Discussion
Design
A combination of both quasi-experimental and observational (case) design should be adopted. The entire intervention would last for about eight weeks, beginning with a period of intensive learning on Breast health education that will encompass knowledge of breast cancer, risk factors, prevention, breast self-examination, and regular taking of mammograms. This packaged lesson would be delivered by a certified health educator for about an hour every day, and will feature presentations, questions and answers, forum discussions, interactive video moments on the five-step method of breast self-examination, counseling session and practicals. A mammography van should be on spot to take mammograms of interested women for 90% discount of the original price.
Proposed chosen site for the intervention
The premises of the Borno state Museum, a place with famous history and cultural heritage, situated within the axis of Maiduguri- the state’s capital is proposed. This site is selected based on the safety and nearness to majority of the Local Government Areas (LGAs), thus allowing for effective participation.
Participants
The inclusion criterion for this intervention involves a focus on all women within the LGAs of Borno state, within ages 18 and 65, irrespective of their cancer history.
Method
Upon arrival at the site, participants would be expected to provide answers to a baseline questionnaire. Information obtained here is crucial to ascertaining eligibility and confirming their telephone numbers in cases of follow-up. More importantly, it will help in accessing the level of knowledge on breast cancer, risk factors, breast self-examination and mammography prior to the intervention through well-structured simple questions. After the intervention, participants would be required to fill theresame set of questionnaire given before the intervention, without having a prior knowledge of this. Health workers would be on standby to help in filling of the questionnaire for women (especially the elderly ones), who can neither read nor write. Furthermore, qualitative data would be collected based on perceived uptake of mammography screening, interviews and open-ended survey questions.
Training Radiographers
A three-day training session is expected to be organized for Radiographers, who will be saddled with the responsibility of taking mammograms of very high diagnostic value.
Availability of an Engineer
A provision would be made for a standby engineer to handle unforeseen technical challenges that may arise from the mammography-machine or automobile-related issues throughout the eight-week duration of the program.
Training of research assistants
Research assistants would be trained to collect valid and reliable data as well as outcome testing.
Involvement of voluntary community health workers
Three weeks prior to the program start date, voluntary health workers in the various primary health care centers distributed across the LGAs in the state would assist in extensive campaigns at water collection points, women’s association meetings and markets especially on market days, where over 90% of women come out to buy and sell. In addition, via posters and open communication. Health workers will be required to organize a brief sensitization lecture to women who visit the health center before the start date on the need to participate in this intervention. They will also help in facilitating meetings when the program kick starts. Health workers conversing with the native language would be required to act as interpreters to transmit key health messages during the intervention process. Incentives have been shown to be an important motivating factor for health workers in this regard and should be made available if possible.
Goal
The primary aim of this will be to reduce breast cancer mortality among rural women by encouraging regular mammography screening.
Objectives
Objectives include raising breast cancer awareness, sufficient knowledge on risk factors and effective breast self-examination.
Theoretical model
The development of this intervention will follow the Health Belief Model (HBM).
Perceived susceptibility: is the belief of an individual that habitual engagement in a particular behavior can lead to acquiring a disease. While delivering presentations, the health educator will expatiate on the risk factors to breast cancer such as hereditary, physical inactivity, excessive alcohol intake, early menarche, late menopause, use of oral contraceptive and hormone replacement therapy, overweight, and obesity. It is expected that participants would start engaging in health protective behaviors such as engaging in exercises, consuming a healthy diet and avoid health risk behaviors like smoking and drinking.
Perceived severity: refers to the belief of an individual of the extent of harm that can result from a disease due to habitual engagement in a behavior. The health educator will further educate the women on the potential negative effect/dangers of breast cancer such as breast hardness and redness, breast lump, severe pains, unintentional weight loss, metastasis, associated high cost of treatment, and finally death. After this, participants are likely to have gotten sufficient knowledge and be convinced of the need to avoid risk factors to breast cancer.
Perceived benefits: this is seen as the belief of an individual about the advantages of suggested methods for reducing the disease. The health educator will demonstrate the five steps of breast self-examination via video clips, a practical session and re-iterate the need for women to undergo mammography screening, as early detection is critical to survival. This is expected to be well received by all participants.
Perceived barriers: refers to the belief of an individual about the actual or imagined cost associated with engaging in a new behavior. The health educator is required to correct misperceptions some people have about going for mammography screening such as fear, or that breast cancer instantly kills. A counseling session will help tackle this. In addition, reassurance of participants on the need to have a mammogram considering the availability of a mammography machine for screening, which saves transport as well as the 90% offered price discount. The participants are likely to view this as an opportunity, one not to miss out on.
Cues to action: is the sudden force influencing an individual to feel the need to take actions. At this stage, the whole message is well digested and assimilated by the participants, and an abrupt force to want to engage immediately in mammography and observe breast self-examination and avoidance of breast risk factors at home.
Self-efficacy: is the confidence in one’s ability to change the behavior. Participants are very hopeful in themselves achieving everything required. This leads to new behavior.
It is important to consider a wide range of factors that can influence breast screening behavior. Cultural factors are one of such. In Borno state, females are not offered there same educational opportunities as compared to males. It is a belief of the people that women should stay at home and be responsible for taking care of the family. This results in high female illiteracy rate. Also, religious values such as gender-bias issues, where women are reluctant to be attended to by male health professionals, is peculiar to this region (13, 14). Social factors such as lack of education and awareness coupled with low income can impede mammography screening uptake. These women are unaware of breast self-examination because of their low level of education, thus are likely to be poor and not have money for taking regular mammograms (14). Finally, psychological factors like fear due to misconception of breast cancer, shyness to share health problems, embarrassment, and previous negative experiences can prevent Nigerian women from going for mammography screening [15].
IMPLICATION
The implementation of this on-site dual approach to breast screening behavior is expected to result in positive health outcomes among underserved women in Borno state. In a systematic review carried out by [7], it was observed in one of the earlier studies that self-examination of the breast among rural women increased from 0 to 93% after extensive health education on breast cancer and breast self-examination, delivered by trained health workers. This agrees with the later findings of [16] on the high statistical correlation between breast education and breast self-examination, with 90.7% of the participants practicing breast self-examination after extensive lectures, pamphlets, and audio-visual aids on breast examination, compared to an initial 0% pre-test. Routine breast self-examination is valuable in noticing early breast changes such as breast lump, which when used in combination with mammography, is very effective in early breast cancer detection and an increased likelihood of survival.
Elsewhere, such awareness emanating from numerous interactive educational sessions prompted 18% of the total population to participate in mammography screening, due to the availability of mammography machines in the health facility, with a high recall rate of 31.6% [17]. Furthermore, a practical component of breast education that involves intensive training on breast palpation using the breast model, and mammography displayed visually in an x-ray film, yielded an uptake of breast self-examination 0.8 times, and mammography 0.7 times. Increased motivation among participants in each unit was noted, with a further clinical breast examination increase rate of 1.3 and 1.5 times for that of mammography [18]. Tracing memory lane down the studies of [19], a well-structured health education material, reduced-price mammograms and a mobile van had a strong impact on mammography use, with 45% of women in the experimental group obtaining mammograms compared with 12% of women at control sites. Such mammogram-seeking behavior has resulted in regular mammography screening, thereby contributing immensely to a 46% reduction in breast cancer mortality [20].
In a joint research carried out by [16], it further reveals that the percentage awareness of risk factors such as age, family history, alcohol consumption, age at menarche and obesity substantially increased with each successive year for the studies conducted over a 4-year period. This affirms a prominent rise in cancer literacy as regards possible risk factors in this group. An expert review discovered that sufficient understanding of the risk factors and practicing health protective behaviors such as physical activity resulted in 20-40% breast cancer reduction. An additional 14% reduction in breast cancer is possible if alcohol use is eliminated or drastically reduced [21]. Communicating health promotion messages to inform and influence individual’s decision that affects health requires several strategies and techniques, which is highly dependent on the intended audience. Taking a closer look at this proposed health promotion intervention, it is seen that the target population (undeserved women), is characterized by low educational levels, low health literacy and low income. Any chosen communication route is one that allows for majority of the audience to be reached. Hence a poster, written in plain language to present health information in a visually appealing, logically organized and comprehensible format with clear headings and bullets is vital. A design that uses an active voice and one that increases comprehension such as use of pictures or graphics to illustrate important points is advised [22]. These posters should be mounted on key areas such as entry to primary health clinics/hospitals, community town halls, markets, entry point to banks and along important roadside /bus stops. Social marketing as a technique to promote mammography screening behavior is yet another strategy, with the four-core marketing mix- product, price, place and promotion to be taken into consideration. Developing an effective press release, directed to news media such as newspapers, TV and radio in particular is a way to achieving this. Such press release should have a strong headline such as “The increasing death rate of breast cancer among women in Borno state- the need for greater awareness on risk factors and breast self-examination, with routine mammography strongly advised”, with a body that is brief and straight to the point. Furthermore, audio-visual materials such as cassettes, compact music discs and DVDs should be made available and sold in the markets and primary health centers at a giveaway price.
Nevertheless, it is imperative to identify some potential difficulties associated with the implementation of this health promotion intervention. The primary barrier is the cost associated with a mobile mammography program [23]. This includes the high cost of maintenance of the mammography unit, mechanical problems with the vehicle, educational services and operational expenses. Secondly, bad weather may have an adverse effect on the machine. Having a dedicated team with an efficient workflow is another challenge. Low literacy level and language issues may also pose an obstacle to preventive services and effective communication of health messages.
