1. 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

2. BREAST CANCER Philippines Ngelangel and Wang, 2002
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

3. 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

4. background

5. BACKGROUND Perceived Benefits Contradictions to 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)

6. 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)

7. 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)

8. 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)

9. HEALTH BELIEF MODEL Variables:
Perceived susceptibility to and seriousness of breast CA:
Death in among relatives and friends
↑awareness
↑information dissemination
Variables:
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
Likelihood of taking recommended preventive health action
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

10. OBJECTIVES General Specific
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.

11. methodology

12. Establishing a Target Population
METHODOLOGY
Creating a Research Design
Establishing a Target Population
Employment of an analytical cross-sectional type of study design
Basis: Fulton’s Health Belief Model of 1987
Sampling
Tool: Questionnaire
Data Analysis

13. Establishing a Target Population
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

14. Establishing a Target Population
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

15. Establishing a Target Population
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

16. Establishing a Target Population
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 Cochran’s and Mantel-Haenzel Statistics
Establishing a Target Population
Sampling
Tool: Questionnaire
Data Analysis

17. Respondents as to Practice of Breast Self-Examination (n=130)
RESULTS
Dependent Factor N %
Practice of BSE
Practice
Do not Practice 58 72
44.62
55.38
Table 1. Distribution of
Respondents as to Practice of Breast Self-Examination (n=130)

18. RESULTS Independent Factors N % Age Group 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
50.00
Table 2. Distribution of Respondents as to Sociodemographic Profile and Health Beliefs (n=130)

19. Family of History of Breast CA Previous Knowledge of BSE
RESULTS
Factors
Practice BSE
Do Not Practice BSE
Crude Odds Ratio
95% confidence interval
Age Group
35 years old or older
Younger than 35 years of age 23 35 33 39
0.777
Civil Status
Never Married
Ever Married 20 38 24 48
1.053
History of Lumpectomy
With history
Without history 3 55 2 70
1.909
Family of History of Breast CA
With family history
Without family history 8 50 7 65
1.486
Previous Knowledge of BSE
With previous knowledge
Without previous knowledge 54 4 28 44
21.214
Health Beliefs
Correct health beliefs
Incorrect health beliefs 41 17
4.824
Table 3. Crude Odds Ratio and 95% Confidence Interval for BSE Practice and Study Variables (n=130)

20. discussion

21. DISCUSSION Regarding Age Groups
Odds ratio (OR) between high risk age group and low risk age group is (95% CI= )
This study failed to show a relationship between the practice of breast self-examination and age of the patient.

22. 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 (OR=1.053, 95% CI= ), 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.

23. 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= ), 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

24. 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% CI= ), 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.

25. 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= , 95% CI= ).
Educated, working and aged 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)

26. 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= ).
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)

27. conclusions

28. 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= )
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.

29. RECOMMENDATIONS
More focus towards increasing awareness of the benefits of BSE
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Exhaustive breast cancer awareness program
Review of BSE to already educated women