involve mammography, physical examination of the breast by a physician or qualified health workers or clinical breast examination (CBE), and breast self-examination [BSE] (Howe, 1981). Despite the advent of modern screening methods, more than 90 percent of cases of cancers of the breast are detected by women themselves, stressing the importance of breast self-examination [BSE] (Howe, 1981). A study on the case histories of patients referred to a unit at KBTH over a three-year period to determine any changes in breast cancer presentation revealed no improvement in breast cancer presentation at the KBTH over the past 5–10 years, in spite of breast cancer awareness programmes (Clegg-Lamptey & Hodasi, 2007). The 40–49 years remains the peak age at presentation as previously detected in other studies.

A high rate of default among patients was also detected (Clegg-Lamptey & Hodasi, 2007).

Breast self-examination is to learn the topography of the breast; which in turn will allow one to notice changes in the future in order to detect breast masses or lumps (Park, 2002). Breast self-examination carried out once monthly, between the 7th and 10th day of the menstrual cycle goes a long way in detecting breast cancer at the early stages of growth when there is low risk of spread, ensuring a better prognosis when treated. Breast self-examination procedures though simple and non-invasive, requiring little time can only be practiced with the right attitude to sustain it and achieve the desired goal (Park, 2002).

Among women, 56% cited breast cancer as one of the top conditions they feared most (WHO, 1997; Spittle & Morgan, 1999).  A study of cancer awareness in Nigeria showed that only 32% knew that a breast lump was a warning sign of cancer, 58.5% were not aware of most warning signs, 9.8% knew of methods of detecting cancer and 50% did not know that cancer was curable when detected early (Uche, 1999). This low level of knowledge of warning signs and detection may be responsible for late presentation, with as many as 64% of patients presenting 6 months after the onset of symptoms (Atoyebi, Atimono, Adesanya, Beredugo & da Rocha-Afodu, 1997). It is clear that breast cancer is not well understood by women (Madong, Obekpa, & Orkar, 1998) and there is a need for information and enlightenment if patients are to present early in hospitals (Wilkes, White, Beale & Cole-Tracy, 1999).

 The association between knowledge of surviving patients and greater acceptability of diagnosis may have a synergistic, cumulative effect. Knowledge of long-term survivors may stimulate early consultation for symptoms, which may lead to an earlier average stage at presentation, resulting in turn in more long-term survivors. We conclude that enhanced awareness has considerable potential for improving the stage at presentation and therefore survival. How to engender that awareness among health care workers as well as the general public and on which particular facets of breast disease to focus are priorities for evaluation, both globally and in local settings (Albert & Schulz, 2004).  

The knowledge and attitude towards breast cancer is so low that majority of affected patients present late in the hospitals when little or nothing can be done again (Adebamowo & Adekunle, 1999). In a study to assess the knowledge and practice of breast self-examination among traders in Ibadan, Oyo state, less than one-third of the respondents (31.7%) were aware of BSE (Balogun & Owoaje, 2005). This is found to be lower than 85.5% of women studied in Port Harcourt and 50% of those studied in South Africa (Pillay, 2002; Jebbin & Adotey, 2004).  A similar study conducted in China showed a lower awareness of 11.9% compared to that of those who were aware in Port Harcourt (Li, 1999).

Balogun and Owoaje (2005) reported in their study that 18% of traders practised breast self-examination and the highest was found amongst those aged 50-59 years and lowest for those aged less than 30 years. The practice of breast self-examination was reportedly higher among women who had no formal education and lowest amongst those with primary education.

In a study done in Washington (United States of America) on BSE beliefs, only 21% of those who did not practice BSE were personally in favour of the procedure as compared with 98% of those that made BSE a regular monthly practice. However, many of those who did not practice BSE still felt that it was a good idea even though they were not in favour of it for themselves (Mary & Salazar, 1994).

Among the women who showed a film on breast cancer to see its effect on their attitude towards breast self- examination, majority felt that the film did not exert a favorable influence on their attitudes toward breast self- examination, the statements that it failed to motivate them, that it gave them no new knowledge, and that it failed to alter an already- existing unfavorable attitude were given with almost equal frequency (Mary & Salazar, 1994).

Although the incidence of breast cancer in developing countries is relatively low (Koet al., 2003), about 50% of all cases of breast cancer are diagnosed in these countries (Haji-Mahmoodiet al., 2002; Sadler et al., 2001). Based on a study during 1975–1990, Asia and Africa have experienced a more rapid rise in the annual incidence rate of breast cancer than that of North America and Europe (Shirazi et al., 2006).

Although mammography remains the best single diagnostic tool in the detection of breast cancer it is not routinely performed in Nigeria due to low level of awareness, ignorance, illiteracy, cost, high technology equipment and expertise required. False negative for mammography is higher in the younger age group, and this is likely to happen in areas where cases below the age of 30 have been widely reported (Anyanwu, 2000; Wu & Yu, 2003; Banjo, 2004).

There is also evidence that most of the early breast tumours are selfdiscovered and that the majority of early self-discoveries are by breast selfexamination (BSE) performers (Okobia et al., 2006).

Cavda et al. (2007) reported that most female physicians and nurses (65% and 70% respectively) believed that BSE was unnecessary; therefore the need to evaluate breast cancer awareness, attitude and practice among female students who are going to be our future health personnel.  In Okobia et al. (2006), the age of the respondents ranged from 15 years to 26 years and above with the mean age group as 21 years. This age pattern is consistent with the present 9-3-4 educational system in Nigeria. The study was appropriate in this age group as most of them were young adults who should find out more information on breast cancer and breast self-examination before they reach the age of common occurrence of the disease and as future doctors, would be able to educate and advice their patients effectively. Most of the respondents surveyed had heard of breast cancer (97.3%) and 85.8% claimed they knew how (BSE) is done; the level of breast cancer awareness of the respondents may have been due to their area of study and level of education. In a similar study, it was found that the women who had tertiary education were more knowledgeable about breast self-examination while those who had primary education were the least knowledgeable (Balogun & Owoaje, 2005). Their primary source of information was the television/radio. This finding is consistent with the study conducted by the Family Planning Association of Hong Kong (1996) which revealed that the promotion activities by the media, billboards and advertisements effectively exposed the public to breast cancer information. Similar observation was reported in an Eastern state of Nigeria (Nwagbo & Akpala, 1996). The least reported primary source of information on breast cancer in the study was the home of the respondents (23%). This is one of the gaps existing in family life education as parents and care givers have no time to discuss pertinent health issues with their children. It might also be due to the fact that some of the parents have no information or knowledge on some of these topics and as such have little or nothing to discuss (Saludeen et al., 2009).

A little more than half (65.4%) of the respondents believed that it is necessary to perform breast self-examination. This showed that the level of concern about screening for breast cancer is still low among the respondents considering their status as medical students and a lot much more would be expected from them as future doctors.

Again, 83.1% of the respondents claimed to have carried out breast selfexamination before; this demonstrates that some attention is being given by the young adults in this study to check their breast for early onset of lump and other symptoms of breast cancer, though not regularly as nearly half (43.5%) of the respondents had not examined their breasts in nearly one year. This may partly be because of the assumption that they are free from breast pathology. As a result of this ignorance, little emphasis may be placed on regular BSE by such respondents (Kayode et al., 2005).

Globally, breast cancer is the most common malignant neoplasm among women (WHO, 2006). Cancer in all forms is responsible for about 12 % of deaths throughout the world (Park, 2007). Breast cancer causes 376,000 deaths a year worldwide; about 900,000 women are diagnosed every year with the disease

(WHO, 2006). This could rates could further increase by 50% to 15 million (WHO, 2003). Although the incidence of breast cancer in developing countries is relatively low (Ko, Sadler, Ryujin & Dong, 2003), about 50% of all cases of breast cancer are diagnosed in these countries (Ko, Sadler, Ryujin & Dong, 2003). 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, Champau & Talebi, 2006). The disease has been reported to have an early onset among Nigerian women (Odusanya & Tayo, 2001).

Cancer is a group of diseases that cause any affected part of the body to change and grow out of control. Most types of cancer cells form a lump or mass called tumour, when the tumour metastasize they are transported to and other part of the body where they continue to grow (Park, 2007). Not all tumours are malignant, some are benign while some are malignant. Benign tumours do not grow and spread the way malignant (cancerous) tumours do, and they are usually not a threat to life (Okubia, Bunker, Okonofua & Osime, 2006). Most types of cancer are named after the part of the body where the cancer first starts. Breast cancer begins in the breast tissues. In breast cancer the cells of the breast grow in a chaotic way. Instead of growing and dividing in a regular and expected order, they grow out of control. If the cancer is not treated, the cells can spread within the breast or even break off and (metastasize) to other parts of the body.

The high incidence of breast cancer necessitates the need for early detection since it aids early initiation of treatment thereby reducing mortality. Dolinsky (2006) stated that the important thing any woman can do to decrease her risk of dying from breast cancer is to learn how to perform breast self examination, have a regular physical examination by their physician and have regular mammogram screening. Among these various diagnostic measures put up for detection of breast lumps, breast self examination is the one that can be performed by individuals on their own and most lumps are detected by women themselves, and besides, it is cheap (Park, 2007). Even though mammography is a better and more efficient way of diagnosing breast cancer, in developing country like Nigeria, clinicians and women still rely on breast examination. This may be due to its availability and very low technicalities.

A breast self examination can help women detect cysts or other benign (noncancerous) breast problems between checkups. It can also help some women detect breast cancer. It is easy to perform breast self-examination, and it only takes a few minutes. Although it might seem strange or inconvenient at first, it is a skill that all women can use throughout life to help ensure good breast health. There is also evidence that most of the early breast tumours are self-discovered and that the majority of early self-discoveries are by breast self examination (BSE) performers (Okubia, Bunker, Okonofua & Osime, 2006).

Kayode, Akande and Osagbemi (2005) also asserted that despite the advent of modern screening methods, more than 90% of cases of cancers of the breast are detected by women themselves, stressing the importance of breast selfexamination. Okobia et al. (2006) also stressed that there is evidence that most of the early breast tumours are self-discovered and that the majority of early self- discoveries are by breast self-examination (BSE) performers. Previous studies on cancer detection practices have focused on women in urban and semi urban setting and little or no research have been conducted among women in rural and remote area. In most Nigerian villages, access to health care services, especially comprehensive diagnostic services is very low, if not completely unavailable hence, individual self health empowerment is very important. Female secondary school teachers are not only educators, but serve as role models and change agents who often offer useful counsel on health promotion especially in a very low literate society. Therefore, this study aimed at assessing breast self -examination practice among female secondary school teachers in Oko, Oyo State. The objectives of the study are to: assess female secondary school teachers’ knowledge of breast self examination, to establish their awareness and sources of information, determine their attitude, and to describe the extent of practice of breast self examination among them.

Statement of the Problem

Most women in Ghana have no access to mammography, a breast cancer detective device, which has a detection sensitivity of 76% (Baines, 1992). As a result, there is a high incidence of breast cancer with an average annual increase ranging from 0.5-3% (Parkin, Bray, Ferlay & Pisani, 2002). In 2002, global summit conference participants  recommended a stepwise process for building the foundation for achieving earlier detection, as follows: promote the empowerment of women to seek and obtain health care; create the infrastructure for the diagnosis and treatment of breast cancer; promote early detection through breast cancer education and awareness (Althuis, Dozier, Anderson, Devesa & Brinton, 2005). Also, the World Health Organization recommends breast self- examination as the gold standard for early detection of breast cancer (WHO, 1997).

Available literature shows that most women in developing countries have low knowledge of BSE leading to low detection rate, late detection and advanced breast cancer cases (Li, 1999; Balogun & Owoaje, 2005).

Nurses impart knowledge to people and influence attitudes and practices. But it is difficult to tell if all the nurses who come into contact with the populace have knowledge on BSE because of differences in their ranks. Besides it is also difficult to tell if all nurses have a positive attitude towards breast cancer  and even practice what they know so that they can tell its efficacy. Thus the need to explore nurses knowledge of breast self examination, to establish their awareness and sources of information, determine their attitude, and to describe the extent of practice of breast self- examination among them.

Purpose of the Study

The purpose of the study was to explore the level of knowledge , attitude and practice of breast self- examination among nurses in Effia Nkwanta Regional Hospital of the Sekondi-Takoradi Metropolis in the Western Region of Ghana.

 

Research Questions

The study was guided by the following research question;

1. What is the extent of knowledge of breast self-examination among nurses?
2. What is the extent of nurses’ attitude towards breast self-examination?
3. What is the extent of the practice of breast self-examination among nurses?
4. What is the difference among nurses in terms of knowledge, attitude and practice towards breast self-examination?

Significance of the Study

Late presentation of patients at advanced stages when little or no benefit can be derived from any form of therapy is common in Ghana when it comes to breast cancer (Biritwum, Gulaid & Amaning, 2000). Recent global cancer

statistics indicate rising incidence of breast cancer and the increase is occurring at a faster rate (WHO, 1997). Worried by this prevailing situation with recent research suggesting that health behaviour may be influenced by level of awareness about breast cancer, this study will assess the knowledge, attitude, and practice of nurses towards BSE. The study hopes to get baseline data on nurses’ knowledge; attitude and practice towards breast self- examination.

Raising awareness of BSE is known to improve the practical implementation of the procedure. This awareness creation is normally done by health workers especially nurses. The findings of the study will help establish the knowledge and the practice of the nurses. The findings of the study will benefit all women in the metropolis. The health directorate of the metropolis will also benefit from the findings of this study by adding to the information on BSE available to the Directorate.

Delimitation of the Study

The study is delimited to female nurses in Effia Nkwanta Regional hospital in Sekondi Takoradi Metropolis in the Western Region of Ghana.

Limitations of the Study

This study was conducted for only one month and a half, which was a very short time for meaningful findings. Also, the issue of accessibility of the participants was a problem. Some of the participants were reporting for duty at night. Thus, the researcher had to visit the hospital several times, and some were in hurry to the extent that they spent few minutes responding to the questionnaire which might have affected the provision of useful data for this study. In addition, some of the nurses were on study leave and therefore could not be reached. However, measures were taken to ensure that accurate data were gathered and analysed to help draw meaningful conclusions for the study.

Definition of Terms

 Breast cancer:  Breast cancer is a cancer that starts in the tissues of the breast.  

Breast self-examination: (BSE) is a screening method used in an attempt to detect early breast cancer. 

Clinical breast examination: A clinical breast examination (CBE) is a physical examination of the breast done by a health professional.  

 

 Screening: Screening is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. Unlike what generally happens in medicine, screening tests are performed on persons without any clinical sign of disease.

Organisation of the Rest of the Study

The rest of the study was comprised in four chapters. Chapter two of the study deals with the review of related literature. Topics such as screening methods for breast cancer, knowledge on breast self- examination, practice of breast selfexamination, and attitude on breast self-examination were captured. Chapter three also addresses the methodology, which includes research design, population, sample and sampling procedures, and data collection and analysis procedures. The chapter four focuses on the results and discussion while the last chapter looks at the summary, conclusions and recommendations. Suggestions for further research were also covered.