Breast cancer knowledge, attitude and self-examination practices of physiotherapy students in India: a cross-sectional study

INTRODUCTION

There is an increased prevalence of breast carcinoma all over the world. Adoption of western lifestyles, urbanization, increase in life expectancy, interaction patterns of individuals with the environment, and chemical causes, can be attributed to the increased incidence of these non-communicable diseases in developing countries.¹ As per Globocan 2018 report of India, the amount of latest breast cancer cases accounted for 15.62% of the total number of cancer cases whereas, the number of deaths due to breast cancer contributed to 12.19% of the total deaths due to cancer.² A notable reason for such a high mortality rate in India is a late-stage presentation.³ In India merely 30% of the breast cancer cases are arrested at early stages, whereas within the developed world 60-70% of cases seek medical intervention at early stages.¹ This variation might not be solely due to socioeconomic differences, but also attributable to the shortage of breast cancer awareness and poor attitude towards breast self-examination (BSE).⁴ The 5-year survival rate could be boosted to 85% with early detection or could decline to 56% with late detection.⁵ American cancer society guidelines suggest some measure for early detection of breast cancer like BSE for girls starting their twenties, clinical breast examination every three years for the women in their twenties and thirties, early mammography every year for women age 40 and above.⁶ BSE is a simple, low-cost, effortless, and efficient procedure that can be disbursed by the women with no complex technical training or any particular equipment required.⁷ BSE comprises of examination of the breasts for lumps, bumps, skin changes over nipples and breasts visually and manually.⁸ Therefore in developing countries, breast self-examination plays a prominent role in the early detection of breast cancer where sophisticated diagnostic screening techniques which don’t seem to be easily accessible and affordable. It makes women tuned in to a way to judge their risk and take suitable measures. The assorted resources of dissemination of data about breast cancer are health-care professionals, educational institutions, and media.⁹

Healthcare professionals are a principal source of knowledge for both their patients as well as for the general population.¹⁰ They’re in an exceedingly significant position to boost the awareness of breast cancer knowledge and breast screening in the community.¹¹ As they hold such a vital role the information they transfer ought to be accurate.¹⁰ But if health professionals themselves aren’t aware and/or don’t practice BSE accurately, a satisfactory level of patient education about BSE won’t be achieved.^12,13 Among these health professionals, physiotherapists have an essential role to play in community rehabilitation, so by conducting this study, we aim to evaluate breast cancer knowledge and attitude and breast self-examination practices in female physiotherapy students of Navi Mumbai. The study will help identify and target opportunities to boost BSE knowledge and practice among health professionals and transferring them to the overall population.

METHODS

This cross-sectional study was conducted among 380 physiotherapy students in different physiotherapy colleges of Navi Mumbai in 2019. A convenient random sampling technique was used for sample collection. The study was conducted after obtaining approval from the institutional ethical committee, permission also obtained from the principal of Physiotherapy College. Female students studying in the final year, intern batch, and perusing master’s degree were included in the study. Informed and written consent was taken before starting the procedure. The method and purpose of this study were explained. Participation was entirely voluntary and confidentiality was ensured. The questionnaire was adapted from the original article.¹⁴ Permission for reusing the questionnaire was obtained from the author. The questionnaire was modified to suit the population and then validated and piloted. The questionnaire was divided into three parts-part A: consent form, part B: socio-demographic variables of the participants, part C: information on the participant’s knowledge, attitudes on breast cancer, and BSE. The responses to the questions and sub-questions in part C had options of ‘yes or agree’, ‘not sure or unsure’, and ‘no or disagree’. Positive questions, attracted scores of 3, 2 or 1 respectively, and were reversed accordingly for all negative items Percentages were interpreted as: ‘≥70%’ indicating excellent, while ‘50-69%’ and ‘<50%’ signify moderate and poor respectively. The data were analyzed using the Statistical Package of social sciences (SPSS), version 20. Chi-square test was used for testing the relationship between categorical variables. Spearman’s correlation analysis was used to test the strength of the relation between all the three variables. 0.05 was considered to be statistically significant.

RESULTS

The study was conducted among 380 physiotherapy students who were in the final year, interns, or postgraduate students from different colleges in Navi Mumbai. The age ranges from 21-26 (mean of 22.17±1.36). About 58 (15.3%) of the respondents had witnessed the incidence of breast cancer in their family. Most of the participants had heard about breast self-examination 334 (87.9%) and the main source of information was the internet (20.1%), followed by college professors (15.9%) and textbooks/newspapers (15.4%) and friends/peers (15.3%) (Table 1).

Knowledge of breast cancer

Most respondents (80.9%) had excellent ‘general knowledge of breast cancer’. About 296 (77.9%) were aware that BSE can help in early detection. Moderate knowledge was seen about the presenting symptoms of breast cancer (54.2%). The most known sign of breast cancer among the respondents in the current study was breast lump or swelling 358 (94.2%) followed by lump or swelling in the armpit 295 (77.6%) and nipple discharge from one breast only 241 (63.4%). There was a widespread lack of awareness (43.5%) among female physiotherapy students about the risk factors associated with breast cancer. The most commonly known risk factor was a family history of breast cancer 313 (82.4%) (Table 2).

Knowledge on BSE

Only one single question each correctly represented the ‘knowledge on who should do BSE’, its ‘frequency’, and its ‘timing’ in Table 3. The respondents in the study had excellent knowledge as to who should perform a BSE (85.6%), moderate knowledge (61.0%) about the frequency of the BSE, and poor knowledge (32.2%) about the timing of BSE. Only 123 (32.4%) respondents were aware that BSE has to be practiced 7-10 days after the menstrual cycle stops. The respondents had excellent knowledge about BSE techniques (71.5%). Majority 319 (83.9%) of the respondents knew BSE must be done standing in front of a mirror, 278 (73.2%) were aware that the right hand has to be used to examine the left breast and vice-versa using finger pads 273 (71.8%). However, less than half of the respondents knew BSE has to be performed using 3 middle fingers only 160 (42.1%) (Table 3).

Overall knowledge about BSE and breast cancer

The present work revealed that 189 (49.74%) of the study sample had moderate overall knowledge of breast cancer and BSE whereas 175 (46.05%) had poor knowledge. Only 16 (4.21%) of respondents in the current study have an excellent overall knowledge of BSE and breast cancer (Table 4).

Level of attitude towards BSE

Attitude to BSE is excellent in the respondents of this study (94.2%). About 105 (27.6%) respondents agreed that they were not well-informed about how to carry out the BSE examination (Table 5).

The practice of BSE

The present study showed about 54 (14.2%) of the respondents practiced BSE just once, whereas 97 (25.5%) of them had never tried BSE. Of these who practice BSE, majority 98 (25.8%) practice BSE correctly (once in a month) (Table 6).

Relationship between overall knowledge, attitude, and practice concerning BSE

There was a statistically significant difference between the overall knowledge (breast cancer, BSE) and BSE practice (χ²=119.06, p=0.000). The difference between overall knowledge and attitude was statistically significant at (χ²=570.08, p=0.000) (Table 7). There was a fair positive correlation between overall knowledge and the knowledge about risk factors of breast cancer (r=0.331 and p=0.000). The same was for the overall knowledge and frequency of BSE practice (r=0.35 and p=0.000). A smaller positive correlation between total knowledge score and attitude towards BSE (r=0.176 and p=0.000) (Table 8).

**Total scores are derived by the sum of the following: correct responses (marked with *; multiply by 3) + unsure (multiply by 2) + incorrect (multiply by 1), Result interpretation: ≥70%=excellent knowledge; ≥50 to <70%=moderate knowledge; <50%=poor knowledge

**Total scores are derived by the sum of the following: correct responses (marked with *; multiply by 3) + unsure (multiply by 2) + incorrect (multiply by 1), Result interpretation: ≥70%=excellent knowledge; ≥50 to <70%=moderate knowledge; <50%=poor knowledge

**Total scores are derived by the sum of the following: correct responses (marked with *; multiply by 3) + unsure (multiply by 2) + incorrect (multiply by 1), Result interpretation: ≥70%=excellent knowledge; ≥50 to <70%=moderate knowledge; <50%=poor knowledge

*Correct practice

*Significant p at ≤0.05 levels

*Significant p at ≤0.05 levels

DISCUSSION

The present study involved female physiotherapy students of Navi Mumbai, the majority between the age group of 22-24 years (mean: 22.17±1.70). Respondents were from the final years, interns, and students perusing a master’s degree. These health care providers can play an important role in educating women through specially designed educational programs in the clinical setting, as well as, through community outreach strategies that suit our social and cultural setting.⁹

In this study, out of 380 respondents, 15.3% reported a positive family history of breast cancer, 36.8% knew somebody (relative or friend) who has had breast cancer whereas 47.9% did not know anybody with breast cancer.

Knowledge about breast cancer and BSE

The need to gauge carcinoma awareness/attitudes and practice of BSE among female students who are visiting be the long-run health personnel is important and recommended.¹³ The result of the current study revealed that our participants had moderate knowledge about breast cancer (59.5%) and BSE (62.6%). All respondents had heard about breast cancer. 8.9% of respondents weren’t sure of hearing about BSE whereas 3.2% had not heard about it. Awareness about the presenting symptoms was moderate (54.2%). The most typical symptoms of breast cancer were breast lump or swelling, followed by lump or swelling in the armpit and nipple discharge from one breast only. 302 (79.5%) of the respondents were unaware that breast cancer mostly presents as a painless lump rather than breast pain which indicates a non-malignant underlying pathology.¹⁰

Similar findings were observed in health professionals at Central India and medical students at Taif University, Saudi Arabia where participants identified the identical common symptoms.^14,15 This concluded lump in the breast, pain in breast, and discharge from nipple are three common symptoms health professionals knew about. Overall risk factor knowledge was poor (43.5%). The most widely known risk factor was family history 313 (82.4%) whereas complex risk factors like early menarche 77 (20.3%) and nulliparity 121 (31.8%) were known by fewer respondents. These results were in contrast to a study carried out on nurses in India who were well acquainted with the risk factors.⁹ Knowledge about risk factors must be improved, during the education of health personnel, specifically the ones that are the least known. The high level of general knowledge (80.92%) on breast cancer issues suggests that positive behavior of the disease should be focused on, instead of general and negative.

Similarly, BSE knowledge is also essential. Most participants in this study were aware that all women above 20 years must undergo regular BSE (85.6). The majority had excellent knowledge about the positions and techniques of BSE 71.5%. However, the correct frequency and timing of BSE known were poor (61.0% and 32.2% respectively). The main sources of data regarding breast cancer and BSE reported were; internet, followed by educators at health institutes and textbooks. A similar finding was seen in a study conducted in health professionals in India where, main sources of knowledge were lectures (64.80%), health worker friend (35.47%), internet (30.13%). This shows mass media plays a crucial role in giving knowledge even to health professionals, therefore an important effort should be made to accentuate the source of media to form carcinoma awareness within the community.⁴ Despite being from the medical background only 16 (4.21%) of the respondents from this study had excellent overall knowledge about breast cancer as well as the self-examination technique. The lacunae in the knowledge were maybe because they did not receive in-depth information about breast cancer in their curriculum or the health awareness camps weren’t intensive for the physiotherapists. There was a strong positive correlation between knowledge about risk factors of breast cancer and the overall knowledge (r=0.331; p=0.000). The understanding of risk factors influenced the general knowledge if awareness and health education schemes are conducted during a meticulous form it'll lead to increased knowledge of the health professionals. Therefore, they must be updated about the danger factors of the disease and the BSE procedure accurately.

Attitude towards BSE

This study revealed an excellent positive attitude towards BSE (94.2%) among the respondents as compared to the (67%) seen in medical students at Taif University.¹⁵ The positive attitude can be attributed to the very fact that they delve within the same field of study, which makes them more inquisitive and empathic towards the health problems within their community.

Most of the participants agreed that the practice of BSE should be encouraged. Studies conducted by Eman et al, similarly showed a majority of the pharmacists involved within the study had a positive attitude towards breast cancer health promotion and thought of it to be their responsibility in addition to as an opportunity to boost the status of their profession.¹⁶ Such results imply that despite the low levels of information and practice respondents are inquisitive to hunt information and follow recommendations about BSE. This finding is unlike the studies where barriers like unpleasantness and fear caused hindrance in practicing BSE.¹⁷ There was a statistically significant difference (χ²=570.084, p=0.000) between the overall knowledge of breast cancer, BSE with the attitude towards BSE. There was a little correlation statistic between overall knowledge score and attitude towards BSE (r=0.176; p=0.001) was seen. This highlights that physiotherapy students, are keen to learn and follow recommendations, and any well-designed health intervention on BSE’s, would be well received.

BSE practice

The practicing of BSE during this group of physiotherapy students was quite alarmingly low.

About one fourth (25.5%) of the population had never tried BSE. Of these who practiced BSE, about 25.8% of them practiced regularly. Either the respondents didn’t practice BSE in the slightest degree, or practiced it correctly. This could result due to either lack of time, forgetfulness, no breast complaints, or incomplete information about the procedure. About 105(27.6%) agreed that they are not well informed about how to perform the examination.

The self-examination practice score during this study was much lower as compared with other studies on health professionals in Indian- dental students (53%), nurses (54%), and health care professionals (33.3%) who performed BSE regularly (once a month).4,5,9 This reflects the poor practice of BSE among health professionals all over India. There was a big statistical difference (χ²=119.063, p=0.000) between knowledge of BSE and regular practice. In this present study, the self-examination practice score is higher among respondents who had better overall knowledge compared to those that failed to. Lectures, seminars, workshops, and on hands training sessions should be developed by the universities to increase awareness about breast cancer.¹⁸

CONCLUSION

Current health care providers in this study possess moderate knowledge of breast cancer, BSE but have positive attitudes on the involvement of BSE, breast cancer education, but unfortunately have poor practice. The Indian population would be greatly benefitted if health care providers would be well versed in promoting breast cancer education. Intensive training programs for the healthcare personnel organized by private or government sectors making them highly aware of BSE, to improve knowledge and making BSE a universal practice among health professionals first.

The concept of the national month of breast cancer awareness should also be embraced in India.

As mass media plays a crucial role in spreading information to health professionals as well, various interventions can be planned on the digital platform to educate them and keep them updated.

ACKNOWLEDGEMENTS

The authors would like to thank all those who helped and guided them in conducting the study. They would like to thank all the participants for the opportunity to conduct this study and for completely co-operating throughout the study. They also conveyed special thanks to parents, brother, sister, and colleagues for their co-operation and for creating a friendly working atmosphere for the successful completion of the research.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Shatabdi P, Prem S, Uday S, Saripella S. Epidemiological Study on Breast Cancer Associated Risk Factors and Screening Practices among Women in the Holy City of Varanasi, Uttar Pradesh, India. Asian Pac J Cancer Prev. 2015;16(18):8163-71.
2. 2. Globocan 2018 (IARC) Section of Cancer Information: incidence and mortality rates of breast cancer in 2018. Available at: http://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. Accessed on: 28 November 2019.
3. 3. Simsek S, Tug T. Benign tumors of the breast: Fibroadenoms. Sted. 2002;1:102-5.
4. 4. Aishwarya K, Anil K, Are health professionals serious about breast self-examination? a study from a medical college and tertiary level hospital of Central India. Int J Res Med Sc. 2017;5(8):3701-7.
5. 5. Doshi D, Reddy BS, Kulkarni S, Karunakar P. Breast self-examination: knowledge, attitude, and practice among female dental students in Hyderabad City, India. Indian J Palliat Care. 2012;18(1):68-73.
6. 6. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA: Cancer J Clin. 2019;69(1):7-34.
7. 7. Mamoona N, Sheeba M, Muhammad F, Aneesa S, Peter B. Knowledge and awareness about breast cancer and its early symptoms among medical and non-medical students of southern Punjab, Pakistan, Asian Pac J Cancer Prev. 2015;16(3):979-84.
8. 8. Omoyeni OM, Oluwafeyikemi PE, Irinoye OO, Adenike OO. Assessment of the knowledge and practice of breast self-examination among female cleaners in Obafemi Awolowo University Ile Ife, Nigeria. Int J Car Sci. 2014;7(1):239-51.
9. 9. Vikas F, Rajeev S, Manoj G, Manish G, Siddharth V, Verma S. Knowledge of risk factors and early detection methods and practices towards breast cancer among nurses in Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. Asian Pacific J Cancer Prev. 2013;14(1):117-20.
10. 10. Shiyam K, Ayesha I, Nauman M, Nehal M. Knowledge, attitude and preventive practices for breast cancer among health care professionals at Aga Khan Hospital Karachi. J Pak Med Assoc. 2009;59:474-8.
11. 11. Eman A, Syed G, Ammar S, Al Shammary HA, Vinci P, Syed S, Mirza B, Knowledge, Attitude and behavior of healthcare providers towards breast cancer in Malaysia: a systematic review. Asian Pac J Cancer Prev. 2015;16(13):5233-5.
12. 12. Al-Azmy SF, Alkhabbaz A, Almutawa HA, Ismaiel AE, Makboul G, El-Shazly MK. Practicing breast self-examination among women attending primary health care in Kuwait. Alexandria J Med. 2013;49(3):281-6.
13. 13. Ameer K, Abdulie SM, Pal SK. Breast cancer awareness and practice of breast self-examination among female medical students in Haramaya University, Harar, Ethiopia. Int J Interdisciplinary Multidisciplinary Studies (IJIMS). 2014;2(2):10919.
14. 14. Ifediora CO, Azuike EC. Tackling breast cancer in developing countries: insights from the knowledge, attitudes and practices on breast cancer and its prevention among Nigerian teenagers in secondary schools. J Prev Med Hyg. 2018;59(4):282-300.
15. 15. Dalal M. Nemenqani, Sahar H. Abdelmaqsoud, Al-Hanouf A, Al-Malki1, Abrar A, et al. Knowledge, attitude and practice of breast self-examination and breast cancer among female medical students in Taif, Saudi Arabia. Open J Prev Med. 2014;4(2):69-77.
16. 16. Eman A, Syed G, Vinci P, and Syed S. Healthcare providers’ knowledge, attitude and behaviour towards breast cancer diagnosis and treatment in Malaysia – a mini systematic review. Trop J Pharm Res. 2016;15(9):2041-5.
17. 17. Salazar MK. Breast self‐examination beliefs: a descriptive study. Public Health Nursing. 1994;11(1):49-56.
18. 18. Sambanje MN, Mafuvadze B. Breast cancer knowledge and awareness among university students in Angola. Pan Afr Med J. 2012;11:70.