Knowledge and practices of breast self examination

among nursing students

Sukhpal Kaur, Indarjit Walia
Abstract : The present study was conducted to investigate the knowledge and practices of
breast self examination (BSE) among nursing students in the month of Sept 2005 at National Institute
of Nursing Education, Post Graduate Institute of Medical Education And Research, Chandigarh. Total
209 students pursuing B.Sc. Nursing (4years), B.Sc. Nursing (Post Basic), and M.Sc. Nursing
participated in the study. A questionnaire containing 12 items to assess their knowledge regarding
BSE and 6 questions regarding practices of BSE was administered. All the participants were asked
to do BSE and a check list was given to them to note the warning signs of breast cancer. Data was
analyzed using descriptive and inferential statistics. The mean age of the par ticipants was
21.2yrs4.17. Maximum expected knowledge score was 12. Participants pursuing M.Sc. nursing
had maximum knowledge score (11.60.55) followed by the scores of B.Sc. nursing-interns
(11.50.66) and B.Sc. nursing-Post Basic (9.81.3). There was a statistically significant difference
in knowledge score as per the professional qualification of the subjects (F= 40.66, p=0.00). Out of
the total, 57.9% participants were practicing BSE on monthly basis (51.2%). Two participants had
changes in contour, changes in symmetry, lump in breast, pain on palpation and palpable nodules.
Conclusion: Participants with higher professional qualification had better knowledge regarding
BSE. Practice regarding BSE needs to be encouraged.

Key words :

Introduction

Knowledge, practices, breast self examination,

nursing students.

Carcinoma breast is one of the world's

leading causes of mortality and is the most
frequent malignancies amongst Indian women
with a steadily increasing incidence. It is
estimated that one out of seven women either
has or will develop breast cancer in her life
time.1 A study conducted In 2001 showed that
out of the total 800,000 new cancer cases,
80,000 cases were of breast cancer.

Correspondence at :
Sukhpal Kaur
Lecturer, NINE
PGIMER, Chandigarh

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The average incidence rate of breast cancer

in India is 16/100,000, varying from 22-28/
100,000 females in urban settings and 6/
100,000 in rural settings. The average age of
reporting the symptoms in India is 45-54
years.2 About 60-80% of the total cases
usually present at a locally advanced stage.3
In the year 2003, about 2,40,000 cases of
breast cancer were diagnosed worldwide, out
of which 40000 patients died of it.2 In early
stages, breast cancer is less aggressive, with
low incidence of metastasis and is potentially
curable. Since the degree of success in treating
this disease is influenced primarily by the stage
at which intervention is introduced, secondary
prevention (early detection) is the mainstay.4
Thus early detection is the key to better
treatment and sur vival. It has been
documented that 85% of localized breast
cancer cases have 5-year survival rate, but it
drops to 56% for the regional disease and 18%
to distant metastasis.5 It poses a dual threat
to women attacking their lives as well as their
families and is a devastating illness both
physically and psychologically.
Breast self examination (BSE) used in
conjunction with mammography and
professional examination is extremely effective
in detecting early breast cancer. Although BSE
is simple, quick, cost free and non-invasive
procedure, less than 50% practice it regularly
in spite of having knowledge. The American
Cancer Society recommend monthly BSE for

all the women who are 20 years or older.

However Breast Cancer Care6 states that
women should start being breast aware from
the age of 18 years and should continue their
breast checks regularly throughout their life.
As per Persson7 BSE does not require any
specialized personnel or equipment, rather it
is painless and inexpensive self-care action
that can be done at home in about ten
minutes. However it has been documented
that all the women who are advised about BSE
and breast awareness by a health care
professional on an individualized or group
basis demonstrate greater knowledge and
confidence and are more likely to practice this
procedure routinely than those who become
aware from other sources.8,9 Nurses are in an
excellent position to make use of many
opportunities to encourage the women to be
breast aware. Their knowledge, their contact
with women and their status as health
professional give them the opportunity to
educate the women about the need for breast
self examination. Thus they can play an
important part in helping women to protect
their health. But before they start teaching the
public, they themselves need to be
knowledgeable and confident regarding the
subject. They need to act as role model for
the public. With this background the present
study was conducted with an objective to
assess the knowledge and practice of nursing
students regarding breast self examination.

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Methodology
The study was conducted at National
Institute of Nursing Education, Post Graduate
Institute of Medical Education and Research
Chandigarh in the month of September 2005.
National Institute of Nursing Education is one
of the premier institutes offering three
programmes - B.Sc. Nursing (4 years), B.Sc.
Nursing (Post Basic) and M.Sc. Nursing. Total
209 Students pursuing all the three courses
participated in the study. Out of the total,
179(85.6%) were undergoing B.Sc. nursing
(4 year) course, 15 were pursuing M.Sc.
Nursing and similar number were pursuing
B.Sc. Nursing (Post Basic) course. The
students are admitted for B.Sc. nursing
(4 year) course after successful completion
of 10+2 with medical subjects. They are
admitted for B.Sc. Nursing (Post Basic)
training after their successful completion of
General Nursing and Midwifer y course
(Diploma in Nursing). The students are
admitted in M.Sc. Nursing after successful
completion of B.Sc. nursing (4 year) or B.Sc.
Nursing (post basic). B.Sc. nursing (4 year)
is of 4 years in duration while M.Sc. Nursing
and B.Sc. Nursing (post basic) are of 2 years
each. The students are to qualify an entrance
test before getting admission into each
course.

Data was collected by a self administered

questionnaire. An informed consent from
each par ticipant was obtained. The
questionnaire consisted of three parts. Part
'A' was about demographic characteristics of
the participants. Part 'B' contained 12 items
to assess their knowledge regarding breast
self examination and third par t has 6
questions regarding practices of breast self
examination. The questions on knowledge
were regarding what is BSE, the importance
of doing BSE, the time, method, technique
and frequency of doing BSE, what should be
noted during BSE and when the person
should consult the doctor etc. Each correct
response was given one mark. After filling up
the questionnaire all the participants were
asked to do their own BSE and a check-list
was given to them to note the warning signs
of breast cancer. Data was analyzed using the
Statistical package for the Social Sciences
(SPSS Version-11).
Results
The average age of the participants was
21.2yrs4.17. Majority (89.5%) were
unmarried. Maximum (96.2%) had completed
12th standard as per academic qualification.
85.6% were undergoing B.Sc. nursing (4yrs)
programme and 15 (7.2%) each were pursuing
B.Sc. nursing (post basic) and M.Sc. nursing
courses. (Table 1)

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Table - 1: Demographic characteristics of the subjects

Demographic characteristics

N=209
N(%)

Mean age (yrs) S.D.

21.2yrs4.17

Marital status

Married
Unmarried

22 (10.5)
187 (89.5)

Academic qualification

Post graduates
Graduates
12th standard

02 (0.9)
06 (2.9)
201(96.2)

Professional qualification (undergoing)

M.Sc. nursing
B.Sc. nursing (4yrs)
B.Sc. nursing (post basic)

The par ticipants pursuing M.Sc.

nursing, B.Sc. nursing (internship) and B.Sc.
nursing (2nd year) had the mean knowledge
score of 11.60.55, 11.50.66, and
11.21.66 respectively. However the mean
knowledge score of B.Sc. nursing (3rd year),
B.Sc. nursing (post basic) and B.Sc. nursing
(1st year) was 10.90.96, 9.81.3, and
9.30.83 respectively. (Table 2)
On comparing three groups i.e M.Sc.
nursing, B.Sc. nursing (4yrs) and B.Sc.
nursing (Post Basic) it was observed that the
three groups differ significantly amongst each

15 (7.2)
179(85.6)
15 (7.2)
other as per the knowledge score (Table 3a).
With pairwise comparison it was noted that
the subjects of B.Sc. nursing (1st year) and
B.Sc. nursing (post basic) were significantly
different from all the other groups (p=0.05).
The mean knowledge score of the subjects
undergoing B.Sc. Nursing (2nd yr) and of
B.Sc. nursing (3rd yr) was alike but was
different from other groups (p=0.05). The
knowledge score of the participants of B.Sc.
nursing (2nd yr), internship and of M.Sc.
nursing was alike but was different from other
groups (p=0.05) (Table 3b).

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Table - 2 : Mean knowledge score of the subjects

Professional qualification

N=209
Max score=12, Min score=07

n(%)

Mean knowledge
score

Range

M.Sc. Nursing (1st and 2nd yr)

15 (7.2)

11.60.55

11-12

B.Sc. Nursing (post Basic)

(1st and 2nd yr)

15 (7.2)

09.81.3

7-11

B.Sc. Nursing (1st yr)

48 (23.0)

09.30.83

7-11

B.Sc. Nursing (2nd yr)

45 (21.5)

11.21.06

7-12

B.Sc. Nursing (3rd yr)

45 (21.5)

10.90.96

9-12

B.Sc. Nursing (Internship)

41 (19.6)

11.50.66

10-12

Table - 3a : ANOVA for knowledge score (M.Sc Nursing, B.Sc. Nursing- Post Basic and
B.Sc. Nursing 1st yr, 2nd yr, 3rd yr and Internship)
Source of variation

Sum of Square

df

Mean Square

Sig

40.662

0.00

Amongst group

166.080

33.216

Within group

165.825

203

0.817

Total

331.905

208

Table - 3b : Post Hoc Test: Student-Newman-Keuls (Pairwise comparison of groups)

Groups

Subsets (p=0.05)
1

B.Sc Nursing (1st yr)

48

9.3

B.Sc Nursing (Post Basic)

15

B.Sc Nursing (3rd yr)

45

10.93

B.Sc Nursing (2nd yr)

45

11.20

B.Sc Nursing (Internship)

41

11.5

M.Sc Nursing

15

11.6

9.8
11.2

B.Sc Nursing (1st yr) < B.Sc Nursing (Post Basic) < B.Sc Nursing (3rd yr) = B.Sc Nsg(2nd yr ) < B.Sc Nursing
(Internship)=M.Sc Nursing
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Practice of breast self examination by the

participants
All the participants were of the opinion
that BSE should be done by every one.
Majority (76.6%) agreed that BSE was taught
in their curriculum by their teachers. More than

half (57.9%) were practicing BSE and

amongst them 51% were practicing BSE
monthly. Among the par ticipants not
practicing BSE (42.1%), majority (75%)
responded that they do not get time for doing
BSE. (Table 4)

Table - 4 : Practice of breast self examination by the participants

Sr No

N=209

Items regarding practice

n (%)

Whether BSE should be done

Yes=209 (100)

Whether they have been taught

Yes=205 (98.1)

Source of information

Teachers
Friends
Mother
Media

160 (76.6)
40 (19.1)
08 (3.8)
01 (0.5)

Participants practicing BSE

121 (57.9)

Frequency of doing BSE

Monthly
Occasionally
Whenever get time
Reasons for not doing BSE

62 (51.2)
41 (33.9)
18 (14.9)

Do not get time

Not interested
Do not consider it important
Feel embarrassed

Percentage knowledge and practices of

participants
More than half of the participants had
their knowledge score above 91%. One fourth

66 (75.0)
12 (13.6)
07 (8.0)
03 (3.4)

of the subjects had knowledge score between

81-90%. The number of students who were
practicing BSE was directly proportional to
their knowledge score. (Fig. 1)

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Figure 1: Percentage knowledge and practices of participants

Participants (percentage)

Knowledge and practices of the participants in

relation to their score
70
60
50

Knowledge

40
Practices

30
20
10
0
91-100

81-90

71-80

61-70

51-60

Score (percentage)

Abnormalities detected during BSE

All the participants were asked to do
BSE. Out of the total two participants had
change in contour, change in symmetry, lump

in breast, pain on palpation and palpable

nodule. Another one had change in symmetry
and pain on palpation. (Table 5)

Table - 5 : Abnormalities detected during breast self examination

Sr No

Abnormalities

n (%)

Changes in contour

2 (0.96)

Changes in symmetry

3 (1.44)

Lump in breast

2 (0.96)

Pain on palpation

3 (1.44)

Palpable nodule

2 (0.96)

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Discussion
Breast cancer if detected early, is
curable in 90% of the cases, but the tragedy
is that most patients do not come to a doctor
till there is very little that can be done. Breast
self examination has been recommended as
an important method for early detection of
breast cancer as in 85% cases there is five
year survival rate when it is detected and
treated early at the localized stage and the
survival rate decreased to 56% once breast
cancer is detected later with the involvement
of regional lymph nodes.5 BSE is a simple, inexpensive, non-invasive procedure which
needs very little time and does not require any
professional help. Of course the person must
learn the steps initially. Nurses commonly
teach and encourage the practice of BSE.
Nurses in their day to day work in the hospitals
or otherwise are in a prime position to make
use of many opportunities to teach breast self
examination to the women. Thus the
possession of this knowledge among nurses
is very important. In the current study the
knowledge of nursing students regarding BSE
and their frequency of practice of BSE has
been explored. As per the results, the mean
knowledge of the participants was 10.71.3,
though the students pursuing M.Sc. had
maximum mean knowledge score followed by
the scores of B.Sc. nursing (4years) and B.Sc.
nursing post basic students. Majority (84%)
of the students had their knowledge score
regarding BSE above 80%. The knowledge
of the students undergoing graduation is
reported to be 38.0% in a study in which the

effect of an educational film on the health belief

model and BSE practice was studied.10
Performance of BSE is recommended
on a monthly basis. In the present study
though 92.5% had the correct knowledge of
frequency of doing BSE, 57.9% were
practicing BSE out of which about half were
practicing on monthly basis, approximately
one third were performing occasionally and
14.9% used to do BSE whenever they got time.
This percentage is quite good as compared
to other studies in which it has been reported
that only 48%, 23% and 24% respectively
practiced BSE regularly. 11,12,13 About one third
of the students performing BSE has been
reported by Budden L.14 However Alsaif15 has
documented 66% of nursing students in
Saudi Arabia who were performing BSE. In
the same study it has also been reported that
62% students had learnt information regarding
BSE in their college curricula, and a significant
relationship between higher levels in nursing
college and BSE practice is also reported. In
the current study it was observed that the
students with higher qualification had better
knowledge regarding BSE and their practices
corresponded to their levels of knowledge.
Thus an inference can be drawn that a need
for continuing medical education for nursing
professionals cannot be overemphasized.
Levels of awareness have a definite binding
on appropriate behavioural changes. Teachers
as the main source of information regarding
BSE has also been reported by the majority
of the students (76.6%) in the present study
followed by other sources such as friends,
mother and media.

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Majority of the students reported the

reason for not doing BSE as 'do not get time'.
The other reasons repor ted were 'not
interested', 'do not consider it important' and
'feel embarrassed'. In fact the students at this
age usually have different priorities and donot
discriminate ability to correlate the seriousness
of the disease with BSE practice. This has
been supported by many other studies in
which the various reasons repor ted are
'forgetting', 'lack of confidence', 'fear of finding
a lump', 'embarrassment', 'too busy' and
thinking 'it is not necessary'.16,17,18
All the students irrespective of their
knowledge regarding BSE were taught the
steps of BSE and were asked to do their own
BSE. Some abnormalities were identified like
change in contour, change in symmetry, lump
in breast, palpable nodule and pain on
palpation in the par ticipants. They were
referred to the concerned depar tment for
treatment.
It is concluded that though the students
had adequate knowledge regarding BSE, they
need to be reinforced about the subject
throughout their study in order to develop
health behavior required to assume their own
responsibility towards prevention. They
should be motivated to transfer the benefit of
their knowledge and behavior to their patients
to achieve a goal of early breast cancer
detection which will help the medical
profession to reduce the morbidity and
mortality of the ever increasing menace of
breast cancer in our society.

Recommendations
Effect of an educational programme on
the knowledge and frequency of BSE should
be determined. All the nursing students
should be taught BSE during their academic
studies. A study should be conducted to
identify reasons for not practicing BSE in order
to select suitable strategies to sustain regular
practice overtime. All the practicing nurses
should be involved in similar educational
programmes (as a part of continuing medical
educaional programme), thus enabling them
to perform periodic BSE and teaching the
same to the other women. Community level
educational programme needs to be
implemented as awareness is likely to improve
compliance and thus a fruitful preventive
outcomes.
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