Knowledge, Attitudes and Practices of Healthcare Professionals Regarding Breast Cancer in the Municipality of Parakou (Benin) in 2024 ()
1. Introduction
Cancers remain a significant public health problem worldwide. Approximately 20 million new cases of cancer were reported in 2022 according to GLOBOCAN 2022. In terms of prevalence and mortality, breast cancer and lung cancer were the most common cancers in women and men, respectively [1]. A recent study illustrated the profound impact of disproportionate cancer mortality among women: an estimated one million orphaned children were registered in 2020 because their mother died of cancer that year. Nearly half of these orphans were the result of maternal deaths from breast or cervical cancer [2]. Population projections indicate that cancer incidence worldwide will reach 35 million by 2050 [1].
In Africa, breast cancer is the second most common cancer in women after cervical cancer [3]. Numerous studies carried out on gynecological and breast cancers have shown that one of the characteristics of cancers in Africa is that patients are seen at advanced stages, which implies heavy, costly treatment, sometimes limited to palliative care [4].
In Benin, a West African country, the leading cancer in women in terms of incidence and mortality is breast cancer. More than 70% of patients are diagnosed at a late stage. Specifically, tumors were classified at AJCC (American Joint Committee on Cancer) stage III (42.3%), stage IV (21.9%), stage II (19.4%), and stage I (5.3%) at the time of diagnosis. In 2013, the 5-year survival rate for breast cancer was 43% in a hospital located in Cotonou [5]. A study conducted in 14 African countries, estimated 3-year survival at 19.3% in Zimbabwe, 44.1% in Mali, and 49.5% in Kenya [6].
Regarding the fight against breast cancer, the plan includes raising awareness of the importance of early detection, particularly through physical examinations carried out by healthcare professionals. Mammography is used primarily to establish a diagnosis and for the monitoring of women with a family history of this cancer. Thus, the cancer control plan gives an important place to frontline healthcare professionals. They are responsible for applying screening methods, motivating women to adhere to screening and monitoring cases with positive screening tests. They are also in charge of ensuring good coordination with cytology laboratories, mammography centers and cancer treatment facilities [7].
Recently, researchers have focused their attention on the knowledge, attitudes and practices of healthcare professionals regarding breast cancer. Studies conducted in low and middle-income countries, particularly in Tunisia [8], Pakistan [9] and Nigeria [10], show the importance of better knowledge of breast cancer by healthcare professionals to improve the management of this cancer. Studies conducted on the knowledge, attitudes and practices of healthcare professionals regarding breast cancer in Parakou (Benin) and Senegal had shown that the majority of healthcare professionals were insufficiently informed about breast cancer and the diagnostic methods [4] [11]. In northern BENIN, more precisely in Parakou, few studies have been published on breast cancer. The need to assess the knowledge, attitudes and practices of health professionals regarding breast cancer in the city of Parakou motivated the choice of this topic.
2. Site and Study Methods
Our study took place in the public and private health facilities in Parakou, the largest city in northern BENIN.
This was a cross-sectional study with a descriptive and analytical aim. Prospective data collection was performed among health professionals from the various public and private health facilities in the municipality of Parakou.
Health professionals (doctors, midwives, state certified nurses) working in the selected health centers, participating in prenatal, general, postnatal, gynecological consultations or family planning activities and present on the sites on the survey days were included in our study. Professionals absent on the collection days, those who did not give their consent, as well as gynecologists (considered experts in the field) were excluded from the survey. This was an exhaustive census of all healthcare providers meeting the inclusion criteria.
The dependent variables were the knowledge, attitudes and practices of healthcare professionals regarding breast cancer. They were assessed using the model of Essi et al. [12]. The level of knowledge was classified into four categories (poor, insufficient, average and good):
Less than 50% correct answers = poor
Between 50% and 65% correct answers = Insufficient
Between 65% and 85% correct answers = Average
More than 85% correct answers = Good
In terms of attitude, the analysis focused on four criteria (correct, approximate, incorrect and harmful):
Less than 50% correct answers = harmful
Between 50% and 65% correct answers = incorrect
Between 65% and 85% correct answers = approximate
More than 85% correct answers = correct
Practices were classified into 3 levels (harmful, inadequate, adequate).
Less than 50% correct answers = harmful
Between 50% and 85% correct answers = inadequate
More than 85% correct answers = adequate
An overall KAP score was calculated by averaging the knowledge, attitude, and practice scores. Three criteria were used to assess the overall KAP:
Average score < 50% = poor KAP score
Average score < 85% = acceptable KAP score
Average score ≥ 85% = good KAP score
The independent variables of our study are related to:
Sociodemographic information: age, sex, professional category, employment sector, level in the health services pyramid, seniority in the profession.
Data related to the knowledge of healthcare professionals about breast cancer: definition, severity, frequency, risk factors, number of cases, suggestive signs, screening methods, methods that can be used for diagnosis, treatment methods, advances in the field.
Data related to the attitudes of healthcare professionals regarding breast cancer: effectiveness or not of breast self-examination, effectiveness or not of clinical breast examination by a doctor, attitude towards a woman at risk, effectiveness or not of mammography, advice on self-examination, advice on mammography, advice on avoiding risk factors, perception of the organization of breast cancer screening in Benin.
Practices of healthcare professionals: systematic practice of clinical breast examination and reasons for not doing so, time of teaching breast examination to patients, main difficulty in the management of tumor mass screening, practice regarding the request for mammography and personal practices of healthcare professionals regarding their own health or that of their partners.
A questionnaire was designed for data collection. The questionnaire was tested on a sample. It was then corrected and validated before the actual collection. The collection took place from June 20, 2024 to August 20, 2024 through a face-to-face interview between the interviewer and the interviewee.
The processing and analysis phase of the collected data was carried out according to a pre-defined analysis plan. The first step consisted of data validation. The completeness of the information collected and entered into Kobotoolbox platform was verified. Statistical analyses of the data were carried out using IBM SPSS Statistics 25 software. Observations are presented using frequency measures, including proportions or percentages for qualitative variables with 95% as confidence intervals. Quantitative data are presented using parameters such as the mean with standard deviation, the median as appropriate, the mode, and the extremes. In terms of hypothesis testing, the Chi2 test was used with an observation of the theoretical numbers for adjustments in the choice of the test. Thus, the links between variables are observed for a significance threshold set at 5%. The measure of association, namely the prevalence ratio, was calculated for the relevant associations.
This study received authorization from the Local Ethics Committee for Biomedical Research of the University of Parakou (No. 567/2024/CLERB-UP/P/SP/R/SA) before data collection. Anonymity and confidentiality of the data collected were respected. Free and informed verbal consent from the people surveyed before any administration of the questionnaire was required.
3. Results
Following our survey of healthcare professionals in the city of Parakou about their knowledge, attitudes, and practices regarding breast cancer, 154 of them were eligible for the study and 130 participated. The participation rate is therefore 84.42%. Lack of time was the most common reason for non-participation.
3.1. Knowledge of Healthcare Professionals Regarding Breast Cancer
3.1.1. Information about Breast Cancer
All participants reported having heard about breast cancer. The most frequent source of information was university education (69.2%) (Table 1).
Table 1. Distribution of healthcare professionals surveyed on breast cancer based on data relating to information on breast cancer (Parakou, 2024).
|
Frequency |
Percentage |
Having heard about breast cancer (n = 130) |
Yes |
130 |
100.0 |
Source of information (n=130) |
|
|
Media |
45 |
34.6 |
Health campaign |
55 |
42.3 |
Collaborators |
23 |
17.7 |
University education |
90 |
69.2 |
Family members |
14 |
10.8 |
Friends |
11 |
8.5 |
Self-study |
1 |
0.8 |
Conference |
1 |
0.8 |
Hospital |
1 |
0.8 |
3.1.2. Continuing Training
Most participants had not attended a continuing training session on breast cancer (77.7%), while only 22.3% had.
3.1.3. Definition and Description of Breast Cancer
The majority of participants (90.8%) defined breast cancer as a malignant tumor. However, 16.9% thought it was a benign tumor, indicating some confusion among this group. Furthermore, 6.9% of healthcare professionals defined breast cancer as inflammation.
The majority of participants (86.2%) identified breast cancer as a malignant condition characterized by symptoms such as dimpling skin, breast discharge, the presence of a lump and nipple retraction.
3.1.4. Risk Factors for Breast Cancer
The majority of respondents (80.8%) identified family history of breast cancer as a major risk factor. Smoking and alcohol consumption were also recognized by 58.5% and 50% of healthcare professionals, respectively (Table 2).
Table 2. Distribution of healthcare professionals surveyed on breast cancer according to the notions of known risk factors (Parakou, 2024) n = 130.
|
Frequency |
Percentage |
Family history of breast cancer |
105 |
80.8 |
Smoking |
76 |
58.5 |
Alcohol consumption |
65 |
50.0 |
Hormone replacement therapy for menopause |
57 |
43.8 |
Age |
56 |
43.1 |
Lack of breastfeeding |
55 |
42.3 |
Genetic predisposition |
52 |
40.0 |
Age at first pregnancy ≥ 35 years |
41 |
31.5 |
Nulliparity |
41 |
31.5 |
Obesity |
37 |
28.5 |
Early age of first menstruation (≤12 years) |
33 |
25.4 |
Benign mastopathy |
28 |
21.5 |
Late menopause (Age ≥55 years) |
27 |
20.8 |
Irradiation |
26 |
20.0 |
Human papilloma virus (HPV) |
25 |
19.2 |
Multiparity |
21 |
16.2 |
Aluminum salts-based antiperspirants or deodorants |
16 |
12.3 |
Endometrial cancer |
13 |
10.0 |
Herpes simplex virus (HSV) |
10 |
7.7 |
Colon cancer |
6 |
4.6 |
Extended breastfeeding |
5 |
3.8 |
3.1.5. Overall Knowledge of Health Professionals Regarding Breast Cancer
The majority of healthcare professionals (78.5%) had a poor level of overall knowledge about breast cancer. A proportion of 16.9% had an insufficient level of knowledge and only 4.6% of them had an average level of knowledge about breast cancer (Figure 1).
Figure 1. Distribution of healthcare professionals surveyed according to their level of overall knowledge about breast cancer (Parakou, 2024).
3.2. Attitudes of Healthcare Professionals Regarding Breast Cancer
3.2.1. Advice on Breast Self-Examination (BSE), Mammography Prescription and Screening in Benin
Regarding advice on self-examination, 61.5% of healthcare professionals always recommended this practice to patients, while 36.2% did so sometimes. Prescribing mammography for women over 50 years of age was less systematic: only 13.8% always did so. In terms of the organization of breast cancer screening in Benin, 50% of healthcare professionals considered it well organized. It was poorly organized according to 26.2% of them. Discussions about risk factors with patients were always practiced by 28.5% of respondents. Finally, advice for an annual examination by a doctor was always given by 37.7% of participants, sometimes by 35.4%, rarely by 22.3%, and never by 4.6% (Table 3).
Table 3. Distribution of healthcare professionals surveyed on breast cancer according to attitudes towards the disease, BSE, CBE, mammography, screening in Benin and risk factors.
|
Frequency |
Percentage |
Nature of the disease (n = 130) |
|
|
Severe |
128 |
98.5 |
Not severe |
2 |
1.5 |
Advice on self-examination for patients (n = 130) |
Always |
80 |
61.5 |
Sometimes |
47 |
36.2 |
Rarely |
3 |
2.3 |
Prescription of mammography to women over 50 years of age (n = 130) |
Sometimes |
44 |
33.8 |
Rarely |
37 |
28.5 |
Never |
31 |
23.8 |
Always |
18 |
13.8 |
Breast cancer screening in Benin (n = 130) |
Well organized |
65 |
50.0 |
Poorly organized |
34 |
26.2 |
Unknown |
28 |
21.5 |
Non-existent |
3 |
2.3 |
Discussion about risk factors with patients (n = 130) |
Sometimes |
74 |
56.9 |
Always |
37 |
28.5 |
Rarely |
15 |
11.5 |
Never |
4 |
3.1 |
Advice to patients on annual exam by the physician (n = 130) |
Always |
49 |
37.7 |
Sometimes |
46 |
35.4 |
Rarely |
29 |
22.3 |
Never |
6 |
4.6 |
3.2.2. Overall Attitude of Healthcare Professionals Regarding Breast Cancer
Nearly half of the healthcare professionals (44.6%) had an approximate approach, while 39.2% of them had an incorrect attitude. Ten percent (10%) of healthcare professionals had a harmful attitude and only 6.2% had a correct attitude regarding breast cancer (Figure 2).
Figure 2. Distribution of healthcare professionals according to their level of attitude regarding breast cancer (Parakou, 2024).
3.3. Practice of Healthcare Professionals Regarding Breast Cancer
Table 4. Distribution of healthcare professionals surveyed on breast cancer according to the number of cases encountered per year and the practices during training and consultations.
|
Frequency |
Percentage |
Average number of breast cancer cases encountered per year (n = 130) |
1 to 3 |
71 |
54.6 |
None |
31 |
23.8 |
Unknown |
19 |
14.6 |
4 to 6 |
6 |
4.6 |
Greater than or equal to 7 |
3 |
2.3 |
Breast examination during initial or continuing training (n = 130) |
Yes |
120 |
92.3 |
No |
10 |
7.7 |
Opportunity to perform breast cancer screening on patients (n = 130) |
Yes |
108 |
83.1 |
No |
22 |
16.9 |
Circumstance (n = 108) |
|
|
Breast clinical examination |
99 |
91.7 |
Mammography |
9 |
8.3 |
On average, 54.6% of healthcare professionals had 1 to 3 cases of breast cancer per year. In terms of education, 92.3% of healthcare professionals received a training on breast examination. Eighty-three-point one percent (83.1%) of healthcare professionals had the opportunity to perform breast cancer screening on patients. The most common means used by these workers to perform breast cancer screening was clinical breast examination (91.7%), while mammography was less frequently performed (8.3%) (Table 4).
3.3.1. Global Practice of Healthcare Professionals in Terms of Breast Cancer
Among the healthcare professionals surveyed, only 5.4% had adequate practices regarding breast cancer. The practices observed were inadequate in almost half (49.2%) of the healthcare professionals surveyed, while 45.4% had harmful practices (Figure 3).
Figure 3. Distribution of healthcare professionals according to their level of practice regarding breast cancer (Parakou, 2024).
3.3.2. Overall Knowledge, Attitude and Practice Score
The overall KAP score showed that 51.5% of healthcare professionals had an acceptable score, while 48.5% had a poor KAP score (Figure 4).
Figure 4. Distribution of healthcare professionals surveyed according to the KAP score regarding breast cancer in the municipality of Parakou in 2024.
3.4. Relationship between the Overall KAP Score of Healthcare Professionals and Their Age, Seniority, Professional Category, Sector of Employment, Level in the Health Services Pyramid
and Continuing Training
The differences between the age of the respondents, seniority in the profession, level in the health services pyramid, employment sector, continuing training and the overall KAP score of the healthcare professionals surveyed were not significant. On the other hand, the socio-professional category had a statistically significant influence on the KAP scores (P-value = 0.012). Midwives were the best performers, with 66.7% achieving an acceptable KAP score, while 44.4% of nurses and 37.5% of general practitioners achieved this score (Table 5).
Table 5. Relationship between the characteristics of healthcare professionals and the overall score of knowledge, attitudes and practices regarding breast cancer in the municipality of Parakou in 2024.
|
Overall KAP score |
N |
P-value |
Poor score |
Acceptable score |
N |
% |
n |
% |
Age |
|
|
|
|
|
|
[20 - 30[ |
37 |
52.9 |
33 |
47.1 |
70 |
0.215 |
[30 - 40[ |
21 |
47.7 |
23 |
52.3 |
44 |
|
[40 - 50[ |
4 |
26.7 |
11 |
73.3 |
15 |
|
[50 - 60[ |
1 |
100.0 |
0 |
0.0 |
1 |
|
Seniority in the profession |
|
|
|
|
|
|
[1 - 10] |
56 |
50.9 |
54 |
49.1 |
110 |
0.314 |
[11 - 20] |
6 |
40.0 |
9 |
60.0 |
15 |
|
[21 - 30] |
1 |
20.0 |
4 |
80.0 |
5 |
|
Socio-professional category |
Nurses |
20 |
55.6 |
16 |
44.4 |
36 |
0.012 |
General practitioner |
25 |
62.5 |
15 |
37.5 |
40 |
|
Midwife |
18 |
33.3 |
36 |
66.7 |
54 |
|
Employment sector |
|
|
|
|
|
|
Private |
45 |
48.9 |
47 |
51.1 |
92 |
0.873 |
Public |
18 |
47.4 |
20 |
52.6 |
38 |
|
Level in the health services pyramid |
Intermediate level |
9 |
52.9 |
8 |
47.1 |
17 |
0.692 |
Peripheral level |
54 |
47.8 |
59 |
52.2 |
113 |
|
Continuing training on breast cancer |
No |
49 |
48.5 |
52 |
51.5 |
101 |
0.982 |
Yes |
14 |
48.3 |
15 |
51.7 |
29 |
|
4. Discussion
4.1. Overall Knowledge of Healthcare Professionals Regarding Breast Cancer
The overall level of knowledge was poor among the majority of healthcare professionals (78.5%); 16.9% had an insufficient level of knowledge and 4.6% had an average level of knowledge. This result is close to that of Zine who reported that the majority of general practitioners were not sufficiently informed about breast cancer in 2016 in Morocco [13]. Obossou showed through his study that the knowledge of risk factors, suggestive signs, diagnostic methods and therapeutic methods of breast cancer by the healthcare professionals surveyed was worse in Parakou in 2025 [11]. On the other hand, Kemfang et al. found that the level of knowledge of healthcare professionals at the General Hospital in Yaounde regarding breast cancer was good [14]. This difference could be explained by the fact that the study population of Obossou and Kemfang included in addition to nurses, midwives and general practitioners as in our study, the specialists or resident doctors whose training and knowledge are reinforced. Gnangnon et al. in Cotonou (Benin) reported that 72.8% of general practitioners had an average knowledge score on breast cancer, 13.1% had a low level of knowledge and only 14.1% had a high level of knowledge [15]. This highlights the importance of strengthening the skills of healthcare professionals in the municipality of Parakou regarding the description, risk factors, suggestive signs, as well as screening and treatment methods for breast cancer. It is indeed essential for them to be well informed about breast cancer. They can exert a significant influence in convincing women to be diagnosed earlier in order to improve the prognosis of this pathology [3].
4.2. Overall Attitude of Healthcare Professionals Regarding Breast Cancer
Among the healthcare professionals, 44.6% of them had an approximate attitude regarding breast cancer, while 39.2% of them had an incorrect attitude. A rate of 10% of healthcare professionals had a harmful attitude and only 6.2% had a correct attitude. On the other hand, Gnangnon et al. had reported in 2022 that 42.4% of doctors had a good attitude, 37% had an average attitude score and 20.6% had a low attitude score [15].
4.3. Global Practice of Healthcare Professionals Regarding Breast Cancer
In the healthcare professionals surveyed, only 5.4% had adequate practices regarding breast cancer. The practices observed were inadequate in almost half (49.2%) of the healthcare professionals surveyed while 45.4% of them had harmful practices. According to a study of Gnangnon et al. in Cotonou in 2022, 60.9% of general practitioners had a high practice score; 35.9% had an average practice score while only 3.3% had a low practice score [15].
4.4. Overall KAP Score
Our study showed that just over half of the healthcare professionals in the city of Parakou in 2024 (51.5%) had an acceptable overall KAP score, while 48.5% had a poor KAP score. On the other hand, none of the healthcare professionals in the municipality of Parakou in 2024 had a good KAP score. According to Obossou in Parakou in 2015, more than half (64.05%) of the healthcare professionals had a poor KAP score [11]. Gnangnon et al. reported that only 6.5% of general practitioners had a low KAP score and the majority of them (77.2%) had an average KAP score [15]. These results could be explained by the fact that only general practitioners were included in the study of Gnangnon et al. The socio-professional category in our study had a statistically significant influence on the overall KAP score (P-value = 0.012). Midwives had a better KAP score than nurses and general practitioners. In the study carried out in Cotonou in 2022, 16.3% of general practitioners had a high KAP score [15]. These results reveal the deficiency in the knowledge, attitudes and practices of general practitioners regarding breast cancer. According to Obossou et al. in 2015, the socio-professional category had a statistically significant influence on the KAP score. His study showed that gynecologists, general practitioners and midwives had a better KAP score than nurses [11].
5. Conclusion
The knowledge of breast cancer among healthcare professionals in the municipality of Parakou in 2024 is insufficient. Furthermore, few healthcare professionals had an appropriate attitude and adequate practices regarding breast cancer. Half of the participants had an acceptable overall KAP score. These gaps in knowledge, attitudes and practices among healthcare professionals contribute to the late detection of advanced forms of the disease. Continuing training is essential to update these healthcare professionals.