Compliance with Breast Self-Examination Instruction in High School Students Barbara A. Cromer, M.D.* Margaret E. Frankel, R.N., M.S.N.** John Hayes, M.A.† Robert T. Brown, M.D.*
Summary: In a prospective study, we measured compliance with breast self-examination, using an anonymous questionnaire, in suburban high school students three months (n 85) and eight months (n = 54) after group instruction. Post-instruction proficiency in performing the procedure and personal health beliefs regarding breast cancer were also evaluated. At three months, 40% of the group reported practicing breast self-examination at some time since instruction; 12% had performed the procedure timed correctly with their menstrual cycle. At eight months, only two girls (4%) had practiced breast self-examination at least once since the three-month evaluation. Proficiency scores overall were high, with 77% scoring 12 points or above on a 15-item questionnaire; however, scores were significantly lower in the 15-year-olds than in the older adolescents. No significant relationships were found between compliance and most personal health beliefs, previous instruction, or level of knowledge of the procedure. Attention should be directed toward assessing the ability and willingness to practice preventive health =
behaviors before instruction programs
Introduction
lthough
rare in adolescents, breast cancer is curthe most common cause of cancer death among adult women in the United States. In an
rently ~LJ~
are
instituted in this age group.
attempt to improve early detection and, ultimately, to prolong survival, preventive health practices, breast self-examination been widely prohave (BSE), moted.1-3 Although the American Cancer Society recommends that such
as
the
practice
age 20 years
health classes. The American Academy of Pediatrics recommends that it begin at 14 years of age.4 Little information
* Division of Adolescent Medicine, Children’s Hospital, Columbus, Ohio Children’s Hospital, Los Angeles, California † Research Information Services, Children’s Hospital, Columbus, Ohio
**
Address correspondence to: Barbara A. Cromer, M.D., Division of Adolescent Medicine, Children’s Hospital, 700 Children’s Drive, Columbus, 0H 43205-2696.
(614) 461-2258
of monthly BSE
begin (personal communication), BSE is routinely taught to younger adolescents in many private offices, clinics, and high school at
is
available
regarding
adolescents’ acceptance of or compliance with this preventive health behavior. Following instruction, how often and how well do adolescents
actually perform BSE?r We designed this study to assess
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
215
compliance with BSE instruction over an eight-month period in girls attending a suburban public high
and those
completing the study. of the initial (43%) Fifty-four stated had received pregroup they
point questionnaire that measured her knowledge of proper examination technique. At the eight-month
school. We also wanted
vious instruction in breast self-examination.
follow-up the students also repeated the health-beliefs questionnaire.
Study Procedure
Compliance Measure
At the initial session the students were gathered by class in the school library (seniors first [n=38], followed by juniors [n=35], and then sophomores [n=41 ] ) . Each student completed two anonymous questionnaires; the first detailed demographic background, and the second examined personal health beliefs concerning breast cancer. Upon completion of the
was assessed with of an anonymous questionnaire, identified only by the student’s locker number, and was expressed as two variables: 1) number of self-examinations performed since instruction, and 2) number of examinations divided by the number of menses since instruction. For statistical comparisons with health beliefs, a complier was defined as one who had practiced BSE at least once since instruction.
to
examine
personal health beliefs and their relationship to compliance. Our hypothesis was that more adolescents would practice BSE after group instruction than prior to instruction and that compliance would be statistically associated with health beliefs. Methods
Sample Post-menarcheal students in the tenth through twelfth grades at a local public high school were eligible for the study. The school serves a predominantly Caucasian, middle- to upper-middle-class suburban community. Adolescents with a
learning disability (determined by the school principal) were excluded. On the first day of the study, 127 female students were available for enrollment in the study. This number represented 80% of the females enrolled in the upper three classes at the school. Of the 127 students, 114 (89%) accepted participation ; informed consent was obtained according to guidelines established by the Human Research Committee of Children’s Hospital, Columbus, Ohio. The most common reason for refusal was not wanting to miss a class. Eighty-five (75%) and 54 (47%) of the initial enrollees completed the study protocol at three and eight months, respectively, after instruction. All the study participants were white, and the mean age was 15.9 years. The Hollingshead scores were wide-ranging, with a mean of 46, a score that reflects an upper-middle-class socioeconomic background. No significant differences were found in demographic background between those beginning
216
questionnaires, those choosing not to participate further in the study were
free
to return to
class. A clin-
ical nurse specialist instructed each remaining group in BSE with the use of a silicone breast model. Pal-
pation and visual inspection techniques were described according to the method developed by the American Cancer Society (Franklin County Unit, 1986). Signs and symptoms of pathology were reviewed. The girls were instructed to perform the procedure at the end of each menstrual cycle, and each student was given an illustrated pamphlet on the proper technique of self-examination. At the end of the session, the students were given the opportunity to practice on the model. Each teaching session lasted 45 minutes.
Follow-up assessment was performed at three and eight months after instruction. On both occasions, the girls were gathered as a group in the school cafeteria and asked to complete an anonymous questionnaire that measured the frequency of practice of BSE in relation to the number of menstrual cycles since instruction, as well as the reasons for nonpractice of BSE if this was appropriate. Each girl also filled out a 15-
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
Compliance
the
use
Proficiency Measure Proficiency in performing
BSE assessed with a 15-point questionnaire which explored the subject’s level of knowledge regarding the recommended frequency and timing of the examination, correct order of steps during the procedure, cor-
was
positioning, proper palpation techniques, and the student’s knowledge of signs of breast pathology (Appendix 1). rect
Health Beliefs A 22-item questionnaire derived from the Health Beliefs Model was used in this study to assess personal attitudes about breast cancer. The Health Beliefs Model is a multivariate model which examines perceived and susceptibility to as as well vulnerability disease, costs and benefits of perceived treatment. As a research tool, this model has consistently accounted for a significant amount of the variance in compliance among patients of all ages.55 Since, to date, no standardized test has been developed to mea-
person’s health beliefs, we designed our own method of assure a
sessment
(Cromer, Frankel, Keder,
Relevant statements were listed in questionnaire format. The student responded on a five-point Likert Scale (i.e., the higher the rating, the stronger the belief) according to her degree of agreement with each of the listed health beliefs. For statistical analysis, health beliefs were grouped as fol-
1989).
I
PR~C~&dquo;~~~ ~~ :~~~~’~ ~~.~=~~~1~~T1~1
I
lows(each group represented by four to six statements): perceived threat of breast cancer (e.g., &dquo;Breast cancer is a serious problem&dquo;), control over one’s health (e.g., &dquo;I feel like I can make a real difference in making me healthy&dquo;), perceived benefits from (e.g., &dquo;Breast cancer found early is more likely to be cured&dquo;) and barriers to (e.g., &dquo;Examining my breasts is a real hassle&dquo;) compliance, and general health motivation (e.g., &dquo;I always do what the doctor tells me&dquo;).
b
,Y
~
.
~ a~.; ~~,,
~~.~:::. ~~~,~~~t&dquo;’ ~~~~‘~r~ .~~~:~~~’~~~T~t~~
k~-
’
3
-~’
f
~
~ f
k
:-.s ,
va
~k
~x
&dquo;a
~~.
w~ t
~ +’
‘~,~ _,
x
I
::.
k
x~
:
9‘~
’~.
~
~ ~
: ~
.
A
k~ f
3
~
~z ’ C :
F
$
b ~ f.’~a
$
~
F §
r~
.
~
,~
b:
y
~~
~
~§
_
b‘ i
3
.
:
,;.~a p F ~ -:
~~
b
n
:::
’.
k
~
~s
f ’
~.:
:
.,: ~,
’.
.~b ~
.~ _
?a~=
k ,~y
~-.
b~~p ....
Data Analysis Student’s t-tests were used to assess the relationships between compliance and each of the following variables: age, socioeconomic status, and proficiency scores. For inferential analysis of
Independent
’
-
;
~
¢
,
nr,
...
,
E,
x.._
.
,
...,.,
&dquo;
a ~
,.
Summary: In a prospective study, we measured compliance with breast self-examination, using an anonymous questionnaire, in suburban high school students three months (n 85) and eight months (n = 54) after group instruction. Post-instruction proficiency in performing the procedure and personal health beliefs regarding breast cancer were also evaluated. At three months, 40% of the group reported practicing breast self-examination at some time since instruction; 12% had performed the procedure timed correctly with their menstrual cycle. At eight months, only two girls (4%) had practiced breast self-examination at least once since the three-month evaluation. Proficiency scores overall were high, with 77% scoring 12 points or above on a 15-item questionnaire; however, scores were significantly lower in the 15-year-olds than in the older adolescents. No significant relationships were found between compliance and most personal health beliefs, previous instruction, or level of knowledge of the procedure. Attention should be directed toward assessing the ability and willingness to practice preventive health =
behaviors before instruction programs
Introduction
lthough
rare in adolescents, breast cancer is curthe most common cause of cancer death among adult women in the United States. In an
rently ~LJ~
are
instituted in this age group.
attempt to improve early detection and, ultimately, to prolong survival, preventive health practices, breast self-examination been widely prohave (BSE), moted.1-3 Although the American Cancer Society recommends that such
as
the
practice
age 20 years
health classes. The American Academy of Pediatrics recommends that it begin at 14 years of age.4 Little information
* Division of Adolescent Medicine, Children’s Hospital, Columbus, Ohio Children’s Hospital, Los Angeles, California † Research Information Services, Children’s Hospital, Columbus, Ohio
**
Address correspondence to: Barbara A. Cromer, M.D., Division of Adolescent Medicine, Children’s Hospital, 700 Children’s Drive, Columbus, 0H 43205-2696.
(614) 461-2258
of monthly BSE
begin (personal communication), BSE is routinely taught to younger adolescents in many private offices, clinics, and high school at
is
available
regarding
adolescents’ acceptance of or compliance with this preventive health behavior. Following instruction, how often and how well do adolescents
actually perform BSE?r We designed this study to assess
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
215
compliance with BSE instruction over an eight-month period in girls attending a suburban public high
and those
completing the study. of the initial (43%) Fifty-four stated had received pregroup they
point questionnaire that measured her knowledge of proper examination technique. At the eight-month
school. We also wanted
vious instruction in breast self-examination.
follow-up the students also repeated the health-beliefs questionnaire.
Study Procedure
Compliance Measure
At the initial session the students were gathered by class in the school library (seniors first [n=38], followed by juniors [n=35], and then sophomores [n=41 ] ) . Each student completed two anonymous questionnaires; the first detailed demographic background, and the second examined personal health beliefs concerning breast cancer. Upon completion of the
was assessed with of an anonymous questionnaire, identified only by the student’s locker number, and was expressed as two variables: 1) number of self-examinations performed since instruction, and 2) number of examinations divided by the number of menses since instruction. For statistical comparisons with health beliefs, a complier was defined as one who had practiced BSE at least once since instruction.
to
examine
personal health beliefs and their relationship to compliance. Our hypothesis was that more adolescents would practice BSE after group instruction than prior to instruction and that compliance would be statistically associated with health beliefs. Methods
Sample Post-menarcheal students in the tenth through twelfth grades at a local public high school were eligible for the study. The school serves a predominantly Caucasian, middle- to upper-middle-class suburban community. Adolescents with a
learning disability (determined by the school principal) were excluded. On the first day of the study, 127 female students were available for enrollment in the study. This number represented 80% of the females enrolled in the upper three classes at the school. Of the 127 students, 114 (89%) accepted participation ; informed consent was obtained according to guidelines established by the Human Research Committee of Children’s Hospital, Columbus, Ohio. The most common reason for refusal was not wanting to miss a class. Eighty-five (75%) and 54 (47%) of the initial enrollees completed the study protocol at three and eight months, respectively, after instruction. All the study participants were white, and the mean age was 15.9 years. The Hollingshead scores were wide-ranging, with a mean of 46, a score that reflects an upper-middle-class socioeconomic background. No significant differences were found in demographic background between those beginning
216
questionnaires, those choosing not to participate further in the study were
free
to return to
class. A clin-
ical nurse specialist instructed each remaining group in BSE with the use of a silicone breast model. Pal-
pation and visual inspection techniques were described according to the method developed by the American Cancer Society (Franklin County Unit, 1986). Signs and symptoms of pathology were reviewed. The girls were instructed to perform the procedure at the end of each menstrual cycle, and each student was given an illustrated pamphlet on the proper technique of self-examination. At the end of the session, the students were given the opportunity to practice on the model. Each teaching session lasted 45 minutes.
Follow-up assessment was performed at three and eight months after instruction. On both occasions, the girls were gathered as a group in the school cafeteria and asked to complete an anonymous questionnaire that measured the frequency of practice of BSE in relation to the number of menstrual cycles since instruction, as well as the reasons for nonpractice of BSE if this was appropriate. Each girl also filled out a 15-
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
Compliance
the
use
Proficiency Measure Proficiency in performing
BSE assessed with a 15-point questionnaire which explored the subject’s level of knowledge regarding the recommended frequency and timing of the examination, correct order of steps during the procedure, cor-
was
positioning, proper palpation techniques, and the student’s knowledge of signs of breast pathology (Appendix 1). rect
Health Beliefs A 22-item questionnaire derived from the Health Beliefs Model was used in this study to assess personal attitudes about breast cancer. The Health Beliefs Model is a multivariate model which examines perceived and susceptibility to as as well vulnerability disease, costs and benefits of perceived treatment. As a research tool, this model has consistently accounted for a significant amount of the variance in compliance among patients of all ages.55 Since, to date, no standardized test has been developed to mea-
person’s health beliefs, we designed our own method of assure a
sessment
(Cromer, Frankel, Keder,
Relevant statements were listed in questionnaire format. The student responded on a five-point Likert Scale (i.e., the higher the rating, the stronger the belief) according to her degree of agreement with each of the listed health beliefs. For statistical analysis, health beliefs were grouped as fol-
1989).
I
PR~C~&dquo;~~~ ~~ :~~~~’~ ~~.~=~~~1~~T1~1
I
lows(each group represented by four to six statements): perceived threat of breast cancer (e.g., &dquo;Breast cancer is a serious problem&dquo;), control over one’s health (e.g., &dquo;I feel like I can make a real difference in making me healthy&dquo;), perceived benefits from (e.g., &dquo;Breast cancer found early is more likely to be cured&dquo;) and barriers to (e.g., &dquo;Examining my breasts is a real hassle&dquo;) compliance, and general health motivation (e.g., &dquo;I always do what the doctor tells me&dquo;).
b
,Y
~
.
~ a~.; ~~,,
~~.~:::. ~~~,~~~t&dquo;’ ~~~~‘~r~ .~~~:~~~’~~~T~t~~
k~-
’
3
-~’
f
~
~ f
k
:-.s ,
va
~k
~x
&dquo;a
~~.
w~ t
~ +’
‘~,~ _,
x
I
::.
k
x~
:
9‘~
’~.
~
~ ~
: ~
.
A
k~ f
3
~
~z ’ C :
F
$
b ~ f.’~a
$
~
F §
r~
.
~
,~
b:
y
~~
~
~§
_
b‘ i
3
.
:
,;.~a p F ~ -:
~~
b
n
:::
’.
k
~
~s
f ’
~.:
:
.,: ~,
’.
.~b ~
.~ _
?a~=
k ,~y
~-.
b~~p ....
Data Analysis Student’s t-tests were used to assess the relationships between compliance and each of the following variables: age, socioeconomic status, and proficiency scores. For inferential analysis of
Independent
’
-
;
~
¢
,
nr,
...
,
E,
x.._
.
,
...,.,
&dquo;
a ~
,.
