Factors Associated with Breast Self Examination BSE Practice Among Female Patients in an Out Patient

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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

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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

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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

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background
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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)

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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)

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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 (OR1.87)
• History of benign breast disease (OR2.51)
• Infertility (OR5.83)
• gt35 years of age (OR18.2)

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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)

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HEALTH BELIEF MODEL
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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.

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methodology
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METHODOLOGY
Creating a Research Design
Establishing a Target Population

• Employment of an analytical cross-sectional type
  of study design
• Basis Fultons Health Belief Model of 1987

Sampling
Tool Questionnaire
Data Analysis
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METHODOLOGY
Creating a Research Design
Establishing a Target Population

• Based on current prevalence rates of breast
  cancer in the country
• EpiInfo2000 software was used

Sampling
Tool Questionnaire
Data Analysis
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METHODOLOGY
Creating a Research Design

• Setting
• FEU-NRMF Medical Center, Quezon City, Philippines
• September 2004
• Subjects
• Cluster sampling
• Out Patient Department Patients
• Women aged 15 and older
• n 130

Establishing a Target Population
Sampling
Tool Questionnaire
Data Analysis
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METHODOLOGY
Creating a Research Design

• 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

Establishing a Target Population
Sampling
Tool Questionnaire
Data Analysis
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METHODOLOGY
Creating a Research Design

• 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 Cochrans and Mantel-Haenzel
  Statistics

Establishing a Target Population
Sampling
Tool Questionnaire
Data Analysis
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RESULTS
Table 1. Distribution of Respondents as to
Practice of Breast Self-Examination (n130)
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RESULTS
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RESULTS
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discussion
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DISCUSSION

• Regarding Age Groups
• Odds ratio (OR) between high risk age group and
  low risk age group is 0.777 (95 CI0.385-1.566)
• This study failed to show a relationship between
  the practice of breast self-examination and age
  of the patient.

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DISCUSSION

• 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 (OR1.053, 95
  CI0.507-2.185), this difference is not
  statistically significant.
• This study failed to support Chees 2003 study,
  which states that women who had married and
  pregnant women practice BSE monthly, due perhaps
  to general anxiety.

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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 (OR1.909, 95
  CI0.308-11.826), 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

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DISCUSSION

• Regarding Family History
• Although 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 CI0.505-4.372),
  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.

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DISCUSSION

• Regarding Previous BSE Knowledge
• Most remarkable finding
• In the present study, the practice of breast
  self-examination was significantly associated
  with previous knowledge of breast
  self-examination (OR 21.214, 95
  CI6.917-65.065).
• 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)

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DISCUSSION

• 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 ones
  skills in performing BSE plus the absence of
  specific training programs (Bhakta, 1995)

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conclusions
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CONCLUSION

• 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.

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RECOMMENDATIONS

• More focus towards increasing awareness of the
  benefits of BSE
• Advertisements
• Exhaustive breast cancer awareness program
• Review of BSE to already educated women