http://doi.org/10.33698/NRF0066 Sukhpal Kaur, Indarjit Walia
Abstract : The present study was conducted to investigate the knowledge and practices of breast self examination (BSE) among nursing students in the month of Sept 2005 at National Institute of Nursing Education, Post Graduate Institute of Medical Education And Research, Chandigarh. Total 209 students pursuing B.Sc. Nursing (4years), B.Sc. Nursing (Post Basic), and M.Sc. Nursing participated in the study. A questionnaire containing 12 items to assess their knowledge regarding BSE and 6 questions regarding practices of BSE was administered. All the participants were asked to do BSE and a check list was given to them to note the warning signs of breast cancer. Data was analyzed using descriptive and inferential statistics. The mean age of the participants was 21.2yrs±4.17. Maximum expected knowledge score was 12. Participants pursuing M.Sc. nursing had maximum knowledge score (11.6±0.55) followed by the scores of B.Sc. nursing-interns (11.5±0.66) and B.Sc. nursing-Post Basic (9.8±1.3). There was a statistically significant difference in knowledge score as per the professional qualification of the subjects (F= 40.66, p=0.00). Out of the total, 57.9% participants were practicing BSE on monthly basis (51.2%). Two participants had changes in contour, changes in symmetry, lump in breast, pain on palpation and palpable nodules.Conclusion: Participants with higher professional qualification had better knowledge regarding BSE. Practice regarding BSE needs to be encouraged.
Key words :Knowledge, practices, breast self examination, nursing students.
Correspondence at : Sukhpal Kaur Lecturer, NINE PGIMER, Chandigarh
Introduction
Carcinoma breast is one of the world’s leading causes of mortality and is the most frequent malignancies amongst Indian women with a steadily increasing incidence. It is estimated that one out of seven women either has or will develop breast cancer in her life time.1 A study conducted In 2001 showed that out of the total 800,000 new cancer cases, 80,000 cases were of breast cancer.The average incidence rate of breast cancer in India is 16/100,000, varying from 22-28/ 100,000 females in urban settings and 6/ 100,000 in rural settings. The average age of reporting the symptoms in India is 45-54 years.2 About 60-80% of the total cases usually present at a locally advanced stage.3 In the year 2003, about 2,40,000 cases of breast cancer were diagnosed worldwide, out of which 40000 patients died of it.2 In early stages, breast cancer is less aggressive, with low incidence of metastasis and is potentially curable. Since the degree of success in treating this disease is influenced primarily by the stage at which intervention is introduced, secondary prevention (early detection) is the mainstay.4 Thus early detection is the key to better treatment and survival. It has been documented that 85% of localized breast cancer cases have 5-year survival rate, but it drops to 56% for the regional disease and 18% to distant metastasis.5 It poses a dual threat to women attacking their lives as well as their families and is a devastating illness both physically and psychologically.
Breast self examination (BSE) used in conjunction with mammography and professional examination is extremely effective in detecting early breast cancer. Although BSE is simple, quick, cost free and non-invasive procedure, less than 50% practice it regularly in spite of having knowledge. The American Cancer Society recommend monthly BSE for all the women who are 20 years or older. However Breast Cancer Care6 states that women should start being breast aware from the age of 18 years and should continue their breast checks regularly throughout their life. As per Persson7 BSE does not require any specialized personnel or equipment, rather it is painless and inexpensive self-care action that can be done at home in about ten minutes. However it has been documented that all the women who are advised about BSE and breast awareness by a health care professional on an individualized or group basis demonstrate greater knowledge and confidence and are more likely to practice this procedure routinely than those who become aware from other sources.8,9 Nurses are in an excellent position to make use of many opportunities to encourage the women to be breast aware. Their knowledge, their contact with women and their status as health professional give them the opportunity to educate the women about the need for breast self examination. Thus they can play an important part in helping women to protect their health. But before they start teaching the public, they themselves need to be knowledgeable and confident regarding the subject. They need to act as role model for the public. With this background the present study was conducted with an objective to assess the knowledge and practice of nursing students regarding breast self examination.
Methodology
The study was conducted at National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research Chandigarh in the month of September 2005. National Institute of Nursing Education is one of the premier institutes offering three programmes – B.Sc. Nursing (4 years), B.Sc. Nursing (Post Basic) and M.Sc. Nursing. Total 209 Students pursuing all the three courses participated in the study. Out of the total, 179(85.6%) were undergoing B.Sc. nursing (4 year) course, 15 were pursuing M.Sc. Nursing and similar number were pursuing B.Sc. Nursing (Post Basic) course. The students are admitted for B.Sc. nursing (4 year) course after successful completion of 10+2 with medical subjects. They are admitted for B.Sc. Nursing (Post Basic) training after their successful completion of General Nursing and Midwifery course (Diploma in Nursing). The students are admitted in M.Sc. Nursing after successful completion of B.Sc. nursing (4 year) or B.Sc. Nursing (post basic). B.Sc. nursing (4 year) is of 4 years in duration while M.Sc. Nursing and B.Sc. Nursing (post basic) are of 2 years each. The students are to qualify an entrance test before getting admission into each course.
Data was collected by a self administered questionnaire. An informed consent from each par ticipant was obtained. The questionnaire consisted of three parts. Part ‘A’ was about demographic characteristics of the participants. Part ‘B’ contained 12 items to assess their knowledge regarding breast self examination and third par t has 6 questions regarding practices of breast self examination. The questions on knowledge were regarding what is BSE, the importance of doing BSE, the time, method, technique and frequency of doing BSE, what should be noted during BSE and when the person should consult the doctor etc. Each correct response was given one mark. After filling up the questionnaire all the participants were asked to do their own BSE and a check-list was given to them to note the warning signs of breast cancer. Data was analyzed using the Statistical package for the Social Sciences (SPSS Version-11).
Results The average age of the participants was 21.2yrs±4.17. Majority (89.5%) were unmarried. Maximum (96.2%) had completed 12th standard as per academic qualification. 85.6% were undergoing B.Sc. nursing (4yrs) programme and 15 (7.2%) each were pursuing B.Sc. nursing (post basic) and M.Sc. nursing courses. (Table 1)
Table – 1: Demographic characteristics of the subjects N=209
| Demographic characteristics | N(%) |
| Mean age (yrs) ± S.D. | 21.2yrs±4.17 |
| Marital status | |
| · Married | 22 (10.5) |
| · Unmarried | 187 (89.5) |
| Academic qualification | |
| · Post graduates | 02 (0.9) |
| · Graduates | 06 (2.9) |
| · 12th standard | 201(96.2) |
| Professional qualification (undergoing) | |
| · M.Sc. nursing | 15 (7.2) |
| · B.Sc. nursing (4yrs) | 179(85.6) |
| · B.Sc. nursing (post basic) | 15 (7.2) |
The par ticipants pursuing M.Sc. nursing, B.Sc. nursing (internship) and B.Sc. nursing (2nd year) had the mean knowledge score of 11.6±0.55, 11.5±0.66, and 11.2±1.66 respectively. However the mean knowledge score of B.Sc. nursing (3rd year), B.Sc. nursing (post basic) and B.Sc. nursing (1st year) was 10.9±0.96, 9.8±1.3, and 9.3±0.83 respectively. (Table 2)On comparing three groups i.e M.Sc. nursing, B.Sc. nursing (4yrs) and B.Sc. nursing (Post Basic) it was observed that the three groups differ significantly amongst each other as per the knowledge score (Table 3a). With pairwise comparison it was noted that the subjects of B.Sc. nursing (1st year) and B.Sc. nursing (post basic) were significantly different from all the other groups (p=0.05). The mean knowledge score of the subjects undergoing B.Sc. Nursing (2nd yr) and of B.Sc. nursing (3rd yr) was alike but was different from other groups (p=0.05). The knowledge score of the participants of B.Sc. nursing (2nd yr), internship and of M.Sc. nursing was alike but was different from other groups (p=0.05) (Table 3b).
Table – 2 : Mean knowledge score of the subjects N=209
Max score=12, Min score=07
| Professional qualification | n(%) | Mean knowledge score | Range |
| M.Sc. Nursing (1st and 2nd yr) | 15 (7.2) | 11.6±0.55 | 11-12 |
| B.Sc. Nursing (post Basic) | 15 (7.2) | 09.8±1.3 | 7-11 |
| (1st and 2nd yr) | |||
| B.Sc. Nursing (1st yr) | 48 (23.0) | 09.3±0.83 | 7-11 |
| B.Sc. Nursing (2nd yr) | 45 (21.5) | 11.2±1.06 | 7-12 |
| B.Sc. Nursing (3rd yr) | 45 (21.5) | 10.9±0.96 | 9-12 |
| B.Sc. Nursing (Internship) | 41 (19.6) | 11.5±0.66 | 10-12 |
Table – 3a : ANOVA for knowledge score (M.Sc Nursing, B.Sc. Nursing- Post Basic and B.Sc. Nursing 1st yr, 2nd yr, 3rd yr and Internship)
| Source of variation | Sum of Square | df | Mean Square | F | Sig |
| Amongst group | 166.080 | 5 | 33.216 | 40.662 | 0.00 |
| Within group | 165.825 | 203 | 0.817 | ||
| Total | 331.905 | 208 |
Table – 3b : Post Hoc Test: Student-Newman-Keuls (Pairwise comparison of groups)
| Groups | n | Subsets | (p=0.05) | |||
| 1 | 2 | 3 | 4 | |||
| B.Sc Nursing (1st yr) | 48 | 9.3 | ||||
| B.Sc Nursing (Post Basic) | 15 | 9.8 | ||||
| B.Sc Nursing (3rd yr) | 45 | 10.93 | ||||
| B.Sc Nursing (2nd yr) | 45 | 11.20 | 11.2 | |||
| B.Sc Nursing (Internship) | 41 | 11.5 | ||||
| M.Sc Nursing | 15 | 11.6 | ||||
B.Sc Nursing (1st yr) < B.Sc Nursing (Post Basic) < B.Sc Nursing (3rd yr) = B.Sc Nsg(2nd yr ) < B.Sc Nursing (Internship)=M.Sc Nursing
Practice of breast self examination by the participants
All the participants were of the opinion that BSE should be done by every one. Majority (76.6%) agreed that BSE was taught in their curriculum by their teachers. More than half (57.9%) were practicing BSE and amongst them 51% were practicing BSE monthly. Among the par ticipants not practicing BSE (42.1%), majority (75%) responded that they do not get time for doing BSE. (Table 4)
Table – 4 : Practice of breast self examination by the participants N=209
| Sr No | Items regarding practice | n (%) |
| 1 | Whether BSE should be done | Yes=209 (100) |
| 2 | Whether they have been taught | Yes=205 (98.1) |
| 3 | Source of information | |
| · Teachers | 160 (76.6) | |
| · Friends | 40 (19.1) | |
| · Mother | 08 (3.8) | |
| · Media | 01 (0.5) | |
| 4 | Participants practicing BSE | 121 (57.9) |
| 5 | Frequency of doing BSE | |
| · Monthly | 62 (51.2) | |
| · Occasionally | 41 (33.9) | |
| · Whenever get time | 18 (14.9) | |
| 6 | Reasons for not doing BSE | |
| · Do not get time | 66 (75.0) | |
| · Not interested | 12 (13.6) | |
| · Do not consider it important | 07 (8.0) | |
| · Feel embarrassed | 03 (3.4) |
Percentage knowledge and practices of participants
More than half of the participants had their knowledge score above 91%. One fourth of the subjects had knowledge score between 81-90%. The number of students who were practicing BSE was directly proportional to their knowledge score. (Fig. 1)
Abnormalities detected during BSE All the participants were asked to do BSE. Out of the total two participants had change in contour, change in symmetry, lump in breast, pain on palpation and palpable nodule. Another one had change in symmetry and pain on palpation. (Table 5)
Table – 5 : Abnormalities detected during breast self examination
| Sr No | Abnormalities | n (%) |
| 1 | Changes in contour | 2 (0.96) |
| 2 | Changes in symmetry | 3 (1.44) |
| 3 | Lump in breast | 2 (0.96) |
| 4 | Pain on palpation | 3 (1.44) |
| 5 | Palpable nodule | 2 (0.96) |
Discussion
Breast cancer if detected early, is curable in 90% of the cases, but the tragedy is that most patients do not come to a doctor till there is very little that can be done. Breast self examination has been recommended as an important method for early detection of breast cancer as in 85% cases there is five year survival rate when it is detected and treated early at the localized stage and the survival rate decreased to 56% once breast cancer is detected later with the involvement of regional lymph nodes.5 BSE is a simple, in- expensive, non-invasive procedure which needs very little time and does not require any professional help. Of course the person must learn the steps initially. Nurses commonly teach and encourage the practice of BSE. Nurses in their day to day work in the hospitals or otherwise are in a prime position to make use of many opportunities to teach breast self examination to the women. Thus the possession of this knowledge among nurses is very important. In the current study the knowledge of nursing students regarding BSE and their frequency of practice of BSE has been explored. As per the results, the mean knowledge of the participants was 10.7±1.3, though the students pursuing M.Sc. had maximum mean knowledge score followed by the scores of B.Sc. nursing (4years) and B.Sc. nursing post basic students. Majority (84%) of the students had their knowledge score regarding BSE above 80%. The knowledge of the students undergoing graduation is reported to be 38.0% in a study in which the effect of an educational film on the health belief model and BSE practice was studied.10
Performance of BSE is recommended on a monthly basis. In the present study though 92.5% had the correct knowledge of frequency of doing BSE, 57.9% were practicing BSE out of which about half were practicing on monthly basis, approximately one third were performing occasionally and 14.9% used to do BSE whenever they got time. This percentage is quite good as compared to other studies in which it has been reported that only 48%, 23% and 24% respectively practiced BSE regularly. 11,12,13 About one third of the students performing BSE has been reported by Budden L.14 However Alsaif15 has documented 66% of nursing students in Saudi Arabia who were performing BSE. In the same study it has also been reported that 62% students had learnt information regarding BSE in their college curricula, and a significant relationship between higher levels in nursing college and BSE practice is also reported. In the current study it was observed that the students with higher qualification had better knowledge regarding BSE and their practices corresponded to their levels of knowledge. Thus an inference can be drawn that a need for continuing medical education for nursing professionals cannot be overemphasized. Levels of awareness have a definite binding on appropriate behavioural changes. Teachers as the main source of information regarding BSE has also been reported by the majority of the students (76.6%) in the present study followed by other sources such as friends, mother and media.Majority of the students reported the reason for not doing BSE as ‘do not get time’. The other reasons repor ted were ‘not interested’, ‘do not consider it important’ and ‘feel embarrassed’. In fact the students at this age usually have different priorities and donot discriminate ability to correlate the seriousness of the disease with BSE practice. This has been supported by many other studies in which the various reasons reported are ‘forgetting’, ‘lack of confidence’, ‘fear of finding a lump’, ’embarrassment’, ‘too busy’ and thinking ‘it is not necessary’.16,17,18
All the students irrespective of their knowledge regarding BSE were taught the steps of BSE and were asked to do their own BSE. Some abnormalities were identified like change in contour, change in symmetry, lump in breast, palpable nodule and pain on palpation in the par ticipants. They were referred to the concerned department for treatment.
It is concluded that though the students had adequate knowledge regarding BSE, they need to be reinforced about the subject throughout their study in order to develop health behavior required to assume their own responsibility towards prevention. They should be motivated to transfer the benefit of their knowledge and behavior to their patients to achieve a goal of early breast cancer detection which will help the medical profession to reduce the morbidity and mortality of the ever increasing menace of breast cancer in our society.
Recommendations
Effect of an educational programme on the knowledge and frequency of BSE should be determined. All the nursing students should be taught BSE during their academic studies. A study should be conducted to identify reasons for not practicing BSE in order to select suitable strategies to sustain regular practice overtime. All the practicing nurses should be involved in similar educational programmes (as a part of continuing medical educaional programme), thus enabling them to perform periodic BSE and teaching the same to the other women. Community level educational programme needs to be implemented as awareness is likely to improve compliance and thus a fruitful preventive outcomes.
References
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Budden L. Registered nurses’ breast self examination practice and teaching to female clients. Journal of Community Health N