Breast Cancer Knowledge among Women in Ebonyi State, Nigeria: Implication for Women Breast Cancer Education

Background Breast cancer mortality rate is increasing among women in developing countries a condition that might be brought about by lack of knowledge of fundamental elements necessary for cancer prevention. To ascertain level of breast cancer knowledge across some socio-demographic variables among women in Method A total sample of 1,845 women was used for the study selected through multistage sampling technique. A 40-items questionnaire eliciting answers on knowledge of cancer symptoms, risk factors, prevention methods and cancer treatment options was used for the study. Descriptive statistics of frequency and percentage were used to answer the research question while Chi-square statistic was used to test the hypotheses at an alpha level of 0.05. more knowledgeable than rural women (47.81%). Chi-square analysis indicated that difference in knowledge was significant for educational attainment, age and location of residence. Breast cancer knowledge of women in Ebonyi State is on the average and differed significantly by education, age and location of women. Consequent it is recommended that breast cancer education should be used to improve their knowledge of the disease, especially for those with non-formal education, older women and those in the rural areas through interventions by government and non-governmental agencies and through curriculum revision for schools.


Introduction
Breast cancer is the commonest of all forms of cancer and one of the major threats to health especially among women [1]. Report on the incidence of breast cancer reveals that one out of every eight women in the world stand a chance of having the disease in her life time [2]. Although the incidence of breast cancer is increasing all over the world, the rate of increase is higher in developing countries where late detection of disease is common [3]. Breast cancer is already a well-known health problem in Nigeria with about 1 death in every 25 reported cases [4]. A major worry about breast cancer in Nigeria is the continuous rise in the number of cases and deaths, a situation which confirms Lakeshore Cancer Center prediction that breast cancer cases may rise to 42 million by 2020 in both males and females in the country [1,5].
The primary reason for this increasing mortality rate is due to lack of early detection of disease [6]. This factor is invariably a direct consequence of lack of breast cancer awareness observed in most developing countries. Knowledge about breast cancer is a fundamental element necessary for the early detection, prevention and treatment of

Journal of Health Education Research & Development
this condition [7]. Knowledge for this study was considered as the possession of accurate understanding of breast cancer, its symptoms, risk factors, prevention, treatment options and centers. Adequate knowledge of breast cancer will equip women with the ability to observe and identify symptoms before the disease starts to spread and seek medical assistance early; while knowledge of causes and risk factors of cancer will help in the prevention of this disease by equipping to adopt preventive measures and appropriate lifestyle modification.
Breast cancer is essentially preventable. Early detection which remains the surest mean of breast cancer prevention can be achieved through Breast Self-Examination (BSE), Clinical Breast Examination (CBE) and Mammography. The frequency of examination is recommended based on age of women and the type of examination being recommended [8]. Again, several treatment options abound including surgery, chemotherapy, radiotherapy and hormonal therapy which women need to know to make informed choices [6,[9][10][11]. The women also need to know where they can access quality cancer care, which include diagnosis, surveillance and advanced treatment options [12]. A comprehensive knowledge of all these components is important for women since it is the first step to preventing the disease and more so, since the disease is obviously of unknown cause, with non-specific treatment and poor prognosis [13].
Nonetheless, some factors are known to influence breast cancer knowledge among women. These factors include, age, education and location. Studies have shown that knowledge significantly correlated with level of education [13,14]. It was observed that women who are educated were more likely to possess satisfactory breast cancer knowledge. Similarly, the disease was found to be more common among women in the urban communities than rural [15]. Although breast cancer occurs frequently among older women, younger women tend to have more knowledge of the disease than the elderly [16].
Statistics indicate rising global incidence of breast cancer and the increase is occurring at a faster rate in developing countries that hitherto enjoyed low incidence of the disease. In Nigeria like in most other developing countries, breast cancer cases are characterized by late presentation of patients at advanced stages of the disease when little or no benefit can be derived from any form of therapy [17]. This trend is quite worrisome and constitutes the stimulus for carrying out this study in Ebonyi State Nigeria, a developing state, which has comparably more illiterate women who live in rural more than urban settlements [18].
The purpose of this study therefore, was to determine levels of breast cancer knowledge among women in Ebonyi State Nigeria and to determine the difference in knowledge by levels of educational attainment, age and location of residence of these women. The study also tested whether the difference in level of knowledge with regard to these socio-demographic variables were significant at 0.05 level of significance.

Design and participants
The cross-sectional survey research design was use for the study. The population of the study comprised 1844496 women aged 35-54 years residing in the thirteen local government areas in Ebonyi State. A sample of 1845 women using the multistage sampling technique was drawn from the thirteen local government areas in the State. This represented less than 1 per cent of the total population of women aged 35-54 years residing in the state.

Instrument
A self-constructed Women's Breast cancer Knowledge Questionnaire (WBCKQ) was used for the study. The instrument consisted of 40 items spread over sections (A-F). Section A elicited questions on personal data and embodied three questions relating to age, residence of respondent and education qualification. Section B, C, D, E and F included series of items of true and false options covering knowledge about breast cancer symptoms, risk factors, prevention, breast cancer treatment options and breast cancer treatment centers respectively. Face validity of the instrument was determined by three experts in health education. Based on the approval of these experts a final copy of the questionnaire was produced and utilized for data collection. The split half method yielded a reliability coefficient of 0.76 using Spearman Brown correlation.

Analysis
Out of 1845 copies of the questionnaire distributed, 1843 (99.9% of those distributed) were found useable. The data collected from each questionnaire were tallied and put into frequencies and simple percentages were used to answer the research questions. Hypotheses were tested using chi-square statistic at an alpha level of 0.05. Table 1 revealed that women's knowledge of breast cancer was average in all the components (symptoms 55%, risk factors 42%, and prevention 57%, and treatment options 52%) except for treatment centers (60%) were the women demonstrated high knowledge. However, the table showed that women's overall knowledge of breast cancer was average. This is evident in a cumulative grand mean score of 48.72 percent.      Summary of data analysis on Table 4 revealed that urban women with average score of 55.61% demonstrated higher knowledge of breast cancer than the rural women with an average score of 47.81 percent.

Discussion
Findings in Table 1 revealed that generally, women in Ebonyi State had average knowledge of all the components of breast cancer. This result disagrees with the popular opinion that women in developing countries like Nigeria have poor knowledge of the disease [6,19]. Fregene and Newman observed that even among the most affluent Nigerian, breast cancer awareness tends to be relatively low in their list of health care priorities [20]. Findings also disagree with those of Oluwatosin, and Oladipo, which reported that women lacked knowledge of vital issues about breast cancer and early detection measures [21]. In this study it was upheld that community-dwelling women in Ebonyi State, Nigeria have rather poor knowledge of breast cancer Nonetheless, this result might have been accounted for by the aggressive campaign mounted by some Non-governmental Organization  Table 2 revealed that education was a strong determinant of knowledge of breast cancer among the women. It was observed that women with post-secondary education in almost all the items had higher knowledge than women with secondary, primary and non-formal levels of education respectively. This result collaborated those of Ozturk, Engin, Kisioglu and Yilmazer which reported that women who graduated from secondary school were 22 times more likely to know and 3 times more likely to perform BSE than others [14]. In the same light Okobia, Bunker, Okonofua and Osime reported that women with higher level of education were significantly more knowledgeable about breast cancer than other women [17]. Table 3 indicated that age had significant influence on knowledge of breast cancer symptoms, risk factors, preventive measures, treatment options and treatment centers respectively. For most of these items, younger women (35-44) had higher knowledge than the older ones (45-54). These findings are not surprising since they agree with most related studies. For instance Self and Aziz reported that women participants less than 40 years, were found to have higher percentage (22.7 percent) of satisfactory knowledge preprogram, than those aged 40 years and above (10.6%) [13]. Grunfeld, Ramirez, Hunter, and Richard also reported that older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poor breast cancer knowledge among older women they observed may help to explain the strong association between older age and delay in seeking help. In the same light, Fregene and Newman observed that breast cancer case ascertainment is low among older African women because of their lower literacy rates, poor socioeconomic status, and diminished awareness of breast cancer [20]. Table 4 indicated that there is difference in the level of knowledge of breast cancer among urban and rural women. This is in line with the observations of Fregene and Newman that understanding and awareness of breast cancer is particularly low within the general population of Africa outside of urbanized areas [20]. Oluwatosin and Oladipo also reported that majority of rural women were not aware of early warning signs of breast cancer and only 1.9% acknowledged a painless lump as an early warning sign [21]. The overall knowledge of treatment of breast cancer was also very poor. However the reason for the disparity in the knowledge of breast cancer between urban and rural women in the present study may be drawn from the opinion of Pheby that Breast cancer is more common in the urban than rural areas [15]. Hoffman et al. also observed a doubling of breast cancer incidence rates in women living in urban areas compared with those residing in the rural [23]. In general high incidence of a disease increases it awareness among community members. It is a common knowledge that urban dwellers in general have more access to health and media services which according to Yucel, Dekremen, Acar, Elldokuz, Albayrak, and Haktanir may enhance their knowledge of health issues especially those occurring in the community [24]. In most rural communities in Nigeria health and media facilities and services are limited, thus rural women are less likely to have adequate knowledge of health information.

Implication for breast cancer education among women
The finding that the women had average knowledge (40-59%) breast cancer, translates to the fact that a good percentage of still lack accurate information concerning the disease, especially in the area of risk factors where the percentage scores range from 33-47%. It is expected that for a disease like breast cancer a high percentage of knowledge is required among the women in order to identify and promptly stop the progression of the disease. Jones et al. observed that adequate knowledge of breast cancer risks especially the role of family and personal history is significantly related to screening behaviour [16]. This implies therefore, that there is a critical need to educate women about breast cancer to improve their knowledge and mounting of effective intervention programmes for dealing with the consequences of breast cancer.
The finding that younger woman have higher knowledge than the older ones is not a cheering situation and has implications for breast cancer prevention and control. This is because breast cancer is predominantly an age-related disease occurring more in older population than younger ones [25,26]. Similarly with respect to the disparity in knowledge across educational levels, findings imply that majority of the women with non-formal and primary education, do not have adequate knowledge of the disease. This is also the case with women in the rural areas. These findings have serious implications on the prevention and control of breast cancer which current data suggest is already in the increase in the Nigeria [18].

Conclusions
Women in Ebonyi State have inadequate knowledge of breast cancer. However knowledge of breast cancer significantly differs among women of diverse educational backgrounds, age and location. Breast cancer knowledge was higher among those with higher levels of education, younger women and women who live in the urban areas. However there is need for improved breast cancer education intervention to enhance women's breast cancer knowledge in the State

Recommendations
Based on the findings of this study the following recommendations are made: Health workers should embark on intensive breast cancer education programmes with emphasis on early detection of symptoms and personal risk assessment through the instrumentality of health care providers and through community based organizations like women associations.
There is also need to maximize the use of the mass-media in the dissemination of cancer education especially through radio and television which enjoy higher listenership.
Programmes for breast cancer education should be mounted for women in the state to improve their knowledge especially for rural women, women with non-formal level of education as well as older women (44 years and above). This can be achieved by designing programmes which specifically target these disadvantage segments of society.
Government should sponsor the integration of breast cancer education into the health education curriculum from an early stage of education and at every level of education to improve the knowledge of the masses through the educational system.