Journal of Cancer Education
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
Demographic characteristics and knowledge of BSE of women electing to attend a BSE training program in victoria, Australia Valerie A. Clarke PhD , Judy Rassaby B SC (Hons) , Sheila Hirst B App Sc (Ad Nsg) , David Hell PhD & Victoria White BA (Hons) To cite this article: Valerie A. Clarke PhD , Judy Rassaby B SC (Hons) , Sheila Hirst B App Sc (Ad Nsg) , David Hell PhD & Victoria White BA (Hons) (1991) Demographic characteristics and knowledge of BSE of women electing to attend a BSE training program in victoria, Australia, Journal of Cancer Education, 6:1, 33-42 To link to this article: https://doi.org/10.1080/08858199109528085
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J. Cancer Education. Vol. 6, No. 1, pp. 33-42, 1991 Printed in the U.S.A. Pcrgamon Press pk
0885-8195/91 $3.00 + .00 © 1991 American Association for Cancer Education
DEMOGRAPHIC CHARACTERISTICS AND KNOWLEDGE OF BSE OF WOMEN ELECTING TO ATTEND A BSE TRAINING PROGRAM IN VICTORIA, AUSTRALIA A. CLARKE PhD*; JUDY RASSABY, B Sc (Ad Nsg)‡; DAVID HELL, PhD§; and
SC (Hons)t; SHEILA HIRST, B VICTORIA WHITE, BA (Hons)
Abstract — Participants in the Mammacheck breast self-examination (BSE) training program were surveyed to assess the characteristics of women choosing to attend BSE training sessions, as well as to assess the factors that related to their BSE practice prior to attending the session. In all, 5,673 women completed questionnaires. In comparison with the general population, women who attended Mammacheck tended to be younger, married, and more highly educated, but did not differ in relation to prior experience of breast problems. Previous BSE practice related predominantly to the amount of knowledge about BSE the women reported that they had acquired before attending a training session. The findings highlight the importance of education and raised the important question of how to teach women with lower education levels and little or no knowledge about BSE. Recommendations are made.
of these risk factors develop breast cancer, so a knowledge of risk factors is of limited utility in targetting educational programs. Given this unpredictability of breast cancer, the most effective measure is diagnosis in the early stages when prognosis is likely to be relatively good. As most breast cancers are, in fact, detected by the women themselves, rather than by their doctors, and are often detected by chance, rather than as a result of a methodical examination,4 it seems that the early detection of breast cancer could be greatly facilitated by the regular practice of breast self-examination (BSE). As such, BSE should provide an efficient, costeffective, noninvasive means of detecting tumours. Even in those geographical areas where there is provision for mammographic screenings, BSE plays a vital role in detecting breast cancer between screenings5 and is useful for women for whom mammography is unsuited and for the small number of women in whom breast lesions remain unidentified by mammography. BSE is particularly effective if women have been personally trained in BSE techniques6 and their examinations are regular and systematic. The effectiveness of BSE in early detection has been documented in a comprehensive meta-analysis of the BSE literature, in which Hill et al7 showed that detected tumours were smaller and
INTRODUCTION Cancer of the breast is the most common cancer among Australian women. One woman in 15 will develop breast cancer during her lifetime.1 In Victoria, the incidence rate is 11%13% above the national average, and the lifetime risk that women will develop this cancer is one in 14. 2 ' 3 Although the causes of breast cancer are unknown, the risk increases with age, rising steeply among women over 40.2>3 Women with a family history of breast cancer, a personal history of benign breast disease, a diet high in animal fat, nulliparity or a later age at the first full-time pregnancy, or exposure to ionising radiation are also at greater risk.1 However, many women who do not experience any
All authors are with the Anti-Cancer Council of Victoria, Victoria, Australia. *Academic Associate, Centre for Behavioural Research in Cancer and Lecturer, Department of Psychology, Deakin University. †Associate, Centre for Behavioural Research in Cancer. ‡Education Program Manager, Education Unit. §Director, Centre for Behavioural Research in Cancer. Research Officer, Centre for Behavioural Research in Cancer. Reprint requests to: Dr. David Hill, Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, 1 Rathdowne Street, Carlton South, Victoria, Australia, 3053.
V. A. CLARKE et al.
lymph node involvement less frequent among BSE practicers than among nonpracticers. These benefits of early detection are reflected in the greater survival rate five years after diagnosis among self-examiners relative to nonexaminers.8 On the other hand, BSE has been criticised for creating unnecessary medical expense and unnecessary emotional distress when women detect false-positive breast changes.9 Leaving aside the extreme view that early detection of breast cancer is of no value, opinions of the perceived utility of BSE depend on the relative weight placed on the economic cost and emotional distress created by false-positives. However, the latter may be more of a concern among health professionals than among women who are potential BSE practicers, given that a recent study comparing the BSE practices of cancer, benign breast disease, and general practice patients demonstrated that prior false-positive detections were not associated with reduced BSE practice.10 One of the aims of BSE training programs is to reduce the anxiety associated with the detection of a breast problem through teaching about the appropriate courses of action and the high probability of successful treatment when detection is early. 11 ' 12 Despite the apparent benefits of BSE and awareness of BSE, there is an enormous gap between awareness and practice,12 a gap which may reflect a lack of knowledge of the techniques of BSE. In America, it is estimated that about 94% of women know about BSE, while in Australia estimates of awareness vary from 90% to 97% of women.13 Estimates of the proportion of North American women who practice BSE vary from a low of 14%14 through 29% 12 to a high of 75%. 15 The American and British literature suggests that there are demographic and experiential factors that differentiate between self-examiners and nonexaminers. Generally those who practice BSE tend to be younger,8 white,8 married,8 or living with their sexual partner,15 to have a family history of breast cancer,15 to have more knowledge about BSE 16 or to have been shown how to do BSE15 — possibly by their general practitioner14 — and to be more motivated to promote their own good health.16 Similarly, those who choose to attend a breast
self-examination training program may differ from those who choose not to do so. 17 ' 18 Attenders are more likely to be younger,17 married or living with a sexual partner,17 of higher social status and more highly educated,18 have a previous experience of breast problems or a family history of breast cancer17 to have more knowledge of BSE, 18 to be health oriented,17 to accept responsibility for their own health,18 and/or to express less anxiety about the possibility of detecting a breast abnormality.17 To enable a large number of women to learn effective BSE techniques, the Anti-Cancer Council of Victoria developed the Mammacheck program which is fully described in both the Mammacheck Training Manual11 and a previous publication19 and has been shown to have a significant impact on the frequency of subsequent BSE practice.20 Briefly, the single session program is facilitated by a trained female health educator who works with a group of 7 to 12 women for a session of approximately 6090 minutes. The session opens with a talk from the health educator explaining the nature of the breast structure, the nature and prevalence of breast cancer, and the benefits of regular practice of BSE. This is followed by an 8-minute video demonstrating BSE techniques using the vertical strip method. The participants practice these techniques on themselves over their clothing, while the facilitator provides advice and encouragement. They then practice on realistic breast models that contain five lumps of different sizes and at different locations within the breast. It is essential to use both light and firm pressure and to cover all areas of the breast to detect all lumps. The session concludes with a group discussion during which participants share their anxieties and concerns, identify the common practical and emotional barriers to regular BSE practice, and develop action plans for their own implementation of a regular BSE program. Before leaving they are provided with printed pamphlets reinforcing the techniques and principles they have learned and calendars and stickers to act as cues to BSE practice. Copies of an audiotape describing the techniques are available at minimum cost. The effectiveness of this program in increasing the proportions of women who regularly
Characteristics of women attending BSE training
practice BSE depends on the extent to which women choose to avail themselves of one of these free sessions. In order to ensure that the program is reaching a broad spectrum of women, the present study was designed to identify and describe the characteristics of those who attended a session during the initial two and a half years of operation of the program so as to develop strategies for targetting women who were not being reached. If the Australian experience is similar to that reported overseas, it is to be expected that, relative to the general population, these women will be younger and better educated, more likely to be living with a sexual partner, and to have a family history of breast cancer or a personal history of breast abnormalities. Those who report that they practice BSE more regularly are likely to differ from those who practice it less regularly in that they are more likely to be younger, married, to have a higher level of education, to have personal experience of breast cancer, to have learned about breast cancer vicariously through the experience of relatives or friends, and to have a greater knowledge of BSE.
METHODS Procedure Data were collected using questionnaires that were administered and collected by the health educators at the conclusion of each training session and forwarded by them to the Centre for Behavioural Research in Cancer at the AntiCancer Council of Victoria. Sample Sample selection. As the study was designed to identify the characteristics of Victorian women who chose to attend a free Mammacheck training session, all women who attended during the first two and a half years of the program, February 1985 to September 1987, were invited to participate in the research. Women were recruited at a hospital-based site through general practitioners, through workplaces, and by word of mouth.19 There were 893 teaching sessions,
with approximately eight women per session. Eighty-three health educators, at 50 different centers throughout Victoria, were involved in presenting the Mammacheck sessions. Each of the 6,059 women who attended a session during the designated time period was asked to complete a questionnaire. Sample. The report is based on the responses of 5,673 women who attended a Mammacheck training session in Victoria, Australia. The response rate was 94%. Questionnaire The questionnaire contained precoded questions assessing demographic variables, sources of information about Mammacheck, awareness of BSE, previous experience with BSE, personal history of breast cancer and of breast lump detection, and incidence of breast cancer among relatives and friends. It also included attitude and belief questions, which will not be considered in this paper. All items considered here are factual or knowledge questions, which generally yield more accurate responses than the more elusive attitude and belief items. Most of the questions had been tested in previous studies. 10 ' 19 Statistical Analysis All analyses were completed using the Statistical Package for Social Sciences. When comparing nonparametric data, chi-square tests were used. For parametric data, analyses of variance with Newman-Keuls tests, and multiple regression analyses were selected. Alpha was set at .001. RESULTS The results will be presented in two parts. The first section will describe the entry characteristics of the sample, which will then be compared with population estimates in the Discussion. The second part will look at the relationship between entry characteristics and reported practice of BSE prior to attending the training session. Entry characteristics Age. The Mammacheck program attracted many younger women. Twenty-nine per cent
V. A. CLARKE et al.
of participants were under 30 years of age, 34% were 30 to 39, 20% were 40 to 49, and 17% were 50 or over. Marital status. Reports of marital status indicated that 19% of the sample had never married, 72% were currently married or living in a de facto relationship, a further 5% were separated or divorced, and 3% were widowed. Education. In response to a question asking participants to report the highest level of formal education, 24% had completed a tertiary qualification at a university or college of advanced education, 11% had some formal education beyond year 12, which is the final year of secondary schooling, 29% had completed year 12, 32% had some secondary schooling (years 7 to 12), and 3% had not reached secondary schooling (year 6 or less). The remaining 1% did not state their educational level. Personal experience of breast disease. Personal experience of breast cancer was very low. Less than 1% (0.6%, 36 women) of the participants had actually had breast cancer, although 15% had found a breast lump on one occasion and a further 6% on two or more occasions. Vicarious experience of breast cancer. Participants were asked a series of questions tapping their family history and vicarious experience of breast cancer. Each question asked for a ' 'yes/ no" response relevant to a particular category of person. For only 17% of participants was there at least one close relative, such as a mother (8%), grandmother (9%), sister (3%), or daughter (0.3%) who had had breast cancer. Many had indirect experience of breast cancer in that 40% had one friend who had it and 27%, two or more friends. Only 15% of the participants had not had any vicarious experience of breast cancer. Sources of information about Mammacheck. Participants were asked how they had heard about the Mammacheck program. Of the total sample, over one-quarter of the women (28%) had heard about it in the workplace, although many had heard about it through a health centre (22%), a friend or relative (17%), or a community group (11%). Some women learned about Mammacheck from a paper or magazine (9%), a leaflet or poster (5%). Very few women gained their information from doctors (2%), the Anti-
Cancer Council of Victoria (1%), or the electronic media (1%). The remaining 4% did not indicate their main source of information. Sources of information about BSE. Participants were asked to indicate the amount they had learned about BSE from each of a number of potential sources prior to attending the training session. A 5-point scale was provided ranging from "nothing at all" (scored 0) to " a great deal" (scored 4). The greatest amount of information had been gained from doctors and nurses (mean = 1.5), pamphlets (1.3), magazines or newspapers (1.3), and TV (1.1), with some information from films (0.9), friends (0.6), or parents (0.4). However, the proportion of respondents claiming to have learned " a great deal" from at least one source was relatively low (20%). Of those who considered that they had learned "a great deal" about BSE, nearly two-thirds (62%) had gained this information from a single source, which was most likely to be a doctor or nurse. More direct learning about BSE was assessed by asking participants if they had seen BSE done prior to their attendance at the Mammacheck session. Approximately half of the participants had seen BSE done on a TV advertisement (56%) or in a film (46%), and a quarter, in real life (27%). Overall, only 27% of women said they had not seen BSE done at all. Frequency of doing BSE. Over a fifth of the women (22%) had not previously done BSE at all, another fifth had done it only once at some time prior to the previous six months (19%), and a quarter had done it once in the past six months (25%). However, a third of the sample (34%) were relatively regular practicers of BSE, doing it at least once every three months. The degree of skill evident in this practice was not assessed.
Factors Relating to Previous BSE Practice Although it is recommended that women should do BSE regularly once a month, a careful examination of the breasts three or four times a year is sufficiently frequent for women to obtain objective benefit 21 by enabling them to retain familiarity with the look and feel of their breasts so as to detect any changes. Hence,
Characteristics of women attending BSE training
women who practiced BSE at least once every Irregular, 40% Nonpracticers; chi-square = three months were described as "Adequate" 154.62, d.f. = 2, P < .001), a film (56% Adpracticers (N = 1918, 34%), those who had equate, 48% Irregular, 27% Nonpracticers; chinever done BSE were described as "Nonprac- square = 212.12, d.f. = 2, P < .001) or in ticers" (N = 1250, 22%), and those falling real life (40% Adequate, 27% Irregular, and between the two groups were described as "Ir- 7% Nonpracticers; chi-square = 318.66, d.f. regular" practicers (N = 2439, 44%). Using = 2, P < .001). this trichotomy, the relationships between BSE Amount of knowledge of BSE. The mean practice and each of the background variables scores obtained by the Adequate, Irregular, and were assessed. Nonpracticer groups on each of the scales (rated Marital status. There were no significant dif- 0 to 4) assessing amount of knowledge about ferences in the proportions who were living in BSE gained from each source are presented in a marital or de facto relationship and those who Table 1. In all cases there were significant difwere not in such a relationship, as approxi- ferences showing that the more frequent pracmately three-quarters of the participants in each ticers had gained more information from each of the three groups were married or in a de source: doctor or nurse (F = 527.58, d.f. = 2 facto relationship (73% Adequate, 71% Irregu- and 4473, P < .001), pamphlet (F = 303.98, d.f. = 2 and 4202, P < .001), magazine or lar and 73% Nonpracticers). Education level. There were significant dif- newspaper (F = 180.82, d.f. = 2 and 4639, P ferences in the reported highest levels of for- < .001), films (F = 124.44, d.f. = 2 and mal education showing a positive relationship 3847, P < .001) TV (F = 113.68, d.f. = 2 between education level and reported frequency and 4118, P < .001), friend (F = 43.47, d.f. = 2 and 3697, P < .001), parent (F = 38.71, of BSE practice (chi-square = 40.49, d.f. = d.f. = 2 and 3620, P < .001), and other (F = 2, P < .001). More of the Adequate practisers 86.87, d.f. = 2 and 1305, P < .001). Newman(39%) than the Irregular practicers (36%) or Keuls tests indicated that in all cases there were Nonpracticers (29%) had some university or colsignificant differences between the Adequate and lege education, while fewer of the Adeqate Irregular practicers and also between the Irreg(33%) and Irregular practicers (34%) than the ular and Nonpracticers. Nonpracticers (42%) had left school before completing year 12. The overall impact of the education/knowlExperience of breast cancer. As expected, edge variables on reported past BSE practice more of the Adequate practicers (1.5%) than of was assessed using a stepwise multiple regreseither the Irregular (0.2%) or Nonpractisers sion analysis, with reported BSE practice as the (0.2%) had a personal experience of breast can- dependent variable. The demographic variables cer (chi-square = 30.89, d.f. = 2, P < .001). of age and marital status were entered at step More of the Adequate (21%) than the Irregular 1, educational level at step 2, and the ten knowl(14%) or Nonpracticers (14%) had a first-de- edge variables at step 3 — these were a comgree relative who had breast cancer (chi-square posite variable indicating the number of modes = 28.45, d.f. = 2, P < .001). in which BSE has been seen (real life, film, Observation of BSE. More of the Adequate and/or TV ad), vicarious experience of breast practicers (88%) than the Irregular practicers cancer through friends and relatives, and infor(76%) or the Nonpracticers (51%) had actually mation from each of the eight possible sources. seen BSE done, and more of them had seen it Personal experience of breast cancer was omitdone in two different modes (27% Adequate, ted due to the extremely small number of sub22% Irregular, and 10% Nonpracticers) or in jects who reported such experience. At step one, three different modes (9% Adequate, 4% Irreg- the demographic variables accounted for almost ular, 1% Nonpractisers; chi-square = 535.28, 1% of the variance (R-square = .009, F = d.f. = 4, P < .001). The patterns were similar 20.25, d.f. = 2 and 4426, P < .001). Educafor each mode of seeing BSE, whether it had tional level accounted for a further 1% of the been seen on a TV ad (65% Adequate, 56% variance (R-square = .018, F = 27.50, d.f.
V. A. CLARKE et al.
Table 1. Mean scores on each of the 0-4 scales assessing the amount of information obtained by Adequate, Irregular, and Nonpracticers of BSE from each nominated source of information Source of Information Doctor or nurse Pamphlet Magazine or newspaper Film TV Friend Parent Other
Previous BSE Practice None
0.7 0.6 0.9
1.4 1.3 1.3
3.0 1.8 1.6
527.58* 303.98* 180.82*
0.4 0.8 0.4 0.3 0.4
0.8 1.1 0.6 0.4 0.8
1.5 1.4 0.8 0.6 1.6
181.48* 113.68* 43.47* 32.61* 86.87*
*P < .001
= 3 and 4425, P < .001), while the knowledge variables accounted for a further 16% of the variance (R-square = .180, F = 74.55, d.f. = 13 and 4413, P < .001). Three variables accounted for most of this variance: information from a doctor or nurse (Beta = .23, P < .001), having seen BSE done (Beta = .21, P < .001), and having read about BSE in a pamphlet (Beta = .14, P < .001). Only two other variables entered the equation: vicarious experience of cancer (Beta = .07, P < .001) and having read about BSE in a newspaper or magazine (Beta = .07, P < .001).
Entry characteristics It was suggested that those most likely to attend the Mammacheck program would be those who were younger, married or living in a de facto relationship, had higher levels of education, had personal experience of breast cancer, had a family history of breast cancer or experience with it through friends, and knew more about BSE. There was some evidence to support these suggestions. Demographic characteristics. Although the age distribution of reported breast cancer suggests that any screening, including BSE, is likely to yield relatively little benefit for women under the age of 40, 3 nearly two-thirds of the sample (63%) were, in fact, in this younger, low-risk group, and only about a third of the
participants (37%) could be described as being at a high risk because of their age. In comparison with Australian Bureau of Census and Statistics figures,22 more of the women in the Mammacheck sample were in the younger age groups. Thus, the Mammacheck program is attracting many younger women, many of whom may not yet need to do BSE regularly. Relative to the Australian population, the Mammacheck sample contained considerably more women who were married (72% sample, 57% population) and fewer who had never married (19% sample, 24% population), were divorced or separated (5% sample, 8% population) or widowed (3% sample, 1 1 % population).22 The sample also had an education bias. Relative to the Australian population,23 the sample contained a comparable proportion of women who had at least some postsecondary education (35% sample, 33% population), but considerably more women who had completed secondary schooling (29% sample, 14% population), and markedly fewer women who had not completed secondary schooling (35% sample, 53% population). These Australian data are consistent with overseas results that suggest that women who attend training programs are more likely to be younger, married or living in a de facto relationship,15'17 and more highly educated than the general population. These demographic differences may reflect the nature of the promotion, in that either the information is more readily available to this group or is presented in a manner which appeals to them, or, given the com-
Characteristics of women attending BSE training
parability with overseas findings, may merely identify the characteristics of women who are likely to attend health-related programs. However, the fact that 28% of these women heard about Mammacheck at their workplace implied that they were employed in a situation where health information was available. This latter finding may partly reflect a bias in the recruitment procedures in the early stages of the introduction of Mammacheck, as many of the sessions were conducted in the workplace, and generally in workplaces associated with white collar occupations.19 Overall, these findings raise the question of how to make Mammacheck available to women who are older, unemployed, and/or have lower levels of education, women who are possibly in greater need of personal instruction than those who are relatively more able to gain their information from other sources. Personal history of breast disease. The proportion of women reporting a personal history of breast cancer was very low (less than 1%), suggesting that this was not a major factor causing women to attend the Mammacheck sessions. The total of 21% of participants reporting that they had found a breast lump on at least one occasion is a similar incidence of breast lump detection to that reported in a population survey conducted in 1988 by the Centre for Behavioural Research in Cancer, which found that 18% of women over 30 years of age had discovered a breast lump.22 The consistency between this sample and the population survey suggests that the Mammacheck sessions are not merely attracting women with special reasons to be concerned about breast cancer, but are serving women who, in respect to their history of breast problems, are typical of the general community. This differs from overseas programs, which attract a greater proportion of women with a personal history of breast abnormalities.17 Vicarious experience of breast cancer. The vicarious experience of breast cancer appears to be high in that 85% of participants had at least one relative or friend who had had breast cancer, but as one in 14 women in Victoria experience breast cancer at some stage during their lives,2 this may not be unreasonably high. Experience with BSE. Most women were fa-
miliar with BSE. They had either seen BSE done in real life, on a film, or in an advertisement, and most of them had learned something about BSE from other people or from the media. This is consistent with both earlier Australian research13 and with American research,12 which suggests that awareness of BSE is relatively high. The large proportion of women who claimed to have seen BSE done on a film or a TV ad is interesting, as at least five years had elapsed since formal TV advertising campaigns on BSE had been broadcast to these respondents. The recall of BSE TV advertising suggests that this media could play a more significant role in future promotion strategies for instructional programs such as Mammacheck. Surprisingly, 27% of women said they had seen BSE done in real life. It seems unlikely that so many women would have seen another woman doing proper BSE. A likely explanation is that these women could have seen BSE modelled by a nurse or doctor or other health professional in another training session or watched a health professional demonstrate on them in an individual session. As 78% of participants had done BSE at least once before attending Mammacheck, many of these women may have previously been shown how to do it. The figure of 78% of women who reported some BSE practice is marginally higher than the highest figure reported in the American research15 and markedly higher than those reported in some other studies. 12 ' 14 Overall, these findings suggest that the majority of participants were at least familiar with the notion of BSE and were attending the Mammacheck session to further develop their skills rather than to learn about a totally new health behaviour. This again raises the practical question of how to reach women who may be less familiar with BSE, or even totally unaware of it.
Factors relating to previous BSE practice It was anticipated that Regular practicers of BSE would differ from the Irregular and Nonpracticers in that they would be younger, more likely to be married, be better educated, have greater experience of breast cancer, and know more about BSE. However, the analyses of the
V. A. CLARKE et al.
differences between the Adequate, Irregular, and Nonpracticers indicated that there were only slight differences in the demographic characteristics that were associated with these groups, in that the Adequate practicers were likely to be more highly educated, to have personally experienced breast problems and/or to have had a friend or relative who had experienced breast problems. There were only slight differences in personal experience and vicarious experience of breast cancer, differences which were unlikely to be major factors which led to BSE practice. These factors may be best described as statistically significant, but insufficiently large to have a substantial impact on the probability of women doing BSE. Knowledge factors were the ones which most clearly distinguished between Adequate and Irregular practicers and between Irregular and Nonpracticers. The Adequate practicers were more likely to have seen BSE done and gained more information from each potential source than did the Irregular practicers. The Irregular practicers also gained more information from each source than did the Nonpracticers. These differences were demonstrated in the regression analysis, which showed that they accounted for a relatively substantial 16% of the variance after partialling out the effects of the demographic variables, further highlighting the important role of knowledge of BSE as a factor relating to the frequency of BSE practice. Despite the important role of these knowledge factors, there remains a further 82% of the variance to be explained by factors that have not been assessed in the present study. Such factors are likely to include the barriers to BSE practice that the Mammacheck program was designed to reduce or eliminate,11 specifically, the emotional barriers, such as fear of finding a lump or fear of losing a breast, and the practical barriers of lack of time, laziness, and forgetting.13 Further, it must be remembered that in health behaviour research it is unlikely that 100% of the variance would be explained. Research is limited by people's capacity to recall the relevant information, by the use of imprecise measuring instruments (such as 5-point rating scales), and by the existence of unidentified variables.
Implications and recommendations First and foremost the study highlights the important role of perceived knowledge of BSE as a factor relating to reported BSE practice. The more women feel that they know about BSE, the more likely they are to practise it. Further, most of the women who attended the program had some prior knowledge of BSE, suggesting that they enrolled in the program to further this knowledge, rather than to learn about a totally new health behaviour. These findings clearly indicate the need to increase women's perceived knowledge of BSE, if we want more women to practise it and if we want those who practise it to do so on a more regular basis. Obviously it is important to devote resources to the education of women in this area of health practice through the provision of resource materials to both the general public and health professionals, and the conduct of training programs like Mammacheck. In order to increase knowledge of BSE, it is essential to find a means of providing information and education for women who are older, single, and/or less-well educated, to reach the women who are not currently being reached by the Mammacheck sessions. Two approaches may need to be taken to achieve this. First, a broad community awareness campaign, and second, the development of more specific and intensive strategies to reach the "hard to reach" groups. The aims of the broad community program would be: 1. to increase awareness of breast cancer and BSE in the community; 2. to encourage "relatively easy to reach" women to attend a BSE instruction program; and 3. to serve as a reminder and reinforcer to women who have received instruction to maintain their BSE practice. A variety of strategies may be used to achieve these aims. The starting point is an intermittent, but ongoing, electronic media program utilising community service radio announcements and interviews with health professionals, women who have had breast cancer, and prominent women in the community. The print me-
Characteristics of women attending BSE training
dia also provide a significant avenue for the promotion of key messages and should be broadly based to utilise not only major print channels, such as women's magazines, but should also include the newsletters of women's community organisations. Posters and brochures should be widely circulated and placed at strategic places within the community, including community centres, libraries, and women's organisations. Such posters should promote BSE as an important health practice and advise women where they can seek further information. However, in order to reach the "harder to reach" groups, more specific strategies must be developed, which will build onto the general community awareness program. Such an approach must clearly define the characteristics of the audience and all possible avenues to reach and work with them. Whenever possible, community participation and community development strategies should be incorporated into the overall plan. As a more personal or individual approach may be required, significant work should be aimed towards working with those having direct contact with women. These may include general practitioners, community health workers, occupational health workers, and community leaders. Although attempts to recruit women through general practitioners were not particularly fruitful in the early stages of Mammacheck due to the shortage of computerised mailing lists and the busy schedules of most practitioners,19 this means of recruitment has been shown to be relatively effective in the UK24>25 and requires further exploration. The availability of local evaluative data showing the impact of training on BSE practice20 and the impact of BSE practice on early detection of breast cancer10 should serve to motivate the general practitioners to devote some of their consultation time to the issue. Furthermore, while general practitioners may play an important role in encouraging women to attend a Mammacheck program, they also have an opportunity to teach and reinforce BSE practice on an individual basis. Such an opportunity may be extremely influential as, in conjunction with a physical breast examination, the doctor can reassure and teach individual women
about their normal breast physiology. At the community level, further work must be undertaken with the identified' 'hard to reach'' women to explore broader health issues and their beliefs about underlying health concepts. The woman's views on reaching their own community must be actively sought and acknowledged. Much of this work will be intensive, requiring work with individuals as well as small groups of women. In addition to the conventional health avenues, contacts with women must be made through the range of social, recreational, work, and religious groups, as well as utilising community contacts such as bingo clubs, hairdressers, and clothing shops. Speakers at established women's groups may not only reach the participants directly, but may sow seeds into the women's own informal communication networks. Similarly, significant women in the community, particularly if they have attended a Mammacheck Program, must be encouraged to discuss the issues and alleviate fears and concerns with their friends and colleagues at home and at work. Finally, it must be clearly recognised that reaching "hard to reach" women in the community requires a long-term investment. However, such an investment will benefit women, not just in terms of breast cancer awareness and BSE awareness, but also in promoting health in its broader context. REFERENCES 1. Giles GG, Armstrong B, Smith L: Cancer in Australia 1982. National Cancer Statistics Clearing House. Scientific Publication No. 1. Melbourne: Anti-Cancer Council of Victoria, 1987. 2. Giles GG, Farrugia H: Victorian cancer registry 1986: Statistical report. Melbourne: Anti-Cancer Council of Victoria, 1990.1 3. Giles G, Jolly D, Lecatsas S, Handsjuk H: Atlas of cancer in Victoria: Incidence 1982-83, mortality 197983. Melbourne: Anti-Cancer Council of Victoria, 1988. 4. Baines, CJ: Some thoughts on why women don't do breast self-examination (Editorial). Can Med Assoc J 128: 255-256, 1983. 5. Shapiro S, Venet W, Strax P, Venet L: Current results of the breast cancer screening randomized trial: The Health Insurance Plan (HIP) of greater New York Study, in Day NE and Miller AB (eds): Screening for breast cancer. Toronto: Hans Huber, 1988. 6. Mant D, Vessey MP, Neil A et al: Breast self-exami-
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