ORIGINAL ARTICLE

ORIGINAL ARTICLE

Evaluation of Knowledge, Practice and Barriers Towards Breast Self-Examination Among Breast Imaging Patient

Siti Nur Anis Binti Ismail*, Ann Erynna Lema Thomas Sudin*

Centre of Medical Imaging, Faculty of Health Sciences, Universiti Teknologi MARA (UiTM), UiTM Kampus Puncak Alam, 42300 Bandar Puncak Alam, Selangor, Malaysia

                                     Keywords: Breast Self-Examination (BSE), Practice, Barriers

1. INTRODUCTION

Breast cancer, the first leading cancer among women aged 24 to 59 in Malaysia based on the Malaysian National Cancer Registry (MNCR) Report 2011[1]. In developing countries, the mortality rate high due to vast numbers of breast cancer detected at advanced stages, including Malaysia [2][3]. According to the American Cancer Society, a 100% to 93% survival rate can accomplish, and the price of diagnosed breast cancer at later stages can be reduced until 72% to 22% if the early stage of breast cancer detected. Early detection of breast cancer is needed to reduce mortality and increase survival rates [4].

Several approaches have been used for screening and diagnostic purposes of breast cancer as well as adjunct evaluation such as mammography, ultrasound, magnetic resonance imaging (MRI), biopsy, clinical breast-examination (CBE) and breast self-examination (BSE) [5][6]. Malaysian Ministry of Health has been encouraging BSE and CBE as a part of breast health awareness campaigns since 1995 while countrywide mammography screening had been implemented in 2012, but it is recommended for high-risk women. Besides, more than 90% of breast cancer cases had been detected by the women themselves, which emphasizing the importance of practicing breast self-examination (BSE) regularly[7]. So, BSE has become a necessary screening technique due to a non-invasive, cheap and straightforward procedure [8]. However, Malaysian study has revealed that low percentages of women performed BSE, and only a few of them performed regularly even though most of them had heard about BSE. Several studies had been conducted to identify the barriers of BSE, and most of the samples used in the previous studies were among students, healthcare workers, and random women or women who were attending healthcare. Thus, this study is conducted to evaluate the knowledge, practice, and barriers towards breast self-examination (BSE) among breast imaging patients.

2. MATERIALS AND METHODS

2.1 Design and sample

A cross-sectional was carried out among breast imaging patients in Radiology Department of Hospital Pulau Pinang, Malaysia, from March to June 2020. A total of 235 patients met the inclusion criteria and had given informed consent to participate in the study. The inclusion criteria for this study were; Malaysian female citizen, a female patient who attend breast imaging on MRI, Ultrasound and Mammography, a female patient who undergo breast biopsy procedure. This study obtained approval from the Universiti Teknologi MARA (UiTM) Research Ethics Committee.

2.2 Instrument

A self-administered questionnaire was used to collect information from the respondents. The questionnaire was adapted and adopted from previous studies dealing with the same topic. A pilot study was carried out among 24 breast imaging patients for the reliability of the questionnaire.

The questionnaire consists of four sections:

(1) Socio-demographic feature, which consists of 6 questions include the information about the respondent age group, marital status, level of education, occupation, family history of breast cancer and other cancers.

(2) Knowledge of breast self-examination (BSE) consists of 16 items.

(3) The practice of BSE which consists of 6 items.

(4) Barriers for BSE, which used Champion’s Revised Health Belief Model Scale that consists of 11 items.

2.3 Data Analysis

The data collected from this research will be analyzed using version 21.0 of the SPSS (Statistical Program in Social Science) statistics for statistical analysis. Descriptive analysis is used to describe, demonstrate or summarize the collected data. Pearson chi-square or Fisher’s exact test and independent-sample t-test will be used to analyze the relationship between socio-demographic data, knowledge, practice and barriers. For the knowledge of BSE, A score of 1 was given for each yes and correct answer while zero for no, wrong or not sure answer. The total of the question for knowledge is 15. Knowledge score was characterized into low for those who had scored less than 0-49% of 15 items, moderate knowledge for 50%-79% and high knowledge for score 80%-100%. For barriers, the 5-point Likert scale is used from “strongly disagree” with a value 1 to “strongly agree” with a value of 5. The highest score is ranging from 11-55 as it contains 11 items.

3. RESULTS

3.1 Socio-Demographic Data

A total of 235 respondents have participated in this study. The socio-demographic variables of the study sample were shown in Table 1. Majority of the respondent was from age 18 to 29 (70.6%), and most of the respondents 194 (82.6%) were university graduate. 162 (68.9%) of respondents were single, with 93 (39.6%) was a student. As stated, 53 (22.6%) of the respondent had a family history of breast cancer, and 78 (33.2%) had a family history of any cancer.

3.2 Knowledge of BSE

Most of the respondents, 181 (77.0%) ever heard of BSE. Majority of the respondents 230 (97.9%) were aware that BSE is essential in detecting breast cancer early. 215 (91.5%) of the respondents answered correctly that BSE could be done in front of the mirror followed by 212 (90.2%) detection of a lump in the breast may be an early sign of cancer, during BSE unusual change in the shape and size of the breast is observed 209 (88.9%) with BSE includes armpit examination to check for any lump 192 (81.7%). However, only a small proportion of the respondents, 20 (8.5%) alert that BSE should be performed after menopause.

Figure 1 showed the pie chart of respondents’ level of knowledge. The level of knowledge among respondents, mostly at a moderate level, 64.68%, scored 50% to 75% of the questions. 20.43% of the respondents were considered as good knowledge level, which scored 75% above, while 14.89% scored below 50% of the items were considered as poor knowledge level.

3.3 Practice of BSE

Based on table 1, most of the breast imaging patients 134 (57.0%) practice BSE, while 101 (43.0%) of the respondents do not practice BSE. Among the respondents that practice BSE, 55 (41.0%) of the respondents regularly practice BSE every month, and most of them 113 (84.3%) start BSE practice at age more than 19 years old. 61 (45.5%) of the respondents take 3 to 5 minutes for each breast during the examination, and 98 (73.1%) correctly perform BSE by palpating with palm and three fingers.

3.4 Barriers of BSE

The highest percentage for BSE barriers was “Doing BSE during the next year will make me worry about breast cancer,” with 24.3% strongly agree, and 34.0% agree. While the statement “Doing BSE would require starting a new habit, which is difficult,” 16.2% and 26.0% of respondents strongly agree and agree. Next, “I am afraid I would not be able to do BSE,” with 15.3% strongly agree, and 17.9% agree as well as “Doing BSE will be unpleasant” with 13.6% strongly agree, and 16.6% agree.

3.5 Relationship between Socio-demographic Variables, Knowledge Level and BSE Practice 

Table 2 showed the association between socio-demographic variables, knowledge level and BSE practice. Respondents aged 18-29 years (60.8%) practiced BSE more than those aged >45 years (52.6%). University graduate’s respondents (61.9%) practice more than those with primary or secondary education (34.1%). Single respondents (61.1%) performed BSE more than married respondents (47.9%). The respondents who were a student (67.7%) and government servants (62.3%) practiced more than respondents who were privately employed (50.9%). A significant association was found on BSE practice with a level of education (p=0.001), marital status (p=0.059), occupation (<0.001), and family history of breast cancer (0.050).

30 (85.7%) of low knowledge respondents do not perform breast self- examination (BSE), which is the highest percentage followed by the moderate knowledge respondents 66 (43.4%) and high knowledge respondents 5 (10.4%). While most of the high knowledge respondents, 43(89.6%) practice BSE followed by moderate knowledge respondents 86 (56.6%) and low knowledge respondents 5 (14.3%). There is a significant association regarding the level of knowledge between BSE practice (<0.001).

3.6 Relationship between BSE Practice and Barriers

Table 3 provides a relationship between BSE performers and non-performers on barriers of BSE that conducted using independent sample t-test. BSE performers had lower mean scores for barriers of BSE (mean=25.6, SD=8.0) compared to non-performers (mean=34.4, SD=8.9). There is a significant association regarding BSE practice with barriers of BSE (<0.001).

4. DISCUSSION

The result of this study showed that majority of the respondents had a moderate level of knowledge regarding BSE. It is similar to the results by Muhammad Sani & Labaran Yau (2018) among women in Sokoto and Kalliguddi, Sharma, & Gore (2019) among female IT professionals[9][10]. According to the previous study done in Nigeria, they suggest that majority of the respondents had scored as good knowledge, which is due to a high level of awareness of BSE [11].

However, these findings are in contrast with the results conducted by Akhtari-Zavare, Latiff, Juni, Said and Ismail (2015) in Klang Valley, Malaysia [6]. Similarly with the results of Ayesha Ahmed, Ibrahim Zahid, Zoya Fatima R Ladiwala, Rija Sheikh (2018)[12]. The high percentage of moderate knowledge, maybe due to the location of the study conducted in an urban area where healthcare facilities are widely available, and information can be easily accessed through the internet and television. Respondents in an urban area also are more up to date with the recent advances in the prevention of the diseases[13][14]. The fact that most of the respondents in this study are educated as they were university graduate and stated that they ever heard of the BSE, which easy for them to access information regarding BSE.

Majority of respondents practiced BSE, but only 41.0% of them practiced it monthly, which represented only 23.4% of the total respondents. Our findings of this study are consistent with the results of previous studies [9][11][13]. Our findings were also higher compared to the study done by Al-dubai et al. (2012) [15].

In contrast, the finding of this study does not support the findings of Bawazir, Bashateh, Jradi, & Breik (2019) that only 30.3% of the women attending primary healthcare centers had practiced BSE although it is a simple procedure[16]. Furthermore, there is contrary found in a study conducted among women attending primary healthcare in Kuwait stated that only 21% of the 520 respondents performed BSE[17]. The percentage of respondents that performed BSE in this study increase because of the increased knowledge of BSE among them. The effect of educational background causes a behavioural change, as most of them had a proper education.

Based on the table, the result showed that “Doing BSE will make them me about the breast cancer during the next year”, “Doing BSE would require starting a new habit, which is difficult”, “I am afraid I would not be able to do BSE” and “Doing BSE will be unpleasant” are the main barriers among respondents in Hospital Pulau Pinang. This finding is coherent with studies done among young Malaysian women by [18].  The result of survey done by (Latiff, Ismail, Md Said, Akhtari-Zavare and Juni (2015) stated that the main barriers of BSE are “Doing BSE will be unpleasant” and “Doing BSE during the next year will make me worry about breast cancer”[6].

However, some other studies have reported inconsistent results. For example, the main barriers for BSE were stated as forgetfulness and negligence, lack of awareness about BSE techniques and lack of time[19]. Also, “I don’t know how to do it”, and “I don’t have any symptoms” were the barriers among young women in Malaysia [20]. The finding of this study can be explained that the women may be afraid of being diagnosed with cancer [21]. Besides, wrong perceptions the women believed may cause all of these worries and fears [6]

Based on the result of this study, there is a relationship between knowledge level and practice of BSE among breast imaging patients in Hospital Pulau Pinang as the p-value is 0.000, which is below than 0.05. The findings of this study agree with the survey done among Iranian women in Hamedan, Iran [22]… Our findings are consistent with the previous study, which signifying that knowledge of BSE is an essential facilitator for the practice of BSE. Knowledge of BSE is one of the factors that affect the performance of women in practicing BSE. Thus, a higher understanding of BSE will demonstrate higher performance rates [23].

The study results also showed that education level, occupation, marital status and family history of breast cancer were significantly associated with the practice of BSE. The finding regarding education level is in line with the study done among female students at Urmia University of Medical Sciences in Northwest Iran [24]. Other studies have also reported that there is a relationship between occupation and education level with BSE performance [13]. Besides, Al-dubai et al. (2012) also stated that there is a significant association between the practice of BSE with socio-demographic data of occupation. The probable explanation for this result could be that most of the respondents with university graduate paid more interests in practicing BSE compared to others. Besides, education is a facilitating component for the acceptance of health information and services [15]. Refer to the Table 1, majority of the respondents who currently a student that related to the educational background which might be the possible reasons that they paid more interest in practicing BSE [24]. Besides, the finding of this study similar with the previous survey conducted among female non-medical students in Universiti Kebangsaan Malaysia (UKM), Bangi by Hassan, Ghazi, Mohamed, & Jasmin (2017) regarding marital status, education level and family history of breast cancer [8]. The results regarding marital status was also supported by the previous studies done among women living in an urban setting in Malaysia and women attending secondary health facility [25][26]. The reason why the married less likely to practice breast self-examination may not be unrelated to extra family responsibilities and maybe a focus for future studies [26]. A possible justification for a strong correlation between BSE practice and family history of breast cancer could be the encouragement in knowing more about breast cancer when having relatives suffering breast cancer either first-degree relative or second-degree relative [8]. It also helps them developed awareness of their vulnerability when realizing the possibility of genetic factors influencing the development of cancer[27]. Also, factors such as marital status, educational level and family history of breast cancer were significant predictors of BSE practice [28]. Nevertheless, other studies showed no significant association between practice of BSE and level of education [17] and between marital status and BSE performance[27].

In contrast, there was no significant relationship between age groups and a family history of any cancer with the practice of breast self-examination (BSE). Other studies have also reported that no relationship between age and practice of BSE [29] as well as between family history of any cancer and BSE practice[15]. However, some studies have shown age is significantly connected with the practice of BSE [27].

According to Latiff, Ismail, Md Said, Akhtari-Zavare, and Juni (2015), the results of logistic regression analysis showed that the barrier to perform BSE was a significant predictor for BSE practice. Based on the independent t-test analysis, the results revealed that barriers of BSE are related to the practice of BSE in which, women practicing BSE had lower barrier score than women that are not practicing. This result of this finding is similar to the HBM theory which assumes that women who trust that they have little barriers to BSE are more expected to practice BSE [30]. It also in line with previous studies who mentioned that barrier scores of women who performed BSE were lower than women who do not perform with the difference was statistically significant[28][30][31]. However, the finding is contraindicated with the study done among women in Samut Songkhram Province, Thailand, which no association found between barriers and BSE practice [32].

This study is like other research studies, which has several limitations. First, this study was conducted among breast imaging patient of Hospital Pulau Pinang only and therefore might not be a representative of all breast imaging patients across Malaysia. Second, the cross-sectional study can only observe the relationship between variables and cannot determine the cause and effect among variables. In doing this research, the self-reported data might be recalled as bias, and the correct BSE techniques of the women also could not be found in this study. Lastly, there is also a lack of cooperation from the respondents itself.

5. CONCLUSION

In conclusion, from the finding of this study, the majority of breast imaging patients of Hospital Pulau Pinang have moderate knowledge level of BSE with 64.68% (n=152). Other than that, 57.0% (n=134) of breast imaging patients practice BSE. Most of the respondent agreed that doing BSE during the next year will make them worry about breast cancer, require starting a new habit which is difficult and afraid they would not be able to do BSE are the main barriers. Lastly, knowledge, barriers, education level, occupation, marital status and family history of breast cancer was significantly associated with the practice of BSE.

This study discovered that even though most of the respondents have moderate knowledge level of BSE and the Malaysian Ministry of Health recommends monthly BSE, the prevalence of regular BSE was still low. Several BSE promotion programs can be done, which focuses on the breast cancer risk factor as well as the BSE techniques so that the awareness of the importance of early breast cancer detection can be enhanced among the women. Furthermore, the role of electronic media such as television, social networking sites could be used as a critical role in conveying health education and belief changes. Future study is recommended to prolong the allocation time for the research and focus on a larger sample size from similar populations in Malaysia. Therefore, the results obtained from the study could be more precise. It is also suggested to determine the cause and effect among the variables.

ACKNOWLEDGEMENTS

Researchers would like to thank all the patients who took part in the study and gratefully acknowledge the management officer and staff of Faculty of Health Science, Universiti Teknologi Mara (UiTM) Puncak Alam that involved in this study.

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