Awareness of Breast Self-Examination among Rural Women in Karnataka

Introduction

The most widespread cause of death among women throughout the whole world is breast cancer. According to a recent study, 1 in 28 women is diagnosed with this lethal disease during their lifetime.¹Based on reports from different registries of national cancer registry project, a surmounting number of occurrences have taken place and currently India, is estimated to be the country with the highest rate of deaths stemming from carcinoma in the world.²

Indian Council of Medical Research (ICMR) claims that India is likely to deal with more than 17.3 lakh new cases of breast cancer by the year 2020. A recently published research in the Journal of Business Research stated that a delayed diagnosis of breast carcinoma can be the cause of death of 76,000 Indian women during a year by 2020. They also concluded that age of death from the disease has substantially decreased as it dropped from 50 to 30 years.³

The most pervasive cancer among urban Indian women and the second most pervasive cancer among rural women is breast cancer. Generally diagnosed at an advanced level due to the absence of cancer screening programs as well as, lack of awareness of the disease in the Indian population. Public sector organizations have hugely emphasized improving cancer awareness to promote early detection and provide all-encompassing treatment, management and rehabilitation. Although these efforts are more apparent in urban population, Indian patients suffering from carcinoma have experienced improved conditions in both their survivals and their lifetime quality. A major impediment in rural areas is the shortage of skilled service providers.⁵

Indian women tend to feel embarrassed to speak issues related to their physical health, which stems from a lack of awareness on screening, risk factors and cultural prohibitions resulting in delayed detection of the disease and finally death.⁶ Recognizing early signs and symptoms via screening by Breast Self-Examination (BSE), clinical breast examination and mammography screening are the approved early detection strategies.⁷ There is a correlation between screening and its advantages and disadvantages as well as perception of its risks through a rationalizing process that revolves around personal and social influence and attitudes.⁸

Paucity of efficient healthcare as well as awareness among people on the importance of screening and early carcinoma detection in rural areas ultimately leads to delayed diagnosis. Lack of carcinoma screening programs in rural areas also enables this. Other factors include delay in obtaining medical health recommendations for a notorious medical condition, fiscal problems, social/cultural reasons that prohibit female patients from visiting doctors for breast ailments, fear towards cancer-like disorders and finally a widespread disregard toward women’s health. In rural areas, poor education in addition to limitations on every individual creates a lack of motivation to visit hospitals and clinics for check-ups.⁹

BSE is a simple, cheap, and harmless intervention. It is also believed to be the most crucial deterrent strategy used by women daily. A complete and flawless BSE should be guaranteed, and the availability of adequate medical support must be provided.¹⁰ The main purpose of this research was to evaluate awareness and the practice of BSE among women in rural areas of Karnataka. This will be valuable in making guidelines for health education with respect to BSE especially among rural communities.

Materials And Methods

This community based cross sectional study was conducted in the rural areas of Doddahulluru, Hosakote, Harohalli, Kanakapura, and Mudigeretown, Karnataka. The target population of the research were women who were between 18 to 70 years and had a history of breast cancer and willing to participate in the study. At 95% confidence interval and 10% permissible error, a sample size of 680 was calculated. After considering a refusal rate of 10%, 748 women were contacted to reach the pre-determined sample size. Ethical approval (PESCP/2015-16/PPD-PHD-01) for the study was obtained from the PES College of pharmacy, Bengaluru.

A specially designed questionnaire was developed to facilitate data collection. Inputs from literature and from a renowned Bengaluru based breast oncologist were used to construct the questionnaire. It consisted of questions on the demographic characteristics of the respondents and a set of questions which dealt with BSE and its sources of information. The responses to the questions on BSE awareness were scored as one for a right answer and zero for a wrong answer.

Informed consent was obtained at the beginning of the session. Both English and Kannada versions of the questionnaires were administered to the participants to obtain base-line data. Some required face to face explanation /interview.

All analysis was done with the aid of statistical package for social sciences SPSS version 18. Numerical variables were presented as frequency distribution and percentage.

After completing the questionnaire, the participants were briefed on breast cancer and were given a demonstration of BSE by the researcher. Participants were taught to perform the correct method of BSE and instructed to do a monthly BSE based on their menstrual cycle. An interactive session was also conducted to clarify any doubts and an educational leaflet was then given to them to reinforce what was taught.

Results

In total, 680 females were included in the research with 28.52% of them between 26 to 35 years and 23.9% of them between 36-45 years. Out of 680, 400 of them were not graduates. A majority (95.7%) of the participants did not report a family-history of breast cancer. (Table. No. 1)

Results of the study demonstrated that 36.6% of the participants knew about breast cancer with most of them obtaining their information from family, friends, TV and other media. Considering awareness of the participants on breast abnormalities to be checked for, 85.14% felt a breast lump should be checked and 76.1% felt that pain in the breast was indicative of an abnormality. (Table no. 2) (Figure 1)

Only 21.1% of the participants were aware that BSE is utilized as a detector of breast cancer, and 16.4% claimed that they performed BSE. Amongst those who performed BSE, 35 of them knew it had to be performed once a month and only 14 of them were aware that the right time for conducting BSE was on the 7th day after the start of menstruation. In barriers to practicing BSE, many were not confident of practicing BSE correctly and detecting breast changes.(Table no. 3)

Amongst the 144 participants who claimed to be aware of BSE as a method of detection of BC, very few were aware of the proper steps of BSE (Table. 4). Only 112 participants performed BSE. About 97.7% of the study participants among 112 participants knew to examine the breast and check for dimpled, swollen, and sore parts of the breast in the mirror and very few , 19.4% and 25%, knew to check for any discharge in the nipple and type of pressure to palpate the breast during BSE.

Discussion

BSE allows women to acquaint themselves with the appearances of their breast and helps in the early detection of breast cancer. This research has showed that the vast majority of the participants were unaware of BSE and only a few of the participants knew the correct frequency and timing to performing BSE. Less percentage of the women (21.1%) claimed that they did some kind of BSE. Regular practice of BSE using the correct method was however almost negligible. Prevalent causes included a shortage of knowledge and self-confidence on the way it is performed. A research among Mexican American exhibited that awareness and confidence were related to BSE¹¹. Similarly, a study by Foxal M.J explained that women who were more open and self-confident about performing BSE were also definitely more willing to do it routinely.¹² This study has indicated that the level of awareness on screening of breast cancer is very low among rural women. In a study conducted by Anita P et al.,  only 1.3% of the participants were aware of BSE as compared to 4% in a study by Kommula et.al.^13,14 Whereas in a study by Nemenqani et al., 28.1% of the study subjects had good knowledge of BSE.¹⁵ In India in different studies it  varied from 0%-52%. Efforts are needed to educate rural women on the various signs and symptoms of breast cancer and methods of screening, like BSE, which will enable them to recognize symptoms of the disease at the earliest and seek timely medical intervention. Appropriate media awareness should be used to create awareness regarding the importance of BSE and the healthcare professionals should utilize every opportunity to promote the practice of BSE.

Assessment of the participants awareness of breast abnormalities showed that most of them acknowledge that breast lump and pain were not normal. However, only 21.1% of them were aware of the fact that BSE was a method of detection of breast cancer and only 16.1% of them had ever done some kind of BSE, though not necessarily using the correct method. This indicated the level of awareness for screening for breast cancer is very low among the rural women. It was 22.61% in a study by Yerpude and Jogdand.¹⁰

Performing BSE is quite negligible and is completely different in various countries. In a study by Gwarzo UM, in Nigeria, the practice of BSE ranged from 19% to 43.2%.¹⁶

In this study, only 109 participants knew what to identify and check during the BSE procedure. In a similar study by Rita Dadzi, 22% of the participants knew that alump in the breast, unexpected swelling or thickness of breast, alteration in shape or size of the breast, red nipple and unusual nipple discharge except for breast milk were signs of breast cancer and were mentioned by 87 (17.5%), 82 (16.5%), 44 (8.9%), and 41 (8.3%), respectively.¹⁷

More than 70% of Indian women are diagnosed with  advanced stages of breast cancer when it is too late to perform any form of therapy.¹⁸ BSE is affordable and can be carried out by most women. The practice is very important as when the patient suspect breast cancer they will most likely report it early to healthcare providers. BSE has been proven to have outstanding correlation with early detection of breast cancer. It can be discovered by women themselves if BSE is performed on a regular basis.¹⁹

It is important that rural women of India are educated on breast cancer, benefits of early detection and correct method of performing BSE which is a rudimentary and inexpensive procedure. This can be extremely beneficial in reducing the morbidity and mortality of breast cancer.

Conclusion

Our study revealed a low literacy of breast cancer among rural women. It is vital for women to be able to carry out self-examination in order to identify the early symptoms of breast cancer. It is important to visit a physician if early signs of breast cancer are visible. It is easier to prevent breast cancer at early stages rather than when the disease becomes more difficult to deal with at a critical stage. Therefore, it is highly recommended to take this into consideration that every individual needs to be more committed towards early awareness of breast cancer in order to avoid complicated treatment situations. The individual’s point of view for prevention is far more effective than the attitude that comes with negligence, which ultimately ends up with catastrophic ramifications when breast cancer attacks.

The low awareness and the inadequate practice of BSE among our study population could be attributed to their lack of exposure to information on breast cancer and BSE. This invariably affected their practice of BSE. Hence, it is mandatory that information needs to be disseminated in rural areas on breast cancer, BSE and its practice.

Conflicts of interest

None

Acknowledgments

We thank parents, teaching and non-teaching staff from two different schools (Government primary school, Doddahulluru, Hosakote and public school, Harohalli, Kanakapura) and Chairperson of Women club, Bharathi Bhavana, Chikkamangaluru taluk.