Nsaful et al. BMC Cancer (2022) 22:893 https://doi.org/10.1186/s12885-022-09991-6 RESEARCH Open Access The impact of a breast cancer educational intervention in Ghanaian high schools Josephine Nsaful1,2*, Florence Dedey1,2, Edmund Nartey3, Juliana Labi4, Nii Armah Adu‑Aryee1,2 and Joe Nat Clegg‑Lamptey1,2 Abstract Introduction: Globally breast cancer is the leading cause of cancer with an estimated 2.3 million new cases and 685,000 deaths in 2020. Late presentation is the hallmark of breast cancer in Ghana for which ignorance and fear are the major reasons fuelled largely by myths and misconceptions. Breast cancer awareness and education needs to start early to bring about a change in knowledge, attitude and practices. However, Breast cancer awareness activities in Ghana have usually targeted adult women. This study assessed the impact of breast cancer education among adolescent high school girls in Ghana. Methodology: A pre‑ post‑test quasi experimental study was conducted at two senior high schools. A self‑adminis‑ tered pre‑educational questionnaire was followed by an educational intervention consisting of a drama, PowerPoint lecture, question and answer session and distribution of breast cancer information leaflets. After 3 months the same questionnaire was administered as a post‑education test to assess the impact of the educational intervention. The total score for each domain was categorised into adequate knowledge > 50% and inadequate knowledge < 50%. Results: The number of participants in the pre‑test and post‑test were 1043 and 1274; the median ages [IQR] were 16.0 [15.0–17.0] for both the pre and post‑test students. General knowledge on breast cancer at pre‑education (29.1%) improved to 72.5% (p < 0.001). Knowledge on signs and symptoms improved from 33.1 to 55% (p < 0.001); knowledge on risk factors improved from 55.3 to 79.2% (p < 0.001), and knowledge on breast self‑examination and screening improved from 9.8 to 22.2% (p < 0.001). The overall performance of the students improved from 17.2 to 59.4% (p < 0.001). Conclusion: There is inadequate knowledge about breast cancer and self‑examination among senior high school girls in Ghana. Our breast cancer educational intervention was effective in improving general knowledge of breast cancer, risk factors, signs and symptoms and breast self‑examination. The overall knowledge base improved from 17.2 to 59.4% 3 months post intervention, accompanied by an increase in the reported practice of breast self‑examination and a greater belief that breast cancer is curable. This study has demonstrated the need for a school breast cancer educational program and that breast cancer education in high schools is effective. Keywords: Breast cancer, High schools, Educational intervention, Adolescents, Breast self‑examination Introduction Globally breast cancer is now the leading cause of can- cer worldwide. Globocan estimated close to 2.3 million new cases and about 685,000 deaths from breast cancer *Correspondence: jnsaful@ug.edu.gh worldwide in 2020 [1]. Out of 195 countries in the world, 2 Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana breast cancer had the highest cancer incidence and Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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In Research examining the knowledge and health seeking Ghana breast cancer (BC) is leading in incidence with an practices of the youth with regard to BC, including the estimated 4500 new cases and about 2000 deaths in 2020 impact of educational interventions among adolescents, [2]. Globocan projects approximately 3 million new cases has been undertaken in both developed [10–13] and less by 2040 worldwide [3]. Despite a higher BC incidence in developed countries [14–18]. There are a few publica- developed countries, a larger proportion (61%) of breast tions available from Ghana on the cancer knowledge base cancer deaths occur in Africa. BC occurs at a younger age among the youth [19–22] but to the best of our knowl- in low-income countries with 50% of cases and deaths edge none on the impact of breast cancer health edu- occurring in women less than 50 years. A higher portion cation among adolescents. This study was designed to of triple negative tumours, known to have a poorer prog- evaluate the BC knowledge and test the feasibility of such nosis, have also been reported [4]. The increasing breast an intervention in Ghanaian high schools. We believe cancer burden in Africa and other developing countries that cancer awareness and education on breast cancer has been attributed to the increase in risk factors brought needs to start at an early age to bring about a change in on by socioeconomic transformation. These include the knowledge, attitude and practices of our people. The women having fewer children and at a later age, obesity aim of this study was to assess the impact of breast can- and physical inactivity [5]. cer education among high school girls in Ghana. Late presentation is the hallmark of breast cancer in Ghana, with 60% of cases diagnosed at stage III and IV. Methodology Ignorance and fear, driven by myths and misconcep- A pre- post-test quasi experimental study was conducted tions are the major reasons for late presentation and at two selected senior high schools, one a private co-edu- non-compliance with treatment [6]. The cause of cancer cational school and the other a public girls’ school. Both has been perceived to be spiritual and several women were boarding facilities as in Ghana most senior high resort to alternative treatments including herbs, prayers schools are boarding. A typical school has students who and homeopathy. These beliefs, attitudes and practices have travelled from across the regions. The headmaster/ responsible for the late presentation, treatment and non- mistress takes responsibility for the students and permis- compliance are deeply rooted and are not unique to the sion was given for the school to participate in the study. uneducated patients [6, 7]. Mindsets are formed from A script for a short drama was given to the drama club childhood and people, when faced with a crisis, fall on 2 weeks ahead for them to rehearse. The procedure was their deeply-held beliefs. A call for more cancer educa- first explained to the students and the option given to tion has been made [7]. opt out. All consenting female students filled out a self- In Ghana the past 5 years have been characterized by a administered pre-educational questionnaire (pre-test). surge in breast cancer awareness activities in the month The questionnaire consisted of 21 multiple choice and of October. However, these educational campaigns are true/false style questions. This covered 4 main domains not sustained throughout the year and the target group on breast cancer, namely 5 questions to assess basic has been women beyond school going age. knowledge, 7 questions on features (signs and symp- The American Cancer Society (ACS) recommends toms), 6 questions on risk factors and 3 questions on the mammographic screening over clinical breast exami- knowledge of breast self-examination. Two additional nation (CBE) and breast self-examination (BSE) as the non-domain questions were asked on respondents’ prac- former has been found to be more effective in reducing tice of breast self-examination. breast cancer mortality. However, they do acknowledge Next, a short drama was performed by the drama club that familiarity with one’s own breast will lead to early depicting a group of young ladies, one of whom presents detection of any breast changes and is of value in low with breast related symptoms. The actors are involved in resourced settings where mammography screening is a discussion which brings out some of the false informa- not readily available [8, 9]. Promoting breast awareness tion about the causes and symptoms of the disease as well including CBE and particularly the technique and prac- as myths and misconceptions in the community. This set tice of BSE in a setting where mammograms are few and the stage for a 40-minute PowerPoint presentation on national breast screening programs are absent can lead to breast cancer. The lecture outlined what breast cancer early detection of breast cancer. The recommended age is, risk factors, signs, symptoms, myths and misconcep- to start regular BSE is 20 years [8]. If myths and miscon- tions, breast self-examination and included a 1-minute ceptions are dispelled and people understand the treat- video recording of the story of a breast cancer survivor. ment of the disease, it should in the long run translate There was a question-and-answer session at the end of into early presentation, compliance with treatment and a the presentation. Lastly, an educational leaflet on breast lower cancer mortality. cancer risk, signs and symptoms and how to perform a N saful et al. BMC Cancer (2022) 22:893 Page 3 of 10 breast self-examination was given to each student to take standard deviations (SD), and categorical variables as home and read. count and percentages. Stata 14.0® was used for the sta- After 3 months the same questionnaire was admin- tistical analysis and p < 0.05 was considered statistically istered as a post-test to the same group of students to significant. assess the impact of the educational intervention. The questionnaires for the pre- and post-test were not paired Ethical considerations on the same individual, allowing students who opted out Ethical approval was obtained from the Institutional of pre-test to participate in post-test, hence our choice to Review Board of Korle Bu Teaching Hospital for Medi- use unpaired probability estimates without affecting the cal Research (KBTH-IRB) (study protocol ID KBTH- outcome. Each correct answer was scored 1 point and IRB/00063/2018). Permission was given by the heads each incorrect answer or non-response a zero. of the schools. Written informed consent/assent was given by each participant after the procedure had been Statistical analysis explained and the option given to withdraw at any stage. Each of the questions in the four domains on basic Those who opted out of the pre-test were not excluded knowledge of breast cancer, features of breast cancer, from participating in the educational intervention. risk factors of breast cancer and knowledge and practise of breast self-examination was equitably scored. Each Results correct answer was scored one (1) point and each incor- The event was attended by 1303 school girls. The num- rect answer or non-response a zero. The score for each ber of participants in the pre-test and post-test was 1043 domain was calculated by summing the score of all the and 1274 respectively giving a response rate of 80.0 and questions in that domain and it ranged from 0 to 5 for 97.8% respectively. All were females. The median ages domain I, 0–7 for domain II, 0–6 for domain III and 0–3 [IQR] were 16.0 [15.0–17.0] for both the pre and post- for domain IV. The total score for each domain was cat- test students. egorised into adequate knowledge > 50% and inadequate knowledge < 50%. A Chi-square test of proportion was General knowledge on breast cancer used to test differences in knowledge, attitude and prac- Table 1 shows the performance on 5 basic general knowl- tice of breast cancer and breast self-examination between edge questions on breast cancer (Domain I). In the pre- pre-education and post-education for each question in education test only 28.8, 18.6 and 11.4% of respondents a domain and for domain total. The overall score was answered correctly when asked whether breast cancer calculated by summing all the scores for domain I-IV. was curable, could occur in men or usually started with Continuous variables were summarised as means and pain, respectively. In answer to the same questions the Table 1 General knowledge on breast cancer Characteristic Correct Answer Incorrect Answer p-value n, (%)a n, (%)a Breast cancer is curable < 0.001 Pre‑Education 300 (28.8) 743 (71.2) Post‑Education 483 (37.9) 791 (62.1) Men can have breast cancer < 0.001 Pre‑Education 164 (18.6) 879 (61.2) Post‑Education 717 (81.4) 557 (38.8) Women less than 30 years can have breast cancer < 0.001 Pre‑Education 802 (76.9) 241 (23.1) Post‑Education 1167 (91.6) 107 (8.4) Breast cancer usually starts with pain in the breast < 0.001 Pre‑Education 119 (11.4) 924 (88.6) Post‑Education 442 (34.7) 832 (65.3) Pregnant women can get breast cancer < 0.001 Pre‑Education 819 (78.5) 224 (21.5) Post‑Education 1076 (84.5) 198 (15.5) a Row percentages Nsaful et al. BMC Cancer (2022) 22:893 Page 4 of 10 post-education correct answers were significantly higher significantly (p < 0.001) post-education scores were still (p < 0.001): 37.9, 81.4 and 34.7% respectively. Pre-edu- inadequate; 29.9, 9.1, 49.4 and 21.0% respectively. cation knowledge on women developing breast cancer below age 30 years and during pregnancy was already Knowledge on risk factors for developing breast cancer adequate but correct answers also improved significantly Knowledge on risk factors for breast cancer is repre- from 76.9 and 78.5% to 91.6 and 84.5% post-education sented in Table  3 (Domain III). With the exception of respectively (p < 0.001). the question on parity less than 50% correctly identified family history, breastfeeding, alcohol and lack of exercise as risk factors in the pre-education test. Knowledge of Knowledge on signs and symptoms of breast cancer these risk factors did increase significantly post-educa- Table  2 shows the performance on 7 questions regard- tion (p < 0.05). As many as 94% consistently inaccurately ing the signs and symptoms of breast cancer (Domain believe handkerchiefs/mobile phones placed in a brasier II). Breast cancer presenting as a lump, and nipple dis- is a risk for developing breast cancer both before and charge were answered correctly in the pre-education test; after the intervention. 83.1, and 71.6%. These also saw significant improvement to 97.4 and 85.1% in the post-education test (p < 0.001). Knowledge on breast self-examination and breast cancer A total of 66.9% correct answers were provided for sore/ screening rash on the breast as a sign/symptom for breast cancer in Table  4 summarizes the knowledge on breast self- the pre-education test which improved non-significantly examination (BSE) and breast screening (domain IV). to 68.3% in the post-education test (p = 0.484). However, Knowledge on the frequency and timing of perform- responses to the presence of a lump in the armpit, severe ing a BSE was correctly answered by 29.2 and 42.3% of pain, change in direction of the nipple and swelling of the respondents pre-education and 43.3 and 45.9% post- breast were poorly answered with correct answers in only education respectively which was significant (p < 0.001). 13.6, 4.6, 38.5 and 9.6% respectively. For these questions, The question on the recommended age at which women although the percentage of correct answers also increased are to start screening mammograms was very poorly Table 2 Knowledge on features of breast cancer Characteristic Correct Answer Incorrect Answer p-value n, %a n, %a Lump in the breast < 0.001 Pre‑Education 867 (83.1) 176 (16.9) Post‑Education 1241 (97.4) 33 (2.6) Lump in the armpit < 0.001 Pre‑Education 142 (13.6) 901 (86.4) Post‑Education 381 (29.9) 893 (70.1) Sore/rash on the breast 0.484 Pre‑Education 698 (66.9) 345 (33.1) Post‑Education 870 (68.3) 404 (31.7) Severe breast pain < 0.001 Pre‑Education 48 (4.6) 995 (95.4) Post‑Education 116 (9.1) 1158 (90.9) Change in direction of the nipple < 0.001 Pre‑Education 401 (38.5) 642 (61.5) Post‑Education 629 (49.4) 645 (50.6) Fluid discharge from the nipple < 0.001 Pre‑Education 747 (71.6) 296 (28.4) Post‑Education 1084 (85.1) 190 (14.9) Swelling or increase in size of breast < 0.001 Pre‑Education 100 (9.6) 943 (90.4) Post‑Education 267 (21.0) 1007 (79.0) a Row percentages N saful et al. BMC Cancer (2022) 22:893 Page 5 of 10 Table 3 Knowledge on factors increasing risk of getting breast cancer Characteristic Correct Answer Incorrect Answer p-value n, %a n, %a Family member had breast cancer < 0.001 Pre‑Education 343 (32.9) 700 (67.1) Post‑Education 752 (59.0) 522 (41.0) Breastfeeding < 0.001 Pre‑Education 474 (45.5) 569 (54.5) Post‑Education 925 (72.6) 349 (27.4) Having more than 5 children < 0.001 Pre‑Education 824 (79.0) 219 (21.0) Post‑Education 1080 (84.8) 194 (15.2) Keeping handkerchief/mobile phone in your brasier 0.693 Pre‑Education 59 (5.7) 984 (94.3) Post‑Education 77 (6.0) 1197 (94.0) Excessive alcohol intake < 0.001 Pre‑Education 498 (47.7) 545 (52.3) Post‑Education 781 (61.3) 493 (38.7) Lack of exercise 0.020 Pre‑Education 453 (43.4) 590 (56.6) Post‑Education 615 (48.3) 659 (51.7) a Row percentages Table 4 Knowledge on breast self‑examination and screening Characteristic Correct Answer Incorrect Answer p-value n, %a n, %a Frequency of doing breast Self‑examination < 0.001 Pre‑Education 305 (29.2) 738 (70.8) Post‑Education 551 (43.3) 723 (56.7) Best time to do breast self‑examination 0.080 Pre‑Education 441 (42.3) 602 (57.7) Post‑Education 585 (45.9) 689 (54.1) Age at which a woman should have first screening mammo‑ < 0.001 gram in Ghana Pre‑Education 27 (2.6) 1016 (97.4) Post‑Education 68 (5.3) 1206 (94.7) a Row percentages answered both pre- and post-education, with only 2.6 Overall performance on breast cancer knowledge and 5.3% answering correctly (p = 0.080). Table 5 represents the analysis of each of the 4 domains Pre-education, 79.3% (n = 827) of students had assessed and an overall assessment of the knowledge pre- heard of breast self-examination. Sub-group analysis and post-education. Adequate knowledge is categorised indicated that of these, 38.6% (n = 319) had practiced as > 50% correct answers and inadequate knowledge as breast self-examination. This proportion of students < 50% correct answers. The overall general knowledge who did breast self-examination significantly increased on breast cancer (domain I) at pre-education was rather (p = 0.005) to 44.9% (n = 514) among the 1146 post- inadequate at 29.1% and improved significantly to 72.5% education students who had heard of breast self-exami- (now adequate) post-education (p < 0.001). The knowl- nation (data not shown). edge on features (signs and symptoms) of breast cancer Nsaful et al. BMC Cancer (2022) 22:893 Page 6 of 10 Table 5 Domain analysis Characteristic Adequate Inadequate p-value n, %a n, %a Domain I General knowledge on breast cancer < 0.001 Pre‑Education 304 (29.1) 739 (70.9) Post‑Education 924 (72.5) 350 (27.5) Domain II Knowledge on features of breast cancer < 0.001 Pre‑Education 345 (33.1) 698 (66.9) Post‑Education 700 (55.0) 574 (45.0) Domain III Knowledge on factors increasing risk of getting breast cancer < 0.001 Pre‑Education 577 (55.3) 466 (44.7) Post‑Education 1009 (79.2) 265 (20.8) Domain IV Knowledge on breast self‑examination and screening < 0.001 Pre‑Education 102 (9.8) 941 (90.2) Post‑Education 283 (22.2) 991 (77.8) Overall Overall knowledge < 0.001 Pre‑Education 179 (17.2) 864 (82.8) Post‑Education 757 (59.4) 517 (40.6) a Row percentages (domain II) also started off as inadequate (33.1%) pre- It has been established that the level of knowledge education and improved significantly to a low adequate about breast cancer among the youth is inadequate. A score of 55% (p < 0.001). The assessment of knowledge on close look at the domains pre-education reveals very risk factors (domain III) pre-education was just adequate low scores for general knowledge (29.1%) and features of with 55.3% correct answers, but post-education saw a breast cancer (33.2%), and even lower scores for breast significant improvement to 79.2% (p < 0.001). The over- self-examination 9.8%. This is similar to breast cancer all knowledge on BSE and screening (domain IV) saw a knowledge levels in other low and middle income coun- significant improvement from 9.8 to 22.2% (p < 0.001) but tries (LMIC) such as Nigeria [16, 23], India [24], Bang- remained inadequate. Finally, the overall performance of ladesh [15] and Siri Lanka [18]. This phenomenon is the students improved significantly from pre-education however, not restricted to LMIC. Adolescents in devel- 17.2% to post-education 59.4% (p < 0.001). oped countries have also been found to be deficient in breast cancer knowledge. College and high school students in the USA have been found to have poor Discussion knowledge on breast cancer, its risk factors and BSE, This study has demonstrated that the designed educa- scoring a mean of 13.5 ± 0.33 (high school students) and tional intervention (drama, lecture, question-and-answer 15.5 ± 0.32 (college students) out of a total score of 30 session, and educational leaflets) significantly improved [10]. This inadequate breast cancer knowledge among knowledge in all domains on breast cancer risk factors, the youth worldwide makes a case for the introduction of signs and symptoms, breast self-examination and the breast cancer education targeted at adolescents. practice of BSE significantly among adolescent females. This study was innovative in using a multi-tooled The overall knowledge on breast cancer improved after approach: first a drama acted out by the students, then a the intervention from 17.2 to 59.4% (p < 0.001). The great- PowerPoint lecture given by doctors, followed by a ques- est improvement was seen in general knowledge about tion-and-answer session and finally breast cancer infor- breast cancer from 29.1 to 72.5% (p < 0.001) and the least mation leaflets for participants to take home and read. improvement in knowledge on BSE from 9.8 to 22.2% Others have applied various educational methods, all (p < 0.001). with good results. An hour long lesson has been proven N saful et al. BMC Cancer (2022) 22:893 Page 7 of 10 to improve the knowledge base of girls on breast can- 70% were aware of breast cancer, mammography and cer and BSE [25]. A quasi-experimental research carried BSE, but this knowledge did not influence their behav- out among Nigerian adolescents used BSE pamphlets, iour, as only 43% practiced BSE and 46% of these stu- and testing done 8 weeks later found an increase in BSE dents felt there was no chance that they might develop knowledge and perception [26]. Another publication breast cancer in the future, while 16% were uncertain of from Nigeria demonstrated that a 45–60 minute educa- their risk. Not surprisingly, those who felt there was no tional session utilizing PowerPoint, video and demon- risk or did not know their risk were less likely to perform stration of BSE resulted in a significant improvement in BSE than those who perceived some risk [31]. Though knowledge, attitude and the practice of BSE 8 weeks after the level of breast cancer awareness and BSE awareness intervention [27]. This study utilized students to act out in Malaysia was as good as 87.6 and 60.6% respectively, a drama in order to make learning a collaborative experi- the knowledge on BSE was poor (40.4%) [32]. In this ence. Also in Nigeria, a study found peer education to be study we found that our educational intervention did not an effective tool and a cost effective means of breast can- change the perception (in 94% of participants) that hand- cer education among adolescents [16]. kerchiefs/mobile phones placed in a brasier is not a risk The use of peer educators has demonstrated similar for developing breast cancer (p = 0.693). The knowledge success in Egypt [28]. A study carried out among ado- that sore/rash is a symptom of breast cancer also did lescents in Mexican middle schools utilized an educa- not significantly improve from 66.9 to 68.3% (p = 0.484). tional intervention which included a reading guide that Knowledge on the recommended age at which women was later discussed at a plenary session. Likewise, this are to start screening mammograms also showed mini- saw significant learning with 53% correct answers pre- mal improvement from 2.6 to 5.3% (p < 0.001). This phe- intervention increasing to 75% correct answers post- nomenon is not unique to our study. For instance, the intervention [29]. In Saudi Arabia an all-female team of impression that pain and weight loss were not the first doctors visiting schools employed a series of short lec- symptoms of breast cancer was not corrected after the tures, discussion groups and role playing on the tech- Nigerian educational intervention [16]. nique of breast examination. They found that not only On the other hand, our intervention did see a sig- did the mean knowledge indexes for breast cancer and nificant increase in the number of students practic- BSE improve after an educational session, but also some ing BSE 3 months post-intervention from 38.6 to 44.9% girls (27%) had started practicing BSE over the 6-month (p = 0.005). Notably, more girls now believed that BC is period post intervention [30]. a curable disease, from 28.8% pre-intervention to 37.9% In a comparison of breast health teaching methods, it post-intervention (p < 0.001). Likewise, an educational was found that interactive teaching methods with simu- intervention in the UK was found to have a sustained lated breast models resulted in higher knowledge reten- improvement in breast knowledge and attitudes 3 and tion 4 weeks after the intervention compared to the 6 months later [13]. A quasi-experimental study in Korea traditional didactic teaching method. It is noteworthy found that a breast cancer educational intervention did however, that there was still significant improvement in improve all aspects of learning a week after the inter- knowledge in both the traditional didactic and the inter- vention. However, 3 months later breast cancer knowl- active methods [12]. Indeed, the use of demonstration edge and attitude on prevention were sustained but the methods and audio-visual media has been found to be improvement was not sustained for self-efficacy and a successful means of breast cancer and BSE education behavioural intentions. This was attributed to the ability among adolescents [14]. Recently the impact of social of short-term interventions to change one’s knowledge media has been explored and the use of youth-targeted but not necessarily the social cognitive factors that would YouTube-styled videos has been promising in educat- reflect in a sustained behaviour change. Such sustained ing adolescents on the breast cancer risk associated with behaviour changes would take long-term interventions smoking [11]. These studies all prove that various teach- involving several booster sessions [33]. ing tools and if possible as was utilized in our study, a An innovative educational intervention carried out combination of teaching methods is effective in achieving in Mexico went further to determine the impact on the learning in breast cancer education. female relatives of the participants and it was found that For breast cancer education to be effective there should there was transference of knowledge so that breast can- be a translation of the knowledge into appropriate health cer knowledge of relatives at home saw improvement seeking and preventive practices and the appropriate from 55 to 61% 4 months post-intervention. This dem- attitude should one detect any breast changes or be diag- onstrates a potential strategy for public education and nosed with breast cancer. For instance, a study done in a change in societal norms [34]. Breast cancer educational Ghanaian University of Allied Health found that at least programs should be designed to achieve sustained gains Nsaful et al. BMC Cancer (2022) 22:893 Page 8 of 10 in knowledge and long-term behavioural change in the We believe that such programs will be a welcome intro- community. duction in our schools. Social media, teachers and electronic media have been found to be the leading sources of information on breast Conclusion cancer and little from health professionals [31, 32]. Get- This paper set out to assess the impact of breast can- ting already limited and constrained healthcare profes- cer education among high school girls in Ghana and sionals into every school and every classroom, though we observed that there is inadequate knowledge about desirable, may not be practical. There is a need for inno- breast cancer and breast self-examination among senior vation in getting cancer education into schools either high school girls in Ghana. This breast cancer educa- as part of the curriculum or seasonal school activities. tional intervention effectively improved general knowl- Schoolgirls themselves have concerns about and admit edge in breast cancer, knowledge on risk factors, signs the need for breast cancer education [35]. A case for and symptoms and breast self-examination. The over- schools to lead in cancer health education has been made all knowledge base improved (by 42.2%) 3 months post in a commentary by Morse in which he makes reference intervention. This was accompanied by a significant to the guidelines and scope of such a program drawn up increase in the practice of breast self-examination and in as far back as 1995 by the ACS [36]. The Centre for Dis- the understanding that breast cancer is a curable disease. ease Control (CDC) also recommends that the youth be This study has demonstrated the need for a school breast taught cancer protective behaviours which include good cancer educational program and proven that breast can- nutrition, physical activity, human papilloma virus (HPV) cer education in high schools is effective. vaccination and reducing harmful exposures to smoking, We recommend that breast cancer education should be alcohol, tanning, certain chemicals, etc [37]. introduced into the school curricula, supported by local In Portugal a training program for biology teachers healthcare professionals. Results of this study indicate was found to be an effective tool in increasing teachers’ that, other than the fundamental facts about the disease, knowledge and perception of cancer and resulted in an areas that need emphasis should include addressing the increase also in students’ knowledge on cancer. This pro- myths and misconceptions and teaching the practice of ject covered education in breast, cervical, colorectal and BSE. For breast cancer education to achieve the desired skin cancer [38]. A Cancer Education Partnership Pro- sustained, behaviour changing effect in LMIC we rec- gram has been developed in the USA for underserved ommend the use of a multi-tooled, culturally acceptable, schools. This introduced children as young as third-grade cost-effective educational approach involving multiple through to high school to the concept of cancer, exposing sessions throughout the school year. them to basic knowledge about cancer risks, prevention, This study was limited in that it did not pair the pre and nutrition and more advanced oncology, genetics and bio- post-test questionnaires, but its strength lies in the large technology as they got older [39]. 2020 saw the introduc- sample size. The study has developed an educational tion of health education in UK curricula which includes tool for use by health professionals which can be used at preventive lifestyles and awareness of cancer screening school visits for the purpose of breast cancer education. [40]. This study has laid the foundation for further research to Schools present the perfect opportunity to gain access be done in adolescent cancer education in Ghana and for to a nation’s youth and it should be possible to introduce the development of educational tools in other cancers. breast cancer education in schools in Ghana and other LMICs. It would be prudent to train teachers to be the primary source of information. A collaboration between Abbreviations BC: Breast Cancer; BSE: Breast Self‑Examination; CBE: Clinical Breast Examina‑ the Health and Education Sectors would be beneficial in tion; LMICs: Low and Middle Income Countries; ACS: American Cancer Society; organizing training programs and developing materials CDC: Centre for Disease Control. for the curriculum/syllabus. This need not be restricted Acknowledgements to breast cancer but can be extended to other cancers and We appreciate the cooperation of the school authorities and students who diseases of public health importance. The schools’ efforts participated in the study. could then be augmented by a team of health profes- Authors’ contributions sionals from the school locality. These healthcare work- Conceptualization; FD, JN, JNCL. Methodology; JN, FD, JNCL. Investigation; JN, ers could be given access to schools periodically during FD, JNCL, JL, NAAA. Data curation and Data analysis; EN. Data interpretation; awareness months to have a more detailed interaction EN, JN. Drafting of manuscript; JN, EN. Editing of manuscript; JN, FD, JNCL, JL, EN, NAAA. Final revision and approval of manuscript; JN, EN, FD, JNCL, JL, with students. Our experience on school visits has been NAAA. The author(s) read and approved the final manuscript. characterized by enthusiasm and cooperation both on the side of the school authorities/teachers and the students. Funding This study did not receive any funding. N saful et al. BMC Cancer (2022) 22:893 Page 9 of 10 Availability of data and materials 11. Bottorff JL, Struik LL, Bissell LJL, Graham R, Stevens J, Richardson CG. A The data and materials of this study are freely available at https:// doi. org/1 0. social media approach to inform youth about breast cancer and smok‑ 6084/ m9.fi gsha re. 200219 63 ing: an exploratory descriptive study. Collegian. 2014;21(2):159–68. 12. Evans RR, Horton JA, Ahmad WA, Davies SL, Snyder SW, Macrina DM. Comparison of breast health teaching methods for adolescent females: Declarations results of a quasi‑experimental study. J Health Education Teaching. 2013;4(1):24–38. Ethics approval and consent to participate 13. Omrani A, Wakefield‑Scurr J, Smith J, Wadey R, Brown N. Breast Education This research was carried out in accordance with the guidelines and regula‑ Improves Adolescent Girls’ Breast Knowledge, Attitudes to Breasts and tions for human research (Helsinki declaration). Institutional ethical approval Engagement with Positive Breast Habits. Front Public Health. 2020;8 was obtained from the Institutional Review Board of Korle Bu Teaching Hospi‑ [cited 2022 May 28]. Available from: https:// www. front iersin.o rg/ articl e/ tal for Medical Research (KBTH‑IRB). (study protocol ID KBTH‑IRB/00063/2018). 10. 3389/ fpubh. 2020. 591927. Permission was given by the heads of the schools for the schools to partici‑ 14. Hindriati T, Nurmisih N, Diniyati D, Rosmaria R. 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