Knowledge, attitude and preventive practices of women for breast cancer in the educational institutions of Lahore, Pakistan.
ABSTRACT Breast cancer incidence rates, pattern of presentation and survival rates vary worldwide. High incidence, advanced stage disease presentation and low survival rates have been reported from Pakistan. Lack of awareness and screening facilities along with poor socioeconomic status are the main causes. A survey based upon multiple choice questionnaires was conducted during an awareness campaign in women educational institutions of Lahore, to assess the baseline knowledge, attitude towards breast self examination (BSE), clinical breast examination (CBE) and source of information used by them. 1155 filled questionnaires were analyzed by SPSS version 12. The majority (83.7%) of the respondents were <30 years old, 60% had >10 and 31.5% had <14 years of education. Only 27% had "good" while 14% had "poor" and 59% had "fair" knowledge scores about breast cancer. Television was the most commonly cited source of information but was associated with lower knowledge score. The knowledge scores and practice of BSE had a positive association with education level. The respondents had better knowledge of life time risk and association of early diagnosis with better chances of cure, but worse knowledge of risk factors as compared to women in educational institutions of other countries. Generally the respondents of present study had low level of knowledge of breast cancer. Properly designed awareness campaign on television and in educational institutions can be effective to raise the knowledge level, the best long term strategy for this purpose.
Knowledge and Preventive Practices of Pakistani Women for Breast Cancer
Asian Pacific Journal of Cancer Prevention, Vol 12, 2011 2419
Knowledge, Attitude and Preventive Practices of Women
for Breast cancer in the Educational Institutions of Lahore,
Samina Khokher1*, Warda Qureshi2, Saqib Mahmood3, Afaf Saleem4, Sumbal
advanced stage disease presentation and low survival rates have been reported from Pakistan. Lack of
awareness and screening facilities along with poor socioeconomic status are the main causes. A survey based
upon multiple choice questionnaires was conducted during an awareness campaign in women educational
institutions of Lahore, to assess the baseline knowledge, attitude towards breast self examination (BSE),
clinical breast examination (CBE) and source of information used by them. 1155 filled questionnaires were
analyzed by SPSS version 12. Majority (83.7%) of the respondents were <30 years old, 60% had >10 and
31.5% had >14 years of education. Only 27% had “good” while 14% had “poor” and 59% had “fair”
knowledge scores about breast cancer. Television was the most commonly cited source of information but
was associated with lower knowledge score. The knowledge scores and practice of BSE had a positive
association with education level. The respondents had better knowledge of life time risk and association
of early diagnosis with better chances of cure, but worse knowledge of risk factors as compared to women
in educational institutions of other countries. Generally the respondents of present study had low level
of knowledge of breast cancer. Properly designed awareness campaign on television and in educational
institutions can be effective to raise the knowledge level, the best long term strategy for this purpose.
Key words: Breast cancer - knowledge - preventive practices - educational institutions - Lahore, Pakistan
Breast cancer incidence rates, pattern of presentation and survival rates vary worldwide. High incidence,
1Surgical Division, INMOL, 2Department of Microbiology and Molecular Genetics, University of the Punjab, 3Department
of Human Genetics and Molecular Biology, University of Health Sciences, 4Central Park Medical College, 5Research and
Development Division, INMOL, Lahore, Pakistan *For correspondence: email@example.com
Asian Pacific J Cancer Prev, 12, 2419- 2424
second major cause of deaths due to cancer in the
women worldwide. 519,000 women died in 2004 due to
Breast Cancer and 69% of these deaths occurred in the
developing countries (WHO 2008a).The incidence as
well as the survival rates vary worldwide with marked
geographical variations. The age standardized rate is
the highest at 99.4 per 100,000 in North America, while
lower rates have been reported from African and Asian
countries. Lowest reported is from central Africa where
it is 16.5 per 100,000. Breast cancer survival rates on
the other hand range from over 80% in North America,
Sweden and Japan to around 60% in the middle income
countries, to below 40% in the low income countries
(Coleman et al., 2008).The low survival rates in these
regions are explained by the lack of awareness and lack
of screening-program resulting in a high proportion of
Breast cancer is the most frequent cancer and the
women presenting with late stage disease and the lack
of adequate facilities for their diagnosis and treatment
Pakistan is a developing country with limited
resources. It has the highest incidence of breast cancer
among the Asian countries, the ASR being 69.1 per
100,000 averaged over the years 1998-2002 (Bhurgri et
al., 2006). It is also the commonest cause of cancer related
deaths in females and typically breast cancer in this
region is characterized by aggressive disease affecting
younger age women with late stage presentations (Malik,
2002; Naeem et al., 2008; Khokher et al., 2010). Fifty
to seventy percent of the breast cancer patients present
when the disease is at an advanced stage (Ghumro et
al., 2002; Gilani et al., 2003; Aziz et al., 2008). Lack of
awareness in addition to low socioeconomic status and
poor access to health care facilities are reported as the
major causes of this picture (Aziz et al., 2004). Negative
socio-cultural perception about breast cancer and strong
Asian Pacific Journal of Cancer Prevention, Vol 12, 2011
Samina Khokher et al
belief in traditional medicine has also been reported as
the reason for delay in presentation in the developing
countries (Odusanya and Tayo, 2001). The data suggests
that factors related to women’s knowledge and belief
about breast cancer and its management contributes
significantly to the medical help seeking behavior. In the
developing countries with limited health resources and
lack of organized screening programs women need to be
“breast aware” (Okobia et al., 2006) to seek medical help
early in the course of disease. Awareness and knowledge
about breast cancer as well as the attitudes and practices
of women however vary among communities and
The Breast Health Global Initiative (BHGI) was
developed in 2006 which proposed breast cancer
awareness and breast self examination (BSE) as a means
of early diagnosis in countries with limited resources
(Anderson et al., 2006).This resulted in many breast
cancer awareness talks and activities in the developing
countries including Pakistan. A series of lectures were
delivered in this context, in the women educational
institutions of Lahore, Pakistan, during 2009. The
present study was conducted during this awareness
campaign to assess the baseline knowledge of breast
cancer, the attitude and practice of BSE and clinical
breast examination (CBE) and to examine these variables
in relation to the socio-demographic characteristics, so
that women groups lacking breast cancer awareness
are identified. The survey also intended to identify the
source of information used by these women and thus the
most suitable medium for future activities to raise their
Materials and Methods
local language Urdu consisting of 13 questions. Each
question had a statement as stem followed by multiple
answer options to be tick marked by the participant. First
three questions were related to the socio-demographic
profile of the participant followed by one question
each on participants own perception of her knowledge
level and of mammography, source of her information
and whether she has ever had BSE or CBE. Last five
questions were formatted to assess their knowledge
about basic breast cancer facts. These include, a question
whether mammography is harmful, a question regarding
knowledge of life time risk of breast cancer, a question
related to the symptoms of breast cancer, a question
related to the most important risk factor for developing
breast cancer and the last question asked whether breast
cancer is curable when diagnosed early versus at any
The activity was arranged in lecture halls of five
women educational institutions of Lahore ; Lahore
College for Women University, Samanabad College
for Girls, Kinnaird College University, Ayesha Model
Degree College and Home Economics College Lahore,
A multiple choice questionnaire was designed in
and at Punjab University at different times from February
2009 to December 2009. The students, faculty members
and the non faculty female employees of the respective
educational institutes participate in the lectures. The
questionnaires were distributed to the participating
audience during the preparatory session of the lecture
and collected back during the introductory session of the
lecture. Informed consent of the participants was taken to
be included in the study. Confidentiality was maintained
by keeping the questionnaires anonymous and not having
any names or identification tags.
Data were entered and analyzed on SPSS Version 12.
The five test questions for assessing the knowledge of the
respondent were marked as a score of 1 for each correct
answer and zero for each incorrect answer. Score of <1
was graded as poor, 2-3 as fair and >4 as good.
917/1,155 (79.3%) participants filled the complete
questionnaire and answered all the questions. Majority
of the respondents were below 30 years of age (83.7%),
with education between 10-14 years (59.7%) and
majority of them (59.7%) were students. Among them
64% considered themselves knowledgeable about breast
cancer while 34.4% had self perception of being deficient
on the subject. Television and hearsay were the most
common sources of information. Majority (60%) of the
respondents had not heard about mammography before.
Majority of the older participants (>31 years) practiced
BSE (56.9) compared with a minority (30.8%) of the
young (<30 years). The highest frequency of BSE (57%)
was found among the professional women on job and in
the most educated women group (46.9%) having >14
years of education. Majority of the women had never
undergone CBE among the older age group (59.3%) as
well as the young (90.6%).
Figure 1 shows the frequency of correct answers of
the five questions related to the knowledge of breast
cancer. Table 1 shows the relationship of the knowledge
scores with their socio-demographic features. Although
television was the source of information in majority of
the participants but only 17% of those citing television
as the source of their information had good knowledge
A total of 1,155 questionnaires were analyzed.
Figure 1. Frequency of Correct Answers (blue
correct, red incorrect)
Knowledge and Preventive Practices of Pakistani Women for Breast Cancer
Asian Pacific Journal of Cancer Prevention, Vol 12, 2011 2421
about this disease (Table 2) this in relation to the sources
of information used by them. As a whole, on a three
point scale the breast cancer related knowledge of the
participants was “Poor” in 14%, “Fair” in 59% and
“Good” in 27% of the respondents.
Data regarding knowledge, attitude and preventive
practices for breast cancer in Pakistan is limited.
There are some reports of these practices in the health
care professionals (Pervez et al., 2001; Ahmed et al.,
2006; Kumar et al., 2009) and other social strata of
women (Jaffary et al., 2005). They reveal low level of
awareness and practice of screening methods among
the local women. To the authors knowledge there is
no such report of a study done in the local educational
institutions. Similar studies however have been reported
from educational institutions of New England (Burak and
Boone, 2008) Yemen (Ahmed, 2010), Malaysia (Hadi et
al., 2010) and India (Yadav and Jaroli, 2010).
During the last few decades breast cancer has
attracted a large amount of attention and media coverage
all over the world. Many types of awareness activities
and presentations have been made in the print media
as well as television and radio broadcasts in Pakistan
as well. Having exposed to these activities, 64% of
the respondents of the present study thought them to
be knowledgeable but only 31% of them had good
knowledge score. Among the respondents having
perception of not being knowledgeable 19.5% had a good
knowledge score. The majority of both groups (60% vs
58%) had barely fair knowledge score. This reflects the
inadequacy and ineffectiveness of the awareness activity
to which the local women have been exposed to so far.
The important sources of breast cancer awareness
and knowledge for the women in Pakistan are television,
print and electronic media, education and interaction with
health care professionals. Awareness campaigns using
leaflets and print media have not been found effective,
as either they are not being read by the target population
or they are not being interpreted properly (Murphy and
Smith, 1993). Television and radio broadcasts on the
other hand have been found to be more effective media
for health education (Grunfield et al., 2002). Television
and radio broadcasts for awareness activities, suit the
women population of Pakistan very well because of easy
access and non reliance on literacy. A study from the
neighbor country India reports television to be the most
common medium through which women heard about
breast cancer (Somdatta and Baridalyne, 2008). The
same was the case with Yemen university students, 82%
of whom stated mass media (Television or radio) as their
source of information. In the present study television was
the most commonly cited (29.4%) source of information
among the respondents. However this group of women
had lowest (17%) good knowledge score. It can therefore
be an effective media for awareness campaign with
regard to access but the quality and content of these
awareness talks needs to be improved and should be in
the easy native language that is understood by females
of all socioeconomic and literacy groups.
Concerns have been raised regarding misleading
presentations in the popular magazines regarding breast
cancer (Burke et al., 2001) and of using them primarily
Table 2. Socio-demographic Features and Source of
Information in Relation to the Knowledge Scores
Feature Poor Fair Good Total
< 10 years
> 14 years
Not Answered 12 38%
Not Answered 3
Source of Information
Not Answered 9 20%
< 20 years
Not Answered 4 25%
335 58% 172 30%
229 58% 105 27%
412 60% 185 27%
213 59% 111 30%
410 59% 191 28%
467% 15 33%
Table 1. The Practice of BSE and CBE in the Various Socio-demographic Groups
Respondents Features BSE
Age groups Young (<30) 298 31%
Old (>31) 98 57%
Education groups ≤ 10yrs 20 29%
10 -14 yrs 206 29%
≥ 14 yrs 171 47%
Profession Job 146 57%
House wife 68 42%
Student 170 25%
NA, not answered
9% 877 91%
Asian Pacific Journal of Cancer Prevention, Vol 12, 2011
Samina Khokher et al
for commercial gains (2006). The same applies to the
other media used for awareness activities. The activities
on television need to be properly designed for the local
target population and address the social taboos and myths
rampant in the society.
The next commonly cited source of information,
“hearsay” (information from person to person) is a
reflection of the local culture and taboos. Culturally
women are reluctant to consult male health care
professionals for problems related to breast (Hussain
and Ansari, 1996). Many of them rely on inter personal
exchange of experiences and knowledge rather than
medical advice. Only 27% of these women secured good
Although only 13% of the respondents cited
education as their source of information but these
respondents showed the highest good knowledge score
(36.4%) in the women population of this study. This
demonstrates a positive association between the years
of education and the knowledge of breast cancer. From
this it is inferred that without education, the local women
lack knowledge and become more vulnerable to hearsay
wisdom or traditional medicines. The positive association
of education level and employment status with the breast
cancer knowledge found here is in conformity with the
previous reports (Alsaif, 2004; Jaffary et al., 2005; Parsa
and Kandiah, 2005; Okobia et al., 2006; Somdatta and
Baridalyne, 2008; Bouton et al., 2010).
The role of BSE in detecting breast cancer at an early
stage is controversial (Hackshaw and Paul, 2003; Knutson
and Steiner, 2007). The American cancer society does not
recommend it for screening as it increases anxiety and
does not improve survival (Larkin, 2001), however in
the low resource countries with no mammography based
screening program, BSE is recommended because it
makes the women “Breast aware” (Okobia et al., 2006).
The frequency of BSE ranged from 25% to 57% in the
present study showing positive association with age
(57% Vs 41%) and employment (57% Vs 42%). The
highest frequency of BSE in the women groups of our
study (57%) was lower than that reported in a report from
Malaysia where 62% of women practiced BSE (Rahman,
2003). It is also less than the 62% frequency reported for
the student nurses in Saudi Arabia (Alsaif, 2004),66%
for nurses in Pakistan (Kumar et al 2009) and the 94%
reported for the nurses in Singapore (Chong et al., 2002).
However this frequency is higher than the 23% found in
the women of Zahedan, Iran (Heidari et al., 2008) and the
24.4% reported for the university students of Malaysia
(Hadi et al 2010) and the 41% reported for the college
women of New England (Burak and Boone, 2008).
The practice of BSE also had a positive association
with the years of education of the respondents in the
present study; 28% of those with less than 10 years of
education, 29% with 10 to 14 years of education and
47% with more than 14 years of education practiced
BSE. Education therefore is associated with a positive
change in the attitude and helps making the women
breast aware. In a similar study carried out in the health
care professionals (Kumar et al., 2009), medical students
were found to be more knowledgeable than the nurses
and others. It is unfortunate that literacy rate of women
in Pakistan is only 31.5% as compared to 60.6% in the
men of Pakistan (Wikipedia, 2011). Measures to increase
the literacy rate of local women population appears to be
the best long term as well as the most effective measure
to increase the level of awareness and to bring a positive
change in the attitude of local women. Majority of the
local women however have access to television and
mass media campaigns have been shown to produce
positive changes in the health related behavior across
large populations (Wakefield et al., 2010).Therefore as
a short term measure we can increase as well as improve
the awareness activities on this medium.
CBE is recommended once every three years in girls
>20 years of age and once every year in women >40
years of age by the American Cancer Society (Smith et
al., 2004). It is being explored as a promising approach
in a large trial in India (Mittra et al., 2010). CBE had
a positive association with the age (39% in the old
compared to 9% in the young) in our study, but no specific
association with the years of education was found and
only a minority of women had ever had CBE. However
the frequency of CBE in the older age group was found
to be more than previously reported (6.9%) by a study
conducted in the women coming to a hospital in Lahore,
Pakistan (Maqsood et al., 2009). The frequency of CBE
in the younger women of the present study was also
more than the 4% reported in the women of Zahedan,
Iran (Heidari et al., 2008).
Advances in the radiologic imaging have made the
diagnosis of breast cancer possible at preclinical and
asymptomatic stage. Many countries in the developed
world have organized screening mammography programs
(Lam, 2004) resulting in diagnosis of breast cancer at very
early stage, when it is only a few mm in size. Adopting
mammography screening guidelines designed for the
developed countries are not beneficial in the developing
countries because of younger age of patients as well
as limited resource availability (Ibrahim et al., 2009).
Limited facility of mammography for opportunistic
screening and diagnostic workup is available in the
hospitals at Lahore. Recently mammography is also
being talked about in the breast cancer awareness
activities. In the present study 60% of the respondents
had no clue about mammography compared with 71%
of the urban women in India (Garg et al., 2009) and 24%
thought that mammography is harmful compared to 14%
of the Turkish women (Akan et al., 2008).
Family history was correctly identified as a risk factor
by 29% of respondents in our study compared with 39%
of the urban Indian women (Garg et al., 2009) , 47% of
Turkish women (Akan et al., 2008) ,91.5% of Malaysian
university students and 93% of college women in New
England (Burak and Boone, 2008).Women’s life time
risk of developing breast cancer was correctly answered
Knowledge and Preventive Practices of Pakistani Women for Breast Cancer
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from “Poor” to “Good” knowledge. On a five point
scale Malaysian university students had 10.8%, 20.4%,
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“Very good”. Considering the extreme groups together
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women in educational institutions of Lahore, Pakistan
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In conclusion, women in educational institutions
of Lahore, Pakistan have low level of breast cancer
awareness but it is higher than the college/university
students of other developing countries. The knowledge
level of these women has a positive association with
their years of education. There is a need to raise their
awareness level for which campaign through television
can be the most effective short term measure. Raising the
literacy rate and education level of local women however
remains the best long term strategy.
The lectures were arranged by INMOL, a cancer
hospital of PAEC, in collaboration with Pink Ribbon,
National Breast Cancer Awareness Campaign, at Lahore
College for Women University, Kinnaird College
University and Home Economics College Lahore. The
lectures at Samanabad College for Girls and Punjab
University were arranged by INMOL in collaboration
with Sanofi Aventis Pharmaceutical Company. The
activity at Ayesha Model Degree College was organized
by the principal author and college authorities. There
were no grants or financial benefits and authors declare
no competing interests.
Asian Pacific Journal of Cancer Prevention, Vol 12, 2011
Samina Khokher et al
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