Knowledge and perceived benefits of exercise among women with breast cancer in tertiary hospitals in Delta State

Abstract

BACKGROUND:

Knowledge of exercise is of paramount importance in improving and reclaiming the health of women with breast cancer and also enables them to reap the enormous benefits associated with healthy physical activity.

AIM:

To assess the knowledge and perceived benefits of exercise among women with breast cancer in Delta State.

METHOD:

Sample of 94 eligible consenting women who are still maintaining follow up with the two tertiary hospitals in Delta state, Federal Medical Center (FMC) Asaba and Delta State University Teaching Hospital (DELSUTH) Oghara were enlisted for the study.

RESULT:

Findings from the study revealed knowledge of the recommended exercise was poor among the women with breast cancer, as only 21(22.3%) had good knowledge. For those knowledgeable, their knowledge source was mainly through the mass media 5(23.8%) and the internet 4(19.0%). On the benefits of exercise as perceived by the women with breast cancer, the result shows that 88 (93.6%) of the women with breast cancer perceived exercise as beneficial. The principal exercise perceived to be beneficial was walking 43(45.7) and treatment of discomfort 25(26.6%) was the main benefit they hoped to gain from exercise. Also demographic profiles of the women were not significantly related to their knowledge about the recommended exercise asp > 0.05.

CONCLUSION:

Knowledge of the recommended exercise was low among women with breast cancer despite their awareness of the benefits. It is therefore essential for health care providers, especially those involved in the care of these patients, to use every avenue to health-educate, counsel and help them in implementing the recommended exercise to enhance their survival.

Keywords

Perceived benefits exercise breast cancer Delta State

1. Introduction

Breast cancer makes up a major public health problem globally as over 1 million new cases are diagnosed yearly, resulting in over 400,000 annual deaths and about 4.4 million women living with the disease [1]. It also affects one in eight women in their lifetime [1]. Breast cancer is responsible for about 19.5% of all cancer cases, with new cases of female breast cancer at 128.5 per 100,000 women per year [2] and 16% of all cancer-related deaths in Nigeria [3].

With the present level of diagnosis and treatment modality, people that survive cancer continued to increase, with women with breast cancer accounting for 22% of total cancer survivors globally in 2012 [4]. Post-treatment side effects of breast cancer cause the patients to have problems which are negatively associated with their overall wellbeing [5]. Some of these post-treatment side effects can be minimised or eliminated with the help of exercise [6,7].

The literature on the knowledge of exercise among breast cancer patients seems to be scarce [8]. Although most oncologists are knowledgeable and had a positive attitude towards exercise, few of them do recommend it to their patients. Lack of exercise discussions and programme availability was due to lack of knowledge and familiarity with the exercise as well as scarce resources [9]. Exercise outcome expectations research among breast cancer survivors revealed that breast cancer survivors have low levels of agreement that exercise may mitigate late and long-term cancer and treatment effects, which may be as a result of inadequate knowledge with regards to the recommended exercise [10]. Maria and her colleagues [11] in a similar study discovered that maintenance of a physically active lifestyle during and after chemotherapy is sometimes difficult and the reported benefits of physical activity (PA) were of paramount importance hence they emphasized that health care professionals should play a crucial “gateway” role in providing information which gives knowledge on the implementation of PA. Also, an article by Siew et al revealed that physical activity participation amongst cancer survivors is low [12]. It is pertinent to note that if healthcare providers that take care of these patients do not discuss and educate the patients on the need and availability of the recommended exercises they can practice for their wellbeing, they will not know. Even when they get the information from other sources, they will be hesitant to implement it because it is not coming from their trusted providers. In essence, this made most patients not able to have good knowledge of exercise guideline they can adopt as a survival programme after their treatment. They were not able to initiate such a programme [9] and may not reap the benefits associated with the programme. They are supposed to be aware of the recommended exercise particularly the one from American College and Sports Medicine (ACSM) for cancer survivors which include endurance (walking, jogging, carrying of lightweights), resistance (shoulder and arm exercises) and flexibility (stretching exercises, sit-ups, press-ups, increased shoulder and arm exercises) exercises [13].

From the foregoing, it is essential to note that there is a paucity of information with regards to knowledge and perceived benefits of exercise among breast cancer patients in Nigeria. Hence the need for health care workers, especially those handling these patients, to provide the needed information which will invariably improve knowledge of women with breast cancer to enable them practice and get the needed benefits inherent in the exercise. Therefore, this study assessed the knowledge and perceived benefits of exercise among women with breast cancer in Delta State, Nigeria.

2. Materials and methods

2.1. Design and study setting

The study adopted a descriptive survey design. The area of the study was two tertiary hospitals that have oncology unit and manage breast cancer patients in Delta State. The institutions include Delta State University Teaching Hospital Oghara and Federal Medical Centre Asaba.

Table 1
Socio-demographic characteristics of participants. Socio-demographic information of the women N = 94

Demographic characteristics Frequency Percentage Range M ± SD

Age 19–64 44.95 ± 8.56

– <40 23 24.5

– 40–49 46 48.9

– 50+ 25 26.6

Marital status

– Married 64 68.1

– Not married 14 14.9

– Widow 9 9.6

– Divorced/separated 7 7.4

Educational status

– No formal/primary education 15 16.0

– Secondary education 30 31.9

– Tertiary education 49 52.1

Employment status

– Unemployed/Self employed 37 39.4

– Employed by other organization 57 60.6

Clinical Characteristics

When were you diagnosed with breast cancer?

– Less than 7 months 13 13.8

– 7 to 9 months 35 37.2

– 10 months and above 45 47.9

– No response 1 1.1

At what stage were you diagnosed?

– Stage 1 47 50.0

– Stage 2 17 18.1

– Stage 3 1 1.1

– Stage 4 24 25.5

– Not sure 5 5.3

Demographic characteristics	Frequency	Percentage	Range	M ± SD
Age			19–64	44.95 ± 8.56
– <40	23	24.5
– 40–49	46	48.9
– 50+	25	26.6
Marital status
– Married	64	68.1
– Not married	14	14.9
– Widow	9	9.6
– Divorced/separated	7	7.4
Educational status
– No formal/primary education	15	16.0
– Secondary education	30	31.9
– Tertiary education	49	52.1
Employment status
– Unemployed/Self employed	37	39.4
– Employed by other organization	57	60.6
Clinical Characteristics
When were you diagnosed with breast cancer?
– Less than 7 months	13	13.8
– 7 to 9 months	35	37.2
– 10 months and above	45	47.9
– No response	1	1.1
At what stage were you diagnosed?
– Stage 1	47	50.0
– Stage 2	17	18.1
– Stage 3	1	1.1
– Stage 4	24	25.5
– Not sure	5	5.3

2.2. Inclusion criteria

Ninety-four (94) eligible women, in the two tertiary hospitals participated in the study out of the 128 patients initially recruited, screened and potentially eligible candidates based on the following inclusion criteria.

Must have completed their primary therapy for breast cancer

Consented to participate in the study

Still maintaining follow up with the hospitals.

2.3. Variables assessed and outcomes evaluation

The variables assessed were the knowledge and benefits of exercise. To assess the outcome of these variables, we used a self-structured questionnaire on knowledge and perceived benefits of exercise in breast cancer women to collect data. The questionnaire has three sections. Section A elicited information on demographic data of the respondents; section B elicited information on knowledge of exercise among the women while section C elicited information on the benefits of exercise as perceived by the women with breast cancer. For face and content validation of the instrument, experts in Oncology, Physical fitness and Measurement and Evaluation were requested to vet the copies of the instruments along with the objectives of the study submitted to these experts for validation. The experts, after due assessment of the instruments indicated their observations and the necessary corrections were effected by the researchers based on the inputs of these experts before using it for pilot test. The instrument was also tested for reliability and reliability coefficient (r) obtained was 0.82; hence the instrument was considered reliable for the study. Ethical approval was obtained from the Health Research Ethics Committee of the FMC Asaba and DELSUTH Oghara, respectively. The generated data were analysed using both descriptive and inferential statistics with the aid of Statistical Package for Social Sciences (SPSS) version 20. The data were summarised using descriptive statistics, frequency and percentage and results presented in tables. In contrast, we analysed the inferential data using non-parametric (Chi-Square and Fishers Exact test) tool at a 0.05 level of significance to ascertain the relationship between the variables.

3. Results

Table 1 presents the demographic characteristics of women. Their age ranged from 19–64 years with a mean and standard deviation of 44.95 ± 8.56 and modal age group of 40–49 years. The women were mostly married 64(68.1%), employed 57(60.6%) and had tertiary education 49(52.1%). The majority 45(47.9%) were diagnosed 10 months and above, and at stage 1 47(50.0%).

Result in Table 2 shows that a few 21(22.3%) of women with breast cancer know the recommended exercise. For those knowledgeable, their knowledge source was mainly through the mass media 5(23.8%) and the internet 4(19.0%). Out of the 21 women that knew about the recommended exercise, 11(52.4%) of them knew that the exercise is graded into endurance, flexibility and resistance exercise and that the exercise should be 3–5 days/week for 20–45 minutes.

Table 2
Objective 1: To ascertain knowledge of the women with breast cancer in Delta State about the recommended exercise guideline for breast cancer survivors. Knowledge of exercise among women with breast cancer n = 94

Frequency Percentage

Knowledge about recommended exercise guideline by ACSM (n = 94)

– Yes 21 22.3

– No 73 77.7

If yes, how did you manage to know about it? (n = 21)

– Television 5 23.8

– Through family and friends 2 9.5

– Breast cancer survivor group 2 9.5

– Internet 4 19.0

– My doctor/nurse 0 0.0

– No response 8 38.1

The knowledge that the exercise is graded into endurance, resistance and flexibility exercise (n = 21)

– Yes 11 52.4

– No 10 47.6

The knowledge that the exercise session is 3–5 days/week for 20–45 minutes (n = 21)

– Yes 11 52.4

– No 10 47.6

	Frequency	Percentage
Knowledge about recommended exercise guideline by ACSM (n = 94)
– Yes	21	22.3
– No	73	77.7
If yes, how did you manage to know about it? (n = 21)
– Television	5	23.8
– Through family and friends	2	9.5
– Breast cancer survivor group	2	9.5
– Internet	4	19.0
– My doctor/nurse	0	0.0
– No response	8	38.1
The knowledge that the exercise is graded into endurance, resistance and flexibility exercise (n = 21)
– Yes	11	52.4
– No	10	47.6
The knowledge that the exercise session is 3–5 days/week for 20–45 minutes (n = 21)
– Yes	11	52.4
– No	10	47.6

Findings from Table 3 show that many 88(93.6%) of women with breast cancer perceived exercise to be beneficial. The principal exercises perceived to be beneficial were walking 43(45.7%) and jogging 15(16.0%). Treatment of discomfort 25(26.6%) was the main benefit hoped to gain from exercise practice among the women. Other notable reasons include promoting and maintaining health 14(14.9%) and maintaining weight 11(11.7%). Very many 82(87.2%) were also satisfied with the exercise.

Table 3

Objective 2: To find out the benefits of exercise generally for breast cancer survivors as perceived by women with breast cancer in Delta State. Benefits of exercise as perceived by the women with breast cancer n = 94

	Frequency	Percentage
Found any type of exercise beneficial
– Yes	88	93.6
– No	6	6.4
Exercises found to be beneficial
– Walking	43	45.7
– Jogging	15	16.0
– Running	7	7.4
– Swimming	1	1.1
– Farming	2	2.1
– Dancing	2	2.1
– None	11	11.7
	13	13.9
Benefits hoped to gain from exercise practice
– To help treat the discomfort	25	26.6
– To boost the immune system	2	2.1
– To help promote and maintain health	14	14.9
– To improve psychological/emotional well being	2	2.1
– To improve the physical well being	6	6.4
– To help avoid or reduce some side effects	2	2.1
– To help lower risk of breast cancer coming back	7	7.4
– To help maintain weight	11	11.7
– To help have more energy	2	2.1
– To help keep bones healthy	5	5.3
– To help feel better about self and also sleep better	8	8.5
– Others	10	10.6
Satisfaction from exercise
– Satisfied	82	87.2
– Disappointed	1	1.1
– Cannot tell any different	11	11.7

From Table 4, findings revealed that the women’s characteristics was not significantly related with their knowledge about the recommended exercise: age (p = .290), educational status (p = .268), occupation (p = .251) and cancer stage on diagnosis (p = .085), and their overall knowledge of the exercise: age (p = .351), educational status (p = .499), occupation (p = .466) and cancer stage on diagnosis (p = .528). Their knowledge or lack of knowledge hence never depended on these characteristics.

Table 4

Relationship between the women’s characteristics and knowledge on recommended exercise

	No	Yes	Total	Chi-square	p-value
Knowledge of recommended exercise
Age				2.475	.290
– <40	16(69.6)	7(30.4)	23
– 40–49	35(76.1)	11(23.9)	46
– 50+	22(88.0)	3(12.0)	25
Educational status				2.637	.268
– No formal/primary	14(93.3)	1(6.7)	15
– Secondary	23(76.7)	7(23.3)	30
– Tertiary	36(73.5)	13(26.5)	49
Occupation				1.319	.251
– Unemployed/self-employed	31(83.8)	6(16.2)	37
– Employed	42(73.7)	15(26.3)	57
Stage of breast cancer on diagnosis				4.924	.085
– Stage 1	32(68.1)	15(31.9)	47
– Stage 2–3	14(77.8)	4(22.2)	17
– Stage 4	22(91.7)	2(8.3)	24
Overall knowledge of the exercise
Age				-	.351*
– <40	18(78.3)	5(21.7)	23
– 40–49	37(80.4)	9(19.6)	46
– 50+	23(92.0)	2(8.0)	25
Educational status				1.390	.499
– No formal/primary	14(93.3)	1(6.7)	15
– Secondary	24(80.0)	6(20.0)	30
– Tertiary	40(81.6)	9(18.4)	49
Employment status				.532	.466
– Unemployed/self-employed	32(86.5)	5(13.5)	37
– Employed	46(80.7)	11(19.3)	57
Stage of breast cancer diagnosis				–	.528*
– Stage 1	38(80.9)	9(19.1)	47
– Stage 2–3	16(88.9)	2(11.1)	17
– Stage 4	22(91.7)	2(8.3)	24

*Indicates where Fishers Exact Test was used.

4. Discussion

The result of the knowledge of the recommended exercise revealed poor knowledge about the exercise recommended by the American Cancer and sports medicine for cancer survivors. The inadequate knowledge transcends through the grading of the exercise, the exercise session and the timing of the exercise. On the overall, women with breast cancer in the two tertiary institutions had poor knowledge about the recommended exercise. These findings agree with Buffart et al. [9], who stated that most patients do not have good knowledge of exercise prescription they can adopt as a survival programme and were not able to initiate such an exercise programme. Hence they remain inactive, which slowly leads to a debilitative or deadly state and can also lead to an increased level of anxiety and reduced level of comfort for many breast cancer clients [14]. This poor knowledge may also be due to the limited programmes developed for cancer survivors. This limitation has exposed the need for individualised, or small-group subsidised structured programmes such as the ‘Cancer Survivors Programme’ in Australia or ‘Pinc Pilates’ in New Zealand [15]. The result of the study was also in agreement with Rachel et al. [10] who revealed that breast cancer survivors have low levels of agreement that exercise may mitigate late and long-term cancer and treatment effects which may be as a result of inadequate knowledge of the recommended exercise. In the same vein, Siew and colleagues [12] in their study discovered that physical activity participation amongst cancer survivors is low. They, therefore, emphasised that health care clinicians need to play a more significant public health role in educating and counselling lifestyle redesign for survivors living with cancer as they cannot practice what they do not know.

On their sources of information on exercise for the few women that knew about the recommended exercise guideline, their sources of information were from internet, family and friends and breast cancer survivor group. We saw that most oncologists and nurses do not recommend or see exercise as important as the treatment they offer to the patients thereby denying the patients the benefits they could have received from it if they had received the information from their most trusted carers and implemented same. The recent survey of oncologists and oncology nurses confirms this report that despite the fact most oncologists and oncology nurses had positive attitudes toward recommending and providing exercise rehabilitation services for their patients, only few cancer survivors indicated that oncologists discussed exercise with them during their treatment consultation [9] and only few cancer-care hospitals provided an exercise programme for their patients [9]. This lack of discussions on exercise and programme availability cum implementation may be due to lack of awareness and familiarity with the exercise as well as scarce resources [9]. Hence it is essential to note that if health care providers that take care of these patients do not discuss and educate the patients on the need and availability of exercise programmes for their wellbeing, they will not know. Even when they get the information from other sources, they will be hesitant to implement it as it is not coming from their trusted health care provider. Also in support of this finding is the study by Opaluch-Bushy and colleague [16] which equally discovered poor knowledge that led to the recommendation that exercise should not be perceived as an optional activity, but viewed as a routine one like eating, washing or grooming. Such report is lacking in the finding of this study. This lack of exercise discussion, in essence, should be corrected with appropriate education by which should go in conjunction with their treatment or after their treatment as the information remains the key to improving their knowledge on how they can keep fit, remain active and healthy [12].

On the benefits of exercise generally as perceived by the women with breast cancer, the result shows that majority of the women agreed that exercise was beneficial to them. The benefits the women hoped to get from the exercise were more of treating the discomfort they had. Although some hoped it would boost their immune system, promote and maintain their health, lower the risk of breast cancer coming back, maintain body weight, help them feel better about themselves and also sleep better. This finding shows that the women knew that many benefits are derivable from exercise despite that majority of them believe it will help to treat the discomfort they experience as a result of their ailment. The finding is in agreement with Linda et al. [17] who stated that regular exercise can help maintain or improve health during and after breast cancer treatment, and can help avoid or reduce some side effects/discomforts of breast cancer treatment amongst other benefits. The finding is also in agreement with ACS [18] who stated that exercise has many benefits including relief of pain which is similar to discomfort, increased energy levels, improved appetite, improved body function and decreased risk of depression and anxiety. The finding also agrees with the study by Ewa and colleagues [19] who stated that current evidence supports the benefits of physical activity for improving risk factors associated with cancer prognosis and improve the overall wellbeing of the patients [20,21]. The result also affirmed other studies on physical activity, exercise and breast cancer [11,22]. The similarity in the reviewed study and the present study may be as a result of patients characteristics and environmental factors.

On the demographic characteristics of the women and their knowledge of the recommended exercise, findings revealed that there is no primary relationship between their demographic characteristics and their knowledge about the recommended exercise. Their age, educational status, occupation and cancer stage on diagnosis had nothing to do with their knowledge of the recommended exercise and also their overall knowledge of the exercise. Their knowledge or lack of knowledge, however, never depended on these characteristics. This finding supports the result in a study by Miyawaki et al. [23] where awareness was discovered to be low among individuals with children and higher knowledge of risk factors whereas high in married women, women with exposure to information, and women with higher knowledge of symptoms. Similarly, time and family commitment was discovered to be the major influencers to practice of exercise in a related study [24]. Therefore, it had nothing to do with age, occupation and cancer diagnosis stage. The result of this study also contradicts their finding that those with higher educational level had a higher level of awareness of the preventive role of exercise, which was not the same in this study hence the practice of exercise is recommended among breast cancer patients even before, during and after treatment as it was discovered to be associated with low mortality and breast cancer recurrence [25].

Form the above discussion; it is important to draw attention to the implication of the study to health workers, especially nurses, oncologists and fitness practitioners in various hospitals in Nigeria. It is their responsibility to educate and counsel women with breast cancer on the need for active participation in health promotional activities, especially exercise. The benefits cannot be overemphasised as it reduces some of the adverse effects that accompany most of the treatments they receive during their care in the hospital and also serve as a means of rehabilitation. The education of the woman, when opportune, should address themes such as; the concept of exercise, benefits of exercise to breast cancer patients, and the recommended exercise guideline for cancer survivors. Advice on physical activity is likely to be well-received given that most women with breast cancer will appreciate if it comes from their trusted providers, including nurses and the oncologists. Participation in structured activity, such as endurance, flexibility and resistance training, should also be advocated for the women and should be developed and implemented on an individual basis. Doing this will make the significance of the study to cut across every female client with breast cancer, health care providers, administrators from the ministry of health and Nigerian government at large.

5. Conclusion

The study revealed poor knowledge of recommended exercise for cancer survivors among women with breast cancer. This outcome may be as a result of no exercise discussions with their health care providers as few that knew about the recommended exercise did not get their information from them. We recommend that exercise should become part of the treatment regimen for breast cancer patients in various hospitals in Nigeria. Hospitals should promulgate a policy gearing towards its implementation as there are supports from the literature that exercise is an effective intervention for proper rehabilitation of women with breast cancer and other cancers in general.

Footnotes

Acknowledgements

Sincere acknowledgement goes to this project’s supervisor, Prof. Chiejina, for her contribution and sacrifice to this work. Special gratitude equally goes to the women that gave their consent for this study, the analyst and other colleagues that assisted in the fieldwork.

Ethics approval

Research was conducted in line with the ethical standard guiding the conduct of research involving humans. Ethical approval was obtained from DELSUTH and FMC research ethics committee.

Conflict of interest/Competing interests

The author declares there is no conflict of interest in any form associated with this study.

Availability of data and material

The data about the findings of this study on knowledge and perceived benefits of exercise are available from the corresponding author, Odikpo L.C. upon reasonable request and for research or clinical purpose.

Funding

This study did not attract any form of external funding or grant; hence it was self-funded by the author.

Authors’ contributions

The author contributed to the study from its inception to the end. The author did the sourcing, writing, collection of data, analysis and interpretation of results for the research study under the supervision of Prof. E.N. Chiejina. The author also did the drafting and preparation of the manuscript.

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