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Female high school students’ knowledge and attitude toward breast cancer | BMC Women’s Health

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In this study, the mean overall knowledge score of all students was low. Students had inadequate knowledge about BC, BSE, and mammography; however, they had moderate knowledge about clinical examination. The present results are consistent with those of Isara (2011), who evaluated the knowledge of 287 students in Nigeria and showed that most students had inadequate knowledge about BC (56.8%) and BSE (75.6%) [19]. Ogunkayode et al. (2021) studied the knowledge, attitude, and practice of BSE among 348 female secondary students aged 10 to 19 in Ibadan, Nigeria. They found that only 9.5% of high school students had good knowledge about BC and BSE [20]. Ibitoye (2019) studied 280 adolescent girls at the Fiwasaye girls’ grammar school in Akure, Nigeria, and showed that students had relatively good knowledge about BC (60%) [1].

Mpulumba examined the knowledge of 962 students regarding BC and BSE in the Democratic Republic of the Congo. They discovered that most female students were aware of BC (61.75%) [21]. The results of the two studies mentioned above were not consistent with those of the current study, which may be explained by the poor education about BC in Iran.

Paknejad (2019) examined 2500 over-20 females in Tehran to measure their knowledge, attitude, and practice of self-examination and determined that 40.57% of women were aware of the signs and symptoms of BC, 23.03% of women were fairly aware of BSE, while the remaining women in the study had low and moderate knowledge [12]. Surprisingly, even though this study was conducted on married women over the age of 20 years, the participants were unaware of BC, which may be due to poor education about this disease rooted in cultural issues.

Karayurt et al. studied the awareness of BC risk factors and BSE of 718 students in Turkey and found that more than half of the students had misconceptions about BC and knew nothing about breast health. Moreover, one half or two thirds of the students knew little about breast health. A lack of education about BC has resulted in students having little knowledge of it, and thus, their awareness of it must be increased through proper education [15].

Many studies have shown that the level of cancer awareness is a significant risk factor for the early detection of BC and, in turn, vital for patient survival. Therefore, there is an urgent need for interventions to increase knowledge and awareness about BC and screening methods [22].

Most of the students in the present study (70.1%) had no information about BSE or had received no education about it. Those students who were informed about BSE had gained their information first from gynecologists and midwives and then via the Internet. Only 36% of students knew BSE was a screening test. Most of them were unaware of the suitable age, intervals, best time, and steps to start the BSE. Most of them knew that they had to refer to doctors or midwives for clinical examinations, but they were unaware of the methods and the intervals. Most of the students did not know mammography is used to look for BC and were unaware of the methods and the age at which to start looking for BC.

Mpulumba showed that most students were unaware of BSE methods, and the results were similar to those of the present study [21].

Similar to the present study, Ranasinghe showed that only 17.1% of study participants were aware of the methods of BSE, and only 9.4% knew BC screening is available. Only 35.6% of students knew mammography is an effective screening method [23].

Ogunkayode et al. showed that most students (74.6%) did not know any BSE methods. Less than half (31.9%) of the study participants were aware of the necessity for monthly BSE, and only 15.2% were aware of carrying out this examination even after menstruation. Moreover, 74.6% of students mentioned a lack of awareness as the main reason for not performing BSE [20].

Sadoh indicated that although 70% of students had heard of BSE, only 60% knew how to perform BSE to detect BC, and few students knew about mammography. Most students had no formal knowledge of examinations. They were unaware of some of the essential steps of BSE, such as examination of the axillary lymph nodes while holding both hands above the head. They did not even know that the best position for the palpation of the breast is lying down [2].

Karayurt showed that female high school students did not have adequate information about BSE, and only a small percentage of students performed monthly breast self-examinations. Most students did not perform BSEs because of a lack of knowledge of the methods (98.5%). This result was confirmed in a study of adolescent girls in Turkey. Only a few of them were aware of the best time for self-examination (13.2%), the frequency of self-examination (21.8%), and the correct methods of self-examination (26.6%) [15].

In Ghana, Fondjo compared 359 female secondary school students aged 15–19 to 677 tertiary school students aged 20–24 and found that almost all of the students were aware of BSE, indicating a significant difference between the level of knowledge of the two groups (33.0% and 67.0%, respectively). Moreover, 91.6% of students knew that BSE is a tool for diagnosing BC [11].

Many people think that adolescents are immune to cancer, and this false belief may make adolescents, like everyone else, reluctant to accept that they are vulnerable to this disease [12]. Therefore, raising awareness can improve future health-seeking behaviors (HSB), such as the application of screening tools. Although BSE has not reduced breast cancer mortality, the WHO recommends that high-risk individuals should perform it [2]. It is emphasized in every country, even in developed countries with organized mammography programs, that women should be aware of normal breasts and report any changes in their breasts to a healthcare provider immediately, because it has been proven that breast cancers are mainly self-diagnosed. One study conducted on black women found that BSE is four to five times as effective as mammography in BC diagnoses, which highlights the necessity of BSE by women [2], as 90% of breast masses are detected by women themselves [21].

Most BC patients have no family history of the disease. Therefore, it is, in fact, essential to provide students with better education about the benefits of BSE for early detection and diagnosis [11]. Recent studies have indicated that most women do not have correct information about BC risk factors and signs and symptoms [22].

The present study has shown that most of the participants knew BC is not just a woman’s disease; this result is inconsistent with Sadoh’s study, in which most participants believed that it is just a woman’s disease [2].

The present study has also shown that most of the students (41.2%) were unaware of the symptoms of BC; however, they knew a painful breast lump was a sign of it. They also believed that old age and family history are risk factors for the disease, which is consistent with Sadoh’s study, in which many adolescents were unfamiliar with the symptoms of BC [2].

Sadoh showed that students were unaware that breast lumps without weight loss could cause cancer or that bloody nipple discharge is not always a sign of cancer [2]. Karayurt’s study showed that most students had little knowledge of the risk factors for BC, which is consistent with the present study. Students mainly identified the risk factors for BC as a personal history of the disease (68.7%) and a family history of the disease (67.0%). In other words, students were aware that BC is related to genetic factors, and awareness of BC, mainly because of the extensive coverage of this risk factor in Turkish media, has a positive effect on breast health among young women. It is believed that lifestyle changes may modify the risks of developing BC. In other words, lifestyle changes can affect young women and help them avoid risk factors [15].

Ranasinghe showed that out of 859 adolescents, almost 60% of them identified risk factors for BC as breast lump history, family history of BC, and radiation exposure. Although most of them knew that breast lumps are warning signs, they knew very little about other warning signs [23].

Mpulumba showed that 59.56% of girls did not know the risk factors for BC. Girls aged 19–22 had more information about this disease than younger girls (less than 14 years), indicating a statistically significant difference between them (p < 0.001) [21].

It is essential to raise female students’ knowledge so as to enable them to develop sustainable attitudes and change their lifestyles through education about the risk factors for BC [21]. Many women do not have a health-related attitude toward the disease, and many of them, in particular women from developing countries, do not participate in screening programs [22].

The students participating in the present study gained their knowledge about BC mainly from books (27.3%) and television (20%); however, they rarely referred to midwives or gynecologists for information (8.4%). The results showed that organized training programs were not enough to increase breast health awareness. After books, the present study found that TV was the most critical source for information about BC. Ogunkayode et al. showed that students gain their knowledge about BC mainly from TV/radio (82.5%) and healthcare givers (81.6%) [13]. Karayurt indicated that nearly half of students had gained knowledge about BC and BSE from the media [15]. Ranasinghe also showed that students had gained knowledge about BC from television and newspapers [23].

These findings show that the media is one of the most important sources of information about BC and BSE, and the role of the media in collaborating with healthcare educators to transfer correct information about BC and BSE to adolescents is highlighted.

Given the importance of the issue at hand, it is vital to improve the education of female students about BC; however, school teachers may not be the best option for the following reasons: (a) they may be unfamiliar with the subject, and (b) they may not conduct the education due to cultural sensitivity. A study conducted in Iran revealed that school teachers are aware of the risk of BC, but only a very small percentage (6%) conduct breast self-examinations. Therefore, midwives and healthcare providers are the best options to educate students [24].

Mpulumba showed that most students (26.72%) gain information about BC through medical staff [21].

Health training programs should start in the early stages of life and can effectively change risk factors for BC. Therefore, healthcare providers can play an essential role in educating students and increasing their awareness of risk factors for BC and their impact on student behavior [15].

The current study showed that most students have a moderate attitude towards BC (73.31%); only 19% of the current participants had a good attitude towards BC. Again, this is due to the lack of student awareness.

In Paknejad’s study, 47.86% of students had a positive attitude about BSE [12]. Fondjo (2018) indicated that 97.1% of students had a good attitude toward BSE, and 96.3% of students confirmed its necessity [11]. Ogunkayode et al. showed that more than half of the students (56%) had a positive attitude towards BSE [20].

Although the current study showed no significant relationship between students’ level of knowledge and attitudes (p = 0.06), other studies have shown that people with good knowledge are more likely to have a positive attitude towards BSE. Ogunkayode realized a significant positive relationship between attitude and knowledge about BC and BSE [20].

No significant difference was found in the current study between the knowledge score (p = 0.61) and attitude (p = 0.69) and parents’ level of education and occupation of students with and without a family history of BC. Most of the students were also unaware that their lifestyle, such as lack of physical activity, obesity, and excessive alcohol consumption, increases BC risk [2].

Some studies have shown that many factors such as age, household income, and family history of cancer are related to women’s level of knowledge and awareness about BC [22]. Karayurt showed no significant relationship between BSE, perceived income level, and family history of BC [15]. This difference between studies can be attributed to the low level of public awareness and the lack of adequate education.

It is essential for adolescents to adopt sensitive basic behavioral patterns about BSE and have sufficient deep information to ensure proper and effective self-examination in the present and future, because being unaware of something makes doing it impossible [20].

Adequate awareness of BC and BSE can affect attitudes towards self-examination and its performance, which can help prevent poor BSE performance and late detection of BC [20].

Limitation

One of the limitations of the current study is a lack of agreement with the questionnaire; there is no comprehensive and useful questionnaire to measure knowledge and attitude about breast cancer. Even though the researchers visited three all-female high schools in three different geographical areas of Fasa to cover a broad spectrum of students in terms of levels of culture, education, and awareness, only students within a limited age range were investigated, and this may limit the possibility of generalizing the results to other communities of women.

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