CANCER PREVENTION : ATTITUDES AND PRACTICES AMONG BLACK SOUTH AFRICAN UNIVERSITY STUDENTS

This study intended to investigate the attitudes and practices of cancer prevention among Black South African university students. The sample included 793 Black University students from non-health courses chosen at random from the University of the North, South Africa. The students were 370 (46.7%) males and 423 (53.3%) females between the ages of 18 to 25 years (M age 21.0 years, SD=3.48). Results indicate that 27.5% of the women said that they knew how to examine their breasts. About one third (34.2%) of those who knew about breast self-examination never did breast self-examination and 25.5% did it the recommended 10 and more times a year. While 87.8% had never had a cervical smear test, 6.8% had at least one the previous year. Overall, 24.2% of the male students knew how to examine their testicles for cancer, and from those who knew this 41.9% had never done it and 22.1% did it the recommended 10 times and more a year. Logistic regression found that attitudes were an independent predictor for testicles self-examination but not for breast self-examination and cervical (pap) smear test. If cancer self-examination and tests are to be adopted on a wider scale, more effective promotion will be required.


INTRODUCTION
Cervical cancer is the most common form of malignancy that affects women in virtually all developing countries.It is also a leading cause of death among women in developing countries where it may account for up to 80% of all gynaecology cancers (Rogo, Omany, Onyango, Ojwang & Stendahl, 1990:249).
In South Africa, the age adjusted burden of cancer in the African population is much less than that in the local White population, and than that in western populations.However, transitional and environmental changes have been taking place.
In developed countries 80% of cervical cancer cases are in the early stages and curable.However, in developing countries 80% of cervical cancer cases are incurable at the time of detection, if they are detected at all (WHO, 1996:346).Reports from developed countries have shown routine screening to be effective in reducing morbidity and mortality from cervical cancer (Ajayi & Adewole, 1998:42).Although regular breast self-examination may reduce breast cancer mortality, the majority of women do not practice it (Salazar, 1994:49).Katz, Meyers and Walls (1995:377) found among College students in USA that both men and women were poorly informed about cancer risk factors, warning signs and self-examination practices for testicular cancer and breast cancer.1994:206).
Research into the social and psychological predictors of preventive health behaviours has consistently found that attitudes towards the behaviour are significantly associated with compliance (Janz & Becker, 1984:1).Investigations of cancer self-examination practice have found similar results, with attitudes towards breast selfexamination, particularly belief in it's benefits or efficacy, being strongly associated with breast selfexamination frequency (Walker & Glanz, 1986:169;Wardle et al. 1995:61;Wardle et al. 1994:296).Although some studies have investigated knowledge and attitudes towards cancer among African populations (Walker, Walker, Jerling, Pinto-Pereira, 1996:400), no study could be found on the actual cancer preventive practices.The data of the present study permitted the evaluation of the association between cancer self-examination attitudes and cancer self-examination practice.
The aims of the study were to evaluate the attitudes, knowledge and preventive practices of breast selfexamination and cervical smear test among young Black South Africa women and the attitudes, knowledge and preventive practices of testicle selfexamination among young Black South African men, and to establish a predictive value between the preventive practice and attitudes.

Data collection
Data were collected by a self-administered questionnaire in a class room situation after informed consent had been obtained.Participants were assured of complete anonymity.

Breast self-examination and cervical (pap) smear practice
Women were asked whether they knew how to examine their breasts for lumps (Yes/No) and if so, how often they examine them.Response options were never, 1 to 2 times per year, 3 to 10 times per year and more than 10 times per year.This last category was considered to represent adequate compliance with a monthly breast self-examination recommendation (Wardle, Steptoe, Smith et al. 1995: 62f.).Women were further asked how long it has been since they had a cervical (pap) smear test, and the reponse options were never, less than one year, 1 to 3 years, and more than 3 years.

Breast self-examination and cervical smear test attitude
This was indexed by a single question on attitude to breast self-examination (how important to health is it for women to examine their breasts at least once a month for possible signs of cancer?), and a single question on attitude to cervical smear test (how important to health is it for women to have a regular cervical smear test?).Both questions were scored from 1 (not at all important) to 10 (very important) (Wardle et al. 1995:62f.).

Testicle self-examination practice and attitude
Men were asked whether they knew how to examine their testicles for lumps (Yes/No) and if so, how often they examine them.Response options were never, 1 to 2 times per year, 3 to 10 times per year and more than 10 times per year.This last category was considered to represent adequate compliance with a monthly testicle self-examination recommendation.
This was indexed by a single question on attitude to testicle self-examination (how important to health is it for men to examine their testicles at least once a month for possible signs of cancer?).The question was scored from 1 (not at all important) to 10 (very important) (pers.com.Prof. Steptoe, 14 September 1999).
Cronbach alpha as well as split-half reliability coefficients for the 'cancer scale ' was .72 and .89for this sample.

Data analysis
Descriptive statistics and regression analyses was used to analyse the data with the SPSS (version 8).

Knowledge and practice of breast selfexamination and cervical (pap) smear test
Overall, 27.5% of the women students said that they know how to examine their breasts.The breast self-examination frequency who knew how to examine their breasts and the frequency of pap smear tests are shown in Table1.About one third (34.2%) of those who knew about breast selfexamination never did breast self-examination and 87.8% had never had a cervical smear test.

Knowledge and practice of testicles selfexamination for cancer (lumps)
Overall, 24.2% of the male students knew how to examine their testicles for cancer.From those who knew how to examine their testicles for cancer 41.9% had never done it, 14% 1-2 times, 22.1% 3-4 times, and 22.1% the recommended more than 10 times.

Attitudes to breast self-examination, cervical (pap) smear and testicles self-examination
In relation to the importance of health benefits of breast self-examination, cervical (Pap) smear, and testicles self-examination women had a mean rating of 6.4 (SD=3.9)for breast self-examination and 5.9 (SD=3.9)for cervical (pap) smear and men had a mean rating of 6.2 (SD=3.9)for testicle selfexamination.
The predictive value of attitudes to breast selfexamination, attitudes to cervical (pap) smear, and attitudes to testicles self-examination was evaluated by logistic regression.For this analysis, breast selfexamination, cervical (pap) smear and testicles selfexamination were coded as never (0) or ever (1).Results revealed that attitudes were an independent predictor for testicles self-examination (Wald=8.80,p<.003, r= .19,Odds Ratio= 1.18) but not for breast self-examination and cervical (Pap) smear test.

DISCUSSION
The low levels of breast self-examination identified in this study are disturbing in view of the fact that the recommendation of the South African Cancer Association for Breast Self-Examination is monthly after the age of 18, 7 days after the period stops, and for Testicular Self-Examination monthly after the age of puberty (pers. com. Cancer Association, South Africa, 14 August 2000).Among European University students 54% of the women reported as never having practiced breast self-examination, 8% monthly, and 36% reporting regular breast selfexamination (Wardle et al. 1995:61).Budden (1995:23) found among 17-45 year old American College women that 99% had performed breast selfexamination in the previous 12 months, though fewer than half rated it as regular.
Only 24.2% of the male students knew how to examine their testicles for cancer.

CONCLUSION
Both the low levels of attitudes, knowledge and preventive practices of cancer self-examination and the low ratings of the importance of cancer selfexamination practice suggest that young women and men in South Africa are unaware of the value of this method of early detection of cancer.If cancer self-examination and tests are to be adopted on a wider scale, more effective promotion will be required.
Knowledge deficiencies and low preventive selfexamination practices for testicular cancer, breast cancer and cervical cancer among young Black South Africans need to be addressed such as in a national pap smear screening programme to reduce the incidence of cancer of the cervix as suggested by Sitas and Norman (1995:156).
If cancer self-examination is to continue to be promoted as part of the cancer prevention effort in South Africa, then it would appear to be vital to improve the succes of cancer self-examination advice in influencing behaviour as well as attitudes (cf.Wardle et al. 1995:67).
Breast self-examination is recommended for the early detection of breast cancer in the European Code against Cancer and by the Cancer Association of South Africa.Early detection of breast, cervical and testicular cancer can reduce cancer mortality.Testicular self-examination is also recommended for the early detection of testicular cancer (Cancer Association of South Africa, 2000; Wardle, Steptoe, Smith, Groll-Knapp, Koller, Smith & Brodziak, 1995:61; Wardle, Steptoe, Burckhardt et al. The sample included 793 Black University students from non-health courses chosen from randomly selected classes from the University of the North, South Africa.The students were 370 (46.7%) males and 423 (53.3%) females between the ages of 18 to 25 years (M age 21.0 years, SD=3.48).Twenty-four percent of the students studied in the Faculty of Mathematics and Natural Sciences, 46.9% in Management Sciences, and 28.4% in Arts and Social Sciences.Most came from a not very welloff (45.5%) or quite poor (24.1%) academic background.