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Perception of women regarding breast cancer in urban and rural community of Ahmedabad district.

INTRODUCTION: Breast cancer accounts for 19-34% of all cancer cases among women in India ranking second to cervical cancer. (1) The peak occurrence of breast cancer in developed countries is above the age of 50 whereas in India it is above the age of 40. In India, the number of new breast cancer cases is about 115, 000 per year and this is expected to rise to 250, 000 new cases per year by 2015. (2)

This study aims to address a gap in the breast cancer research that surrounds the issues of urban and rural women. There is a general lack of information in this area and this study will help to gain a greater understanding, improve the level of knowledge and address the perceptions of breast cancer, and as such, lead to improvements in health promotion and education aimed at this target group.

MATERIALS AND METHODOLOGY: The study is a Community based cross-sectional study conducted from May 2013 to September 2013 in Urban and Rural settings of Ahmedabad district. A pre-designed and pre-tested proforma was used to collect baseline data by house to house visits. Informed consent was also taken before the initiation of survey. Data was entered into MS Office-Excel 2007 and analysis was done in Epi info version 3.7.1.

Z test and Chi square test were used to test statistical significance

RESULTS AND OBSERVATIONS:
TABLE 1: Age wise distribution of respondents in urban and rural area

Age (in yrs.)   Urban[N=250]   Rural[N=250]

20-24             18(7.2%)      36(14.4%)
25-29             30(12%)       26(10.4%)
30-34            57(22.8%)       55(22%)
35-39            54(21.6%)       45(18%)
40-44             25(10%)         15(6%)
45-49            34(13.6%)      37(14.8%)
>50              32(12.8%)      36(14.4%)


Table 1 shows that a total of 500 women in the reproductive age group were studied in Ahmedabad district. 250 women were taken from urban and rural areas each for the study.

Maximum no. of women were in the age group of 30-40 years, 111 women (44.4%) in urban areas and 100 women (40%) in rural areas.

There was no statistical significant difference in the mean age of studied women of urban (35.71 + 29.04) & rural areas (35.71 + 25.6) ([x.sup.2] = 10.02, P> 0.05).

The study shows that in urban area, women were equally distributed in socio-economic class II-IV whereas in rural area majority of the respondents belonged to class III and class IV.

When the women were asked about whether they have ever heard about breast cancer, 87.2% of urban women replied of having heard about it, while only 67.2% rural women had any knowledge regarding the breast cancer.

Hence, a total of 386 women out of 500 women (77.2%) including both urban and rural women were further interviewed with the questionnaire.

When the perceptions of urban and rural women were compared regarding the causative risk factors of breast cancer, it was revealed that 87% of urban women and almost 80% of rural women knew that family history was a positive risk factor, whereas 7.73% rural women didn't have any idea about it.

90.82% urban women knew that previous breast cancer in a women was also a risk factor while only 40.85% rural women knew about the same.

Response to smoking as a risk factor gave almost similar results in urban and rural women, 61-62% women said yes while almost 38-39% women said that smoking is not a causative risk factor for breast cancer.

In urban areas, 71.1% women said alcohol to be causative in breast cancer while 66% rural women denied the fact saying it is not a risk factor in cancer.

Where almost 43-44% urban women said old age may or may not be a breast cancer risk factor, 12.38% women did not have any knowledge relating to it, also upto 65% rural women said old age is not a risk factor for breast cancer.

43.11% urban women knew that oral contraceptives were associated with breast cancer while 52.38% rural women said OCPs are not associated with breast cancer.

Majority of the urban women (47.24%) said that high fat diet is not associated with breast cancer whereas 41.6% rural women believed high fat diet to be a risk factor. Also 44.64% rural women didn't know about the exact relation of high fat diet with breast cancer.

Majority of the urban women (90.36%) and rural women (64.28%) had the knowledge of excess weight being associated with breast cancer.

There is statistically significant difference (p<0.05) of perception between urban and rural women regarding all the above study variables except smoking where p>0.05.

The above table shows the perception of urban and rural women regarding the menstruation associated risk factors in the causation of breast cancer. Almost 50% urban women believed that early onset of menses at less than 12 years of age was a positive risk factor for breast cancer whereas almost 45% rural women were not sure about its relation with the cancer causation. This was statistically significant at 95% confidence interval.

Considering late menopause at age more than 55 years as a risk factor for breast cancer, almost 73% urban women and 80% rural women said yes, it is causative factor.

All the urban women (100%) said breast feeding was a protective factor in breast cancer while only 58.33% rural women supported this fact. Perception regarding late menopause and breast feeding was not statistically significant amongst urban and rural women.

Most of the urban (67.83%) and rural (55.35%) women believed that late first pregnancy was not a causative risk factor in breast cancer. This was statistically significant with p<0.05 confidence level.

The above table shows that a significant (p<0.05) higher number of urban women (92.2%) perceived painless breast lump was an important symptom of breast cancer. On the other hand, a significant (p<0.05) higher number of rural women believed ulceration (27.38%) and pain in the breast region (89.28%) were important risk factors for the same.

The table shows perception of urban and rural women for the nipple associated breast cancer potential symptoms. It was concluded that a significant (p<0.05) higher number of rural women (82.14%) perceived nipple ulceration while 100% rural women said nipple discharge/bleeding was a potential symptom in identifying the breast cancer. A significant (p<0.05) higher number of urban women perceived nipple inversion or retraction (80.73%) were important symptoms for early identification of breast cancer.

There was found to be a statistical significant difference (p<0.05) between the urban and rural access to information. Where majority of the women(310 out of 386) accepted media and newspapers as the most common source of information, almost 56.21% urban women and 24.09% rural women were included in this group. Nearly 10% rural women came to know about the facts of breast cancer from their friends and elders. Hospitals were a source of information for 17.09% urban women. Hence, this reveals the major source of information is still the media and newspapers (80.31%) for both the urban and rural women.

DISCUSSION: It was apparent that the participants in this research had very low levels of knowledge about breast cancer and the issues surrounding the disease. They appeared to hazard guesses or offer occasional correct facts but, overall, they were very hesitant and very doubtful as to whether the information they were providing was accurate. Many of their responses to questions were 'I don't know'. (3,4) Paul et al 4 and Vahabi (5) have stated that generally there is a very low level of knowledge and understanding, in some cases especially in rural women similar to that found in this study.

Though 87% of the urban women had heard about breast cancer, only 67% rural women were aware about it. Though 87% of the urban women had heard about breast cancer, only 67% rural women were aware about it. Another major risk determinant, family history of breast cancer increases the risk. (6) In our study, 87.15% urban women and 79.16% rural women were aware of this fact and this finding is in agreement with previous research by Paul et al. (4)

It was interesting to find that some 26% rural women could co-relate breast feeding with breast cancer. This was similar to the study by Evans et al. (7) Other factors responsible for breast cancer according to them were increased use of OCPs, late first pregnancy and early marriage.

Perception of Breast Cancer Symptoms: It was found that over 70% of the surveyed women were able to perceive painless breast lump and nipple discharge/bleeding as symptoms of breast cancer. Knowledge of symptoms was poorer among rural women. All of these conditions however, are considered to warrant hospital referral in a significant proportion of women as stated by Dixon and Mansel. (8)

The low level of knowledge found in this study is similar to reports from other Indian states, (9,10) as well as developing countries. (11) Uche (12) reported only 32% of the women having knowledge of breast lump as a warning sign for breast cancer, 58.5% being unaware of most warning signs and only 9.8% knowing methods of detecting breast cancer.

The results are important, as according to Ramirez et al, 1 there is moderate evidence to suggest that one of the major determinants of delay behaviour among patients is the discovery of a breast symptom other than a lump The summary message is that women would benefit from clear information about the variety of symptoms that may be indicative of a potential cancer. However, any intervention to improve knowledge of symptoms should also aim to limit anxiety and to ensure that medical facilities are not overloaded by help-seeking for benign symptoms, particularly by low risk women.

SUMMARY AND CONCLUSIONS: Despite numerous breast cancer early detection campaigns being organized locally and a lot of activities being done by the Government at national level, women in this study still displayed knowledge deficits. This study has supported research indicating the low levels of knowledge and perceptions of risk around breast cancer, and the factors that influence these perceptions.

In this study, mostly rural women identified that they have little to no knowledge of breast cancer and that their perceptions and awareness. They identified that the main things that influenced these perceptions were age, family history, staying in rural area, experience and the media. I contend that these findings further highlight the need for developing and implementing effective breast cancer education and prevention programs among the general public in Ahmedabad.

Along with this, cancer prevention program should emphasize the provision of factual information about breast cancer in the context of an exploration of inaccurate beliefs about cancer that may inhibit health behavior. Hence, there is an urgent need for an intensive breast cancer awareness campaign and availability of screening centers prioritized in rural areas.

The last few years have seen widespread use of internet social media such as Facebook and Twitter in India. There is a lot of potential to exploit these online social media as a means of disseminating information on breast cancer.

As this was a small study, there is still a need for further and more detailed research in this area.

DOI: 10.14260/jemds/2014/3037

REFERENCES:

(1.) Ramirez AJ, Westcombe AM, Burgess CC, Sutton S, Little johns P, Richards MA. Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 1999, 353 (9159): 1127-1131.

(2.) Odusanya OO, T ayo OO. Breast cancer knowledge, attitudes and practice among nurses in Lagos, Nigeria. Acta Oncol 2001, 40 (7): 844-848.

(3.) Baum, M., Saunders, C. and Meredith, S. (1994) Breast Cancer: A Guide For Every Woman. Oxford: Oxford University Press.

(4.) Paul C, et al. Knowledge and perceptions about breast cancer incidence, fatality and risk among Australian women. Australian and New Zealand Journal of Public Health, 1999: 23 (4): 396-400.

(5.) Vahabi M. Knowledge of breast cancer and screening practices. Health Education Journal, 2005: 64 (3): 218-228.

(6.) Grindel CG, Brown L, Caplan L, Blumenthal D. The effect of breast cancer screening messages on knowledge, attitudes, perceived risk, and mammography screening of African American women in the rural South. Oncol Nurs Forum. 2004 Jul 13; 31(4): 801-8.

(7.) Evans DG, Burnell LD, Hopwood P, Howell A. Perception of risk in women with a family history of breast cancer. Br J Cancer 1993, 67: 612-14

(8.) Dixon JM, Mansel RE. ABC of Breast Disease: Symptoms assessment and guidelines for referral. BMJ 1994, 309: 722-726

(9.) Doshi D, Reddy BS, Kulkarni S, Karunakar P. Breast Self-examination: Knowledge, Attitude, and Practice among Female Dental Students in Hyderabad City, India. Indian J Palliat Care. 2012 Jan-Apr; 18 (1): 68-73.

(10.) Ramalingam S, Nivedhitha S, Divya P, Madhurima P, Poonguzhali R. Knowledge and Attitude about Breast Cancer and Breast Self-Examination among school teachers in an urban area of Coimbatore. Asian Student Medical Journal 11:1, 2012.

(11.) Rao SP, Nair S, Kamath VG. Acceptability and Effectiveness of a Breast Health Awareness Program for rural women in India. IJMS, 2005; 59 (9): 398-402.

(12.) Uche EE. Cancer awareness among a Nigerian population. Trop Doct 1999, 29 (1): 39-40.

Kriti Agarwal [1], Nayan Gupta [2], Janmesh Shah [3], Raj Aggarbattiwala [4]

AUTHORS:

1. Kriti Agarwal

2. Nayan Gupta

3. Janmesh Shah

4. Raj Aggarbattiwala

PARTICULARS OF CONTRIBUTORS:

1. 4th Year Resident, Department of Community Medicine, BJ Medical College, Ahmedabad.

2. 4th Year Resident, Department of Surgery, BJ Medical College, Ahmedabad.

3. 4th Year Resident, Department of Community Medicine, Medicine, BJ Medical College, Ahmedabad.

4. 3rd Year Resident, Department of Surgery, BJ Medical College, Ahmedabad.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Nayan Gupta, Room No. A/307, New P. G. Hostel, Civil Hospital Campus, Ahmedabad-380016, Gujarat. Email: drnayan84@gmail.com

Date of Submission: 06/07/2014. Date of Peer Review: 07/07/2014. Date of Acceptance: 10/07/2014. Date of Publishing: 21/07/2014.
Table 2: Socio-Economic Status of the respondents

SOCIAL       Urban     Rural
CLASS       [n=250]   [n=250]

Class-I     40(16%)   15(3%)
Class-II    55(23%)   35(17%)
Class-III   70(27%)   75(31%)
Class-IV    65(26%)   75(30%)
Class-V     20(8%)    50(19%)

Table 3: Whether women have ever heard of breast cancer

Ever heard of     Urban        Rural        Total
breast cancer    [N=250]      [N=250]      [N=500]

Yes             218(87.2%)   168(67.2%)   386(77.2%)
No              32(12.8%)    82(32.8%)    114(22.8%)

Table 4: Perception regarding some risk factors of breast cancer

Sr.   Associated risk factors           Urban        Rural
No.                                    [N=218]      [N=168]

1.    Family history   Yes           190 (87.15)   133(79.16)
      of breast        No             28(12.84)    22(13.09)
      cancer           Not sure           0         13(7.73)

2.    Previous         Yes           198(90.82)    72(42.85)
      breast           No             20(9.17)     41(24.40)
      cancer           Not sure           0        54(32.14)

3.    Smoking          Yes           132(60.55)    104(61.94)
                       No             86(39.44)    64(38.09)
                       Not sure           0            0

4     Alcohol          Yes            155(71.1)    57(33.92)
                       No             63(28.89)    111(66.07)
                       Not sure           0            0

5     Older age        Yes            97(44.49)    59(35.11)
                       No             94(43.11)    109(64.88)
                       Not sure       27(12.38)        0

6     Oral             Yes            94(43.11)    61(36.30)
      contraceptives   No             43(19.72)    88(52.38)
                       Not sure       81(37.15)    19(11.30)

7     High fat diet    Yes            71(32.56)    70(41.66)
                       No            103(47.24)    23(13.69)
                       Not sure       44(20.18)    75(44.64)

8     Excess weight    Yes           197(90.36)    108(64.28)
                       No             21(9.63)     53(31.54)
                       Not sure           0         7(4.16)

Sr.   Associated risk factors          Total        P
No.                                   [N=386]     value

1.    Family history   Yes           323(83.67)   P<0.05
      of breast        No            50(12.95)
      cancer           Not sure       13(3.36)

2.    Previous         Yes           270(69.94)   P<0.05
      breast           No            61(15.80)
      cancer           Not sure      54(13.98)

3.    Smoking          Yes           236(61.13)   P>0.05
                       No            150(38.86)
                       Not sure        0(0.0)

4     Alcohol          Yes           212(54.92)   P<0.05
                       No            174(47.28)
                       Not sure        0(0.0)

5     Older age        Yes           156(40.41)   P<0.05
                       No            203(52.59)
                       Not sure       27(6.99)

6     Oral             Yes           155(40.15)   P<0.05
      contraceptives   No            131(33.93)
                       Not sure      100(25.90)

7     High fat diet    Yes           141(36.52)   P<0.05
                       No            126(32.64)
                       Not sure      119(30.82)

8     Excess weight    Yes           305(79.01)   P<0.05
                       No            74(19.17)
                       Not sure       7(1.81)

Table 5: Perception regarding the menstruation associated risk factors
of breast cancer

Sr.   Associated risk factors       Urban        Rural        Total
No.   (correct response)           [N=218]      [N=168]      [N=386]

1     Early onset   Yes           108(49.54)   54(32.14)    162(41.96)
      of menses     No            87(39.90)    39(23.21)    126(32.64)
      (<12 years)   Not sure      23(10.55)    75(44.64)    98(25.38)

2     Late          Yes           159(72.93)   135(80.35)   294(76.16)
      menopause     No             17(7.79)     13(7.73)     30(7.77)
      (>55 years)   Not sure      42(19.26)    20(11.90)    62(16.06)

3     Breast        Yes             0(0.0)     43(25.59)    261(67.61)
      feeding       No             218(100)    98(58.33)    98(25.38)
                    Not sure        0(0.0)     27(16.07)     27(6.99)

4     Delayed       Yes           45(20.64)     12(7.14)    57(14.76)
      first         No            147(67.43)   93(55.35)    240(62.17)
      pregnancy     Not sure      26(11.92)     63(37.5)    89(23.05)

Sr.   Associated risk factors       P
No.   (correct response)          value

1     Early onset   Yes           P<0.05
      of menses     No
      (<12 years)   Not sure

2     Late          Yes           P>0.05
      menopause     No
      (>55 years)   Not sure

3     Breast        Yes           P>0.05
      feeding       No
                    Not sure

4     Delayed       Yes           P<0.05
      first         No
      pregnancy     Not sure

Table 6: Potential Breast Cancer Symptoms

Sr.   Breast related potential         Urban        Rural
No.   symptoms of breast cancer       [N=218]      [N=168]

1.    Painless         Yes           201(92.20)   88(52.38)
      breast lump      No             17(7.79)    67(39.88)
                       Not sure        0(0.0)      13(7.73)

2     Bruising of      Yes           35(16.05)    46(27.38)
      breast/          No            97(44.49)    117(69.64)
      ulceration       Not sure      86(39.44)     5(2.97)

3     Pain in breast   Yes           137(62.84)   150(89.28)
      region           No            81(37.15)    18(10.71)
                       Not sure        0(0.0)       0(0.0)

Sr.   Breast related potential       Total [N=386]   P value
No.   symptoms of breast cancer

1.    Painless         Yes            289(74.87)     P<0.05
      breast lump      No              84(21.76)
                       Not sure        13(3.36)

2     Bruising of      Yes             81(20.98)     P<0.05
      breast/          No             214(55.44)
      ulceration       Not sure        91(23.57)

3     Pain in breast   Yes            287(74.35)     P<0.05
      region           No              99(25.64)
                       Not sure         0(0.0)

Table 7: Nipple related breast cancer symptom

Sr.   Nipple related               Urban        Rural        Total
No.   potential symptoms of       [N=218]      [N=168]      [N=386]
      breast cancer

1     Nipple       Yes           127(58.25)   138(82.14)   265(68.65)
      ulceration   No            91(41.74)     11(6.54)    102(26.42)
                   Not sure        0(0.0)     19(11.30)     19(4.92)
2     Nipple       Yes           82(37.61)     168(100)    250(64.76)
      discharge/   No            136(62.38)     0(0.0)     136(35.23)
      bleeding     Not sure        0(0.0)       0(0.0)       0(0.0)

3     Inversion/   Yes           176(80.73)   61(36.30)    237(61.39)
      retraction   No            42(19.26)     5(2.97)     47(12.17)
      of nipple    Not sure        0(0.0)     102(60.71)   102(26.42)

Sr.   Nipple related               P
No.   potential symptoms of      value
      breast cancer

1     Nipple       Yes           P<0.05
      ulceration   No
                   Not sure
2     Nipple       Yes           P<0.05
      discharge/   No
      bleeding     Not sure

3     Inversion/   Yes           P<0.05
      retraction   No
      of nipple    Not sure

Table 8: Source of Information about Breast Cancer (multiple
response given) percentages from total (386)

Sr.   Source of information      Urban        Rural     Total [N=386]
No.

1     Media and newspapers    217 (56.21)   93(24.09)    310(80.31)
2     Elders / Friends         21(5.44)     38(9.84)      59(15.28)
3     Hospitals                66(17.09)    28(7.25)      94(24.35)
4     Camps and posters        32(8.29)     46(11.91)     78(20.20)
5     Self                     43(11.13)    45(11.65)     88(22.79)

Sr.   P value
No.

1     [x.sup.2] =
2     47.98 P<0.05
3
4
5
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Title Annotation:ORIGINAL ARTICLE
Author:Agarwal, Kriti; Gupta, Nayan; Shah, Janmesh; Aggarbattiwala, Raj
Publication:Journal of Evolution of Medical and Dental Sciences
Geographic Code:9INDI
Date:Jul 21, 2014
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