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Original Research (Original Article) 


Abdullah Nasser Alomair et al, 2020;4(2):429–434.

International Journal of Medicine in Developing Countries

Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia

Abdullah Nasser Alomair1, Dania Ghazi Felemban2, Mohannad Sami Felemban3, Jameel Abdullah Awadain4, Ammar Saud Altowairqi5, Nawaf Fawzan Alfawzan1, Fatimah Mohammed Almazayen6, Abdulrahman Jalwi Korkoman7, Nawaf Saad Alrusayyis8

Correspondence to: Abdullah Nasser Alomair

*King Saud University, College of Medicine, Riyadh, Saudi Arabia.

Email: Anasseralomair [at] gmail.com

Full list of author information is available at the end of the article.

Received: 18 December 2019 | Accepted: 04 January 2020


ABSTRACT

Background:

Breast cancer is the most common of all female cancers in the Kingdom of Saudi Arabia. This study aims to determine knowledge, attitude, and practice toward Breast Self-Examination (BSE) and also to explore the knowledge about breast cancer, among Saudi female students at King Saud University (KSU) in Riyadh.


Methodology:

A cross-sectional descriptive study was carried out among 422 female students at KSU by using a self-administered questionnaire.


Results:

The study showed that the majority of participants (57.4%) had a moderate level of knowledge of breast cancer. The major source of information (39.8%) about BSE was mass media. Among the participants, 52.2% of the respondents had adequate overall knowledge toward BSE, 64.01% of participants had a positive attitude toward BSE, and only 18% of all respondents perform BSE. There was a significant difference between the overall knowledge and practice of BSE (p < 0.005).


Conclusion:

Most female students had a poor practice of BSE. Mass media is an important source of information about BSE to improve awareness among the community.


Keywords:

Breast cancer, breast self-examination, Riyadh.


Introduction

Every year, breast cancer kills more than 500,000 women around the world. In resource-poor settings, a majority of women with breast cancer are diagnosed at an advanced stage of disease; their 5-year survival rates are low, ranging from 10% to 40%. In settings where early detection and basic treatment are available and accessible, the 5-year survival rate for early localized breast cancer exceeds 80%.

Breast cancer can be detected early through two strategies: early diagnosis and screening [1]. More than one million women are estimated to be diagnosed with breast cancer every year. In 2018, it is estimated that 627,000 women died from breast cancer that is approximately 15% of all cancer deaths among women. While breast cancer rates are higher among women in more developed regions, rates are increasing in nearly every region globally [2]. According to the Saudi Cancer Registry 2004, breast cancer ranked first among females in Saudi Arabia, as it represented 22.4% of all newly diagnosed female cancers [3]. Breast cancer typically produces no symptoms when the tumor is small, later on when it has grown, it could be represented by one or more of the following symptoms and signs: painless lump in the breast, lump under the armpit, breast pain, swelling or thickness of the breast’s skin, spontaneous discharge of the nipple particularly blood, and erosion or inversion in the nipple [4]. Screening for early detection and diagnosis of diseases and health conditions is an important public health principle. The three screening methods recommended for breast cancer include breast self-examination (BSE), clinical breast examination, and mammography [2]. Mammography is the method of choice for the early detection of breast cancer. However, its limited use in developing countries due to the high cost and limited availability make BSE a convenient and cost-effective method, though less reliable [5]. The World Health Organization has concluded that BSE still has the potential to provide an early diagnosis of breast cancer in many parts of the world. BSE is recommended to be performed routinely on a monthly basis in all the women aged above 17 years and the importance of raising knowledge on breast cancer via BSE is noted. BSE is an easy-to-apply, economical, safe, non-invasive procedure with no special material/tool requirements, and it is an effective diagnostic method for breast cancer, which only takes 5 minutes to play [6]. On BSE, the women lie down on her back and place her right arm behind the head. The exam is done while lying down, not standing up. This is because when lying down, the breast tissue spread evenly over the chest wall and is as thin as possible, making it much easier to feel all breast tissues. The women can use the finger pads of the three middle fingers of her left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue. While standing in front of a mirror with her hands pressing firmly down on her hips, look at the breasts for any change of size, shape, contour, or any dimpling, redness, or scariness of the nipple or breast skin. The pressing down on the hips position contract the chest wall muscle and enhances any breast changes by examining each underarm while sitting up with her arm only slightly raised so you can easily feel in the area. Raising the arm straight up tightens the tissue in this area and makes it harder to examine. Several studies have shown that barriers to diagnosis and treatment can be addressed by increasing women’s awareness of breast cancer [7,8]. Studies done in Saudi Arabia among 6380 students show that only 39.6% reported that they had ever heard about BSE. This group had a significantly higher knowledge level on breast cancer risk factors and presentation (p = 0.0001). Although the general attitude of the students toward learning BSE was positive and 82.4% requested to learn it, only 14.4% knew the correct frequency and timing of BSE in relation to the menstrual period [9]. A previous study done in the United Arab Emirates among 392 participants shows that BSE was ever practiced by 89 of the participants (22.7%), whereas only 3.3% were practicing monthly and 77.3% admitted that they were not practicing BSE. Among the participants who practiced BSE, 34.8% of them practiced at the correct timing in relation to menstruation and 16.9% of them were putting marks on the calendar for the next BSE [10]. A study done on Jordanian Women, 519 female students, shows that 67% of the participants reported that they had heard about BSE, only 26% of them indicated they themselves practiced BSE in the previous 12 months, and only 7% stated that they performed BSE on a regular monthly basis. Others reported performing BSE every 2–3months (9%), once every 6 months (5%), and once a year (6%). A total of 73% of the participants indicated that they had never performed a BSE. Also, a study done in Turkey among 718 female students shows insufficient knowledge about BSE and a low percentage of students reported that they had performed BSE monthly. The most common reason for not doing breast self-examination was because they do not know how to perform BSE (98.5%). Most of the students had little knowledge of the risk factors for breast cancer. There was a significant relation between BSE practice and age, education level, and knowledge about breast cancer [11]. Studies done in Lagos University Teaching Hospital, Nigeria, among 135 participants, show that 97.3% of the respondents were aware of breast cancer and BSE, 35.6% of the respondents felt that BSE should be carried out monthly, followed by 33.3% who felt it should be carried out daily, 28% felt it should be done weekly, and 3% felt it should be done yearly. Regarding the attitude of respondents to BSE, most of the respondents (98.5%) thought BSE was necessary and 84.3% claimed to have carried out BSE before. Regarding the practice of BSE, 80.2% of the respondents claimed that they carry out BSE regularly [12]. Breast cancer awareness in developing countries is not well documented, and what is known is far from encouraging [5,13], as comparatively few women in these areas have adequate knowledge of the risk factors and preventive measures or screening techniques for early detection. The lack of knowledge and incorrectly held beliefs about breast cancer prevention among females are responsible for the negative perception of the curability of cancer detected early and of the efficacy of the screening tests [9]. It is, therefore, important to assess the level of knowledge, attitude, and practice of BSE toward breast cancer in our communities.


Subjects and Methods

A cross-sectional study was conducted to identify knowledge, attitude, and practice of BSE toward breast cancer in female students at KSU colleges in Riyadh from January to May 2019. There were 2,123 female students as our sample size required 384 students, and we added 10% (=38) to the sample size to avoid any miss leading results, due to the absence of some students during data collection; so, the final sample size was 384 + 38 =422 students. We used the multi-stage sampling method. In stage 1, the sample size of students was distributed proportionally among the educational levels of each college. In stage 2, the sample size of each class was distributed proportionally according to the level. While in stage 3, the sample size required from each class was selected by a simple random sample. The colleges included in our study selected by simple random sampling methods were College of Science, Engineering, Computer & Information, and Business administration. Data were collected by the self-administered questionnaire which included the following: personal data, knowledge of students about BSE, and questions regarding the attitude of students toward BC. Finally, they were asked regarding the practice of BSE. The questionnaire of the study was pretested on 25 female students regarding BSE and breast cancer, and the sample of the pilot study was not included in the actual study. The questionnaire was pre-tested to determine the length of the interview, question sequence, and the identification of difficult words and consistency of answers to check questions. The questionnaire was initially constructed in the English language, which was later translated into the Arabic language. The data were checked for completeness, coded, and then entered into the computer by Statistical Package for Social Sciences. Then, the data were analyzed by using descriptive Statistical tools (frequencies, percentage). The mean and standard deviation (SD) will be also calculated for continues variables, and data were presented in tables and graphs by using computer applications (Portable IBM SPSS Statistics version 19 and Microsoft Word).


Results

The study targeted female students at KSU; 422 students participated in the study. The results of statistical analysis were presented in the main four sections. The first section presented the assessment of baseline characteristics of the studied sample, the second section presented the assessment of the knowledge level of BC, the third section presented the assessment of the students’ attitude level of BSE, and the fourth section presented the assessment of the students practice level of BSE. Our study was conducted among females, where 57.1% were within the age range of 19–25 years and 42.9% were above 24 years. Regarding marital status, we found that 61.1% were married, and 38.6% were not married. More than half of participants (61.1%) had knowledge about BSE but 38.9% did not (Table 1). Different studies conducted in the Kingdom have shown that knowledge of females regarding BC is low (58.6%) and only 1.4% had gained a high level of knowledge. A most common source of information (23%) was the mass-media-TV, while 8.9%, 6.7%, 7.2%, and 15% of participants their source were contacting health personnel, relatives and friends, internet, and other sources, respectively (Figure 1).

Table 1. Assessment of the baseline characteristics of the studied sample.

Parameters Frequency Percentage %
Age Between 19 and 25 238 57.1
Above 24 180 42.9
Marital status Married 257 61.1
Not Married 163 38.6
Class 2nd 225 54
3rd 192 46
Knowledge about BSE Yes 255 61.1
Adequate Knowledge 218 52.1
Inadequate Knowledge 199 47.2
No 162 38.9

Figure 1. Source of information.

It is apparent in Table 2 that 36.7% of the participants knew that family history has role in BC and 52.3% of them were uncertain that parity after 30 years was one of the risk factors, and 49.4% of the participants didn’t know that early puberty was one of the risk factors, and among the participants, 39.1% knew that hormonal replacement therapy is one of the risk factors, and 45.5% knew that large breast is not risk factor for BC, finally 53.5% knew that lactation reduces probability of BC. The majority of students in the third level (62.5%) had adequate knowledge toward BSE while the majority of students in second level (53.6%) had inadequate knowledge.

Data showed that the majority of the participants strongly disagree that doing BSE is wasting time (67.6%), 40.5% of the participants disagree to get treatment from a traditional healer, while 46.3% feared to think about breast cancer. About 52.3% of the participants were interested in doing BSE, 44.1% of participants agree to go to a specialist doctor, and 48.4% would not stop BSE if there were no changes (Table.3). More than half of the participants in 2nd level (61.3%) had adequate knowledge toward BSE and BC, while the majority of students in the 3rd level (67.2%) had a high knowledge level. Most of the participants (81%) don’t do BSE and only 18% of participants do BSE (Figure 2).

Table 4 shows that the majority of the students reported that they usually perform BSE once in a month (81%), while 8% reported that they never do BSE. On the other hand, 31% of the participants didn’t perform it properly.


Discussion

Figure 2. Prevalence of BSE practice.

Table 2. Distribution of students according to their knowledge of breast cancer.

No. Yes No Uncertain
NO. % NO. % NO. %
1 Family History play role in breast cancer 153 36.7 138 33.1 126 30.2
2 Parity after 30 years increase the risk 84 20.1 115 27.6 218 52.3
3 Early puberty increase the risk 44 10.6 206 49.4 167 40
4 Use of HRT* for long period increase the risk 163 39.1 43 10.3 211 50.6
5 Lack of physical exercise increase the risk 87 20.9 201 48.2 129 30.9
6 Lactation reduce probability of breast cancer 223 53.5 57 13.7 137 32.9

*HRT: hormonal replacement therapy.

Table 3. Distribution of students according to their attitude toward BSE.

NO. Strongly disagree disagree Uncertain Agree Strongly Agree
No. % No. % No. % No. % No. %
1 Doing BSE is wasting time 282 67.6 106 25.4 16 3.8 8 1.9 5 1.2
2 If there is lump, I prefer to get treatment from a traditional healer 105 25 169 40.5 72 17.3 64 15.3 7 1.7
3 feared to think about breast cancer 193 46.3 121 24 45 10.8 50 12 8 1.9
4 Interested in doing BSE 14 3.4 13 3.1 33 7.9 218 52.3 138 33.1
5 If there is lump, I will go to specialist doctor 11 2.6 9 2.2 41 9.8 184 44.1 172 41.2
6 If there is no abnormal changes I will stop BSE 93 22.3 202 48.4 56 13.4 52 12.5 14 3.4
7 Breast cancer can’t be treated 199 47.7 117 28.1 78 18.7 10 2.4 4 1.0

Breast cancer is the most common cancer in women worldwide that is why women’s awareness of breast cancer is crucial. The need to evaluate the knowledge, attitudes, and practice of BSE among females is necessary and recommended. Thus, the present study was conducted to determine the knowledge, attitude, and practice of BSE toward BC. The majority of our participants had information about BSE (61.1%), while in the study done in Turkey, 62% of participants had adequate knowledge toward BSE & BC [11], also similar to a study done in Palestine [14]. Mass-Media and T.V played a significant role as the main source of information about breast cancer (39.8%), while 48.5% in Turkey, 53% in Palestine, and 16.10% in Yemen [15] acquired the knowledge about BSE from media [16]. The result of the current study revealed that 36.7% of participants knew that the family history of BC plays a major role in developing BC, while 28.2% in a study done in Nigeria [10]. There were 39.1% of our participants, who knew that hormonal replacement therapy plays a role in developing BC, comparing to 8.2% in Turkey, and 62% in Yemen. Among the participants of the current study, 10.6% knew that early puberty is one of the risk factors of BC. The high knowledge about the breast cancer among the respondents in this study reflected high attitude to BSE for them; regarding the attitude, 67.7% strongly disagreed that BSE is wasting of time, and 1.9 % were afraid to finding a lump during practice similar to the result in Turkey and Iraq [17]. Referring to our result, the students have a positive attitude to go to specialist doctors and disagree to use a traditional healer if there is a lump. Similar findings reported by another survey from Saudi Arabia, positive attitude was endorsed by only 39.6% of females and there were 14.4% of participants who reported never hearing of BSE [18]. In addition, in the UAE, 90% of nurses had a positive attitude to providing knowledge on the risk factors of breast cancer and 83% reported that they had taught BSE to others [10]. A positive result of BSE attitude indicated to increase the intervention between females and public health educators; therefore, we can expect an increase in positive attitudes in the coming period. The majority of the students reported that they usually perform BSE once a month (81%), while 8% reported that never do BSE. Other studies conducted in the kingdom revealed that only 17% of the respondents reported that they perform BSE monthly, while 39% never performed it. Some causes reported by students who had poor BSE practice were the absence of symptoms in the breast (45.7%), carelessness (23.3%), and lack of knowledge about steps of BSE (20.8%). Another study conducted at King Abdulaziz University in Jeddah revealed that 33% of Saudi nursing students perform BSE monthly [19]. On the other hand, about 66% of the nursing students reported regular performance of BSE in a study conducted in Riyadh [20]. Among women in the UAE, only 13% performed BSE regularly [10]. This is comparable to what was observed in a study from the Islamic Republic of Iran which found that only 13.4% of the women respondents practiced BSE regularly [21]. Similarly, among 124 Chinese women in Hong Kong, less than half practiced BSE and only 16% performed the examination routinely [22]. While in developed countries, a high rate of practice on regular frequency was achieved. BSE practice appears to be correlated with the higher level of education and healthcare services offered in those regions as compared to the developing world.

Table 4. Distribution of students according to their practice toward BSE.

NO. Always Usually Never
NO. % NO. % NO. %
1 Do BSE once a month. 8 11 59 81 6 8
2 Do BSE between day 7 until day 10 after menses. 2 2 37 51 34 47
3 Undress until the waist when doing the BSE. 21 29 25 34 27 37
4 Palpate axillary area when doing the BSE. 35 48 21 29 17 23
5 Hands should be raised up alternately above the head when doing the BSE. 45 62 15 20 13 18
6 Doing the BSE in front of the mirror. 39 53 27 37 7 10
7 Doing the BSE by tips of fingers. 53 73 16 22 4 5
8 DO BSE in supine position. 18 25 33 45 22 30

Conclusion

Although adequate knowledge about BSE and a good attitude toward BSE were encouraging; most of the female students in our sample did not perform BSE. This might be an obstacle to screening programs and early diagnosis of breast cancer. Therefore, more intensified awareness programs among female students are necessary to keep in view their current status of breast cancer and BSE knowledge. Also, further studies are needed to identify the causes of the low practice of BSE. More utilization of media as an important source of knowledge is required to improve awareness among the community.


List of Abbreviations

BSE Breast self-examination
BC Breast cancer
KSU King Saud University
SD Standard deviation
WHO World Health Organization

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The study was approved by King Saud University, College of Medicine, Institutional Review Board at Date of 28 November 2018 with Research project No. E-16-2117.


Author details

Abdullah Nasser Alomair1, Dania Ghazi Felemban2, Mohannad Sami Felemban3, Jameel Abdullah Awadain4, Ammar Saud Altowairqi5, Nawaf Fawzan Alfawzan1, Fatimah Mohammed Almazayen6, Abdulrahman Jalwi Korkoman7, Nawaf Saad Alrusayyis8

  1. King Saud University, College of Medicine, Riyadh, Saudi Arabia
  2. University of Groningen, Groningen, The Netherlands
  3. King Faisal Hospital, Riyadh, Saudi Arabia
  4. Alsharayea Primary Healthcare, Makkah, Saudi Arabia
  5. Taif University, Taif, Saudi Arabia
  6. Ministry of Health, Qatif, Saudi Arabia
  7. King Khaled University, Abha, Saudi Arabia
  8. Sharqa University, College of Medicine, Riyadh, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alomair AN, Felemban DG, Felemban MS, Awadain JA, Altowairqi AS, Alfawzan NF, Almazayen FM, Korkoman AJ, Alrusayyis NS. Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. IJMDC. 2020; 4(2): 429-434. doi:10.24911/IJMDC.51-1576668182


Web Style

Alomair AN, Felemban DG, Felemban MS, Awadain JA, Altowairqi AS, Alfawzan NF, Almazayen FM, Korkoman AJ, Alrusayyis NS. Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. https://www.ijmdc.com/?mno=78483 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1576668182


AMA (American Medical Association) Style

Alomair AN, Felemban DG, Felemban MS, Awadain JA, Altowairqi AS, Alfawzan NF, Almazayen FM, Korkoman AJ, Alrusayyis NS. Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. IJMDC. 2020; 4(2): 429-434. doi:10.24911/IJMDC.51-1576668182



Vancouver/ICMJE Style

Alomair AN, Felemban DG, Felemban MS, Awadain JA, Altowairqi AS, Alfawzan NF, Almazayen FM, Korkoman AJ, Alrusayyis NS. Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. IJMDC. (2020), [cited October 15, 2021]; 4(2): 429-434. doi:10.24911/IJMDC.51-1576668182



Harvard Style

Alomair, A. N., Felemban, . D. G., Felemban, . M. S., Awadain, . J. A., Altowairqi, . A. S., Alfawzan, . N. F., Almazayen, . F. M., Korkoman, . A. J. & Alrusayyis, . N. S. (2020) Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. IJMDC, 4 (2), 429-434. doi:10.24911/IJMDC.51-1576668182



Turabian Style

Alomair, Abdullah Nasser, Dania Ghazi Felemban, Mohannad Sami Felemban, Jameel Abdullah Awadain, Ammar Saud Altowairqi, Nawaf Fawzan Alfawzan, Fatimah Mohammed Almazayen, Abdulrahman Jalwi Korkoman, and Nawaf Saad Alrusayyis. 2020. Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 429-434. doi:10.24911/IJMDC.51-1576668182



Chicago Style

Alomair, Abdullah Nasser, Dania Ghazi Felemban, Mohannad Sami Felemban, Jameel Abdullah Awadain, Ammar Saud Altowairqi, Nawaf Fawzan Alfawzan, Fatimah Mohammed Almazayen, Abdulrahman Jalwi Korkoman, and Nawaf Saad Alrusayyis. "Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 429-434. doi:10.24911/IJMDC.51-1576668182



MLA (The Modern Language Association) Style

Alomair, Abdullah Nasser, Dania Ghazi Felemban, Mohannad Sami Felemban, Jameel Abdullah Awadain, Ammar Saud Altowairqi, Nawaf Fawzan Alfawzan, Fatimah Mohammed Almazayen, Abdulrahman Jalwi Korkoman, and Nawaf Saad Alrusayyis. "Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia." International Journal of Medicine in Developing Countries 4.2 (2020), 429-434. Print. doi:10.24911/IJMDC.51-1576668182



APA (American Psychological Association) Style

Alomair, A. N., Felemban, . D. G., Felemban, . M. S., Awadain, . J. A., Altowairqi, . A. S., Alfawzan, . N. F., Almazayen, . F. M., Korkoman, . A. J. & Alrusayyis, . N. S. (2020) Knowledge, attitude, and practice of breast self-examination toward breast cancer among female students at King Saud University in Riyadh, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 429-434. doi:10.24911/IJMDC.51-1576668182