Background

Breast cancer is a public health concern. Its upward prevalence in Africa particularly Nigeria is alarming [1,2,3]. Breast cancer contributes to the highest cancer morbidity and mortality rate among women in developing countries [1, 4,5,6]. About 1.15 million new cases of breast cancer are diagnosed every year worldwide, and 502,000 women die yearly from the deadly disease [7, 8]. More than 70% of new cancer cases will occur in developing countries by 2020. More so, in Nigeria, breast cancer is the leading cause of cancer mortality in women with an annual incidence of 33.3 per 100,000 in women [9, 10]. Despite the high prevalence, several studies have documented a low level of breast cancer awareness in developing countries [11,12,13,14].

Effective management of breast cancer depends largely on its early detection through periodic mammograms, clinical breast examinations (CBE), and monthly breast self-examination (BSE) [15,16,17, and]. There have been overwhelming barriers to screening and treatment of cancer in developing countries [18, 19]. Moreover, majority of the cancer patients present themselves late for treatment especially when little or nothing can be done. This owes to lack of knowledge regarding the risk factors, symptoms, screening methods and treatments associated with different cancers [18, 20, 21]. In Nigeria, the cost of breast cancer screening through mammography is high and requires a specific manpower resource which makes it not very attainable. However, breast self-examination remains the cheapest, non-invasive and simple to follow the procedure as it requires no special skill and material. It is an effective screening method for breast cancer that only takes 5 min to apply [1, 4, 22, 23].

Studies have attested to the positive association between the performance of BSE and the detection of breast cancer [24,25,26]. BSE allows a woman to be aware of her usual breast structure and helps her notice any abnormal changes in her breast tissue [27, 28]. The assessment of the public awareness, attitudes towards, and practice of BSE is of fundamental importance to the successful implementation of breast cancer control activities [29]. However, the awareness and practice of clinical breast self-examination and breast self-examination are reported to be low [5, 9, 30].

The American Cancer Society recommends breast self-examination for women starting from when they are in their 20s to ensure early detection and access to care [31]. This requires a proper orientation and adequate knowledge on cancer risk factors, symptoms, screening methods, and basic practical procedure on how to conduct a BSE [31]. The adolescence is a time of rapid development that provides teaching opportunities for shaping health behaviours into adulthood [2, 32]. A study among Iranian women reveals high levels of educational needs on breast self-examination [33]. Studies have been conducted in Nigeria to investigate the knowledge, attitude and practice of BSE among adolescents [2, 19, 34, 35], but none of the studies had focused on the impact of an educational programme to equip adolescents with the right knowledge about and procedure for carrying out a BSE which is also non-existing in the student curricula. Poor knowledge, low practice and negative attitude towards BSE were reported among secondary school teachers who are supposed to be a source of information, change agents and role models on sexual health for adolescents in school [34]. Moreover, another study on adolescent secondary school students in Nigeria affirms poor knowledge of breast cancer and BSE and the need to fill this gap among the adolescents [2]. Hence, this study was developed as an educational and promotional programme for BSE. This study therefore evaluate the impact of education on the knowledge, attitude towards and practice of education practices of BSE.

Material and Methods

Study Design and Setting

In this quasi-experimental study of one group, a pre- and post-assessment was conducted at Fiwasaye Girls Grammar School in Akure, Ondo State, Nigeria. The school is a girl-only public school established in 1960 with a total student population of about 3096 students at the time of the study. The school was chosen because it has the highest population of adolescent girls in Akure, Ondo State.

Population and Sampling Procedure

Students in the senior secondary classes (SS1–3) aged between 12 and 19 years were purposefully involved in this study because the researchers believed that they would have fully developed breast and will fit the purpose of the study.

Sample size was calculated based on a student population of 3500, proportional distribution of 70%, margin of error 5% and confidence interval of 95%. Sample size calculated yielded 296 and was approximated to 300. A total of 300 students were selected across the arms of the senior secondary students (SS1–3) through multi-stage clustering and simple random sampling in three stages.

  1. Stage 1

    3 classes in each arm of SS1–3 were randomly selected making a total of 9 classes

  2. Stage 2

    100 students were selected from the selected classes in each arm to have a total population of 300 students using a YES/NO ballot system.

  3. Stage 3

    The selected 300 students were divided into 6 groups, group A–F through balloting in no particular order.

Study Instrument

A self-administered questionnaire adapted from previous studies and validated for this study was used for data collection [2, 5, 9, 11, 13, 14, 23, 25]. The instrument comprised sections A–C of 30 items with categorical and continuous variables. Section A assessed the students’ demographic characteristics (age groups, class, religion and ethnicity). Section B consists of variables on the students’ level of knowledge of breast cancer and BSE (10 questions). The knowledge scores were classified as poor knowledge, less than 50%; fair knowledge, 50 to < 75%; good knowledge, 75% or more. Section C explores the students’ scores regarding their attitude (10 questions) towards and practice (5 questions) of breast self-examination on Likert scales.

The instrument was pilot tested for face validity and reliability testing among 20 students of St Louis Girls’ Grammar School, Akure. The questionnaire was administered to students twice within a 2-week interval, and the responses were analysed and compared. Content and construct validation were done through expert opinion of three specialists in adolescents health and health promotion outside the research team. The Cronbach’s alpha reliability of the instrument was found to be 0.8.

Data Collection Process

Data were collected between September and November 2018, starting with a pre-assessment questionnaire to ascertain the students’ knowledge, attitude towards and practice of BSE. This was followed by 6 sessions of educational training on BSE of about 45–60 min with 50 students in each session. The educational training programme consisted of powerpoint and video presentations of BSE, and also included a practical demonstration on BSE. The students were asked to write questions for further clarification on paper to encourage participation, confidentiality and prevent stigmatisation. As a follow-up, a leaflet on BSE and the telephone number of the presenters were given to the students should they require further information or have more questions. Attendance for each of the session was collected.

The instrument was re-administered to the same group of students after 8 weeks of the educational programme to evaluate the post-educational knowledge, attitude and practices of breast self-examination.

Only 280 students out of the 300 recruited for the study completed the whole process of the intervention. Eight (8) of the students fell sick within the period, and total 12 students dropout the study after pre-test assessment for personal reasons.

Data Management and Statistical Analysis

Data collected were cross-checked, coded and entered into the Statistical Package for the Social Science (SPSS) version 20. Descriptive statistics including frequencies, percentages and measures of central tendencies, chi-square tests, and independent t test were used to examine the association and difference between relevant variables with a significance level (p value) set at 0.05.

Ethical Consideration

The study protocol was approved by the Research Committee at the School of Midwifery in Akure, Ondo State, Nigeria, while administrative approval was obtained from the principal of Fiwasaye Girls Grammar School. Written and verbal informed consents were obtained from the students after a detailed explanation of the study. All ethical principles regarding confidentiality, justice, rights to participation, etc. were adhered to throughout the study.

Results

Characteristics of Study Participants

The participants in this study ranged in age from 12 to 20 years with a mean age 13.21 ± 5.68. Of the 280 respondents, 179 (63.9%) were in the age group of 15–17, and the minority 27 (9.6%) were in the age group of 18–20. Regarding the religion of the respondents, almost 255 (91.1%) were Christians and 25 (8.9%) were Muslims. About 249 (88.9%) were Yoruba and 31 (11.1%) were Igbo by ethnicity. Table 1 below presents the details of socio-demographic data of the respondents.

Table 1 Socio-demographic characteristics of the students (n = 280)
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Knowledge of Breast Cancer and Breast Self-Examination

In Table 2 on the knowledge of breast cancer among the female adolescents, the data shows that the participants has a fairly high degree of knowledge at 68.9% which increased to 97.1% post-education intervention. About 187 (66.8%) of the female adolescents have heard of breast cancer before the education intervention, and afterward 257 (91.8%) became aware of breast cancer. In the pre-test 200 (71.4%) of the adolescents indicated that they do not have a first-degree relative (parent or siblings) who have been diagnosed with breast cancer and post-education intervention, this number increased to 261 (93.2%) which likely indicates poor knowledge of characteristic symptoms of breast cancer.

Table 2 Students’ Knowledge of BSE pre- and post-intervention
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The level of knowledge of BSE of the respondent before the education programme shows that only 25.4% of the participants had good knowledge of how to conduct a BSE which increase to 56.8% post-education (Fig. 1).

Fig. 1
figure 1

Students’ cumulative knowledge of breast self-examination pre- and post-education programme

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An independent t test to evaluate the effect of the educational intervention on respondents knowledge of BSE indicate that the mean score of post-intervention was higher (M = 4.56, SD = 1.44) compared with pre-intervention (M = 2.10, SD = 1.04). Further, the result demonstrates a significant difference between pre and post t (558) = 14.49, p = 0.01, two-tailed).

Attitude to Breast Self-Examination

On adolescents attitude regarding breast self-examination, in the pre-education phase, 109 (38.9%) of the respondents agreed that there were many benefits associated with BSE while post-education, 272 (97.1%) agreed that breast self-examination has huge benefits. During the pre-education phase, 25 (8.9%) of the respondents agreed that BSE is a low-cost method of detecting breast cancer at its early stage. This proportion increased to 219 (78.3%) during the post-education phase. The majority 270 (96.4%) of the respondents agreed that BSE is time-consuming in the pre-education phase while in the post-education phase, this proportion was reduced to 136 (48.6%), which further revealed the impact of the education given to the female adolescents. During the pre-education assessment, only 43 (15.3%) of the respondents felt that they could accurately detect any abnormality in their breasts, but this figure increased to 222 (79.3%) post-educational intervention. These results showed the impact of the education programme on the adolescent’s attitude towards BSE in Fig. 2 and Table 3.

Fig. 2
figure 2

Attitude to breast self-examination pre- and post-education

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Table 3 Students’ attitude level of BSE pre- and post-intervention
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The Practice of Breast Self-Examination

The practice of BSE among female adolescents was presented in Fig. 3. During the pre-education period, about 40% of the students were practising BSE while in the post-intervention phase, there was significant increase of more than 80%. A t test evaluation of the effects of educational intervention on the practice of BSE indicate that the mean score of the post-intervention was higher (M = 30.01, SD = 4.52) than pre-intervention (M = 28.08, SD = 2.21). Furthermore, the result demonstrates that there was a statistically significant difference in behaviour between pre- and post-intervention (t (558) = 6.38, p = 0.01, two-tailed).

Fig. 3
figure 3

Practice of BSE

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Discussion

BSE is a useful and an essential screening strategy for early detection of breast lumps for breast cancer. It is believed that helping adolescents develop proper BSE health habits will lead to the maintenance of good health and early detection of breast anomaly in adulthood [36]. The adolescent’s knowledge and awareness of breast cancer in this study was fairly good. This finding is congruent with a study on knowledge and awareness of breast cancer among female secondary school students in Nigeria in which about 194 (97%) have heard of breast cancer [35] but differs with (56.8%) knowledge of breast cancer in another Nigerian study [2]. In other related studies, 95% knowledge of breast cancer was reported among female university students in Ghana [37] while poor levels of knowledge of breast cancer were documented among female students in Jordan and Malaysia [38, 39].

The knowledge about the characteristic symptoms of breast cancer among this study participant was inadequate as indicated in the significant increase in the number of adolescents who indicated that they do not have relatives who has been diagnosed with breast cancer post-educational intervention as against the pre-test percentage. Several other studies also confirm the lack of proper knowledge on risks and symptoms of breast cancer [18, 20, 21].

Generally, the students’ pre-knowledge about BSE was very poor despite their high level of breast cancer awareness. Only a few of the participants could perform BSE on themselves with majority not knowing how to perform BSE correctly. Knowledge regarding BSE was also not sufficient among the adolescents in Turkey where only 13.2% have knowledge about the appropriate time for a BSE, 21.8% know the frequency in performing a BSE and 26.6% know the correct procedure of BSE [36]. Similarly, only 35% of adolescents in this study are familiar with the steps involved in BSE, and only a few students could detect a breast anomaly while the majority of the students affirmed the need for an educational programme on BSE.

Advocacy for proper orientation and information on BSE not only for adolescent but also for teachers and women in general has been reiterated in several studies. An assessment of BSE knowledge among female secondary school teachers in Nigeria and Kuwait shows insufficient knowledge of BSE [34, 40]. Likewise, inadequate information on BSE was overwhelming among adolescents in different studies [25, 35, 40, 41].

This study shows a significant increase in the level of knowledge of breast cancer among the respondents from 25.4% pre-intervention to 56.8% post-intervention. There was also a positive impact on the adolescents level of knowledge about BSE between the pre- and post-intervention t (558) = 14.49, p = 0.01 (two-tailed). Related evaluation of the effectiveness of online education in teaching BSE yielded a positive association on pre- and post-intervention knowledge about BSE among the 1679 woman participants in a BSE online training programme [42]. A similar improvement was recorded in the post-assessment of a peer education programme regarding knowledge of breast cancer and practice of BSE among Mansoura University female students at (t = 43.020, p = 0.000) and the post-education II (t = 38.566) [25].

The pre-intervention attitude towards BSE was rather poor in this study. A low percentage of the adolescents believed BSE is beneficial, and only a few students affirmed BSE as a low-cost approach to detecting breast cancer. The majority of the participants expressed the view that BSE is time-consuming, may sometime be painful and a practice that can be easily forgotten about. The negative attitude towards the practice of BSE was admitted in previous studies [33, 43]. Participants expressed a lack of knowledge, not having any symptoms suggestive of cancer and being afraid of being diagnosed with breast cancer as the main barriers to practising BSE. However, the adverse attitude towards BSE seems to be higher of among respondents in another study in Malaysia [41]. More encouraging, the adolescents’ attitude towards BSE became more positive after the educational intervention in this current study, and this was congruent with the findings in other related studies [25, 41].

The level of the practice of BSE among female adolescents was very poor at the pre-education assessment; only small number of the students were likely to conduct a BSE following the five steps of the procedure in the next month which however the figure increased significantly at post education. Furthermore, a small number of the adolescents were determined to complete BSEs once a month for the next 6 months at pre-education, and this proportion increased to 99 (35.4%) post-education intervention. These results indicated the poor practice of BSE related to inadequate knowledge and lack of motivation among adolescents. Several other studies across Africa and beyond also reported the poor practice of BSE [5, 38, 40, 41, 44, 45]. Health education is a motivational approach to enhance knowledge and practice. There was a significant increase in BSE performance post-educational intervention to more than 80% against 40% pre-evaluation.

Conclusion

BSE is a public health strategy for women starting from when they are in their early teens in order to detect breast anomaly and seek timely medical intervention. This study on the knowledge and practice of BSE pre- and post-intervention among adolescents reveals an increase in the level of awareness of breast cancer but an inadequate and insufficient knowledge about BSE. An unenthusiastic attitude towards BSE practice was also observed. However, these parameters increased in positive relativity with the application of an educational programme. Therefore, there is a need to embark on more focused educational, motivational and evaluation intervention programmes of BSE for adolescents and women.

Limitation of the Study

The study was conducted in a girl-only school in Akure and might not represent the general outcome of the vast network of schools in Akure. However, the study findings lay credence to the impact of accurate education on the knowledge, attitude towards and practice of BSE particular among adolescent girls.