PERCEPTION OF MAMMOGRAPHY EXAMINATION BY MIDDLE-AGED WOMEN IN PUBLIC SCHOOLS IN NNEWI NORTH LOCAL GOVERNMENT AREA, ANAMBRA STATE, NIGERIA. OKPALEKE MICHAEL SUNDAY 1 NWAJAGU ADAORA DOREEN 1, UCHE EZECHUKWU1, UGWUANYI DANIEL CHIMUANYA1, OGOLODOM MICHAEL PROMISE1 Department of Radiography, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria. CORRESPONDING AUTHOR Michael Sunday Okpaleke, Department of Radiography, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria. Abstract Background: The degree of acceptance of mammography examinations as breast cancer screening tool has not been fully documented in the locality despite the increasing incidence of breast cancer in Nigeria. Purpose: To assess the knowledge and perception of female teachers in selected public schools in Nnewi LGA of Anambra State, Nigeria about mammography. Method: This prospective cross-sectional study was carried out among the 449 female staff (aged 35-56 years) of the three public Primary and eight public Secondary Schools in Nnewi LGA. Simple random sampling was used to enlist 250 consenting female teachers from these schools for the study. A structured questionnaire containing fifteen research questions was used for data collection which was validated by two experts and a pilot study was done in one of the schools. The reliability coefficient obtained using the Cronbach alpha technique for the study was 0.71. The chi-square test statistics were used to analyze the data at a 0.05 level of significance. Result: A total of 125 completed questionnaires were returned and used for the study. The study showed that 108(84.8%) of the respondents had knowledge of mammography before the study. 105(84%), 85(68%), 75(60), and 35(28%) of the respondents aged 46—56 years sourced information about mammography through social media, family/friends, radio, and awareness campaigns respectively. Out of the 125 respondents, only 8 (6.4%), have undergone mammography examination and out of these 7(5.6%) had a tertiary level of education. Age and educational qualification significantly influence the perception of the school teachers (p < 0.05) towards mammography examination. Conclusion: There is a high awareness of mammography examination in the studied population through social media. The level of awareness and compliance to mammography examinations when medically indicated were affected by age, educational qualification (p < 0.005), and fear of possible breast cancer positive result respectively. BACKGROUND OF THE STUDY According to WHO, breast cancer, is the most common cancer globally, accounting for 12% of all new cases of cancer. It is also the second most common cause of death in the world. 1,2 . In Nigeria, there are more than 100,000 cases of breast cancer per year. It constitutes 12% of new cases of cancer in Nigeria and 25% of all cancers in women 2 . The more depressing thing about breast cancer in Nigeria is that it is on the increase. The incidence of breast cancer from 1966 to 1969 was 13.7%. Between 1998 and 1999, it rose to 24.7% while by 2009 to 2010 it has reached 54.3 %. 3. As of 2012, Ibadan Cancer Registry (IBCR) gave age Standardized Rate (ASR) for breast cancer as 520 per 100,000 while the figure from Abuja Cancer Registry (ABCR) was 64.6% 3. These figures are alarming and require urgent action Most breast cancers are found in women over 50 years whose risk of developing cancer ranges from 1.6% to 3.6%3. In Nigeria, breast cancer cases are on the increase as a result of urbanization and lifestyle changes. It is the leading cause of cancer deaths in Nigeria. Breast cancer usually starts as small growths in the breast which are often too small to be felt. Some symptoms of the disease include pain in the breast, nipple discharge, irritation and dimpling of the breast skin, and changes in size or shape of the breast1. Risk factors for breast cancer include but not limited to being a female, exposure to oestrogen, increasing age, radiation therapy to the breast, family history of breast cancer and alcohol intake4 While breast cancer starts as small growths in one corner of the breast, (usually in the breast ducts or lobules), it can grow to affect the whole breast and even spread by both direct contact and metastasis (the commonest cause of death) to other organs of the body. Breast Cancer comes not only with high morbidity but also with high mortality. Survival rate after diagnosis was, in the time past, depressingly low. Improvement in treatment outcome from the early 1980s came with the introduction of a multi-modal approach to treatment anchored on early detection of the disease. Early detection of breast cancer takes its root from awareness of the people of what the disease is all about, the presenting signs and symptoms, the fact that there is available cure, the need for and where to seek help as well as the accessibility, effectiveness and affordability of such help. One of the earliest activities expected at the health facilities when patients come to seek help is early and correct diagnosis of the health condition. For cancer patients, this could make the big difference between survival and death. For the health workers, the consulting room diagnostic procedure for lumps generally is by palpation. This unfortunately is not good enough for breast cancer the lump of which becomes palpable only after about the 30th division of the cancer cells which may take up to two years. In other words, by the time cancer growth becomes detectable by palpation, the disease is already two years old in the body. And this is greatly inimical to effective and complete recovery following treatment. There is thus a need for more sensitive modes for the early detection of cancer. The leading tool for breast cancer screening which is detecting small lumps of cancer before they become palpable by hand is mammography 2. Mammography is the process of using low-energy X-rays to examine the human breast. Other imaging modalities such as ultrasound, thermography, magnetic resonance, positron emission tomography (PET), scinti-mammography, optical imaging, electrical impedance based imaging and computed tomography (CT) can serve as a tool for screening, for diagnosis, staging, patient follow-up and for diagnosis of breast pathology. Ultrasound is used mostly as a useful tool in describing abnormalities detected in mammograms especially in the dense breasts but its sensitivity declines in detecting non-palpable tumours. Magnetic resonance imaging (MRI) is the best imaging modality for the diagnosis of breast cancer because it does not involve harmful radiation but it is more expensive than other imaging modalities and it lacks specificity. PET/CT increases the accuracy of images by adding atomic image registration and localization. Scinti-mammography and PET can be used as adjunct imaging tools for detecting and staging breast cancers but they lack sensitivity to detect small tumors. Optical imaging makes use of near infrared wavelength to detect lesions inside the breast. It is suitable for dense breasts, to image large and palpable abnormalities, and used when multiple tumors are suspected but it is expensive5. The added advantages mammography has over other breast examination modalities are that it is cheap, readily available and it helps in the detection of tiny-palpable tumors and small abnormal tissue growth confined to the milk duct in the breast. It has reduced radiation risk and no side effect5. Also, mammography has proven to have a significant impact in screening asymptomatic individuals. Despite awareness and availability of mammography, one of the things that can affect the patronage of the procedure by the population is their perception of the procedure. Like many others, the word “Perception” has multiple but closely related definitions depending on the source of the definition. Perception can be said to be “the ability to see, hear, or become aware of something through the normal human senses of sight, hearing, taste, smell and touch, Perception can also be seen as “the way that someone thinks and feels about a company, product, service”. In psychology, it is a process by which individuals organize and interpret their sensory impressions in order to give meaning to their environment” 6. Perception is of the mind. It is the outcome of a mental process that takes place in the thalamus and cerebral cortex of the brain utilizing selected, and not all, stimuli captured by the body’s sense organs. All of these stimuli are not utilized in the process in which the outcome manifests as perception. Only those stimuli selected by the organs form the starting point of the process. This selection is based on so many factors which may include spatial configuration, pattern, brightness, loudness, intensity, peculiarity, and others. In addition, there are certain other attributes or dispositions of the perceiver which affect his perception of events, conditions or individuals. These will include the perceiver’s interest, expectations, attitude, motive, mood, socio-cultural cum religious background, economic status, educational level and even cognitive structure. The great importance of perception lies in the fact that it eventually transforms into realities forming the basis of the perceiver’s actions. These actions may range from such everyday activities or choices such as what to eat or drink wear or live, to more serious choices like schools to attend, ventures and investments to embark upon, projects to engage in and even medical facilities or services to access or accept. Before the advent of mammography, breast examination for any disease entity followed largely the standard medical physical examination sequence of inspection, palpation, percussion, and auscultation. While this served its purpose at a time, the peculiar nature of the breast and the seriousness of some of the diseases that may befall it clearly made it necessary that any device or procedure that could enhance the diagnosis of breast diseases will be much welcome. Mammography examination fell in that category. Mammography finds ready uto se in both screening and diagnosis of breast diseases, especially tumors. Knowing the ravages breast cancers cause, it is no surprising mammography found early use in cancer screening and diagnosis. While the incidence of breast cancer in the developed world is as high as twice that of developing countries, Nigeria inclusive, mortality from breast cancer in developed countries is now on the downward trend while that of developing countries keeps rising. The difference takes its root from the fact that developed countries have developed and put into practice, programs aimed at diagnosing breast cancer at early stage when it is easily amenable to treatment while in developing countries patients still present in late stages of the disease. One of the tools used in this early diagnosis of breast cancer is mammography and this is known to reduce breast carcinoma mortality by 63%7. Studies have shown that the awareness of mammography among women has not been very encouraging. In the study conducted among women attending outpatient clinics of University College Hospital Ibadan, Western Nigeria, Obajimi et al (2013) 8 established that the proportion of patients who have knowledge about mammography was as low as 5%.. However, in another similar study conducted among secondary school Teachers in Owerri Imo State Nigeria, 42.5% of the study population have heard about mammography9 but another related study in Port Harcourt Rivers State, showed that average of 23.5% women have heard about Mammography as a breast cancer screening tool10.The awareness of mammography is also poor among female health professionals and civil servants ranging from 5% to 40.5% 11, 12 but high awareness level of 80.7% has been reported13 . It is important to note that hearing about mammography does not translate to having adequate knowledge of the procedure nor an inducement to the hearers to make use of mammography when medically indicated. In the study by Akhigbe and his group 13, while 80.7% have heard about mammography, only 23.7% of the respondent had a very good knowledge about the importance of screening mammography 13 and this is a very poor outcome. Also, the situation is not different even among some health professionals. Similarly, in another related study conducted among female health professionals in Lagos state, only fourty- two (5.1%) of the women had previously heard of mammography. Of these, two women (4.8%) knew that mammography was a picture or photograph of the breast while one (2.4%) said that it is an X-ray taken to check the condition of the breast. There were six respondents (7.2%) who knew that it is used for breast cancer detection while the remainder 33 (78.6%) of those aware only heard about it as a screening method for breast disease but were unaware of what it is or how it is done 14. The different levels of in-depth knowledge of mammography can be attributed to the quantum and accuracy of the different sources of information about mammography. Such sources would include family and friends, books, magazines, social media, Radio, Television, health awareness campaigns, talks at Clinic 9,13,8. This was also highlighted in a study conducted on breast cancer and mammography awareness among women attending General Out- Patient Clinics of Ain Shams University Hospitals Egypt. The researchers found out that Television (42.9%) was the greatest source of information on mammography. Others were Internet (23.9%), Clinic talks (22.6%), Radio and Newspapers (3.9% each) (Manzour et al, 2019)7. These findings collaborated an earlier study which found that television accounted for 68.2%, Newspapers (83.2%), Family and friends (28.6%), and Health care providers (14.1%) of the awareness on mammography 15 There are factors that influence the sources through which information about mammography gets to the potential users. These would include cultural and religious factors as well as age, educational level, and socioeconomic status. This was collaborated by related studies which found out that 71.7% and 71.4% of the women who have heard of mammography actually had tertiary level of education respectively 13,12. The whole essence of imparting the knowledge about mammography is to induce the hearers into making use of it either as a screening or diagnostic tool. In the study earlier referred to above, conducted among secondary school Teachers in Owerri Imo State Nigeria, 15.8% have undergone the procedure either as a screening or diagnostic tool 14. Some members of the public may be afraid to undertake the mammography examination probably due to fear of radiation injury, incidental discovery of breast cancer or may find the procedure very embarrassing7. As a result, some people may have an indication to undergo mammography examinations but may not make themselves available for the procedure8. It is therefore obvious that the greatest factor influencing the acceptability or non- acceptability of mammography as a screening tool for breast cancer is the perception of the procedure by the women. This is because perception is the foundation of action or inaction. Therefore, the aim of this study is to assess the perception of mammography by middle-aged women in public schools in Nnewi LGA of Anambra State and the factors that influence such perception in other to enable stakeholders to understand the extent of awareness and acceptance of mammography examination in the locality as a breast cancer screening tool and to develop better strategies in the use of mammography as important diagnostic/screening tool in the fight against cancer in the society. MATERIALS AND METHODS A descriptive survey design was adopted for this study. The study was carried out among 449 female staff (aged 35-60 years) of 11 Primary and Secondary Schools in Nnewi North L.G.A, of Anambra State, Nigeria. Ethical approval for this study was obtained from the Faculty of Health Science and Technology, College of Health, Nnamdi Azikiwe University, Nnewi Campus with reference number NAU/FHST/2021/RAD66. The target populations for this study were all the 449 female staff of the public Primary and Secondary schools in Nnewi North LGA of Anambra State. Returns from those outside the middle age group were discarded. For this study, the middle-aged group was taken to be from age 35 to 56 years as gathered from National Population Commission. A simple random sampling technique was used to enlist 250 consenting female staff of the eleven primary and secondary public schools. A proportionate simple random technique was used in determining the number of questionnaires to be allocated to each school. The questionnaires were pre-tested using ten teachers in one of the selected Secondary Schools and validated by two lecturers in Enugu State University of Science and Technology and Nnamdi Azikiwe University Awka, Nigeria. The primary source of data was obtained through pre-tested questionnaires distributed among all consenting female staff of all the public Primary and Secondary Schools in the LGA. Permissions were first sought and obtained from the Headmasters/Headmistresses and the Principals of the Schools. For each of the schools, the questionnaires were distributed by the researcher directly to consenting female staff of each school visited. They were then requested to fill and return them to the researcher who waited till the close of work each day to collect the completed questionnaires. A total of 250 questionnaires were distributed to the respondents out of which 220 questionnaires were completed and returned. RESULT Out of the 220 respondents that returned their questionnaire (table 1) 95 (41.2%) were outside the middle age group and were thus discarded in line with the exclusion criteria. Those eligible to be in the study group are those in age groups 35-45 years and 46-56 years. The total number (n) of questionnaires used for the study was thus 125 (table 2). Table 1: Classification of returned questionnaires by Age g