A PRELIMINARY PSYCHOMETRIC ASSESSMENT OF THE ATTITUDE OF HEALTH TRAINEE UNDERGRADUATE STUDENTS TOWARDS BREAST-SELF EXAMINATION IN GHANA

Breast self-Examination (BSE) is the cheapest most recommended Breast Cancer (BC) preventive tool for resource-deprived settings. There is paucity in the attitude research domain and comparative gender assessments of the BSE knowledge, attitude and performance (KAP) literature. Purpose: The purpose of this study was to assess the combined and exclusive gender BSE attitude of undergraduate health trainees and to determine significant differences between scores of both genders. Methodology: participants included 5 undergraduate health trainee classes purposively sampled from 2 faculties. Online cross-sectional method was used to assess BSE attitude of 336 purposively sampled Kwame Nkrumah University of Science and technology (KNUST) College of Health Sciences (CoHS) students. Data was analyzed using descriptive and inferential statistical analyses. Main findings: Compared to the construction groups’ average norm of 101.17 (SD = 9.55), our study participants’ (SPs) BSE attitude was lower (92.51; SD = 11.80). However, using popular mid-point and 3part attitude scoring methods, our SPs’ attitude scores were comparable to sub-regional and national findings. Moreover,the male participants scored a generally high BSE attitude but significantly lower compared to their female counterparts (p < 0.5). Recommendations: There is the need to adjust the curriculum of all health trainees in developing nations to reflect relevant BC preventive measures. Furthermore, BSE research, education as well as advocacy should involve more males as important BC BSE stake holders.


Introduction
Breast Cancer (BC) is a life-threatening malignant tumor that starts from the cells of the breast tissue (Ali & Coombes, 2002 ;Kudzawu et al., 2016) and spreads through the lymphatic system to invade important body parts and organs through metastasis (Peepliwal & Tandale, 2013). This disease causes very high morbidity and mortality among many females and relatively fewer males. Undoubtedly, female global BC incidences, and mortality are on the increase and currently form 12.5% (i.e., 2,261,419 out of 18,094,716) of all 2020 cancer cases in all ages globally and 6.9 % mortality (684 996 out of 9 894 402 deaths) of all ages as well as all sexes according to the International Agency for Research on Cancer (IARC) report . IARC's Globocan report also predicts an increase in future breast cancer incidence and mortality burden worldwide from the 2020 estimates of 2.26 Million and 685 000 to increase to 3.19 Million and 1.04 million respectively in 2040, IARC (2020). There is also evidence that male BC incidence is on the rise globally (Al-Naggar, Al-Naggar, 2012; Giordano et al.,2004 ;RamBihariLal Shrivastava et al., 2013;Stang et al., 2008) and on the African continent, Al-Naggar, Al-Naggar, (2012). On the African front, the later quoted Ojara 1978;Bhagwandeen, 1972;Giordano, Buzdar &, Hortobagyi, 2002 ;Sasco, Lowenfels & Pasker-de Jong, 1993) to have reported over three decades ago that there was 5 to 15% increases in male breast cancer incidence even amid scarcity of data. Currently, BC is the commonest female malignant disease accounting for the majority of cancer related mortality in Ghana (Korankye et al., 2016;Ohene -Yeboah & Adjei, 2012). The statistics do not look good and are worsening at an alarming rate. Early BC detection through relevant screening methods will not only decrease mortality rates by 25-30% Azaiza & Cohen (2006), it can go a long way to enhance treatment by considerably reducing morbidity, mortality, and improving women's overall quality of life (Ali, & Coombes, 2002;Didarloo, Nabilou & Khalkhali, 2017). The American Cancer Society (2016) recommends clinical breast examination (CBE), mammography and Breast Self-Examination (BSE) as the most effective prevention tools against the high rising BC morbidity and mortality. Ideally, women between 20 and 30 years and above 40 years should undergo a thorough CBE by a qualified health care provider every three years (Abdul-Lateef & Shabaan, 2019 ; Wieland & Hartman, 2011). However the high cost makes it inaccessible for women in Low and Middle Income Countries (LMICs) such as Ghana.This plausibly explains why as high as 60% of BC cases are discovered at a later stage (Black & Richmond 2019;Mena et al., 2014), a hallmark of BC health seeking behaviour with poor treatment outcomes, Opoku, Benwell & Yarney (2012). Thus, for women in LMICs, BSE is by far the cheapest non-intrusive BC preventive tool most researchers, health professionals and promoters unequivocally recommend. Although BSE Knowledge Attitude and Performance (KAP) has received a fair share of research effort around the globe, a perusal of the literature revealed so many challenges. An important one is the fact that generally in terms of gender, majority of the BSE research effort has justifiably concentrated on women probably because of their relatively higher BC incidence, morbidity and mortality. Men have been underrepresented, meanwhile they are becoming important BC BSE stakeholders for numerous compelling reasons including rising male BC incidents, bereavement due to loss of their female significant others, majority possibly being at the forefront of relevant decisions making bodies that impact important BC BSE activities and many more explained in detail in an ongoing follow-up article. Some other problems are that BSE research studies have generally exclusively focused on females and there is also underrepresentation of health professional trainees -other than nurses. Thus, the BSE KAP of this cohort, especially the mixed gender, has not received much research attention.
Many of these BSE KAP researchers use mostly nurses and nursing trainees because they consider them BC (future) educators whose BSE KAP scores by virtue of their exposure via curriculum, could be used as a benchmark for comparing the scores of their non -nursing compatriots and the general populace. Even in instances where there are mixed gender health trainees, some researchers, for example (Misauno et al., 2011;Sheikh Alaudeen., & Ganesan, 2019), have limited some aspects of their BSE KAP research participation to only the female students. That state of affair needs to change because in this 21 st century, a particular gender domination of most health professions such as medicine, nursing, laboratory technology, physician assistantship etc., is quickly becoming a thing of the past and every health professional, male or female, is duty bound to offer life-saving BSE education to their clients. This is substantiated by the evidence that compared to women who become cognizant of BSE from diverse sources, those that obtained personalized instructions from health care professionals exhibited superior knowledge and portrayed higher confidence as well as higher propensity to routinely practise BSE (Misauno et al., 2011). Again, generally female knowledge of BC and BSE are quite high but actual BSE performance is disappointingly low globally. The key to understanding this disappointingly abysmal translation of BC/ BSE knowledge into BSE practice is the attitude which social psychologists define as "…a positive or negative evaluative reaction towards a stimulus such as a person, action, object, or concept…" p. 639 of (Passer & Smith, 2011quoting Crano & Prislin 2006, which predispose us (humans) to act and feel in a certain way, Lahey (2012), emphasis ours. It encompasses 3 aspects, namely; cognition comprising covert mental processes such as knowledge; emotions or feelings, and overt behaviour (Passer & Smith, 2011;Lahey (2012). Attitude informs the propensity of an individual to personally engage in, and/or encourage other people to engage in important preventive health behaviour such as BSE.

Problem statement
While globally BSE has received much research effort among various female professionals (Ali et al., 2019;Azaiza & Cohen, 2006 ;Didarloo, A., Nabilou, B., & Khalkhali, H. R. 2017;Ibnawadh et al., 2017;Kudzawu et al., 2016;Nde et al., 2015b;Race & Silverberg, 1996) etc., and a few among males (Al-Naggar & Al-Naggar 2012; Giordano, Buzdar & Hortobagyi 2002;Stang & Thomssen, 2008, etc), the same cannot be said of Sub-saharan Africa (SSA). In fact, on the African continent, a recent very comprehensive systematic review conducted by Udoh et al., (2020) involving 21 research articles that met the inclusion criteria from 264 potentially eligible BSE studies done in the SSA, concluded among others that there is "…limited literature on women's attitudes towards BSE…" (p. 6). Thus, even among the extant predominantly female BSE literature, there is paucity in the attitude aspect of the whole BSE KAP research areas, as most have focused on the knowledge and practice areas at the expense of attitude. In Ghana BSE KAP research is not encouraging. Even though some BC/ BSE studies have been conducted, only 2; Fondjo et al., (2018) and Sarfo et al., (2013) who assessed attitude as part of their studies, met the inclusion criteria in Udoh et al.'s review. Sarfo et al's research among female university students of the Presbyterian University College of Ghana, Asante Akyem Campus found that the majority (95%) had heard of both BC and BSE from media and their curricular sources, only 80% out of that number knew how to perform the latter. Also they found an unspecified majority having a good attitude towards BC but was silent on attitude towards BSE. Fondjo et al., (2018) recently compared KAP of BC BSE among 1,036 female KNUST undergraduate and secondary students in a very comprehensive study. They also found that although 90.9% of their participants were aware and 54% highly knowledgeable of BSE, only 8.1% practiced BSE monthly as recommended. Also comparatively, the undergraduate female students were more knowledgeable, had a more positive attitude and practiced BSE more often and accurately than their secondary compatriots even though most (96.3%) agreed BSE was a good preventive breast-health practice. More so, they reported almost 97% of all female undergraduates and secondary school participants had a good attitude with the former having significantly higher. In Kumasi, Ghana, another study among 50 Garden City University College (GUCC) undergraduate midwives by Nsemo et al., (2020) has been published. Among others, they reported all 50 students (100%) of the students had good knowledge, 84% positive attitude and 68% ever performed BSE prior to study. However, 52% do not engage in BSE regularly due in part to forgetfulness (28%) and fear of finding a mass (6%). Thus, not only is research evidence on BSE KAP among KNUST undergraduate nursing trainees lacking, research among non-nursing health professional trainees (i.e., medical, dental, physician assistantship, etc.,) has never been carried out to the best of the authors' knowledge. Again, globally, most BSE KAP studies use self constructed, self administered questionnaire constructed from literature, and there is not only the need to compliment their research efforts, but also, the need to investigate how psychometrically based BSE results using universally accepted valid and reliable psychometric test compare with international, continental, sub-regional and national BSE attitude findings. As far as the authors are concerned, no study has assessed mixed and exclusive gender attitudes towards BSE among health professional trainees in Ghana. Also none has determined if there is significant differences in the average gender BSE attitude scores among this cohort.This study therefore aims to: (i) determine the attitude of mixed gender health trainee undergraduate students towards breast self-examination, (ii) determine the attitude of exclusive male and female health trainee undergraduate students towards breast self-examination and (iii) determine if there is a significant difference between average breast self-examination attitude scores of female and male health trainee undergraduate students. For this 3rd objective, we hypothesized that: H0: There are no significant differences between the mean scores for breast selfexamination of both genders, and H1: There are significant differences between the mean scores for breast selfexamination of both genders.

Materials & Methods
Being a preliminary study and focusing on undergraduate health trainees, a purposive sampling method was used to select participants from 5 undergraduate classes from 2 faculties in the CoHS, KNUST. To qualify to participate in this research, participants had to be students in KNUST, must be in undergraduate level, must be a health trainee student in CoHS, 17 years and above. Online cross -sectional method was used in this study to ascertain the attitude toward BSE among 336 voluntary participants. For the entire research, the questionnaire was developed into a 5 section Google form link, giving participants access to respectively demographic characteristics consisting of 8 questions, BSE attitude measure consisting of 24 items, 18-item Multidimensional Health Locus of Control scale (MHLC), 5-item Satisfaction with Life Scale (SWL), and 5 self-constructed questions assessing actual BSE performance. The Google link was forwarded to participants for voluntary participation after going through the participants' information sheet which included more information about the study and guarantees of confidentiality. The first voluntary 20 participants were used to pretest all measures used and their Cronbach's Alpha values reported with the description of each of the measures used for achieving the objectives above.

Measures Used
The measure used for this manuscript is Breast Self-Examination (BSE) obtained from Corcoran & Fisher (2000). This BSE attitude psychometric measure was developed by Race and Silverberg (1996), consists of 24 items and measures attitude towards BSE. Drawing from the attitude category of previous research based on an adapted version of the Health Belief Model (Champion 1992;Salazar & Carter 1993). Race and Silverberg developed this BSE to cover perceived seriousness, BC susceptibility, health motivation, breast abnormality activities, performance issues (i.e., time availability, difficulty, self-touch etc.) and concern for others. Each item is a 6 -point likert scale from strongly disagree (1) to strongly agree (6)

Procedure
The researchers solicited voluntary participation from purposively sampled CoHS undergraduate students. Ethical consent process was undertaken in two ways; either online or in hard copy through the class representatives. After giving them information including objectives of the study and assurances of confidentiality, the investigators appealed for their voluntary participation.
Those that accepted to participate through direct contact were required to fill a hard copy consent form, and those contacted indirectly through their class representatives and social media were given a link to the soft copy of the exact consent form to fill. After consent, the link to the Google form was distributed to participants to logon to complete. Ethics clearance (ref number CHRPE/AP/066/21) was obtained from the Committee on Human Research, Publication and Ethics (CHRPE) in KNUST, Kumasi, Ghana. On the whole 336 students responded excluding 20 of the early participants used for pretesting to determine if the questionnaire and instructions of measures were comprehensible and suitable. The data was analyzed using SPSS version 20.

Data Analysis
A descriptive analysis was used to determine the overall attitude of all study participants, and that of exclusive male and female health undergraduate students towards BSE. For the 3 rd objective an independent sample t -test was used to determine if there was a significant difference between average attitude scores of both genders.

Results
This study had 336 participants and out of that majority (59.8%) of them were females while the male respondents were 40.2%. The participants' age range was between 17 and 38 years (M = 21 years, SD = 2.9). Table 1 summarizes the demographic characteristics of the Study Participants (SPs).  1 and 2, the psychometric test instruction, popular BSE researchers' mid-point cutoff and the 3 range attitude scoring criteria were used for easy comparison and discussion with extant BSE attitude research evidence.

Objective 1 3.1.1 Using the psychometric test instruction
The overall average mixed gender score of the current study participants' (SPs) on the breast selfexamination measure (BSE) is 92.51 (SD = 11.80).

Using Mid -Point Cut -Off
With a maximum BSE attitude score of 144, 72 is the midpoint (median) and scores below and above indicate low and high attitude respectively. The average attitude scores of all participants, exclusive male and female participants are as summarized in Table 2 below.   Table 3 above the exclusive male BSE average score was 89.42 (SD = 12.29) and 3.7% as well as 96.3% of the male participants had BSE average scores below and above the 72 mark cutoff point with respective means of 48.40 (SD= 17.60) and 91.00 (SD= 8.91). Similarly, the exclusive female BSE average score was 94.59 (SD= 11.02) and 1.5% and 98.5% of the female participants scored below and above the 72 cutoff point with mean scores of 43.67 (SD = 20.13) and 95.36 (SD= 8.91) respectively.

Using the 3 range attitude scoring method
Using the 3 range attitude scores of low (1-48), moderate (49-96) and high (97-144), the BSE scores of all participants were computed and summarized in Table 4 below. Thus, 61.9%, 36.9% and 1.2% of the study participants had moderate, high and low attitude to breast self-examination, respectively. Also a cross tabulation was performed on gender and the results reported in Table 5 below.

Objective 3:
The current study also sought to determine whether there was significant difference between the mean scores of both genders using an independent sample t-test. The results are as reported in Table 6 below. From the hypotheses in objective 3 above, the p-value (0.365) was greater than the significance level of 0.05, hence we fail to reject the null hypothesis and conclude equal variance assumed at 95% level of confidence. Finally, since the p-value (0.000) obtained was less than the significance level of 0.05, the null hypothesis was rejected at 95% confidence interval, and therefore conclude that there is a significant difference between the mean attitude scores towards BSE for both genders.

Discussion
The objectives of the current study were to psychometrically determine the overall attitude of study participants (SPs), determine the exclusive male and female health trainee undergraduate students' attitude towards BSE and determine if there was a significant difference between scores of both genders. The female participants in the current study out-numbered their male compatriots by a nearly 3:2 ratio. The SPs' age range was between 17 and 38 years and their mean age was 21 years (SD ± 2.9) -well within the prescribed age of practice of BSE. Per the preamble under results above objective 1, the Study Participants' (SPs) scores are discussed based on 3 different approaches of attitude measurement namely; the psychometric test instruction, popular mid-point cut-offs and the 3 -range criterion of attitude assessment. A significant finding is that the overall average score on the Breast self-Examination (BSE) measure obtained by the combined mixed gender SPs is 92.51 (Table 2). This figure is lower compared with Race and Silverberg's (1996) USA construction proups' (CG's) mean BSE score of 101.17 [(SD=9.55), (Corcoran and Fishers, 2000;131)]. This finding may be explained by the cultural, demographic and gender differences between the American CG and the current SPs. Mixed gender participation in this current study may have lowered our SPs' overall average score on this BSE psychometric measure. Future research could focus on validation and standardization of this BSE measure to develop culturally relevant norms to allow for use with many more Ghanaian who do not understand english language and for easy interpretation of local test scores to guide and enhance BSE research. Another significant finding is that based on the mid-point criterion, 98.5% of the female SPs' scored high attitude with an average score of 94.54 above the cut-off (Table 3). This finding agrees with research evidence by (Ibnawadh, et al., 2017) who had 98.2% medical students and 96.4% of the non-medical students having a high attitude to endorse BSE as a necessity in Saudi Arabia. In the sub -saharan Africa (SSA), this finding is in line but higher than 73.6% of Nigerian secondary students who had positive attitudes, (Ifediora & Azuike, 2018). It is also similar but higher than findings by Sarfo et al., (2013) and Fondjo et al., (2018) who found "majority" and 97.1 % respectively having "good attitude" in female university undergraduate students in the Presbyterian University College of Ghana, Asante Akyem Campus and combined undergraduate and Senior Secondary School (SSS) female students in KNUST, Kumasi, Ghana respectively. This finding however contradicts findings by . who found 68% of Indian female Information Technology (IT) professionals to have poor attitude. The difference may be attributable to varying cultural and religious factors such as social stigma and norms. A female minority (1.5%) of the current SPs maintain a very low attitude towards BSE and future research should not only be intensified to identify them and their reasons for such a low BSE attitude, but also urgently educate them. Psychoeducation about BSE should remain a priority given that they may soon graduate and become important BC BSE stakeholders. Similarly, even though it is a well-known fact that male hardly engage in BSE for obvious reasons of low incidence of, or general ignorance about BC, the current study results revealed a surprising high average attitude score of 91.00 (SD=8.91) for the overwhelming majority (96.3%) of males who scored above the 72 mid-point cutoff. This is a welcoming result for BC interventions, education, advocacy and research since more males possibly control funding and breast health delivery systems. Also as husbands and family heads, this high male attitude, if replicated in the general population, would go a long way to conscientize males about their own and female sexual, reproductive and physical health, minimize the fear of divorce, reduce stigma, enhance quick interventions and reduce the male gender negative socio-cultural factor contributing to undue delays in BC orthodox health seeking behaviour observed by Opoku, Benwell & Yarney (2012). This finding of high male attitude towards BSE supports the objectives of the current study and the call for the involvement of many more males in BC advocacy, education and research. It must be added however that 3.7% of males have a low attitude, and similarly, there is the urgent need for replication of this study to find the actual percentage of the general male population to guide BC BSE education. Another finding worth noting is that using the 3 range (Low, Moderate and High) attitude scoring method, 1.2%, 61.9% and 36.9% of our SPs maintain respectively low, moderate and high overall attitude ranges towards BSE (Table 4). This replicates similar findings by Nde et al, (2015b;p.4), who observed an overall, 2.4% low, 63.3% moderate and 34.3% high attitude in Cameroonian female undergraduate students. A similar study using similar attitude scoring found a reverse trend of 9% low, 29% neutral (moderate) and 62% positive attitude among 183 female Malaysian Pharmacy Students towards BSE which may be explained by cultural differences since they had nearly 82% Chinese among their SPs, Ali et al., (2019). Again, cross tabulation figures in (Table  5) confirmed the general perception that females maintained a relatively higher attitude towards BSE. Thus, their percentages (1.5% versus 1 % low; 73.3% versus 54.2% moderate, and 25.2% versus 44.8%) of high attitude for males and females respectively reflect the trend discussed above. Although most males perceived BSE as not necessary citing low incidence of BC among same gender, they maintained a surprisingly 98.5% moderate to high BSE attitude compared with 99% for females' overall score. Another important finding is that there is a gender-based significant difference between their mean BSE attitude scores in favor of female gender with a p-value of (0.000) at 95% confidence interval (Table 6). Even though there are no studies comparing attitude of both genders, this finding is in line with qualitative research evidence by Al-Naggar & Al-Naggar, (2012) in Malaysia which suggests that males maintain a relatively lower attitude towards BSE because of lower BC incidences among them. They noted a similar global masculine attitude towards BSE when they wrote their participants "…considered that BSE is not important for men because they have a low probability of getting breast cancer…", Al-Naggar & Al-Naggar (2012: 243). That notwithstanding, they reported the majority of their SPs encouraged their family members to practise BSE. The fact that majority of their male participants encourage their significant family members to perform BSE is an attestation to the point being made in this research to include and encourage male participation in BSE KAP research and education as they are becoming important stakeholders.

Limitations
The outcomes of the current research must be carefully interpreted because the study is not without limitations. In the first place, the evidence so adduced were obtained from only 336 purposely sampled undergraduate health trainee student participants, which may not be very generalizable to the entire KNUST and Ghanaian population. That notwithstanding, this has provided a basis for a much bigger BSE attitude study in Ghana to involve different health trainees and mixed gender at a time and the general populace as a whole. This will also hopefully encourage the use of psychometric tests in the assessment of BSE KAP concepts and spur much more interdisciplinary collaborative research efforts.

Conclusion and Recommendations
BSE KAP research has previously justifiably focused on the female population, but it is time to rope in many more males who are fast becoming important stakeholders as male BC incidents increase. Moreover, with more males taking on previously female dominated professions that require them to educate their clients on BC and BSE, as heads of families and possibly majority decision makers of organizations and boards on issues affecting BC BSE research and education, it becomes critically important to involve them in research and education on the subject. There is also the potential for males to be involved by reminding their significant others of life saving BSE. Also, healthcare professionals and trainees have received enough research attention, more effort must be focused on the non-health professional population. More so, we reiterate the call by Misauno et al., (2011) for the need to adjust the curriculum used for training not only for nurses but all health trainee students in developing nations around the globe to reflect relevant BC preventive measures. Moreover, from the evidence adduced in the current study, researchers, advocates and activists must involve males at all levels in BC BSE KAP research and education for reasons given above. Finally, to make the conclusions of the current study more generalisable, an expanded follow-up multidisciplinary investigation with bigger randomly sampled SP drawn the entire university student population is highly recommended. This is because there may have been a potential bias that health undergraduate students were more knowledgeable of BC and may have been inclined to show acceptable attitudes towards BC BSE issues. This could also be replicated in the general populace to achieve a better evidenced-based knowledge on BSE KAP in Ghana.
Funding: This research received no external funding.