UNIVERSITY OF GHANA 
 
SOCIAL MARKETING: THE USE OF SOCIAL COGNITIVE THEORY TO 
INFLUENCE BREAST CANCER SCREENING IN GHANA 
 
BY 
 
 
ARKO MATTHEW 
(1O442648) 
 
 
 
 
THIS THESIS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEGON IN PARTIAL FULFILLMENT OF THEREQUIREMENT FOR 
THE AWARD OF AN MPHIL IN BUSINESS ADMINISTRATION 
(MARKETING OPTION) DEGREE 
 
 
 
 
 
 
 
JUNE, 2015
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DECLARATION 
I do hereby declare that this work is the result of my own research and has not been 
presented by anyone for any academic award in this or any other university. All 
references used in the work have been fully acknowledged. 
I bear sole responsibility for any shortcomings.  
 
 
 
 
………………………………                                     ……………………….. 
     ARKO MATTHEW                                                           DATE 
          (10442648) 
  
 
 
 
 
 
 
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CERTIFICATION 
I hereby certify that this thesis was supervised in accordance with procedures laid down 
by the University. 
 
 
 
 
…………………………..                                                  ………………… 
  DR. DANIEL QUAYE             DATE 
     (SUPERVISOR)  
 
 
 
 
        ………………………….                                           ........................... 
DR E. Y. TWENEBOAH-KODUAH     DATE                    
         (CO-SUPERVISOR) 
 
 
 
 
                                                            
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 DEDICATION 
This work is dedicated to my wife, Sophia Arko, and my children, Dasia, Belicia and 
Giosia for their sacrifice, prayer support and absolute care. 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
My sincere thanks go to the Almighty God for his abundant grace which has enabled 
me to complete this course. My profound thanks also goes to Dr. Daniel Quaye, my 
main supervisor and Dr. E. Y. Tweneboah- Koduah, my assistant supervisor, for all the 
encouragement and help they gave me. I am grateful for all the ideas, their constructive 
criticisms and the unqualified encouragement given me which has contributed 
enormously to the accomplishment of this work. 
I am also grateful to all those who contributed in diverse ways to accomplish this task, 
especially Kofi Kyei Adesi, a Senior Radiographer at the Radiotherapy Department for 
his willingness to help any time his assistance was needed. 
Finally, my heart- felt appreciation goes to my wife, Sophia Arko, my mother- in- law, 
Victoria Hemans, and everyone whose effort made this work a success. 
 
 
 
 
 
 
 
 
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ABSTRACT 
Breast cancer is the most common type of cancer among women in both high-resource 
and low-resource countries. According to the Breast Cancer Research Foundation, 
breast cancer accounts for 12% of all female cancers with the majority (60%) of breast 
cancer deaths occurring in less-developed countries. Despite the increasing rate of 
breast cancer deaths, there are a lots of women who do not examine their breast on 
regular basis and a lot more who do not seek medical assistance as early as possible. 
Currently, there is no national data available on breast cancer screening and the factors 
that influence screening behaviour among Ghanaian women. Although some literature 
about barriers to breast screening exist in Ghana, the factors which prevent women 
from screening their breast is under researched. There is therefore the need to 
investigate the factors which are likely to influence breast cancer screening among 
Ghanaian women so as to tackle this public health burden with effective preventive 
strategies. 
The goal of this study was to adapt the social cognitive framework to examine the 
factors that are likely to influence breast cancer screening in Ghana. 
A quantitative research was conducted among women at the Madina market, a Sub 
Metro within Accra Metropolitan area. Using non- probability sampling, a total of 300 
respondents, made up of women from 18 years and above were contacted. A closed 
ended self-administered questionnaires were used to collect information on 
demographics, personal, immediate and wider environmental influences, and finally 
breast cancer screening behaviour. Finally, Pearson‘s correlation test was used to 
analyse the data collected. 
This study has contributed to new knowledge of breast cancer epidemiology in 
Ghanaian women. Immediate environmental factors, wider external environmental 
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factors and personal characteristics were identified as having significant relationship 
with breast screening behaviour. This study revealed that the factors which influenced 
breast cancer screening among Ghanaian women included immediate environmental 
factors, wider external factors as well as personal characteristics. Further investigations 
are recommended, probably to replicate similar research in other countries in Africa 
and India which may share common characteristics with Ghana. Again, future research 
should focus on qualitative research since this study adopted quantitative approach. 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
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 TABLE OF CONTENTS 
 
Content           Page 
DECLARATION .......................................................................................................... i 
CERTIFICATION ....................................................................................................... ii 
DEDICATION............................................................................................................ iii 
ACKNOWLEDGEMENT .......................................................................................... iv 
ABSTRACT ................................................................................................................ v 
TABLE OF CONTENTS ........................................................................................... vii 
LIST OF TABLES .................................................................................................... xiii 
LIST OF FIGURES .................................................................................................. xiv 
 
CHAPTER ONE ........................................................................................................ 1 
1.0 Introduction ........................................................................................................ 1 
1.1 Research Background ......................................................................................... 1 
1.2 Research Gaps .................................................................................................... 5 
1.3 Research Problem ............................................................................................... 7 
1.4 Research Purpose ............................................................................................... 8 
1.5 Research Objectives ........................................................................................... 9 
1.6 Research Hypotheses .......................................................................................... 9 
1.7 Significance of the Study .................................................................................... 9 
1.8 Research scope ................................................................................................. 10 
1.9 Chapter Outline ................................................................................................ 11 
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CHAPTER TWO ..................................................................................................... 13 
LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK ....................... 13 
2.0 Introduction ...................................................................................................... 13 
2.1 The Concept of Social Marketing ..................................................................... 13 
2.2 Defining Social Marketing ................................................................................ 14 
2.3 Social Marketing Focuses on Behaviour Change .............................................. 16 
2.4 Effectiveness of Social Marketing to Behaviour Change ................................... 18 
2.5 Interventions Addressed Using Social Marketing .............................................. 18 
2.6 Social marketing intervention mix .................................................................... 20 
2.7 Upstream and Downstream Social Marketing ................................................... 22 
2.8 Behaviour Change Theories .............................................................................. 24 
2.8.1 Health Belief Model: .................................................................................. 25 
2.8.2 The theory of reasoned action ..................................................................... 26 
2.8.3 Trans-theoretical model or stage of change theory ...................................... 27 
2.8.4 Diffusion of Innovation .............................................................................. 28 
2.8.5 Exchange theory......................................................................................... 29 
2.8.6 Social cognitive theory ............................................................................... 30 
2.9 Key Elements of Behaviour Change Models. .................................................... 32 
2.10 Health Issues and their influences ................................................................... 33 
2.10.1 HIV/AIDS ................................................................................................ 34 
2.10.2 Physical Activity ...................................................................................... 34 
2.10.4 Social cognitive theory and adolescent eating behaviour........................... 37 
2.10.5 Social cognitive theory and smoking ........................................................ 38 
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2.11 Media influence on behaviour change ............................................................. 38 
2.12 Personal factors and behaviour change ............................................................ 39 
2.12.1 The Role of Knowledge in behaviour change ........................................... 39 
2.12.2 The Role of Individual Skills and Modelling in Behaviour Change ........... 40 
2.12.3 The Role of Self- Efficacy in Behaviour Change ...................................... 41 
2.13 The Conceptual Framework ............................................................................ 42 
2.13.1 Introduction.............................................................................................. 42 
2.13.2 Components of the Conceptual Framework .............................................. 43 
 
CHAPTER THREE ................................................................................................. 47 
CONTEXTUAL STUDY OF THE RESEARCH ................................................... 47 
3.0 Introduction ...................................................................................................... 47 
3.1 A brief background of Ghana ............................................................................ 47 
3.2 Breast cancer situation in Ghana ....................................................................... 48 
3.3 Breast cancer terminologies defined.................................................................. 48 
3.4 Signs and symptoms of breast cancer ................................................................ 49 
3.5 Risk factors for breast cancer ............................................................................ 49 
3.6 The types of breast cancer screening ................................................................. 50 
3.6.1 Breast Self-Exams ...................................................................................... 51 
3.6.2 Clinical breast exams ................................................................................. 51 
3.6.3 Mammogram.............................................................................................. 51 
3.7 Breast screening challenges faced by Ghanaian women .................................... 51 
3.8 Radiotherapy Centres in Ghana......................................................................... 53 
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3.9 Government‘s Programmes and Institutions to fight breast cancer .................... 53 
3.9.1 Ministry of Health ...................................................................................... 53 
3.10 The activities of NGO‘s to fight breast cancer in Ghana .................................. 54 
3.10.1 Breast Care International .......................................................................... 54 
3.10.2 Breast Cancer Foundation ........................................................................ 54 
3.10.3 UT Bank in Ghana ................................................................................... 55 
3.11 Radiotherapy centre at the Korle-Bu Teaching Hospital .................................. 55 
3.12 Breast cancer statistics at the Radiotherapy Centre, Korle-bu for 2013 and 2014
 ............................................................................................................................... 56 
 
CHAPTER FOUR.................................................................................................... 58 
RESEARCH METHODOLOGY ............................................................................ 58 
4.0 Introduction ...................................................................................................... 58 
4.2 The underlying paradigm and epistemological assumption................................ 58 
4.3 Research Approach ........................................................................................... 61 
4.4 Research Design ............................................................................................... 63 
4.5 Data Sources..................................................................................................... 64 
4.6 Population of study ........................................................................................... 65 
4.7 Sample size ...................................................................................................... 65 
4.8 Sampling Technique ......................................................................................... 65 
4.9 Data Analysis Techniques................................................................................. 66 
4.10 Descriptive Statistics ...................................................................................... 66 
4.11 Ethical Considerations .................................................................................... 66 
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4.12 Quality Criteria ............................................................................................... 67 
4.12.1 Validity .................................................................................................... 67 
4.12.2 Reliability ................................................................................................ 68 
4.13 Data Collection Methods ................................................................................ 68 
4.14 Questionnaire design ...................................................................................... 69 
4.14.1 Question wording ..................................................................................... 70 
4.14.2 Question sequencing ................................................................................ 70 
4.15 Fieldwork Data Collection .............................................................................. 72 
 
CHAPTER FIVE ..................................................................................................... 74 
DATA ANALYSIS AND INTERPRETATION ...................................................... 74 
5.0 Introduction ...................................................................................................... 74 
5.1 Background/Demographic Information ............................................................. 74 
5.2 Behaviour Change Influencing Factors ............................................................. 77 
5.2.1 Immediate environmental factors ............................................................... 78 
5.2.2 External environmental factors ................................................................... 79 
5.2.3 Personal Influencing factors ....................................................................... 81 
5.3 Behaviour Change ............................................................................................ 82 
5.4 Significant Test ................................................................................................ 83 
5.5 Discussions of findings ..................................................................................... 85 
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CHAPTER SIX ........................................................................................................ 89 
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............................ 89 
6.0 Introduction ...................................................................................................... 89 
6.1 Summary .......................................................................................................... 89 
6.2 Major Findings ................................................................................................. 89 
6.3 Conclusions ...................................................................................................... 91 
6.4 Recommendations ............................................................................................ 91 
6.4.1 Recommendations for practice: .................................................................. 92 
6.4.2 Recommendations for future research: ....................................................... 93 
6.5 Contributions of the study ................................................................................. 93 
 
REFERENCING ...................................................................................................... 95 
APPENDIX 1: QUESTIONNAIRE....................................................................... 118 
 
 
                                                            
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  LIST OF TABLES 
 
TABLE                                                                                                                    PAGE 
Table 3.1: the summary of breast clinic records for 2013 and 2014. ........................... 57 
Table 5.1: Sample distribution ................................................................................... 76 
Table 5.2: Sample distribution ................................................................................... 77 
Table 5.3: the summary of immediate environmental statistics. .................................. 79 
Table 5. 4: the summary of external environmental statistics. ..................................... 80 
Table 5.5: the summary of personal characteristics statistics. ..................................... 81 
Table 5.6: a summary of behaviour change statistics .................................................. 82 
Table 5.7: the summary of hypothesis 1. .................................................................... 84 
Table 5. 8: the summary of hypothesis 2. ................................................................... 84 
Table 5. 9: the summary of hypothesis 3 .................................................................... 85 
 
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LIST OF FIGURES 
 
FIGURE                                                                                                          PAGE 
Figure 2.1: Source: Conceptual Framework Adapted From (Bundura, 1986; MacFadyen 
et al, 1998) ................................................................................................................. 43 
 
 
 
 
 
 
 
 
 
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CHAPTER ONE 
1.0 Introduction 
This chapter introduces the reader to the background of the study which includes the 
general overview of issues concerning breast cancer and screening behaviour, research 
gap, the research problem, objectives of the study, research hypotheses, significance of 
the study, the scope, and finally, chapter disposition of the study which ends the chapter 
by outlining how the various chapters of the entire research work were organised. 
1.1 Research Background 
Breast cancer among women has become one of the global issues today (Breast Cancer 
Research Foundation, 2014). Indeed it is one of the most common cancers among 
women worldwide (America Cancer Society, 2015). It has been established in recent 
times that cancer in general has been killing more people than malaria, tuberculosis 
(TB) and HIV/AIDS all put together (Center for Disease Control and Prevention, 
2014). Again it has been established that, with close to 14 million people who are 
diagnosed with cancer, about 8 million die from the condition worldwide every year 
(Center for Disease Control and Prevention, 2014).  Also, it has been observed that out 
of over 55% of new cancer cases that are reported, more than 60% of cancer deaths 
occur in less-developed countries of the world, with breast cancer becoming the second 
most diagnosed form of cancer globally (Ferlay, Shin, Bray, Forman, Mathers & 
Parkins, 2010). Again, it has been established that, the most frequently diagnosed 
cancer among women in 140 out of 184 countries worldwide is breast cancer (Breast 
Cancer Research Foundation, 2014). Bray and Møller (2005) state that the worldwide 
incidence of cancer could increase to as many as 17 million new cases per year by 2020 
of which it is estimated that about 1.5 million will occur in Africa.  
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According to the Breast Cancer Research Foundation (2014), nearly 1.7 million women 
worldwide were diagnosed with breast cancer in 2012 with incidence rates varying 
across the world. It further shows that, breast cancer has been identified as the most 
common cancer in women worldwide and this represents about 12% of all cancer cases 
among women (Breast Cancer Research Foundation, 2014). For example, in the United 
Kingdom, research reveals that the most common cancer is breast cancer and that it is 
growing at an alarming rate (UK Cancer Research, 2014). In the UK, about 49,900 
women were diagnosed with breast cancer in 2011, that is, more than 130 women 
everyday (UK cancer research, 2014). However, this estimation is quite different in the 
US where breast cancer is second to skin cancer and further estimates that 231,840 new 
breast cancer cases will be diagnosed in women and about 40,920 will die from it 
(American Cancer Society, 2015).  
In Africa, the burden of cancer is increasing tremendously partly as a result of certain 
factors such as the population growth and aging (Jemal, Bray, Forman, O‘Brien, Ferlay, 
Center & Parkin, 2012). Other factors are the rising prevalent risk factors, economic 
transition, physical inactivity and reproductive behaviour of Africans (Jemal et al., 
2012). Although the incidence of breast cancer has been reported to be lower in sub-
Saharan Africa as compared with western nations, the survival rate in Africa is poor 
when compared with those in the developed world (Fregene & Newman, 2005; 
Agarwal et al., 2009). The study shows that, the seriousness attached to cancer in 
general in Africa is not encouraging partly as a result of limited resources and other 
health problems such as TB, HIV/AIDS, malaria and others (Jemal et al., 2012). A 
study on breast cancer in Sub – Saharan Africa, concluded that, there is the likelihood 
for breast cancer to grow substantially in Africa (Fregene & Newman, 2005), and more 
so, as a result of adopting western lifestyle and dietary pattern.  
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In Ghana, it is estimated that 2,062 new breast cancer cases are reported annually, out 
of which about 1,137 deaths are recorded annually, representing 16.5% of all women 
cancer deaths (Mena, Wiafe & Sauvaget, 2014). Furthermore, the extant literature 
establishes that about 60% of the cases of breast cancer in Ghana are detected at late 
stages where nothing could be done about it (Mena, Wiafe & Sauvaget, 2014; Opoku, 
Benwell & Yamey, 2012). This is to say that, breast cancer can be rendered to almost 
complete cure if it is reported at its initial stages (Okobia, Bunker, Okonofua, & Osime, 
2006).  
 Research has revealed that, breast screening is in three categories; self-breast exams, 
clinical exams and mammogram (Center for Disease Control and Prevention, 2014). 
However, the most expensive among the methods is mammogram and this is an X-ray 
of the breast (Oluwatosin, 2012). According to Oluwatosin (2012), mammograms are 
the best ways to detect breast cancer early before it is big enough to feel or cause 
symptoms. When breast cancer is detected at the early stage, its management and 
outcome is certain (American Cancer Society, 2015). It has been reported that when 
people also become aware and educated on screening tests, they demonstrate high level 
commitment, confidence and knowledge and eventually tend to put them into practice 
more than those who have not received any information (Oluwatosin, 2012). 
 A study by Opoku, Benwell & Yamey (2012) on breast cancer screening practices in 
Ghana reported a low turnout. Similar to the study in Ghana, several studies have also 
reported low knowledge of breast cancer and its screening methods in many nations 
across the world (Mhamdi et al., 2012). It has been discovered that the average age 
when women diagnose for breast cancer in Ghana is 46.29 years with a range of 18 to 
80 years as compared to an average age of over 65 years in Europe and America 
(Anim, 1993; NCRNM, 2007).  Research further shows that, mammograms are usually 
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used in the developed countries for breast screening and this is contrary to most 
developing countries where mammograms are found in very few hospitals and not 
easily accessible to most women (Sambanje & Mafuvadze, 2012). In Ghana, most 
specialized breast cancer detection centers are located in large cities such as Accra and 
Kumasi (Ministry of Health, 2001). As a result, most Ghanaian women report late due 
to the high transportation costs for those living outside the big cities to the centres, 
coupled with high costs of hospital admission, surgery, radiologic examinations and 
laboratory (Clegg-Lamptey, Dakubo & Attobra, 2009). The delays in presentation 
coupled with subsequent prognosis, laziness, lack of time, forgetfulness, fear and lack 
of confidence among other reasons  are given as failure on the part of women to engage 
in breast examination (Mason & White, 2008; Nafissi, Saghafinia, Motamedi & Akbari 
2012; Ghazali, Othman & Cheong, 2013). Contrary to the case of Ghana and Africa in 
general, research establishes a high degree of knowledge about the methods of breast 
screening in the developed countries (Anderson, Braun & Lim, 2003). 
It has been reported that, breast cancer awareness and screening are low especially in 
less-developed and developing countries and this has culminated to the high death rates 
as compared with the industrialized world (Sambanje & Mafuvadze, 2012). This gives 
a vivid picture that breast cancer menace is not well understood especially in Ghana 
and as a result there is the need for more education on the grievous repercussions on the 
society and individuals. Breast cancer still pose a huge threat to people worldwide, 
especially underdeveloped and developing countries and it is believed that aggressive 
and consistent education will help to drastically reduce this social canker (WHO, 2011). 
It has been observed that many social and health problems have behavioural causes and 
as a result social marketing offers a unique opportunity to promote behaviours that 
result in health and well-being improvement of individuals (Mc Dermott et al., 2005). 
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Social marketing has been defined as the process which applies marketing principles 
and techniques to create, communicate and deliver value in order to influence target 
audience behavior that benefit society as well as individuals (Kotler & Lee, 2008). 
Social marketing presents a framework that can be used to define a social marketing 
campaign (Thompson, 2013). It has been applied successfully to promote or decrease 
other health related issues like HIV/AIDS (Tweneboah‐Koduah, & Owusu‐Frimpong, 
2013), physical activity (Coreil, Bryant & Henderson, 2005), smoking, diabetes and 
other issues that have individual and societal benefit (UK Center for Disease Control, 
2005). The researcher strongly believes that social marketing has the ability to 
influence behaviour change. 
Again it has been observed that, health interventions and programs are most successful 
when they are grounded in the appropriate health behaviour change theories (Anderson, 
1998). As a result of this, the study settles on social cognitive theory as a framework to 
identify and explain the factors which are likely to influence breast cancer screening in 
Ghana. This theory has been adapted for this work because, it has been proven 
successful in influencing many health related issues (Bandura, 1997) and therefore it is 
believed that by adapting this theory as a model, the purpose and the objectives of this 
study would be achieved.    
1.2 Research Gaps 
A careful observation and analysis of the available literature on breast cancer screening 
and its influencing factors reveal several and wonderful contributions to the subject 
both in Ghana and other parts of the world. In Ghana, literature has mainly looked at 
issues related to the knowledge, attitudes, beliefs, behaviours and breast cancer 
screening practice in Ghana (Opoku, Benwell, & Yarney, 2012), cost effects and cost 
effectiveness of breast cancer control in Ghana (Zelle et al., 2012), women‘s cultural 
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perceptions and attitudes towards breast cancer (Asobayire & Barley, 2014), factors 
related to incomplete treatment of breast cancer (Obrist et al., 2014). Despite these 
valuable contributions made toward breast cancer screening in Ghana, the screening 
rate is still low in Ghana (Mena, Wiafe & Sauvaget, 2014). 
Other literature  reveal that most of the studies beyond Ghana concentrated on areas 
such as  the risk of breast cancer following fertility treatment (Reigstad, Larsen & 
Myklebust, 2015), the need for greater women awareness of warning signs and 
effective screening methods (Montazeri & Vahdaninia, 2008), knowledge, attitude and 
practice of women towards breast cancer (Harirchi et al., 2012; Uwuseba, 2010; Sunil 
et al., 2014), rational for targeting the Ras/MAPK pathway in triple-negative breast 
cancer (Giltnane & Balko, 2014), and breast cancer preventive behaviors (Khazaee-
Pool, Montazeri & Majlessi, 2014). Other research also focused on breast cancer cause, 
beliefs and survivors (Gonzalez, Lim & Wang-Letzkus, 2014), breast cancer 
survivorship and global statistics (Siegal, Ma, Zou & Jemal, 2014), breast cancer 
screening among women (Munyaradzi, January & Maradzika, 2014; Eguvbe, Akpede 
& Arua., 2014). 
 All these literature give wonderful and meaningful insights and contributions to the 
subject of study. However, there seems to be inadequate information in relation to why 
most women in Ghana do not screen their breast at all and the irregularities associated 
with it. The issues discussed suggest that the factors which influence breast screening in 
Ghana is under researched. None of these work assessed in detail, the environmental 
and personal factors which facilitate or hinder breast screening exercise in Ghana.  
Again the social cognitive theory has not been applied to understand these factors in 
Ghana and this presents gaps related to issue and context which need to be addressed.      
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1.3 Research Problem 
Much of the research on breast cancer screening reveal an invaluable contributions to 
improve breast cancer screening among women. However, it in revealed that the level 
of breast cancer screening is limited in many parts of the world (Harirchi et al., 2012; 
Montazeri et al., 2008). In Ghana, a lot of work has been done in the area of breast 
cancer screening, however, literature examined show that most women have poor 
knowledge in breast cancer screening (Ohene-Yeboah & Adjei, 2012). Also, they 
identify that the practice of breast self-examination was low (Opoku et al., 2012; 
Somdatta & Bandalyne, 2008). Research further reveals that, early warning signs and 
effective screening methods were very low and inadequate among women and as a 
result it has increased the death rate in Ghana (Mena, Wiafe & Sauvaget, 2014). A 
study on knowledge, beliefs, attitudes, behaviours and breast cancer screening practice 
in Ghana reported a very poor knowledge of breast cancer and screening methods 
(Opoku, Benwell & Yarney, 2012).  
What is even more serious in Ghana is that, many interventions designed to encourage 
early detection of breast cancer among women have not yielded much result in 
reducing breast cancer rate (Opoku et al., 2012). Most women have been seen as not 
reporting obvious abnormalities early for the necessary treatment (Mena, Wiafe & 
Sauvaget, 2014). Research reveals that in the developed nations, a lot of breast cancer 
cases are identified by the patients themselves (Harvey, Miller, Baines & Corey, 1997). 
However the difference is that they report any changes as early as possible for 
treatment (Harvey, Miller, Baines & Corey, 1997). What then accounts for late 
presentation of breast cancer cases in developing countries and for that matter, Ghana? 
Literature reveal that there are some non-governmental organisations and well-meaning 
groups which also organise breast programmes to encourage women in Ghana to 
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increase breast screening and thereby reduce the death rate (Clegg-Lamptey & Hodasi, 
2007). In spite of these efforts made to increase breast cancer screening in Ghana, the 
situation is not any better (Opoku et al., 2012). In Ghana, most women who are 
diagnosed with breast cancer are within the ages of 40 and 49 (Ohene-Yeboah & Adjei, 
2012). However, there is lack of modern health facilities with only few centres in the 
country (Dzakah, 2010). Ohene-Yeboah & Adjei (2012), also linked the lack of 
awareness of early signs and screening behavior to the low levels of formal education 
in Ghana. Other challenges identified in Ghana are the traditional and religious beliefs 
which influence behavior (Avong, 2000). Cultural beliefs have been reported to 
influence successful introduction of public health education programmes, while at the 
same time certain chronic diseases are attributed to supernatural forces in Ghana 
(Adongo et al., 1997). As a result, Sossou (2011), advocated for women‘s full 
participation in cultural and socio-political procedures to breakdown some of these 
barriers.   
 A careful observation from literature reviewed shows that, the current research on 
factors that account for low breast cancer screening in Ghana do not fully explain the 
issue in detail. There are both internal and external factors which are likely to influence 
the screening behaviour of these women in Ghana and this has not been addressed 
adequately. Again, none of these studies really focused on social marketing principles 
to understand the issue in context.  As a result, the study will adapt the social cognitive 
theory to analyse and test the factors which are likely to influence breast cancer 
screening in Ghana. 
1.4 Research Purpose 
The purpose of this research is to test the factors which are likely to influence breast 
cancer screening behaviour in Ghana. 
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1.5 Research Objectives  
To achieve this purpose the study outlines the following related objectives: 
1. To examine the relationship between immediate environmental factors and breast 
cancer screening behaviour in Ghana. 
2. To examine the relationship between the wider external environmental factors and 
breast cancer screening behaviour in Ghana. 
3. To examine the significant relationship between personal characteristics and breast 
cancer screening behavior in Ghana. 
1.6 Research Hypotheses 
To achieve the formulated objectives of this research, hypotheses have been designed 
to serve as a guide to the literature review, information gathering and other aspects of 
the research activities. In view of that, the researcher has developed the following 
hypotheses for testing: 
• H1: There is a positive relationship between immediate environmental factors and 
breast cancer screening behaviour. 
• H2: There is a positive relationship between wider external environmental factors and 
breast cancer screening behaviour. 
• H3: There is a significant positive relationship between personal characteristics and 
breast cancer screening behaviour. 
1.7 Significance of the Study 
The significance of the study can be seen from four perspectives: practice, current 
research and policy and future research. 
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From the perspective of significance to practice, the study will provide a useful 
guideline to especially women in Ghana to increase breast cancer screening. In 
addition, where to go and what to do if they discover abnormalities in their breast.  
In terms of research significance, the study will strengthen the current research on the 
application of social marketing to health issues especially in the area of breast cancer 
screening in Ghana. It will therefore respond to the paucity of literature on social 
marketing and breast cancer screening behaviour amongst women. 
Concerning significance to policy, the study will provide strong guidelines to advocacy 
groups and government Agencies to understand issues relating to breast screening in 
Ghana in order to enable them formulate effective policies to sensitize women on breast 
cancer screening. Again, it will provide meaningful guidelines for social marketers 
trying to design interventions to influence a particular societal or health related 
problem.   
Finally as a descriptive research, the study will also pave way for further research. 
Consequently, insights gained into the problem may serve as a useful purpose for 
providing the basis for further research in cognate areas of breast cancer screening. 
1.8 Research scope 
The scope of this research covers these broad areas as follow: 
First of all, the general issues regarding breast cancer and screening behaviour. This 
work focuses on breast cancer screening as a major problem all over the world 
especially in the developing and the underdeveloped nations. The low rate of breast 
cancer screening which has resulted in the increased death rate of the phenomenon in 
Africa especially, Ghana.  
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 Again, this research also focuses on identifying the factors which are likely to 
determine or influence breast cancer screening in Ghana. This has been discussed using 
women at the Madina market, Accra Ghana, to assess their general screening behaviour 
and the likely factors which influence their behaviour. 
Also, this research covers the application of social marketing techniques and principles 
to influence individual behaviour change. It gives a wider elaboration on the 
contribution of social marketing to influence different health and societal issues by 
specifically adapting the social cognitive theory as a model to influence breast cancer 
screening in Ghana.  
 Finally as it has been established already, this study focuses on only women from 
18years and above since they are more vulnerable and pruned to the disease. The scope 
will only encapsulate breast cancer screening in Ghana and will not cover the treatment 
of breast cancer. 
1.9 Chapter Outline 
This thesis is organised into six (6) chapters, the details of which are outlined below:  
Chapter One: Introduction 
This is the introduction of the research and comprises the research background, 
research problem, and research purpose, objectives of the study, research questions, 
research significance, the scope and finally, the chapter organisation of research.  
Chapter Two: Literature Review 
Chapter two presents a review of relevant literature on social marketing and how it can 
be helpful to increase breast cancer screening. It also involves using the social cognitive 
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theory to know how environmental and personal characteristics influence breast cancer 
screening in Ghana. 
Chapter Three: The Context of the Study  
 The third chapter involves the context of the study which covers brief overview of 
Ghana and the study area, Madina market, general issues about breast cancer and 
screening behaviours in Ghana, and finally breast cancer screening statistics at the 
radiotherapy unit of the Korle-bu Teaching hospital. 
Chapter Four: Research Methodology 
Chapter four deals with the methodology, research strategy, study population, sampling 
techniques, data collection instrument and method, data processing and analysis, and 
ethical considerations. 
Chapter Five: Data Presentation and Analysis  
Chapter five entails data presentation, discussion and analysis of findings. The data is 
tabulated and presented in forms that can be easily interpreted whilst testing the factors 
which are likely to influence breast cancer screening in Ghana. 
Chapter Six: Conclusion  
This comprises the summary, conclusions, recommendations and implications to 
research, practice and policy and the future research directions. The references and 
appendices follow this chapter.     
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CHAPTER TWO 
LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 
2.0 Introduction  
It is vital to conduct a study of this nature and its purpose in both theoretical and 
empirical literature. There is also the need to provide the conceptual framework for the 
study. Again, a review of theoretical and empirical literature will help position the 
study and provide a strong background for any empirical contribution this work would 
have to offer for future research. 
 Literature review according to Saunders, Lewis & Thornhill (2009), provides the basis 
on which research is built and its main purpose is to help the researcher develop a good 
understanding and in-depth knowledge into relevant previous research and trends that 
have emerged. Again literature clearly shows the need for the researcher to exhibit 
complete awareness of current state of knowledge in the area of study, how the research 
fits in terms of wider perspective and the limitations that accompany it (Gill & Johnson, 
2002). 
On the basis of that, this thesis seeks to identify and understand the factors which are 
likely to influence behaviour change in the area of breast cancer screening. This chapter 
therefore reviews literature on the nature of social marketing and the role it plays in 
influencing behaviour change. Again, it further looks at the various theories judiciously 
used by social marketers to explain how behaviour change occurs. Finally, the 
researcher adapts and explains the social cognitive theory as the conceptual framework 
for this study. 
2.1 The Concept of Social Marketing 
The term social marketing could be traced back to the 1950‘s when an American 
academic, Wiebe (1951), started people thinking when he analysed contemporaneous 
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social advertising campaigns and asserted that, indeed the ones that looked like the 
commercial marketing are the best. He concluded that it is possible to ‗sell brotherhood 
like you sell soap‘. As a buildup on that ideology, people started thinking differently 
and seriously that strategies applied by profit making organisations to influence their 
target customers might also be used by the non-profit making organisations as well. 
The term social marketing as a discipline is rooted in commercial marketing and has 
been applied successfully to the resolution of health and social challenging issues. 
However, social marketing became known as a discipline in the 1970‘s when Kotler & 
Zaltman (1971) used the term ‗social marketing‘ for the first time in their journal of 
marketing article ‗‗social marketing; an approach to planned social change‘‘. Today,  
the components of social marketing have been added to major domestic and 
international behaviour change programmes (Debus, 1987; Ramah, 1992; Smith, 1989).  
 In many developing and developed worlds, social marketing concept is expanding 
greatly and that many social and health issues have been improved through social 
marketing thinking (Manoff, 1985). Many reformed groups and government have 
consciously applied social marketing to influence many social issues such as improved 
nutrition, family planning, alcohol prevention, antismoking, speeding, drug abuse and 
myriad of issues (Centre for Disease Control, 2005). As a result, it has been identified 
that social marketing is very effective in influencing voluntary lifestyle of individuals 
(CDC, 2005; Department of Health, 2004).       
2.2 Defining Social Marketing 
Social marketing is not a theory in itself, rather it takes its root from many other 
disciplines such as psychology, sociology, and anthropology and communication theory 
to understand and influence people‘s behavior (Kotler & Zaltman, 1971). It uses the 
principles and structures of commercial marketing to influence behavioural change 
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(Kotler & Zaltman, 1971). As a growing discipline many scholars have come up with 
their own definitions based on their experiences. However the very first and formal 
definition of social marketing was that given by Kotler & Zaltman (1971). They define 
social marketing as ‗the design, implementation and control of programmes calculated 
to influence the acceptability of social ideas and involving considerations of product 
planning, pricing, communication, distribution, and marketing research.‘  
This first definition was criticised severely by Rangun & Karim, (1991) and argued that 
it lacked clarity. Again an argument was put forward by Hirscbman, (1991) that people 
could not differentiate between social marketing and societal marketing. Again this 
definition projects a level of limitation to the objective of influencing the acceptability 
of social ideas. As a result of the lack of clarity with the original definition, Andersen 
(1995), shared his own idea and described social marketing as, ―the application of 
commercial marketing technologies to the analysis, planning, execution and evaluation 
of programmes designed to influence the voluntary behaviour of target audiences in 
order to improve their personal welfare and that of society.‖   This definition however 
projects social marketing as having a strong grounding in marketing and incorporate the 
marketing mix elements of product, price and promotion. Again it emphasizes on 
voluntary behaviour change and at the same time, the purpose of achieving socially 
desirable goals that benefit individuals and the entire society (Niblett, 2005; Kotler & 
Lee, 2008). Some other recent definitions of social marketing from a few veterans have 
been captured as follows: 
―Social marketing is the application of commercial marketing principles and tools 
where the primary goal is the public good (Donovan, 2011)‖. 
―Social marketing critically examines commercial marketing so as to learn from its 
success and curb its excesses (Hastings, 2011)‖. 
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―Social marketing is the activity and processes for understanding, creating, 
communicating and delivering a unique and innovative offering to overcome a societal 
problem (Deshpande & Rundle-Thiele, 2011)‖. 
―Social marketing is the use of marketing principles and techniques to promote the 
adoption of behaviour that improve the health or well-being of the target audience or of 
society as a whole (Weinreich, 2010)‖. 
―Social Marketing is the systematic application of interactive marketing principles and 
techniques that harness audience participation to deliver value and achieve specific 
behavioural goals for a social good (Bernhardt, 2011)‖.  
It is established that there is no single universally accepted definition of social 
marketing, and as a result all these definitions contribute significantly to the 
development of social marketing (Donovan, 2011). However, research postulates that, 
social marketing has moved on from the early definitions that emphasize on the 
application of commercial marketing principles to social issues to reflect other concepts 
and techniques that are not related to marketing (French & Blair-Stevens, 2010). For 
the purpose of this study which seeks to test the factors which are likely to influence 
breast cancer screening in Ghana, the researcher followed French & Blair-Stevens 
(2010) who define social marketing as ―the systematic application of marketing 
alongside other concepts and techniques to achieve specific behavioural goals for social 
good‖. 
2.3 Social Marketing Focuses on Behaviour Change 
It has been observed that the bottom line of social marketing is to pursue a programme 
that ultimately leads to behaviour change (Niblett, 2005). The extant literature reveals 
that communication campaign is not the ultimate goal of social marketing campaign as 
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seen by people who do not understand the discipline. However, communication 
becomes instrumental in influencing behaviour change (Niblett, 2005). The sole 
emphasis on behaviour change makes the field of social marketing unique and distinct 
from other disciplines (Andreasen, 1993). Kotler & Lee (2008) suggest that social 
marketing campaigns normally influence the target audience to pursue one or more of 
the behaviours below: 
 To accept a new behaviour such as going for HIV test. 
 To reject a potentially undesirable behaviour such as starting smoking. 
 To modify a current behaviour such as not eating heavy foods late. 
 To abandon an old undesirable behaviour, example sex without condom. 
It has been observed that social marketing can also be used to encourage one time 
behaviour, for instance encouraging people to test for tuberculosis, or to remind the 
target audience of a behaviour which needs to be repeated, for instance visiting the 
dentist (Kotler & Lee, 2008). It goes further to establish that even though behaviour 
change is the ultimate aim, the emphasis of social marketing is basically to reward a 
good behaviour rather than punishing the bad ones through legitimate or any other 
means. However, research establishes that if unexpected things happen that motivate 
negative behavior, certain behavioural controls could be adopted to influence a change 
(French & Blair Stevens, 2010). In order to materialize that, it becomes the 
responsibility of the social marketers to provide an enabling environment to facilitate 
the desired behaviour change. Behavior change as a focus also calls for social 
marketers to fully understand and appreciate the characteristics and attitude of the 
target group which they seek to influence (Morris & Clarkson, 2009). The purpose of 
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knowing the characteristics of the audience is for the social marketer to know at a 
glance the strategies to implement to result in behaviour change. 
2.4 Effectiveness of Social Marketing to Behaviour Change 
The Centre for Disease Control and Prevention (2012) encourages the use of social 
marketing principles in public health interventions to increase campaign effectiveness. 
Other literature reveal that social marketing impacts voluntary health-related behavior 
by applying marketing together with other principles to change attitude, increase 
knowledge and motivate individual or societal change to improve personal as well as 
societal benefit (Andresen, 1995; Glassman & Braun, 2010). By this, social marketers 
must design and offer programme benefits or reduce barriers that discourage behaviour 
change (Glanz, Rimer & Viswanath, 2008). 
Literature has established that social marketing provides an effective framework for 
behaviour change campaigns and a powerful tool for organizations that are trying to 
change health behaviour (Stead et al., 2007). The extant literature examined health 
campaigns that adopted social marketing as the core strategy and found it to be a very 
effective tool in influencing policy as well as professional practices. They went further 
to define social marketing intervention, as those campaigns which adopt social 
marketing principles in their development and implementation (Stead et al., 2007). 
2.5 Interventions Addressed Using Social Marketing  
Research has identified that the application of social marketing for a range of 
interventions seems to be rising all over the world (Boyle & Proctor, 2009; Domegan, 
2008; O‘Shaughnessy, 1996) and that the growing benefits and the widening spectrum 
of the discipline has also become evident in academic research (Kotler & Zaltman, 
1971; Leonard, Spotswood, & Tapp, 2012; McDermot, Stead, & Hastings, 2005) and 
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policy and practice contexts (Lee & Miller, 2012; Samad, Nwankwo, & Gbadamosi, 
2010). 
 At the early stages of the conceptualization of social marketing, its successful 
application was in the area of family planning programme and other programmes aimed 
at controlling diseases Manoff (1985). The technique of social marketing and its 
thinking has spread worldwide and in several countries has become the centre of health 
improvement. In Canada, social marketing has been advocated to be included in the 
national health programmes (Mintz, 2005) and this is not different in America, where 
the idea of social marketing has been endorsed to be part of the new America 2020 
health strategy (AASM, 2012). Again in the UK, the development of social marketing 
strategies as the core for national campaigns between 2004-2009 are evident (French & 
Mayo, 2006), and then in France social marketing is the major principle in the French 
Epode program (AASM, 2012), which is similar to that of the Netherlands, JOGG 
programme and finally the new WHO Europe health 2020 programme (AASM, 2012). 
For example, social marketing is consistently been advocated for as a core health 
strategy in the US to influence voluntary lifestyle behaviour including smoking, 
drinking, drug use and diet (Centre for Disease Control, 2005). Again, both US 
Department of Agriculture (USDA), US Department of Health and Human Services 
(USDHHS) and other organisations have used social marketing to promote the 
prevention of obesity, physical activity, decrease fat consumption, breast feeding and 
other  health behaviours that are preventive (Coreil, Bryant & Henderson, 2000). 
Taking other examples, the white paper that contributes to public health awareness and 
behaviour change in the UK has endorsed the use of social marketing (Department of 
Health, 2004) and this has been used successfully to improve health and reduce health 
inequalities (NCC and DH, 2005). 
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 In other geographical locations, the concept of social marketing has been used 
successfully to improve access to portable water (Mong, Kaiser, Ibrahim, Rasoatiana 
Razifimbololona & Quick, 2001), eradicate leprosy (Williams, 1999), increase 
tuberculosis medicine adherence (Marks & Greathead, 1994), promote immunizations 
and universal iodization legislature (Donovan & Henley, 2003; Jooste, Marks & van 
Erkom Schurink, 1995) and HIV/AIDS and condom use (Tweneboah-Kodua, 2014; 
Harvey, 1999). This leads to the discussions of the interventions mix use by social 
marketers. 
2.6 Social marketing intervention mix 
When the concept of social marketing was developed as a discipline in the 1970s, 
researchers like Kotler & Zaltman (1971) discovered that there are some similarities in 
that, the same marketing principles that were used in commercial marketing could be 
used to sell ideas, behaviours and attitude. This idea explains the rationale behind 
different definitions given by different writers that show the adoption and adaptation of 
commercial marketing principles and techniques for social good (Dann, 2010). The 
social marketing intervention mix is a framework that can be used to define social 
marketing campaign and according to Thompson (2013), these core tools of marketing 
are manipulated carefully to produce the most effective mix. Social marketers seek to 
effectively combine the intervention mix variables to offer something valuable to the 
target audience and this is the one that comes closest to satisfying consumer needs 
(Cannon, 1992; Kotler, Armstrong, Saunders & Wong, 1999). The marketing mix 
which is popularly known as the 4Ps of marketing- product, price, place and 
promotion- have been adopted to fit social marketing practices and are used somewhat 
differently from commercial marketing. 
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When used in social marketing campaigns, product refers to the behaviour social 
marketers want the target audience to adopt or avoid (Kotler & Zaltman, 1971), and 
may range from physical product (condoms), services (medical exams), practices 
(breast feeding or examination) and even more intangible (environmental protection). 
Price refers to the financial or any other sacrifice the target audience must give up in 
order to benefit from the behaviour being promoted. Kotler & Zaltman (1971) suggest 
that price in social marketing could be monetary or in most cases intangibles such as: 
time, effort, embarrassment and others. In setting price for social campaigns, research 
suggest that the costs should not outweigh the perceived benefits of engaging in that 
behaviour (Rungan, Karim & Sandberg, 1996). 
The place element refers to the various channels which deliver the products or 
programmes, or easily make the product accessible (Kotler & Zaltman, 1971). For a 
tangible product, it refers to the distribution systems which are not different from that 
of commercial marketing, such as the retail outlet, warehouse, salesforce and others. 
For an intangible products, it refers to the exact places where the service are delivered 
such as the doctor‘s office, mass media vehicles and others. In both situations, the 
distribution variable covers timing, cost, coverage, transportation, location and 
accessibility (Cowell, 1994; Woodruffe, 1995). The final element of the intervention 
mix is promotion. This consists of the integrated use of advertising, media advocacy, 
public relations, personal selling, entertainment vehicles, social media and other 
technologies such as the media to communicate the impulse of the campaign. In all of 
this, research becomes crucial in determining the most efficient and effective way to 
blend these variables to achieve social goal (Cowell, 1994).  
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Social marketing has its own variables that are used in campaigns to support the 
traditional marketing mix making it 8P‘s instead of the traditional 4P‘s, according to 
Kotler & Lee (2008) and these are: 
Publics: these refer to the internal and external groups involved in the campaign. This 
is because social marketers have different audience their message targets. These are 
called the stakeholders in social marketing campaigns. 
Partnership: these are organizations within the community that have similar goals and 
can team up with the social marketer to bring the needed change. Because behaviour 
change is so complex and one organisation cannot solve complex social issues alone, 
forming alliances with others become the best way to achieve the set goals. 
Policy: sometimes social campaigns need policy change to support and sustain 
behaviour change for a long time. This is achieved by moving upstream to alter the 
environmental changes which in turn will motivate individuals to change their 
behaviour. 
Purse strings: this includes donations, funds, governmental grants and others that 
come in to help social marketers to start off. This is because social marketers are not 
profit makers and therefore will need to depend on the funds from these sources for 
their campaigns.  
2.7 Upstream and Downstream Social Marketing 
Since the mid-90s, scholars have suggested that social marketing scope should be 
broadened beyond individuals, or group of target audience, and attempt to influence 
those in the position to shape the determinant of human behaviour (Goldberg, 1995; 
Andreasen, 2006). As a result of this, literature categorize behaviour change 
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interventions on a continuum from downstream to upstream social marketing 
intervention approaches (McKinlay, 1975, 1993; Verplanken & Wood, 2006). The 
extant literature explain that downstream approach focuses on exhorting behaviour 
change through information campaign. 
Downstream approach focuses on trying to influence behaviour change among people 
who already exhibit a significant risk factors. The interventions at the downstream level 
attempt to influence the decisions of individuals who are at risk (Verplanken & Wood, 
2006). Again, Ruiter, Abraham & Kok (2001), have put forward that it is necessary to 
target and inform individuals about potential health risks in order to facilitate health 
behaviour change. Changing behaviour at the downstream demands the provision of the 
necessary information to the target audience for decision making. However research 
shows that since downstream focuses on the micro level factors, it is paramount to 
tackle the motivation, skills and knowledge of individuals (Fisher, Fisher, Amico, & 
Harman, 2006; Fisher, Fisher, Bryan & Misovich, 2002).  
The second approach, upstream marketing on the other hand attempts to bring about 
desired individual behaviour change, often without the conscious cooperation of 
individuals (Wilkinson & Marmot, 2006). There is a widespread believe that engaging 
in upstream marketing is as important as downstream interventions (Verplanken & 
Wood, 2006). The literature further asserts that upstream social marketing interventions 
focus on influencing the environment in which that particular behaviour is 
demonstrated (Verplanken & Wood, 2006). The upstream interventions focus on social 
norms and environmental supports which facilitate desired behaviour change. These 
factors are also known as the macro factors and comprise of social structural influences 
on health and health systems, government policies and the social, physical, economic 
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and environmental factors that are beyond the control of individuals (Oliver, 2005; 
Andreasen 2006; Goldberg, 1995).  
Upstream intervention proposes that influencing these factors can help address societal 
problems and that the upstream represents target audience with different interventions 
(Hoek & Jones, 2011). There is a strong evidence that upstream social marketing has 
been instrumental in influencing smoking, bans on tobacco and marketing of smoke 
free legislation (Pollay, 2004). Undoubtedly, upstream interventions provide social 
marketers with possibilities to influence behaviour of those that shape the environment 
in which much of the behavioural challenges faced by societies operate (Gordon, 2013). 
This leads to behaviour change theories applied in social marketing. 
2.8 Behaviour Change Theories 
According to literature, theory application to the design and implementation of complex 
behaviour change is necessary and effective (Glanz & Rimer, 1995; Medical Research 
Council, 2008). Although is observed that not all interventions make use of theories in 
influencing behaviour change (Albarracin et al., 2005; Davies, Walker, & Grimshaw, 
2010; Hardeman, Johnston, Johnston, Bonetti, Wareham, & Kinmonth, 2002; Molloy, 
2010), research reveals that there is an evidence for the increasing trends of applying 
theories to many interventions (Noar, Palmgreen, Chabot, Dobransky, & Zimmerman, 
2009). It is evident from literature that when it comes to larger intervention effects, the 
use of theories by social marketers to inform the development of behaviour change 
intervention is paramount to the success of that intervention (Albada, Auseums, 
Bensing, & van Dulsem, 2009; Ammerman, Lindquist, Lohr, & Hersey, 2002; Fisher & 
Fisher, 2000; Glanz & Bishop, 2010; Swann et al., 2003; Taylor, Conner, & Lawton, 
2012; Webb, Joseph, Yardley, & Michie, 2010). 
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 In designing interventions to yield positive behaviour change, research depicts that 
social marketers should understand behaviour change theories and develop special 
abilities on how to use them ((Glanz, Lewis, & Rimers, 1990). Theories and models 
social marketers apply are many and there is little formal consensus as to the type of 
theory to use for specific social problem and the situations that are appropriate 
(Lefebvre, 2000). In furtherance of this, the following have been identified as some of 
the major theories used by social marketers to influence behaviour change: 
2.8.1 Health Belief Model: 
This is one of the most frequently used theories among public health practitioners and 
has been adopted by social marketers to influence behaviour change (Strecher & 
Rosenstock, 1997). The theory was originally designed to explain the rationale behind 
people neglecting programmes aimed at preventing or detecting diseases and attempts 
to explain the conditions that are necessary for behaviour change to occur (Strecher & 
Rosenstock, 1997). The extant literature also reveals a variety of demographic, social, 
psychological and structural variables that may impact on individual‘s perceptions and 
health related behaviors. Reviewing this model across numerous health and screening 
behaviours such as using seat belt, physical activity and others found substantial 
contribution it has made (Janz & Becker, 1984). The core components of the health 
belief model include the following: 
 Perceived susceptibility: this is where the individual sees himself as susceptible 
or vulnerable to a particular health situation.  
 Perceived severity: the feelings about the severity of the consequences of a 
specific problem. 
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 Perceived benefits: the belief that engaging in the preventive behaviour offers 
advantage over the current behaviour and these benefits might reduce the threats 
or susceptibility and severity. 
 Perceived barriers: the belief about the potential negative aspect of taking 
specific action. 
 Cues to action: this refers to the bodily or environmental actions that stimulate 
action. 
 Self-efficacy: the self-belief to take action. 
2.8.2 The theory of reasoned action  
This theory was developed by Ajzen (1991), and organises itself around the constructs 
of behavioral and normative beliefs, attitudes and intentions and behaviour. According 
to the theory, the most significant determinant of behaviour is the intention to perform 
that behaviour and behavioural intention is in turn influenced by three important 
factors: 
 Attitude toward the behaviour: this can be measured in terms of a belief about 
both the outcome and attributes associated with the behaviour and its relative 
importance. 
 Subjective norms associated with the behaviour: this measures the personal 
assessment of a person‘s feelings as to the extent of how other relevant people 
in his life would think of the action as being reflected upon, that is whether they 
would look favourably or unfavourably on the expected action. 
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 Perceived behavioural control: this is simply the perception of individuals in 
relation to the strength of external factors that make it easier or challenging to 
carry out the behaviour. 
2.8.3 Trans-theoretical model or stage of change theory 
According to the basic idea of this theory, individuals do not make and carry through 
decisions, especially complex behavioural ones, in a simple binary fashion (Prochaska 
& DiClemente, 1983). They suggest that individuals move through stages on their way 
of adopting a new behaviour or changing their old behaviour. The model has undergone 
considerable field testing since 1983, including smoking cessation, condom use, 
quitting cocaine and others (Prochaska & Velicer, 1997). It suggests five stages of 
behaviour change as follows: 
 Pre-contemplation: this is the first stage where the individual may be aware of 
the new behaviour but not interested in it, at least at this point in the person‘s 
life. 
 Contemplation: at this stage the person begins to consciously evaluate the 
personal relevance of the new behaviour. 
 Preparation: the stage where the individual decides to act and tries to put in 
place the necessary measures needed to carry out the new behaviour. 
 Action: the individual performs the behaviour once and determines whether it 
was worthwhile or not. 
 Confirmation or maintenance: the final stage where the individual is committed 
to the behaviour and has no desire or intention to regress. 
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2.8.4 Diffusion of Innovation 
This is another most powerful theory used to influence the behaviour of large groups of 
people (Kotler & Roberto, 1989). The extant literature shows the application of this 
theory to social marketing programmes. The theory states that for a particular 
innovation, individuals may fall into one of the segments which is represented in 
certain proportions, based on when the person accepts the new behaviour (Rogers, 
1983). These segments differ with respect to communication patterns, demographics 
and other variables. The five adopter segments include the following: 
 Innovator (2.5%): they constitute the least percentage and have the need for 
novelty and to be different. 
 Early Adopter (13.5%): they recognize the importance of adoption from contact 
with innovators. 
 Early Majority (34%): this group have the need to imitate or match up with 
others with a certain amount of deliberateness. 
 Late Majority (34%): this category of people have the need to join the 
bandwagon when they see that the early majority has legitimated the change. 
 Laggard (16%):  in every innovation, this group of people are the last to try a 
new product. They are more reluctant and will always try only after other 
groups have tried and probably the product is at the saturated stage of its life. 
The other aspect of this theory involves the determinant of speed of diffusion and the 
extent of the innovation (Oldenburg, Hardcastle & Kok, 1997). An individual‘s 
decision to accept or reject an innovation is determined by factors such as:  
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 Relative advantage: whether the new behaviour is better, easier, and simpler 
than what they currently do. 
 Compatibility: the extent to which the new behaviour is consistent with the 
audience‘s lifestyle, cultural/ethnic beliefs, practices and self-image. 
 Trial ability: it measures whether the new behaviour can be tried before making 
a final commitment. 
 Communicability: it determines how a behaviour could be understood clearly 
and easily. 
 Risk: this measures whether the behaviour could be adopted with minimal risk 
and uncertainty.                                                       
This theory uses opinion leaders and peer-to-peer influence in most cases to 
disseminate information about new ideas or behaviour change to the target audience 
(Rogers, 1983). 
2.8.5 Exchange theory 
Marketing attempts to influence individual voluntary behaviour by offering benefits or 
incentive in an environment that welcomes voluntary exchange (Rothschild, 1999). The 
exchange theory encourages individuals to act in ways that give them the greatest 
benefits for the least cost (Bagozzi, 1978). This theory is grounded in psychology and 
economics and reveals that, in order for individuals to increase their readiness to 
change, social marketers should offer them with something beneficial in an exchange 
(Housten, & Gassenheimer, 1987). Exchange involves the transfer of tangible or 
intangible things between two or more social actors (Bagozzi, 1979). The theory further 
postulates that individuals are likely to adopt a new behaviour if they become aware 
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that the perceived benefits of the new behaviour far outweighs the perceived costs 
associated with it (Maibach, 1993). Kotler (2000) also reveals that for an exchange to 
occur, five important prerequisites are needed to be fulfilled. 
 There should be at least two parties. 
 Each party should have something that might be of value to the other party. 
 Each party is capable of communication and delivery. 
 Each party is free to accept or reject the offer. 
 Each party believes it is appropriate or desirable to deal with the other party. 
2.8.6 Social cognitive theory 
 The social cognitive theory provides a comprehensive view of explaining human 
behaviour (Baranowski, Perry & Parcel, 1997). This theory of behaviour change 
postulates that human behaviour is reciprocally determined by internal personal factors 
and environmental factors (Bundura, 1986, 1997; Maibah & Cotton, 1995). It 
recognizes the two-way relationship that exist between personal and environmental 
factors. That is the environment shape people‘s behaviour, and the people in turn shape 
their environment through their behaviour and expectations (Maibach & Cotton, 1995). 
The theory views the environment as not just one that reinforces or punishes behaviours 
but also one that provides the platform where people can watch others perform the 
same behaviour and learn from the consequences of those behaviours (bandura, 1986; 
MacFadyen, Hastings, MacKintosh & Lowry, 1998).  
According to Bandura (2011), there are two classes of broadly grouping the 
environmental factors. There are those factors that are close to the individual and have 
direct influence on their behaviour change and this is termed the micro or immediate 
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environment. They include the influence of the family, friends, neighbours and peer 
network (MacFadyen et al., 1998). These factors are likened to subjective norms in the 
theory of reasoned action (Janzen & Haire 1991).  
However the second group of factors are those that are more indirect to behaviour 
change and are wider and external and may influence other factors as well (Bandura, 
1991; McFadyen et al., 1998). These factors have been identified to be physical or 
structural issues, social and cultural, political and legal and economic factors (Baker, 
2002; Jobber, 2003; Kotler 7 Armstrong, 2004; Wilson & Gilligan, 2005). 
The final level of behavioural influence is that of personal characteristics. The personal 
factors comprise of the attitudes, beliefs, knowledge, needs, skills and self-efficacy 
(Bandura, 1986). Research indicates that in most cases, putting blames on individuals 
for not changing their behaviour when structural changes to motivate individuals have 
not been made does not make sense (Hastings, MacFadyen & Anderson, 2000). 
Therefore research expresses the need to focus attention on the upstream factors of 
behavior change (Andreasen, 2006). 
Wilkinson and Marmot (2003) argued that individuals should not be left with the whole 
responsibility of their behaviour. Hollingworth et al, (2006) also calculate that focusing 
on the environmental influence will help to reduce certain social problems. Smith 
(1998) argued that individual behaviour change can only be made easier if social 
marketers resort to considering the environmental influence first, when all possible 
structural changes have been adopted. Stokols (1996) advocates that both individual 
and environmental factors complement each other and therefore, there must be an 
interplay between the environment and the individual. In an attempt to change 
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behaviour, social marketers must have an accurate analysis of the complex environment 
in which the campaign appears. 
Kotler (2000) admonishes that the purpose of this environmental analysis is to 
understand and monitor the environmental factors and be able to predict the impact on 
the behaviour change. The extant literature reveals that, any environmental analysis 
must consider the current as well as the future trends and development that may have 
adverse effect on behaviour. It goes on to establish that these factors may passively or 
actively inhibit desirable social change. 
2.9 Key Elements of Behaviour Change Models. 
It is worthwhile to understand the variables that are essential to behaviour change 
models. Below provides a summary of the list of the variables common to these models 
when attempting to evoke a behaviour change, adapted from Witte (1997).  
Threat: The theories project a danger or a harmful event of which people may or may 
not be aware. Raising awareness that the threat exists and focusing on severity and 
susceptibility of audience is paramount. 
Fear:  Emotional arousal caused by perceiving a significant and personally relevant 
threat. Fear can powerfully influence behaviour and, if it is channelled in the 
appropriate way, can motivate people to seek information, but it can also cause people 
to deny they are at-risk. 
Response Efficacy: It is the perception that a recommended response will prevent the 
threat from happening. Provision of evidence of examples that the recommended 
response will avert the threat. 
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Self-Efficacy: An individual‘s perception of or confidence in their ability to perform a 
recommended response. The individuals‘ confidence can be raised to respond 
positively and help to ensure they can avert the threat. 
Barriers: Something that would prevent an individual from carrying out a 
recommended response. These barriers exist in the form of physical, cultural or any 
other however, an attempt should be made to remove or reduce those barriers. 
Benefits: These are the Positive consequences of performing a recommended response. 
Communicating the benefits of performing the recommended response is vital. 
Subjective Norms: What an individual thinks other people think they should do. 
Understand with whom individuals are likely to comply. 
Attitudes: An individual‘s evaluation or beliefs about a recommended response. 
Measure existing attitudes before attempting to change them. 
Intentions: An individual‘s plans to carry out the recommended response. Determine if 
intentions are genuine or proxies for actual behaviour. 
Cues to Action: External or internal factors that help individuals make decisions about 
a response. Effective communication should be provided to trigger individuals to make 
decisions. 
Reactance: When an individual reacts against a recommended response. Make sure 
individuals do not feel they have been manipulated or are unable to avert the threat.  
2.10 Health Issues and their influences 
Some health related issues and the factors which influenced them are discussed here 
below: 
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2.10.1 HIV/AIDS  
 An extensive review of the literature on theories and AIDS campaigns, Freimuth 
(1992) concludes that, knowledge is not a sufficient condition for behaviour change. 
The literature reveals a close relationship between changes in knowledge and change in 
behavior (Yoder, 1997). The same literature reveals that in the new era of HIV/AIDS 
prevention and care, cultural issues should be regarded a crucial factor. Based on this, 
Michael-Johnson & Bowen (1992) define culture as a ―set of beliefs, values and 
individual goals that pattern behaviour‖. Cultural factors are central in organizing 
concept in developing programs for HIV education and assessing their outcomes. In an 
attempt to explain culture, Bird (1996) includes media as part of culture which carries 
huge influence on how people respond to messages. However both personal factors and 
environmental factors were seen as catalyst for HIV/AIDS campaigns. 
2.10.2 Physical Activity  
A campaign on the factors which influence physical activity places emphasis on the 
social and physical environment and reveal a lot of internal and external influences 
(Giles-Corti & Donovan, 2002; Carnegie et al., 2002). The literature revealed that 
personal characteristics as well as the environment play major influence in physical 
activity. Exercise habits by individuals were influenced by social status and 
environmental context (McCormack et al., 2004; McNeil et al., 2006; Perula et al., 
1998).  Social class of the individual and the socio-economic characteristics of the 
geographic area were identified as influential factors (Giles-Corti & Donovan, 2002; 
Pascual et al., 2005). The extant literature stated that, the physical environment such as 
the existence of physical accessibility to centers, gyms, swimming pools, safety and 
attractiveness of neighborhoods and local areas are all influences of physical activity. 
Finally, people‘s negative attitude, perceptions and opinion toward exercise coupled 
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with their lack of knowledge determine the extent to which people engage in physical 
activity (Varo-Cenarruzabeitia et al., 2003; Rutten et al., 2001). 
Another study revealed physical activity as multidimensional and complex (Dishman, 
Sallis & Orenstein, 1985). Factors that influence physical activity have been 
categorized as facilitators or barriers and impediment for individual participation (Sallis 
& Owen, 1997). According to literature (Sallis, Prochaska & Taylor, 2000; Buckworth 
& Dishman, 2002), these factors are broadly grouped as follows: demographic and 
biological factors, psychological, cognitive and emotional factors, behavioural 
attributes and skill, social and cultural factors, physical environment factors and, 
physical activity characteristics. Demographic and biological factors are age, ethnicity, 
gender, income, socioeconomic status, marital status, ethnicity and body mass index 
(Sjöström et al., 2006; Santos et al., 2008).  
The psychological, cognitive, and emotional factors were attitudes, barriers to exercise, 
control over exercise, enjoyment over exercise, expected benefits, health locus of 
control, intention to exercise, knowledge of health and exercise, lack of time, mood 
disturbance, normative beliefs, perceived health or fitness, personality variables, body 
image, psychological health, self-efficacy, self-motivation, stage of change, stress, and 
value of exercise outcomes (Sallis & Owen, 1999; Muntner et al., 2005). Behavioural 
attributes and skills were the activity history during childhood/youth, activity history 
during adulthood, alcohol, contemporary exercise programme, dietary habits, past 
exercise program, process of change, school sports, and skilled for coping with barriers.  
Social and cultural factors were classified to be class size, exercise models, group 
cohesion, past family influences, physical influence, social isolation, and social support 
from friend/family. Physical environmental factors were the actual access to facilities, 
perceived access to facilities, adequate lighting, climate/season, and cost of 
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programmes, disruptions in routine, enjoyable scenery, heavy traffic, home equipment, 
high crime rates in the region, hilly terrain, neighbourhood safety, presence of 
sidewalks, satisfaction with facilities and urban location (Santos et al., 2008; Sallis & 
Owen, 1999). 
Finally physical activity characteristics such as activity intensity, type and perceived 
effort, these influenced physical activity among adults. It was concluded that the factors 
which influenced physical activity are numerous and that immediate and wider 
environmental factors together with personal factors combined to determine physical 
activity (Caspersen, Nixon & Durant, 1998; Trost et al., 2002). 
2.10.3 Social Cognitive Theory and Obesity 
Research into obesity adapting the social cognitive framework concluded that there are 
multiple factors such as genetic, environmental, cultural and socio-economic status 
influence how people respond to corporal weight (Fernandez-Alvira et al., 2013; Puhl 
& Heuer, 2009; Rey-Lopez et al., 2008; Haug et al., 2009; Van der Horst et al., 2007; 
Franzini et al., 2009). Research focused on child and adolescent obesity reveals 
individual factors such as gender, socio-economic position, physical activity and sleep 
duration acting as influence to behaviour change (Rey-Lopez et al., 2008; Haug et al., 
2009; Singh et al., 2010). Evidence suggested that environmental and family factors 
influenced adopted habits especially in children (Van der Horst et al., 2007; Bolivar et 
al., 2010; Nelson et al., 2006; Feng et al., 2010). Finally, the neighbourhood 
environment creates opportunities and barriers for obesogenic behaviours and facility 
availability (Bodor et al., 2008; Tappe et al., 2013). The three major constructs of the 
theory were fully analysed and was concluded that all the factors contributed 
significantly to behaviour change (Franzini et al., 2009; Bolivar et al., 2010).     
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2.10.4 Social cognitive theory and adolescent eating behaviour 
Another campaign analysed was using the social cognitive theory as a framework to 
explain the multiple socio-environmental and personal factors that interact to influence 
individual eating behaviour patterns (Glanz & Rimer, 1995; Baranowski et al., 2000). 
The results proved positive and the influences were identified as follows: 
At the individual level of influence, Story et al, (2002) identified that, individual 
preferences and perceptions of food have strong influence on food selection (Birch, 
1999; Baranowski et al., 2000; Birch & Fisher, 1998; French et al., 1999; Horacek & 
Betts, 1998). Again, the perceived self-efficacy for healthful eating was seen to have 
greater influence (French et al., 1999; Gracey et al., 1996). A person‘s knowledge was 
discovered to be helpful in adopting healthful eating behaviour (Contento, Manning & 
Shannon, 1992). The general lifestyle in relation to perceived time constraints and 
convenience strongly impacted on adolescent food choices (French et al., 1999; 
Neumark-Sztainer et al., 1999). Again it is noticed that taste has greater influence 
followed by cost when it comes to food selection (Glanz et al., 1998). The reason being 
that most adults are price sensitive (Glanz et al., 1998; French et al., 1999). 
At the micro level, the family was seen as the first and the most influential factor 
followed by the peers, Story et al, (2002). This is so because the family is the provider 
of food and also influences food attitudes, preferences and values. Adolescence are 
marked with the influence of peers and conformity of groups (Steinburg, 1996). Peers 
are seen as exerting major influences on adolescent behavior (Neumark-Sztainer et al., 
1999; French et al., 1999). The extant literature mark that, peer influence may be direct 
or indirect. 
Story et al, (2002) in their work concluded that, factors within the larger society can 
invariably affect adolescent eating behaviour. These factors included the media, 
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cultural norms, social norm and production and distribution food systems and their 
availability. The focus of their work did not reflect much on the macro factors. 
However media influence was taken into account and was seen as posing a strong 
influence on food choices (Roberts et al., 1999).  
2.10.5 Social cognitive theory and smoking 
A work done by Cunningham (2011) on social cognitive theory and smoking assessed 
the factors that might influence people‘s smoking behaviour and identified ten (10) 
strong factors that  are interconnected as follow: 1. Peer Pressure 2. Social Rewards 3. 
Risk-taking Behaviour 4. Parental Influence 5. Misinformation 6. Genetic 
Predisposition 7. Advertising 8. Self-medication 9. Media Influence 10. Stress Relief. It 
was concluded that both personal and immediate influences were very vital in 
determining the smoking habit of people. 
2.11 Media influence on behaviour change 
A work done by Kotler & Lee (2008) observed that, mass media promises the ability to 
disseminate well defined behavioural focused messages to large audiences repeatedly 
over a time, on an incidental manner, and at a low cost per head. The literature reveals 
that multiple method of disseminating information might be used in the cases of health 
campaigns. According to Hornik & Yanovitzky (2003), media influence can be direct 
or indirect to the individual in the pathway to behaviour change. They further state the 
media may influence individuals directly by invoking cognitive and emotional 
responses. This can result in reduction or removal of obstacles leading to change which 
can help people to adopt healthy or recognize unhealthy social practices and to 
associate valued emotions with change achievement (Kotler & Lee, 2008). However 
Fishbein & Azjen (2010) argue that media changes strengthen intentions to effect 
changes that have the potential to result in new behaviour.  
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It has also been identified that behaviour change can be achieved through indirect 
media influence (Farquhar, 1978). Mass media messages can set an agenda for and 
increase the frequency, depth or both, of inflaming an interpersonal discussion about a 
particular health issue within the context of an individual social network. Again, media 
messages reach large audience and therefore changes within an individual‘s social 
network might influence the person‘s decision without them directly exposed to the 
message (Fortmann et al., 1986). Finally, media discussions about a particular health 
issue may lead to changes in public policy which inevitably may lead to removal of 
barriers of individual behaviour change (Durkin, Biener & Wakefi, 2009; Farrelly et al., 
2009). 
 Furthermore, research on media influence on tobacco usage found media messages 
contributing significantly to reductions in tobacco usage (National Cancer Institute, 
2008). It was concluded that media activities and messages contribute greatly to 
behaviour change (Wakefi, 2008; Sly, Arheart & Dietz et al., 2005; Niederdeppe, 
Farrelly, Hersey, & Davis, 2008).    
2.12 Personal factors and behaviour change 
This section examines the role of knowledge, skills and self-efficacy in behaviour 
change.  
2.12.1 The Role of Knowledge in behaviour change 
Bandura (1994) reveals that when it comes to health education campaigns, reliance on 
persuasive communications is the best and most effective way to encourage people. In 
such health messages, emphasizing on fear appeals that show the ravage of disease are 
used to motivate people and recommended preventive practices are provided as guides 
for action. Knowledge is prerequisite in an attempt to influencing people about the 
potential dangers associated with health issues (Niederdeppe et al., 2008). Sound 
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information on health issues must be provided to guide people on how to regulate their 
behaviour and firm belief about themselves. In the most effective manner, health 
communications should instil in people the belief that they have the capability to 
change their health habits and should instruct them on how to do it. As a result, 
research states that knowledge on health issues empower people to adopt a particular 
health behaviour (Bandura, 1994, 1997). 
2.12.2 The Role of Individual Skills and Modelling in Behaviour Change  
Bandura (1994) stipulates that, convincing people to change their risky behaviour is not 
enough. People may have a high level of knowledge about a particular health issue yet, 
they may choose to continue such risky health practices. It is also been observed that 
people need guidance on how to translate their concerns into efficacious actions 
(Bandura, 1997). According to Bandura (1997), the ability to learn by social modelling 
provides highly effective method for increasing human knowledge and skills. 
Modelling has a special dynamic power of simultaneously transmitting knowledge and 
valuable skills to large numbers of people. Modelling influences should be designed to 
build self-assurance and convey strategies for how to resolve risky practices. It is true 
that the influence of modelling on beliefs about one‘s capabilities depends on 
comparisons with others. Bandura (1986) pushes strongly that to increase the impact of 
modelling, the characteristics of models such as the age, sex, status, the type of problem 
and the situation in which they apply the skills should be made to appear similar to the 
people‘s own circumstances.  
It is observed that knowledge and heightened awareness of health risks are important 
preconditions for self-directed change (Bandura, 1997). However the truth is that, 
information alone does not necessarily exert much influence on health impairing habits 
(Farrelly et al., 2009). To achieve a self-directed change, it requires that people need to 
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be given reasons to alter risky behaviour and also the behavioural means and be given 
resources and social supports to do so (Bandura, 1994). Effective self-regulation of 
behaviour is not achieved by an act of will, however, it requires certain skills in self-
motivation and self-guidance (Bandura, 1986). Strong belief in one‘s efficacy to 
exercise personal control is crucial to determine success in applying self-regulative 
skills (Farrelly et al., 2009). 
2.12.3 The Role of Self- Efficacy in Behaviour Change 
According to Bandura (1997), perceived self-efficacy is concerned with people‘s belief 
that they can exert control over their own motivation, thought process, emotional states 
and patterns of behaviour. Literature on self-efficacy reveals that, people‘s belief about 
their capabilities affect what they choose to do, how much effort they mobilize, how 
long they will persevere in the face of difficulties and whether they engage in self- 
encouraging thought patterns (DiIori, Dudley, Watkins & Maibach, 2000; Grembowski 
et al., 1993). It is observed that when people lack a sense of self-efficacy, they do not 
manage situations effectively even though they know what to do and possess the 
required skills (Floyd et al., 1993). Numerous studies conducted to link perceived self-
efficacy to health promoting and impairing behaviour such as smoking, exercise, 
weight control, HIV prevention and diabetes show that, perceived self-efficacy can 
affect every aspect of personal change (DiIorio, Faherty, & Manteuffel, 1992; Floyd et 
al., 1993; Gecht, Connell, Sinacore, Prohaska, 1996; Grembowski et al., 1993; King, 
Marcus, Pinto, Emmons, & Abrams, 1996; Strecher, DeVellis, Becker, & Rosenstock, 
1986; DiIorio et al., 2000).   
 
 
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2.13 The Conceptual Framework 
2.13.1 Introduction  
Following the background of theoretical and empirical foundations underpinning this 
study on social marketing: the use of social cognitive theory to influence breast cancer 
screening, the researcher adapts the social cognitive theory as conceptual framework, 
which focuses on factors or antecedents that are likely to result in behaviour change as 
identified by Bandura (1986). 
A framework according to the researcher can be referred to as a model, which is simply 
a diagrammatical representation of ideas, constructs, or concepts put together. As 
Ostrom (2005) posited, the use of frameworks in research allows the identification of 
the elements and the specification of the relationships amongst these elements that the 
researcher needs to consider for prescriptive analysis. Some of the well-known theories 
used by social marketers to influence behaviour change have already been highlighted 
above.  However, for the purpose of this work, the researcher believes that by adapting 
the social cognitive theory as a framework, it will satisfy the objectives and the purpose 
of this work. 
Therefore, the conceptual framework for this study identified key environmental and 
personal factors that may be considered in an attempt to influence people to change 
their behaviour in relation to breast cancer screening in Ghana using the situation at 
Madina market, Accra, as the context of study. The conceptual framework adapted for 
this work is presented diagrammatically in figure 2.1 
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Figure 2.1: Source: Conceptual Framework Adapted From (Bundura, 1986; 
MacFadyen et al., 1998) 
 
2.13.2 Components of the Conceptual Framework 
The major components of the conceptual framework for this study include: Immediate 
Environment, Wider-External Environment, Personal Characteristics as well as 
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Behaviour Change. As shown in the diagram above, the three constructs combine to 
influence individual behaviour change. These constructs have been elaborated below: 
2.13.2.1 Immediate Environmental Influence  
These factors according to the social cognitive framework are those that are relatively 
direct and very close to the individual (Bandura, 1997). The variables within the 
immediate environment are made up of the influences of friends, family, local 
community and significant others. The immediate environment helps to shape the 
behaviour of individuals in the society and pose a great challenge for individuals. In 
terms of individual‘s preferences, needs and how decisions are made is basically as a 
result of greater influence exerted by the immediate environmental influence. However, 
most of these factors within the immediate environment can be controlled by the 
individual but the extent is dependent on the psychology of the person. From the 
construct, there is a direct relationship between immediate environment and behaviour 
change. The framework suggests that in order to encourage people to engage in breast 
screening, the immediate environment plays a critical role in determining the extent to 
which people will endorse the idea.  This has also been examined from the literature 
and as a result, the researcher posits that: 
H1: there is a positive relationship between the immediate environment and breast 
cancer screening behaviour. 
2.13.2.2 Wider Environmental Influence  
The social cognitive theory also explains the factors that are wider from the individual 
and these factors exert more indirect influence on behaviour change (Bandura, 1986). 
They are powerful factors that the individual has no control over (Bandura, 1991; 
MacFadyen et al., 1998). From the construct, these influences have been identified to 
be physical or structural issues, social and cultural, political and legal and economic 
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factors (Baker, 2002; Jobber, 2003; Kotler & Armstrong, 2004; Wilson & Gilligan, 
2005). Until there are changes in the wider context factors, behaviour change at the 
individual level will be extremely difficult if not impossible (Bandura, 1997). This 
explains the reason why many social marketers move upstream to influence behaviour 
change. In most cases, internal motivation is influenced by the cultural beliefs, family 
norms and economic situations prevailing. In the light of this, the researcher postulates 
that: 
H2: there is a positive relationship between wider external forces and breast cancer 
screening behaviour. 
 2.13.2.3 Personal Characteristics  
The internal factors are those within the individuals that serve to influence their 
behaviour (Bandura, 1986). According to Bandura (1991), the internal variables within 
the individual are the level of education or knowledge, self-efficacy, skills, goals and 
aspirations and symbolic needs of that individual. As aforementioned, these variables 
do not stand alone to influence the individuals to change their behaviour. Maibach & 
Cotton (1995) emphasizes that it would be unethical to engage in victim blaming by 
putting an unfair degree of responsibility for their own predicament on people who are 
already suffering and disempowered. The environment then becomes crucial in 
determining how the individual can facilitate behaviour change (Grembowski et al., 
1993). Simply telling people to screen their breast without the requisite knowledge, 
skills and structures or facilities to visit will invariably result in negative reaction. The 
personal variables have been applied successfully in other health related issues and the 
results have been phenomenal (Gecht, Connell, Sinacore, Prohaska, 1996; Grembowski 
et al., 1993; King, Marcus, Pinto, Emmons, & Abrams, 1996). Hence, the researcher 
deems it expedient to incorporate these variables to test its impact on breast cancer 
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screening in Ghana for any meaningful contribution to existing literature. This study 
therefore put the hypothesis that: 
H3: there is a significant positive relationship between personal factors and breast 
cancer screening behaviour. 
2.13.2.4 Behaviour change 
Behaviour change has been examined differently by scholars, however, behaviour 
change itself is a process which involves several steps beginning with understanding 
the existing knowledge, attitude and behaviour as well as the nature of competition 
(MacFadyen et al., 1998). From the construct, Bandura (1986) postulates that, 
behaviour change is reciprocally determined by three strong factors. Thus for a 
behaviour change to occur, the framework suggests the interplay of personal 
characteristics, immediate influences and finally the wider social influences. These 
factors are both internal and external within the individual‘s environment that 
determine behaviour change. 
In summary, the researcher believes that, there are forces that influence behaviour 
change and by adapting the social cognitive theory as a framework, it will help to 
understand these factors which are likely to influence breast cancer screening in Ghana. 
 
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CHAPTER THREE 
CONTEXTUAL STUDY OF THE RESEARCH 
3.0 Introduction 
Every research is conducted within a particular context and a discussion of adequate 
knowledge about such a setting is very necessary in order to facilitate the reader‘s 
understanding of the context within which the research is situated. Therefore in 
accordance with the aim and purpose of the study, this chapter provides a brief 
background of Ghana and narrows it to Madina, a suburb of Accra Metropolitan Area. 
It also discusses general issues related with breast cancer and breast screening exercise 
in Ghana. Finally, the discussions will be focused on the Oncology units in Ghana, 
followed by breast cancer statistics at the Korle-Bu Radiotherapy Centre to show the 
current state of breast cancer screening in Ghana. 
3.1 A brief background of Ghana 
Ghana is a country situated on the West Coast of Africa with a population estimate of 
27,059,987 as of July 11, 2015 (World Population Review, 2015), sandwiched in-
between Ivory Coast to the west and Togo, the east. It is bordered by Burkina-Faso to 
the north and the Gulf of Guinea to the south. Geographically, Ghana is the closest 
country to the centre of planet earth than any other country. Out of the estimated 
population, around 50.9% represents the male population and 49.1% represents the 
female population (World Population Review, 2015).  
This research focuses on Madina Market which is situated at the La-Nkwantanang 
Madina Municipal Assembly, located at the northern part of Greater Accra Region, a 
few distance away from the University of Ghana. According to the Ghana Statistical 
Service (2010), the total population is around 111,926, representing 2.8% of the 
region‘s total population. The females constitute 51.5% and males, 48.5%. Trading is 
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the main activity in the Municipality with the Madina market as the main one. The 
items traded include both perishable and non-perishable goods. 
3.2 Breast cancer situation in Ghana   
It is reported that one of the health problems confronting the world and for that matter 
Ghana is the menace of breast cancer (Opoku, Benwell &Yamey, 2012). It is estimated 
that in Ghana, 2,062 new breast cancer cases are reported annually out of which about 
1,137 deaths are recorded annually, representing 16.5% of all women cancer deaths 
(Mena, Wiafe & Sauvaget, 2014). Furthermore, the extant literature establishes that 
about 60% of the cases of breast cancer in Ghana are detected at late stages where 
nothing could be done about it (Opoku, Benwell & Yamey, 2012). 
 Again, breast cancer knowledge and screening in Ghana have been reported very low 
(Mena, Wiafe & Sauvaget, 2014). Even though in Ghana, regional and area breast 
cancer statistics are not known, the recorded estimate gives a fare idea of what is 
prevailing in Ghana. The researcher would want to use the women at the Madina 
market to assess the situation since most of them may have challenges to screen their 
breast.  
3.3 Breast cancer terminologies defined 
According to the American Cancer Society (2014), cancer is a disease in which cells in 
the body grow out of control. Breast cancer is a malignant cancer tumor that starts in 
the cells of the breast and is mostly found in women although men can get it, too. In 
other words, when cancer starts in the breast, it is known as breast cancer. Breast cancer 
shows most commonly as a painless breast lump and a smaller proportion with no lump 
symptoms. To become breast aware means getting to know the state of the breast at 
different times of the month. Breast screening refers to tests and exams used to find a 
disease like cancer in people who do not have any symptoms. It is reported that the 
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earlier breast cancer is found, the better the chances that treatment will work. The 
ultimate goal of this exercise is to find cancer before they start to cause symptoms.  
3.4 Signs and symptoms of breast cancer  
Finding new lumps or mass is the commonest symptom of breast cancer. If a lump is 
painless, hard and has an uneven edges, then it is likely to be a cancer. However, some 
cancers have been identified as soft, tender, rounded and painful. As a result, the best 
thing for a person to do is to report anything new or unusual as early as possible. Other 
symptoms include the following: 
 Swelling of all parts of the breast 
 Skin irritation or dimpling 
 Breast pain 
 Nipple pain or the nipple turning inward 
 Redness, scaliness, or thickening of the nipple or breast skin 
 A nipple discharge other than breast milk 
Source: American Cancer Society (2014). 
3.5 Risk factors for breast cancer 
According to the American Cancer Society (2014), the exact cause of breast cancer is 
not known, however, there are certain risk factors that are associated with the disease. 
They define a risk factor as something that affects the chance of getting a disease such 
as cancer. The following factors have been identified: 
Gender: breast cancer is much common in women than men and being a woman is the 
greatest risk for breast cancer. 
Age: every woman is at risk for breast cancer and her risk increases with age. The 
society reports that approximately 77% of women with breast cancer are age 50 or 
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older at the time of diagnosis. However in Ghana the ages are in between 40-49 (Clegg-
Lamptey & Hodasi, 2007). 
Family history: a woman‘s risk of getting breast cancer doubles if she has a close 
blood relation with the disease. 
Personal history of breast cancer: a woman who has been diagnosed with breast 
cancer in one breast has a greater chance of getting cancer in the other breast. 
Delays in giving birth: never giving birth or giving birth after age 30 increases the risk 
of developing breast cancer. 
Race: white women are more susceptible to breast cancer than the African-American 
women, though the latter are more likely to die of the disease. 
Alcohol usage: especially those women who take in alcohol two or more drinks daily 
(Hamajima et al., 2002). 
Obesity: an excessive weight gain after menopause also increases the risk for women 
(Flegal, Carroll, Ogden & Johnson, 2002). 
Physical inactivity: although some studies have disproved that (Steindorf et al., 2003). 
Long menstrual period: women who begin their menstrual period before age 12 and 
end it after the age of 55 also shows slight risk of breast cancer.   
3.6 The types of breast cancer screening 
According to the National Cancer Institute (2015), screening tests are used because it 
has been shown to be very potent in locating cancers early and as a result can reduce 
the chance of a person dying from these cancers. Three types of tests have been 
recommended by health care providers to screen for breast cancer (Center for Disease 
Control and Prevention, 2014). 
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3.6.1 Breast Self-Exams 
This may be done by the individual where the person checks the breasts for lumps, 
changes in size or shape of the breast, or any other changes in the breasts or underarm. 
It is important to know how the breasts usually look and feel. This has been identified 
as the type with the lowest financial cost, however, it demands time and effort to do it 
at certain regular times in a year. The center reports that doing breast self-exams has 
not been shown as a way to decrease the chance of dying from breast cancer. 
3.6.2 Clinical breast exams 
This is where the person visits a facility for breast examination by professional medical 
assistant, who uses his or her hands to feel for lumps or other changes. The doctor will 
carefully feel the breasts and under the arms for lumps or anything else that seems 
unusual. This type comes with some level of financial burden. 
3.6.3 Mammogram  
Mammography is the most common screening test for breast cancer. A mammogram is 
an x-ray of the breast. This test may find tumors that are too small to feel. Mammogram 
has been recommended as the main and the most efficient test by the American Cancer 
Society to detect breast cancer early. The Center establishes that even with 
mammogram, they are less likely to find breast tumor in women younger than 50 years 
than in older women. The reason identified was because younger women have denser 
breast tissue that appears white on a mammogram and this can be harder to find when 
there is dense breast tissue. 
3.7 Breast screening challenges faced by Ghanaian women 
According to World Health Organisation (2011), many countries still have turbulent 
challenges with respect to unfavourable policy and, economic and regulatory 
environments. Clegg-Lamptey, Dakubo & Attobra (2009), reported that there are a lot 
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of challenges Ghanaian women generally face when it comes to breast cancer 
awareness and screening. 
 First of all, most specialized breast cancer detection centers are located in large cities 
such as Accra and Kumasi (Ministry of Health, 2001). As a result of this, most 
Ghanaian women report late due to the high costs of transportation for those living 
outside the big cities to visit the centres coupled with high hospital admission, surgery, 
radiologic examinations and laboratory (Clegg-Lamptey, Dakubo & Attobra, 2009). 
Ghanaian women delay in reporting any changes they identify in their breast together 
with subsequent prognosis, laziness, lack of time, forgetfulness, fear and lack of 
confidence among other reasons  are given as failure on the part of women to engage in 
breast examination (Nafissi et al., 2012; Ghazali et al., 2013). 
Clegg-Lamptey et al, (2009), reported that there is lack of systematic national screening 
programmes involving the use of mammogram to screen the women and for further 
examination. This is reflected in the weak health care system and poor access to health 
facilities in Ghana (Ohene-Yeboah & Adjei, 2012). In Ghana, most women who are 
diagnosed with breast cancer are within the ages of 40 and 49 (Ohene-Yeboah & Adjei, 
2012). However, there is lack of modern health facilities with only few centres in the 
country (Dzakah, 2010). Research confirms that the health sector faces resource 
constraints and that the number of doctors are woefully inadequate (NPC, 2011). 
Again, considering the rate of poverty in Ghana, a lot of patients are unable to make a 
down payment demanded for screening, diagnosis and treatment (Opoku et al., 2012). 
Ohene-Yeboah & Adjei (2012), also linked the lack of awareness of early signs and 
screening behavior with the low levels of formal education in Ghana. Other challenges 
identified in Ghana are the traditional and religious beliefs which influence behavior 
(Avong, 2000). Cultural beliefs were reported to impede the successful introduction of 
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public health education programmes, and certain chronic diseases are attributed to 
supernatural forces (Adongo et al., 1997).  
3.8 Radiotherapy Centres in Ghana   
Currently, there are only five radiotherapy centres operating in Ghana (Anderson, 
Cazap & El Saghir, 2010). These centres have been listed below: 
1. The Korle-Bu Teaching hospital, Accra. 
2.  Peace and Love hospital, Accra. 
3. Peace and Love hospital, Kumasi. 
4. The Komfo Anokye Teaching hospital, Kumasi. 
5. Sweden Ghana Medical Centre, Tema. 
It has also been reported that, Radiation Radiotherapists are scarce in Ghana and are 
mostly concentrated at Korle-Bu and Komfo Anokye Teaching hospitals (Anderson et 
al., 2010). 
3.9 Government’s Programmes and Institutions to fight breast cancer 
The government of Ghana is committed to fighting against breast cancer through the 
following ways: 
3.9.1 Ministry of Health 
The Ministry of Health was formed in 1957 by the government of Ghana and is 
responsible for the health of Ghana. It involves in providing public health services, 
managing Ghana‘s health care industry, and building Ghana‘s hospitals and medical 
education system.  
It was reported by Ghana News Agency in 2010 that, the government of Ghana has 
secured 13.5 million dollars loan to improve radiotherapy facilities at the Korle-Bu 
Teaching hospital and the Komfo Anokye Teaching Hospital to strengthen cancer 
screening and prevention. 
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The Ghana News Agency also reported in 2015 that a new national strategy for cancer 
control in Ghana that provides key strategies and interventions for the management and 
control of major cancers for the next five years was launched in Accra. 
3.10 The activities of NGO’s to fight breast cancer in Ghana  
There are a number of organisations and activities that support breast cancer 
programmes by the government of Ghana. Some of these NGO‘s are identified below: 
3.10.1 Breast Care International 
Breast Care International is an NGO founded in October 2002. They are dedicated to 
the establishment of breast cancer awareness centres throughout Ghana. This would 
enable them to create breast cancer awareness among Ghanaian women, especially the 
rural women since they are the majority, and educate them of the existence of the 
disease, undertake screening exercises, diagnosis, treatment, rehabilitation as well as 
research into the various breast pathologies especially breast cancer in Ghana. 
Many organisations donate to BCI and one of such groups is the Golden Star Ladies 
Club. The members of the Bogoso and Wassa branches of Golden star ladies club in the 
Western Region of Ghana donated GH14000 from their 2013 breast cancer awareness 
and fund raising activities to the Breast Care International to support breast cancer 
activities in rural areas. 
3.10.2 Breast Cancer Foundation 
A non-governmental organisation, the Judith-Ellen Awuah-Darko Foundation for breast 
cancer (JEAD), has been launched in Accra. It was founded in 2010 to promote breast 
cancer awareness, screening and treatment, with a particular focus on rural 
communities. The Foundation has currently screened over 6000 people who live in 
rural communities in the Eastern Region of Ghana and has counselled many women. It 
has also carried out 16 screening exercises in some rural communities in Ghana. 
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3.10.3 UT Bank in Ghana 
As part of their corporate social responsibilities, UT Bank has shown its commitment to 
fighting breast cancer in Ghana. In 2011, the bank collaborated with the cancer society 
of Ghana, Citi FM and GIZ to launch the ‗Pledge Pink‘ 2011 which includes breast 
examination and other health screening in Accra and other regions where UT has 
presence.  
3.11 Radiotherapy centre at the Korle-Bu Teaching Hospital 
This study was also linked to the Korle-bu teaching hospital in Ghana to show some 
statistics at the radiotherapy centre for better understanding.   
The Korle-Bu Teaching hospital is located in the Ablekuma South Sub metro within 
Accra, the capital of Ghana. It was established on October 9, 1923 and currently 
assumes the third largest hospital in Africa and the leading national referral centre in 
Ghana. At the moment, the Hospital has 2,000 beds and 17 clinical and diagnostic 
Departments/Units. It has an average daily attendance of 1,500 patients and about 250 
patients‘ admissions. 
The National Centre of Radiotherapy and Nuclear Medicine became operational in 
1997 through a collaborative effort between the Government of Ghana, acting through 
the Ministry of Health and the International Atomic Energy Agency (IAEA), and 
through the Ghana Atomic Energy Commission (GAEC). What gave rise to the project 
was the recognition of the fact that over 50% of all cancer patients require 
Radiotherapy at one stage or the other in the course of the disease. In addition 40% of 
all the cancer cures result directly from the use of Radiotherapy. 
 
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3.12 Breast cancer statistics at the Radiotherapy Centre, Korle-bu for 2013 and 
2014 
Even though at the moment, there is no accurate consolidated national statistics on 
women who screen their breast regularly in Ghana, the researcher in a bid to understand 
the issue collected information about the number of women who attended breast clinic 
at the Radiotherapy Department, Korle-Bu teaching hospital, Accra. It compared month 
by month records regarding the number of patients who visited the clinic in 2013 and 
2014 respectively. The data gathered at the radiotherapy department indicated a general 
decrease in patients who attended breast clinic from 784 to 673, from 2013 to 2014. 
This represents a decrease of 7.62% in the total number of women who attended the 
breast clinic for breast examination. The table 3.1 summarizes the figures collected at 
the centre:  
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Table 3.1: the summary of breast clinic records for 2013 and 2014. 
 
Source: Radiotherapy Centre, Korle-bu Teaching Hospital  
The evidence from research has revealed that there is currently low breast cancer 
awareness and screening behaviour among Ghanaians which invariably has resulted in 
high death rate. The statistics gathered also proves a low turnout. The researcher 
believes social cognitive framework can help to understand the factors which are likely 
to influence breast cancer screening in Ghana, using the situation at the Madina market, 
Accra. 
MONTH YEAR VARIANCE 
2013 2014 
January 56 36 -20 
February 81 72 -9 
March 63 66 +4 
April 47 63 +16 
May 63 59 -4 
June 60 74 +14 
July 59 70 +11 
August 79 64 -15 
September 70 67 -3 
October 62 31 -31 
November 95 56 -39 
December 50 15 -35 
TOTAL 784 673 -111 
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CHAPTER FOUR 
RESEARCH METHODOLOGY 
4.0 Introduction 
This chapter aims at discussing the main methodological dimensions employed in this 
thesis by first looking at the research paradigm and epistemological assumption, 
research approach, research design, data sources and research strategy. The issues 
related with data collection, population, sampling techniques, questionnaire design and 
administration and data analysis techniques. Finally, the quality criteria applied to this 
study as well as the ethical considerations of quality criteria applied to this study are 
then discussed. 
4.1 Research Methodology Defined 
Research methodology refers to the procedural framework within which the research is 
conducted (Saunders et al., 2009; Amaratunga et al., 2002). Again, methodology can be 
seen as a way of thinking about and reality of studying. Method, has been defined by 
Strauss & Corbin (1998) as ―a set of procedures and techniques for gathering and 
analyzing data. A research methodology also serves as a set of rules for reasoning, by 
which the evaluation of facts can be used to draw inferences (Eldabi et al., 2002). 
Methodology can also be explained as the way in which the researcher investigates and 
seeks answers to pre-defined research problems (Taylor & Bogdan, 1984).  
4.2 The underlying paradigm and epistemological assumption 
It is suggested that in any research, individual values, philosophical assumptions, 
theoretical backing, and the research methods should all be related to each other and to 
the aims of the research (Buame, 1996). Therefore, it is essential to discuss the 
philosophy and paradigm underlying the research of this nature. 
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 According to Wittgenstein (1961), a paradigm is a ―world-view. The concept of 
―paradigm‖ has been defined as ―a set of assumptions about the social world, and about 
what constitute proper techniques and topics for inquiry‖ (Punch, 1998). Paradigm has 
also been defined by Kuhn (1962) as the ―entire constellation of beliefs, values, 
techniques, and theories shared by members of a scientific community‖. According to 
Mangan et al, (2004), the concept of paradigm is pivotal to the research process in all 
areas of study and that it is a very general conception of the nature of scientific 
endeavour within which a given enquiry is undertaken (Ritzer, 1975).  
The two schools of philosophy according to some scholars can be referred to as logical 
positivism or deductive theory testing and phenomenology also known as interpretive 
inquiry, inductive theory building or social constructionism (Romano, 1989; Bonoma, 
1985; Easterby-Smith et al., 1991; Parkhe, 1999; Amaratunga et al., 2002; Mangan et 
al., 2004). The phenomenology (interpretive science) inquiries uses qualitative and 
naturalistic approaches to inductively and holistically understand social phenomenon 
from the researchers own perspective of context-specific settings whereas logical 
positivism uses quantitative and experimental methods to test hypothetical-deductive 
generalizations (Amaratunga et al., 2002). 
 According to Easterby-Smith et al, (1991), researchers who follow the positivist world 
view or approach to science inquiry also known as quantitative researchers‘ belief that 
the world is external and objective where definite structures affect people in similar 
ways and vice versa. Positivism searches for causal explanations and fundamental laws, 
and generally reduces the whole phenomenon to simplest possible elements in order to 
facilitate analysis (Taylor & Bogdan 1984; Easterby-Smith et al., 1991; Remenyi et al., 
1998; Silverman, 1998; Creswell, 2009).  
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Contrary to the positivists‘ are the phenomenologist (interpretive science) inquiry who 
rejects the positivists‘ beliefs on the ground that human behavior is significantly 
influenced by the setting in which it occurs, therefore, it is necessary to study this 
behavior in these settings (Marshall & Rossman, 1989). Phenomenologist therefore 
view the world to be socially constructed and subjective where researchers‘ see 
themselves as part of the phenomena being study, with the researcher interfering as 
little as ―humanly‖ possible during the inquiry. In this circumstance, the researchers 
make use of their own experiences and create their ―own‖ reality (Locke et al., 1993).  
Based on these approaches, the researcher believes that an objective reality exists by 
adapting the social cognitive framework to know the factors that are likely to influence 
breast cancer screening in Ghana. The researcher also formulated hypotheses based on 
the constructs and tested them by using self-administered structured questionnaires, 
took sample from the population of the study and generalized the findings of the study 
to the whole. 
The researcher also believes in a body of knowledge and that is the epistemological 
assumption.  The term epistemology is about what constitutes acceptable knowledge in 
a field of study (Saunders et al., 2009). It comes from the Greek term episteme meaning 
knowledge and logos meaning theory. It is a theory of knowledge and has been a 
subject of philosophical debate from the time of Aristotle (Stough, 1969).  The term 
epistemology refers to beliefs about the way in which knowledge is construed. It 
questions whether it is possible to identify and communicate the nature of knowledge 
as being ―hard‖, ―real‖ and capable of being transmitted in a tangible form (Eldabi et 
al., 2002).  Epistemology concerns itself with posing and resolving the problem of how 
―valid‖ knowledge is possible (Macdonnel, 1986). It deals with the nature, origin, scope 
and limits of human knowledge (Buame, 1996). In setting out for knowledge, 
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epistemological positions on an issue looks at whether knowledge is something that can 
be acquired or something personally experienced (Burrell & Morgan, 1979). 
According to Eldabi et al, (2002), they hold the view that knowledge is ―hard‖, 
objective and tangible and that the researcher should adopt the role of an observer. 
However, to view knowledge, as personal, subjective, and unique in nature, requires a 
researcher to become involved with their subjects. Research suggest that adhering to 
the former is to be positivist and to the latter is to be interpretivist (Weick, 1984). This 
implies that, epistemological assumptions dwells on what is the acceptable truth by 
specifying the criteria and process of assessing truth claims (Chua, 1986). Again, it 
assumes that knowledge can be acquired with knowable degrees of certainty using 
objectively-correct scientific methods (Long et al., 2000; Neuman, 2003) and concepts 
such as reliability, validity and statistical significance with the purpose of describing 
some part of reality (Hanson & Grimmer, 2007). Taking the opposite side, it is assumed 
that knowledge can be gained through individual understanding of a particular 
viewpoint in the form of participant observation (Morgan & Smircich, 1980). 
The researcher believes that knowledge is hard, objective and tangible and as a result 
seeks to understand the social setting by identifying factors that are likely to influence 
breast cancer screening and relationships among the constructs in explaining the 
phenomenon. 
4.3 Research Approach 
This section of the methodology explores the differences of inductive and qualitative 
research as against deductive and quantitative research and provides explanations for 
why this particular study has pursued a largely deductive and quantitative approach. 
Scholars of research methodology have identified two main approaches to research 
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inquiries: qualitative (inductive) and quantitative (deductive) (Blaikie, 2005; McGivern, 
2006) and researchers in social marketing have applied both methodologies (Dilorio et 
al., 2000; Tweneboah Koduah & Owusu Frimpong, 2013) 
Qualitative research has been described by Bryman (1993) as an ―approach that studies 
the social world, and seeks to describe and analyze the culture and behavior of humans 
and their groups, from the point of view of those being studied emphasizes getting 
close to the subject(s) of study and assuming the role of a participant to describe a 
social reality from the perspective of the subject rather than observer‖. It is also 
concerned with rich and detailed description, understanding and insight rather than 
measurement (McGivern, 2006). As a result, qualitative research methods are 
associated with face-to-face contact with people in their research setting, together with 
verbal data and observations (Eldabi et al., 2002). Qualitative research also involves 
small sample size in the form of in-depth interviews which are recorded and later 
transcribed, field notes through observation, written documents and archives (McGiven, 
2006). The extant literature shows that despite the strengths of this approach, the less 
structured and standardized approach can render the information acquired relatively 
low in reliability (McGiven, 2006). It may also be influenced by the researchers own 
personal feelings, opinions and biases (Eldabi et al., 2002).  
On the other hand, quantitative research approach begins with abstract logical 
relationship among concepts and then moves towards concrete empirical evidence 
(Neuman, 2007). It has been defined as an extreme of empiricism according to which 
theories are not only justified by the extent to which they can be verified but also by an 
application of facts acquired (Amaratunga et al., 2002). Quantitative researches are also 
used to measure how people feel, think or act in a particular way, it seeks to quantify 
data and apply some statistical analysis, which is often formalized, well structured, and 
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data is usually obtained from large samples (Tull & Hawkings, 1993). Saunders et al, 
(2009), reveal that for a quantitative study, the vital skills needed for the researcher are 
the ability to develop hypotheses and test them with proper statistical techniques, and 
interpret the statistical information into descriptive information. 
This study employed the quantitative approach as it seeks to engage in rigorous 
analysis of statistical data to achieve the stated objectives and hypotheses based on the 
conceptual model adapted from literature. The justification is that, results derived from 
quantitative research are assumed to be measurable and presentable in the form of 
numbers and statistics (Hultman, 2008). The aim is to make generalizations based on 
the processed results of the investigation. The quantitative method is formalized, 
structured, and approaches the research problem from a broad perspective (Hultman, 
2008). Again, most researchers who used the social cognitive model to influence 
behaviour change have employed the quantitative approach (Dilorio et al., 2000; Haug 
et al., 2009 & Singh et al., 2010).  Consequently, it explains why this study adopted a 
quantitative approach. 
4.4 Research Design 
Research design constitutes a framework or blueprint for collection, measurement, and 
analysis of data (Cooper & Schindler, 2001). Consequently, the choice of research 
design becomes very critical since it influences a large number of subsequent research 
activities (Churchill & Iacobucci, 2006). Research design has been classified in several 
ways by scholars (Miles & Huberman 1994; Saunders, Lewis & Thornhill, 2007), but a 
widely accepted method is to classify them according to the fundamental objective of 
the study as being exploratory, descriptive and/or, causal (Churchill & Iacobucci 2006; 
Hair et al., 2006).   Exploratory study is the one that seeks new insights into a 
phenomenon; descriptive research provides an accurate description of a situation and 
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causal research seeks to establish the relationship between variables in a situation 
(Malhotra & Birks 2007). 
In an effort to determine which type of research design to adopt for this research, the 
nature of the study and its specific objectives were carefully taken into consideration.  
Consideration of a number of influencing factors concluded that a descriptive research 
was the most suitable for the purpose of this study. The main factors that influenced the 
choice were that the research problem was highly structured in addition to the fact that 
there was enough existent evidence available to formulate empirically testable 
hypotheses.  
4.5 Data Sources 
Sources used for data collection can be categorized into two forms: primary and 
secondary (Yin, 1994). Primary sources of data are collected and accumulated 
specifically for the research problem at hand, whereas secondary sources contain data 
that have been gathered and assembled at a previous time for other purposes other than 
the current research problem (Hair et al., 2006; Tull & Hawkins, 1993; Yin, 1994). The 
advantage of secondary data is that it can usually be collected at a lower cost and more 
rapidly than primary data. On the other hand, since it was usually collected for a 
different purpose, its content might correlate poorly with the researchers‘ current needs 
(Hair et al., 2006; Yin, 1994). 
This is one of the reasons why primary data sources were utilized for this study. 
Moreover, considering the relative complexity and depth of the information required by 
the current study, no presently available secondary sources were located that were 
sufficient. The primary data source was data collected through the design of a 
structured questionnaire which were administered directly to the women at Madina 
market, Accra. 
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4.6 Population of study 
According to Bryman & Bell (2007), the study population is the world of units from 
which the sample size is drawn for the research. The target population for this research 
comprised of women from 18years and above at the Medina market, a Sub metro 
within Accra Metropolitan Area, Ghana. According to Ghana Statistical Service (2013), 
currently, Accra has an estimated population of about 3,888,512 inhabitants.  
4.7 Sample size  
For many research questions and purposes, it becomes impossible to either collect or 
analyse all the data available in a population due to time, money, and often, access 
restrictions. Saunders et al. (2007) emphasise that a census investigation does not 
necessarily provide more useful results than a well-planned sample survey. As long as 
the study sample is representative, generalisations about the underlying population can 
still be drawn (Churchill & Iacobucci 2006; Zikmund, 1994). Also, according to Hair et 
al, (2006) for a sample to be representative, it should not be less than 100 whereas other 
researchers also argue that it should be 200 (Coakes & Steed, 2005). Consequently, 
following the argument of Coakes & Steed (2005), and considering time limitation and 
financial resources allocated for the study, a sample of 300 respondents at the Madina 
market were selected for the study.  
4.8 Sampling Technique  
The sample was selected using non-probability purposive sampling technique. This 
technique does not rely on chance based selection but on researchers own judgement 
(Malhotra & Birks, 2007). A combination of the convenience and judgemental 
sampling techniques were employed. This is because there is no sample frame and 
samples have to be determined on the field with some degree of judgement needed 
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when collecting the data. Also, sampling technique used was based on the purpose of 
the study (Mahmound, Tweneboah Koduah & Danku, 2011).  
4.9 Data Analysis Techniques  
When the fieldwork was completed and the data had been collected, compiled, edited, 
coded, and computerized, the next stage involved statistical analysis. At this stage, the 
choice of the most suitable statistical techniques was based on the type of measurement 
scales used in the research instrument and the nature of the questions asked (Hair et al., 
2006). This thesis involved a number of different statistical methods. However, the 
main statistical packages utilized for this thesis were the Statistical Package for Social 
Sciences SPSS version 20.0. 
4.10 Descriptive Statistics 
Descriptive statistics can be used to transform raw data into a form that makes it easier 
to understand and interpret, and it can also be used to assess missing data, outliers, and 
normality (Hair et al., 2006). Various descriptive statistical methods were utilized 
throughout the analysis of the data and the results presentation of this thesis. In the 
beginning of the results presentation chapter (Chapter 5), measures for frequency 
distribution and central tendency (mean) were used, as well as measures for dispersion 
(standard deviation). The expectation was that this type of statistics would help explain 
the descriptive findings in the thesis. 
Descriptive statistics was employed in the study. Pearson‘s correlation was conducted 
to establish relationships for further analysis with a significant level of 0.05. 
4.11 Ethical Considerations 
In research, one very important consideration a researcher must not overlook is the 
issue of ethical considerations such as openness to respondents and appropriate 
treatment of confidential information in research (Miles & Huberman1994; Malhotra & 
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Birks 2007). Verbal consent was obtained from each participant who volunteered to 
participate in the study. The study objectives and protocol were explained to every 
respondent and they were given the opportunity to ask questions and seek clarification 
on the information given. Also respondents were assured of the fact that the study is 
only for academics purposes and not for any other purpose that will conflict with their 
interest. 
4.12 Quality Criteria 
When conducting research, it is of utmost importance to judge its quality. Clearly, a 
study never gets better than the actual measures employed when conducting it (De 
Vaus, 2002). When establishing the quality standards, Yin (1994) explains that the 
quality of research can be assessed in terms of different measures of validity and 
reliability. This final section of the chapter discusses the different measures for validity 
and reliability in this thesis, and explains the measures that have been taken to avoid 
research quality deterioration. 
 4.12.1 Validity 
Validity has been defined by Peter (1979) as ―the degree to which instruments truly 
measure the constructs that they are intended to measure.‖ Based on this definition, it 
becomes clear that validity in a measure is vital for the credibility of a study‘s results 
(Blumberg et al., 2005; Cooper & Schindler, 2003). For this study, two types of validity 
were particularly important; these were content validity and criterion validity (Hair et 
al., 2006). The first type, content validity, refers to how well a construct‘s measurable 
components actually represent that construct. This is often assessed by letting a panel of 
experts judge the dimensionality of a certain construct, which shows that it focuses 
primarily on judgment (Cooper & Schindler, 2003; Hair et al., 2006). In this thesis, the 
issue of content validity was dealt with during the questionnaire pretesting phases, 
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when the draft version of the questionnaire was screened and pretested by experts and 
potential respondents.  
4.12.2 Reliability 
Construct reliability is assessed when a researcher evaluates whether the utilized 
measures are free from random error and are therefore capable of generating results that 
are consistent (Zikmund, 1994). It differs from validity in that it looks at the agreement 
between two efforts of measuring the same trait through maximally similar methods as 
opposed to measuring the same trait through maximally different methods. Although 
reliability is an underlying condition for a measure to be valid, it does not give 
sufficient prove for validity (Churchill & Iacobucci, 2006). The reliability concept can 
be further broken down into two dimensions: repeatability and internal consistency 
(Zikmund, 1994). As the name implies, repeatability refers to how stable a utilized 
measure is if it was to be administered to the same respondent at two separate points in 
time. The internal consistency measure looks at how stable a certain measure is across 
its various items and can be measured through, for example, split-half or equivalent-
form method (Carmines & Zeller 1979; Peter, 1979).  
4.13 Data Collection Methods 
The study employs the survey method of quantitative primary data collection because it 
cannot control the independent variables, and also, observation is too time consuming 
and expensive (Saunders et al., 2007).  According to Babbie (2004), this is probably the 
best method available to social scientists for gathering primary data from a population 
too large to be observed directly; accordingly, the survey strategy is also the most 
common research strategy when it comes to collecting explanatory research (Hair et al., 
2006; Kent, 2007; Zikmund, 1994). Considering the sizeable population anticipated for 
this study in addition to the inability of an observational method to collect the 
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information required in a timely and cost-effective fashion, the only data collection 
method deemed appropriate for the study at hand was the survey. 
Having selected the survey method, the next decision involved choosing the actual 
means of obtaining information from the informants. The options available were 
personal interviews, telephone interviews, or self-administered questionnaires 
(Malhotra & Birks, 2007). The study adopts the personally administered questionnaires 
as telephone interviews are not conducive for the purposes of this study while personal 
interviews are expensive (Tull & Hawkins, 1993). Comparing with the other methods, 
questionnaires are usually much cheaper to administer (Hair et al., 2006). In addition, 
there is a sense of anonymity and much less time constraint associated with self-
administered questionnaires than for other primary data collection methods (Saunders 
et al., 2007). The standardised nature of written questionnaires also facilitates 
comparisons of different respondents‘ answers in subsequent data analysis (Churchill & 
Iacobucci, 2006).  
4.14 Questionnaire design 
 The researcher designed a structured questionnaire, which comprised of closed-ended 
questions to gather data from the field to empirically test the conceptual model 
proposed in chapter two. Questions regarding finding answers to each research 
objective and hypothesis concerning the various constructs identified in the study‘s 
framework were developed. Later, the constructs were translated into measurable 
terms, as it was impossible to measure the constructs at the conceptual level. This 
operationalization involved developing a scale that would capture the meaning of each 
of the predetermined conceptual constructs (Corbett & Le Roy, 2006). Having 
established the operationalisation of the constructs in the conceptual model through 
multiple indicators, the next decision concerned how to measure each of these 
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indicators. Hence, the researcher developed a set of questions based on the various 
constructs and adopted a five-point Likert scale where possible answers ranged from 
Strongly Disagree (1) to Strongly Agree (5), for all the three constructs under social 
cognitive framework and that of behavioural change with respondents required to 
indicate their level of agreement or disagreement with respect to the statements 
provided on each of the indicators on the questionnaire in measuring the constructs. 
Moreover, the first section of the questionnaire aimed to capture the survey 
respondents‘ demographics. The entire questionnaire for this particular study was 
created with the guidance of four decision points as explained below: 
4.14.1 Question wording 
Seeing that the present study employed a self-administered questionnaire, the choice of 
words and phrases for each question became vitally important due to the fact that the 
questions would be interpreted solely on the basis of printed instructions and 
definitions. Knowing that a poorly phrased question can cause a respondent to refuse to 
answer, or answer erroneously (Churchill & Iacobucci 2006), extra attention was paid 
to phrase the questions clearly and concisely with a minimum of ambiguous or 
confusing terms. In addition, according to scholarly recommendations (Saunders et al., 
2007; Malhotra & Birks, 2007), generalizations, implicit alternatives, assumptions, 
double-barreled questions, and leading or biased wordings were also avoided.  
 4.14.2 Question sequencing 
The sequence in which the questions are posed is as important as the words and phrases 
used in the question construction (Churchill & Iacobucci, 2006). Questions presented in 
an improper sequence might influence the nature of respondents‘ answers and even 
cause grave inaccuracies in the overall survey findings (Churchill & Iacobucci 2006). 
Some of the guidelines in this area advise that the questions should be placed in a 
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logical sequence from the respondent‘s perspective. The opening questions should be 
uncontroversial and easy to answer, and these should be followed by the more difficult 
questions (Saunders et al., 2007). Again, Hair et al, (2006) suggested that the 
―flowerpot‖ approach should be adopted when applicable (i.e. starting with broader 
questions and eventually narrowing down from general to specific), and classificatory 
questions should be posed at the end along with demographic information (Saunders et 
al., 2007). These guidelines were incorporated and followed to the farthest extent 
possible throughout the questionnaire construction phase of this thesis. 
4.14.3 Physical Questionnaire Design 
Similar to the wording and sequencing of the questions on a survey questionnaire, the 
overall physical design of the questionnaire also plays a role in how the questionnaire is 
received by the respondents, which consequently influence response rate (Frohlich, 
2002). Therefore, it is important that the questionnaire‘s physical format allows for 
clear communication (Hair et al., 2006). The importance of the questionnaire‘s physical 
features was not underestimated in this study, and careful attention was paid to issues 
such as size, shape, and quality of the paper, as well as print quality, choice of color, 
and layout. For directions on how to physically construct a successful questionnaire, 
relevant literature was consulted. 
 4.14.4 Pretesting of Questionnaire 
Having designed the questionnaire it is recommended that the finalised version of the 
questionnaire be pretested to ascertain the suitability, applicability and clarity of the 
questions before proceeding with the main data collection (Hair et al., 2006).  It further 
states that, the final version of the questionnaire is pretested to make sure that there are 
no problems regarding the clarity of the questions, instructions, determinant of 
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appropriate levels of independent variables, reliability and that face validity is 
satisfactorily (Hair et al., 2006). The face validity can be ensured by inviting experts in 
the field who can also review the questionnaire (Nunnally & Bernstein, 1994; Zikmund, 
1994). This study invited experts who agreed that the scale logically appears to reflect 
what has been set out to measure, for which face validity was achieved. The clarity of 
the questions and instructions were tested by interviewing a pilot group of respondents 
having similar characteristics to those who were used for the main study, and asking for 
their opinion about the clarity and relevance of each of the questions in addition to the 
overall instructions (Kent, 2007). The two stages led to some modifications in the 
questionnaire in terms of phrasing and design, which further increased the overall 
quality for the main data collection phase (Dodds, Monroe & Grewal, 1991; Nunnally 
& Bernstein 1994; Saunders et al., 2007). 
 In view of this, the questionnaire was initially pilot-tested with 10 women and the 
results of the pilot-test proved to be satisfactory. The researcher also sought the 
assistant of experts who agreed that the questionnaire logically reflects what it has been 
set out to measure. Nonetheless, some minor wording mistakes were found and 
corrected in the questionnaire‘s version, which were finally distributed in the field 
research. 
4.15 Fieldwork Data Collection 
Data collection constitutes one of the major phases of the research process. The 
structured questionnaires were purposively distributed among the sampled respondents. 
Purposive as used by the researcher refers to selecting respondents for participation in 
the study mainly because they are representatives of the population of interest and meet 
the specified needs of the study (Dillon, Madden & Firtle, 1993). 
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Many activities preceded the actual data collection in selecting the respondents for the 
study. The first step was to seek for their consent. Respondents who gave their approval 
were then sought to participate in the research. Furthermore, the researcher explained 
the purpose of the research to the respondents and assured them of confidentiality of 
information provided and the use of the information not for any other purpose other 
than the intended study. This was done to maintain confidentiality of individual 
responses and reporting aggregate survey results whilst considering the ethical issues 
requiring the researcher to encourage participation without any undue pressure (Salant 
& Dillman, 1994). 
Based on this, the researcher collected data from respondents who were willing to 
participate in the survey on the field. The entire data collection lasted for three weeks 
(from the third week in April to the first week in May 2015). Initially, data collection 
was meant to last for two weeks but due to the time spent for respondents to finish their 
personal dealings before gaining access to them, hence, the need for the extension. In 
all, the researcher contacted 320 women, out of which 300 women responded positively 
to fill the questionnaires. Some of the women contacted had low education and were 
helped. The response time for the questionnaire was about 10-15 minutes. The 
researcher obtained a valid returned sample size of 285 out of the total of 300 
administered, representing 95% of the sample size. The fifteen (15), representing 5% of 
the total questionnaires administered were not returned. 
 
 
 
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CHAPTER FIVE 
DATA ANALYSIS AND INTERPRETATION  
5.0 Introduction 
This section analyses and discusses quantitative information collected from respondents 
for the purpose of the study. A total of 300 questionnaires were distributed to 
respondents of which 285 were returned. Thus, the study recorded 95% response rate. 
The chapter employs percentage frequency, descriptive mean, and correlation analysis 
in addressing the specific research questions and objectives of the study. The analysis 
and interpretation of the empirical data for the study are presented as follows. 
5.1 Background/Demographic Information 
This section of the chapter investigates into the biographical features of the respondents 
sampled for the study. The major focus is on the age, marital status, educational 
attainment, occupation, and their monthly income.  Again, information on respondents‘ 
religion, whether they screen their breast, the type of breast cancer screening exercise 
they do and the number of times they do breast examinations in a year were collected. 
Below is the presentation of background information on the respondents. 
Tables 5.1 and 5.2 present information on the demographic characteristics of the 
respondents in this study. In terms of age majority of the respondents were between the 
ages of 35-44 years (36.8%). The next dominant age group was between 45-54 years 
also representing 28.1% of respondents. The rest were 25-34 years, 14.7%; 18-24 years, 
10.5%; 55-64 years, 6.3% and 65 years and above 3.5%.  Majority of the respondents 
were married representing 49%, followed by the single 42%, and divorced and widows 
representing 6.3% and 2.5% respectively. It was recorded that the highest education 
attainment was A-Level/SHS making up to 43% of the total score, followed by JHS 
21%, primary 16.8%, tertiary 15.1% and finally those with no education 2.8%. 
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Regarding occupation of respondents, 43.2% were self-employed, 21.1% unemployed, 
15.7% employed, 14.7 were students and 5.3% represented the retired. Majority had 
incomes between GH¢101-GH¢ 500 representing 43.8%; 28.1% were earning monthly 
incomes between GH¢ 501-GH¢ 1000, those earning less than GH¢ 100 were 16.8% 
and over GH¢ 1000 were 11.2%. The sampled respondents were found to come from 
the various common religious groups in Ghana. Majority 51.9% of the respondents 
were Muslims. This was followed by Christian respondents; 45% and the least of the 
respondents was Atheist; representing 2.8%. 
The respondents were also asked whether they screen their breast or not. It was found 
that 165 of them representing 57.9% were not screening their breast at all, however, 
120 representing 42.1% responded yes. In an attempt to inquire the number of times 
respondents do have breast examination within a year, it was observed that, out of the 
120 respondents who said yes, most of the respondents, 56 (46.7%) do have the 
examination once in a year, 25 (20.8%) of the respondents reported to have the 
examination twice in a year, 24 (20%) of the respondents had none in the course of the 
year and finally, 15 (12.5%) represented those that practice breast examination three or 
more times in a year.   
 
. 
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Table 5.1: Sample distribution 
Variables   Frequency   Percent 
Age 
 
   
18 - 24 
 
30 
 
10.5 
25 - 34 
 
42 
 
    14.7 
35 - 44 
 
105 
 
36.8 
45 - 54 
 
80 
 
     28.1 
55 - 65 
 
18 
 
     6.3 
65 and above 
 
10 
 
3.5 
 
Marital Status 
 
   
Married 
 
140 
 
49.1 
Single 
 
120 
 
42.1 
Divorced 
 
      18 
 
    6.3 
Widowed 
 
      7 
 
    2.5 
 
Educational Attainment 
 
   
No Education 
 
      8 
 
     2.8 
Primary Education 
 
      48 
 
16.8 
JHS 
 
      62 
 
21.8 
A-Level/SHS 
 
124 
 
43.5 
Tertiary 
 
      43 
 
15.1 
 
 
   
     Occupation 
 
   
Unemployed 
 
60 
 
     21.1 
Self-employed 
 
123 
 
43.2 
Employed 
 
      45 
 
    15.7 
Retired 
 
      15 
 
    5.3 
Student 
 
      42 
 
    14.7 
 
 
   
     Monthly Income 
 
   
Less than GHC 100 
 
       48 
 
     16.8 
GHC 101 - GHC 500 
 
       125 
 
     43.8 
GHC 501 - GHC 1000 
 
       80 
 
     28.1 
Over GHC 1000 
 
       32 
 
11.2 
 
 
 
  
 
Source: Field study 2015 
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Table 5.2: Sample distribution 
Variables   Frequency   Percent 
Religion 
 
   
Christian 
 
129 
 
45.3 
Muslim 
 
      148 
 
51.9 
Atheist 
 
      8 
 
    2.8 
 
Whether you screen 
Or not 
 
   
Yes 
 
120 
 
42.1 
No 
 
165 
 
57.9 
 
Type of Screening 
 
   
Self-breast exams 
 
65 
 
54.2 
Clinical breast exams 
 
50 
 
41.7 
Mammogram 
 
       5 
 
    4.1 
 
Number of Exams in a Year 
 
   
Once 
 
56 
 
46.7 
Twice 
 
25 
 
20.8 
Three or more 
 
15 
 
12.5 
 None 
 
24 
 
     20 
 
 
 
  
 
Source: Field study 2015 
 
5.2 Behaviour Change Influencing Factors 
This section evaluates behaviour change influencing factors from respondents‘ point of 
view. Behavioural change as outlined in this section is assessed on the bases of 
immediate environmental factors, external environmental factors, and personal 
influencing factors. Individual statements captured under these dimensions were 
presented to respondents for evaluation base on the factors that influence their 
behaviour towards breast cancer screening. Respondents were required to use a 5 point 
Likert scale to measure each statement on a performance indicator value where 1 
represents Strongly Disagree, 2 - Disagree, 3 - Neutral, 4 - Agree, 5- Strongly Agree. It 
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must be noted that all negative statements were reverse coded during the analysis stage 
to take positive direction to ensure uniformity in approval ratings. For instance, the 
statement ―I think breast cancer screening is difficult and demands time‖ is reverted to 
mean ―I think breast cancer screening is easy and less time consuming‖, hence, 1→5, 
2→4, 3→3, 4→2, 5→1 on the measuring scale.  An aggregated mean rating for each 
statement as well as overall mean for each indicator was calculated for the purpose of 
comparison. Standard deviations were also calculated to throw light on the variat ions in 
the responses given by respondent as well as indicating reliability of claims by the 
study. 
5.2.1 Immediate environmental factors 
In the assessment of immediate environmental factors as a component of behavioural 
change indicator, the study recorded an overall mean rating of 2.96 as aggregated from 
respondents‘ score ratings, representing a moderate approval to the statement. 
Specifically, the statement that respondents mostly affirmed to was that they have been 
influenced by the advice of health workers on breast screening and this attained a 
respective mean and standard deviation of 3.56 (high) and 1.29. This was followed by 
the statement that they were influenced by the activities of breast cancer organisation 
with a mean and standard deviation of 3.34 and 1.22.The next approved statement was 
that they were sure the people around them engage in breast cancer screening and 
related issues with a mean and standard deviation of 3.25 and 1.30. 
The statement which suggests that respondents‘ workplace is concerned and regularly 
talks about breast cancer screening and related issues also attracted a moderate approval 
rating with mean and standard deviation of 3.23 and 1.40. On the other hand, the 
statement which attracted least approval rating from respondents was ―my family is 
concerned about breast cancer screening because they have history with breast cancer‖ 
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as it attracted respective approval mean rating and standard deviation of 1.83 and 1.18. 
This information is summarise in table 5.3.       
Table 5.3: the summary of immediate environmental statistics. 
Variables N M SD 
My friends encourage me a lot to engage in breast cancer screening 
exercise 283 2.75 1.28 
I receive support and advice from my parents/husband regarding breast 
cancer screening 283 2.69 1.22 
My family is concerned about breast cancer screening because they have 
history with breast cancer 284 1.83 1.18 
My religious affiliation talks and encourages me to involve in breast 
exams 282 3.09 1.36 
I am influenced by the activities of breast cancer organisations 274 3.34 1.22 
My workplace is concerned and regularly talks about  breast cancer 
screening and related issues 280 3.23 1.40 
I have been influenced by the advice of a health worker on breast 
screening before 283 3.56 1.29 
I am sure the people around me engage in breast screening 279 3.25 1.30 
Totals  281 2.96 0.77 
Source: Field study 2015 
 
5.2.2 External environmental factors 
Responses obtained in the assessment of external environmental factors as a component 
of behavioural change in breast cancer screening are analysed in this section. 
Respondents in general terms approved to moderate level, the presence of favourable 
external environmental factors. An overall assessment rating of 3.23 (approximately 
neutral/moderate) was obtained. In specific terms, respondents most agreed to the 
statements that free breast cancer screening exercise should be organised as part of the 
activities that mark cancer day celebration in Ghana with a rating mean and standard 
deviation of 4.50 and 0.99 respectively. Again, there was high (M = 3.62, SD = 1.16) 
favorable rating for the statement that breast screening exercise and education are 
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regarded as important in respondents‘ societies. There was a moderate approval ratings 
for the statements ―the media is very instrumental when it comes to providing 
education on breast cancer issues‖  ( M = 3.46, SD = 1.22), and the fact that 
respondents believe breast cancer screening issues are intensively promoted in Ghana 
with a mean and standard deviation of 3.40 and 1.22 respectively. In addition, the 
statement which suggests that respondents think government is concerned about breast 
cancer screening issues and that they consider the cost involved in breast cancer 
screening as less expensive attracted a moderate approval ratings as evidence in 
respective mean rating score of 3.18 and 2.99. On the other, the statement that attracted 
least approval rating was the fact that issues about breast are regarded as forbidden 
subject in respondents‘ culture with a corresponding mean and standard deviation of 
1.93 and 1.21.  This is summarized in table 5.4. 
Table 5. 4: the summary of external environmental statistics. 
Variables N M SD 
For me, the cost involved with breast cancer screening is very expensive 279 2.99 1.32 
The media is very instrumental when it comes to providing education on 
breast cancer issues 285 3.46 1.22 
I believe breast cancer screening issues are intensively promoted in Ghana 280 3.40 1.21 
There are enough structures or hospitals for breast cancer screening 
exercise 283 2.72 1.32 
Issues about breast are regarded as forbidden subject in my culture 285 1.93 1.21 
Breast screening exercise and education are regarded as important in my 
society 285 3.62 1.16 
Free breast cancer screening exercise should be organised as part of the 
activities that mark cancer day celebration in Ghana 285 4.50 0.99 
I think the government is concerned about breast cancer screening issues 285 3.18 1.26 
Totals 283 3.23 0.62 
Source: Field study 2015 
 
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5.2.3 Personal Influencing factors 
The study considered among other factors, personal influence as a determining element 
towards breast cancer behaviour and hence collected empirical data on personal 
influences of the sampled respondent to examine how they affect behavioural change 
towards breast cancer issues. From the table below, the picture which emerged from the 
analysis of responses obtained from respondents suggest that there is generally high 
approval (M = 3.80) towards favorable personal influencing factors. Specifically, 
respondents gave the highest favorable approval rating  mean 3.99 (approximately 
agree) with a standard deviation of 1.19 to statement that respondents do not have high 
fear in locating lump in their breast in the process of breast cancer screening.  
Again, the statement ―I have received education on how to examine the breast and what 
to look for‖ also received an approval up to an agreed level (M = 3.97, SD = 1.07) from 
the respondents. On the other hand, the statement which received the least approval 
from the respondents was the fact that respondents consider breast cancer screening as 
an easy less time consuming task with respective mean and standard deviation of 3.60 
and 1.14. The table below in 5.5 summarises the personal factors. 
Table 5.5: the summary of personal characteristics statistics. 
Variables N M SD 
I have received education on how to examine the breast and what to 
look for 282 3.97 1.07 
I think breast cancer screening is difficult and demands time 284 3.60 1.14 
I have high fear in locating lump in my breast 283 3.99 1.19 
I immediately report any changes in my breast as early as possible 280 3.66 1.21 
I don't screen my breast because I don't know how to do it 283 3.81 1.38 
Total  282 3.80 0.76 
Source: Field study 2014 
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5.3 Behaviour Change  
At this stage, the study steps to an investigation into the actual behaviour towards 
breast cancer related practices. Respondents were again required to rank their approval 
against related statements using the same five-point measuring scale. Descriptive result 
of the analysis is presented as follows. 
In general, respondents‘ approval for the adherence to unfavourable practices towards 
breast cancer issues was high as evidence in the overall approval rating of 3.82 
(approximately agreed). Specifically, the statement that respondents gave highest 
approval rating to was the fact that respondents do not screen their breast as it normally 
expected (M = 4.54, SD = 0.76). Again, respondents gave high approval to the 
statement that they have not examine their breast for the past two years (M = 4.44, SD 
= 1.01) although they will immediately report any changes in their breast as early as 
possible (M= 4.33, SD = 0.86). On the other hand respondents showed least agreement 
to the statements ―I regularly visit the health center to screen my breast‖ and ―I have 
personally educated women to screen their breast‖ with respective means and standard 
deviations of (M = 2.92, SD = 1.15) and (M = 2.87, SD = 1.28). See table 5.6 for 
details. 
Table 5.6: a summary of behaviour change statistics 
Variables N M SD 
I have not examine my breast for the past two years 285 4.44 1.01 
I regularly visit the health centre to screen my breast 285 2.92 1.15 
I have personally educated women to screen their breast 283 2.87 1.28 
I immediately report any changes in my breast as early as 
possible 283 4.33 0.86 
I do not screen my breast on regular basis as it is expected  285 4.54 0.76 
Totals    284 3.82 0.63 
Source: Field study 2015 
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5.4 Significant Test 
This section of the study tests statistically, the various hypotheses stated at the 
introductory stage of the study. It employs the Pearson‘s Correlation as a statistical tool 
in examining the validity or otherwise of the hypotheses. In all, three related 
hypotheses were stated and tested, these are ―there is a positive relationship between 
immediate environmental factors and breast cancer screening behaviour‖, ―there is a 
positive relationship between wider external environmental factors and breast cancer 
screening behaviour‖, and ―there is a significant positive relationship between personal 
factors and breast cancer screening behaviour‖. The results of the tests are presented 
below: 
Hypothesis 1: There is a positive relationship between immediate environmental 
factors and breast cancer screening behaviour. 
A correlation test of significance on the relationship between immediate environmental 
influence and breast screening behaviour produced a proof of significant relationship 
between the two variables. At a moderate correlation value of 0.551 produced a 
significant value of 0.000 where (p < 0.05). This means that respondents who have had 
their immediate environment impacted on them positively (eg. receiving support and 
encouragement from friends and family on breast cancer screening) do significantly 
adhered to positive breast cancer practices (eg. reporting immediately to the appropriate 
authority whenever a change in the breast is detected) than their counterpart 
respondents who have been less positively impacted by their immediate environment. 
Hence, affirming the hypothesis. This is shown in table 5.7. 
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Table 5.7: the summary of hypothesis 1. 
  
Immediate 
Environmental Influence Breast screening 
Immediate Environmental 
Influence 
Pearson R 
1 .551 
  Sig.(P)   .000 
  N 285 283 
Breast screening Pearson 
Correlation 
.551 1 
  Sig. (P) .000   
  N 283 285 
 
Source: Field study 2015 
 
Hypothesis 2: There is a positive relationship between wider external 
environmental factors and breast cancer screening behaviour. 
In testing for the hypothesis ―there is a positive relationship between wider 
environmental factors and breast screening behaviour‖, the study found a weak-
moderate but a significant (r = 0.432, p < 0.05) correlation between wider external 
environmental factors and behaviour change. This result indicates that as the wider 
external environmental factors favourably impacting on respondents, their positive 
behaviour towards breast cancer improves moderately and this means that the 
hypothesis is supported. The table below in 5.8 summarises it. 
Table 5. 8: the summary of hypothesis 2. 
 
External Environmental 
Influence Breast screening 
External Environmental 
Influence 
Pearson R 
1 .432 
  Sig. (P)   .000 
  N 285 284 
Breast  screening Pearson R .432 1 
  Sig. (P) .000   
  N 284 285 
Source: Field study 2015 
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Hypothesis 3: There is a significant positive relationship between personal 
characteristics and breast cancer screening. 
In fine, the researcher sets to evaluate the relationship between respondents‘ personal 
influencing attributes of breast cancer deeds and their screening behaviour. Results 
obtained from the correlation test were found to be in consistent with the claim that 
―there is a significant positive relationship between personal influence and screening 
behaviour‖. A strong positive correlation coefficient value of 0.749 was obtained at a 
significant level of 0.000 where (p) was found to be less than the test statistic of (0.05). 
This finding suggest that respondents‘ positive attitude towards breast cancer issues 
improves at a high rate when personal influences improve favourably. See table 5.9 for 
the summary. 
Table 5. 9: the summary of hypothesis 3 
  Personal Influence Breast screening 
Personal Influence Pearson R 1 .749 
  Sig. (P)   .000 
  N 285 284 
Breast screening Pearson R .749 1 
  Sig. (P) .000   
  N 284 285 
Source: Field study 2015 
 
5.5 Discussions of findings 
The sample distribution focused on women with those within the ages of 35-44 (36.8) 
forming the majority of the respondents, followed by those from 45-54 (28.1). This 
finding is in line with Ohene-Yeboah & Adjei (2012), who reported that in Ghana, most 
women who are diagnosed with breast cancer are within the ages of 40 and 49. In terms 
of education, those with A-Level/SHS recorded the highest of 43.5% followed by JHS 
and primary levels of 21.8% and 16.8% respectively. This is also in line with Ohene-
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Yeboah & Adjei (2012), who linked low levels of formal education with a lack of 
awareness of early warning signs and screening behaviour. Considering occupation and 
monthly income, the majority of the respondents (43.2%) were self-employed whiles 
21.1% formed the unemployed group. These figures are linked to monthly income 
where the majority (43.8%) receive GHC101-GHC500 followed by GHC501-1000 
(28.1%). Those who receive over GHC1000 were the least (11.2%). These findings 
support Opoku et al, (2012) who linked high poverty rate to the low rate of breast 
screening. The study also found that Muslims were the majority of 51.9% followed by 
Christians of 45.3%. This supports literature that people‘s religious beliefs can 
influence their behaviour (Avong, 2000). About the issue of whether or not women 
screen their breast, the majority (57.1%) said no and 42.1% responded yes. This affirms 
literature that breast screening is low in Ghana (Mena, Wiafe & Sauvaget, 2014). The 
types of breast screening exercise reported that most women screen their breast by 
themselves (54.2%), followed by clinical examination (41.7%) and mammogram 
(4.1%). This is proven right as the cost of mammography is very high in Ghana (NPC, 
2011). Finally, the number of times breast screening was done in a year revealed that 
47.7% of them do it once per year, and 20% of them reported that in a year they do not 
do. This also support literature that breast screening practice in Ghana is low (Mena, 
Wiafe & Sauvaget, 2014).  
These have practical implications for social marketers and that with the adaptation of 
the social cognitive framework (Bandura, 1997), these issues can be addressed to 
encourage women to screen their breast and at the required interval of time. 
 
 
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Research Objective I: 
The first objective was to establish how the immediate environmental factors influence 
breast screening behaviour in Ghana. A review of literature indicated immediate 
environmental factors as a prerequisite for behaviour change (Bandura, 1997). The 
immediate environment as one of the constructs in the framework consists of the 
influence of friends, family, the local community and significant others (Bandura, 
1986, 1997; MacFadyen et al., 1998). The framework put these factors together to form 
the construct of the immediate environment and collectively was tested. 
The test statistics showed an aggregate mean score of 2.96, representing a moderate 
approval to the statements, with the mean scores ranging from 1.83-3.56. Further, the 
analysis of the Pearson‘s correlation test showed a positive relationship between 
immediate environmental factors and breast screening behaviour. It showed a moderate 
correlation value of 0.551 and a significant value of 0.000 where p< 0.05. The 
correlation value of 0.551 shows about 55% prediction in breast cancer behaviour with 
an improvement in immediate environmental influence.  
Research Objective II: 
The second objective was to establish how wider environmental factors impact on 
breast screening behaviour. The framework revealed the wider environmental factors as 
influencing behaviour change (Bandura, 1986, 1997). The construct also identified 
social norms, cultural factors, structural issues and socio-economic factors collectively 
determining this construct (MacFadyen et al., 1998; Wilson & Gilligan, 2005). The 
analysis of the Pearson‘s correlation indicated a weak positive relationship between the 
wider external environment and breast screening behaviour. The correlation test 
produced a correlation value of 0.432 at a significance of 0.000 where p< 0.05.  The 
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aggregate mean was 3.23 and the mean scores ranged in-between 1.93-4.50, with free 
breast cancer screening on cancer days (4.50) exerting higher influence followed by the 
media (3.46) and that order. The correlation value of 0.432 is an indication that breast 
screening behaviour will improve by 43% with the improvement in external influence.  
Research Objective III: 
The last objective was to establish the significant relationship between personal 
characteristics and breast screening behaviour. The descriptive statistics of variables 
showed a mean score ranging from 3.60-3.99, with an aggregate average mean of 3.80. 
This clearly indicates that there is generally high approval towards favourable personal 
influencing factors. Findings of the Pearson‘s correlation analysis concerning this 
objective also revealed a strong positive relationship between personal factors and 
breast screening behaviour. The results showed a correlation value of 0.749 at a 
significance of 0.000 and p< 0.05 indicating that breast screening behaviour will 
improve remarkably (74%) if individual‘s personal characteristics such as education 
and self-efficacy improve. This construct in the framework was identified as 
influencing behaviour change and the factors which combined to form this construct are 
education, self-efficacy, and skills and aspirations, goals and needs (Bandura, 1986, 
2011; Maibach & Cotton, 1995). All these factors collectively constitute personal 
characteristics, influencing behaviour change.  
 
 
 
 
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CHAPTER SIX 
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 
6.0 Introduction 
This chapter concludes the study. It begins with a summary of the research which 
includes previous literature reviewed and findings with interpretations presented in 
chapter five. This study identifies and describes the factors that are likely to influence 
breast cancer screening in Ghana. It also highlights the critical lessons drawn from the 
study. The chapter concludes with implications for social marketers and 
recommendation for further studies. 
6.1 Summary 
The aim of the study was to test the factors that are likely to influence breast cancer 
screening in Ghana by adapting the social cognitive theory as propounded by Bandura 
(1986). It also sought to know the relationships between the constructs of the 
framework and behaviour change. In order to achieve these objectives, data were 
collected through questionnaires from three hundred women in Madina market, Accra, 
Ghana. Out of which two hundred and eighty five were valid for analysis. The variables 
that constituted the constructs used in the study were examined for their central 
tendency using mean and standard deviation. Pearson‘s correlation was used to estimate 
the nexus between the dependent variable and the independent ones.  
6.2 Major Findings 
The major findings of the study have been outlined below: 
First, the study discovered that, out of 285 respondents, 165 of them representing 
57.9% do not screen their breast at all. Again, when respondents were asked the 
number of times they screen their breast in a year, the result proved that, 56 out of 120 
respondents were screening once per year and 24 (20%) of them were not screening per 
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year. The results also showed that those who screen their breast twice a year were 25 
(20.8%) and three times or more, 15 (12.5%). This means that, out of the total of 285 
respondents, only 40 women (15+25), representing 14% examine their breast the right 
way as recommended by social marketers of at least twice a year. 
On the issue of the type of breast screening exams, the study found that, respondents 
adhered to self-breast exams (54.2%) and clinical examination (41.7%) than the use of 
mammogram (4%). 
Also, with regards to occupation, the study revealed that self-employed respondents 
were the highest (43.2%), followed by the unemployed of 21% with monthly income 
range of GHC101-GHC500 (43.8%). This was followed by those who receive 
GHC501-GHC1000 (28.1%) as monthly income. 
In terms of educational level, the study discovered that, 124 out of 285 respondents had 
A-Level/SHS education which was followed by 48 respondents with primary level of 
education. Only 43 out of the total respondents of 285 had tertially education. 
The study also discovered that, in terms of immediate influences, the advice of health 
workers was rated higher which was followed by the activities of breast cancer 
organisations. However, the influence of the family was rated very low, as far as breast 
screening is concerned. 
Another major finding which is at the heart of this study is that, in examining the 
external factors which influence breast screening in Ghana, the major influence was 
seen to be free organisation of breast screening. This was rated higher followed by the 
education on breast screening and also the influence of the media. 
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Moving to the personal factors which influence breast screening, the study found that, 
most women have higher fear in locating lump in their breast, and a number of them do 
not screen their breast because they do not know how to do it. 
Finally, the major findings on breast screening behaviour discovered that, most women 
are not screening their breast as normally expected, and a lot more have not examined 
their breast for the past two years. The study also found that, most women do not visit 
the health centres to screen their breast. 
6.3 Conclusions 
This study adapted the social cognitive theory (Bandura, 1986) as a framework to 
understand the factors that are likely to influence breast cancer screening in Ghana. The 
study formulated three objectives based on the constructs, and hypothesis based on the 
objectives. The answers to the three research objectives indicate that all the three 
factors or antecedents; immediate environmental factors, wider environmental factors 
and personal characteristics, were found to have a significant relationship with 
behaviour change. This result confirms that all the three factors result in behaviour 
change as explained by the framework. Even though the extent of how these constructs 
relate to behaviour change differ according to the analysis, they all had positive 
relationship with breast screening behaviour. This means, all the three constructs are 
good predictors of behaviour change and this has strategic implications for social 
marketers and policy makers.  
6.4 Recommendations 
Research generally has both managerial and theoretical implications. Managerial 
implications provide insights for practitioners while theoretical and research 
implications provide insights that form the bedrock of future research. It is within these 
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implications that the recommendations for this study are provided. The study therefore 
makes the following recommendations based on the major findings: 
6.4.1 Recommendations for practice: 
i. Social marketers in an attempt to designing interventions for their social 
campaigns should consider adopting the social cognitive framework as it gives 
insight into why a particular behaviour is adopted or not. 
ii. It is recommended that, social marketing intervention programmes should be 
designed to encourage more women to screen their breast and to do so two or 
three times in a year. 
iii. It is also recommended that, social marketing intervention programmes should 
focus on educating women in Ghana on the screening methods, especially, how 
to screen the breast by themselves and possibly, clinical exams, since 
mammogram is expensive and their incomes do not support that. 
iv. In terms of occupation and income, it is recommended that, intervention 
programmes should consider reducing the cost of breast screening and even 
making it free to encourage more women to screen their breast since many 
women live on low income. 
v. On educational level, it is proposed that since formal education is low in Ghana, 
social intervention programmes should focus on using the local dialects in their 
campaigns for better understanding of the issue. 
vi. Taking into consideration the level of immediate environmental influences, it is 
recommended that, social marketing campaigns should target and partner with 
health workers and breast cancer organisations since they exert great influence 
on breast screening. 
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vii. Since free breast screening, education and media play major role in influencing 
women, it is recommended that, social marketing campaigns should target and 
partner with the various media houses for more education on breast screening. 
viii. In terms of personal influence, it is recommended that social campaigns should 
focus on reducing breast screening fear and rather give women hope to screen 
their breast since breast cancer can be rendered to a complete cure if it is 
reported early. 
ix. It is also recommended that, intervention programmes should take into account 
an attempt to influence upstream forces. For example, influencing government 
and policy makers to expand facilities to other parts of Ghana to encourage 
women to screen their breast. 
x. Finally, on breast screening behaviour, it is recommended that, social marketing 
campaigns should highlight the risks of not screening the breast within the 
normal times and the benefits of screening the breast as well. 
6.4.2 Recommendations for future research: 
i. This study was conducted in Accra, Ghana, and can be replicated in other 
jurisdictions to confirm the findings or otherwise. It is therefore recommended to be 
replicated in other countries with similar economic conditions as Ghana. 
ii. Finally, other studies can employ different methodology that may help unearth 
information that may not have been seen in the course of this study. This 
new methodology may be mainly qualitative in nature since this study 
adopted a quantitative approach.  
6.5 Contributions of the study 
This study contributes both to knowledge and practice: 
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1. In terms of knowledge, the study has contributed to the extension of the 
application of the social cognitive theory to influence breast cancer screening in 
Ghana. 
2. In terms of practice, the study recommends strategies to policy makers and the 
government to design appropriate interventions to influence breast cancer 
screening in Ghana. 
 
 
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APPENDIX 1: QUESTIONNAIRE 
 
                                                   UNIVERSITY OF GHANA 
                                     UNIVERSITY OF GHANA BUSINESS SCHOOL 
                    DEPARTMENT OF MARKETING & CUSTOMER 
MANAGEMENT 
                                             RESEARCH QUESTIONNAIRE 
The researcher is a Master of Philosophy (MPhil) marketing student at the University 
of Ghana Business School, Accra. The researcher seeks to ascertain social marketing: 
using social cognitive theory to influence breast cancer screening in Ghana. This is 
in partial fulfillment of requirements leading to the award of a master of philosophy 
degree in marketing. Information provided for the purposes of this research will be 
treated confidentially and used for academic purposes only. Please take a few minutes 
to fill out this questionnaire. 
Section A: General Information on Respondent 
1. Respondent‘s age: 18-24 [  ]     25-34 [   ]   35-44 [   ]    45-54 [   ]      55-65 [  ]    65-
above [   ] 
2. Marital status:       Married [   ]    Single [  ]      Divorced [  ]     Widowed [  ]                             
3. Educational Attainment: No Education [   ]    Primary Education   [  ]         JHS [  ]                                          
                                A-Level/SHS [  ]      Tertiary   [  ]                                                                                                                                                                                           
4. Occupation: Unemployed [   ]              Self-employed [   ]               Employed [   ]                                                         
                                              Retired [   ]                 Student [  ]              
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5. Monthly Income:   Less than GH¢100 [   ]     GH¢ 101- GH¢500 [   ]   GH¢501- 
GH¢1000 [   ]                       Over GH¢1000 [   ] 
6. Religion: Christian [  ] Muslim [  ] Traditionalist [  ] Atheist [  ] Others [  ] 
7. Have you ever done breast screening? Yes [  ]     No [  ] 
8. What type of breast cancer screening exercise? Self-breast exams [  ] Clinical breast 
exams [ ]    Mammogram [  ]    others (specify)……………………………….. 
9. How many times do you do breast exams in a year:  Once per year [  ] twice per year 
[  ]         Three/more times per year [  ]   none [  ]    others 
(specify)……………………………..                                                                                                                                                          
Section B: Behavior change influences 
On a scale of 1-5, please indicate by ticking [√] the level to which you agree or disagree 
with the following statements.       Strongly Disagree (SD) = 1  Disagree (D) 
= 2        
Neutral (N) = 3             Agree (A) = 4            Strongly Agree (SA) = 5 
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120 
 
 Immediate environmental influence 
No
. 
Statement 1    
SD 
2 
D 
3 
N 
4 
A 
5 
SA 
10 My friends encourage me a lot to engage in breast 
cancer screening exercise  
     
11 I receive support and advice from my 
parents/husband regarding breast cancer screening 
     
12 My family is concerned about breast cancer screening 
because they have history with breast cancer  
     
13 My religious affiliation talks and encourages me to 
involve in breast exams 
     
14 I am influenced by the activities of breast cancer 
organizations 
     
15 My workplace is concerned and regularly talks about  
breast cancer screening and related issues 
     
16  I have been influenced by the advice of a health 
worker on breast screening before 
     
17 I am sure the people around me engage in breast 
screening  
     
 
 
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121 
 
External environmental influence 
No. Statement 1     
SD 
2 
D 
3 
N 
4 
A 
5 
SA 
18 For me, the cost involved with breast cancer 
screening is very high 
     
19 The media is very instrumental when it comes to 
providing education on breast cancer issues 
     
20 I believe breast cancer screening issues are 
intensively promoted in Ghana  
     
21 There are enough structures or hospitals for breast 
cancer screening exercise 
     
22 Issues about breast  are regarded as forbidden 
subject in my culture 
     
23 Breast screening exercise and education are 
regarded as important in my society   
     
24 Free breast cancer screening exercise should be 
organized as part of the activities that mark cancer 
day celebration in Ghana   
     
25 I think the government is concerned about breast 
cancer screening issues 
     
 
 
 Personal influence 
No. Statements 1 
SD 
2 
D 
3 
N 
4 
A 
5 
SA 
26 I have received education on how to examine the 
breast and what to look for  
     
27 I think breast cancer screening is difficult and 
demands time 
     
28 I have high fear in locating lump in my breast      
29 I immediately report any changes in my breast as 
early as possible 
     
30 I don‘t screen my breast because I don‘t know how 
to do it 
     
 
 
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Section C: Behavior change 
On a scale of 1-5, please indicate by ticking [√] the level to which you agree or disagree 
with the following statements.        Strongly Disagree (SD) = 1  Disagree (D) 
= 2 
Neutral (N) = 3            Agree (A) = 4      Strongly Agree (SA) = 5  
No. Statements 1 
SD 
2 
D 
3 
N 
4 
A 
5 
SA 
31 I have not examined my breast on a regular basis       
32 I regularly visit the health center to screen my breast      
33 I have personally educated women to screen their breast      
34 I immediately report any changes in my breast to my 
doctor 
     
35 I do not screen my breast regularly as it is expected 
normally 
     
 
THANK YOU 
 
 
 
 
 
 
 
 
 
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