Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53
ORIGINAL ARTICLE
KNOWLEDGE AND PRACTICE OF BREAST SELF-EXAMINATION AMONG
STUDENTS IN A PRIVATE HIGHER LEARNING INSTITUTION IN MALAYSIA
Amal R. Nimir1, Sami A. R. Al-Dubai2, Mustafa A. Alshagga3, Ahmed M. Saliem4
1
Division of Basic Medical Sciences, Faculty of Medicine, Cyberjaya University College of Medical Sciences, CyberjayaMalaysia
2
Department of Public Health, Faculty of Medicine, International Medical University, Kuala Lumpur-Malaysia
3
School of Biomedical Sciences, Faculty of Science, University of Nottingham Malaysia Campus, Jalan Borga, 43500,
Semenyih, Selangor, Malaysia
4
Department of Anatomy, Faculty of Medicine, Perdana University-Royal College of Surgeons in Ireland, Serdang-Malaysia
ABSTRACT
Breast cancer is one of the most frequently encountered malignancies among young females in Malaysia, which accounts
for 30.4% of newly diagnosed cancers. All women at or above the age of 20 are considered at risk of developing breast
cancer. This is a cross-sectional study. The study was conducted in a private medical university in Malaysia during year
2012. Two hundred students were recruited in this study using universal sampling. Data collection was done using a selfadministration questionnaire. Chi-square test was used to assess the association between the practice of breast selfexamination and socio-demographic variables. Only 19.5% of the study sample has sufficient knowledge about BSE which
is acquired mostly from local media. Having a family history of malignancy other than breast cancer seems to be the only
significant variable associated with knowledge about BSE (P=0.002). Other variables such as demographic data,
menstrual history and social history were also tested, but found to be not significant. Frequent community-based
awareness programs are needed so that all women can know and practice BSE, which in turn helps to alert the women to
any abnormal changes in the breasts so that they will be able to seek medical advice immediately.
INTRODUCTION
Despite an increased global effort to reduce the
incidence of breast cancer, it continues to be the
most common cancer and the second leading cause
of cancer deaths in women in the United States
(Miller and Baines, 2011). Breast cancer is the
most common form of cancer affecting women in
Malaysia. About one in 19 women in this country
are at risk, compared to one in eight in Europe and
the United States (MOS, 2012). It accounts for
30.4% of newly diagnosed cancer and it is the
commonest cancer of females of all ethnic groups.
According to the Malaysian Clinical Practice
Guidelines on management of breast cancer, all
women at or above the age of 20 are at risk of
having it and in favor of monthly Breast SelfExamination (BSE) (Kocic et al. 2011; Lee, 2003).
The primary factors that increase risk of breast
cancer in women include certain inherited genetic
mutations, a personal or family history of breast
cancer. Other factors that increase breast cancer
risks include a long menstrual history, obesity,
recent use of oral contraceptives, postmenopausal
hormone therapy, ethnicity characteristics, or
consumption of one or more alcoholic beverages
per day (Lee et al. 2004).
According
to
American
Cancer
Society
recommendations, women should know how their
breasts normally feel and report any breast
changes promptly to their health care providers.
The clinical examination and BSE have been
advocated for many years as screening modalities
for detection of the breast cancer (Peter et al.,
1978; Hadi et al., 2010). The basic steps in BSE of
the breasts are as follows. First, the women views
her breasts in front of a mirror, first with arms
down and then with arms elevated. Women should
know that irregularity of size of the breast is
common and normal. They should look for a new
abnormality in appearance such as asymmetry,
flattening or dimpling. Any new change in the
nipple, including ulceration is noted. Then, she
lies supine with a small pillow or folded towel
under the shoulder of the side to be examined.
The arm is raised above the head. After that, the
palpation is performed with the flat of the fingers
of opposite hand in a methodical fashion to include
the entire breast. The full procedure is then
repeated and applied for the other side (Louis,
1980). We conducted this study to analyse whether
associations
existed
between
demographic
variables, knowledge of breast cancer, and the
practice of breast self-examination.
Hypotheses
The study attempted to test following hypotheses
All the hypotheses were tested at 0.05 level of
significance.
Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53


There will be a significant difference
between knowledge of BSE and selected
demographical variables among degree
college female students.
There will be a significant association
between performing BSE and selected
demographical variables.
Assumption
The study assumed that:

The degree college female students will have
some knowledge on BSE.

Feel free to express their attitude toward
BSE.

BSE helps in early detection of breast
cancer.
MATERIALS AND METHODS
The design of the study is cross-sectional. The
study was conducted in the Management Science
University (MSU), which is a private university
located in Selangor-Malaysia. The study is done
within two months starting from January 2012 and
it was approved by the management of the
university as well as the Faculty of Medicine and
the Faculty of Health Life Sciences.
Universal sampling used for respondent selection
by which the total number of students recruited in
the study is 200. Hundred students are doing
Bachelor of Medicine and Bachelor of Surgery
(MBBS) course in the International Medical School
(IMS) and another 100 from Faculty Health Life
Sciences (FHLS) who are doing nursing program.
Only female students were involved in this study.
Data collection was conducted using self
administered questionnaires. The questionnaire
consists of three parts, demographic data,
knowledge about breast cancer and practice of
breast-self-examination. We use investigator
triangulation and consider the ideas and
explanation generated by additional researchers
studying the participant.
The use of investigators, method and data
triangulation to record the construction of reality
was used (Nahid, 2003). An open-ended
perspective used, allowed the participant in the
research to assist the researcher as well as with
the data collection. Engaging multiple methods,
such as observation, interviews, and recording lead
to more valid, reliable and diverse construction of
realities. Several researchers and peer researchers
interpret the data at different time and locations.
Analysis
We used SPSS (version 16) to analyse our data. Chisquare test was conducted to assess the
association between the practice of breast selfexamination and socio-demographic variables.
RESULTS
The total number of the students involved in this
study was 200, aged between 18-22 years. Table 1
shows the socio-demographic data, relevant
menstrual, family, and social histories in relation
to the knowledge about BSE. Having a family
history of malignancy other than breast cancer
seems to be the only significant variable
(p=0.002).
The majority of the study sample (86.5%) reported
that they had heard or read about breast cancer in
Malaysia. Newspaper was identified as the main
source of information about BSE by 38.2% of the
participants, whereas TV/Radio was mentioned as
the second source of information by 31.9% of them
(Table 2).
The χ2 computed to find the association between
knowledge about BSE and selected variables. We
selected few questions to identify those who have
good knowledge about BSE (Table 2). Those who
gave correct answers for all the following
questions are only 39 students (19.5%):
1.
Do you know Breast Self-Examination can be
the early detection of any abnormal changes
in your breast?
2.
At what age do you think should Breast SelfExamination started?
3.
How often a person should perform Breast
Self-Examination?
4.
How a Breast Self-Examination is done?
5.
Where do you usually perform Breast SelfExamination?
We followed a previous study done in 2003 to
identify the knowledge and practice of Breast Selfexamination
(Chee
et
al.,
2003).
Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53
Table 1: Significance of knowledge about breast self-examination in relation to socio-demographic data,
menstrual history, family history and social history
Socio - demographic
1.
2.
3.
4.
5.
6.
7.
8.
9.
Knowledgeable
(Total 39)
Not
Knowledgeable
(Total 161)
χ2
P
value
24 (20.5%)
15 (18.1%)
93 (79.5%)
68 (81.9%)
0.184
0.668
23 (18.0%)
4 (28.6%)
9 (23.1%)
3 (15.8%)
105 (82.0%)
10 (71.4%)
30 (76.9%)
16 (84.2%)
1.410
0.703
16 (16%)
23 (23%)
84 (84%)
77 (77%)
1.561
0.212
9 (23.7%)
9 (20.0%)
21 (17.9%)
29 (76.3%)
36 (80.0%)
96 (82.1%)
0.610
0.737
35 (20.6%)
4 (13.3%)
135 (79.4%)
26 (86.7%)
0.855
0.355
6 (22.2%)
33 (19.6%)
0
21 (77.8%)
135 (80.4%)
5 (100%)
1.341
0.511
1 (5.9%)
25 (16.4%)
13 (41.9%)
16 (94.1%)
127 (83.6%)
18 (58.1%)
12.851
0.002
1 (12.5%)
38 (19.8%)
7 (87.5%)
154 (80.2%)
0.260
0.610
9 (22.0%)
30 (19.7%)
0
32 (78.0%)
122 (80.3%)
7 (100%)
1.858
0.395
Age :
 Less and equal 22
 More than 22
Race :
 Malay
 Chinese
 Indian
 Others
Course :
 MBBS
 Nursing
Resident :
 Rural
 Sub – urban
 Urban
How old were you when you started
your period?
 Younger than 15 years
 15 or older
Do your family have history of
breast cancer?
 Yes
 No
 I don’t know
Do your family have other cancer
such as ovarian or prostate cancer?
 Yes
 No
 I don’t know
Do you smoke?
 Yes
 No
Do you exercise?
 Regularly
 Not regularly
 No
Students who answered 2-3 of the above questions
are considered moderately knowledgeable (70.7%)
and those who answered only one or none have
poor knowledge (9.8%).
Although 95.5% of the participants reported having
some knowledge about BSE, only 79.5% of them
indicated having ever practiced BSE. Table 3 shows
no significant association between doing BSE and
selected variables. Hence the null hypotheses
were accepted and research hypotheses were
rejected.
Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53
Table 2: Knowledge about breast self-examination
NO
1.
2.
3.
4.
5.
6.
7.
8.
VARIABLES
Do you know breast cancer is one of
the commonest cancer afflicting
Malaysian women from age 20 yrs
Have you ever heard of Breast SelfExamination?
VALID
NO.
(%)
YES
173
86.5
NO
16
8
I DONT KNOW
11
5.5
YES
191
95.5
NO
9
4.5
How do you hear about it?
(a)
Home
YES
52out of 191
27.3
(b)
TV / Radio
YES
61 out of 191
31.9
(c)
Newspaper
YES
73 out of 191
38.2
(d)
Peer Group
YES
5 out of 191
2.6
Do you know Breast Self-Examination
can be the early detection of any
abnormal changes in your breast?
At what age do you think should
Breast Self-examination started?
How often a person should perform
Breast Self-Examination?
How a Breast Self-Examination is
done?
Where do you perform Breast SelfExamination?
DISCUSSION
Many literatures support the argument that regular
practice of BSE influences treatment, prognosis
and survival rates of breast malignancy (Facione et
al., 2000; EA et al., 2002; Chee et al., 2003). A
very high percentage (95.5%) reported that they
YES
191
95.5%
NO
9
4.5%
< 19 years old
85
42.5%
>19 years old
115
57.5
Daily
21
10.5
Weekly
45
22.5
Monthly
39
19.5
Yearly
95
47.5
Palpate with one finger
4
2
Palpate with palm and
minimum 3 finger
I don’t know
71
35.5
125
62.5
In front of the mirror
Lying on bed
In bathroom
110
15
34
69.2
9.4
21.4
have read or heard about BSE which is much higher
compared
to
Sudanese
medical
students
(Abderahaman & Yousif 2006). In spite of being
aware about BSE, only 19.5% has sufficient
knowledge which considered low compared to a
study done among Singaporean nurses (Chong et
al., 2002).
Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53
Table 3: Significance of doing and not-doing breast self-examination in relation to socio-demographic data,
menstrual history, family history and social history
Socio-demographic
1 Age :
.
 Less and equal 22
 More than 22
2 Race :
.
 Malay
 Chinese
 Indian
 Others
3 Course :
.
 MBBS
 Nursing
4 Resident :
.
 Rural
 Sub – urban
 Urban
5 How old were you when you started your
. period?
 Younger than 15 years
 15 or older
6 Do your family have history of breast
. cancer?
 Yes
 No
 I don’t know
7 Do you have a family member who has
. other cancer such as ovarian or prostate
cancer?
 Yes
 No
 I don’t know
8 Do you smoke?
.
 Yes
 No
9 Do you exercise?
.
 Regularly
 Not regularly
 No
Have you done Breast SelfExamination before?
YES (Total 159)
NO (Total
41)
χ2
P value
0.130
0.718
4.746
0.191
92 (78.6%)
67 (80.7%)
25 (21.4%)
16 (19.3%)
105 (82%)
10 (71.4%)
27 (69.2%)
17 (89.5%)
23 (18%)
4 (28.6%)
12 (30.8%)
2 (10.5%)
79 (79.0%)
80 (80.0%)
21 (21.0%)
20 (20.0%)
0.031
0.861
28 (73.7%)
36 (80.0%)
95 (81.2%)
10 (26.3%)
9 (20.0%)
22 (18.8%)
1.002
0.606
135 (79.4%)
24 (80.0%)
35 (20.6%)
6 (20.0%)
0.005
0.941
21 (77.8%)
136 (81.0%)
2 (40.0%)
6 (22.2%)
32 (19.0%)
3 (60.0%)
5.053
0.080
15 (88.2%)
121 (79.6%)
23 (74.2%)
2 (11.8%)
31 (20.4%)
8 (25.8%)
1.333
0.514
7 (87.5%)
152 (79.2%)
1 (12.5%)
40 (20.8%)
0.327
0.567
32 (78.0%)
122 (80.3%)
5 (71.4%)
9 (22.0%)
30 (19.7%)
2 (28.6%)
0.387
0.824
The main source of information about BSE is found
to be from newspaper. This finding indicates the
advocacy of newspapers followed by TV/Radio.
This finding is in consistent with other studies done
in Malaysia and Turkey (Sami et al., 2012;
Muhyittin et al., 2008).
Correct BSE is only practiced by the knowledgeable
students (19.5%). In contrast, some studies found
that majority of older women performed BSE on
regular manner (Smiley et al., 2000; Chong et al.,
2002). The results of our study is still higher that
done among South Asian women living in UK where
only 12% of the study sample perform BSE on
monthly regular manner (Choudhry et al., 1998).
A survey conducted among nurses and midwives in
Turkey found no significant relation between
sociodemographic factor and BSE practice. A study
conducted in Chennai supported this study as no
significant association found between demographic
variables and level of knowledge of breast cancer
and BSE practice among working women (Aruna,
2010). On the other hand, some other studies
revealed that there is a statistically significant
Malaysian Journal of Public Health Medicine 2014, Vol. 14 (3): 47-53
association between some demographic variables
(marital status, educational status and family
history of breast cancer) and knowledge and
practice of BSE (Parisa et al., 2005; Alam, 2006;
Muhyittin et al., 2008). Family history of breast
cancer is the persistent association in the above
mentioned studies while having family history of
malignancy other than breast cancer is the only
associated variable in ours.
working women in Chennai. Prism's Nurs
Pract.2010; 5:34–6.
4.
5.
Mammography stays as the most sensitive available
means for early detection of breast cancer, but
both clinical breast examination (CBE) and breast
self-examination (BSE) have the potential to
advance the diagnosis of breast cancer without the
expense of a mammography facility (EA et al.,
2002; Chee et al., 2003). Most studies have found
that breast cancer detected by BSE are smaller
than those detected without screening and are
more likely to be confined to the breast.
Furthermore, survival after a diagnosis of breast
cancer tends to be longer among women who
practice BSE than among women who do not.
However, neither observational nor randomized
studies of BSE provide evidence that this screening
modality reduces breast cancer mortality. A recent
randomized study in Shanghai, China, found that
women assigned to extensive BSE instruction and
women assigned to another health intervention
had similar distributions of cancer size and stage
at diagnosis and similar breast cancer mortality
rates (Weiss, 2003).
CONCLUSION
Though it has limitations such as small number of
students involved and incomplete questionnaire;
however this study revealed an imbalance between
the knowledge and practice of BSE among
students. Hence, frequent community-based
awareness programs are needed so that all women
can know and practice BSE, which in turn helps to
alert to any abnormal changes in the breasts and
provoke to seek medical advice immediately.
6.
Choudhry, U.K., Srivastava, R. & Fitch, M.I.
Breast cancer detection practice of South
Asia women: knowledge, attitude and
beliefs. Oncol. Nurs Forum 1998; 25: 16931701.
7.
Facione, N.C., Giancarlo, C. & Chan, L.
Perceived risk and help seeking behavior for
breast cancer. Cancer Nursing 2000; 23:256–
264.
8.
Greenwald,
P., Nasca,
P.C., Lawrence,
C.E., Horton, J., McGarrah, R.P., Gabriele,
T. & Carlton, K. Estimated Effect of Breast
Self-Examination and Routine Physician
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Engl J Med 1978; 299:271-273.
9.
Grunfeld, E.A., Ramirez, A.J., Hunter, M.S.
& Richards, M.A. Women’s knowledge and
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Hadi, M.A., Hassali, M.A., Shafie, A.A. &
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Hisham, A.N. & Yip, C.H. Spectrum of breast
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Kocic, B., Filipovic, S., Vrbic, V. & Pejcic, I.
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