8 Original article
Effects of a training program about breast cancer and breast self-examination among female students at Taif University Dalia E. Desoukya,b and Azza A. Tahaa,b a Department of Public Health and Community Medicine, College of Medicine and Applied Medical Sciences, Taif University, Taif, Kingdom of Saudi Arabia and bDepartment of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Koom, Egypt
Correspondence to Dalia E. Desouky, PhD, Al Salama Street, 21944 Taif, Kingdom of Saudi Arabia Tel/fax: + 966 537 125 590; e-mail: [email protected]
Received 28 September 2014 Accepted 22 December 2014 Journal of the Egyptian Public Health Association 2015, 90:8–13
Background Breast cancer is the most common type of cancer in Saudi women. It is spreading three times faster in the Kingdom than in other countries. One-third of breast cancers are preventable through healthy life styles. Objective This study aimed to assess the impact of a training program on breast cancer and breast self-examination (BSE) among female students at Taif University. Participants and methods This study was carried out using a pre–post test design on a sample of female university students from seven colleges in Taif University (Faculty of Science, Faculty of Economics and Management, Faculty of Art, Faculty of Education, Faculty of Medicine, Faculty of Pharmacy, and the Faculty of Applied Medical Sciences) in the academic year 2012–2013. Results None of the participants had ever practiced BSE before training, and only 16% of them believed that BSE is necessary, whereas 8.7% were willing to teach others BSE. There was limited knowledge of breast cancer. After the training program, a significant improvement was observed in all knowledge items, and 83.6% of the students practiced BSE compared with 0% practice before training. Conclusion This study showed the effectiveness of the intervention program in improving students’ knowledge of breast cancer and their practice of BSE. Thus, campaigns focusing on females in this age group should be carried out in the Saudi society. Keywords: attitude, breast cancer, breast self-examination, knowledge, practices, training program J Egypt Public Health Assoc 90:8–13 & 2015 Egyptian Public Health Association 0013-2446
Introduction The incidence of and mortality caused by breast cancer (BC) are increasing in most countries of Africa and Asia [1]. In the eastern Mediterranean region, BC is reported to be the most common type of female malignancy in almost all national cancer registries [2]. In Saudi Arabia, breast cancer ranked first among females accounting for 25.1% of all newly diagnosed female cancers (1308 female breast cancer cases) in 2009 [3]. Educational programs play an important role in BCpreventive behavior, and educational interventions have a positive impact on the knowledge, practices, early detection, and health beliefs related to BC [4]. Health education activities are more effective among younger groups such as students as they show a more positive attitude toward health education on BC and early screening [5].
tries, BSE remains a method of choice for early detection of BC because of resource constraints [8]. Unfortunately, there are few studies on the awareness of BC and the practice of BSE among Arab women and point to a lack of knowledge of BC among women [9]. In the Kingdom of Saudi Arabia, several studies have shown a low level of knowledge of BC and a low rate of practicing BSE [10–12]. The aim of this study was to test the effects of a training program on the knowledge, attitude, and practice of BSE in Saudi students of Taif University to raise the awareness among the students of BC and to encourage them to practice BSE.
Participants and methods Study design and setting
Early detection of BC provides women with more treatment choices and a greater chance of long-term survival [6]. Breast self-examination (BSE) is a simple, noninvasive screening method [7]. In developing coun0013-2446 & 2015 Egyptian Public Health Association
This study was carried out using a pre–post test design on a sample of female students of Taif University. This was carried out during the period from October 2012 to March 2013. DOI: 10.1097/01.EPX.0000460082.28774.71
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Training program on breast cancer Desouky and Taha 9
Sampling
The target population included all female students of the seven colleges of Taif University from the first grade. The Faculty of Applied Medical Sciences of Taif University (female section) has initiated a health awareness campaign on BC and BSE among female university students. The campaign was conducted in the following faculties: the Faculty of Science, Faculty of economics and management, Faculty of Art, Faculty of Education, Faculty of Medicine, Faculty of Pharmacy, and the Faculty of Applied Medical Sciences. The aim of the campaign was to raise awareness among the students of BC and BSE, and to encourage them to practice BSE. According to the office of the student’s affairs, the total number of female students registered in the seven colleges in the academic year 2012–1213 was 1893. After excluding nonrespondents, the response rate was 89.64%. The total number of participants in the study was 1697, including 157 students from the Faculty of Medicine, 153 students from Faculty of Pharmacy, 162 students from Faculty of Applied Medical Sciences, 311 students from Faculty of Science, 326 students from Faculty of Economics and Management, 298 students from Faculty of Art, and 290 students from the Faculty of Education. Official approvals were obtained from the Scientific Research Committee of Taif University and from the deanships of the colleges included in the study. After a verbal consent was obtained from the respondent students, they completed the questionnaires. The study was carried out in three phases: first, the preintervention phase; second, the intervention phase; and third, the postintervention phase. In the first phase, the study tool used was a predesigned questionnaire that contained questions on family history of BC, knowledge of risk factors (12 questions), warning signs (five questions), screening methods (four questions), and sources of information (eight questions), in addition to questions on their attitudes toward BSE (two questions) and a single question on the practice of BSE. The answer choices for knowledge were true or false. The attitude of the participants toward BSE was assessed using a two-item scale: agree or disagree. The practice of BSE was also assessed using a two-item scale: yes or no. None of the participants practiced BSE before the intervention; thus, practice assessment was postponed to the third phase. In the second phase, an educational and a practical session were carried out on 1 day in the main theater of each faculty. Students were classified into four main groups according to the academic list obtained from the administrative office of each college. One group attended the educational session and another group attended the practical session at the same time. This was organized by the administrative staff of each faculty, who informed students where they would receive training. The educational method used was a lecture (for 45 min) including a slide show. Diagrams were used to show methods of performing BSE including areas of the breast to be examined and how to move the fingers over the breast.
In all colleges, the lecture was in the Arabic language, except the three colleges of applied medical sciences (Medicine, Pharmacy, and Nursing), where the lecture was in the English language. The lecture covered items on risk factors and methods of prevention of BC, the benefits of BSE, clinical examinations, and mammography screening. In addition, pamphlets illustrating the signs, symptoms, risk factors of BC, importance of its early detection by BSE, and positions and procedures of BSE were distributed to all students. Students were then asked to attend the practical session for 15–20 min, where each group was divided into a maximum of 10 participants. The practical application session was carried out using three different sizes of breast models (with and without breast lump) as simulation methods. This was done by eight trained medical college staff who had received comprehensive education on BC and BSE, and were trained on BSE practice through a training session at the Faculty of Medicine. The third phase was carried out 6 months after conducting the health education program using a posttest questionnaire with the same knowledge and attitude items as in the pretest questionnaire. The practice of BSE was assessed using three questions on the frequency, timing, and positions of practice. The questionnaire included the steps of BSE when looking at the mirror, lying down, and when having shower. The responses for the questionnaire items were done and not done. Finally, a question on barriers to BSE was added for those not practicing BSE. Statistical analysis
The data were coded, tabulated, and analyzed using the statistical package for the social sciences (SPSS, version 20; IBM Corp., Armonk, New York, USA). Qualitative data were expressed as numbers and percentages, and the w2-test was used to test the relationship between variables. Qualitative variables were compared before and after training using McNemar test. All these tests used tests of significance at a 5% level.
Results Table 1 shows that less than 50% of the participants failed to provide correct answers for all questions on risk factors, except for the family history (59%). However, there was a significant improvement in all knowledge items of risk factors after the intervention phase. Table 2 shows that in the intervention phase, changes in the shape of the breast and the presence of a breast lump were the most commonly known signs of BC among the participants; a few participants mentioned skin changes, nipple retraction, and nipple discharge as early warning signs. Clinical examination was the most known screening method for BC, followed by mammography BSE, biopsy, and ultrasound. Only 16.4% of the participants mentioned the necessity of BSE, and only 8.7% were willing to teach others how to perform it. A significant improvement was observed in the participants’ knowl-
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10 Journal of the Egyptian Public Health Association
edge on all items of BC signs and screening methods in the post-test. In addition, 81.1% of the participants reported that BSE is necessary and 66.9% were willing to teach others the method of BSE. Table 3 shows an improvement in the participants’ attitude after the intervention program as 81.1% believed that BSE is necessary compared with 16.4% before the intervention and 66.9% of the participants were willing to teach others BSE after the intervention compared with 8.7% before the intervention. Table 4 shows that in the postintervention phase, 68.2% of the students reported practicing BSE at any time, whereas only 14.9% practiced it in the proper time after menstruation. This table shows that most of the students practiced all items of BSE in the three positions correctly after the intervention program. Figure 1 shows that the most common sources of information on BC were TV and radio, mentioned by 62% of the participants, and the least common source was friends (1.3%) and family physicians (0.9%). Figure 2 shows that after the training program, 83.6% of students mentioned practicing BSE on a monthly basis. Figure 3 shows that on asking about barriers toward BSE, 39.9% of those who did not practice it reported forgetfulness as the main barrier, followed by fear of discovering a breast lump (24.8%), laziness (16.9%), lack of time (7.6%), dislike to touch her breast (6.1%), and not being at risk (4.7%). Table 1. Comparison of preintervention and postintervention knowledge of risk factors of breast cancer among female students at Taif University Knowledge of risk factors
Pretest (%)
Post-test (%)
P-value
Family history Early menarche No breast feeding Late menopause 1st child birth430 years Infertility Obesity Hormonal contraceptives Radiation Other breast cancer Ovarian cancer Old age
59 7.9 11.5 8.3 7.4 11.6 19 20.8 25.2 15.5 22.3 47.2
87.8 63.3 51.5 63.7 47.8 49.9 51.5 41.6 54.4 49.7 37.2 89.1
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
Figure 4 shows that a significant relationship was found between BSE practice and the presence of a family history of BC (P = 0.028).
Discussion In terms of the knowledge of the participants on the risk factors of BC, the present work showed a low level of knowledge among the participants in the preintervention phase (Table 1). This unsatisfactory knowledge level has been reported in other Saudi studies [5,9]. The highest knowledge level of risk factors of BC was for family history and old age, a result that is in consistence with that observed in Saudi studies carried out on students [9,13–15]. In contrast to these results are those obtained in another Saudi study [16], where the most frequently known risk factors among the participants were non-breast-feeding and the use of female sex hormones. This can be attributed to the older age of the participants in this study, being female teachers, and the young age of our participants, being female students, and being the first time to carry out this awareness campaign in Taif University. The lowest knowledge level was related to early menarche and having the first child after the age of 30 years, a result that was also found in a previous Saudi study [16]. A significant improvement in the knowledge of risk factors has been reported after the intervention phase (Table 1) in other studies that used an educational intervention program [17]. In this work, changes in the shape of the breast and the presence of a breast lump were the most commonly known signs of BC in the preintervention phase (Table 2). This is in agreement with a study carried out in UK, where 70% of women mentioned painless lump as a sign of BC [18]. However, another Saudi study reported results that were not in agreement with ours. In that study, swelling in the skin/axilla and skin changes were reported by 59.9% and 49.7% of the respondents respectively as the most common early warning signs of BC [13]. A few of the participants reported skin changes, nipple retraction, and nipple discharge as early warning signs. This is consistent with the results of another study carried out on university Students in the Al Madina Al Munawara region [13]. The significant improvement in
Table 2. Participants’ knowledge of signs and screening methods of breast cancer Knowledge items Knowledge of warning signs of breast cancer Presence of a lump Nipple retraction Change in the shape of the breast Nipple discharge Change in the breast skin Knowledge of screening methods BSE Mammography Ultrasound Clinical examination Biopsy BSE, breast self-examination.
Pretest (%)
Post-test (%)
P-value
73.8 12.7 44.5 29.3 16.9
91.3 42.6 87.0 69.1 84.9
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
17.4 21.0 13.8 75.8 15.6
90.2 88.7 88.2 84.9 78.5
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
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Training program on breast cancer Desouky and Taha 11
Table 3. Attitude of the participants towards breast self-examination Pretest (%)
Post-test (%)
P-value
16.4 8.7
81.1 66.9
o0.0001 o0.0001
62
ds ph ys ici an s
en
rn e
t
rs
fri
te in
ily
ily
fam
fam Figure 2.
83.6% 90 80 70 60 50 40 30 20 10 0
16.4%
Yes
No
Participants’ practice of breast self-examination after the educational program.
Figure 3.
39.9 40 35 30 25 20 15 10 5 0
24.8 1.9
tr ga
no
tb
ein
ch to u to
sli
ke
isk
st br ea
tim of ck La
4.7
di
fd ro Fe a
6.1
e
s es laz in
p um
ov er in
gl
ln es s
7.6
isc
In terms of knowledge of screening methods of BC, clinical examination was the most commonly known screening method for BC (Table 2). This finding is in agreement with studies that showed a low level of knowledge on screening methods of BC among compar-
0.9
1.3
Distribution of the participants according to their source of knowledge of breast cancer.
fo r
the participants’ knowledge of BC signs after the intervention phase is in line with studies that showed the effectiveness of health education in improving the knowledge of participating females on early signs of BC [19,20].
1.8
2.5
em be
re s
es
29
m
T.V
10.9
lec tu
az in
&
ra di o
17.
bo ok s
70 60 50 40 30 20 10 0
ge tfu
Frequency of BSE after training Don’t remember 897 (63.2) Monthly 522 (36.8) Practicing time Any time 968 (68.2) Before menstruation 87 (6.1) During menstruation 153 (10.8) After menstruation 211 (14.9) Practicing position In mirror 826 (58.3) During shower 315 (22.2) Lying down 174 (12.3) 3 methods 104 (7.3) When looking at the mirror Look at breasts with arms raised over the head Done 1234 (86.9) Not done 185 (13.1) Look at breast with hands on the thigh Done 1309 (92.2) Not done 110 (7.8) When in lying down position Place a towel or a pillow under the shoulder before examining the breast on that side Done 948 (66.8) Not done 471 (33.2) Place hand above the head before examining breasts on that side Done 1257 (88.5) Not done 126 (11.5) When having shower Start by raising an arm behind her head Done 1336 (94.1) Not done 83 (5.9) Use soapy hand to press firmly on the breast against the chest wall Done 1372 (96.6) Not done 47 (3.4) Using hand pad during examination (fingers are flat together and examination is done in a circular motion) Done 1332 (93.9) Not done 87 (6.1) Using the right hand to examine the left breast and vice versa Done 1411 (99.4) Not done 8 (0.6) Examine one breast at a time Done 1376 (96.9) Not done 43 (3.1) Practice examination in a circular clockwise direction Done 1143 (80.5) Not done 276 (19.5) BSE, breast self-examination.
Percent
N (%) (n = 1697)
Percent
Practices of BSE
Figure 1.
ag
Table 4. Practice of breast self-examination of the participant students after the intervention program
m
Do you think BSE is necessary Are you willing to teach others BSE BSE, breast self-examination.
Percent
Attitudes
Participants’ opinions on barriers toward breast self-examination.
able samples of secondary female students and nursing students [5,9]. However, our results are not in agreement with those found in two Saudi studies carried out in Buraidah and Al
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12 Journal of the Egyptian Public Health Association
women referred to health centers and in India on women from a semiurban area [29,31].
Figure 4.
95.6 83.3 100
Percent
80 60 16.7
40
4.4
20 0
Yes BSE Yes FH
No BSE No FH
Relationship between breast self-examination (BSE) practice and a family history (FH) of breast cancer (w2 = 4.8, P = 0.028).
Madina Al Munawara; BSE was the most commonly known screening method in the first study [16] and mammogram was the most commonly known screening method in the second study [13]. A significant improvement in participants’ knowledge of the methods of screening of BC was also found in another study that conducted health education programs for university students [21]. About two-thirds (62%) of the participants reported that their main sources of information on BC were the radio and TV (Fig. 1). This is in agreement with other studies carried out in Saudi Arabia and other developing countries [16,22–25]. In another Saudi study, the print media were the main source of information [16]. These results indicate that sources of information should be taken into consideration when carrying out health awareness campaigns in the Saudi society. The participants showed a negative attitude toward BSE in the preintervention phase (Table 3). This negative attitude was noted in other studies carried out in Nigeria in 2009 and Iraq in 2012 [15,25]. The encouraging attitude expressed by the participants after the interventional program was also found in studies carried out on females from different age groups in Saudi Arabia and other countries [5,26–29]. Surprisingly, the present study showed that none of the participant students had ever practiced BSE in the preintervention phase. This alarming result is in agreement with two studies carried out in India, where only one participant reported practicing BSE in the first study and none of them had ever practiced BSE in the second study [30,31]. This result is in contrast to many studies carried out in Saudi Arabia and other Arab and foreign countries that reported higher rates of BSE practice among women of all ages [11,13,16,23,27,32]. This result can be attributed to the low level of knowledge of BC and BSE found in this study and to the young age of the participants as the practice of BSE is more frequently associated with older age [33]. The high rate of BSE practice (83.6%) after the training program (Fig. 2) was also observed in two other studies carried out in Iran on
In the postintervention phase, 68.2% of the students reported practicing BSE at any time. The high result of wrong practicing time was also found in a Nigerian study [32]. According to the practice method, the vast majority (93.9%) of the students used their hand pad BSE (Table 4). Our result is not in agreement with those found in other studies, where the students used their finger tips for examination [25,32]. However, the high level of correct practice observed after training was also found in studies that used interventional educational programs [17,32]. The same result of high levels of correct practice was reported by an Egyptian study after an interventional training program [34]. In terms of barriers toward BSE, forgetfulness was the main barrier reported by the participants who did not practice BSE (Fig. 3). This was in agreement with other studies where forgetfulness was reported as the main barrier [24,28,35]. The second barrier was fear of discovering a breast lump (24.8%), a result that was reported in other studies [27,35]. In the present work, a significant relationship was found between BSE practice and having a family history of BC (Fig. 4), which is in line with studies that concluded that the experience of others or oneself with BC makes women more concerned about their health, breast diseases, and BSE [36,37]. The improvement in the knowledge and attitude of the participants toward BC and BSE observed after our intervention program was also reported in other studies that used the same method [28,29,38,39]. Study limitations
One of the limitations of the study was that the effect of the intervention program was assessed 6 months after it was conducted; thus results reported on the immediate effect, which may or may not be sustained. Reinforcement methods to remind students of the importance of regular practice of BSE were not used. Another limitation was that the university students had the same educational level; thus, the effect of education on the knowledge of BC and practice of BSE was not assessed.
Conclusion and recommendations The study showed the effectiveness of an intervention training program in improving students’ knowledge of BC and their practice of BSE. Thus, campaigns focused on females in this age group should be carried out in the Saudi society using the positive attitude of the participants observed in many Saudi studies to improve their awareness of this fatal disease.
Acknowledgements The researchers gratefully acknowledge the support provided by the Faculty of Applied Medical Sciences and all colleges in the study. They also thank all the students who kindly participated in this work.
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Training program on breast cancer Desouky and Taha 13
Conflicts of interest There are no conflicts of interest.
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Effects of a training program about breast cancer and breast self-examination among female students at Taif University Dalia E. Desoukya,b and Azza A. Tahaa,b a Department of Public Health and Community Medicine, College of Medicine and Applied Medical Sciences, Taif University, Taif, Kingdom of Saudi Arabia and bDepartment of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebeen El-Koom, Egypt
Correspondence to Dalia E. Desouky, PhD, Al Salama Street, 21944 Taif, Kingdom of Saudi Arabia Tel/fax: + 966 537 125 590; e-mail: [email protected]
Received 28 September 2014 Accepted 22 December 2014 Journal of the Egyptian Public Health Association 2015, 90:8–13
Background Breast cancer is the most common type of cancer in Saudi women. It is spreading three times faster in the Kingdom than in other countries. One-third of breast cancers are preventable through healthy life styles. Objective This study aimed to assess the impact of a training program on breast cancer and breast self-examination (BSE) among female students at Taif University. Participants and methods This study was carried out using a pre–post test design on a sample of female university students from seven colleges in Taif University (Faculty of Science, Faculty of Economics and Management, Faculty of Art, Faculty of Education, Faculty of Medicine, Faculty of Pharmacy, and the Faculty of Applied Medical Sciences) in the academic year 2012–2013. Results None of the participants had ever practiced BSE before training, and only 16% of them believed that BSE is necessary, whereas 8.7% were willing to teach others BSE. There was limited knowledge of breast cancer. After the training program, a significant improvement was observed in all knowledge items, and 83.6% of the students practiced BSE compared with 0% practice before training. Conclusion This study showed the effectiveness of the intervention program in improving students’ knowledge of breast cancer and their practice of BSE. Thus, campaigns focusing on females in this age group should be carried out in the Saudi society. Keywords: attitude, breast cancer, breast self-examination, knowledge, practices, training program J Egypt Public Health Assoc 90:8–13 & 2015 Egyptian Public Health Association 0013-2446
Introduction The incidence of and mortality caused by breast cancer (BC) are increasing in most countries of Africa and Asia [1]. In the eastern Mediterranean region, BC is reported to be the most common type of female malignancy in almost all national cancer registries [2]. In Saudi Arabia, breast cancer ranked first among females accounting for 25.1% of all newly diagnosed female cancers (1308 female breast cancer cases) in 2009 [3]. Educational programs play an important role in BCpreventive behavior, and educational interventions have a positive impact on the knowledge, practices, early detection, and health beliefs related to BC [4]. Health education activities are more effective among younger groups such as students as they show a more positive attitude toward health education on BC and early screening [5].
tries, BSE remains a method of choice for early detection of BC because of resource constraints [8]. Unfortunately, there are few studies on the awareness of BC and the practice of BSE among Arab women and point to a lack of knowledge of BC among women [9]. In the Kingdom of Saudi Arabia, several studies have shown a low level of knowledge of BC and a low rate of practicing BSE [10–12]. The aim of this study was to test the effects of a training program on the knowledge, attitude, and practice of BSE in Saudi students of Taif University to raise the awareness among the students of BC and to encourage them to practice BSE.
Participants and methods Study design and setting
Early detection of BC provides women with more treatment choices and a greater chance of long-term survival [6]. Breast self-examination (BSE) is a simple, noninvasive screening method [7]. In developing coun0013-2446 & 2015 Egyptian Public Health Association
This study was carried out using a pre–post test design on a sample of female students of Taif University. This was carried out during the period from October 2012 to March 2013. DOI: 10.1097/01.EPX.0000460082.28774.71
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Training program on breast cancer Desouky and Taha 9
Sampling
The target population included all female students of the seven colleges of Taif University from the first grade. The Faculty of Applied Medical Sciences of Taif University (female section) has initiated a health awareness campaign on BC and BSE among female university students. The campaign was conducted in the following faculties: the Faculty of Science, Faculty of economics and management, Faculty of Art, Faculty of Education, Faculty of Medicine, Faculty of Pharmacy, and the Faculty of Applied Medical Sciences. The aim of the campaign was to raise awareness among the students of BC and BSE, and to encourage them to practice BSE. According to the office of the student’s affairs, the total number of female students registered in the seven colleges in the academic year 2012–1213 was 1893. After excluding nonrespondents, the response rate was 89.64%. The total number of participants in the study was 1697, including 157 students from the Faculty of Medicine, 153 students from Faculty of Pharmacy, 162 students from Faculty of Applied Medical Sciences, 311 students from Faculty of Science, 326 students from Faculty of Economics and Management, 298 students from Faculty of Art, and 290 students from the Faculty of Education. Official approvals were obtained from the Scientific Research Committee of Taif University and from the deanships of the colleges included in the study. After a verbal consent was obtained from the respondent students, they completed the questionnaires. The study was carried out in three phases: first, the preintervention phase; second, the intervention phase; and third, the postintervention phase. In the first phase, the study tool used was a predesigned questionnaire that contained questions on family history of BC, knowledge of risk factors (12 questions), warning signs (five questions), screening methods (four questions), and sources of information (eight questions), in addition to questions on their attitudes toward BSE (two questions) and a single question on the practice of BSE. The answer choices for knowledge were true or false. The attitude of the participants toward BSE was assessed using a two-item scale: agree or disagree. The practice of BSE was also assessed using a two-item scale: yes or no. None of the participants practiced BSE before the intervention; thus, practice assessment was postponed to the third phase. In the second phase, an educational and a practical session were carried out on 1 day in the main theater of each faculty. Students were classified into four main groups according to the academic list obtained from the administrative office of each college. One group attended the educational session and another group attended the practical session at the same time. This was organized by the administrative staff of each faculty, who informed students where they would receive training. The educational method used was a lecture (for 45 min) including a slide show. Diagrams were used to show methods of performing BSE including areas of the breast to be examined and how to move the fingers over the breast.
In all colleges, the lecture was in the Arabic language, except the three colleges of applied medical sciences (Medicine, Pharmacy, and Nursing), where the lecture was in the English language. The lecture covered items on risk factors and methods of prevention of BC, the benefits of BSE, clinical examinations, and mammography screening. In addition, pamphlets illustrating the signs, symptoms, risk factors of BC, importance of its early detection by BSE, and positions and procedures of BSE were distributed to all students. Students were then asked to attend the practical session for 15–20 min, where each group was divided into a maximum of 10 participants. The practical application session was carried out using three different sizes of breast models (with and without breast lump) as simulation methods. This was done by eight trained medical college staff who had received comprehensive education on BC and BSE, and were trained on BSE practice through a training session at the Faculty of Medicine. The third phase was carried out 6 months after conducting the health education program using a posttest questionnaire with the same knowledge and attitude items as in the pretest questionnaire. The practice of BSE was assessed using three questions on the frequency, timing, and positions of practice. The questionnaire included the steps of BSE when looking at the mirror, lying down, and when having shower. The responses for the questionnaire items were done and not done. Finally, a question on barriers to BSE was added for those not practicing BSE. Statistical analysis
The data were coded, tabulated, and analyzed using the statistical package for the social sciences (SPSS, version 20; IBM Corp., Armonk, New York, USA). Qualitative data were expressed as numbers and percentages, and the w2-test was used to test the relationship between variables. Qualitative variables were compared before and after training using McNemar test. All these tests used tests of significance at a 5% level.
Results Table 1 shows that less than 50% of the participants failed to provide correct answers for all questions on risk factors, except for the family history (59%). However, there was a significant improvement in all knowledge items of risk factors after the intervention phase. Table 2 shows that in the intervention phase, changes in the shape of the breast and the presence of a breast lump were the most commonly known signs of BC among the participants; a few participants mentioned skin changes, nipple retraction, and nipple discharge as early warning signs. Clinical examination was the most known screening method for BC, followed by mammography BSE, biopsy, and ultrasound. Only 16.4% of the participants mentioned the necessity of BSE, and only 8.7% were willing to teach others how to perform it. A significant improvement was observed in the participants’ knowl-
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10 Journal of the Egyptian Public Health Association
edge on all items of BC signs and screening methods in the post-test. In addition, 81.1% of the participants reported that BSE is necessary and 66.9% were willing to teach others the method of BSE. Table 3 shows an improvement in the participants’ attitude after the intervention program as 81.1% believed that BSE is necessary compared with 16.4% before the intervention and 66.9% of the participants were willing to teach others BSE after the intervention compared with 8.7% before the intervention. Table 4 shows that in the postintervention phase, 68.2% of the students reported practicing BSE at any time, whereas only 14.9% practiced it in the proper time after menstruation. This table shows that most of the students practiced all items of BSE in the three positions correctly after the intervention program. Figure 1 shows that the most common sources of information on BC were TV and radio, mentioned by 62% of the participants, and the least common source was friends (1.3%) and family physicians (0.9%). Figure 2 shows that after the training program, 83.6% of students mentioned practicing BSE on a monthly basis. Figure 3 shows that on asking about barriers toward BSE, 39.9% of those who did not practice it reported forgetfulness as the main barrier, followed by fear of discovering a breast lump (24.8%), laziness (16.9%), lack of time (7.6%), dislike to touch her breast (6.1%), and not being at risk (4.7%). Table 1. Comparison of preintervention and postintervention knowledge of risk factors of breast cancer among female students at Taif University Knowledge of risk factors
Pretest (%)
Post-test (%)
P-value
Family history Early menarche No breast feeding Late menopause 1st child birth430 years Infertility Obesity Hormonal contraceptives Radiation Other breast cancer Ovarian cancer Old age
59 7.9 11.5 8.3 7.4 11.6 19 20.8 25.2 15.5 22.3 47.2
87.8 63.3 51.5 63.7 47.8 49.9 51.5 41.6 54.4 49.7 37.2 89.1
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
Figure 4 shows that a significant relationship was found between BSE practice and the presence of a family history of BC (P = 0.028).
Discussion In terms of the knowledge of the participants on the risk factors of BC, the present work showed a low level of knowledge among the participants in the preintervention phase (Table 1). This unsatisfactory knowledge level has been reported in other Saudi studies [5,9]. The highest knowledge level of risk factors of BC was for family history and old age, a result that is in consistence with that observed in Saudi studies carried out on students [9,13–15]. In contrast to these results are those obtained in another Saudi study [16], where the most frequently known risk factors among the participants were non-breast-feeding and the use of female sex hormones. This can be attributed to the older age of the participants in this study, being female teachers, and the young age of our participants, being female students, and being the first time to carry out this awareness campaign in Taif University. The lowest knowledge level was related to early menarche and having the first child after the age of 30 years, a result that was also found in a previous Saudi study [16]. A significant improvement in the knowledge of risk factors has been reported after the intervention phase (Table 1) in other studies that used an educational intervention program [17]. In this work, changes in the shape of the breast and the presence of a breast lump were the most commonly known signs of BC in the preintervention phase (Table 2). This is in agreement with a study carried out in UK, where 70% of women mentioned painless lump as a sign of BC [18]. However, another Saudi study reported results that were not in agreement with ours. In that study, swelling in the skin/axilla and skin changes were reported by 59.9% and 49.7% of the respondents respectively as the most common early warning signs of BC [13]. A few of the participants reported skin changes, nipple retraction, and nipple discharge as early warning signs. This is consistent with the results of another study carried out on university Students in the Al Madina Al Munawara region [13]. The significant improvement in
Table 2. Participants’ knowledge of signs and screening methods of breast cancer Knowledge items Knowledge of warning signs of breast cancer Presence of a lump Nipple retraction Change in the shape of the breast Nipple discharge Change in the breast skin Knowledge of screening methods BSE Mammography Ultrasound Clinical examination Biopsy BSE, breast self-examination.
Pretest (%)
Post-test (%)
P-value
73.8 12.7 44.5 29.3 16.9
91.3 42.6 87.0 69.1 84.9
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
17.4 21.0 13.8 75.8 15.6
90.2 88.7 88.2 84.9 78.5
o0.0001 o0.0001 o0.0001 o0.0001 o0.0001
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Training program on breast cancer Desouky and Taha 11
Table 3. Attitude of the participants towards breast self-examination Pretest (%)
Post-test (%)
P-value
16.4 8.7
81.1 66.9
o0.0001 o0.0001
62
ds ph ys ici an s
en
rn e
t
rs
fri
te in
ily
ily
fam
fam Figure 2.
83.6% 90 80 70 60 50 40 30 20 10 0
16.4%
Yes
No
Participants’ practice of breast self-examination after the educational program.
Figure 3.
39.9 40 35 30 25 20 15 10 5 0
24.8 1.9
tr ga
no
tb
ein
ch to u to
sli
ke
isk
st br ea
tim of ck La
4.7
di
fd ro Fe a
6.1
e
s es laz in
p um
ov er in
gl
ln es s
7.6
isc
In terms of knowledge of screening methods of BC, clinical examination was the most commonly known screening method for BC (Table 2). This finding is in agreement with studies that showed a low level of knowledge on screening methods of BC among compar-
0.9
1.3
Distribution of the participants according to their source of knowledge of breast cancer.
fo r
the participants’ knowledge of BC signs after the intervention phase is in line with studies that showed the effectiveness of health education in improving the knowledge of participating females on early signs of BC [19,20].
1.8
2.5
em be
re s
es
29
m
T.V
10.9
lec tu
az in
&
ra di o
17.
bo ok s
70 60 50 40 30 20 10 0
ge tfu
Frequency of BSE after training Don’t remember 897 (63.2) Monthly 522 (36.8) Practicing time Any time 968 (68.2) Before menstruation 87 (6.1) During menstruation 153 (10.8) After menstruation 211 (14.9) Practicing position In mirror 826 (58.3) During shower 315 (22.2) Lying down 174 (12.3) 3 methods 104 (7.3) When looking at the mirror Look at breasts with arms raised over the head Done 1234 (86.9) Not done 185 (13.1) Look at breast with hands on the thigh Done 1309 (92.2) Not done 110 (7.8) When in lying down position Place a towel or a pillow under the shoulder before examining the breast on that side Done 948 (66.8) Not done 471 (33.2) Place hand above the head before examining breasts on that side Done 1257 (88.5) Not done 126 (11.5) When having shower Start by raising an arm behind her head Done 1336 (94.1) Not done 83 (5.9) Use soapy hand to press firmly on the breast against the chest wall Done 1372 (96.6) Not done 47 (3.4) Using hand pad during examination (fingers are flat together and examination is done in a circular motion) Done 1332 (93.9) Not done 87 (6.1) Using the right hand to examine the left breast and vice versa Done 1411 (99.4) Not done 8 (0.6) Examine one breast at a time Done 1376 (96.9) Not done 43 (3.1) Practice examination in a circular clockwise direction Done 1143 (80.5) Not done 276 (19.5) BSE, breast self-examination.
Percent
N (%) (n = 1697)
Percent
Practices of BSE
Figure 1.
ag
Table 4. Practice of breast self-examination of the participant students after the intervention program
m
Do you think BSE is necessary Are you willing to teach others BSE BSE, breast self-examination.
Percent
Attitudes
Participants’ opinions on barriers toward breast self-examination.
able samples of secondary female students and nursing students [5,9]. However, our results are not in agreement with those found in two Saudi studies carried out in Buraidah and Al
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12 Journal of the Egyptian Public Health Association
women referred to health centers and in India on women from a semiurban area [29,31].
Figure 4.
95.6 83.3 100
Percent
80 60 16.7
40
4.4
20 0
Yes BSE Yes FH
No BSE No FH
Relationship between breast self-examination (BSE) practice and a family history (FH) of breast cancer (w2 = 4.8, P = 0.028).
Madina Al Munawara; BSE was the most commonly known screening method in the first study [16] and mammogram was the most commonly known screening method in the second study [13]. A significant improvement in participants’ knowledge of the methods of screening of BC was also found in another study that conducted health education programs for university students [21]. About two-thirds (62%) of the participants reported that their main sources of information on BC were the radio and TV (Fig. 1). This is in agreement with other studies carried out in Saudi Arabia and other developing countries [16,22–25]. In another Saudi study, the print media were the main source of information [16]. These results indicate that sources of information should be taken into consideration when carrying out health awareness campaigns in the Saudi society. The participants showed a negative attitude toward BSE in the preintervention phase (Table 3). This negative attitude was noted in other studies carried out in Nigeria in 2009 and Iraq in 2012 [15,25]. The encouraging attitude expressed by the participants after the interventional program was also found in studies carried out on females from different age groups in Saudi Arabia and other countries [5,26–29]. Surprisingly, the present study showed that none of the participant students had ever practiced BSE in the preintervention phase. This alarming result is in agreement with two studies carried out in India, where only one participant reported practicing BSE in the first study and none of them had ever practiced BSE in the second study [30,31]. This result is in contrast to many studies carried out in Saudi Arabia and other Arab and foreign countries that reported higher rates of BSE practice among women of all ages [11,13,16,23,27,32]. This result can be attributed to the low level of knowledge of BC and BSE found in this study and to the young age of the participants as the practice of BSE is more frequently associated with older age [33]. The high rate of BSE practice (83.6%) after the training program (Fig. 2) was also observed in two other studies carried out in Iran on
In the postintervention phase, 68.2% of the students reported practicing BSE at any time. The high result of wrong practicing time was also found in a Nigerian study [32]. According to the practice method, the vast majority (93.9%) of the students used their hand pad BSE (Table 4). Our result is not in agreement with those found in other studies, where the students used their finger tips for examination [25,32]. However, the high level of correct practice observed after training was also found in studies that used interventional educational programs [17,32]. The same result of high levels of correct practice was reported by an Egyptian study after an interventional training program [34]. In terms of barriers toward BSE, forgetfulness was the main barrier reported by the participants who did not practice BSE (Fig. 3). This was in agreement with other studies where forgetfulness was reported as the main barrier [24,28,35]. The second barrier was fear of discovering a breast lump (24.8%), a result that was reported in other studies [27,35]. In the present work, a significant relationship was found between BSE practice and having a family history of BC (Fig. 4), which is in line with studies that concluded that the experience of others or oneself with BC makes women more concerned about their health, breast diseases, and BSE [36,37]. The improvement in the knowledge and attitude of the participants toward BC and BSE observed after our intervention program was also reported in other studies that used the same method [28,29,38,39]. Study limitations
One of the limitations of the study was that the effect of the intervention program was assessed 6 months after it was conducted; thus results reported on the immediate effect, which may or may not be sustained. Reinforcement methods to remind students of the importance of regular practice of BSE were not used. Another limitation was that the university students had the same educational level; thus, the effect of education on the knowledge of BC and practice of BSE was not assessed.
Conclusion and recommendations The study showed the effectiveness of an intervention training program in improving students’ knowledge of BC and their practice of BSE. Thus, campaigns focused on females in this age group should be carried out in the Saudi society using the positive attitude of the participants observed in many Saudi studies to improve their awareness of this fatal disease.
Acknowledgements The researchers gratefully acknowledge the support provided by the Faculty of Applied Medical Sciences and all colleges in the study. They also thank all the students who kindly participated in this work.
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Training program on breast cancer Desouky and Taha 13
Conflicts of interest There are no conflicts of interest.
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