105Gráfico 3-9: Conjunto de medidas de ancho y

All the women identified the breast change themselves except for Int. 15 whose lump was noticed by her friend. Some of the women had the habit of touching and feeling their breast periodically because of messages about breast examination they had heard on television or radio. For others their attention was drawn to examine their breast because of the unusual asymmetry they had observed in the breast size or a sense of discomfort/pain they felt in the breast. The first sign identified by most of the women was a lump in the breast, some noticed swelling of their breast, and two of them felt pain in the breast. Their initial impression was that it was nothing serious. This attribution arose from different reasons. For some, what they discovered initially was small in size, was not apparent to others, and their breast still appeared normal. Moreover, signs they expected to be associated with serious illness such as pain and interruption in the ability to go about their normal duties were absent. For many of the women, the change at that time was not perceived to be something that could potentially worsen and have detrimental health effects.

“It wasn’t big and I thought it won’t worry me, I thought that this will not bring me any problem that’s why I did not go to the hospital” [Int. 5]

“I didn’t think it will progress like this” [Int. 15]

In spite of this initial impression that what they had identified was not serious, the women had now become aware of the change in their breast. This sense of awareness led them to repeatedly re-examine their breast and make efforts at understanding

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what it was. They employed various means to achieve this. The women relied on what information they had of breast illnesses and compared what they had identified on themselves to this. Such information included common knowledge of what was culturally/traditionally known regarding breast illness or diseases of lumps and body swellings that were similar to what they had identified in their breast. For example, swellings were commonly regarded as boils and the expectation was that at a point in the swelling process it would discharge pus and subsequently resolve. This disease process was known to be common in the breast especially during breastfeeding. And even during breastfeeding if a lump or swelling did not burst to discharge pus, continuing to breastfeed led to its spontaneous resolution. Although they were not breastfeeding, the women actively monitored their breast symptoms expecting these outcomes. This watchful waiting was also sometimes encouraged by friends and relatives with the same outcome expectations. The expectations were heightened if there was previous personal experience of similar change. For example, Int. 15 had experienced painful breast swelling which burst and discharged pus while breastfeeding her third child. As the pain she experienced now was similar to what she had before, she expected it to resolve spontaneously as the previous one had.

“What I know is that as a woman when you deliver and your child is breastfeeding it can swell, even that for 3 days……the way it was hurting I was thinking, as for something that is swollen it will burst and discharge then you are free and that’s all” [Int. 6]

“I realised that when the thing wants to burst it does not burst like the way boils do and fluid comes out, rather the surface ulcerates. I was waiting for it to

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burst but it didn’t it was still there. I tried some other herbal medicine but even that it still could not burst” [Int. 13]

The women also looked to the past experiences of other women who had seemingly similar breast illness to make sense of what they had discovered in their breast. Sometimes they actively sought the opinion of other women on what they had noticed in their breast and the information they got contributed to their interpretation of their symptom. For example, Int. 3, although she was experiencing her breast symptom for the first time and did not know what it was, thought it was not serious. This was reinforced by the assurance she got from the women around that it was nothing serious.

“I will complain to the elderly people who buy things from me that there is a lump in my breast and they say it is not anything just apply medicine to it”[Int. 3]).

“My mother said it was nothing, that my child had coughed into my breast, I should allow him to continue to breastfeed and it will loosen up” [Int. 10]

The women also based their judgments on what they may have observed in relatives or friends.

“I had seen women with breast disease some their breast became very huge they used herbal medicine at home and for the majority it resolved” [Int. 10]

Nine of the women had been exposed to breast cancer messages via media (television, radio, posters) or in their local church/social groups either before or after the identification of their breast symptom. This also served as another source of

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information for them to appraise their symptom. Their accounts of the messages they had heard suggested they had learnt general lessons like performing routine examinations of their breasts and reporting to the hospital if they found a lump in their breast. They had also learnt that a breast lump could be cancer and would need to be examined at the hospital for diagnosis. However, this information was not used in their appraisal processes. Int. 3 at one point agreed with her husband who attributed her breast shrinkage associated with the lump to having slept on the breast. Furthermore, because these messages were point in time events, the women could not have access to them at the time of symptom appraisal. For example, Int. 4 had noticed her breast symptom 2 months before she heard about breast cancer in a community education programme and decided to visit the hospital. For Int. 9, noticing a lump towards the armpit but not directly in the breast, the absence of pain and the fact that the symptom identified did not worry her i.e. negatively affect her daily functioning, made her think this was not something that needed to be reported to the hospital.

“I hear always about breast diseases….as for the breast I did not really see anything in it, it was my armpit that I noticed something” [Int. 9]

“Our pastor’s wife is a nurse and taught us periodically to examine our breast. She said breast can develop cancer so you must take the right steps else you can die. I had heard this on radio and TV too. I had heard about breast disease so even though it was not paining me I had to do something about it…..but it was not worrying me and we had entered the Christmas season too so I wanted to work small” [Int. 12]

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The women’s account of the campaign messages they had heard did not include information of what other signs or symptoms could be present or absent in addition to a breast lump and yet would be suggestive of breast cancer. It also did not include information on how different or similar breast cancer symptoms could be to what they commonly or traditionally knew breast swellings and lumps to be, and how they evolved. Images of breast cancer that Int. 10 saw were huge swollen breasts, while she had noticed only a small lump in her breast. Int. 13 was exposed to breast cancer messages in the first private hospital she visited when her breast swelling was not resolving in spite of applying herbal preparations. The information focused on death if one refused surgery to cut off the breast and abandonment by family and friends when offensive ulcers developed. She found this threatening and scary and this deterred her from seeking help in that health care facility. In the end, these women’s appraisal of the symptom was not different from those who had not been exposed to breast cancer messages (6 women).

Ultimately, all the women lived in a state of awareness of changes in their breast and observed progression of the changes.

“The lump is still in it and sometimes you feel it has become heavy and later I even saw some fluid coming out of the tip like some oily stuff” [Int. 3]

“As time went by the breast started becoming hard” [Int. 9].

Their inability to appreciate the seriousness of what was going on with them was further expressed in their non-disclosure of the breast changes they had identified to a physician in spite of regular contact for other medical conditions.

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“It has been swollen for over a year, I did not do anything about it….I was seeing

the doctor monthly for my hypertension medication” [Int. 6]

Ultimately, the women were ignorant of the implication of what they were experiencing.