It was a descriptive cross-sectional KAP type study, carried out over 6 months, from 15th January 2020 through 15th June 2020, in two communities: Yaoundé VI and Monatele in Cameroon.

Yaoundé VI is in the southwestern part of Yaoundé and is one of the largest in Yaoundé town. Monatele is the capital of the Lekie division in the Centre Region located about 70 km from Yaoundé. These communities were chosen because we had a good knowledge of them and we found it easy to interact with the inhabitants. They have a mixed population both English and French speaking, and several markets with usually many social gatherings. The houses in the neighbourhood are easily accessible making it relatively easy to interview women. They also have large populations attracted by the diverse economic activities of the area.

The study targeted women older than 15 years who could speak comprehensively or by means of a translator and who gave their consent. Were excluded all women who did not complete the interview or who did not completely fill the questionnaire. Sampling was done by cluster method at the level of the neighbourhoods and random sampling at a level of the households, markets, gatherings. Minimal sample size was estimated using the Lorenz formula [14]: N = p * (1 − p) * (Z/d)², where N = sample size p = 0.47 from research carried out among female undergraduate students in Cameroon [13], Z = 1.96, d = 0.05. This gave a minimal size of N = 383 participants.

Our operational definition of BSE was a monthly examination of breasts conducted by women following the five major steps of BSE which include: examining both the breasts for size, shape, colour and contour while looking in front of the mirror with their arms straight, on the hips, and over the head, to palpate or feel the breast both in standing and lying position using the three finger pads [15]. For each participant, a questionnaire used had 4 sections: Socio-Demographic information and past history (21 questions), a second part which tested knowledge on BSE (11 questions), identification of attitude towards BSE (9 questions), Verification of BSE practice (8 questions). Knowledges, attitudes and practices levels were stratified according to poor, insufficient, satisfactory and good levels.

Data collected on questionnaires were entered into a data base using CS Pro version 7.3. Statistical analysis was carried out using Microsoft Excel 2007 and IBM SPSS version 23.0. The tools used to assess our results were the mean with its standard deviation, the median and the frequency. To seek associations between different variables, odds ratios with their 95% confidence intervals. P was considered significant for any value less than 5%.

Ethical clearance N˚2284 IEC-UD/05/2020/T was obtained from the Ethical Committee of the University of Douala/Faculty of Medicine and Pharmaceutical Sciences. Administrative authorizations were also obtained from the Chief Medical Officer of the Centre Regional Ethics Committee for Research on Human Health Research and Monatele Health District. Each participant consented before being included, and all information obtained was treated with respect of confidentiality.

For the 402 women, the mean age was 26.55 ± 9.57 years with extremes of 15 and 70. The median age was 24 and the mode 20 years. The sociodemographic characteristics are presented in Table 1.

The most represented age group was 20 - 30 (54.2%), 256 (63.7%) were interviewed at Monatele, 250 (62.2%) were from the Centre Region origin, 165 (41%) were students, 250 (62.2%) were not married, 260 (64.7%) had reached secondary school, and 368 (91.5%) were Christians.

The mean number of pregnancies was 2.18 ± 2.3 pregnancies with extremes of 0 and 10. The others obstetrical and breast cancer past histories of participants are presented in Table 2.

Of the 402 participants, 117 (29.1%) had never been pregnant before, 190 (47.3%) had 1 - 3 term deliveries, 390 (97%) were of reproductive age, 301 (74.9%) had no family history of BC, 96 (23.9%) knew someone outside of their family with BC. Out of 269 who had given birth, 154 (57.2%) did it before the age of 20 yrs.

Overall, 371 (92.3%) of the participants had heard about BC meanwhile only 50% had heard of BSE. The following Table 3 summarizes the findings on Knowledge.

Overall, 371 (92.3%) of the participants had heard about BC meanwhile only 50% had heard of BSE. Health personnel represented the major source of information

*Not all women had given birth.

*some participants had multiple sources of information and/or multiple responses.

on BSE (22.6%) followed by TV and radio (12.7%); 154 (38.3%) participants said BC can be detected by frequent BSE while 241 (60%) of them said early detection of BC can improve survival chances. Only 10 (2.5%) know the right age at which BSE should begin with 73 (18.2%) saying BSE should begin before the age of 19. Of the total, 46 (11.4%) knew BSE should be done monthly and 42 (10.45) said BSE should be done 1 - 7 days after menses, 57 (14.2) knew all what to look for when doing BSE.

Table 4 shows overall knowledge on BSE classified into four groups according to Essi et al. [16].

Out of 402 participants, 213 (53%) had poor knowledge, 62 (15.4%) had insufficient knowledge, 90 (22.4%) had moderate while only 37 (9.2%) had good knowledge.

The following Table 5 summarizes the findings on attitude.

Out of 402 participants, 121 (30.1%) said they could find BC by themselves by doing BSE, 113 (28.1%) feared detecting BC and 190 (47.3%) said BSE is useful. Also, 182 (45.3%) said BSE is not a disgraceful practice. Finally, 397 (98.8%) of the participants were willing to learn about BSE. Overall, out of 402 participants, 205 (51.0%) had a low attitude towards BSE.

Summary of practices is shown in Table 6.

Out of 420 participants, 262 (65.2%) reported not practicing BSE while 140 (34.8%) practiced it.

Of those who practiced BSE, 24 (17.2%) did so between 1 and 7 days after their menses, 31 (22.1%) reported starting BSE by the age of 19 - 20 years, 37 (26.4%) practiced BSE in all 3 positions while 39 (27.8%) rightly used the palm and at least 3 fingers to palpate the breast, 47 (33.5%) did not follow any particular pattern while doing BSE.

In summary the findings for the overall practice shows that 288 (71.6%) participants had poor practice while only 5 (1.2%) had good practice of BSE.

Out of 262 participants who reported not practicing BSE, several reasons were mentioned: 172 (65.64%) said they had not heard about it while 43 (16.41%) said they didn’t know how to do it.

To seek associations between variables, we used variables which had heterogeneous distribution. After dichotomization, we did binary logistic regressions to find independent associations between variables.

*some participants had multiple positions.

The mean age of the participants was 26.55 ± 9.57 years with extremes of 15 and 70. The age group of 20 - 30 was the most represented with 218 (54.2%) participants out of 402 (Table 1). This result is similar to the findings in Buea in 2012 [17] and Nigeria in 2016 [18] but different from the findings in Douala; 30 - 39 in 2017 [19]. The later study was carried out among health professionals who in majority were older than the participants of our study group. Out of 402, 260 (64.7%) had reached secondary school only, 250 (62.2%) were from Centre Region, explained by the fact that this study was carried out in the Centre region (Table 1). Students made up 156 (41%) of the participants different from the result of studies in Buea [1] and Bambili [13] where all the participants were students, 250 participants (62.2%) were single and 368 (91.5%) were Christians (Table 1), similar to the results in Ghana [20]. Cameroon [21] and Ghana are made up mostly of Christians [22].

Out of 402 participants, 117 (29.15%) had never been pregnant before while 190 (47.3%) had 1 - 3 term deliveries (Table 2), 390 (97%) were of reproductive age close to findings in vietnam where 90.8% were of reproductive age [23]: the participants in both studies were less than 50 years old. Only 38 (9.5%) had a family history of BC (Table 2).

Table 3 shows the variables used to calculate the overall knowledge in Table 4. Half of the participants had heard about BSE before (Table 3). This was close to the findings in Bambili in 2017 where 47% of the participants had heard about BSE [13]. This however is different from the findings in Buea in 2015 [1]; 73.5% amongst university students, Buea in 2012 on BSE and BC awareness; 74.17% [17], Nigeria in 2017 among Female undergraduates in the University of Uyo [12]; 78.3% and the United Arab Emirates in 2019; 68.9% [24]. In our study less than half of the participants were students while other studies were carried out on students only.

A majority of the participants (92.3%) had heard of BC (Table 3), close to 88.1%, 88.8% and 100% found respectively in Bambili in 2017 [13], Malaysia in 2012 [25] and Nigeria [12]. Almost 38.3% said BC can be detected early by frequent BSE (Table 3). This is lower than 51.7% found in Nigeria [12], 88.6% in Buea Cameroon [1] and 77.6% in Malaysia [25]. Six out of ten participants agreed that early detection of breast cancer can improve survival chances (Table 3). This is different from findings in Nigeria in 2017; 89.1% [12], and Ethiopia in 2017 by Kalayu et al; 89.9% [26].

Only 18.2% believed BSE should begin before 19 years while only 10 (2.5%) knew the right age at which BSE should begin (Table 3), close to 3.2% found in Bambili in 2017 [2]. This opinion might be due to the fact that there is an increasing number in BC cases. Only 11.4% knew BSE should be done monthly. This percentage is lower than 37.3%, 25.9%, 62.9% and 58.4% found respectively in Buea in 2015 [1], Bambili in 2017 [13], Palestine in 2015 [15] and UAE in 2019 [24]. This lower level may be explained by the relatively low exposure to BSE information. A majority (61.9%) did not have any idea of how often BSE should be done. This value almost triples that found in Nigeria in 2017 [12].

Health personnel (22.6%) and media (TV/radio) (12.7%) were the major sources of information on BSE in our study. In a study in Buea in 2015 health personnel (15.1%) and peers (12.7%) were the main factors that influenced performing BSE [1]. In 2015 in Palestine, 45.4% were taught on it by health staff [15]. In Ethiopia in 2017, the main sources of information were mass media (39.8%) and health personnel (22.3%) [26]. This shows that the two means of information are the most used.

Only 10.45% knew the right time BSE should be done (1 - 7 days after menses) (Table 3), close to 8.8% and 7%, found in Egypt [27] and in Bambili [13], but lower than 30.5% and 42.8% found in Ethiopia [26] and in the UAE [26]. About 66.7% participants did not know the right period to do BSE, 14.2% knew all what to look for when doing BSE and 9.2% said BSE should be done in all three positions (Table 3). Similar results were found in Buea [1].

Overall, the level of good knowledge was 9.2% (Table 4), close to 9.6% found in Buea [1], lower than 15.5% in Palestine [15] and 30.25% in Ethiopia [26]. Of the total, 22.4% had moderate knowledge, and 68.4% had insufficient/poor knowledge (Table 4). This poor knowledge is almost twice that found in Ethiopia (37.6%) [26], and greater than 43.3% found in Palestine [15]. This difference may be explained by the fact that the later studies were carried out in a milieu where majority of the persons were university students.

About 30.1% of participants said they could find BC by themselves by doing BSE (Table 5). This value was greater than 8.7% found in the UAE in 2019 [24], and lower than 59% found in Buea in 2015 [1]. Only 28.1% feared detecting BC (Table 5), value close to 26.5% and 29.9% found in Buea [1] and Palestine [15]. These close levels may be explained by the fact that BC is perceived as a terminal disease and is the leading cause of cancer death in women [1].

In our study, 44.5% were motivated by campaigns and TV shows (Table 5). This result is lower than 81.9% in Buea [1]. About 47.3% of the participants found BSE is useful (Table 5). This finding is lower than 93%, 96.3%, 88.6% found in Bambili in 2017 [13], Ghana in 2018 [20], and Buea in 2015. This observed difference may be due to the difference in overall knowledge on BSE. BSE was considered a waste of time for only 2% of the participants (Table 5). This is lower than 6.3% found in 2018 in Ghana [20]. In the later study more participants had heard of and practiced BSE.

Finally, 98.8% of the participants were willing to learn or learn more about BSE (Table 5), 51.0% had a generally low attitude towards BSE, different from 2.4% found in Buea in 2015 [1]. This may be explained by the fact that participants in the later study had better knowledge and perception of the importance of BSE.

Only 65.2% reported not practicing BSE (Table 6). This result is close to 72.3% and 71.7% found in the UAE in 2019 [24] and Ethiopia in 2017 [26]. Out of 140 (34.8%) who practiced BSE, 24 (17.2%) did so between 1 and 7 days after their menses (Table 6). In the South West Region of Cameroon in 2018, 93.8% of women who practiced BSE did not wait to perform it at a specific time of the month, whereas 3.1% performed BSE the week and 0.3% the second week following their menses [28]. In their studies 74.6% had not heard of BSE [28] while 50% of our participants had heard of BSE before (Table 5).

Out of 140 who had practiced BSE, 77.6% did so within the past month (Table 6). In a study in Buea in 2015, 29.5% claimed to have performed BSE within the past 12 months [1]. Major reasons for not practicing BSE were lack of knowledge on BSE (65.64%) and not knowing how to (16.41%). Similar reasons were found in 2015 in Buea [1], Ethiopia in 2017 [26] and the United Arab Emirates [24]. Lack of knowledge plays an important role in BSE practice.

Overall, 71.6% of the participants had poor practice, 19.9% insufficient practice while only a critically low 8.4% had moderate to good practice. This result was different from that found in the United Arab Emirates in 2015: 15.5% of good practice [15] [19] and in Douala in 2017 where practice was estimated as very poor in 28.3%, poor in 36.4%, good in 9.7%, and excellent in 25.6%. This difference can be explained by the fact that the later studies were carried out among nursing students and health professionals respectively who have a relatively higher knowledge of breast cancer and BSE (Table 4).

In our stuy, there was no independent association between sociodemographic, obstetrical characteristics, past history of BC and participant’s knowledge (Table 7). Age (<30 years) (aOR = 0.373 (0.214 - 0.650); p: 0.001), level of education (university) (aOR: 0.179 (0.097 - 0.332) p < 0.001), occupation (Student/teacher/health personnel) (aOR: 0.538 (0.320 - 0.904) p: 0.019) and a family history of BC/knowing someone with BC (aOR: 0.507 (0.316 - 0.813) p: 0.005) and being from Yaoundé community (aOR: 0.373 (0.214 - 0.650) p: 0.001) protected from poor attitude (Table 8). Only a family history of BC or knowing someone with BC protected from Poor/insufficient practice (aOR: 0.391 (0.173 - 0.882) p: 0.024) (Table 9). Only Poor/insufficient knowledge independently increases Poor/insufficient practices of BSE (aOR: 6.251 (1.941 - 20.133) P: 0.002) (Table 10). Same result was found in Buea [1].