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

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 Group
Department of Community & Family Medicine
FEU-NRMF Medical Center
BREAST 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 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, shyness
 Economical- costs, timeliness
 Educational- knowledge, misconceptions
background
BACKGROUND

Perceived Benefits
 Cost-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)
BACKGROUND

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)
BACKGROUND

Perceived Susceptibility
50%
of cases of breast cancer are
detected by women themselves
Ngelangel 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)
BACKGROUND

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 MODEL
Variables:
Perceived
susceptibility to
and seriousness
of breast CA:
Death in among
relatives and friends
↑awareness
↑information
dissemination
Age
Sex
Geography
Economic status
Educational attainment
Social status
Knowledge of breast CA
Family factors
Perceived threat of
breast CA:
Anxiety due to family history
Higher education
Awareness
Physician recommendation
Cues to action:
Advertising
Advice
Government programs
Information dissemination
Perceived benefits of
preventive action:
Early detection
↑survivability
↓mortality
More treatment options
Perceived barriers to
preventive action:
Embarrassment
Concerns on cost
Inconvenience
Doubts in western medicine
Likelihood of
taking
recommended
preventive
health action
OBJECTIVES

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.
methodology
METHODOLOGY
Creating a Research Design
Establishing a
Target Population
Sampling
Tool: Questionnaire
Data Analysis
• Employment of an
analytical crosssectional type of
study design
• Basis: Fulton’s
Health Belief Model
of 1987
METHODOLOGY
Creating a Research Design
Establishing a
Target Population
Sampling
• Based on current
prevalence rates of
breast cancer in the
country
Tool: Questionnaire
• EpiInfo2000 software
was used
Data Analysis
METHODOLOGY
Creating a Research Design
•Setting:
Establishing a
Target Population
Sampling
Tool: Questionnaire
Data Analysis
•FEU-NRMF Medical
Center, Quezon City,
Philippines
•September 2004
•Subjects
•Cluster sampling
•Out Patient
Department Patients
•Women aged 15 and
older
•n= 130
METHODOLOGY
Creating a Research Design
Establishing a
Target Population
Sampling
Tool: Questionnaire
Data Analysis
• 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
•Perceived
•Perceived
•Perceived
Benefits
Barriers
Susceptibility
Seriousness
METHODOLOGY
Creating a Research Design
Establishing a
Target Population
Sampling
Tool: Questionnaire
Data Analysis
• 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 MantelHaenzel Statistics
RESULTS
Dependent Factor
Practice of BSE
Practice
Do not Practice
N
%
58
72
44.62
55.38
Table 1. Distribution of
Respondents as to Practice of Breast
Self-Examination (n=130)
Factors
RESULTS Independent
Age Group
N
%
35 years old and older
Younger than 35 years of age
56
74
43.08
56.92
Civil Status
Never Married
Ever Married
44
86
33.85
66.15
History of Lumpectomy
With history
Without history
5
125
3.85
96.15
Family of History of Breast CA
With family history
Without family history
15
115
11.54
88.46
Previous Knowledge of BSE
With previous knowledge
Without previous knowledge
82
48
63.08
36.92
Health Beliefs Regarding BSE &
Breast Cancer
Correct beliefs
Incorrect Beliefs
65
65
50.00
50.00
RESULTS
Practice
BSE
Do Not
Practice
BSE
Crude
Odds Ratio
95%
confidence
interval
23
35
33
39
0.777
.385 - 1.566
Civil Status
Never Married
Ever Married
20
38
24
48
1.053
.507 - 2.185
History of Lumpectomy
With history
Without history
3
55
2
70
1.909
.308 - 11.826
Family of History of Breast CA
With family history
Without family history
8
50
7
65
1.486
.505 - 4.372
54
4
28
44
21.214
6.917 - 65.065
41
24
4.824
2.283 - 10.193
Factors
Age Group
35 years old or older
Younger than 35 years of age
Previous Knowledge of BSE
With previous knowledge
Without previous
knowledge
Health Beliefs
Correct health beliefs
discussion
DISCUSSION

Regarding Age Groups
Odds
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 selfexamination and age of the patient.
DISCUSSION

Regarding Civil Status
Although
the practice of breast selfexamination 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.
DISCUSSION

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
DISCUSSION

Regarding Family History
 Although
the practice of breast selfexamination 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.
DISCUSSION

Regarding Previous BSE Knowledge
 Most
remarkable finding
 In the present study, the practice of breast selfexamination 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)
DISCUSSION

Regarding Correct and Incorrect Health Beliefs
(as measured by the validated BSE
questionnaire)
 In
the present study, the practice of breast selfexamination 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)
conclusions
CONCLUSION

Previous knowledge of breast selfexamination 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.
RECOMMENDATIONS

More focus towards
increasing awareness of
the benefits of BSE
 Advertisements
 Exhaustive
breast cancer
awareness program

Review of BSE to already
educated women