Breast Self-Examination Practice Among Female Secondary School Students In Osogbo , Western Nigeria

DOI: http://dx.doi.org/10.24018/ejmed.2020.2.2.173 1 Abstract—BACKGROUND: Breast cancer is the most common invasive cancer affecting women worldwide. It comprises 22.9% of invasive cancers in women and 16% of all female cancers. It affects about 12% of the women population worldwide. In Nigeria, about one breast cancer death is reported in every 25 cases identified and the practice of breast self-examination has been reported to range from 19% to 43.2%. This cross sectional study assessed the knowledge, attitude and practice of breast self-examination (BSE) among female secondary school students in Osogbo Metropolis. METHODS: A total of 400 respondents were selected using multistage sampling technique. Data were collected using pretested self-administered semi structured questionnaire, analyzed using Statistical Package for Social Sciences and presented using appropriate tables and charts. Level of significance set at < 0.05. RESULTS: The mean age ± SD is 14.77 ± 1.46 years. 390 (97.5%) respondents reported that they have heard of breast cancer while 235 (58.8%) respondents stated that they have heard of breast self-examination (BSE). 15 (3.8%) respondents said the procedures is time wasting while 82 (20.5%) respondents said the procedures were strenuous. 199 (49.8%) strongly disagree that performing breast selfexamination may expose them to breast cancer. Individuals with poor knowledge are one time less likely to do breast selfexamination (OR = 1.245, CI = 0.647 2.394) while in terms of attitude, those with unfavorable attitude are one time less likely to do breast self-examination (OR = 1.025 CI = 0.949 -1.107). CONCLUSION: This study revealed a larger proportion of respondents have heard about breast cancer and breast selfexamination but with inadequate knowledge of the correct procedures of breast self-examination (BSE) thereby resulting into poor attitude & practice of breast self-examination (BSE). This challenge therefore indicates an urgent need for continuous awareness and sensitization programs in the communities.


I. INTRODUCTION
Breast cancer is an uncontrolled growth of abnormal cells in the milk producing glands of the breast or in the ducts that deliver milk to the nipples. Breast cancer is the most common invasive cancer affecting women worldwide. It comprises 22.9% of invasive cancers in women and 16% of all female cancers [1]. It affects about 12% of the women population worldwide [2].Report on the incidence of breast cancer reveals that one out of every eight women in the world stands a chance of having the disease in her life time [3]. In the developing countries, the rate of breast cancer is reportedly higher than developed countries [4]. Approximately half of the breast cancer cases and 60% of the deaths are estimated to take place in developing countries [5]. The high incidence of breast cancer necessitates the need for early detection which enhances early initiation of treatment thereby reducing mortality. The various diagnostic measures for early detection of breast cancer include breast self-examination (BSE), clinical breast examination (CBE) and mammography [6].
Breast self-examination (BSE) is a screening method that people perform the procedures on their own in an attempt to detect early breast cancer. Breast self-examination is easy to perform and cheap but despite these the rate of practice of breast self-examination is low and varies in different countries. Studies have cited the reasons for the low practice of breast self-examination which is as a result of inadequate knowledge of breast self-examination, lack of time, lack of self-confidence in their ability to perform the technique correctly, fear of possible discovery of a lump, and embarrassment associated with handling of the breast [7]. Breast self-examination is often carried out once in a month, between the 7 th and 10 th day of the menstrual cycle, to detect breast cancer at the early stages of growth thereby ensuring a better prognosis when treated [8].The method involves the woman herself looking at and feeling each breast for possible development of lumps, discharge other than breast milk, swelling of the breast, skin irritation or dimpling, nipple abnormalities (such as pain, redness, scaliness, or turning inward).In Nigeria, the practice of breast self-examination has been reported to range from 19% to 43.2% [9].
A study of BSE done among female students of the University of Ibadan, Ibadan reported that 82.5% of students have heard of BSE, 53.2% of them knew what BSE is used for while only 25% practice BSE regularly and 30% practice BSE infrequently [10]. A research on the knowledge, attitude and practice of respondents about breast self-examination among female secondary school teacher in a rural community in Oyo State showed that 54% of the respondent had poor knowledge, 48% had poor attitude and 62% demonstrated a poor practice [11].
In a study done by Yakubu and others on knowledge, attitude, and practice of breast self-examination among female nurses in Aminu Kano teaching hospital, Kano, Nigeria stated that 100% respondents unanimously agree that BSE is useful and 84.3% of the respondents responded that they can encourage BSE to others [12]. Sani et al stated in their research on influence of educational level on knowledge and practice of breast self-examination among Breast Self-Examination Practice Among Female Secondary School Students In Osogbo, Western Nigeria I.N. Usman, S.O. Olanrewaju, and S.O. Usman women in Sokoto, Nigeria that 65% of the respondents practiced BSE while 35% did not practice BSE and among the 65% of the respondents that practiced BSE, only 52.7% practiced BSE monthly [13]. A research done on Knowledge, attitude and practice of breast self-examination among female undergraduate students in the University of Buea stated that 41% of the respondents in the study had ever performed BSE, 29.5% have performed BSE within the past 12 months. Only 3% had performed BSE regularly (10-12 times) within the past 12 months [14].

II. SPECIFIC OBJECTIVES
• To determine the knowledge of breast selfexamination (BSE) among female secondary school students in Osogbo Metropolis. • To evaluate the attitude of breast self-examination (BSE) among female secondary school students in Osogbo Metropolis. • To assess the practice of breast self-examination (BSE) among female secondary school students in Osogbo Metropolis.

III. METHODS
This descriptive cross-sectional survey was carried out in Osogbo Metropolis, the capital of Osun state, South-West Nigeria. The study population consists of female secondary school students in selected secondary schools.
A semi-structured questionnaire was used to seek information about the socio-demographic characteristics of the female students, knowledge, attitude and practices of breast self-examination by female secondary school students on breast self-examination. Ethical approval to carry out the study was obtained from the ethical review committee of Ministry of Health, Abeere, Osun State. A multi-stage sampling technique was used to select the adolescent girls from the selected schools in Osogbo metropolis.

Sample Size Estimation
Sample size calculation was done using Leslie Fischer's formula, for population >10,000 with a 5% or 0.05 degree of precision and 95% confidence interval. There seems to be no data available as regards the proportion of female secondary school students practicing breast self-examination in Osogbo Metropolis, but a study on Breast self-examination practice among female senior secondary school students in Abuja, reported 34.6% (15). The Leslie Fischer's formula for sample size when population is > 10,000 is: n = Z 2 PQ/d 2 Where: n = minimum sample size, Z = standard normal deviation at 95% confidence interval which is 1.96, d = degree of precision or error margin which is 5% (taken P = proportion of the target population from previous studies (estimated at 34.6% which is 34.6/100 = 0.35), Q = alternate proportion (1-P) which is 1-0.346=0.65 n = (1.96) 2 (0.35)(0.65) = 349 (0.05) 2 Adding a 5% attrition rate, the minimum sample size (n) = 5/100×349=17 Therefore, minimum sample size (n) is 349+ 17= 366.
STATISTICAL ANALYSIS Data was statistically analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 software. All data were expressed as Mean ± Standard Deviation (SD). Statistical test of significance were performed by Chi-Square test. Level of significance was set with p-value less than 0.05.

IV. RESULTS
SOCIO-DEMOGRAPHIC DATA 400 respondents participated in the study and the mean age ± SD is 14.77 ± 1.46. Based on the level of education of respondents, 84 (21.0%) are in SSS1, 105 (26.3%) are in SSS2 while 211(52.8%) are in SSS3. In term of the type of school of the respondents 349 (87.3%) are from private schools while 51 (12.8%) are from public school. Age category of the respondents shows that 300 (75.1%) are between 13-15 years, 93 (23.4%) are between 16-18years, and 7 (1.8%) are 19 above. As regards the position of the respondents in their family, 143 (35.8%) reported that they were first born, 106 (26.5%) were second born 83 (20.8%) were third born, 53 (13.3%) were last born of their family while 15 (3.8%) respondents chose others.    The pie chart below shows the respondents attitude towards breast selfexamination in this study. Out of the 400 respondents, 366 (91%) have a favourable attitude towards breast self-examination while 34 (9%) have an unfavourable attitude towards breast self-examination.

PRACTICE OF BREAST SELF EXAMINATION (BSE)
Practice of breast self-examination (BSE) (n=400)  The pie chart below shows the respondents practice of breast selfexamination in this study. Out of the 400 respondents, 44 (11%) have good practice of breast self-examination while 356 (89%) have poor practice of breast self-examination.

PREDICTORS OF PRACTICE OF BREAST SELF-EXAMINATION
According to the  [15] but it is in contrast to Assuit, South Egypt study that revealed that 87.9% of the respondents reported to have heard about Breast Self-Examination (BSE) [16]. Related to this is a study done at University of Ibadan , Nigeria which described that 82.5% have heard of BSE and only 11% female individuals practice the procedure regularly (10). It was observed in this study that having heard about BSE does not necessarily imply to high performance rate of breast self-examination (BSE). The poor practice of BSE among the respondents in this study was because they do not know how to perform the procedure and perhaps they appear not to also know the specific period to perform breast selfexamination. However, 84.3% of the respondents stated that they would like to know more about breast self-examination (BSE) and its procedure, which implies that young adolescent girls are eager to learn more about breast selfexamination (BSE) which will enhance positive attitude and behaviour towards the practice of breast self-examination (BSE) at an early stage of life.
Findings of this study indicated that 27.3% of the respondents practiced BSE, but only 19.5% performed breast self-examination in the past six months. This illustrated that a very low percentage of the female secondary school students were really practicing BSE. In disparity to this study, there is high level of practice of BSE among women of about 65.3% in a research done at Sokoto Nigeria (13).
The peak proportion of the respondents obtained their first information from their school whereas the least source of information on BSE was obtained from the church. Contrast observations about the respondents' first information were stated in a research held among female secondary school teachers in Ilorin, Nigeria where 29.9% of those studied indicated that the information were obtained from the television, This may be as a result of insufficient health education by health workers to females on BSE (8).
Furthermore, only 19.5% respondents were aware that the correct period of menstrual cycle for breast selfexamination was after menstruation while 13.0% respondents examined their breasts at any time they felt like. This does not agree with a previous research outcome on breast self-examination among female undergraduates in Enugu which revealed that 62% respondents declared that they examined their breasts after menstruation while 54.6% examine their breasts at any time they felt like [17]. The poor knowledge on the methods and timing of breast selfexamination might be because the respondents were not taught the procedures of BSE as this does not necessarily fall into the syllabus of any of the main courses the respondents or in other cases, little attention paid to such topics by school instructors because this area of study in general is not taken as seriously as one would expect.
The educational status has significant effect on knowledge on BSE in which the respondents' level of education may determine their knowledge on BSE. .This was in agreement to a BSE study among women in Sokoto Nigeria in which there was significant relationship between the educational level and the knowledge of BSE among those respondents (13). Respondents in the higher level of education were older in age and possibly taught the procedure of BSE (who to routinely perform BSE, age to start BSE, how often BSE have to be done, procedures for BSE, signs and risk factors of BSE, among others) by their teachers. This is similar to a previous study done among female secondary school students in which the higher level of education determines the knowledge on BSE [15].
The age of the respondents is significantly associated with the practice of BSE which is likely due to the fact that respondents with adequate knowledge on BSE will definitely practice BSE as they will be aware of the importance of early detection of breast cancer in reducing mortality rate and worsening of the disease. This is similar to other study done among young adolescent girls in Abuja, Nigeria [15] and as well in concordance with the research on the influence of educational level on knowledge and practice of breast selfexamination among women in Sokoto [13]. Knowledge on BSE is insignificantly associated with the attitude of BSE which is likely due to the fact that respondents with adequate knowledge on BSE does not implies that the respondents will have a good behaviour towards BSE practice. This is similar to the outcome reported by the Authors of a research carried out on knowledge, attitude and practice of breast selfexamination among female undergraduate students in the University of Buea, who reported that 51.4% admitted that they were not afraid to detect breast cancer while 26.5% were afraid. 88% of the respondents approved that BSE was important and useful in the early detection of breast cancer [14].

VI. CONCLUSION
This study revealed a larger proportion of respondents have heard about breast cancer and breast self-examination but with inadequate knowledge of the correct procedures of breast self-examination (BSE) thereby resulting into poor attitude & practice of breast self-examination (BSE). This challenge therefore indicates an urgent need for continuous awareness and sensitization programs in the communities, as well as the review of high school subject curriculum to include breast self-examination (BSE) teaching and practice & general sexual and reproductive health programs.
There is need for the development of more efficient educational programs aiming at demonstrations of the correct procedures of breast self-examination (BSE) so as to enhance early detection of breast cancer and proffer prompt treatments to reduce the mortality rate of the breast cancer.

VII. ACKNOWLEDGEMENTS
Our sincere appreciation goes to all participants that took part in this study, my supervisor and all staff members of the Department of Community Medicine, Ladoke Akintola University of Technology, Osogbo, Nigeria.

VIII. FINANCIAL & NON-FINANCIAL COMPETING INTEREST
The authors declare no financial or non-financial competing interest.

IX. CONFLICT OF INTEREST
Authors declare they have no conflict of interest.