EFFECT OF BEHAVIOURAL CHANGE COMMUNICATION ON FEMALE MENIAL WORKERS’ UTILISATION OF BREAST CANCER SCREENING IN OYO AND OSUN STATES, NIGERIA By RY Jaiyeola Aramide OYEWOLE A B.A., M.A., M.Ed (Ibadan) BR LI N A Thesis in the Department of AdultA Education Submitted to the Faculty of EDducation In partial fulfillment ofB theA requirements For thFe D eIgree of DOCT OOR OF PHILOSOPHY TY of the SI R UNIVERSITY OF IBADAN IV E N U NOVEMBER, 2017 ABSTRACT Early detection through screening has been acclaimed to be the antidote for preventing breast cancer related morbidity and mortality among women. Regardless of its significance, there exist poor knowledge and negative attitude towards breast screening, particularly among low socio-economic status women. However, this trend can be changed through behavioural communication interventions. Previous studies focused largely on the use of the mass media, despite its inherent weaknesses to bring about desired change in health behaviour. This study, therefore, examined the effect of Behavioural Change Communication (BCC) on female menial workers‟ utilisation of breast cancer screening in Oyo and Osun states, Nigeria. The moderating effects of age and educational attainment were also determined. Y The study was anchored on Health belief model, Diffusion of Innovation, and RPlanned behaviour theories, while the pretest-posttest control group, quasi-experimentaAl design of 2x3x2 factorial matrix was adopted. One private and public university each with Teaching hospital that has a breast cancer unit was purposively selected from the twoR states. Female menial workers‟ who are outsourced staff of the two universities IwBere selected. The participants were randomised into BCC (50) and Control (50) groupsL, while treatment lasted eight weeks. Instruments used were Breast Cancer Disease AwNaren ess Scale (r=0.80) Breast Cancer Screening Questionnaire with four subscales (AKnowledge/Awareness- r=0.71, Sources of Information- r=0.85, Screening Method- r=0.91 and Utilisation - r=0.72), and BCC and control packages and guides. Data were subjeDcted to percentages and Analysis of Co-variance and Duncan posthoc test at 0.05 level of Asignificance. + Participants were mainly married women (98.0B%) aged between 20 and 50 years; with educational attainment of elementary (64.0% )I and secondary (32.0%). Knowledge about breast cancer before the intervention was 1F4.0% and 99.8% after the intervention, while the source of their information about breaOst cancer was solely from print and electronic media. There was a significant main effect of treatment on female menial university workers‟ 2 utilisation of breast cancer screenin g in Oyo and Osun states (F(1, 91)=72.16, ŋ =.42). Participants in BCC had a higIhTer pYost treatment mean score of 48.70 than those in the control group ( =30.22). There was a significant main effect of educational attainment on female 2menial university workeSrs‟ utilisation of breast cancer screening (F(1, 91)=22.06, ŋ =.32); while age had none. PRarticipants with high educational attainment had higher breast screening utilisation ( =40.E92) than those with low educational attainment ( =38.12). There were no significant two-way interaction effects of treatment and age, treatment and educational attainment, aInVd age and educational attainment on breast cancer screening utilisation. The three-wayN interaction effect was not significant. BehaUvioural change communication was effective in creating awareness and fostering utilisation of breast cancer screening among female menial university workers‟ in Oyo and Osun states, Nigeria. Education was a determining factor in the adoption of breast cancer screening. Therefore, women, particularly those with low educational attainments should be well exposed to behavioural communication interventions to create and sustain awareness to enhance adoption of breast cancer screening. Keywords: Behavioural change communication, Breast cancer screening, Female menial university workers, Wordcount: 493 ii CERTIFICATION We certify that this research work was carried out by Jaiyeola Aramide OYEWOLE (Matric No 58084) in the Department of Adult Education, University of Ibadan, Ibadan Nigeria. AR Y ................................................. R Supervisors IB Abidoye .A. Sarumi Temidayo .O. Og uLndiran. B.A. (Hons), M.ED, Ph.D, PGDE MBBS (IbAadNan) MHSC (Toronto) (Ibadan) FRCS (Edinburgh) FACS, FWACS Associate Professor, Department of Adult SeAniorD Lecturer/Consultant Surgeon Education, University of Ibadan, Ibadan IBDivision of Oncology, Department of Nigeria. F Surger College of Medicine, University of O Ibadan and University College Hospital, Ibadan. Nigeria TY RS I IV E UN iii DEDICATION This work is dedicated to God the Father, God the Son and God the Holy Spirit, for divine intervention and authorisation for completion. Y R A BR N LI A D BA OF I ITY S ER V NI U iv ACKNOWLEDGEMENTS First, l acknowledge the Triune God for the mercies that l received to finish this programme. I sincerely appreciate the patience of my supervisors - Dr Abidoye Sarumi and Dr Temidayo Ogundiran - in putting up with me. Their seed shall forever find mercy before God and man. Dr Sarumi confessed my doctorate until it became a reality. I appreciate his unflinching faith in me. Dr Ogundiran demonstrated a high level of tolerance and gYreat understanding of the human frailities present in me and deliberately gave me a chanRce. I am grateful to him. A My gratitude goes to several people who helped me tremendously in thRe course of this work. They are too numerous to mention. Although their names are not ImBentioned here, they are in God‟s book of remembrance and also etched in gold in my hea rLt. I thank Prof. Deborah Egunyomi, the Head, DepartmentA of NAdult Education. Her tenures witnessed my prefield and my final defense. I guess she chose to be there both times as a supportive senior birthday mate. Worthy of thanks and Dmention is Prof Kehinde Kester who painstakingly corrected my mistakes in the courIseB of A writing and who took it upon himself to literally sit on my neck and gave me no breFath ing space until I submitted the final copy, May he always find help. My husband- Engr. Olusola O Oyewole did his humanly possible best to assist me throughout the course of thisT wYork, although he despaired several times and wondered whether this work will ever Ibe completed. I thank him for hoping against hope. Words are inadequate to thank my cShildren, three of whom I gave birth to in the course of this work. I do not regret the inEterRruptions. Rather, I thank God for their lives. It simply means I had three Ph.D degrees Vunofficially during this programme. Morolake, MoniyeOluwa, Mosopefoluwa and MofopefIoluwa Daniel- Syon, are appreciated for being there all the way. U I amN profoundly indebted to my parents –Rev. Lanre and Deaconess Ronke Matthews - who stood firmly in the gap calling on the throne ceaselessly for the successful completion of this work. I appreciate my siblings who contributed their quotas in cash and kind to see me complete this work - Eyitayo, Adeola and Olayinka. Solademi Adepeju, my unique and selfless sister supported me tremendously in cash and in kind. May God remember her labour of love and be there for her and her seed always. Amen. I appreciate the spiritual covering and support provided by my spiritual parents and oversights: Pastor Olubi Johnson, Pastor Dr Sarah Johnson, Pastor Gboyega Adesiyan, the v Yoruba congregation, as well as every member of Scripture Pasture Christian Centre, Sanngo, Ibadan. Revd. (Dr) Moses Babatunde Adebayo is appreciated for providing me the financial platform to fund part of this project. I thank Oluwaseyi Adelaja, my prayer partner, friend and sister for her supportive role in the course of this work. May she fulfill destiny. I wholeheartedly thank the following people for their immense contributions to the successful completion of this work; Daddy (Prof) and Mummy (Dr) Ayo Ogunkunle, Professors Soola, Izevbaye, Ayoade, Odejide, Adegbite, Aremu, Akinsola, AkinYtayo, Olorunnisola and Olatokun. I am thankful to Drs Bola Ajiboye, Pat Ajayi, Bola LanrRe Abass, Bimbo Owoseni, Kola Olawale, Bola O‟James and many other good friends. I thaAnk Dr Wole Fajembola, a man of renown who stooped to be my friend and adviser iRn the course of writing. I thank all lecturers in the Department of Adult Education, ULnivIeBrsity of Ibadan who supported and provided me useful suggestions while l was writin g this thesis. Likewise, I thank all academic and non- academic staff of BowAen NUniversity Iwo, for their encouragement and Mrs Bukola Ayeni, in particular for her secretarial help. I am equally grateful to Mrs Yinka Oyedele and Mr Samuel NsAsienD, librarians at Nigerian Tribune for their great help all the time l utilized the TribunIeB Library as well as Mrs Tope Abiodun, the Receptionist, at Tribune House. Mr BukolFa S cott laboured assiduously as my main research assistant, l thank him immensely for hisO contributions to the success of this work. To everyone who helpeYd m e with words of encouragement, chastisement and, sometimes derision in the courTse of this work I say thank you. Indeed, mercy has triumphed over judgement. The battSle iIs over and God has granted me victory, for the captive of the mighty is released and the prey of the terrible is delivered. To God is the glory forever. Amen. R VE I JaiyeUola AN. Oyewole November, 2017 vi TABLE OF CONTENTS Page TITLE PAGE ……………………………………………………………………........i ABSTRACT ……………………................................................................ ………….ii CERTIFICATION ……………………………………………………………………iii DEDICATION ………………………………………………………………………...iv Y ACKNOWLEDGEMENTS………………………………………………………A......R.v TABLE OF CONTENT ………………………………………………………….......vii LIST OF TABLES …………………………………………………………B…R……….x LIST OF FIGURES ………………………………………………… L……I…………..xi CHAPTER ONE: INTRODUCTION 1.1 Background to the Study ………………………………A…N…………………….1 1.2 Statement of the Problem …………………………D……………………………5 1.3 Objectives of the Study ………………………A…………………….................6 1.4 Research Questions ………………………IB…………………………………….7 1.5 Hypotheses of the Study ……………F… ……………………………………….7 1.6 Significance of the Study ……………………………………………………...7 1.7 Scope of the Study ………Y…… O……………………………………................9 1.8 Operational Definitions of Terms ……………………………………………...10 CHAPTER TWO: REIVTIEW OF LITERATURE AND THEORETICAL FRAMEWORK R S 2.1 Nature of CEancer ……………………………….………………………………11 2.2 The CIoVncept of Breast Cancer ………………….………………………12 2.3 ANwareness of Breast Cancer …………………..………………………….........15 2.4 UHealth Consequence of Breast Cancer Disease ………………………………...15 2.5 Concept of Cancer Screening ……………………………………………..........16 2.6 Breast Self Examination …………………………………………………..........19 2.7 Mamography …………………………………………………………………….21 2.8 Awareness and Knowledge of Breast Cancer Screening ……………................22 2.9 Sources of Information …………………………………………….………….....22 vii 2.10 Method of Breast Cancer Screening ……………………………………………24 2.11 Interpersonal Communication…………………………………………………..25 2.12 Group Communication………………………………………………………….29 2.13 BCC and Utilisation of breast cancer screening ………………………………29 2.14 Age and Utilisation of breast cancer screening ……………………………….30 2.15 Educational Attainment and breast cancer utilization ………………………...31 2.16 Theories reviewed for the study………………………………………………..32 Y 2.17 Diffusion of Innovation Theory ………………………………………………R32 2.18 Theory of Planned Behaviour …………………………………………R…A…..36 2.19 Health Belief Model …………………………………………………………38 2.20 Model adopted for the study …………………………………L…I…B…………41 CHAPTER THREE: METHODOLOGY 3.1 Research Design…………………………………………N………………………45 3.2 Population of the study……………………………D…A…………………….........45 3.3 Sampling and sampling technique………………………………………………46 3.4 Inclusion criteria………………………… AIB………………………………………46 3.5 Instrumentation………………………… ………………………………………..46 3.5.1. Pre-test Questionnaire………………F……………………………………………46 3.5.2. Breast cancer Awareness Scal e…O……………………………………………..…47 3.5.3 BCC (treatment) PackaTge aYnd Guide …………………………………………..47 3.5.4 Pilot Study……………I……………………………………………………….…49 3.5.5 Reliability Test…S………………………………………………………………..49 3.6 Method ofE DatRa Analysis ……………………………………………………….49 3.6.1 ControVl of Extraneous Variables ………………………………………………..50 CHAPTENR IFOUR: RESULTS AND DISCUSSIONS OF FINDINGS 4.1 Demographic Characteristics of the Respondents…………………………........51 4.2 U Response to Research Questions………………………………………………..56 4.3 Testing of Research Hypothesis……………………………………………......63 CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.1 Summary ………………………………………………………………………..72 5.2 Conclusion ………………………………………………………………………74 5.3 Policy Implications ……………………………………………………………...75 5.4 Recommendations ……………………………………………………………….75 viii 5.5 Contributions to Knowledge …………………………………………...............76 5.6 Limitations of the Study ………………………………………………………..78 5.7 Suggestions for Further Studies ………………………………………………..78 REFERENCES………………………………………………………………………80-99 APPENDICES………………………………………………………………………100-118 Appendix I: Pilot Study Questionnaire on Effect of Behavioural Change CommunicationY and Utilisation of Breast Cancer Screening R Appendix II: Pre - and Post- Study Questionnaire on Effect of BehaviouAral Change Communication and Utilisation of Breast Cancer Screening. R Appendix III: Behaviour Change Communication Intervention Module IB Appendix IV: Photograph of the Study Participants L Appendix V: Letter of Permission to Engage Participants in the SNtudy Appendix VI: Request Letter to Utilize Amphitheatre forD ResAearch Experiment A F I B Y O ITS VE R NIU ix LIST OF TABLES Table 3.1: 2x3x2 Factorial Model of Experimental Design ………………………. 43 Table 4.1: Information about Cancer Disease ……………………………………… 54 Table 4.2: Information about Breast Cancer ……………………………………….. 54 Table 4.3: Causes of Breast Cancer ………………………………………………… 55 Table 4.4: Breast Cancer Awareness and Knowledge Level ………………………… 57 Table 4.5: Breast Cancer Detection ………………………………………………… Y58 Table 4.6: Lifetime Chance of Having Breast Cancer ……………………………R…. 58 Table 4.7: Source of Breast Cancer Information ……………………………R…A…… 59 Table 4.8: Types of Breast Cancer Screening Method Adopted and UtBilized ………. 59 Table 4.9: Performing Breast Self Examination ………………………I……………. 60 Table 4.10: Summary of 2x2x2 Analysis of Covariance (ANCOV AL) Showing the Significant Main and Interactive Effect of ATreNatment Group, Age and Educational Attainment among Women …………………………… 61 Table 4.11: Duncan Post-hoc Analysis Showing the SDignificant Differences among Various Treatment Group and theI CBon Atrol Group in Breast Self- Examination among Women … …………………………………………….62 Table 4.12: Estimated Marginal MeaOns (FEMM) Showing the Differences in Breast Self-examination amon g Women Across the Three Groups ……………… 62 Table 4.13: Estimated MargTinaYl Means (EMM) Showing the Differences in Breast Self-examinatiIon among Women across Ages …………………………… 64 Table 4.14: Estimated SMarginal Means (EMM) Showing the Differences in Breast SelEf-exRamination among Women across the Educational Attaintment …… 65 Table 4.15: VEstimated Marginal Means (EMM) Showing the two-way Interactive I Effect of treatment and Age on Breast Self-Examination among Women… 66 TableU 4.1N6: Estimated Marginal Means (EMM) Showing the Two-way Interactive Effect of treatment and educational attainment on Breast Cancer Screening among Women …………………………………………………. 67 Table 4.17: Estimated Marginal Means (EMM) Showing the Two-way Interactive Effect of Educational Attainment and Age on Breast Self-Examination among Women …………………………………………………………….. 68 Table 4.18: Estimated Marginal Means (EMM) Showing the three-way Interactive Effect of Treatment, Age and Educational Attainment on Breast Cancer Screening among Women ……………………………………………...... 69 x LIST OF FIGURES Figure 4.1: Distribution of Respondents by Age ……………………………………. 49 Figure 4.2: Distribution of Respondents by Ethnicity ……………………………... 50 Figure 4.3: Distribution of Respondents by Marital Status ………………………… 50 Figure 4.4: Distribution of Respondents by Religion ……………………………… 51 Figure 4.5: Distribution of Respondents by Job Description …………………….... 52 Figure 4.6: Distribution of Respondents by Education …………………………….. Y52 Figure 4.7: Distribution of Respondents by Work Experience …………………A….R. 53 LIB R DA N A F I B O SI TY VE R I UN xi CHAPTER ONE INTRODUCTION 1.1 Background to the study Globally, cancer is responsible for more than seven million deaths annually (Mardani- Hamule and Shahraky-Vahed, 2010). Breast cancer is particularly one of the major causes of cancer deaths worldwide (Torbaghan, FamarFarma, Moghaddam and Zarei, 2014). In the developed world, cancer is the second leading cause of death accounting for 21 per centY (2.5 million) of deaths, while, in the developing world, cancer ranks third, accountingA foRr 9.5 per cent (3.8 million) of deaths (World Health Organization, 1998). R Altogether, about 24.6 million people live with cancer worldwide.B It is assumed that, if the trend continues, by 2020, as many as 15 million new casesL wIill be diagnosed per annum, out of which 70 per cent will be in developing countriesN (W HO, 1998). By then, the trend globally will be 56.8 per cent and 35.6 per cent per 100A,000 for black and white women aged 45-65 years, respectively. Besides, the black womDen will be having a lower five year survival rate at 77 per cent compared to 90 per cenAt for the white women. In addition, the disease will appear in more advanced forms at aI yBounger age in blacks than in whites. Torbaghan et al. (2014) submit Fthat the incidence of breast cancer is rapidly increasing in developing nations of th eO world. Parking, Bray, Ferlay and Pisani (2012) report that, among indigenous Africans, about 650,000 people out of estimated 965 million are annually diagnosed of canceIr,T shYowing that lifetime risk of dying from cancer in African women is two times higheSr than that in developed countries. The available Rstatistics in Nigeria, also suggest substantial increase in the incidence of breast cancer in rEecent times. It is on record that 40 Nigerians die everyday from breast cancer (Jedy-IAVgba, 2012). The peak age of breast cancer is about ten years earlier than the experiencNe of many Western women (Sylla and Wild, 2011). In 2008, of the 12.7 million new canceUr cases, 56 per cent reportedly occurred in developing countries and Nigeria had the highest fatality ratio (Sylla & Wild, 2011). It is on record that Nigeria contributed 15% to the estimated 681,000 new cases that occurred in Africa in 2008 (Jedy-Agba, 2012). In terms of women‟s morbidity and mortality, breast cancer leads all other cancers. This could be attributed to the fact that most women are not informed or are insufficiently informed about the need for health behaviour change as a deterrent to untimely death resulting from breast cancer (Pasket 1999; Olowookere, 2012). Breast cancer is the most commonly diagnosed cancer in women worldwide; however, survival rates have improved 1 where breast screening is introduced (Wardle, Robb, Vernon and Waller, 2015). There is a very high percentage of women with poor knowledge of breast screening because the need for screening has not been adequately communicated to them. Reduction in mortality from breast cancer depends on successful interventions aimed at early detection and treatment. Many women in Nigeria are not aware of the screening methods available for breast cancer, such as breast self examination (BSE) or mammography, neither are they aware of the need to regularly carry out this exercise (Azubuike and Okwuokei, 2013). Y Foremost amongst the important strategies in reducing breast cancer mortaliRty is the uptake of screening to achieve early detection of cancer. Potentially, early diagnAosis usually results in treatment before metastasis and signifies better outcome of BmaRnagement. It is important to appreciate the fact that women‟s status is affected by complIex biological, social, and cultural factors that are highly interrelated (WHO, 2013). TLhus, to reach women effectively, health systems must take into account the biologicNal, social, economic, health, nutrition, psychological and individual and behavioural factAors that increase health risks for women. Women of lower socio-economic status unAderDestimate the importance of curative medical owing to ignorance and poverty. WIomBen often face neglect, deprivations, and abandonment on a daily basis because pro curement of good health sometimes seems impossible as a result of poverty. The implFication of this is that such women‟s health usually suffers and deteriorates. O Olowookere, Onibokun andY Oluwatosin (2012) submit that, despite the benefits of screening, many women, parItiTcularly poor and lowly educated minority do not participate in screening owing to high Scost and lack of awareness. Until some women are faced with ill health, they knowE anRd care little about breast cancer screening and information. For some, their physiological state does not matter and poses no question until the body refuses to function Nas eIx Vpected; it is then that the search for medical help begins. Some other women are evUen afraid to discuss their biological problems and questions until when it is somewhat late. Those who bother when unhealthy go to wrong places instead of the designated health centres. The behaviour and attitude of these lowly educated women can be corrected or changed through behavioural change communication interventions (BCC). Darton (2008) submits that negative behaviour towards breast cancer screening exercise can modify and change over time. In spite of the enormous benefit of screening for early detection of breast cancer, many women of low socio-economic status do not participate in screening owing to high cost 2 and lack of awareness. In a study conducted among rural California American Indian women, it was discovered that there were cultural and socio-economic barriers to breast cancer screening. These barriers included lack of knowledge regarding the need for breast cancer screening, as well as lack of knowledge regarding treatment and very high cost of medical care (Hodge, 2009). Also, in a study conducted among traders and full time housewives in Lagos State, Nigeria, Adetifa and Ojikutu (2009) found that breast cancer was prevalent within this category of poor and unemployed sit-at-home women. Y Further, the study conducted by Wu, Tsu-Yin, Liu Yi-Lan &Chung ScottR, (2012) among women in China, reported a strong link between huge financial cAost, beliefs, knowledge and awareness about utilisation of breast cancer screening amonRg women. This report is in consonance with a release by the Breast Health Global InitiIatBive that indicated a lack of public awareness regarding early detection of breast cancer . L Further, the report also highlighted the importance of the involvement of community aNnd lay health officers in the sensitisation and awareness creation programs among the rurAal and poor women. Azubuike and Okwuokei (2013) reported tAhat Dexcept knowledge regarding breast cancer is readily available and wrong beliefs abouBt the disease countered, women susceptible to breast cancer disease may not adopt sFcre enIing methods as a potent strategy for early detection and reduction of breast canceOr mortality. In the same vein, Olowookere et al (2014) argue that providing poor women wi th knowledge and information of affordable screening methods may result in massive upYtake and utilisation among the poor. Despite the argumentIsT of Allen, Van Groningerg, Barksdale, and McCarthy (2010) that breast self-examinatSion may not be exactly sensitive and specific to diagnose breast cancer, the truth Eis tRhat BSE is still the cheapest and most readily available method of screening withVin the reach of women in low- resource countries, Semiglazov, Sagaidak, MoiseyenNko Iand Mikhail (1993) and Thomas et al (1997), cited in Olowookere (2012) assert that BUSE provides a unique opportunity for women to be breast aware and to detect breast problems. It is simple, inexpensive and effective. Clinical breast examination is also simple and inexpensive while mammography is complex and expensive but may enhance better prognosis. (Aldridge, 2005) In Nigeria, the mass media channels have the power to reach heterogeneous audience and possess the potential to disseminate breast cancer messages. This is done by sensitising women on important health issues relating to them through mass media campaigns to influence health behaviour change in cancer screening and prevention among others. Media 3 campaigns starts with promotion, information dissemination and health discussions to change public opinion and eventual policy change by influencing perceptions and intentions, highlighting prevalence and consequences of risky behaviour (Yanovitsky and Stryker 2001; Okorie, 2013) Mass media campaign is premised on the fact that success in behaviour change is more likely when the intention is to promote one-off/episodic behaviour, like taking vaccination and doing screening, but this is not very correct with breast cancer. RatherY, for breast cancer, success is more likely when a campaign complement concurrent chRanges in available services, such as cancer screening. In addition, mass media campaign isA more likely to succeed when campaigns obtain high population exposure, that is, maintainRs exposure over time and through multiple channels. Success in behaviour change isI B more likely when campaign messages are based on sound research of the target gro uLp and should be tested during campaign development to ensure that the change messNage is understood, persuades and convincing for uptake.(Okorie, Oyesomi & Adedeji, D200A4) Owing to the weaknesses inherent in using theA mass media to effectively bring about change in health behaviour, the use of behaviouBr change communication (BCC) has been advocated. Creating, changing and adaptiFng eIarlier methods and strategies of information, education and communication (IEC) toO addressing behaviour change is the rationale behind the uptake of BCC. The BCC is an approach to behaviour change focused on communication.The assumptioTn iYs that through the combination of Interpersonal and group communication platforms indIividuals and communities can somehow be persuaded to behave in ways that will make theSir lives safer and healthier. BCC programmes are designed to bring about behaviours EthaRt will improve health status and related long term outcomes. BCC is strategically dVesigned programmes that influence behaviour. BCC interventions fall into three broNad cIategories:  UMass media (radio, television, billboards, print materials, internet and so on).  Interpersonal communication ( client-provider interaction, group presentation)  Community mobilization. Any of these three communication strategies can generate the results measured by these core indicators: change in knowledge, attitudes, intentions and behaviour. BCC utilised a mix of media channels and participatory methods to communicate health behaviour change messages. Health behaviour change messages refer to the motivational, volitional and actional processes of abandoning health conditions and health - compromising behaviours in 4 favour of adopting and maintaining health-enhancing behaviours (WHO, 2002). Basically, the goal of BCC is to understand the social structures that influence individuals‟ knowledge, attitudes and behaviours. Hence, a BCC intervention would take into serious consideration the demographics, socio-economic factors, epidemiology, politics, cultural and social norms of the target audience. Moreover, BCC intervention takes cognisance of the values, concerns, needs, behaviours, habits, beliefs and difficulties of each target group. For BCC intervention tYo be successful, the skills and knowledge required of the intervention programme Rincludes adequate knowledge of anthropology, sociology, psychology, social work, RcomAmunication and education on the part of the interventionist/health educator. BCC eBmbarks on training sessions to inculcate skills and knowledge in participants and often orLgaInises stimulation and discussion of group learning. A manual or module is usually cre ated to address issues in behaviour change. To be effective, communication experts uAsuaNlly translate or even produce the manual or module in the first language of the targDet audience. (This was done in this study.) Modules designed for effective BCC is hingAed on educating target groups to learn actively by participation and by doing exaIcBtly as instructed. This is because the devastastation that befalls women diagnoFsed with breast cancer remains inestimable, and early detection remains a major effectOive approach that should be employed to combat the disease. Several studies (Pasket,1 999; Hodge, 2009; and Torbaghan, FamarFarma, Moghaddam & Zarei, 2014; )T haYve attested to the positive impact of preventive behaviour change communication to creIate screening awareness as well as actual uptake of screening as a preventive measure foSr early detection of breast cancer for swift cure (Knowlden and Sharma, 2011;AhmEadRian and Samah, 2012). 1.2 StatemVent of the problem LNack Iof awareness and ignorance about the potency of breast screening has resulted in high Umorbidity and mortality rates among Nigerian women. Breast cancer is one of the major causes of cancer deaths among women worldwide and specifically in Nigeria with mortality figure of about 40 deaths per day and 1200 deaths per month.To reduce the scourge of the disease, it has been advocated that women should cultivate the habit of early detection through screening examination as a form of prevention aimed at improving women‟s health. Breast cancer screening is a form of health check to detect the illness at an asymptomatic stage. 5 However, owing to unawareness, family secrecy in women with history of BRCA 1 and poverty, most Nigerian women, particularly those with lower socio-economic status (including menial university workers) neglect or ignore the importance of breast cancer screening. This underscores the importance of behavioural change communication to bring about positive disposition towards breast cancer screening Generally, many women in Nigeria are neither aware of the screening methods available for breast cancer nor are they aware of the need to regularly carry out bYreast screening exercise (BSE) or Mammography. Thus, reduction in mortality from breasRt cancer depends on successful interventions aimed at early detection and treatment througAh BCC. The efficacy of breast cancer screening is sufficient to advocate its uptake consRidering the fact that it is cost- effective and prolongs life. This has raised concerns. In thIisB regard, BCC could be introduced to sensitize women, particularly those at the lower ruLng of the ladder of the society regarding the need for the uptake of breast cancer screeNning exercises. Although the literature discusses breast screening and its effectiveness amAong women generally, there is a dearth of studies on the use of the BCC in changing womDen‟s health behaviour towards breast cancer screening, particularly among those withB lowA education and low income status. In addition, the literature has shown that thFe u sIe of BCC for behavioural change could be affected by a number of factors, whOich include age and educational attainments of the individual recipients. 1.3 Objectives of the study Y The study examined the IeTffect of behavioural change communication on menial female workers‟ utilisation of breSast cancer screening in Oyo and Osun states, Nigeria. The specific objectives were to: R 1. Assess VtheE awareness and knowledge of breast cancer disease and the consequences of brNeastI cancer among female menial university workers. 2U. Determine the awareness and knowledge of breast cancer screening among female menial university workers. 3. Ascertain the source of information about breast cancer screening, 4. Examine the methods of breast cancer screening adopted and utilised by female menial university workers. 5. Determine the effect of BCC on utilisation of BSE among female menial university workers 6 6. Ascertain the effects of age and education attainment on the utilisation of BSE among female menial university workers. 1.4 Research questions: The study provided answers to the following questions: RQ1: What is the level of awareness and knowledge of breast cancer disease as well as its consequences among the female menial university workers? Y RQ2: What is the level of awareness and knowledge of breast cancer screening amRong the female menial university workers? A RQ3: What are the sources of information on breast cancer screening amBongR female menial university workers? I RQ4: What are the methods of breast cancer screening adopted and uLtilised mostly by female menial university workers? AN 1.5 Hypotheses D The following hypotheses were tested in the studyB: A H01: There is no significant main effect Fof BIehaviour Change Communication on breast cancer screening H02: There is no significant main effe cOt of age on breast cancer screening H03: There is no significant maTin Yeffect of educational attainment on breast cancer screening H04: There is no significant tIwo-way interaction effect of treatment and age on breast cancer screening S H05: There is nEo sRignificant two-way interaction effect of treatment and educational attainment on bVreast cancer screening H06: TheNre iIs no significant two-way interaction effect of age and educational attainment on breasUt cancer screening H07: There is no significant three-way interaction effect of treatment, age and educational attainment on breast cancer screening. 1.6 Significance of the study This study is significant because, it created significant awareness of the need for uptake of breast cancer screening as the antidote for breast cancer related morbidity and mortality. In addition, previous studies on community campaigns for promoting cancer 7 screening have largely been conducted in Western countries and non-African populations. However, for reasons of differences in culture, community identities, community participation and ownership between communities in Western and African countries, it is not possible to directly adopt the results of these Western countries, (Park, 2011; BMC, Public Health 2011) Again, this study would create awareness regarding breast cancer screening and sensitise millions of unsuspecting women prone to the disease to engage in early screeYning and subsequently reduce mortality rate as a result of cancer. Moreover, the sRcreening awareness would educate women with symptoms on how to effectively mAanage their condition if it is detected early and remedy is possible. This study will BalsoR help to relieve hospitals and professional health care personnel of the burden of cariIng for this group of people, especially when such patients present themselves late. L Furthermore, the study is significant because early deNtection will serve as a good source of health information for first degree family membersA of patients to seek help from the hospital early enough. In addition, the results of theA stuDdy will expose the gap in previous strategies used in health behaviour change (HIBBC) and propose an effective strategy for communicating health behaviour change messa ges. Most importantly, future inteOrvenFtion may apply the findings of the study to effectively communicate HBC to othe r categories of people to achieve reduction in morbidity from breast cancer.The study TwilYl serve as a veritable tool to discover the effectiveness of group communication in heIalth information dissemination as well as help to demystify people‟s preconceived ideSas about breast cancer. The study is significant because, through the behavioural changEe cRommunication strategies employed, the study participants could utilise the two step Vcommunication theory of information dissemination which, in turn, would increase NothIer people‟s knowledge about breast cancer and influence such people‟s accepUtance of the accessible screening methods. Also, the study will help the participants to know the appropriate places and people to turn to when in need of medical assistance. The study will also help health care professionals to adopt the group communication strategy in educating the masses about the issue of breast cancer screening. Above all, the study will alert the government about the need to make breast screening centres available and accessible to women of all categories in the country at affordable costs. 8 1.7 Scope of the study The study examined the effect of BCC on menial female university workers‟ utilisation of breast cancer screening in Oyo and Osun States, Nigeria. The study was delimited to two universities because there is a general assumption that the various categories of workers within the university system are enlightened enough to personally attend to their health needs. In addition, the study was restricted to two foremost and prominent public and private mission universities in Oyo and Osun States. University of Ibadan was selectedY for the study because it boasts of a teaching hospital that has a breast cancer unit and is aR notable cancer treatment centre in Africa. Bowen University was selected becauAse it is a comparatively new private mission university with a newly built teacBhinRg hospital with relatively low concentration on breast cancer treatment. I The study was further restricted to female menial workers who wLere outsourced staff of the universities. The selection of the population of study and thNe restriction to female menial university workers was because although this women DworAk within the university campus, they do not see themselves as part of the universitAy community. They belong to the low socio-economic ladder and they are the poor cateBgory in the university, as attested to by their educational status and monthly wages. Beside sI, the study was delineated to cover a special behavioural communication therapeutic intFervention which has a worldwide acceptability in the communication for development ( CO4D) paradigm. Y 1.8 Operational definitioInTs of terms Behaviour Change CSommunication (BCC): This is the use of behaviour and communication thEeorRies and research to develop interventions that influence menial female workers‟ behavViour and the social contexts in which they occur. Breast caNnceIr screening: This refers to tests and examinations used to detect breast cancer in femUale menial university workers who may not have noticed any obvious sign or any symptoms of the disease but who may have been infected. The cheapest and simplest method of breast screening is referred to as breast self-examination, a screening method that provides unique opportunity for women to become aware and to identify breast problems which may constitute danger to their health in the future. This is done by women themselves in the privacy of their homes. Cancer: This is a malignant tumour/ulcer in various parts of the breast that may lead to death if not detected early. 9 Chemotherapy: This is use of chemicals and pharmaceuticals to combat cancer and to provide respite for the affected women. Familial: This means affecting several members of the same family but not necessarily passed down from one generation to another generation. Female University Menial Workers: These are female workers at a lower cadre in Bowen University, Iwo Osun State and University of Ibadan, Oyo State, Nigeria, respectively. Mammogram: This is a special x-ray machine for detecting breast cancer disease: Y Utilization: This refers to adoption, knowledge and use of specific breast screening sRtrategies by menial female university workers to detect lump. A R LI B N AD A IB OF ITY RS IV E N U 10 CHAPTER TWO REVIEW OF LITERATURE AND THEORETICAL FRAMEWORK Behaviour change communication (BCC) has been defined to mean the strategic use of communication to promote positive health outcomes which are based on proven theories and models of behaviour change. Basically, BCC employs a systematic process, beginning with formative research and behaviour analysis, followed by communication planning and implementation, as well as monitoring and evaluation. Audience are carefully segmenYted, messages and materials are pre-tested, and all forms of communication are used toR achieve defined behavioural objectives. The poor outcomes for cancer diagnosis at an advAanced stage have been the reason behind many investigations into techniques to detecBt thRe disease before symptoms manifest. Screening, a form of secondary prevention Lof Icancer is aimed at improving outcomes through early diagnosis. Studies have sho wn that the benefits of screening far outweigh any harm attached to screening tecAhnoNlogies. Besides, breast self-examination is free and can equally screen cancer before it erupts. This chapter is devoted to examining and utilizDing formulated theories to explain, predict and understand the breast cancer screeIniBng. A In addition, in-depth review of related literature as well as empirical review of spFecif ic variables used in the course of this study is undertaken. O 2.1 Nature of cancer Y Cancer is the name gIivTen to a collection of related diseases. In all types of cancer, some of the body‟s cells bSegin to divide without stopping and spread into surrounding tissues. Cancer can start aElmoRst anywhere in the human body, which is made up of trillions of cells. Normally, humVan cells grow and divide to form new cells as the body needs them. When cells growN oIld or become damaged, they die, and new cells take their place. When cancer develUops, however, this orderly process breaks down. As cells become more and more abnormal, old or damaged, they survive when they should die, and new cells form when they are not needed. These extra cells can divide without stopping and may form growth, lump or a mass called tumours; they are named after the part of the body where the tumour originates. Cancerous tumours are malignant, which means they can spread into, or invade, nearby tissue. (American Cancer Society, 2013) In addition, as these tumours grow, some cancer cells can break off and travel to distant places in the body through the blood or the lymph system and form new tumours far 11 from the original tumour. Unlike malignant tumours, benign tumours do not spread into, or invade, nearby tissues. Benign tumours can sometimes be quite large; however, when removed, they usually do not grow back. Conversely, malignant tumours sometimes do. Cancer is a genetic disease; that is, it is caused by changes to genes that control the way human cells function, especially how they grow and divide. Cancer has the ability to invade adjacent tissues and even distant organs. It can lead to the eventual death of the affected patient if the tumour has progressed beyond the state when it can be successYfully removed. (American Cancer Society, 2013) R Human beings have, battling cancer since their existence. One of the Afirst written descriptions of cancer and cancer treatment is found in an Egyptian pBapyRrus dating from around 3000 B.C. Cancer is a public health problem worldwide affecLtinIg all kinds of people. (American Cancer Society, 2013) .Cancer can occur at any site or ti ssue of the body and may involve different types of cells. The term “primary tumour” is Nused to denote cancer in the organ of origin, while “secondary tumour” denotes cancDer tAhat has spread to regional lymph nodes and distant organs. When cancer cells multiplAy and reach a critical size, the cancer is clinically evident as a lump or ulcer localized toB the organ of origin in early stages. As the disease advances, symptoms and signs of inva sIion and distant metastases becomes clinically evident (WHO, 1997). F There are different types of can cOer. This study investigated breast cancer and how promotion and utilization of avTailYable screening methods can prevent or reduce breast cancer among common women. I S 2.2 The concept oRf breast cancer The breVastE is the most common spot of cancer in women and Breast cancer is a kind of tumouNr thaIt threatens a woman‟s life. A tumour is an abnormal enlargement of some parts of theU body. It is a mass of tissues composed of unusual cells that have multiplied more than they should, that are not part of the body‟s normal design, and that serve no useful purpose. It is very common for some women to find swellings in the breast, which could start as a small lump in one breast, usually with no pain initially, but later the swelling could progress with enlargements, unbearable pains and stinging-like sensations. The breast is the commonest site of cancer in women. Cancer is the leading cause of death for women aged 30 and above. According to American Cancer Society (2013) more than 3.5 million cases of cancer are diagnosed in the U.S every year and breast cancer 12 incidence in the United States is 1 in 8 (about 13%). In 2011, an estimated 500,000 cases in new invasive breast cancer are expected to be diagnosed in women in the U.S. along with 67,770 new cases of non-invasive breast cancer. Also, about 2,761, new cases of invasive breast cancer will be diagnosed in men in 2020. (less than 1% of all new breast cancer cases occur in men). About 67,890 women in the U.S. are expected to die in 2020 from breast cancer. Every woman is at some risk of developing breast cancer, being the most comYmon cancer in women, accounting for 23% of all cancers, (Akpo, Akpo and Akhator R2009) A woman‟s risk of breast cancer approximately doubles if she has a first degAree relative (mother, sister, and daughter) who has been diagnosed with breast cancer. ThRe probability of developing the disease increases throughout life (Okediran 2005; BLernIeBr, Ayub, Kakil and Ibrahim 2008). The World Health Organisation recorded that about A548N,000 deaths occurred in 2007 as a result of breast cancer (WHO, 2008). Breast cancer incidence rose to 25.7% from 19.67% between 1981 and 1995, followed closely bAy ceDrvical cancer (Durosinmi, 2004). In Jos, Plateau State of Nigeria, between 1995 andI 2B002, breast cancer was reported to account for 56.6% of all cases of cancer diagnosis (FAk po, Akpo and Akhator, 2009). Mortality cancer figure in Nigeria peaked 15.9% from 12O.45% in 2002 according to Globacan (2002). Breast cancer begins in the bre ast tissue that is made up of glands for milk production, called lobules, and the duct thTat cYonnect the lobules to the nipple. Breast cancer typically is detected during a screeninIg examination, before symptoms have developed, or after symptoms have developeSd, when a woman feels a lump and she is hospitalized (American Cancer Society, 2E01R3). Most breast lumps turn out to be benign, that is they are not cancerous, do Vnot grow uncontrollably nor spread, and are not life- threatening. When breast cancer is NsuspIected, a clinical evaluation is necessary to confirm the diagnosis. Depending on the exUtent, breast cancer may be localized or invasive. Localized/in-situ cancer refers to the breast cancer that has not grown beyond the layer where it originated, while invasive is when the breast cancer has broken through the ductal or glandular walls and spread to the surrounding breast tissue. Breast cancer has 4 stages: Stage 0 is in situ cases of non-spread; Stage I is early stage of invasive cancer; Stage II and III refers to medium and higher invasive cancer respectively and Stage IV is the advanced stage of invasive cancer. Breast cancer typically produces no symptoms when the tumour is small and it is most easily cured. Therefore, it is very 13 important for women to follow recommended screening guidelines for detecting breast cancer at an early stage. Also, when breast cancer has grown to a size that can be felt, the most common sign is a painless lump. Sometimes, breast cancer might have spread to underarm lymph nodes and caused a lump or swelling, even before the original breast tumour is large enough to be felt. Other less common signs and symptoms include: breast pain or heaviness; persistent changes to the breast, such as swelling, thickening or redness of the breast skin; niYpple abnormalities, such as spontaneous discharge, especially if bloody; and erosion, inveRrsion or tenderness of the breast. However, pain or lack of it does not indicate the Apresence or absence of breast cancer. Any persistent abnormality in the breast should beR evaluated by a physician as soon possible for, as of today, the cause of breast canceIr Bis not known. The predisposition to breast cancer can be any of the factors mentioned b eLlow: Age: the incidence of breast cancer increases with age until Na woman is eighty years old. Approximately 80% of women aged 50 and above arDe suAsceptible (Oregon State Cancer Registry, 2003). It is relatively uncommon in youngAer women although ongoing studies are producing an incredible data of adolescent victimBs (Olowokere, 2012). It begins to increase significantly at approximately age 40. Accord iIng to Olapade et al. (2004) the age range at which women develop breast cancer is 44 yFears and 51% of them are yet to reach menopause. Family History: Breast cancer risk is hOigher among women whose close blood relatives have this disease. The relatives can Tbe Yfrom either the mother‟s side or the father‟s side or another member of the family. HavIing a mother, sister or daughter with breast cancer doubles a woman‟s risk (Olapade, 2S004). Personal HistoryE: AR woman with cancer in one breast has a greater chance of getting new cancer in the oVther breast or in another part of the same breast. Race: WNhiteI women (Asians, Hispanic, and Americans) and Africans are slightly more likelyU to die of cancer whereas Indian women have a lower risk of getting breast cancer. Menstrual Period: Women who have begun periods early (before 12 years of age) or who went through the change of life (menopause) after the age of 55 years have slightly increased risk of breast cancer. Oral Contraceptives: In young women, oral contraceptives use confers a small term increase in breast cancer risk. The excessive risk disappears by the years after stopping contraceptive. 14 Not having children: Women who do not have children or who had their first child at age 30 and above have slightly higher risk of breast cancer, while having been pregnant more than once and at an early age reduces breast cancer risk. Other latent and inexplainable medical reasons may also be adduced for the incidence of breast cancer. The interest of this study is in creating breast cancer awareness among rural women as well as promoting the available screening methods to enable susceptible women to detect the disease early and thereby contain its spread to forestall morbidity and mortality RY . 2.3 Awareness of breast cancer disease among women A Many women in Nigeria are not aware of the screening methods avaRilable for breast cancer, such as breast self examination (BSE) and mammography, nor aIrBe they aware of the need to regularly carry out this exercise. (Azubuike and Okwuokei, 2 0L13).Creating awareness among women in this regard requires concerted effort, with empNhasis on the need to screen to achieve early detection of cancer. Because of poverty aAnd ignorance, university female menial workers of lower socio-economic status unAderDestimate the importance of curative medical care. B Olowookere, Onibokun and OluwaFtos inI (2012) submit that, despite the benefits of screening, many poor women the medically underserved and ethnic minority do not participate in screening owing to hig hO cost and lack of awareness. Most women know and care little about health educatTion Yand information, until they are faced with ill health. For some women, their physiologIical state does not matter and poses no question until the body refuses to function as expSected; it is then that the search for medical help begins. Some other women are even EafraRid to discuss their biological problems and questions until when it is somewhat lateV, while those who bother when unhealthy look in the wrong places other than designated heIalth centres. N 2.4 U Health consequences of breast cancer disease The consequence of positive diagnosis of onset of breast cancer in any woman is devastasting regardless of medical assurance for management and survival. This is because a woman becomes overwhelmed with the fear of the known and the unknown. However, early detection remains a major effective approach that should be employed to combat and reduce or avert the consequences of breast cancer. Several studies have attested to the positive impact of preventive behaviour change communication to create screening awareness as well 15 as actual uptake of screening as a preventive measure for early detection of breast cancer for swift cure (Torbaghan et al. 2014; Knowlden & Sharma, 2011; Ahmadian & Samah, 2012). In spite of the enormous benefits of screening for early detection of breast cancer, many women of low socio-economic status do not participate in screening owing to high cost and lack of awareness. In a study conducted among rural California American Indian women, it was discovered that cultural and socio economic barriers to breast cancer screening exist. These barriers include lack of knowledge regarding the need for breast cancer screeninYg, as well as lack of knowledge regarding treatment and very high cost of medical care R(Hodge, 2009). A Again in a study conducted among traders and full time housewivesR in Lagos State, Nigeria, Adetifa et al. (2009) found that breast cancer is prevalent wiIthBin this category of poor and unemployed sit-at-home women. Further, in the study co ndLucted by Wu, Tsu-Yin, Liu Yi-Lan and Chung Scott (2012) among women in China, thNe study reported a strong link between huge financial cost, beliefs, knowledge and awarAeness about utilization of breast cancer screening among women. This report is in cAonsDonance with a release by the Breast Health Global Initiative that indicated lack of IpBublic awareness of the importance of early detection of breast cancer and highlighted t he importance of community and lay health officers to be involved in the sensitizationF and awareness creation programmes among the lowly and poor women. Azubuike a nOd Okwuokei (2013) reported that, except knowledge regarding breast cancer is reaTdilyY available and wrong beliefs about the disease countered women susceptible to breastI cancer disease may not adopt screening methods as a potent strategy for early detectioSn and reduction of breast cancer mortality. R 2.5 The coVnceEpt of cancer screening CNanceIr screening is looking for cancer before a person has any symptoms. Screening tests Ucan help find cancer at an early stage, before symptoms appear. When an abnormal tissue or cancer is found early, it may be easier to treat or cure it. By the time symptoms appear, the cancer may have grown and spread. This can make the cancer harder to treat or cure. The first cancer screening test was developed by George Papanicolaou in 1943 when he proffered a method of identifying precancerous and malignant cervical cells (Wardle, Robb, Vernon and Waller 2015). Screening is a form of prevention aimed at improving people‟s health; it is a form of secondary prevention aimed to improve outcomes through earlier diagnosis. (Wardle et al., 2015) Prevention is divided into primary, secondary and tertiary 16 prevention. Primary prevention is modification of risk factors, such as smoking, diet, alcohol intake, before an asymptomatic stage of development of the disease so that its progression can be halted or retarded. Secondary prevention is called screening which, in clear terms, means a deliberate search for any factor that predisposes one to a particular disease as well as a conscious effort to locate any alien growth within the body that is an obvious threat to good health (Wardle et al., 2015). Tertiary prevention refers to the rehabilitation of patients or treatmYent interventions once an illness has manifested itself. R Screening, which is regarded as secondary prevention takes the formA of health checks, such as breasts self-examination (BSE), blood pressure measuRrement, height measurement, weight check, urine test, cervical smears and mammogLramIsB. There are 2 types, as observed by Ogden (2000); the first is opportunistic screening – seizing the opportunity (of hospital visitation) to examine or check out a patient and to Nmeasure any aspect of health which has the tendency to result in morbidity or mortaAlity. The second is population screening – which involves setting up services speAcifDically aimed at identifying erupting medical problems. A third type identified byI B(Oyewole, 2015) is accidental/intervention screening. This is screening done impromFptu , without any special appointment particularly during a special project intervention or Ofor research purposes. According to Olaniyan (2004) , screening is the application of simple inexpensive tests to large population of healthy pTersYons in order to classify them as likely or unlikely to have a disease that is the object of thIe screen. There is evidence that screening for breast cancer has a favourable effect on mSortality from breast cancer (Harvey, 1997). Methods that can be employed for theE eaRrly detection of breast tumour include self- examination, clinical examination byV physician, mammography, biopsy and genetic studies. ScNreeIning became a popular facet of biomedicine in the 20th century. The drive to detecUt an illness at an asymptomatic stage of its development (secondary prevention) was evident across the Western world in 1900 (Williamson and Pearse, 1938; cited in Ogden, 2000). Screening received impetus from Multiphasic Screening, which became popular in the USA between 1940 and 1951, Sweden in 1969, Japan and Germany in 1970. Beginning from 1973, the medical centre at King‟s Cross London, organized a computerized screening of 15,000 individuals a year for the purpose of detecting breast cancer, and carved out a working part in 1985 to consider the validity of breast screening (Ogden, 2000). 17 The screening programme in the United Kingdom, according to Forrest (1986), concluded that the evidence of the efficacy of breast cancer screening was sufficient to encourage screening as a tool for preventing untimely death with regard to other diseases. This led to the establishment and adoption of a screening programme with 3-year intervals. The rise and wide acceptance of screening programmes proclaimed it as an invaluable and productive means of improving the health of a country‟s population such as England (Morris, 1964; cited in Ogden 2000). Y A number of studies have evaluated the effectiveness of interventions to increRase rates of screening for breast cancer owing to its many advantages (Marcus and CArane 1998; Freeman and Chu, 2005) Screening is an invaluable and productive meanRs of improving people‟s health. It is a cost-effective method of preventing any diseasLe aInBd provides statistics on the prevalence and incidence of a wide range of disorders and illnesses. Effective screening requires that the disease must be an important proAblemN which can be recognized at the latent or early symptomatic stage, with clear notaryD history from patient. Also, suitable test or examination of reasonable sensitivity and spAecificity must be carried out while the population endorses screening, which must be a Bcontinuous process. In addition, there must be adequate facilities for assessment anFd trIeatment which must be acceptable by all concerned and it must be economicaOlly balanced in relation to possible expenditure on medical treatment at large. Besides, t he disease must be sufficiently prevalent and serious to make early detection appropriTate Yand the screening test must have good sensitivity and be geared for positive predictiveI value in the target population. Wilson (1965), ciSted in Ogden (2000) outlines the following screening criteria: the disease- it must be Rsufficiently prevalent or sufficiently serious to make early detection appropriate; thVe sEcreen- the disease must be sufficiently well defined to permit accurate diagnosisN; foIllow-up- there must be a possibility or probability that the disease exists undiaUgnosed in many cases as well as economy-there must be a screening test that has a good sensitivity and specificity and a reasonable positive predictive value in the population to be screened. The numbers of individuals who attend different screening programmes vary greatly and it is determined according to factors such as the country, the illness being screened and the time of screening programmes. Maclean (1984) observes that women who attended breast screening are more likely to be of high socio-economic status, more sympathetic to screening and more likely to have suffered less anxiety following the invitation/recommendation to attend. 18 Owens (1987) avers that age and gender have also been suggested as important factors for uptake of screening and older women are more likely to attend breast screening than younger women. It is crucial for health educators and professionals to promote screening at all times because belief in the effectiveness of screening was associated with an organized approach to screening and time spent on screening (Harelock, 1988). 2.6 Breast self-examination (BSE) Y Women should observe their breasts while sitting, standing or laying down wRith arms at both sides and overhead especially for presence of skin and nipple abnoRrmaAlities. These abnormalities may become more obvious by raising both arms overhead or by pressing the hands on the hip. With the help of the fingers, the breast should be paLlpaIteBd while lying down on the back with pillow at a level ground meticulously, methodical ly, and gently. Abnormal variations in breast size and any sign of redness or retractionA of Nthe skin are best identified by careful observation in good light. As a result of screenDing, about 5-10% of cases of breast cancer have been discovered during physical examination for other purposes. Breast self-examination is a cheap, easyB, pAI hysical and manual method for early detection of breast tumours and it proFtect s women from the development and later complications of the disease. Thus, knowledge and consistent practice could protect women from severe morbidity and mortality aOrising from breast cancer (Frank, 2004). Education of women to perform breast self-exaYmination should be the main objective of cancer societies worldwide. IT Evidence indicateSs that regular BSE may reduce breast cancer morbidity by 18% yet most women do nEot pRractise it. Park (2002) notes that the level of awareness about BSE is low and even Vthose that are aware do not know the correct steps in BSE and often those aware of Nthe Icorrect steps do not perform it regularly. This has resulted in the high rates of mortaUlity and morbidity from breast cancer. In a study conducted and reported by Salazar, (1994) and Michielutte (1999) among American women aged 21-65 years, who have performed BSE it was discovered that of 719 women aged 60 years and above, only 73% had been been taught BSE and only 41% had performed BSE. (Skaer, 1996) Data from North America suggests that there is a reasonable public awareness of the importance but compliance with regular BSE is reported by a minority of young women (Wardle, 1995). Also, Tanjaisiri(2002) reported that, among Togan-American women aged 40 and above, only 40% had ever performed BSE; whereas, among Vietnamese women in 19 Texas, 55% had performed BSE, compared to other studies which reported low level of awareness (Ho, 2005). Report from the United Kingdom is not so different. Among students aged 17-30 years from 20 European countries in a sample of 16,486, 54% reported never having practised BSE, only 8% practise regularly, while 36% practiced occasionally. In the United Kingdom, women are encouraged to be breast aware from the age 18 but they do not engage in BSE. (Wardle, 1995). Y In a study conducted among 193 nurses in Poland, 63% knew almost evRerything about BSE, while only 50% did BSE but not correctly (Frank, 2004). ThiRs inAdicates that, despite medical education, nurses are not knowledgeable enough to do breast self examination correctly and consistently. From a sample of women aged 2I0B-64 years, living in ten cities of (Northern Italy) only 58% practise BSE (Ferro, 1992). D eLspite medical education and seemingly easy access to medical services, a study bAy KNulk (2003) among nurses in Dublin showed inadequate knowledge about the diseasDe and lack of individual preventive actions by nurses, as only 24% of them performed rAegular monthly BSE. Petro- Nustus and Mikhaut (2002) reported that, among 519 womenB from two major universities in Jordan, 67% had heard or read about BSE; only 25% hFad evIer practiced BSE in the previous 12 months and only 7% performed it on a regular monthly basis. In German among 532 women 8O4% were well informed about BSE; while only 43.1% practise BSE every month. In a sYtudy conducted by Aslaif (2004) and (Wuyet) 2005 among female nursing students, onIlyT 66% performed BSE. Among 109 patients of a university maternity hospital, in theS city of Natal, 54% practised BSE (Davin, 2003). Also among 410 female health woErkerRs in Tehran, Iran, only 63% claimed to know how to perform BSE, while 6% performed it monthly. TheN sitIua Vtion in Nigeria is not different. In a study conducted among female school teachUers in Lagos, Nigeria, 62% practised BSE with 11% on a monthly basis (Odusanya, 2001). Also, in a study carried out by Balogun and Owoaje (2006) among female traders in Ibadan, Oyo State, less than one third of the respondents (31.7%) were aware of BSE. According to Jebbin and Adoley (2004) only 85% of the 200 women studied in Port Harcourt had heard of BSE, but only 39% practiced BSE occasionally, while 24% did not practise it at all. In a similar study among 76 health workers, 60% of doctors and 53.7% of nurses practise BSE occasionally, while only one doctor could describe how to perform it correctly (Jebbin and Adoley, 2004). 20 The importance of knowing how to perform BSE correctly lies in its ability to detect masses that may be missed on mammography. Up to 15-18% of mammograms are negative in the presence of palpable cancer; detect interval lesions that may appear between the patient‟s screening mammograms; or evaluate a lump discovered by the patient on BSE. Ideally, the clinical breast examination (CBE) should take place one to two weeks past the onset of menstruation. The examination should be conducted unhurriedly in a setting that allows for minimal distraction and adequate patient privacy. (Oregon Breast and CerYvical Program, 2003). R A 2.7 Mammography R This is a soft tissue x-ray of the breast. It is indicated for roLutiInBe screening with or without complaints from women (above 35 years), the evaluation of a breast lump and the evaluation of the opposite breast. Searching for hidden canAcer Nin those who have metastasis without a mammography should be done between 35D and 40 years every 2 to 3 years, between 40 and 49 years annually and above 50 yeaArs more often since they stand a higher risk of being victims (Oregon Breast and CervicIalB Program, 2003). There are studies in which mammogra phy was used as a screening method for the detection of breast cancer. Ferros (199O2) rFeported that only 9% of women aged 20-64 years living in Northern Italy had had a mammography, which is very low compared to 45% reported among Vietnamese wTomYen living in Texas. In Germany, only 55.5% of the women had a mammography (KlugIe 2005) Franok et al. (1998) reported that only 33% had mammography among nuSrses taking part in qualifying courses. This is low bearing in mind their medical expoEsurRe and background. Among wVomen in California, only 25% received yearly mammograms (Tanjasiri, 2001) while onlNy 50I% of women attending rural and urban primary care clinics had mammograms in theU past year (Michielutta. 1999). Also, among Hispanic women 40 years and above, 38% had never heard of mammography, only 30% had received a mammography and only 30% had it in the prior 2 years (Skaer, 1996). Also, Odusanya and Taiwo (2001) reported that only 8% of nurses in Lagos, Nigeria had a mammogram in the last three years. According to Okoye (2004), regular mammography screening is not possible in Nigeria due to lack of equipment and enough trained personnel. In some cases, the available machines are the ones discarded from other centres abroad and this result in increased patient radiation dose and poor image quality. Research has demonstrated that, for women 40 years 21 and above, utilisation of mammography screening for early detection of breast cancer can reduce mortality from this disease by up to 30% (Urban and Taylor, 1993). Given the foregoing picture, it is clear that certain elements must be put in place to sensitize the susceptible populace for the need to know and change their attitude towards their health and to utilize the knowledge positively to their advantage. To achieve this, effective and rapid communication paraphernalia must be employed in message dissemination. In this regard, the platforms of interpersonal communication within a group come to the fore. RY 2.8 Awareness and knowledge of breast cancer screening A To educate the poor about screening methods, the intervention progrRammes must be specific. Pasket (1999) classifies intervention methods for screeningL foIrB breast cancer with emphasis on mammography into community-based and practi ce-based. Practise-based intervention is both clinic-based and predicated on medicaAl mNodel, while the community- based method includes engaging the community as a settDing, an agent, target and a resource. McLeroy et al. (2003) divide interventionA programmes into tailored and target intervention. Target interventions are generic iBn nature and attempt to address common factors among population subgroups usingF m asIs media campaigns, print formats and many more. Kreuter et al. (2005) emphasOize that tailored intervention employs behavioural construct to tailor and customize health behaviour change messages based upon participants‟/demographics anTd Yresponses. Allen & Bazargan-Hejazi (2005) posits that tailored counselling, knowledIge and information dissemination allow researchers to employ direct health tactics on Sa large scale. Incorporating culture into tailored breast cancer prevention and coEntroRl intervention may increase their effectiveness in diverse populations. Krueter et al V(2005). Participants in the tailored interactive group demonstrated more significanNt foIrward movement in their stage of mammography readiness. Champion et al (2006U) Lay health advisors (LHAs), also referred to as community health advisors (CHAs), peer volunteers, peer educators, lay health educators or lay community health workers play an integral role in tailored community based interventions. Earp et al. (2002) submitted that LHAs effectively serve as links between the professional health care system and the community. Moreover, Mayo et al. (2004) posit that LHAs have the unique position to access medically underserved populations and possibly prevail on them to utilize available screening 22 methods. LHAs are in a unique position to offset barriers frequently associated with screening methods. (Kidders, 2008) Earp et al. (2002) list the following as the advantages inherent in utilising LHAs for screening intervention purposes. Firstly, they are viewed as peers and thus are more adept to engage intervention participants and assist them in overcoming community- specific barriers. Secondly, they are able to interact within the community‟s social networks spontaneously and informally. Thirdly, they have a connectivity that offers the potential for the interventioYn to have an ongoing, spill-over effect in the community. Fourthly, they are entrencheRd in the community‟s social networks and they possess the unique ability to inRflueAnce beliefs, attitudes and behaviours of numerous community social groups. This study adopted the tailored intervention approach. It used a IlaBy health advisor, in the researcher supported by medical professionals who disseminat edL the information to the specific target female menial workers in the two universities studNied. 2.9 Sources of information about breast cancer screenAing In Nigeria, the mass media channels have the powDer to reach heterogeneous audience as well as possess the potential to fashion breastI cBanc Aer messages and report the same.This is done by sensitising women on important hFeal th issues relating to them through mass media campaigns to influence health behavioOur change in cancer screening and prevention among others. However, little success has been recorded in the use of mass media campaign strategies over the years. ThisT is Ybecause while utilising mass media campaigns/platforms to change behaviour, continuatIion of the screening exercise tends to suffer setbacks. (Kreps, 2008; Kreps and SivaramS 2009; Wakefield, Loken and Hornik 2010; Okorie, Oyesomi and Adedeji 2014) R EssentiVallyE, mass media campaigns create and place messages in the media that reach large audNiencIes while exposure is passive. This, reflects mere routine use of mass media. MediUa campaigns start with promotion, information dissemination and health discussions to change public opinion and eventual policy change by influencing perceptions and intentions, highlighting prevalence and consequences of risky behaviour (Yanovitsky and Stryker 2001; Okorie 2013) Behaviour Change Communication (BCC) came into being due to the inadequacies of both the mass media campaign and the efforts of Information, Education and Communication (IEC) strategies hitherto employed by health educators and health promoters. Creating, changing and adapting earlier methods and strategies of Information, Education and 23 Communication to address behaviour change is the rationale behind the uptake of Behaviour Change Communication. 2.10 Methods of breast cancer screening Many communication initiatives have succeeded in enhancing public awareness, but have failed in going beyond awareness to stimulating positive change in attitudes and practices toward creating lasting social change. Communication to acheive enduYring behaviour change among individuals, groups and communities with a lasting effect Rmust be deliberate, inclusive and premised on data from research findings. Further, comAmunication must employ multiprong approaches; policy advocacy, social and commBuniRty mobilization, interpersonal communication, group communication and more. I ehaviour change communication (BCC) has become a central objective of public hea ltLh interventions over the last half decade, as the influence of prevention within the heaNlth services has increased to implement behaviour change for development. TheD incAreased influence of prevention correspond with improved mutual and bi-lateral aid iAn the areas of individual growth and the need for the global community to show tangible IreBsult for allocated funds expended BCC is a research-driven approach for promoting and sustaining behaviour change in individuals and communities, and is imOpleFmented through the development and distribution of specific health messages via a var iety of communication channels. It is a process of any intervention with individuals, cTomYmunities and societies to develop communication strategies to promote positive behaviouIrs which are appropriate to such settings. BCC is providing peSople with information and teaching them how they should behave in a desirable way. IEt haRs proved to be an instructional intervention which has close interface with educationV and communication. It is a strategic, group-oriented form of communication to achievNe a Idesired change in behaviour of a target group. The strategy for it will vary from groupU to group. The following are important for the BCC strategy: vulnerability or risk factor of the target group; vulnerability or risk factor of the target group which is to be addressed; the conflict and obstacles in the way to desired change in behaviour; type of message and communication media which can best be used to reach the target group; type of resources available and assessment of existing knowledge of the target group about the issue which is going to be dealt with. BCC is critical to the prevention, management and treatment of many important health conditions. There has been steady complexity in rapid translation of basic science discoveries 24 into effective interventions. One method of overcoming this issue is to create a pipeline, similar to the model employed by the pharmaceutical industry, in which the translation of basic science can be supported as it moves to intervention. Hence, as with development of more effective drugs; surgical techniques and medical devices, the development of more powerful health-related behavioural interventions is dependent on improving the understanding of human behaviour, and then translating that knowledge into new and more effective interventions with enduring effects. Y Formerly, health intervention attempts employ the Information educatRion and communication (IEC) approach to reach their target audience. However, thRereA has been a paradigm shift in the last two decades to BCC. The IEC method became ineffective all by itself. A new concept called BCC emerged. BCC has become the main fIoBcus of public health involvement since the beginning of 2010 and this has increased thLe attention given to it within the health services sector. The pervasiveness of the iAnfluNence of prevention correlates with the goals of the Millenium Development Goals D(MDGs) for individual and global development. There are many and varied definitions of BBCAC. Basically, BCC is a research- driven approach for promoting and sustaining behaFvio uIr change in individuals and communities, and is implemented through the developmOent and distribution of specific health messages via variety of communication channels (R ahman, Leppard, Nasreen, and Rashid 2011). Rahman et al. (2011) corroborates thTat Ybehaviour change communication uses behavioural and communication theories andI research to develop interventions that influence individual behaviours and the socialS contexts in which they occur. This is done in a bid to understand the social structureEs thRat influence individuals‟ knowledge, attitudes and behaviour. In addiVtion, BCC advocates must be aware of the values, concerns, needs, behaviours, habits, beNliefIs and difficulties of each audience. BCC is best located in the gamut of single or multiU communication approach to achieving significant success. 2.11 Interpersonal communication. Interpersonal communication is exchange of information between two or more people. This involves message sending and message receiving. This can be conducted using both direct and indirect methods. Successful interpersonal communication is when the sender and the receiver understand the message. Interpersonal communication involves face-to-face conversations and activities between different categories of people, such as husband and wife, 25 teacher and student as well as physician and patient. Interpersonal communication can drive behaviour change, especially when it is done within a group. The personal touch means that communication experts can introduce behaviour and attitude change messages at just the right time. A combination of interpersonal communication and group communication can bring about lasting behaviour change. Moreover, interpersonal communication is humanity‟s most important characteristic and its greatest accomplishment. It is humans‟ ability to turn meaningless grunts into spYoken and written words, through which humans make known their needs, wants, idReas and feelings. Interpersonal communication is a complex process that can be dAescribed in simplified terms by a sender and a receiver who exchange messages coBntaRining ideas and feelings, mixed together. The sender encodes the messages using verbIal, vocal and visual elements. The words form the verbal element, while the vocal elem eLnt includes the tone and intensity of voice articulated in language form. The visual elemNent incorporates everything the receiver can see because it is a non-verbal element anAd powerful element for getting receiver‟s attention. The receiver takes in the messages Dand decodes them by sorting out and interpreting the elements according to someone‟Bs eAI xperiences, beliefs and needs. Essential ingredients of interpersonal communicationF ar e the communicators, message, channel, noise, context and feedback. For interpersonaOl communication to occur there must be at least two people involved, that is, a sender an d a receiver of the message otherwise known as the communicators. However, theT proYblem with this view is that it presents communication as a one-way process where a Iperson sends a message and another receives it .Conversely, communication is an interSactive process in which one person talks, the other listens and while listening, exchangEes nRon-verbal feedback and, subsequently, the cycle rotates and the listener eventually becVomes the speaker and vice-versa throughout the period of the communication exchange. I The UMesNsage: Message not only means the speech used or information conveyed, but also the non-verbal messages exchanged such as facial expressions, tone of voice, gestures and body language. Non-verbal signals can convey additional information about the spoken message. In particular, it can reveal more about emotional attitudes which may underlie the content of speech communication. Channel: The channel refers to the physical means by which the message is transferred from one person to another. In face-to-face context, the channels which are used are speech and vision. 26 Noise: Noise has a special meaning in communication relationship. It refers to anything that distorts the message, in such a way that what is received is different from what is intended by the speaker. Physical noise can interfere with communication, use of complicated jargon, inappropriate body language, inattention, disinterest and cultural differences can be considered noise in the context of interpersonal communication. In other words, any distortions or inconsistencies that occur during an attempt to communicate can be seen as noise. Y Context: Communication is influenced by the context in which it takes place. HowevRer, apart from looking at the situational context of where the interaction takes place, the soAcial context also needs to be considered, for example the roles, responsibilities and relatiRve status of the participants. The emotional climate and participants' expectations of LtheI iBnteraction will also affect the communication encounter. Feedback: This consists of messages the receiver returns, wAhicNh allows the sender to know how accurately the message has been received, as well Das the receiver's reaction. A receiver may also respond to the unintentional message as weAll as the intentional message. Feedback messages range from direct verbal statements, Bto subtle facial expressions or changes in posture that might indicate to the senderF th aIt the receiver feels uncomfortable with the message or otherwise. Feedback allowsO the sender to regulate, adapt or repeat the message in order to improve communication. Principally, InterpersonTal cYommunication is inescapable, irreversible, complicated and contextual. We cannot but cIommunicate in fact; the very attempt not to communicate is communicating somethinSg. Communication is not only words since we constantly communicate to tEhosRe around us through the channels of tone of voice, gesture, posture, facial expressiVon, and many more. Interpersonal communication is irreversible meaning it is not possiNble Ito take back something once it has been said. Interpersonal communication is also Ucomplicated that is no form of communication is simple, particularly in interpersonal relationship. Hence, due to the number of the variables involved, complexity in meaning and interpretation set in. Thus, if communication is not specific and explicit, it may fail. In other words, communication does not happen in isolation. It may have psychological, relational, situational, environmental, and cultural contexts. Group communication is between 3 and 20 individuals for a small group and may be regarded as interpersonal communication within a group. Groups generally work in a context that is both relational and social. Quality communication such as helping behaviours and 27 information-sharing causes groups to be superior to the average individual in terms of the quality of decisions and effectiveness of decisions made or actions taken. However, quality decision-making requires that members both identify with the group and have an attitude of commitment to participation in interaction. 2.12 Group communication Group communication refers to the interaction between members of a small grouYp of individuals with a facilitator. Communication in a group has the potential of expRonential growth since a major characteristics of a group is not just focus on relationsRhip Abuilding but on some sort of task completion and goal accomplishment. A significant benefit of communication in a group is synergy. (Ellis and Fisher, 1994). In this rIeBgard, members in a group have the potential to gain in performance as well as heighten eLd quality of interactions when complementary member‟s characteristics are added toA theN existing ones. The platform for sharing of information, decisions as well as reinforcement of newly acquired information is created through group communication. Given the AfeaDture of interdependence in a group, a common identity, purpose and same faith Bis shared. (Larson, 2010). Basically, communicating in a group meets instrumenFtal nIeed of enriching the existing knowledge of a phenomenon as well as provide informOation that may be utilized for security and protection. Again, group communication meets in terpersonal needs by giving access to inclusion, control and support. Y In addition, effective IcTommunication in a group satisfies identity needs by creating building blocks for socialS inclusion and acceptance. There are many types of sizeable groups but the most commEonR distinction made is between task- oriented groups and relation-oriented groups. Task oVriented groups are formed to solve a problem, promote a cause, or generate ideas or NinfoIrmation for immediate and future benefits of members. (Mckay, Davis and FanniUng, 1995). Group cognition, as posited by Stahl (2004), is a proposal for a new science or focus within the human sciences. Thus, when small groups engage in cooperative problem- solving or collaborative knowledge building there are distinctive processes of interest at the individual, small group and community levels of analysis, which interact strongly with one another. The science of group cognition is the study of the processes at the small-group level which deals with human meanings in unique situations necessarily relying upon interpretive case studies and descriptions of inter-personal processes. 28 Group discussion has many returns, in that it enhances information dissemination and reception in both the affective and cognitive domains. It is both recipient and subject- centered. It stimulates receiver to think about issues and problems discussed. In addition, it provides opportunity for sharing, fosters positive group support, increases feeling of belonging and reinforces previous knowledge, if any. This study, a non-laboratory experiment, investigated the small group phenomena without isolating the study subjects from their natural habitats. The group consisteYd of women who were individuals and who made individual contributions to the study dRiscourse based on their understanding. In addition, the group operated and existed withinA community and social contexts drawing upon personal exposure to breast cancer issRues. This is an essential feature of a real world context and it was considered inapprLoprIiaBte to exclude them by confining the interaction to a controlled laboratory setting. The women were not controlled in any way. The participants‟ liberty was not Ncompromised but they felt comfortable as if in a natural setting. This was in additioDn toA obtaining a signed consent form of voluntary participation from each participant. Vygotsky (1930;1978) argue that learningB taAkes place inter-subjectively (in dyads or triads) before it takes place intra-subjectivFely (Iby individuals). In this sense, the science of etnomethodology, according to Garfinkel (1967), is based on the fact that people in a given culture or linguistic community share Oa vast repertoire of social practices for accomplishing set objectives or tasks. Maxwell Y(2004) opines that the analysis of unique case studies can result in the description of IsoTcial practices that are generalizable. This is to say that the methods developed in spSecific situations are likely to be typical of a broad range of cases under similar conEditioRns. Stahl, (2006) states further that; „small groups are the engines of knowledge buiVlding‟. The knowledge that groups build up in manifold forms is what becomes internalizNed bIy their members as individuals. 2.13 U BCC and utilisation of breast cancer screening Behaviour change communication came into being due to the inadequacies of both the mass media campaign and the efforts of Information, education and communication (IEC) strategies employed by health educators and health promoters. Creating, changing and adapting earlier methods and strategies of IEC to addressing behaviour change is the rationale behind the uptake of BCC. 29 Behaviour change communication is an approach to behaviour change focused on communication. The assumption is that, through the combination of interpersonal and group communication platforms, individuals and communities can somehow be persuaded to behave in ways that will make their lives safer and healthier. BCC programmes are designed to bring about behaviours that will improve health status and related long term outcomes. BCC is strategically designed programs that influence behaviour, BCC interventions fall into three broad categories: Y  Mass media (radio, television, billboards, print materials, internet and so on.R),  Interpersonal communication ( client-provider interaction, group preseRntatAion),  Community mobilization. Any of these three communication strategies can generate tLhe IrBesults measured by these core indicators; change in knowledge, attitudes, intentions and behaviour. BCC utilises a mix of media channels and participatory methods to communiNcate health behaviour change messages. Health behaviour change messages refers to tAhe motivational, volitional and actional processes of abandoning health conditions AandD health compromising behaviours in favour of adopting and mainting health-enhancingB behaviours (WHO, 2002) Information, education and comFm uInication essentially involve talking and encouraging people, patients, and comOmunities through the medium of interpersonal, group and mass media, but this seems to be inadequate in effecting behaviour change in target audience. Basically, the goal Tof YBCC is to understand the social structures that influence individuals‟ knowledge, attituIdes and behaviours. Hence, a BCC intervention would take into serious considerationR, thSe demographics, socio-economic factors, epidemiology, politics, cultural and sociEal norms of the target audience. Moreover, BCC intervention takes cognisance oIf Vthe values, concerns, needs, behaviours, habits, beliefs and difficulties of each target groNup. 2.14 U Age and utilisation of breast cancer screening The incidence of breast cancer increases with age until a woman is eighty years old. Approximately 80% of women aged 50 and above are susceptible (Oregon State Cancer Registry, 2003). It is relatively uncommon in younger women although on-going studies are producing an incredible data of adolescent victims (Olowokere 2012) Breast cancer begins to increase significantly at approximately age 40. According to Olapade et al. (2004), the age range at which women develop breast cancer is 44 years and 51% of them are yet to reach 30 menopause. Studies have shown (Maclean, 1984) that women who attend breast screening are more likely to be of high socio-economic status, more sympathetic to screening and to have suffered less anxiety following the invitation/recommendation to attend. Age and gender have also been suggested as important factors for uptake of screening. Owens, (1987) notes that older women are more likely to attend breast screening than younger women. Evidence from North America suggests that there is a reasonable public awareness of the importance but compliance with regular BSE is reported by a minority of young women (Wardle, 19Y95). Also, Tanjaisiri, (2002) found that among Togan-American women aged 40 and aboRve, only 40% had ever performed BSE. Among Vietnamese women in Texas, 55% hadA performed BSE, compared to other studies which recorded low level of awareness (HBo, 2R005). I 2.15 Educational attainment and breast cancer utilization L Despite medical education and theoretically easy accAessN to medical services, a study by Kulk (2003) among nurses in Dublin showed inadequDate knowledge about the disease and lack of individual preventive actions by nurses, as only 24% of them performed regular monthly BSE. Petro Nustus and Mikhaut (2002) BrepAorted that, among 519 women from two major universities in Jordan, 67% had hearFd or rIead about BSE; only 25% had ever practiced BSE in the previous 12 months and onlOy 7% performed it on a regular monthly basis. In Germany of 532 women , 84% were well informed about BSE, only 43.1% practised BSE every month. InT a sYtudy conducted by Aslaif (2004) and Wuyet (2005) among female nursing students, onIly 66% performed BSE. Among 109 patients of a university maternity hospital, in the Scity of Natal, 754% practised BSE (Davin, 2003). Also among 410 female health worEkersR in Tehran, Iran, only 63% claimed to know how to do BSE, while 6% performed it monthly. ThNe siItu Vation in Nigeria is not different. In a study conducted among female school teachUers in Lagos, Nigeria, 62% practised BSE, with 11% on a monthly basis (Odusanya, 2001). In a similar study among 76 health workers, 60% of doctors and 53.7% of nurses practiced BSE occasionally, while only one doctor could describe how to perform it correctly (Jebbin and Adoley, 2004). The fact that these individuals were educated afforded them the opportunity of engaging in BSE having been aware of the immense advantages of doing so. This means that being educated enhances the uptake of breast screening methods among those that are aware of it. The findings of this study lends credence to this fact that, truly, 31 literate and enlightened female menial workers find it convenient to utilize the knowledge of breast self-examination as taught in the study intervention programme. 2.16 Theories reviewed for the study This work reviewed three major theories; Diffussion of Innovation, Theory of Planned Behaviour and Health Belief Model, that are popularly employed to study and predict health- related behaviour change. This is in conformity with previous studies in this regard (FishYbein and Ajzen, 1975; Rosenstock et al., 1994; Prochaska and Velicer; 1997, AjzRen,1998; Smedslund, 2000; Armitage and Conner, 2000; Ajzen, 2002; Burrkholder aRnd ANigg, 2002; Noah and Zimmerman, 2005; Taylor, Bury, Campling, Carter, GarfieBld, Newbould and Rennie, 2006). LI 2.17 Diffusion of innovations theory N Everett Rogers (1962) propounded the diffusion of Ainnovations (DOI) theory, and it has since evolved and developed as a communication thDeory. Although it is deeply rooted in anthropology and sociology, it explains how nBew Aideas and practices spread within and between communities (Tarde, 1903, Bailey 195 7I;1975) The theory is used in communication to explain how, over time, an idea orO proFduct gains momentum and diffuses (or spreads) through a specific population or soc ial system. Consequently, as a result of the diffusion, people, as part of a social systemY, adopt a new idea, behaviour, or product. This means that people adopt or start to do soImTething differently. It marks a new beginning and utilisation of something new. An innovSation is an idea, behaviour, object that is perceived as new by its audience (KinaidE 20R04). Innovation can be defined as all scientific, technological, organizational,V financial and commercial activities necessary to create, implement and market new or imNproIved products or processes (OECD, 1997). For adoption to take place, the person must Urecognize the initiative, lifestyle, behaviour, or item for consumption as new or innovative. It is in the course of this that diffusion is achievable. The key elements of diffusion of innovations are; innovation, communication channels, time and social system (Mahagan, Muller and Bass, 1990). Diffusion theory advocates that innovation can reach the poorest people since it is a natural phenomenon that happens. Whether the innovation involves a new idea, a new pattern of behaviour or a new technology, it is a natural physical phenomenon that describes the spread of an object in space and time. This study employed the method of the diffusion of innovations theory to spread the new idea 32 of breast self examination by hitherto unreached segment of the society, the female menial workers in Oyo and Osun States of Nigeria. Klein (1999) observes that ideas confine a man to certain social groups and social groups confine a man to certain ideas. Many ideas are more easily changed by aiming at a group than by aiming at an individual and truly the diffusion of innovations method has been used to spread new ideas and practices in a wide variety of settings. The basic premise, confirmed by empirical research, is that new ideas and pracYtices spread through interpersonal contacts largely consisting of interpersonal commuRnication. (Ryan & Gross 1943; Beal and Bohlen 1955, Katz; Levine and Hamilton 19R63; AHagerstrand 1967; Rogers 1995, Valente and Rogers 1995; and Valente 1995). Given the importance of interpersonal contacts in diffusion, this study relied on methods of netLwoIrkB analysis. Network analysis is a set of methods that enables researchers to locate in dividuals who are more central to a community and thus perhaps more influential to inNitiate the diffusion of a new idea or practice. (Limas et al. 1991; Wiist and Snider 1991A; AAPSS, Annals, 566). Leaders who employ interventions designed to use interpAersoDnal communication for promoting behaviour change are often referred to as peIeBr influence, peer education, interpersonal counselling, outreach or peer networks. Im plicit in the peer promotion model is the assumption that some individuals willO actF as role models for others directly or indirectly. (Broadhead et al. 1995). Moreover, the diffusionT ofY innovation theory is the process by which an innovation is communicated through certaIin channels over time among members of a social system or defined social class, suchS as the female menial workers selected for this study. It is a 5- step process. ER NI V U 33 RY RA LI B AND  Knowledge- The female menial workers becoAme aware of how to perform breast self- examination. IB  Persuasion- The female menial wor kers form a favourable attitude toward the innovation(breast self- examinaOtion)F  Decision- The female meYnial workers engage in breast self- examination activities that lead to a choice toI Tadopt the continuous practice of the innovation.  Implementation- FSemale menial workers put breast self- examination innovation to use. R  ConfirmatiEon- Female menial workers evaluate the results of breast self- examination innovIatVion decision already made and progress positively in this regard. UN 34 Y RA R LI B DA N IB A Essentially, the diffusion of innovaFtion theory allows for compatibility, trialability, observability, homophily and thYe s p Oecific channels for communicating the innovation. Compatibility is the degree to which breast self- examination is perceived as being consistent with past experiences anSd exIi Tsting values, costs less, and improves in some other manner upon existing practices, as well as the needs of potential adopters. An innovation must be considered socially acRceptable to be implemented. Trialability is the degree to which breast self-examinatioVn mEay be experimented with on a regular and consistent basis. Obsevability is the degreNe toI which the results of breast self- examination practice is known and visible first to theU receiver and to others. The concept of homophily, that is similarity in socio-economic characteristics of the female menial workers, influences effective dissemination of the utilisation of BSE by the target group. The channels of interpersonal and group communications strengthen the effective dissemination of the need for breast self - examination by female menial workers in the intervention group. (Apperson and Wikstom, 1997) In conclusion, the major debate is about what efforts are most successful in encouraging the spread of an innovation. Is it Mass media or through interpersonal 35 communication within a specific social class? Truly, the mass media can spread knowledge of innovations to a large audience rapidly, but does this translates to the acceptance and utilisation of this innovation on a continuous and consistent basis? Rogers (1995) maintains that persuading opinion leaders is the easiest way to enforce positive attitudes towards an innovation. The types of opinion leaders that effect changes are dependent on the nature of the social system. Interpersonal ties are usually more effective in the formation and change of strongly held attitudes. Research has show that firm attitudes are developed throYugh communication exchanges about the innovation with peers and opinion leadersR. These channels are more trusted and have greater effectiveness in dealing with resistancAe or apathy on the part of the receivers. Change agents, must, if possible, communicate toR opinion leaders a convincing argument in favour of the innovation that accentuates LtheI cBompatibility of the innovation system norms. Hence, this study submits that interperson al communication within a group is a veritable platform for behaviour change communAicaNtion. 2.18 Theory of Planned Behaviour. ADB OF I ITY RS IV E UN The Theory of Reasoned Action (TRA) was propounded by Ajzen and Fishbein (1980) while trying to estimate the discrepancy between attitude and behaviour. It was discovered that TRA was related to voluntary behaviour and behaviour appeared not to be 100% voluntary and under control. This resulted in the addition of perceived behavioural control; 36 and the theory was called the theory of planned behaviour (TPB). The theory of planned behaviour predicts deliberate behaviour. The theory of reasoned action suggests that a person‟s behaviour is determined by her intention to perform the behaviour and that this intention is, in turn, a function of her attitude toward the behaviour and her subjective norm. The best predictor of behaviour is intention. Intention is the cognitive representation of a person‟s readiness to perform a given behaviour, and it is considered to be the immediate antecedent of behaviour. This study adapted the theory of planned behaviour inY its intervention attempt. The theory, according to Ajzen (2006), claims that human behRaviour is guided by three kinds of considerations, namely: A  beliefs about the likely outcomes of performing breast self- examRination and the evaluation of these outcomes(behavioural beliefs) IB  beliefs about the normative expectations of others in pLerforming breast self- examination and motivation to comply with these expAectNations(normative beliefs)  beliefs about the presence of factors that may facilitate or impede performance of breast self examination and the perceived power oDf these factors(control belief) These three kinds of considerations c AIoBmbined will result in the formation of a behavioural intention, although certain difFfic ulties of execution of the intended behaviour may require that perceived behavioural control may be examined alongside the intention. This translates to the fact that behav iOoural control is an important element in determining whether specific behaviour inteTndYed will actually be carried out. For this study, feSmalIe menial workers in the two universities studied were guided in the uptake and utilisatRion of breast self -examination because their attitudes, subjective norms and perceived beEhavioural control were based on corresponding beliefs and behavioural intentions. TIhVe method of intervention employed was a face-to-face discussion within a group. ThNe study revealed how perceptions control performing breast self examination. And such Uthe intervention was designed to raise perceived behavioural control among these women. Specifically, the intervention was directed to behavioural beliefs so as to make the women‟s attitude toward breast self-examination more favourable, so as to affect intentions and behaviours. This method is not just a possible approach but seems to be a very effective approach for beahaviour change communication. Following the intervention, there was much more variability in the perceived behavioural control among the women. This revealed a strong co-efficient for the factor of behavioural control in the prediction of intentions and behaviour. The intervention upheld the 37 view that the merger of behavioural, normative and control beliefs will eventually result in actual behaviour/control and ultimately result in positive intentions and actual behaviour. This is based on the fact that this intervention, directed at behavioural, normative, and control beliefs, succeed in producing corresponding changes in attitudes, subjective norms and perceptions of behavioural control, which further influence intentions in the desired direction. Hence, a strong link is established between intentions and behaviour. According to Golliwitzer (1999), sustaining behaviour change over time requires an implementaYtion intention, meaning a specific plan detailing when, where and how the desired behavRiour will be performed.The formulation of the manner and procedure of the BSE will makeA it easier for the women to carry out their intended actions. BR I 2.19 Health Belief Model L The origin of the health belief model (HBM) backA to Nthe 1950s, when it was first developed by social psychologists Hochbaum, RosenstoDck and Kegeis working in the U.S. public health services. The model was developeAd in response to the failure of free tuberculosis (TB) health screening programmeI. BSince then, the HBM has been adapted to explore a variety of long-and short-term health behaviours, including sexual risky behaviours and the transmission of HIV/AIDS. It Ois a Fpsychological model that attempts to explain and predict health behaviours. This is don e by focusing on the attitudes and beliefs of individuals through which several social pTsycYhologists seek to understand the infrequent acceptance of preventive practices and preI-illness screening tests (Dunn and Roggers, 1986) However, it was formally proposed byS H. Becker (1964) as an attempt to improve on a simple stimulus- response mode. IEt wRas initially proposed to explain why people did not participate in preventive heaVlth programmes. TNhe HIBM offers a catalogue of variables that influence health action, rather than an explaUnation for how they operate. It took a phenomenological orientation (that is it is a person‟s perceptions of the world that determines what he will do, not necessarily the actual environment). Several studies have suggested that the HBM does predict behaviour, although the variance explained remains low. Accordingly, many derivatives were proposed. Examples include Langie‟s model of perceived vulnerability, perceived benefits of changing health behaviour, barriers and costs, health locus of control, and situational constraints. Moreover, Antonovsky and Kats model of preventive health behaviour included three classes of variables: predisposing motivation (influenced by desire to avoid illness, to be 38 approved by others and to meet one‟s own values); blockage variables (lack of knowledge, resources); conditioning variables (perceived susceptibility will modify the above variables and previous illness experience). The HBM is based on the understanding that a person will take a health-related action if such a one:  feels that a negative health condition (that is, breast cancer) can be avoided,  Has a positive expectation that by taking a recommended action, he/she will avoYid a negative health condition (that is, submitting oneself to breast cancer screening mRay help in detecting the disease early enough) and A  believes that he/ she can successfully take a recommended health actBion R(that is, she can do screening, which may result in early diagnosis and prevent theL spIread of the disease). Rosenstock (1974) formulated the health belief model more foNrma lly. This consists of four DA IB A OF TY RS I VE NI compUonents: perceived susceptibility, perceived seriousness, perceived benefits and perceived barriers. In relation to the focus of this study, the components of this diagram can be interpreted thus: 39  Perceived susceptibility: the female menial‟s judgement of her risk of contracting breast cancer,  Perceived severity/seriousness: threat of breast cancer and impact of breast cancer on her life style  Perceived benefits and feasibility of taking action: the benefits provided by breast self examination and the ease of performing the exercice  Cues to action: when breast self-examination is seen as favourable, change in attiYtude towards practicing BSE will usually occur when those who ignore to participate Rin breast screening are plagued with the disease. RA A recent addition to the HBM is the concept of self-efficacy; that iIs,B the female menial workers‟ confidence in the ability to successfully perform breast sel f-Lexamination. AN BA D F I Y O T RS I VE UN I 40 Source: Adapted from Theory at a Glance: A Guide for Health Promotion Practice (1997) Concept Breast Screening Breast Screening Use Education 1. Perceived Susceptibility Female menial workers believe Female menial workers believe they can get breast cancer. they may have undetected lump already. 2. Perceived Seriousness Female menial workers believe Female menial workers believe that the consequences of getting the consequences of haYving breast cancer are significant breast cancer Rwithout enough to try to avoid it knowledge orR treAatments are significanIt Benough to try to avoid. 3. Perceived Benefits Female menial workers believe Fem alLe menial workers believe that the recommended action of Nthat the recommended action of participating in screeninAg getting screened for breast would reveal their heaAlth Dstatus cancer would benefit them – and may possibly Bprotect them possibly by allowing them to from getting bre aIst cancer. g e t e a r l y t r e a t m e n t o r preventing them from untimely OF death. 4. Perceived Barriers FeYma le menial workers identify Female menial workers identify ITtheir personal barriers to breast their personal barriers to S cancer screening presenting themselves for R (that is, cultural barriers in screening (that is, getting to the E which women are too clinic or being seen at cancer IV uncomfortable to present clinic by someone they know) N themselves at the screening and explore ways to eliminate U centres) and explore ways to or reduce these barriers (that is, eliminate or reduce these brainstorm transportation and barriers (that is, teach them to disguise options. carry out BSE. 5. Cues to Action Female menial workers receive Female menial workers receive reminder cues for action in the reminder cues for action in the form of incentive (such as form of incentives (such as a handbags with the printed key chain that says, “BSE a 41 message BSE a must for all good way to arrest cancer”) or women) or reminder messages reminder messages (such as (such as messages in market posters that say, Women above and shopping places). 40 must do breast screening. Are you 40 or more? Please present yourself for screening. 6. Self-efficacy Female menial workers Female menial workers receive confident in performing BSE as guidance (such as informYation well as engage screening on where to get screRened) or regularly training (such asA practice in performingB BSRE). I Steven and Rogers (1986) argue that although the threatened inLdividual is energised to act, the behaviour will not occur unless an external influencAe, liNke mass media, interpersonal or group communication campaigns, encourages it. The health belief model also assumes that psychAoloDgical or demographic variables may indirectly affect the likelihood of self-productivIeB act through their influence on one or more of the model‟s components to determine Fthe impact of the HBM variables in preventive regimes. (Janz and Becker (1984) and Steven and Rogers (1986) constructed a significance ratio for each component. The ratio wOas formed by dividing the total number of positive, statistically significant resultsT byY the total number of studies that assessed significance. Twenty four correlation stuIdies were considered, and barriers had the most frequently reported impact on beRhavSiour (93.0%), followed by susceptibility (86.0%) benefits (74.0%) and severity (50.0%). Janz aInVd B Eecker (1984) claimed that, despite the impressive body of findings linking HBM diNmensions to health actions, it is important to remember that the HBM is a psychUological model. As such, it is limited to accounting for as much of the variance in individuals‟ health-related behaviours as can be explained by their attitudes and beliefs. With respect to exclusive breast feeding, exclusivity is a function of a woman‟s personal perceptions, modifying factors, and cues to action. The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. These concepts were proposed as accounting for people‟s “readiness to act”. An added concept, cues to action, would 42 activate the readiness that stimulates overt behaviour. This concept was added by Rosenstock (1988) to help the HBM better fit the challenges of changing habitual unhealthy behaviours. 2.20. Model adopted for the study AWARENESS (Alertness, ACQUAINTANCE sensitization) (knowledge, Information Dissemination) AR Y ADHERENCE (Practice, observance, BR commitment ADVI CLE I(Persuasion, ACCEPTANCE Influence, (Reception, ACNonvince) recognition, approval) AD 5 A’S OF Behaviour Change CommunicationI B Source: Researcher, 2017. F The model adopted for this st udOy evolved from the combination of the three theories employed for the study. It is a meYrger of diffusion of innovations theory, planned behaviour theory and health belief moIdTel. Hence the model is titled the 5A‟s of behaviour change communication. Awareness: This is thRe fiSrst contact of the female menial workers with the message on breast cancer from a behEaviour change communicator. AcquaintancIeV: The receiver is alerted and sensitized to the information on the disease called breast caNncer and how to screen or detect the disease as well as the very important steps to take tUo prevent morbidity and mortality. Advice: The female menial worker is then informed appropriately on one of the cheapest, easiest and simplest method of screening for breast cancer- breast self-Examination. The best time to do a BSE is a week after the menstrual cycle starts that is, one week after the last menstrual cycle (LMP). It must be done on a particular date and time of the month and any unusual discovery is swiftly reported. Acceptance: At this stage, the female menial worker understands the implication of screening, is very familiar with the details and intricases of the practice of BSE, can easily 43 detect any strange abnormality in the breast during self-examination and is willing to report same for further screening by medical personnel as may be determined by them Adherence: The female menial worker has adopted the behaviour change and there is no need for further persuasion to carry out the adopted practice. It has become a lifestyle and it is done regularly and correctly without any external influence to do so. The significance of 5A‟s of Behaviour change communication model is nestled inY its connection and combination of the two theories and one model utilized in the study-DRiffusion of innovations, theory of planned behaviour and health belief model. A The model, 5A‟s of Behaviour change communication emphasizes the Rimportance of sensitization and awareness creation regarding the realities surrounding IbrBeast cancer disease as well as the potential antidote to forestalling mortality from the Ldisease. Hence, once a woman is acquainted with the details of the workings of breasNt cancer, with expert advice, she could adopt the strategy of breast self examination whicAh will alert her to any impending eruption of breast cancer. Accepting and adherence Ato tDhe procedural practice of breast self examination would enable a woman to reporIt Bany unusal signs that may be benign or cancereous. If cancerous, early detection wFuld enhance early treatment and cure as well as forestall morbidity. O ITY ER S V UN I 44 CHAPTER THREE METHODOLOGY 3.1 Research design The study was a pre-test – posttest, control group quasi-experimental design with a 2x3x2 factorial matrix.There was an experimental group and a control group. The experimental group participated in the training workshop on breast cancer screening methods, while the control group received lectures on handling women‟s health generally and notYhing specific about breast cancer screening. The summary of the research design is showRn in the table below. A Table 3.1: 2x3x2 Factorial Model of Experimental Design R Groups Pre-Adult Young- Adult LAdIuBlt Less Moderately Less ModeratNely Less Moderately Educated Educated Educated EducAated Educated Educated (C1) (C2) (C1) (CD2) (C1) (C2) BCC(A1) A1+B1+C1 A1+B1+C2 A1+B2+C1 AA1+B2+C2 A1+B3+C1 A1+B3+C2 CONT(A2) A2+B1+C1 A2+B1+C2 A2+B 2I+BC1 A2+B2+C2 A1+B3+C1 A2+B3+C2 KEY: F A1: Experimental Group O A2: Control group B1: Pre-Adult ITY B2: Young Adult S B3: Adult R C1: Less EduIcVated E C2: ModNerately Educated 3.2 UPopulation of the study The populations of the study consisted of female menial university workers between the ages of 25 and 60. The selection was a nonprobability purposive sampling of women within the susceptible age bracket for breast cancer. The sample is characterized by the use of judgement and a deliberate effort to obtain representative samples by including presumably typical age groups in the sample. 45 3.3 Sample and sampling technique The study employed the nonprobability sampling and the likely error inherent in this procedure was mitigated by using knowledge, expertise and care in selecting the samples used. This is in consonance with Kerlinger (1973:129). The participants in the study were 100 women (following a previous study conducted in Lagos State, Nigeria) from Bowen University and University of Ibadan respectively. These women were selected using the nonprobability purposive sampling and simYple randomisation technique. The participants were in 2 groups–intervention group andR control group. The Bowen University participants were given treatments, while the wRomAen from the University of Ibadan belonged to the control group. The researcher worBked in conjunction with undergraduates from both universities in the administration Lof Ipretest and posttest questionnaires. Also, the medical team of Bowen University got inAvolvNed because the hospital was used as a screening centre during the project. With Dthe assistance of Bowen Hospital management, participants reported at the hospital for screening and the medical officers in charge attended promptly to them with properI dBocu Amentations of attendees and their case files. A few referrals were then made toF th e University College Hospital, Ibadan for the attention of the breast oncology team. O 3.4 Inclusion Criteria: Y To be eligible to participaIteT in the study, the participants must be:  menial workerRs inS the universities in Oyo and Osun States  within the Eage bracket of 25 and 60 years  staff oIfV an outsourced organisation within the university  wNilling to actively participate voluntarily in the study, and  Ube actively involved in at least 90% of the study‟s activities. 3.5 Instrumentation 3.5.1 Pre- test questionnaire Breast cancer screening questionnaire (divided into four sub-scales: knowledge/ awareness, sources of information, method and utilization) 46 3.5.2 Breast cancer awareness scale The questionnaire scale was drawn to determine the baseline knowledge of participants regarding breast cancer screening. The information was then collated and `analyzed to determine their knowledge level. 3.5.3 BCC (treatment) package and guide The Breast Cancer Utilization Package (BCUP) was adopted by the researcher. It included an eight-week teaching module for the participants. Experts and specialiRsts Ywere invited to give lectures and to conduct practical sessions on breast cancer screening. The module is in Appendix A. RA Pilot Study B The objective was to make it possible for the researcher to e stLablIish the psychometric properties of the four instruments for the study. The instruments for the study were revalidated by means of an internal method of validation. EAxpNerts in test construction went through the tests and made suggestions and necessary coDrrections. The pilot study was carried out by administering the instruments on 25 women fArom University College Hospital Ibadan who were randomly selected. The Cronbach c oeIfBficient method was used therefore to test the internal consistency of the items of the meaFsuring instruments. Reliability Test O A. Scale: Knowledge of Awareness Reliability Statistics TY Cronbach's N of I Alpha ItemRs S .714 8 IV E B . ScaleN: Source of Information U Cronbach's N of Alpha Items .853 8 47 C. Scale: Screening Method Cronbach's N of Alpha Items .908 5 D.Scale: Breast Screening Utilisation Cronbach's N of AR Y Alpha Items .717 6 BR I E.Breast Cancer Disease Awareness Scale L Cronbach's N of N Alpha Items A .798 40 D BA The participants for the interventionF gr oIup were selected by identification of women who were less likely to know about brOeast cancer screening. These were low income earners (female cleaners, who were staff of B owen University Ventures) who might otherwise have little or no information regarding bYreast cancer screening. Initial visitations and consultations were made to identify williInTg participants and to take due permission from appropriate authorities in each grRoupS. Next, letters were then issued out to resource persons listed to participate in the iEntervention programme. The resource persons were representatives of the Chief MedicIalV Officer of Bowen University Hospital, representatives of the Division of Oncology, Department of Surgery, University College Hospital Ibadan, and a cancer patient surviUvor.N These resource persons agreed to collaborate with the researcher to carry out the intervention programme for the experimental group. Following this, the management of Bowen University, Iwo was duly informed and a venue was designated for the intervention programme to prevent contamination. Health talks were given on a weekly basis for a period of 8 weeks on a consistent and systematic basis for the experimental group by the resource persons. Each week, there were questions and answer sessions and participants were allowed to interact with resource persons on a one-to-one basis. Beginning from the 5th week, participants in the experimental group 48 were conducting BSE for themselves and also visited Bowen University Hospital for clinic- based examination with additional women(non-participants who heard the information from the participants) who made self-initiated visitation to Bowen University Hospital, having been told of the BSE training and the CBE opportunity available at the hospital. 3.6 Method of data analysis The data collected during the treatment sessions were analyzed using the AnalysYis of Covariance (ANCOVA). The socio-demographic variable; knowledge, attitude and Rpractice about the screening were analyzed using SPSS, and T-test at 0.95 level of sAignificance. ANCOVA is a statistical form of analysis of variance that was invented by FRisher (1951). It tests the significance of the differences among means of experimental grIouBps after taking into account initial differences among the groups, and the correlation of Lthe initial measures and dependent variables. It has the ability to control errors, adjust Ntreatment means between the experimental group and the control group, take the correDlatioAn between the pre-test and post- test measures into account and increase precision in randomized experiments and adjusted means worked out by the two techniques adopte AIdB (HCTQ & HCEQ) using the standard error means. 3.6.1 Control of extraneous variables F The following measures Owere, taken to minimize and control the intervening/extraneous variableTs wYhere the total elimination of such was not possible: a) The use of random selecItion process to choose participants into treatment and control groups: The participanSts for this study met the criteria for selection as laid down, that is they were low incoRme females eligible for breast cancer screening. b) The testing conEditions were made uniform for all the participants in the groups in terms of sittingN arraIn Vgements, time of the day and messages received. c) AlUthough the same instrument was used as pretest and post pre-test measures, the time interval between the two tests (8 weeks) to a large extent, took care of the habituation of the participants subjected to the instruments. d) The language of communication was Yoruba. The instruments were prepared in English but translated into Yoruba to remove linguistic noise as well as to achieve maximum comprehension of the transmitted message by the target participant. e) The 2x3x2 factorial design was used for the study. f) The treatment manual was followed meticulously by the researcher. 49 g) The statistical analysis of the data used in the study that is Analysis of Covariance (ANCOVA) helped to control any other variations that might not be easily or adequately handled by the measures taken so far, which include sampling and treatment procedures. With the above steps dutifully taken, it was believed that wherever there was a significant change in behaviour, such changes could be attributed to the efficacy of the treatment programme despite the extraneous variable. Y 3.7. Table showing distinct socio-demograhic differences between female Rmenial workers in Iwo and Ibadan Centres respectively. A RESPONDENTS IWO BIBRADAN Age Majority of women surveyed in Iwo were MajoriIty of women between 36 and 45 years. su rvLeyed in Ibadan were ANbetween 26 and 35 years. Ethnicity Women surveyed were mostly YoruDba Women surveyed were mostly Yoruba Marital Status All respondents were marriIedB A 82% of respondents were married Religion 82% of respondentOs weFre Christians 62% of respondents were Christian while 38% were TY Muslims Education In IwSo, I64% attended elementary school The Ibadan respondents wRhile the remaining 32% attended attended elementary, Esecondary school and none for post secondary and post V secondary. secondary schools. Work NI 68% of the respondents have been cleaners While only 8% have been ExpeUrience for about 3 to 4 years. cleaners for 3 to 4 years. 50 CHAPTER FOUR RESULTS AND DISCUSSION OF FINDINGS This chapter presents the result of the research and discussions of findings in relation to previous related studies. This chapter is in two parts. The first part details the demographic characteristics of the respondents, while the second part dealt with the results of the variables used. Y 4.1 Demographic Characteristics of the respondents R Figure 4.1: Distribution of respondents by age A LIB R 58 60 52 N 50 40 A 30 22 22 24 D 20 12 8 10 IB A 2 0 20-25 26-35 F 36-45 50 & above OIbadan IwoY T Figure 4.1 shows a cIross-sectional analysis of the respondents‟ socio-demographic features. Specifically,R theS table shows that, in Ibadan, 22.0% were between the ages of 20 and 25 years, 52.0% wEere between the ages of 26 and 35, 24.0% were between the ages of 36 and 45 and 2.0%I wVere 50years and above. However in Iwo, 22.0% were between the ages of 20 and 25, 8N.0% were between the ages of 26 and 35, 58.0% were between the ages of 36 and 45, wUhile 12.0% of the respondents were 50 years and above. The results showed that the majority of those surveyed in Ibadan were between the ages of 26 and 35, while the respondents in Iwo were between ages 36 and 45. The literature recorded that by year 2020, women 45 years and above would suffer most from breast cancer disease. The experimental group fell within this category. The timely intervention of this study would serve as a way out for the population that may be affected in the next few years. 51 % Figure 4.2: Distribution of the Respondents by Ethnicity 100 96 100 80 60 40 20 Y 0 4 R 0 Ibadan Iwo A Yoruba Others RIB In terms of ethnicity, figure 4.2 reveals that all the respon deLnts surveyed in Ibadan were Yoruba (100.0%), whereas in Iwo (96.0%) were Yoruba, wNhile (4.0%) were from other ethnic groups. The conclusion here is that the respondents suArveyed in both study areas were largely Yoruba. The reason adduced for this is thAat bDoth study areas are located in the southwestern part of the country, which compriseBs mainly of the Yoruba ethnic group. Figure 4.3: Distribution of the Respo OF nd eInts by Marital Status 98 100 90 Y 80 IT 70 RS60 E Ibadan50 40 IV Iwo 30 2 1U0 N0 0 2 0 0 Single Married Divorce Widow Figure 4.3 shows that in Ibadan, 8.0% of the respondents were single, 82.0% were married, while 10.0% were widows. In Nigeria, most female menial workers are married and sometimes act in the capacity of breadwinners in their families. The pursuit to provide for their dependent poor children is a major catalyst that triggers their search for menial jobs to 52 % overcome poverty. The 10.0% who were widows in the Ibadan control group and the 82.0% who were married and still engage in menial work for survival attested to this. The same is applicable in Iwo since almost all the respondents were married (98.0%). It is evident from this analysis that those surveyed for the study were mainly married women. Basically, in Nigeria, most women within the age range of 25 years and above would normally be married. Therefore, this study is in consonance with other similar studies. Figure 4.4: Distribution of the Respondents by Religion AR Y 100 82 R 80 62 60 38 LI B 40 18 20 0 DA N Ibadan Iwo Christianity IIsBlam A In terms of religion, Figure 4.4 indiFcate s that, in lbadan 62.0% were Christians, while 38.0% of the respondents were MuOslims. In Nigeria, the two prominent religions are Christianity and Islam; the majority of the citizens would naturally belong to either.The University of Ibadan is a federTal iYnstitution and secular; hence, there is no dominant religion among its formal and inSformIal employees. As such there are no religious considerations regarding employmeRnt services. Conversely, in Iwo, 82.0% of the respondents were Christians, while 1E8.0% were Muslims. This implies that those who were mostly surveyed at both study arIeVas were Christians. The majority of women surveyed in lwo were Christians although,N traditionally, lwo town is view to be predominantly Muslim. Since the female meniUal workers worked for a Christian mission university, it is not unusual to discover that most of the outsourced employees would have the religious leanings of the employer. 53 % Figure 4.5: Distribution of the Respondents by Job Description In terms of occupation, Figure 4.5 shows that all respondents (100.0%) surveyed in both Ibadan and Iwo were all cleaners. 100 90 80 70 RY 60 A Ibadan 50 40 LIB R Iwo 30 20 10 AN 0 cleaner AD B The study targeted female menial work eIrs, specifically cleaners who were outsourced staff of the two universities studied. TOheseF women aged between 25 and 50+ years resident both in Iwo and Ibadan had been in the cleaning employment from a few months to more than five years. Y Figure 4.6: Distribution oIfT the Respondents by Education RS 94 100 V8E0 NI 64 60 U 40 32 20 0 4 4 2 0 0 None Elementary Secondary Post-Secondary Ibadan Iwo Figure 4.6 shows that, in Ibadan, 4.0% of the respondents attended elementary school, 94.0% attended secondary school, while 2.0% had post-secondary education. The academic distribution of the Ibadan control group shows that the least literate of the women had been to 54 % elementary school, while the highest number attended secondary school, and a few had been exposed to post-secondary education. This reveals that the participants in Ibadan were not stark illiterate; rather they were a moderately educated group of women who could read and write and, as such, can clearly understand health messages, particularly, breast cancer messages, health consequences of the disease on them and the inherent advantages in their uptake of screening. However in Iwo, 4.0% of the respondents did not pass through formal education, 64Y.0% attended elementary school, and the remaining respondents 32.0% attended secondaryR school. The report from Iwo is a little different, because the majority of the particRipanAts had only elementary education and a moderate category had secondary educatioBn, none had post- secondary education. The marked disparity in the two groups could Ibe adduced to their locations. Participants from Ibadan were from a relatively more exp osLed and elite community than the participants from Iwo, which could be categorizedA as Nbelonging to the rural-urban community. The implication is that the Ibadan participants were more literate than their Iwo counterparts. It could be concluded that, while secAondDary school certificate holders were those who were mostly surveyed in Ibadan, tIhBose who attended elementary school were mostly surveyed in Iwo. The experimeFnta l group had women with least educational qualifications. Thus, the study captureOd the less educated and fulfilled one of the study‟s objectives. Figure 4.7: Distribution oTf thYe Respondents by Work Experience SI 68 70 60 52 50 VE R 36 40 30 2 UN I 18 0 14 8 10 4 0 0 Less one year 1-2 years 3-4 years 5 years & above Ibadan Iwo Moreover, Figure 4.7 shows that in Ibadan, 36.0% of the respondents had been cleaners for less than a year, 52.0% of them had been cleaners between a year and two, 8.0% for 3 to 4 years, 4.0% had been cleaners for at least 5 years. However in Iwo, 14.0% of the respondents had been cleaners for at least 1 to 2 years, 68.0% had been into the cleaning 55 % profession 3 to 4 years, and about 18.0% of the respondents had been cleaners for at least 5 years. There is a noticeable difference in the duration of time that participants from Iwo and Ibadan had been in the cleaning profession within the university community. A total of 52.0% participants from Ibadan had worked as cleaners for between one and two years, while in Iwo 68% had worked as cleaners for between three and four years. This could be translated to mean that participants from Iwo had been around the university community for a longer period of time and ought to have access to health messages. Y 4.2 Response to research questions R RQ1: What is the level of awareness and knowledge of breast cancer disease aAs well as its consequences among the female menial university workers? R Table 4.1: Information about cancer disease IB Questions Ibadan LIwo Do you know about the disease called cancer? Before AAfNter Before After Yes 76.0%D 96.0% 14.0% 100.0% No IB18 A.0% 4.0% 74.0% 0.0% No Response F 6.0% 0.0% 12.0% 0.0% Source: Field Survey, 2015 O Table 4.2: Information aboutY br east cancer Questions IT Ibadan Iwo Have you heard about caSncer of the breast? Before After Before After Yes ER 76.0% 96.% 14.0% 100% No V 18.0% 4.0% 74.0% 0.0% Couldn’tN ReIcollect 6.0% 0.0% 12.0% 0.0% SourUce: Field Survey, 2015 56 Table 4.3: Causes of breast cancer Questions Ibadan Iwo What do you know /think causes breast cancer? What do you know or think Before After Before After causes breast cancer? Lumps 10.0% 50.0% 10.0% 90.0% Y Hereditary 1.0% 10.0% 2.0% 5.0% R Occultic/Satanic Affliction 50.0% 10.0% 70.0% 1.0% A Genetic Changes 2.0% 10.0% 5.0% 1.0% Dietary Factors 10.0% 0.0% 3.0% 1.0% R Environmental factors 5.0% 0.0% 0.0% 0.0% LI B Poverty 10.0% 0.0% 0.0% 0.0% Don’t know 12.0% 20.0% 10.0% A2N.0% Source: Field Survey, 2015 D Table 4.1 shows that, in Ibadan, before thAe intervention exercise, 76.0% of the respondents knew about cancer diseases. This isI Bexpected given the fact that the cleaners are located within the university system whFerei n issues of cancer is readily discussed and sometimes actual contact with cancer Opatients or their relations is a real possibility. Also, 18.0% said they never knew aboYut cancer. This is also a possibility, given the fact that majority of the cleaners, specTifically, 68.0% of the cleaners had worked for less than one year while 52.0% had wSorIked for between one and two years. Besides, 6.0% of the respondents claimed Rthey never could tell whether they knew about the cancer diseases or not. These womenE were probably insensitive to the available information around them or the information oInV cancer did not get to them. In other words, the sources disseminating breast cancer mNessage is still not making impact in some quarters. This lends credence to the fact that cUertain women still remain unreached and are susceptible. Therefore, efforts must be made to reach them with the consequences of cancer and the advantages of screening. After the intervention exercise, 96.0% of the respondents knew about the cancer diseases, while 4.0% of the respondents claimed they did not know about the cancer disease. In Iwo, before the intervention exercise, 14.0% of the respondents knew about the cancer disease, while 74.0. % never had a prior knowledge of cancer and 12.0% of the respondents could not tell whether they actually knew about cancer or not. The finding of the 57 study revealed that only 14.0% had knowledge of cancer disease before the intervention. This supports the effort of the intervention exercise. It is of utmost necessity that the issue of educating and communicating breast cancer messages receive urgent attention, given the number of people who are yet unaware of the disease and who are very well susceptible and may be unable to deal with the full blown disease. Additionaly, 12.0% of the respondents could not ascertain whether they had heard about the disease or not. This made the total number 86.0% female cleaners in Iwo who were truly not aware because the messagYe on breast cancer had not reached them from any known source. However, after the inteRrvention exercise, 100.0% of the respondents gained knowledge about the cancer diseaRse aAnd had fully comprehended the information about the disease. The discovery of this study attest to the need for a convenient method of disseminating breast cancer messages tIo Bthe unreached poor who have the tendency to contract the disease without know iLng anything about its management. On the whole, it could safely be concluded tNhat the respondents became knowledgeable about the cancer disease after the intervAention exercise in both study locations. This implies that the intervention exeArciDse carried out particularly in the experimental site yielded good results and the IgBeneral health messages disseminated in the control group also produced positive result. Table 4.2 shows that, in Ibadan, Fbefore the intervention exercise, 76.0% of the respondents had heard about the can cOer of the breast, 18.0% of the respondents had never heard about it and 6.0% could notY recollect whether they had actually heard about the cancer of the breast or not. HoweveIr Tafter the intervention exercise, 96.0% of the respondents had heard about the canceRr of Sthe breast, while 4.0% have not. In Iwo, beEfore the intervention exercise, 14.0% of the respondents claimed they have heard about tIhVe ailment called cancer of the breast, while 74.0% of the respondents had never heard of Nthe ailment and 12.0% of the respondents claimed that they had forgotten about hearinUg about the ailment. However, after the intervention exercise, the entire respondents (100%) claimed that they had heard about the ailment called breast cancer. The results in the experimental group attested to the fact that the awareness and knowledge of breast cancer disease increased tremendously after the intervention programme. This, points to the need for the intervention as well as its effectiveness in sensitizing the participants to utilise the breast self- examination method of screening. As captured in Table 4.3 with regard to the participants in Ibadan, the women‟s viewed the causes of breast cancer to be lumps (10.0%), dietary factors (10.0%), 58 environmental factors (5.0%), and poverty (10.0%); 50.0% of them felt that breast cancer is caused by satanic/occultic affliction. Their understanding did not improve significantly after the intervention about causes of breast cancer. Comparatively, in Iwo, the participants also believed strongly that breast cancer is caused by satanic and occultic affliction with 97.0% confirming it. However, after the intervention programme, the knowledge of the Iwo participants increased and 90.0% of the women understood that lumps in the breast could eventually cause breast cancer and not satanic or occultic affliction. The results fromY Iwo after the intervention further established the necessity of communicating correct infoRrmation about the causes of breast cancer disease to the ignorant. The prior understanAding of the participants from the control and experimental groups revealed that, if breastR cancer patients believe that the cause of the disease is by satanic/occultic affliction, thIeBn remedy and cure would be sought for in inappropriate places, thus, increasing the n umLber of morbidity from the disease. N RQ2: What is the level of awareness and knowledgeD of bAreast cancer screening among these women? Table 4.4: Breast cancer awareness and knIoBwle Adge level Question Ibad an Iwo Do you know if breast cancer OBFefore After Before After can be cured? Yes 10.0% 40.0% 20.0% 95.0% No Y 50.0% 50.0% 70.0% 3.0% Don’t know ITS 40.0% 10.0% 10.0% 2.0% Source: Field Survey, 2015 From tableE 4.4R, it is obvious that 90.0% of the participants in Ibadan were not aware of the possibIilVity of cure from breast cancer disease; while only 10.0% affirmed that cure for breast caNncer is possible. Still after the intervention, only 40.0% became aware that breast canceUr can be cured, while 60.0% still were unsure. In Iwo, 80.0% of the participants did not know that it is possible to receive cure from breast cancer, while only 20.0% responded positively, that it is possible to be cured from breast cancer. Noneteheless, after the intervention, in Iwo, 95.0% of the participants confirmed that cure is possible for a breast cancer patient while 5.0% were not sure. In Iwo, a large percentage now had the information and understanding of the truth that breast cancer is curable. This means that the understanding of the appropriate place to consult for cure is also understood. 59 Table 4.5: Breast cancer detection Questions Ibadan Iwo How do you think breast Before After Before After cancer can be detected and treated early? BSE 5.0% 30.0% 2.0% 80.0% CBE 20.0% 20.0% 10.0% 5.0% Mammogram 5.0% 10.0% 0.0% 5.0% Y Cancer Awareness 10.0% 10.0% 5.0% 10.0% AR Don’t know 60.0% 30.0% 83.0% 0.0% R Source: Field Survey, 2015 IB Table 4.5. Reveals that before intervention in Ibadan, the m ajLority of the participants (60.0%) did not know that breast cancer can be detected and treNated early, while only 40.0% knew. After the intervention, the number of those without tAhe knowledge of early detection and treatment reduced to 30.0% while 70.0% still did notD know. In Iwo, before the intervention, a largeB maAjority 83.0% did not know, while only 7.0% knew. Nevertheless, after the interventio nI, 100.0% knew about the available screening methods for breast cancer, with 80.0% forF breast self-examination, 5.0% for clinical breast examination, 5.0% for mammogram , Oand 10.0% from cancer awareness programmes. The significance of Table 4.5 is thaTt thYe participants from the experimental group were now fully aware of the different types oIf available methods of detecting breast cancer disease early and the importance of breast aSwareness campaign programmes could make susceptible women to be aware of early discRovery and early treatment of the disease. Table 4.6: VLifEetime chance of having breast cancer Question I Ibadan Iwo What doN you think is your Before After Before After lifetimUe chance of having breast cancer? None 1.0% 10.0% 1.0% 10.0% Minimal 5.0% 10.0% 2.0% 15.0% Moderate 10.0% 10.0% 2.0% 25.0% High 10.0% 10.0% 2.0% 30.0% Don’t know 74.0% 60.0% 93.0% 20.0% Source: Field Survey, 2015 60 Table 4.6 shows that most of the Participants (74.0%) from Ibadan did not know their lifetime chance of contracting breast cancer prior to the intervention programme. After the intervention, the number decreased to 60.0% who still did not know. In Iwo, 93.0% did not know but, after the intervention, about 80.0% knew and only 20.0% still did not know. RQ3: What are the sources of information on breast cancer screening among women? Table 4.7: Sources of breast cancer information Questions Ibadan Iwo Y What is your source of information about Before After Before After cancer of the breast? R Print and/ or electronic media 26.0% 26.0% 8.0% A0% Medical Personnel 20.0% 20.0% 0.0R% 0% Friends and family members 24.0% 24.0% 0% 0% Others/Behaviour change communication 30.0%(o 30.0%L( IB0% 100%(Bthers others) CC) Source: Field Survey, 2015 N Table 4.7 shows that in Ibadan, the respondents had Ainformation about cancer of the breast before intervention through print and/or electronDic media (26%), medical personnel (20%), and friends and family (24%), while others dAid not specify (30%). However, after the intervention exercise, the respondents sourced foIrB information about cancer of the breast from print and/or electronic media (26%), mediFcal personnel (20%) friends and family members (24%) and others (30%) In Iwo, bef orOe the intervention exercise, 8% received information about breast cancer from print anYd/or electronic media only. However, after the intervention exercise, the entire respondenItTs claimed that the intervention seminar at Iwo was their source of information on breast cSancer. Table 4.8: Types Rof breast cancer screening method adopted and utilized. Questions E Ibadan Iwo Have you sIuVbjected yourself to any of these Before After Before After breast caNncer screening? BSE U 10% 20% 0% 100% CBE 2% 2% 0% 100% Mammogram 0% 0% 0% 0% No response 88% 78% 100% 0% Source: Field Survey, 2015 Furthermore, Table 4.8 showed that, in Ibadan, before the intervention exercise, 10.0% of the respondents had subjected themselves to BSE and 2.0% had before opted for the 61 (CBE) breast screening programme, while the rest 88.0% had not at anytime subjected themselves to any type of screening. After the intervention exercise however, 20.0% had done BSE, 2.0% had done CBE and 78.0% no reponse. But in Iwo, none of the respondents had subjected herself to any of the breast cancer screening methods prior to the intervention programme. However, after the intervention exercise, the entire respondents (100%) had subjected themselves to the breast self-examination and clinic-based examination methods. Table 4.9: Performing breast self-examination Y Questions Ibadan Iwo A R Do you know how to perform breast Before After Before ARfter self examination? Yes 0.0% 2.0% 0.0% IB100.0% No 3.0% 3.0% 0.0% L 0.0% Don’t know 97.0% 95.0% N100.0% 0.0% Source: Field Survey, 2015 A Table 4.9 shows that both participants from IAbadDan and Iwo were not knowledgeable about how to perform breast self-examination beBfore the intervention programme. After the intervention, 95.0% of the participants fromF I baIdan still did not know how to perform BSE, while the entire participants in Iwo, Ohaving participated in the intervention programme, learned how to perform BSE. This me ans that the knowledge of BSE that the Iwo participants were exposed to informed TtheiYr knowledge and understanding of the importance of performing breast cancer screIening. S VE R UN I 62 4.3 Testing of research hypotheses H01: There is no significant main effect of behaviour change communication on breast self-examination among women Table 4.10: Summary of 2x2x2 Analysis of Covariance (ANCOVA) showing the significant main and interactive effect of treatment group, age and educational attainment among women Source Type III Df Mean F Sig. Partial YRemarks Sum of Square Eta R Squares SquAared a 9156.930 8 1144.616 10.12 .000 R.471 Corrected Model 1 IB 1352.450 1 1352.450 1N1.95 L.001 .116 Intercept 8 Pretest 130.907 1 130.9D07 A1.157 .285 .013 8160.549 1 8160.549 72.15 .000 .442 S Treatment BA 5 233.146 1F I 233.146 22.06 .001 .322 S Education O 1 Age 44.152 1 44.152 .390 .534 .004 NS Education * Age .8T15 Y 1 .815 .007 .933 .002 NS Treatment * Age S.I156 1 .156 .002 .970 .001 NS Treatment * Education 232.678 1 232.678 2.057 .155 .022 NS Treatment * EduEcatiRon * 19.945 1 19.945 .176 .676 .002 NS Age V Error NI 10291.910 91 113.098 TotaUl 175158.000 100 Corrected Total 19448.840 99 a. R Squared = .471 (Adjusted R Squared = .424) *Significant at 0.05 The Table 4.10 shows that there was significant main effect of treatment on breast self-examination among women (F (1, 91) = 72.155, p < .05, = .422). This implies that there is a significant impact of the treatment in the groups test scores on breast self-examination among women. Therefore, the null hypothesis, which states that there is no significant main 63 effect of treatment on breast self-examination among women, was rejected. Table 4.9 also shows the contributing effect size of 42.4%. For further clarification on the margin of differences between the treatment group and the control group, a Duncan post-hoc pairwise analysis which shows the comparison of the adjusted mean was computed and the result is as shown in Table 4.11 Table 4.11: Duncan Post-hoc Analysis showing the significant differences among various Treatment group and the Control Group in Breast Self-Examination amYong women R Treatment N Subset for alpha = 0.05 A 1 I2B R Control 50 30.22 Behaviour Change Communication 50 L48.70 Sig. .001 N 1.000 Table 4.11 reveals that experimental group (behDavioAur change communication) ( X = 48.70) had the highest mean compared to the contArol group ( X = 30.22). By implication, behaviour change communication is more pote nIt Bin enhancing breast self-examination among 2 women. The coefficient of determination (Adjusted R = .424) overall indicated that the differences that exist in the group accouFnted for 42.4% in the variation of breast self- examination among women. In o OYrde r to obtain further information on the performance of each group, an Estimated MaIrTginal Means (EMM) was computed. The result is presented in Table 4.13. Table 4.12: EstimateRd MSarginal Means (EMM) showing the differences in breast self-examination amoEng women across the three Groups IV N Mean SD Std. Error 95% Confidence Interval for N Mean U Lower Bound Upper Bound Behaviour Change 50 48.7000 7.9802 1.12857 46.4321 50.9679 Communication 1 50 30.2200 12.609 1.78321 26.6365 33.8035 Control 18 100 39.4600 14.016 1.40162 36.6789 42.2411 Total 17 64 Table 4.12 shows that participants exposed to behaviour change communication obtained the highest mean score (Grand Mean = 48.70), followed by the control group (Grand Mean = 30.22). This indicates that behaviour change communication is effective in enhancing breast self-examination among women. Interpretation and Discussion Table 4.10, 4.11 and 4.12 capture the rejection of the first hypothesis of the stYudy- H01: There is no significant main effect of behaviour change communication on breRast self- examination among women. The findings revealed that there was significant maAin effect of treatment on breast self-examination among women (F (1, 91) = 72.155, p .0I5, = .004). Hence, the null hypothesis was accepted. This denotes that there is no sigFnificant difference in the breast self-examination among the old and the young particip anOts. Table 4.13 further reveals the mean score of young women (estimated mean = 38.57)Y and old women (estimated mean = 37.50). Young women had slightly higher breast selIf-Texamination knowledge than their counterparts who were old but the difference was notS significant. Interpretation and dRiscussion The inVcideEnce of breast cancer increases with age. However, the knowledge is common witIh younger women. Approximately, 80% of the women aged 50 and above are susceptibNle (Oregon State Cancer Registry, 2003). Younger women are fast becoming victims accorUding to recent and other ongoing studies which reveal an incredible data of young women victims (Olowokere 2012). The second hypothesis revealed that there was no significant main effect of age on breast self-examination among women (F (1, 91) = .390, p > .05, = .004). Hence, the null hypothesis was accepted. This denotes that there is no significant difference in the breast self-examination among women of old and young participants. 66 Younger women acquire the knowledge of breast self examination faster than the older ones although with minimal significance. According to Olapade et al.(2004), the age at which women develop breast cancer is 44 years and 51% of them are yet to reach menopause. Evidence from North America suggests that where there is a reasonable public awareness of the importance of screening, women attempt to utilize the knowledge obtained to benefit them. Nonetheless, compliance with regular BSE is reported by a minority of young women (Wardle, 1995). Moreover, reports from the United Kingdom are not so different amYong students aged 17-30 years from 20 European countries. In a sample of 16,486, 54% Rreported never having practised BSE, only 8% practise regularly while 36% practiseRd oAccasionally. (Wardle, 1995). In the United Kingdom, women are encouraged to be brBeast aware from the age 18 but they do not engage in BSE regularly, contrary to stipulatedI instruction and the knowledge available to them. Also, Tanjaisiri, (2002) reported that aLmong Togan-American women aged 40 and above, only 40% had ever performed BSAE. N H03: There is no significant main effect of educatiDonal attainment on Breast cancer screening among women. A Table 4.14: Estimated Marginal Means (EMIMB) showing the differences in breast self- examination among women across the edFuca tional attainment Educational N MeOan SD Std. 95% Confidence Interval Attainment Y Error for Mean IT Lower Bound Upper S Bound High R 48 40.9167 15.54107 2.24316 36.4040 45.4293 Low VE 52 38.1154 12.44699 1.72609 34.6501 41.5806 Total I 100 39.4600 14.01617 1.40162 36.6789 42.2411 InterUNpretation and Discussion Table 4.14 demonstrates that there was main effect of educational attainment on breast self-examination among women (F (1, 91) = 22.061, p < .05, = .322). Therefore, the null hypothesis was rejected. The EMM on Table 4.13 further indicates that the mean score of the women with high educational attainment (estimated mean = 40.92), while that of the women with low educational attainment (estimated mean = 38.12). This implies that women with high educational attainment had higher breast self-examination knowledge than their 67 counterpart with low educational attainment. Studies have shown for example (Maclean, 1984) that women who attended breast screening were more likely to be of high socio- economic status, more sympathetic to screening and to have suffered less anxiety following the invitation/recommendations to attend. In a study conducted among 193 nurses in Poland, 63% knew almost everything about BSE (Frank, 2004). This indicates that medical education acquired by nurses made them knowledgeable about breast self examination. The situation in Nigeria is not different. In a study conducted among female scYhool teachers in Lagos, Nigeria, 62% practised BSE due to the information/ knowledge acqRuired to do so (Odusanya, 2001). Also, in a study carried out by Balogun and Owoaje (2A006) among female traders in Ibadan, Oyo State, less than one third of the respondBentRs (31.7%) were aware of BSE. Hence, from the above, it may be safe to concludeL thIat women with high educational attainment had high disposition towards screening. H04: There is no significant two-way interaction effeNct of Behaviour Change Communication and age on Breast cancer screeninAg among women Table 4.15: Estimated Marginal Means (EMM) showDing the two-way interactive effect of treatment and age on Breast Self-ExaminaItiBon a Among women. Experimental/Control Age FM ean Std. Error 95% Confidence Interval Lower Upper Y O Bound Bound Behaviour Change High 47.798 2.324 43.182 52.413 Communication ITSLow 49.514 2.190 45.163 53.865 R High 28.987 2.717 23.590 34.384 Control E Low 30.869 2.341 26.219 35.520 IV InterpreNtation and discussion UThe above table shows that there was no significant interaction effect of treatment and age on breast self-examination among women (F (1, 91) = .002, p > .05, = .001). Hence, the null hypothesis was accepted. This demonstrates that age did not significantly moderate the efficiency of the treatment in enhancing breast self-examination among women. Age has also been suggested as important factor for uptake of screening Owens (1987) avers that both young and old would present for screening if adequately informed about the need for it. 68 Regardless of age, any woman would want to avoid morbidity and mortality as a result of breast cancer. H05: There is no significant two-way interaction effect of behaviour change communication and educational attainment on breast self-examination among women Table 4.16: Estimated Marginal Means (EMM) showing the two-way interactive effect of treatment and educational attainment on Breast cancer screening among women Y Experimental/control Educational Mean Std. 95% Confidence InteRrval Attainment Error Lower RUpAper Bound B Bound Behaviour Change High 48.535 2.330 43.90L6 I 53.164 Communication Low 48.777 2.121 44.5 64 52.990 High 33.247 2.183 AN28.911 37.583 Control Low 26.609 2.40D2 21.839 31.379 The result in table 4.16 indicates that there was nBo sAignificant interaction effect of treatment and educational attainment on breast self-exa mIination among women (F (4, 17) = 2.057, p > .05, = .022). Therefore, the null hypothesFis was accepted. Interpretation and Discussion O This result implies that Yeducational attainment of women did not influence the effectiveness of treatment in IenThancing breast self-examination among women. Frank (2004) asserts that, in spite of theS clear understanding and the educational attainment of some nurses in Poland, their upEtakRe of breast self examination practice was not influenced. This indicates that, despite mVedical education, nurses are not knowledgeable enough to do breast self- examination Icorrectly and consistently. In a sample of women aged 20-64 years, living in ten citiesU of NNorthern Italy only 58% practice BSE (Ferro, 1992). Despite medical education and seemingly easy access to medical services, a study by Kulk 2003 among nurses in Dublin showed inadequate knowledge about the disease and lack of individual preventive actions by nurses, as only 24% of them performed regular monthly BSE. Petro-Nustus and Mikhaut (2002) reported that, among 519 women from two major universities in Jordan, 67% had heard or read about BSE, only 25% had ever practised BSE in the previous 12 months and only 7% performed it on a regular monthly basis. 69 H06: There is no significant two way intervention effect of age and educational attainment on breast self-examination among women Table 4.17: Estimated Marginal Means (EMM) showing the two-way interactive effect of educational attainment and age on breast self-examination among women Educational Age Mean Std. Error 95% Confidence Interval Attainment Lower Upper Bound Bound RY High 40.087 2.532 35.058 45R.116A High Low 41.695 2.455 36.819 B46.571 High 36.698 2.568 31.596 I 41.799 Low L Low 38.688 2.046 34N.624 42.753 A As revealed in Table 4.17 there was no signiDficant interaction effect of age and educational attainment on breast self-examination amAong women (F (1, 91) = .007, p > .05, = .002). Therefore, the null hypothesis was accepteIdB. Interpretation and Discussion F This result revealed that age andO educational attainment did not significantly influence breast self-examination among wYome n. The implication of this hypothesis is that, although there is the tendency for younIgTer women to embrace the utilization of breast self-examination for fear of dying early if Sthey refuse, the older women too are prone to think the same way. As such, there seemsR to be no significant difference between the old and the young in the utilization of BSEE. The picture is the same with the educational attainment of the participants. Both less eduIcVated and moderately educated participants approached the issue of BSE with slight sigNnificance in those moderately educated. U 70 H07: There is no significant three way intervention effect of Behaviour Change Communication, age and educational attainment on Breast Self-Examination among women Table 4.18: Estimated Marginal Means (EMM) showing the three-way interactive effect of treatment, age and educational attainment on breast cancer screening among women Experiment/control Educational Age Mean Std. 95% Confidence Interval Attainment Error Lower Upper Bound RYBound High 47.309 3.649 40.061 A 54.556 High R Behaviour Change Low 49.762 3.087 43B.630 55.893 Communication High 48.287 2.952 L4I2.423 54.151 Low Low 49.267 3.0N06 43.296 55.237 High 32.865 A2.942 27.022 38.708 High Low 33.629D 3.688 26.303 40.955 Control High B25A.108 4.243 16.679 33.537 Low Low I 28.110 2.570 23.005 33.215 F Table 4.18 indicates that there Owas no significant interaction effect of treatment, age and educational attainment on breYast self-examination among women (F (1, 91) = .176, p > .05, = .002). By implication, the Tnull hypothesis was accepted. Interpretation and DiscuSssiIon This analysis dRenotes that the impact of the treatment, age and educational attainment in enhancing breasEt cancer screening among women was not very significant. Forrest (1986); Harvey, (199I7V) Wardle et al. 2015 applauded the strength of screening in their different studies, tNhe treatment advocated in this work, corroborated the position of these researchers becauUse women responded positively although, age and educational attainment does not significantly enhance the effective uptake of this practice among women. 71 CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATIONS This chapter presents the summary of the study. It also concludes and gives some recommendations. It outlines limitations of this work and suggests areas for further studies. 5.1 Summary The main thrust of this research was to examine whether behaviour change communication (BCC) strategy is effective in the utilization of breast cancer awarenessY and screening among women in Oyo and Osun States of Nigeria. This is in an attempt to aRscertain the role of behaviour change communication as a tool to improving women‟s hAealth and to establish the theoretical perspectives that encourage women‟s health Rcommunication. Moreover, the study sought to discover the most suitable type of comLmIuBnication to adopt in communicating health to women and to reveal impedimen ts to women‟s health communication in a bid a to recommend ways of achieving anNd improving women‟s health through communication.The research is in five chapters. A Chapter one dealt with the introduction of thAe stDudy, wherein the background to the study was discussed and all variables that wouldI bBe used in the study was listed, including the statement of the problem, the objectives, sig nificance of the study, scope and operational definitions of terms used in the studyO. ThFe study examined relevant theories and reviewed related literature. This was made up of the theoretical framework, conceptual review of relevant literature as well as reTvieYw of empirical studies. The review of literature has shown that Nigerian women have nIot fully grasped the full import of the need to screen for breast cancer to achieve early deStection to forestall morbidity and mortality. The review of previous studies showed thEat thRe knowledge of BSE does not translate to the practice of BSE. Hence, this study is paVrticularly interested in converting knowledge to attitude change and enforcing practice oNf BISE, especially since it is the easiest and cheapest way to discover any breast lumpU in the first instance. The study used the non-laboratory experimental method in which 50 participants who volunteered to participate in the study were taken through eight week intervention programme by means of behaviour change communication messages. Fifty women were participants in the control group as well. This means that the experimental group was exposed to attitude and behaviour change messages by informed trainers who lectured and taught them how to perform BSE. For a period of 48 months, these participants were followed up closely to determine their screening and uptake as well as the extent of their influence on 72 their immediate environment. It was discovered that the participants adopted the screening and attitude and behaviour change was achieved in a significant number of the participants. The control group was not exposed to any intervention. Chapter four presented the results and discussion of the hypothesis utilized for the study in relation to the previous related studies. The results revealed that the experimental group was influenced by the method of intervention which is exposure to knowledge of BSE and the need to practise it correctly and regularly to prevent avoidable death since eYarly detection prevents morbidity and mortality. The interpersonal communication withinR a group approach worked because it allowed for face-to-face encounter which built communication parties. RtrusAt among the For the relationship between pre-and post-knowledge and practiseI Bof screening among the experimental group, it was discovered that the knowledge oLf the participants were insufficient before the intervention whereas the knowledge AincNreased after the intervention. This implies that there was significant effect of treDatment on breast cancer screening behaviour. In essence, there was significant differeAnce in the posttest behaviour of women exposed to treatment in breast cancer awarenessI aBnd counselling. The experimental group had higher breast cancer screening behaviour mFean score than in the control group. Besides:  There was no significant main effect of age on breast self-examination among women while there was main effect oOf educational attainment on breast self-examination among women. Y  There was also no siIgnTificant interaction effect of treatment and age on breast self- examination aRmonSg women as well as significant interaction effect of treatment and educationaEl attainment on breast self-examination among women.  The aIwVareness of breast cancer screening among women was low and inadequate.  TNhe methods of breast cancer screening utilized by the women include breast self Uexamination and clinical breast examination.  The sources of information on breast cancer screening among women included print and/ or electronic media, medical personnel, friends and family and others (specifically, the behaviour change communication intervention), while others did not specify. 73 5.2 Conclusion The findings of this study revealed that women were not adequately informed about breast cancer screening before study intervention and that the use of interpersonal communication within a group is a veritable channel of communicating health behaviour change messages among the lowly educated in society. Moreover, the strategy of behaviour change communication worked for the intervention group because of the combination of the theories of diffusion of innovaYtion, theory of planned behaviour and health belief model utilized and applied in the dissemRination of information about breast cancer screening methods. A In the addition, the study revealed that the correct method of prBactiRsing breast self- examination is pertinent to the sampled population. It is hoped that thLe sItudy having exposed the sample population to the need for breast cancer screening with adequate knowledge of BSE will result in low morbidity and mortality. N Again, it is envisaged that the intervention of the DstudAy will reduce financial waste via treatment and forestall psychological and emotional pain associated with late presentation of breast cancer to physicians by the vulnerable. TBhe Afindings of the study will inform policy makers on the types of effective policy intFerv eIntion strategies to employ in communicating health behaviour change messages to thOe vulnerable. The study revealed some of the reasons why the mass media is not achieving significant result in its intervenYtion and communication efforts of disseminating health behaviour messages to womeInT. Examples are sporadic and inconsistent media messages on breast cancer screening Sand the insufficient messages relayed on how to practise breast screening. ERFinallyV, the study exposed the gaps in previous strategies used in health behaviour change cNommIunication approaches, such as single approach of leaflet distribution, special once–Uin-a-year cancer day awareness programme and many more. The result of the study proposed a multipronged approach to interpersonal communication within a group as a new method and effective strategy for communicating health behaviour change messages among women. This is with the intent that every stakeholder stands to benefit from the results of this current situation regarding disseminating health behaviour messages to the lowly in the society. 74 5.3 Policy implications This study explored a different approach to communication intervention, in that it fused interpersonal communication with group communication to achieve behaviour change. Hitherto, communication approaches have been singular and, where multipronged they used one method/type at a time or rather systematically. Besides, attempts at combining methods have not been documented even if they have been experimented. Hence, this study is significant to have employed the strategy of interpersonal communication within a speciYal or purposive group. Usually, interpersonal communication is restricted to dyads anRd triads, regarded as small group. In this study, the group was not the regular definedA constituted group in studies of communication. Thus, both dyads and triads communiRcation methods fused to achieve exponential results in reaching a considerable significaInBt number of people whose behaviour towards health check/screen changed. L It is important for policy makers saddled with interventioNn programmes to fuse/merge multiple communication approaches to achieve behaviour chAange in target groups. Although the mass media is designed to reach a vast populace,A it mDay not be strong enough to achieve attitudinal change or sustained practice because IthBis requires reinforcement and continuity, in financial terms, heavy funding and honest ma nagement of such funds is required to achieve significant change through the avenue oOf mFass media. However, the approach of interpersonal communication within a target group may appear slower but has a long term positive and lasting effect eventually. In facTt, ifY policy makers and funding organizations provide adequate funding (such that is availablIe in media campaigns) the interpersonal communication within a group will achieve a fastSer and lasting result of knowledge, attitudinal change and practice among the target gErouRp swifter than individuals‟ unfunded effort. 5.4 RecomIVmendations BNased on the findings of this study, there is a need to intensify the level of knowledge, awareUness and utilization of BSE specifically amongst lowly placed women so as to improve and sustain its practise. Moreover, health service providers and physicians should promote BSE du#ring their contact with female patients. In order to function as effective promoters of breast screening in a bid to control cancer through early detection, advocacy groups should also possess the accurate knowledge and the appropriate attitude and practice concerning the disease and its early detection. In the light of the foregoing, the following are advised: 75  Regular planning of educational programmes which will give information about the symptoms, findings on the breast cancer research and the importance of BSE for the early diagnosis among groups/ associations.  Reaching a wider public audience by the interaction (via interpersonal communication avenues) between the health care students, who have sufficient knowledge about this subject, and their peers about the education and this subject;  Extended intervention that is duly monitored and evaluated; Y  Frequent educational programmes and awareness to target groups in Rorder to constantly remind them of the need for BSE; A  Incorrect practice among the sensitized women demonstrates the Rinadequacy of education among women regarding BSE. Institutions involvedL inI pBublic education for early diagnosis of breast cancer (BC) should continue to teach women of all educational levels about BSE. Specifically, the teaching Nof BSE techniques should be of priority for all women, regardless of their educDatioAnal level.  Acquisition of higher education positively afAfects the practice of BSE in women and propels their uptake of the new behaviourB as well as the continued practice of it with or without any external influence. I 5.5 Contributions to knowledge O F The major contribution of thYis work to knowledge is formulation of a new model for uptake of Behaviour change IcoTmmunication among lowly women in the society. The model evolved from the fusion oSf health belief model, diffusion of innovatios theory and the theory of planned behavioEur.R Significantly, Vthis study created awareness and sensitize the underresearched and lowly women to thIe need for breast cancer screening, particularly regular monthly breast self examUinatNion check as a potent antidote to preventing morbidity and mortality from breast cancer disease. 76 AWARENESS (Alertness, ACQUAINT ANCE sensitization) (knowledge, Information Dissemination) ADHERENCE (Practice, observance, commitment ADVICE (Persuasion, ACCEPTANCE Influence, (Reception, Convince) recognition, approval) Y 5 A’S OF Behaviour Change Communication R Source: Researcher, 2017. A Awareness: This is the first contact of the female menial workers with the mRessage on breast cancer from a behaviour change communicator. IB Acquaintance: The receiver is alerted and sensitized to the informa tiLon on the disease called breast cancer and how to screen or detect the disease as well aNs the very important steps to take to prevent morbidity and mortality. A Advice: The female menial worker is then informeAd apDpropriately on one of the cheapest, easiest and simplest method of screening for breaBst cancer- breast self-Examination. The best time to do a BSE is a week after the menFstru aIl cycle starts that is, one week after the last menstrual cycle (LMP). It must be donOe on a particular date and time of the month and any unusual discovery is swiftly reported. Acceptance: At this stage, TtheY female menial worker understands the implication of screening, is very familiar wIith the details and intricases of the practice of BSE, can easily detect any strange abnormSality in the breast during self-examination and is willing to report same for further scEreeRning by medical personnel as may be determined by them Adherence: TVhe female menial worker has adopted the behaviour change and there is no need for fNurthIer persuasion to carry out the adopted practice. It has become a lifestyle and it is done Uregularly and correctly without any external influence to do so. Moreover, The significance of 5A‟s of Behaviour change communication model is nestled in its connection and combination of the two theories and one model utilized in the study-Diffusion of innovations, theory of planned behaviour and health belief model. The model, 5A‟s of Behaviour change communication emphasizes the importance of sensitization and awareness creation regarding the realities surrounding breast cancer disease as well as the potential antidote to forestalling mortality from the disease. Hence, once a woman is acquainted with the details of the workings of breast cancer, with expert advice, 77 she could adopt the strategy of breast self examination which will alert her to any impending eruption of breast cancer. Accepting and adherence to the procedural practice of breast self examination would enable a woman to report any unusal signs that may be benign or cancereous. If cancerous, early detection wuld enhance early treatment and cure as well as forestall morbidity. Further contribution of this work to knowledge is that non-medical personnel should carry out health risk research to corroborate or contradict the findings of medical personnel, forY this will lend credence to medical research R Currently, available data on sensitization of women for utilization of bAreast cancer screening is limited to the elite women. However, the focus of this study waRs on lowly and semi-literate women- a segment hitherto under-researched. The studLy IwBas able to increase awareness regarding the importance and the practice of BSE amo ng women of low socio- economic status and encourage utilization of BSE. N Moreover, because cancer burden is under-reporteDd aAnd under-researched in Nigeria, effective method of communicating the need forA screening has not been determined. However, this study submitted that interpersonBal communication in a group could be a veritable tool to accomplish sensitizationF an dI achieve utilization by the not-so-educated category of women. O 5.6 Limitation of the study Y The intervention was IcoTnducted in the rural-urban community of Iwo in Osun State of Nigeria. Hence, the resulSts may be generalized with relative caution. The study participants were not stark illiEteraRtes; therefore, intervention and post intervention assessments was not a one-time activVity. Rather subsequent interventions followed systematically over a period of 48 monthNs. I 5.7 U Suggestions for further studies BCC is critical to the prevention, management and treatment of many important health conditions. However, the initiation and maintenance of behaviour can be very difficult. It is not enough for behavioural and social scientists to do rigorous research and develop effective interventions; There must also be delivery channels (communicators) in place to disseminate these interventions to the public, policy makers, and other decision-makers to ensure that they are implemented, adopted and maintained. In this regard, further research 78 may investigate a combination of the methods adopted in this study with the mass media making it a three-pronged approach. Future studies may also investigate the experiences of participants while attempting to influence people within their sphere of influence. They may also attempt a comparative analysis among other regions in the country to compare results which could be generalized. Y RA R B N LI DA IB A F Y O T RS I VE UN I 79 REFERENCES Adderly-Kelly B.B., and Green P.M. 1997. Breast cancer education, self-efficacy and screening in Older African- American Women. 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Improving breast cancer outcomes among women in China: practices knowledge and attitudes related to breast bancer creening. International Journal of Breast cancer. Article ID 921607. 98 Yanovitzky, I. and Blitz C. L. 2000 Effect of media coverage and physician advice on utilization of breast cancer screening by women 40 years and older. Journal of Health Communication vol, 5 pp 117 – 134. Yanovitzky, I. and Bennet, C. 1999 Media attention, institutional response, and health behaviour change: the case of drunk driving, 1978 – 1996. Communication Research 26(4): 429-453. AR Y R IB L AN BA D F I Y O SI T ER IV N U 99 APPENDIX I PILOT STUDY QUESTIONNAIRE ON EFFECT OF BEHAVIOURAL CHANGE COMMUNICATION AND UTILISATION OF BREAST CANCER SCREENING Dear Respondents, Kindly respond by filling in the gaps or by circling the appropriate number. When necessary choose as many options as apply. Thank you Y SECTION A R Demographic information. A 1. Age {in years}: 1. 20-25 2. 26-35 3. 36-45 4. 5R0 and above 2. Ethnic Group: 1. Yoruba 2. Igbo 3. Hausa 4. Other, pls, sIpeBcify---------- 3. Marital Status: 1. Single 2. Married 3. Divorced 4.Widow L 4. Religion: 1 Christianity 2. Islam 3. Other, pls, specNify--------------------- 5. Domicile: {Iwo/ Ibadan} ......................... vii. LGAD....A............................. 6. Occupation: 1. Housewife 2. Trader 3. Cleaner BA 7. Highest grade of school completed: I 1. None 2. Elementary 3. SeconFdary 4. Tertiary 5. Other---------------- 8. How long have worked as a cleaner O 1. Less one year; 2. 1T-2 yYears; 3. 3-4 years; 4 5 years & above. SECTION B SI Breast Cancer (knowlRedge) 9. Do you know abEout the disease called cancer? Yes........... No........... Don‟t know...... 10. Has anybIoVdy close you had any type of cancer? Yes........... No........... Don‟t know......... 11. If yesN to no 11, cancer of which part of the body?............................................................. 12. HUave you heard about cancer of the breast? Yes.......... No............ Cannot remember. 13. What do you know about cancer of the breast? .............................................................. 14. What is the source of your information about cancer of the breast? 1. Print and/ or electronic media 2. Internet 3. Medical journals/books/leaflet. 15. Have you listened to a health talk on breast cancer before? Yes... No.... Cannot remember................. 100 16. If yes to 15, what type of heath talk? 1. Radio 2.TV 3. Public lecture in church/ mosque 4. Other public lecture (where................) 5. Other------------------- 17. As a health problem in women, how will you rate cancer of the breast? ------------ 18.What do you know or think cause (s) cancer of the breast? 1. I don‟t know 2. Lumps become cancer if not removed 3. Poverty 4. Environmental factor 5. It is inherited 6. Genetic changes 7. Dietary factors 8. Occultic /satanic affliction. 9. Other------------------------- Y 19. Who do you think is at risk of developing breast cancer? R 1. I don‟t know 2. Any woman 3. Any woman with a breast lump A 4. Women with a family history of breast cancer .5. Promiscuous women 6. It is thRe disease of the elites 7. Low socio-economic class 8. Other................................... IB 20. What symptoms/signs (manifestation) of breast can cLer do you know? ..................................... N 21. Do you think cancer of the breast is preventable? YesD......A.... No.......... don‟t know........ 22. If yes, how may it be prevented? 1........................A.... 2..................... 3............................. 23. Do you know if cancer of the breast can IbeB cured? Yes....... No...... ... don‟t know .................... 24. If yes, what factors (s) might contributeF to its curability? .................................................. 25. How do you think breast canc erO can be detected and treated early? 1. Breast self examination 2. MammogramY 3. Clinical breast examination. 4 Cancer awareness programmes 5. Don‟t knIowT 6. Other...................... 26. Do you know if canceSr of the breast can occur in men? Yes........ No.......... don‟t know..... 27. Has someone yEou Rknow ever had cancer of the breast? Yes...... No...... Don‟t know.......... 28. If Vyes, what is/are the person(s) relationship to you? ...............N......I........................................ 29. WUhat type of treatment did the person receive? 1. Medical 2. Traditional 3. Spiritual 4. Nothing. 5. Other..................................... 30. What was the outcome for the person? 1. Treated and cured 2.Still receiving treatment 3. Dead 4. Other................................................. 31. What do you think is your life time chance of having breast cancer? 1. None 2. Minimal 3. Moderate 4. High 5. Don‟t know. 101 SECTION C Screening {testing} for {early detection} breast cancer 32. Are you aware of any breast cancer screening programme? Yes............ No............... 33. If yes, which?....................................................................................................................... 34. Have you subjected yourself to any? Yes.............. No............ Don‟t know………… 35. If yes, which?....................................................................................................................... 36. Will you be willing to subject yourself to be tested for breast cancer? Yes........... No..Y....... Don‟t know…………………………… R 37 If not, why not? 1. I do not consider it necessary 2. I am afraid of a positAive finding 3. Breast cancer does not run in my family 4. I believe I will not have breRast cancer 5. It may lead to removal of my breast 6. Other............................... I B 38. Who do you think should go for breast cancer screening? ........... ..L................................. 39. Do you know breast Self Examination (BSE)? Yes.........NAo..N........ If No, pls go to no44. 40. If yes, when do you do BSE? 1. Before my monthly period 2. After my monthly period 3. In-between-period 4. During my period A5.ADnyday of the cycle 6. Others, pls, specify..... B 41. How often do you do BSE? 1 MonthlFy I 2 Every three to six monthly 3.At least once yearly 4. Anytime I feel like doiOng it 5. Whenever I hear/read about it 6. Other, pls specify............ 42. If you do not do monthly BTSEY, why do you not do it? 1. It does not run in my family 2. I do not know how to do IBSE 3. Fear of discovering something 4. I believe I will not develop a lump. 5. MyS friends/ colleagues don‟t do it. 6. Other...................................... 43. Have you heard abRout mammogram? Yes................... No......................... 44. Have you dVoneE a mammogram? Yes.......................... No........................... 45. Do yoNu kInow of someone who has done a mammogram? Yes……… No............... Cannot rUemember………………….. 46. Will you be willing to do periodic mammogram to screen for breast cancer? Yes................ No.............. Don‟t know......................... 47. What other screening test{s} for breast cancer do you know? 1.......................... 2...................... 3............................... 48. Will you recommend regular breast screening for your friends/ colleagues/sister/mother? Yes................ No .......... don‟t know....................... 102 APPENDIX II PRE AND POST STUDY QUESTIONNAIRE ON EFFECT OF BEHAVIOURAL CHANGE COMMUNICATION AND UTILISATION OF BREAST CANCER SCREENING SECTION A Demographic information. Y 7. Age {in years}: 1. 20-25 2. 26-35 3. 36-45 4. 50 and aRbove 8. Ethnic Group: 1. Yoruba 2. Igbo 3. Hausa 4. Other, pls, specify----A------ 9. Marital Status: 1. Single 2. Married 3. Divorced 4.Widow R 10. Religion: 1 Christianity 2. Islam 3. Other, pls, specify-------I-B------------- 11. Domicile: {Iwo/ Ibadan} ......................... vii. LGA................ ..L............... 12. Occupation: N 1. Housewife 2. Trader 3. Cleaner A 7. Highest grade of school completed: D 1. None 2. Elementary 3. SecondaryI B4 A. Tertiary 5. Other---------------- 8. How long have worked as a cleaner 1. Less one year; 2. 1-2 years;O 3. F3-4 years; 4 5 years & above. SECTION B Breast Cancer (knowledge) TY 9. Do you know about theS disIease called cancer? Yes........... No........... Don‟t know...... 10. Has anybody closeR you had any type of cancer? Yes........... No........... Don‟t know......... 11. If yes to no 11E, cancer of which part of the body?............................................................. 12. Have youI hVeard about cancer of the breast? Yes.......... No............ Cannot remember. 13. WhatN do you know about cancer of the breast? .............................................................. 14. WUhat is the source of your information about cancer of the breast? 1. Print and/ or electronic media 2. Internet 3. Medical journals/books/leaflet. 15. Have you listened to a health talk on breast cancer before? Yes... No.... Cannot remember................. 16. If yes to 15, what type of heath talk? 1. Radio 2.TV 3. Public lecture in church/ mosque 4. Other public lecture (where................) 5. Other------------------- 17. As a health problem in women, how will you rate cancer of the breast? ------------ 103 18.What do you know or think cause (s) cancer of the breast? 1. I don‟t know 2. Lumps become cancer if not removed 3. Poverty 4. Environmental factor 5. It is inherited 6. Genetic changes 7. Dietary factors 8. Occultic /satanic affliction. 9. Other------------------------- 19. Who do you think is at risk of developing breast cancer? 1. I don‟t know 2. Any woman 3. Any woman with a breast lump 4. Women with a family history of breast cancer .5. Promiscuous women 6. It is the disease oYf the elites 7. Low socio-economic class 8. Other................................... R 20. What symptoms/signs (manifestation) of breast cancer do yAou know? ..................................... R 21. Do you think cancer of the breast is preventable? Yes.......... No........I..B don‟t know........ 22. If yes, how may it be prevented? 1............................ 2................ ...L.. 3............................. 23. Do you know if cancer of the breast can be cured? Yes..N..... No...... ... don‟t know .................... A 24. If yes, what factors (s) might contribute to its curaAbiliDty? .................................................. 25. How do you think breast cancer can beI dBetected and treated early? 1. Breast self examination 2. Mammogram 3. CliFnic al breast examination. 4 Cancer awareness programmes 5. Don‟t know 6. Other...................... 26. Do you know if cancer of the brea stO can occur in men? Yes........ No.......... don‟t know..... 27. Has someone you know ever hYad cancer of the breast? Yes...... No...... Don‟t know.......... 28. If yes, what ITis/are the person(s) relationship to you? .........................................S.................... 29. What type of tEreatRment did the person receive? 1. Medical 2. Traditional 3. Spiritual 4. Nothing. 5. Other..................................... 30. WhatN wasI t Vhe outcome for the person? 1. Treated and cured 2.Still receiving treatment 3. DeUad 4. Other................................................. 31. What do you think is your life time chance of having breast cancer? 1. None 2. Minimal 3. Moderate 4. High 5. Don‟t know. 104 SECTION C Screening {testing} for {early detection} breast cancer 32. Are you aware of any breast cancer screening programme? Yes............ No............... 33. If yes, which?....................................................................................................................... 34. Have you subjected yourself to any? Yes.............. No............ Don‟t know………… 35. If yes, which?....................................................................................................................... 36. Will you be willing to subject yourself to be tested for breast cancer? Yes........... No..Y....... Don‟t know…………………………… R 37 If not, why not? 1. I do not consider it necessary 2. I am afraid of a positAive finding 3. Breast cancer does not run in my family 4. I believe I will not have breRast cancer 5. It may lead to removal of my breast 6. Other............................... I B 38. Who do you think should go for breast cancer screening? ........... ..L................................. 39. Do you know breast Self Examination (BSE)? Yes.........NAo..N........ If No, pls go to no44. 40. If yes, when do you do BSE? 1. Before my monthly period 2. After my monthly period 3. In-between-period 4. During my period A5.ADnyday of the cycle 6. Others, pls, specify..... B 41. How often do you do BSE? 1 MonthlFy I 2 Every three to six monthly 3.At least once yearly 4. Anytime I feel like doiOng it 5. Whenever I hear/read about it 6. Other, pls specify............ 42. If you do not do monthly BTSEY, why do you not do it? 1. It does not run in my family 2. I do not know how to do IBSE 3. Fear of discovering something 4. I believe I will not develop a lump. 5. MyS friends/ colleagues don‟t do it. 6. Other...................................... 43. Have you heard abRout mammogram? Yes................... No......................... 44. Have you dVoneE a mammogram? Yes.......................... No........................... 45. Do yoNu kInow of someone who has done a mammogram? Yes……… No............... Cannot rUemember………………….. 46. Will you be willing to do periodic mammogram to screen for breast cancer? Yes................ No.............. Don‟t know......................... 47. What other screening test{s} for breast cancer do you know? 1.......................... 2...................... 3............................... 48. Will you recommend regular breast screening for your friends/ colleagues/sister/mother? Yes................ No .......... don‟t know....................... 105 SECTION A Demographic information. 13. Age {in years}: 1. 20-25 2. 26-35 3. 36-45 4. 50 and above 14. Ethnic Group: 1. Yoruba 2. Igbo 3. Hausa 4. Other, pls, specify---------- 15. Marital Status: 1. Single 2. Married 3. Divorced 4.Widow 16. Religion: 1 Christianity 2. Islam 3. Other, pls, specify--------------------- 17. Domicile: {Iwo/ Ibadan} ......................... vii. LGA................................. Y 18. Occupation: R 1. Housewife 2. Trader 3. Cleaner A 7. Highest grade of school completed: R 1. None 2. Elementary 3. Secondary 4. Tertiary 5. OtherI--B-------------- 8. How long have worked as a cleaner L 1. Less one year; 2. 1-2 years; 3. 3-4 years; 4 5 AyeaNrs & above. SECTION B D Breast Cancer (knowledge) A 9. Do you know about the disease called cance r?I YBes........... No........... Don‟t know...... 10. Has anybody close you had any type of Fcancer? Yes........... No........... Don‟t know......... 11. If yes to no 11, cancer of which pa rOt of the body?............................................................. 12. Have you heard about cancer oYf the breast? Yes.......... No............ Cannot remember. 13. What do you know about cTancer of the breast? .............................................................. 14. What is the source of SyouIr information about cancer of the breast? 1. Print and/ or Relectronic media 2. Internet 3. Medical journals/books/leaflet. 15. Have you lisEtened to a health talk on breast cancer before? Yes... No.... Cannot remember.....I..V.......... 16. If yeNs to 15, what type of heath talk? 1. Radio 2.TV 3. Public lecture in church/ mosqUue 4. Other public lecture (where................) 5. Other------------------- 17. As a health problem in women, how will you rate cancer of the breast? ------------ 18.What do you know or think cause (s) cancer of the breast? 1. I don‟t know 2. Lumps become cancer if not removed 3. Poverty 4. Environmental factor 5. It is inherited 6. Genetic changes 7. Dietary factors 8. Occultic /satanic affliction. 9. Other------------------------- 106 19. Who do you think is at risk of developing breast cancer? 1. I don‟t know 2. Any woman 3. Any woman with a breast lump 4. Women with a family history of breast cancer .5. Promiscuous women 6. It is the disease of the elites 7. Low socio-economic class 8. Other................................... 20. What symptoms/signs (manifestation) of breast cancer do you know? ..................................... 21. Do you think cancer of the breast is preventable? Yes.......... No.......... don‟t know....Y.... 22. If yes, how may it be prevented? 1............................ 2..................... 3...................R.......... 23. Do you know if cancer of the breast can be cured? Yes....... No...... ... Adon‟t know .................... R 24. If yes, what factors (s) might contribute to its curability? ..............L.....I...B............................ 25. How do you think breast cancer can be detected and treat ed early? 1. Breast self examination 2. Mammogram 3. Clinical breast exaAminNation. 4 Cancer awareness programmes 5. Don‟t know 6. Other...................... 26. Do you know if cancer of the breast can occur in menD? Yes........ No.......... don‟t know..... 27. Has someone you know ever had cancer of tIheB br Aeast? Yes...... No...... Don‟t know.......... 28. If yes, what is/are the person(s) relationship to you? ............................................................. F 29. What type of treatment did the per sOon receive? 1. Medical 2. Traditional 3. Spiritual 4. Nothing. 5. Other..................Y................... 30. What was the outcome foIr Tthe person? 1. Treated and cured 2.Still receiving treatment 3. Dead 4. Other............S..................................... 31. What do you tEhinkR is your life time chance of having breast cancer? 1. None 2.V Minimal 3. Moderate 4. High 5. Don‟t know. I SECTUION C Screening {testing} for {early detection} breast cancer 32. Are you aware of any breast cancer screening programme? Yes............ No............... 33. If yes, which?....................................................................................................................... 34. Have you subjected yourself to any? Yes.............. No............ Don‟t know………… 35. If yes, which?....................................................................................................................... 36. Will you be willing to subject yourself to be tested for breast cancer? Yes........... No......... Don‟t know…………………………… 107 37 If not, why not? 1. I do not consider it necessary 2. I am afraid of a positive finding 3. Breast cancer does not run in my family 4. I believe I will not have breast cancer 5. It may lead to removal of my breast 6. Other............................... 38. Who do you think should go for breast cancer screening? .............................................. 39. Do you know breast Self Examination (BSE)? Yes.........No.......... If No, pls go to no44. 40. If yes, when do you do BSE? 1. Before my monthly period 2. After my monthly period 3. In-between-period 4. During my period 5.Anyday of the cycle 6. Others,Y pls, specify..... R 41. How often do you do BSE? 1 Monthly 2 Every three to six monthly 3.AAt least once yearly 4. Anytime I feel like doing it 5. Whenever I hear/read about Rit 6. Other, pls specify............ IB 42. If you do not do monthly BSE, why do you not do it? 1. It doe sL not run in my family 2. I do not know how to do BSE 3. Fear of discovering sAomNething 4. I believe I will not develop a lump. 5. My friends/ colleagues don‟t do it. 6. Other...................................... 43. Have you heard about mammogram? Yes...................D No......................... 44. Have you done a mammogram? Yes.............I..B...... A..... No........................... 45. Do you know of someone who has done a mammogram? Yes……… No............... Cannot remember………………….. F 46. Will you be willing to do periodic mOammogram to screen for breast cancer? Yes................ No........T......Y Don‟t know......................... 47. What other screening testI{s} for breast cancer do you know? 1.......................... S 2...................... 3............................... 48. Will you recomEmRend regular breast screening for your friends/ colleagues/sister/mother? Yes..........V...... No .......... don‟t know....................... I UN 108 APPENDIX III 3.4.5. Procedure (Modules used for the Study) Schedule and Content of the Intervention programme RY RA LIB AN D IB A F O SI TY R IV E UN 109 RYA LIB R DA N A F I B Y O T SI VE R NIU 110 RY RA LI B DA N BA F I Y O T SI VE R NIU 111 RYA LIB R DA N A F I B Y O T SI VE R I UN 112 RYA LIB R DA N A F I B Y O T SI VE R NIU 113 RY RA LI B DA N BA F I Y O T SI VE R I UN 114 RYA LIB R DA N A F I B Y O T SI VE R UN I 115 RY RA LI B DA N BA F I Y O T SI VE R I UN 116 RY RA LI B DA N BA F I Y O T SI VE R I UN 117 RYA LIB R DA N A F I B Y O T SI VE R NIU 118 Y RA R B N LI A AD F I B O SI TY VE R I UN 119 RY RA LI B N AD A IB F O SI TY VE R NIU 120 RY RA LI B N AD A IB OF TY SI VE R NIU 121 RY RA LI B N AD A IB F O SI TY VE R NIU 122 APPENDIX V Human Communications Department Faculty of Social & Management Sciences Bowen University, Iwo Osun State, April 21, 2010 Y The Coordinator, R Bowen University Ventures, RA(Cleaning Unit) Iwo, Osun State. LI B AN Dear Sir, D REQUEST FOR PERMISSION TO ENGAGIEB BO AWEN UNIVERSITY VENTURES WORKERS (CLEANING UNIT) IN A FIEL D EXPERIMENT STUDY I write to request for permission to engage tFhe female cleaners working in the Bowen University ventures department in a fi eOld experiment study. The cleaners will participate voTlunYtarily in a focus group discussion/training on the need for breast cancer screening. I This training will be fromS April 22 – June 10, 2010. Thank you for youEr faRvourable response in this regard. Yours faithfullVy NI JaiyeUola Oyewole 123 APPENDIX VI Human Communications department Faculty of social & Management Sciences Bowen University, Iwo Osun State. April 21. 2010 Y The Head of Department, R Mass Communications Department, A Faculty of social and Management Sciences BRBowen University, I Iwo, L Osun State. AN AD Dear Madam, IB REQUESTS FOR USE OF THE AMOPHIFTHEATRE I write to request for permissioTn toY use the Amphitheatre for a research experiment. I promise to not to tamperS wiIth the facilities in the hall and I shall take responsibility for any incidence arising fromR my use of the place within next few weeks. I shall make use oEf the hall one hour every Thursday from April 22 through June 10. 2010. Thank you foIr Vyour positive an swift response in this regard. Yours SinNcerely U Jaiyeola Oyewole 124 Y AR LIB R N A AD IB O F ITY ER S IV UN 125