With an estimated 2.3 million new cases in 2020, female breast cancer surpassed lung cancer as the most commonly diagnosed cancer (Sung et al, 2021). In 2020, breast cancer was the leading cause of cancer-related death (685 000 deaths) (Lei et al, 2021) and affected 25% (more than 1.5 million) of all cancer cases in women of all ages, with a higher incidence in young women (Jalil et al, 2019). In the UK, over 41 000 women are diagnosed with breast cancer each year (McCready et al, 2005). It is also the most common cancer among women in low–middle-income countries such as Pakistan (Rasool et al, 2019). Asia's highest rate of breast cancer is found in Pakistan and the proportion of women with breast cancer is anticipated to rise in the next few years (Saeed et al, 2021).
Early detection and treatment are crucial to improving chances of survival and reducing morbidity associated with breast cancer (Winters et al, 2017). Breast self-examination is a simple, low-cost, non-invasive technique that women can use to detect abnormalities or changes in their breast tissue (Koc et al, 2019). It can allow women to identify changes in breast tissue even if they do not have access to regular healthcare services, which has been reported in lower-income countries such as Pakistan (Seifu and Mekonen, 2021). Awareness of the need for self-examination is crucial for women to take charge of their health and identify abnormalities or changes early (Ibitoye and Thupayegale-Tshwenegae, 2021). Early detection can significantly improve survival rates and reduce morbidity (Black and Richmond, 2019) and allows women to receive timely medical treatment, leading to better health outcomes and improved quality of life (Barrios, 2022).
Women's awareness of breast self-examination varies by country. In Pakistan, 67% of women were reported to have sufficient awareness of how to perform the exam (Ali et al, 2020), 56% in Ethiopia (Asmare et al, 2022), 20% in Thailand (Suwannaporn and Chuemchit, 2022), 60% in Saudi Arabia (Alshahrani et al, 2019), and 70% in India (Gupta et al, 2020). Lack of awareness can have serious consequences, including delayed detection of breast cancer, missed opportunities to promote breast cancer screening, increased morbidity and increased mortality (Alomair et al, 2020; Mengie et al, 2020).
Lady health visitors are key figures in Pakistan's healthcare system, particularly in the context of community health and maternal and child health services. Their responsibilities include educating communities on hygiene, nutrition, family planning and disease prevention, as well as treating minor ailments, wounds and common infections. Lady health visitors and community midwifery students play a crucial role in promoting women's health and educating women about breast cancer and early detection. If they do not have sufficient knowledge of breast self-examination, they may miss opportunities to promote breast cancer screening to women in their communities (Asmare et al, 2022). It is crucial for healthcare professionals to be aware of breast self-examination and its importance in promoting early detection of breast cancer (Suwannaporn and Chuemchit, 2022).
Assessing healthcare professionals' understanding of breast self-examination is essential to improving healthcare services provided to women in Pakistan. This study's aim was to evaluate understanding of breast self-examination among lady health visitor and community midwife students in Pakistan. The findings will provide valuable information on understanding of breast self-examination among students in these roles and identify gaps in knowledge and training.
Methods
This descriptive cross-sectional study was conducted at the Horizon School of Nursing and Health Sciences in Karachi from December 2022–April 2023.
Sampling
A total of 50 lady health visitor and community midwife students were recruited from the Horizon School of Nursing and Health Sciences through convenience sampling. All female students willing to participate were included, while students on Generic BSN or paramedical courses were excluded. The sample size was calculated using open EPI with a 95% confidence interval and a total population of 55 students on the relevant courses. The obtained sample size was 50 students.
Data collection
The data collection tool was designed by the authors based on a review of the literature and consisted of two sections. The first collected participants' sociodemographic data, including whether they had received any training on breast self-examination. The second section assessed the participants' awareness of breast self-examination through 10 multiple choice questions, including what the exam entails, how often it should be performed, what to look for when self-examining and the benefits of regularly self-examining. Four experts, all of whom had an MSc in nursing and 5–7 years of experience, reviewed the tool, and their suggestions were incorporated to create the final version. Content validity was assessed, with a calculated content validity index of 0.83.
The primary investigator distributed the questionnaire and consent forms in the students' classroom. A 20-minute explanation of the study was provided, after which students were given approximately 20 minutes to complete the questionnaire, which was given in English. While the majority of students understood English, any queries were explained in Urdu and a full translation was not deemed necessary. Data were collected between October 2022 and January 2023.
Data analysis
The participants' total scores out of 10 were converted into a percentage. Participants scoring <50% were categorised as having poor understanding 50–70% was categorised as moderate understanding, and >70% was categorised as good understanding. The Statistical Package for Social Sciences (version 26) was used for data entry and analysis. Frequencies and percentages were calculated.
Ethical considerations
Ethical approval was granted by the Horizon School of Nursing and Allied Health Sciences in Karachi (reference: HSNHS/2022/281). Participants were asked to provide written informed consent after being informed about the study's objectives and purpose. Their right to leave at any time was guaranteed, and they were assured of confidentiality and anonymity.
Results
Table 1 shows participants' sociodemographic characteristics. Half (50.0%) were 18–20 years old, and the majority were Muslim (78.0%), single (78.0%) and studying to be community midwives (70.0%).
Table 1. Sociodemographic characteristics
| Variable | Frequency, n=50 (%) | |
|---|---|---|
| Age (years) | 18–20 | 25 (50.0) |
| 20–25 | 16 (32.0) | |
| >25 | 9 (18.0) | |
| Religion | Muslim | 39 (78.0) |
| Hindu | 3 (6.0) | |
| Christian | 8 (16.0) | |
| Study programme | Lady health visitor | 15 (30.0) |
| Community midwife | 35 (70.0) | |
| Marital status | Single | 39 (78.0) |
| Married | 11 (22.0) |
Figure 1 shows whether the participants had ever received any training on breast self-examination. Only 2.0% had received. As shown in Figure 2, all participants reported that they would like to receive training on breast self-examination.
Table 2 shows participants' understanding of breast self-examination. Only 10.0% had moderate understanding, while 90.0% answered less than half of the questions on breast self-examination correctly.
Table 2. Understanding of breast self-examination
| Understanding | Frequency, n=50 (%) |
|---|---|
| High | 0 (0.0) |
| Moderate | 5 (10.0) |
| Poor | 45 (90.0) |
Discussion
Studies have shown that women who lack knowledge and understanding of breast self-examination may not perform the exam correctly or regularly (Asmare et al, 2022). This is a significant public health issue, especially in low-income countries with limited access to healthcare services (Yeshitila et al, 2021). In Pakistan, lady health visitors and community midwives provide essential services to women in the community. However, there is a lack of research on their understanding of breast self-examination, particularly among students, who are future healthcare providers. Assessing their understanding is essential to identify gaps and develop effective training programmes to improve knowledge and their ability to raise awareness of breast self-examination to women in their community.
Only one participant had attended training on breast self-examination. Similarly, a study in Vietnam reported that most participants did not receive training on breast self-examination (Tuyen et al, 2019). This may indicate limited availability of training programmes on breast self-examination as a result of resource constraints or lack of access to healthcare services.
Cultural attitudes to health and healthcare may also play a role in low attendance at training programmes. Some cultures may view discussions around breast health as taboo or uncomfortable, leading to a reluctance to attend training or learn about breast self-examination. A study from Pakistan found that women were hesitant to discuss breast cancer openly, as they viewed breasts as sexual organs (Saeed et al, 2021). Women may feel uncomfortable talking about their bodies publicly, which prevents understanding of potential body health issues. Religious misunderstandings, social pressures and a lack of accurate knowledge all play a role in Pakistani women delaying seeking healthcare and the absence of breast cancer screening programmes (Saeed et al, 2021).
Saeed et al (2021) reported that women in Pakistan frequently did not understand breast cancer's causes and available treatments. Additionally, Shamsi et al (2020) reported that women frequently lacked understanding of the significance of discovering a breast abnormality, leading to a delay in diagnosis of breast cancer (Shamsi et al, 2020). In the present study, only 10.0% of participants scored >50% when asked about breast self-examination, and none scored >70%. In Malaysia, Mut et al (2019) reported that only 1.6% of secondary school students had good understandingof breast self-examination. In Vietnam, only 22.7% of female textile workers had sufficient knowledge of breast self-examination (Tuyen et al, 2019). However, awareness varies across countries, with a study from Saudi Arabia reporting that most female students at a university had good understanding of breast self-examination (Eid et al, 2021). A study in Ethiopia reported good understanding regarding breast self-examination in over half of the participants, who were female students at a university (Getu et al, 2022).
Variations in understanding across countries may be the result of differences in educational programmes and materials. Populations with greater access to breast health resources and educational materials are likely to have a better understanding of the importance of breast self-examination. Access to healthcare may also play a role in understanding breast self-examination.
Education on breast self-examination can empower individuals to take control of their breast health and be proactive about detecting any changes or abnormalities (Nisha and Murali, 2020). Following self-examination with a clinical breast examination at a healthcare facility, may improve early identification of breast cancer in low- and middle-income nations, where the majority of cancers are identified at a relatively late stage (Dewi et al, 2019). Educating individuals on breast self-examination can help raise awareness about breast cancer and the importance of regular screening, which may reduce stigma surrounding breast cancer and encourage more individuals to undergo regular screening (Johnson, 2019). This will have a resulting effect on treatment outcomes and survival chances (Ginsburg et al, 2020). Early detection can also reduce the need for more invasive treatments and improve quality of life for individuals with breast cancer (de Sanjose and Tsu, 2019).
Limitations
As this study involved a convenience sample of students from one school in Pakistan, it is possible that the sample may not represent the whole population. Further studies are needed to confirm whether these findings are representative of the general public's understanding of breast self-examination.
Implications for practice
This study highlights a significant lack of understanding about breast self-examination among lady health visitors and community midwife students in Pakistan. With 98% reporting no prior training and 90% exhibiting poor understanding, urgent action is needed. Implementing structured training in healthcare education programmes and organising regular workshops may enhance healthcare professionals' skills and promote early detection of breast abnormalities, ultimately improving women's health outcomes.
Conclusions
Students training to be lady health visitors and community midwives in Pakistan will go on to have an important role in women's health. The lack of understanding of breast self-examination reported suggests a need for education and awareness campaigns. It is crucial that training be incorporated into nursing school curricula to guarantee that future healthcare professionals are adequately prepared with key skills. Healthcare professionals should be equipped to inform patients about breast health and the importance of routine self-examinations.
Key points
- This study found low understanding of breast self-examination among lady health visitors and midwife students, with 98% lacking training and 90% showing poor understanding.
- Urgent implementation of breast self-examination training in healthcare education is needed to improve early detection and enhance women's health outcomes.
- Regular workshops are essential to ensure healthcare professionals are kept up-to-date and effective in educating and supporting women in performing breast self-examinations.
- Addressing this gap could lead to better detection of breast abnormalities and improved breast cancer outcomes in communities.
CPD reflective questions
- How can the study findings be used to inform improvements in healthcare education programmes regarding breast self-examination?
- What practical strategies could be implemented to address the lack of understanding among healthcare professionals?
- How might the absence of training affect access to early detection services for breast abnormalities in communities?
- What role does ongoing professional development play in ensuring healthcare providers remain proficient in promoting awareness of breast self-examination?
- How can healthcare professionals effectively navigate cultural beliefs and norms to encourage breast self-examination practices among women?