*Corresponding Author:

Dr. Amal K. Suleiman
Department of Clinical Pharmacy, Pharmacy School, Princess Nora University, Riyadh, Kingdom of Saudi Arabia.
E-mail: albarqok@yahoo.com

Abstract

Background: Despite huge efforts to increase the level of breast cancer awareness, breast self‑examination (BSE) is still poorly practiced across Jordan. This baseline study aimed to assess the awareness of female Jordanian students about breast cancer and their practice of BSE. Materials and Methods: Using a cross‑sectional research design, a self‑administered survey was used, via a pre‑validated pre‑piloted questionnaire was distributed to 900 female students aged between 18 and 37 years recruited from the University of Jordan in Amman. The questionnaire was divided into four domains: Socio‑demographic characteristics; the respondent’s knowledge of breast cancer and BSE; their attitude towards risk factors for breast cancer; their experience of breast cancer screening and BSE. Statistical analysis was performed using Epi‑Info version 6.4 statistical Software. Results: The overall response rate was 93.3%. Approximately half of the respondents 435 (51.8%) were aware of breast cancer. Of these, 99 (22.7%) believed that it was caused by a medical condition, followed by old age (71; 16.4%), lack of breastfeeding (58; 13.3%), heredity (56; 12.8%), late marriage (44; 10.3%), pregnancies in older women (33; 7.5%), the use of brassieres (18; 4.1%), excessive breastfeeding (17; 3.9%), being unmarried (14; 3.2%), and spirituality (11; 2.6%). Overall, 152 participants (34.9%) were aware of BSE, but only 93 (11%) had performed it. Conclusions: The current status of awareness of breast cancer in Jordanian students and their use of BSE are insufficient. Women need to be encouraged to self‑monitor in order to detect abnormalities in their breasts. Appropriate educational interventions are urgently required to encourage women to engage in regular BSE.

Key words

Awareness, breast cancer, knowledge, practice, self-examination

Introduction

Breast cancer is the most common cancer among females, and represents a major global health problem.[1] Almost 70% of women with breast cancer are aged over 50 years, and only 5% are younger than 40 years old.[1] Approximately 700,000 cases are reported annually worldwide, of which 57% of these cases present in developing countries.[1-3] The global incidence of breast cancer is rising, particularly in developing countries that formerly had a low incidence.[2,4] Omotara et al. proposed that the incidence of breast cancer is increasing in the developing world due to increased life expectancy, increased levels of urbanization and the adoption of western lifestyles.[5] According to a recent report by the World Health Organization, the largest increase in cancer incidence over the next 15 years will be in Middle Eastern countries.[2] The mortality rate from all types of cancer in the Middle East is currently 70%, compared to 40-55% in western countries. Furthermore, by the year 2020, the number of new cancer cases diagnosed each year is estimated to increase by 40%.[2] Urgent interventions are, therefore, needed to raise awareness of all cancers in this region in order to improve the rates of early detection and increase the chance of curative treatment.

In Jordan, cancer is the second most common cause of death after cardiovascular disease,[6] and breast cancer was the most common of all cancers in women over the last decade.[7] In 2008, the latest year for which the Jordan National Cancer Registry has available data, 4606 new cases in Jordanian citizens and 1608 additional non-Jordanian cases were recorded. The early detection of breast cancer can be achieved through a combination of monthly breast self-examination (BSE), regular clinical breast examinations and annual mammography beginning at the age of 40 years, are the best ways to limit morbidity and mortality associated with breast cancer.[8-10] It is essential for the target population to have comprehensive knowledge, appropriate attitudes and practice of the screening methods. This is supported by evidence that earliest breast tumors are self-discovered and that the majority of early discoveries are made by BSE performers.[9] Some studies have reported that improved knowledge and attitudes have a positive effect on the screening attendance of women.[10,11]

Breast cancer awareness in developing countries is not well documented, and what is known is far from encouraging,[11-17] 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.[18] It is, therefore, important to assess the level of awareness of risk factors in our communities. This study aimed to assess awareness of breast cancer, and practice of breast cancer screening among female students in Jordan.

Materials and Methods

Using a cross-sectional research design, this study examined the knowledge of Jordanian female students with regards to breast cancer, in addition to their awareness and practice of breast cancer screening techniques, including BSE.

The target population of the study was all the Jordanian female students registered at Jordan University without inclusion or exclusion criteria of the target population. The total number of female students was around 18,900 students registered in the university during the time of this study. Based on the rule-of-thumb, sample size was determined with 643 students having 99% confidence intervals, and a margin of error of ± 5%. This study location was selected because the governorate estimated that the number of female breast cancer cases was highest in Amman, affecting 52.3 out of 100,000 females.

A quantitative research approach was conducted using a self-administered survey. Researcher used a prevalidated prepiloted questionnaire was adapted from a previous study conducted in Northeast Nigeria.[5] After attaining permission to use the questionnaire, the questionnaire was translated into Arabic language, modified to be applicable in Jordan, and then translated back to English to assure the translation equivalency and appropriateness. The final Arabic version was approved by a bilingual Arabic professor of pharmacy. The questionnaire was piloted on a convenience sample of fifteen out of the main target sample so that final modifications could be made to the questionnaire. Cultural differences were discussed by the author, and the data from the pilot sample were excluded from the final analysis. The study protocol was approved by the departmental Ethics Committee at our institution.

The questionnaire included four sections: (i) The demographic background of the respondent; (ii) the respondent’s knowledge of breast cancer and BSE; (iii) their attitude towards risk factors for breast cancer; and (iv) their current practice for breast cancer screening and BSE.

Data collection took place between 2^nd June 2012 and 10^th September 2012. Based on a convenience sampling method 900 questioners were distrusted to ensure the highest response, participating was invited by a formal covering letter to complete the prepiloted questionnaire. The covering letter explained the main objectives of the study and assured participants of the confidentiality and anonymity of data. The questionnaire was hand-delivered by researcher to the students with appropriate instructions regarding its completion, and picked up at a later time after completion, with no reminders. Subjects were informed about the increased incidence of breast cancer in Jordan, especially among younger women. Respondents were informed that participation in the study was voluntary where, a small box was created fixed at the main entrance of the pharmacy school allows participants to drop the completed questionnaires. Thus, their responses would be confidential and analyzed only as part of a cohort.

The questionnaire data were anonymized, numbered and assessed manually for errors, before being entered into a computer database for analysis and data were assessed in an observational manner using Epi-Info version 6.4 Statistical Software.

Results

Of 900 questionnaires distributed to all colleges of the University of Jordan, 840 were completed and returned, yielding a response rate of 93.3%. Table 1 reveals the demographic characteristics of the female students who participated. The study group was aged from 18 to 37 years (median, 5.0). Of the 840 female students that responded, only 435 (51.8%) had any awareness of breast cancer as shown in Table 2. The majority of these respondents had obtained their knowledge from either friends or health workers [Figure 1].

Figure 1: Source of breast cancer information among participating female students at Jordan University, Amman

Table 1: Demographic characteristics of participating female students at Jordan University, Amman

Table 2: Breast cancer awareness among participating female students at Jordan University, Amman

Table 3 indicates that, of the 435 respondents who were aware of breast cancer, 99 (22.7%) perceived the cause to be brought about by a medical condition. This was followed, in descending order, by 58 (13.3%) who felt that the lack of breastfeeding caused breast cancer, 56 respondents (12.8%) who attributed the cause to heredity, 71 (16.3) to old age, 44 (10.3) to individuals marrying at a later age, 33 (7.5) to pregnancy at a later age, 18 (4.1%) to the use of brassieres, 17 (3.9%) to excessive breastfeeding and 11 (2.6%) to spirituality.

Table 3: Perceived risk factors for breast cancer among participating female students at Jordan University, Amman

A total of 340 (78.2%) out of the 435 did not agree that breast cancer patients should be isolated or stigmatized and 308 (70.8%) did not believe that the disease was a punishment from God. The majority agreed that breast cancer patients should live in the community (95.6%) and be supported (97.9%). Nevertheless, 292 (67.1%) of the respondents were afraid of patients with the disease [Table 4].

Table 4: Assessment of attitudes towards breast cancer among female students who were aware of breast cancer at Jordan University, Amman (n=435)

With regards to BSE, only 152 (34.9%) of those aware of breast cancer knew of BSE as a method for the early detection of breast cancer, and only 93 (61.1%) had ever undergone screening or performed BSE themselves [Table 5]. Of those 93, 23 (24.7%) did so on the advice of health workers, and 28 (30.2%) did so as part of a routine medical examination. As for those respondents who were aware of breast cancer, 198 (45.5%) would undergo screening or perform BSE if it was of benefit to them, 111 (25.5%) if their family agreed, and 84 (19.3%) only if there was a known cure for breast cancer.

Table 5: Awareness and practice of BSE among participating female students at Jordan University, Amman

Discussion

The evaluation of public awareness, attitudes and practice of BSE is of fundamental importance for the successful implementation of breast cancer control activities.[19] There are no known proven means to prevent breast cancer, which increases our reliance on the methods for early detection in order to improve patient outcomes. The primary goal of breast cancer awareness programs in developing countries is to promote and develop awareness about the importance of its early detection.[5]

Projections show that the population in Jordan will have increased from the current figure of 6.3-7.1 million by 2020, with the number of breast cancer cases in Jordanians increasing from 5110/year into 7281/year.[3] Cancer is increasing at a faster rate than population growth, for unknown reasons, but these projections should be used to properly plan for future cancer care requirements and to pinpoint resources to improve survival rates.

The current study revealed that Jordanian women had worryingly poor levels of knowledge of breast cancer. This finding is supported by the study of Jaradeen,[20] which revealed a low mean level of knowledge about breast cancer (49%) in 150 female hospital workers in Jordan. In addition, Ahmed et al.[21] found that knowledge of breast cancer was low among 411 Jordanian woman aged 18-70 years in Amman, the capital of Jordan. As the current study involved highly educated university students, it was expected that they would have greater awareness and knowledge of breast cancer than the general population. However, the findings were disappointing.

In the current study, of the 435 respondents who were aware of breast cancer, 51.8% obtained their information on breast cancer from friends and health workers. This was in contrast to the results of a study conducted in South Eastern Nigeria by Ibrahim and Odusanya,[19] which showed that health workers were the main source of information about breast cancer. Friends and family also seem to play a major role in terms of breast cancer awareness in Middle Eastern communities, as exemplified by the finding that 25.5% of the respondents who were aware of breast cancer would only undergo breast cancer screening if their family agreed. In the Middle East, breast cancer comes with a heavy cultural stigma, as exemplified by the study in which Laura Bush stated that, “Women in [the] Middle East are sometimes abandoned by their family when the disease is diagnosed, [and] such stories are discouraging”.[22]

In this study, the majority of women who were aware of breast cancer (308, 70.8%) did not believe that breast cancer was a punishment from God, which was in contrast to the findings of previous studies from developing countries.[5,12] The majority of respondents in the current study (78.2%) disagreed that breast cancer patients should be isolated and nearly all agreed that these patients should be allowed to live freely in their community (95.6%). This may be due to the Islamic religious beliefs of the majority of respondents, which encourages communities to support those suffering from any kind of disease.[20]

The current study shows that the practice of BSE was low amongst the sample tested. Only 152 (34.9%) of those aware of breast cancer knew of BSE as a method for detecting breast cancer, and only 93 of those respondents (61.1%) had ever performed it. This is in line with the findings of Abdel Hadi,[23] who found that 37.3% of his study population practiced BSE. In studies of other populations, the percentage of BSE awareness was 52% among Jordanian nurses,[24] 37% among Australian students,[25] and 31% among Pennsylvanian women.[26] Other studies that showed low rates of BSE practice suggested that the practice is globally low among women, regardless of their age and occupation.[21,23] However, the rates reported in this current study were higher than those described by previous Egyptian and Iranian studies, in which only 6% and 2.65% of the general study populations practiced BSE monthly, respectively.[21,27]

The current study suggested several reasons why Jordanian female students did not partake in breast cancer screening practices. More than a third of students who were aware of breast cancer did not feel that screening was necessary, and 28.8% of women reported being too busy. The provision of systematic health education (e.g. at college) may help to encourage breast cancer screening and change perceptions regarding screening. It is important to raise women’s awareness regarding the potentially life-saving benefits of BSE practice. In addition, the accessibility of screening practices should be expanded with government support.

Limitations of the study

One of the limitations of the study is that the participants in the questionnaire enrolled in the study voluntarily. The results might therefore be biased as the sample was not selected at random. The students who chose to participate may have had different attitudes or knowledge than those who did not volunteer.

Conclusions

In contrast to western nations, most patients in developing countries, including Jordan, present with an advanced stage of cancer, when little or no benefit can be derived from therapy. The findings of this study are in keeping with previous research in which breast cancer awareness has been found to be low among women in developing countries. Breast cancer awareness among Jordanian students was less than 50% and knowledge was limited in its range and accuracy. The findings of this study suggest a number of avenues for future research and could be used to contribute to the development of preventative and screening programs for breast cancer across the population. This study emphasizes the need to raise breast cancer awareness and to teach individuals about the importance of practices for early detection techniques, such as BSE, which will enable breast cancer to be detected at an earlier stage. Interventions should be developed with the aim of providing information and services for all age groups, educational levels, cultures and social strata. In order to improve women’s awareness and knowledge of breast cancer, it is important to initiate interventions that seek to provide health education, and to encourage preventive healthcare behaviors. The data presented here indicate an important myths factors about breast cancer among female Jordanian students that can provide insight and background, into exploring the strategies for promoting awareness among women according to the students.

Acknowledgment

Thanks to Dr. Natalie Morris of Oxford Science Editing for her assistance in manuscript English editing, and Dr.Abbas Al barq for his unconditional support.

References

1. Boyle P, Levin B. World Cancer Report 2008. W HO, IARC Non-serial Publication; 2008.
2. WHO. Towards a Strategy for Cancer Control in the Eastern Mediterranean Region, 2009. Available from: http://www.emro.who. int/dsaf/dsa1002.pdf [cited on 2012 Jun 24].
3. Cancer Care and Control in Developing Countries, 2012. Available from: http://gtfccc.harvard.edu/icb/icb.do?keyword=k69586 and pageid=icb.page342749#a_icb_pagecontent708845_ftnref3.[Last cited on 2012 May 04].
4. Bray F, McCarron P, Parkin DM. The changing global patterns of female breast cancer incidence and mortality. Breast Cancer Res 2004;6:229-39.
5. Omotara B, Yahya S, Amodu M, Bimba J. Awareness, attitude and practice of rural women regarding breast cancer in Northeast Nigeria. J Community Med Health Educ 2012;2:2-4.
6. Directorate of Information Studies and Research, Ministry of Health Jordan. Mortality in Jordan 2005. Amman, JO: Ministry of Health, The Hashemite Kingdom of Jordan; 2008.
7. Jordan National Cancer Registry, 2009. Available from: http://www. moh.gov.jo/MOH/Files/Publication/Annual%20Incidence%20of%20 cancer%20in%20Jordan%202009.pdf. [Last cited on 2012 May 28].
8. Berkiten A, Sahin NH, Sahin FM, Yaban ZS, Acar Z, Bektas H. Meta analysis of studies about breast self examination between 2000-2009 in Turkey. Asian Pac J Cancer Prev 2012;13:3389-97.
9. Bener A, Alwash R, Miller CJ, Denic S, Dunn EV. Knowledge, attitudes, and practices related to breast cancer screening: A survey of Arabic women. J Cancer Educ 2001;16:215-20.
10. Sadler GR, Ko CM, Cohn JA, White M, Weldon RN, Wu P. Breast cancer knowledge, attitudes, and screening behaviors among African American women: The black cosmetologists promoting health program. BMC Public Health 2007;7:57.
11. Akhigbe AO, Omuemu VO. Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city. BMC Cancer 2009;9:203.
12. Okobia MN, Bunker CH, Okonofua FE, Osime U. Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study. World J Surg Oncol 2006;4:11.
13. Reisi M, Javadzade SH, Sharifirad G. Knowledge, attitudes, and practice of breast self-examination among female health workers in Isfahan, Iran. J Educ Health Promot 2013;2:46.
14. Fouladi N, Pourfarzi F, Mazaheri E, Asl HA, Rezaie M, Amani F, et al. Beliefs and behaviors of breast cancer screening in women referring to health care centers in Northwest Iran according to the champion health belief model scale. Asian Pac J Cancer Prev 2013;14:6857-62.
15. Boulos DN, Ghali RR. Awareness of breast cancer among female students at Ain Shams University, Egypt. Glob J Health Sci 2013;6:154-61.
16. Ranasinghe HM, Ranasinghe N, Rodrigo C, Seneviratne Rde A, Rajapakse S. Awareness of breast cancer among adolescent girls in Colombo, Sri Lanka: A school based study. BMC Public Health 2013;13:1209.
17. Azage M, Abeje G, Mekonnen A. Assessment of factors associated with breast self-examination among health extension workers in west Gojjam zone, Northwest Ethiopia. Int J Breast Cancer 2013;2013:814395.
18. Obeidat RF, Lally RM. Health-related information exchange experiences of Jordanian women at breast cancer diagnosis. J Cancer Educ 2013;11:290.
19. Ibrahim NA, Odusanya OO. Knowledge of risk factors, beliefs and practices of female healthcare professionals towards breast cancer in a tertiary institution in Lagos, Nigeria. BMC Cancer 2009;9:76.
20. Jaradeen NK. Breast cancer risk-factors and breast self examination practice among Jordanian women. Bahrain Med Bull 2010;32:534-9.
21. Ahmed F, Mahmud S, Hatcher J, Khan SM. Breast cancer risk factor knowledge among nurses in teaching hospitals of Karachi, Pakistan: A cross-sectional study. BMC Nurs 2006;5:6.
22. Bush L. Raising breast cancer awareness in the Middle East. NCI Cancer Bull 2007;4:9.
23. Abdel Hadi MS. Breast cancer awareness among health professionals. Ann Saudi Med 2000;20:135-6.
24. Abu Salem O, Hassan AM. Breast self-examination among female nurses. J Pak Med Assoc 2007;32:31-3.
25. Ludwick R, Gaczkowski T. Breast self-exams by teenagers: Outcome of a teaching program. Cancer Nurs 2001;24:315-9.
26. Rutledge DN, Barsevick A, Knobf MT, Bookbinder M. Breast cancer detection: Knowledge, attitudes, and behaviors of women from Pennsylvania. Oncol Nurs Forum 2001;28:1032-40.
27. Haji-Mahmoodi M, Montazeri A, Jarvandi S, Ebrahimi M, Haghighat S, Harirchi I. Breast self-examination: Knowledge, attitudes, and practices among female health care workers in Tehran, Iran. Breast J 2002;8:222-5.