Developing proper health practices should commence as early as possible, and should lead to lifetime maintenance of good health. Adolescent females are an important target group for promotion of proper health habits, in particular with regards to breast health. To our knowledge there are no published data on knowledge, attitudes and practices among adolescent females on breast cancer in Sri Lanka, and few published studies worldwide [15, 16].
The knowledge regarding risk factors for breast cancer in this sample was poor. The majority of respondents were not aware of early warning signs such as nipple changes and a lump in the armpit. The knowledge on screening methods was also unsatisfactory with a majority being unaware of either mammogram or BSE.
Notably, students from two schools where recent seminars on breast cancer had been held had better knowledge, especially of BSE. This seems to be an effective mode of education. Students also made suggestions to distribute printed leaflets and to incorporate information about breast cancer into the school curriculum in the subject of health sciences in the GCE Ordinary Level (OL) classes (grades 9–11). The latter seemed to be more appropriate than including it during AL classes as some students leave school after completing OL classes. Mass media such as television and newspapers were cited as sources of information by many, but such means of communication appeared largely ineffective, judging by the degree of unawareness on core knowledge. A more individualized approach allowing two-way communication seems to be more effective.
The findings of this study shed light on the fallacy of complacency of having health education “in the books” and expecting students to be knowledgeable about it. The process of imparting knowledge effectively can be hampered by many factors such as ineffective teaching, lack of understanding by the recipient, cultural taboos and social pressure barring teaching in certain settings (such as mixed gender schools). Even if knowledge is acquired it does not necessarily transfer positively into attitudes and practice. For example, in this sample 17% claimed to know how to perform BSE, but only one third of them had ever attempted it.
Similar studies have evaluated the knowledge of women on BSE in other countries. A study of 200 women aged 20 or older in Jeddah, Saudi Arabia showed that nearly 80% had heard about BSE, but only 48% knew how to do it [17]. A larger study in Northern Saudi Arabia also showed general awareness of breast cancer and BSE to be poor [18]. A knowledge, attitudes and practices (KAP) survey in Ghana (n-232) showed that a formal educational programme can significantly improve knowledge on BSE [19]. In Karachchi, Pakistan, a survey of 373 participants showed that 49% of the sample had heard about BSE, 38% knew how to do one but only 26% had ever done it [20]. A meta-analysis of 18 studies of BSE in Turkey conducted between 2000 – 2009 showed that married women and those who have had a family member with breast cancer were more likely to perform BSE [21]. A survey of young college students in UK showed that greater perception of hindrances to BSE and also having a higher severity perception of breast cancer were characteristics of women who were not doing BSE despite being knowledgeable about it [22]. However, studies have also shown that improved literacy rates in general positively influences positive health behaviour towards breast cancer [23].
While it is accepted that the standards of teaching with regard to breast cancer should improve, there are doubts as to who are the best teachers to teach the students. Class teachers may not be the best option in this regard for two reasons; a) unfamiliarity with the subject and b) cultural sensitivity (especially teaching the topic in non-gender segregated schools) which might leave them uncomfortable to discuss the topic. There are no studies from Sri Lanka in this regard, however a study in Iran showed that school teachers were reasonably aware of breast cancer risk but the percentage actually performing BSE was very small (6% out of a sample of 578 women) [24]. The way out is to employ public health midwives and public health nurses who are the grass root level healthcare workers in the community. However they may also need proper training before undertaking this task as the experience in some countries is that level of knowledge on breast cancer and BSE is rather unsatisfactory among healthcare workers as well [25].
One limitation of this study is that it was confined to one district of the country. However, this is the most populous district of Sri Lanka (where the capital city Colombo is located) and students in the Colombo district have better access to information and health services in schools than in other districts. Therefore it is reasonable to assume that the results would be similar if not poorer in other areas of the country, though this fact has to be confirmed by further studies.
At the end of the study we provided participants with an educational brochure on breast cancer, and held a series of discussions with them to answer queries on the subject. Overall, our findings urge the healthcare providers and educationists to rethink their strategy of imparting knowledge to adolescents on early diagnosis of breast cancer. It is a timely need given the rising statistics of breast cancer among females in Sri Lanka, which at least partly can be prevented by screening which begins at home with BSE. It may be argued that since the expected prevalence of breast cancer in adolescent girls is low and therefore BSE has little relevance in that age group. However, targeting adolescents in health education has far reaching implications in a country like Sri Lanka. As these girls grow older, breast cancer becomes the most common cancer in females; health education in schools is a key strategy that the government can use ensure that all females in the country are educated in this regard, school education is free and compulsory for all children in Sri Lanka. The government has no other opportunity to educate all females in the country in any other stage in their life after school. Teaching BSE effectively via mass media is a challenge due to cultural reasons. Adolescent schoolgirls can also play an important role in promoting methods for early detection of breast cancer, and in particular BSE, as they would disseminate their knowledge to older female family members and friends. If more and more are educated a critical mass of knowledgeable females will exist in the community that will enable a sustainable knowledge transmission.
It is also possible that vigorously promoting BSE among adolescents can raise some concerns. For example, while adolescents are less likely than elderly women to have an underlying breast malignancy, they may have benign breast lumps such as fibroadenomata, the detection of which can cause considerable anxiety and unnecessary investigations and surgery, at great cost to the patient and to the healthcare system. At the same time BSE is not the best method of screening, since by the time a malignant growth becomes palpable it may have already spread via blood and lymphatics. However, in a resource limited setting like ours, an alternative screening method (e.g. mammogram) is too costly to be standard practice and is also technically inappropriate in adolescents. Considering all this we argue that BSE is a key skill that needs to be taught to adolescents because it is a quick and simple procedure that costs nothing to the patient and because, having learned the skill early in life, the girls can through their adult life practicing it and teaching it to others.
