Print version ISSN 0103-2100
Acta paul. enferm. vol.24 no.4 São Paulo 2011
Workshop on breast self-examination: a strategy for self-knowledge of adolescents*
Taller de autoexamen de mamas: una estrategia para el autoconocimiento de adolescentes
Maria da Conceição GregoI; Conceição Vieira da Silva OharaII; Sônia Regina PereiraIII; José Roberto da Silva BrêtasIV
in Sciences from the Nursing Post-Graduation Program of the Universidade Federal
de São Paulo - UNIFESP- São Paulo (SP), Brazil
IIAssociate Professor of the Universidade Federal de São Paulo UNIFESP - São Paulo (SP), Brazil
IIIAssistant Professor of the Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil
IVPsychologist, Assistant Professor of the Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil
To verify the repercussions of knowledge transmitted through a breast self-examination
workshop, and identify the multiplication of information by adolescent participants.
METHODS: This was a quantitative survey-type study, conducted with 474 adolescents from three elementary and middle schools in the municipality of Embu das Artes, in 2006 and 2007.
RESULTS: Data from structured and semistructured questions, answered by the participants, showed the frequencies of responses above 50% about the "repercussions of the content of the workshop" and below 50% on the "multiplied actions".
CONCLUSION: The workshop helps to elaborate the concept of the adolescents themselves about their bodies, informs about breast cancer and the benefits of adopting healthy attitudes and practices in their daily lives, using the technique of breast self-examination as an pedagogical instrument.
Keywords: Adolescent; Adolescent health; Self-examination; Health education; Questionnaires.
Verificar la repercusión del conocimiento transmitido por medio del Taller
de autoexamen de mamas e identificar la multiplicación de las informaciones
por las participantes adolescentes.
MÉTODOS: Se trata de un estudio cuantitativo, tipo Survey, realizado con 474 adolescentes de tres escuelas de Enseñanza Media y Fundamental del municipio de Embu de las Artes, en el 2006 y 2007.
RESULTADOS: Los datos de las preguntas estructuradas y semiestructuradas, respondidas por las participantes, mostraron las frecuencias de las respuestas encima del 50% de la estimativa sobre la "repercusión del contenido del Taller" y abajo del 50% sobre la "acción multiplicadora".
CONCLUSIÓN: El taller auxilia en la elaboración del concepto de sí por parte de las adolescentes, de su cuerpo, informa sobre el cáncer de mama y los beneficios de la adopción de prácticas y actitudes saludables en su cotidiano, empleando la técnica del autoexamen de mamas como instrumento pedagógico.
Descriptores: Adolescente; Salud del adolescente; Autoexamen; Educación en salud; Cuestionarios.
The workshop on Breast Self-Exam (BSE) for adolescents is a systematic activity that is part of the workshop program on Sexual Orientation, developed at public elementary and high schools in the district of Santo Eduardo, through the University extension Project "Corporalidade e Promoção da Saúde" (Body and Health Promotion), which is connected to the Programa de Integração Docente-Assistencial do Embu - PIDA-EMBU (Professor-Healthcare Integration Program of Embu), sponsored by UNIFESP, in the Estância Turística de Embu das Artes.
The pedagogical strategy was elaborated based on body self-awareness, having as a reference the fact that the body changes during puberty, which favors self-awareness among the participants, using the Breast Self-Exam (BSE) technique as a pedagogical instrument that facilitates the perception of normal pubertal-mammary development parameters in a ludic fashion, so that participants are able to identify and be aware of abnormalities, prioritizing self-care through the learning of habits and behaviors related to breast cancer risk factors and approaches to prevent health aggravation(1-3). The present study adopted the terms puberty and adolescence for they comprehend and approach the biological development of secondary sexual characters and the psychological components that are determined, modified, and influenced by society
Based on the connection between Self-Care and Self-Awareness, it is possible to say that self-awareness is a consequence of introspection, reflection and self-interpretation. When adolescents become aware of themselves, they get in touch with their inner-self, their basic truths that satisfy their needs and their own personal desires, before they can return to the external world. Self-care is not only something momentaneous, from adolescence to adulthood, but a milestone of when people start taking care of themselves throughout their existence(4).
Self-care can be understood as an active social behavior from a public health perspective, a set of self-care approaches(5) that encompass activities of daily living through which individuals perform self-care activities prioritizing their own benefit in all stages of life, in order to maintain life, health and well-being. Once such behavior is settled it offers a self-awareness pathway, and supports an attitude shift which implies in constant learning for people beyond their daily living. Therefore, learning does not mean acquiring more information, but expanding the capacity to produce results. It is a learning process that helps people, especially children, adolescents and young adults build their own projects of future life (7-8).
Men are not products of their bodies; instead, they build them through interactions with the others and an immersion in the symbolic, visual, individual, social and cultural universes. The social and cultural structures in which individuals are inserted explain the origin of their social representations, their imaginary and the use of their bodies; that is, socially-built bodies(9).
The workshop on BSE provides adolescents with an instrument of corporal perception that presents a new approach on how to look at their body structure. According to the concept that the social construction of the body affects the well-being of a population, pedagogical activities understand and interfere in their daily living, bringing preventive actions and promoting health, in order to develop a useful behavior for social living and enhance citizenship(10- 11).
In the period the present study, the National Cancer Control Institute (NCCI) reported in the estimates for 2008 that the number of new breast cancer cases would be 49,400 with an estimate risk of 51 cases in every 100,000 women; there are estimates foreseeing that in 2020 breast cancer will reach one million cases. Cancer is a current problem to nurses; it is a public health(12) concern, due to its magnitude (high morbidity) and transcendence (high social and economy cost). The same document highlights the role of nurses who work with primary prevention, providing health education. Moreover, it reinforces that BSE does not diagnose breast cancer, and the use of such technique should go beyond the morphological alteration detection; its role is to teach women to better know their bodies and to have a greater participation and control of their health(13- 14).
Similarly, the bi-monthly magazine of the Conselho Regional de Enfermagem de São Paulo(15), highlighted the importance for professionals to develop and implement the role of health educators, so as to guide individuals, their families and communities on cancer risk factors as well as ways to prevent them, while promoting educational programs on health to spread health activities and interventions.
Based on such assumptions and having the community as the structural context for the present research, BSE workshops focused on schools, highlighting to adolescents that the Breast Self-Exam techniques can be an instrument of self-awareness, which reveals the importance of their body shapes, helping them accept or exclude new values on self-care.
The objectives of this study were: to assess the impact of the knowledge transmitted by the Breast self-exam workshops in the participants' daily lives, as well as to identify whether information was multiplied through social relationships among the studied population.
The present is a quantitative survey, whose method allows the comparison and verification of how people, groups or things behave or act regarding the prevailing conditions of reality(16).
The population in this study was comprised of female adolescents aged 10-24, who took part in the workshops in 2006 and 2007, and were attending the following public middle and high schools in the morning or afternoon: E.E. Alexandrina Bassiti; E.E. Jardim da Luz; and E.E. Odete Maria de Freitas, located in the district of Santo Eduardo in Embu, São Paulo.
A pilot study was performed in 2005 to define the population's sociodemographic profile, so that the WHO premises on adolescence and puberty could be safely applied. Such premises state that adolescence is the period ranging from 10 years old to 19 years old, and youth is the period ranging from 15 to 24 years old, while the Brazilian Children and Adolescents' Statute defines adolescence as the period ranging from 12 to 18 years old(1-3).
The instrument for data collection was a questionnaire with 15 closed questions and 1 open question, which was answered by 474 girls out of 571 participants between 2006 and 2007. It encompasses variables such as age and schooling - Q1; and Q2 intended to categorize the population through the studied variables: practice of BSE - Q3 to Q6; risk factors - Q7 to Q11; Multiplying action - Q8 to Q12; body self-awareness - Q15; and a description of the participant's body, according to their perception - Q16. With regard to the open question, data were presented through category tables and symbolic representation sets.
Data were analyzed according to the studied variables, and presented in tables, through the statistical programs: SPSS 13.0, and Excel 2000.
The study expectation was to find a 50% rate of positive response regarding adherence to the Self-Exam as an instrument of self-awareness and multiplication of the received information, based on a similar study in which the author(17) had an average rate of 23% of positive response in a population of 127 adolescents from three suburban schools in Ohio, USA.
It is also worth highlighting that the present study was evaluated and approved by the Research Ethics Committee of Universidade Federal de São Paulo, protocol number 1530/07. All methodological procedures complied with Resolution 196/96 with regard to Norms for Researches with Human Beings(18).
The prevalence of positive responses over 50% of the previously established estimation was found in the following questions: Q3, 4, 5, 6, 7, 8, 9, 10, 11, 14, and 15. Results below 50% include the "multiplying action" (Q12), "Why didn't you teach others?" (Q12.1), and "Who did you teach?" (Q13).
The average age found (Q1) was 14 years old, and regarding schooling (Q2), 82.3% of the participants were students in 6th, 7th, and 8th grades, and 17.8% were on the 1st and 2nd year of high school.
Schooling identified that 82.3% of the participants were in the 6th, 7th, and 8th grades, which is the best period of life to offer workshops, for adolescents stay longer at school. On the other hand, 17.8% of participants were in the 1st and 2nd years of high school. This shows that above the 8th grade, the number of students decreases.
Variables offering positive answers to the practice of BSE were: "Have you been looking at yourself in the mirror?" with a 90.1% rate; "Before the shower/bath, have you been looking at your breasts?" with a 77.8% rate; and "Have you been examining or touching your breasts more often?" with a 69.6% rate. Breast touching had a positive response of 69.6% indicating that adolescents touch their breasts on a daily basis, in comparison to a 30.4% rate of negative responses and no answers.
Regarding risk factors related to breast cancer, it was possible to verify that food habits changed after the workshops, and more adolescents were being more careful with their food. The question asking whether food habits had changed presented a 69.4% positive response, in comparison with negative responses.
Other risk factors, such as smoking and drinking show significant frequency of 95.6% of adolescents who did not smoke, and 83.1% of adolescents did not drink. Questions asking whether adolescents had "cut down on smoking", or "quit smoking" resulted in a 3.4%, rate, much lower than expected. As to similar questions about drinking, another reality was revealed: The answer "I continue to drink" corresponds to 8.2% of the total; the answers "I cut down on drinking" and "I quit drinking" correspond to 15.2% of adolescents who have a close relationship with alcohol drinking.
Regarding "the practice of physical exercises," good results appeared in 94.3% of the responses, indicating that adolescents adhere to the practice of physical exercises as a prevention of health aggravation, showing commitment with the quality of life. Concerning "appointment with a gynecologist," 69% of the responses were "I have never been to one," 17.1%, "I started going to the gynecologist," and 12.4% were "I continue to go to the gynecologist." The rate of 12.4% represents 59 adolescents out of 474, expressing that adolescents are interested in having medical control.
The information multiplication by adolescents was measured through the question "Did you teach the BSE to another person?", which had a 71.9% rate of negative responses, below the expectation that at least half of the participants could become a multiplier.
Data in Table 1 show the distribution of responses regarding schooling; Pearson's Chi-Square test was used to test the association between the answers and the level of education. There is a statistically significant association between the question "Have you been looking at yourself in the mirror?," (p=0.015), answers from those who changed their diets after the workshop, (p=0.047) and in relation to alcohol drinking (p=0.002).
Regarding the questions "Did you teach the BSE to another person?" (Q12) and "Participating in the Breast Self-Exam Workshop helped me know my body better" (Q15) and their association with schooling, there was no association with the reason for not teaching the BSE to others.
When measuring the association between the question "Why didn't you teach others?" (Q12.1) and schooling, there was an association between the variables (p=0.012). It is relevant to highlight the alternative "I don't feel at ease", with 24.7%, a much lower rate than expected. Such choice shows the fragility of adolescents when speaking about their body. With regard to the adolescents who reported they had transmitted the information obtained in the workshop, 65.2% responded to have found it "easy" to speak about BSE and 25.7% responded to have found it "difficult". The adolescents answered questions about themselves, and the results were contrary to the ones obtained in the previous question, exposing the difficulty they find in discussing matters about their bodies with others.
The workshop results regarding self-awareness among adolescents were measured through the question "Did your participation in the workshop help you better know your body?" The result, 87.8% positive responses, compared with a 12.2% negative rate gives substance and validates the self-awareness and self-care strategies in the prevention of breast cancer and the promotion of healthy habits for a good quality of life among adolescents.
The other questions did not present statistically significant associations with schooling, BSE knowledge and practice in the prevention of breast cancer.
The collected data analysis was difficult due to the lack of theoretical reference when establishing the study expectations. Most of the studies focused on the awareness of breast cancer and there were very few national studies. Therefore, the expectation of 50% of positive answers was established after a pre-test, that is, a rate that was 30% higher than the one reached by the study performed in Ohio, USA(17).
The workshop identified that the number of adolescents is larger in middle school, which is ideal for the development of a strategy. Such number decreases in high school, because, according to the pedagogical coordinators, after 8th grade some students start working and need to be transferred to the evening shift, which makes it difficult for them to attend classes and develop activities regarding health education.
The goal when teaching the BSE technique was to verify the importance adolescents gave to "looking" at their own breasts after the workshop, generating physical and functional self-awareness and an affective meaning, as later revealed by the positive results obtained of over 50%. The BSE technique familiarizes girls with their breasts and body contour, and also works with feelings of inhibition, fear and shame, as mentioned in similar studies performed with young nursing students(19).
The breasts growth is the only hint of the start of sexual maturation, showing they are ready for adult life. Adolescents have feelings of weakness, fear and anxiety when they lose their child body, but not the childish mind(20). Positive answers of over 50% given by adolescents regarding their body show the importance of knowing how their organs work, and how their women's bodies will function in future sexual intercourse.
Regarding risk factors on breast cancer, the results obtained show the acceptance to change feeding habits. Among the negative answers, adolescents who did not change their feeding habits recognize they should change them. In order to reach feeding habits awareness, the present study used the representation of the link between a healthy body and what is imposed as a mass model of an ideal body by the media, the Internet and other current communication means(21).
Another study(22), showed evidence on the prevalence of food disorders associated to body satisfaction since the age of 7. Such fact has to do with the influence of the contemporary world, technology, media and the consumption strategy related to the body for financial purposes, which cause physical and social modifications.
The workshop covered practical situations so that adolescents could follow a healthy diet, making it easy for them to develop and elaborate their self-image, and consequent self-awareness and self-care. It is fundamental that the society is flexible with adolescent with regard to a healthy self-image, preserving their integrity and self(23).
With regard to the practice of physical activities, many adolescents during the workshops stated they practiced sports, such as walking to school, and were favorable to physical exercises at school; moreover, they required changes in these activities: women focused exercises, separated from men, should also be practiced.
In different schools, reports about alcohol drinking were expressed as "common" even by younger students and naturally seen by them due to the fact drinking was common among close family members, parents, and friends, characterizing it as a habit in the daily living. As to smoking habits, there was a decrease in the percentage of consumption. Two studies(24- 25) described that school friends' pressure or consumption by a family member might influence alcohol drinking among adolescents, as well as the easy access to alcohol purchase, favoring a predisposition to the risk factor. The authors identified that, among students in secondary or high schools, about 80.5% have already drunk alcohol, at least once before, 28% have smoked, at least once before, and 5% often smoke; a frequent relationship found in the present study.
Going to the gynecologist has obtained negative answers as expected. It would be unrealistic to think that after the first menstruation, every adolescent should see a gynecologist, for this involves cultural family standards which should be respected. Based on family value standards, the workshop achieved its goal when informing and guiding on the importance of going to a gynecologist to diagnose any anomalies found in the adolescent's breasts and body, making them aware of the need for self-care, and demystifying the belief that going to a gynecologist is allowed only to married women. It should also be a common practice for those who have an active sexual life, to prevent childbearing and pregnancy problems and promote health among adolescents(26- 27).
With regard to the multiplying action, the percentage obtained was lower than expected. It was possible to verify that 71.9% of adolescents presented conflicts and immaturity when talking about their own bodies, which causes them embarrassment when surrounded by other women(19, 21, 28).
Considering the positive results of over 50% obtained by the BSE workshop, it is relevant highlighting that healthy practices, as well as the benefits adopting them(6) make it easier for adolescents from different social conditions to use them, and realize aspects of their own bodies through the experiences lived, without embarrassments and in several different situations, taking into account their own choices and their social group(29)
The workshops repercussion in the adolescents' daily living brought optimistic results, both due to the receptivity of information obtained and the changes applied to their daily living. With positive answers of over 50%, it is possible to say that the participants acquired knowledge about their bodies after the workshops, and started performing the BSE themselves. Participants found out about what they did not know and learned important things about themselves.
Breast touching through the Self-Exam was recognized as an instrument of body perception, generating thoughts, reflections, understanding and awareness about the body structure. Not only the concern about body shape matters, through the workshops, adolescents had the opportunity to experience a pedagogical activity on Health Education, in which they acquired new body awareness, and were able to talk about their anxieties regarding body changes and the real and ideal body concepts.
Curiously, during this workshop, adolescents with breast nodules as well as servers and teachers having with a history of breast cancer were found. Such adolescents participated in the workshop and enriched the activity, reporting the finding, treatment, follow-up, and prognosis of the nodules, which interested the other students. This justifies the workshops for women, for it generates a sense of collaboration and fulfillment, especially when they have the opportunity of narrating their experiences, which highlights the importance of knowing one's body and preventing health aggravations.
The nurse's role regarding Health Education generated rich experiences. Besides participating in the workshops, they built relationships, clarified the adolescents' doubts, and deeply integrated with teachers and the school principals. Although the information multiplication had results lower than 50%, the school principals invited the researchers to participate in a school celebration day and perform a BSE workshop with students, parents, and other guests. The workshop was also incorporated to the educational curriculum during the research period.
The workshops tried to adapt to the reality of the community, facilitating new practices and habits to be established, bringing information and prevention awareness to that social environment so that adversities did not discourage them in the personal and social sides to think about a healthy body perception and development.
When using the self-exam technique as a pedagogical instrument for self-awareness, a prevention action on Health Education is put into practice, allowing adolescents to build a subjective concept of themselves, and promoting self-care in their daily living. When information regarding breast cancer is contextualized, individuals are able to understand the benefits of incorporating healthy habits to their lives, aiming to have quality of life during adulthood. The researchers believe that that the present study will be the start for the multiplication of Breast Self-Exam Workshops in Health projects.
1. Zeferino AMB, Barros Filho AA, Bettiol H, Barbieri MA. Acompanhamento do crescimento. J Pediatr (Rio J). 2003;79(Supl 1):S23-32. [ Links ]
2. Roman EP, Ribeiro RR, Guerra-Júnior G, Barros-Filho AA. Antropometria, maturação sexual e idade da menarca de acordo com o nível socioeconômico de meninas escolares de Cascavel (PR). Rev Assoc Med Bras (1992). 2009;55(3):317-21. [ Links ]
3. Dávila Leon O. Adolescência y juventud: de las nociones a los abordajes. Ultima Década. 2004;(21):83-104. [ Links ]
4. Foucault M. A hermenêutica do sujeito. 2a ed. São Paulo: Martins Fontes; 2006. [ Links ]
5. Queiroz A. Foucault: o paradoxo das passagens. Rio de Janeiro: Pazulin; 1999. [ Links ]
6. Torres GV, Davim RMB, Nóbrega MML. Aplicação do processo de enfermagem baseado na teoria de Orem: estudo de caso com uma adolescente grávida. Rev Latinoam Enferm. 1999;7(2):47-53. [ Links ]
7. Bitencourt C, Gonçalo C. O desenvolvimento do autoconhecimento como estrutura básica para aprendizagem organizacional. In: Encontro Nacional dos Cursos de Pós-Graduação em Administração - EnANPAD, 199, Foz do Iguaçu. [ Links ]
8. Magalhães ML. Promoção da saúde individual. [Ciências na Escola] 2006. Disponível em: www.redebrasil.tv.br/salto/boletins2001/sel/se1txt4.htm. [ Links ]
9. Le Breton D.A. Sociologia do Corpo. Petrópolis, RJ: Vozes; 2006. [ Links ]
10. Marcondes E, coordenador. Pediatria básica. São Paulo: Sarvier; 1991. [ Links ]
11. Merleau-Ponty M. Fenomenologia da percepção. São Paulo: Freitas Bastos; 1971. [ Links ]
12. 12.Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Estimativa 2006: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2006. [ Links ]
13. Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Ações de enfermagem para o controle do câncer: uma proposta de integração ensino-serviço. 2a ed. Rio de Janeiro: INCA; 2002. [ Links ]
14. Brasil. Ministério da Saúde. Instituto Nacional de Câncer. Controle do câncer de mama. Documento de consenso. Rio de Janeiro: INCA; 2004. [citado 2004 Out18] Disponível em: http://www.inca.gov.br/publicacoes/Consensointegra.pdf [ Links ]
15. São Paulo. Conselho Regional de Enfermagem - SP. A conscientização apenas não basta. Rev COREN-SP. 2006;(64):4-7. [ Links ]
16. Babbie ER. Métodos de pesquisa de Survey. 2a. ed. Belo Horizonte: Editora UFMG; 1999. [ Links ]
17. Ludwick R, Gaczkowski T. Breast self-exams by teenagers: outcome of a teaching program. Cancer Nurs. 2001;24(4):315-9. [ Links ]
18. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução n.196 de 10 de outubro de 1996. Diretrizes e normas regulamentadoras de pesquisas em seres humanos. Mundo Saúde. 1996;21(1):52-61. [ Links ]
19. Silva RM, Rodrigues DP, Gurgel AH, Farias LM. Autoexame das mamas em mulheres jovens e a relação com o autocuidado. Rev RENE. 2000;1(1):9-13. [ Links ]
20. Aberastury A. Adolescência. Potro Alegre: Artes Médicas; 1980. [ Links ]
21. Outeiral JO. Adolescer: estudos revisados sobre adolescência. 3a ed. Rio de Janeiro: Revinter; 2008. [ Links ]
22. Fernandes AER. Avaliação da imagem corporal, hábitos de vida e alimentares em crianças e adolescentes de escola públicas e particulares de Belo Horizonte [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais; 2007. [ Links ]
23. Schilder P. A imagem do corpo: as energias construtivas da psique. São Paulo: Martins Fontes; 1981. [ Links ]
24. Silber TJ, Souza RP. Uso e abuso de drogas na adolescência: o que se deve saber e o que se pode fazer. Adolesc Latinoam. 1998;1(3):148-61. [ Links ]
25. Romano M, Duailibi S, Pinsky I, Laranjeira. Pesquisa de compra de bebidas alcoólicas por adolescentes em duas cidades do Estado de São Paulo. Rev Saúde Pública. 2007;41(4):495-501. [ Links ]
26. Halbe HW, Halbe AFP, Ramos LO. A saúde da adolescente. RBM Rev Bras Med. Ed: Out 2000N1. Ciber Saúde. Disponível em http://www.drcarlos.med.br/saude_adol.html: http://www.moreirajr.com.br/revistas.asp?fase=r003&id_materia=86 [ Links ]
27. Ministério da Saúde. DST-AIDS. Kehdi I. Adolescente deve ir ao ginecologista. Bem Estar & Saúde. Jornal de Brasília; 2003 [citado em 2003 jun 7] Disponível em http://www.sistemas.aids.gov.br [ Links ]
28. Crespin J, Reato LFN. Hebiatria: medicina da adolescência. São Paulo: Roca; 2007. [ Links ]
29. Barros Filho C. O habitus e o nada. Rev FAMECOS. 2002;(17):74-88. [ Links ]
Author: Received article
30/04/2010 and accepted 19/02/2011 *Article
extracted from the Masters' Dissertation "Breast Self-Exam Workshops: a self-knowledge
strategy for adolescents", performed in three schools in Embu das Artes (SP),
connected to the Programa de Integração Docente -Assistencial
do Embu (PIDA) - Universidade Federal de São Paulo UNIFESP (SP), Brazil.
Maria da Conceição Grego
R. Durval do Nascimento Miele 38 - Vila Clementino - São Paulo - SP - Brazil CEP. 04026-070
Received article 30/04/2010 and accepted 19/02/2011
*Article extracted from the Masters' Dissertation "Breast Self-Exam Workshops: a self-knowledge strategy for adolescents", performed in three schools in Embu das Artes (SP), connected to the Programa de Integração Docente -Assistencial do Embu (PIDA) - Universidade Federal de São Paulo UNIFESP (SP), Brazil.