Knowledge of breast self-examination in women in Sierra Leone

Curationis 30(4): 38-44 This research is a follow up of a Breast Week which was organized in Freetown, Sierra Leone. The specific objective of this study was to assess the effectiveness of the knowledge and teachings given to the women who participated in this project. A quantitative approach with an exploratory descriptive design was adopted and an observational checklist guided the data collection process. A sample size of 120 women (10%) who participated in the Breast Week was obtained through systematic sampling. During the Breast Week women were taught how to examine their breasts using breast self-exam ination (BSE) to detect abnorm alities of the breasts. This study was undertaken one year later by the researcher to ascertain whether the information on breast self-examination provided during the Breast Week was being utilised and whether what was taught was being put into use. Data were analyzed using SPSS version 11.5. Reliability and validity were ensured through the use of a structured observational checklist and a pilot study was undertaken. The observations were all observed and recorded by the same researcher. The majority of the 120 women (91.7%) stated that they had never practiced BSE before the Breast Week. After receiving health education on BSE, 95% were able to demonstrate an effective method of undertaking BSE. It is thus recommended that every opportunity should be utilized in health care settings to teach BSE and to reinforce the practice, especially in poverty stricken countries where other forms of screening methods are unavailable. Correspondence address: Joan H E. E. Shepherd National School of Midwifery P.C.M. Hospital Fourah Bay Road Freetown, Sierra Leone E-m ail: joanheev@yahoo.com Introduction and problem


Introduction and problem statement
Empowerment of women with information on b re a s t s e lf-e x a m in a tio n is o f p aram o u n t im p o rtan ce esp ecially in countries without m odem technologies for breast cancer screening.Breast cancer is one of the diseases affecting women in S ie rra L e o n e as in m an y o th e r countries.W hilst figures for the number o f women affected by breast cancer in Sierra Leone are not known, 4789 new cases o f fem ale b reast c a n c e r w ere reported amongst South African women in 1997.These com prised 16.4% of all cancers reported in women in that year (National Department of Health, 2003:2).D uring clin ic al p ractice, one o f the researchers noted that the num ber of women admitted to the wards with breast lumps and terminal stage breast cancer appeared to be increasing.For some of these wom en surgery was the line o f m a n a g e m e n t c o m b in e d w ith chemotherapy.It was not known whether these women knew about breast cancer and how to exam ine their breasts for abnormalities nor their reason for seeking h e lp so la te .T h e r e s e a r c h e r 's o b serv atio n s w ere su pported by the senior specialist surgeon o f the main referral hospital in Freetow n, and by nurses w orking in the female surgical wards.An assessm ent o f the available re c o rd s re v e a le d in c o m p le te documentation of outcome of treatment.Furtherm ore, no empirical studies had b een u n d e rta k e n to v e rify th e se observations.The researcher therefore initiated a Breast Week and a call for w o m en to u n d e rg o a free b re a st examination and routine teaching on how to examine their breasts was promoted through the media and by the tutors and students o f the nursing college.This stu d y w as a fo llo w up m e a su re , undertaken one year later to ascertain whether the information on BSE provided during the Breast Week was being utilised and whether what was being taught was being put into practice.E arly screening for the d etection of breast cancer is widely accepted as an important determinant in the success rate o f su rg e ry (R o s e n fe ld , 2 0 0 4 :3 8 4 ).
Unfortunately women in Sierra Leone have no access to modern technologies in the detection and treatment of cancers except that of surgeiy.Lack of knowledge on how to perform simple life saving diagnostic breast checks such as breast self-examination further compounds this problem.Emphasis has been placed on early detection as being vital, as most cases o f patients with breast cancer in the developing countries, are incurable at the time of diagnosis.There is also s u b s ta n tia l e v id e n c e fro m s tu d ie s co n d u c te d in A fric a th at w om en in developing countries are more likely to obtain inadequate or no access to modern technology (W HO, 1997:2).For women to be aware o f the threat they face with b rea st c a n c e r and be ab le to m ake d e c is io n s on h ow to c o m b a t such threats, they need to be well informed.The American Cancer Society states that at least 90% o f the women who develop breast carcinom a discover the tumors themselves (Klotter, 2002:1).Information is generally associated w ith positive view s and po w er to m ake d ecisions affecting one's life.Often women have no access to the information they need in order to bring about change.

The Breast Week
It was against this background that a Breast Week was launched in November 2002.The Breast Week was advertised on ra d io p ro g ra m m e s an d in th e communities by nurse-midwife tutors and nurse-m idwives in training.Following this, a radio discussion on breast cancer and breast self-examination was held in Freetown prior to the Breast Week.A call fo r w om en to undergo a free breast examination and routine teaching on how to examine their breasts was promoted.
Women had their breasts examined and at the same time were taught what to o b serve for and w hen to report any a b n o rm a litie s d etected .D uring this period, the women were also asked to repeat the breast exam ination to the ex a m in e r.On su c c e ssfu l re p e a t performance they received counselling on where to seek help in the event o f any deviation from the normal.

Significance
The need to evaluate the effectiveness of health education in the early detection of breast cancer is desirable.BSE is an integral part of a w om an's reproductive health and general wellbeing.Breast selfexamination (BSE) is a simple, inexpensive w ay o f sc re e n in g fo r b re a st abnorm alities, especially in countries w here w om en cannot gain access to m o d ern tec h n o lo g y .T he im p act or effectiveness of a programme aimed at behavioural change is of great importance in the health care d e liv ery system .F u rth e rm o re , m e th o d s u sed in the delivery of health care should be relevant to the major health problems of its citizens especially the vulnerable groups.The goal of health education in BSE is to create awareness and increase the competence o f w om en to m eet th e ir n eed s and challenges in improving their health.An assessment of the knowledge and skills used in empowering women in BSE is therefore o f relevance.

Literature review
Early detection of breast cancer is aided by breast cancer screening m ethods.Three methods are used to detect cancer o f the breast -clinical breast-examination, m am m ography (X-ray screening) and b re a s t se lf-e x a m in a tio n (B S E ) (Rosenfeld, 2004:385).

Clinical breast-examination (CBE)
This is examination o f the breasts by a trained physician.Periodic examinations by a physician, in combination with an annual mammogram for women over fifty, are recommended by the World Health Organization, where possible (LoBuono, 2001:2) It has also been suggested that women with a family history of cancer sh o u ld c o n s id e r a m ore in te n siv e screening programme (LoBuono, 2001:2).In a US breast cancer detection study (LoBuono, 2001:2) 39% o f cancers 1cm in size were detected by clinical breast exam ination, w hereas in situ cancers a c c o u n te d fo r 18% o f th e c a n c e rs detected by mammography that would not have otherw ise been detected by clinical breast exam in atio n , 22% o f invasive cancers less than 1cm in size were detected by mammography, which according to the researchers, clinical b re a st e x a m in a tio n co u ld not have succeeded in doing.

Mammogram (Mammography)
The mammogram is an x-ray examination of the breast and is used as a screening method for breast cancer, as well as in its diagnosis (Northrup, 1999:328).The use o f the m am m ogram as part o f breast c a n c e r sc re e n in g has b een w id e ly promoted especially in countries where such facilities are available.According to M ittra , B aum , T h o rn to n , and Houghton (2000:1), mammography is a complex, expensive and partially effective test.They argue that there is sufficient circumstantial evidence to suggest that clinical breast examination is as effective as mammography in reducing mortality from breast cancer and that comparison between the two screening methods in a randomized trial is worth researching.Use o f the m am m ogram h o w ev er is not w ith o u t its ow n risk s.R e g u la r m ammograms are not routinely advised for young women under the age o f 35 w ho are not at high risk.R osenfeld (2 0 0 4 :3 8 9 ) sta te s th a t th e ris k o f develo p in g rad ia tio n -in d u ced breast tumours is high in girls and teenagers.In addition to this, the density o f the breast tissu e in y o u n g e r w om en m ak es it difficult to distinguish a mass or dense spot on the mammogram.Therefore less accurate pictures are obtained.
A c c o rd in g to K e ite l an d K o p ala (2 0 0 0 :3 6 ), so m e d o c to rs c re d it mammograms with reducing breast cancer mortality, while others condemn them as being unreliable.In an attempt to achieve b etter o utcom es, K eitel and K opala (2000:36) reiterated that the technology could be improved.In addition, it was stressed that the m ammogram alone is in su ffic ien t as a screening tool and should be used in com bination with manual examination.A similar comment was made by Northrup (1999:331) that the mammogram is a very sensitive method for detecting breast cancer, however, it was described as not perfect.Rosenfeld (2004:384) however states that the sensitivity of the mammogram ranges from 75-88% but is low er in younger women.The National Cancer Institute recommends that women in their 40's have a mam m ogram every 1 -2 years, whereas th e A m e ric a n C a n c e r S o c ie ty recommends that women be screened first at age 40 and then every year thereafter (M ittra, Baum, Thornton & Houghton 2000:1).Despite this differing view, they both agree on an annual m am m ogram after 50 years of age.This has implications for women below age 40 as breast cancer affect different age groups.In effect, w o m en w h o do n o t fa ll u n d e r the recommended age group for mammogram have but little option than to rely on BSE and/or clinical breast examination.
In addressing the use of breast cancer detection techniques for women over 40 years, D r Nancy Baxter o f the Canadian Task Force on Preventive Health Care cautions that in addition to breast selfexamination, women over 40 years should turn to m am m ography and professional breast exam ination instead o f relying on breast self-examination (Baxter, 2001:1).T h e re is s u f f ic ie n t c irc u m s ta n tia l evidence to suggest that a com bination of regular mammograms and examination by a physician is as effective in reducing the m ortality rate from breast cancer (M ittra et al, 2000:1).The high cost of screening m am m ography has been a persistent problem causing widespread u nderu tilizatio n in the U nited States resulting in a growing number of facilities offering low-cost screening mammograms (Bassett, Jackson, Fu and Fu, 2005:19).While some developing countries cannot a ffo rd th e c o s t o f p ro c u rin g a mammogram, women can benefit from learning the techniques of breast selfexamination.

Breast self-examination (BSE)
B reast self-ex am in atio n is a sim ple, in e x p e n siv e , n o n -in v asiv e and nonhazardous m eans o f detecting breast cancer at an early stage (R osenfeld, 2004:391).Breast self-exam ination is re p o rte d to be less e ffe c tiv e th an a mammogram or examination by a trained physician.H ow ever, it is a valuable approach, particularly in a country like S ie rra L e o n e th a t c a n n o t a ffo rd sophisticated screening services for the entire population at risk.D iffe re n c e s in th e te c h n iq u e o f performing BSE do exist (Sm eltzer andBare 2000:1264).Smeltzer andBare (2000: 1264) state that what is important, is that the pattern selected is used consistently, done th o ro u g h ly and d elib erately to ensure the exam ination involves the whole breast.According to the Breast Cancer Society o f Canada, 70% of all breast grow ths w hether m alignant or benign, are discovered during breast self-examination; nine out of ten growths are detected by women themselves, and eight out o f ten breast growths are noncancerous.In order for a woman to detect breast cancer early she needs to be aware o f the changes that are suggestive of breast cancer.This intervention involves p e rfo rm in g m o n th ly b re a s t se lfexamination, observing for and noting abnorm al changes in the breasts and reporting to the doctor promptly.

Performance of Breast Self-Examination
Periodic breast self-examinations are very important for the early detection of breast cancer.According to Smeltzer andBare (2000:1263), BSE forms an essential part o f a w om an's health care and should be conducted preferably five to seven days after m enstruation.T he best tim e to examine the breasts is after the menstrual period when the breasts are not tender o r s w o lle n (N o rth ru p , 1 9 9 9 :3 1 3 ).M enopausal women and those who do not have regular periods are advised to examine their breasts on a monthly basis -that is on the same day every month (H ussain, 2002:1).The World Health Organization recommends that women over twenty years o f age should examine th e ir b reasts reg u la rly every m onth (Hussain, 2002:1).

Examination.
Breast self-exam ination (BSE) is still regarded and promoted as a practice that em powers women, as a way of taking control in the face o f this widely feared disease.In 1994, the Canadian Task Force, as part of its conclusion recommended that there was insufficient evidence to recommend for or against BSE (Mittra et al, 2000:2).They however cautioned that w om en are not being advised to stop performing BSE and stressed that those who request to be taught the procedure, should be instructed to perform it in a proficient manner (M ittra et al, 2000:2).Napoli In developing countries where women cannot access m odem diagnostic tools such as a mammogram, women rely on BSE as the available option.Chiffriller (2003:1) writes that, "Examining your breasts is your greatest weapon to fight breast cancer".

Purpose
T he p u rp o se o f th is stu d y w as to determine the effectiveness of knowledge re g a rd in g B SE e d u c a tio n g iv e n to w om en in F reeto w n and its im p act towards early detection o f breast cancer.

•
To establish the ability of women to perform BSE in Sierra Leone

•
To determine the effectiveness of knowledge given to women regarding BSE education during the breast week.
• To make recommendations regarding the use of BSE as a screening method.

Operational definitions
• Breast self-examinationsystematic self examination of the breasts by a woman for the purpose o f detecting abnormalities.
• Effectiveness -positive changes in behaviour in terms o f examining the breast for abnormalities, and where appropriate, reporting abnormalities detected, to the hospital.
• Health Education -to teach topics that pertain to caring for oneself and one's health needs so as be knowledgeable.
• Health Promotion -the active participation in the promotion of healthy lifestyle and the prevention or early detection of a disease through acquisition of knowledge in the relevant area.
• Women -refers to the women who participated in the Breast Week and who participated in the follow up study.

Conceptual framework
An appropriate framework for this study is one b a se d on th e in d iv id u a l's participation in health care promotion.(Orem, 1980:44).This means that the idea of a woman observing her breasts for abnormalities will help her in the maintenance of the integrity of the structure o f the breasts as w ell as its functions through early detection o f d e v ia tio n fro m th e n o rm a l.T he therapeutic self-care demands then act as m otivators to her, to p eriodically examine her breasts as part of her normal routine care.T he need for clients to incorporate newly prescribed, complex self-care m easures into their self-care system s requires the perform ance o f s p e c ia liz e d k n o w le d g e an d s k ills a c q u is itio n th ro u g h tra in in g and experience (Orem, 1980:54).

Research design
A q u a n tita tiv e a p p ro a c h w ith a d escriptive-observational design was a d o p te d fo r th is study.D ire c t observation techniques, which involved direct observation o f the participants' skills in performing BSE were utilized.To facilitate the process a checklist was developed by the researcher on the basis o f the current literature on BSE.The ch eck list d em anded "y e s" and " no" responses in relation to the performance o f tasks or activities set out.

Population and Sample
The target population for this study was those women who attended the Breast Week.A total num ber o f over 1 200 women participated in the Breast Week held in November 2002 in Freetown, Sierra Leone.The criterion for inclusion in the study was limited to only those women who participated in the Breast Week A sample o f 120 women, system atically selected from the population of over 1200 wom en who participated in the breast cancer week was used.The study was carried out a year after the Breast Week.
Every tenth woman on the registration list of women who took part in the Breast Week was selected through systematic random sampling as a participant for this study.D u rin g th e B re a s t W eek, participants had been inform ed o f the possibility o f a future study.Student midwives who had participated in the B reast W eek, assisted in tracing the p a rtic ip a n ts u sin g th e in fo rm a tio n recorded in the register during the Breast W eek. T he stu d e n t m id w iv es w ere assigned to the participants living in close proximity to their residential areas.
Tracing participants continued until the sample size was achieved.Participants were asked to present them selves on specific dates and at a time when they were available.

Data Collection
D irect observation of the participants, using a checklist, addressed the practical a s p e c t and sk ills a c q u is itio n .T he checklist was divided into the following se c tio n s: b re a st in s p e c tio n , b re a st palpation and detection of abnormalities.
The women were asked to explain and give reasons for every observation made during the procedure.Data were collected over a period of four weeks.The practical room in the nursing education institution was utilised as the venue for the study.E ach p a rtic ip a n t p ro c e e d e d to the examination room alone where she was ask e d to p e rfo rm a b re a s t se lfexamination under the direct observation o f th e re se a rc h e r.P riv a c y o f the participants was ensured throughout the procedure.A systematic way o f recording the observed activ ities or actions is paramount in any scientific study (Polit & Hungler, 1997:269).Therefore as a means of ensuring validity and avoiding subjectivity, a checklist was used in the o b s e rv a tio n o f th e w o m a n 's performances.

Data Analysis
Data were analysed using SPSS 11.5 and were presented using frequencies and percentages.

Validity and reliability
R eliability and validity were ensured th ro u g h the use o f a stru c tu re d observational checklist and a pilot study was undertaken.The checklist was pre tested on five women from the target po p u latio n .T hese w om en w ere not included in the final sample size o f 120.The observations were all observed and recorded by the same researcher.

Ethical considerations
Permission to undertake this study was sought from the University's Research Ethic Committee, the Ethics Committee on Health, Freetown, Sierra Leone, the Consultant in-charge of the main referral hospital in Freetown and the participants.Each of the participants were approached w ith a p articipant inform ation letter inform ing them about the study and requesting their permission and approval to participate in the study.Anonymity, confidentiality and privacy were ensured.P a rtic ip a tio n in th e re se a rc h w as voluntary.Participants were offered the opportunity to withdraw from the study at any time and were assured o f no ill effects.An atmosphere of good rapport had been established during the Breast W eek and none o f the p a rtic ip a n ts withdrew from the study.Participants were given a pamphlet on breast selfexamination (BSE) and a pink ribbon as a token of appreciation for participating in the study.

Findings Performing BSE after Breast Week
Almost all of the women (91.7%) stated that they had never practiced BSE prior to the Breast Week, as compared with only 5% who stated that they had not performed BSE since the Breast Week In the follow up study, 32.5 % o f the re s p o n d e n ts in d ic a te d th a t th ey examined their breasts once a month, the sam e n u m b e r o f w o m en said th ey e x a m in e d th e ir b re a sts so m etim e s.Despite the information provided on the im portance o f regular perform ance of BSE, 34.2% o f the women indicated that they examined their breasts after their monthly period, while 3.5% women stated th a t th ey p e rfo rm e d b re a s t c h e c k s whenever they felt something was wrong.The majority o f the respondents (68.3%) stated that they examined their breasts w hen having a bath.T his finding is supported by Keitel and Kopala (2000:38) who report that most women perform BSE whilst bathing or taking a shower.

The breast selfexamination Inspection of the breasts
One hundred and ten of the respondents at the start o f the examination mentioned that they would first take a look at the breast to inspect the shape and skin tissu e for ab n o rm a litie s.Ten o f the respondents did not make mention o f the first step o f inspecting the breasts.

Palpation of the Breast Tissue
M ost o f the respondents (75 %) started palpating their breasts from the axillary portion o f the breast, whilst 25 % began from the center.A lm ost all (95.8 %) palpated their breasts in a circular manner to check for breast lumps or any other abnormality.Only 4.2 % were observed to start the palpation in quadrants, which is a d iv is io n o f fo u r s e c tio n s .Furthermore, 88.3 % of the respondents used the pads o f the fingers to check the breast tissue, whilst 11.7 % o f the women did not use the pads of their fingers, but instead used their finger tips.Use o f the finger tips makes abnormalities situated deep within the breast tissue difficult to palp ate.W ith th e e x c e p tio n o f one respondent, all exam ined the second b re a s t in th e sam e m an n er.O ne respondent had undergone a mastectomy.She how ever m entioned that she still examines the scar area for any further changes that may be abnormal.

Examination of the Nipples
On com pletion of palpating the breast tissue 91.7% squeezed their nipples to detect abnorm alities such as a bloody nipple discharge or offensive pus-like discharge, which are also associated with cancer of the breast.Very few women (8.3%) did not examine the nipples for abnormalities.Omission of any area can lead to missed abnormalities.Hence it is im portant that the w hole breast and surrounding areas are properly examined.

Detection of Breast Abnormalities during the Study
Only one o f the respondents reported palpatin g a lum p in h er rig h t breast during the demonstration.The researcher confirm ed this, by palpating the breast herself.Further analysis revealed that this woman had had the lump detected during the Breast Week and had been referred to the surgeon, who she had seen.He had recom m ended surgery, but she had not been able to afford this.The re se a rc h e r used th is o p p o rtu n ity to counsel the woman on the importance and n eed fo r p ro m p t a c tio n a fte r detection o f breast abnormalities.

Discussion of key findings
One of the objectives of the Breast Week was to em pow er the wom en with the necessary knowledge and skills in BSE in order to enhance their participation in self care in relation to care of their breasts and in so doing promote positive health outcomes.Women were counseled and taught the importance o f routine BSE in helping them make informed decisions.

Performance of BSE after Health Education during the Breast Week
The performance o f BSE requires both knowledge and skills in order to promote health performing habits.Responses of th e p a rtic ip a n ts sh o w ed th a t the in fo rm a tio n g iv e n on b re a st se lfexamination was fully understood and is being utilized as one o f their health practices.This was determined by the num ber o f women who examined their breast before and after the breast week.
On analysis of the findings, 91.7% of the participants had never practiced BSE prior to the breast week; in comparison, the percentage of women who are now practicing BSE after the information and skills imparted during the breast week was noted to be higher (95 %).This change in behavior was significantly different with p = 0.000.In this study, it was observed that 5% of the women did not practice BSE despite th e in fo rm a tio n p ro v id e d on the im portance o f regular perform ance of BSE.Consistent with this finding is the view expressed by N orthrup (1999:331) as she noted that despite awareness of BSE most women do not examine their breasts.However, the number of women in the study who did not practice BSE is re la tiv e ly sm all co m p ared to those currently practicing BSE.One possible explanation could be that these women misinterpreted the information as a good indicator o f their breast status and thus they did not see the need for future checks.Another possible explanation for th is m isin te rp re ta tio n c o u ld be the respondent's level o f knowledge.The need for ongoing education and health promotion is of importance especially to d is a d v a n ta g e d w o m en .W o m e n 's support groups or community projects on reproductive health issues should use such projects as a platform for reinforcing positive health habits and dissemination o f information.

BSE and self-care practices in women
Despite the controversy surrounding the effectiveness of the practice of BSE in d e v e lo p in g c o u n trie s , b re a s t se lfexamination has been recommended as a u s e fu l s c re e n in g to o l fo r b re a st ab n o rm alities such as b reast can cer especially in countries where women do not have access to m odern screening m ethod.T his study has show n that teaching women in Sierra Leone breast self-exam ination enabled them to be involved in their self-care practices.The a c q u is itio n o f k n o w le d g e by the re s p o n d e n ts led to an in c re a se d aw areness in BSE perform ance as a health related activity.In the context of S e lf-C a re , O rem (1 9 8 0 :5 4 ), v iew s individuals as biopsychosocial beings who engage in decisions and take action towards their wellbeing and health.Their ability to practice breast self-examination was enhanced with the assum ption of responsibilities for self-care.They also mentioned early detection and reporting of breast abnormalities to the hospital for m edical interventions, as one o f the b e n e fits o f p e rfo rm in g b re a st selfexamination.Clinical studies indicate that m ost lum ps are detected by w om en themselves during bathing or when taking a shower (Napoli, 2001:1).Findings in this study seem to follow this trend as 68% o f the women stated that they perform BSE when having their bath.

Performance of BSE
In practice, the perform ance o f BSE in v olves three im p o rtan t steps.The checklist specifically addressed each step in BSE.During the observation of the women, these three aspects o f BSE performance were addressed by most of the women except for a few.Inspection of the breasts is one o f the first steps in BSE, 91.7% of the women mentioned this step before proceeding to the actual palpation o f the breast tissue and 91.7% dem onstrated know ledge with regards squeezing the nipples for abnormalities.On observation, almost all of the women were able to examine their breasts for a b n o rm a litie s.M ost o f the w om en demonstrated how to examine the breast tissue and the nipples for abnormalities.However, 8.3% o f the women could not remember all the steps involved in BSE.T hese w om en om itted squeezing the nipples after palpation o f the breast tissue.
These weaknesses or gaps in knowledge required a repeat demonstration of the correct technique used in BSE.This was done by one o f the researchers.Two categories o f w om en w ere identified during the study, those who mastered the skills and those who did not m aster the skills of examining their breasts using key points.However, failure of a woman to examine the axillary portion of the breasts as part of the breast during BSE might result in her m issing enlarged lym ph nodes or abnorm alities in this area.
The need for health professionals to perform additional physical examinations on wom en involving the breasts is of im p o rta n c e in all h e a lth s e ttin g s .Acknowledging that the majority o f the women in this study can perform BSE, the absence o f a policy on breast cancer and BSE is an indicator o f the status of w om en's health in any country.More effort should be directed at national level to e n su re k n o w le d g e and sk ills acquisition in the practice of BSE.The need for modem te c h n o lo g y to a s s is t in o r c o n firm d ia g n o s is o f b re a s t a b n o rm a litie s detected during B SE is an issue for consideration at national level.Some of the respondents indicated that this will give a b etter p ictu re o f the disease.Specific m ention was not m ade o f a m a m m o g ra m , th e te c h n o lo g y w as described as a machine.

Detection of Breast Abnormality
The objectives o f teaching BSE is for women to know about breast cancer and its risks, how to exam ine their breasts regularly, report early any abnormalities associated with breast cancer and to seek prompt medical advice.This in effect will help them to get a better prognosis and thus increase the survival rate from breast cancer.Despite the information provided on early reporting and prompt treatment, one o f the three respondents who had a b re a s t lu m p had n o t had th e lum p re m o v e d as a d v ise d by th e b re a s t su rg eo n .T h is fin d in g can p o ssib ly explain some of the reasons why women seek help very late when abnormalities are detected.Financial constraints can be an inhibiting factor in decision making for women with breast problem s who need surgery.The effectiveness of health e d u c a tio n and p ro m o tio n on b reast cancer and BSE practice in term s o f utilizing appropriate medical facilities for treatment can be hampered by the high cost o f medical services in a country like Sierra Leone where patients are expected to pay for their medical care.The objective o f teaching women to report to hospital, seekin g early treatm en t fo r a b etter outcome can be undermined as a result o f this.

Recommendations
F in din g s in th is study h ig h lig h t the is s u e s s u rro u n d in g w o m e n 's participation in their breast health.In the light o f this, recom m endations in key areas o f nursing practice are m ade as follows:

Nursing Practice
The issue of breast cancer and BSE is relevant in nursing and deserves special attention.The role of a nurse as a teacher, co u n selo r and educator is crucial in w o m e n 's h e a lth and c a n n o t be underestimated in the health education of clients as discussed in O rem 's Self-Care M odel.Nurses should use every opportunity to teach BSE and to reinforce the practice when seeing women in health settings.

Nursing Education
N u rsin g c u rric u la m u st in c lu d e in fo rm a tio n on b re a s t c a n c e r and m ethods o f screening for the disease.Breast Self-Examination must be taught as a method o f empowering women in their self-care.

Policy Implications
From the study, it became apparent that th e w o m en r e a liz e d th a t th e re are limitations to BSE as they indicated that the help o f professionals is needed after they have detected abnormalities in their breasts.In this respect, w om en's health It is apparent from this study that in a country such as Sierra Leone, where means of accessing modem technology of screening for breast cancer are n o n -e x iste n t, the need to teach women a simple method of early detection of breast cancer seems to be beneficial.D ow nright condem nation o f teaching women BSE does not seem to be practical in these situations where women do not have any other option or opportunities for their breast checks.In the absence of modern screening methods such as the mammogram, women are motivated to be involved in their breast care as part of their daily routine.
The study concluded that the majority o f the w om en w ho had been given inform ation on how to perform BSE continued the practice.It was found that the majority of the respondents (91.7%) could perform BSE despite a few lapses in the technique.M ention was made by the women o f the need for review by experts when abnormalities are detected during BSE.The ultim ate reason for teaching women BSE is its ability to raise aw a re n ess o f the d an g ers o f b reast cancer and the need to identify and report a b n o rm a litie s early .B ased on the findings of the study, it can be concluded that the inform ation given during the b rea st w eek w as u n d ersto o d by the majority of the women and the practice of BSE is being utilized by the women.Gaps observed in the practice o f BSE were identified and corrected through reinforcem ent o f health teachings on BSE by the researcher.
(2001:1) reiterated that women them selves, in the course o f norm al everyday practices such as showering, dressing, and m aking love, find most n o n -m a m m o g ra p h y -d e tec te d b re a st tumours.
issu e s n eed m o re a tte n tio n by g o v e rn m e n t and p o lic ie s on b re ast c a n c e r.W h ile th e se fin d in g s are discussed, further efforts are needed by g o v e rn m e n ts and p o licy m ak ers to provide w om en with other screening options.In this regard, women who detect breast lumps or abnormalities during BSE will need further checks to confirm the diagnosis or histological confirmation of b re a s t tu m o rs.N u rses can a lso be influential in lobbying for changes in health policy to cater for disadvantaged women who cannot afford the cost of surgery or treatment.ConclusionBreast self-examination is described as a sim ple tech n iq u e and is cred ited as h e lp in g e a rly r e p o rtin g o f b re a st abnorm alities.In the literature there appears to be some controversy over BSE in th e re d u c tio n o f b re a st c a n c e r mortality.A lthough the usefulness o f teaching women BSE has however being questioned by researchers in developed countries and has not been accepted as an effective m ethod o f screening for breast cancer, nevertheless, this study has highlighted its benefits in raising awareness and detecting breast lumps in three women in the study.BSE is seen as a m eans o f e m p o w erin g w om en to improve their quality o f life with the aim o f early detection and better prognosis.The role of know ledge in breast selfexamination as one o f the techniques in b re a st c a n c e r sc re e n in g c a n n o t be u n d e rv a lu e d in d is a d v a n ta g e d communities.
The performance of BSE requires both knowledge and skills in order to promote health perform ing habits.H ence the choice o f O rem 's S elf Care N ursing Model.This model was selected because it addresses the key concepts o f this research.The self-care aspect in O rem 's words centers on "being alert to types of hazards that are likely to occur and taking a c tio n to id e n tify an d a tte n d to deviations from o n e 's structural and functional norms"