Background: Breast cancer (BC) is the most prevalent cancer among Indian women. The Indian Council of Medical Research found 1.5 lakh new cases in 2016. In 2020, globally 2.3 million women were diagnosed; 685,000 deaths occurred. Lack of awareness about risk factors, signs, symptoms, and preventive practices is the main cause for its increasing incidence. Breast self-examination (BSE) has a role in the early detection of cancer. Its treatment is effective when diagnosed in the early stages.
Objective: The objective of this study was to determine the impact of health education on preventive practices of BC among women.
Subjects and Methods: A community-based interventional follow-up study was conducted in a rural field practicing area of government medical college, Hyderabad. Using multistage sampling, 260 women in the 20–50 years of age group were selected. Data regarding knowledge of BC were collected by pretested questionnaire in the preintervention phase. In the intervention phase, health education on BC and BSE was imparted through audiovisual aids and flip charts. In the postintervention phase, the impact of health education was assessed 2 weeks later using the same questionnaire. Data were entered in MS Excel and analyzed by Epi Info version 7.
Results: In pre and postintervention phases, the knowledge regarding BSE practice increased from (5%) to (77.7%); obesity (20.8%) to (71.5%) ;breast lump (7.7%) to (71.2%) ;advancing age (5.8%) to (68.5%); nipple discharge (3.8%) to (63.1%); alcohol (6.6%) to (61.9%) and family history (13.5%) to (60%).
Conclusion: The study highlights the importance of health education on preventive practices of BC in increasing knowledge.
Keywords: Awareness, breast cancer, breast self-examination, health education, intervention
|How to cite this URL:|
Gogolla BR, V. Kumari S M, Priyanka S. Impact of health education on preventive practices of breast cancer among women from rural field practice area of a Medical College in Hyderabad, Telangana State. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=362527
| Introduction|| |
Cancers, the most common noncommunicable diseases (NCDs), are due to genetic, physiological, environmental, and lifestyle factors. By 2030, the World Health Organization aims to achieve sustainable development goal 3.4 to reduce premature mortality from NCDs, including cancers by one-third. Breast cancer (BC) is the leading cancer among women worldwide. The GLOBOCAN 2018 report shows the age-standardized BC incidence rate per 100 thousand females was highest in Australia (94.2) and lowest in South–Central Asia (25.9) region. The high mortality rate in South Asian Countries is almost similar with most developing countries. It resulted in 2 million new cases and 6,27,000 deaths. Globally, there are more lost DALYS to BC than any other cancer in women.
In National Cancer Registry (2012–14), BC accounts to 27% among Indian women and in 2015, there were 1,55,000 new cases. In recent times, the incidence of BC surpassed cervical cancer in India. On average, 1 in 28 Indian women is likely to develop BC. The incidence begins to rise in the early 30s and peaks at 50–64 years. One in 22 women in an urban area and 1 in 60 women in a rural area develop BC during her lifetime.
In India, early BC constitutes only 30% of the cases, whereas in developed countries, 60%–70% of cases are detected in early stages and prompt treatment is given. Breast self-examination (BSE) is one of the basic methods for early detection of BC. The low level of awareness among women, lack of trained human resources contribute to advance stage diagnosis and high morbidity and mortality rate in BC cases.,,
The American Cancer Society recommends early BC detection, BSE is important once a month from 20 years of age, to check for the presence of any lump and/or abnormalities. The abnormalities are to be reported to the health-care personnel at the earliest. Once in 3 years, women between 20 and 30 years of age should have a clinical breast examination (CBE) as part of a preventive health checkup by a health-care professional. A woman must undergo a yearly mammogram after the age of 40. If there is a family history, then a mammogram is necessary from the age of 35 years. A mammogram can detect BC 3 years before it can be palpable by clinical examination. Magnetic resonance imaging should be preferred over mammogram in a female with dense breasts.
BC awareness programs are more concentrated in the cities and have not reached the remote and rural parts of the country. Women often do not present for medical care early due to various factors such as illiteracy, lack of accessibility, lack of awareness, financial constraints, and social stigma.
Few studies have assessed the knowledge, attitude, and practice of women toward BC in India. Very few of these studies are done on community-dwelling women who constitute the majority of at risk women. Keeping in consideration, the increasing incidence of BC and the importance of screening to control it as it is a public health problem, the present study was designed to assess the impact of health education influencing preventive practices of BC among rural women.
| Subjects and Methods|| |
A community-based interventional follow-up study was conducted in Patancheru, the rural field practice area of Osmania Medical College which covers a population of 1,50,000. It was done between March 2016 and October 2017. Women between the 20 and 50 years of age group residing in the study area willing to participate in the study and had given consent were included in the study. Pregnant women, lactating mothers, women with a history of BC, psychiatric illness, visitors, and guest women were excluded from the study.
The sample size was determined using the formula n = Z2 P (1 − p) ÷ E2 with a power of 80%, confidence limit of 95%, and allowable error of 5%. The calculation was based on the assumption that 21.2% of women had >50% of knowledge regarding BSE as reported in a study. The calculated sample size was 257 which was rounded off to 260.
A multistage random sampling technique was done to select the required sample size. At the first stage, subcenter Chitkul was selected by lottery method out of three subcenters. In the second stage, out of five villages, two villages Chitkul and Ganapathiguda were selected by considering the last digit of the currency note. Using the family household survey register at the rural field practice area, the eligible women line listed were 531 in the study area. Through systemic random sampling, every second woman was included in the study till the desired sample of 260 was achieved from both the villages.
The ethical clearance was obtained from Institutional Ethical Committee, Osmania Medical College, Hyderabad, India. The study was conducted in three phases: preintervention, intervention, and postintervention. In the preintervention phase, sociodemographic data, knowledge regarding risk factors, clinical features, and screening methods of BC such as BSE, CBE, and mammography were assessed using a validated, pretested, semi-structured questionnaire in their vernacular language. During data collection, written consent was taken from the participants. Confidentiality was ensured in all the stages of data collection and management.
In the intervention phase, health education was given to the subjects through audiovisual aids and flip charts, and a demonstration of BSE was done by focus group discussion with each group consisting of 5–8 members. Two weeks later, in the postintervention phase, the knowledge regarding BC was reassessed using the same tool.
Data were entered and analyzed using Microsoft Excel 2010 version and Epi Info version 7 (Epi-Info statistical software Centers for Disease Control and Prevention, Atlanta, Georgia, USA). The result obtained was presented in the form of tables and figures. The categorical variables were presented by percentage. The association between the variables was measured by the Chi-square test. Statistical significance was done at a 95% confidence interval, i.e., P < 0.05 was statistically significant.
| Results|| |
[Table 1] shows the demographic characteristics of 260 women who participated in the study. About 34.6% belonged to the 20–30 years of age group. The majority of the women (94.6%) were married. More than half (51.6%) were illiterates and 22.3% were up to high school. In the present study, 65.4% belong to the nuclear family. The majority (33.5%) were from the lower middle and the least (5.4%) were from lower class socioeconomic status.
|Table 1: Distribution of respondents according to sociodemographic characteristics (n=260)|
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[Figure 1] shows (65.4%) the study population had never heard of BC. Among those who heard about BC, the major source of information was mass media (75.5%), friends were the source of information in 16.7%, and health-care personnel in only 10%.
|Figure 1: Pie chart showing awareness of study population regarding BC. BC: Breast cancer|
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[Table 2] shows awareness regarding risk factors for BC in the preintervention phase was as follows: genetic or family history of BC (13.5%), advancing age (5.8%), obesity (20.8%), nulliparity (10.4%), alcohol (6.6%), physical inactivity (4.6%), fatty diet (3.1%), hormone replacement therapy (HRT) (1.9%), and others (8.5%) which includes oral contraceptive pills, dense breasts, personal history of BC, and radiation therapy to the chest. In the postintervention phase, a statistically significant improvement was seen among the women, especially regarding genetic or family history (60%), advancing age (68.5%), obesity (71.5%), nulliparity (54.6%), and alcohol (61.9%)
|Table 2: Preintervention and postintervention knowledge on risk factors of breast cancer (n=260)|
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[Table 3] shows awareness on the BC symptoms and signs, during the preintervention phase, only few were aware of breast lump (7.7%), nipple discharge (3.8%), increase in the size of the breast (8.5%), wrinkled skin of the breast or nipple (6.5%), and changes in the breast skin color (1.9%). None of them were aware of the axillary nodules. Only 5.8% were aware about pain, nipple retraction, and itchiness. In the postintervention phase, a significant increase in awareness on all the symptoms and signs of BC was observed indicating the importance of health education.
|Table 3: Preintervention and postintervention knowledge of breast cancer symptoms and signs (n=260)|
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[Table 4] shows in the preintervention phase, knowledge regarding screening methods to detect BC was extremely low, namely BSE (5%), CBE (10.8%), and mammogram (6.1%). In the postintervention phase, knowledge regarding BSE was (77.7%), CBE was (67.3%) and mammogram was (71.1%). A significant increase in the knowledge level on screening methods for BC was found in the present study which was found to be statistically significant.
|Table 4: Preintervention and postintervention knowledge on screening methods (n=260)|
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| Discussion|| |
The present study found that about one-third (34.6%) have heard of BC. Similar findings were observed by Sharma et al., which found that only 43.67% had knowledge of BC. The low level of knowledge found in this study was similar to results from other Indian studies.,, The current study results were in contrast to the study conducted by Kumarasamy et al., where 89% of women were aware of BC. Among those who heard about BC in the study, the major source of information was mass media (75.5%). Friends were the source of information in 16.7% and health-care personnel in only 10%. The current study results can be compared with the study conducted by Somdatta and Baridalyne where television (42%) was the most common source, followed by neighbors and relatives (41%) and hospital staff (19%).
In the present study, the awareness regarding risk factors for BC at the baseline was very low in the preintervention phase as follows: genetic or family history of BC (13.5%), advancing age (5.8%), obesity (20.8%), nulliparity (10.4%), alcohol (6.6%), physical inactivity (4.6%), fatty diet (3.1%), HRT (1.9%), and others (8.5%). Similar findings were observed in the study by Abd El Aziz et al., where the knowledge of risk factors for BC was recognized only by less than one-fifth of the sample before the intervention. In the postintervention phase, a statistically significant improvement (P < 0.05) was seen among the women, especially regarding genetic or family history (60%), advancing age (68.5%), obesity (71.5%), nulliparity (54.6%), and alcohol (61.9%).
In the present study, awareness regarding BC symptoms and signs was also extremely low during the preintervention phase. Only few were aware of breast lump (7.7%), nipple discharge (3.8%), increase in the size of the breast (8.5%), wrinkled skin of the breast or nipple (6.5%), and changes in the breast skin color (1.9%). None of them were aware of the axillary nodules. Concurrent findings were observed in Sehrawat et al., where knowledge regarding signs and symptoms of BC among rural women was low. In the postintervention phase, a statistical significant association (P < 0.05) was seen in knowledge on all signs and symptoms.
In the present study, a very low level of knowledge regarding BSE (5%) was noticed at the baseline before the intervention. After the intervention with audiovisual aids and flipcharts, a statistically significant improvement in the knowledge regarding BSE (77.7%) was found in the present study. These findings were in concurrence with the study by Lee and Wu. Similar findings were also seen in Gupta study where a significant improvement in knowledge was found in the postintervention phase. After the interventional program, a 71.8% of increase in knowledge about BSE was observed in a study conducted by Nisha and Murali.
In the present study, knowledge regarding CBE in the preintervention phase was 10.8% which significantly improved after the intervention to more than two-thirds (67.3%). Similar findings were observed by Hussien et al., where a significant increase in the knowledge regarding CBE was found postintervention.
Knowledge regarding mammogram also was very low (6.1%) at the baseline, but after the intervention, a significant increase in knowledge (71.1%) regarding mammogram as a screening method for BC was observed. A study by Hussien et al. found that the participant's knowledge regarding mammography has increased from baseline to 6 months postintervention. Knowledge regarding mammography at the baseline was 65.2% which is higher than the present study findings and in postintervention knowledge increased to 85.5%.
Limitations of the study
Considering the small sample size and the rural women in this study had a low-literacy rate, the results may not be generalized to other settings. The study lacked a long-term follow-up on these women to evaluate their future preventive and promotive practices.
| Conclusion and Recommendation|| |
The current study found an extremely low level of knowledge and awareness regarding various risk factors, symptoms and signs, and preventive practices related to BC in the preintervention phase. These aspects significantly improved after the intervention phase highlighting the importance of health education in increasing the knowledge regarding risk factors, signs, symptoms, and preventive practices of BC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Bhagya Rekha Gogolla,
Department of Community Medicine, Kamineni Academy of Medical Sciences and Research Centre, LB Nagar, Hyderabad - 500 068, Telangana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]