Rural women ’ s knowledge of prevention and care related to breast cancer

Kev words Breast cancer, signs and symptoms o f breast cancer, breast self-examination, health care provider, rural women Abstract: Curationis 32 (2): 38-45 According to the experience o f the researcher, an oncology nurse, women living in the rural areas o f Thulamela municipality in the Limpopo Province, have many differ­ ent perceptions o f breast cancer. Perceptions are based on previous disease experi­ ences. As with previous illnesses, changes in the breast caused by breast cancer are self-managed and treated. When these women seek medical advice for breast cancer related problems, they already have advanced cancer. The purpose o f the study was to investigate if women are knowledgeable o f the signs and symptoms o f breast cancer, breast self-examination, as well as appropriate health care to take responsibil­ ity to prevent admission with advanced breast cancer. The research study was an exploratory and contextual survey. The sampling method was convenient (n=200). Data were gathered during a structured interview using a checklist. Data analysis was done by means o f descriptive statistics. The results o f the study indicated a low level o f knowledge regarding the signs and symptoms o f breast cancer. The average level o f knowledge for the signs and symptoms o f breast cancer was less than 10% (n=20). With regards to breast self-examination the results varied between 8.5% (n=17) and 13% (n=26). Biomedical medicine was the preferred treatment choice for the majority o f the respondents. The study provided evidence that women were unable to take responsibility for their breast health. Their lack o f knowledge o f the signs and symptoms o f breast cancer and breast self-examination would not enable them to prevent presenting with advanced disease. A breast health care strategy for women living in Thulamela should be designed, implemented and evaluated to pre­ vent presentation with advanced breast cancer.


Background, rationale and problem statement
Breast cancer is a m alignancy which is easily treated and cured if detected early.However, if detected late, the p ro g n o sis is unfav o u rab le (C rane-Okado, 2001:129).Previously, women lacked strategies for detecting breast cancer early, but at present, through breast self-examination, a clinical breast examination, or mammogram, changes in the breast can be detected at a rela tively early stage.T hough these strategies are w idely publicised, the high incidence of breast cancer is still a concern.According to the World Health Organization and In te rn a tio n a l U nion A g ain st C an cer (2005), breast cancer is the most com m on cancer among women worldwide.One in eight American women will de velop breast cancer (Smyke, 1993:95).In Africa, the problem is equally con-ceming.The Cape Town Declaration on Cancer Control in Africa (2006), urged governments in the African re gion to recognise cancer as a critical public health problem alongside HIV/ AIDS, malaria and tuberculosis.In South Africa, The Cancer Associa tion o f South Africa reports that breast cancer is one o f the most common can cers affecting women (CANSA, 2004:1).The M edical Research Council (2006) reported that 3156 women died in 2000 due to breast cancer, and that breast cancer was the second-ranked cause o f cancer deaths in females in South Africa.Though black women in South Africa have a low incidence o f breast cancer, the incidence is rising (Walker, Adam & Walker, 2004:81).The authors also report that in those women who were admitted, the mean age was rela tively young (54.1 years o f age, with a margin o f error o f 10.9 years) and they typically presented with advanced pro gression o f the disease.Vorobiof, Sitas and Vorobiof (2001:125s) state that sev eral determinants influence rural women in their decision to obtain early medi cal help, as well as to refrain from pro posed therapeutic methods.
One determ inant is a negative attitude towards the disease.After detecting an abnormality, some women block their anxiety from their conscious awareness and claim that they did not notice that something was wrong in their bodies.This behaviour causes a delay in the treatment o f patients who could ben efit from early treatment.Some women also refuse to give consent to treatment, while others wait and think about the situation or deliberately delay taking any action (Barraclough, 1996:17).
Lack o f knowledge has been identified as a determ inant that creates problems with the m anagem ent o f the patients (Barraclough, 1996:6), and is particu larly evident with regards to the addi tional signs and sym ptom s o f breast cancer.W hile Barraclough (1996:6) observes that som e w om en knew a lump in the breast can be a sign o f breast cancer, they do not know that other symptoms, such as a nipple dis charge or inversion, m ay also indicate breast cancer.Vorobiof and Vorobiof (2001:126s) found the idea o f a pain less lump in the breast being poten tially cancerous and therefore lifethreatening a difficult concept for many black women to accept.
A cco rding to D onegan and S pratt (1995:8), women who lack knowledge about breast cancer may be surprised if someone who appears to be well is diagnosed with breast cancer.The di agnosis o f breast cancer may also be traumatic if it is made during screening and the person was not aware o f any symptom o f the disease.Some women accept the diagnosis and treatment with a fighting spirit, while others are af fected by both the emotional and cul tural meaning regarding the breasts.
Unfortunately Black women with breast cancer present with far advanced dis ease (Walker 2004).Walker (2004) found that 21.1% o f women presented with stage III and 63.1% presented with stage IV breast cancer.Early detection and treatm ent are the only weapons women have to prevent death due to breast cancer.The successful outcome o f breast cancer depends heavily on early diagnosis and treatment.Self-ex amination o f the breasts is an im por tant tool for women to detect changes in their breasts as a first line o f defence against breast cancer.Equally impor tant is the decision where to obtain health care if a problem is suspected.If a woman is not knowledgeable about the signs o f breast cancer, she will in terpret the signs from her own previ ous experience which could delay ob taining appropriate health care. .

Problem statement
The researcher, an oncology nurse, ex perienced that women living in the ru ral areas o f Thulamela m unicipality in the Limpopo Province, have many dif ferent perceptions o f breast cancer.These perceptions are based on their experience o f previous diseases.As with previous diseases they typically resort to self-m anagem ent and treat ment.Some women even associate b reast cancer w ith a chronic ulcer (Tshipfula) or an abscess which they can treat themselves.W hen they do eventually seek medical advice, the cancer has progressed to an advanced stage, putting them be yond medical treatment to cure the dis ease.Cultural perceptions also exist that may affect a delay in seeking medi cal advice, as removal o f one or both b re a sts is o ften u n a c c e p tab le i f a woman is to remain attractive to her partner.
The research problem for the study was therefore to investigate if women o f the Thulamela municipality in the Limpopo Province are know ledgeable o f the signs and symptoms o f breast cancer, breast self-examination, and appropri ate health care, so as to prevent admis sion with advanced breast cancer.

Purpose of the study
The purpose o f the study was to deter mine the knowledge o f women in the Thulamela municipality regarding the signs and symptoms o f breast cancer, breast self-examination, as well as their decision o f w here they will obtain health care.This knowledge will be a prerequisite to develop culture-specific health promotion interventions for edu c a tin g ru ra l w om en liv in g in the Thulamela municipality in the Limpopo Province regarding breast cancer.

Theoretical framework
O rem 's self-care theory was used to guide this study (Berbiglia, 2006:255).O rem 's theory was used because the theorist provided it as a key for ena bling a person to care for him/herself.A c c o rd in g to L e d d y and P e p p e r (1998:179-180), the self-care theory in dicates the purpose o f nursing as help given to people to m eet their self-care needs.Self-care is the practice o f ac tivities that individuals initiate and per form on their own behalf in maintain ing life, health, and wellbeing.
There are three systems within O rem 's professional nursing practice model, namely: • the compensatory system where the nurse is responsible for total care; • the partially compensatory sys tem where the nurse and patient share responsibility for care; and • the supportive-educative sys tem where the client has primary responsibility for health with the nurse acting as a consultant.
The current study focussed primarily on the supportive-educative system.Before women can be educated, their current level o f knowledge must be in vestigated to serve as the basis for an educational intervention.

Research methods and design
The research methods and design will be described in terms o f the context; population; design and data gathering; and data analysis.

Design and data gathering
The design o f the study was a quanti ta tiv e su rv e y (B u rn s & G ro v e , 2001:256).The data gathering method for the study was a self-report method using a structured interview.Accord ing to Bums and Grove (2005:396)

Ethical considerations
According to Brink (2002:38), it is every researcher's responsibility to ensure that the ethical code is maintained at all times.The principle o f beneficence w as m a in ta in e d as the re se a rc h er strived to avoid inflicting psychologi cal harm by practicing culture-sensitive nursing.Health education regarding breast cancer was given to the total group o f women after the data were collected.The principle o f respect o f human dignity was also preserved.The right o f self-determination o f the par ticipants was acknowledged.The par ticipants volunteered to take part in the study after being informed about it in their own language and they could also term inate their participation at any time.The interview was conducted in the preferred language o f the partici pants.Privacy was ensured by taking the particip an ts aside w hen others were present.Anonymity and confi d en tiality w as also ensured, as no names were written on the checklists, only a sequential number.

Validity and reliability
Validity refers to the degree to which an instrument measures what it is sup posed to m easure (Polit & Hungler, 1997:471).Reliability has been defined as the accuracy and consistency o f the measuring instrument.A research in strument can be considered reliable if it yields results on separate occasions under comparable conditions.Measures that were taken to assure the validity and reliability o f the study are • The checklist was given to a professional nurse trained in oncology nursing to determine content validity.

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The checklist was pre-tested to ensure that all questions were understood and that the re quired data were produced.

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The checklist was formulated and specifically planned to ad dress the rural black w om en's knowledge regarding self-examination for breast cancer, signs and symptoms o f breast cancer and preferred choice o f treatment.

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The researcher collected all the data, thus avoiding data gath ering variability.

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The researcher was available in person to answer and explain any unclear aspects to the par ticipants.

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The respondents were ad dressed in their own language to improve understanding o f the questions and build trust.

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The checklist was the correct instrument to tick o ff the re sponses o f the respondents, thus ensuring that all data were captured correctly.
• Using the checklist ensured structural coherence through all 200 interviews.

Results
The results o f the study will be pre sented in the format o f the checklist.The dem ographic data w ill be p re sented first, and thereafter the results regarding the breast self-examination, signs and symptoms o f breast cancer and the choice o f treatment.

Demographic data
The majority o f the women (47%; n=94) came from small business groups, and 41.5% (n=83) from self-help groups.

Knowledge of breast selfexamination
Three specific questions were asked regarding breast self-examination.The questions focussed on the frequency o f breast self-examination, the optimal time o f self-examination and the palpa tion technique.

Frequency of breast self-examination
The first question focussed on the fre quency o f breast self-examination.The majority o f the group (92%; n=184) did not know the correct frequency o f breast self-examination.W hen inves tigated in term s o f the groups from which the women were recruited, only one group, the self-help group, had 18% (n=36) correct.Both the small business and self care groups gave no correct answer. In

Method of examination demonstrated
The third question regarding breast self-examination focussed on the cor rect method o f breast self-examination.F our specific aspects w ere in v esti gated.These aspects were the correct palpation technique, exam ining the whole breast, as well as both the nip ple and axilla.The results are presented in Figure 2. Again, the level o f knowl edge was low, the highest correct per centage being exam ining the whole breast (21 %; n=42).
W hen the demographic variables were taken into account, the m ost know l edgeable w om en w ere found to be Venda women between the ages o f 30-39 forming part o f the self-help group and having a secondary level o f edu cation.

Knowledge of the signs and symptoms of breast cancer
Eight signs and sym ptom s o f breast cancer were investigated.The signs and sym ptom s o f breast cancer in cluded in the checklist were: • change in the size o f the breast; • change in the contour o f the breast; • mass or thickening; • skin retraction, dimpling; • nipple retraction; • persistent rash in nipple area; • nipple discharge; and • superficial veins on the chest.
In Figure 3, an overview o f the wom en's level o f knowledge regarding the signs and symptoms o f breast cancer is provided.From Figure 3, it is clear that the overall level o f knowledge was low.The highest percentage is 15.5% (n = 3 1) for knowing that the size o f the breast would change.Changes in the contour o f the breast (13%; n=26) and knowledge about superficial veins on the chest (12%; n=24) were second and third.The least known signs were skin retraction and nipple retraction, both being 8.5% (n= 17).
Regarding a mass or thickening, three possibilities were listed, namely a mass in the breast, the axilla or supraclavicu lar.Again, there was little variance in the level o f knowledge -16% (n=32) of the women knew o f a mass in the breast and 15.5% (n=31) about a mass in the axilla.Concerning the mass or thicken ing in the supraclavicular area, only 7.5% (n=15) were knowledgeable.
Investigating the results in terms o f the demographic variables, a definite trend was noticeable: • In terms o f the groups the women belong to, the self-help group was by far the most knowledgeable, ranging from 15.7% (n=l 3) to 34.9% (n=29).
The level o f knowledge o f the small business activity and the care group is similar and quite low (below 5%).In the socio cultural groups, the Venda was the only group with some knowledge, ranging from 10.7% (n= 15) to 22.9% (n=32).

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The educational level indicated again that having a secondary education was most profitable in terms o f knowledge o f breast cancer.It must be noted that the percentage for the tertiary education group might be m is leading, as there were only 8 (n=8) respondents in the group (12.5% o f the respondents rep- resents one respondent with a correct answer).

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The age groups also present a clear pattern.Those younger than 20 years o f age and older than 60 years o f age did not have any knowledge o f breast cancer.The 30-39 age group had the most knowledgeable re spondents, with a range o f 11.7% (n=20) to 27.3% (n=48).

Preferred treatment
Four options were offered in the check list.These were self treatm ent, tradi tional medicine, faith healing and bio medical treatment.An "Other" option was also provided.The results indi cate that biomedical treatment was pre ferred by the majority (68.5%; n=139) o f the respondents.Traditional m edi cine is preferred by 8% (n=16) o f the group and faith healing by 5% (n=10).
Only 1 % (n -2 ) o f the respondents in dicated that they prefer to treat them selves.
Most o f the women who chose tradi tional or faith healing belonged to the care group, in both cases 13% (n=3  Koller, & Vega, 2006).According to the afore-m entioned authors, the majority o f health problems o f these groups can be attributed to the social conditions in which people live and work.These social determinants will have to be in vestigated and incorporated in a health prom otion intervention specifically developed for Tsonga women.

Limitations
The limitations o f the study were the following: • The study focussed on women involved in self-help or small business activities, which may also not be representative o f all women in the area.

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The generalisability o f the re sults is limited as a result o f the contextual nature o f the design and the convenient sampling method.For example, the women in the activity groups may not represent all the women ofThulamela.

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The high level o f education suggests that the groups may not be representative, yet the fact that the overall level o f knowledge was so low may suggest that the educational level is not an indicator o f knowledge regarding breast cancer.

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The data gathered was self-re ported, and therefore subject to recall bias.

Conclusion
T he study p ro v id ed e v id en ce that women living in Thulamela municipal ity in the Limpopo Province were not in the position to perform breast selfcare and were therefore unable to take resp o n sib ility for th eir ow n breast health.Their lack o f knowledge o f the signs and symptoms o f breast cancer and breast self-examination would not enable them to prevent presenting with advanced breast cancer and maintain life, health, and wellbeing.Nurses, es pecially oncology nurses, have a vital role to play in promoting breast health and empowering women to apply selfcare to prevent late presentation with breast cancer.A breast health care strat egy for wom en living in Thulam ela municipality should be designed, im plem ented and evaluated to prevent presentation with advanced breast can cer.
The right o f the participants to fair treatment was upheld by fair and non-discriminatory selection based on research require m ents.T he E thics C o m m ittee o f Tshw ane U niversity o f Technology approved the proposal o f the study.

FIGURE 1 :
FIGURE 1: Level of education and knowledge of correct frequency of breast self-examination.

FIGURE 3 :
FIGURE 3: An overview of the women's level of knowledge regarding the signs and symptoms of breast cancer.

Method of examination demonstrated
W hen the correct frequency o f breast self-examination was cross tabulated with the level o f education, correct anFIGURE 2: