CHAPTER TWO

LITERATURE REVIEW

1.1. The Concept of Health Education

Health education is any combination of learning experiences designed to facilitate voluntary

actions conducive to health (Green and Kreuter 1999). Health education teaches about physical,

mental, emotional and social health. It motivates students to improve and maintain their health,

prevent disease, and reduce risky behaviors. The maxim of ‘prevention is better than cure’

underpins the importance of health education. Health education curricula and instruction help

students learn skills they will use to make healthy choices throughout their lifetime. Curing a

patient’s illness is good, but many other people may fall sick from the same disease and it may

not be possible to cure all of them at the same time. If the disease can be prevented, everybody

is helped. This is where health education comes in. It is sum of all experiences which influence

habits, attitudes and knowledge relating to individual, family and community health. In other

words, it is a process that causes change in knowledge and attitude. It motivates a person to

acquire health information and put it into practice (Ekeke et al., 2012).

Health education according to Moronkola (2017) is also a process that bridges the gap between

health information and health practices, little wonder why Moronkola (2017) presented that

health education is a distinct academic programme that has its own philosophy, aims and

objective. The aims of health education as summarized by Aspaugh and Ezell(2013)are: to

inform and educate people on the need for a healthful life for quality living that will facilitate

productivity; encourage people to change negative attitude and practices to positive ones

that promote personal and community health; encourage people to be aware and use

available health care services; make people see the need to prevent diseases rather than

spending more time and money to treat them; encourage people to continue in their local ways

that promote health.

1
Studies have discovered that promoting and establishing healthy behaviours for younger

people is very useful to their growth and development. According to Akani et al., (2000)

education and health are inseparable and ensuring that children are healthy and able to learn is

an essential part of an effective education system. Schools according to Ajibola, (2017) are

places where good health promotion begins, starting in kindergarten and continuing through

high school. Thus, well-designed, well-resourced, and well-sustained health education in

Nigerian primary and secondary schools are pivot for a sustainable health in the

nation. Moronkola, (2017), reiterated the place of health education in school health programme

in that children are taught life skills, not merely academic skills with the aim of increasing a

child’s health knowledge, thereby fostering a positive attitude towards promoting healthy

behavior. The school has direct contact with more than 95% of a nation’s young people aged

5-17 years, which constitutes about 23% of the population ofa nation for about 6 hours a day,

and for up to 13 critical years of their social,psychological, physical and intellectual

development Ekeke (2015).

The need for the teaching of health education as a school subject in Nigeria secondary school

cannot be over emphasized when viewed from the under listed backdrop: a lot of health

challenges that occur later in life are caused by lack of information on healthy living;

preventable or treatable infectious diseases such as malaria, pneumonia, diarrhoea, measles and

HIV/AIDS account for more than 70 percent of the estimated one million under-five (5) deaths

in Nigeria; malnutrition is the underlying cause of morbidity and mortality of a significant

proportion of children under-5 in Nigeria; it accounts for more than 50 percent of deaths of

children in this age bracket; lack of proper and prior knowledge of a child about his/her health

could subsequently lead to death (Ekeke, 2018). With regards to the above, one needs to be

well informed to be able to make the right choices in daily life opportunities for one to enjoy

good health, and in doing this health education needs to be taught in schools.

2
1.2. The Concept of Breast Cancer

Cancer is a generic term for a group of diseases in which abnormal cells divide without control

and can affect any part of the body in various forms (World Health Organization, 2018). Breast

cancer is one of the most common cancers worldwide. Breast cancer typically produces no

symptoms when the tumor is small and is most easily treated. When breast cancer has grown

to a size that can be felt, the most common physical sign is a painless lump (American Cancer

Society, 2018). However, the disease is curable if it is detected early, and some of its risk

factors are modifiable. There is marked variation in morbidity and mortality of breast cancer

between the developed and developing countries (Youlden et al., 2014).

Breast cancer is characterized by the uncontrolled growth of cells in the milk-producing glands

of the breast. Breast cancer is a major global public health problem with an estimated over 1.5

million new cases worldwide and over 459,000 related deaths annually (Amin et al.,2018). The

breast and cervix are the major cancer killers for women above 30 years in developing countries

(WHO, 2018). In Nigeria, breast cancer is the most prevalent form of cancer of all female

cancers. It accounts for about 46% of female cancer reported in Abuja and Ibadan population-

based cancer registry between 2009 and 2010 (Jedy-Agba et al., 2012). Early diagnosis of

breast cancer has a positive effect on the prognosis, as well as limits the development of

complications and disability; it also increases life quality and survival. For breast examination,

three tests were recommended by American Cancer Society: clinical method, mammography,

and breast self-examination. Of these three methods recommended, breast self-examination

(BSE) remains the cheapest and easiest method for early diagnosis of breast cancer in Nigeria.

Other screening techniques such as mammography and clinical examination are not commonly

done in Nigeria due to low level of awareness, ignorance, illiteracy, and cost. Breast self-

examination (BSE) is a method of breast examination in which a woman inspects and examines

her breasts for lumps and changes in shape and colouras a result of abnormal growth of cells

3
in the mammalian gland. It is also the awareness of the woman about her breasts' normal

appearance, feel, and ability to identify changes that occur in terms of the breast size or shape,

the existence of lumps, dimples in the skin, skin redness, and discharge (Salawu & Akindiya,

2018).

1.2.1. Risk Factors of Breast Cancer

Demographic Factors

Gender

Breast cancer is a disease that is unique to women and is a rare malignancy in men, accounting

for less than 1% of all cases of cancer (Giordano et al., 2017). Breast cancer occurs more often

in older adult males who have had hormonal imbalance, exposure to radiation, and family

history of breast cancer, and the most common risk factor for this disease among men is

mutation of BRCA2 gene (Yousef 2017).

Age

After gender, age is the most important known risk factor for breast cancer (Thakur et al.,

2017). The incidence rate of breast cancer increases significantly with age and reaches its peak

in the age of menopause and then gradually decreases or remains constant (Kinm and Yoo

2015). In a case–control study, the age more than 50 years was associated with the incidence

rate of breast cancer (Mahouri et al., 2007). However, breast tumors in younger women appear

in larger size, advanced stages, positive lymph nodes, and weaker survival (Assi et al., 2013).

Blood group

The results of a review study showed that women with blood group A and Rhesus positive have

a higher risk of developing breast cancer, while women with blood group AB and Rhesus

negative have a lower risk of developing breast cancer (Meo et al., 2017). Although these

results were confirmed by a study in 2015 (Saxena et al., 2013), many researchers found no

relationship between the blood group and breast cancer(Flavarjani et al., 2014).

4
Reproductive Factors

Age of menopause

The age of menopause over 50 years is associated with an increased risk of breast cancer (Dai

et al., 2009).

Full-term pregnancy

Among parous women, the risk of breast cancer decreases with increasing parity (Ma et al.,

2010). In a case–control study, older age during the first childbirth was the most important risk

factor for breast cancer, with relative risk of more than six times (OR, 6.34; 95% CI, 2.04–27).

A study indicated that every childbirth reduces the risk of PR+ and ER+ cancers by up to 10%

(RR per birth, 0.89; 95% CI, 0.84–0.94), and women who were older at their first childbirth

had a 27% increased risk of developing breast cancer (RR, 1.27; 95% CI, 1.07–1.50). The

results of the studies showed that full term pregnancy is considered as a protective factor (Ma

et al., 2010) The results of a study showed that breast cancer is more likely to occur in

nulliparous women than women who have more than three children (OR, 1.98; 95% CI, 1.12–

3.49) (Balekouzou et al., 2017).

Pregnancy characteristics

The first pregnancy especially, plays an important role in the risk of developing breast cancer.

The results of studies showed that the risk of breast cancer is almost doubled in women who

give birth to their first child before the 33 weeks of gestation (OR, 2.1; 95% CI, 1.2–3.9)

(Melbye et al 1991). In a study, the risk of developing breast cancer increased in multiple births

(OR, 1.8; 95% CI, 1.1–3.0) Moreover, the results of this study showed a relationship between

placental abruption in the first pregnancy and an increased risk of developing breast cancer

(OR, 1.8; 95% CI, 1.1–3.0) (Innes and Byers 2004). The results of various studies indicated

the protective role of preeclampsia in breast cancer which can be due to decreased levels of

estrogen hormone and insulin-like growth factor 1 (IGF1) and increased levels of IGF-1-

5
binding protein, hCG, and AFP.58 The result of a case–control study showed an inverse

relationship between nausea and vomiting during pregnancy and the risk of developing breast

cancer (Innes and Byers 2004).

Hormonal Factors

Contraceptive methods

The role of contraceptive pills in the incident of breast cancer has been addressed in various

studies (Marchbanks et al., 2002). Williams et al (2018) showed a relationship between the

current use of contraceptives and breast lobular tumors (OR, 1.86; 95% CI, 1.08–3.20).

Researchers, regarding the association of medroxyprogesterone acetate with breast cancer,

have stated that this correlation may be due to the diagnosis of mammary tumors or the growth

of existing mammary tumors (Skegg et al., 1995). An increased risk of developing breast cancer

diminishes 5–10 years after the discontinuation of hormonal contraceptives (Zalforoli et al.,

2018).

Postmenopausal hormone therapy

A reanalysis of 51 epidemiological studies showed that risk of developing breast cancer

increases with the hormone replacement therapy (HRT) use, and this risk decreases following

the discontinuation of HRT use and diminishes after 5 years (Beral et al., 1997).

Hereditary Factors

Genetic factors

Although several genetic factors contribute to the incidence of breast cancer, approximately

40% of hereditary breast cancer cases occur due to mutations in the BRCA1 and BRCA2 genes

inherited through the dominant autosomal method (Cobian et al., 2017)

Family history of breast cancer

Family history of breast cancer is one of the major risk factors, which has been mentioned in

various studies (Sweeney et al., 2004). Researchers reported that women with a family history

6
of breast cancer (two or more cases in women younger than 50 years or three or more cases at

any age) who are negative in terms of BRCA mutations are approximately 11 times more likely

to develop breast cancer (Metcalfe et al., 2009). The history of early-onset breast cancer in

immediate relatives is a risk factor for the occurrence of breast cancer in BRCA1 and BRCA2

carriers.

1.3. Awareness of Female Undergraduates on Breast Cancer

A large number of studies in Nigeria concerning clinical presentation of breast cancer among

Nigerian women reported late presentation of the disease. This late presentation is directly

related to the level of awareness about breast cancer, the risk factors and practice of the

screening methods among Nigerian women. According to a study carried out by Saulawa

(2022), he opined that Majority of undergraduate pharmacy students of ABU, Zaria were aware

or have heard about breast cancer. This is similar with the findings reported from university of

Ibadan (Chioma and Asuzu, 2007) and university of Ilorin (Salaudeen et al., 2009) Southwest

Nigeria respectively. However, this is contrary to a study conducted in Malaysia where the vast

majority of the female university students had inadequate knowledge of breast cancer (Hadi et

al., 2010) This finding may be attributed to the fact that healthcare students offer a little bit of

cancers in their taught curricular. The findings in this study revealed a fair level of knowledge

and awareness of breast cancer risk factors among students. This is similar to a study conducted

in Al-mukalla city among female university students in Yemen (Ahmed, 2010). A study

conducted in a university teaching hospital in southwestern Nigeria reported the knowledge of

breast cancer risk factors as satisfactory among medical doctors but inadequate among a large

percentage of nurses, pharmacists, laboratory scientists and physiotherapists (Ibrahim and

Odusanya, 2009). The fair level of awareness obtained in this present study may be as a result

of increased media exposure of the participants especially social media. On the screening

methods assessed for detecting breast cancer in this study majority of the participants were

7
more familiar with BSE, followed by CBE and mammography respectively. This finding is

similar to a study conducted among university female students in Yemen (Ahmed, 2010). BSE,

CBE and mammography are recognized methods of screening for breast cancer and adoption

of mammography screening has led to reduction in mortality from the disease in women over

50 years (Olsen et al., 2005). Although, some countries with population-based breast cancer

screening programme use all the three methods, some recommend use of either one or two

(Shapiro et al., 1998). The American Cancer Society guidelines for cancer screening

recommend annual mammogram and CBE for women above the age of 40 years. Furthermore,

monthly BSE is made optional with emphasis on the importance of breast cancer awareness

(Smith et al., 2005), though regular BSE does not influence mortality from breast cancer, it

assists women in detecting benign breast lumps and in creating more awareness about breast

changes (Thomas et al., 2002). Women with breast cancer in Nigeria are relatively younger

than their Caucasian counterparts, hence, adopting mammography screening guidelines

designed for Caucasian population may not be beneficial in Nigeria since a large proportion of

women with breast cancer are younger than the recommended age group for screening

(Adebamowa and Ajayi, 2000; Anyanwu, 2000).

1.4. Effective Awareness among Female Undergraduateson Breast Cancer

Awareness about Mammography

Mammography is the gold standard for breast cancer screening in developed countries with

some evidence showing improved survival particularly among women 50–69 years in some

randomised controlled trials in developed countries where breast cancer prevalence is high

(Zackrisson, & Frisell, 2017). Whether the same benefits will be recorded in parts of the world

with lower prevalence of breast cancer however remains contentious. In the United States,

Women with average risk of breast cancer are recommended to undergo annual screening

mammography starting at age 45 years up to age 54 years after which they should transition to

8
biennial screening or continue screening annually (Smith et al., 2016). It is also recommended

that women between ages 40 and 44 years should have the opportunity to begin annual

screening. Nigeria currently has no National breast cancer screening guideline, as such

screeningrecommendations are made based on international guidelines. Reports from various

parts of Nigeria show very low mammography screening uptake (Obajimi et al., 2011). While

lack of geographic access may be suggested as a factor limiting uptake in areas with no

mammography services, reasons for poor uptake in places with geographic access are not well

understood. A possible explanation is lack of financial access, given that health costs are

largely out of pocket with less than 5% of the population covered by the National Health

Insurance Scheme (Okoronkwo et al., 2015) (Okebukola & Brieger, 2016). There are reasons,

however, to believe that other factors aside cost contribute significantly to poor mammography

up‐ take given that other forms of inexpensive or free screening similarly demonstrate poor

uptake (Okobia et al., 2006). Understanding the drivers of poor mammography screening is

therefore key for planning an effective breast cancer screening and interventional programme.

Awareness about risk factors

Awareness is an important condition for stimulating behavioral-change. Breast cancer risk can

be reduced by reducing exposure to modifiable breast cancer risk factors via behavioral

changes (Colditz and Wei, 2012). Awareness regarding both modifiable (e.g. alcohol

consumption) and non-modifiable (e.g. family history of breast cancer) risk factors may

promote positive health behaviors and the use of recommended preventive health services

(Schwarzer, 2008). A meta-analysis conducted in 2014 observed a significant, modest

relationship between risk perceptions and health behaviors (Sheeran et al., 2014). Modifying

risk behaviors among younger women may not only reduce their likelihood of developing

breast cancer at a younger age but also reduce their likelihood of developing post-menopausal

breast cancer by decreasing exposure to risk factors over time (McTiernan, 2003). Public

9
awareness of the link between risk factors and breast cancer can serve as a catalyst for policy

change. Knowledge of alcohol as a risk factor for cancer was found to be a significant predictor

of public support for policies to reduce alcohol consumption in other developed nations (Buykx

et al., 2015). Higher public awareness of alcohol as a risk factor for breast cancer may garner

more attention and support for strategies to reduce alcohol consumption. Thus, it is important

to understand the level of awareness regarding risk factors among young women in order to

improve awareness and stimulate behavioral change.

Raising awareness about helpful resources, care services and support groups

Many local entities everything from hospitals to churches to employee groups offer resources

and support for women fighting breast cancer. Words can be spreads about their presence. This

action can bring about confidence among young and older women fighting breast cancer to be

able to reach out for all kind of support, the have an assurance that there is a group of people

who cares. This support systems also have a way of uniting fellow breast cancer fighters; this

platform gives a sense of relief to fighters after listening to the stories of survivors.

2.0. Theoretical Framework

2.1. Health Belief Model

At the time there were medical diagnostic tools such as chest X‐rays for tuberculosis (TB)

screening that were underused because many people with TB did not recognize their symptoms

and did not seek medical care for what they deemed a mere cough. There was a parallel need

to increase use of preventive services such as immunization and medical adherence in general,

in addition to health screening. At the beginning, the health belief model was rooted in

information giving to increase people’s awareness of and concern about the serious health risks

associated with certain preventable illnesses, including illnesses that could be cured if caught

early enough. Health educators also wanted people to understand that they could reduce these

health risks by taking certain actions. The (primarily) psychologists theorized that people are

10
afraid of getting serious illnesses and that health‐related behaviors reflect both a person’s level

of fear of perceived health threats and the expected fear‐reduction potential of taking a

recommended action. People consider whether the outcomes of the behavior change outweigh

its practical and psychological obstacles. In short, individuals assess the net benefits of

changing their behavior to reduce the threat to their health and decide whether to act (Murphy,

2005). The model identifies and organizes interventions around four aspects of this assessment:

perceived susceptibility to ill health, or risk perception, perceived severity of ill health,

perceived benefits of behavior change, and perceived barriers to taking action. Later, health

belief theorists added the concept of self‐efficacy as a factor in health behavior decision

making. Individuals’ perceptions of risks, benefits, and obstacles add up to their readiness to

act or lack of readiness. If a person is ready to change behavior to obtain the perceived benefits,

health promotion messages through mass media, peer education, and other interventions—act

as cues to action, transforming readiness into overt behavior. These cues are particularly

important when unhealthy behaviors are habitual such as not wearing seat belts, overeating,

not exercising, or smoking. The health belief model can also help identify leverage points for

change. A smoker who may not think he is capable of quitting on his own —that is, who has

low self‐efficacy—can be coached on proven ways to quit and encouraged to enroll in a

supportive smoking cessation program (Rimer & Glanz, 2005). The health belief model of

behavioral change was later categorized as individual centered. In addition to the health belief

model, the category includes social cognitive theory (in spite of the word “social,” it focuses

on individual learning through observation), the theory of reasoned action, the stages of change

model, and the AIDS risk reduction model. Although they differ in several ways, all these

theories focus on the individual’s perceived susceptibility to a threat to health and benefits that

would result from changing behavior, as well as on constraints to such change. They assume

that people are rational and will do the right thing once they are provided adequate information

11
and understand that change is in their personal self‐interest. The model would be effective

unless a person is neither concerned about nor afraid of negative health consequences, or is

simply not rational, or not currently in a rational frame of mind (e.g., when intoxicated).

According to this model, behavioral beliefs and modifying factors are effective in shaping

behavior and when a woman is susceptible to breast cancer (perceived susceptibility) and aware

of the threat of disease on their health (perceived severity) and also know the benefits of

screening methods (perceived benefits) than its barriers (perceived barriers), she most likely

will follow the screening methods (Avci 2008 ).

The findings of a study caried out by Darvishpor et al., (2018)showed that self-efficacy,

perceived benefits and perceived barriers could predict BSE behaviour and the perceived

benefits and barriers could predict mammography. So educational interventions must be

considered to improve health behavioursas skills for BSE. Further, increasing understanding

of the benefits and the elimination of barriers to health behavioursthrough correct training is

required. Also, proper planning is recommended for the implementation of educational

interventions to promote screening programs.

2.2. Theory of Planned Behavior

The theory of planned behavior (TPB) allows researchers to identify the determinants of

environmental behavior and subsequently target these factors in interventions. Multiple studies

on conservation behaviors have recently applied this theoretical framework in both

organizational and domestic settings. The theory of planned behavior (TPB) remains one of the

most widely used frameworks for studying individual behaviors. A search using Google

Scholar revealed that this theory has been cited almost 90,000 times as of 2019 (Yureiv et al.,

2019). The Theory of planned Behaviour argues that behaviors stem from individual intention

and perceived behavioral control (PBC). Intention, defined as “indicators of how hard people

are willing to try to perform the behavior” (Ajzen, 1991, p. 181), in turn, depends on three

12
direct predictors: attitude, subjective norm, and PBC. The TPB suggests that the three

determinants of intention are influenced by behavioral, normative, and control beliefs,

commonly called indirect predictors. Behavioral beliefs refer to the perceived advantages and

disadvantages of performing a certain behavior; normative beliefs are “a person’s subjective

probability that a particular normative referent wants the person to perform a given behavior”

(Ajzen, 2012) and control beliefs are related to various factors (time, cost, available

infrastructures, etc.) that impede or facilitate a behavior. Since its development almost three

decades ago, the TPB has frequently been applied to understand the factors underlying various

pro-environmental behaviors: the use of alternative transportation (Muñoz et al., 2016), waste

recycling (Echegaray and Hansstein, 2017), saving water (Lam, 2006), energy conservation

(Allen and Marquart-Pyatt, 2018), low carbon consumption (Jiang et al., 2019), and others.

Recently, an increasing number of articles have used the TPB to explore theproenvironmental

behaviors of employees.

3.0. Empirical Studies

In order to study the effect of health education intervention on women's concept and behavior

of breast cancer screening, Sun et al., (2019) investigated 600 women in urban and rural areas

using a questionnaire. The subjects were randomly divided into experiment group and control

group. The experiment group was given health education intervention related to breast cancer,

and the control group was given health education intervention on common diseases except

breast cancer. In the control group, the detection time was irregular, or no breast test was

performed for more than one year. In the experimental group, after intervention, subjects

underwent breast examination twice a year, and the patients with breast nodules were tested

once every 3 months and 6 months. The results showed that the implementation of breast self-

detection and breast clinical detection before health education intervention in the experiment

group was increased and more regular, and the frequency was also increased. After health

13
education unrelated to breast cancer, the implementation of breast self-detection and breast

clinical detection in the control group increased, but it was not significant. It proves that this

educational intervention model could help women improve their knowledge about early

detection of breast cancer, and provide some help for improving women's prevention of breast

cancer.

To determine the predictors of practice of breast self-examination among female undergraduate

students of Ebonyi State University, Abakaliki, Nigeria, Osai et al., (2022) designeda

descriptive cross-sectional study. A three-stage sampling design was used to select 365 female

students of the university. Data were collected using a pretested self-

administeredquestionnaire. Completion of one academic year qualified students for inclusion.

Good knowledge of breast self-examination was determined by proportion of respondents who

scored 50% and above of 15 variables used to assess knowledge. Results: The mean age of the

students was 22.1 ± 2.5 years. Majority (76.4%) were aware of breast selfexamination and

health workers; 37.0% were the major source of information. A minor proportion (5.8%) have

had their close relatives diagnosed with breast cancer. Majority (55.3%) had good knowledge

of breast selfexamination. Majority (63.6%) have everpracticed breast selfexamination;

however, only 15.9% of the respondents examined their breasts on a monthly basis. Predictors

of ever practiced breast selfexamination included having good knowledge of breast

selfexamination (adjusted odds ratios [AOR] =6.4, 95% CI: 3.9–10.4), having a close relative

diagnosed with breast cancer (AOR = 4.0, 95% CI: 1.1–15.1), and mother of respondent being

selfemployed (AOR = 0.5, 95% CI: 0.5–1.5). It was concluded Awareness of breast

selfexamination and practice were high among the respondents; however, only a minor

proportion practiced breast selfexamination every month. Having good knowledge of breast

selfexamination was associated with its practice. Having a close relative diagnosed with breast

cancer encouraged the respondents to prevent the occurrence of breast cancer, thus enabling

14
the practice of breast selfexamination. Moreover, the practitioners of breast selfexamination

taught and encouraged others to examine their breasts. There is a need to increase knowledge

of breast selfexamination through public health education using the media.

Sadoh et al., (2021) carried out a study Improving knowledge about breast cancer and breast

self-examination in female Nigerian adolescents using peer education: a pre-post interventional

study This was a pre-post interventional study carried out in October –December 2016 on

female students of four secondary schools in Benin City. Pre-peer training, using a pre-tested

self-administered questionnaire, knowledge about BC and BSE was assessed in about 30% of

each school population. This was followed by training of 124 students selected from the schools

(one student per class) as peer trainers. The peer trainers provided training on BC and BSE (the

intervention) for their classmates. Within two weeks of peer training knowledge about BC and

BSE was reassessed in 30% of each school population. Selection of students for assessment

pre and post intervention was by systematic sampling. Correct knowledge was scored and

presented as percentages. Chi square test, student t test and ANOVA were used to assess

associations and test diferences with level of signifcance set at p<0.05. There were 1337 and

1201 students who responded to the pre and post-training questionnaires respectively. The

mean BC knowledge score (20.61±13.4) prior to training was low and it statistically

signifcantlyimproved to 55.93±10.86 following training. It was conludedthat Peer education

strategy can be used to improve BC and BSE knowledge in adolescents. This strategy is low

cost and could be very useful in low resource settings.

15
 REFRENCES

Ahmed F, Mahmood N, Shahid S, et al (2016). Mutations in Human Interferon α2b Gene and

Potential as Risk Factor Associated with Female Breast Cancer. Cancer

BiotherRadiopharm.;31(6):199–208.

Ajibola, C.A. "Teaching Health Education in Primary and Secondary Schools.

Ajzen, I., 2012. Martin Fishbein’s legacy: the reasoned action approach. Ann. Am. Acad. Pol.

Soc. Sci. 640 (1), 11–27.

Akani N.A, Nkanginieme K.E.O., and Oruamabo R.S., (2000) "An Evaluation of Health

Knowledge of Head Teachers in Obio-akpo Primary Schools and the Effect of Short Term

Training on this Knowledge," Benin Journal of Education Studies, vol. 14, no. 1, pp. 32-45,

Allen, S., Marquart-Pyatt, S.T., 2018. Workplace energy conservation at Michigan state

university. Int. J. Sustain. High. Educ. 19 (1), 114–129.

American Cancer Society (2018). Breast Cancer Facts and Figures 2017-2018. Retrieved from:

[Link]

[Link]. Accessed on 23/03/2019.

Amin, S. M., Ewunonu, H. A., Oguntebi, E, & Liman, I. M. (2017). Breast cancer mortality in

a resource-poor country: A 10-year experience in a tertiary institution. Sahel Medical Journal;

20:93-7.

Avci IA (2008). Factors association with breast self-examination practices and belief in female

workers at a Muslim community. Eur J Oncol Nurs. 2008;12(2):127–33.

[Link] PMid:18242140.

Balekouzou A, Yin P, Pamatika CM, et al (2017). Reproductive risk factors associated with

breast cancer in women in Bangui: a case–control study. BMC WomensHealth.;17(1):14.

Beral V, Bull D, Doll R, Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast

Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological

16
studies, including 83 000 women with breast cancer from 16 countries. Lancet.

2004;363(9414):1007–1016.

Buykx P. Gilligan C., Ward B., Kippen R., Chapman K. (2015) Public support for alcohol

policies associated with knowledge of cancer risk Int. J. Drug Pol., 26 (4), pp. 371-379.

Colditz G.A, E.K. Wei (2012) Preventability of cancer: the relative contributions of biologic

and social and physical environmental determinants of cancer mortality Annu. Rev. Public

Health, 33 , pp. 137-156.

Dai Q, Liu B, Du Y. Meta-analysis of the risk factors of breast cancer concerning reproductive

factors and oral contraceptive use. Front Med China. 2009;3(4):452–458.

Echegaray, F., Hansstein, F.V., (2017). Assessing the intention-behavior gap in electronic

waste recycling: the case of Brazil. J. Clean. Prod. 142, 180–190.

Ekeke J-T. and. Diepiribo, A.D. (2012) "Health education in the school curriculum and

entrepreneurship skills," Educational Research Journals, vol. 2, no. 9, pp. 292-299.

Ekeke, JT "Healthful School Environment, In Akpanim, N. Ekpe., Imelda, L. An., Jake,

Laguador M., Ngozika, A. And Oleforo (Eds) (2015) School Environment in Nigeria and the

Philippines, Bloomington: Author House," pp. 148-156.

Flavarjani AM, Hedayatpour B, Nourian SM, Bashardoost N(2014). Study of the association

between blood types and breast cancer among Isfahanian women with breast cancer. Adv

Biomed Res.;3(1):43.

Giordano SH, Buzdar AU, Hortobagyi GN. Breast Cancer in Men. Ann Intern Med.

2002;137(8):678–687.

Green L.W. and Kreuter M.W. (2005). Health Promotion Planning: An Educational and

Environmental ApproachCalifornia: Mayfield Publishing.

Innes KE, Byers TE (2004). First pregnancy characteristics and subsequent breast cancer risk

among young women. Int J Cancer.;112(2):306–311.

17
Jedy-Agba, E, Curado, M. P., Ogunbiyi, O, Oga, E, Fabowale, T, Igbinoba, F, …&

Adebamowo, C. A. (2012). Cancer Incidence in Nigeria: A Report from

PopulationbasedCancer Registries. [Link]

accessed on 29th April, 2019.

Jiang, X., Ding, Z., Liu, R., (2019). Can Chinese residential low-carbon consumption behavior

Lam, S.-P., 2006. Predicting intention to save water: theory of planned behavior, response

efficacy, vulnerability, and perceived efficiency of alternative solutions. J. Appl. Soc. Psychol.

36 (11), 2803–2824.

Ma H, Henderson KD, Sullivan-Halley J, et al. Pregnancy-related factors and the risk of breast

carcinoma in situandinvasive breast cancer among postmenopausal women in the California

Teachers Study cohort. Breast Cancer Res. 2010;12(3):R35.

Mahouri K, Dehghani Zahedani M, Zare S. Breast cancer risk factors in south of Islamic

Republic of Iran: a case-control study. East Mediterr Health J. 2007;13(6):1265–1273.

Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast

cancer. N Engl J Med. 2002;346(26):2025–2032.

McTiernan, 2003 Behavioral risk factors in breast cancer: can risk be modified? Oncologist, 8

(4), pp. 326-334.

Melbye M, Wohlfahrt J, Andersen A-MN, Westergaard T, Andersen PK. Preterm delivery and

risk of breast cancer. Br J Cancer. 1999;80(3-4):609–613.

Meo SA, Suraya F, Jamil B, et al. Association of ABO and Rh blood groups with breast cancer.

Saudi J Biol Sci. 2017;24(7):1609–1613.

Metcalfe KA, Finch A, Poll A, (2009). Breast cancer risks in women with a family history of

breast or ovarian cancer who have tested negative for a BRCA1 or BRCA2 mutation. Br J

Cancer.;100(2):421–425.

18
Moronkola, O.A. (2017) “The nature of Health Education. Health Education for Tertiary

Institution Students (Ed). Ibadan. Nigeria School Health Association, pp. 1-4.

Murphy, E. M. (2005). Promoting healthy behavior. Washington, DC: Population Reference

Bureau.

Okobia, M. N., Bunker, C. H., Okonofua, F. E., & Osime, U. (2006). Knowledge, attitude and

practice of Nigerian women towards breast cancer: A cross‐sectional study. World Journal of

Surgical Oncology, 4, 11.

Okoronkwo, I. L., Ejike‐Okoye, P., Chinweuba, A. U., & NwaneriA. C. (2015). Financial

barriers to utilization of screening and treat‐ ment services for breast cancer: An equity analysis

in Nigeria. Nigerian Journal of Clinical Practice, 18(2), 287–291. [Link]

org/10.4103/1119-3077.151070.

R. Schwarzer (2008),Modeling health behavior change: how to predict and modify the adoption

and maintenance of health behaviors Appl. Psychol., 57 (1) , pp. 1-29

Rimer, B. K., & Glanz, K. (2005). Theory at a glance: A guide for health promotion practice

(2nd ed.). Washington, DC: National Cancer Institute.

Salawu, M. M., & Akindiya, O. E. (2018). Practice of breast self- examination among female

undergraduate students of Adeleke University, Ede, Osun State. Research. Journal of Health

Science. Vol 6(4).

Saxena S, Chawla VK, Gupta KK, Gaur KL. Association of ABO blood group and breast

cancer in Jodhpur. Indian J Physiol Pharmacol. 2015; 59(1):63–68.

Sheeran P, P.R. Harris, T. (2014) Epton Does heightening risk appraisals change people’s

intentions and behavior? a meta-analysis of experimental studiesPsychol. Bull., 140 (2) , p. 511

Skegg DC, Noonan EA, Paul C, Spears GF, Meirik O, Thomas DB. Depot

medroxyprogesterone acetate and breast cancer: a pooled analysis of the World Health

Organization and New Zealand studies. JAMA. 1995;273(10):799–804.

19
Sweeney C, Blair CK, Anderson KE, Lazovich D, Folsom AR (2004). Risk factors for breast

cancer in elderly women. Am J Epidemiol.;160(9):868–875.

Thakur P, Seam RK, Gupta MK, Gupta M, Sharma M, Fotedar V. Breast cancer risk factor

evaluation in a Western Himalayan state: A case–control study and comparison with the

Western World. South Asian J Cancer. 2017;6(3):106–109.

Williams LA, Nichols HB, Hoadley KA, et al. Reproductive risk factor associations with

lobular and ductal carcinoma in the Carolina Breast Cancer Study. Cancer Causes Control.

2018;29(1):25–32.

World Health Organisation (2015). Breast Cancer: Prevention and Control Geneva: World

Health Organisation.

World Health Organisation (2018). Cancer. Retrieved from; [Link]

Wu MH, Chou YC, Yu JC, et al. Hormonal and body-size factors in relation to breast cancer

risk: a prospective study of 11,889 women in a low-incidence area. Ann Epidemiol.

2006;16(3):223–229. Tamakoshi K, Yatsuya H, Wakai K, et al; JACC Study Group. Impact of

menstrual and reproductive factors on breast cancer risk in Japan: Results of the JACC study.

Cancer Sci. 2005;96(1):57–62.

Youlden, D.R., Cramb, S.M., Yip, C.H., Baade, P.D. (2014) Incidence and mortality of female

breast cancer in the Asia-Pacific region. Cancer Biol Med, 11(2): p 101- 115. Doi:

10.7497/[Link].2095-3941.2014.02.005

Yousef AJ. Male Breast Cancer: Epidemiology and Risk Factors. Semin Oncol.

2017;44(4):267–272.

20