Journal of the Scientific Society

: 2020  |  Volume : 47  |  Issue : 1  |  Page : 8--12

The effect of structured training program on awareness and behavior regarding breast self-examination among community health workers of South Delhi

Mamta Parashar1, Blessy Joseph1, Jasleen Kaur2, Mitasha Singh3,  
1 Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
2 Department of Community Medicine, Hamdard Institute of Medical Sciences, New Delhi, India
3 Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India

Correspondence Address:
Dr. Mitasha Singh
Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana


Background: Breast cancer is one of the malignant diseases where early diagnosis and treatment leads to a good prognosis. Breast self-examination (BSE) is the most cost-effective screening technique. Objective: The objective of the study is to assess the effect of training on awareness and behavior of BSE among the community health workers (CHWs). Methodology: A community-based interventional study was conducted among 148 Accredited Social Health Activist and Anganwadi Workers of the selected wards of South Delhi district in the year 2018. The study was done in three phases: baseline survey followed by intervention in the form of training session, which involved the use of nursing manikins for the demonstration of BSE technique and video demonstration, depicting proper performance of BSE. After a period of 2 weeks, the same questionnaire and training models were used on the same CHWs to assess the effect of the intervention on their awareness and behavior. Results: Although most of the CHWs were in the age group of 20–40 years and educated till higher secondary and above, only 40% had ever heard of self-breast examination and an even lesser number had ever performed self-breast examination before. The intervention helped in the increase of knowledge about the symptoms of breast cancer considerably. The confidence levels among CHWs and barriers seeking help in CHWs also improved and more people approached their doctors regarding changes seen in the breast, mainly lumps on self-examination. Conclusion: It was determined that the awareness and behavior change after training was positive. There is also effective improvement seen in confidence level and health-seeking behavior.

How to cite this article:
Parashar M, Joseph B, Kaur J, Singh M. The effect of structured training program on awareness and behavior regarding breast self-examination among community health workers of South Delhi.J Sci Soc 2020;47:8-12

How to cite this URL:
Parashar M, Joseph B, Kaur J, Singh M. The effect of structured training program on awareness and behavior regarding breast self-examination among community health workers of South Delhi. J Sci Soc [serial online] 2020 [cited 2020 Aug 5 ];47:8-12
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Full Text


Worldwide, breast cancer is the most invasive cancer in women.[1] Breast cancer comprises 22.9% of invasive cancers in women and 16% of all female cancers.[2] It ranked number one cancer among Indian females with age-adjusted rate as high as 25.8/100,000 women and mortality 12.7/100,000 women. The age-adjusted incidence rate of carcinoma of the breast was found as high as 41/lakh women for Delhi, followed by Chennai (37.9), Bengaluru (34.4), and Thiruvananthapuram (33.7).[3]

Breast being a visible organ, the mortality due to breast carcinoma can be prevented by the early detection and treatment of breast cancer.[4] The earlier the breast cancer is detected, the better the effectiveness of the treatment and likelihood of survival. Due to the lack of access to diagnostic facilities, especially for women in low-resource settings, it is essential to empower them with breast self-examination (BSE) as a primary modality for screening.[5] BSE requires no invasive intervention or any apparatus, protects women's privacy, and can be done comfortably alone by them. Its purpose is to make women familiar with both the appearance and feel of their breasts as early as possible so that they will be able to easily detect changes in their breast.[6] Several studies[7],[8] have revealed that a positive association exists between the performance of BSE and the detection of breast cancer.

Although BSE is a simple, quick, and cost-free procedure, it appears that many women either perform it incorrectly or not at all.[5] Community health workers (CHWs) are in an excellent position to make use of many opportunities to encourage women to be breast aware and practice BSE regularly. Thus, they can play an important role in educating women, as they are more frequently in contact with the patients and their relatives than other health professionals.[8] Moreover, since these workers are from the community, they are trusted and accessible, which makes it easier for them to help the people.[9] They can advise women in the community about BSE on an individualized or group basis only when they are themselves well equipped with a thorough knowledge and confidence.[10] The present study was conducted with an aim to assess the effect of training on awareness and practice of BSE among the CHWs.


Study design

This was community-based interventional study.

Study setting

The study was conducted in the selected wards of South Delhi. Ten wards within 10 km distance of the medical college were selected purposively from South Delhi district.

Study duration

The study was conducted from April to September 2018.

Study population

The study was conducted among CHWs, i.e., Accredited Social Health Activist (ASHA) and Anganwadi Workers (AWWs) of the selected wards of South Delhi district.

Inclusion criteria

ASHA and AWWs in the age group of 20–45 years who gave consent to participate in the study were included in the study.

Exclusion criteria

Those with a history of carcinoma or lump in the breast were excluded from the study.

Sample size

A study done among women in urban Ahmedabad demonstrated, the practice of BSE was found to increase to 19.6% from a baseline of 2.4%.[11] Assuming that among nurses the intervention would lead to an increase in the practice of BSE by at least this level, the sample size was calculated using Open Epi version 3.01 (Open Source Epidemiologic Statistics for Public Health, Atlanta, GA, USA) taking a power of 80% and level of significance of 5%. The minimum required sample size was 124. After adjusting for a dropout of 20%, the sample size required was rounded off to 150.


The study sample of 150 was distributed equally among ten selected wards. Hence, 15 workers from each ward were recruited for the purpose of the study. The desirable number of participants from each ward was selected using simple random sampling. The list of CHWs of the selected wards was sought, and after obtaining permission from the concerned authority, workers in all the selected wards were imparted training.

Study tool

Self-designed pretested semi-structured questionnaire: This included questions pertaining to: (a) sociodemographic profile and (b) awareness and behavior: Modified breast module of cancer awareness measure (BCAM) questionnaire[12]Intervention: (a) nursing Manikins for the demonstration of BSE technique, (b) video depicting proper performance of BSE.

Study procedure

After obtaining permission from the child development project officer of the selected areas, the data were collected from the study participants.

The study was conducted in three phases:

Phase 1: Baseline survey in which the sociodemographic information of participants was obtained. Further, the awareness and practice related to BSE was obtained after explaining the purpose of the study and obtaining informed consent from the participantsPhase 2: Intervention in the form of training sessionPhase 3: After a period of 2 weeks, the participants were followed up and the BCAM questionnaire was reintroduced. The attitude and confidence of participants in performing BSE were also studied.

Data collection and intervention procedure

The survey and intervention were performed during the monthly meetings of the workers. The selected study participants, along with other CHWs, were given training of a total 60–70 min after collecting the initial data. It included three sessions of brief 5-min talk about breast cancer by the investigator followed by 30-min video film and 30–35-min demonstration on BSE. The content of the film included the importance of BSE, anatomy of the breast, methods of performing BSE, and the schedule for BSE. After the film was over, they were given a demonstration of BSE on the nursing manikin. Participants were given an opportunity to practice the BSE and identify the small breast masses present in a silicone breast cancer examination training model. These demonstrations were done at a common place convenient for all workers in the community. Questions from the respondents were encouraged and a demonstration was performed by the few respondents themselves. After 2 weeks of intervention, the same questionnaire and training models were used on the same participants to assess the effect of the intervention on their awareness and practice. The women who identified any problem in their or in any other women's breast were examined by the investigator, and in case of any suspicion, they were referred to the attached tertiary care hospital for further higher investigations. After the training, a booklet containing the above information and photographs of breast cancer patients with other relevant information on BSE technique was given to the participants as a self-help material.

Ethical considerations

Permission was obtained from the Institutional Ethical Committee before the start of the study. Informed consent of each participant was sought and obtained.

Analysis and statistical tools

All the data regarding pre- and postintervention knowledge and practice variable were entered and analyzed using Microsoft Excel Spreadsheet. The data were checked for completeness, and two participants did not report for postintervention; hence, the final analysis was conducted on 148 participants. Proportions and frequencies were calculated for categorical variables.


A total of 148 participants were included in the final analysis of the study. Before the intervention, nearly two-third (65%) of the participants had heard of BSE and less than half (44.6%) had ever performed BSE on themselves. Majority of ASHA workers (73.3%) had heard of this procedure. Only 28.4% had attended training on BSE in the past 1 year [Table 1].{Table 1}

There was an overall increase in the proportion of participants having correct knowledge regarding the signs and symptoms of breast cancer after the intervention. The preintervention proportion of participants with correct knowledge ranged from 33.8% to 73%. This proportion of correct knowledge increased postintervention ranging from 79.7% to 97.3% [Table 2].{Table 2}

The confidence, skills, and behavior in relation to changes in the breast among the participants improved after the intervention. Only 4.1% of the participants used to check their breasts once every month and this proportion increased to 98.6% after the intervention. Majority (85.5%) also correctly demonstrated the BSE technique after the intervention. The confidence level improved slightly (very confident: 18.9% preintervention to 20.3% postintervention). The proportion of participants visiting to doctor after detecting a lump on the breast increased from 13.5% preintervention to 21.6% postintervention [Table 3].{Table 3}


This community-based intervention study assessed the CHWs for the awareness and behavior regarding breast cancer, its risk factors, and BSE. The study population predominantly belonged to the age group of 20–40 years similar to another study conducted in Delhi among nursing staff where the mean age was 35.8 years.[13] Yerpude et al. and Karunakaran et al. also conducted a similar study on women of rural South India with major representation from 31 to 40 years of age group.[14],[15] Majority of the above studies catered to the general population except for a study by Rao et al., who conducted intervention on auxiliary nurse–midwives.[16] Besides this, in our study, standard pretested and validated questionnaire, BCAM, was used to assess the awareness in contrast to others studies where a self-designed questionnaire was used.

Majority (83%) of the participants in our study were married, which was in concordance with a study from Turkey,[17] Delhi,[13], and rural South India.[14],[15],[16] Nearly two-thirds (63.5%) of the participants were educated till higher secondary and above. This distribution was also presented by Yerpude et al. and Rao et al. from rural South India.[14],[16] More than one-third of the study population from a study conducted by Karunakaran et al. in Kerala had attained education up to high school.[15] It has been found in our study that although 65% of the participants had heard of BSE, only 44.6% had ever performed it themselves. Majority of those who had previously heard of BSE were ASHAs. A lower awareness (25%) about BSE was reported by Seif and Aziz, among nursing and medical faculties.[18] The difference could be due to different methodologies and study settings.

In preintervention test about the knowledge of symptoms of breast cancer, 33.8%–73% of the participants had answered correctly. Post intervention, this knowledge increased to between 79.7% and 97.3% similar to a study conducted in Rwanda, in which the mean score increased from 75% to 93.8% after the intervention.[12] In a somewhat similar community-based intervention study by Rao et al., in South India where ANMs were trained for BSE who further trained the females residing in the same community, it was observed that the median knowledge score regarding symptoms increased after the intervention.[16] Gutnik et al. developed a training model to implement clinical breast examination screening in Malawi through breast health workers and reported that pretraining knowledge increased from 49% to 91%.[19] The biggest domains of knowledge improvement according to them were causes of breast cancer, risk factors, signs and symptoms, and treatment.[20] The difference in the increase of knowledge observed could be due to the selection of health workers in our study as opposed to laywomen by Gutnik et al.[19]

In the current study, 4.1% of the participants reported that they checked their breasts once every month, and this proportion increased to 98.6% after the intervention. Rao et al. also reported an increase (93%) in women performing SBE following the intervention.[16] Other studies from rural Kerala and Puducherry showed that only 16.5% and <15% practiced SBE on a monthly basis, respectively.[15],[20] Karunakaran et al. in their study from Kerala conducted a training program for AWWs and ASHA workers who further spread awareness among laywomen in their working area. The knowledge among the females of the community after awareness camp was observed to be 94%. Around 65% of the women knew at least one symptom of breast cancer, whereas 73% did not know the risk factors of breast cancer.[15] The improvement was lower in our study. Karunakaran et al. also reported that regular SBE was done by women who had a family history of breast cancer or had a recent training by CHW.[15]

The incidence of breast cancer in developing countries will continue to increase as life expectancy increases, increase in negative lifestyle choices, changes in reproductive factors as well as the scarcity of adequate facilities for detection and treatment. Low- and middle-income countries such as India with a double burden of breast and cervical cancers need cost-effective interventions to curb the rise.[21] Public education and creating awareness is and will be an important component for the early detection. Adequate care must be taken to ensure that techniques are sensitive to the culture and in the language of the region. To reach women of any community in relation to sensitive issues such as breast cancer, CHWs can play an indispensable role. Although training module including video and demonstration of SBE using mannequins has been utilized by many studies, the content of training for health workers has not been optimized or standardized by any competent authority, which is a limitation of our study as well. The development of standard curriculum will help to expand similar programs in other settings and this could be a further research area.


In context to developing country such as India, ANMs, ASHA, and other female paramedical staff can guide the women for screening and diagnosis of breast cancer along with raising awareness about breast cancer. However, for this to materialize, it has to be made sure that they themselves are trained in an effective manner to perform breast cancer screening regularly. At work, training programs and regular CMEs can help aid better delivery of breast care to the women.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1McGuire A, Brown JA, Malone C, McLaughlin R, Kerin MJ. Effects of age on the detection and management of breast cancer. Cancers (Basel) 2015;7:908-29.
2World Health Organization. Breast Cancer Burden. World Health Organization; 2015. Available from: [Last accessed on 2019 Jul 10].
3Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women. Asia Pac J Clin Oncol 2017;13:289-95.
4Coughlin SS, Ekwueme DU. Breast cancer as a global health concern. Cancer Epidemiol 2009;33:315-8.
5Birhane K, Alemayehu M, Anawte B, Gebremariyam G, Daniel R, Addis S, et al. Practices of breast self-examination and associated factors among female debre berhan university students. Int J Breast Cancer 2017;8026297:1-6.
6Ibrahim NA, Odusanya OO. Knowledge of risk factors, beliefs and practices of female healthcare professionals towards breast cancer in a tertiary institution in Lagos, Nigeria. BMC Cancer 2009;9:76.
7Bhakta P. Asian women's attitudes to breast self-examination. Nurs Times 1995;91:44-7.
8Moodi M, Mood MB, Sharifirad GR, Shahnazi H, Sharifzadeh G. Evaluation of breast self-examination program using health belief model in female students. J Res Med Sci 2011;16:316-22.
9Bala DV, Gameti H. An educational intervention study of self breast examination (SBE) in 250 women beneficiaries of urban health centers of west Zone of Ahmedabad. Healthline 2011;2:46-9.
10Linsell L, Forbes LJ, Burgess C, Kapari M, Thurnham A, Ramirez AJ. Validation of a measurement tool to assess awareness of breast cancer. Eur J Cancer 2010;46:1374-81.
11Bittencourt L, Scarinci IC. Training community health workers to promote breast cancer screening in Brazil. Health Promot Int 2019;34:95-101.
12Pace LE, Dusengimana JV, Keating NL, Hategekimana V, Rugema V, Bigirimana JB, et al. Impact of breast cancer early detection training on Rwandan health workers' knowledge and skills. J Glob Oncol 2018;4:1-0.
13Khokhar A. Effect of a training programme on knowledge of nurses from a missionary hospital in India regarding breast cancer and its screening. Asian Pac J Cancer Prev 2012;13:5985-7.
14Yerpude PN, Jogdand KS. Knowledge and practice of breast self-examination (SBE) among females in a rural area of South India. Natl J Community Med 2013;4:329-32.
15Karunakaran U, Thekkandathil N, Joseph M, Kannankai S, Kumaran JA. Clinical breast cancer screening – A camp-based study among rural women in North Kerala. J Evid Based Med Health 2017;4:3323-8.
16Rao RS, Nair S, Nair NS, Kamath VG. Acceptability and effectiveness of a breast health awareness programme for rural women in India. Indian J Med Sci 2005;59:398-402.
17Yılmaz M, Durmuş T. Health beliefs and breast cancer screening behavior among a group of female health professionals in turkey. J Breast Health 2016;12:18-24.
18Seif NA, Aziz MA. Effect of breast self-examination training program on knowledge, attitude and practice of a group of working women. J Egypt Nat Cancer Inst 2000;12:105-15.
19Gutnik L, Moses A, Stanley C, Tembo T, Lee C, Gopal S. From community lay women to breast health workers a pilot training model to implement clinical breast exam screening in Malawi. PLoSONE 2016;11:e0151389.
20Veena KS, Kollipaka R, Rekha R. The Knowledge and attitude of breast self-examination and mammography among rural women. Int J Reprod Contracept Obstet Gynecol 2015;4:1511-6.
21Jamison DT, Breman JG, Measham AR, Claeson M, Evans DB, Jha P, et al., editors. Cost-effective strategies for noncommunicable diseases, risk factors, and behaviors. Priorities in Health. Ch. 5. Washington (DC): The International Bank for Reconstruction and Development, the World Bank; 2006. Available from: [Last accessed on 2019 Aug 16].