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Breast Cancer Awareness among Rural Women in Terengganu, Malaysia

1* Wan Suliana Wan Sulong, 2Harmy Mohammed Yusoff, 1Zainab Mohd Shafie, 1Farrahdilla Hamzah, 1Nor Ayliwati Ali

1School of Nursing Science, Faculty of Medicine, UniSZA, Gong Badak Campus, 21400 Kuala Nerus, Terengganu

2 Faculty of Medicine, UniSZA, Medical Campus, 20400 Kuala Terengganu, Terengganu

*Corresponding Author Email:

Received: 2nd November 2022 Accepted: 24th December 2022 Published:17th January 2023 ABSTRACT

In Malaysia, breast cancer cases show increasing in numbers especially those diagnosed at the advanced stages and becoming a high health burden to the country. Most of these cases are reported in rural areas. The late presentation at the time of diagnosis resulted in a low survival rate and poor prognosis to the affected women. This study conducted to determine the level of knowledge, attitude, and the perception toward breast cancer especially among women in rural Terengganu. A cross-sectional study was conducted in 2017 among 383 women in rural areas in Terengganu. Multivariable analyses using multiple logistic regression revealed that perceived barrier scores (p < 0.002) were found to be significantly associated with preventive activities after controlling the cofounders. This study revealed that women in rural Terengganu have good awareness of breast cancer, including general knowledge and its’ risk factors but they perform poorly when it comes to its preventive activities. There is a crucial need to increase the awareness regarding breast cancer so that early intervention can be carried out because the worrying number of advanced cases are reported from the rural area in Malaysia.

Keywords: breast cancer, breast cancer awareness, rural


Breast cancer is the commonest cancer in women, and it’s become the main cause of cancer-related morbidity and mortality globally. It shows increasing trends in developing and developed countries where the incidence rate has surpassed other types of cancer (WHO, 2018). In Malaysia, breast cancer is currently on a rising number and most cases are presented at the advanced stage, especially among women in rural areas. Based on Malaysia National Cancer Registry 2012- 2016, breast cancer showed a rising number of cases from 18,206 to 21,634 between 2007 to 2011 and 2012 to 2016.

The highest age specific incidence of breast cancer in Malaysia is among the age group of 45 to 69 years old regardless the ethnicity (Azizah et al., 2019). Better cancer treatment selection, a higher survival rate and increased in the quality of life for affected women are related with early detection of breast cancer through preventive activities (Lee et al., 2019). According to clinical practice guideline - management of breast cancer (3rd ed.), early detection is very vital because almost half (47.9%) of the reported cases of breast cancer was diagnosed at the advanced stages.

Malaysia Ministry of Health recommended an opportunistic mammogram for women, but its uptake is wide-ranging along the countries and the screening is difficult because of low awareness and the accessibility of the test in the rural areas (Htay et al., 2021). A strong belief in complementary and

alternative therapies also influence the affected women and delayed them to seek out for the appropriate treatment. They presented at the health care facilities at the advanced stage of the disease and limit the treatment alternatives that can be offered to them. The women especially in rural area did not grasp the opportunity to involve in preventive activities despite having several risk factors for the disease throughout their lives due to lack of understanding of the purpose, how to get involve and the importance of early breast cancer screening.

Several studies have been reported worldwide in various populations and categories to determine the level of breast cancer awareness and its screening practices, especially among women. Globally, most of the women have the knowledge of breast cancer which includes the general knowledge, risk factors and its screening activities but the practice toward the preventive activities basically is low (Liu et al., 2018; Shah P. et al., 2020; Wu & Lee, 2019). In similarity, there were studies in Malaysia also reported the same result (Ali et al., 2019; Nurulhuda et al., 2018). This finding is mostly related to the health belief where if they are not perceived susceptible to have breast cancer, they were less likely to involve in preventive behaviour (Hochboum, 1958). But after engaging in the health education sessions through face-to- face seminars, web based or mass media health campaign and screening program, the awareness of the disease is boosted thus improved the practices towards the screening


activities (Nurulhuda et al., 2018; Wu & Lee, 2019;

Schliemann et al., 2020).

Awareness of breast cancer provides women with the knowledge of the disease thus will enhance the practices of early screening (Akhtari-Zavare et al., 2015; Yip et al, 2015) provided with the availability of the screening programs (Yilmaz & Durmus, 2016) and correct information regarding the screening activities (Aidalina & ASJ, 2018). The awareness of breast cancer among women is associated with the health seeking behavior where their belief is influencing the action to engage in health-protection behaviours which leads to screening practice (Hochbaum, 1958). According to this health belief model (HBM), women that highly perceived severity and susceptibility to have breast cancer were more likely to involve in preventive behaviour. This model also believes that women with high health motivation have more benefits and feel fewer barriers to participate in breast cancer awareness programs relating to early detection such as Breast Self-Examination (BSE), Clinical Breast Examination (CBE) and mammograms.

Similar findings have been documented in several study regarding breast cancer awareness among urban and rural women all over the world. They found that knowledge of breast cancer is significantly lower among rural women compared to urban women therefore the uptake of the screening activities is lower among them (Norlaili et al., 2013; Sayed et al., 2019;

Schliemann et al., 2022; Tran, L., & Tran, P. ,2019). HBM emphasises the uptake of screening will increase if a woman perceives her susceptibility in developing breast cancer due to personal risk factors or she beliefs that breast cancer is a serious problem that will affect the quality of life if present at a later stage of the disease (Hochboum, 1958). Women in urban area were more aware of breast cancer and most of them practiced early screening due to availability of screening programs (Akhtari-Zavare et al., 2015) and correct information regarding the screening activities (Aidalina & ASJ, 2018). In contrast to women in rural area, women in urban find the information about breast cancer from more variable resources such as internet, mass media, friends and also health care providers (Al- Dubai et al., 2011; Schliemann et al., 2020).

Unfortunately, rural women have lack of opportunity to gather information regarding the disease and its preventive activities compared to urban women due to lack of information resources (Mohan et al., 2021), distant of health care facilities (Farid et al., 2014) and strong belief of complementary and alternative treatments (Fouladi et al., 2019).

Therefore, awareness to join early screening of breast cancer as a preventive measure is an important task aimed at reducing the number of mortality and morbidity cases among women, especially those residing in rural areas in Malaysia.

Breast cancer screening activities are crucial to be promoted either through formal or informal health education campaign or screening program to increase awareness and improve uptake of the activities at the community level. Although preventive activities cannot stop the occurrence of breast cancer, but it provides a better treatment choice, lower cost of treatment, and offer good prognosis if the cancer is diagnosed at the earlier stage.

Thus, it’s increasing the researcher’s interest in focusing on improving women’s knowledge regarding the breast health including the knowledge about breast cancer, its’ risk factor and breast cancer screening activities especially for those women resides in rural Malaysia. This study tries to determine the level of knowledge, attitude, and the belief toward breast cancer especially among women in rural Terengganu.

2. MATERIALS AND METHODS Study design and sample size.

This cross-sectional study conducted from December 2016 until April 2017 involving rural area in Hulu Terengganu: Klinik Kesihatan Kuala Berang and Klinik Kesihatan Kuala Telemong, and one area in Dungun: Klinik Kesihatan Bukit Besi. Rural area in this study is defined as an area that is located 35 km from the main city, Kuala Terengganu and these clinics were selected given that they are located more than 40 km and 95 km. The researcher selects these clinics for the study since a significant number of breast cancer cases were retrieved from the cancer registry book at the Surgical Out-Patient Department Clinic, Hospital Sultanah Nur Zahirah for the whole Terengganu are came from these areas. A cross-sectional study design was employed in this study due to its cost-effectiveness, capability of handling a large number of respondents using a survey method, and less time- consuming. This study involves women aged between 20 and 60 years who had been interviewed by opportunistic approached during their follow up care or health visit at the clinics. The respondents were able to read and understand the questionnaire, no history of mental illness and residing in the rural area for at least five years. The exclusion criteria are health care personnel and women who have breast diseases.

The sample size was calculated using the means with population standard deviation, width of confidence interval and margin error (Naing, 2003). Sample size obtained for this study was 383 with 95% confident interval and margin error from women who attending health clinics in rural Terengganu.

Study frame and data collection

A systematic sampling method was used in this study in which women attending rural health clinics were sampled at regular intervals. In the study area, the number of patients attended to in the Outpatient Department is approximately 200 people per day. The female patient is two third of total patients. The researcher will select eligible female patients from the list to become the respondent. Hence, the researcher was able to select 20 respondents daily to answer the questionnaire. The researcher proceeded with the data collection after the approval from National Medical Research (NMR) of Ministry of Health Malaysia (MOH), and “Jabatan Kesihatan Negeri Terengganu (JKNT). The respondent was approached during their visit to health clinic, informed about the study, and a written consent was obtained. The objective of the research also explained to the respondents. Respondents were then allocated 10 to 20 minutes to response to the questionnaire.

They were allowed to ask the researcher for any clarification if they had any doubt while completing the questionnaire. The questionnaire was collected upon completion from each respondent.

(3) Study Instrument

The questionnaire was adopted from the Champion Health Belief Model relative to the Malaysian culture (Champion, 2008). The instrument consisted of three parts; Part A recorded the respondents’ socio-demographic background.

Part B focused on the knowledge of breast cancer, comprising general knowledge, knowledge of breast cancer risk factors, and related preventive activities/measures. Part C comprised questions about the perception of breast cancer using the HBM. The present questionnaire through the process of forward and backward translation, content validation and face to face validation and modified to Malay language. The pilot study was conducted to test the suitability of the questionnaire used for the rural women. It includes the clarity of the questions, the suitability of the comprehension and socio- cultural needs, and the required time needed to fill the questions. The pilot study was conducted in Kuala Terengganu district, a different area from the actual study location. A total of 30 individuals from the public participated in the pilot study. The overall reliability of the questionnaire was good with a Cronbach Alpha of 0.910, ranging from 0.85 to 0.90 represents a good level of stability (Bolarinwa, 2015).

Questionnaire that assesses the knowledge of general, risk factors and preventive activities of breast cancer showed good internal consistency with a Cronbach’s Alpha of 0.834. While the perception towards breast cancer which used HBM models also showed good consistency with Cronbach’s Alpha of 0.922. Questionnaire were revised and improved according to the comment and suggestion to ensure clarity, language- appropriate and correct sequencing.

Data analysis

Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0. Descriptive analysis was used to analyse the demographical data. Meanwhile, a Multiple Logistic Regression (MLR) analysis was employed to answer the research questions relating to factors associated with knowledge of breast cancer among rural women. Several variables such as correct BSE techniques, preventive activities, and demographic variables (i.e., age, marital status, occupation, and educational level) were tested using single logistic regression. Thereafter, the significant factors were subjected to further analysis using MLR.


Table 1 showed the result of mean values for age is 34.3 years old. Most of the respondent were married (75.2%), single (20.6%) and the others are widowed (4.2%). Almost all of them are Malay (99%) and more than half of them at least have attended primary level of education (60.6%) involving either ordinary, Islamic religious school, or secondary school. The mean number of children was 2.33 (2.44). More than half of the women breastfeed their babies (60.6%) and practiced family planning (37.6%).

Table 1: socio-demographic characteristics of the respondents (n=383)

Variables Frequency (%) Mean (SD)

Age 34.35 (9.56)


Malay 382 (99.7)

Chinese 1 (0.3)

Marital status

Single 79 (20.6)

Married 288 (75.2)

Single mother 16 (4.2)


Student 23 (6.0)

Housewife 222 (58.0)

Others 138 (36.0)

Education status

Primary level 232 (60.6)

Secondary level 91 (23.8)

Tertiary level 60 (15.7)

Number of children 2.33 (2.44)


No 151 (39.4)

Yes 232 (60.6)

Practice of family planning

No 239 (62.4)

Yes 144 (37.6)

The study also found that almost 340 respondents which account for 88.77 % have moderate level of knowledge regarding breast cancer and only 10.44% of them reflected a low level of knowledge regarding the disease as shown in Figure 1.

Figure 1: Simple bar chart showing the level of knowledge regarding breast cancer among women in rural Terengganu (n = 383)

The maximum score for the general knowledge was 73% while the mean total score was 27.75 (4.05) as shown in Table 2.

Most of them (87.2%) agreed that breast cancer is the most common cancer among women and one of the main killers of women in Malaysia (83%). Most of them knew that the healing rate is higher if the cancer is detected at the earlier stage (77.8%) as shown in Table 3. Table 2 shown the maximum score for knowledge of breast cancer risk factors was 58%

with a corresponding total mean score (SD) was 43.9 (8.79).

The knowledge score on risk factors of breast cancer was considered satisfactory as more than half of the women were able to correctly identify its’ risk factors. Among 383 women,


only 42.8% agreed that they were at high risk for breast cancer if their biological mother has the disease while surprisingly 74.1% of them believed they were at risk if their mother-in-law had breast cancer as shown in Table 4. Meanwhile, the total score for the prevention of breast cancer was 42% while the total mean was 8.87 (2.34) per showed in Table 2. The level of knowledge on preventive activities in this study can be concluded as moderate given that they are able to recognize and practice BSE and CBE as a part of useful tools for preventive activities of breast cancer. Table 5 showed more than half of the women were able to correctly answer that BSE should be performed once in a month (61.9%) and annually for CBE (84.3%).

Table 2: Descriptive statistics of knowledge

Items Mean (SD) Minimum Maximum

Total scores of general knowledge about breast cancer

27.75 (4.05) 10.00 38.00

Total scores of knowledge about risk factors of breast cancer

43.9 (8.79) 15.00 75.00

Total scores of knowledge about preventive activities of breast cancer

8.87 (2.34) 5.00 21.00

Table 3: General knowledge on breast cancer among women in rural Terengganu (n =383)

Items Strongly

disagree Disagree Neutral Agree Strongly agree Mean (SD) Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%)

Breast cancer is the most common cancer among women in Malaysia.

11 (2.9) 16 (4.2) 22 (5.7) 207 (54.0) 127 (33.2) 4.10 (0.9)

Breast cancer does not affect young women.

16 (4.2) 42 (11) 51 (13.3) 209 (54.6) 65 (17.0) 2.31 (1.01)

Breast cancer is an infectious disease.

9 (2.3) 17 (4.4) 43 (11.2) 173 (45.2) 141 (36.8) 1.90 (0.93)

Breast cancer is one of the killers of women in Malaysia.

13 (3.4) 22 (5.7) 30 (7.8) 159 (41.5) 159 (41.5) 4.12 (1.01)

The healing rate is higher if the cancer can be detected in earlier stage.

19 (5) 28 (7.3) 38 (9.9) 182 (47.5) 116 (30.3) 3.91 (1.07)

Inflamed axillary nodes are the sign of breast cancer.

10 (2.6) 28 (7.3) 74 (19.3) 189 (49.3) 82 (21.4) 3.8 (0.95)

Lump or mass in the breast is the sign of breast cancer.

8 (2.1) 26 (6.8) 74 (19.3) 194 (50.7) 81 (21.1) 3.82 (0.91)

(5) Fluid discharge

mixed with blood from the nipple is the sign of breast cancer.

9 (2.3) 24 (6.3) 92 (24.0) 171 (44.6) 87 (22.7) 1.79 0.94)

Table 4: Knowledge of breast cancer risk factors among women in rural Terengganu (n=383) Items


disagree Disagree Neutral Agree Strongly agree Mean (SD) Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%)

I am at high risk for breast cancer if my mother has breast cancer.

41 (10.7) 101 (26.4) 77 (20.1) 118 (30.8) 46 (12.0) 3.07 (1.22)

I am at a high risk for breast cancer if my mother-in-law has breast cancer.

10 (2.6) 19 (5.0) 70 (18.3) 171 (44.6) 113 (29.5) 2.07 (0.95)

As I grow older, the higher the risk I develop breast cancer.

27 (7.0) 91 (23.8) 90 (23.5) 139 (36.3) 36 (9.4) 3.17 (1.11)

Psychological factors such as stress increases the risk of breast cancer.

37 (9.7) 104 (27.2) 130 (33.9) 91 (23.8) 21 (5.5) 2.88 (1.05)

The frequency I undergo chest x-ray or ultrasound increases the risk of breast cancer.

41 (10.7) 140 (36.6) 145 (37.9) 38 (9.9) 19 (5.0) 2.62 (0.97)

The frequent intake of fatty foods and high cholesterol increases the risk of breast cancer.

15 (3.9) 76 (19.8) 114 (29.8) 151 (39.4) 27 (7.0) 3.26 (0.98)

If I start menstruating early (below 12 years old), it increases the risk of breast cancer.

41 (10.7) 132 (34.5) 149 (38.9) 44 (11.5) 17 (4.4) 2.64 (0.97)

If I am menopause at the age of 50, it increases the risk of breast cancer.

39 (10.2) 110 (28.7) 154 (40.2) 64 (16.7) 16 (4.2) 2.76 (0.99)

If I suffer from diabetes, it increases the risk of breast cancer.

47 (12.3) 147 (38.4) 141 (36.8) 39 (10.2) 9 (2.3) 2.52 (0.92)

If I breastfeed a child for two years, it reduces the risk of breast cancer.

20 (5.2) 48 (12.5) 93 (24.3) 145 (37.9) 77 (20.1) 3.55 (1.10)

(6) I am at a high risk of breast cancer if I take alcohol.

29 (7.6) 64 (16.7) 121 (31.6) 132 (34.5) 37 (9.7) 3.22 (1.08)

I am at high risk for breast cancer if I take a family planning pill.

38 (9.9) 107 (27.9) 155 (40.5) 67 (17.5) 16 (4.2) 2.78 (0.99)

I am at a high risk of breast cancer if I smoke.

30 (7.8) 66 (17.2) 102 (26.6) 149 (38.9) 36 (9.4) 3.25 (1.09)

I am not at risk of breast cancer if my husband is smoking.

14 (3.7) 74 (19.3) 135 (35.2) 116 (30.3) 44 (11.5) 2.73 (1.02)

I am not at risk of developing breast cancer if I exercise at least 3 times a week.

26 (6.8) 52 (13.6) 103 (26.9) 152 (39.7) 50 (13.1) 3.39 1.09)

Table 5: Knowledge on preventions of breast cancer among women in rural Terengganu (n = 383)

From multivariable analyses using multiple logistic regression revealed that married women (p < 0.021), perceived barrier scores (p < 0.002) and self-efficacy scores (p < 0.008) were

found to be significantly associated with preventive activities after controlling the cofounders. No interaction and multicollinearity problems were detected. The Hosmer-

Items Frequency (%)

BSE should be done

Once a month 237 (61.9)

Several time in a month 80 (20.9)

Several time in a year 50 (13.1)

Not sure 16 (4.2)

The correct time to do BSE is

During menstruation 53 (13.8)

After menstruation 81 (21.1)

Just before menstruation 16 (4.2)

Anytime 230 (60.1)

Not sure 3 (0.8)

CBE should be done

One time in a year 323 (84.3)

Every 2 years 47 (12.3)

Every 5 years 0 (0.0)

Not sure 13 (3.4)

For the women who are not at risk for breast cancer, mammography should be done at the age of

30 years 255 (66.6)

40 years 100 (26.1)

50 years 20 (5.2)

Not sure 8 (2.1)

For the women who are not at risk for breast cancer, mammography should be done

One time in a year 241 (62.9)

Every 2 years 104 (27.2)

Every 5 years 28 (7.3)

Not sure 10 (2.6)


Lemeshow test (p = 0.052), overall, correctly classified percentage (79.6%), and area under the ROC curve (64.4%;

95% CI: 0.572, 0.715; p < 0.021) were applied to check the fit of the statistical model. Resultantly, the final model indicated that an increase in one unit score of married women increased the odds of engaging in breast cancer preventive activities by 2.67 times (adjusted ORb = 2.67, 95% CI: 1.16, 6.18).

Meanwhile, an increase in a unit score of perceived barriers had 24 percent lesser odds of practicing breast cancer preventive activities (adjusted ORb = 0.976, 95% CI: 0.957, 0.996). An increase in the unit score of self-efficacy was associated with a 10 percent higher odds of preventive activities toward breast cancer (adjusted ORb = 1.10, 95% CI:

1.01, 1.21). Total scores of knowledges about risk factor of breast cancer and health motivation scores also show significant association towards the knowledge in single logistic regression but when analysed further, there result show no association between the variable.

Table 6: Multivariable analysis of associated factors for preventive activities of breast cancer among women in rural Terengganu (n = 383)


Crude ORa (95%


Adjusted ORb (95% CI)

Wald Statisticsb(df)

P Valueb Marital


Single 1.00 1.00 Married 3.18

(1.40, 7.24)

2.67 (1.16,


5.30 (1) 0.021


mother 2.37 (0.54, 10.38)

2.07 (0.46,


0.91 (1) 0.341

Perceived barrier scores

0.969 (0.950, 0.989)

0.976 (0.957,


5.31 (1) 0.021

Self- efficacy scores

1.13 (1.03,


1.10 (1.01,


4.94 (1) 0.026


The mean age (SD) for this study was 34.3 years old (9.56). A study conducted in Jerteh, Terengganu showed that the mean age was 40.48 which is higher from the current study, but the total number of samples was smaller (n=86) (Rosmawati, 2010). Thus, the respondent in the present study is considered a good representation of rural women in the study location.

The result revealed that only a few of them in the study (5.8%) had a low education level compared to the current study with 60.6% of them have attended primary level of education.

Other study conducted among 1192 respondents showed that 38.3% of the respondent were above 51 years old and 48.6%

of them at least attained a secondary level of education. The higher number of respondents from this study was due to larger population which accounted for more than 1.4 million (Farid et al., 2014).

Knowledge on breast cancer (general, risk factors and preventive activities)

The total score for general knowledge in this study is considered satisfactory as more than half of them could identify important information regarding breast cancer and its symptoms despite almost 60% of them attaining only primary educational level. Most of them agreed the disease can affect younger women below the age of 40 years. The respondents were also able to correctly identify breast cancer signs such axillary lymph node inflammation, breast lumps or masses, and nipple discharge. The satisfactory level of general knowledge on breast cancer in the current study may be due to the involvement of younger age group women where they were more flexible in searching for the disease information.

Studied women in several research found to have appropriate understanding about breast cancer where they knew the disease is the most common and the leading cause of death for Malaysian women (Al-Dubai et al., 2011; Hadi et al., 2010;

Akhtari-Zavare et al., 2015; Dahlui et al., 2011). As seen in Al- Dubai et al’s study, 71.2% of the women stated that breast cancer can occur in either or both breasts and 79.4% stated that younger women (below 40 years old) may develop the disease (Al-Dubai et a.l, 2011). Meanwhile in other study, their participants were also able to recognise potential symptoms for breast cancer, such as lump under armpit (73.5%), nipple discharge (72.1%), change in breast shapes (78.2%) and pain in the breast region (78.5%) (Hadi et al., 2010). From the global point of view, research have shown that almost half of respondents have average knowledge about breast cancer and able to identify changes of shape or size of the breast (Heena et al., 2019) is the most common symptoms of the disease. They also were able to recognize swelling or a nodule in the breast and nipple discharge were the most classical signs of breast cancer (Mahfouz et al., 2013; Bogusz et al., 2016).

According to National Breast Cancer Foundation, 2015, there were three major presentations of breast cancer which includes changes in breast appearance, changes in the breast and nipple sensation and also abnormal nipple discharge. If the women lacked in this knowledge, it would cause them to present later to the health care facilities which might result in a more advanced state of the disease being diagnosed.

Knowledge about breast cancer is crucial to women to know what to do if they have any concerns about their health, especially breast problems. Besides that, having good knowledge about breast cancer is beneficial not only to self, but also to family and community.

Knowledge about breast cancer risk factors is vital to women, especially if they belong to the high-risk group. Such knowledge could empower women in understanding the risk of developing the disease and increased participation in appropriate actions, such as engaging in early screening and preventive practices including CBE and mammogram. In this study, knowledge score on risk factors of breast cancer was 58%, which is considered satisfactory as more than half of the women were able to correctly identify its’ risk factors. More than half of the respondents in the current study recognized increasing age, family history of breast cancer, frequent intake


of fatty food and cholesterol, alcohol consumption and cigarette smoking as the common risk factors for breast cancer. Furthermore, women believed if they breast feed their baby for two years, exercise regularly for at least three times per week, consume healthy diet, and avoiding alcohol and cigarette smoking will reduce the chance of developing the disease.

Old age, history of breast cancer among family members, and smoking are the potential factors for breast cancer respectively (Hadi et al., 2010). Likewise, family history, ageing and non-breastfeed women were associated with high risk in developing breast cancer (Dahlui et al., 2012). Meanwhile, from a worldwide perspective, a study conducted among 395 female health workers in Riyadh, Saudi Arabia, found that only 14 to 26% of them correctly stated that regular consumption of high-fat diet, alcohol use, having a first child later in life, early menarche, late onset of menopause and obesity were the potential factors (Heena et al., 2019).

According to the American Cancer Society (2011), women are considered to have good knowledge if they could identify more than four out of the nine risk factors of breast cancer.

The level of knowledge on preventive activities in this study can be concluded as moderate given that they are able to recognize and practice BSE and CBE as a part of useful tools for preventive activities of breast cancer. Almost half of the respondents knew that they should perform monthly BSE, annual CBE and mammogram if they are at higher risk to develop breast cancer in the future. Among the 383 respondents, 323 women knew that CBE should be performed annually but they failed to point out that BSE should be undertaken every month after the cessation of menstruation.

They also recognize mammogram as one of the screening methods, but the uptake was found to be very low among the respondents. These findings might be because they lacked clear information regarding the mammogram test and indirectly misunderstood the procedure as being troublesome.

Although some of the women in the study perceived barriers to performing preventive activities, especially mammograms, they were keen to undergo the procedure if they have been told clearly about it.

In line with that, a finding of the study in 2013 reported that only 41.5% of the 1,960 rural women from selected districts of Pahang and Perak in Malaysia practice of preventive activities against breast cancer (Farid et al., 2014). This finding also consistent with a study conducted among women with family history of breast cancer in Selangor, Malaysia also revealed that those respondents have poor practice of breast screening (BSE: 35.9% , mammogram: 19.1%) although they have significant kin with breast cancer (Subramaniam et al., 2013).The study found that women only practice breast cancer preventive activities if they have enough knowledge regarding breast cancer especially its risk factors, clinical manifestations, and screening activities that available to them.

Moreover, numerous global studies have reported the similar result to the current study where they found although there was an increased knowledge of breast cancer awareness among the participant but the practices toward the screening activities is low (Al Thoubaity, 2019; M., S. L., & G., S. 2017;

Yilmaz & Durmus, 2016). The respondent knew about BSE,

CBE and mammogram but only quarter of them ever been examined by the health care personnel and only few of the had underwent mammogram and breast ultrasound. The practice of BSE also low where only a few of them performed it in regular period (Al Thoubaity, 2019). Similar finding in India, the researcher found that only 3.5 % of the women heard about BSE but none of them practiced it since they did not have the knowledge on how to do it correctly (M., S. L., &

G., S., 2017).

Having knowledge on breast cancer will enable more women to receive treatment at earlier stage if they are able to seek help at the right time before the cancer progressed to advanced stage. It is important to highlight the practice of preventative activities like mammography and CBE so that the suggested preventive measures by the MOH will be more widely utilised by Malaysian women. According to the most recent NHMS, which was conducted in 2019, it reported that the prevalence of BSE practice reduced to 49% while mammogram increased to 21%. From the finding, the current study's prevalence of preventive practices was low because the majority of respondents were in their middle years. Hence, they were not triggered to engage in health screening activities since they believed they were not at risk of developing the disease. The middle-aged women pursue certain healthy lifestyles and believe that these might be substituted for health screenings or other preventive measures. Given that early screening is helpful in identifying diseases in their early stages even when symptoms are not immediately apparent, it should be encouraged among women especially for the middle-aged people.

Breast cancer awareness

Awareness is when a person realised or have the knowledge that something exists. It also refers to understanding a subject based on information or experiences. In current study, breast cancer awareness refers to women’s understanding of breast cancer and its risk factors, their participation in preventive activities including practise of regular CBE, BSE and mammograms as early detection methods, and their commitment to have a healthy lifestyle. These preventive activities are essentials to women as it assists them in detecting any breast changes that might be the early signs of breast cancer.

From a local perspective, research in urban or rural area revealed that numerous of their respondents had moderate to good knowledge and attitudes toward breast cancer, but poor practices associated to engagement in early screening behaviour (Alaudeen & Ganesan, 2019; Ali et al., 2019;

Nurulhuda et al., 2018; Mohan et al., 2021; Schliemann et al., 2020). From those studies, the researchers found that although the women have sufficient knowledge of breast cancer awareness but the uptake of screening activities is very low due to several factors such as young age (Alaudeen &

Ganesan , 2019; Nurulhuda et al., 2018), did not received clear information regarding the disease and screening activities that available (Schliemann et al., 2020, Ali et al., 2019) and the distant to health care facilities (Mohan et al., 2021). However, a previous study found that women who live


in urban area tend to practice early screening programs due to the availability of the screening tools and information of breast cancer (Kanaga et al., 2011; Norlaili et al., 2013). They have more access to information of breast cancer especially from the internet, social media, health care facilities and others (Norlaili et al., 2013). Women in rural areas were less aware compared to those in urban areas, and a significant association was reported between education and awareness (Kanaga et al., 2011). Greater knowledge and awareness of breast cancer, as well as improved positive health behaviours toward preventive activities, are characteristics of the majority of urban women with higher educational levels. These studies emphasised there are crucial needs to improve the knowledge, understand the perception and recognise the sociodemographic barriers among women in prompting them to engage in any breast cancer screening activities. The researchers concluded that women should be educated about breast cancer prior any trials or attempts to join them in the early detection programs.

Many initiatives have been carried out to improve breast cancer awareness among Malaysian, particularly among younger group of women, however the perception that breast cancer affects older women more severely compared to young women still persists (Johnson & Dickson-Swift, 2008). Cases of breast cancer are known to present at a younger age among Indian, Taiwanese, Singaporean and Malaysian as compared to United State of America (Norlaili et al, 2013). Breast cancer was found to affect younger women in Malaysia (Rosmawati, 2010) compared to Western women where it is common in menopausal and post-menopausal women (Chelliah et al, 2013). Most of the women were presented at an advanced stage with a larger tumour size. In line with that, a study in Shah Alam, Selangor found that breast cancer presented in young women at advance stages were more aggressive compared to older women (Al-Dubai, et al, in 2011).

Therefore, increasing breast cancer awareness among young generation especially in Malaysia is critical to enhance the practice of early screening by reducing the fear, denial, myths, and misconception that these women have about the disease.

Furthermore, an effective screening for breast cancer might be made available in primary health care setting, making it easily accessible to all women.

Research have been conducted across the globe in various populations and categories to determine the level of breast cancer awareness and its screening practices, especially among women (Liu et al., 2018; Mena et al., 2014; Poum et al., 2014; Shah P. et al., 2020; Wu & Lee, 2019; & Yip, et al., 2015).). One study in Philippines revealed that almost half of the respondent (51%) ever heard about BSE but only 33 % and 29 % had knowledge about CBE and mammogram pre intervention but the awareness increased after the respondent is engaged in health education and screening program (Wu &

Lee, 2019). Meanwhile study in China found that almost all the respondents had awareness on breast cancer but their in- depth knowledge such as its risk factors and early symptoms were poorly reported (Liu et al., 2018). There was a study in India found that respondents present late at the health care facilities because of unaware the nature and severity of the breast cancer and they did not know the availability of government service provided for breast cancer screening in

their area (Shah P. et al., 2020). Finding by a study in Dezful city, Iran revealed a significant association between the awareness and attitudes toward BSE. In other words, the higher the level of awareness among women regarding breast cancer, the more they exhibited positive attitudes toward the disease (Marzouni et al., 2015). Women in the urban middle- income class was found to precisely explain breast cancer and its preventive activities compared to urban low-income and rural Kenyan women (Muthoni & Miller, 2010). These studies concluded that the knowledge, attitudes and perspectives of breast cancer need to be addressed for successful and effective campaigns related to breast cancer awareness, such as early screening methods and preventive measures.

Women must be made aware of breast cancer symptoms, risk factors, and preventive measures so that they can be prepared early if they develop any breast problems in the future. Hence, the key to practice early screening is associated with the knowledge prior to the screening where the women must be explained about breast cancer, the risk factors and the available screening program. Therefore, educational programs on breast cancer play an important role in enhancing women awareness regarding early detection and preventing late presentation of breast cancer.

Recommendation for future study

It is suggested that future intervention, studies should be extended to many other rural areas in Malaysia with a variety of ethics and races. This study did not implement any educational activities due to the limited time allocated for the study. Therefore, a well-prepared educational activity such as outreach program and mobile mammogram screening should be implemented in future studies. Hence, the practice of preventive activities and the level of breast cancer knowledge could be increased among women.


The finding in this study demonstrates that rural women already have the knowledge of the breast cancer but the awareness regarding preventive activities and identifying the risk factors of breast cancer is still at low to moderate levels.

Therefore, awareness programs such as outreach programs, roadshows and educational activities are very important steps to be improved. These awareness program have been proven to increase the knowledge of breast cancer as reported in studies conducted in other part in Malaysia. Consequently, the awareness program may be appropriate for future samples with similar socio-demographic criteria for better practice of preventive activities in the other rural areas in Malaysia.


We would like to express our thankfulness and gratitude to Fundamental Research Grant Scheme (FRGS), National Medical Research Register (NMMR-17-1752-97 (IIR), Ministry of Higher Education Malaysia, and Director of Sultanah Nur Zahirah Hospital. Furthermore, appropriation and support to all respondents from the rural area in Terengganu and voluntary respondents in the pilot study. The authors declare not conflict of interest related to publication of this manuscript.


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