Breast cancer (BC) in women worldwide, continues to be the leading cause of cancer-related death and morbidity. With 2.3 million new cases in 2020, it ranked as the world's fifth leading cause of cancer-related deaths worldwide (Lei et al., 2021). Interestingly, BC ranks first in terms of incidence and mortality among countries with robust health systems such as Australia and the United States of America (Arnold et al., 2022).

Although BC is common in wealthy nations such as America approximately 627,000 BC-related deaths are recorded in sub-Saharan Africa accounting for 15% of all deaths globally (Anyigba et al., 2021). Africa has the highest mortality rate (18 per 100,000) compared with other parts of the world, despite having one of the lowest age-standardized incidence rates of BC (37 per 100,000 women annually), followed by Asia (30 per 100,000 women annually), according to a study on the disease conducted by Sun et al., (2017). The West African sub-region has the highest mortality rate (21 per 100,000 women annually (Sun et al., 2017).

In Ghana, Breast and Cervical Cancers constitute the two leading causes of cancer death among women (Ayanore et al., 2020). According to GLOBOCAN 2020, Ghana recorded 4,482 new cases in 2018 representing an incidence rate of 18.7%. Recent studies on BC in Ghana reported 31.8% of cancer incidence in 2020 (Akuoko et al., 2022).

Breast cancer is classified as heterogeneous by the WHO, however nearly all cases involve women who have no particular risk factors other than age or sex. Over the years, women have been linked to 99% of all incidences of BC. Risk factors such as sex, age, oestrogen, family history, gene mutations, unhealthy lifestyle, etc., may increase likelihood of developing BC (Dixita Das, 2022).

The only way to decrease BC incidence is through timely diagnosis and treatment. Mammography, Magnetic Resonance Imaging (MRI), Clinical Breast Examination (CBE), and Breast Self-Examination (BSE) have been studied and implemented over the years. These measures have proven effective in early BC diagnosis and treatment (Sun et al., 2017).

The challenge in Ghana, Africa, and the rest of the world is delayed detection fuelled by many barriers. Lim et al., (2015) identified knowledge, perception, and family influence as strong predictors of the attendance of women to BC screening centres. Khazaee-pool et al., (2014) identified among Iranian women that, culturally, they were groomed to preserve their breasts for their male spouse's satisfaction. This culture does not therefore encourage them undergo BC screening, which involves exposing their breast to others. In another study, concerning the fear of medical processes, many respondents mentioned all the attitudes of health workers, and financial difficulties as barriers to BC screening. (Rajendram et al., 2022).

Given the current dispensation of technology and its abundance of information globally, Ghanaian adolescent girls were found to have insufficient awareness of BC and BSEs (Nsaful et al., 2022). Unlike Iran and Singapore, where research has been conducted on knowledge, perceptions, and family influence on BC screening among young girls, Ghana has limited studies in this area. It is therefore difficult to assess the role of these factors in BC screening among adolescent girls in Ghana.

The objective of this research was therefore to explore the social perception of BC screening and the practice of BSE among Senior High School girls in the Eastern Region.

Single-sex schools have the opportunity to provide gender-tailored teaching. In other words, educators adapt approaches to better suit the learning styles and interests that may be more relevant in a single-sex classroom (Dustmann et al., 2018). In this case, the Methodist Girls Senior High School may have the opportunity to be more exposed to female-related diseases, such as BC, as well as its screening, than their counterparts in mixed-sex schools. The girls in this institution, therefore, formed a relevant stratum that provided better insight into the role of single-sex education in improving BC screening in Ghana.

Secondly, Senior High Schools provide more general academic education. Students take a core curriculum of subjects such as English, Mathematics, Science, and Social Studies, besides elective subjects from various programmes, including Arts (social sciences and humanities), Business, General Science, or Agriculture. This path prepares students for further academic study at the university level (Aggrey et al., 2022). Among the Senior High School strata in the Akuapim North Municipality, the Okuapeman SHS has the highest female population. This school was therefore selected to represent the Senior High School category in this research.

Third, Senior High Technical Schools strongly emphasize practical skills and vocational training. While they also cover some core subjects, a larger portion of the curriculum focuses on technical areas such as carpentry, mechanics, or electronics. This equips students with the skills needed to enter directly into the workforce after graduation (Aggrey et al., 2022). The municipality has three (3) Senior High Technical Schools of which Presbyterian Senior High/Tech School (Adukrom) was the highest with girls. The girls in this school were also used to represent the Senior High Technical Schools in the municipality.

Finally, schools for deaf students (schools with special needs) in Ghana have a communication philosophy focused on sign language (Ghanaian Sign Language) or a combination of sign language and spoken language, depending on student needs. While resources are limited, Ghanaian schools incorporate some assistive technologies like amplification systems or basic visual aids into classrooms (Obosu et al., 2016). In the Akuapim North municipality, Mampong/Akwapim SHTS for the Deaf was the only school with this challenge hence was selected for the study.

The participants were therefore selected using the disproportionate stratified sampling method. The choice to use the disproportion became necessary to ensure enough representation from the least populated stratum, thus the special needs school. A minimum sample of 110 was randomly selected from each stratum to achieve the total minimum sample size. The following schools were Senior High and Technical Schools chosen for the study.

Hard copy questionnaires were obtained and administered to participants in each school.

To prevent student responses from becoming contaminated, the survey was completed as soon as possible within each stratum. The questionnaire consisted of four sections. Demographic factors such as age, religion, parents' employment, parents' educational attainment, length of schooling, household income, boarding status, etc., were recorded in the first part. The second section of the survey, examined the perceptions of the participants. To achieve this goal, 13 wrongful social perception questions were asked for the respondents to correctly respond to. These responses was scored as good perception or poor perception. The third section of the questionnaire evaluated the participants' understanding and application of BSE. Regarding this, the respondents were asked to provide the frequencies of their Breast Self-Examination. The fourth section examined other potential personal obstacles to BC screening among teenage girls in the Akuapim North Municipal District. Seven factors were listed for the respondents to choose the best factor that applied to them.

To reduce the impact of biases in the study, strategies were put in place to attain data reliability and quality. Preparing assistants in research, giving pretesting questions, and distributing questionnaires and consent forms were among the strategies used. Data entry and processing were also performed. The answers to the questionnaires were taken through the validity process and recorded on a day-to-day basis. The data were also scrutinized for errors and gutted.

The data gathered were entered into the database of Stata software (Version 18). To identify patterns and trends in the datasets, statistical manipulations were performed as part of the data analysis process. Frequencies and percentages were used in the study's data analysis. Furthermore, the statistical study included an association test utilizing the chi-square test. Tables and graphs were also used in the data presentation.

The committee of the Ghana Health Service Ethical Review Board granted ethical approval (GHS-ERC: 072/07/24). Before visiting the Senior High School institutions, an introduction letter was also acquired from the university.

Each participant was given an explanation of the study's purpose before being shown an informed consent form. Only after accepting the conditions listed on the informed consent form was a participant registered. The information supplied was guaranteed to be kept private. Before any questions were asked, the participants were informed that they might leave the study at any point if they were uncomfortable with the way the questions or the study were going. The information gathered for the study was securely stored on the lead investigator's Google Drive. After being cleaned of any identifying information, the downloaded dataset was put on a compact disc and sent to the Department of Epidemiology and Disease Control at the School of Public Health.

Participants in this research who have lost a family member or friend to Breast Cancer may be at risk. The recollection of a loved one may cause emotional distress. Participants with a family history of the condition may have been uncomfortable answering some of the questions in this survey.

The study benefited both the sampled population and the academics. This study informed government authorities and the study population on how social attitudes influence Breast Cancer screening. Furthermore, the extent of the effect of social perception has influenced legislation, as well as the development of education and awareness programs for educational institutions and the public.

Five hundred and twenty students (520) from the four selected schools in the Akuapim North Municipality in the Eastern Region were interviewed. Adukrom Presbyterian Senior High Technical School accounted for twenty-eight percent (n = 147) of the respondents, followed by Mamfe Methodist Girls Senior High School (23.1%), Okuapemman Senior High School (23.7%), and Mampong School for the Deaf Senior High Technical School (25.0%). The average age ranged from 13-25years (sd = 1.87). Among those who responded, 337 people, or 64% of the total, were under the age of 18. Nine percent (n = 47) were in year three, 64% (n = 331) were in year two, and 27% (n = 142) were in year one.

The predominant programme of study of the respondents was General Arts, with 37.69% (n = 196) followed by Home Economics with 37.31% (n = 194). Two percent (n = 9) of the respondents studied Agriculture, 1.15% (n = 6) studied Business, 14.23% (n = 74) studied General Science, 2.12% (n = 11) studied Technical Courses, and 5.77% (n = 30) studied Visual Arts.

The majority were boarders with 90.19% (n = 469). The most common religion of the respondents was Christianity with 89.23% (n = 464) followed by Muslims, with 6.92% (n = 36). Among Other religions had 3.46% (n = 18), and 0.38% (n = 2) were traditionalists.

With respect to parents' educational levels, the leading educational level was secondary for both fathers and mothers with 37.30% (n = 194), and 33.26% (n = 173) respectively.

Most of the parents of the respondents were in service and sales with mothers 81.15% (n = 422) and fathers 65.58% (n = 341).

The household income per month for the majority of the respondents 35.96% (n = 187) was below GHC 500.00. The second predominant household income per month of the respondents 19.81% (n = 103) is between GHC 5000.00 and GHC 10,000.00.

A substantial percentage of the respondents 20.58% (n = 107) had BC in their family.

The majority of the respondents 67.31% (n = 314) were Akans, followed by Ewes 14.42% (n = 75). The remaining ethnic groups constituted 18.27% (n = 95) of the sample.

Table 4.1 summarizes the demographic information of the study participants.

We explored the impact of the social perception of Breast Cancer screening and practice of Breast Self-Examination among Senior High School girls in the Eastern region of Ghana. We found that only 6% of the respondents had a good perception of BC. Perception about Breast Cancer and other communicable diseases has been poor across many cultures and age groups around the world. Earlier scholarly works (Beidler et al. 2023) showed that, regardless of race, people erroneously believed that having Breast Cancer was a greater risk than not having children, drinking alcohol, or having undergone a breast biopsy. Others (Hing et al., 2021) also linked breast surgery to incapacitating side effects because of a misunderstanding. (Suwankhong et al., (2023) In the case of Iranian women, despite their propensity to undergo BC screening, there is a strong cultural idea that the breasts are sexual parts that should not be addressed in public.

In this study, we also discovered that the social perception of BC was substantially influenced by an individual's age, school, form, programme of study, family history of BC, and father's educational attainment. The relationship between these sociodemographic dynamics and the perception of BC was found in previous scholarly works, where even though the overall social perception was poor, relatively older respondents had a better perception of Breast Cancer than younger respondents did. In Ghana, women between the ages of 18 and 30, who were married, had jobs, had postsecondary education, and were mostly Christians, were found to have a greater knowledge of BC. These women employed screening methods for BC (Shirazu et al., 2023; Dinegde et al., 2020). (Amegbedzi et al. 2022) In addition, fourth-year students in particular were more than four times as likely as first-year students to have adequate knowledge and practice Breast Self-Examination. These findings may be due to health education on communicable and non-communicable diseases while studying in the Senior High School. Similarly, naturally, as students progress through their academia, they automatically read widely, including health-related materials. This certainly will open their knowledge to non-communicable diseases such as Breast Cancer, making room for seniors in school to acquire more knowledge. Neither household income/month, boarding Status, religion, mother’s educational level, nor ethnicity were associated with perceptions of BC. This, however, contradicts the findings that traditional and spiritual beliefs, as well as their associated therapies, have significant roles in the social perception of Breast Cancer (Akuoko et al., 2022).

Generally, most of the respondents in this study had heard about the BSE, with a higher proportion hearing it for the first time on mass media, thus TV and radio. However, fewer than half of those surveyed knew enough about Breast Self-Examination. Two-thirds of the respondents think that Breast Self-Examination will effectively detect BC, while nearly half of the respondents recommended it to others. Given four basic steps in the BSE which were randomly arranged for the respondents to correctly arrange, only 11% were able to arrange them appropriately. This clearly explains that awareness does not necessarily equals adequate knowledge. These outcomes are likewise mentioned in other scholarly works. Television is the primary source of knowledge on BSE (19.9%); however, only 3% of respondents have frequently practised BSE (Nde et al., 2015, Buunaaim et al., 2020, Aphrodite et al., 2021). Nsaful et al. (2022) similarly found among Ghanaian senior high school students that, even the current dispensation of technology and its abundance of information globally, they have an inadequate understanding of BC and BSE.

Among the 520 respondents in this study, we found that only 13% indicated that they perform it anytime, whereas fewer than one-tenth of the respondents correctly indicated they perform it every month. Similarly, prior research revealed that just 13.1% of respondents used BSE, although over half (52.5%) of respondents had heard of it (Dinegde et al., 2020, Dadzi & Adam, 2019b, Dechasa et al., 2022, Mihret et al., 2021; Rajendram et al., 2022, Tapera et al., 2019). In another study, slightly more than three-quarters (73.5%) of the participants had previously heard about BSE; however, only 9.0% of people were proficient in BSE. (Nde et al., 2015).

A greater proportion of the respondents in the study were afraid of positive results as a barrier to BC Screening. A similar proportion of the respondents also feared pain or discomfort as a barrier to BC screening. The least barrier in the choices of the respondents was religious beliefs. In similar studies, the most common barriers to BSE were ignorance, believing oneself to be in danger, traditional and spiritual beliefs, and not seeking medical assistance (Al-Sharbatti et al., 2013, Akuoko et al., 2022, Amin et al., (n.d.).

In Asoogo & Duma's, (2015) qualitative study, the participants expressed words or phrases for surgical procedures with BC as ‘chopping my breast off’, ‘cutting me up’, and ‘amputating me’. These remarks were taken to imply a genuine dire of medical intervention and the ensuing postponement of seeking medical attention. (Khazaee-pool et al., 2014) Among Iranian women, culturally, they were groomed to preserve their breasts for their male spouse's satisfaction. This culture does not therefore encourage them to undergo BC screening, which involves exposing their breast to others.

In summary, results of our study revealed that there is no significant correlation between BSE practices and perception level. This finding contradicts the findings of earlier scholarly works. Rodríguez-Amador & Gómez-González (2023) found BSE for women as a concept and practice that is understood through beliefs, perceptions, knowledge they have about the disease, detection methods, consequences and life experiences. Additional research has shown that women's social and cultural contexts, where breasts are connected to sex, influence the significance attached to them (Kwok et al., 2006).

The strengths of this study include its thorough assessment of Breast Cancer awareness and knowledge of screening methods, its identification of key sociodemographic factors that influence perception, and its recognition of both psychological and social barriers to screening. It also underscores the central role of mass media as an information source and exposes the significant gap between awareness and actual screening practices among senior high school girls.

The current research is exploratory, and its limitations should be considered while evaluating the results. It is impossible to overlook selection and response bias because this study relied on participants who voluntarily agreed to participate. In some schools, the class teachers and housemasters/mistresses encouraged female students to be part of the study. These respondents may have given misleading responses because of social desirability. Furthermore, respondents and their respective schools may not be representative of the entire Senior High School Girls and Senior High Schools in Ghana since the research design was cross-sectional and limited to Akuapim North Municipality in the Eastern Region. As a result, the findings should be taken cautiously and may not apply to all senior high school girls in Ghana.

The Ghana Education Service should collaborate with BC campaign groups to educate Senior High School girls about non-lump BC signs and symptoms, since knowledge in this area is poor.

The ministry should intensify the use of mass and social media platforms to educate the public on diseases and other health-related issues, since they are the main source of information for most respondents.

In this survey, most senior high school girls revealed poor perception of both Breast Cancer and Breast Cancer screening. Age, school, form, study program, family history of BC, and father's educational attainment were associated with how senior high school girls viewed Breast Cancer.

Even though a majority of the SHS girls had previously heard about the BSE, only a few had adequate knowledge about its performance. In addition, only a few of the respondents were familiar with other screening methods, including mammograms, Clinical Breast Examination (CBE), breast magnetic resonance imaging (MRI), and ultrasound. Moreover, mass media (TV and Radio) remain the main source of information for most of the respondents.

Even among those who have adequate knowledge of BSE, only a handful of the respondents indicated that they perform it correctly every month.

The major barriers to BC screening found in this study were fear of positive results, fear of pain or discomfort, and social stigma. This research revealed no substantial association between the level of perception and the practice of BSE.