Background

Breast cancer is the most prevalent cancer in women and generally the second most common cancer globally, with approximately 1.4 million cases diagnosed annually [1]. In 2018, 2.1 million incident cases of breast cancer were diagnosed worldwide (second most common cancer overall after lung cancer) representing nearly 12% of all incident cancer cases and an estimated 627,000 deaths were expected to occur globally [2, 3]. Generally, the breast cancer rate is higher in the developed world than the developing countries, which may be as a result of certain lifestyles and reproductive factors that are more common in the developed world. The difference may be exaggerated due to relatively low awareness, screening practices, and diagnoses in the developing countries, though the rates are increasing rapidly in many developing countries [4].

In Ghana, breast cancer is becoming a great public health challenge among women. With about 2,900 incident cases occurring annually, and one-eighth of them dying from it, the disease has become the most common cancer-related death among Ghanaian women [5, 6]. Previous studies have revealed an increased breast cancer burden in Ghana over the past decade. Clegg-Lamptey et al. [7] reported in 2009 that breast cancer now accounts for about 16% of all cancers and the most common cancer female cancer in Ghana. Naku et al. [8] estimated the incidence of breast cancer to be 76 per 100 000 Ghanaian women.

It is anticipated that the incidence of breast cancer will increase as Ghana’s population ages and women adopt western lifestyles [9]. Studies have shown that breast cancer is increasingly becoming common among younger Ghanaian women, and they present at a more advanced stage of the disease [5, 7, 10]. The advance stage at diagnosis is due to patients’ delay in seeking healthcare, which can be up to 10 months after the onset of symptoms, as a result of lack of awareness of the disease at its early stage and stigma associated with the disease [8, 11, 12].

Like most cancers, the primary risk factor for breast cancer in women is older age. Many other risk factors alter the exposure of breast tissues to reproductive hormones [4]. Some of these are modifiable, and include weight gain or being overweight/obese, long term use of the postmenopausal hormone, alcohol consumption, and physical inactivity [4, 13]. Long menstrual history (younger age at menstruation and/or end later age at onset of menopause), never given birth, having one’s first child after age 30, and current use of hormonal contraceptives are other reproductive factors that influence the risk of breast cancer [11, 12]. Personal medical or family history of breast cancer are also known to increase one’s risk for breast cancer [4].

Early diagnosis of breast cancer can increase the chance of early case detection and favourable outcomes, resulting in improved survival rates and quality of life of women and is therefore important public health strategy at all settings [2]. However, studies have demonstrated that factors related to women´s awareness, knowledge and perceptions about the disease may contribute significantly to health-seeking behaviours [14, 15].

Notwithstanding that mammography is known to be the most effective screening tool for early detection of breast cancer [16], Breast-Self Examination (BSE) may be useful in resource-limited countries to detect any abnormalities in the breast as it provides an opportunity for women to be familiar with their breasts and promptly report any changes [17]. Additionally, clinical encounters by women provide the opportunity for women to have a number of important clinical activities such as breast cancer risk assessment, education about lifestyle, counselling, and clinical breast examination (CBE) that may not otherwise be done [17]. There are no current national breast cancer screening protocols in Ghana or countrywide literacy initiatives, and there is limited availability of mammography or ultrasound machines [5]. Although the effectiveness of BSE and CBE in detecting breast cancer is debatable [16], they have been campaigned as major screening tools given their availability at little to no cost among limited-resource settings in most developing countries.

Women who practice regular breast screening have been known to have a lower risk of developing an advanced form of breast cancer than those who do not. Reports have shown low uptake of breast cancer screening among women in many sub-Saharan African countries and this results in late detection and increased mortality in affected women [18].

Even though the incidence and mortality of breast cancer have been on the increase, there is a paucity of the empirical literature on student’s awareness, risk factors and screening practices in Ghana. This population is especially important because they have abundant access to health information as health students and they are potential sources of information for non-health students and the general population. College students have a significant influence on colleague students and also, findings regarding this target group have implications for their capacity in the role of promoting screening for breast cancer as potential health professionals. This study, therefore, explored breast cancer awareness, selected risk factors, and screening practices among female undergraduate students, to provide information for the control, prevention, and early treatment of the disease.

Materials and methods

Data collection tools and procedure

A structured pre-tested questionnaire was used to collect data from participants. The questionnaire contained closed-ended questions adapted from previously published studies that adapted validated questions and had the following sections: demographic information, breast screening practices, risk factors of breast cancer (Behavioural, reproductive, and hormonal factors), and awareness of breast cancer.

Consenting participants were handed printed copies of the questionnaire and were given 24 hours to fill their responses and return them anonymously to the researchers. The objectives of the study were explained to all participants before the questionnaires were given out. Filled questionnaires were checked daily by the researchers for consistency and omissions before collection. Where there were inconsistencies, participants were made to correct them in the presence of the researchers before they were taken.

Definition of variables.

Table 1 presents the definitions of some of the study variables measured in this study.

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Table 1. Definitions of key study variables used.

https://doi.org/10.1371/journal.pone.0253373.t001

Results

General characteristics of respondents

All 385 participants returned their completed questionnaire. The mean age of the study population was 22 ± 2.78. The majority (55.8%) were between 20 and 24 years old, while 1.3% were 30 years and above; 16.4% were currently married and 83.1% were single; 74.0% were Christians and 18.9% were Muslims. Regarding ethnicity, Akans were the majority (38.4%), followed by Ewes (30.9%), while 14.3% belonged to the Ga-Dangbe ethnic group. Respondents constituting 26.2% (n = 101) were in their first year of study, 21.8% were in the second year, 30.2% in the third year and 21.8% were fourth-year students. The comparative majority (52.5%) were studying Nursing and midwifery, 22.3% were Medical students, and 19.7% were Allied Health Sciences students (Table 2).

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Table 2. General characteristics of respondents.

https://doi.org/10.1371/journal.pone.0253373.t002

Breast cancer awareness and risk perception

Regarding breast cancer awareness, 281 (73.0%) of the respondents reported having ever heard of breast cancer. The remaining items in Table 2 were asked of the 281 women who had heard of breast cancer. The social media remained the most important source of information on breast cancer (181;64.4%), followed by teachers (173; 62%) and the electronic media (172; 61%). As presented in Table 2, the majority (200; 71.1%) of respondents were aware of mammography as a screening method for breast cancer; 196 (69.8%) were aware of BSE; while 28 (10.0%) of them did not know of any the screening methods. Family history of breast cancer (n = 236, 83.9%), genetics (n = 229, 81.7%) female sex (n = 173, 71.9%) and individual lifestyle (n = 176, 62.6%) were the most frequently indexed risk factors for breast cancer. Meanwhile, nulliparity (n = 100, 35.6%), early menses/menopause (n = 116,41.3%), and Obesity (n = 159, 56.6%) were the least known risk factors. Putting money in the brassiere was implicated as a potential risk factor for breast cancer by more than a third (n = 106, 37.7%) of study participants. The most common presentation of breast cancer aware of was a lump in the breast (n = 259, 92.2%), followed by nipple discharge (n = 219, 77.9%), and lymph node in the armpit (n = 191, 68%) while pulling off a nipple (n = 47, 16.7%), nipple itch (n = 55, 19.6), and swollen nipple (n = 97, 34.5) were the least known sign/symptom of breast cancer.

Among students who were aware of breast cancer, 129 (45.9%) thought that they do not have the chance of getting breast cancer, while 46 (16.4%) did not know whether they were at risk or not (Table 3).

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Table 3. Breast cancer awareness and risk perception.

https://doi.org/10.1371/journal.pone.0253373.t003

Breast cancer risk factors

Among the 385 study participants, menarche occurred below age 12 in 48 (12.5%) of them, while 72 (18.7%) were more than 14 years at menarche. The prevalence of current oral pill/injectable contraceptive use was 13.2% (n = 51). The occurrence of breast cancer in the family was confirmed in 55 (14.3%) of the respondents; 14 (4%) had their first-degree relatives (Mother, Sister) affected with the disease, while 41 (11%) were second-degree relatives. Four (1%) of the students had a personal history of breast cancer. Regarding behavioural factors, 39 (10.1%) did not engage in physical activity and 77 (20%) currently use at least one standard of alcohol per day (Table 4).

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Table 4. Selected breast cancer risk factors.

https://doi.org/10.1371/journal.pone.0253373.t004

Breast cancer screening practices

Of the 385 participants, 212 (55.1%) ever applied at least one breast cancer screening method. Of these, 164 (42.6%) practised BSE, 39(10.2%) had undergone CBE, and 9 (2.3%) were screened for breast cancer via mammography. Of those who performed BSE, 136 (82.9%) did it at least once in every month; 6 (3.7%) examine their breast yearly, and 22 (13.4%) did it at random; 115 (70.1%) of them learned BSE skills from their school-teachers, 112 (68.3%) from the media, 37 (22.6%) were taught by their friends, and 26 (15.9%) learned it from their mothers. The most common (28.1%) reason for not practising BSE was “1 do not know how to perform it” followed by “I have no family history of breast cancer” (23.1%) and “I am not at risk of breast cancer” (17.2%), while 63 (28.5%) had no reason for not doing BSE (Table 5).

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Table 5. Breast cancer screening practices.

https://doi.org/10.1371/journal.pone.0253373.t005

Predictors of breast self-examination

Table 6 shows the results of bivariable and multivariable logistic regression analyses aimed at identifying variables associated with the odds of performing regular BSE. After adjusting for confounding effect of the variables, women who were between 25 and 29 years old were 5.13 (95%CI: 1.18–22.26; P = 0.03) times more likely to perform regular BSE compared to those less than 20 years. Further, women with no religious affiliation had 60% less odds of performing regular BSE compared to Christians. Women who expressed optimism regarding breast cancer risk (AOR: 0.04; 95%CI: 0.02–0.09; p<0.001) and those who did not know their risk level (AOR: 0.02; 95%CI: 0.005–0.57; p<0.001) were less likely to perform regular BSE compared to those who were pessimistic about breast cancer risk.

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Table 6. Logistic regression analysis of predictors of regular breast self-examination for breast cancer.

https://doi.org/10.1371/journal.pone.0253373.t006

Discussion

This study though has demonstrated considerable awareness about the existence of breast cancer, insufficient knowledge, and misconceptions regarding its risk factors and causes and disease presentation also existed among participants. Less than three-quarters of our study participants had heard about breast cancer. This is unexpectedly far lower than the 100% observed in medical students in Harar, Ethiopia [23], 98.7% among University of Ibadan female students [24], 95% previously reported among female students of Faculty of Health and Medical Sciences in Ghana [25], and 88.1% among Teacher Training college students in Cameroon [26]. The difference in the awareness rate found in this study and that of the aforementioned studies cannot directly be explained. However, breast cancer has been adopted in the curriculum of the first two aforementioned studies in an attempt to create awareness among students and might have had a positive impact on the students’ awareness about the disease. Ours finding further show unsatisfactory levels of awareness and understanding of breast cancer risk factors and disease presentation. More than one-third of participants were not recognised increasing age, nulliparity, obesity, and early menstruation and late menopause as potential risk factors for breast cancer, while 5% did not know any risk factor for breast cancer. This finding confirms reports from previous studies in Ethiopia [27], Nigeria [28], Egypt [29], and Angola [30] where general knowledge and risk factors of breast cancer were found to be low among female college students. Knowledge gaps have also been identified among the general population elsewhere [31, 32]. About one-third of our respondents held the belief that putting money in the brassiere can result in breast cancer. This is in line with other studies among women in the general population [33, 34] as well as university students [24] that suggest that women still have misperceptions about the cause of breast cancer with some attributing it to the spiritual origins. Additionally, as reported by previous studies elsewhere, [23, 26] awareness of other clinical manifestations of breast cancer other than breast lump was worryingly low. These existing knowledge gaps and misconceptions may impact health-seeking behaviours and uptake of breast screening resulting in late diagnosis which in turn may lead to complications and death. Thus, the need for health education programmes aiming to increase awareness about the causes, risk factors and clinical presentation of breast cancer is warranted.

Predictors of breast cancer risk are varied, including individual lifestyle, reproductive status, and genetics. This study attempted to identify some of these risk factors among the students. First menstruation at an early age (early menarche) is known to be associated with increased levels of endogenous hormones (estrogen and progesterone) in a woman’s lifetime which increases the risk of breast cancer [17]. In this study, about 13% of participants had their menarche at an age younger than 12 years. In the Lublin region of Poland, menarche occurred at 11 years in only about 3% of women attending screening a programme [35].

Among the most extensively researched risk factors of breast cancer is the use of exogenous hormones in the form of oral contraceptives and hormone replacement therapy (HRT) [36]. Lina et al. [37] in their study to assess the association between the use of hormonal contraception and the risk of invasive breast cancer among 1.8 million Danish women demonstrated that current and recent users of hormonal contraception had 20% increased risk of breast cancer compared with those who had never used hormonal contraception. We found in this study that, about 13% of women were current users of oral pills/injectables. None of them was however on HRT.

A positive family history of breast cancer in a first-degree relative is the most commonly known risk factor for the disease [38]. Women with a family history of breast cancer in a mother or sister have up to a 3-fold increase in the risk of developing breast cancer [38]. In this present study, about 14% of the participants had a positive family history of breast cancer, among whom 4% occurred in first degree relatives (mother and sister), and hence have increased risk of the disease. Our result is higher than that reported in the previous study in Ghana, where 1.4% of women had a first-degree family history of breast cancer [8]. and another study among university students in Ajman, UAE, where a positive family history of breast cancer was found in 9% of students and about 1% with the first-degree relative affected with breast cancer [39]. Researchers have devoted much attention to understanding the role that genes play in the development of breast cancer. This has helped in recognizing that some women could be at increased risk as a result of inherited predisposition. It must be acknowledged however that other than genes, families also share other factors such as cultural background and environmental exposures, which are themselves potential predictors of breast cancer [39].

The relationship between alcohol consumption and an increased risk of developing breast cancer has been the subject of many studies. Compared with non-alcohol drinkers, women who drink even in small amounts, have increased risk of breast cancer. The risk increases with an increased amount of alcohol consumed per day [40]. In many traditional African societies including Ghana, alcohol consumption is not common among females and the youth and people usually frown on alcohol intoxication [41]. The prevalence of alcohol consumption in African women varies from 1% in Malawi to 30% in Burkina Faso with about 81% of women in Africa reporting lifetime abstinence [42]. The prevalence of current alcohol consumption (20%) among female undergraduates found in this study is similar to levels (19.6%) reported among women in the WHO African regions in 2012 [43]. Martinize et al. [42] reported that about two-thirds of Ghanaian women abstain from alcohol in their lifetime. Kofi Adesi Kyei and colleagues found in their previous 5-year retrospective review to identify predominant lifestyle risk factors of breast cancer among Ghanaian women that alcohol contributed to about 19% to the disease with respect to preventable risk factors [44] and concluded that alcohol is not the most important preventable risk factor for breast cancer in Ghana. However, having 2 in 10 future female health professionals drinking alcohol is significant enough to warrant public health action due to the health consequences of alcohol on women.

Many studies have reported an inverse relationship between regular physical activity and breast cancer risk. Several biologic mechanisms have supported the protective effect of physical activity on breast cancer which includes effect on immune, endogenous sex steroid hormone production, and antioxidant system [44–46]. In this present study, 1 in 10 women was not physically active. Of those who were, the majority engaged in brisk walking. Comparing the most active and least active women, most studies estimate the risk reduction of breast cancer to be between 20 and 40% and recognise the dose-response relationship with risk increase levels of risk reduction [47–49]. Several mechanisms might be the cause of this inverse association with physical activity. Increased levels of activity are known to reduce body weight, thus reducing the risk of breast cancer. Physical activity may also influence the production, metabolism, and excretion of endogenous hormones that can result in lower levels of bioactive oestrogen, insulin, and other growth factors [50].

Accurate and early diagnosis of breast cancer depends mainly on the "opportunist approach". Given the challenges faced by resource-limited countries, improving breast cancer awareness and the application of screening methods remains a practical option for early detection and treatment of breast cancer. Similar to reports from previous studies done in different parts of the world including Ghana at different times, the performance of breast cancer examination is generally low [51–56]. Notably in this study, less than half of the participants performed BSE, 10% had CBE, and an even lower percentage (2.3%) had Mammography. This is a worrying phenomenon owing to the fact that breast cancer is increasingly becoming common in this part of the world, hence women and young ladies need to frequently subject themselves to screening for early detection and treatment to avoid complications and death. The low coverage of breast cancer screening among our study population could perhaps be explained by their young age as breast cancer has been known to be common among older women.

While the effectiveness of BSE to detect breast malignant tumour remains debatable, its importance in breast self-awareness creation in resource-limited countries with non-existent population screening programmes cannot be overemphasis, thus deserves consideration. The level of BSE practice in this study is, however, higher than that reported among over 10,000 undergraduate students from 24 countries across Africa, Asia and America. (9.1%) [57], and that of other studies among students in Ethiopia (39.4%), Cameroon (3%), Libya (23.5%) [53, 58, 59]. The rising trends in the incidence of breast cancer in Africa may be explained by the lack of health consciousness of young women to examine themselves for the timely identification of any breast abnormality. In this study, lack of skills, no family history of breast cancer and pessimism about the risk of the disease were the most important reasons for not performing BSE. This is a worrying finding since these are future healthcare professionals who are required to educate others in the community about the disease and the need for primary prevention. University students are among the well-informed group of women in Ghana. Their lack of skills in performing breast screening and the need for periodic screening, therefore, is indicative of a greater lack of skills and awareness among the general population of less-educated women. Similar, in Ethiopia, being healthy and lack of knowledge were the overriding factors given [53]. In a previous study among Presbyterian university college students in Ghana, varied reasons including, lack of time, forgetfulness, procrastination, and fear were the reasons for not performing BSE [25]. The social media could be an important tool that can be harnessed to educate women on the need for regular and correct practice of BSE since it remained the most important source of education for women who performed BSE in this study.

Expectedly, this study demonstrates that risk perception, an important component of behavioural change paradigm, is a sufficient enough variable that is capable of affecting women’s breast cancer screening behaviour. Women who did not believe to be vulnerable to breast cancer and those who did not know their risk status were less likely to practice BSE regularly compared to those who were pessimistic about their risk of the disease. Our result confirms the assertion of the Health Belief model that women who with a higher risk for breast cancer, perceive breast cancer as a serious threat, have a lower perception barrier, and who hold a higher perception of the benefits are more likely to perform regular BSE [60]. Erbil and Bolukbas also suggest that women’s health beliefs and attitudes remain the predominant factors that influence whether or not they will get themselves screened for breast cancer [61]. Among Korean women, those with lower perceived comparative risk were more likely to have no intention of getting a mammogram [62]. Further, this study demonstrated that who were not affiliated to any religion were less likely to examine their breast regularly compared to their counterparts who belonged to the Christianity religion perhaps due to exposure to breast cancer information in churches.

It is interesting to note that other risk variables such as physical activity, Alcohol consumption, and contraception use, and positive family history did not influence breast BSE in this present study. This is a worrying finding because women with risk factors are expected to perform regular breast examinations to detect the disease at its early stage to prevent complications and death. It can be suggested that university women do not practice BSE even though they have some risk factors of breast cancer.

There are three limitations of our study worth mentioning. First, the findings cannot be generalised beyond the study population since they are young and well-educated women. University students are not representative of young adults in general, and the risk perception, risk factors, and breast cancer screening practice may differ from that of the general population. Secondary, all data were self-reported with no objective measures to assess the accuracy of these reports. Lastly, the instrument used was not tested for its validity, however, questions used were taken from validated tools from previous studies at other settings. Nevertheless, the results of this study provide some understanding regarding perceived risk and the practice of breast screening among future health professionals, which can be useful for directed health promotion and education.

Conclusion

The research concludes that the awareness of breast cancer and its causes, risk factors, and disease manifestation was generally unsatisfactorily low. Additionally, even though some students possess some important risk factors of the disease, the practice of BSE coverage which was influenced by risk perception and religion was low. Improved methods of risk communication are recommended to ensure that women have appropriate risk information to make informed choices about risk management options and preventative interventions. Social media can also be a reliable tool for health education on breast cancer.

Supporting information

Acknowledgments

SOA acknowledge the support provided to her by all faculty in the department of Physician Assistantship, University of Health and Allied Sciences, Ho, Ghana. Sincere thanks go to all study participants.