CHAPTER II

REVIEW OF LITERATURE
A lot of research has been carried which aims to explore the knowledge about breast cancer and
the attitudes and beliefs regarding its screening practice among women in different parts of the
world. To make our review of literature more focused we have documented studies beginning
with studies conducted in the western world and then moving on to those carried out in Middle
Eastern and South East Asian countries.india.
Shrivastava, Saurabh RamBihariLal (2013) With the rising incidence of breast cancer and
absence of any uniform breast screening strategy in most of the nations, it is important to assess
the knowledge and practice of BSE in various age groups. Irrespective of the multiple benefits of
BSE, various studies identified a wide knowledge application gap with regards to BSE, the
practice of BSE remaining low and variable in different nations like 54% in England ; varying
from 19% to 43.2% in Nigeria , and varying from 0 to 52% in India. In a study done in Korea,
27% of students were engaged in BSE which was higher than what was observed in students
(10.1%) from Nigeria
Among the health-care providers, around 90.3% women performed BSE in Sao Paulo ; while in
Turkey 28% of the nurses and 32% of physicians did not practice BSE . Similarly, in a cross-
sectional study conducted in Iran it was revealed that most of the female health care workers (63-
72%) did not practice BSE . Studies done with an aim to assess the knowledge about BSE among
men have shown low level of knowledge
.
This was mainly because most of the pamphlets and
information-education-counseling materials usually deals only with womens breast cancer
related issues
Pinar erbay dundar, dilek ozmen(2006 ) conducted a study on the knowledge and attitude of
breast self examination and mammography among rural area women in turkey. It is a cross
sectional studies were performed in 244 womon 20-64 years old. This study result women's
responses 23.4% of them had no knowledge about breast cancer, 27.9% had no concept of BSE,
89.3% had never had a mammography and 75.0% had never had CBE. 27.9% of the women
participants, expressed no previous knowledge of mammography. Only 5.1% of them, had had
an annual mammography or over a two year period. Although 72.1% of the participants reported
having a knowledge of BSE, only 40.9% of the women in the practised group ever indicated
having practised BSE in the previous 12 months. In this BSE practice group, while 29.5% stated
they had examined themselves irregularly, only 10.2% stated that they performed BSE on a
regular monthly basis. A total of 59.1% of the participants indicated they had never performed
BSE. 10.6% of the study group stated that they had had mammography tests and 25.0% had
CBE.
Anyanwu SN (2000) Conducted a study to assess the knowledge, attitude and practice of breast
self-examination (BSE) among female medical students in University of Lagos. The study was
designed as a cross sectional survey of female students .This study results is majority of the
respondents, 40.7% were from the age group 21-22 drawn from first to sixth year medical
students.97.3% had heard of breast cancer and breast self-examination.54.8% of the respondents
heard of breast cancer from television/ radio. Most of the respondents, 85.8% knew how to
perform breast self-examination correctly. Only 65.4% of the respondents thought that breast
self-examination was necessary. 43.5% of the respondents said that the last time they performed
breast self-examination less than a year ago. Majority of the respondents, 69.6% preferred to
perform breast self-examination in the morning while 47.7% of the respondents preferred to
carry out breast self-examination in front of the mirror.

Mc Donald, Thorne and co workers (1999) of the Howard University Cancer Centre, reported
their findings in a group of 120 randomly selected African American women who were
interviewed to determine their perceived severity of breast cancer, perceived barriers to breast
cancer screening, and perceived benefits of mammography. Additionally, knowledge about
breast cancer causes, risk factors, symptoms and screening was also assessed. 75.8% women
performed BSE, knowledge about breast cancer was poor. On the contrary in our study we found
that only 12 % of women performed BSE regularly while an additional 23% were irregular
performers and the overall awareness about breast cancer was moderate at 52%

Whereas McDonald et al conducted their study based on the Health Belief Model, ours did not
incorporate Friedman, Nelson et al (7) in their paper in the American Journal of Preventive
Medicine in 1994 noted that whereas over 90% of women were aware of breast self examination
(BSE) practice, a mere 27% perform BSE monthly. They found that a majority of their subjects
knew about most of the recommended BSE steps. The most frequently endorsed barrier was
forgetting, or being too busy. In our study on the other hand the overall performance of BSE was
quite low with only 12 out of 80 or 15% women reporting a once a month performance, and 23%
reported performing BSE irregularly. The most common reason for non performance stated by
women on our study was, not knowing the correct method of performing it while being too busy
was the second most important reason.
In another study on breast cancer detection practices of 57 South Asian women aged 40 years
and over, residing in Toronto, Canada, Chaudhury and Srivasatava (10) whos paper was
published in Oncology Nursing Forum in November 1998 and founded that only 12% of the
participants practiced BSE monthly and a majority (i.e. 54%) said that they did not know much
about breast cancer. Our study revealed a similar percentage of BSE performers (12% claimed
they were regular while 23% were irregular performers) and overall awareness level about breast
cancer of 52%. The investigators used an interview guide designed specifically for their study.

Stephanie Kung et al (11) conducted a research on Screening for Breast Cancer and Cervical
Cancer in a large city in northwestern Germany and published their results in the European
Journal of Public Health. They noted that knowledge about available procedures for early
detection of breast cancer was good and rates of BSE were high (43%). These findings did not
correlate with ours, with Indian women in our study sample having less than adequate
knowledge about breast cancer (52%), and practice of BSE being quite low at 12 %.

Wardle et al (12) published their findings in the European Journal of Cancer Prevention in
February 1995. Their study group involved young women between 17 to 30 years of age whereas
our study was focused on middle aged and older women (40 years and above). They evaluated
the attitudes to BSE by means of a questionnaire and their results showed that 54% of women
reported as never having practiced BSE, whereas in our study 38% women had never heard of
BSE and, additionally 24% women claimed that they had heard of BSE but never performed it.
Furthermore, only 8% reported regular and 36% occasional performance. In our study too only
12 % performed BSE monthly and 23% irregularly

Avci IA (14) conducted a descriptive correlational study to identify knowledge levels and
performance frequency of BSE and to examine variables related to breast cancer screening
behaviours in a sample of 103 Muslim female workers at a hazelnut factory in Ordu city, Turkey.
He published his results in the European Journal of Oncology in April of 2008 which showed
that only 26.2% of the women reported knowledge about BSE and BSE performance was as low
as 4.3%. Our study on the other hand revealed that 62% women had heard of BSE, however a
smaller percentage claimed to be regular performers (12%).

Bener, Alvash, Miller and Denic (18) in 2001 conducted a cross sectional questionnaire based
survey to evaluate knowledge, attitudes and practices related to breast cancer screening among
1750 Arabic women aged 40 to 65 years who attended primary health care centers and reported
in the Journal of Cancer Education that knowledge about breast cancer screening was low and
only 12.7% of the study population practices BSE. Our study group too included women over 40
years of age. Overall awareness in our study group rated higher (52%) but BSE performance was
similar to the Arabic study (12 % were regular and 23% were irregular performers.)

In the July 2002 issue of the Saudi Medical Journal, Alam AA (19) published a study to assess
the knowledge of breast cancer and its risk factors among women in Riyadh and reported that
knowledge about breast cancer and BSE was as high as 82% however, only 41.2% of the women
performed BSE with a lesser percentage performing it regularly, on a monthly basis. In
comparison, our study revealed a lesser overall awareness (52%) and an even lower monthly
performance of BSE (12%).Knowledge about risk factors and protective factors was found to be
moderate and it was also concluded that knowledge varies according to marital status and the
level of education in these women. Even though marital status did not have any impact on
awareness levels( since all of the women included in our study were married, this variable could
not be highlighted), the level of education correlated positively with awareness with more
educated women having a greater degree of knowledge about breast cancer, its risk factors and
protective factors. Alam AA also determined that 18.2% of the 864 participants had had a
mammography done, our study did not investigate this factor.

K.J.Somaiya A cross sectional study conducted over a period of two months among 80 women
were interviewed by means of a structured questionnaire (after obtaining written informed
consent) in the surgical outpatient department in Mumbai. Breast cancer awareness was found
to be 52% in this group of women even though 95% women claimed to have heard of the
disease. Only 12% of all women had received information about breast cancer from health
professionals while a majority (60%) stated their source of information to be family and friends.
Level of breast cancer knowledge was significantly associated with age (younger women more
aware than older), income (women belonging to higher income group found to be more aware
than those who were economically deprived), literacy (graduates and post graduates more
knowledgeable), parity (women bearing lesser number of children being more aware),
occupation (teachers and businesswomen being the most aware versus farmers who were the
least aware). 38% women had never heard of BSE and among those that had heard of it, 15%
were regular while 23% were irregular performers. Thus performance of BSE was found to be
inadequate in this group. Not knowing the correct method was the most frequently reported
reason for non performance.