Knowledge, attitudes and practices regarding mammary gland hyperplasia among adult women: a cross-sectional study in Shandong province, China.

No patients or members of the public were involved in the design, conduct, reporting or dissemination plans of this research. This cross-sectional study was conducted at Shandong First Medical University Affiliated Central Hospital in Jinan, Shandong, China, from July to September 2023. The subjects were adult women from Shandong province, China. The study included adult women aged 20 years or older residing in Shandong province who possessed normal cognitive and communication abilities, with basic reading, comprehension and language expression skills. Given the electronic nature of the survey, these abilities were practically operationalised by the women’s ability to independently use a smartphone, access the WeChat survey link, read and fully understand the electronic informed consent form, and voluntarily complete the questionnaire. Women under 20 years of age were not included, as MGH is more prevalent in adult women, and individuals aged 20 years and above generally demonstrate greater social maturity and more stable KAP, which improves the representativeness and interpretability of the findings. Adult women were excluded if they had a current or past history of high-risk breast lesions, including malignant tumours (breast cancer), intraductal papilloma or atypical hyperplasia; suffered from severe psychiatric disorders, cognitive dysfunction or were in the acute phase of illness; or were currently pregnant or lactating. Electronic informed consent was obtained, and all participant data was anonymised. We developed the KAP questionnaire based on a review of relevant literature and the ‘Clinical Practice Guidelines for Diagnosis and Treatment of MGH: 2021 Guidelines of the Chinese Society of Breast Surgery (CSBrS)’. 17 20 Two experts in breast health and statistics critically evaluated the instrument for content validity, and we incorporated their feedback into the final version. This expert review was conducted through informal oral consultation, focusing on the relevance, clarity and clinical appropriateness of questionnaire items. A pilot study was conducted prior to the formal survey to ensure the reliability, clarity and applicability of the questionnaire. Pilot participants were recruited according to the same inclusion criteria as the main study to ensure consistency and external validity. A total of 41 eligible adult women participated in the pilot study. Following completion of the pilot survey, qualitative feedback was collected from participants regarding the clarity of question wording and the overall fluency of the questionnaire. In addition, internal consistency reliability was assessed using Cronbach’s α coefficient. Based on participant feedback and reliability analysis results (Cronbach’s α=0.7628), items with lower reliability or ambiguous wording were removed or refined. The revised questionnaire was then finalised for use in the formal study. The questionnaire contained four dimensions ( online supplemental appendix file 1 ): Demographics (11 items); Knowledge (10 items); Attitude (10 items); and Practice (10 items). For the Knowledge dimension, single-choice items scored 1 point for correct answers, while multiple-choice items scored 5 points for selecting all correct options, 3 points for partially correct options and 0 points otherwise (including ‘uncertain’ or incorrect selections); the total knowledge score ranged from 0 to 38 points. Both the Attitude and Practice dimensions used a 5-point Likert scale (1–5 points per item). The total Attitude score ranged from 10 to 50 points. The Practice dimension comprised 10 items, but excluded two open-ended, unscored questions, resulting in a total Practice score range of 8–40 points. The KAP questionnaire was converted into an electronic format using the professional online survey software platform ‘Wen Juan Xing’ (Changsha Ranxing Information Technology). A quick response code was generated to allow participants to access and complete the survey via WeChat. Convenience sampling was employed for participant recruitment, which involved promoting the study to community management personnel and distributing the electronic questionnaire link through WeChat groups to residents. To ensure data quality and integrity, measures were implemented to restrict submissions to one response per IP address. All data were collected anonymously, and no personally identifiable information was recorded. Access to the survey was restricted to one submission per IP address to reduce the likelihood of duplicate participation and to ensure participant uniqueness. All electronic data were stored securely and were accessible only to the research team. The collected raw data were then exported from the ‘Wen Juan Xing’ platform into an Excel spreadsheet. Subsequently, the research team conducted a thorough data cleaning process to evaluate all questionnaires for completeness, internal consistency and logical coherence. Questionnaires with missing or incomplete responses were excluded during the data cleaning process. As a result, only complete questionnaires were included in the final analysis, and no imputation methods were applied for missing data. Women who declined to provide informed consent were not enrolled in the study. Among the enrolled participants, those who submitted an incomplete survey, or appeared to have completed the questionnaire inattentively (ie, had a response time less than 60 s or greater than 1800 s) were excluded. A total of 796 women were initially invited to participate in the online survey, of whom 7 declined participation and 22 withheld their consent for the use of their data in scientific research. Consequently, 767 questionnaires were collected. During data cleaning, 11 questionnaires were excluded due to excessively short (1800 s) completion times, 22 were excluded because participants did not consent to the use of their data for scientific research and 14 were excluded due to logical inconsistencies. Finally, 742 valid questionnaires were included in the analysis. The participant recruitment and data screening process is illustrated in figure 1 . We determined the minimum required sample size (n) using the standard formula for cross-sectional studies, assuming the maximum sample size where the proportion (p) is 0.5: The Type I error (α) was set to 0.05, corresponding to a Z-score of 1.96 (for a 95% confidence level). The SE (δ) was set at 0.05. Substituting these values yields a required sample size of 384. Assuming an effective questionnaire recovery rate of 90%, the final target is to collect at least 430 completed questionnaires. All statistical analyses were performed in IBM SPSS Statistics for Windows, V.26.0 software (IBM, Armonk, New York, USA). As KAP scores were skewed distribution, these variables were summarised using the median and IQR. Categorical data were presented as frequencies and percentages (n, %). The Mann-Whitney U test and the Kruskal-Wallis test were used to compare scores between groups. Spearman correlation analysis was used to assess the relationships between the KAP dimensions. Multivariable logistic regression was performed to identify factors associated with KAP scores, which were dichotomised at the median. Variables with p<0.10 in univariate logistic regression were included in the multivariable models. A two-sided p<0.05 was considered statistically significant.

742 valid questionnaires were included in the final analysis (effective response rate 94 %). The majority of respondents were aged 20–50 years (79.3%), and 69.3% had completed college and above. Adult women had insufficient knowledge (median 19, IQR 14–23) positive attitudes (median 37, IQR 34–39) and proactive practices (median 30, IQR 27–33) ( table 1 ). Data are presented as frequency (percentage) for categorical variables and median (IQR) for KAP scores due to non-normal distribution. P values were calculated using the Mann-Whitney U test for comparisons between two groups and the Kruskal-Wallis H test for comparisons among three or more groups. p<0.05 was considered statistically significant. KAP, knowledge, attitude and practice. In the knowledge dimension, participants showed high awareness of MGH as a benign condition (61.2%) and its association with breast nodules (67.5%). A large proportion correctly identified family history (68.9%) and irregular menstruation (68.3%) as risk factors. Recognition was high for symptoms such as breast tenderness (83.2%) but low for breast redness and swelling (37.5%). Participants were knowledgeable about breast ultrasound (67.8%) and mammography (55.0%) as examination methods, and recognised early detection (76.1%) and early diagnosis and treatment (75.9%) as crucial roles of regular physical examinations. However, awareness of self-breast examination remained limited (39.8%). Finally, participants acknowledged preventive measures like maintaining a happy mood (86.4%) and engaging in moderate exercise (72.9%), and saw regular check-ups (75.2%) and stress relief through communication (67.7%) as beneficial habits for MGH patients ( online supplemental table 1 ). Participants’ views on the relationship between MGH and breast cancer varied, with 41.2% considering it very close. Concerns about having MGH were expressed by 47.0% of participants. Moreover, 31.4% believed that MGH has little impact on health. About 47.2% did not think that breast self-examination could prevent MGH. The importance of breast screening was recognised by 67.1% of participants. If diagnosed with MGH, 87.6% were inclined to seek a cure. Additionally, 45.1% somewhat agreed that MGH could be cured. The influence of family history was evident, with 68.5% indicating they would pay more attention to breast health in such cases. Stress and anxiety were relatively prevalent, with 49.9% experiencing it in daily life. The likelihood of getting angry or agitated was moderate, with 52.2% indicating it happens sometimes ( online supplemental table 2 ). Participants’ daily routines varied, with 51.6% reporting mostly regular practices. Regarding diet, 52.8% maintained a mostly regular diet. Monitoring of the menstrual cycle was less frequent, with 34.0% indicating they keep track occasionally. The use of contraceptive pills was infrequent, with 65.3% never having taken them. Smoking and alcohol consumption were relatively rare, with 60.3% reporting they rarely or never engage in these habits. Consumption of barbecue or fried chicken was moderate, with 57.4% indicating they eat them occasionally. Regular participation in physical exercises was reported by 43.4%. Maintaining a good mood in daily life was relatively common, with 55.7% reporting they could mostly do so ( online supplemental table 3 ). Spearman correlation analysis indicated weak positive correlations between practice scores and both knowledge (r=0.137, p<0.001) and attitude (r=0.152, p<0.001). No significant correlation was observed between knowledge and attitude scores (r=0.022, p=0.558) ( table 2 ). Data are presented as Spearman correlation coefficients (r) followed by p values in parentheses. p<0.05 was considered statistically significant. In the multivariable logistic analysis for knowledge, several factors significantly influenced knowledge scores. Compared with medical work, all other occupational categories (student, education work, company employee, physical labour, retired, other) showed significantly lower knowledge (ORs ranging from 0.243 to 0.511). Divorced adult women demonstrated significantly lower knowledge (OR=0.222, 95% CI 0.068 to 0.728, p=0.013). Furthermore, having family members with breast hyperplasia (OR=0.549, 95% CI 0.344 to 0.874, p=0.011) or being uncertain about it (OR=0.496, 95% CI 0.297 to 0.831, p=0.008), as well as not having had a breast examination (OR=0.535, 95% CI 0.354 to 0.809, p=0.003) or being uncertain about it (OR=0.198, 95% CI 0.051 to 0.780, p=0.021), were significantly associated with lower knowledge ( figure 2A ; online supplemental table 4 ). For Attitude, no statistically significant factors were identified in the multivariable logistic regression model ( online supplemental table 5 ). For practice, not having undergone a prior breast examination was significantly associated with a lower practice (OR=0.664, 95% CI 0.466 to 0.947, p=0.024) ( figure 2B ; online supplemental table 6 ).

Women’s health is a cornerstone of global public health, and breast health represents a critical component across their lifespan. Mammary gland hyperplasia (MGH), a common type of benign breast disease, is widely prevalent among women and often presents with symptoms such as breast pain, palpable nodules and discomfort, thereby imposing both physical and psychological burdens. Despite its benign nature, recent epidemiological and cohort studies have demonstrated that MGH and other proliferative benign breast diseases are associated with an increased long-term risk of breast cancer, particularly among women with high mammographic breast density or proliferative histological features. 1 3 Furthermore, large-scale epidemiological research has shown that age, reproductive history, hormonal exposure and genetic predisposition are associated with the occurrence of MGH. 3 4 Early detection of MGH is clinically important, as its common manifestations, such as breast pain and palpable lumps, often resemble those of breast cancer. 5 In the absence of adequate knowledge, women may either experience unnecessary anxiety by mistaking benign symptoms for malignancy, or conversely, neglect early warning signs, thereby delaying appropriate medical evaluation. 6 Early identification of MGH therefore plays a crucial role not only in confirming benign disease, but also in facilitating differential diagnosis and excluding potential malignant conditions. In addition, the management of MGH relies largely on long-term lifestyle modification and psychological regulation rather than pharmacological treatment alone. 7 Insufficient understanding of treatment and management strategies may lead to poor adherence, recurrent symptoms, excessive medical interventions or persistent psychological distress. The knowledge, attitudes and practices (KAP) model is a valuable tool for assessing public health literacy. 8 9 It is frequently applied to identify knowledge gaps, attitudinal barriers and behavioural patterns, thereby providing crucial evidence to inform the design of effective health education interventions. 10 12 While the clinical and pathological aspects of MGH are well documented, 13 systematic investigations into the KAP of the general adult female population in mainland China remain limited. 14 16 Understanding women’s perceptions and attitudes towards MGH can help healthcare professionals establish effective communication, deliver personalised medical care and issue tailored health recommendations. Therefore, this study aimed to investigate the KAP towards MGH among adult women in Shandong province, a populous and representative region of China. Based on existing literature and the KAP theoretical framework, we hypothesised that adult women would demonstrate insufficient knowledge but relatively positive attitudes and practices regarding MGH, and that higher knowledge and more positive attitudes would be associated with better health practices.

This study identified several key findings regarding KAP towards MGH among adult women in Shandong province. Overall, participants demonstrated insufficient knowledge, despite generally positive attitudes and proactive health practices. In addition, weak but statistically significant positive correlations were observed between knowledge and practice, as well as between attitude and practice, whereas no significant association was found between knowledge and attitude. These findings highlight a notable knowledge–practice gap and provide an important basis for interpreting subgroup differences and associated factors identified in subsequent analyses. Our findings that adult women in Shandong province demonstrated relatively low levels of maternal and child healthcare knowledge but overall positive attitudes and proactive health practices are consistent with other studies examining women’s health knowledge in China and internationally. For example, Chinese reproductive-age women showed insufficient knowledge and suboptimal practice levels toward uterine adenomyosis, indicating gaps in gynaecological health awareness among women. 21 Similarly, studies of cervical precancerous lesion awareness among women in Beijing have documented limited knowledge despite generally favourable attitudes toward screening. 22 Globally, systematic reviews of women’s KAP regarding breast cancer screening reveal widespread poor awareness, though attitudes toward early detection are often positive. 23 Comparable trends have been reported in other contexts, such as women’s knowledge of cardiovascular disease risk and its association with positive health attitudes 24 and limited breast and cervical cancer awareness in rural African settings. 25 Together, this evidence suggests that while women may exhibit limited health knowledge across diverse health issues, positive attitudes often coexist and could be leveraged through targeted education to improve health behaviours and outcomes. Regarding knowledge, the participants displayed a reasonable understanding of MGH as a benign condition and its association with breast nodules. They also recognised certain risk factors, such as family history and irregular menstruation. However, there was limited awareness of self-breast examination, a critical component of early detection. Additionally, a proportion of participants incorrectly identified chemotherapy as a treatment option for MGH. This indicates a potential confusion among women between the management of benign breast conditions and malignant breast cancer, thereby highlighting gaps in disease-specific knowledge. The limited awareness of self-breast examination observed in this study is consistent with broader findings that indicate a lack of breast self-examination knowledge and adherence among women in developing countries, emphasising the need for targeted educational efforts to promote this essential practice. 26 27 The study found diverse attitudes among participants towards MGH, with a notable proportion expressing concerns about having the condition. A considerable number of participants did not believe that breast self-examination was beneficial for MGH; however, breast self-examination is not intended to prevent the condition, but rather to facilitate early detection and timely medical evaluation, which may support earlier diagnosis and appropriate management. The variations in attitudes towards MGH observed in this study are consistent with the complex interplay of cultural, social and individual factors that influence health behaviours. Existing research has highlighted the significance of cultural norms, social support and perceived risk as crucial determinants of health-related attitudes. 28 30 Therefore, culturally tailored interventions are essential to address attitudes towards preventive practices effectively. Furthermore, the substantial concern expressed by a significant proportion of participants about having MGH underscores the emotional impact of health-related conditions. This finding emphasises the need for psychosocial support and counselling services. 29 31 Emotional responses to health-related conditions can significantly influence decision-making and adherence to health practices. Thus, integrating psychosocial support in healthcare settings is crucial to better address the emotional needs of adult women facing health-related concerns like MGH. 32 33 Positive practices included maintaining a regular diet and exercise routine, while less common practices involved regular breast examination and menstrual cycle monitoring among women of reproductive age; however, this finding should be interpreted with caution, as a substantial proportion of participants were aged 46 years or older and may have been perimenopausal or postmenopausal, for whom menstrual cycle monitoring is no longer applicable. These results emphasise the importance of promoting healthy habits and preventive measures related to breast health. The variation in breast health practices reflects the complexity of behaviour change, with different age groups showing varying levels of engagement in preventive practices. Targeted interventions for specific life stages may lead to more significant improvements in health behaviours. The lower frequency of breast examination and menstrual cycle monitoring aligns with findings indicating barriers to preventive practices, such as limited knowledge, time constraints and inadequate access to healthcare services. Several studies have reported these barriers, highlighting the need for targeted interventions to address and overcome them. 34 35 The observed associations among KAP provide further insight into this discrepancy. Although higher knowledge and more positive attitudes were both associated with better practices, these correlations were weak in magnitude, suggesting that improved knowledge alone may not be sufficient to drive behavioural change. Moreover, the absence of a significant correlation between knowledge and attitude indicates that awareness of MGH does not necessarily translate into positive perceptions or concern. These findings are consistent with the KAP theoretical framework and underscore the need for interventions that simultaneously address cognitive, attitudinal and behavioural components. 8 9 From a behavioural perspective, these findings can be interpreted within frameworks such as the health belief model, which suggests that health behaviours are influenced not only by knowledge, but also by perceived susceptibility, perceived severity, perceived benefits and perceived barriers. In this context, limited knowledge may fail to translate into behavioural change if perceived risk or perceived benefits of action remain low, helping to explain the weak associations observed between KAP. These patterns are in line with previous KAP studies in Chinese women, such as research on KAP toward breast ultrasound screening, where limited knowledge did not always translate into improved health behaviour and attitude often played a more significant mediating role between knowledge and practice. In that study, although overall attitudes and practices were relatively high, the association between knowledge and behavioural practice remained modest, highlighting the complex interplay of cognitive and behavioural determinants in preventive health actions. 36 The results of the study unveil significant disparities across various demographic groups concerning KAP, which represent key influencing factors further examined through multivariable logistic regression analysis. Notably, the observed discrepancy between knowledge and practice among different age groups is particularly noteworthy. Conventionally, younger adult women are presumed to have better access to education and health information, potentially translating into higher knowledge levels. 37 However, the study’s finding that older women exhibit better practice scores despite potentially lower knowledge levels challenges this assumption. This may be attributed to the cumulative life experience and greater healthcare system exposure in older women, which fosters an understanding of proactive health behaviours and establishes stronger preventive routines. Furthermore, passive education during clinical breast examinations critically determines health practices. These examinations provide direct counselling and serve as prompts for regular self-examination, thereby increasing awareness and promoting proactive behaviours. The association between reproductive experience, particularly breastfeeding history, and breast health practices merits attention. Breastfeeding confers numerous health benefits, including reducing the risk of breast cancer and promoting breast health among mothers. 38 39 Adult women with reproductive experience, especially those who have breastfed, may possess heightened awareness and knowledge of breast health due to their personal experiences and exposure to breastfeeding-related healthcare information. Furthermore, the act of breastfeeding may foster a deeper connection with one’s own breast health, prompting adult women to prioritise regular self-examinations and preventive healthcare practices. Consequently, reproductive milestones such as breastfeeding present a key opportunity for targeted health education. Integrating breast health initiatives into breastfeeding support programmes could synergistically enhance both awareness and practice, thereby improving long-term health outcomes for women of childbearing age. The multivariate logistic regression analysis provided insights into the factors influencing KAP. For example, certain occupational groups, such as medical workers, showed higher knowledge scores, likely due to their professional exposure. Conversely, certain demographic factors, such as being divorced and not having direct family members with MGH, were associated with better knowledge, suggesting the potential influence of personal experiences and awareness. These findings are consistent with existing research that indicates how occupation and professional exposure can significantly impact health-related knowledge and practices. The higher knowledge scores among medical workers in this study align with previous findings, emphasising the influence of occupational knowledge and experiences on health behaviours. 40 Additionally, the association between educational level and knowledge about MGH is consistent with prior studies, which have reported that higher education levels are linked to increased health-related knowledge. 41 42 Based on the present findings and existing literature, several targeted interventions may be considered for healthcare providers to improve the management of MGH. First, structured health education programmes focusing on symptom recognition, differential diagnosis and appropriate management strategies could be integrated into routine clinical encounters, particularly during breast examinations and reproductive health visits. 43 Second, healthcare providers may emphasise the role of lifestyle modification and psychological regulation, such as stress management, physical activity and emotional support, as key components of long-term MGH management. 44 45 Third, tailored educational materials delivered through community health services or digital platforms may help bridge the observed knowledge–practice gap, especially among non-medical occupational groups. 46 In addition, workplace-based health promotion programmes may be particularly effective for reaching women in non-medical occupations, while community-based and media-based health campaigns could further enhance the dissemination of accurate breast health information to the general population. 47 48 It should be noted that the effectiveness of these interventions was not directly evaluated in the present study; therefore, these recommendations are informed by prior evidence and should be further validated through interventional research. This study had limitations. first, due to the cross-sectional design of this study, causal relationships between KAP cannot be established and the observed associations should be interpreted with caution. Additionally, the lack of a control group and limited generalisability due to the specific regional focus reduces the broader applicability of the results. Moreover, cultural norms, regional health beliefs and local healthcare accessibility in Shandong province may influence women’s perceptions and behaviours regarding breast health. Therefore, caution is warranted when generalising these findings to women in other regions or cultural settings. Self-reporting and recall biases in the data collection process might also affect the accuracy of the findings. 49 Furthermore, the study does not account for all potential confounding variables and fails to validate the questionnaire used adequately.

This study indicated relatively low knowledge levels regarding MGH among adult women in Shandong province, despite generally positive attitudes and proactive health practices. These findings highlight a clear knowledge–practice gap and underscore the need for more targeted and context-specific health education strategies. From a practical perspective, the results suggest that breast health education should move beyond general awareness campaigns and focus on improving symptom recognition, differential diagnosis and appropriate management, particularly among non-medical occupational groups. The findings may also inform the development of targeted educational and screening initiatives within community and primary healthcare settings in Shandong province, and potentially in other regions with similar demographic and healthcare contexts. Future research should prioritise interventional and longitudinal studies to evaluate the effectiveness of theory-informed educational programmes and to further explore causal pathways linking knowledge, attitudes and health practices.