Knowledge, Attitude and Performance Regarding Breast Self-examination among Students of Medical Institutes

INTRODUCTION

Breast cancer is a major public health concern worldwide and the leading cause of mortality among women, affecting 2.1 million women annually and accounting for 23% of all female cancers.^[1,2] Its incidence has been estimated to increase by up to 5% every year.^[3] Early detection through breast self-examination (BSE) is crucial, especially in low- and middle-income countries where mammography screening is costly and, therefore, a limited healthcare infrastructure. In Afghanistan, breast cancer is often diagnosed at more advanced stages due to cultural reasons and a lack of awareness.^[4]

Breast cancer originates from breast duct cells, and it is the most common type of cancer associated with genetic mutations. It can also occur in men, although rarely.^[5] The most common types of breast cancer are ductal carcinoma, which begins in the ductal cells of the breast, and lobular carcinoma, which originates in the lobules that produce milk.^[6] Factors such as genetics, lifestyle and hormonal imbalances can increase breast cancer risk.^[7] Treatment options include surgery, chemotherapy, radiotherapy, immunotherapy, targeted therapy and complementary alternative medicine.^[8]

While significant improvements in survival from this disease have been reported in high-income countries, the risk continues to rise, and survival rates in middle and low-income countries remain low. Improvement in survival began in the 1990s when countries established early detection programs for breast cancer, which were associated with comprehensive treatment programs including effective medical treatments.^[4,9] Afghanistan, with limited data on cancer burden, faces challenges due to weak healthcare infrastructure, lack of data management technology and poverty, leading to inadequate treatment options.^[10,11]

The three recommended screening methods for breast cancer are BSE, clinical breast examination and mammography.^[12] The World Health Organization recommends early detection strategies such as screening or BSE in low- and middle-income countries to increase awareness of early signs and symptoms. In Afghanistan, approximately 3173 breast cancer cases were reported in 2020, comprising 25.8% of all cancer cases among females.^[13] Of the available and recommended methods for breast cancer screening, in most developing countries, mammography is often unavailable. BSE is a cost-effective method for detecting breast cancer early, therefore, training and empowering women to perform BSE is important for early detection.

Several studies have assessed the awareness, attitude and performance of BSE among female students across various countries. In Jimma, Ethiopia, most participants had good awareness, but only 21% performed it correctly, with urban women four times more likely to perform it compared to rural women. In Ahvaz, Iran, 43.9% of medical students had good awareness, and 52.7% performed BSE.^[14] A multinational study across 24 countries found that 50.4% were aware of BSE, but 59.3% never performed it.^[15] In Eritrea, only 31% of the students were aware of BSE, and 11.7% of them practiced it.^[16] In Cameroon, 73.5% had heard of BSE, only 9% knew how to perform it, and only 3% performed it regularly. In Pakistan, the internet (25.6%) and teachers (18.4%) were the main sources of information, with half aware of the risk factors. In Turkey, 83.1% had knowledge of BSE, but half of the students (50.9%) did not know when to perform it.^[17] In Ethiopia, television/radio (43.2%) was the main source of information; 56% had sufficient knowledge, and 45.8% practiced BSE. In Malaysia, 79.3% had good knowledge and 33% performed BSE. In Kathmandu, 72.5% of healthcare personnel had sufficient awareness, but practice was poor. In Palestine, 15.5% had good overall knowledge, and only 4.1% practiced BSE.^[18] These findings indicate varying levels of knowledge, attitude and practice regarding BSE, emphasising the need for continuous education to improve early detection and outcomes.

Afghanistan faces challenges in integrating BSE into the community due to resource constraints and insufficiently trained personnel. As mentioned, data on the knowledge, attitude and practice of BSE is available from other countries. However, there are no such data from Afghanistan, making this study the first to identify gaps in knowledge, attitude and practice. The findings aim to recommend effective strategies to raise awareness among young females and males about preventive measures and how to perform BSE themselves.

MATERIALS AND METHODS

This is a quantitative cross-sectional analytical study. It was conducted at three medical institutes in Kabul: Ibn Sina Institute, Mellat and the Jamal Al-Shifa Institutes, covering the departments of nursing, midwifery and prosthodontics. A stratified random sampling was used, and the sample size was determined using the Epi Info [Figure 1]. The study included all female students from Ibn Sina, Mellat and Jamal Al-Shifa medical institutes, totalling 1993 individuals.

Close

Figure 1:

Samples size determination.

Export to PPT

The inclusion criteria were female students enrolled in the autumn semester of 2023 in Ibn Sina, Mellat and Jamal Al-Shifa Medical Institutes. They were systematically sampled and included based on allocation quotas and their willingness to participate in the study. The exclusion criteria were faculty members and other staff, students from different institutes and students who did not consent to participate.

Based on the calculations using EPI INFO 7.2.5.0 software, considering a 50% expected frequency, a 95% confidence interval and a 5% standard error, the sample size was determined to be 322 individuals from the general population. With an additional consideration of a 10% non-response rate, the final sample size reached 354 individuals.

Data were collected using a questionnaire developed from a review of similar studies conducted in the past.^[19,20] The questionnaire consisted of four sections: demographic information, questions related to knowledge, attitude and performance. After this phase, data were entered into a Statistical Package for the Social Sciences 26, reviewed for accuracy and analysed using the same software. Microsoft Excel was used to create graphs and charts.

To prevent bias, we reviewed all questionnaires for errors, used random sampling to minimize selection bias and conducted pilot testing to identify potential issues.

RESULTS

Out of a total of 354 distributed questionnaires, 347 were returned, resulting in a response rate of 98.0%. Participants ranged in age from 17 to 40 years, with a mean age of 21.0 and a standard deviation of 2.9. The majority were single (87.6%), with 12.4% married. Most participants resided in urban areas (85%), while 15% resided in rural areas. Regarding family history, 11.5% had a history of breast cancer, and 88.5% did not.

Information sources for participants included doctors (27.4%), teachers (24.8%), mass media (22.8%), friends (11.5%), family (7.8%) and others (5.8%) such as chapters, teachers and books. In terms of academic status, 123 students (35.4%) were in the first semester, 133 students (38.3%) were in the second, 21 students (6.1%) were in the third, and 70 students (20.2%) were in the fourth semester. The majority of the participants were in the second semester, while fewest were in the third semester. Furthermore, 28.2% of students are from nursing, 56.5% are from midwifery and 15.3% from prosthetics.

The education level of mothers was predominantly illiterate (47%), with primary education at 32.9%, secondary education at 8.6% and higher education at 11.5%. Economic status was reported as good (15.6%), moderate (71.2%) and low (13.3%) [Table 1].

DISCUSSION

The study found that the majority of participants (45.2%) had good knowledge, with an average knowledge score of 6.9 (standard deviation [SD] = 3.63). The majority of students (76.7%) had an average attitude, scoring 13.3. Only 23.1% of participants had performed self-breast examination. The average age of participants was 21.0 (SD = 2.9), consistent with ages reported in studies from Karachi (21 years),^[21] Ahvaz, Iran (23.3 years)^[14] and also in a study conducted in 24 countries with low, medium and high income across Asia, Africa and America (20.7 years),^[15] suggesting similarities in university student populations.

The proportion of students with good knowledge (45.2%) is similar to studies conducted in Ahvaz, Iran (43.9%)^[14] and Gondar, Ethiopia (56%),^[22] but higher in Palestine (15.5%)^[18] and lower in Malaysia (79.3%).^[23] These variations in findings may be due to differences in medical knowledge levels and information availability.

Attitude scores showed that 76.7% had a moderate attitude, comparable to Palestine (75.3%)^[18] and Cameroon (63.3%),^[19] but higher than Malaysia (35.1%)^[23] and Gondar, Ethiopia (46%)^[22] These differences could be attributed to cultural, social and economic factors, as well as the healthcare awareness programs.

The study also found that 23.1% of the participants had previously performed BSE. This rate is similar to studies conducted in Karachi, Pakistan (33.1%)^[21] and Malaysia (33%),^[23] but lower compared to studies conducted in Ahvaz, Iran (52.7%)^[14] and Gondar, Ethiopia (45.8%),^[22] and higher compared to the study in Palestine (4.1%).^[18] These differences likely reflect variations in participants’ knowledge and practice levels.

This study demonstrated that the primary source of information for the participants was doctors (27.4%), which differs from other studies where major sources included mass media in Palestine (57.6%),^[18] academic lectures in Karachi (35.9%),^[21] the internet in Peshawar (25.6%)^[24] and television/radio in Gondar (43.2%).^[22] This variation is likely due to cultural differences.

CONCLUSION

This study found that students from Kabul Medical Institutes had poor knowledge and average attitudes toward BSE. Although most had heard of the practice, their primary sources of information were doctors and teachers. Only about a few had ever performed a BSE. Significant correlations were identified between knowledge levels and factors such as field of study and semester, as well as between attitude levels and field of study and semester. About half of the participants believed that initial breast cancer screening is the responsibility of healthcare professionals. Despite average attitudes, the actual practice of self-examination was low. Major barriers included concerns about breast cancer and embarrassment. These findings highlight a significant gap between students’ knowledge and their practice of BSE, indicating a need for focused intervention.