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 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

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 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)

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 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

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.

methodology

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

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

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

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

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

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)

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)

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 .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 Previous Knowledge of BSE With previous knowledge Without previous knowledge 54 4 28 44 21.214 6.917 - 65.065 Health Beliefs Correct health beliefs Incorrect health beliefs 41 17 4.824 2.283 - 10.193 Table 3. Crude Odds Ratio and 95% Confidence Interval for BSE Practice and Study Variables (n=130)

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 self-examination and age of the patient.

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=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 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.

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% 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 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)

conclusions

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.

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