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Breast Cancer Knowledge and Awareness among High School and College
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Article in Cancer Research · June 2012

DOI: 10.1080/09500693.2012.664294

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 International Journal of Science Education, Part B
2012, 1–15, iFirst Article

Breast Cancer Knowledge and

Awareness among High School and
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College Students in Mid-Western USA

Benford Mafuvadzea, Angellar Manguvob, Jiaxin Hea,
Stephen D. Whitneyb and Salman M. Hydera∗
a
Department of Biomedical Sciences and the Dalton Cardiovascular Research Center,
University of Missouri, Columbia, MO, USA; bDepartment of Educational Psychology,
University of Missouri, Columbia, MO, USA

Early detection of breast cancer and its subsequent treatment lead to better patient prognosis and
survival rates. However, despite advanced screening and detection techniques, the disease all too
frequently remains undetected until it has reached an advanced stage. Despite a number of
means of disseminating breast cancer awareness, such as public health programs, public and
private media and the internet, breast cancer remains a major health problem which exerts a
tremendous economic burden on the health care system. Consequently, promoting early
awareness of the disease to students at both high school and college levels might potentially lead
to improved health habits later in life. This study investigated breast cancer awareness among
college and high school students. A self-administered questionnaire was given to 355 high school
students and 132 college students in a mid-western area of the USA to determine their
perceptions of breast cancer, risk factors and the need for breast self-examination. Despite many
annual efforts to disseminate breast cancer awareness and the availability of information about
the disease, our study showed that both college and high school students have a poor
understanding of breast cancer. Most participants, however, were receptive to the provision of
more information at school. Based on our findings, we recommend more breast cancer awareness
programs targeting high school and college students. Breast cancer awareness could be included
as a component of the high school curriculum, as well as via the internet and public health programs.

Keywords: Breast cancer knowledge; Risk factors; College and high school students; Breast
self-examination

∗
Corresponding author: Department of Biomedical Sciences and the Dalton Cardiovascular
Research Center, University of Missouri, Columbia, MO, USA. Email: hyders@missouri.edu

ISSN 2154-8455 (print)/ISSN 2154-8463 (online)/12/000001–15

# 2012 Taylor & Francis
http://dx.doi.org/10.1080/09500693.2012.664294
 2 B. Mafuvadze et al.

Introduction
Breast cancer is the second most common form of cancer (after cancers of the skin)
among women in the USA and is also the second leading cause of cancer deaths in
American women. In 2010, the American Cancer Society estimated that in 2011,
approximately 207,090 new cases of invasive breast cancer and 54,010 cases of carci-
noma in situ breast cancer would be diagnosed, while an estimated 39,840 deaths
would occur. Although breast cancer is more prevalent in older women, in recent
years the incidence of premenopausal early-stage breast cancer has increased, possibly
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as a consequence of changes in demographics and lifestyle (Dellapasqua, Colleoni,

Gelber, & Goldhirsch, 2005). The emergence of breast disease and the subsequent
development of cancer tend to be more aggressive in young patients compared with
breast cancer progression in the older population (Anders et al., 2008). The high
mortality rate among young women who lack formal breast cancer awareness and
subsequently develop the disease is likely due to late diagnosis, at which point the
cancer has already reached an advanced stage (Rosenberg & Levi-Schwartz, 2003).
It is, therefore, imperative to design educational programs that will instill in young
women at the high school and college levels an awareness of the importance of
early detection and screening practices (Johnson, Petrillo, & Porter, 2011). The
American Cancer Society recommends monthly breast self-examinations (BSEs)
for all women over 20 years of age (American Cancer Society, 2010). There have
been very few studies carried out in the USA on breast cancer awareness among
high school and college students. However, as highlighted by Karayurt, Ozmen,
and Cetinkaya (2008), adolescents are extremely receptive to having the benefits of
healthy behaviors instilled into them. If adopted at an early age, behaviors such as
self-examination of the breasts will likely continue into adulthood and throughout
life, with long-term positive health ramifications (Ludwick & Gaczkowski, 2001).
Despite the ready availability of information pertaining to breast cancer, studies
carried out worldwide show that there remains widespread ignorance about the
disease, even among the well-educated. A lack of knowledge, not only about the
root causes of breast cancer, but, perhaps more importantly, about how to detect
the disease at an early stage, inevitably leads to misconceptions regarding its curability
and the effectiveness of early screening (Dandash & Al-Mohaimeed, 2007). While
many activities in American universities and schools are aimed at promoting breast
cancer awareness, there is a feeling among some breast cancer experts that, in
recent years, more focus has been placed on activities aimed at raising funds to
support breast cancer research at the expense of disseminating information on the
importance of early detection, screening and preventive methods (Jacobsen & Jacob-
sen, 2011). With this in mind, we investigated the level of breast cancer awareness
among college and high school students in an area in which a number of events
such as fundraising walks, organized sports and ‘wear pink day’ are held every
October to promote breast cancer education.
Previously, most studies aimed at investigating the level of understanding of breast
cancer among US college students focused on female students in medical programs
 Breast Cancer Awareness among School Students 3

(Ahmed, Mahmud, Hatcher, & Khan, 2006; Ibrahim & Odusanya, 2009; Powe, Under-
wood, Canales, & Finnie, 2005), with very few studies involving college students in
non-medical programs. Obviously, determining breast cancer awareness in students in
non-medical programs, who have not obtained esoteric knowledge, will lead to a
better assessment of how poorly or how well the disease is understood (Ahmed, 2010).
We, therefore, focused on college students in a pre-service teacher program, the majority
of who were around 20 years of age, the age at which it is recommended that women
begin regular BSEs. Pre-service teachers possessing an awareness of breast cancer and
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its early detection will, in their subsequent careers as high school teachers, be in a
position to impart that information to their pupils. Most studies on breast cancer aware-
ness among college and high school students included only female students (Ahmed,
2010; Dandash & Al-Mohaimeed, 2007; Milaat, 2000; Sait, Al-Amoudi, Tawtai, &
Abduljabbar, 2010; Yadav & Jaroli, 2010). We chose to also include male students in
our study because even though the incidence of breast cancer in men is low, the more
aware the males are, the better will be their capacity to understand the effects of the
cancer and provide support when a female partner or relative develops the disease
(McMenamin et al., 2005). Furthermore, if men are also well informed on all aspects
of the disease, they can contribute to educating female partners, relatives, students,
etc. on the benefits of screening and the importance of early detection.
Our findings concur with studies carried out in other parts of the world (Ahmed,
2010; Dandash & Al-Mohaimeed, 2007; Karayurt et al., 2008; Milaat, 2000; Sait
et al., 2010; Yadav & Jaroli, 2010), showing that, when it comes to breast cancer
awareness, most college and high school students possess only limited knowledge.
We contend that these findings further highlight the need for developing and imple-
menting effective breast cancer education and prevention programs among high
school and college students in the USA.

Methods
This study was designed to evaluate the level of breast cancer awareness among high
school students and college students in a teacher-training program. In particular, we
focused on perceptions about the causes of breast cancer, incidence of breast cancer
in the USA, risk factors associated with breast cancer and knowledge of BSEs. Partici-
pants were drawn from students enrolled in a Teacher Development Program class at a
large mid-west land grant university, as well as senior and junior high school students at
a public school. The study was approved by the University’s Institutional Review Board
and permission was granted by the school principal. The purpose of the study was
explained to participants and those who freely agreed to participate were enrolled in
this study. A total of 355 high school (171 females and 184 males) and 132 college
(99 females and 33 males) students volunteered and successfully completed the survey.

Instruments
We used a modified version of the Breast Cancer Perceptions and Knowledge Survey
previously used by Powe, Daniels, Finnie, and Thompson (2005). The instrument
 4 B. Mafuvadze et al.

used by Powe, Daniels, et al. (2005) used 12 items to assess breast cancer perceptions
and knowledge among African-American women. We expanded on these items by
using questions used previously in other publications on breast cancer awareness.
We drew most of the questions on risk factors from a survey conducted by McMena-
min et al. (2005). Overall, our questionnaire had a total of 30 questions, of which 15
assessed knowledge about breast cancer risk factors, 11 assessed perceptions of breast
cancer and 4 assessed knowledge about breast cancer incidence in the USA. While the
original questionnaire used by Powe, Daniels, et al. (2005) used the ‘agree–disagree
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format’, we included the option ‘I don’t know’ to make sure that participants who
were not knowledgeable would not just make a guess. In order to fully assess the
knowledge of the purported risk factor, we asked the participants to indicate
whether a given factor would, increase, decrease or had no effect on breast cancer
risk or alternatively indicate if they ‘didn’t know’. Each correct answer (based on
American Cancer Society, 2010) was assigned a score of 1, while an incorrect
answer or ‘don’t know’ was awarded a score of 0. For each participant, a total score
was computed by summing the number of correct answers.
A demographic section of the questionnaire was used to acquire participants’ infor-
mation such as gender, age, high school attended (for college students), marital status,
current academic class and knowledge of someone with breast cancer. Based on pre-
vious studies (McCready, Littlewood, & Jenkinson, 2005), we hypothesized that these
factors could potentially influence breast cancer knowledge among the participants.
In addition, we also asked participants to identify their sources of information on
breast cancer and their opinion on provision of more information on breast cancer
in schools. The reliability coefficient of the survey conducted by Powe, Daniels,
et al. (2005) was 0.70, with a sample of 179 African-American women. For the
current study, a Cronbach alpha value of 0.82 was obtained for a combined sample
of 482 college and high school students.

Statistical Analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS, Version
14). Descriptive statistics with cross-tabulations were performed and frequencies
were generated for correct and incorrect answers for all items. As stated previously,
the knowledge indices were calculated for each student by summing the number of
correct answers. The Pearson chi-square test was used to examine the association
between variables, with significance level set at p , 0.05.

Results
Table 1 describes the socio-demographic nature of the respondents; the majority
(82.6%) of the college students were aged below 20 years and single (97.7%), and
a majority (84.1%) had attended public high schools. Most (78%) of the college stu-
dents in this study were in their second year of university education (sophomore)
(Table 1). The majority of the high school students (92.7%) were aged between 16
 Breast Cancer Awareness among School Students 5

Table 1. Demographic characteristics of the participants in this study

College students (N ¼ 132) High school students (N ¼ 355)

Characteristic % (n) Characteristic % (n)

Age (years)a Age (years)a

Less than 20 82.6 (109) Less than 16 7.0 (25)
20–30 16.7 (22) 16–20 92.7 (329)
Gender Gender
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Male 25.0 (33) Male 51.8 (184)

Female 75.0 (99) Female 48.2 (171)
Marital status Year of education
Single 97.7 (129) Junior high 6.8 (24)
Married 2.3 (3) Senior high 93.2 (331)
High school attended Knowledge of someone
Public school 84.1 (111) with breast cancera
Private school 15.9 (21) Yes 50.7 (180)
No 49.0 (174)
Academic level
Freshman 11.4 (15)
Sophomore 78.0 (103)
Junior 9.8 (13)
Senior 0.8 (1)
Knowledge of someone with breast cancer
Yes 72.7 (96)
No 28.8 (38)

a
One participant did not provide a response to the question.

and 20, and most of them (93.2%) were in their last year of high school. While 72.7%
of the college students reported knowing someone with breast cancer, only 50.7% of
the high school students reported the same.
Because our results showed that there was no difference in the overall understand-
ing of breast cancer among college students based on gender, education level or
nature of high school attended, data for college students were presented together
without distinguishing between male and female students. However, our data with
regard to high school students showed that female students were slightly (but signifi-
cantly) more knowledgeable than male students on several items.

Understanding of Risk Factors for Breast Cancer

Tables 2 and 3 summarize the level of knowledge among responders regarding certain
risk factors. In concurrence with previous studies carried out in the USA (Powe,
Daniels, et al., 2005; Powe, Underwood, et al., 2005), the most widely realized risk
factor was a positive family history of breast cancer. Most participants were aware
that regular exercise could potentially decrease breast cancer risk; most were also
aware that being overweight and eating a diet of fatty foods with few vegetables
 6 B. Mafuvadze et al.

Table 2. High school students’ knowledge of breast cancer-associated risk factors

Female (N ¼ 171) Male (N ¼ 184)

Cor % Inc % D/K % Cor % Inc % D/K %

Risk factor (n) (n) (n) (n) (n) (n)

A family history of breast 89 (153) 7 (13) 3 (5) 78 (144) 7 (13) 15 (27)

cancera
HRTa 27 (47) 11 (19) 61 (105) 27 (49) 18 (33) 55 (102)
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Eating fatty foods, with 52 (89) 15 (27) 32 (55) 46 (85) 18 (34) 35 (65)
little vegetablesa
Cigarette smokinga 18 (131) 54 (94) 27 (46) 15 (28) 59 (109) 25 (47)
Being overweighta 52 (89) 18 (32) 29 (50) 43 (79) 21 (39) 36 (66)
Using oral contraceptivesa 14 (24) 29 (50) 57 (97) 13 (23) 32 (59) 55 (102)
Alcohol consumptiona 46 (75) 17 (28) 36 (57) 49 (86) 13 (23) 38 (67)
Regular exerciseb 72 (123) 13 (23) 14 (23) 64 (117) 13 (24) 23 (42)
Breast feedingb 12 (22) 48 (83) 38 (65) 7 (12) 45 (84) 48 (88)
Having children before 30 13 (23) 52 (89) 35 (59) 10 (18) 52 (96) 38 (70)
years of ageb
Frequent mammogramsc 46 (80) 33 (58) 19 (33) 29 (53) 30 (55) 41 (76)
Wearing tight brasc 50 (87) 15 (26) 34 (58) 36 (66) 23 (43) 41 (75)
A hard blow to the breastc 51 (87) 17 (29) 32 (54) 34 (63) 21 (39) 45 (82)
Breast implantc 17 (29) 41 (69) 42 (72) 19 (35) 35 (65) 46 (84)
A stressful lifec 14 (25) 59 (100) 27 (46) 16 (29) 55 (101) 29 (53)

a
Factor increases risk.
b
Factor decreases risk.
c
Factor has no effect on risk.
Cor, correct; Inc, incorrect; D/K, do not know.

potentially increase breast cancer risk. In agreement with previous studies performed
in Saudi Arabia (Milaat, 2000) and Turkey (Karayurt et al., 2008) on breast cancer
awareness among college and high school students, our findings showed that most
participants were unaware of the increased risk of using oral contraceptives and
hormone replacement therapy (HRT). Most participants were also unaware of the
potential of cigarette smoking, particularly if begun prior to the first pregnancy, to
elevate the risk of breast cancer. Furthermore, and perhaps not surprisingly, the
majority of both high school and college students were not aware that early pregnancy
(under 30 years) and prolonged breast feeding (1-1/2–2 years) have been linked to a
reduced risk of breast cancer. Contrary to an earlier study by Powe, Daniels, et al.
(2005), most college and female high school students did not subscribe to commonly
held misperceptions such as wearing tight bras and receiving a hard blow to the breast
could increase breast cancer risk. Although previous studies did not demonstrate any
association between breast implants and increased breast cancer risk (Brinton et al.,
2000), most participants in our study believed that breast implants increased breast
cancer risk. Overall, our results show that college students were more knowledgeable
 Breast Cancer Awareness among School Students 7

Table 3. College students’ knowledge of breast cancer-associated risk factors

Risk factor Cor % (n) Inc % (n) D/K % (n)

HRTa 25 (33) 6 (8) 67 (89)

Eating fatty foods, with little vegetablesa 48 (63) 20 (26) 33 (43)
Cigarette smokinga 15 (20) 64 (84) 21 (28)
Being overweighta 53 (70) 20 (26) 27 (36)
Using oral contraceptivesa 21 (27) 40 (53) 39 (51)
Alcohol consumptiona 74 (98) 2 (3) 24 (31)
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Regular exerciseb 77 (102) 18 (24) 5 (6)

Breast feedingb 14 (19) 53 (70) 33 (43)
Having children before 30 years of ageb 18 (24) 53 (70) 29 (38)
Frequent mammogramsc 57 (75) 30 (39) 12 (16)
Wearing tight brasc 49 (65) 18 (23) 33 (44)
A hard blow to the breastc 51 (67) 23 (30) 27 (35)
Breast implantc 24 (32) 35 (46) 41 (54)
A stressful lifec 14 (18) 62 (81) 25 (33)

a
Factor increases risk.
b
Factor decreases risk.
c
Factor has no effect on risk.
Cor, correct; Inc, incorrect; D/K, do not know.

about breast cancer risk factors than high school students, with a mean score of 8.2 +
0.17, compared with 5.7 + 0.21 and 4.9 + 0.21 for female and male high school
students, respectively, out of a possible score of 15.

Breast Cancer Perceptions

We selected some of the common misperceptions identified and used in previous
studies and used them to assess our participants (Tables 4 and 5). Overall, college
and female high school students were more knowledgeable than male high school
students. In addition, they did not generally subscribe to some of the commonly
held misperceptions such as breast cancer does not affect men, is more common in
women with big breasts, does not affect women under the age of 30 and can be
caused by a hard blow (Tables 4 and 5). There is a general misperception that cancer-
ous breast lumps are usually painful; interestingly most of the participants in this
study expressed that they did not know whether this was true or false. In addition,
nearly half the college students and more than two-thirds of the high school students
in our study were not aware that a change in color or shape of the nipple could be a
sign of breast cancer.

Understanding of Breast Cancer Incidence in the USA

Consistent with previous studies (McMenamin et al., 2005), most of the partici-
pants in this study had a poor understanding of breast cancer statistics. For
 8 B. Mafuvadze et al.

example, most of the participants underestimated the percentage of sufferers who

survive for more than 5 years following a diagnosis of breast cancer, with only
12.9%, 14.6% and 8.8% of the college, male and female high school students,
respectively, giving the correct answer of greater than 60%. In agreement with
the earlier study (McMenamin et al., 2005), which was conducted in an Irish popu-
lation, we also found that many over-estimated a woman’s risk of developing breast
cancer, with nearly 50% of the participants indicating that 15 – 40% of women are
likely to develop the disease. While a majority of the participants correctly indicated
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that breast cancer is one of most prevalent and leading causes of cancer death in
American women, most did not realize that breast cancer chiefly afflicts the
elderly, with only 2.3%, 8.2% and 7.6% of the college, male and female high

Table 4. High school students’ perceptions of breast cancer

Female (n ¼ 171) Male (n ¼ 184)

Cor % Inc % D/K % Cor % Inc % D/K %

Item (n) (n) (n) (n) (n) (n)

Breast cancer is one of the most 70 (120) 9 (15) 21 (36) 73 (134) 5 (9) 22 (41)
prevalent cancers in women in
the USAa
Breast cancer can affect mena 80 (136) 8 (13) 13 (22) 77 (141) 10 (18) 14 (36)
The best time to check for 20 (34) 8 (14) 72 (123) 14 (25) 10 (18) 76 (140)
lumps in the breast is just after
the period endsa
One of the best ways to find 91 (156) 3 (5) 6 (10) 79 (146) 4 (8) 16 (29)
breast cancer early is by
checking the breasts every
montha
A change in the color or shape 37 (63) 10 (17) 53 (91) 25 (46) 7 (13) 67 (123)
of a woman’s nipple could be a
sign of breast cancera
October is the NBCAMa 52 (88) 10 (17) 39 (66) 43 (79) 10 (18) 47 (87)
Women aged less than 30 years 90 (153) 6 (4) 5 (14) 76 (139) 4 (7) 21 (38)
do not get breast cancerb
Breast cancer is more common 64 (110) 8 (14) 26 (47) 46 (85) 12 (22) 41 (75)
in women with big breastsb
Lumps in the breast that are 46 (78) 21 (33) 34 (60) 3 (57) 26 (48) 42 (77)
cancerous are usually painfulb
Being hit on the breast can 69 (118) 13 (17) 21 (36) 59 (109) 12 (22) 28 (51)
cause cancerb
A woman’s chance of surviving 83 (141) 4 (6) 14 (24) 65 (119) 10 (19) 25 (46)
breast cancer is very low, even if
it is found earlyb

a
Statement is true.
b
Statement is false.
Cor, correct; Inc, incorrect; D/K, do not know.
 Breast Cancer Awareness among School Students 9

Table 5. College students’ perceptions of breast cancer

Cor % Inc % D/K %

Item (n) (n) (n)

Breast cancer is one of the most prevalent cancers in women in 73 (96) 6 (8) 21 (28)
the USAa
Breast cancer can affect mena 81 (107) 7 (9) 12 (16)
One of the best ways to find breast cancer early is by checking 98 (130) 0.8 (1) 1 (1)
the breasts every montha
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The best time to check for lumps in the breast is just after the 28 (37) 7 (9) 64 (84)
period endsa
A change in the color or shape of a woman’s nipple could be a 49 (64) 7 (9) 45 (59)
sign of breast cancera
Women aged less than 30 years do not get breast cancerb 95 (125) 1 (1) 5 (6)
Breast cancer is more common in women with big breastsb 74 (98) 5 (7) 21 (27)
Lumps in the breast that are cancerous are usually painfulb 50 (66) 16 (21) 33 (44)
Being hit on the breast can cause cancerb 69 (91) 8 (11) 21 (28)
A woman’s chance of surviving breast cancer is very low, even if 91 (120) 0 (0) 9 (12)
it is found earlyb
Afro-American women are more likely to develop breast cancer 36 (48) 8 (11) 55 (73)
than white American womenb

a
Statement is true.
b
Statement is false.
Cor, correct; Inc, incorrect; D/K, do not know.

school students, respectively, giving the correct answer of between 50 and 75 years
as the most affected group.

Awareness of the Need for BSEs

Consistent with the findings of Powe, Underwood, et al. (2005), in a similar study,
we found that while the majority of our participants agreed that monthly BSE was
important for early detection of breast cancer, less than 30% of the college students
and less than 20% of the female high school students were aware of the correct
time to self-exam (Tables 4 and 5). Moreover, only 66% of the female college students
and 40% of the female high school students reported that they had received infor-
mation on how to perform a BSE. Interestingly, only half of these students reported
that they could perform it with confidence.
Overall, our results demonstrated a serious deficiency in breast cancer awareness
and understanding among both college and high school students. College students
had an overall mean score of 15.5 + 0.32, while female and male high school students
had overall mean scores of 13.5 + 0.33 and 11.9 + 0.37 (mean + SEM), respect-
ively, out of a possible total score of 30. High school students who knew someone
with breast cancer were slightly more knowledgeable with a mean score of 13.9 +
0.32 than those who did not know someone with the disease with a mean score of
11.5 + 0.37.
 10 B. Mafuvadze et al.
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Figure 1. Number of sources from which individual participants reported receiving breast cancer
information. For high school students, response from both males and females is shown as separate
bars. For college students, the data are combined (see the text)

Sources of Breast Cancer Information

We asked participants if they had received any information on breast cancer from any
source in the previous month (yes/no) and, if so, to identify the sources of this infor-
mation. Eighty-nine percent of the college students indicated that they had received
some information on breast cancer in the recent past, with 62.1% of them indicating
that they had received information from at least two or more sources (Figure 1). In
contrast, only 65% of the high school students indicated that they had received
some information about breast cancer in the recent past. Interestingly, of those
high school students who did not receive any information about breast cancer, the
majority appeared to be of the male gender (40%). The most frequently identified
sources of information by both college and high school students were radio/TV and
the internet. Of interest, however, was the high number of high school students
who indicated that they had received breast cancer information from a friend.
Interestingly, while 81.1% of the college students and 64.5% of the female high
school students suggested that more information pertaining to breast cancer should
be provided in schools, a majority (54.2%) of the male high school students were
neutral to the idea.

Discussion
National Breast Cancer Awareness Month (NBCAM) was founded in 1985 in the
USA. Throughout the month of October, a number of breast cancer awareness cam-
paigns are held by various organizations and institutions. In recent years, however, a
greater emphasis has been placed on activities aimed at raising funds for breast cancer
research, at the expense of disseminating information on the importance of screening,
 Breast Cancer Awareness among School Students 11

early detection and awareness of associated risk factors. Data from our study, in agree-
ment with previous studies carried out in Europe (Karayurt et al., 2008) and Asia
(Ahmed et al., 2006; Milaat, 2000; Yadav & Jaroli, 2010), show that breast cancer
awareness can be increased in both college and high school students. While breast
cancer is more prevalent in older women, high school and college-aged students are
still at risk and clinical evidence shows that young breast cancer patients have a
high mortality rate due to late diagnosis of the disease (Rosenberg & Levi-Schwartz,
2003). It is essential, therefore, that we develop strategies to ensure that adolescents
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and young, college-aged adults are made aware of the need for developing health
habits that will facilitate early detection of breast cancer (Ludwick & Gaczkowski,
2001). Even though this study is limited by the collection of data from a single locality,
we found that student-held perceptions concerning breast cancer were similar to
findings from previous studies carried out in the USA and other parts of the world.
This study, in agreement with previous studies performed in the USA with different
groups of women (McMenamin et al., 2005; Powe, Daniels, et al., 2005; Powe,
Underwood, et al., 2005), shows that when it comes to breast cancer risk factors,
high school and college students are moderately knowledgeable. Although some of
these risk factors are not easily modifiable, others, such as the use of oral contracep-
tives and HRT, alcohol consumption, obesity and physical inactivity, can be altered in
order to reduce risk. As was found in earlier studies (McMenamin et al., 2005; Powe,
Daniels, et al., 2005), the most widely recognized risk factor was a positive family
history of breast cancer, suggesting that most students are aware of the role of
genetic factors. Given an increased awareness in recent years regarding the effects
of obesity and physical activity on health, it was not surprising that most of the par-
ticipants correctly identified that regular exercise could decrease breast cancer risk.
One study from the Women’s Health Initiative reported that as little as 1.25–2.5
hours per week of brisk walking reduced a woman’s risk by 18% (McTiernan et al.,
2003). Similarly, most of the participants correctly acknowledged that being over-
weight could increase the risk of developing breast cancer (Tables 2 and 3), which
is particularly true if the weight is gained after menopause (Bianchini, 2002). Interest-
ingly, a majority of both high school and college students were unaware of the poten-
tial breast cancer risk associated with HRT and oral contraceptives (Tables 2 and 3).
An understanding of the risks associated with oral contraceptives is particularly
important for students within the age group included in this study because many
are at the point of making important reproductive choices. While previous studies
linking smoking and breast cancer have been somewhat inconclusive, recent evidence
provided by Xue, Willett, Rosner, Hankinson, and Michels (2011) suggests that the
earlier a female begins smoking, the greater her risk of developing breast cancer.
Not surprisingly, breast cancer risk increases with smoking duration. Luo et al.
(2011) suggested that these findings highlight the need for interventions aimed at edu-
cating adolescents and high school and college-aged students about the potential link
between smoking and breast cancer, with the ultimate goal of reducing the number
who start to smoke. Similarly, even though current epidemiological evidence suggests
a link between early child-bearing (under 30), sustained breast feeding (1.5–2 years)
 12 B. Mafuvadze et al.

and reduced risk of breast cancer (Fishman, 2010), most of the participants were
unaware of such a link, answering that early pregnancy and breast feeding had no
effect on breast cancer risk.
Contrary to previous studies (Karayurt et al., 2008; McMenamin et al., 2005),
most of our participants did not subscribe to common misconceptions such as
breast cancer can be caused by wearing tight bras and that it does not affect men.
However, consistent with findings from an earlier study by Milaat (2000) in Saudi
Arabia, most of the participants did not realize that a change in color or shape of a
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woman’s nipple could be a sign of breast cancer. According to Ezzat et al. (1997),
ignorance of the early warning signs of disease can be devastating, resulting in late
presentation of advanced cases.
Consistent with previous studies (McMenamin et al., 2005), most of the partici-
pants in our study had a poor understanding of breast cancer statistics, which Giger-
enzer and Edwards (2003) suggested is likely due to medical data being presented in
confusing terms such as conditional probabilities, rather than as natural frequencies.
For example, in both our study and that of McMenamin et al. (2005), participants
demonstrated a poor understanding of the age of onset of breast cancer and the
rates of long-term survival if detected early. Furthermore, a majority of both college
and high school students did not realize that early diagnosis of the disease results in
good prognosis and that over 60% of individuals diagnosed with the disease will
survive beyond 5 years. Fewer than 15% of the participants in this study realized
that breast cancer primarily affects older women, with most indicating that 30–50-
year-olds were most likely to develop the disease.
Consistent with previous studies, we found that both high school and college stu-
dents lacked sufficient knowledge to perform BSEs. Sixty-six percent of the female
college students and 40% of the female high school students reported having received
information on BSEs, though only half of these students indicated that they were
confident in performing it. Improper BSEs may miss lumps in the breast, leading
to a false assurance of good health. Women who think themselves as healthy may
also feel it unnecessary to undergo regular clinical screening. We, therefore,
suggest that educational policy-makers and health educators find culturally accepta-
ble ways to provide information on proper ways to perform BSEs in schools and
colleges.
This study highlights the important role played by the media in providing breast
cancer information. Both college and high school students indicated that they had
received information through radio/TV and the internet. The ubiquitous presence
of the internet, and its overwhelming use by teens and young adults, means that
potentially, unlimited information is available to those individuals who need it
most. Since many students in high school and college nowadays use social media
such as Facebook and Twitter, this could be an effective means of further raising
awareness about breast cancer among students. Since high school students who
knew someone with breast cancer were significantly more knowledgeable than those
who did not, it appears that breast cancer survivors play an important role in
making young people aware of the disease. A significant number of high school
 Breast Cancer Awareness among School Students 13

students indicated that they had received information about breast cancer from a
school friend, a factor which further highlights the need for promoting proper
breast cancer education at high schools since ‘gossip’ among peers could be a way
in which misconceptions about the disease are spread.
In this study, we specifically assessed breast cancer awareness among college stu-
dents in a pre-service teacher program because previous studies have shown that tea-
chers’ beliefs can influence their thinking and how they view certain subject matters
(Hall, 2005; Rosenfeld & Rosenfeld, 2008). It is our belief that teachers who are
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more knowledgeable about breast cancer have the capacity to play a more meaningful
role in student-targeted breast cancer awareness campaigns. We, therefore, feel it is
essential to provide more information about breast cancer to in-training teachers.
Most men tend to think of breast cancer as a female disease, possibly explaining
why a significant number of male high school students in this study indicated that
were ‘neutral’ when asked if it was necessary to provide more information on the
subject in schools. Knowledgeable men can, however, play an important role in
shaping the opinions of their partners, other women, students and colleagues regard-
ing breast cancer risks, attitudes and beliefs, hence the need to target both male and
female students in breast cancer awareness campaigns. Perhaps not surprisingly, most
female high school students, and college students of both sexes, would welcome the
provision of more information about breast cancer in schools.
Our findings concur with previous studies, showing that in the USA and the world
at large, many students at the high school and college levels are ignorant about breast
cancer, the risk factors leading to its onset, early signs and the importance of screening
and early diagnosis. Our studies demonstrate once again the need for more compre-
hensive breast cancer awareness programs aimed at adolescents and young adults. As
observed by Johnson et al. (2011), such programs can have a profound effect on stu-
dents, making them aware at an early age of the risks of breast cancer and providing
them with early detection and screening information which will help many avoid the
disease in their adult lives. We propose that during NBCAM, schools might select one
day which would be specifically devoted to making students aware of the dangers of
breast cancer, as well as providing the information necessary for screening and early
detection. On this day, which might be identified as ‘breast cancer awareness day’,
all school activities, wherever possible and appropriate, should focus on breast
cancer. We have little doubt that incorporation of such a program into the school
curriculum, in addition to information provided by the internet and public health
programs, would be enormously beneficial to those of school age. Ensuring early
exposure of students to information about breast cancer vital to their future well-
being would benefit them for the rest of their lives.

Acknowledgements
We thank all the participants from the mid-west land grant university and high school
for their time and effort in responding to the survey. We also thank Mr Matthew Cook
for his suggestions and reading the manuscript.
 14 B. Mafuvadze et al.

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