Form or Flesh: Social Factors that Impact Women's Practice of Breast Self-Examination

The purpose of the qualitative study was to understand the meanings of the social factors identified by Caucasian middle-class women and their practice of breast self-exam (BSE). The meaning of breast selfexam is discussed in relationship to body image and the social definition of being a woman. Introduction Much of the research on adult leaning reveals the psychological nature of learning. However, very little research has been published about the social influences upon adult learning, specifically, women’s learning (Hayes & Flannery, 2000). Similarly the research on breast self-exam coming from health education is also psychological in nature. These studies looked at factors that predict compliance or barriers to monthly practice of BSE and reflect the psychological perspective that has dominated this issue. While these studies are important they present an isolated view of the practice of breast self-exam. Importantly, women have been barraged through the media about breast cancer and the importance of early detection. Breast self-exam is important due to breast cancer being the leading type of non-cutaneous cancer in the United States for women. One new breast cancer is diagnosed every three minutes in the United States. In spite of all the programs, printed materials and media reminders, only 8-10 per cent of women perform breast cancer on a monthly basis (American Cancer Society, 2000). Give all the information on breast cancer, one must ask why such a small number of women practice BSE monthly and what influences women to choose to use this learning or to disregard it? Review of the Literature To better understand the meaning making of the practice of breast self-exam and the social factors that impact women’s practice of and experience with breast self-exam, four bodies of literature were reviewed: Social Constructionism, women as gendered learners, the concept of body image, and the practice of breast self-exam. Social construction of knowledge is concerned with the analysis of socially constructed reality. McCarthy (1996, p. 23) states that knowledge is defined as “any and every set of ideas and acts accepted by one or another social group or society of people--or ideas and acts pertaining to what they accept as real for themselves and for others. ” Following this knowledge is an historical construct, which is subject to constant changing of forms and changing the ways people navigate and position themselves in their worlds. Gergen locates knowledge in language, not just the utterance of words but also the deeper understanding of the intent behind the vocalizations (1995). Realizing that communication takes many forms, Rorty (1989, p. 9) believes that “all experience and behavior is essentially linguistic. ” Therefore, understanding language as a construct of knowledge brings a view of culture that encompasses multiple social reality and tremendous cultural diversity. Understanding women as gendered learners means to understand the socially constructions that influencing women’s learning (Hayes & Flannery, 2000). Gender is a social construct, one that is fluid, responding to being created and re-created depending upon the social situation one is located in. Additional social constructs identified have been race (Johnson-Bailey & Cevero, 1996), and class (Lutrell, 1984) that shape women’s learning. Learning for women is also contextual. Hayes and Flannery (2000) place women workers as segregated by gender and occupying traditional female jobs. Research on social constructions which influencing women learning are emerging, other need to be identified, and one such construct is that of body image. Body image is a social construct; comprised of multidimensional self-attitude towards one’s body, the size, shape and aesthetics of the body, beliefs about one’s attractiveness, as well as the perceptions of how others view one’s own body (Brand & Hong, 1997; Cash & Pruzinsky, 1990). Body image is formed to a degree as a function of the culturally defined images of desirable body appearances for women. These culturally defined images most often occur in the mass media as ideal images of the female body. Being objectified by others, women learn the art of self-objectification (Brand & Hong, 1997). Her body becomes an object for display. This female gendered body image is a culturally created image that resides in the minds of many men and women. Lastly, the research on breast self-examination performance and nonperformance provide varied and often inconclusive results. Social factors of age and education give mixed results on performance (Worden, Costanza, Foster, Lang & Tidd, 1983; Sensiba & Stewart, 1995). The literature on social support and one’s personal history also provide inconclusive results. Alagon and Reddy (1984) found self-confidence in one’s competence to perform BSE and a feeling of control over one’s health were significant predictors of the practice of BSE. Social factors produced mixed results for the practice of BSE, and knowledge alone does not provide reason for women to practice breast self-exam. What needs to be understood is how body image as a social construct influences the practice of breast selfexam. Methodology A qualitative phenomenological approach focused on in-depth interviews was employed to capture the lived experiences of the 15 participants. The participants were selected to reflect Caucasian, middle-class women who practice monthly BSE, occasionally practiced BSE or did not practice BSE. Semi-structured, face-to-face interviews were used as the primary method of data gathering. The interviews were audiotaped and transcribed verbatim. Follow-up interviews were conducted to gain clarity and to aid in triangulation process. The transcripts were analyzed using thematic coding. To ensure trustworthiness, data collection and analysis were rigorously conducted and supervised. The findings of this study are not generalizable due to the specific and purposeful nature of the sample. Findings This study identified the social influences on women’s practice of breast self-exam and then explained the importance these influences had upon the women and their practice of BSE. Three specific groupings of participants emerged based upon their practice of BSE, as did themes pertaining about social influences, breasts and BSE education on women’s lives. Grouping of the Participants Based upon their Practice of BSE While conducting data analysis participant grouping naturally emerged based upon their practice of BSE. Each group displayed specific commonalities. Age and educational backgrounds vary in each of these groupings. Women that practice monthly BSE. These five women all learned BSE from their gynecologist and share five commonalities. First, is satisfaction with their bodies and acceptance of body image and breast size. Not one woman would alter the size of her breast if given the opportunity. This group could not describe the ideal breasts as described by society and also have developed the ability to resist the impact of the media, and bra and clothing manufactures as social influences. Secondly, their concept of health or wellness if viewed in totality, the human body is not broken down into separate pieces to be cared for. These women take time for all self-care behaviors. This provides these women with a sense of empowerment. BSE is more than finding a lump or cancer early, it provides a greater objective—control over one’s health. Kate summarizes this thought, “breast self-exam, it’s like brushing your teeth, I mean I don’t treat my breasts any differently than I do other things that require care. Every part of me gets the health piece. ” Next, these women can articulate their empowerment by anticipating potential problems and discussing their plan of action if they found a lump. Barbara notes her power in this plan, “well, then my options come in. That I can act on it, I can take charge and say what I am comfortable having done. ” The fourth commonality is the understanding of what is normal breast tissue. As regularly practicing BSE, they know their own breast tissue and this eliminates worry because they know their body. The final commonality is their ability to openly discuss their bodies and breasts with other women also; these women are more likely to initiate discussions about BSE with female relatives and friends. For these women health is a resource, it is an enabler for these women to live active lives. Women that occasionally practice BSE. These women exhibit four commonalities that revolve around their breast. Foremost is the desire to change the size or shape of their breasts: these women identified a societal ideal of perfection and recognized their own imperfections. Secondly, these women articulated what the perfect pair of breasts should look like. The words for this notion of perfect breasts were similar for these five women: “firm, centered, cleavage, C cup size, perkier and be able to go without a bra. ” These women compared themselves to an ideal that is based upon the media and advertising. Next, as girl children growing and developing secondary sex characteristics these women recalled negative comments from authority figures that haunt them today. Maggie had two teachers tell her sit up “or your boobs will hang down to your gut. ” Lee’s mother nominated her for the “chairperson of the itty bitty titty committee. ” Lastly, these women are very casual in their practice of BSE and expressed fears about breast cancer. They give the impression that this is due to a lack of self-confidence in their BSE technique and /or not knowing what is normal breast tissue. This group of women has been greatly influenced by the media and clothing manufacturers. Their breasts have become objects that they notice and want others to notice also. Their breast dissatisfaction impacts how they view themselves as women and this connection appears to be a link to their occasional practice of