Breast cancer is the most common cancer women catch. Its incidence is increasing in developing countries because of the increasing life expectancy, the increasing urbanization and the adoption of Western lifestyles. Although a reduction in risk factors can be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed at a very late stage. Therefore, early detection to improve the outcomes and women survival to breast cancer remains the cornerstone of breast cancer control [1].

Breast cancer screening is almost non-existent in sub-Saharan Africa except in South Africa. Mammography is considered the only effective screening method but remains a complex and resourceintensive method. However, the inexpensive practice of breast selfexamination helps women to be self-reliant and responsible for their own health, even though it is poorly applied in sub-Saharan Africa mainly because of socio-cultural beliefs and lack of awareness campaign [2]. The objective of this study is therefore to study the knowledge, attitudes and practices of women using health services of a hospital in southern Benin for the breast cancer screening.

We conducted a descriptive cross-sectional study exploring the knowledge, attitudes and practices of women in southern Benin on breast cancer screening. The study was conducted at the Mother and Child Hospital (HOMEL) from July 1st to September 30th, 2017. The target population was women not younger than 30 years old and who came to the HOMEL for consultation during the study period. Were excluded those who were under 30 years old as well as those who refused to participate in the survey.

These women were chosen because of the age group at risk when it comes to women with breast cancer (≥ 30 years old). Indeed, while in Europe and in the United States, the average age of women with breast cancer at the time of diagnosis is around 60 years old, in Sub-Saharan Africa this average age is around 45 years old with peak standing between 35 and 45 years old [3,4].

We used a convenience and exhaustive sampling and excluded women who refused to take part in the survey. The data were collected via a structured questionnaire containing 16 items on the sociodemographic status of the participants; their knowledge of breast cancer definition, risk factors and screening methods; their attitudes and practices. The questionnaire was developed with reference to risk factors, symptoms of breast cancer and early detection methods developed in the literature and widely acknowledged by experts and researchers [3].

The bias of this study is related to the fact that this hospital is frequented by a population that come to the center with gynecological or obstetric problems in mind and therefore could have a better knowledge of the pathology than the general population.

Participation rate in the survey

The consultation service of the HOMEL registered during the survey period 366 women, 149 of which were at least 30 years old. Forty-nine women refused to participate in the study, leading to a participation rate of 67.1%.

Epidemiological profile

The average age of the respondents was 35.2 years old with extremes ranging from 30 to 48 years. The age bucket of 30 to 35 years old was the most represented (63%). They were shopkeepers (43%), Christian (79%) and never went to school (17%) (Table 1).

Table 1: Socio-demographic characteristics of women surveyed at CHU-MEL.

Definition, risk factors, symptoms and breast cancer screening methods

The definition of breast cancer was known in 37% of cases; 35% had no idea and 28% gave various answers such as "the bewitching, the lack of personal hygiene, coins put in bras, and hereditary diseases". The notion of breast cancer screening was known to 95 women and the source of information was respectively the media (52.6%), a health staff (20%), a friend (15.8%) and sensitization campaigns (11.6%).

More than half (51%) of the women had no knowledge of the risk factors of breast cancer (Table 2). For the symptoms of breast cancer, the highest level of knowledge was for the presence of a breast nodule (58% of interviewers) and the least was breast retraction (9% of interviewees) and breast asymmetry (8% of interviewees) (Table 2).

Table 2: Distribution of women studied by knowledge of risk factors, first symptoms, and breast cancer screening methods.

Breast self-examination was the known mean of detection for half of women (54%). Table 3 shows the distribution of women according to the practice of screening.

Table 3: Distribution of women by the screening method they use.

Moreover, more than 8 out of 10 respondents stated that they had never received breast screening by health personnel during a clinical examination.

Our study targeted women admitted for prenatal consultation at the Mother and Child Hospital (HOMEL), with an average age of 35.2 years old. Indeed, while in Europe and the United States, the average age of women with breast cancer at the time of diagnosis is around 60, in sub-Saharan Africa this average age is around 45 with a peak between 35 and 45 years old [2]. More than 3 out of 10 women had no idea what breast cancer was and 28% had cultural beliefs such as "craziness, lack of personal hygiene, putting coins in bras and hereditary diseases". This low rate of breast cancer knowledge can be explained in part by the fact that the majority of women in our study sample had a low level of education. This same trend was observed by Keita in Morocco [4].

The participants in the study were mostly women traders with a low level of education. According to Berraho et al. [5], the knowledge of the Moroccan population regarding certain risk factors or protection against cancer was better in subjects with higher levels of education compared to illiterates. Access to education must be an integral part of sustainable development policies. The media was the information channel for half of them. Serhier et al. [6] made the same finding where the source of information on breast cancer risk factors among medical students in Casablanca was mainly media 25% and the web 24%. The Faculty of Medicine as a source of information was cited by 7.7% of students. As a result, the use of breast cancer screening advertising campaigns on radio, TV and in social media would be an important contribution to improving the level of women's knowledge.

The risk factors for breast cancer were poorly known to women in our study. In a Faculty of Medicine in Casablanca, the knowledge of risk factors for breast cancer among students was slightly low with an average of just 10.6 (standard deviation of 2.9) [6]. Benaicha et al. [7] noted in a population of Moroccan women using care facilities that for the symptoms of breast cancer, the highest level of knowledge was breast mass (72.2%) and the lowest level was “elevated breast retraction” (41.3%). In our population, almost 4 out of 10 women (35%) had no knowledge of the warning signs of breast cancer. The palpation of a breast nodule was noted by only 6 out of 10 women and skin retraction by less than 1 out of 10 women. This lack of awareness of suggestive signs explains the delay in consultation observed by most African authors [2,8].

Breast self-examination was the best known screening method for women (54%). It was performed in half of the cases and was poorly performed in more than 9 out of 10 cases. In Morocco, it was known to 6 out of 10 women (62.7%). A statistically significant association was found between the dependent variable (knowledge of risk factors and symptoms of breast cancer) and age (p<0.01); professional occupation (p<0.01); living in a relationship (p=0.01); high socio-economic level (p<0.01); school attendance (p<0.0001), acceptance of clinical breast examination and social coverage (p=0.004) [4]. In Cameroon, among the 195 female health professionals at Yaoudé General Hospital, 157 (80.7%) performed breast cancer screening on themselves but less than a quarter (23.5%) regularly practiced it on a monthly basis [9]. In Jordan, they were 93 out of 900 (11%) to perform it [3].

In the absence of evidence of the effect of breast self-examination on the reduction of breast cancer mortality, many international health organizations nevertheless recommend that women practice BSE that put them in a position to be in charge of their own health. In the absence of an organized mammography screening system in poor countries, Breast self-examination continues to be recommended in Africa as a screening tool [10]. Health professionals should therefore be more involved in rising in these countries women's awareness on this gesture. More than 8 out of 10 respondents said they had never received breast screening by health staff during a clinical examination in our study. The same is true in Morocco, where more than half (51.5%) of participants did not have a clinical breast examination performed by health professionals. In Yemen [11], they were 89%. The health worker is an important player in cancer prevention. These are opportunities missed by health professionals to inform, guide and screen women.

A study conducted in Tunisia on the knowledge, attitude and practice (CAP) of nurses in breast cancer screening shows that only 46.4% have a CAP score greater than or equal to 16. Lack of knowledge, time and workload were among the situations that prevented the adoption of preventive breast screening behavior for 45.7% and 43.8% of nurses respectively [12]. In Morocco [13], general practitioners claimed to examine the breasts during a routine consultation in 68% of cases and asked for a mammogram in case of clinical signs in 97.6% of cases. As for Cameroon [9], the level of knowledge of health personnel about breast cancer, its risk factors and its screening methods is good. On the other hand, a significant proportion (41.5%) of staff considers that breast cancer screening can be done by ultrasound. It is therefore, necessary to adapt the training and retraining programs both at the level of the training units and at the hospital level for health workers.

The study has been carried out with the approval of administrative authorities at different levels. Confidentiality and anonymity of the data have been respected.

The results of this survey show that women's knowledge, attitudes and practices about breast cancer screening were not satisfactory. Appropriate educational campaigns need to be conducted by health actors to improve breast cancer early identification in our country.