Factors Associated with Breast Self Examination (BSE) Practice Among Female Patients in an Out Patient Clinic in the Philippines MARIA FIDELIS C. MANALO,

Factors Associated with Breast Self Examination (BSE) Practice Among

Female Patients in an Out Patient Clinic

in the Philippines

Factors Associated with Breast Self Examination (BSE) Practice Among

Female Patients in an Out Patient Clinic

in the Philippines

MARIA FIDELIS C. MANALO, MD, MSc Epidemiology

and Josenia Tan, Paolo Porciuncula, Richard Santos &

CFM III-C Research GroupDepartment of Community & Family Medicine

FEU-NRMF Medical Center

MARIA FIDELIS C. MANALO, MD, MSc Epidemiology

and Josenia Tan, Paolo Porciuncula, Richard Santos &

CFM III-C Research GroupDepartment of Community & Family Medicine

FEU-NRMF Medical Center

BREAST CANCERBREAST CANCER

Philippines Second to lung cancer in

prevalence 5 year survival is 40%

Ngelangel and Wang, 2002 Women at risk:

Those in rural areas, with low educational attainment, history of benign disease, infertility, and age beyond 35

Protected women: Those with dysmenorrhea,

number of live births and breast feeding

BREAST SELF EXAMBREAST SELF EXAM

Devised in 1950s, before mammography

Inexpensive, available and simple Mixed opinions on its usefulness:

Beneficial: Reduced mortality and morbidity

Non-beneficial: (Thomas, 1997; Semiglazov, 1993)

No significant differences in mortality and morbidity

Adherence to its use: (Maxwell, 2002)Psychosocial- embarrassment, shynessEconomical- costs, timelinessEducational- knowledge, misconceptions

backgroundbackground

BACKGROUNDBACKGROUND

Perceived BenefitsCost-effective:

Diagnostic modality of choice in the Philippines Saves 3 million PhP annually (Ngelangel, 2002)

Early detection resulting to small tumor sizes (Harvey, 1997)

Improved survival rates (Huguley, 1988) Contradictions to Perceived Benefits:

Mortality rates show no significant difference for those educated of BSE and those who were not (Thomas, 1997; Semiglazov, 1993)

BACKGROUNDBACKGROUND Perceived Barriers

Small proportion adhere to BSE guidelines (Houts, 1991; Kash, 1992)

Factors: Skill, training and technique (Phillip, 1986)

Anxiety (Lerman, 1993) Culture (Graham, 2002) Fatalistic view of Filipinos (Ngelangel, 1989)

Religion, forgetfulness, psychology, resources, education (Maxwell, 2000)

BACKGROUNDBACKGROUND

Perceived Susceptibility50% of cases of breast cancer are

detected by women themselvesNgelangel in 2002 lists factors

increasing susceptibility to breast cancer:

Lower than high school education (OR=1.87)

History of benign breast disease (OR=2.51)

Infertility (OR=5.83) >35 years of age (OR=18.2)

BACKGROUNDBACKGROUND Perceived Seriousness

Early detection results in greater chance of long term survival

Randomized trials of mammographic screening showed reduced mortality by 30% (Kerlikowske, 1995)

Size and spread of cancer are important in giving diagnosis and prognosis (Wardle, 1995)

Contradictions to Perceived Seriousness BSE did not show any effect in the

size or stage of the breast cancers at diagnosis (Thomas, 1997; Semiglazov, 1993)

HEALTH BELIEF MODELHEALTH BELIEF MODEL

Perceived susceptibility to and seriousness

of breast CA:Death in among

relatives and friends↑awareness↑information

dissemination

Perceived susceptibility to and seriousness

of breast CA:Death in among

relatives and friends↑awareness↑information

dissemination

Variables:AgeSex

Geography Economic status

Educational attainmentSocial status

Knowledge of breast CAFamily factors

Variables:AgeSex

Geography Economic status

Educational attainmentSocial status

Knowledge of breast CAFamily factors

Perceived threat of breast CA:

Anxiety due to family historyHigher education

AwarenessPhysician recommendation

Perceived threat of breast CA:

Anxiety due to family historyHigher education

AwarenessPhysician recommendation

Cues to action:Advertising

AdviceGovernment programs

Information dissemination

Cues to action:Advertising

AdviceGovernment programs

Information dissemination

Likelihood of taking

recommended preventive

health action

Likelihood of taking

recommended preventive

health action

Perceived benefits of preventive action:

Early detection↑survivability

↓mortalityMore treatment options

Perceived barriers to preventive action:

EmbarrassmentConcerns on cost

InconvenienceDoubts in western medicine

Perceived benefits of preventive action:

Early detection↑survivability

↓mortalityMore treatment options

Perceived barriers to preventive action:

EmbarrassmentConcerns on cost

InconvenienceDoubts in western medicine

OBJECTIVESOBJECTIVES

General To identify the factors associated with the

practice of Breast Self Examination (BSE) among female patients consulting an out-patient clinic in the Philippines.

Specific To categorize the beliefs of the women

regarding the practice of BSE based on the health belief scoring system.

To determine the relationship of age, civil status, history of lumpectomy, family history of breast cancer, previous BSE knowledge and health beliefs on the BSE practice of the women.

methodologymethodology

METHODOLOGYMETHODOLOGY

Establishing a Target

Population


Population

SamplingSampling

Creating a Research DesignCreating a Research Design

Data AnalysisData Analysis

Tool: Questionnaire

Tool: Questionnaire

•Employment of an analytical cross-sectional type of study design

•Basis: Fulton’s Health Belief Model of 1987

•Employment of an analytical cross-sectional type of study design

•Basis: Fulton’s Health Belief Model of 1987



Population


Population

SamplingSampling



Tool: Questionnaire

Tool: Questionnaire

•Based on current prevalence rates of breast cancer in the country

•EpiInfo2000 software was used

•Based on current prevalence rates of breast cancer in the country

•EpiInfo2000 software was used



Population


Population

SamplingSampling



Tool: Questionnaire

Tool: Questionnaire

•Setting:•FEU-NRMF Medical Center, Quezon City, Philippines

•September 2004

•Subjects•Cluster sampling•Out Patient Department Patients

•Women aged 15 and older

•n= 130

•Setting:•FEU-NRMF Medical Center, Quezon City, Philippines

•September 2004

•Subjects•Cluster sampling•Out Patient Department Patients

•Women aged 15 and older

•n= 130



Population


Population

SamplingSampling



Tool: Questionnaire

Tool: Questionnaire

•Guided Interviews•The “Health Beliefs about BSE and Breast Cancer Questionnaire” developed by Manalo et al (2000) was used as tool

•Contains 4 domains:

•Perceived Benefits•Perceived Barriers•Perceived Susceptibility

•Perceived Seriousness

•Guided Interviews•The “Health Beliefs about BSE and Breast Cancer Questionnaire” developed by Manalo et al (2000) was used as tool

•Contains 4 domains:

•Perceived Benefits•Perceived Barriers•Perceived Susceptibility

•Perceived Seriousness



Population


Population

SamplingSampling



Tool: Questionnaire

Tool: Questionnaire

•Devising a health belief scoring system

•Correctness of responses based on findings on review of related literature

•Analysis through Statistical Package for Social Sciences Program version 7.5

•Calculations using Cochran’s and Mantel-Haenzel Statistics

•Devising a health belief scoring system

•Correctness of responses based on findings on review of related literature

•Analysis through Statistical Package for Social Sciences Program version 7.5

•Calculations using Cochran’s and Mantel-Haenzel Statistics

RESULTSRESULTS

Dependent Factor N %

Practice of BSEPracticeDo not Practice

5872

44.6255.38

Table 1. Distribution of Respondents as to Practice of

Breast Self-Examination (n=130)

Independent Factors N %

Age Group 35 years old and olderYounger than 35 years of age

5674

43.0856.92

Civil StatusNever Married Ever Married

4486

33.8566.15

History of LumpectomyWith historyWithout history

5125

3.8596.15

Family of History of Breast CA With family history Without family history

15115

11.5488.46

Previous Knowledge of BSE With previous knowledge Without previous knowledge

8248

63.0836.92

Health Beliefs Regarding BSE & Breast Cancer

Correct beliefsIncorrect Beliefs

6565

50.0050.00

RESULTSRESULTS

RESULTSRESULTSFactors Practice

BSE

Do Not Practice

BSECrude

Odds Ratio

95% confidence

interval

Age Group 35 years old or older Younger than 35 years of age

2335

3339

0.777 .385 - 1.566

Civil Status Never Married Ever Married

2038

2448

1.053 .507 - 2.185

History of Lumpectomy With history Without history

355

270

1.909 .308 - 11.826

Family of History of Breast CA With family history Without family history

850

765

1.486 .505 - 4.372

Previous Knowledge of BSE With previous knowledge Without previous

knowledge

544

2844

21.214 6.917 - 65.065

Health Beliefs Correct health beliefs Incorrect health beliefs

4117

2448

4.824 2.283 - 10.193

discussiondiscussion

DISCUSSIONDISCUSSION

Regarding Age GroupsOdds ratio (OR) between high

risk age group and low risk age group is 0.777 (95% CI=0.385-1.566)

This study failed to show a relationship between the practice of breast self-examination and age of the patient.

DISCUSSIONDISCUSSION Regarding Civil Status

Although the practice of breast self-examination is more common among those who are not married compared to those who are married (OR=1.053, 95% CI=0.507-2.185), this difference is not statistically significant.

This study failed to support Chee’s 2003 study, which states that women who had married and pregnant women practice BSE monthly, due perhaps to general anxiety.

DISCUSSIONDISCUSSION Regarding Lumpectomy History

Although the practice of breast self-examination is more common among those with history of lumpectomy compared to those without such history (OR=1.909, 95% CI=0.308-11.826), this difference is not statistically significant.

This study failed to show that possible anxiety from a previous lumpectomy relates to adherence.

National Breast Cancer Committee tells of BSE screening leads to detection of lumps with a correlated increased anxiety

Lerman (1995) mentions of general and specific anxiety

Research on this has been arbitrary


Regarding Family HistoryAlthough the practice of breast self-

examination is more common among those with family history of breast cancer compared to those without such family history (OR= 1.486, 95% CI=0.505-4.372), this difference is not statistically significant.

This study failed to support the previous findings that there is general anxiety in women with family history (Lindberg, 2001) which could lead them to practice BSE.

DISCUSSIONDISCUSSION Regarding Previous BSE Knowledge

Most remarkable findingIn the present study, the practice of breast

self-examination was significantly associated with previous knowledge of breast self-examination (OR= 21.214, 95% CI=6.917-65.065).

Educated, working and aged 35-50 years old women practice BSE more (Chow, 2000)

These women have higher health alertness and awareness

However, some would claim to be knowledgeable but unable to perform accurately (Dimitrikaki, 2003)


Regarding Correct and Incorrect Health Beliefs (as measured by the validated BSE questionnaire) In the present study, the practice of breast self-

examination was significantly associated with correct health beliefs (OR= 4.824, 95% CI= 2.283-10.193).

Perceived susceptibility and risk to breast cancer are the strongest predictors of BSE proficiency.

Most incorrect perception fell under the perceived barriers of the women

Could be attributed to lack of faith in one’s skills in performing BSE plus the absence of specific training programs (Bhakta, 1995)

conclusionsconclusions

CONCLUSIONCONCLUSION

Previous knowledge of breast self-examination and and correct health beliefs play an important role in the promotion and utilization of BSE. Previous BSE knowledge (OR= 21.214) Correctness of BSE beliefs (OR= 4.824)

The overall impact would lead to reduction in serious clinical and financial consequences to a woman should she fail to detect breast cancer early enough.

RECOMMENDATIONSRECOMMENDATIONS

More focus towards increasing awareness of the benefits of BSEAdvertisementsExhaustive breast

cancer awareness program

Review of BSE to already educated women

Documents

Factors Associated with Breast Self Examination (BSE) Practice Among Female Patients in an Out Patient Clinic in the Philippines MARIA FIDELIS C. MANALO,