Factors influencing the practice of breast self-examination among female tertiary students in the Tamale Metropolis

INTRODUCTION

Breast cancer is a leading cause of cancer-related morbidity and mortality among women globally, accounting for millions of new cases and deaths each year.^1,2 Recent global estimates show that in 2022, about 2.3 million women were newly diagnosed, and more than 666,000 deaths were recorded, with sub-Saharan Africa contributing over 146,000 cases and 71,000 deaths.^1,3 The incidence of breast cancer continues to rise in both developed and developing countries, but survival outcomes differ sharply depending on access to screening and early treatment.^2-4 In low- and middle-income countries, mortality rates are disproportionately high due to late-stage presentation and limited healthcare resources.^3,4 In Ghana, breast cancer remains the most common cancer among women, with 27,385 new cases and 17,944 deaths in 2022 alone.⁵ It is estimated that breast cancer accounts for about 31.8% of all female cancers in Ghana, with over 70% of women presenting late with advanced disease.^6,7

The aetiology of breast cancer is multifactorial, with gender, ageing, family history, and prolonged hormonal exposure among the key risk factors.^8,9 In sub-Saharan Africa, changes in reproductive patterns, lifestyle factors such as smoking, sedentary living, poor dietary habits, and hormonal contraceptive use have further contributed to rising incidence rates.^4,10 While breast cancer was historically diagnosed in older women, evidence shows that in Ghana and other African countries, it increasingly affects younger women, many of whom present late with aggressive disease forms.¹¹ These circumstances have compounded poor survival rates in resource-limited countries, often below 50% as compared to high-income countries.¹

Early detection through screening is a proven intervention to improve survival outcomes, with mammography, clinical breast examination (CBE), and breast self-examination (BSE) identified as key approaches.^12,13 Although mammography remains the gold standard, its availability and affordability are limited in many African contexts, making BSE a practical and low-cost option.^4,13 BSE enhances women’s awareness of their breast health, helps them identify abnormal changes, and empowers them to take control of their well-being.^2,10 It has been shown that more than 90% of breast cancer cases can potentially be detected by women themselves through consistent practice of BSE.¹⁰ However, the effectiveness of BSE depends on regular practice and proper technique, which remain suboptimal in many countries.^9,12

In Ghana, the practice of BSE is generally low despite awareness of its benefits. Reports indicate uptake levels as low as 12% among women in some regions, while a study in the Volta Region revealed that 56% of tertiary female students practised BSE effectively.^7,14 Among young women, particularly those in tertiary institutions, gaps in health education and limited knowledge about breast cancer continue to hinder BSE practice among young women, including those in tertiary institutions.^15,16 Given the rising burden of breast cancer in Ghana and the low prevalence of BSE practice among young women, it becomes essential to identify the underlying factors influencing whether female tertiary students adopt or neglect this life-saving practice. This study, therefore, sought to determine the factors influencing the practice of breast self-examination among female tertiary students in the Tamale Metropolis.

METHODS

Study design and setting

This study employed a quantitative cross-sectional design to assess factors influencing breast self-examination practice among female tertiary students. The design was appropriate because it enabled data collection from many participants within a short time in a cost-effective manner. The study was conducted in the Tamale Metropolis and involved students from the University for Development Studies, Tamale Nurses and Midwives Training College, and Tamale Community Nursing Training College. The study was conducted over a three-month period, from January 2024 to March 2024.

Study population

The study population consisted of female tertiary students enrolled in different programs within the Tamale Metropolis. Participants were drawn from the University for Development Studies (UDS), the Tamale Nurses and Midwives Training College (TNMTC), and the Tamale Community Nursing Training College (TCNTC). According to institutional records, TNMTC had a total female student population of 381, while TCNTC enrolled 1,399 female students at the time of the study, and the total female students admitted to UDS in 2023 were 5,630.

To be eligible, participants had to be female students within reproductive age (15-45 years) and enrolled in programs across the three tertiary institutions. Students with a history of breast-related issues, those outside the reproductive age range, students who were not mentally sound, or those who did not provide consent were excluded from the study. Male students were also excluded.

Sample size and technique

The sample size for this study was determined using Cochran’s formula to yield a representative sample for proportions.¹⁷

Where n is the sample size, z (at 95% confidence interval) =1.96, p (estimated proportion of students that practise BSE) =56%, q = 1-p and d = margin of error of 5%.¹⁴

Given that students were clustered within institutions, a design effect (DEFF) was applied to account for potential intra-school correlation. Using an average cluster size (m = n/number of clusters =126) and a conservative intra-class correlation coefficient (ICC =0.0023), the DEFF was calculated;

DEFF = 1+ (m-1) × ICC

DEFF = 1+ (126-1) × 0.0023

DEFF = 1+0.287 = 1.287

Multiplying the initial sample size by the DEFF to estimate the final sample size

The final sample size = 378 × 1.287 = 486

Therefore, the final sample size was 486.

A multistage sampling approach was employed to select participants from the three tertiary institutions in the Tamale Metropolis. First, all three institutions were purposively selected to ensure inclusion of both health and non-health student populations. Within each institution, students were stratified by program type (health versus non-health) and level/year of study to ensure representation across the different groups.

A proportionate stratified allocation was initially considered based on the total female student population of each institution (TNMTC: 381; TCNMTC: 1,399; UDS: 5,630); however, to ensure sufficient representation of nursing and midwifery students- who were directly relevant for breast self-examination practices- the sample sizes were pragmatically adjusted. Consequently, 174 participants were selected from TNMTC, 112 from TCNMTC, and 200 from UDS, keeping the total sample at 486.

Within each stratum, simple random sampling was applied to select participants, giving each eligible student an equal chance of inclusion. This approach ensured a representative, feasible, and statistically robust sample, while accounting for intra-institution clustering in the DEFF calculation with an average cluster size of 126.

Data collection procedure and tool

Data were collected using a structured, self-administered questionnaire distributed to female tertiary students from all year groups and programs (health and non-health) across the three institutions. The questionnaire, written in English, was completed at participants’ convenience, with research assistants available to clarify issues while ensuring confidentiality and anonymity. Completed questionnaires were checked for completeness before data entry.

The tool was adapted from validated instruments and included three sections: sociodemographic data, knowledge, and practice of breast self-examination (BSE). Knowledge was assessed using 15 items, with scores ≥8 indicating good knowledge, while practice was measured using 13 items, with scores ≥7 classified as good practice¹⁴

Validity and reliability

The questionnaire was adapted from previously validated tools used in similar studies and reviewed for reliability and ethical appropriateness.^10,14 It was pretested using 10% of the sample size (49 participants), and participants provided feedback on clarity, structure, and relevance. The internal consistency of the knowledge scale was confirmed with a Cronbach’s alpha of 0.74. Based on the feedback and pretest results, necessary modifications were made to improve clarity, consistency, and reliability. This ensured that the final instrument was valid and suitable for assessing the knowledge and practice of breast self-examination among female tertiary students.

Data analysis

Questionnaire data were edited, coded, cleaned, and analysed using the Statistical Package for Social Sciences (SPSS) version 26. Descriptive statistics, including frequencies, percentages, and cross-tabulations, summarised participants’ sociodemographic characteristics, knowledge, and breast self-examination practices. Chi-square tests assessed associations between independent variables and breast self-examination practice. Variables significant at the bivariate level were entered into logistic regression models to estimate crude and adjusted odds ratios with 95% confidence intervals. Statistical significance was set at p<0.05 to identify independent predictors while controlling for confounders.

Ethical considerations

Ethical approval for the study was obtained from the University for Development Studies Ethical Committee (UDS/RB/192/23). Permission was also granted by the heads of the three tertiary institutions. Participants were informed about the study purpose, and written consent was obtained before participation. Participation was voluntary, and respondents could withdraw at any time without consequences. Confidentiality and privacy were ensured by excluding personal identifiers and securely storing data accessible only to the research team. Ethical principles regarding participants’ rights, dignity, and privacy were strictly observed.

RESULTS

Socio-demographic characteristics of respondents

Among 486 participants, the majority of them (41.2%) were from the University for Development Studies. Most participants were studying health-related programs (72.2%) and were in their second year (42.8%). The largest age group was 20-24 years (57.8%), while 7.6% were aged less than 20 years. Most participants were single (87.0%) (Table 1).

Knowledge of participants on breast self-examination

The study revealed that 70.8% of participants demonstrated good knowledge of BSE (Table 2). Most respondents had heard of breast self-examination (95.1%) and considered it very important for the timely detection of breast cancer (95.3%). About 62.3% reported being taught how to perform BSE, mainly by healthcare providers (24.3%), lecturers (17.5%), and the media (13.6%). Monthly practice was identified by 64.2% as the correct frequency, while 65.0% recognized a week after menstruation as the best time.

Overall knowledge was classified based on total correct responses, where scores ≥8 were considered good knowledge and scores <8 were considered poor knowledge. Percentages are based on the total sample size (n=489).

Overall practice of breast self-examination (BSE) was classified based on total practice scores, where scores ≥7 were considered good practice and scores <7 were considered poor practice. Percentages are based on the total sample size (n=489).

COR = Crude Odds Ratio; AOR = Adjusted Odds Ratio; CI = Confidence Interval; Ref = Reference category. Variables with p<0.05 were considered statistically significant.

Practice of self-breast examination

The practice of BSE among participants was 63%. About 79% had inspected their breasts previously, and 60.9% were currently practicing BSE. Regarding timing, 23.3% practiced within the last month, while 40.1% could not recall their last practice. Monthly practice was reported by 39.3%, while 54.9% performed BSE after menstruation. It was revealed that morning was the most common time of practice (56.8%). Most used the palm and three fingers technique (56.8%) (Table 3).

Bivariate and multivariate logistic regression of factors influencing the practices of BSE

The analysis revealed that both knowledge and academic level played a central role in breast self-examination practice. It was shown that students from Tamale Nurses and Midwifery Training College were 8.6 times more likely to practice BSE compared to those from Tamale Community Nurses and Midwifery Training Colleges (AOR=8.58, 95% CI: 4.28-17.19, p<0.001). Nurses and students in year three were more than three times as likely to demonstrate good practice (AOR=3.46, 95% CI: 1.48-8.10, p=0.004), while those in year four also showed significantly higher odds (AOR=3.41, 95% CI: 1.26-9.18, p=0.015) compared to year one. Most strikingly, participants with good knowledge were almost five times more likely to practice effectively (AOR=4.88, 95% CI: 2.84-8.38, p<0.001), underscoring the powerful influence of knowledge and academic progression (Table 4).

DISCUSSION

This study revealed that 70.8% of participants demonstrated good knowledge of breast self-examination (BSE), and 95.1% had heard about it, reflecting relatively high awareness among tertiary health students. Similar findings have been documented in Northern Ghana, Nukpezah et al and Salifu et al, where BSE was widely known and considered important for early detection.^15,18 These outcomes suggest that ongoing health campaigns and structured education are improving awareness in Ghanaian institutions.^19,20 By contrast, Mihret et al. ²¹ in Northwest Ethiopia reported that only 27.6% had good knowledge and nearly half had never heard of BSE, highlighting persistent disparities in access to breast health information across African settings. This difference may be explained by variations in curriculum integration, exposure to health education, and the strength of institutional and public health promotion programs, which tend to be more consistent and reinforced in Ghanaian tertiary health training settings compared to some other contexts.

Beyond general awareness, 62.3% of participants in the present study reported being taught how to perform BSE, primarily by lecturers and healthcare providers. This supports the observation of Reddy et al, who found that women trained by professionals were more likely to practice BSE correctly.²² Likewise, Nukpezah et al highlighted the role of nurses and lecturers as key educators in Tamale.¹⁸ In contrast, a study conducted in Croatia reported that mass media such as television and social platforms were the dominant information sources.²³ This variation may be explained by differences in health education delivery systems, where Ghana relies more on structured institutional teaching that allows direct guidance and skill demonstration, whereas other settings depend more on broad public media campaigns that may increase awareness but provide less practical skill acquisition.²⁴

Correct knowledge of BSE practice was also notable, as 64.2% identified monthly practice as appropriate and 65.0% recognized one week after menstruation as the ideal time, which echoes the concept that BSE is best performed between the 5^th and 7^th day of the menstrual cycle.^25,26. A similar result was found in Gaza, where about 70% of women correctly identified this timing as the best period for performing BSE.²⁷ However, Khonji et al reported widespread uncertainty among Bahraini students, showing how structured teaching not only imparts information but also ensures that students connect knowledge with underlying biological explanations, strengthening adherence.⁸

The practice rate in this study was 63%, with 60.9% currently practising, reflecting how knowledge translates into action when reinforced by education. This rate is higher than the 17% observed by Ahmed et al in Bangladesh and 17.4% reported by Mihret et al in Ethiopia, but lower than the over 80% found by Nukpezah et al in Tamale.^18,21,28 Institutional emphasis, therefore, appears to shape behaviour by influencing both the exposure to and the repetition of practical skills, which are essential for translating knowledge into consistent action. Hlormenu et al support this by noting that structured education improves the uptake of preventive health behaviours.²⁹ Furthermore, the strong association between knowledge and practice, where informed participants were nearly five times more likely to perform BSE, suggests that knowledge increases perceived risk awareness, confidence, and perceived benefits of early detection. This reinforces findings by Udoh et al and Dinegde et al, highlighting that both educational progression and depth of understanding are key drivers of preventive health behaviour.^30,31

Participants reported lumps as the main reason for practising BSE (86.8%), which aligns with studies in Malaysia and Bangladesh, which both noted lumps, asymmetry, and nipple changes as key warning signs.^28,29 Sarker et al also highlighted skin changes as a commonly recognised symptom.³⁰ In contrast, Al-Shiekh et al reported that fewer than one-third of respondents in Gaza could comprehensively identify early signs, pointing to regional knowledge gaps.²⁷

It was further revealed that students from Tamale Nurses and Midwifery Training College were 8.6 times more likely to practice BSE compared to their counterparts from Tamale Community Nursing and Midwifery Training Colleges. This marked difference highlights the influence of institutional focus and curriculum design on preventive health behaviours. Hlormenu et al explained that when structured education is embedded within training programs, students are more likely to translate knowledge into routine practice.³¹ Similarly, Kassie et al argued that weak translation of interventions into practice remains a barrier in many low- and middle-income countries, suggesting that strong institutional emphasis can bridge this gap.³² The findings, therefore, reinforce Tiongco et al, who stressed that although breast cancer incidence is relatively low among young women, nurturing preventive behaviours such as BSE during their academic years fosters a long-term culture of self-care and early detection.³³

This study was limited by its cross-sectional design, which restricts the ability to establish causality between knowledge and practice of breast self-examination. Self-reported responses may also have introduced recall or social desirability bias, potentially affecting the accuracy of the findings. Additionally, the study focused only on selected tertiary institutions in Tamale, which may limit the generalizability of the results to other populations.

CONCLUSION

The study demonstrated that tertiary students generally possessed good knowledge of breast self-examination, which strongly influenced their ability to practice it effectively. Academic progression and the type of institution were also identified as key factors influencing practice among the respondents. The findings also highlighted that students were proactive in recognising symptoms and were willing to seek professional care when abnormalities were detected. Strengthening structured health education within tertiary institutions is essential to sustain these positive attitudes and promote early detection of breast cancer.

ACKNOWLEDGEMENTS

The authors sincerely acknowledge the support of the participating students and institutions for their cooperation throughout the study. Special appreciation goes to the lecturers and healthcare providers who contributed to creating awareness of breast self-examination among the students.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the University for Development Studies Ethical Committee (UDS/RB/192/23)

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