Awareness, Knowledge and Practice of Breast Self-Examination among Women in Majengo Health Center, Moshi Municipality, Kilimanjaro Region, Tanzania: Descriptive Cross-Sectional Study

Introduction

Currently, breast cancer is one of the most frequently detected cancers and is the major leading cause of death among women globally [1]. Breast cancer is a global health concern and a leading cause of morbidity and mortality among all the cancers that affect women [1]. In 2008, proportion of Breast Cancer in Sub-Saharan Africa was calibrated to be 23.5 per 100,000 [2].

Breast cancer has been notified as a huge public health catastrophe in high Income Countries (HIC), Middle Income Countries (MIC) and Low-Income Countries (LIC) because of its high incidence-prevalence rate, the over-burdened health system and direct medical expenditure [3]. Globally statistical perspectives, accounted double increment of annual incidence of Breast Cancer,occurring more rapidly in countries with a low incidence rate of breast cancer [4,5].

Finding from MEWATA and Morse et al., 2014 in Tanzania [6]. show that BC is the leading cause of deaths among women compared to all other cancers affecting women. Forty thousand (40,000) BC associated deaths are estimated to occur each year [6]. Thereby representing almost hundred percent increment of Breast Cancer Burden. This is supported by the literature showing a rise in breast cancer incidence rates in Sub-Saharan Africa [7]. The high incidence of breast cancer necessitates the requirements for early identification and detection because this would provide wide room of the treatment options available to the affected women and thereby improve survival rates [8]. Other studies reveled that in most of the Low-income countries (LIC) with limited resources, breast cancer is detected in a late advanced stage of the disease when compared with Higher Income Countries (HIC) and thus has a poor outcome and high fatality rate [1,9-16]. Screening for early detection and diagnosis of Breast Cancer and breast health conditions and health position is an important public health principle [17].

Breast self-examination (BSE) is a check-up that a woman/ Female do by herself around her breast at home to look for abnormal changes or problems affecting the breast tissue. BSE is still recommended as a general approach and cornerstone in a higher increment of breast health awareness and thus potentially allow for early diagnosis of any anomalies because it is free, painless and easy to practice, costless, not time consuming [18]. Currently, It is recommended that women with age of 20 years should be educated on the pros and cons of performing a monthly BSE [16]. “Breast Cancer awareness” literally should proceed among women and make them to present early to hospital and be able to recognize symptoms of breast cancer [19]. Some literatures reported that factors related to women's knowledge about breast cancer and practice of BSE and its management may add effective potential advantage to medical help-seeking behaviors’ [19,20]. Recent studies in Angola, Nigeria, Senegal and Kenya shown low level of awareness and knowledge on Breast Self-examination as recommended way of detecting early warning signs of Breast Cancer [21-26]. Presence of poor understanding of barriers associated with Breast Self-examination discourages most women from seeking early intervention or even to admit that symptoms they may be experiencing are related to breast cancer and even not practicing BSE or practicing it irregularly. Due to double increment of Breast Cancer Mortality and its morbidity accompanied with low and insufficient awareness, Knowledge and Practice of BSE among women, there is huge need for a study to determine and assess awareness, Knowledge and practice of BSE among women in our communities. Therefore, this study aimed to determine and assess awareness, knowledge and practice of breast self-examination among Urban women attending Clinics at Majengo Health Center, Moshi Municipality, Kilimanjaro Region, Tanzania.

Methods

Study Design and Sampling Method

A cross-sectional study was carried out among urban women attending Clinics at Majengo Health Center between 25th March, 2017 and 21st May, 2017 in Moshi municipality, Kilimanjaro, region, Tanzania.

A Systemic random sampling method was used to select women who attended Clinics at Majengo Health Center. A total of 300 urban women met the inclusion criteria and had given informed consent to participate in the study. The inclusion criteria for this study was; women aged between 20 and 65 years old. This study obtained approval from the Ethical Committee of Kilimanjaro Christian Medical University College (KCMUCo). Permission from Moshi Municipal director and from doctor in charge of Majengo Health center to interview women aged between 20 and 65 years who met inclusion criteria attending clinics at Majengo Health center from 25th March, 2017 to 31st May, 2017 was granted.

Instrument

Data was collected via a strucructured questionnaire which was developed by the researcher based on an extensive review of the literature. The content validity was evaluated by experts from Community Health Department at Kilimanjaro Christian Medical University College (KCMUCo) to examine each item for congruence. The reliability of the questionnaire was determined by using test–retest reliability conducted among ten (10) Urban women attending Clinics at Bondeni Dispensary in to test flow, language understood between respondents and researcher/Skilled trained research assistants’ data collectors, consistence and to ensure effectiveness of data collection tool. Necessary corrections and adjustments of the tool were made before going to the field.

The questionnaire obtained information on respondents’ socio demographic characteristics, awareness of breast cancer and BSE, Knowledge on BSE, barriers for BSE practice, practice of BSE and source of information. Socio demographic variables included: age, marital status, family income, family history of breast cancer (yes/no), personal history of breast disease (yes/no), hormonal drug usage (yes/no) and check the breast by doctor (yes/ no). Questionnaires were translated in Swahili language because most of the participants understand well the language and for easy collection of information.

Analysis

Descriptive statistics (Mean, range, tables, figures and graphs) were used to summarize and present data. Data was processed and analyzed by using SPSS Version 20. Descriptive statistics (Mean, range, tables, figures and graphs) were used to summarize and present data. Awareness on BSE of respondent was analyzed by finding the proportional of women with awareness on BSE. This was done by taking number of women who were aware on BSE divide by total number of respondents included into the study. Information on awareness of women on BSE, in which being aware and not aware of BSE among respondents was analyzed.

For respondents who were aware of BSE on this section which contain three (3) questions, Women’s level of awareness on BSE was analyzed based on a two scales (“1”, “0”). A score of ‘1’ was awarded for a correct response while a score of ‘0’was awarded for wrong response, and a total score computed for each woman out of maximum score of 3. The women’s awareness on BSE was categorized into two; adequate awareness which was considered for those who scored 2 and above out of 3 and Inadequate awareness which was considered for those who had score of 1 and below out of 3.

Knowledge on BSE was analyzed by finding the proportion of women with knowledge on BSE. This was done by taking number of women who know about BSE divide total number included into the study. Information on knowledge on BSE of women which contain thirty-teen (13) questions in which being knowledgeable and Non-knowledgeable was determined. For respondents who were Knowledgeable on BSE, their level of knowledge was determined based on a two scales (“1”, “0”). A score of ‘1’ was awarded for a correct response while a score of ‘0’was awarded for wrong response, and a total score computed for each woman out of maximum score of 13. The women’s knowledge on BSE was categorized into two; adequate knowledge was which considered for those who had score of 7 and above out of 13 and Inadequate knowledge which was considered for those who had score of 6 and below out of 13.

BSE practice was analyzed by finding proportion of women who practice BSE. This was done by taking number of women practicing BSE divide by total number of respondents included into the study. Information on practice of BSE in which being regularly (For those who practiced BSE at right time with respect to menstruation, correct required interval periodic time and correct posture on performing BSE) or irregularly (For those who practiced BSE at right time with respect to menstruation, correct required interval periodic time and correct posture on performing BSE or perform one or two option correctly) BSE among respondents was analyzed.

Barriers on practicing BSE was analyzed according to each barrier as categorical data in terms of percentage and frequency.

Results

Respondent Rate

A total of 300 urban women attended were selected as the sample

of the study. However, 1

(0.3 %) refused to participate. The respondents’ rate derived in this study was 99.7%.

Social Demographic and Economic characteristics of the Participants

A total of 300 urban women from Majengo health center participated in this study. table 01 summarizes Social Demographic and Economic characteristics of the participants. Participants’ age ranged from 20 – 56 with mean age of 28.82 years (SD±6.628). Most of them are at the age category of 20-29 which accounted to 188(62.7%).

                                                Table 1 : Socio-Demographic Characteristics of the Study Respondents Women

Awareness on BSE

Mass media such as Radio and TV were identified as the main source of information on Breast Self-Examination by 36% and 25% of respondents’ women who were aware of Breast Self- Ex-amination respectively followed by relatives (19%).

Figure 1: Source of Information on BSE among Respondents (N=300)

Less than half of the women 95(31.7%) among 300 respondents’ women heard about Breast Self-Examination, among those who heard (95 respondents’ women) about Breast Self- Examination, only less than half 26(9%) had adequate level of awareness on Breast Self- Examination

Fewer than half of the respondents’ women 94 (31.3%) among 300 respondents had knowledge on performing Breast Self-Exam- ination (BSE). Majority 108(36%) of knowledgeable women on performing BSE reported learning about it from TV and /or Radio program while others learnt it from school lectures 96(32%), ar- ranged seminars 69(23%), clinics 24(8%) and Books/Magazine/ Newspaper(3(1%)) . Few 3(1%) respondents knew the appropriate age (20 years) for starting practicing BSE among women. Less than half 76(25.3%) of respondents women knew the appropriate time (with respect to menstruation period which is before, after and mid-cycle) for performing Breast Self-Examination BSE.

Only 94(31.3%) respondents’ women out of 300 knew the correctpostures when performing BSE. Only 108 (36%) of the respon- dents can detect early signs of Breast cancer. Majority 189(63) of respondents women strongly agreed that interval of every month for performing BSE is the best. Most 76(25.5%) of the respondent women strongly agreed BSE is best method for detecting early signs of Breast cancer. Among those who were knowledgeable (94 respondents’ women) about performing Breast Self- Examination, only less than half 31(33%) had adequate level of Knowledge on Breast Self- Examination Table 02 summarizes Knowledge on BSE among respondents

                                                     Table 2: Knowledge on BSE among Respondents (N=300)

Practice of BSE

Less than half 94(31.3%) out of 300 total participants, reported to practice BSE. About 30 (10%) respondents reported to perform BSE in a correct periodic interval of every month. Among those respondent women who reported not practicing BSE which were 206(68.7%) out of 300 respondent women, their commonestreason for not practicing BSE was Forgetfulness 260 (86.7%)” Ofthe respondents who practice BSE (94 respondents’ women out of 300 total participant), only less than half 25(26.6%) practice BSE regularly.Table 03 summarizes practice of BSE among respondents.

                                                       Table 3: Practice of BSE among Respondents (N=300)

Barriers on practice BSE

Majority of respondents (88.7%) reported lack of family history of breast cancer so why bother doing it, Forgetfulness (260(86.7%)), Lack of motivation/ influence from the society (219(73%)), Lackof Knowledge of performing BSE (179(59.7%)) and Lack of Self-confidence 74(58%) as their commonest barriers in practicing BSE. Table 4 summarizes barriers on practicing BSE among respondents

                                                   Table 4 : Barriers on Practicing BSE among Respondents (N=300)

Discussion

Breast cancer is the second underlying cause of women death globally and is the leading cause of death in Low Income Countries (LIC) including Tanzania [6]. Early detection of warning signs of Breast cancer is well identified by screening method like Breast Self-Examination (BSE). Awareness/Knowledge on BSE practice among women is crucial and considered as a key for practice of BSE in order to detect early signs of Breast cancer in order to prevent breast cancer among women [7].

Awareness of a disease like breast cancer precedes knowledge and screening practices (Breast Self-Examination). Patients in communities with high level of awareness is usually present with less advanced stages of breast cancer as a result of adoption of screening methods like Breast Self-examination [27]. In this study 95(31.7%) were aware of BSE and among them, only 26(27%)had adequate awareness concerning BSE and their main source of information was Mass media like Radio and TV. Due to low level of awareness among respondents found in this study, means most of women in community not have information about BSE and this will lead to low practice of BSE because this will act as barrier toward practicing BSE among women who not aware. These findings contradict those reported in other studies done in different areas with different populations. Self-breast examination awareness level varied among populations; it was reported to be very high awareness of BSE among respondents in a study done in Tanzania and Nigeria [28-39,6]. However similarly low BSE awareness was reported in studies done in Nigeria [33]. In sub urban and urban communities 52.8% claimed to have heard about BSE 52.8% attested that they have heard about breast self-examination[40]. Possibly reasons for high awareness compared to this study is because of among those studies, respondents reported to have more exposure to sources of information and society influence than in this study. Possible reasons for low awareness in some study is because of some studies have been done in the rural areas where there is low exposure of participants to Mass media compared to this study done in urban setting. However more awareness will bring influence of knowledge on BSE practice among women.

Knowledge has positive influence on disease like breast cancer and precedes screening practices (Breast Self-Examination). Patients in communities with high level of knowledge on BSE is usually present with less advanced stages of breast cancer as a result of adoption of screening methods like Breast Self- examination. In this study out of 300 total respondents only less thanhalf 94(31.3%) knew how to perform BSE and among them only 31(33%) had adequate knowledge concerning BSE. Majority of the respondents 108(36%) obtained their knowledge of performing BSE from TV and radio program. Due to low level of Knowledge among respondents found in this study, means most of women in community not have Knowledge about BSE and this will lead to low practice of BSE because this will act as barrier toward practicing BSE among women who not knowledgeable on BSE. This is contrary compared with other studies in which it was reported that, respondent had less than 50% of knowledge on how to perform BSE as in this study, like study done in urban southwest Nigeria done by Oladimeji et al., 2015 reported only 29.2% and similar study in Northern Nigeria done by Azubuike et al., 2015 reported only 46.1% [7,41]. Other study done in Nigeria showed to be slightly more than 50% which reported only 54% knew how to perform BSE compared to this study. Also from this study only 76(25.3%) Knew the correct time that Before/after and mid-cycle is the correct time to perform BSE and majority 200(66.7%) of respondents don’t know appropriate time (with respect to menstruation period) for performing BSE which is slightly lower compared with the similar study done in Nigeria by Oladimeji et al., 2015 reported that out of 271 total participants responded to the question of when is the right time to perform BSE. Only 8.1% of these knew correctly that ‘mid-cycle’ was the right time to perform BSE and the highest proportion 219 (80.8%), reported incorrectly that the right time for a woman to perform BSE was ‘anytime’. However, a greater number of knowledgeable women on BSE practice might influence practice of BSE among women [41].

Breast self-examination (BSE) was the most common breast screening practice among respondents followed by clinical breast examination (CBE) and also BSE still remains the most readily available methods of screening particularly in low resource countries like Tanzania where accessibility, affordability and availability of sophisticated diagnostic screening methods are difficult to access in terms of cost. Akpo et al. (2009) stated that all the participants (100.0%) practice breast self-examination but 50.0% knew how to correctly do breast self- examination [19]. In this study about 31% of respondent women practiced BSE and among those who practice BSE, only 25(26.6%) had regular practice. Among those who don’t practice BSE reported main reasons for not practicing BSE were reason for not performing BSE was, to don’t know to perform BSE 179(59.7%), Not sure on their ability on detection of early signs of Breast cancer when performing BSE 174 (58%), Fear of positive findings 107(35.7%) and Not interested 44(14.7%). Due to this low level of BSE practice among respondent found in this study, means that majority of women into the community do not practice BSE and this will result late diagnosis of Breast cancer signs and chronic stage of disease among women who were at risk, also increase difficultness in treatment of Breast cancer due to late presentation finally increase morbidity and mortality among women. This is contrast in other studies done in different areas with different populations like Performance of self-breast examination among female health workers remain low and variable in different respondents;like studies done by Oche et al., 2009 and Bello et al., 2011 in Nigeria among nurses 54%, 30%, 13.0% [31,40,42]. had ever carried out BSE. In the studies done among doctors 68% performed BSE. Another study conducted on non-health professionals indicated 95% had ever done BSE [40,33,34]. The only common difference in those studies in terms of knowledge on BSE is posture when doing BSE in which it was reported to be high (more than 50%) compared to this study (28%). The possible reasons for being high in practicing BSE among respondents in different studies compared to this study is because other studies done in more urban areas and cities in which respondents are more exposed to mass media as the main source of information, due to high influence from the society as well as a large group of respondents be literate like those study done among nurses and doctors. But in case of being low, this might be due to other studies to be carried in rural areas compared to this study which carried in urban settings. However, BSE practice might be hindered by several barriers facing women during performing BSE.

Majority of respondent women (more than 50%) reported that, barriers which hinder their practice of BSE for detecting early signs of Breast cancer were Lack of family history of breast cancer so why bother doing it 266(88.7%), Forgetfulness 260(86.7%), Lack of motivation/ influence from the society 219(73%), Lack of Knowledge of performing BSE 179(59.7%) and Lack of Self- confidence174(58%). Rest of the respondent women (less than 50%) reported that other barriers which hinder their practice of BSE were Fear of finding abnormal mass107(35.7%), Not at risk44(14.7%), Lack of time36(12%), Is not necessary32(10.7%), Embarrassing behavior27(9%), Dislike touching Breast21(7%) and Reluctance to practice BSE 17(5.7%). Due to these barriers found in this study, means without being eliminated and minimized, still majority of women within the society will face difficultness in practicing BSE, finally lead to late diagnosis of the disease, difficult treatment of disease due to its chronicity, morbidity due to several mamodectomy and finally more morbidity among women. The samebarriers have been shown in same previous studies done in different populations at different areas in which respondents reported barriers in performing and practicing BSE were not having a family history of breast cancer Fear of finding a lump, Forgetfullness, ignorance of technique [30,31]. not considering it necessary and feeling of discomfort at touching the breast [33,31]. were other reasons provided for non-performance of BSE. Many studies expressed, most important factor for not doing BSE is lack of knowledge regarding the conduct of BSE, some believed they can never have breast cancer, others felt they were violating their bodies by palpating their breasts while some were scared of being diagnosed with breast cancer [33]. Fewer others factors that hindering performance of BSE were: did not believe in the efficacy of the test, they did not have any symptom/ they did not have any problem with their breasts, while some said they did not have time, forgetfulness, procrastination, laziness, as lack of trust in their ability to perform BSE/ lack of self- confidence to do it, anxiety, and lastly, lack of awareness [33,34, 43-45,6,22-23,40,42, 46,47]. This means removal or minimizing of these barriers which hinder practice of BSE among women will have positive influence in practicing BSE [48,49].

Conclusion

This work reveals low level and incomplete awareness, knowledge and practice of BSE accompanied with more barriers hindering BSE practice among women in Moshi municipality, Kilimanjaro region. Educational efforts must be continued and expanded to include awareness, knowledge and practice of BSE toward detecting early signs of breast cancer among women in Moshi municipal, Kilimanjaro region [50-54].

Acknowledgments

We acknowledge the efforts and a lot Contributions from Dr. Adinani Juma, Community Department and Institute of Public Health of Kilimanjaro Christian Medical University College (KCMUCo) and all urban women attending Clinics at Majengo Health Center, Moshi municipality, Kilimanjaro Region, Tanzania who gave consent to participate into the study.

I am deeply gratefull and would like to express my deepest sincerity of gratitude and thanks Dr.Adinan Juma for his valuable guidance, encouragement, sincere coordination, good suggestions, heartfelt support and serious effort throughout this research preparation.

Author Contributions

Conceived and designed the Whole work: Ridhiwani H. Manyuti and Dr. Adinani Juma . Performed data Collection from the field: Ridiwani H. Manyuti. Analyzed the data: Ridhiwani H. Manyuti. Contributed materials/analysis tools: Ridhiwani H. Manyuti and Dr. Adinani Juma. Wrote the paper: Ridhiwani H. Manyuti and Dr. Adinani Juma.

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