Salina Shrestha-Bogati

Diaconia University of Applied Sciences

Master Degree Programme in Global Health Care
Master of HealthCare
Thesis, 2020

KNOWLEDGE, ATTITUDES AND PRACTICES

REGARDING BREAST CANCER AMONG COLLEGE
STUDENTS IN NEPAL
A Descriptive Study
ABSTRACT

Salina Shrestha- Bogati

Knowledge, attitudes and practices regarding breast cancer among college students in
Nepal.
57 p., 5 appendices
May, 2020
Diaconia University of Applied Sciences
Master´s Degree Programme in Global Health Care
Master of Healthcare

The purpose of this thesis was to find out the knowledge, attitudes and practices of
breast cancer among college students in Nepal. The aim of this study was the student
benefits from the awareness programme that was provided during the thesis process and
to improve their knowledge of breast cancer.

The quantitative research methodology was used in this thesis. Survey questionnaires
were used as a research instrument. There were altogether 86 female students and 29
male students participated in data collection process. Thirty-one closed ended questions
along with demographic profile were formulated to gather data. The questions were
divided into 5 subtypes: knowledge regarding breast cancer, screening practices of
breast cancer, seeking behaviour, sources of breast cancer information and attitude re-
garding breast cancer. A survey questionnaire was distributed to the students and data
were collected. An awareness programme was conducted and post data were collected
to evaluate the difference in knowledge level of students. Data were analysed quantita-
tively using SPSS software. Data were analysed in terms of frequencies, percentages,
Pearson’s correlation test and T-test analysis for different categorical variables.

The knowledge level of female participants regarding breast cancer in pre data was
found to be poor level which increased to very good level after awareness programme.
Similarly, screening practices were found to be poor level in pre-test results and after
the awareness programme, it was increased to excellent level. Only 9% participants
were performing breast self-examination for the reason that the participants did not
know exactly how to perform it. The Ttest, p=0.0001 denotes there was significant in-
crease in knowledge level post awareness programme. The knowledge level of male
participant was at good level. All male participants responded that they supports women
with breast cancer and almost all responded that breast cancer patients should be cared
and support by the family and community.

The students had poor knowledge level regarding breast cancer. Only few students
knew about breast self-examination and were performing correctly. This shows that the
people in Nepal are still lacking knowledge regarding breast cancer, hence high mortali-
ty rate from breast cancer compared to developed countries. The simple steps of educat-
ing women about awareness regarding breast cancer can help them detect breast cancer
early and have optimal survival rates with cancer treatment.

Keywords: Breast cancer, Awareness, Knowledge, Attitudes, Practices

Diakonia-ammattikorkeakoulu
CONTENTS

1 INTRODUCTION .................................................................................................... 1
2 THEORETICAL BACKGROUND .......................................................................... 3
2.1 Awareness in breast cancer ................................................................................. 4
2.2 Knowledge of breast cancer ................................................................................ 4
2.2.1 Knowledge and attitudes of male students regarding breast cancer ............. 5
2.2.2 Sources of information ................................................................................. 6
2.3 Attitudes of women towards breast cancer ......................................................... 6
2.4 Knowledge of screening practices ...................................................................... 7
2.5 Health seeking behaviour of breast cancer ......................................................... 9
2.6 Assessment of awareness programme: Pre-post test ........................................ 10
2.7 Breast cancer organization in Nepal ................................................................. 12
3 PURPOSE, AIM AND RESEARCH QUESTIONS ............................................... 13
4 METHODOLOGY AND THE RESEARCH PROCESS ....................................... 15
4.1 KAP Study ........................................................................................................ 16
4.2 Study area and participants ............................................................................... 17
4.3 Research instrument .......................................................................................... 18
4.4 Questionnaires formulation............................................................................... 19
4.5 Data collection .................................................................................................. 21
4.6 Data analysis .................................................................................................... 22
4.7 Ethical considerations ....................................................................................... 23
5 RESULTS ............................................................................................................... 25
5.1 Knowledge of breast cancer .............................................................................. 26
5.2 Attitudes towards breast cancer ........................................................................ 29
5.3 Practices of breast examination ........................................................................ 30
5.4 Health seeking behavior of breast cancer ......................................................... 31
5.5 Sources of breast cancer information ............................................................. 32
5.6 Pre and Post-test knowledge differences .......................................................... 34
5.7 Results of male participants .............................................................................. 38
6 DISCUSSION ......................................................................................................... 41
6.1 Discussion of the results ................................................................................... 41
6.2 Reliability and validity of the study .................................................................. 46
6.3 Limitation of the study ...................................................................................... 47
7 CONCLUSION ....................................................................................................... 48
REFERENCES........................................................................................................... 50
APPENDIX 1. Consent form ..................................................................................... 55
APPENDIX 2. Questionnaires for female participants .............................................. 56
APPENDIX 3: Questionnaires for male participants ................................................. 60
APPENDIX 4 WHO Pen protocol ............................................................................. 63
APPENDIX 5 Summary of previous research findings …………………………… 64
List of Abbreviations and Symbols
WHO World Health Organization
BSE Breast Self-Examination
Ed Edition
SPSS Statistical Package For The Social Sciences
CSN Cancer Society Nepal
RFN Rose Foundation Nepal
NCRS Nepal Cancer Relief Society
CBE Clinical Breast Examination
BC Breast Cancer
WPR World Population Review
FB Facebook
IBM International Business Machines Corporation
CDC Centres for Disease Control and Prevention
 1

1 INTRODUCTION

Breast cancer is a leading cause of death and disability among young women in re-
source constrained countries. The incidence of breast cancer in low income country
continues to be lower than in most high-income countries. However, the mortality
rate from breast cancer is very high. This high mortality rate is likely due to a lack of
awareness about breast cancer detection and treatment, inadequate facilities for de-
tection and diagnosis, as well as poor access to treatment. In many developing coun-
tries, the incidence of breast cancer is now rising sharply due to changes in reproduc-
tive factors, increase urbanization, adoption of western lifestyle, and increased life
expectancy. (Lawrence et al, 2010.)

There are 2.1 million new cases every year, and the mortality rate from breast cancer
is 627,000 deaths among women which is approximately 15% of all cancer deaths.
Breast cancers were more common in developed countries previously, however it is
estimated that breast cancer rates are inflating in nearly every area worldwide. The
negative outcomes of breast cancer can be reduced by using preventative measures.
They can also, be reduced if it is detected at an early stage. However, in developing
countries, due to the incidence of breast cancer that is diagnosed at late stage; these
strategies cannot eliminate the majority of breast cancers or improve the outcome.
Therefore, early detection of breast cancer is the cornerstone of breast cancer control
in order to improve breast cancer outcomes and survival chances. By participating in
awareness programmes that teach women how to recognize the early signs and
symptoms, breast cancer diagnosis can be made at earlier stages; which can result in
faster treatment. (WHO, 2018.)

According to WHO 2017, deaths due to breast Cancer in Nepal remained 1,054
which is 0.65% of all deaths. The age adjusted Death Rate is 9.21 per 100,000 popu-
lation. Nepal ranks 163th position in the world in breast cancer mortality rate inci-
dence. Statistical data collected from Globocan 2018, shows there were 2068 new
breast cancer cases diagnosed in Nepal in 2018. This is 13% new cases per 100,000
 2

women and resulting in 1018 (5.2%) mortalities. The graph below compares the data
with other countries, including: India, Bangladesh, Pakistan, UK and USA.

FIGURE 1. Comparison of Age standardized rates of incidence and mortality related

to breast cancer in women in Nepal and other countries. (Globocan, 2018)

The purpose of this thesis was to find out the knowledge, attitudes and practices of
breast cancer among college students in Nepal. Knowledge of breast cancer and
awareness regarding practices is common in developed countries. However, in Ne-
pal, being a conservative cultural community; women seem to be reserved and hesi-
tant to talk about their intimate problems. Research has shown that there is a deficit
in awareness regarding breast cancer. (Shrestha, 2012; Garg, 2016.) There are lim-
ited research done and are published in Nepal that are focused on this topic. Hence,
research on this topic would be preeminent and possibly very beneficial for Nepalese
population. Students are focused in this study because they are the integral part of
community who plays vital roles in providing further knowledge in their family and
society. Hence educating the students about breast cancer and the practice of breast
self-examination assists them to detect breast cancer in early phase. This thesis also
evaluates the knowledge of participants after the awareness programme. To carry out
this thesis, a college from Kathmandu, Nepal was involved for data collection pro-
cess.
 3

2 THEORETICAL BACKGROUND

There are three steps to diagnose cancer early as shown in figure 2. The first step the
WHO focus in diagnosing cancer is also “Awareness”. A multifaceted team approach
and coordination is required in improving awareness and access to care that focuses on
people-centred services at all levels of care. Step 2 includes diagnosing and staging after
the sign and symptoms are detected. The medical professional teams are required to
assess the patient clinically and diagnosed the stage. Step 3 includes the treatment after
the cancer stage is diagnosed. The oncologists after diagnostic testing and confirming
the cancer stage starts the treatment according to the requirement. To access high quali-
ty treatment on time is essential for cure which in low-income countries is less than
30% of available treatment services. (WHO, 2020.)

FIGURE 2. Steps for early diagnosing and screening guidelines by WHO

 4

2.1 Awareness in breast cancer

Awareness is defined as to have the knowledge of existence, or understand of

a subject based on evidence or experience (Cambridge Dictionary, 2018.) Breast aware
is being aware of any abnormal changes in breast, how they look and feel. Breast aware
helps detect any changes in breast appearance and seek medical assistance. (CIWA,
2014). Awareness in breast cancer is very important because detecting cancer in early
phase can save life. Awareness regarding breast cancer helps people to acknowledge
about the disease which not only benefits reducing breast cancer stigmas but also im-
proving health literacy. Awareness in the context of this thesis can be defined as the
combination of knowledge, attitudes, practices and health seeking behaviour. After ex-
ploring knowledge level, attitudes and practices of participants, the aim is to improve
their awareness level towards breast cancer by providing them information on breast
cancer. The awareness programme details of the study are described in data collection
section (See section 4.5).

2.2 Knowledge of breast cancer

According to Garg (2016), there is lack of awareness of breast cancer in low income
countries. This is because the women are unaware of the risk factors and sign and symp-
toms of breast cancer. Majority of women in developing countries often look for pain as
early symptoms of breast cancer and almost all women were unaware that a painless
mass could be the first sign and symptom of a breast cancer. The earlier studies in Iraq,
by Hamad et al (2018), in Saudi Arab by Sindi et al (2019), Kotepui et al (2014)
found good knowledge level of breast cancer. The overall mean knowledge was good
level. Most participants responded family history of breast cancer as a risk factor of
breast cancer which descended by age, oral contraceptives use and drinking alcohol.

Previous studies (in Jordan by Suleiman (2014), in Angola by Sambanje and Mafuvadje
(2012), by Siddeeq (2017) and in Libya by Elzahaf et al (2019)) found poor level of
knowledge of breast cancer among students. The majority of the participants were not
aware of sign and symptoms and risk factors of breast cancer such as change in colour
 5

or shape of the nipple. 80% participants responded that cancerous lumps in breasts are
painful. It was found that participants with better knowledge of breast cancer
were associated to family members who had history of breast cancer. Only few partici-
pants were aware of breast cancer. There was a significant association between educa-
tional status and occupation of the participants with their knowledge regarding breast
cancer and breast self-examination.

The cross sectional study conducted in Nepal by Shrestha (2012) found poor level of
knowledge regarding breast cancer. More than half participants (61%) responded pain-
less lump as a sign for breast cancer followed by blood discharge from nipple.
Knowledge on risk factors of breast cancer in the participants was very low. In another
study conducted by Shrestha et al (2017), 78% participants responded growth of extra
lump in breast as a primary sign and symptoms of breast cancer. It was followed by
painless breast mass, change in shape and size of breasts.

2.2.1 Knowledge and attitudes of male students regarding breast cancer

A study carried out in Kenya with 237 male participants found majority (92%) of partic-
ipants were aware of breast cancer. However, only 10% participants had correctly an-
swered two or more risk factors of breast cancer. Most participants considered breast
cancer a severe disease. There were low knowledge level regarding early detection
methods and screening practices. Almost half of male participants were aware of meth-
ods to detect breast cancer such as mammography, clinical breast examination or BSE.
Majority participants responded that their partner shares their well-being with them.
Almost all male participants would decide about their wives health checkup for ob-
served breast lump. Excellent number of participants (90%) responded they would en-
courage and support their partners to visit hospitals and meet health professionals within
a week time period of observing breast lump. Few participants (20%) would let their
wives to visit and examined by a male traditional healer. Majority participants had no
objection to treat their wives by a male health care worker. (Sayed et al, 2019.)
 6

2.2.2 Sources of information

The most common source of information regarding breast cancer responded by partici-
pants in different study were Media/Radio/TV/Newspaper/FB, (Shrestha, 2012; Al-
Dubai, 2014; Hamad, 2018), medical professionals, friends and seminars. (Kotepui et al,
2014.) The study carried by Suleiman (2014) in Jordan found the sources to attained
knowledge regarding breast cancer were friends and health workers. In a study by Sindi
(2019), the students responded the main source to be awareness campaigns (67%) and
media (48%).

2.3 Attitudes of women towards breast cancer

A study in Kenya found the women distress to be diagnosed of breast cancer because
they fear of being considered undesirable and divorced by husbands. A fear of social
rejection was a reason to neglect treatment for breast cancer. For example, they fear of
mastectomy. The result also found that female does not find comfortable discussing
about breast health with male members in a family. Male members complained they are
left out. For example, “our sisters don’t tell us anything about breasts. Whatever they
are told, when they come home they hide it.” Males were encouraged in the involve-
ment in their partner’s breast health. They responded males should not ignore any
symptoms their wives possess and take them for checkup. They also agreed that hus-
bands should involve in the care of their wives during the treatment process by visiting
the doctor with their wives. In this way the female does not feel left alone and gets emo-
tional support from the family. Majority of the women participants responded that they
need permission from their husband or head of the family for checkup, consultants or
treatment. (Sayed et al, 2019.)

In a quantitative study done in 840 Jordanian female students, found excellent attitudes
towards breast cancer patient. 78.2% of total 435 participants disagreed that breast can-
cer patients should be isolated. Majority disagree that breast cancer is a punishment
 7

from God. Almost all responded that breast cancer patients should be supported by
community. 29.4% responded women should be afraid of breast cancer. (Suleiman,
2014). A study in Libya found majority (90%) of female students had good attitude to-
wards breast cancer. It also showed no significant difference between attitude and de-
mographic factors (Elzahaf et al, 2019.) A study in Saudi Arab by Sindi et al (2019)
found the misconception the female has regarding breast cancer, such as using tight bra
for longer period or use of deodorant can cause breast cancer. The students also be-
lieved evil eye can cause breast cancer.

2.4 Knowledge of screening practices

Women need to know that breast cancer is treatable when detected early. People need to
know about simple steps they can take, like doing self-breast examination and partici-
pating in breast screening that can help detect cancer early. It is a fact that breast self-
examination helps in detecting cancer in early stage. Most respondents (207, 95.4%)
were aware of breast self-examination. 79.3% participants performed BSE in which
only 39% were performing monthly. Almost half participants had already performed
Clinical breast examination. Two third of participants were unaware of mammogram
screening. (Kotepui et al, 2014.)

A cross sectional study carried in India with 206 female participants found very good
knowledge level of breast cancer among the participants. The average score for attitude
and practices was at poor level. The correlation between knowledge and attitudes to-
wards breast self-examination shows statistically significant difference. (Doshi et al,
2012.)

Research done in Jordon by Suleiman (2014) shows that knowledge regarding practices
for breast cancer was found to be poor level as only 34.9% participants knew
about BSE and only half of them were performing it. Similarly, study in Angola
by Sambanje and Mafuvadje (2012) found very good knowledge of BSE among partici-
pants. However, only 40.2% participants could perform BSE confidently and more than
half did not know the right time to perform BSE.
 8

A study in Kenya found poor knowledge level of participants regarding methods for
early detection of breast cancer. The reasons for not performing breast self-examination
were lack of knowledge and had the perception that they do not possess any breast ab-
normalities. Only few were aware of clinical breast examination. A study in Malaysia
found excellent knowledge of BSE. However, few were practicing it. (Sayed et al, 2019;
Al-Dubai, 2014.)

Hamad et al (2018) emphasize that 60% participants were unaware of BSE and only one
third knew how to perform. Poor knowledge was found for right time to perform
BSE. Study in Libya by Elzahaf et al (2019), states that the majority of participants
(82.5%) were aware of BSE as a screening method of breast cancer followed by ultra-
sound. However, only 28.5% students knew the right way to perform BSE. Sindi et al
(2019) found the participants in Saudi Arab were aware of BSE and had good
knowledge level in practicing BSE (61%). The reason for not performing BSE were the
participants had no idea how to perform BSE, some thought they do not expect to get
breast cancer and there is no need, few participants felt discomfort, fear and shy.

According to Shrestha (2012), there was poor level of knowledge 26% regarding
screening practices. 66% respondents knew the reason to perform BSE is to find breast
lump. Only 19 out of 110 participants were actually performing BSE. Only 3 partici-
pants were aware of mammogram and 4 were aware of ultrasound as a screening meth-
od for breast cancer. All respondents were not aware regarding the age to perform
mammogram. The reason for not attending screening were the participants did not know
about breast cancer, do not know where to get information and guidance, and afraid of
finding abnormality. Shrestha et al (2017) found excellent knowledge reading breast
self-examination. For example, 82% participants knew breast self-examination can help
detect breast cancer at early stage and only 10% were aware of mammogram as a
screening method for breast cancer. 72% participants agreed BSE as a screening of own
breast to check any anomalies. Excellent level of knowledge (80%) was found for the
right time to perform BSE.
 9

2.5 Health seeking behaviour of breast cancer

Research shows the delay in breast cancer treatment process after the symptoms had
been observed. This delay in seeking right treatment option, worsens the disease pro-
cess. Delays in treatment initiation were associated with family income, education, pre-
vious breast symptoms, self-treatment, and travel time to the hospital. The main chal-
lenges include the low quality of data registries, inadequate multidisciplinary coordina-
tion, and a lack of resource-appropriate prioritization of breast cancer control programs.
(Fan et al, 2015.)

A study in Africa found a barrier to health seeking behaviour were low self-image, a
feeling after acknowledging having breast cancer, and its accompanying humiliation
from the family and society. The result also found that women place first priority to
their family before their health due to the fear of disgrace their breast cancer can cause
to their family members by the society. The health of a woman in Africa is not given
importance, hence inhibiting them from going to hospitals or participating in education-
al programmes. Fear was one of the reasons for women for not seeking treatment after
they noticed any symptoms of breast cancer. For example, fear of diagnosis, fear of ex-
amining by a male doctor, fear of divorce or left out of family, fear of mastectomy, fear
of death and fear of stigmatized by society. (Akuoko et al, 2017)

A study in Kenya found 90% participants would seek medical professional assistance
within a week period time if they noticed breast cancer symptoms. Almost half (49%) of
the participants responded that their partners would make the health care seeking deci-
sions. Maximum number of participants reported they would seek a lower level health
facility. 51% answered dispensary and 16% answered health centre. The distance of
hospital from their home could influence their choice of facility. The results were also
found that some participants still believe in witchcraft and curses and prefer traditional
healers rather than medical assistance. This might be because the community are still
unaware about the breast cancer knowledge. Health-seeking behaviours believing more
on traditional healers and seeking first help from them were common among the partici-
pants who do not consider breast cancer symptoms seriously to seek help from medical
 10

professional by visiting a hospital. The participants from community members and

healthcare professionals responded that the people habit of seeking traditional healer
treatments delay them in seeking medical assistance. As a result, the disease has already
progressed into advance stages where treatment options are limited, and chances of sur-
vival rates are less. Some participants also responded the facility like availability; af-
fordability and accessibility of traditional healers attract them. Another reason partici-
pant responded for not seeking medical help at first choice was long distance from
home to hospital and difficult to get doctor's appointment. (Sayed et al, 2019.)

Majority of participants in a study in Pakistan found that they seek medical consults
with in a week if any sign and symptoms were observed. The reason for not seeing
health professionals were affordability, nervousness, family problems, fear of diagnosis,
wrong perception that breast mass would remedy itself. Some responded that cancer is
not curable and their partners were opposed of the cure. (Gilani et al, 2010.)

It has been observed that breast cancer is frequently diagnosed at later stage among pa-
tients with lower income (48%) and educational status contributing to poorer survival.
Delay in early detection could be due to differences in socio demographic and cultural
factors, a strong belief in traditional medicine, negative perception of disease, poverty
and poor education and coupled with fear and denial. Around 80% of patients with
breast cancer reported to refer to health care centers in late stage when the disease had
become incurable. A variety of psychosocial and cultural factors predispose women to
delay or avoidance of screening for breast cancer symptoms at early stages when treat-
ment is most likely to be successful. Awareness of breast cancer was higher (80%)
among literate women than illiterate ones (65.4%). (Pakseresht et al, 2016.)

2.6 Assessment of awareness programme: Pre-post test

Study shows increased in awareness in post test results after providing awareness talk to
participants. Research conducted in India focusing 1030 science students age ranged
between 18 and 23 years, showed good awareness of breast cancer. However, the
 11

knowledge regarding sign and symptoms and BSE was poor. A power point presenta-
tion regarding information on breast cancer was provided to the students after pre-test.
In the pre-test the participants thought the older age women are affected by breast can-
cer and breast cancer are caused by trauma, whereas after the awareness session, post
test results showed participants were aware that cancer can affect any age group. The
risk factor knowledge also improved considerably. Only 18% knew about BSE but were
not performing regularly. The reason for not performing were lack of privacy, embar-
rassing, some thought it was not important and many did not know how to perform it.
Post-test showed that majority were aware of BSE. 90% students said they would per-
form BSE regularly. Others were still embarrassed to perform it. 90% women said they
will pass the knowledge to their family members and friends. (Madhukumar et al,
2017.)

The study conducted in India selecting 110 working women participants randomly
showed inadequate knowledge regarding breast cancer in pre-test. Information regard-
ing cancer was provided through email. Post test results showed increased knowledge
regarding breast cancer among the participants. The participant´s scores regarding sign
and symptoms, risk factor, diagnostic techniques, risk prevention of breast cancer im-
proved significantly which conclude that awareness program on breast cancer was sig-
nificantly effective in improving the knowledge of participants. (Kang & Bisht, 2014.)

A study carried in Turkey with 244 participants found good level (53.7) of knowledge
in pre-test which significantly increased to excellent level in post-test results (85.2%)
after the education program. The knowledge regarding BSE also increased from good
level in pre-test (50.8) to excellent level (80.3%) in post-test. The mean score for
knowledge of risk factors of breast cancer was 3.65 in pre-test and was increased to 9.36
in post-test. There was significant difference in pre- and post-test. Similarly, the mean
score for screening of breast cancer was 3.58 in pre-test which was increased to 6.65 in
the post-test. The result found the overall knowledge score also increased from 9.05 in
pre-test to 16.5 in post-test. (Yilmaz et al, 2017.)
 12

2.7 Breast cancer organization in Nepal

There are different organizations in Nepal that are actively working on prevention of
cancers, raising awareness and free health camps. The organizations involved are Nepal
Cancer support group, Rose foundation, Nepal cancer hospital and research centre, Ne-
pal breast cancer foundation, Rotary club, Nepal cancer relief society, Rotaract, Cancer
society Nepal and many small community organizations. These are non-governmental
and non-profitable organizations working raising awareness about cancers, symptoms
and treatments with the aim of fighting against the spread of cancer in Nepal. Some or-
ganization works towards helping cancer patients and their families deal with cancer
through a holistic approach. The objectives are public awareness and screening pro-
grammes, advocacy and counseling services, training, workshops, rehabilitation service,
financial support to cancer patients, research activities and cancer education pro-
grammes. (Cancer Society Nepal, 2018; Rose Foundation Nepal, 2017)

A researcher contacted 5 colleges/universities in Kathmandu through email for data

collection process. Few did not respond to email at all. Few were reluctant to held mass
awareness programme due to viral epidemic. One College, which is located in Kath-
mandu, Nepal responded quickly and provided the personnel’s contact information. The
approach was taken positively. The research proposal was sent and permission was
granted. The college provided the information on date, time and venue to conduct the
programme. The researcher flew to Nepal to conduct the awareness programme and
collect the data for this thesis. Everything needed for the awareness programme was
discussed beforehand with Dr.Shahi and the college, so it was well prepared. Finally,
the information regarding breast cancer was provided and the data were collected with
the permission from the college.
 13

3 PURPOSE, AIM AND RESEARCH QUESTIONS

The purpose of this thesis is to find out the knowledge, attitudes and practices regarding
breast cancer among college students in Nepal. The aim of this study was to provide
information regarding breast cancer to students by conducting an awareness programme
and to improve their knowledge of breast cancer. The objective of this programme was
the student gets aware of breast cancer sign and symptoms, risk factors and screening
practices especially BSE so that they could benefit from it. The goal was also to include
the male participants in this study to explore their knowledge level and attitudes towards
breast cancer. There are limited studies done in Nepal on knowledge, attitude and prac-
tices of breast cancer among females. However, the research on similar topic among
male participant`s and general students could not be traced by the researcher. This might
be because the studies have not been carried out yet or the articles were not published.
The studies have found poor knowledge level and practices among the Nepalese wom-
en. (Shrestha 2012; Shrestha et al 2017). There is a necessity of further research focus-
ing students to determine levels of development because students are believed to be
knowledgeable, smart, access to technology and youths of this generation. It can be as-
sumed that young students are best knowledgeable compare to middle age, elderly peo-
ple and people in rural area where there are deficits of education, technology and re-
sources. Therefore, this study can provide a general overview of level of awareness and
attitude among students both male and female in metropolitan population. The findings
would also provide a clue of what could be expected from the countryside populations;
meanwhile urban people are likely to have better access to information. This is essential
in planning and implementing suitable awareness design strategies in future.

Research Questions

1. What is the knowledge level regarding breast cancer among female students?

2. What are the attitudes towards breast cancer among students?

3. What are the screening practices of breast cancer among students in Nepal?
 14

4. What are the health seeking behaviors of students regarding breast cancer?

5. Are there differences in knowledge level, attitudes and practices of students re-

garding breast cancer before and after awareness programme?

6. What are the knowledge level and attitudes regarding breast cancer among male

students?
 15

4 METHODOLOGY AND THE RESEARCH PROCESS

The quantitative methodology is coherent, structured and determined. It aims to meas-

ure the extent of deviation, measurement of variables and the impartiality of the method.
This study aims to measure the knowledge, attitudes and practices concerning breast
cancer and the objectivity of the process is well maintained throughout the study. It de-
pends on the basis of sample size and provides significance to the validity and reliability
of findings. The findings were analysed in a collective way and conclusions; sugges-
tions were illustrated in a generalised way. (Kumar, 2019.)

This study is a quantitative research. This is a descriptive, cross sectional study which is
the most used designs in the social sciences. This design is best suited to studies aimed
at finding out the knowledge level, attitude by taking a cross section of the population
(Kumar, 2019). Hence, the quantitative research method is used in this thesis to explore
the knowledge level of breast cancer among students in Nepal. The research methodol-
ogy process of this study is shown in table 1.
 16

TABLE 1. Research methodology process

Research Methodology Process

-Database / e- journals
Literature Review (Pubmed, Google schol-
ar,
ResearchGate)
-Government Reports
Narrowing the Topic

Purpose

Literature Quantitative Research (Descrip- Theoretical

Review tive, cross- sectional study) framework

Research Questions
(6 questions)
-Research proposal
to College
Research Instrument / -E-mail, Calls
Survey Questionnaire - Permission
formulation

-College visit in Nepal

Data Collection (altogether 86
-Awareness Programme (56
females and 29 males)
female students participated)
-Pre data-post data collection
Data Analysis /SPSS (Frequen-
cy, Percentages, Pearson’s Cor-
relation,
T-test)

Results ( Answering re-

search questions)

Discussion, Conclusion and Rec-

ommendation for improvement
Areas
 17

4.1 KAP study

KAP stands for Knowledge, Attitude and Practices. The knowledge refers to the under-
standing of breast cancer. Attitude states to their belief or stigmas concerning breast
cancer. Practice is the way to determine the knowledge and attitude through their ac-
tions, in this case breast self-examination practices. Hence, it is an assessment which
measures the Knowledge, Attitude and Practices of a population. In this research, KAP
theory is followed to explore the knowledge, attitude and practices regarding breast
cancer among female students in Nepal. KAP Survey helps researcher to study what
participants in community know about breast cancer, what is their attitudes toward
breast cancer and people with breast cancer, how they behave in seeking healthcare and
are they familiar with breast self-examination practices. KAP surveys can help recog-
nize needs, cultural beliefs, obstacles in delivering information, and also identifying
solutions to enable understanding, improving quality of life and achieving set goals. The
education delivered during awareness programme benefits the students by understand-
ing the sign and symptoms of breast cancer, risk factors, when to seek medical help and
foremost breast self-examination practices knowledge from which they can detect the
breast cancer at early stage. The researcher can also explore the area that needs to focus
and develop more for future. ( Kaliyaperumal, 2004; Alhaj, 2018)

4.2 Study area and participants

The research was conducted in one College in Kathmandu, capital city of Nepal. The
author contacted Dr. Shahi, who has already performed cancer awareness programme
and has published article in similar field. After discussing with Dr. Shahi and the col-
lege, it was concluded that the awareness programme would benefit female students the
utmost and participation of females exclusively would make the students comfortable in
discussing the topic freely. Only female students were invited because breast cancer is a
very sensitive topic and a conservative society in Nepal, it is not discussed openly. This
was observed and the researcher was overwhelmed by the questions raised by the stu-
 18

dents and discussed openly on the topic after the information was provided. There were
altogether 80 female students studying in Bachelor in Computer Science and Infor-
mation Technology and Bachelor of Management level. The population sample size was
calculated from Raosoft, 2004, sample size calculator with 95% confidence level and
5% margin error. According to sample size calculator, the sample size would need to be
67 students. However, only 56 female students, studying in bachelor level participated
voluntarily in awareness programme. The researcher thought the participant’s number
was less than the sample size calculator, thus could affect validity and reliability. Per-
mission was requested from the college head to collect data from grade 11 and 12 stu-
dents in the same college. The researcher, on granting permission, approaches herself to
higher secondary students and explained about the research, ethical considerations and
distributed the questionnaires. 30 female students participated and filled up the pre
questions. Due to time limitations and on-going exam of the students, the awareness
programme was not held, thus post data were not obtained.

The researcher explained about the research, aim and purpose of the research. The ethi-
cal considerations were discussed before the questions were distributed. The pre-
questionnaires were distributed and filled by the participants. The questionnaires were
collected, and the awareness programme was conducted. The pre and post question-
naires were differentiated beforehand with the pre and post printed in the form itself for
easier handling and avoiding the confusion that can create when the questionnaires were
mixed. Similarly, the post questionnaires were filled by the same participants after the
information were delivered. The participants took around 20-30 minutes to fill up the
form.

While reading articles, the researcher came across with the data collected from male
students as well. This was rare but the researcher found it very important to know what
the male society knows about breast cancer. Nepal is a male dominant country. Most
decisions are made by male. Hence, their knowledge and attitudes regarding breast can-
cer can have direct effect on females sharing their disease or feelings. 29 male students
filled up the questionnaires voluntarily after getting permission from the college Head.
4.3 Research instrument
 19

Research instrument is defined as “An instrument that becomes a means of collecting

information for a study”. The first applied step in carrying out a study is a formation of
a research instrument. (Kumar, 2019.) Thus, this research constructs a questionnaires as
primary data collection as a research instrument. The objective of questionnaire in quan-
titative research is to achieve significant data in reliable and valid manner. It is helpful
to determine the reliability and validity of the data obtained. (Taherdoost, 2016). The
students were interviewed through survey questionnaires. Survey questionnaires are
easy to fill for the participants since it is a multiple choice or closed ended question
type.

4.4 Questionnaires formulation

The questions were formulated focusing on research questions. The questionnaires were
constructed reading thoroughly previous articles and findings. The articles were
searched from pubmed, google scholar and research gate. Similar articles were chosen
and the findings that answer the research questions were used to formulate the question-
naires. More articles were searched, read through, collected ideas and formulated more
questions for the data collection. This process has been repeated several times in order
to make sure the formulated questions meet the standard to answer all research ques-
tions. The questions were formulated from CDC (Centers for disease control and pre-
vention, 2018) assessing breast cancer information such as risk factors, sign & symp-
toms, screening and previous studies by Rafique (2018), Sarwar (2015), Siddeeq (2017),
Rao et al (2017), Aydogan (2015), Doshi et al (2012), Gilani et al (2010), Giri et al
(2018) along with other mentioned articles in background. The questions were divided
into 5 subtypes which is shown in table 2: Questions 1-5 provides Demographic charac-
teristics. Questions 6-14 answers knowledge regarding breast cancer. Questions 15-18
provides answers for practices of breast self-examination. Questions 19-23 provides
answers for health seeking behavior. Questions 24-26 is for sources of breast cancer
information and questions 27-31 provides answer for attitude regarding breast cancer.
31 closed ended questions along with demographic profile were formulated to gather
data as in appendix 2. The correct answers for the questionnaires were referred from
 20

CDC (Centers for disease control and prevention, 2018). Each participant will be scored
based on knowledge and attitude regarding breast cancer on the number of answers pro-
vided. For the male participants, 23 closed questions were formulated as in appendix 3.
The questionnaires were divided in three parts: Knowledge, Sources and Attitudes re-
garding breast cancer as shown in table 3. The questions are formulated in simple lan-
guage that participants could easily answer. The main questionnaire was formed in Eng-
lish language. It was translated in simple understandable Nepali language by the re-
searcher for the ease of participants. Nepali language is researcher’s mother tongue;
hence it was easy to translate the questionnaires. The students felt the English version
was easier for them to answer; the researcher translated or explained when the partici-
pants had confusions.

TABLE 2. Formulation of questionnaire sub types according to research questions

among female students

Research questions Questionnaire subtype Questions

1. What is the knowledge Provides answers to 6-14
level regarding breast Cancer knowledge of breast cancer.
among female students Sources of information 24 -26

2. What are the attitudes to- Provides answer to attitude 27-31

wards breast cancer among regarding breast cancer
students?

3. What are the screening Provides answers to screen- 15-18

practices of breast cancer ing practices of breast cancer
among students in Nepal?

4. What are the health seeking Provides answers to health 19-23

behaviors of students regard- seeking behavior
ing breast cancer?

5. Are there differences in Pre data versus post data 1 - 31

knowledge level, attitudes
and practices of students re-
garding breast cancer before
and after aware-
ness programme?
 21

TABLE 3. Formulation of questionnaire sub types according to research ques-

tions among male students

Research questions Questionnaire subtype Questions

Provides answers to 5 -13
6. What are the knowledge the knowledge regarding
level and attitudes of breast breast cancer among male
cancer among male stu- students
dents? Provides answer regarding 14 - 16
the sources of information.
Provides answers to attitudes 17 - 23
among male students.

4.5 Data collection

Data were collected using structured questionnaire. Structure interviews are defined as
an interview in which the questions, their wordings and order are predetermined. Every-
thing related to interview question is predetermined and any deviation from it is not
permitted. Interview schedules in this study is a written list of closed ended questions,
thoroughly pre-tested for standardised wording, meaning and interpretation, prepared
for use for data collection. (Kumar, 2019.)

By the end of the study, the objective is to know the awareness level. 86 female students
and 29 male students were participated in data collection process. The researcher along
with Dr. Shahi provided information to the students. Introduction to breast cancer, sign
and symptoms, risk factors, possible treatment methods, screening practices of breast
cancer; BSE, mammography and the statistical female breast cancer data worldwide and
in Nepal were covered. The purpose of awareness programme was to make the partici-
pants aware about the risk factors, risk groups by knowing their history background,
keen observation for signs and symptoms and not to ignore if any detected. There were
many steps to be planned before implementing an awareness programme. The female
students attended the awareness programme where the data collection process took
place. The researcher made a 26 powerpoint slides to present during the awareness pro-
 22

gramme. The content of the slides included purpose of the thesis, introduction to breast
cancer, sign and symptoms of breast cancer, risk factors, stages of breast cancer, statis-
tical figures of breast cancer of the world and in Nepal, preventive measures, screening
methods, BSE: How to perform BSE, mammography, treatment and conclusion. The
education time was around 40 minutes and 15 minutes for discussions. In addition, the
dummy was used to show how the breast self-examination needs to be done correctly.
This is because breast self-examination has proved to be the initial way of detecting
breast cancers. If done correctly, the lumps can be detected at initial stage, which im-
proves treatments options and better cure. In the end, there were open discussions,
where the participant’s queries were discussed and answered. The pre data were filled
by the participants before the awareness programme. After an awareness programme, 56
female students filled up the post questionnaires. The goal was to do post-test analysis
for evaluation of awareness programme. The same questionnaires were provided to
same participants who had already filled up the pre- questionnaires and are available to
awareness program. This way the author can evaluate the participant’s knowledge be-
fore education program and compare it after the awareness education.

4.6 Data analysis

Data analysis is defined as “The processes of assessing data using analytical and logical
reasoning to assess each element of the data collected.” (Business dictionary). Data
processing in quantitative research starts with editing, followed by coding, which en-
tails developing a code book, pretesting it, the actual coding and verifying the coded
data. A code book provides a set of rules for assigning numerical values to answers
obtained from respondents. (Kumar, 2019)

Data are analysed using IBM SPSS(statistical package for social science) statistics 19.
SPSS is the most widely used software for statistical analysis of quantitative data.
(Greasley, 2007). Data are calculated as frequencies and percentages for different cate-
gorical variables. Data are also analysed as pre-test and post-test analysis. For
knowledge items, categorical responses Yes, No, Do not know were applied. The de-
mographic data are taken as independent variables whereas the knowledge, practices,
 23

attitudes and sources are dependent variables. When data are calculated, for positive
responses yes, 1 score is given and 0 is scored for incorrect answer and do not know
answers. The overall knowledge score was calculated by adding all positive scores of
knowledge category, first calculating the frequency and then converting it into the per-
centage. A total score of 100 is calculated for each participant percentage score. 80% or
more score is measured as excellent knowledge; a score between 60% and 79% is
measured as very good knowledge. A score between 40% and 59% is measured as good
knowledge and a score less than 40% is measured as poor knowledge.

Descriptive statistics with cross-tabulations were executed and frequencies were calcu-
lated for correct and incorrect answers for all questionnaires. Correlation was analysed
by using Pearson´s correlation coefficient and with significance level set at p. p-value of
<0.05 was considered statistically significant. The findings were evaluated at a 0.05
significance level with a 95% confidence interval. For comparisons between pre- and
post-test knowledge, the t-Test analysis was used. To determine the relationship be-
tween continuous variables, the multiple linear regression analysis was applied.

4.7 Ethical Considerations

Ethics is the moral values of professional conduct that are considered desirable for good
professional practice. There are many ethical issues to consider in relation to the partici-
pants in a research activity. It is important that the consent is voluntary. (Kumar, 2019.)

The author was committed to respect other’s work. The references were provided for
each data used in the text and in the reference section according to Diak’s guidelines for
writing thesis papers. (Finnish Advisory Board on Research Integrity, 2012). There are
ethical actions necessary in research which comprises protection of the participant’s
rights, balancing benefits and risks in a study, submitting a research proposal for institu-
tional review and obtaining permissions. (Burns and Grove, 2005.) During the research
process, the author followed all the above mentioned ethical actions. The author submit-
ted the research proposal to the concerned head of the College. The proposal was then
forwarded and discussed with the academic team of the college for permission to con-
 24

duct the research. Meanwhile the topic breast cancer is sensitive and when dealing with
young females, many things needs to look after and study before getting the permission.
The permission to conduct the research was granted by the College. The researcher took
the ethical approval from the university/college for this research. Informed consent has
to be taken from each participant before data collection. Informed consent denotes that
participants are well informed about the need and types of the information sought, how
and where information are going to be used and how they should participates in the
study. (Kumar, 2019.) The head of the College advice the author not to take the in-
formed consent individually as it is not common in Nepal; the college permission letter
is alone enough. The researcher explained ethical considerations to the students and
provided full autonomy to participate. Informed consent was taken verbally. None was
forced to fill up the questionnaires. Data provided will be kept confidential and anony-
mous. Data will be destroyed after they are documented. Data are used only for this
study. This study is not done for personal financial benefits. The ethical guidelines is-
sued by the Finnish National Advisory Board on Research Ethics (Finnish National
Board on Research Integrity, 2009) were followed by the author throughout the research
process.
 25

5 RESULTS

Altogether 86 female students and 29 male students were participated in this study. The
demographic study shows majority of the participants were aged between 16 to 20 and
were single. One third of the participants were doing 10+2 studies whereas nearly two
third were doing their bachelor studies. Most said their first period started age between
12-14 years, few said below 12 years. Almost all participants (99 %) had heard of
breast cancer and 98% thinks breast cancer is not a communicable disease. Only 6%
had family history of breast cancer as shown in table 4.

TABLE 4. Demographic data of participants (n=86)

Age (n=86) Frequency Percent%

16-20 81 95
21-25 1 1
26-30 2 2
30-35 2 2
Marital status
Married 2 2
Unmarried 84 98
Educational status
10 + 2 30 35
Bachelor 56 65
Age when your first period started
10 to 11 6 7
12 to 14 70 81
15 to 16 10 12
Family history of breast cancer 5 6
Have you heard of breast cancer? 85 99
Breast cancer is not communicable disease? 84 98
 26

5.1 Knowledge of breast cancer

The findings show the overall mean knowledge score for pre-test was 5.07 out of a
maximum score of 16, which is equal to 35.6%. It can be concluded that the knowledge
score of participants before the awareness programme was at poor level. The results in
table 5 shows the percentage of right answer responded by the participants regarding
risk factor of breast cancer. 71% responded previous history of breast cancer as a
risk factor, which descended to 70% family history of breast cancer, 69% drinking
alcohol. Risk factors such as breastfeeding, obesity, reproductive history, first preg-
nancy after age 30, age and oral contraceptive use were responded by less than 30%.
It was good to know that only 3% thought spiritual belief as a risk factor. It can be
concluded that most participants believe previous history, heredity and alcohol con-
sumption is the main risk factor rather than reproductive history.

TABLE 5. Response of participants: Risk of breast cancer

Response of participants: Risk of breast cancer (n = 86) Frequency Percent %

Age 9 10
Reproductive history: early menstrual age 12 and 55 14 16
Family history of breast cancer 60 70
Having the first pregnancy after age 30 10 12
Drinking alcohol 59 69
Obesity 22 26
Previous history of breast cancer 61 71
Oral contraceptive use 9 10
Breast feeding 25 29
Spiritual 3 3

Regarding sign and symptoms of breast cancer most of the respondents (73%) answered
pain in the breast region as the symptoms for breast cancer. It was followed in descend-
ing order by 43% painless lump. All other sign and symptoms of breast cancer such as
change in breast shape, nipple discharge, discoloration of skin, lump under armpit and
inversion of the nipple were responded in poor level as shown in figure 3.
 27

Sign and symptoms of breast cancer(n=86)

Painless lump
27 43
Change in breast shape
73 40 Nipple discharge
Lump under armpit
30
19 26 inversion of the nipple
Pain in the breast region
Discoloration of the skin

FIGURE 3. Response of participants: sign and symptoms of breast cancer

The findings show the knowledge regarding methods to reduce breast cancer with phys-
ical activity was in very good level (65%). The other options like breast feeding, alcohol
consumption limitation and avoiding hormonal replacement therapy was in poor level as
shown in figure 4.

Methods to reduce risk of breast cancer(n=86)

70
60
50
40
30 65
20 43
10 28 22
0
Physical activity Breast feeding Limit alcohol Avoid hormone
replacement
therapy

FIGURE 4. Methods to reduce risk of BC

Majority of participants responded knowing signs and symptoms could detect breast
cancer at early stage. Methods such as knowing the risk factors groups and regular
screening, performing BSE and regular mammogram after age of 40 were responded in
poor level as shown in figure 5.
 28

Methods to detect breast cancer early(n=86)

90 85
80
70
60
50
40 33
30 19
20 13
10
0
knowing the sign knowing the risk performing BSE regular
and symptoms factors groups and mammogram after
stage regular screening age of 40

FIGURE 5. Methods to detect BC early

Majority responded that breast cancer can be detected early. Almost all participants
agreed that early detection can improve chances of survival and 76% said breast cancer
is curable as shown in figure 6.

90

90

85 79
76
80

75
PERCENT%
70

65
Can breast Can early Is breast cancer
cancer be detection curable?
detected early? improve
chances of
survival?

FIGURE 6. Results showing knowledge level

The findings illustrate the correlation between the overall knowledge of the respondents
in pre data and their attitude towards breast cancer is statistically not significant, p=0.68
which is higher than (p ≤ 0.05) as shown in table 6. The overall knowledge of students
is not associated with their attitudes towards breast cancer. According to rule of thumb
for interpreting the size of a correlation coefficient, Pearson correlation, r=.04 is close to
0 which means there is a weak relationship between attitudes and knowledge. This con-
 29

cludes that knowledge of the participants is not correlated with changes in attitude.
Knowledge and attitudes of participants were not strongly correlated.

TABLE 6. Correlation between overall knowledge and attitude towards BC

Correlation (n=86) Overall Knowledge Attitude

Pearson Correlation 1 0.044
Sig.(2-tailed) 0.686

The result shows there is statistically significant correlation between overall knowledge
of participants in pre data and their screening practices of breast cancer, p=0.007 as
shown in table 7. There is association between overall knowledge of students and
screening practices. For example, those participants who had higher level of knowledge
had higher screening practices behavior. According to rule of thumb for interpreting the
size of a correlation coefficient, Pearson correlation, r=.288 is less than 0.3 which
means negligible correlation.

TABLE 7. Correlation between overall knowledge and screening practices of BC

Correlation (n=86) Overall Knowledge Screening practices

Pearson Correlation 1 0.288
Sig.(2-tailed) 0.007

5.2 Attitudes towards breast cancer

Regarding the attitudes towards breast cancer, majority (91%) of participants responded
that breast cancer patient should not be isolated. All participants thought breast cancer is
not a punishment from God. Almost all participants (94%) felt breast cancer patient
should be supported and care by the family and community whereas there are still 6%
who do not feel the same. More than half responded that breast cancer patient should
not breastfeed. 71% responded women should be afraid of breast cancer as shown in
table 8.
 30

TABLE 8. Attitudes towards breast cancer.

Attitudes towards breast cancer (n= 86) Frequency Percent %

Breast cancer patient should not be isolated? 78 91
Breast cancer is a punishment from God? 0 0
Patient supported by the family and community? 81 94
Breast cancer patients should breastfeed? 54 63
Women should not be afraid of breast cancer? 61 71

5.3 Practices of breast examination

The overall knowledge for methods of screening of breast cancer was found to be poor
level. For example, only 24% participants were aware of BSE, 7% ultrasound and 23%
mammography. More than half of the participants (60%) did not know any methods of
screening as shown in figure 7.

Screening methods of breastcancer

24
BSE
7
60 Ultrasound
mammography
23
donot know

FIGURE 7. Screening methods

 31

The knowledge regarding breast self-examination was found to be poor level. Few par-
ticipants were aware of BSE. Only 9% participants practices BSE. The reasons for not
performing BSE were they felt inconvenient and uncomfortable, some thought it was
not necessary. Most responded (64%) they do not know how to perform it. There was
poor level of knowledge found regarding right time to perform BSE. Only 20 % gave
the correct answer that BSE should be performed monthly as shown in table 9.

TABLE 9. Practices of breast cancer

Screening methods of breast cancer(n=86) Frequency Percent%

BSE 21 24
Ultrasound 6 7
Mammography 20 23
Do not know 52 60
Have you ever done BSE? 8 9
Reason for not performing BSE
Inconvenient/uncomfortable 12 14
Not necessary 11 13
Do not know how to do 55 64
Others 7 8

Correct BSE frequency

Daily 2 2
Weekly 2 2
Monthly 17 20
Yearly 6 7
Do not know 28 33

5.4 Health seeking behaviour of breast cancer

Most respondents reacted that they will seek medical advices immediately if sign and
symptoms are noticed. The reason for not seeking medical help were scared 5%, wor-
ried about bad results 6%, uncomfortable talking about the symptoms 2%, hospitals
remotely 1% and difficult to get doctor´s appointment 1%. 93% responded that they will
 32

see doctor if any abnormality is found during BSE. The findings show that most stu-
dents mainly seek medical consults. Only 1 % responded to hide the news from family
if breast cancer symptoms were detected. The reason for hiding the news is the thought
that breast cancer is incurable as shown in table 10.

TABLE 10. Health seeking behaviour

Health seeking behaviour Frequency Percent%

Seek medical advices if sign and symptoms noticed? 83 97

Reason for not seeking help

Scared 4 5
Worried about the bad results 5 6
Would not feel comfortable talking about the symp- 2 2
toms
Too busy to visit a doctor 0 0
Too many other things to worried about 0 0
Hospitals far away 1 1
Worried about the doctor’s fees 0 0
Difficult to get doctor’s appointment 1 1

Do if notice any abnormality during BSE

Pray 1 1
Traditional, spiritual treatment methods 0 0
See a doctor 80 93
Do nothing 0 0
Others, specify 2 2

Hide the news after you detect breast cancer 1 1

symptoms?
Fear of rejection from family 0 0
Expensive treatment 0 0
Breast cancer is incurable 1 1
Fear of mastectomy 0 0
Others, specify 1 1

5.5 Sources of breast cancer information

The most common source of information informed by the participant is media (73%)
such as TV, radio, Facebook, followed by 42 % family or friends, 17% informed
health professionals and 7% others as shown in figure 8.
 33

sources of breast cancer

information
Family, friends
7 42
health professionals

73 17 Media, TV/ Radio

Facebook, Newspaper
others,

FIGURE 8. Sources of breast cancer information

The most participants responded awareness programme (72%) and medical consults
(73%) as a method to receive more information about breast cancer. 65% of the partici-
pants knew where they can get the information regarding breast cancer as figure below.

Methods to receive information

7
awareness program
72

73 medical professionals
consults
others

.
FIGURE 9. What helps to know more about breast cancer?
 34

5.6 Pre and Post-test knowledge differences

There was an increase in knowledge level of the participants after the awareness pro-
gramme. It can be concluded that awareness programme helped them increase their
knowledge level regarding breast cancer. The knowledge levels of female students when
comparing risk factors and sign and symptoms data: pre-test results was 35.6% and
post-test was 70%. The overall knowledge (comparing data from questions 6-14) was
found to be 41.6% in pre data which increased to 77% after awareness programme. Sim-
ilarly, Screening practices findings were 18.5% in pre-test results whereas after the
awareness programme, it was increased to 86 % which can be said to have excellent
knowledge score as shown in table 11.

TABLE 11. Overall knowledge pre and post awareness programme (n=56)

pre% post%
Knowledge about BC(risk factor & sign and symptoms) 35.6 70
Overall knowledge level 41.6 77
Attitude towards BC 50.2 56
Practice of BSE 18.5 86

T- test was used to calculate the difference in knowledge of breast cancer (risk factor
and sign and symptoms) pre and post awareness programme. The data from 56 partici-
pants who attended the awareness programme and filled up the pre and post question-
naires were used to calculate the paired samples test. The result is shown in table 12.
The p=0.001 denotes that the effect of awareness programme has been seen and there
was statistically significant increase in knowledge level post awareness programme. The
overall mean knowledge score for pre-test was 5.07 out of a maximum score of 16
which significantly increased to 11.73 in post-test. The awareness programme was asso-
ciated to increment of knowledge level in post test results.
 35

TABLE 12. T test for pre and post samples

Paired samples test t df Sig. (2-tailed)

Std. devi- Std. Error 95 % confidence interval
Mean ation Mean of the Difference
Lower Upper
Pre 5.0714 2.44099 0.32619 -7.62192 -5.69950 -13.887 55 0.0001
Post 11.7321 3.07773 0.41128

The figure 10 and table 13 shows the differences in risk factor and sign and symptoms
of breast cancer pre and post awareness programme. The findings shows that after the
awareness programme majority of participants were aware of risk factors such as oral
contraceptive use, obesity, having first pregnancy after age of 30, age and reproductive
history. Similarly, more than half of respondents answered all sign and symptoms of
breast cancer. The green bar denotes the post data and the increase in knowledge is easi-
ly distinguishable.

100
90
80
70
60
50
40
30
20
10 pre-data
0 post-data

FIGURE 10. Comparison of risk factors and sign and symptoms of breast cancer

After the awareness program, 100% responded that early detection can improve chances
of survival. 98% said breast cancer can be detected early and 93% understood breast
cancer is curable as shown in table 13.
 36

TABLE 13. Comparison of pre and post-test data

Risk factor of Breastcancer pre-data post-data

Age 10 64
Reproductive history: early menstrual age of 12 and 16 76
55
Family history of breast cancer 70 91
Having the first pregnancy after age 30 12 89
Drinking alcohol 69 93
Obesity 26 78
Previous history of breast cancer 71 80
Oral contraceptive use 10 90
Breast feeding 29 35

Sign and symptoms

Painless lump 43 69
Change in breast shape 40 82
Nipple discharge 30 55
Lump under armpit 26 58
Pulling in/ inversion of the nipple 19 53
Pain in the breast region 73 76
Discoloration of the skin 27 80

Methods that can help reduce the risk of

breast cancer
Physical activity 65 89
Breast feeding 43 85
Limit alcohol 28 80
Avoid hormone replacement therapy 22 45
Methods to detect breast cancer ear-
ly(n=86)
knowing the sign and symptoms stage 85 87
knowing the risk factors groups and regular
screening 33 82
performing BSE 13 80
regular mammogram after age of 40 19 64
Can breast cancer be detected early? 79 98
Can early detection improve chances of
survival? 90 100
Is breast cancer curable? 76 93

The common source of information for health professionals was distinctly raised after
awareness programme compare to other sources as shown in figure 11.
 37

90 84
80 73
70
58
60
50 47
42
40 pre %
30 post%
20 17

10 7
2
0
Family, friends health Media, TV/ others,
professionals Radio Facebook,
Newspaper

FIGURE 11. Sources of information

There were not considerable differences in attitudes towards breast cancer pre and post
awareness programme. The percentage slightly decreased from 9 to 5% for breast can-
cer patient should be isolated. Almost everyone supported that breast cancer patients
should be cared and supported by family and community. The results can be seen in
table 14.

TABLE 14. Results showing attitudes towards breast cancer

Attitudes towards breast cancer (n= 86) Pre result % Post result %
Breast cancer patient should be isolated? 9 5
Breast cancer is a punishment from God? 0 0
Patient supported by the family and community? 94 98
Breast cancer patients should breastfeed? 63 49
Women should not be afraid of breast cancer? 71 63

The mean value of screening methods of breast cancer and correct BSE frequency
time in pre-test was 18.5% and raise to 86% in post-test result. This concludes that
 38

participants have gained knowledge on screening methods of breast cancer and they
know BSE should be performed monthly. They are also familiar with the screening
methods.

5.7 Results of male participants

The male participant’s age was between 19 to 32, with majority participants between
age 19 to 21. Almost all participants (90%) were single and were studying bachelors’
level. 17% responded family history of breast cancer. Majority of male participants
(96%) had heard about breast cancer and responded breast cancer is not a communica-
ble disease (98%).

The findings from the male participants shows more than half participants (68%) re-
sponded previous history of breast cancer and family history as a risk factor of breast
cancer. There was poor knowledge level for risk factors such as drinking alcohol,
breastfeeding, obesity, reproductive history, first pregnancy after age 30, age and oral
contraceptive use. None thought spiritual belief as a risk factor. It can be concluded that
most participants believe previous history, heredity and alcohol consumption is the
main risk factor which was similar in female data. The most of respondents (71%) an-
swered pain in the breast region as the sign and symptoms for breast cancer. Sign and
symptoms such as painless lump and lump under armpit were found to be in good level
whereas change in breast shape, discoloration of skin, inversion of the nipple and nipple
discharge were at poor level. The overall knowledge level of male participant was
44.3% which according to KAP score is a good knowledge. Majority reacted they know
where to get more information regarding breast cancer. The findings show that 79%
chose physical activity as a method that can help reduce the risk of breast cancer fol-
lowed by 32% breast feeding, 29% alcohol consumption limitation and 25% avoiding
hormonal replacement therapy. Majority responded that knowing signs and symptoms
could detect breast cancer at early stage. Few participants responded to knowing the risk
factors groups and regular screening, performing BSE and regular mammogram after
age of 40. More than half participants (68%) believe that breast cancer can be detected
early and almost all (96%) responded early detection can improve chances of survival
 39

which was an excellent knowledge level. Majority of participants believe breast cancer
is curable as shown in table 15.

TABLE 15. Knowledge of breast cancer among male participants

Risk factor of Breast cancer % Methods to reduce risk of BC %

Age 25 Physical activity 79
early menstrual age of 12 and 55 14 Breast feeding 32
Family history of breast cancer 68 Limit alcohol 29
Having first pregnancy after age 30 25 Avoid hormone replacement therapy 25
Drinking alcohol 39
Obesity 36 Methods to detect breast cancer early
Previous history of breast cancer 68 Knowing sign and symptoms stage 86
Oral contraceptive use 14 Knowing risk factors groups and screening 29
Breast feeding 18 Performing BSE 32
spiritual 0 Regular mammogram after age of 40 29

Sign and symptoms Can breast cancer be detected early? 68

Painless lump 46 Early detection improve survival chances? 96
Change in breast shape 32 Is breast cancer curable? 89
Nipple discharge 7 Methods to get more information
Lump under armpit 43 Awareness program 89
Pulling in/ inversion of the nipple 11 Medical professional consults 64
Pain in the breast region 71 Others 14
Discoloration of the skin 21 Get information on breast cancer? 96

Concerning attitudes of breast cancer among male participants, all respondents agreed to
support women with breast cancer. Majority (96%) supported that breast cancer patients
should be supported and care by family and community. Less than half participants re-
sponded women should be afraid of breast cancer. Few responded breast cancer patient
should be isolated and believed breast cancer is a punishment from god. It concludes
that although in small number, but the stigma regarding breast cancer still exists in soci-
ety. Young people still think it is a punishment and patient need to be isolated.
 40

Attitudes of male participants (n=29)

can men have breast cancer? 21

Do you support women with BC 100

Women shouldnot be afraid of breast
43
cancer?

Breast cancer patients should breastfeed? 66

%
patient supported by the family and
96
community?

Breast cancer is a punishment from God? 7

Breast cancer patient should be isolated? 14

0 20 40 60 80 100 120

FIGURE 12. Attitudes of male participants

The most common sources of information were media, radio, TV, newspaper, Face-
book. 89% responded awareness programme as a method to get more information on
breast cancer followed by 64% medical professional consults.

Sources of breast cancer information( n=29)

7 Family, friends
42

health professionals

73
17 Media, TV/ Radio
Facebook, Newspaper
others,

FIGURE 13. Sources of information

 41

6 DISCUSSION

6.1 Discussion of the results

The overall knowledge (sign & symptoms and risk factor) of the participants in this
study were at poor level (less than 40%) which supports with the earlier studies (Turkey
by Yilmaz et al, in Jordan by Suleiman, in Iraq by Hamad et al, in Libya by Elzahaf et
al, Sambanje and Mafuvadje and in Nepal by Shrestha). Poor level of knowledge among
the students might be due to lack of awareness regarding breast cancer. The proven
ways to detect breast cancer early is self-awareness. The knowledge of sign and symp-
toms, risk factors of breast cancer, habit of performing breast self-examination regularly
once a month helps a person notice any changes in their body, hence alerting them to
seek health professional for early diagnosis. Also regular mammography for certain age
group women helps to detect breast cancer. Women should be acknowledging about the
screening programmes.

Majority participants in this study responded pain in the breast as the main sign and
symptoms, which supports to the findings that 80% Angola students believe the same.
The findings associates to the misperception that cancerous breasts lump are painful in a
study by Shrestha and Garg. People still wait for the pain to get excess to treatment
when it is already late. This could lead women who detect a painless lump in the breast,
assumes it to be harmless and they do not seek assistance from health professionals.
Many women may not seek care when they detect the sign and symptoms because they
are unaware of what it represents. It was distinct that most respondents were not aware
of evident risk factors, sign and symptoms that can relate to breast cancer. For instance,
30% and below participants were aware of the sign and symptoms of breast cancer such
as nipple discharge, discoloration of the skin, lump under armpit and inversion of the
nipple.

The study found low levels of knowledge observed for risk factors such as breastfeed-
ing, obesity, reproductive history, first pregnancy after age 30, age and oral contracep-
tive use. This results supports with the study by Gupta et al, Shrestha & Elzahaf et al in
 42

which poor knowledge was observed for important risk factors such as reproductive
history and having first pregnancy after age of 30. Women usually assumed that use of
alcohol and tobacco were more important risk factors than reproductive history, which
is one of the most determining risk factor of breast cancer.

The participants were unaware of the most of the major risk factors that can cause breast
cancer. This finding supports the study carried in Jordan by Suleiman who found poor
level of knowledge for risk factor of breast cancer among participants. For example, 99
(22.7%) responded risk factor to be medical condition, 56 (12.8%) respondents to he-
redity. A study in Libya by Elzahaf et al also found poor level of knowledge regarding
risk factors. A lack of knowledge regarding risk factors among the participants was
observed in many studies. Awareness regarding breast cancer and providing knowledge
regarding risk factors and sign and symptoms is a preventive measure. It help one for
early diagnosis of disease and better treatment options which leads to improved chances
of saving lives. (Rouse, 2018.) Using preventive measures in breast cancer would be
identifying risk factors and then reducing the risks that can cause breast cancer. For ex-
ample, living healthy lifestyles, maintaining a healthy weight, eating healthy foods, ex-
ercising regularly, sleeping well, avoiding smoking and limiting alcohol consumption,
avoiding unnecessary radiation, avoiding hormonal therapies and oral contraceptive use,
performing BSE monthly, participating in screening programmes, and identifying risk
groups.

The findings show that participants have poor knowledge of screening methods. 60%
responded they do not know about screening methods, which supports to the study car-
ried in Iraq by Hamad et al. Lack of knowledge of the participants was the most com-
mon reasons for not performing BSE, similar to findings of recent study of Sayed et al
in Kenya. Only 9% performed BSE. The common reason for not performing BSE were
the participants had no idea how to perform BSE, some thought there is no need or they
do not fall in risk groups and few participants felt discomfort, fear and shy. More than
half respondents do not know the screening methods for breast cancer. This result is in
contrast with the study carried out by Sindi et al, in Saudi Arab, Hamad et al in Iraq and
Sayed et al in Kenya where the BSE performance rate were more than 50%. This might
be due to lack of awareness of BSE in Nepal. Women, mostly young females feel shy to
see their own body parts. This might be because of the Nepalese cultural values, con-
 43

servative thoughts have shaped them. It was also found that people have heard of BSE
but ignores to perform it. Women themselves or their partners had detected symptoms
of breast cancer. Hence, knowledge plays a key role to improve health seeking behavior
of women and also participate in screening practices.

The findings revealed that almost every student (99%) have heard of breast cancer in
this study in contrast to the study done in Jordan students by Suleiman which concluded
51.8% being aware of breast cancer. This could be because internet and technologies
has ruled the world. As a significance of this, people are update with the media, news,
educative learning. In Nepal most youths and adults use Facebook. The awareness and
educative things shared in social network have been very productive. This supports to
the findings that 73% responded media, FB to the sources of information about breast
cancer which was the highest of all. These findings supports to the study of Hamad et
al, 2018, in Iraq and Iheanacho et al, 2013 in Nigeria. Media plays an important role in
spreading information to all corners in a country. In addition to this, the government
should also provide awareness program in regular basis to schools and community.

Most respondents (97%) reacted that they will seek medical advices immediately if sign
and symptoms are noticed which supports by a study in Kenya where 90% participants
also responded they would seek medical professional assistance within a week period
time if they noticed breast cancer symptoms. The reason for not seeking medical help
were scared, worried about bad results, uncomfortable, hospitals remotely and difficult
to get doctor´s appointment. The findings show that most students mainly seek medical
consults. Delay in early detection could be due to differences in socio demographic and
cultural factors, a strong belief in traditional medicine, negative perception of disease,
poverty and poor education combined with fear and denial. Results revealed that majori-
ty of patients with breast cancer seek health facility at late stage when the treatment
options are limited and disease is incurable. Health-seeking behaviors believing more
on traditional healers and seeking first help from them were common among the partici-
pants who do not consider breast cancer symptoms seriously to seek help from medical
professional by visiting a hospital. This might be because the community is still una-
ware about the breast cancer knowledge. Awareness regarding breast cancer is im-
portant in seeking medical professional consults that enhances detecting breast cancer at
earlier stage.
 44

Half of the respondents had positive attitude towards breast cancer which supports by a
study in Jordanian female students by Suleiman and in Libya by Elzahaf at al where
majority of female students had good attitude towards breast cancer. Majority partici-
pants disagreed that breast cancer patients should be isolated and breast cancer is a pun-
ishment from God. A fear of social rejection was a reason to neglect treatment for breast
cancer. The result also found out that female does not find comfortable discussing about
breast health with male members in a family. Males should be encouraged in the in-
volvement in their partner’s breast health. Husbands should participate and involve in
the care of their wives during the treatment process by visiting the doctor with their
wives. In this way the female does not feel left alone and gets emotional support from
the family.

The stigma of breast cancer and the associated societal implications of its treatments,
especially mastectomy discourage women from seeking treatment early. Education need
to address the reality that is concerned about the stigma of cancer. They distress being
rejected by their community and their partners, fear the potential loss of the breast, or
believe there are no effective therapies for the disease especially when they have expe-
rienced their relative´s death with breast cancer. The facility of better primary
healthcare, education, and better medical outcomes will reduce stigma and fear that will
arise from complex technologies treatment, such as mammography or adjuvant therapy.
(Lawrence, 2010.) The breast cancer survivor can be the best teacher in providing coun-
seling. They are the example that breast cancer is curable. They have already been
through the complications and can support the women overcome physically and psycho-
logically. Acknowledging the community will lead to positive attitude towards breast
cancer and enhances supporting behavior towards women with breast cancer. Creating
awareness about breast cancer could be an effective strategy to reduce mortality due to
breast cancer in low- and middle-income countries. There is a crucial need to explore
the awareness deficits and stigma surrounding breast cancer, both in the general popula-
tion and among health care professionals. It is important to understand the barriers for
strategic and effective awareness campaigns and interventions on prevention and early
detection. In order to increase knowledge for early detection of breast cancer, education
is needed. (Gupta et al, 2015)
 45

The findings of this thesis revealed that there was poor knowledge level of breast cancer
among female students in the pre-test which significantly increased to very good
knowledge level after the awareness programme. The educational programme was
proved to be beneficial on increasing knowledge level regarding breast cancer for the
participants. The preventive measure to detect breast cancer early is to know the risk
factor, screening programmes and sign and symptoms. Therefore, by providing training
programs in the community can increase knowledge and create awareness towards
breast cancer. The results supports with the findings by Yilmaz et al in Turkey and in
India by Madhukumar which states there was a significant increase in knowledge level
from the pre to the post-test after awareness programme.

Male participants were also included in this research and their knowledge level and atti-
tude were studied. Men are the support to the suffered family members and society.
Though male participants had good knowledge level in this study, only 21% responded
men can have breast cancer which agrees with the study in Kenya by Sayed et al that
only 30% of participants were aware that men can have breast cancer. Breast cancer is
not common among males; however 1% men are affected by breast cancer. (Breast-
cancer.org, 2020). Thus, men should also be focused to awareness programmes. All
male participants responded that they supports women with breast cancer and 96% re-
sponded that breast cancer patients should be cared and support by the family and
community. It was good to know male participants attitude towards female breast can-
cer patients. Nepal is a male dominant country. In many developing Asian and African
country, male plays a vital role in a family. They are the decision makers for everything
at home. They are the one who decides if a female member in a family needs to seek
medical consults if sick or traditional healers. Women´s health completely depends on
them. Therefore, it is very important in male dominant countries to teach, involve male
participants in breast cancer awareness programme. This can be very fruitful in a long
run. If the head of the family knows about the breast cancer, they can teach other mem-
bers of a family and can provide right decision in health seeking behavior and treatment.

To carry out the research for this thesis, a guidance and support from an organization
was needed. To conduct awareness programme alone was not possible, it is a huge task.
Therefore, a college from Kathmandu, Nepal was involved for data collection process.
 46

In addition, a researcher contacted Dr. Shahi. The reason to involve him in this project
was to get assisted in implementing awareness programme.

6.2 Reliability and validity of the study

In quantitative research, “reliability refers to the consistency, stability and repeatability

of results”. (Twycross & Shields, 2004). Validity is the extent to which any measuring
instrument measures what it is intended to measure. Validity is the quality of research
being used to support the argument being made (Thatcher, 2010). In this thesis, validity
of the questionnaires from knowledge, attitudes and practices of breast cancer was test-
ed through Pearson correlation. The testing criteria were

 Valid if the correlation value, Pearson correlation > r table, in this case for df
value(n-2)84, r>.21 for two tail tests at significance by pvalue 5% (0.05) .
 Invalid if correlation value, Pearson correlation is < r table, 0.21.
Hence, it can be concluded that the questionnaires for knowledge, practices and atti-
tudes were analyzed to check the validity. The table 16 shows the

Pearson correlation for knowledge is 0.668 > 0.21 = Valid.

Pearson correlation for Attitude 0.510>0.21 = Valid.
Pearson correlation for Practices is 0.769>0.21=Valid.

TABLE 16. Validity of the questionnaires

Knowledge Attitude Practices

Pearson Correlation 0.668** 0.510** 0.769**
Sig. (2-tailed) 0.000 0.000 0.000
N 86 86 86
** Correlation is significant at the 0.01 level (2-tailed).

In this thesis, a researcher assured all the findings were based on the data collected. The
data was collected by the researcher, herself. The questionnaires were explained by the
 47

researcher when it was not understood by the participants. The data analysis was done
very carefully. All the data were rechecked while inserting the values in the software.
The data was analyzed according to the research questions. Data analysis of this study
was done using SPSS programme. The researcher gets acquainted with the SPSS soft-
ware. A noteworthy time was spent in learning the tools and making preeminent use of
the available tools. The analyzed data was presented in the forms of tables and figures
for the quick understanding. The researcher made sure that the analysis was done cor-
rectly by re-checking the analysis process. A pilot testing could have been worth taking
to calculate the findings and reconstruct the questionnaires accordingly into more sim-
pler and understandable form. Hence, this could have altered in case of reliability.

6.3 Limitation of the study

The study, however, is subject to several limitations. The sample size for the data col-
lection was not sufficient as stated by sample size calculator. Only one college was in-
volved. The results could have altered if the study has increased number of participants.
It could have been better if other college student were also included to provide the gen-
eralized result of the population. The result of this study might be biased as the sample
size was limited and they were not selected randomly. The level of knowledge of stu-
dents after awareness programme was assessed soon after providing the education;
hence, it was not assured if the participants are applying the education to their daily hab-
it and behaviors. It is recommended that studies should be carried out for time intervals
for evaluating the effectiveness of the educative programme. Due to time limitation, the
concentration level of the students regarding awareness programme was relatively less.
A less interest and rapidity was also observed when filling up the questionnaires. This
might be because the pre data and post data along with the awareness programme was
conducted on the same day, making the students lethargic after their lectures. This limi-
tation needs to be measured when interpreting the findings of this study.
 48

7 CONCLUSION

The findings showed significant difference in knowledge level of students prior to

awareness program and after the program. The students had poor knowledge level re-
garding breast cancer, sign and symptoms, risk factors, practices and screening of breast
cancer according to pre data results. The awareness programme had intense effects on
breast cancer knowledge, risk factors, sign and symptoms, practices and health beliefs
of women. The students had increased knowledge concerning breast cancer after the
educational program.

Breast cancer is curable when detected early and treated at first stage. Although Nepal
has very low incidence rate of breast cancer, almost half of affected person is dying.
(WHO 2017). This can be altered as in developed countries. Education regarding gen-
eral awareness program, screening for breast cancer is common in developed countries,
however in the developing countries, conservative community, women seems to be re-
served talking about their problems.

In conclusion, in order to raise the knowledge about the early detection practices like
BSE, mammography and all the possible preventive practices, more awareness strate-
gies need to be developed. Early detection is very important in breast cancer in order to
overcome with best possible outcome. Therefore, the practice should be developed in
proper cooperation and coordination with the education networks and media in order to
effectively implement the awareness program. It is recommended that the college
should offer educative awareness programme to students regularly. This way the educa-
tion can be spread not just to students but also to their family members. The other way
to raise awareness is by providing evidence based training regarding breast cancer to
healthcare providers and community workers so they can share and educate this
knowledge to other population in the society. The plan should not only include
healthcare delivery but also promote awareness and early detection. The interventions
should specifically focus on the needs of women who cannot easily get access to health
systems. The simple steps of educating women about awareness regarding breast cancer
and when to seek medical assistance can help them detect breast cancer early. This leads
to better treatment and high survival rates.
 49

The findings also showed that men supports women with breast cancer and believes the
breast cancer patient should be loved, cared and support by family and community. The
men should also be involved in education program so that they can provide support to
the women. Further research needs to be done to study knowledge and attitudes of male
in larger population size to generalize the findings.

This study found that women’s beliefs to breast screening practices were significantly
increased in the post-test. However, education programme should be persistent for the
reason that better knowledge level can influence positive behavior about early detection
of breast cancer. The screening practices such as breast self-examination will teach in-
dividual to raise awareness in detecting the breast cancer at early stage hence, this study
stress the necessity to teach individuals about the importance of early detection tech-
niques. To provide the necessary information and services to reach all age group, educa-
tional and social level; the interventions should be developed aiming to deliver
healthcare education and to encourage preventive healthcare behaviors. This finding can
be used as a reference for future studies in similar context.
 50

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APPENDIX 1. Consent Form

Namaste! I am Salina Shrestha-Bogati, currently studying Master´s in Global Health

Care from Diaconia University of Applied Sciences in Finland. I am doing my thesis
research on Knowledge, attitudes and practices of Breast Cancer among college students
of Nepal. The main purpose of this research is to explore the knowledge of breast cancer
among students. The aim of this research is that the college student benefits through
information shared on Awareness programme. Your responses will be kept confidential
and anonymous. The data will be destroyed after the findings are documented. The
results will be published in master thesis in June 2020. Your honest answer will be
appreciated. Participation is voluntary. The ethical approval has been done by the school
and Diaconia University of Applied Sciences for this study. Thank you for responding
and for your time. Please, take a few moments to answer the questions. Thank you.
This survey is intended for college students.

Please feel free to contact if any queries at [email protected]. Below is the consent
form you could sign and give me approval to use your data in this study.

I have read and understood the information provided to me. I am aware of this research
and the data can be used for this study. I agree to give my consent for this study.

Name of the participant Signature

Date

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APPENDIX 2. Questionnaires for Female participants

Demographic characteristics
1. Age-
2. Marital status-
3. Educational status-
4. Age when your first period started -
5. Family history of breast cancer- Do you know if someone in your family is/was diag-
nosed of breast cancer?
a. Yes b. No

Knowledge of Breast cancer

6. Have you heard of breast cancer?

a) Yes b) No

7. Is breast cancer communicable disease?

a) Yes b) no c) Do not know

8. What do you think is risk factor of breast cancer. Tick all that apply
a) Age
b) Reproductive history: early menstrual before age of 12 and menopause
after age of 55.
c) Family history of breast cancer
d) Having the first pregnancy after age 30.
e) Drinking alcohol
f) Obesity
g) Previous history of breast cancer
h) Oral contraceptive use
i) Breast feeding
j) Spiritual

9. Do you know sign and symptoms of breast cancer? Tick all that apply
a) Painless lump
b) Change in breast shape
c) Nipple discharge
d) Lump under armpit
e) Pulling in/ inversion of the nipple
f) Pain in the breast region
g) Discoloration of the skin
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10. What methods do you think can help reduce the risk of breast cancer? Tick all
that apply
a) Physical activity
b) Breast feeding
c) Limit alcohol
d) Avoid hormone replacement therapy
e) All of the above

11. What do you think can detect breast cancer in early stage? Tick all that apply
a) Knowing the sign and symptoms
b) Knowing the risk factors groups and regular screening
c) Performing BSE
d) Regular mammogram after age of 40.

12. Can breast cancer be detected early?

a) Yes b) No c) Do not know

13. Can early detection improve chances of survival?

a) Yes b) No c) Do not know

14. Is breast cancer curable?

a) Yes b) No c) Do not know

Practices of Breast Examination

15. Do you know the methods of screening of Breast Cancer? Tick all that apply
a) Breast self-examination
b) b) Ultrasound
c) c) Mammography
d) d) Do not know

16. Have you ever done breast self-examination?

a) Yes b) No

17. If no, why?

a. Not convenient/uncomfortable
b. Not necessary
c. Do not know how to do
d. Others, Please specify-

18. How often should BSE be performed?

a) Daily b)Weekly c) Monthly d) Yearly e) Do not know
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Health Seeking Behavior of Breast Cancer

19. If you notice sign and symptoms of breast cancer in you, do you seek medical
advices immediately?
a) Yes b) No

20. If No, why? Tick all that apply

a) Scared
b) Worried about the bad results
c) Would not feel comfortable talking about the symptoms
d) Too busy to visit a doctor
e) Too many other things to worry about
f) Hospitals far away
g) Worried about the doctors’ fees
h) Difficult to get doctor’s appointment

21. If you notice any abnormality during BSE, what will you do?
a) Pray
b) Traditional, spiritual treatment methods
c) See a doctor
d) Do nothing
e) Others, specify

22. Will you hide the news from your family after you detect breast cancer symptoms?
a) Yes b) No

23. If yes, why?

a) Fear of rejection from family
b) Expensive treatment
c) Breast cancer is incurable
d) Fear of mastectomy
e) Others, specify.

Sources of breast cancer information

24. From whom did you hear about breast cancer? Tick all that apply
a) Family, friends
b) Health professionals
c) Media, TV/ Radio, Facebook, Newspaper
d) Others, specify-

25. What do you think can help you know more about breast cancer? Tick all that apply
a) Awareness program
b) Medical professionals consult
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c) Others, specify.

26. Do you know from where can you get information about breast cancer?
a) Yes b) No

Attitudes towards breast cancer

27. Breast cancer patient should be isolated?

a. Yes b. No

28. Breast cancer is a punishment from God?

a. Yes b. No

29. Breast cancer patient should be supported and cared by the family and community?

a. Yes b. No

30. Breast cancer patients should not breastfeed?

a. Yes b. No

31. Women should be afraid of breast cancer?

a. Yes b. No

Thank you very much for your time and effort. It is very well appreciated.
 60

APPENDIX 3: Questionnaires for Male participants

Demographic characteristics
1. Age-
2. Marital status-
3. Educational status-
4. Family history of breast cancer- Do you know if someone in your family is/was diag-
nosed of breast cancer?
a. Yes b. No

Knowledge of Breast cancer

5. Have you heard of breast cancer?

a)Yes b) No

6. Is breast cancer communicable disease?

a) Yes b) No

7. What do you think is risk factor of breast cancer. Tick all that apply
a) Age
b) Reproductive history: early menstrual before age of 12 and menopause after age
of 55.
c) Family history of breast cancer
d) Having the first pregnancy after age 30.
e) Drinking alcohol
f) Obesity
g) Previous history of breast cancer
h) Oral contraceptive use
i) Breast feeding
j) Spiritual

8. Do you know sign and symptoms of breast cancer? Tick all that apply
a) Painless lump
b) Change in breast shape
c) Nipple discharge
d) Lump under armpit
e) Pulling in/ inversion of the nipple
f) Pain in the breast region
g) Discoloration of the skin
 61

9. What methods do you think can help reduce the risk of breast cancer? Tick all
that apply
a) Physical activity
b) Breast feeding
c) Limit alcohol
d) Avoid hormone replacement therapy

10. What do you think can detect breast cancer in early stage? Tick all that apply
a) Knowing the sign and symptoms
b) Knowing the risk factors groups and regular screening
c) Performing BSE
d) Regular mammogram after age of 40.

11. Can breast cancer be detected early?

a) Yes b) No

12. Can early detection improve chances of survival?

a) Yes b) No

13. Is breast cancer curable?

a) Yes b) No

Sources of breast cancer information

14. From whom did you hear about breast cancer? Tick all that apply
a) Family, friends
b) Health professionals
c) Media, TV/ Radio, Facebook, Newspaper
d) Others, specify-----

15. What do you think can help you know more about breast cancer? Tick all that apply
a) Awareness program
b) Medical professionals consult
c) Others, specify.

16. Do you know from where can you get information about breast cancer?
a) Yes b) No

Attitudes towards breast cancer

17. Breast cancer patient should be isolated?

 62

a. Yes b. No

18. Breast cancer is a punishment from God?

a. Yes b. No

19. Breast cancer patient should be supported and cared by the family and community?

a. Yes b. No

20. Breast cancer patients should not breastfeed?

a. Yes b. No

21. Women should be afraid of breast cancer?

a. Yes b. No

22. Do you support women with breast cancer?

a. Yes b. No

23. Can men have breast cancer?

a. Yes b. No

Thank you very much for your time and effort. It is very well appreciated.
 63

APPENDIX 4 WHO Pen protocol

 64

APPENDIX 5. Summary of previous research findings

Author Topic Participants/ Methods Findings

settings
Suleiman, Awareness 840 univer- Cross Out of 840 participants, half of them
A. and attitudes sity students sectional (51.8%) were aware of breast can-
2014 regarding Jordan research cer. Result found poor level of
breast cancer design knowledge for risk factor of breast
and cancer among participants. Result
breast self‑ found excellent attitudes towards
examination breast cancer patient. The sources to
among fe- attained knowledge regarding breast
male Jorda- cancer were friends (45.2%) and
nian students health workers. Less than 20%
thought media as a source for breast
cancer education.

Author Topic Partici- Meth- Findings

pants/ set- ods
tings
Sam- Breast 595 univer- cross- Result found inadequate knowledge of breast
banje, cancer sity stu- sec- cancer among university students. The majori-
M., & knowled dents in tional ty of the participants were not aware of sign
Ma- ge and medical survey and symptoms and risk factors of breast can-
fuvadze, aware- and non- cer such as change in color or shape of the
B. ness medical nipple. Study showed very good knowledge of
(2012). among programs. BSE. However, only 40.2% participants could
universi- perform BSE confidently and more than 50%
ty stu- Angola did not know the right time to perform BSE
dents in
Angola

Au- Topic Partici- Meth- Findings

thor pants/ ods
settings
Hama knowledge of 100 fe- de- hamad et.al found only 35% participants had
d, K., breast cancer male stu- scrip- overall good knowledge level of breast cancer.
Kha- risk factors dents tive, Good knowledge level was found for sign and
lil, H. and practice Iraq cross- symptoms with 86% saying painless lump in
& of breast self sec- breast .Regarding BSE, 60% participants were
Awlla examination tional unaware of BSE and only 32% knew how to
, H. among fe- study perform. Poor knowledge(25%) was seen for
(2018 male students right time to perform BSE. The reasons for not
). of soran performing BSE were the participants were
technical unaware how to perform which followed by
institute. do not expect to get breast cancer and do not
think BSE is important
 65

Author Topic Participants/ Meth- Findings

settings ods
Sindi, R., Awareness 250 medi- A A study found good knowledge score (61%)
Alzah- Level, cal stu- Cross for medical students and poor knowledge
rani, A., Knowledge dents and Sec- score (45%) for non-medical students. There
Alzah- and Atti- 250 non- tional were significant correlations between overall
rani, N., tude to- medical Study knowledge and attitude, and between overall
Salman, wards students. knowledge and practice of BSE. The partici-
B., Al- Breast- Saudi Arab
shareef, Cancer pants were aware of BSE and had good
S., between knowledge level in practicing BSE(61%). The
Tabas- Medical reason for not performing BSE were the par-
sum, A., and Non- ticipants had no idea how to perform BSE,
Iqbal, M. Medical some thought there is no need and few partici-
& Ah- University pants felt discomfort, fear and shy. the stu-
mad, R. Students in dents responded the main source to be aware-
(2019). Makkah ness campaigns (67%) and media (48%)
Region:

Author Topic Participants/ Methods Findings

settings
Elzahaf Knowledge, 200 Female descrip- majority (87.5%) of participants with poor
, R., Attitude, students. tive cross‑ knowledge level regarding breast cancer.
Mekraz and Practice Libya sectional 98% students responded lump in breast as a
, E., Regarding survey common symptoms. The common risk fac-
Arhaim Breast Can- tors of breast cancer the participants re-
, S. & cer among
sponded were family history (83%) and the
Almans Female Stu-
ouri, dents at least 13.5% responded early onset of men-
M. College of arche (13.5). The majority of partici-
(2019) Medical pants(82.5%) were aware of BSE as a
Technology screening method of breast cancer followed
by ultrasound (47.5%). However, only
28.5% (n = 57)students knew the right way
to perform BSE

Author Topic Partici- Meth- Findings

pants/ set- ods
tings
Yılmaz, The Effects semi- A study carried in Turkey with 244 participants
M., of Training 244 women empiri- found good level (53.7) of knowledge in pre-
Sayın, on Turkey cal sin- test which significantly increased to excellent
Y. & Knowledge gle level in post-test results (85.2%) after the edu-
Cengiz, and Beliefs group cation program. The knowledge regarding BSE
About Breast pre-test also increased from good level in pre-test (50.8)
H. Cancer and & post- to excellent level (80.3%) in post-test. The
(2017). Early Diag- test mean score for knowledge of risk factors of
nosis Meth- research breast cancer was 3.65 in pre-test and was in-
ods Among model creased to 9.36 in post-test. There was signifi-
Women. cant difference in pre- and post-test.
 66

Author Topic settings Methods Findings

Sayed, S., Breast 442 Cross- Study found majority (92%) of partic-
Ngugi, A.K., Cancer women Sectional
Mahoney, knowledge, and 237 study ipants were aware of breast cancer.
M.R., Kurji, perceptions male. However, only 10% participants had
J., Talib, and prac- Kenya
Z.M., tices in a correctly answered two or more risk
Macfarlane, rural
S.B., Wynn, Community factors of breast cancer. Most partici-
T.A., Saleh, in Coastal pants considered breast cancer a se-
M., Lakhani, Kenya
A., Nderitu, vere disease. There were low
E., Agoi, F.,
knowledge level regarding early de-
Zujewski, Z.
& Moloo, Z. tection methods and screening prac-
(2019).
tices. A study in Kenya found 90%
participants would seek medical pro-
fessional assistance within a week
period time if they noticed breast can-
cer symptoms. Almost half (49%) of
the participants responded that their
partners would make the health care
seeking decisions.

Author Topic Participants/ Methods Findings

settings
Pakseresht, Stage at 172 fe- Cross Awareness of breast cancer was higher
S., Ingle, Diagnosis males, Sectional (80%) among literate women than
G.K., Garg, and Delay Delhi, India study illiterate ones (65.4%). One of the
S., and in Seeking reasons for increased cancer mortality
Sarafraz, Medical in developing countries is delay in
N.( 2016). Care seeking medical advice. Delay in early
among detection could be due to differences
Women in sociodemographic and cultural fac-
with tors, a strong belief in traditional med-
Breast icine, negative perception of disease,
Cancer, poverty and poor education and cou-
Delhi, pled with fear and denial.
India
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Author Topic Participants/ Methods Findings

settings
Shrestha Aware- 50 females Descrip- Regarding the meaning of breast cancer, 39
S, ness on Nepal tive (78%) of the respondents stated growth of
Chhetri breast study extra lump in breast. More than three fourth
S, Napit self 82% of the respondent’s state breast self-
J. 2017 exami- examination is the method of diagnosing
nation
breast cancer at early stage. Regarding the
among
repro- sign and symptoms of breast cancer, more
ductive than three fourth (82%) of the respondents
age answered painless abnormal growth in breast,
women. seventy eight percent (78%) of the respond-
ents answered change in size and shape of the
breasts. 60% of the respondent’s state health
workers as source of information.

Author Topic Participants/ Methods Findings

settings
Shrestha. Breast can- 110 women cross- Among 110 women only 26% women
K,. 2012. cer sectional knew about the breast screening. and
knowledge Kathmandu, descrip- women who were doing breast self exam-
and screen- Nepal tive study ination were 19, mammogram 3,and ul-
ing practice trasound were 4 in number. Out of 26
among
respondents only 31 % women had
women
visited to knowledge of mammogram. Result of this
kist medi- study shows low knowledge on breast
cal college cancer, risk factors and screening practice
among women groups of this study

Author Topic settings Methods Findings

Gupta, A., A review of India Peer re- High mortality rates are due to
Shridhar, K., breast cancer view lack of cancer awareness, the
Dhillon, awareness presence of humiliation, fear,
P.K.(2015). among wom- gender inequity and reduced
en in India: engagement in screening behav-
Cancer lit-
iors, such as breast self-
erate or
awareness examinations. The barriers to
deficit? breast cancer care, limited ac-
cess to treatment, and limited
knowledge of health profession-
als are major barriers to cancer
prevention and detection in de-
veloping countries.
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Awareness programme in Nepal