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    -  Baburajan C
    -  Pushparani MS
    -  Lawenya M
    -  Lukose L
    -  Johnson AR

 
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ORIGINAL ARTICLE
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Are rural women aware of breast cancer and do they practice breast self-examination? A cross-sectional study in a rural hospital in South India


 Department of Community Health, St. John's Medical College, Bangalore, Karnataka, India

Date of Submission09-Sep-2019
Date of Decision11-Nov-2019
Date of Acceptance16-Nov-2019
Date of Web Publication27-Jan-2021

Correspondence Address:
Avita R Johnson,
Department of Community Health, St. John's Medical College, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_799_19

PMID: 33753612

  Abstract 


Background: Breast cancer is the most common cancer among Indian women. Breast self-examination (BSE) remains a feasible screening method in resource-poor settings, yet diagnosis in advanced stages remains common. We aimed to assess the awareness of breast cancer and the practice of BSE among women in a rural area of south India.
Methods: A cross-sectional hospital-based study in rural Ramanagara district, Karnataka, with 416 adult women who were interviewed using the Breast Cancer Awareness Measure.
Results: Less than one in ten women knew that lump in the breast is a symptom of breast cancer. Majority 338 (81.2%) were not able to state even a single symptom of breast cancer and 365 (87.7%) not able to state even one risk factor of breast cancer. Majority 354 (85.1%) of the women in the study had never heard of BSE. None of the women in the study performed monthly BSE. Only 40 (9.6%) of the women actually performed BSE within the last 6 months. Women with higher education and those who reported a history of a lump in the breast in self or family were significantly more likely to state at least one symptom of breast cancer and were more likely to practice BSE.
Conclusion: The rural women in this study had poor awareness regarding breast cancer and poor practice of BSE. Awareness of at least one symptom of breast cancer was associated with an 18 fold increase in the practice of BSE. This study has revealed an urgent need to focus on health awareness regarding breast cancer and BSE among rural women.


Keywords: Awareness, breast cancer, breast self-examination, rural women
Key Message Women in rural Karnataka have poor awareness of breast cancer and poor practice of breast selfexamination. Those more aware of breast cancer were more likely to self-examine, indicating a need for community-based education.



How to cite this URL:
Baburajan C, Pushparani MS, Lawenya M, Lukose L, Johnson AR. Are rural women aware of breast cancer and do they practice breast self-examination? A cross-sectional study in a rural hospital in South India. Indian J Cancer [Epub ahead of print] [cited 2021 Jul 25]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308055





  Introduction Top


Breast cancer remains a public health problem with 2.09 million cases and 627,000 deaths in the world each year.[1] Breast cancer has overtaken cervical cancer to become the most common cancer among Indian women.[2] While mortality due to breast cancer is decreasing in developed countries, in India both hospital- and population-based cancer registries indicate that the incidence, as well as mortality of breast cancer, is on the rise.[3],[4],[5] The age of the incidence of breast cancer in Asian countries is between 40 and 50 years, while it is 60–70 years in Western countries,[6] indicating that Asian women in their productive years are being affected. Though breast cancer allows for early diagnosis and successful treatment, survival seems to be poor in developing countries owing to a lack of awareness and screening along with poor access to timely and standard care.[7],[8]

In addition to the dearth of a national level agenda for breast cancer screening and early detection, there are several sociocultural barriers that exist in Indian society such as negative attitude to breast self-examination (BSE), poor health-seeking behaviour and lack of priority to the health of women as they reach the end of their child-bearing years.[9] Evidence points out that early detection and treatment can improve breast cancer survival rates.[10] For rural Indian women, the lack of a mammogram and breast examination by an experienced clinician makes BSE the only feasible screening method available. The poor awareness and practice of BSE could lead to delayed diagnosis and adversely affect the outcome of breast cancer.[11]

This study was therefore conducted with the objective to assess the awareness of breast cancer and the practice regarding BSE among women in a rural area of south India.


  Methods Top


This was a cross-sectional study conducted in a rural missionary-run hospital in Ramanagara District, about 70 km from Bangalore city, in south India for a duration of 8 weeks in July–August 2016. Institutional ethics committee approval and permission from the hospital authorities were obtained before the commencement of the study. The required minimum sample size was calculated to be 384, with 5% absolute precision, based on a previous study, where 51% of women had awareness of at least one symptom of breast cancer.[12] Women aged 18 years and above, who were either availing services or visiting a patient in the hospital, were invited to participate in the study. The participants were chosen by the method of convenience sampling. Written informed consent was taken from each subject before administering the study tool in the local language.

The study tool used was the Breast Cancer Awareness Measure (Breast-CAM).[13] The Breast-CAM was developed by Cancer Research UK, King's College London and University College London in 2009, and it records awareness of symptoms and risk factors of breast cancer and awareness and practice regarding BSE. It was translated into the local language Kannada for use in rural area. The subjects were also administered a questionnaire to capture sociodemographic details. The women who participated in the study were then given health education about breast cancer and taught how to perform BSE.

Data collected were entered in Microsoft Excel and then analysed using SPSS version 17. Sociodemographic variables and outcome variables (awareness of at least one symptom of breast cancer and practice of BSE at least once in the last 6 months) were described in terms of frequency, percentages, mean and standard deviation. Association between the outcome variables and various sociodemographic variables were analysed using inferential statistics such as Chi-square test or fisher's exact test as applicable. P value of <0.05 was considered as statistically significant.


  Results Top


A total of 416 women participated in the study. The mean age of the women was 31.60 ± 13.7 years. The majority were Hindu by religion (92.3%). Majority of the subjects were housewives (354, 85.1%) and 385 (92.5%) were unmarried. The median years of marriage were 5 years (Interquartile range (IQR) = 1.5, 20). Most of the married women (71.4%) had previously delivered at least one child. The majority belonged to the upper and upper-middle class (65.6%) and were residing in joint families (82.5%).

While all the women in the study had heard of breast cancer, 338 (81.2%) were not able to state even a single symptom of breast cancer. Commonly stated symptoms were discharge from the nipple, change in the shape or size of the breast, pain in the breast, change in nipple position and redness over the breast [Table 1]. Less than one in ten women knew that lump in the breast is a symptom of breast cancer. History of a breast lump in the family or in self was reported by 11 (2.6%) the subjects. Awareness of at least one symptom of breast cancer was significantly associated with higher education level, higher socioeconomic class and history of a breast lump in self/family [Table 2]. There was no association between awareness of symptoms of breast cancer with age, religion, marital status or parity. After regression analysis, women with higher education were found to be nearly nine times more likely to state at least one symptom of breast cancer as compared to women who were illiterate. Odds Ratio (OR)=8.88 [95% confidence interval (CI)=2.72–28.98]. Socioeconomic status, however, did not retain significant association after regression analysis. Women who reported the history of the lump in the breast in self or family were over five times more likely to state at least one symptom of breast cancer as compared to women who did not report this history. OR = 5.31 (95% CI=1.41–19.96) [Table 3].
Table 1: Awareness of symptoms of breast cancer among women in the study n=416

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Table 2: Association between awareness of at least one symptom of breast cancer with various sociodemographic factors n=416

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Table 3: Multiple logistic regression of factors associated with awareness of at least one symptom of breast cancer n=416

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Regarding risk factors for breast cancer, 365 (87.7%) women were not able to state even one risk factor. Commonly stated risk factors were the history of breast cancer, being overweight, excess alcohol consumption and family history of breast cancer [Table 4].
Table 4: Awareness of risk factors for breast cancer n=416

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Majority (354, 85.1%) of the women in the study had never heard of BSE. Out of the 62 women who had heard of BSE, only 27 (43.5%) of these women felt confident about noticing changes in the breast by BSE. The source of information regarding BSE was commonly television (51.6%), relatives (24.2%), doctors (12.9%) and books (9.7%). It was felt by 12 (19.4%) of the women, that BSE should be performed once a month, while 21 (33.9%) felt it should be done weekly and 29 (46.8%) felt it should be done less often than once in a month. However, none of the women in the study performed monthly BSE. Only 40 (9.6%) women in this study had actually performed BSE at least once in the last 6 months. The practice of BSE was significantly associated with higher education, being a housewife, higher socioeconomic status and a history of a breast lump in self or family. Women who were able to state at least one symptom or one risk factor of breast cancer were significantly more likely to perform BSE [Table 5]. After regression analysis, awareness of at least one symptom of breast cancer was associated with an 18-fold increase in the practice of BSE. OR = 18.63 (7.44–46.66) [Table 6]. None of the other sociodemographic variables, however, retained significance after regression analysis. Of the 354 participants who had not heard about BSE prior to the study, 351 (99.2%) expressed a willingness to learn how to perform BSE.
Table 5: Association of Practice of breast self.examination (BSE) with various factors n=416

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Table 6: Multiple logistic regression with factors associated with the practice of Breast Self-examination with various factors n=416

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  Discussion Top


The present study found that women residing in a rural area of Karnataka had poor awareness of breast cancer. 81% of the women were unaware of even a single symptom of breast cancer. Similarly, a study conducted in rural and peri-urban women in India reported poor awareness regarding the symptoms of breast cancer, with only 21.4% of women being able to state at least one symptom. In a study conducted in an urban resettlement area in India, 51% knew about at least one symptom.[12] This disparity in the awareness level of women between urban and rural areas may be due to the lack of exposure and access to information and poorer educational status of rural women.

The most common symptom women are usually aware of is the presence of a breast lump.[12] This was seen in a study in urban Delhi where 57% of women cited lump in the breast as a symptom of breast cancer.[15] However, less than one in ten women in our study were aware that a lump in the breast could mean breast cancer. This is an alarming finding, especially given the fact that breast lumps are often an accidental finding among breast cancer patients and this lack of awareness would lower the index of suspicion among women with regards to breast cancer.[16] In the present study, awareness of at least one symptom of breast cancer was significantly associated with higher education level, higher socioeconomic class and history of a breast lump in self/family. A study conducted in a rural area of central India similarly found that women who had higher education status were more knowledgeable regarding the symptoms of breast cancer.[17] A community-based study among women in Trichy, Tamil Nadu revealed that the knowledge of breast cancer and SBE was significantly higher among educated women,[18] a fact supported by studies in other developing countries like Iran, which also found that women with higher education status had better awareness of symptoms and risk factors of breast cancer.[19] This underscores the fact that lack of education is a major reason for low awareness of breast cancer among women. A large majority of the rural women in our study were not able to state even one risk factor for breast cancer. Past history or family history of breast cancer, being overweight, nulliparity and alcohol consumption were among the mentioned risk factors in our study, which was similar to a hospital-based study in south India, where women commonly stated the same risk factors.[20]

Most of the women in the study had never heard of BSE. Most of those who had heard of BSE were not aware of how often it should be done and were not confident about noticing changes in the breast by BSE. Less than one in ten women actually performed BSE once in the last 6 months and none performed monthly BSE. This was only slightly better than the results of a hospital-based study among rural women in central India, where none of the 360 women in the study had performed BSE.[21] But these figures are very different from those in other developing countries such as Brazil, where studies have shown that 80% of women perform BSE.[22] This indicates the probable role played by higher education levels, targeted health interventions and a different sociocultural context in overcoming barriers to BSE in developing countries. The practice of BSE was significantly associated with higher education, higher socioeconomic status and history of a breast lump in self or family. Women who were able to state at least one symptom of breast cancer were significantly more likely to perform BSE. This was also similarly found in studies from other developing countries such as Malaysia[23] and Brazil.[22] This is of public health importance as it indicates that improving awareness regarding the symptoms and risk factors for breast cancer will also improve the practice of BSE.

Even though BSE as a screening method has been shown to have high false-positivity,[24] in the absence of a robust community-based breast cancer screening program, it remains one of the 'affordable, acceptable and appropriate technologies' in line with the principles of primary healthcare. It was encouraging to note that nearly all the women in the study, who had previously not heard of BSE, expressed a willingness to learn how to perform BSE.


  Conclusion Top


The rural women in this study had poor awareness regarding breast cancer, with 81.2% not able to state even a single symptom of breast cancer, and 87.7% not able to state even one risk factor of breast cancer. Less than one in ten women knew that lump in the breast is a symptom of breast cancer. 85.1% of the women in the study had never heard of BSE. None of the women in the study performed monthly BSE. Only 9.6% of the women actually performed BSE within the last 6 months. Women with higher education and those who reported the history of a lump in the breast in self or family were significantly more likely to state at least one symptom of breast cancer and were more likely to practice BSE. Awareness of at least one symptom of breast cancer was associated with an 18-fold increase in the practice of BSE. This study has revealed an urgent need to focus on health awareness regarding breast cancer and BSE among rural women by exploring various mechanisms of community engagement, including involving grassroots-level health workers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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