ENSIGN GLOBAL UNIVERSITY, KPONG EASTERN REGION, GHANA FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH ASSESSING AWARENESS AND KNOWLEDGE OF BREAST AND CERVICAL CANCER AMONG FEMALE STUDENTS: A CASE STUDY OF AKWAMUMAN SENIOR HIGH SCHOOL, ASUOGYAMAN DISTRICT, GHANA EUNICE ASABEA ADDO (247100306) NOVEMBER, 2025 i ENSIGN GLOBAL UNIVERSITY, KPONG EASTERN REGION, GHANA FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH ASSESSING AWARENESS AND KNOWLEDGE OF BREAST AND CERVICAL CANCER AMONG FEMALE STUDENTS: A CASE STUDY OF AKWAMUMAN SENIOR HIGH SCHOOL, ASUOGYAMAN DISTRICT, GHANA BY EUNICE ASABEA ADDO (247100306) A THESIS SUBMITTED TO THE FACULTY OF PUBLIC HEALTH, DEPARTMENT OF COMMUNITY HEALTH, ENSIGN GLOBAL UNIVERSITY, KPONG IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH NOVEMBER, 2025 ii DECLARATION I, Eunice Asabea Addo, hereby declare that this submission is my own work towards the award of the Master of Public Health (MPH) degree and, to the best of my knowledge, it contains no material previously published by another person nor material which has been accepted for the award of any other degree of any University, except where due acknowledgement has been made in the text. 08/10/2025 Eunice Asabea Addo (247100306) ………………………… ……………… (Student’s Name & ID) Signature Date Certified by: Dr. Edward Kofi Sutherland ……………………………... …………………… (Supervisor’s Name) Signature Date Certified by: Dr Stephen Manortey …………………………… …………………… (Head of Academic Program) Signature Date iii DEDICATION This work is dedicated to Joana Mercy Akua Asare Addo and Prince Enzo Duodu Adddo, whose unwavering love and support kept me going till this far. To my loving parents and family, whose unwavering support, prayers, and encouragement have been a constant source of strength throughout my academic journey. And to every young woman striving for knowledge and empowerment: you are the reason for this research. iv ACKNOWLEDGEMENT First and foremost, I express my deepest gratitude to God for granting me the strength, wisdom, and perseverance to complete this thesis. I would like to sincerely thank my supervisor, Dr. Edward Kofi Sutherland, for his invaluable guidance, support, and constructive feedback throughout this research process. His encouragement and insights have been instrumental to the success of this work. Special thanks to Mr. JayJay Ansa Addo-Koranteng (Chief Executive Officer for Bravehearts Expeditions) for his continued support throughout this program I also acknowledge the administration and female students of Akwamuman Senior High School for their cooperation and participation in this study. Your willingness to share your time and experiences made this research possible. I am also grateful to my lecturers, colleagues, and friends, especially Isaac Kofi Piyuori, Job Agyeman and Uche Obgu for their contributions, suggestions, and moral support during the course of this program. Finally, I extend my profound thanks to my family for their continuous love, patience, and sacrifices throughout my academic journey. v ABBREVIATION/ACRONYMS BC Breast Cancer CC Cervical Cancer CHPS Community-Based Health Planning and Services GHS Ghana Health Service GPI Gender Parity Index HDI Human Development Index HICs High-Income Countries HIV Human Immunodeficiency Virus HPV Human Papillomavirus LMICs Low- and Middle-Income Countries MoH Ministry of Health NCD Non-Communicable Disease SDG Sustainable Development Goal SSA Sub-Saharan Africa WHO World Health Organization vi ABSTRACT Background: Breast and cervical cancers are significant public health concerns, particularly for women in low- and middle-income countries like Ghana. Despite ongoing awareness efforts, knowledge gaps and misconceptions persist among adolescent girls, who are a critical population for early intervention. This study was conducted to assess awareness and knowledge of these cancers among female students at Akwamuman Senior High School in the Asuogyaman District of Ghana. General Objective: This study aims to assess the level of awareness and knowledge of breast and cervical cancer among female students at Akwamuman Senior High School in the Asuogyaman District, Ghana. Methods: A cross-sectional quantitative study design was employed using a stratified random sampling method. A total of 394 female students were selected proportionally from different academic levels and programs. Data was collected through a structured, pre-tested questionnaire administered via Kobo Collect. Descriptive statistics, chi-square tests, and logistic regression analyses were conducted using STATA version 18 to evaluate associations between awareness, knowledge, and socio-demographic variables. Results: Awareness of breast cancer was high (97.2%), but only 31.7% of participants had "Good Knowledge" of the disease. Misconceptions were widespread, with 60.9% of students incorrectly believing that wearing tight bras can cause breast cancer. Practical knowledge was more encouraging, with 69.3% reporting they knew how to perform breast self-examinations. Awareness of cervical cancer was moderate (75.4%), yet specific knowledge on key preventive measures such vii as HPV vaccination (32.5%) and Pap smear screening (42.4%) was low. Healthcare providers were the most cited source of information, followed by schools and media platforms. Older students and those in higher academic levels tended to have better awareness and knowledge, though these demographic factors were not statistically significant predictors in multivariate analyses. However, a strong and statistically significant positive association was observed between awareness and knowledge for both breast and cervical cancer. Conclusion: Overall, female students at Akwamuman Senior High School have a modest awareness of cervical cancer and an almost universal awareness of breast cancer; nevertheless, there are notable disparities in their in-depth knowledge and the prevalence of misconceptions regarding both illnesses. The close connection between awareness and knowledge emphasizes how important basic knowledge is. But a change from broad awareness to precise, all- encompassing understanding is taking place. These findings demonstrate the pressing need for specific, research-based educational interventions in classrooms. In order to promote early detection and enhance long-term results, these programs must specifically address common misconceptions, demystify common risk factors and preventative measures—most notably, HPV vaccination and Pap smear screening for cervical cancer—and provide students with useful self- examination skills. viii TABLE OF CONTENTS DECLARATION .............................................................................................................................. ii DEDICATION ................................................................................................................................ iii ACKNOWLEDGEMENT .............................................................................................................. iv ABBREVIATION/ACRONYMS .....................................................................................................v ABSTRACT .................................................................................................................................... vi LIST OF TABLES ........................................................................................................................ xiii LIST OF FIGURES....................................................................................................................... xiv LIST OF MAPS ..............................................................................................................................xv LIST OF APPENDICES ............................................................................................................... xvi CHAPTER ONE ...............................................................................................................................1 1.0 INTRODUCTION ......................................................................................................................1 1.1 Background .................................................................................................................................1 1.2 Problem Statement ......................................................................................................................4 1.3 Rationale of Study.......................................................................................................................5 1.4 Conceptual Framework ...............................................................................................................7 1.5 Research Questions .....................................................................................................................9 1.6 General Objective .......................................................................................................................9 1.7 Specific Objectives ...................................................................................................................10 1.8 Profile of Study Area ................................................................................................................10 ix 1.9 Scope of Study ..........................................................................................................................13 1.10 Organization of Report ...........................................................................................................13 CHAPTER TWO ............................................................................................................................15 2.0 LITERATURE REVIEW ..........................................................................................................15 2.1 Introduction ...............................................................................................................................15 2.2 Epidemiology of Cervical Cancer .............................................................................................15 2.3 Knowledge and Awareness of Cervical Cancer among Young Females ...................................17 2.4 Sources of Information on Cervical Cancer Among Young Females .......................................19 2.5 Factors Influencing Awareness and Knowledge of Cervical Cancer ........................................19 2.6 Epidemiology of Breast Cancer ................................................................................................20 2.7 Knowledge and Awareness of Breast Cancer Among Young Females .....................................22 2.8 Sources of Information on Breast Cancer Among Young Females ..........................................23 2.9 Factors Influencing Awareness and Knowledge of Breast Cancer ...........................................24 CHAPTER THREE .........................................................................................................................26 3.0 METHODOLOGY ....................................................................................................................26 3.1 Introduction ...............................................................................................................................26 3.2 Research Methods and Design ..................................................................................................26 3.3 Data Collection Techniques and Tools ......................................................................................26 3.4 Study Setting .............................................................................................................................27 3.5 Study Population .......................................................................................................................27 x 3.6 Inclusion and Exclusion Criteria ...............................................................................................27 3.6.1 Inclusion Criteria: ..................................................................................................................27 3.6.2 Exclusion Criteria: .................................................................................................................27 3.7 Study Variables .........................................................................................................................28 3.7.1 Dependent Variables ..............................................................................................................28 3.7.2 Independent Variables ............................................................................................................28 3.8 Sampling ...................................................................................................................................28 3.9 Pretesting...................................................................................................................................31 3.10 Data Handling .........................................................................................................................31 3.11 Data Analysis ..........................................................................................................................31 3.12 Ethical Consideration ..............................................................................................................32 3.13 Limitations of Study ...............................................................................................................33 3.14 Assumptions ............................................................................................................................33 CHAPTER FOUR ...........................................................................................................................34 4.0 RESULTS ..................................................................................................................................34 4.1 Introduction ...............................................................................................................................34 4.2 Sociodemographic Characteristics of Respondents ..................................................................34 4.3 Awareness of Breast Cancer among Respondents ....................................................................37 4.3.1 Overall Awareness Levels of Breast Cancer ..........................................................................39 4.4 Knowledge of Breast Cancer among Respondents ...................................................................40 xi 4.5.1 Overall Level of Knowledge of Breast Cancer ......................................................................44 4.6 Awareness of Cervical Cancer among Respondents .................................................................44 4.5.1 Overall Level of Awareness of Cervical Cancer ....................................................................47 4.7 Knowledge level of Cervical Cancer among Respondents .......................................................48 4.6.1 Overall Level of Knowledge of Cervical Cancer ..................................................................51 4.8 Bivariate Analysis of Factors Influencing Breast Cancer Knowledge Levels ..........................52 4.10 Bivariate Analysis of Factors Influencing Cervical Cancer Knowledge Levels.....................54 4.12 Multivariate Analysis of Factors Influencing Breast Cancer Knowledge Levels ...................57 4.14 Multivariate Factors influencing Cervical Cancer Knowledge Levels ...................................59 CHAPTER FIVE .............................................................................................................................63 5.0 DISCUSSION ...........................................................................................................................63 5.1 Introduction ...............................................................................................................................63 5.1 Sociodemographic Characteristics ............................................................................................63 5.3 Age and Class Level: The Role of Educational Progression ....................................................63 5.3 Awareness and Knowledge level of Breast Cancer ...................................................................65 5.5 Awareness and Knowledge level of Cervical Cancer ...............................................................67 5.4 Factors Influencing Awareness and Knowledge level of Breast Cancer ..................................68 5.6 Factors Influencing Awareness and Knowledge level of Cervical Cancer ...............................70 CHAPTER SIX ...............................................................................................................................73 6.0 CONCLUSIONS AND RECOMMENDATIONS ....................................................................73 xii 6.1 Conclusions ...............................................................................................................................73 6.2 Recommendations .....................................................................................................................74 REFERENCES ................................................................................................................................76 APPENDIX .....................................................................................................................................94 APPENDIX I: INFORMED CONSENT ........................................................................................94 APPENDIX II: ASSENT FORM ....................................................................................................98 APPENDIX III: SURVEY QUESTIONNAIRE ...........................................................................101 APPENDIX IV: ETHICAL CLEARANCE FORM ENSIGN GLOBAL .....................................109 UNIVERSITY ...............................................................................................................................109 APPENDIX V: APPROVAL LETTER FROM AKWAMUMAN SENIOR HIGH ...................... 110 SCHOOL ....................................................................................................................................... 110 APPENDIX VI: APPROVAL LETTER FROM ASUOGYAMAN HEALTH DIRECTORATE . 111 xiii LIST OF TABLES Table 1. Proportional Allocation by Class.......................................................................................29 Table 2. Proportional Allocation by Courses Offered .....................................................................30 Table 4.1: Sociodemographic Characteristics of Respondents .......................................................35 Table 4.2: Responses to Questions on Awareness of Breast Cancer ...............................................38 Table 4.3: Sources of information about breast cancer (multiple response) ...................................39 Table 4.4: Responses to questions on knowledge regarding breast cancer transmission and prevention .......................................................................................................................................41 Table 4.5: Responses to multiple-response questions on breast cancer knowledge .......................42 Table 4.6: Responses to questions on awareness level of cervical cancer ......................................45 Table 4.7: Sources of information about cervical cancer (multiple responses) ..............................46 Table 4.8: Responses to questions on knowledge regarding cervical cancer transmission and prevention .......................................................................................................................................49 Table 4.9: Responses to multiple-choice questions on cervical cancer knowledge ........................50 Table 4.11: Bivariate Analysis of Factors Influencing Breast Cancer Knowledge Levels .............53 Table 4.11: Bivariate Analysis of Factors Influencing Cervical Cancer Knowledge Levels ..........55 Table 4.15: Multivariate Analysis of Factors Influencing Breast Cancer Knowledge Levels ........58 Table 4.17: Factors influencing Cervical Cancer Knowledge Levels .............................................60 xiv LIST OF FIGURES Figure 1.0: Conceptual Framework of Study (Knowledge, Attitude, Practice Model) ...................7 Figure 2.0: Map of Asuogyaman District.......................................................................................12 Figure 4.3.1: The levels of breast cancer awareness among respondents ......................................40 Figure 4.4.1: The levels of breast cancer knowledge among respondents .....................................44 Figure 4.5.1: The levels of cervical cancer awareness among respondents ...................................47 Figure 4.6.1: The levels of cervical cancer knowledge among respondents ..................................51 xv LIST OF MAPS Figure 2.0: Map of Asuogyaman District…………………………………………………….……12 xvi LIST OF APPENDICES APPENDIX I: INFORMED CONSENT ........................................................................................94 APPENDIX II: ASSENT FORM ....................................................................................................98 APPENDIX III: SURVEY QUESTIONNAIRE ...........................................................................101 APPENDIX IV: ETHICAL CLEARANCE FORM ENSIGN GLOBAL .....................................109 UNIVERSITY ...............................................................................................................................109 APPENDIX V: APPROVAL LETTER FROM AKWAMUMAN SENIOR HIGH ...................... 110 SCHOOL ....................................................................................................................................... 110 APPENDIX VI: APPROVAL LETTER FROM ASUOGYAMAN HEALTH DIRECTORATE…………………………………………………………………………………111 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Background Breast neoplasia and cervical carcinoma represent two of the most critical health dilemmas confronting women on a global scale, especially in low- and middle-income nations (LMICs). These malignancies are principal contributors to premature mortality in the female population, with breast neoplasia being the most frequently diagnosed form of cancer and cervical carcinoma occupying the position of the fourth most prevalent cancer among women internationally (Vu et al., 2018); (Sung et al., 2021). In the year 2020, there were 2.3 million newly identified instances of breast cancer worldwide, culminating in approximately 685,000 fatalities (Arnold et al., 2022). Similarly, cervical cancer accounted for 604,127 new cases and 342,000 deaths in the same year, with approximately 90% of these deaths occurring in LMICs (Sung et al., 2021); (WHO, 2021); (Burmeister et al., 2022). On a global scale, the prevalence of breast and cervical malignancies has exhibited a significant upward trend over the decades (source). The incidence rate of breast cancer has escalated at an estimated annual rate of 3.1% over the preceding thirty years, whereas the mortality rate has experienced an increase of 1.8% per annum during the identical timeframe (Sung et al., 2021). Cervical cancer, on the other hand, is projected to cause 443,000 deaths annually by 2030, with 98% of these deaths occurring in LMICs (Burmeister et al., 2022); (Rocha et al., 2024). The disparity in outcomes between high-income countries (HICs) and LMICs is stark, with LMICs experiencing higher mortality rates due to late-stage diagnosis, limited access to healthcare services, and poor implementation of prevention and screening programs (Denny et al., 2017); (Hull et al., 2020). 2 In Africa, breast and cervical cancers are particularly significant public health concerns. Sub- Saharan Africa (SSA) has some of the highest mortality rates for both cancers globally, with breast cancer mortality rates ranking among the world’s highest and a five-year survival rate of less than 40% (Denny et al., 2017); (Black and Richmond, 2019). Sub-Saharan Africa (SSA) bears the most significant global burden of cervical cancer, exhibiting the highest rates of both new cases and fatalities. Despite being the second most common cancer among women continent-wide, the disease poses a critical and disproportionate public health challenge in SSA, especially when observed among the younger female demographic (Burmeister et al., 2022). Studies indicate that the burden of these cancers in Africa is exacerbated by socio-economic challenges, poor healthcare infrastructure, and limited awareness and knowledge about the diseases and their prevention (Denny et al., 2017); (Rademaker, Bhandary and Harder, 2022). In Ghana, breast and cervical cancers are the most common cancers among women and the leading causes of cancer-related deaths (Bray et al., 2018); (Anaba et al., 2024). Breast cancer accounts for 20.4% of all cancer cases in the country, with a high mortality rate due to late diagnosis and limited access to early detection and treatment services (Okyere Asante et al., 2023). Cervical cancer follows closely, accounting for 13.5% of cancer cases, with an estimated 3,151 new cases and over 2,000 deaths annually (Bruni et al., 2019). Despite the availability of screening methods such as Pap smears and Visual Inspection with Acetic Acid (VIA), cervical cancer screening utilization remains low in Ghana, with studies citing deficits in knowledge, awareness, and access to healthcare services as major barriers (Binka, Nyarko and Doku, 2016); (Sampson, Nkpeebo and Degley, 2021). Evidence suggests that knowledge and awareness of breast and cervical cancer are critical determinants of preventive health behavior and early detection (Elbarazi et al., 2023). However, 3 studies conducted in Ghana and other African countries reveal significant gaps in knowledge and awareness. For instance, a study conducted in Ghana found that only 28% of women had adequate knowledge of cervical cancer, while 68.4% were unaware of the disease altogether (Ebu et al., 2014). Similarly, a study among female university students in Ghana reported poor cervical cancer screening behavior despite fair perceptions of the disease (Binka, Nyarko and Doku, 2016). These findings are consistent with studies conducted in other African countries, such as Ethiopia, where knowledge of cervical cancer screening remains alarmingly low, with only 50% of women in Ethiopia being aware of the disease and its prevention (Aweke, Ayanto and Ersado, 2017). Within the Ghanaian context, female students represent a vital demographic for breast and cervical cancer awareness and prevention efforts. As future leaders and potential advocates for health education, their knowledge and attitudes toward these cancers are critical in shaping public health outcomes. However, research indicates that even among educated populations, awareness and knowledge levels in the sub-Saharan African region remain suboptimal (Binka, Nyarko and Doku, 2016); (Pierz et al., 2020); (Effiong, Afolabi and Chinedu, 2023). This highlights the need for targeted interventions aimed at improving knowledge, attitudes, and practices toward breast and cervical cancer among female students in Ghana (Rerucha, Caro and Wheeler, 2018); (Williams et al., 2018). To the best of the authors’ knowledge, and based on a review of existing literature, no study has specifically examined the awareness and knowledge of breast and cervical cancer among senior high school students in the Asuogyaman District. This study therefore sought to assess the level of awareness and knowledge of these cancers among female students at Akwamuman Senior High School in the Asuogyaman District of Ghana. 4 1.2 Problem Statement Despite advancements in prevention, early detection, and treatment, breast and cervical cancers continue to disproportionately impact women in low- and middle-income countries (LMICs), including Ghana (Bouvard et al., 2021); (WHO, 2024a); (WHO, 2024b). Ghana faces a rapidly intensifying burden of breast cancer. Data shows that the incidence rate rose substantially from 23.8 per 100,000 in 2008 to 37.8 per 100,000 by 2018 (Anaba et al., 2024). The recorded 4,645 new cases of breast cancer in 2020 represent over a 100% increase from the 2,240 cases documented in 2012, with nearly half of all cases proving fatal (Anaba et al., 2024). Breast cancer is currently attributed to 12.4% of all cancer-related deaths among the nation’s female population. Additionally, the prevalence of cervical cancer (35.4%) in Ghana far exceeds the Sustainable Development Goal (SDG) target of fewer than 4 cases per 100,000 women (Mensah and Mensah, 2020); (Anaba et al., 2024). Numerous studies indicate that a significant proportion of Ghanaian women present with advanced stages of these diseases, largely due to poor knowledge, myths, stigma, and inadequate screening uptake (Binka, Nyarko and Doku, 2016); (Martei, Vanderpuye and Jones, 2018); (Agbokey et al., 2019); (Sampson, Nkpeebo and Degley, 2021). Despite national policies and international initiatives promoting early detection and public education, awareness of breast and cervical cancer among young women remains alarmingly low (Betty Pearce, Lydia Aziato, and Gloria AchempimAnsong, 2023); (Afaya et al., 2024a); (Anaba et al., 2024). Adolescents and young adults, particularly senior high school students, represent a critical demographic for health promotion and disease prevention. Early knowledge of cancer risk factors, signs and symptoms, and screening methods has been shown to positively influence attitudes and behaviors later in life (Heena et al., 2019); (Nsaful et al., 2022); (Dedey et al., 2024). However, research focused on this age group, especially in the Ghanaian context, is limited. The few available studies suggest that 5 many young women harbor misconceptions about breast and cervical cancer, are unaware of available screening services, and lack access to structured health education on the subject (Ebu et al., 2014); (Binka et al., 2019). Moreover, disparities in cancer awareness between urban and rural areas, and across different regions of Ghana (Ken-Amoah et al., 2022); (Adzigbli et al., 2025), further highlight the need for localized studies. In semi-urban and rural districts like Asuogyaman, where healthcare infrastructure and health promotion activities may be inadequate (Sokey and Adisah-Atta, 2017); (Binka et al., 2019); (Wongnaah et al., 2025), young women are especially vulnerable to misinformation and neglect. Without a localized assessment of breast and cervical cancer awareness among adolescent girls in educational institutions, Ghana risks overlooking critical insights into the knowledge gaps, attitudinal barriers, and behavioral patterns that shape early prevention. This lack of context specific evidence limits the ability of educators, health policymakers, and healthcare providers to design age-appropriate, culturally sensitive, and school-based interventions that can empower young women with life-saving information. 1.3 Rationale of Study In Ghana, national frameworks such as the Non-Communicable Disease (NCD) (Policy, 2022) and The National Strategy for Cancer Control in Ghana (2012–2016) prioritize early detection, awareness creation, and access to screening services, particularly for women and girls, and are currently undergoing review to reflect updated epidemiological trends and WHO targets (Ministry of Health, 2011); (Ministry of Health, 2022). Despite these policy efforts, breast and cervical cancers continue to claim the lives of many Ghanaian women, largely due to late-stage diagnosis, low screening rates, and limited knowledge about the diseases. 6 Data from the Ghana Demographic and Health Survey shows that only 5.0% of Ghanaian women of reproductive age have undergone cervical cancer screening, and 18.4% have been screened for breast cancer (Anaba et al., 2024). These low screening rates are particularly concerning among adolescents and young women, a critical demographic for early intervention. Research consistently demonstrates that awareness regarding cervical cancer and its crucial preventive measures remains limited within this demographic. For example, a study conducted among female senior high school students in the Lower Manya Krobo Municipal area revealed significantly low knowledge levels: only 17.7% were aware of the Human Papillomavirus (HPV) vaccine, and only 29.3% were knowledgeable about cervical cancer screening methods (Manortey and Agyemang, 2018). The rationale of this study is therefore rooted in the fact that it will generate context-specific data that contributes to the global discourse on youth engagement in cancer prevention while serving as a reference in designing culturally appropriate and age-sensitive health promotion strategies. This study will benefit multiple stakeholders by providing localized, evidence-based insights into adolescent knowledge gaps and barriers to cancer prevention. Policymakers and public health planners can use the findings to inform policy and strengthen health advocacy. Educational authorities will gain data to support integrating cancer and reproductive health education into school curricula. Healthcare providers and NGOs will be better equipped to design adolescent friendly outreach and screening programs that address both informational and cultural challenges. Female students and their families stand to benefit from increased awareness, leading to early detection and reduced stigma. Researchers will also gain a foundation for further inquiry into youth cancer education and regional health disparities. This study is particularly timely and relevant as it aligns directly with the United Nations Sustainable Development Goal (SDG) 3, which aims to ensure healthy lives and promote wellbeing for all at all ages (Howden-Chapman et al., 2017). Target 3.4 specifically seeks to reduce 7 premature mortality from non-communicable diseases (NCDs) through prevention and treatment by 2030 (Howden-Chapman et al., 2017). The study also contributes to SDG 5 (Gender Equality) by addressing a gender-specific health burden and empowering young women to take control of their health. Figure 1.0: Conceptual Framework of Study (Knowledge, Attitude, Practice Model) Source: (WHO (1978); UNICEF (1988) This study adopts a conceptual framework grounded in the Knowledge dimension of the Knowledge–Attitude–Practice (KAP) model to guide the assessment of breast and cervical cancer awareness and knowledge among female students. The framework illustrates how sociodemographic factors influence students’ knowledge of breast and cervical cancer, and how awareness subsequently contributes to knowledge acquisition. Sociodemog raphic C haracteristics A ge , Class, Course of study, Religion, Ethnic group Knowledge level of B reast and Cervica l C ancer Awareness level of Breast and Cervical C ancer 1.4 Conceptual Framework 8 The KAP model, originally developed in public health research, explains that health-related behaviors evolve through three progressive stages: knowledge, attitude, and practice (Launiala, 2009); (WHO, 2008). The model assumes that individuals must first acquire knowledge about a health issue before developing positive attitudes and adopting preventive behaviors. However, since the present study is limited to the cognitive domain, the framework emphasizes the knowledge component, which reflects the extent of understanding individuals possess about breast and cervical cancer. Knowledge is influenced by exposure to information, personal experience, and socio-demographic characteristics such as age, educational level, field of study, and access to health information sources (Tarkang & Zotor, 2015); (Rahman et al., 2020). Within this framework, socio-demographic factors—including age, class, course of study, religion, ethnic group, serve as independent variables that determine the degree to which individuals are exposed to and comprehend information about breast and cervical cancer. These background factors influence one’s opportunity to access health information, interpret messages, and develop knowledge about these diseases. For instance, students in health-related programs or those at higher levels of study often have greater exposure to cancer-related information compared to those in non-health disciplines (Akpo et al., 2022). Awareness represents the initial stage of the knowledge process, defined as the state of having heard of or being conscious of the existence of breast and cervical cancer, as well as available screening and prevention options (Ndejjo et al., 2017). Awareness acts as a precursor to knowledge, since individuals who are aware of a disease are more likely to seek additional information that enhances their understanding (Yahya et al., 2019). Within this framework, awareness may mediate the relationship between socio-demographic characteristics and knowledge acquisition. However, 9 due to the scope and page limitations of this study, this mediating effect is not examined in detail and is recommended for future research. Finally, knowledge, the principal outcome variable, refers to a comprehensive understanding of breast and cervical cancer — encompassing risk factors, symptoms, preventive measures, and screening methods such as breast self-examination, clinical breast examination, Pap smear, and HPV vaccination (Abotchie & Shokar, 2009); (Al-Dubai et al., 2012). The level of knowledge is expected to vary based on individuals’ awareness levels and socio-demographic characteristics. 1.5 Research Questions 1. What is the level of awareness and knowledge of breast cancer among female students at Akwamuman Senior High School? 2. What is the level of awareness and knowledge of cervical cancer among female students at Akwamuman Senior High School? 3. What factors influence the level of knowledge about breast cancer among female students at Akwamuman Senior High School? 4. What factors influence the knowledge level about cervical cancer among female students at Akwamuman Senior High School? 1.6 General Objective To assess the level of awareness and knowledge of breast and cervical cancer among female students at Akwamuman Senior High School in the Asuogyaman District of Ghana. 10 1.7 Specific Objectives 1. To assess the level of awareness and knowledge about breast cancer among female students in Akwamuman Senior High School. 2. To determine the level of awareness and knowledge about cervical cancer among female students at Akwamuman Senior High School. 3. To identify the factors influencing level of knowledge about breast cancer among female students at Akwamuman Senior High School. 4. To investigate the factors influencing the level of knowledge about cervical cancer among female students at Akwamuman Senior High School. 1.8 Profile of Study Area The Asuogyaman District constitutes one of the 33 Municipal and District Assemblies within Ghana's Eastern Region. Its establishment in 1988, under Local Government Instrument (L.I. 1431), was a direct outcome of Ghana’s national decentralization program. This district was officially created following the re-demarcation and division of the former Kaoga District, which was historically headquartered in Somanya (Asuogyaman District Assembly, 2023). Geographically, the district lies between latitudes 6º34' N and 6º10' N and longitudes 0º1' W and 0º14' E, covering an estimated surface area of 1,507 square kilometres, approximately 5.7% of the Eastern Region's total area (Asuogyaman District Assembly, 2023). The district’s geographical boundaries are comprehensively delineated: it adjoins the Kwahu Afram Plains North to the north, the Upper Manya Krobo District to the west, and the Lower Manya Krobo District to the south. To the east, it shares borders with the South Dayi, Ho West, and North Tongu Districts. Due to the presence of the Volta Lake, which intricately traverses the area, the Asuogyaman District has 11 emerged as a central location supporting significant tourism, aquaculture, and agricultural development (Asuogyaman District Assembly, 2023). According to the 2021 National Population and Housing Census, the district has a population of 101,256, composed of 52,802 females (52%) and 48,723 males (48%). This figure was projected to increase to approximately 105,627 by 2023, highlighting the district's steady population growth (GSS, 2021). The district's economy is primarily agrarian, with agriculture employing about 60% of the population. Major crops grown include yam, cassava, plantain, banana, and pepper, while livestock rearing includes cattle, goats, sheep, pigs, and poultry (Asuogyaman District Assembly, 2023). Notably, the district is Ghana’s leading producer of tilapia, with an annual output of 12,000 metric tonnes. In addition to agriculture, the district's markets located in Akosombo, Atimpoku, Frankadua, Marine, and Sapor play a vital role in the movement of commodities such as maize, cassava, yam, and fish to larger markets in Accra, Tema, and Koforidua (Asuogyaman District Assembly, 2023). The district has a road network of about 185.9 kilometres, of which 130.2 kilometres are tarred, and 55.7 kilometres remain untarred. Electrification in the district has significantly improved due to its proximity to the Akosombo Hydro-electric Plant, with most major towns such as Akosombo, Atimpoku, and Anum connected to the national grid (Asuogyaman District Assembly, 2023). The district has a total of 30 health facilities, including one hospital, 11 health centers, two private hospitals, and 16 functional CHPS centers. Educational infrastructure comprises 283 schools (184 public and 99 private) including basic and second-cycle institutions. The district records a Gender Parity Index (GPI) of 1.02, 1.04, and 1.07 for Kindergarten, Primary, and Junior High School levels, respectively. The overall school completion rate stands at 74% (Asuogyaman District Assembly, 2023). 12 Figure 2.0: Map of Asuogyaman District Source: (Asuogyaman District Assembly, 2023) 13 1.9 Scope of Study This study is confined to assessing the level of awareness and knowledge of breast and cervical cancer among female students at Akwamuman Senior High School, located in the Asuogyaman District of Ghana. The focus is specifically on female students because they are the primary at-risk population for these types of cancers. The study covered three main areas: the sources from which students receive information about breast and cervical cancer, the depth of their knowledge and awareness, and the factors that influence their understanding of these health issues. The findings are limited to this particular institution and may not be generalized to other schools or regions without further research. 1.10 Organization of Report This report is organized into six chapters, each focusing on a key aspect of the research. Chapter One (Introduction) provides the background of the study, problem statement, research objectives, research questions, significance of the study, scope of study, and the organization of the report. Chapter Two (Literature Review) examines existing literature relevant to breast and cervical cancer, including global and local perspectives on awareness, knowledge, and influencing factors among young women, especially students. Chapter Three (Methodology) outlines the research design, target population, sampling techniques, data collection methods, and data analysis procedures used in the study. Chapter Four (Results) presents the data collected from the field, including demographic information and findings related to the specific objectives of the study. Chapter Five (Discussion) interprets and discusses the findings of the study in relation to the existing literature, highlighting key patterns, differences, and implications. 14 Chapter Six (Conclusions and Recommendations) summarizes the main findings, draws conclusions based on the objectives, and provides recommendations for stakeholders such as school authorities, health educators, and policy makers. 15 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction This chapter reviews existing literature relevant to breast and cervical cancer awareness and knowledge, with a focus on female adolescents and school populations. By reviewing available literature, this chapter aims to provide an empirical foundation for the current study and to highlight gaps that this research seeks to address within the context of Akwamuman Senior High School in the Asuogyaman District of Ghana. 2.2 Epidemiology of Cervical Cancer Globally, cervical cancer represents the second leading cause of both cancer incidence and mortality among women of reproductive age. A significant feature of this distribution is the pronounced disease burden concentrated within nations characterized by the lowest Human Development Index (HDI) scores (Arbyn et al., 2020); (Mattiuzzi and Lippi, 2020); (Sung et al., 2021). In 2018 alone, an estimated 570,000 new cases and 311,000 deaths were recorded globally, positioning cervical cancer as the fourth most frequently diagnosed cancer in women (Bray et al., 2018). According to more recent data, around 660,000 new cases were identified in 2022, with approximately 350,000 deaths, 94% of which occurred in low- and middle-income countries (Sahasrabuddhe, 2024); (WHO, 2024b). The geographical distribution of cervical cancer is notably uneven. The highest incidence and mortality rates are found in sub-Saharan Africa, Central 16 America, and Southeast Asia (WHO, 2024b). For instance, cervical cancer is the most commonly diagnosed cancer in 28 countries and the leading cause of cancer death in 42 countries, most of which are located in sub-Saharan Africa and South-East Asia (Ferlay et al., 2019); (WHO, 2024b). In contrast, the rates in North America, Australia/New Zealand, and Western Asia (including Saudi Arabia and Iraq) are 7 to 10 times lower (Small et al., 2017). These regional differences are attributed to variations in HPV vaccination coverage, availability of cervical screening, treatment infrastructure, HIV prevalence, and broader socioeconomic determinants such as gender inequality and poverty (WHO, 2024b). The disease also has a notable demographic dimension. Over the past three decades, there has been a substantial increase in the proportion of young women affected by cervical cancer, ranging from 10% to 40% (Sung et al., 2017). It disproportionately impacts younger women, leading to devastating socio-familial consequences; approximately 20% of children who lose their mother to cancer experience this loss due to cervical cancer (Guida et al., 2022). This burden is worsened among women living with HIV, who are six times more likely to develop cervical cancer compared to the general population (Stelzle et al., 2021); (WHO, 2024b). HIV infection not only increases susceptibility to HPV but also accelerates the progression from HPV infection to cancer (Stelzle et al., 2021); (WHO, 2024b). Approximately 5% of all cervical cancer cases are directly attributable to HIV (Ibrahim Khalil et al., 2022); (WHO, 2024b). The aetiology of cervical cancer is well-established, with persistent infection by high-risk human papillomavirus (HPV) identified as the primary cause (Arbyn et al., 2020); (WHO, 2024b). HPV is a common sexually transmitted infection, and while most infections are cleared by the immune system, persistent infection with oncogenic HPV types can lead to the development of abnormal 17 cervical cells (Tripathi and Sahu, 2022); (WHO, 2024b). If untreated, these abnormalities can progress to cancer, typically over a span of 15 to 20 years (Tripathi and Sahu, 2022). However, in immunocompromised individuals, particularly those with untreated HIV, this progression can occur more rapidly, within 5 to 10 years (WHO, 2024b). Additional risk factors influencing this progression include the specific HPV genotype, immune status, co-infection with other sexually transmitted infections, early age at first pregnancy, number of births, use of hormonal contraceptives, and tobacco smoking (Yang et al., 2022); (WHO, 2024b); (Wu et al., 2025). Vaccination against HPV between the ages of 9 and 14 is highly effective in preventing infection and subsequent malignancies (Rahangdale et al., 2022); (WHO, 2024b). Furthermore, routine screening starting at age 30 or 25 for women living with HIV can detect precancerous changes that, if treated promptly, can prevent progression to cancer (WHO, 2024b); (WHO, 2024c). Across all ages, early detection followed by timely and high-quality treatment remains a cornerstone of effective cervical cancer control (Kessler, 2017); (WHO, 2024c). 2.3 Knowledge and Awareness of Cervical Cancer among Young Females In the United States, a study by (Akinlotan et al. 2017) revealed that 3.2% of respondents were not aware of any of the risk factors. Among participants who accurately identified one or more risk factors, only 60.5% were aware that multiple sexual partners posed a risk (Akinlotan et al., 2017). Furthermore, participants were less aware of the higher risk of cervical cancer due to having sex at a young age (51.5%), or smoking cigarettes (49%). In general, only eight percent of the study sample identified all ten risk factors for cervical cancer (Akinlotan et al., (2017). 18 A European study conducted among Maltese women showed that 74.94% of the participants were able to identify more than 3 symptoms when prompted, with the most identified symptoms being post-menopausal bleeding, persistent pelvic pain and weight loss (Deguara, Calleja and England, 2021). Additionally, 46.44% were unable to identify any risk factors, while only 10.32% of participants were able to correctly identify the two most important factors, which are multiple sexual partners and HPV infection. Only 38.1% of the research population knew that HPV infection is a risk factor (Deguara, Calleja and England, 2021). Evidence from women in Kampong Speu Province, Cambodia found that 74 and 34% of women had heard about cervical cancer and the Papanicolaou (Pap) Smear test, respectively (Touch and Oh, 2018). Furthermore, 35% of women were aware that cervical cancer is preventable by vaccination (Touch and Oh, 2018). Similarly, an Indian study found that, majority of the respondents, 96.6% have good knowledge about cervical cancer screening, nevertheless the vast majority (98.9%) of the women have never been vaccinated against cervical cancer (Krishnaveni, Roy and Sambathkumar, 2018). A comprehensive analysis of demographic and health survey data from five sub-Saharan African countries revealed that overall cervical cancer awareness was limited, with only 39% of women aged 30-49 reporting ever having heard of cervical cancer (Olivieri et al., 2025). This study documented cervical cancer awareness varying across countries: in Benin it’s low at 11%, in Mozambique 36%, in Madagascar 38%, in Mauritania 49%, and in Cameroon 53% (Olivieri et al., 2025). One study in Ethiopia among female students revealed that more than half of the participants (59.6%) were unaware of the primary cause of cervical cancer, while only 19.5% correctly 19 identified HPV as the main cause (Tesfaye et al., 2019). Additionally, 83.9% did not know of any other potential causes (Tesfaye et al., 2019). A hospital-based case-control study conducted in two Ghanaian teaching hospitals revealed profoundly low levels of cervical cancer knowledge among women, with the study revealing that 78.9% of women had never heard of the Pap smear test (Nartey et al., 2025). Similarly, another Ghanaian study among high schoolers revealed that most students (mean age = 17) did not know that early sexual debut (before 18 years) is a risk factor for cervical cancer (72%) and that a blood test cannot detect cervical cancer (71%) (Ampofo et al., 2024a). 2.4 Sources of Information on Cervical Cancer Among Young Females Research among Ghanaian senior high school students provide insights into young women's preferences for health information sources. A comprehensive multi-site cross-sectional survey of 2,400 female students aged 16-24 years found that doctors were endorsed by 87% of students as preferred sources of cervical cancer education, followed by nurses at 80%, and credible health organizations at 78% (Ampofo, Boyes and Mackenzie, 2023). Additional research examining cervical cancer information sources in urban Ghanaian communities revealed that health facilities served as the most popular source of cervical cancer information, followed by mass media and religious organizations like the church/mosque (Bonful et al., 2022). 2.5 Factors Influencing Awareness and Knowledge of Cervical Cancer A study by (Mijiti et al. 2023) in Kashi, China showed that living in the urban(AOR = 1.358,95% CI:1.111–1.659), occupation of non-farming and non-housewife(AOR = 2.680,95%CI:2.126– 3.377), education level of high school and above (AOR = 1.388,95%CI:1.125–1.712), and four or 20 more access to knowledge(AOR = 1.446,95%CI:1.099–1.903) were protective factors for cervical cancer knowledge knowing. A parallel study conducted on Omani women demonstrated that specific socioeconomic factors— namely marital status, educational attainment, and household income—were statistically associated with achieving adequate knowledge scores regarding [topic implied, likely cancer screening/prevention], indicated by P < 0.05. Conversely, variables such as age, family history of cancer, the husband’s educational level, parity, and abortion history were found to have no statistically significant association with knowledge scores (P > 0.05) (Alwahaibi et al., 2018). Furthermore, regular health checkups, education level, gender, marital cohabitation status, and income were identified as significant factors influencing breast cancer awareness (Islam et al., 2025). Participants in a Bangladeshi study who underwent regular health checkups were significantly more informed (87.03%, p < 0.001). Multivariate logistic regression analyses indicated that each additional year of schooling increased the likelihood of awareness by 16–20% (Islam et al., 2025). These previous findings do not differ from that of the sub-Saharan African region. According to (Okunowo et al. 2018), prior counselling by doctors/nurses and knowing someone with cervical cancer significantly increased the knowledge of cervical cancer, while high level of education was significantly associated only with increased knowledge of cervical cancer and awareness of Pap smear among Nigerian participants. 2.6 Epidemiology of Breast Cancer Breast cancer is a disease in which abnormal breast cells grow out of control and form tumors (WHO, 2024a). From 2000 to 2018, the global incidence of breast cancer in women rose markedly, from approximately 1.05 million cases in 2000 to 2.09 million in 2018 (Bray et al., 2018). Despite 21 this sharp increase, the number of deaths has shown variable trends rising from 370,000 in 2000 to around 520,000 in 2012, but subsequently declining to 310,000 by 2018 (Torre et al., 2015); (Bray et al., 2018); (Siegel, Miller and Jemal, 2020); (Shang and Xu, 2022). By 2020, breast cancer surpassed lung cancer to become the most commonly diagnosed cancer globally, with 2.3 million new cases accounting for 11.7% of all cancer cases (Sung et al., 2021). Among women, breast cancer constitutes one-quarter of all cancer diagnoses and one-sixth of cancer deaths, ranking first in both incidence and mortality in the majority of countries (Sung et al., 2021). However, notable exceptions exist, particularly for mortality, where lung cancer remains the leading cause of cancer death in regions such as Australia/New Zealand, Northern Europe, North America, and China, and cervical cancer dominates in many sub-Saharan African countries (Shang and Xu, 2022). Breast cancer occurs in every country and affects women at any age after puberty, though incidence increases with advancing age (Shang and Xu, 2022); (WHO, 2024a). In 2022 alone, there were 2.3 million new diagnoses and 670,000 deaths worldwide (WHO, 2024a). Global data show stark disparities in breast cancer burden based on levels of socioeconomic development. In very high Human Development Index (HDI) countries, 1 in 12 women will be diagnosed with breast cancer in their lifetime, and 1 in 71 will die from it (WHO, 2024a). In contrast, in low-HDI countries, the lifetime risk of diagnosis is lower (1 in 27) but the mortality risk is disproportionately higher, with 1 in 48 women dying from the disease (Shang and Xu, 2022); (WHO, 2024a). Breast cancer originates from abnormal cells in the milk ducts or lobules of the breast. While noninvasive forms (in situ) are not life-threatening and may be detected early, invasive cancers can spread to surrounding breast tissue, lymph nodes, and distant organs such as the lungs, liver, brain, and bones. This progression, known as metastasis, can be fatal. Most people do not exhibit 22 symptoms in the early stages, making early detection critical (Scully et al., 2012); (WHO, 2024a). When symptoms do appear, they may include a painless lump or thickening in the breast, changes in breast size or appearance, skin dimpling, nipple abnormalities, or abnormal nipple discharge (WHO, 2024a). Multiple risk factors are associated with breast cancer, the most significant being female gender, with women accounting for approximately 99% of cases. Other established risk factors include increasing age, obesity, alcohol consumption, tobacco use, family history of breast cancer, radiation exposure, reproductive history, and postmenopausal hormone therapy (Sung et al., 2021); (WHO, 2024a). Nonetheless, about half of all breast cancers occur in women with no identifiable risk factors other than being female and over 40 years old (Sung et al., 2021); (WHO, 2024a). While a family history of the disease increases the risk, most women diagnosed with breast cancer do not have a known familial link, indicating that absence of family history does not equate to low risk (Sung et al., 2021). Certain inherited mutations, particularly in BRCA1, BRCA2, and PALB2 genes, substantially elevate risk, and women with these genetic predispositions may consider preventive strategies such as prophylactic surgery or chemoprevention (Sung et al., 2021); (WHO, 2024a). 2.7 Knowledge and Awareness of Breast Cancer Among Young Females In a Pakistani study by (Hussain et al., 2022) reported poor knowledge about breast cancer’s risk factors. Few participants recognized overweight and obesity (34.9%), lack of breastfeeding (28.3%), and low consumption of fruits and vegetables (43.5%) as contributors to the disease Hussain et al., (2022). Moreover, another study in Oman revealed that out of the total of one hundred and eighty-nine participants, 80% had information of breast cancer (Chattu, Kumary and 23 Bhagavathula, 2018). Participants had better knowledge of symptoms but less knowledge about risk factors (Chattu, Kumary and Bhagavathula, 2018). A recent mixed-methods study conducted among adolescents and young adults with breast cancer in Nigeria revealed that 72% of participants lacked knowledge of early symptoms and signs of breast cancer, while 41% could not name a single risk factor when asked unprompted (Ntekim et al., 2025). This study further demonstrated that although 85% of young women knew that a breast lump was a possible sign of breast cancer, their knowledge of other critical early warning signs remained severely limited (Ntekim et al., 2025). The research identified that only 15.2% of participants suspected their initial symptoms could indicate breast cancer, while 43.5% were completely unsure about the significance of their symptoms, and 41.3% dismissed them as minor or non-serious (Ntekim et al., 2025). In the Ghanaian context specifically, research among secondary school students in the Tamale Metropolis of Ghana revealed that 88.7% of students showed moderate to high levels of breast cancer awareness, while only 11.3% demonstrated low levels of awareness (Boateng et al., 2025). Interestingly, a significant majority of students (72.5%) disagreed with the statement that breast cancer can spread to other parts of the body, while 22.7% agreed (Boateng et al., 2025). 2.8 Sources of Information on Breast Cancer Among Young Females A study among young women in the United Arab Emirates revealed that the main source of information about breast cancer was social media (74.7%), such as Facebook, Twitter, and Instagram (Rahman et al., 2019). Additionally, the main source of information about BSE was social media (57.2%), followed by health professionals (34.9%) (Rahman et al., 2019). Research conducted among Nigerian university students revealed that social media platforms served as the primary source of breast cancer information for 56.9% of respondents, significantly 24 outpacing traditional educational channels (Ekpunobi et al., 2025). Schools and universities represented the second most common information source at 51.1%, while healthcare professionals, despite their clinical expertise, were cited by only 36.5% of students as primary information sources (Ekpunobi et al., 2025). Similarly, in southwestern Nigeria, the major sources of breast cancer and breast self-examination information were television, health workers and internet (Effiong, Afolabi and Chinedu, 2023). In Ghana specifically, research examining communication channels for breast cancer screening awareness revealed that mass media serves as the most common source of information, with 86 participants (44.8%) identifying mass media as their primary information source (Dzidzornu et al., 2024). Within the mass media category, radio emerged as the highest subcategory, representing 34 participants (39.5%) of those who relied on mass media for breast cancer information (Dzidzornu et al., 2024). 2.9 Factors Influencing Awareness and Knowledge of Breast Cancer Multivariate logistic regression analysis from a study in rural southwest China established a statistically significant correlation (all P < 0.05) between breast cancer awareness and three key factors: educational level, contraceptive use, and a prior history of breast disease (Zhu et al., 2024). The data indicated that having a history of breast disease was positively associated with awareness (Odd ratio (OR) = 1.907, 95% CI= 1.128~3.223). The most robust predictor, however, was educational level, with the highest odds ratios for awareness observed in women who had attained a junior college education or above (OR) = 5.536, 95% CI = 1.898 ~16.148) (Zhu et al., 2024). Another study by (Zhang and Lu, 2022) in Western Yuhan revealed via multiple linear regression analysis that educational grade was the most significant influential factor underlying the level of 25 knowledge female college students had with regards to the treatment of breast cancer (P < 0.05) (Zhang and Lu, 2022). Moreover, evidence from Qatar confirms that awareness of breast cancer was significantly related to education level, and receipt of information about breast cancer and/or BCS from a variety of sources, particularly doctors and the media (Donnelly et al., 2015). Similarly, a study in Lesotho identified four key factors associated with breast cancer awareness: education level, media exposure (radio and print), and wealth status (Afaya et al., 2023). Women with higher educational attainment were significantly more likely to be aware of breast cancer compared to those with no formal education [AOR = 12.56; 95% CI: 4.35–36.28]. Media exposure also played a role; those who listened to the radio at least once a week [AOR = 1.96; 95% CI: 1.63–2.37] or read newspapers or magazines less than once a week [AOR = 1.91; 95% CI: 1.48– 2.46] were more likely to be aware than those with no such exposure (Afaya et al., 2023). Additionally, women in the richest wealth quintile had higher awareness compared to those in the poorest quintile [AOR = 2.55; 95% CI: 1.67–3.9] (Afaya et al., 2023). 26 CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction This chapter outlines the methodological approach employed in this research study. It details the study design, study site, population, sampling techniques, data collection methods, data handling procedures, statistical analysis, ethical considerations, and expected outcomes. The methodology has been carefully structured to ensure the reliability, validity, and reproducibility of the findings, while adhering to ethical research principles and addressing the study's objectives effectively. 3.2 Research Methods and Design This investigation utilized a quantitative, cross-sectional study design to systematically assess the awareness and knowledge levels of the female student population. The cross-sectional approach was deemed particularly suitable for this research because it facilitates the simultaneous collection of data at a single temporal point, thereby furnishing a representative snapshot of the current knowledge, attitudes, and relevant practices within the defined target group (Wang and Cheng, 2020). This design enables the examination of multiple variables simultaneously while maintaining cost-effectiveness and time efficiency (Setia, 2016). 3.3 Data Collection Techniques and Tools Data was collected using a validated structured questionnaire developed in consultation with academic supervisor, based on the study objectives and existing literature (Manortey and Agyemang, 2018) and administered via Kobo Collect, a reliable mobile tool for real-time data collection in field settings (UN-OCHA, 2024). The questionnaire included sections on sociodemographic characteristics of participants, awareness and knowledge of breast and cervical 27 cancer, attitudes and preventive practices regarding breast and cervical cancer, as well as barriers and facilitating factors influencing access to screening and preventive healthcare services. 3.4 Study Setting The study was conducted at Akwamuman Senior High School, located in the Asuogyaman District of Ghana. This school was selected due to its accessibility, the diversity of its student population, and its representation of female adolescents within the district. The Asuogyaman District is situated in the Eastern Region of Ghana, characterized by its semi-urban population making it a suitable context for exploring awareness and knowledge of breast and cervical cancer among young women. 3.5 Study Population The study population comprised female students enrolled at Akwamuman Senior High School. This population represents adolescent and young adult females. 3.6 Inclusion and Exclusion Criteria 3.6.1 Inclusion Criteria: • Female students currently enrolled at Akwamuman Senior High School • Students who provide informed consent/assent (and parental consent where applicable) • Students available during the study period and are willing to complete the survey questionnaire 3.6.2 Exclusion Criteria: Students were excluded from the study if they are male, unable to comprehend the questionnaire, unwilling or unable to provide informed consent/assent, absent during the data collection period, or have known medical conditions that may impair their ability to participate. 28 3.7 Study Variables 3.7.1 Dependent Variables A dependent variable is the outcome of interest for a study (National Library of Medicine, 2025). The primary dependent variables in this study are the levels of knowledge and awareness of breast and cervical cancer. 3.7.2 Independent Variables The independent variables are the factors that may influence the interest for a study (National Library of Medicine, 2025). These primarily include demographic characteristics such as age, class (SHS level), academic programme, religion, and ethnic group. Other independent variables include exposure to sources of information and participation in health-related programs or workshops. 3.8 Sampling A stratified random sampling technique was employed to ensure proportional representation across all academic years. Stratification was based on academic levels (SHS 1, 2, 3) and courses offered. Following stratification, a simple random sampling method was used to select participants from each stratum. The sample size was calculated using the Cochran formula (Snedecor and Cochran, 1989) with a 95% confidence interval and 5% margin of error: 𝑍2 × 𝑝 × (1 − 𝑝) 𝑛 = (𝑒)2 where: n = required sample size z = reliability co-efficient (1.96 for 95% confidence interval) p = estimated prevalence of adequate cancer knowledge e = margin of error (5% or 0.05) 29 Based on Manortey and Agyemang’s study (Manortey and Agyemang, 2018), the cervical cancer awareness rate (p) is approximately 63% (0.63). Using a 95% confidence level (Z = 1.96) and a margin of error of 5% (0.05), the sample size was calculated as follows: 𝑛 = 3. 𝑛 = = 358 Adjusting for a 10% non-response rate (36), the final sample size = 358 + 36 = 394 participants The total number of female students at Akwamuman Senior High School is 500. The proportional allocation of the sample size was calculated using: Number Of Students Per Grade/Course 𝑛 = 𝑥 Population Sample Size Total Number of Female Students in The School Table 1. Proportional Allocation by Class Class Student Population Proportional Sample SHS 1 175 (150 / 500) × 394 = 138 SHS 2 165 (180 / 500) × 394 = 130 SHS 3 160 (170 / 500) × 394 = 126 30 Total 500 394 Source: Akwamuman Senior High School Table 2. Proportional Allocation by Courses Offered Course SHS 1 Sample SHS 2 Sample SHS 3 Sample General Science (25/175) ×138 = 20 (20/165) ×130 = 16 (15/160) ×126 = 12 General Arts (50/175) ×138 = 39 (50/165) ×130 = 39 (40/160) ×126 = 32 Business (35/175) ×138 = 28 (35/165) ×130 = 28 (30/160) ×126 = 24 Home Economics (30/175) ×138 = 24 (30/165) ×130 = 24 (30/160) ×126 = 24 Visual Arts (15/175) ×138 = 12 (20/165) ×130 = 16 (25/160) ×126 = 20 Agriculture (20/175) ×138 = 16 (10/165) ×130 = 8 (20/160) ×126 = 16 Total 138 130 126 Source: Akwamuman Senior High School 31 3.9 Pretesting Pretesting was conducted with 10% of the intended sample size at a different secondary school with similar characteristics that is not part of the study site to validate the questionnaire and assess its reliability. This process helped to identify potential issues with the clarity, relevance, and structure of the questions. Feedback from the pretest was used to refine the questionnaire to ensure it was understandable and contextually appropriate. 3.10 Data Handling To ensure the confidentiality and security of participant data, all responses were anonymized, and no personally identifiable information was collected. Data collected through the KoboCollect application was encrypted and stored on password-protected devices. Once uploaded to a secure server, the data was accessible only to authorized members of the research team. Backups of the data was stored to prevent data loss. The collected data will be archived for a stipulated duration of five (5) years to facilitate future reference and verification checks. Prior to analysis, a data cleaning protocol was executed to systematically identify, verify, and correct any anomalies, inconsistencies, or missing values within the dataset, thereby ensuring data quality and integrity 3.11 Data Analysis Data analysis was conducted using STATA version 18. Descriptive statistics was used to summarize participants' demographics and responses to questions on key variables, calculating frequencies and percentages for categorical variables and means, medians, and standard deviations for continuous variables. The next analyses centered around awareness and knowledge levels of breast and cervical cancer which were assessed using composite scores derived from multiple indicators within the survey. Each dependent variable (awareness and knowledge) was measured using several items based on students’ responses to factual questions about causes, symptoms, prevention, and treatment of breast and cervical cancer. For breast cancer, the awareness score was 32 computed based on three key questions. Each correct or affirmative response was scored as one (1), and incorrect or unknown responses were scored as zero (0). The total breast cancer awareness score, therefore, ranged from 0 to 3. A median split approach was used to categorize respondents into two levels: “Poor Awareness” (scores below the median) and “Good Awareness” (scores equal to or above the median). The breast cancer knowledge score was derived from responses to 12 items covering areas such as risk factors, common myths, symptoms, prevention strategies, and treatment options. Each correct response was scored as one (1), and the total raw score was standardized to a 0–20 scale. Again, a median split was applied to classify respondents as having “Poor Knowledge” or “Good Knowledge”. Similarly, for cervical cancer, the awareness score was based on three items. The maximum awareness score was 3, and categorization followed the same median split strategy. The cervical cancer knowledge score was calculated using 14 indicators, which included knowledge of risk factors, symptoms, prevention, and treatment-related knowledge. Each accurate answer received a score of one (1), and the final score was standardized to a scale of 0 to 20. Classification into “Poor Knowledge” and “Good Knowledge” categories was based on the calculated median score. Inferential statistics, including chi-square tests and logistic regression, was applied to assess associations between variables. Chi-square tests were used to examine associations between variables, and logistic regression analysis was performed to identify predictors of cancer awareness and preventive practices (at 95% confidence intervals). A p-value of <0.05 was considered statistically significant. Results are presented in tables and charts for clarity and ease of interpretation. 3.12 Ethical Consideration Ethical approval was obtained from the Institutional Review Board of Ensign Global University. Approval letters were obtained from the Asuogyaman District Health Directorate and the Headmistress of Akwamuman Senior High School. Informed consent and Assent form was 33 obtained from all participants and their guardians where applicable. Participation was voluntary, and confidentiality was maintained throughout the study. Data was used solely for research purposes, and participants' right to withdraw at any time was respected without consequences. 3.13 Limitations of Study While this study provides valuable insights into the awareness and knowledge of breast and cervical cancer among students, certain limitations must be acknowledged. Firstly, the crosssectional design limits the ability to establish causal relationships between variables. Secondly, the use of self-administered questionnaires may have introduced response bias, including social desirability bias and recall bias, particularly in questions requiring prior knowledge or personal health practices. Additionally, the study sample was limited to female students at Akwamuman Senior High School, which may affect the generalizability of the findings to other populations or regions. Lastly, although efforts were made to ensure accurate responses, the potential for misinterpretation of certain medical or technical terms by respondents cannot be entirely ruled out. 3.14 Assumptions This study was based on the assumption that all participants will respond to the questionnaire honestly and to the best of their knowledge. It was also assumed that the selected sample of female students from Akwamuman Senior High School is representative of the wider student population. Furthermore, it was assumed that the students have had some exposure to health-related information which may influence their level of awareness and knowledge about breast and cervical cancer. 34 CHAPTER FOUR 4.0 RESULTS 4.1 Introduction This chapter presents the findings of the study on the awareness and knowledge of breast and cervical cancer among female students at Akwamuman Senior High School, in the Asuogyaman District of Ghana. The results are organized according to the study’s specific objectives. Descriptive statistics are first provided to summarize the demographic characteristics of the respondents, followed by analyses addressing each of the specific objectives. Both univariate and multivariate analyses are used to highlight significant patterns and associations within the data. The findings form the basis for the discussion and recommendations in the subsequent chapters. 4.2 Sociodemographic Characteristics of Respondents A total of 394 questionnaires were administered to eligible female students of Akwamuman Senior High School. All 394 were successfully retrieved, cleaned, and used for the final analysis, yielding a 100% response rate. Table 4.1 presents the sociodemographic summary of the respondents. These 394 respondents had a mean age of 16 years (SD = 1.17). The age distribution revealed that the majority of participants (56.9%) fell within the 17-20 years age bracket, while 43.2% were aged between 12-16 years. Regarding class distribution, the sample was fairly well-distributed across the three senior high school levels, with SHS 1 students comprising 36.5% of the sample, followed closely by SHS 3 students at 36.3% and SHS 2 students representing 27.2% of the respondents. The distribution of courses of study revealed a predominant enrollment in General Arts, which accounted for more than half of the respondents (52.5%,). Home Economics students constituted 35 17.5% of the sample, while General Science students represented 14.5%. These are followed by Visual Arts students (9.4%), Business students (5.3%), as well as Agriculture students who represented the smallest proportion at 0.8%. Religious affiliation among respondents was predominantly Christian, with 87.8% identifying as Christians. Islamic adherents constituted 10.9% of the sample, while those practicing African Traditional Religion represented a minimal 1.3%. As for ethnic composition, Ewe ethnic group represented the largest proportion at 31.7%, followed by Akan at 28.7%, and Ga-Dangme at 23.4%. The Mole-Dagbon ethnic group comprised 4.8%, while Guan represented 3.0%. Other ethnic groups (including Krobo, Wa, Dagomba, Efutu, Chamba, Ga, Hausa, Busanga, Fulani, British, Yoruba) collectively accounted for 8.4% of the respondents. Table 4.1: Sociodemographic Characteristics of Respondents Variables Percentages Frequency (N=394) (%) Mean age: 16.76 ± 1.17 Age groups (years) 12 – 16 170 43 17 – 20 56 224 Class SHS 1 144 36 36 SHS 2 107 27 SHS 3 143 36 Course of Study Agriculture Business General Arts General Science Home Economics Visual Arts Christianity Religion African Traditional 3 21 207 57 69 5 37 346 0.8 5.3 52.5 14.5 17.5 1.3 9.4 87.8 Religion 43 10.9 Ethnic Group Akan 113 28.7 Ewe 125 31.7 Ga-Dangme 92 23.4 Guan 12 3.0 Mole-Dagbon 19 4.8 Other 33 8.4 Source: Field Survey, 2025 37 4.3 Awareness of Breast Cancer among Respondents Table 4.2 and 4.3 shows an overview of breast cancer awareness among female students at Akwamuman Senior High School. An overwhelming majority of respondents (97.2%) reported having heard about breast cancer before, with only 2.8% indicating no prior knowledge of the condition. Regarding formal education about breast cancer in schools, the majority of participants (69.5%) reported receiving occasional formal education about breast cancer in school, while 22.8% indicated regular exposure to such education. Only 7.6% reported never receiving any formal education about breast cancer in school. Awareness of breast cancer initiatives showed encouraging results, with 85.5% of participants correctly identifying October as the globally dedicated breast cancer awareness month. However, knowledge gaps were evident, as 8.1% incorrectly identified January, and 6.4% selected November as the awareness month. Analysis of information sources reveals a varied approach to breast cancer education among participants. Healthcare providers emerged as the most frequently cited source of information, with 55.6% of respondents indicating they obtain breast cancer information from this source. School and teachers constituted another significant information source, utilized by 45.7% of participants. Media platforms, including television, radio, internet, and social media, served as information sources for 37.8% of respondents. Notably, family and friends represented the least utilized source, with only 14.0% of participants relying on this informal network for breast cancer information. 38 Table 4.2: Responses to Questions on Awareness of Breast Cancer Questions Frequency (N) Percentages (%) Heard of breast cancer? Yes 383 97.2 No 11 2.8 Have you received formal education about breast cancer in school? Yes, regularly 90 22.8 Yes, occasionally 274 69.5 No, never 30 7.6 Which month is dedicated as breast cancer awareness month globally? January 32 8.1 October 337 85.5 November 25 6.4 Source: Field Survey, 2025 39 Table 4.3: Sources of information about breast cancer (multiple response) Questions Yes No Total Where do you get information about breast cancer? N (%) N (%) N (%) School/Teachers 179 (45.7) 213 (54.3) 392 (100.0) Healthcare providers 218 (55.6) 174 (44.4) 392 (100.0) Family/Friends 55 (14.0) 337 (86.0) 392 (100.0) Media (TV, radio, internet, social media) 148 (37.8) 244 (62.2) 392 (100.0) Source: Field Survey, 2025 * Two persons did not respond and thus total respondents for sources of information equals 392. 4.3.1 Overall Awareness Levels of Breast Cancer Overall, a majority of respondents (~77%) demonstrated "Good Awareness" of breast cancer while the remaining ~23% were categorized as having "Poor Awareness." The median cut off point used was 3. A score greater than (≥3) was considered as “Good Awareness and a score less than (≤3) was considered “Poor Awareness” 40 Figure 4.3.1: The levels of breast cancer awareness among respondents 4.4 Knowledge of Breast Cancer among Respondents Table 4.4 and 4.5 shows an overview of breast cancer knowledge among female students at Akwamuman Senior High School. With regards to basic knowledge about breast cancer prevention, a substantial majority of participants (72.8%) correctly identified that breast cancer can be prevented, while 22.8% expressed uncertainty and only 4.3% incorrectly believed it cannot be prevented. However, concerning misconceptions were evident in participants' understanding of breast cancer causation. A striking 60.9% incorrectly believed that wearing tight bras can cause breast cancer, with only 20.1% correctly rejecting this myth and 19.0% expressing uncertainty. While 42.3% correctly identified lifestyle factors as risk contributors, awareness of genetic predisposition was notably lower at 22.8%. Hormonal changes as a risk factor were recognized by 41 38.0% of participants. Importantly, 18.7% acknowledged their lack of knowledge regarding risk factors. The most commonly recognized symptom was the presence of a lump in the breast (59.3%), followed closely by breast pain (57.8%). However, awareness of other important symptoms was considerably lower, with only 29.8% recognizing changes in breast shape or size, and 29.5% identifying nipple discharge or bleeding as potential symptoms. Encouragingly, only 2.5% indicated complete lack of knowledge about symptoms. Practical knowledge related to breast cancer management showed more positive outcomes. A majority of participants (69.3%) reported knowing how to perform breast self-examinations, and 62.9% were aware of treatment options for breast cancer. Among those aware of treatments, surgery was the most commonly known option (67.6%), while awareness of other conventional treatments was lower: chemotherapy (26.1%) and radiation therapy (16.2%). Notably, few participants (4.6%) mentioned traditional medicine as a treatment option. Regarding prevention strategies, among participants who believed breast cancer could be prevented, regular screening was the most frequently cited method (72.8%), followed by healthy lifestyle practices (49.0%). Table 4.4: Responses to questions on knowledge regarding breast cancer transmission and prevention Questions Frequency (N) Percentages (%) Can breast cancer be caused by wearing tight bras? Yes 240 60.9 No 79 20.1 42 I don't know 75 19.0 Can breast cancer be prevented? Yes 287 72.8 No 17 4.3 I don't know 90 22.8 Are you aware of any treatment options for breast cancer? Yes 248 62.9 No 146 37.1 Do you know how to perform breast self- examinations? Yes 273 69.3 No 121 30.7 Source: Field Survey, 2025 Table 4.5: Responses to multiple-response questions on breast cancer knowledge Questions Yes Which of the following are risk factors for breast cancer? Genetics (family history) 89 (22.8) Hormonal changes 148 (38.0) 43 Lifestyle factors (e.g., smoking, diet) 165 (42.3) I don't know 73 (18.7) What are the symptoms of breast cancer? Lump in the breast 233 (59.3) Change in breast shape or size 117 (29.8) Pain in the breast 227 (57.8) Nipple discharge or bleeding 116 (29.5) I don't know 10 (2.5) If yes, how can breast cancer be prevented? Regular screening 260 (72.8) Healthy lifestyle 175 (49.0) I don't know 4 (1.1) If yes, which treatments do you know? Surgery 163 (67.6) Chemotherapy 63 (26.1) Radiation therapy 39 (16.2) Traditional medicine 11 (4.6) I don't know 18 (7.5) Source: Field Survey, 2025 44 4.5.1 Overall Level of Knowledge of Breast Cancer Regarding respondents’ overall level of breast cancer knowledge, over half of the participants (68.3%) were categorized as having "Poor Knowledge," while only 31.7% were categorized as having "Good Knowledge." The median cut off point of 10 was used. A score greater than (≥10) was considered “Poor knowledge” where a score less than (≤10) was considered “Good knowledge” Figure 4.4.1: The levels of breast cancer knowledge among respondents 4.6 Awareness of Cervical Cancer among Respondents Table 4.6 and 4.7 presents an overview of cervical cancer awareness among female students at Akwamuman Senior High School. The findings reveal varying levels of cervical cancer awareness among the study participants, with notable gaps in knowledge and education exposure. Regarding basic awareness, three-quarters of respondents (75.4%) reported having heard about cervical cancer before, while nearly one-quarter (24.6%) had no prior Awareness of the condition. 45 Formal educational exposure to cervical cancer information in school settings demonstrated concerning patterns. Only 14.7% of participants reported receiving regular formal education about cervical cancer in school, while approximately half (52.0%) indicated receiving such education only occasionally. Notably, one-third of respondents (33.3%) reported never receiving any formal education about cervical cancer in school. Examination of information sources revealed that healthcare providers served as the primary source of cervical cancer information for 51.3% of participants, representing the most frequently cited source. Media platforms, including television, radio, internet, and social media, constituted the second most common information source at 40.0%. School and teachers were identified as information sources by 36.6% of respondents, while family and friends represented the least utilized source at only 9.3%. Regarding cervical cancer awareness initiatives, participants demonstrated poor awareness of global awareness campaigns. Less than half of respondents (43.4%) incorrectly identified November as the dedicated cervical cancer awareness month globally. Approximately only onethird (32.7%) correctly identified January as the dedicated cervical cancer awareness month globally, while nearly one-quarter (23.9%) selected February. Table 4.6: Responses to questions on awareness level of cervical cancer Questions Frequency Percentages (N) (%) Heard of cervical cancer? Yes 297 75.4 No 97 24.6 46 Have you received formal education about cervical cancer in school? Yes, regularly 58 14.7 Yes, occasionally 205 52.0 No, never 131 33.3 Which month is dedicated as cervical cancer awareness month globally? February 94 23.9 January 129 32.7 November 171 43.4 Source: Field Survey, 2025 The median score value for the level of cervical cancer awareness used was 2. Table 4.7: Sources of information about cervical cancer (multiple responses) Questions Yes N (%) Where do you get information about cervical cancer? School/Teachers 142 (36.6) Healthcare providers 199 (51.3) 47 Family/Friends 36 (9.3) Media (TV, radio, internet, social media) 155 (40.0) Source: Field Survey, 2025 4.5.1 Overall Level of Awareness of Cervical Cancer Overall, when assessing awareness of cervical cancer, the results revealed a moderate distribution, with 68.27% of students categorized as having "Good Awareness," and 31.73% falling under "Poor Awareness”. The median value used was 2 and so any score above (≥2) was considered “Good Awareness” where any score below (≤2) was considered “Poor Awareness’. Figure 4.5.1: The levels of cervical cancer awareness among respondents 48 4.7 Knowledge level of Cervical Cancer among Respondents Table 4.8 and 4.9 presents an overview of cervical cancer awareness among female students at Akwamuman Senior High School. Regarding preventability, majority of respondents (72.8%) correctly identified that cervical cancer can be prevented, while 22.8% were uncertain and only 4.3% incorrectly believed it cannot be prevented. However, awareness of specific preventive measures showed concerning gaps. Knowledge of the HPV vaccine, a critical primary prevention tool, was limited, with only 32.5% of participants being aware of its existence and role in cervical cancer prevention. Similarly, awareness of cervical cancer screening through Pap smears was suboptimal, with 42.4% reporting awareness while 57.6% lacked knowledge about this essential secondary prevention method. Among the established risk factors, Human Papillomavirus (HPV) infection and multiple sexual partners were each recognized by only 30.3% of participants. Poor hygiene was identified by 29.0% of respondents, though this represents a misconception as poor hygiene is not a direct risk factor for cervical cancer. Notably, smoking, a well-established risk factor, was recognized by merely 9.4% of participants, while early sexual activity was identified by only 12.0%. Others responses (26.2%) stated that they did not know about any risk factor of cervical cancer. Symptom recognition presented similar challenges. Pain during intercourse was identified by 29.5% of participants, pelvic pain by 24.6%, and vaginal discharge with bad odor by 24.9%. A higher percentage of participants selected "I don't know" for symptoms (31.8%) indicating a considerable knowledge gap. Among those who correctly identified cervical cancer as preventable, knowledge of prevention methods varied considerably. Regular screening was recognized by 57.2% of this subset, and healthy lifestyle by 56.1%. However, vaccination as a prevention method was identified by only 49 17.3%, consistent with the low overall awareness of the HPV vaccine. The minimal "I don't know" responses (3.2%) in this category suggests that those who understand cervical cancer's preventability generally have some knowledge of prevention methods. Table 4.8: Responses to questions on knowledge regarding cervical cancer transmission and prevention Questions Frequency (N) Percentages (%) Can cervical cancer be prevented? Yes 287 72.8 No 17 4.3 I don't know 90 22.8 Do you know about the HPV vaccine, which prevents cervical cancer? Yes 128 32.5 266 67.5 No Are you aware of cervical cancer screening (Pap smear)? 167 42.4 Yes 227 57.6 50 No Source: Field Survey, 2025 Table 4.9: Responses to multiple-choice questions on cervical cancer knowledge Questions Yes Which of the following are risk factors for cervical cancer? Human Papillomavirus (HPV) infection 119 (30.3%) Multiple sexual partners 119 (30.3%) Poor hygiene 114 (29.0%) Smoking 37 (9.4%) Early sexual activity 47 (12.0%) I don't know 103 (26.2%) What are the symptoms of cervical cancer? Abnormal vaginal bleeding 97 (24.5%) Pain during intercourse 115 (29.5%) Pelvic pain 96 (24.6%) Vaginal discharge with a bad odor 97 (24.9%) I don't know 124 (31.8%) 51 If yes, how can cervical cancer be prevented? Regular screening 159 (57.2%) Healthy lifestyle 156 (56.1%) Vaccination 48 (17.3%) I don't know 9 (3.2%) Source: Field Survey, 2025 • . 4.6.1 Overall Level of Knowledge of Cervical Cancer Regarding respondents’ overall level of knowledge of cervical cancer, 58.12% of students were found to have "Good Knowledge," whereas 41.88% exhibited "Poor Knowledge." The median value of 5.7 was used. Where any score above (≥5.7) was considered “Good Knowledge”, and any score below (≤5.7) was considered “Poor Knowledge” Figure 4.6.1: The levels of cervical cancer knowledge among respondents 52 4.8 Bivariate Analysis of Factors Influencing Breast Cancer Knowledge Levels Table 4.11 presents an overview of bivariate analysis examining the associations between sociodemographic factors, breast cancer awareness levels, and knowledge levels among respondents. Chi-square tests were employe