|Year : 2016 | Volume
| Issue : 2 | Page : 765-769
Missed opportunities for breast awareness information among women attending the maternal and child health services of an urban tertiary hospital in Northern Nigeria
Lofty-John Chukwuemeka Anyanwu1, Oluseun Mubo Anyanwu2, Ahmed Ashuku Yakubu3
1 Department of Surgery, Paediatric Surgery Unit, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
2 Department of Pharmacy, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Surgery, General Surgery Unit, Aminu Kano Teaching Hospital and Bayero University, Kano, Nigeria
|Date of Web Publication||25-Jul-2016|
Lofty-John Chukwuemeka Anyanwu
Department of Surgery, Paediatric Surgery Unit, Aminu Kano Teaching Hospital, Bayero University, P.O. Box 2536, Kano
Source of Support: None, Conflict of Interest: None
Background: Breast cancer is the most common cancer that affects women worldwide. Many women, however, are not exposed to information that will promote awareness and early detection of this disease. We undertook this study to determine the missed opportunities to breast awareness information at the maternal and child health (MCH) services of our hospital.
Materials and Methods: Between July and September 2011, we conducted a cross-sectional survey of women attending the postnatal and immunization clinics (ICs) of our hospital. Data were collected using a structured interviewer-administered questionnaire. A total of 492 respondents were randomly selected. Data were analyzed using SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL, USA).
Results: The mean age of the respondents was 27.67 years (standard deviation 5.92 years). Only 56.1% (276/492) had a postsecondary education, and 58.7% (289/492) were multiparous. Among the respondents, 81.7% had been exposed to breast awareness information at the antenatal clinic, 6.55% at the postnatal clinic, and 5.24% at the IC. There was a statistically significant association (P < 0.05) between missed opportunity for breast awareness information and family income (P = 0.019) and also with the level of education (P = 0.007).
Conclusion: Most of the opportunities to educate women on breast awareness were missed at the postnatal and ICs of our hospital. Integrating breast health education into MCH care programs in developing countries will assist in the early detection of breast pathologies.
Keywords: Antenatal clinic, breast awareness, breast cancer, developing countries, integration, maternal and child health, missed opportunity, postnatal clinic
|How to cite this article:|
Anyanwu LJC, Anyanwu OM, Yakubu AA. Missed opportunities for breast awareness information among women attending the maternal and child health services of an urban tertiary hospital in Northern Nigeria. J Can Res Ther 2016;12:765-9
|How to cite this URL:|
Anyanwu LJC, Anyanwu OM, Yakubu AA. Missed opportunities for breast awareness information among women attending the maternal and child health services of an urban tertiary hospital in Northern Nigeria. J Can Res Ther [serial online] 2016 [cited 2020 Jul 13];12:765-9. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/765/163791
| > Introduction|| |
Breast cancer is a global health problem affecting millions of women around the world with devastating consequences. Worldwide, it is estimated that in the year 2004, 519,000 women died of this disease. The incidence of breast cancer is increasing in most developing countries, a phenomenon being attributed to factors such as aging of the population, delay in time of first pregnancy, decrease in number of children and breast feeding, and a move toward high-calorie Western diets.
The incidence of breast cancer during pregnancy is estimated at 1:3000, and is believed to be increasing due to the delayed onset of childbearing among women.,, A recent review of breast cancer patients in Nigeria showed that the incidence of breast cancer in Nigeria rose significantly from 13.7/100,000 in the period 1960–1969 to a near double (24.7/100,000) by 1998–1999.
It is believed that early detection of breast cancer improves outcome in a cost-effective fashion, assuming the treatment is available. Unfortunately in sub-Saharan Africa, early detection of the disease is hampered by limited awareness and understanding of the disease even among health care professionals.
In this study, our purpose was to determine the proportion of opportunities to educate women on breast awareness, which was missed at the maternal and child health (MCH) services of our hospital.
| > Materials and Methods|| |
Between July and September 2011, we conducted a cross-sectional survey of women (aged 15–49 years) attending the postnatal and infant immunization clinics (ICs) of our hospital.
In order to obtain a representative sample of women, a systematic sampling technique was used to select the respondents daily until the desired sample size was attained.
The women were interviewed to find out if they had been taught how to do a breast self-examination (BSE) in any of the MCH clinics (antenatal clinics [ANCs], postnatal clinics (PNCs), and infant ICs) within the last 2 years before the interview. For those who answered in the affirmative, the method of the discussion (group or one-on-one) and the cadre of the hospital staff (nurse, physician, etc.) who gave the instruction was asked. A pretested structured questionnaire was used in the interview process. Questionnaires were administered by trained female interviewers fluent in both the English and Hausa (dominant local language) languages. The questionnaire also was used to collect information on sociodemographic variables including age, religion, ethnicity, occupation, educational level, average monthly family income, and parity.
Data were analyzed using SPSS version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics were computed for continuous variables while proportions were used for categorical characteristics of the respondents. The Chi-square test was used to test for association. Multivariate logistic regression was done to identify significant predictors. The level of significance was set at P < 0.05 for all tests.
| > Results|| |
A total of 492 women were interviewed, and their sociodemographic characteristics are shown in [Table 1]. The mean age of the respondents was 27.67 years (standard deviation 5.92 years). Only 56.1% (276/492) had a postsecondary education, and 58.7% (289/492) were multiparous. Fifty percent of the respondents had been exposed to breast awareness information in MCH clinics of the hospital. Among those who had received breast awareness instructions, the ANC was the location of the breast awareness information cited by 81.7% (187/229), while 6.55% (15/229) of the instructions occurred at the PNC, and 5.24% (12/229) occurred at the IC. Instructions were mostly given in a group discussion (96.1%). A nurse/midwife gave the instructions 93.4% of the time; a physician was the instructor 4.8% of the time, while only 1.4% of the instructions were given by a health educator [Figure 1].
|Table 1: Socioeconomic characteristics of respondents in relation to missed opportunity for breast awareness information|
Click here to view
|Figure 1: Breast self-examination instructors by profession. 1 = Nurse/Midwife, 2 = Physician, 3 = Health educator|
Click here to view
On bivariate analysis [Table 1], the level of education showed a significant association (P = 0.007) with having a missed opportunity for breast awareness information. Women who had received only a primary school education or less, were more likely to report a missed opportunity (73.3%; 22/30) than women who had received a postsecondary education (43.5%; 120/276).
Family income also showed a significant association (P = 0.019) with reporting a missed opportunity for breast awareness information, as women whose monthly family income was Naira 20,000 (≈$122.70 US) or less were more likely to report a missed opportunity (50%; 17/34) than those who had a monthly family income of Naira 201,000 (≈$1233.13 US) or more (39.22%; 20/51).
A logistic regression analysis [Table 2] using age, the number of living children, family income, the level of education, employment status, and the Ethnic group as independent variables, however, did not identify any significant predictors.
|Table 2: Logistic regression analysis on missed opportunity for breast awareness information|
Click here to view
| > Discussion|| |
In the developing world, lack of breast screening services, combined with socioeconomic, cultural and political factors, underpin a propensity for women to present with advanced breast cancer. As a result of misconceptions and unfounded beliefs, women may tend to hide their breast cancer symptoms at an early stages when treatment is most likely to be effective.
In economically developed countries, guidelines outlining optimal approaches to early detection, diagnosis and treatment of breast cancer are defined, and have been disseminated.,,, In most low and medium income countries (LMICs), however, the infrastructure and resources for routine screening mammography are often unavailable.
Many organizations such as the World Health Organization and the Breast Health Global Initiative, do not recommend routine mammography screening for poor countries, focusing instead on BSE, which is a cheaper option.,, Thus, for an early detection programs to be effective, there is a need for public education and enlightenment to foster active participation of the patients in diagnosis and treatment.
Many studies have shown that breast cancer is a leading cause of morbidity and mortality among women in LMICs.,, Breast cancer occurs 10–15 years earlier in black women compared to their white counterparts. In Africa, breast cancer has overtaken cervical cancer as the most common malignancy affecting women and the incidence rates appear to be rising. Cancer complicates approximately 1 in 1000 pregnancies and accounts for 1/3 of maternal deaths during gestation.
In developing countries, a lack of public awareness about breast cancer means that patients ignore their symptoms till the very late stage. MCH care – which is the health services that women seek for themselves before, during, and after pregnancy and for their children's health, may thus provide a window of opportunity to educate women in LMICs on breast awareness which will minimize delayed diagnosis.,
In view of the period during and after pregnancy may be one of the only times that many women receive formal health care in LMICs, it is important not to miss this opportunity to provide breast awareness education. Although about 60% of the deliveries in LMICs occur at home, about 75% of the women, however, do see a health care provider at least once during their pregnancies.,
The results from our study showed that only 5.24% of the women have ever been educated on breast awareness in the 2 years preceding the study at the IC, and only 6.55% of the respondents received such information at the PNC. The majority of those (81.7%) who received breast awareness education got their instruction at the ANC. It can thus be inferred that among this group of women, most of the opportunities to educate them on breast awareness were missed at the PNC and IC.
It is believed that integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost-sensitive manner. When women obtain different types of care in one visit, they reduce the travel time and expense of multiple visits and have more time to be productive. The integration of a breast health care program into the existing MCH program in the country will ensure that women of reproductive age are furnished with the information that will encourage early detection of breast cancer. Health care personnel in rural areas, e.g. nurses, midwives, or community health extension workers who provide MCH care can also be trained to educate women on breast health and to carry out breast examinations.,,
The year 2002 guideline of the Society of Obstetricians and Gynaecologists of Canada recommended that all women should be encouraged to practice BSE in pregnancy and lactation, and that clinicians should screen all pregnant patients for breast cancer with thorough breast examinations early in pregnancy. Furthermore, the obstetrician is advised to examine the breast at any time in the postpartum period if the woman is not breastfeeding.
Although, a thorough breast examination must be an integral part of the initial prenatal examination, the physiological changes occurring in the breast during pregnancy may mean that clinical examination becomes more difficult as the pregnancy progresses.,
At the moment, clinical breast examination (CBE) is not routinely done at the ANC or PNC in Nigeria. The majority (96.1%) of the breast awareness instructions given to the women in this study were done in group discussions, which precludes any intimate breast examination.
A major challenge to the integration of breast health programs with MCH in LMICs may be the availability of skilled manpower. It is estimated that the number of nursing and midwifery staff in Africa is only 11/10,000 population, compared with 79/10,000 in Europe. Data from our study show that majority (93.4%) of the instruction on breast awareness were given by nurses/midwives [Figure 1], a picture that shows an over-reliance on scarcely available middle-level manpower. Some workers have shown that well-trained community-based health care providers are also beginning to assume responsibility for tasks that were previously conducted by mid-level health care providers.
In order to increase coverage of the populace in breast health programs in LMICs, task-shifting or the delegation of clinical tasks (such as breast awareness education and CBE) from higher level health care providers to mid- or lower-level health care providers is therefore necessary.,,, It is thus pertinent that policies be made at the National level to integrate these skills into the training of this category of health care personnel. Studies have shown that integrating training and giving health care providers the opportunity to enhance their skills and responsibility levels have a positive effect on both qualities of counseling and staff commitment.
Our data [Table 1] showed that there was a statistically significant association (P < 0.05) between reporting a missed opportunity for breast awareness information and family income (P = 0.019) and also with level of education (P = 0.007). There was, however, no statistically significant relationship between reporting a missed opportunity for breast awareness information and the employment status of the women (P = 0.269). These figures may reflect health care utilization differences among the study respondents. Poor or illiterate women may have less access to MCH care and thus less exposure to breast awareness information, thus report more missed opportunities.
Adamu had earlier reported that educational level, family wealth index, and place of residence were strong predictors of MCH care utilization in both northern and southern Nigeria. Other workers have documented similar findings with regards to the ability of women to utilize MCH care.,,,, It is assumed that women who are working and earning money will have better autonomy and the financial ability to pay for services. This, however, is not usually the case. Furuta and Salway have shown that in many settings, women have no control over their own earnings. Practices which place women under the care of their husbands or male relatives are common in northern Nigeria, and are believed to result in a loss of autonomy for women, leading to poor decision making power which could affect the use of MCH care., Educated women are however better able to break away from traditional practices to use modern health care services in order to enhance their health.
The logistic regression model employed in this study did not identify any significant predictors of having a missed opportunity for breast awareness information among the women in the study [Table 2]. This may reflect the effects of unidentified societal or system-related barriers to MCH care utilization. Anderson et al. have documented that in some LMICs who already have fairly well established health care systems, the public is reluctant to use them in part because of system-related barriers such as long wait times, insensitivity of staff, or lack of female medical professionals.
Shulman et al. in a chronicle of breast cancer morbidity and mortality history in the USA have shown that mortality from breast cancer in the USA had declined significantly prior to 1974 (before the widespread use of mammography). They attribute this decline to more effective breast education programs, increased breast cancer awareness, detection of tumors palpable with self or CBE, and better diagnostics. In many LMICs, the lack of breast cancer education and the presence of other competing causes of mortality and morbidity means the community knowledge of breast cancer is relatively limited. A window of opportunity for the improvement of breast cancer survival in LMICs by early detection using cost-effective methods of breast health education and BSE can thus be inferred from the findings of Shulman et al.
In most developing countries, however, it may not be enough to simply establish a system to address breast cancer and expect the public to use it. Cultural attitudes play an important role in the acceptance and utilization of any screening program. The importance of educating women on the symptoms and risk factors of breast cancer, as well as addressing perceptions and misconceptions, in a culturally sensitive manner cannot be over emphasized. Activities designed to promote early detection of breast cancer must involve the men on whom the decision for intervention for women's health rests.,
Given the resource constraints of LMICs such as Nigeria, integration of breast health programs that are cost-effective and culturally acceptable into MCH programs, will go a long way in helping women become more breast aware and thus aid the early detection of breast cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Nojomi M, Namiranian N, Myers RE, Razavi-Ratki SK, Alborzi F. Factors associated with breast cancer screening decision stage among women in Tehran, Iran. Int J Prev Med 2014;5:196-202.
Hirko KA, Soliman AS, Hablas A, Seifeldin IA, Ramadan M, Banerjee M, et al.
Trends in breast cancer incidence rates by age and stage at diagnosis in Gharbiah, Egypt, over 10 Years (1999-2008). J Cancer Epidemiol 2013;2013:916394.
Barnes DM, Newman LA. Pregnancy-associated breast cancer: A literature review. Surg Clin North Am 2007;87:417-30, x.
Ives A, Semmens J, Saunders C, Puckridge P. A growing dilemma – Breast cancer and pregnancy. Aust Fam Physician 2002;31:929-32.
Hughes TM. Pregnancy Associated Breast Cancer (PABC) the Surgical Issues. Available from: http://www.sah.org.au
. [Last accessed on 2013 Dec 10].
Jedy-Agba E, Curado MP, Ogunbiyi O, Oga E, Fabowale T, Igbinoba F, et al.
Cancer incidence in Nigeria: A report from population-based cancer registries. Cancer Epidemiol 2012;36:e271-8.
Anderson BO, Shyyan R, Eniu A, Smith RA, Yip CH, Bese NS, et al.
Breast cancer in limited-resource countries: An overview of the Breast Health Global Initiative 2005 guidelines. Breast J 2006;12 Suppl 1:S3-15.
Formenti SC, Arslan AA, Love SM. Global breast cancer: The lessons to bring home. Int J Breast Cancer 2012;2012:249501.
Bhikoo R, Srinivasa S, Yu TC, Moss D, Hill AG. Systematic review of breast cancer biology in developing countries (part 2): Asian subcontinent and South East Asia. Cancers (Basel) 2011;3:2382-401.
Coughlin SS, Ekwueme DU. Breast cancer as a global health concern. Cancer Epidemiol 2009;33:315-8.
Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database Syst Rev 2003;(2). DOI:10.1002/14651858.CD003373.
Harris R, Kinsinger LS. Routinely teaching breast self-examination is dead. What does this mean? J Natl Cancer Inst 2002;94:1420-1.
Thomas DB, Gao DL, Ray RM, Wang WW, Allison CJ, Chen FL, et al.
Randomized trial of breast self-examination in Shanghai: Final results. J Natl Cancer Inst 2002;94:1445-57.
Akinyemiju TF. Socio-economic and health access determinants of breast and cervical cancer screening in low-income countries: Analysis of the World Health Survey. PLoS One 2012;7:e48834.
Shulman LN, Willett W, Sievers A, Knaul FM. Breast cancer in developing countries: Opportunities for improved survival. J Oncol 2010;2010:595167.
Khokhar A. Breast cancer in India: Where do we stand and where do we go? Asian Pac J Cancer Prev 2012;13:4861-6.
Porter P. Westernizing women's risks? Breast cancer in lower-income countries. N Engl J Med 2008;358:213-6.
Galukande M, Kiguli-Malwadde E. Rethinking breast cancer screening strategies in resource-limited settings. Afr Health Sci 2010;10:89-92.
Vorobiof DA, Sitas F, Vorobiof G. Breast cancer incidence in South Africa. J Clin Oncol 2001;19 18 Suppl: 125S-7S.
Adisa AC, Easson AM. Breast cancer – A review for African Surgeons. In: Hospital and Healthcare Innovation Book 2009/2010. Woodbridge, U.K: International Hospital Federation, Pro-Brook Publishing; 2009. p. 90-108.
Ringheim K, Gribble J, Foreman M. Integrating Family Planning and Maternal and Child Health Care: Saving Lives, Money and Time. Policy Brief. Population Reference Bureau; Washington DC, 2011. p. 1-4.
Research to Practice Team. Postpartum Family Planning. Family Health International 2009. Available from: http://www.fhi.org
. [Last accessed on 2013 Mar 06].
Paul VK, Singh M. Regionalized perinatal care in developing countries. Semin Neonatol 2004;9:117-24.
Anderson BO, Yip CH, Ramsey SD, Bengoa R, Braun S, Fitch M, et al.
Breast cancer in limited-resource countries: Health care systems and public policy. Breast J 2006;12 Suppl 1:S54-69.
Helewa M, Lévesque P, Provencher D, Lea RH, Rosolowich V, Shapiro HM, et al.
Breast cancer, pregnancy, and breastfeeding. J Obstet Gynaecol Can 2002;24:164-80.
Ring AE, Smith IE, Ellis PA. Breast cancer and pregnancy. Ann Oncol 2005;16:1855-60.
Prata N, Passano P, Sreenivas A, Gerdts CE. Maternal mortality in developing countries: Challenges in scaling-up priority interventions. Womens Health (Lond Engl) 2010;6:311-27.
Benson J, Nicholson LA, Gaffikin L, Kinoti SN. Complications of unsafe abortion in sub-Saharan Africa: A review. Health Policy Plan 1996;11:117-31.
The CATALYST Consortium/TAHSEEN Project. Integration of Family Planning/Reproductive Health and Maternal and Child Health Services: Missed Opportunities and Challenges. USAID; 2003. Available from: http://www.usaid.gov/pdf_docs/pnadf087.pdf
. [Last assessed on 2013 Dec 10].
Adamu HS. Utilization of Maternal Health Care Services in Nigeria: An analysis of Regional Differences in the Patterns and Determinants of Maternal Health Care Use. [Dissertation]. Liverpool, UK: University of Liverpool; 2011.
Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bull World Health Organ 2007;85:812-9.
Awoyemi TT, Obayelu OA, Opaluwa HI. Effect of distance on utilization of health care services in rural Kogi State, Nigeria. J Hum Ecol 2011;35:1-9.
Ajaegbu OO. Perceived challenges of using maternal health care services in Nigeria. Arts Soc Sci J 2013;2013:1-7.
Dairo MD, Owoyokun KE. Factors affecting the utilization of antenatal care services in Ibadan, Nigeria. Benin J Postgrad Med 2010;12:3-13.
Furuta M, Salway S. Women's position within the household as a determinant of maternal health care use in Nepal. Int Fam Plan Perspect 2006;32:17-27.
Duze MC, Mohammed IZ. Male knowledge, attitudes, and family planning practices in Northern Nigeria. Afr J Reprod Health 2006;10:53-65.
[Table 1], [Table 2]