Addressing the disproportionate breast cancer burden in LMICs: Outcomes from an interventional study evaluating preventing teachings in high schools

doi:10.21203/rs.3.rs-3101943/v1

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Addressing the disproportionate breast cancer burden in LMICs: Outcomes from an interventional study evaluating preventing teachings in high schools

https://doi.org/10.21203/rs.3.rs-3101943/v1

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Background:

The WHO opines that the current disproportionate breast cancer burden and poor outcomes in LMICs fuel global inequalities, which are further compounded by a lack of ‘awareness’ in these regions. Targeting teenage high schoolers in these countries has been mooted as a viable solution. This paper evaluates a Harvard-endorsed initiative to achieve this, in what was a global first.

Method:

A 12-month, quasi-experimental (pre-and-post-tests) study of three randomly-selected schools in Southeast Nigeria. Exposure to anti-breast cancer teachings with integrated engagement-enhancing measures was the intervention.

Results:

Compared to 81.3% at baseline, breast cancer awareness was unchanged at one-month post-intervention (OR-1.10; CI 0.96-1.26), but significantly rose to 92.1% at the 12-month mark (OR-0.37; CI 0.26-0.52). Knowledge of breast self-examination (BSE), assessed as a marker of behavioural change, increased steadily. Levels at the baseline were 62.0% and 85.0% lower than that at one (OR-0.38; CI 0.34-0.42) and 12 months (OR-0.15; CI 0.12-0.19), respectively.

General, non-specific breast cancer knowledge did not improve over 12 months, but specifics related to early symptoms and risk factors, did. While, over the 12 months, ‘knowledge’ of preventive behaviours was not consistently improved relative to baseline, its actual ‘practice’ increased at both the one (+13.5%) and twelve (+17.3%) month marks, even though its correct timing only improved after 12 months (+6.9%; p=<0.01) and not at one month (+0.8%; p=0.17).

Even though knowledge among females was consistently higher than in males at all phases, prolonged intervention (at 12 months) not only allowed males to match females on a few parameters, but also ensured that knowledge reversal, evident among males at the one-month mark, became eliminated.

Knowledge among under-15-year-old participants matched that of the older ones on eight of eleven parameters.

Conclusion:

Provided anti-breast cancer interventions focus on specific, not general, messages, and inbuilt measures that enhance engagement (like the repetition of teachings and the inclusion of exam/assessment techniques) are in place, targeting high schools appear reasonably impactful on knowledge and preventive practices for all relevant ages and gender. Such outcomes, known to engender better breast cancer outcomes, might hold the keys to finally stemming the inequalities in LMICs.

Breast cancer

high school

intervention

knowledge

secondary school

teenage

LMICS

Over the years, breast cancer incidence has risen steadily, from just the one-case-in-every-20-women living in the 1960s, to the one-in-eight that is evident in recent years.² Currently, it holds the record, not just as the world’s most commonly diagnosed cancer, but also as the global leading cause of cancer mortality in women.^3-5 It accounts for about 12% of all cancer cases worldwide,⁵ and causes more disability-adjusted life-years lost than any other malignancy.⁴ In 2020, there were 2.3 million new diagnoses of breast cancer globally among women, along with about 685,000 deaths.^3-5 As at the end of 2020, it was either the leading or second leading cause of female cancer-related deaths in 95% (173 of 183) of countries, and the leading cause in 58% (107 of 183), compelling the World Health Organisation (WHO) to state that, if cancer as a significant public health issue is to be addressed, no country’s health ministry should ignore breast cancer.⁵

Between 1990 and 2020, twenty countries, all in the high-income or upper-middle-income (HIC and UMIC) countries, successfully reduced their breast-cancer mortalities by at least 2% per year for three consecutive years, leading to a 40% global reduction in breast-cancer mortality within that period.^5,6 These same countries have 60% of their breast cancer cases diagnosed early (stages I or II).⁵ Unfortunately, these positives do not apply to low- and low-middle-income countries (LMICs),⁶ with the WHO observing that more than 70% of preventable breast cancer deaths occur in women under the age of 70 years in LMICs.⁵ In fact, while the 5-year breast-cancer survival rates are over 90% in HICs like Australia, it is only 66% in India and 40% in South Africa, with Sub-Saharan Africa faring even much worse.⁵ These numbers highlight worrying global disparities.

Worryingly, these numbers are set to worsen. A 2023 Executive Summary by the WHO noted that new breast cancer cases and deaths across all ages and gender in the African region are expected to rise by 91.2% and 93.0% between 2020 to 2040, respectively, comparing poorly to places like Europe (12.8% and 25.5% respectively), Western Pacific (21.0% and 45.2%), South-east Asia (50.7% and 62.3%) and the Americas (39.1% and 52.3%).⁵ These disproportionate burdens make the survival chances of a woman with breast cancer dependent on the country where she lives, with the WHO and experts further arguing that these striking inequalities are being compounded by a lack of ‘awareness’ regarding the benefits of early detection and effective therapies in several LMICs.^3,5,7,8 This work focuses on a new initiative designed to address this poor awareness.

Unchecked, the far reaching effects of these inequalities may stretch beyond health issues. According to the WHO, the central roles women play in societies imply that mitigating the scourge of breast cancer and its associated risks will ultimately protect families, communities and economies, while on the other hand, ignoring them will not only heighten the challenges against gender, equity and socio-economic balance, but will further threaten international peace and security.^4,5 In addition, it is estimated that, for every 100 deaths arising from breast cancer in women under the age 50 years in Sub-Saharan Africa (a region with half of all global breast-cancer deaths), an estimated 210 children would become maternal orphans.⁵ This can further create an inevitable, self-perpetuating social and financial ripple in LMICs. In fact, if current trends remain, burdens from breast-cancer is expected to increase to an annual 2.74 million new cases and 857,000 deaths by 2030, and, thereafter, up to 3.19 million cases and 1.04 million deaths by 2040.⁵ To curtail these, a major and urgent change in direction is needed. This work aims to assist with this.

Sadly, most LMICS lack the universal, government-sponsored anti-breast cancer programmes needed to address the present and impending poor outcomes.^9,10 Fortunately, however, health promotion, by ensuring that women in these countries become ‘breast aware’, offers a realistic, cheap, and sustainable adjunct to all existing anti-breast cancer interventions.¹¹ This is so, because, being breast aware have been shown to help detect breast cancers early^9,12 given that it can stimulate positive behavioural changes (like regular self and clinical breast examinations)¹³ and medical help-seeking^14,15 that ultimately aid breast cancer diagnosis.^16,17 Promoting breast awareness is, therefore, vital in LMICS,^18-20 and might play a role in mortality reduction.^21,22 As already stated, this work evaluates the impact of a novel initiative designed to achieve this.

Pleasingly, health promotion, of which being breast aware is part of, is one of the three pillars of the WHOs Global Breast Cancer Initiative (GBCI) that was established in 2021 on a tripod that also includes timely diagnosis and comprehensive treatment.⁵ GBCI aims to reduce mortality while improving global survival. If its annual goal of 2.5% improvement is achieved, up to 2.5 million lives can be saved over a 20-year period.⁵ To be successful and sustainable, however, the WHO argues that anti-breast cancer efforts need to concurrently support health promotion and empower women.⁵ Unfortunately, given that current efforts are proving to be a formidable task for health-care systems, policy makers, and other stakeholders,⁴ meeting the GBCI stated targets will be hard to achieve without a major re-think in the overall approach to the breast cancer fight. This paper assists with this re-think, and can be considered a direct response to the WHOs GBCI.

This work builds from the viewpoints expressed in fairly recent publications, which all argued that targeting young, mostly teenage adults in high schools of LMICs can assist in addressing the poor statistics from the concerned countries.^1,11,23 Such ‘targeting’ includes the inclusion of anti-breast teachings and other measures that enhance engagements (e.g., repetitions and in-built assessment systems like examinations and quizzes) into the regular curricula of high schools. ‘Engagement’, as has been shown in the cited papers, is lacked by almost all known health promotion activities, but is crucial to any long-term retention of knowledge needed to ensure lasting impact of anti-breast and anti-cervical cancer interventions.^1,11,23-25 In October 2019, in what was a global first, an initiative that inculcated these principles and was endorsed by the Harvard Medical School (Appendix 1) became part of the teachings for students of all ages and gender enrolled in all public high schools in a State of South-east Nigeria. This work evaluates the efficacy of that intervention, with the specific aims being to:

Ascertain the changes in levels of awareness, knowledge and preventive practices against breast cancer over a 12-month period.
Explore the gender differences in knowledge, if any, with respect to any observed changes.
Explore the age differences in knowledge, if any, with respect to any observed changes above.

If found effective, the proposed initiative may provide a model that will offer new dimensions that can provide sustainable, cost-effective, adaptable, and timely complement to anti-breast cancer initiatives in LMICs, in ways that can address the poor outcomes and inequalities highlighted earlier. This paper is part of a larger work that explored breast and cervical cancers. The first part on cervical cancer has already been published.²⁶

The pre-test and post-test quasi-experimental design is a widely established statistical method for the immediate evaluation of the efficacy of new concepts, as is the case with this work.^27,28 It obviates the need for randomisation, and yet allows a dependent variable (like ‘knowledge’, in this work) to be tested before and after an intervention (‘anti-breast cancer teachings’, in this work).^27,29

Participants: The study participants were students from three schools selected from the 261 public senior schools where the proposed initiative have been functional since 2019 in Nigeria’s Anambra State. Anambra State, with a 2016 population of 5,527,800 people,³⁰ is one of Nigeria’s 36 states. As at 2020, Nigeria had an estimated population of 206,139,589, which was 2.61% of the global total.³¹

Recruitment: Participants were recruited with the help of the government ministry in charge of Senior Secondary Schools (SSS) education in Anambra State. A Purposive (Judgement, Selective or Subjective) sampling method, which allows a researcher to rely on his/her own judgment in choosing the participants based on well-defined characteristics pertinent to a study, was used.²⁷ Firstly, this allowed large schools from the 261 to be grouped into three different clusters of female-only, male-only, and mixed/co-educational, each with 30, 25 and 206 schools, respectively. Focusing on large schools, defined as those with 500 or more students across the relevant classes,²⁶ ensures that robust numbers are used.³² The second part of the participant selection was using the stratified random sampling to choose one school from each of the three clusters, in line with the quasi-experimental methods approach for improving study validity.²⁷

Inclusion Criteria: Every male and female student enrolled in the SSS classes I, II and III (the three levels of SSS study in Nigeria) were included in the study. SSS in Nigeria is similar to high schools in some other countries, and both terms are used interchangeably in this work. It was important to include males for a number of reasons. Firstly, given that 0.5%–1% of all breast cancers occur in men,³³ they stand to benefit directly from any empowerment program. Secondly, the required behaviours needed by women to tackle the cancer (clinical examinations, screenings and treatments) will only succeed with financial and moral support from males.¹¹ Finally, every man has woman in his life, and empowering them provides a viable avenue for reaching many more women. Privately-owned schools were excluded from this study, as their set up was not under the supervision of the education body overseeing the targeted schools.

Following the above criteria, the selected schools were (i) New Era Girls Secondary School, Onitsha, for girls-only (ii) Okongwu Memorial Grammar School, Nnewi, for boys-only, and (iii) Kenneth Dike Memorial Secondary School, Awka, for the co-educational/mixed cluster.

Sample Size: This estimate was derived from data obtained from a previous study that focused on a similar student demographic, and found that 84.6% of the participants had heard about breast cancer before an initial intervention.²³ Given this, and allowing for a 95% Confidence Interval and 5% error margin, the estimated minimum sample size needed for this study was 187 for each study phase.

Details of the Campaign (Intervention) and Data collection (Text Box 1): The initiative, code-named the “Arm our Youths (ArOY) Health Campaign”, was developed with significant input from the United States’ Harvard Medical School (Appendix 1). Its key components were the structured anti-breast cancer teachings in the 261 schools mentioned above, along with the two ‘engagement-enhancement’ measures that included ‘examinations or assessments’ and the “repetition of teachings”. Questionnaires were used to concurrently collect data from all three schools. Data collection was at periods corresponding to the different phases of the Study: Phase 1 (at 0-Month or pre-intervention), Phase 2 (at One-month post-intervention), and Phase 4 (at 12-month post-intervention). Unfortunately, Phase 3 (6-month post-intervention) had no data, as the COVID-19 lockdowns were in full force at the time. Phase 4 was partially affected as well, as schools were partly locked down then. Following the principle of “intention to treat”, these phases were retained as such during the analysis.³⁴ Data collection were by resource persons resident in Nigeria.

TEXT BOX 1: THE INTERVENTION AND MEASURES THAT ENSURE ENGAGEMENT

Teachings: The curriculum used for the Campaign was developed using validated content that had been tested in a previous intervention,² and had inputs of the USA’s Harvard Medical School (Appendix 1) and a 28-man multi-stakeholder implementation committee (Appendix 4). The inputs ensured that the final teachings were culturally, religiously, and professionally appropriate for the targeted audience. Civic Education, a subject compulsory for all students, was used for the teachings, so as to ensure that every student in the eligible schools was reached. The teaching for breast cancer covered various aspects of the cancer, which included General Awareness, Risk Factors, Symptoms, and Breast Self-Examination (BSE). Alongside the teachings, books specially made for the campaign were made available to all the participating schools (an average of 10 per school). These were kept in the school libraries, and provided extra sources of knowledge for the participating students. Teachers who anchored the Campaign were required to draw regular attention to these books. Teachings commenced on September 16^th, 2019.
Repetitions: The teachings were repeated for all three classes that make up the senior secondary school (SSS 1, 2, and 3) in Nigeria. These repetitions served as one of the two measures in place for enhancing engagement with the Campaign. Each class has three terms, and 45 minutes was allocated for breast cancer teachings per term (held within week 3 of each school term), implying three repetitions per class over the 12 months of this study. This strategy was in place to maximize the chances of gaining the required pieces of knowledge, sustaining them, and imbibing them to become habits, given that repetitions are known to transform practices into habits.^3,4 In real life, this measure would amount to nine teachings for each cohort throughout their three senior secondary school years.
Examination and Assessment: This, alongside repetitions, was also in place to maximize engagement with the Campaign, and ensured that anti-breast cancer questions were included in all Civic Education examinations (including the mid and end-of-term exams) in the high school classes. Scores from these exams contributed to the final outcomes (pass or fail) for the Civic Education subject.
Campaign Flag-off and Workshops: The Campaign officially commenced following a flag-off ceremony that was officially held on September the 10^th, 2019. Afterward, all the Civic Education teachers, as well as Guidance Counsellors (for schools with no Civic Education teachers), attended a 2-day workshop that was held from September 11^th to 12^th, 2019. These teachers were all trained at these workshops, a measure that helped ensure that their delivery strategies (teachings and assessments) of the Campaign were standardized. A total of 321 teachers from 261 schools (some schools have more than eligible teachers) were split into two groups of roughly equal parts, with each group attending on one of the two days.

Text Box 1 Reference:

Ifediora C, Veerman L, Azuike E, Ekwochi U, Obiozor W. Outcomes from integrating anti-cervical cancer teachings into the curriculum of high schools in a South-Eastern Nigerian State. BMC Public Health. 2022;22(1). doi:10.1186/s12889-022-14231-4
Ifediora CO, Azuike EC. Knowledge and attitudes about cervical cancer and its prevention among female secondary school students in Nigeria. Journal of Tropical Medicine International Health. 2018;23(7):714-723.
Lally P, Gardner B. Promoting habit formation. Health Psychology Review. 2013;7(sup1):S137-S158.
Lally P, Van Jaarsveld CH, Potts HW, Wardle J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology. 2010;40(6):998-1009.
J. How are habits formed: Modelling habit formation in the real world. European Journal of social psychology. 2010;40(6):998-1009.

The Questionnaire (design, despatch, and return): Details of the pre-intervention (Appendix 2) and post-intervention questionnaires (Appendix 3) are in Textbox 2.

TEXT BOX 2: QUESTIONNAIRE STRUCTURE, DESPATCH & COLLATION (APPENDICES 2 AND 3)

The Questionnaires were adapted from the ones used in a similar study.¹¹ The slight modification necessitated piloting, which was done with 20 high school students in the same class as the targeted participants, but who were in schools not selected for the study. Feedback from them, alongside inputs from professional associates, helped with the final pre-intervention (Appendix 2) and post-intervention questionnaires (Appendix 3). The structure of the questionnaires, along with details of their despatch, are revealed in Textbox 2.

STRUCTURE:

The questionnaires for all the phases are 10-page documents divided into 4 parts. Parts 1 and 2 for all the phases are identical. Part 1 (Page 1 on both documents) contained the Introduction, Participant’s Information, and Consent, while Part 2 (Page 2) contained the seven major questions designed for collecting the basic demographics of the participants. Questions 7 and 8 of Page 2 for each questionnaire cover “Awareness” of breast cancer and breast self-examination in each phase. Part 3 is different in Phase 1 compared to Phases 2 and 4, and will be discussed below. Part 4 (pages 7 to 10) on all the questionnaires explored knowledge of cervical cancer, which is not covered in this paper.

Part 3 (Pages 3 to 6) of the Pre-intervention or Phase 1 questionnaire (Additional File 2): This explored knowledge of breast cancer and breast self-examination (BSE). Question 1 focused on Early Symptoms. Question 2 explored Knowledge of BSE, while questions 3 to 7, as well as 10, were designed to collect information on General Knowledge. Question 8 focused on the Risk Factors of Breast Cancers, while questions 11 and 12 explored the actual practices (not knowledge) of Breast Self-Examination. Question 9 explored Attitudes to Breast Cancer, but was not included in this work.

Part 3 (Pages 3 to 6) of the Post-intervention or Phases 2 and 4 questionnaires (Additional File 2): This also explored knowledge on breast cancer and breast self-examination (BSE). Questions 1 to 3 were not included as they did not contribute to this study’s goals. Questions 4 and 5, as well as 10, were designed to collect information on General Knowledge, while Question 6 focused on Knowledge of BSE. Question 7 was on Risk Factors, Question 8 explored the Early Symptoms, while Question 11 was on the actual practices (not knowledge) of Breast Self-Examination. Question 9 explored Attitudes to Breast Cancer, but, as stated earlier, was not included in this work.

DISTRIBUTION:

Questionnaires for Phase 1 (pre-intervention or baseline) were administered in the week starting from September 16^th, 2019, while those for Phases 2 (one-month post-intervention) and 4 (12 months post-intervention) were despatched at the first week of November 2019 and the week starting September 14, 2020, respectively. For each, research assistants (RAs) in Nigeria delivered the questionnaires on days pre-arranged with administrators of the various participating schools. For each school, questionnaires were completed on the same day and time, with the RAs providing the needed guidance. Completed questionnaires were returned the same day.

As stated, data collection for Phase 3 did not eventuate. It was to commence in the first week of April 2020, but, on March 31, 2020, activities in Nigerian schools were suspended due to the COVID-19 pandemic. They restarted on September 7, 2020.

Text Box 2 Reference:

Ifediora C, Azuike E. Sustainable and cost-effective teenage breast awareness campaigns: insights from a Nigerian high school intervention study. Journal of Evaluation in Clinical Practice. 2018;DOI: https://doi.org/10.1111/jep.13101doi:https://doi.org/10.1111/jep.13101

Data Analysis: Data analysis was with the Statistical Package for the Social Sciences, SPSS (IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp, released 2021). Both Descriptive and Inferential components were included. Details are in Textbox 3.

TEXT BOX 3: DATA ANALYSIS)

Using the descriptive component, the key demographics of the participants were summarised as either actual numbers, percentages, or proportions, while the inferential analysis adopted Binary Logistics Regression (BLR) and Chi-square (χ²) to respectively generate the Odds Ratios (OR) and χ² statistics. Also generated were the 95% Confidence Intervals (CIs) and Probability (p) values, of which only p-values of <0.05 were deemed significant.

The variables needed for the BLR analysis are either dependent (outcome) or independent (predictor). Apart from ‘Basic Awareness’, which was explored by the two questions that explored the proportion of participants who have ‘Ever Heard About Breast Cancer’ or ‘Ever Heard of Breast Self-Examination, BSE’, there were two sets of outcome variables. One included a set of 11 questions covering ‘Knowledge Levels’ at the various study phases for the four main aspects of breast cancers covered in this work. These were ‘General Knowledge’ (explored with two questions), ‘Risk Factors’ (3 questions), ‘Early Symptoms’ (3 questions) and ‘BSE’ (3 questions).

The second set was the 16 questions used to explore changes in behaviour from the intervention, including the ‘Actual Practice of BSE’ (2 questions) and the ‘Specific of BSE Techniques’ (Justification for including the BSE is covered in the Discussion). All these questions were among the positively worded ones in the questionnaires (which has both positively and negatively worded questions), as past papers^1,2 show that the positively worded questions are representative of participants' views. The ones chosen for this work were selected to represent the respective breast cancer aspects they fall under, a validated approach that has been used in past studies.³ The three phases of the study (1, 2, and 4) make up the predictor variables. BLR analyses of these main outcome and predictor variables assisted with addressing the first research aim.

To enrich the study, provide deeper insights, and address research aims 2 and 3, the impact of Gender (Males Vs Females) and Age Groups (<15 Vs ≥15 years) on knowledge changes were also explored, with both serving as predictor variables against the same outcome variables above. All the variables used in this work are shown in Appendix 5.

Text Box 2 Reference:

1. Ifediora C, Azuike E. Tackling breast cancer in developing countries: insights from the Knowledge, Attitudes and Practices on breast cancer and its prevention among Nigerian teenagers in secondary schools. Journal of Preventive Medicine and Hygiene. 2018;59(4):282.

2. Ifediora C, Azuike E. Knowledge and attitudes about cervical cancer and its prevention among female secondary school students in Nigeria. Tropical Medicine & International Health. 2018;23(7):714-723. doi:doi:10.1111/tmi.13070

3. Ifediora C, Veerman L, Azuike E, Ekwochi U, Obiozor W. Outcomes from integrating anti-cervical cancer teachings into the curriculum of high schools in a South-Eastern Nigerian State. BMC Public Health. 2022;22(1). doi:10.1186/s12889-022-14231-4

Basic Summary (Table 1)

A total of 2,685, and 2,814 responses were received for phases 1 and 2 respectively, while 500 were returned for Phase 4. In years, the mean ages were 15.93+/-0.02, 15.99+/-0.05 and 16.93+/-0.13 across the three phases, respectively. All other details are summarised in Table 1.

Impact Of the Interventions on Knowledge at the Various Phases (Tables 2A and 2B)

Table 2A shows results from the descriptive statistics, while Table 2B show the inferential outcomes.

Awareness of Breast Cancer and BSE: Basic awareness of breast cancer, as indicated by the proportion of those who had ever heard of it, were 81.3% and 79.9% at phases 1 and 2, respectively, rising to 92.1% at 12 months. The difference between phases 1 and 2 were not statistically significant (OR 1.10; CI 0.96-1.26) but, compared to Phase 4, levels ate phases 1 (OR 0.37; CI 0.26-0.52) and 2 (OR 0.34; CI 0.24-0.48) were significantly lower. Relative to the two post-intervention phases, baseline (Phase 1) awareness of BSE was statistically lower, being 62.0% lower relative to Phase 2 (OR 0.38; CI 0.34-0.42) and 85.0% lower at Phase 4 (OR 0.15; CI 0.12-0.19). Compared to Phase 4, knowledge at Phase 2 was also 61.0% lower (OR 0.39; CI 0.32-0.49).

General Knowledge: There were no positive changes in General Knowledge for breasts cancers as judged by the two questions that explored these at one and 12-month marks relative to the baseline (Table 2A). In fact, relative to the baseline, knowledge that ‘BSE can detect cancer’ was statistically reversed after one month (-3.8%; p = 0.01), even though it became statistically indifferent at the 12-month mark (-0.4%; p = 0.88).

Early Symptoms: The knowledge on all three questions were significantly raised across board at the one-month and 12-month marks post-intervention.

Risk Factors: After one month, there were increases in the correct knowledge of all three questions, even though only two of these three (‘lumps in armpits’; +15.2%; p = <0.01 and ‘one-sided nipple discharges; +9.6%; p = <0.01) were significant. At 12 months, however, knowledge levels were increased significantly for all three.

BSE: The changes here were not consistently improved at both the one and 12-month marks. Of the three questions, only the one on timing (‘BSE is best done after 7-10 days post period onset’) was statistically increased at one month (+5.5%; p=<0.01). At 12 months, however, this knowledge became statistically insignificant relative to the baseline (+3.9%; p=0.12). Knowledge that ‘BSE is for all women aged 20 years or older’ was not statistically increased at one month (+1.0%; p = 0.50), even though level at the 12-month, it was (+8.2%; p = <0.01). Knowing that ‘BSE should be done monthly’ showed no statistical improvements at either the one or 12-month marks.

Phase 4 Compared to Phase 2: Overall, when compared to knowledge at the one-month post intervention (Phase 2), knowledge levels at 12 months (Phase 4) were either statistically increased (in three of the 11 parameters) or remained the same (eight of the 11).

Impacts of Gender and Age on Various Knowledge Variables (Tables 3 and 4)

Gender: Table 3 shows the comparisons for both gender, while Table 4 shows each gender in isolation. At Phase 1, knowledge levels among males were below that for females on nine of the 11 variables explored, while at Phase 2, they were lower on all 11. At Phase 4, however, they became statistically non-different on three of the 11, remaining lower on eight. Among the females only, knowledge at Phase 1 were significantly lower in 10 of 11 parameters relative to Phases 2, and in seven of 11, relative to Phase 4. The trend in males-only were strikingly different, as Phase 1 levels were actually higher than those at Phase 2 in six of the 11 parameters (with the other five being statistically non-different). At the 12-month mark (Phase 4), however, baseline knowledge in males became lower on two of the 11, and non-different on the remaining nine.

Age (Table 3): Knowledge between the under-15-year-olds and the 15-or-older participants were statistically non-different on nine of the 11 parameters at baseline, with one being better than the other in one of the remaining two. Post intervention, however, knowledge improvements for the younger group were less on three parameters in each of phases 2 and 4, with similarities on the remaining eight.

Impacts of the Intervention on BSE Practices/Behaviours (Tables 5A to 5B)

As shown in tables A and 5B, Phase 1 participants were 44% less likely to have ever practiced BSE relative to those at Phase 2 (OR 0.56; CI 0.50-0.64), and 52% less likely than those at Phase 4 (OR 0.48; CI 0.39-0.60), recording +13.5% and +17.3%, respectively. Despite these increases, the proportion that practiced BSE at the right time (monthly) only became statistically significant at Phase 4 with a +6.9% increase at 12 months (p=<0.01), having just recorded a fractional and insignificant change at Phase 2 (+0.8%; p=0.17).

Fourteen other components that captured specifics of BSE were also explored (Tables 5A and 5B). Twelve of the 14 were statistically increased at both phases 2 and 4, with the averages being +8.0% and +10.1%, respectively. Relative to Phase 2, participants at Phase 1 were statistically indifferent in terms of the monthly (right time) practice of BSE, but were 62% less likely to do so compared to those at the 12-month mark (OR 0.38; CI 0.26-0.56).

Table 6 presented the impact of the knowledge of various aspects of BSE on the actual practice and timing. It was found that those who have heard about breast cancer were just over one-and-half times more likely to have practised a BSE (OR 1.65; CI 1.35-2.03), even though the improvements in correct timing among them was not significant (OR 1.34; CI 0.81-2.22). In contrast, those who have heard about BSE (not just the cancer) improved significantly on both the practice (OR 2.35; CI 2.07-2.67) and correct timing (OR 1.54; CI 1.15-2.05). Correct knowledge of the three other questions asked on BSE were all associated with a significantly increased likelihood of practising BSE.

Compared to a 2018 study of a similar group, the 81.3% of participants that had heard about breast cancer in this work was similar to the 84.6% from then, while the 32.8% that did same for BSE was much lower than its corresponding 55.2%.²³ Post-intervention, the numbers for breast cancer was statistically unchanged at one month (+1.4%; p=0.19) but rose significantly at 12 months (+10.8; p=<0.01), while that of BSE increased significantly and steadily at both the one (+23.7%; p=<0.01) and 12-month (+43.9%; p=<0.01). A head-to-head comparison of post-intervention knowledge levels at 12 months relative to one month, suggest that, even though improvements were only observed in three of the 11 parameters, none was statistically reversed in the remaining eight, implying that knowledge gained at one-month post-intervention were largely sustained at 12 months, and even further improved in a few (Table 2). These are all important observations, as they appear to suggest that prolonged interventions with inbuilt repetitions and other engagement-enhancing measures might be linked to increase in the overall awareness of breast cancers and BSEs.

Following from above, this work went on to find that participants who were aware of both breast cancer and BSE were statistically more likely to practice BSEs at one and 12 months post intervention, mostly with the correct techniques (Table 6). Getting the BSE done at the right time, however, required prolonged intervention, but that too, was achieved after 12 months. This later observation is in contrast to that from a previous study, which lacked repetitions and examination assessments needed to enhance engagement, and observed no such increase in BSE practice after six months.¹ This would appear to make the case that long-term interventions, with in-built engagement measures, might be the key to entrenching the desired behavioural changes. Replicating such on a widescale in LMICs might contribute to the mitigation of the identified breast cancer inequalities explained earlier, given that such knowledge is associated with positive behavioural changes^13-15 that ultimately enhance breast cancer diagnosis.^16,17

It should be noted that, even though controversies exist about BSEs, as, in isolation, it does not lead to reductions in the rates of breast cancers,³⁵ its inclusion in this work is as part of the overall push for being ‘breast aware’, and serves as a marker for detecting the impact of this study’s impact on behaviour. This work does not promote it in the age group targeted, even though experts have argued that, in low-resource LMIC settings where late-stage at diagnosis pervade, teaching BSE might play a role in mortality reduction as it improves awareness and stimulates earlier diagnosis.^8,21,22

While significantly increased knowledge levels were observed at both the one and 12-month post-intervention phases for ‘specific’ aspects of breast cancer like ‘early symptoms’ and ‘risk factors’, this was not the case for the ‘non-specific, general knowledge’, where none of the two questions that assessed it was improved at either the one or 12-month marks. This whole pattern replicates observations from the previous study, which ultimately recommended that anti-breast cancer interventions should not be generalised, but rather focused on specific aspects like symptoms, risk factors, practices, and timing.¹ To be effective, it appears, any breast cancer intervention in LMICS might ensure specific teachings.

This work also provided some insights on how the integration of males into anti-breast cancer interventions, a key feature its proposed principles, actually work. While females had statistically better knowledge at baseline (on nine of the 11 assessing questions) and at the one-month mark (on all 11), prolonged intervention (at 12 months) appears to let males to close the gap a bit, as they matched the females on three of the 11 at this stage, even though the females remained statistically better on the remaining eight. Curiously, assessing males in isolation (Table 4) revealed that their baseline knowledge were statistically better than at one-month post-intervention (in six of 11 parameters), suggesting a potentially negative impact if the intervention is brief. However, after 12 months, the levels picked up, with knowledge actually becoming better on two of the 11, and statistically non-different on the remaining nine. Even though future qualitative research may be needed to unravel the real cause of this short term knowledge reversal, the practical implication might be that interventions have to be repetitive and prolonged if any meaningful impact on males are to be realised.

The observation that knowledge of younger participants (<15 years) matched those of the older ones on eight of the 11 parameters at both the one and 12-month post-intervention marks might imply that targeting younger participants can be equally effective, and partly justifies the inclusion of all three classes of senior secondary schools. However, the significantly lower levels on three parameters in each of the post-intervention phases may support the caution from the authors against the push by some stakeholders to extend the anti-cancer campaign to the junior classes. Most of the younger ones in junior classes may not be very matured to handle such lessons. Moreso, there is also a chance that such teachings may be misunderstood by parents, whose children might not have even attained puberty at those younger classes. The fine balance needed for intervention in junior schools can be worked out on a case-by-case basis by stakeholders in various communities in LMICs.

Strengths and limitations

One strength is the inclusion of pre-tests and post-tests. This allowed the documentation of baseline knowledge, making the quantification of observed changes feasible. A second strength is the inclusion of males. This allowed insights on how a gender that is not hugely affected by a cancer can become part of an intervention. A third strength was that, in addition to ‘Knowledge’, a measure of self-reported the ‘Preventive Practices’ (BSE) was assessed, giving a glimpse on how the knowledge translated to behavioural change.

Despite the strengths, a few limitations are also acknowledged in this work. One derives from the very nature of quasi-experimental designs. They cannot establish outcome causalities and also lack the ability to randomize, thereby potentially limiting their widespread applicability.²⁷ To mitigate these limitations and increase validity, introducing a measure of randomness in choosing study participants is recommended,²⁷ and, as is evident in the Methods, this work adopted that, thereby further strengthening it.

A second limitation came from the potential impact of the COVID-19 lockdowns and school closures, which led to no data being was collected at Phase 3 (6-month mark), while that at Phase 4 (12 months) was limited. Teachings during the lockdown were also not possible, and this might have had an unquantifiable impact on the levels of knowledge garnered.

A third limitation may be attributable to the inability to do the study longer than 12 months. The implication is that the potential impact after the students in SSS III might have left school (post-intervention impact), could not be assessed.

Summary and Recommendations:

Findings from this work indicate that anti-breast cancer interventions to high school students, even though largely impactful on behaviour and practice, can only be sustained in an effective and all-encompassing manner if engagement-enhancing measures (like assessments/examinations and repetitions) are all in place over time, not short term. There are benefits to both knowledge and actual practice. Not included in this work, but potentially valuable for entrenching engagement, is a system that can reward participation. For instance, prizes to winners of inter-class or inter-school quiz competitions can further incentivize both the students and their teachers.

Ensuring that the teachings focus on specific aspects of breast cancer (symptoms, risk factors, and so on), and not just general talks, might be essential to any success. As such, we recommend that policy makers include teachers’ training exercises that will guarantee this, in any plan to roll out this initiative. The researchers have an online training portal to this effect, and similar versions may be necessary.

Finally, there is a huge potential for this measure to benefit all gender and age groups in all three classes of high schools, and these are recommended, particularly the inclusion of males. Each location can adapt these as it suits them.

Ethics Approval and Consent for Participate: This study was approved by the Griffith University Human Research Ethics Committee (GU Ref No: 2019/649). Informed consent' was obtained from all the parents of the participants. The Participant Information Sheet (Page 1 of Appendices 2 and 3) made clear that participation was voluntary, and that Consent was implied with procession to questionnaire-completion. The relevant governmental agencies were involved, and consents were also obtained from school principals and parents. Institutional guidelines from the Griffith University were followed for this study.

Consent for Publication: Not applicable.

Availability of data and materials: All data generated or analysed during this study are available on Figshare via: https://doi.org/10.6084/m9.figshare.23538246.v1.

Competing Interest:

Assoc Prof Christian Ifediora: He is the founder of the Foundation involved in delivering the campaign being evaluated.
Prof Lennert Veerman: No competing interests.
Prof Williams Obiozor: No competing interests.
Dr Obinna Ifediora: No competing interests.

Funding: No external source of funding was received.

Acknowledgements: The support and co-operation of the Otuocha Post Primary Schools Service Commission (PPSSC) Educational Zone of Anambra State, Nigeria, is hereby acknowledged. The assistance from Dr Emmanuel Azuike and Prof Uche Ekwochi are also appreciated.

Author Contributions:

Assoc Prof Christian Ifediora (Principal Researcher); (Family Medicine); OCI Foundation (Nigeria) and Griffith University (Australia). Contributed to all aspects of the study’s design, field work, and writing up. Emails: [email protected] and [email protected].
Prof Lennert Veerman (Co-Principal Researcher); (Public Health); Griffith University, Australia. Contributed to all aspects of the study’s design, field work, and writing up. Email: [email protected].
Prof Williams Obiozor (Adult Education); Nnamdi Azikiwe University, Awka, Nigeria. Contributed to all aspects of the study’s design, field work, and writing up. Email: [email protected].
Dr Obinna Ifediora (International Security), the University of Queensland, Australia. Contributed to all aspects of the study’s design, analysis, and writing up. Email: [email protected].

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Table 1: Demographics and characteristics of three senior secondary schools in South-east Nigeria

S/N	Variables		Phase 1 (N = 2685) Pre-Intervention	Phase 2 (N = 2814) 1-Month Post-Intervention	Phase 4 (N = 500) 12-Month Post-Intervention
1	Age (Years)	Mean (SE*)	15.93 (0.032) (N=2559)	15.99 (0.049) (N=2555)	16.93 (0.130) (N=500)
1	Age (Years)	SD*	1.603	2.458	2.904
2	Age Ranges (Years)	<15	405 (15.8%)	505 (19.8%)	50 (10.0%)
		≥15	2154 (84.2%)	2050 (80.2%)	450 (90.0%)
			(N = 2559)	(N = 2555)	(N = 500)
3	Gender	Male	1153 (44.3%)	1039 (67.3%)	161 (34.3%)
		Female	1451 (55.7%)	505 (32.7%)	308 (65.7%)
			(N = 2604)	(N = 1544)	(N = 479)
4	Gender of School	Boys- only	661 (25.1%)	601 (23.0%)	127 (26.3)
		Girls-only	726 (27.5%)	1012 (38.7%)	213 (44.1%)
		Mixed	1251 (47.4%)	1002 (38.3%)	143 (29.6%)
			(N = 2638)	(N = 2615)	(N = 483)
5	Class of Study	SSS* 1	712 (28.2%)	1061 (40.4%)	8(1.7%)
		SSS* 2	959 (38.0%)	853 (32.5%)	3 (0.6%)
		SSS* 3	851 (33.7%)	713 (27.1%)	472 (97.7%)
			(N = 2522)	(N = 2627)	(N = 483)

NOTES*: N: Number; SE: Standard Error; SD: Standard Deviation; SSS: Senior Secondary School

TABLE 2A: PROPORTIONS, FREQUENCIES, AND CHANGES OF AWARENESS AND KNOWLEDGE ON ASPECTS OF BREAST CANCER WITH INTERVENTION IN HIGH SCHOOLS

S/N	Questions	Correct Phase 1 Responses Baseline/0-Month Pre-Intervention	Correct Phase 2 Responses One Month Post-Intervention (Change from Baseline; with p-values)	Correct Phase 4 Responses 12 Months Post-Intervention
S/N	Questions			Correct (%)	Change from Baseline	Change from One Month Post
AWARENESS (Part 2: Questions 7 and 8 in Appendices 2 and 3)
1	Ever heard of Breast Cancer?	81.3%	79.9% (-1.4%) p = 0.19	92.1%	+10.8 p = <0.01*	+12.2% p = <0.01*
2	Ever heard of breast self-exam (BSE)?	32.8%	56.5% (+23.7%) p = <0.01*	76.7%	+43.9% p = <0.01*	+20.4% p = <0.01*
KNOWLEDGE
General Knowledge (Part 3: questions 2 to 7, as well as 10 in Appendix 2; Questions 4 to 6, and 10 in Appendix 3)
1	Breast cancer occurs in women ≥ 20 years	53.6%	54.0% (+0.4) p = 0.77	55.7%	+2.1% p = 0.42	+1.7% p = 0.52
2	Breast self-exam can detect cancer	62.6%	58.8% (-3.8%) p = 0.01*	62.2%	-0.4% p = 0.88	+3.4% p = 0.21
Risk Factors (Part 3: Question 8 in Appendix 2; Question 7 in Appendix 3)
3	Early onset of Periods	23.2%	35.3% (+12.1% p = <0.01*	30.9%	+7.7% p = <0.01*	-4.4% [p = 0.08]**
4	Having no babies	15.0%	31.3% (+16.3%) p = <0.01*	30.7%	+15.7% p = <0.01*	-0.6% p = 0.82
5	Breast Cancer in Family	24.4%	35.0% (+10.6%) p = <0.01*	32.8%	+8.4% p = <0.01*	-2.2% p = 0.42
Early Symptoms (Part 3: Question 1 in Appendix 2; Question 8 in Appendix 3)
6	Lumps in breasts	59.9%	61.2% (+1.3%) p = 0.37	67.2%	+7.3% p = 0.01*	+6.0% p = 0.02*
7	Lumps in armpits	26.7%	41.9% (+15.2%) p = <0.01*	46.0%	+19.3% p = <0.01*	+4.1% p = 0.15
8	One-sided nipple discharges	36.4%	46.0% (+9.6%) p = <0.01*	52.3%	+15.9% p = <0.01*	+6.3% p = 0.03*
Breast Self-Examination, BSE (Part 3: Question 2 in Appendix 2; Question 8 in Appendix 3)
9	BSE is for all women aged ≥20 years	52.7%	53.7% (+1.0%) p = 0.50	60.9%	+8.2% p = <0.01*	+7.2% p = <0.01*
10	BSE should be done monthly	39.0%	40.2% (+1.2%) p = 0.42	37.4%	-1.6% p = 0.55	-2.8% p = 0.31
11	BSE is best done 7-10 days after a period	26.2%	31.7% (+5.5%) p = <0.01*	30.1%	+3.9% p = 0.12	-1.6% p = 0.52

NOTES: - P = Probability Value (These were obtained from Binary Logistics Regression, details of which are in Table 2B below) - Appendix 2 = Questionnaires for Phase 1 - Appendix 3 = Questionnaires for Phase 2 and 4 - *Statistically Significant - **Negative (Reverse) Significance - Phase 3 data was not collected due to COVID-19 pandemic lockdowns - * Statistically significant - Only positively worded questions in the two sets of Questionnaires (Part 3 of Appendices 2 and 3) were included.

TABLE 2B: BINARY LOGISTICS REGRESSION ANALYSIS ON AWARENESS AND KNOWLEDGE OF VARIOUS ASPECTS OF BREAST CANCER WITH INTERVENTION IN HIGH SCHOOLS

S/N	Questions (Variables)	Phase 1 Vs Phase 2 (N = 5,499)				Phase 1 Vs Phase 4 (N = 3,185)				Phase 2 Vs Phase 4 (N = 3314)
		OR	Lower	Upper	p	OR	Lower	Upper	p	OR	Lower	Upper	p
AWARENESS (Part 2: Questions 7 and 8 in Appendices 2 and 3)
1	Ever heard of Breast Cancer?	Number (N) = 5240				N = 3134				N = 3096
		1.10	0.96	1.26	0.19	0.37	0.26	0.52	<0.01*	0.34	0.24	0.48	<0.01*
2	Ever heard of breast self-exam (BSE)?	N = 5195				N = 3103				N = 3080
		0.38	0.34	0.42	<0.01*	0.15	0.12	0.19	<0.01*	0.39	0.32	0.49	<0.01*
KNOWLEDGE
General Knowledge (Part 3: questions 2 to 7, as well as 10 in Appendix 2; Questions 4 to 6, and 10 in Appendix 3)
1	Breast cancer occurs in women ≥ 20 years	N = 4718				N = 2880				N = 2674
		0.98	0.88	1.10	0.77	0.92	0.75	1.13	0.42	0.93	0.76	1.15	0.52
2	Breast self-exam (BSE) can detect cancer	N = 4768				N = 2894				N = 2704
		1.17	1.04	1.31	[0.01]**	1.02	0.82	1.26	0.88	0.87	0.70	1.08	0.21
Risk Factors (Part 3: Question 8 in Appendix 2; Question 7 in Appendix 3)
3	Early onset of Periods	N = 4637				N = 2793				N = 2654
		0.55	0.49	0.63	<0.01*	0.68	0.54	0.85	<0.01*	1.22	0.97	1.54	0.08
4	Having no babies	N = 4497				N = 2674				N = 2547
		0.39	0.34	0.45	<0.01*	0.40	0.31	0.51	<0.01*	1.03	0.81	1.31	0.82
5	Breast Cancer in Family	N = 4477				N = 2678				N = 2519
		0.60	0.53	0.68	<0.01*	0.66	0.52	0.84	<0.01*	1.10	0.87	1.40	0.42
Early Symptoms (Part 3: Question 1 in Appendix 2; Question 8 in Appendix 3)
6	Lumps in breasts	N = 4739				N = 2836				N = 2695
		0.95	0.84	1.07	0.37	0.73	0.58	0.92	0.01*	0.77	0.62	0.97	0.02*
7	Lumps in armpits	N = 4554				N = 2739				N = 2541
		0.51	0.45	0.57	<0.01*	.428	.342	.536	<0.01*	0.85	0.68	1.06	0.15
8	One-sided nipple discharges	N = 4590				N = 2741				N = 2575
		0.67	0.60	0.76	<0.01*	0.52	0.42	0.65	<0.01*	0.78	0.62	0.97	0.03*
BSE (Part 3: Question 2 in Appendix 2; Question 8 in Appendix 3)
9	BSE is for all women aged ≥20 years	N = 4952				N = 2936				N = 2922
		0.96	0.86	1.08	0.50	0.72	0.58	0.88	<0.01*	0.74	0.61	0.91	<0.01*
10	BSE should be done monthly	N = 4525				N = 2746				N = 2533
		0.95	0.85	1.07	0.42	1.07	0.86	1.34	0.55	1.12	0.90	1.41	0.31
11	BSE is best done 7-10 days after periods	N = 4534				N = 2610				N = 2619
		0.76	0.67	0.87	<0.01*	0.83	0.65	1.05	0.12	1.08	0.85	1.38	0.52

TABLE 3: GENDER AND AGE INFLUENCES ON BREAST CANCER KNOWLEDGE

S/N	Questions (Variables)	GENDER (Males Vs Females)			AGE GROUP (<15 years Vs ≥15 years)
S/N	Questions (Variables)	Phase 1 (OR) p-value	Phase 2 (OR) p-value	Phase 4 (OR) p-value	Phase 1 (OR) p-value	Phase 2 (OR) p-value	Phase 4 (OR) p-value
General Knowledge (Part 3: questions 2 to 7, as well as 10 in Appendix 2; Questions 4 to 6, and 10 in Appendix 3)
1	Breast cancer can occur in any woman aged ≥20 years	0.57 (0.48-0.67)	0.26 (0.22-0.31)	0.43 (0.28-0.65)	0.91 (0.73-1.13)	0.90 (0.73-1.11)	0.63 (0.34-1.18)
1	Breast cancer can occur in any woman aged ≥20 years	<0.01*	<0.01*	<0.01*	0.40	0.32	0.15
2	Breast self-exam (BSE) can detect cancer	0.43 (0.36-0.50)	0.20 (0.17-0.24)	0.48 (0.31-0.74)	0.79 (0.63-0.99)	0.76 (0.62-0.94)	0.49 (0.26-0.93)
2	Breast self-exam (BSE) can detect cancer	<0.01*	<0.01*	<0.01*	0.04*	0.01*	0.03*
Risk Factors (Part 3: Question 8 in Appendix 2; Question 7 in Appendix 3)
3	Early onset of Periods	1.84 (1.51-2.23)	0.72 (0.60-0.87)	0.86 (0.55-1.36)	1.54 (1.20-1.97)	1.21 0.97-1.50	1.39 (0.71-2.74)
3	Early onset of Periods	<0.01*	<0.01*	0.52	<0.01*	0.09	0.34
4	Having no babies	1.16 (0.92-1.47)	0.39 (0.32-.48)	0.31 (0.18-.54)	1.25 (0.93-1.69)	0.91 (0.72-1.15)	1.75 (0.88-3.49)
4	Having no babies	0.20	<0.01*	<0.01*	0.14	0.43	0.11
5	Breast Cancer in Family	1.35 (1.12-1.64)	0.44 (0.36-0.54)	0.55 (0.34-0.89)	1.15 (0.89-1.48)	1.08 (0.87-1.35)	0.74 (0.34-1.58)
5	Breast Cancer in Family	<0.01*	<0.01*	0.02*	0.31	0.51	0.43
Early Symptoms (Part 3: Question 1 in Appendix 2; Question 8 in Appendix 3)
6	Lumps in breasts	0.45 (0.37-0.53)	0.23 (0.19-0.27)	0.51 (0.32-0.80)	0.91 (0.73-1.14)	0.96 (0.77-1.18)	0.23 (0.12-0.47)
6	Lumps in breasts	<0.01*	<0.01*	<0.01*	0.42	0.68	<0.01*
7	Lumps in armpits	0.73 (0.60-0.88)	0.34 (0.28-.41)	0.31 (0.21-0.50)	0.86 (0.66-1.11)	0.79 (0.63-0.98)	0.34 (0.16-0.75)
7	Lumps in armpits	<0.01*	<0.01*	<0.01*	0.25	0.04*	0.01*
8	One-sided nipple discharges	0.72 (0.60-0.85)	0.28 0.24-0.34	0.66 0.42-1.02	1.04 0.83-1.31	0.85 (0.69-1.05)	0.62 (0.31-1.25)
8	One-sided nipple discharges	<0.01*	<0.01*	0.06	0.74	0.13	0.18
BSE (Part 3: Question 2 in Appendix 2; Question 8 in Appendix 3)
9	BSE is for all women aged ≥20 years	0.72 (0.61-0.84)	0.39 (0.33-0.48)	0.71 (0.47-1.06)	0.81 (0.65-1.01)	0.90 (0.73-1.10)	0.84 (0.44-1.60)
9	BSE is for all women aged ≥20 years	<0.01*	<0.01*	0.09	0.06	0.28	0.60
10	BSE should be done monthly	0.80 (0.67-0.94)	0.41 (0.34-0.50)	0.53 (0.34-0.84)	0.94 (0.75-1.18)	1.02 (0.82-1.27)	0.72 (0.35-1.47)
10	BSE should be done monthly	P=0.01*	<0.01*	0.01*	0.59	0.85	0.37
11	BSE is best done 7-10 days after periods	0.59 (0.49-0.72)	0.45 (0.37-0.55)	0.48 (0.29-0.79)	0.82 (0.63-1.07)	0.47 (0.37-0.61)	0.78 (0.37-1.67)
11	BSE is best done 7-10 days after periods	<0.01*	<0.01*	<0.01*	0.14	<0.01*	0.53

TABLE 4: GENDER-SPECIFIC COMPARISONS OF BREAST CANCER KNOWLEDGE OVER TIME

S/N	Questions (Variables)	MALE ONLY		FEMALE ONLY
S/N	Questions (Variables)	Phases 1 Vs 2 (Number; n=2139) (Odds Ratio, OR) Probability, P-value	Phases 1 vs 4 (n=1316) (OR) P-value	Phases 1 Vs 2 (n=3045) (OR) P-value	Phases 1 vs 4 (n=1762) (OR) P-value
General Knowledge (Part 3: questions 2 to 7, and 10 in Appendix 2; Questions 4 to 6, and 10 in Appendix 3
1	Breast cancer can occur in any woman aged ≥20 years	1.59 (1885) (1.32-1.92)	1.10 (n=1200) (0.77-1.57)	0.73 (n=2670) (0.62-0.85)	0.82 (n=1593) (0.62-1.09)
1	Breast cancer can occur in any woman aged ≥20 years	<0.01*	0.60	<0.01*	0.17
2	Breast self-exam (BSE) can detect cancer	1.88 (n=1870) (1.56-2.26)	0.97 (n=1187) 0.68-1.38	0.89 (n=2736) 0.75-1.06	1.09 (n=1620) 0.82-1.46
2	Breast self-exam (BSE) can detect cancer	<0.01*	0.84	0.18	0.55
Risk Factors (Part 3: Question 8 in Appendix 2; Question 7 in Appendix 3)
3	Early onset of Periods	0.90 (n=1900) (0.74-1.11)	0.98 (n=1188) 0.67-1.45	0.35 (n=2579) 0.10-0.43	0.46 (n=1515) 0.34-0.63
3	Early onset of Periods	0.30	0.94	<0.01*	<0.01*
4	Having no babies	0.79 (n=1825) 0.62-1.00	0.97 (n=1146) 0.59-1.57	0.26 (n=2517) 0.22-0.32	0.26 (n=1445) 0.19-0.36
4	Having no babies	0.05	0.89	<0.01*	<0.01*
5	Breast Cancer in Family	1.19 (n=1813) 0.96-1.47	1.14 (=1145) 0.75-1.72	0.39 (n=2510) 0.32-0.46	0.46 (n=1451) 0.34-0.63
5	Breast Cancer in Family	0.11	0.55	<0.01*	<0.01*
Early Symptoms (Part 3: Question 1 in Appendix 2; Question 8 in Appendix 3)
6	Lumps in breasts	1.46 (n=1904) 1.22-1.75	0.63 (n=1201) 0.44-0.91	0.74 (n=2685) 0.63-.88	0.72 (n=1555) 0.52-0.98
6	Lumps in breasts	<0.01*	0.01*	<0.01*	0.04*
7	Lumps in armpits	0.85 (n=1871) 0.69-1.05	0.69 (n=1183) 0.46-1.04	0.39 (n=2539) 0.33-0.46	0.30 (n=1477) 0.22-0.40
7	Lumps in armpits	0.13	0.07	<0.01*	<0.01*
8	One-sided nipple discharges	1.23 (1881) 1.01-1.50	0.53 (n=1183) 0.37-0.77	0.49 (n=2563) 0.42-.570	0.49 (n=1480) 0.37-0.66
8	One-sided nipple discharges	0.04*	<0.01*	<0.01*	<0.01*
BSE (Part 3: Question 2 in Appendix 2; Question 8 in Appendix 3)
9	BSE is for all women aged ≥20 years	1.43 (n=2010) 1.20-1.71	0.74 (n=1253) 0.52-1.04	0.79 (n=2806) 0.68-0.92	0.72 (n=1608) 0.56-.95
9	BSE is for all women aged ≥20 years	<0.01*	0.08	<0.01*	0.02*
10	BSE should be done monthly	1.435 (n=1890) 1.18-1.75	1.38 (n=1189) 0.93-2.04	0.74 (n=2511) 0.63-0.87	0.92 (n=1479) 0.69-1.22
10	BSE should be done monthly	<0.01*	0.11	<0.01*	0.55
11	BSE is best done 7-10 days after periods	0.94 (n=1825) 0.75-1.18	0.94 (n=1120) 0.60-1.46	0.72 (n=2564) 0.61-0.84	0.75 (1451) 0.56-1.02
11	BSE is best done 7-10 days after periods	0.60	0.77	<0.01*	0.07

TABLE 5A: PROPORTIONS, FREQUENCIES, AND CHANGES ON BREAST SELF-EXAM (BSE) AND ITS ACTUAL TECHNIQUES WITH INTERVENTION IN HIGH SCHOOLS

S/N	Questions	Correct (%) Pre-intervention Responses (Baseline)	Correct (%) One Month Post-Intervention Responses	Correct 12-Month Post-Intervention Responses
S/N	Questions		(Change from Baseline) Probability, P-value	Correct (%)	Change from Baseline	Change from One Month Post
Actual Practice of BSE (Part 3 Questions 11 and 12 in Appendix 2; Question 6 in Appendix 3)
1	Ever Done Breast Self-Exam, BSE?	31.7%	45.2% (+13.5%) p = <0.01*	49.0%	+17.3% p = <0.001*	+3.8% p = 0.15
2	Practice Monthly BSE	3.4%	4.2% (+0.8%) p = 0.17	10.3%	+6.9% p = <0.001*	+6.1% p = <0.01*
Specifics of BSE Techniques (Part 3: Questions 11 and 12 in Appendix 2; Question 11 in Appendix 3)
3	Stand in front of a mirror	51.3%	59.1% (+7.8%) p = <0.01*	62.8%	+11.5% p = <0.01*	+3.7% p = 0.14
4	Lie down	26.3%	41.3% (+15.0%) p = <0.01*	35.5%	+9.2% p = <0.01*	-5.8% p = [0.03]**
5	Right hand for Left breast & vice versa	45.1%	54.2% (+9.1%) p = <0.01*	61.6%	+16.5% p = <0.01*	+7.4% p = 0.01*
6	Use Finger Pads/Pulps	30.5%	43.7% (+13.2%) p = <0.01*	48.2%	+17.7% p = <0.01*	+4.5% 0.11
7	Use Three middle fingers	18.8%	29.7% (+10.7%) p = <0.01*	30.4%	+11.6% p = <0.01*	+0.7% p = 0.78
8	Move fingers in circular motions	38.2%	46.3% (+8.1%) p = <0.01*	49.0%	+10.8% p = <0.01*	+2.7% p = 0.34
9	Move fingers in vertical strips	35.4%	43.8% (+8.4%) p = <0.01*	45.1%	+9.7% p = <0.01*	+1.3% p = 0.64
10	Fingers can be moved in Wedges	32.7%	41.0% (+8.3%) p = <0.01*	42.4%	+9.7% p = <0.01*	+1.4% p = 0.60
11	Press nipples one after the other	40.3%	42.7% (+2.4%) p = 0.10	48.7%	+8.4% p = <0.01*	+6.0% p = 0.03*
12	Examine armpits	34.8%	46.3% (+11.5%) p = <0.01*	50.7%	+15.9% p = <0.01*	+4.4% p = 0.12
13	Examine breast size and shape	44.0%	47.9% (+3.9%) p = 0.01*	47.0%	+3.0% p = 0.27	-0.9% p = 0.75
14	Look for nipple deviation/drawn in	37.5%	35.3% (-2.2%) p = 0.13	40.6%	+3.1% p = 0.24	+5.3% p = 0.05
15	Raise opposite hand	36.9%	45.5% (+8.6%) p = <0.01*	44.2%	+7.3% p = 0.01*	-1.3% p = 0.63
16	Undress to waist	30.2%	37.7% (+7.5%) p = <0.01*	37.2%	+7.0% p = 0.01*	-0.5% p = 0.86
	AVERAGES FOR BSE TECHNIQUES	35.9%	43.9% (+8.0%) (p likely <0.01)	46.0%	+10.1% (p likely <0.01)	+2.1% (p likely >0.05)

TABLE 5B: BINARY LOGISTICS REGRESSION ANALYSIS ON KNOWLEDGE CHANGES IN BREAST SELF-EXAM (BSE) AND ITS ACTUAL TECHNIQUES WITH INTERVENTION IN HIGH SCHOOLS

S/N

Variables

(Statements)

Phase 1 Vs 2 (5,499)

Phase 1 Vs 4 (3185)

Phase 2 Vs 4 (3314)

Lower

Upper

Lower

Upper

Lower

Upper

Knowledge BSE (Part 3 Questions 11 and 12 in Appendix 2; Question 6 in Appendix 3)

Ever Done BSE?

Number (N) = 4569

N = 2899

N = 2506

0.56

0.50

0.64

<0.01*

0.48

0.39

0.60

<0.01*

0.86

0.70

1.06

0.15

Practice Monthly BSE

N = 4569

N = 2899

N = 2506

0.81

0.60

1.09

0.17

0.31

.211

.454

<0.01*

0.38

0.26

0.56

<0.01*

Specifics of BSE Techniques (Part 3: Questions 11 and 12 in Appendix 2; Question 11 in Appendix 3)

Stand in front of a mirror

Number (N) = 4713

N = 2851

N = 2734

0.73

0.65

0.82

<0.01*

0.62

0.51

0.77

<0.01*

0.85

0.69

1.06

0.14

Lie down

N = 4468

N = 2711

N = 2551

0.51

.446

.574

<0.01*

0.65

0.52

0.81

<0.01*

1.28

1.02

1.60

0.03*

Use right hand for Left breast and vice versa

N = 4493

N = 2735

N = 2560

0.70

0.62

0.78

<0.01*

0.51

0.41

0.63

<0.01*

0.74

0.59

0.92

0.01*

Use Finger Pads/Pulps

N = 4448

N = 2690

N = 2526

0.57

0.50

0.64

<0.01*

0.47

0.38

0.59

<0.01*

0.84

0.67

1.04

0.11

Use Three middle fingers

N = 4330

N = 2622

N = 2452

0.55

0.48

0.63

<0.01*

0.53

0.41

0.68

<0.01*

0.97

0.76

1.229

0.78

Move fingers in circular motions

N = 4429

N = 2679

N = 2518

0.72

0.64

0.81

<0.01*

0.65

0.52

0.80

<0.01*

0.90

0.72

1.12

0.34

Move fingers in vertical strips

N = 4393

N = 2664

N = 2501

0.70

0.62

0.80

<0.01*

0.67

0.54

0.83

<0.01*

0.95

0.76

1.18

0.64

Fingers can be moved in Wedges

N = 4403

N = 2663

N = 2508

0.70

0.62

0.79

<0.01*

0.66

0.53

0.82

<0.01*

0.94

0.76

1.17

0.60

Press nipples one after the other

N = 4405

N = 2667

N = 2510

0.90

0.80

1.02

0.10

0.71

0.57

0.88

<0.01*

0.79

0.63

0.98

0.03*

Examine armpits

N = 4387

N = 2651

N = 2494

0.62

0.55

0.70

<0.01*

0.52

0.42

0.65

<0.01*

0.84

0.68

1.05

0.12

Examine breast size and shape

N = 4382

N = 2656

N = 2496

0.86

0.76

0.96

0.01*

0.89

0.71

1.10

0.27

1.04

0.83

1.29

0.75

Look for nipple deviation

N = 4381

N = 2653

N = 2496

1.10

0.97

1.24

0.13

0.88

0.70

1.09

0.24

0.80

0.64

1.00

0.05

Raise opposite hand

N = 4423

N = 2673

N = 2524

0.70

0.62

0.79

<0.01*

0.74

0.60

0.92

0.01*

1.06

0.85

1.31

0.63

Undress to waist

N = 4392

N = 2674

N = 2498

0.72

0.63

0.81

<0.01*

0.73

0.59

0.92

0.01*

1.02

0.82

1.28

0.86

TABLE 6: BINARY LOGISTICS REGRESSION ANALYSIS SHOWING THE RELATIONSHIP BETWEEN KNOWLEDGE OF ASPECTS OF BSE AND THE ACTUAL PRACTICE OF BSE

S/N	Knowledge BSE	Has Ever Done BSE	Correctly Timed BSE Monthly
1	Ever Heard of Breast Cancer? (n=2966)	1.65 (1.35-2.03)	1.34 (0.81-2.22)
1	Ever Heard of Breast Cancer? (n=2966)	p = <0.01*	0.25
2	Ever Heard of Breast Self-Exam (BSE)? (n=2950)	2.35 (2.07-2.67)	1.54 (1.15-2.05)
2	Ever Heard of Breast Self-Exam (BSE)? (n=2950)	p = <0.01*	p = <0.01*
3	BSE is for all women aged ≥20 years. (n=2790)	1.59 (1.36-1.85)	1.22 (0.86-1.73)
3	BSE is for all women aged ≥20 years. (n=2790)	p = <0.01*	0.26
4	BSE should be done monthly. (n=2488)	1.38 (1.17-1.61)	1.48 (1.04-2.10)
4	BSE should be done monthly. (n=2488)	p = <0.01*	0.03*
5	BSE is best done 7-10 days after periods. (n=2538)	1.19 (1.01-1.40)	1.60 (1.12-2.29)
5	BSE is best done 7-10 days after periods. (n=2538)	0.04*	0.01*

Competing interest reported. Assoc Prof Christian Ifediora, the lead author, is the founder of the Foundation involved in delivering the campaign being evaluated.

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Addressing the disproportionate breast cancer burden in LMICs: Outcomes from an interventional study evaluating preventing teachings in high schools

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