Open Access

Research
Awareness of breast cancer and breast self-examination
among female undergraduate students in a higher teachers
training college in Cameroon

Carlson-Babila Sama1,2,&, Bonaventure Dzekem2,3, Jules Kehbila2,4, Cyril Jabea Ekabe2,4, Brice Vofo2,5, Naomi Liteba Abua2,
Therence Nwana Dingana2,6, Fru Angwafo III7

1
Bambalang Sub-Divisional Hospital, Northwest Region, Cameroon, 2Galactic Corps Research Group (GCRG), Cameroon and Faculty of Health
Sciences, University of Buea, Cameroon, 3Clinical Research Education, Networking and Consultancy (CRENC), Douala, Cameroon and Health
Services Partner Cameroon, 4Grace Community Health and Development Association (GRACHADA), Kumba, Cameroon, 5Ntam Medicalised Health
Centre, Kumba, Cameroon, 6Catholic General Hospital, Njinikom, Northwest Region, Cameroon, 7Gynaeco-Obstetric and Paediatric Hospital and
Department of Surgery, University Teaching Hospital, Yaoundé, Cameroon

&
Corresponding author: Carlson-Babila Sama, Bambalang Sub-Divisional Hospital, Northwest Region, Cameroon

Key words: Breast cancer, breast self-examination, knowledge, practice, female students, Cameroon

Received: 19/10/2016 - Accepted: 16/09/2017 - Published: 29/09/2017

Introduction: The incidence of breast cancer (BCa) in Cameroon is on the rise and accounts for a leading cause of mortality. An understanding of
the knowledge and practices on breast cancer and breast self-examination (BSE) among teachers are important first steps which will guide the
designing of interventions aimed at raising awareness across the general population. Methods: We conducted a cross-sectional study in April 2016
involving 345 consenting female undergraduate students in the Higher Teachers Training College, Bambili, Cameroon. Data was collected using a
pretested self-administered questionnaire and analysed using descriptive methods. Results: The mean age of the respondents was 22.5±3.2years
and a vast majority (n = 304, 88.1%) had heard about BCa primarily from the television/radio (n=196, 64.5%). Overall, less than a quarter (n=65,
21.4%) of respondents who had heard about BCa had sufficient knowledge on its risk factors and signs/symptoms. A plurality (53.3%) thought
BCa can be prevented via vaccination while over a third (38.7%) opined that BCa can be treated spiritually. Less than half (47%) of respondents
who had heard about BCa had heard about BSE amongst which only 55 (38.5%) had ever practiced it. Conclusion: Though most students are
aware of the existence of breast cancer, their overall knowledge on its risk factors and clinical presentation is insufficient with a concomitant low
practice of BSE. These highlighted gaps warrants intensification of sensitization campaigns and educational programmes in order to raise
knowledge levels and enhance prevention strategies that would aid in reducing the burden of breast cancer in Cameroon.

Pan African Medical Journal. 2017; 28:91 doi:10.11604/pamj.2017.28.91.10986

This article is available online at: http://www.panafrican-med-journal.com/content/article/28/91/full/

© Carlson-Babila Sama et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)
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Introduction an extensive review of literature [10-12,18]. The validity of its
contents was established through consultation with experts and was
pretested on 41 first cycle students from HTTC who were eventually
Worldwide, breast cancer is the second most frequent cancer and
restrained from participating in the final study. Other than concerns
the fifth cause of cancer-related mortality [1]. It is the most
about some ambiguous words which were simplified in the revised
common cancer to affect women and it is second only to lung
version, all pilot students reported they easily understood the
cancer as the principal cause of cancer-related deaths among
questionnaire. It had three sections: socio-demographic
women [1-3]. In low- and middle-income countries (LMICs), it
characteristics, knowledge about breast cancer, and a section on
remains a significant public health challenge as incidence rates have
BSE. Data collection facilitators (1 student per academic level)
been shown to increase yearly by as much as 5% with over 1
underwent a 2-hour training one day prior to the census. Coding of
million projected new cases annually by 2020 [2-5]. The emergence
questionnaires rather than using names was done in order to ensure
of breast disease and subsequent development of cancer appears to
confidentiality. Consenting participants were handed printed copies
be more aggressive in young women compared to its progression in
of the questionnaire and allowed time to fill their responses and
older women [6,7]. In 2008, the prevalence of breast cancer in
return them anonymously to the facilitators. The completeness of
women ≥15 years in sub-Saharan Africa was estimated at 23.5 per
returned questionnaires was visually checked on a daily basis by the
100,000 women and approximately 35,427 women died from the
principal investigators. The study was approved by the ethics
disease (crude mortality rate of 12.8 per 100.000 women) [8,9]. In
committee of the regional delegation of public health for the
Cameroon, the incidence of breast cancer is higher than the worlds
Northwest Region and all recruited students signed a consent form.
average; estimated at 2625 per 100,000 women with a resultant
high mortality [3,5]. The high morbidity and mortality due to breast
Scoring of knowledge: Each of the questions on knowledge of
cancer can be in-part reduced if the lesion is detected early enough
risk factors and clinical presentation (signs/symptoms) of breast
[2]. In this regard, women need to be "breast aware" by being able
cancer was equitably scored. Categorical responses (Yes/No/Don't
to identify the risk factors and symptoms of breast cancer as well as
know) were applied for the question items. We assigned one point
risk reduction strategies.
(1) to a correct answer and zero (0) for don't know or an incorrect
answer. The overall knowledge score was calculated by summing
Though still clouded in controversy, breast self-examination (BSE)
scores of all knowledge questions (16 on risk factors and 12 on
still has an important role to play in the early detection of breast
signs/symptoms) yielding a possible range of overall scores from 0
cancer in resource-constraint settings where routine clinical breast
to 28. Scores were divided into two categories: insufficient
examination and mammography may not be feasible. In such
knowledge (< 50% of correct answers) and sufficient knowledge (≥
settings, BSE is recommended because it is free, private, painless,
50% of correct answers).
easy, safe, and requires no specific equipment. It has also been
shown to improve breast health awareness and thus potentially
Statistical analysis: Data from the questionnaires were entered
allow for early detection of breast anomalies [10-13]. The American
and analysed using statistical package for the social sciences (SPSS
Cancer Society also recommends that women from the age of 20
Inc., Chicago, IL) version 20.0. We summarised continuous
years onwards should be educated on the benefits of performing
variables as means and standard deviations (SD), and categorical
BSE monthly [14]. It had been demonstrated that factors related to
variables as count and percentages.
women´s awareness, knowledge and perceptions about breast
cancer may contribute significantly to medical help-seeking
behaviours [15-17]. Thus, considering the potential pivotal role
played by teachers in information dissemination, this study sought Results
to assess the awareness, knowledge and perceptions of breast Socio-demographic characteristics : Of the 420 questionnaires
cancer and practice of breast self-examination among female distributed, 391 (93.1%) were returned amongst which 345 were
undergraduate students in a higher institution of teaching as this properly filled, thus subjected to analysis. The participants were
will be essential in informing policy for targeted interventions between 17 and 34 years (mean = 22.5 ± 3.2) of age. Half (49.9%)
through the provision of guided educational training programs. of them were in the age range 21-25 years. A vast majority (90.7%)
were Christians while almost two-thirds (64.6%) of the respondents
were in their first year of studies. Sixty-two (18%) were married
(Table 1).
Methods
Awareness, knowledge and attitudes on breast cancer: Of
Study design, setting and participants: We conducted a the 345 participants, 41 (11.9%) reported to have never heard
descriptive cross-sectional study on the 11th of April 2016 at the about breast cancer. Television/radio (n =196, 64.5%) and health
Higher Teachers Training College (HTTC) Bambili, University of personnel (n =190, 62.5%) were the main sources of knowledge for
Bamenda in the Northwest Region of Cameroon. Bambili is a centre the 304 (88.1%) participants who had heard about breast cancer
of attraction for a youthful multi-ethnic population who either move (Figure 1). Further analysis will include only the 304 participants
there for studies or to explore the diverse economic activities who knew what breast cancer was. Of these, 18 (5.9%) had a
triggered by the presence of the university. The undergraduate family history of breast cancer and about one fifth (21.1%) of these
program in HTTC is a three year course and annually, this college female students responded “No” to the question item “will you allow
graduates about 500 trained teachers. The target population was a male doctor to examine your breast” Table 2summarizes the
first cycle female undergraduate students. To consider equal perceptions towards breast cancer among the 304 participants.
chances of participation, the students were informed about a free Exposure to radiation (n =179, 58.9%), hormone replacement
and voluntary participation in a breast cancer survey 1 week earlier therapy (n = 177, 58.2%), smoking (n = 177, 58.2%), alcohol
via oral message during lecture hours. On the said day of the consumption (n = 142, 46.7%) and high fat diet (n = 138, 45.4%)
survey, students were consecutively approached in their respective were the most frequently indexed risk factors for breast cancer.
lecture halls for inclusion. Meanwhile, late menopause (n = 28, 9.2%), early age at first
menstruation (n = 25, 8.2%) and not having a child (n = 24, 7.9%)
Study procedures and data collection: A structured and self- were the least recognized risk factors. Witchcraft was implicated as
administered questionnaire was developed by the researchers after

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a potential cause of breast cancer by a third (n =106, 34.9%) of the first child at late age, early menarche, late menopause, positive
respondents. The most common symptom of breast cancer personal history, and nulliparity as potential risk factors of breast
identified was lump in the breast (n =248, 81.6%) while over 77% cancer. Knowledge gaps about risk factors has also been reported
(n =235) of the respondents did not know that lump under the elsewhere among the general population [19,23], university
armpit could be a sign of breast cancer. students in Angola [24], female medical students in Saudi Arabia
[25], nurses in Pakistan [26] and female teachers in Malaysia [27]
The mean knowledge score on risk factors was 5.2 ± 2.7 (range: 0- and Kuwait [28]. With regards to misperceptions, 17.8% and 34.9%
14). Only 32 (10.5%) of respondents had sufficient knowledge of of participants cited wearing of tight brassieres and witchcraft
risk factors of breast cancer. The mean score for knowledge on respectively as risk factors of breast cancer. This is in line with a
signs/symptoms of breast cancer was 5.4 ± 3.1 ranging from 0 to community survey in semi-urban Cameroon [11], studies on rural
12. One hundred and eleven (36.5%) had sufficient knowledge on women [29] and market women [16] in Ibadan, Nigeria and female
the signs/symptoms of breast cancer. The overall knowledge score medical students in Ethiopia [6] that suggests women still attribute
ranged from 0-23 with a mean score of 10.7 ± 4.8. Overall, less the occurrence of breast cancer to a mystical origin. Among others,
than a quarter (n = 65, 21.4%) of participants had sufficient they considered it “a spiritual attack”, “God's curse”, and “attack
knowledge on breast cancer. With respect to their attitudes if from the enemy”. This observation was not that different from
diagnosed with breast cancer, almost half (n =145, 47.7%) said reports in a more developed setting; female teachers in Saudi
they will go to a prayer house, 58 (19.1%) will use traditional Arabia attributed the occurrence of breast cancer to God and belief
medicine and only 105 (34.5%) will agree to perform mastectomy if in the evil eye [30] while 96.8% of Arab-speaking women in Qatar
necessary (Table 3). Of the 304 participants who had heard about attributed its occurrence to fate/destiny and less than one-fifth to
breast cancer, 287 (94.4%) agreed that breast cancer could be Gods' punishment and bad luck [31]. As observed elsewhere
prevented amongst which breast examination was the commonest [6,18,28,32] the commonest symptom of breast cancer identified by
mode of prevention cited (n =237, 82.6%). Over half (n =153, our respondents was breast lump. However, knowledge about other
53.3%), 104 (36.2%) also thought breast cancer could be signs/symptoms was unsatisfactory. Thus, the need for further
prevented by vaccination and physical exercise respectively (Table health education on the risk factors and clinical presentation of
4). A minority (n =35, 11.5%) did not know that breast cancer breast cancer is desirable.
could be treated. Of those who knew (n =269, 88.5%), 248
(92.2%) and 104 (38.7%) said it could be treated medically and Most (94.4%) of our participants perceived that breast cancer could
spiritually respectively (Table 4). be prevented which is similar to the 95% reported by Suh et al [11].
Though breast examination was mentioned by the majority (82.6%)
Awareness and practice of breast self-examination: Less as a preventive method, a plurality (53.3%) of them incorrectly
than half (n =143, 47%) of those who knew about breast cancer mentioned vaccination against breast cancer as a preventive
had heard about breast self-examination (BSE). Majority (n = 47, method. Interestingly, 12.9% of these respondents also identified
32.9%) did not know how often BSE should be performed while sucking of the breast by a male partner as a method of preventing
only a quarter (n =37, 25.9%) correctly stated that it should be breast cancer. This idea may have emanated, in part, from a recent
performed monthly (Table 5). As little as 10 (7%) participants knew social media circular within the study setting which suggested girls
that the appropriate time to perform a BSE was few days after should make their breast more available to a male partner as
menstruation. Despite a substantial proportion (n =88, 61.5%) of regular sucking will help in reducing their risk of developing breast
students who had never performed BSE, most (n =133, 93%) cancer. This calls for urgent actions by authorities to foster
recognised the importance of BSE for their health. Reasons for not awareness on breast cancer in university milieus as such an act has
performing BSE are summarised in Figure 2. Of the 95 participants not been proven to prevent breast cancer, and may also promote
that responded to the question item on the appropriate age to sexual immorality; thus increasing the risk of acquiring sexually
commence BSE, only 3 (3.2%) correctly stated that 20 years was transmitted infections including HIV/AIDS as well as unwanted
the appropriate age to commence BSE. pregnancies. Though a small proportion, it however remains
disturbing that 11.5% of our respondents agreed that breast cancer
cannot be treated. This observation concurs to that of Oluwatosin et
Discussion al [33] in the Akinyele locality in rural Nigeria where the women had
even attributed a local name for breast cancer; “jejere” which
means “that which devours”. Oladimeji and colleagues [16] also
Our findings have shown considerable awareness about the
noted that 30% of women in their study considered breast cancer a
existence of breast cancer, but insufficient knowledge and
fast killer. These may be an indication that the myth suggesting that
misperceptions on its risk factors and causes as well as infrequent
"breast cancer equals death" is still deeply rooted across
practice of breast self-examination. In this study, 88.1% of
communities. These wrong assumptions may partly account for
participants had heard about breast cancer. This is higher than the
some of the reasons why patients present late to hospitals with
81.2% and 64% observed in a group of Malaysian [19] and Iranian
advanced disease states. Other than seldom mass campaigns for
[20] women respectively. It is however much lower than the 100%
breast health awareness and screening organized by the ministry of
among female medical students in Harar, Ethiopia [6], 98.7%
public health, there is no national screening program for breast
among female students in the University of Ibadan, Nigeria [21] and
cancer in Cameroon. Introduction of such a program will greatly aid
95% among female university students in Ghana [22]. The lower
in increasing awareness, eliminate mythical concerns as well as lead
rate of awareness on the existence of breast cancer in our study
to early detection of breast anomalies, hence better prognosis. In a
with respect to these studies may be due to the fact that breast
20-year retrospective analysis of the profiles of 531 breast cancer
cancer is part of a medical curriculum while it has been adopted in
patients followed up at the Yaoundé General Hospital, Cameroon,
the curricula in the other two universities in a bid to raise
Ngowa and collaborators [34] noted that there was a mean delay of
awareness. Though about 9 in 10 of our participants knew about
10.35 months with some taking up to 52 months between the
breast cancer, our findings reveal a poor understanding and
apparition of the first signs of breast cancer and presentation for
misperceptions on its risk factors, signs/symptoms, prevention and
first medical evaluation. As a consequence of this late presentation,
treatment. More than two-thirds of the respondents did not identify
none of the patients presented with carcinoma in situ. More than
gender, increasing age, race/ethnicity, and positive family history,
half of them had solicited traditional treatment and visited spiritual

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houses at first intention before their first medical evaluation. Lack of What is known about this topic
awareness on breast cancer, ignorance, cultural beliefs and the fear
of mastectomy as a treatment modality in hospitals were major  Generally, Cameroonian female students have poor
setbacks to early presentation. These observations equally knowledge on breast cancer and infrequently practice
concurred to findings in this study with regards to the attitudes of breast-self-examination.
our participants if they developed breast cancer.
What this study adds
Early detection of breast cancer plays a pivotal role in reducing
related mortalities. Until circumstances are favourable for routine
 Narrows awareness, knowledge levels and practice to a
mammographic screening in resource-limited settings, emphasis
group of undergraduate teachers;
should be oriented towards encouraging women to regularly
practice BSE. Freeman and collaborators [35] had reiterated the  Breast lump is the most commonly known symptom of
need for young girls to be properly taught BSE as this will greatly breast cancer: important knowledge deficits on
influence their practice as they grow older. Though controversies signs/symptoms and treatment of breast cancer were
still exists over its effectiveness in reducing mortality [36], the noted;
technique remains an important tool for early detection especially in  These students have poor attitudes, misperceptions and
low- and middle-income countries where access to diagnostic and myths regarding breast cancer; many will avert
curative facilities may be problematic [4,10,12,37]. In this study, mastectomy, majority will seek spiritual/traditional
only 38.5% of the participants had ever performed a BSE. It is healing.
comparable to the 41% reported by Nde et al [10] among female
undergraduate students in the University of Buea, Cameroon, the
42.6% among female undergraduate students in Kirkuk University, Competing interests
Iraq [38], the 37.3% among health extension workers in Ethiopia
[12] and 29% in Senegal [39]. Similarly, though close to three- The authors declare no competing interest.
quarters of female undergraduate students in the Ahmadu Bello
University, Zaria, Nigeria had heard about BSE, only about one in
five had ever practiced it [40]. Our findings suggests the need to
increase awareness of BSE as a screening tool as it renders women Authors’ contributions
more “breast aware” and thus potentially allow for early detection of
breast cancer. In so doing, various breast-conserving procedures Carlson-Babila Sama, Bonaventure Dzekem, Naomi Liteba Abua and
including lumpectomy, segmentectomy, and quadrantectomy may Fru Angwafo III contributed to study conception, design, data
be warranted in patients with early stage cancers rather than the collection and analysis and drafting of initial manuscript. J Jules
generally feared mastectomy. Raising awareness on the possibilities Kehbila, Cyril Jabea Ekabe and Therence Nwana Dingana provided
of breast reconstruction surgery is also warranted as this may keen reviews to the drafted manuscript. All authors read and
improve medical help seeking attitudes of sufferers. approved the final version prior to submission.

Limitations: Other than the lack of a statistical sample estimate,

our findings are confined to a group of young educated women Tables and figures
which does not necessarily reflect the situation among women in
rural areas, thus a potential limitation. Furthermore, this study was
Table 1: Socio-demographic characteristics of the included 345
conducted in a single department in the university, thus, may not
female undergraduates from HTTC, University of Bamenda,
portray the full picture of awareness/perceptions of breast cancer
Cameroon, April 2016
and practice of BSE among female students in the entire university
Table 2: Frequency distribution of knowledge and misperceptions
and other state/private universities within the country. Also, the
towards breast cancer in 304 female undergraduates from HTTC,
students were not assessed on their ability to correctly perform BSE.
University of Bamenda, Cameroon, April 2016
Table 3: Perceived attitudes regarding development of breast
cancer of 304 female undergraduates from HTTC, University of
Conclusion Bamenda, Cameroon, April 2016
Table 4: Perceptions about prevention and treatment options of
Female undergraduate students in the Higher Teachers Training breast cancer among female undergraduates from HTTC, University
College Bambili have insufficient knowledge on breast cancer with of Bamenda, Cameroon, April 2016
poor practice of BSE. Massive health education campaigns designed Table 5: Knowledge, practice and perceived importance of breast
to enlighten not only female university students in this setting, but self-examination among female undergraduates from HTTC,
also the public at large on the potential causes, risk factors, University of Bamenda, Cameroon, April 2016
signs/symptoms, prevention and treatment of breast cancer should Figure 1: Distribution of participants according to sources of
be promoted. The unique role of mass media, particularly knowledge about breast cancer
television/radio to reach a large audience at the same time should Figure 2: Reasons for not performing breast-self examination
be fully explored in order to provide comprehensive information
about breast cancer. These breast awareness campaigns should also
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Table 1: Socio-demographic characteristics of the included 345

female undergraduates from HTTC, University of Bamenda,
Cameroon, April 2016
Variables Frequency Percentage (%)
Age
≤20 111 32.2
21 – 25 172 49.9
26 – 30 60 17.4
> 30 2 0.6
Religion
Christian 313 90.7
Muslim 24 6.9
Others 8 2.3
Marital status
Married 62 18.0
Single 283 82.0
Academic level
1st year 223 64.6
2nd year 95 27.5
3rd year 27 7.9

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Table 2: Frequency distribution of knowledge and misperceptions towards breast cancer in 304 female undergraduates from HTTC,
University of Bamenda, Cameroon, April 2016
Variables Frequency Percentage (%)
Perceived causes/risk factors for
developing breast cancer
Gender 33 10.9
Increasing age 51 16.8
Positive family history 103 33.9
High fat diet 138 45.4
Smoking 177 58.2
Race/ethnicity 97 31.9
Exposure to radiation 179 58.9
Alcohol consumption 142 46.7
First child at late age 66 21.7
Early age at first menstruation 25 8.2
Late menopause 28 9.2
Inactivity and sedentary lifestyle 122 40.1
Obesity 108 35.5
Hormone replacement therapy 177 58.2
Personal history of breast cancer 84 27.6
Not having a child 24 7.9
Witchcraft& 106 34.9
Wearing tight brassiere& 54 17.8
Perceived signs/symptoms related to
breast cancer
Lump in the breast 248 81.6
Discharge from the breast 166 54.6
Pain or soreness in the breast 193 63.5
Change in the size of the breast 174 57.2
Discoloration /dimpling of the breast 104 34.2
Ulceration of the breast 111 36.5
Weight loss 64 21.1
Changes in the shape of the breast 195 64.1
Inversion/pulling in of nipple 79 26.0
Swelling or enlargement of the breast 155 51.0
Lump under armpit 69 22.7
Scaling/dry skin in nipple region 81 26.6
&
Wrong answer

Table 3: Perceived attitudes regarding development of breast cancer of 304 female undergraduates from HTTC, University of
Bamenda, Cameroon, April 2016
Variable Frequency Percentage (%)
Will be scared 242 79.6
Will consult to a doctor 273 89.8
Will use traditional medicine 58 19.1
Will go to a prayer house 145 47.7
Will agree to perform mastectomy if necessary (removal of the
105 34.5
breast)

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Table 4: Perceptions about prevention and treatment options of breast cancer among female undergraduates from HTTC, University of
Bamenda, Cameroon, April 2016
Perceived methods of preventing breast cancer (n = 287)
Variables Frequency Percentage (%)
Dieting 92 32.1
Physical exercise 104 36.2
Vaccination 153 53.3
Breast examination 237 82.6
Sucking of breast by male partner 37 12.9
Perceived methods of treating breast cancer (n = 269)
Variables Frequency Percentage (%)
Medically 248 92.2
Spiritually 104 38.7
Traditionally 47 17.5

Table 5: Knowledge, practice and perceived importance of breast self-examination among female undergraduates
from HTTC, University of Bamenda, Cameroon, April 2016
Knowledge/Practice Response Frequency Percentage (%)
Ever heard about BSE
Yes 143 47.0
No 164 53.0
Frequency of BSE
Daily 14 9.8
Weekly 14 9.8
Monthly& 37 25.9
Every 3 months 18 12.9
Every 6 months 8 5.6
Yearly 5 3.5
Don’t Know 47 32.9
Appropriate time of BSE
Few days before menses 7 4.9
Few days after menses& 10 7.0
During menses 8 5.6
No specific time 48 33.6
Don’t know 70 49.0
Impression on importance of
BSE
Important 133 93.0
Not important 10 7.0
Ever performed BSE
Yes 55 38.5
No 88 61.5
Previous training on BSE
Yes 25 17.5
No 118 82.5
Desire training on how to do
BSE
Yes 136 94.4
No 8 5.6
&Correct answers

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Figure 1: Distribution of participants according to sources of knowledge about breast cancer

Figure 2: Reasons for not performing breast-self examination

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