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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 30-38

The effect of peer education on adolescent students’ knowledge and performance of breast self-examination


1 Department of Women’s Health and Maternity Nursing, Faculty of Nursing, Kafrelsheikh University, Kafr El-Sheikh, Egypt
2 Department of Maternal & Newborn Health Nursing, Faculty of Nursing, Helwan University, Helwan, Egypt

Date of Submission10-Oct-2017
Date of Acceptance30-Jan-2018
Date of Web Publication3-Sep-2018

Correspondence Address:
Hala A El Fttah Ali
Department of Women’s Health and Maternity Nursing, Faculty of Nursing, Kafrelsheikh University, Kafr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_39_17

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  Abstract 


Background Awareness of breast cancer causes and the screening program can help in reduction of morbidity and mortality among women.
Aim The aim of this study was to examine the effect of peer education on adolescent students’ knowledge and performance of breast self-examination (BSE).
Methods A quasi-experimental study (pretest and post-test evaluations) was conducted. The study was conducted at the Faculty of Nursing, Kafrelsheikh University. A convenience sample of all students (260 peer students) from third level of Faculty of Nursing was recruited for the study. The students were divided equally into two groups: group 1 was assigned to individual education and group 2 was assigned to group education. The study was conducted from the first of December 2016 to the end of February 2017. Three tools were used to collect the data: a personal data record, BSE knowledge questionnaire, and BSE performance checklist.
Results Despite the satisfactory knowledge level between the two groups did not differ significantly at baseline evaluation, the satisfactory knowledge level was reported to be more enhanced among the students in the education group than in the individual education group after intervention. The frequency of adequate performance of BSE did not differ significantly between the studied groups at baseline; however, after intervention, the frequency of adequate performance of BSE was significantly higher in the students in the group education group. The level of mother education significantly affected the knowledge and the performance level in the study groups. After intervention, the students with educated mother had significantly higher frequency of satisfactory knowledge level than students with uneducated mother in the individual education group and also in the group education group.
Conclusion The peer education positively affects the knowledge and performance level of BSE of adolescent students.
Recommendation Peer educational programs based on BSE should be propagated for various age groups to raise public awareness and achieve generalization about breast cancer prevention.

Keywords: breast cancer, breast self-examination, nursing educational program, peer education


How to cite this article:
El Fttah Ali HA, Hussein SR. The effect of peer education on adolescent students’ knowledge and performance of breast self-examination. Egypt Nurs J 2018;15:30-8

How to cite this URL:
El Fttah Ali HA, Hussein SR. The effect of peer education on adolescent students’ knowledge and performance of breast self-examination. Egypt Nurs J [serial online] 2018 [cited 2018 Nov 18];15:30-8. Available from: http://www.enj.eg.net/text.asp?2018/15/1/30/240356




  Introduction Top


Cancer is a leading cause of death worldwide. Breast cancer is a global health issue, and the most common form of cancer among women in developed and developing countries (Dolar et al., 2012). According to the who report, ∼519 000 women die of breast cancer yearly and more new cases are found, which is estimated to be about one million women developing breast cancer each year. Early recognition of breast abnormality is an essential factor that needs particular attention (WHO, 2011).

The most widespread cancer among women is breast cancer. It is becoming an issue of concern in women’s health (Austein, 2006). Breast self-examination (BSE) was recommended by the American Cancer Society and National Cancer Institute as one of three screening practices for early detection of breast cancer. A woman who was advised about BSE by healthcare providers demonstrated greater knowledge and assurance and was likely to practice it regularly (Abu-Salem and Hassan, 2007; Hacihasanoglu and Gözüm, 2008).

Breast cancer incidence has increased, and it is frightening for women as it affects all ages. Marital and sexual relationships as interpersonal relationships are depressingly affected. Breast cancer prevalence in developing country is almost as high as in developed countries. Likewise, breast cancer is the most common cancer among Egyptian women. Breast cancer represents 18.9% of every one of cancer cases ‘35.1% in women and 2.2% in men’ the same as reported by Omar et al., 2003. Breast cancer occurrence in Egypt is represented at 24 per 100 000 cases, and mortality rate associated with breast cancer is 9.3% of all cancers (Mortada and El Safie, 2013).

Although the importance of BSE is controversial, BSE as a selection for breast cancer awareness and its early detection was recommended by American Cancer Society. BSE benefits women, as women become familiar with both the appearance and the feeling of their breasts and identify any changes in their breasts as early as possible (American Cancer Society, 2008). Although breast cancer detection in the early stages has a higher chance of responding effectively to treatment, owing to its late diagnosis ‘in the highly developed stages of the disease’, Arabic women currently face a significant risk of elevated mortality owing to breast cancer (Bener et al., 2008).

Fortunately, BSE is particularly a simple, noninvasive, inexpensive, affordable, and easily reached method for younger and high-risk women to discover early changes in their breasts (Secginli and Nahcivan, 2006). The early detection of breast cancer is the most significant and beneficial area of protection techniques and has been positively linked to decrease in mortality and morbidity of the sickness (Mele et al., 2005). Furthermore, BSE is easy and can be done by anyone without any special equipment. It is also a financially secure and noninvasive process. There is also verification in the literature that 90% of breast cancer is revealed by chance, and women doing BSE monthly often distinguish a mass in their breasts earlier. In addition, other articles’ status that BSE encourages and enables women to take responsibility for their own health matters (Beydag et al., 2007).

Endorsement of self-care, an approach adopted early in life, may pay lifelong bonuses. The adolescent period is a time of quick change, where provision of adequate knowledge may affect health behaviors into adulthood. For example, training breast self-care may encourage positive behaviors such as performing BSE and undergoing regular professional breast examinations. For younger women, BSE education and observance are a gateway to health promotion behaviors which set the phase for adherence to clinical breast examination and mammography showing later in life (Mohamed et al., 2013).

Creating alertness and disseminating information about breast cancer is the first step toward increasing the number of women performing early investigative methods for breast cancer. Education can be successful as long as its intention group comprises both adolescent and adult women (Gursoy et al., 2009). Lamentable, the nurse plays a vital role in teaching BSE and she is in a suitable position to teach breast cancer awareness with no extra cost. Breast cancer realization includes knowledge of breast cancer danger factors, signs, symptoms, and screening methods (Royal College of Nursing, 2002).

Significance

In Egypt, breast cancer is generally detected at late stages (∼60% of cases are detected in the third stage of breast cancer), when treatment options are restricted, and death rate is high, as breast cancer is a highly serious disease especially with late diagnosis. Therefore, early detection of breast cancer leads to healthier outcome and prognosis of breast cancer. BSE makes women more aware regarding breast structural abnormalities, which in turn, may direct to an earlier diagnosis of breast cancer (Ibrahim et al., 2008).

For years, BSE has been a main field of interest for many researchers. However, in both Egypt and other countries, studies using peers in relation to BSE education are extremely limited. This study provides data about the effect of peer education on adolescent students’ knowledge and performance of BSE, which has not been considered before. In these ways, this study contributes definitely toward the research that will most certainly continue regarding BSE and the effects of BSE peer education in enhancing awareness and facts about this important health issue. Likewise, the first step toward increasing the number of women using early diagnostic methods for breast cancer can be enhanced by creating awareness and propagating information about breast cancer. Education can be successful as long as its intention group encompasses both adolescent and adult women.

Study hypotheses

To achieve the aim of this study, two hypotheses were tested:
  1. Adolescent students who receive peer education of BSE will have higher knowledge and performance scores.
  2. Adolescent students who receive peer education of BSE classes in groups will have higher knowledge and performance scores than those who receive individual classes.



  Materials and methods Top


Aim

This study aimed to examine the effect of peer education on adolescent students’ knowledge and performance of BSE.

Research design

A quasi-experimental research design (pretest and post-test) was used.

It is a research design that searches for knowledge and examination of causality in situations in which complete control is not possible; it lacks at least one of the three characteristics of the experimental design, which are manipulation, control, and randomization. The pretest is done before the introduction of the new teaching approach (Lobiondo-Wood and Gerl, 2003).

Study setting

The present study was conducted at Faculty of Nursing, Kafrelsheikh University.

Sampling

A convenience sample of all students (260 peer students) from third level of Faculty of Nursing was included. The actual field work was carried out from the first of December 2016 to the end of February 2017.

Inclusion criteria

The patients were recruited when they fulfilled the following inclusion criteria:
  1. Female third-level students.
  2. Age from 18 to 22 years.


Sample size

The target variable in this study is the third-level students of Faculty of Nursing. Based on the data obtained from previous study that assessed the knowledge and performance scores before and after education and considering the level of significance of 5% and power of study of 80%, the sample size was calculated using the following formula: n=[(Zα/2+Zβ)2×{2(SD)2}]/(mean difference between the two groups): 2=[(1.96+0.84)2×2(8.9)2]/(41.6−37.2)2=129.1. Hence, 130 participants are required in each group.

Recruitment technique

Third-level students (n=260) were divided equally into two groups. Group 1 (n=130) was assigned for individual education and group 2 (n=130) was assigned for group education.

Tools of the study

The data were collected through using the following tools:
  1. A personal data record: The researchers developed it after reviewing relevant literature. It was written in English language. Questionnaire was distributed and piloted on volunteer students out of the main sample of the study, and any necessary modifications were done. It consisted of the sociodemographic data of students such as age, residence, and mother’s education.
  2. BSE knowledge questionnaire: The knowledge section consisted of multiple-choice questions to measure the participants’ knowledge on breast cancer, knowledge about BSE, the referred person ‘who is asked if breast size changed in addition to the source of knowledge, for example, radio, TV, friends and family, hearing any information about BSE? What are the time and the number of BSE? What is the preferred method of BSE? In this part, questions were asked and scored. There were 11 multiple-choice questions included in the pre-education and posteducation sessions (Mohamedet al., 2013).
  3. BSE performance checklist: Checklist regarding the items of BSE performance was carried out by students such as making self-examination by touching the skin, BSE follow-up, preferred method of BSE, methods of BSE, and part of the hand used in BSE. There were 19 steps included in pre-education and posteducation sessions (Mohamedet al., 2013).
  4. Evaluating score: The correct responses of the pre-education and posteducation sessions were summed up to get the total knowledge and performance scores for each participant. Questions related to the participants’ knowledge were asked and scored. One point was allocated for correct answer and 0 point for wrong answer. This applied before and after the education. The total points that can be scored from the questionnaire were between 0 and 11. Satisfactory knowledge was considered if the students achieved 70% from the total answers required. In addition, the participants’ performance was scored. One point was allocated for correct step and 0 point for the wrong one. This was applied before and after the education. The total points that can be scored from the checklist were between 0 and 19. Adequate performance was considered if they achieved 70% from the total steps required. The correct responses of the pre-education and posteducation sessions were summed up to get the total score for each contributor (Hasnain and Sheikh, 2009; Mohamedet al., 2013).


Validity of tools

The four tools used in this study were reviewed by a panel of three experts in the maternity nursing specialty before introducing them to the participants to ensure its validity, and their comments were considered.

Administrative design

Ethical approval was granted from the Ethics Committee of the Faculty of Nursing. Official permission was obtained from the Dean of Faculty of Nursing, Kafrelsheikh University.

Ethical consideration

Informed consent was obtained from each participant after clarifying the study nature, and they were assured about the confidentiality of the collected data. Moreover, the participants were informed that they have the right to pull out during the study period. Rights of all subjects were protected. All data were confidential and were used only for research aims. All students had an equal chance to be involved in the study, and to protect the included students’ rights, a copy of the educational program was given to them. The aims of the study were obviously explained to each participant.

Pilot study

The purpose of the pilot study was to test content clarity and applicability of implementing the designed tools and educational program and time required to fill each tool. The pilot study was done on 10% of the study sample, involving 26 students. Evaluation of the contents of the educational program and the ease of its language was also considered. The pilot group was excluded from the study sample.

Research procedure

Preparatory phase

A review of the past and current local and international available related literature covering a variety of aspects of the students was done using available books, articles, periodicals, and magazines was required to be acquainted with all aspects of the study problem and also to develop related tools for data collection and the content of the educational program.

For data collection and educational program accomplishment, the researcher helped interviewing the students and began assessment (pre-education session) for each group. The researcher started by introducing herself to the students and gave them a concise idea about the study and its aims and predictable outcomes, and then, written consent was obtained from them. The interview took from 15 to 20 min. The researcher told the students that there would be some kind of posteducation assessment after 1 month for each group. Ten volunteer from third-level students were trained to be able to express and educate peer education. The training for peer educators consisted of the construction of the objects that would be given to the students and the principles of group and individual training.

Program implementation

The implementation of educational program was carried out at first. The researcher educated the peer educators in the class through power point presentation, and this session lasted about 3 h. The information and training that would be given to the students consisted of topics such as breast cancer incidence in Egypt, danger factors, early detection methods, breast cancer symptoms, importance of early detection methods, and how to do BSE. A practical session on BSE was implemented at the end of the lecture. Peer training in that study was conducted individually and in group sessions. To reduce any unfairness owing to educators’ act, each student was assigned to attend four education sessions. According to this plan, 130 students took part in the individual education and the same number of students took part in the group education. Individual session lasted about 30 min, and eight students were instructed daily, whereas the training sessions were completed in 1 month, and the instructor gave a booklet to the students at the end of the session. Booklet that was created after a sound literature review by the researcher consisted of information and pictures of the patient that will be presented to the students about (breast cancer and how to do BSE). To implement the group training method, five groups were formed, each with 26 students. The session lasted for 60 min. At the end of the group sessions, the same booklet used in individual training was given to the group students, and the training sessions were completed in 1 week. The data were collected in two phases, a pre-education phase, and a posteducation session, which was conducted 1 month after the educational program.

Evaluation of the outcomes

After the completion of the educational program, the posteducation evaluation was done for both groups in the study 1 month after the education, to evaluate the outcomes of the implemented program.

Outcomes of the study

The outcomes were assessed in this study were as follows: to determine the effect of peer education on adolescent students’ knowledge and performance of BSE.

To determine the effect of peer education on BSE classes in groups and those who received individual classes.

Limitations

One of the limitations of the study was the small size of the study groups, which was not enough to show the effectiveness of the program. Moreover, the number of peer educators was excessively limited in the study.

Statistical analysis

Statistical analysis of the data was performed using the SPSS, version 20.0 program (Chicago, US, South Waker Drive). All data were expressed as number and percentage. The comparisons of the categorical data were made by χ2-test. The level of significance was set at value less than 0.05.


  Results Top


The current results will include the following five parts: personal data of the study groups, the frequency of the satisfactory knowledge level before and after intervention between the individual and group education groups, study group’s performance of BSE before and after intervention between the individual and group education groups, relation between students’ mother education and their knowledge and performance level of BSE (posteducation program) between study groups, and relation between students’ residence and their knowledge and performance level of BSE (posteducation program) between study groups. Peer education of BSE was approved on a sample of 260 adolescent peer female students with age range between 18 and 22 years from third level of Faculty of Nursing, Kafrelsheikh University. According to the study aim and hypotheses, the following findings will support the study hypotheses and achieve the study aim.

[Table 1] demonstrates the personal characteristics of the students in the individual education and group education groups. The two groups were matched for age, residence, and the level of educational status of the mothers of the students.
Table 1 Personal data of the study groups

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Despite the satisfactory knowledge level between the two groups did not differ significantly at baseline evaluation, the satisfactory knowledge level was reported more frequently among the students in the group education than in the individual education group (54.6 vs. 41.5%, respectively, P=0.035) ([Table 2] and [Figure 1]).
Table 2 The frequency of satisfactory knowledge level before and after intervention between the individual and group education groups

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Figure 1 The frequency of the satisfactory knowledge level before and after intervention between the individual and group education groups.

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As shown in [Table 3] and [Figure 2], the frequency of adequate performance of BSE did not differ significantly between the studied groups; however, after intervention, the frequency of adequate performance of BSE was significantly higher in the students in the group education group.
Table 3 Performance of breast self-examination before and after intervention between the individual and group education groups

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Figure 2 Performance of breast self-examination among study groups before and after education.

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As shown in [Table 4], the level of mother education significantly affected the knowledge level in the study groups. After intervention, the students with educated mother had significantly higher frequency of satisfactory knowledge level than students with uneducated mother in the individual education group (48.3 vs. 26.8%, P=0.021), and also in the group education group (60.2 vs. 37.5%, P=0.025), the level of mother education significantly affected the performance level in the study groups. After intervention, the students with educated mother had significantly higher frequency of adequate performance level than students with uneducated mother in the individual education group (48.3 vs. 26.8%, P=0.021) and also in the group education group (64.3 vs. 40.6%, P=0.018).
Table 4 Relation between students’ mother education and their knowledge and performance level of breast self-examination (posteducation program) between the study groups

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As shown in [Table 5], the urban students in the individual group had significantly more frequent satisfactory knowledge than rural students (87.9 vs. 34.7%, P<0.001) after intervention. Moreover, the urban students in the individual group had significantly more frequent adequate performance than rural students (65.3 vs. 12.1%, P<0.001) after intervention.
Table 5 Relation between students’ residence and their knowledge and performance level of breast self-examination (posteducation program) between the study groups

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  Discussion Top


This study aimed to assess the effect of peer education on adolescent students’ knowledge and performance of BSE. The present study findings revealed that the peer education on adolescent students affects positively the knowledge and performance level of BSE, and the satisfactory knowledge levels were reported more frequently among the students in the group education than in the individual education group after intervention. The study findings supported the study hypotheses and achieved the study aim. The same previous conclusion was given by an effective protocol for learning to carry out skillful manual BSE; it is a system of advance palpable skills enabling clinicians and women to detect small imitation lesions in tactually exact breast models and to transmit that skill to breast tissue (Mark et al., 2013). With increasing of the breast cancer prevalence, and also lack of established nationwide breast screening in Egypt, it becomes essential to assess the knowledge and practice of BSE in a variety of age groups. Adolescence students are outlook mothers that are the elementary of the family that the corn stone of the public. So, it was significant to study the knowledge level of this group. In the current study, the satisfactory knowledge level between the two groups did not differ significantly at baseline evaluation, and the satisfactory knowledge level was reported more frequently among the students in the group education group than in the individual education group (54.6 vs. 41.5%, respectively, P=0.035).

Fortuitously, the frequency of adequate performance of BSE did not differ significantly between the studied groups; however, after intervention, the frequency of adequate performance of BSE was significantly elevated in the students in the group education. It is a very fear-provoking health threat to all populations worldwide, as a breast cancer presents equally. Educating and informing adolescence about this serious disease is both confronted and important risk in the health of prospect generations of women. Healthcare providers need to educate adolescents about BSE to help them develop behaviors and practices which can support them to become positive in taking responsibility for their health issues (breast health). Additionally, the identity of late adolescence phase demonstrates dependence on peers regarding development of personal values. Young people in late adolescence favor spending time with their peers instead of their parents or healthcare providers (Gursoy et al., 2009; Tasci and Usta, 2010; Yadav and Jaroli, 2010).

Thus, the peer groups have a great influence on this age group and are also very important to most young people. The approach of using peers to train and teach young people in late adolescence about health was supported by Ericson’s theory. Peer groups method promotes participants to assist each other to increase and reassure their success, and they support each other’s learning attempts, give confidence, guide, and prize group members (Field et al., 2007). As a result, it was found that this method produced improved results when compared with other instructional methods such as using videos or receiving information from teachers. There are sources that recommend using peers for health education so as to reach larger groups of the general public.

Furthermore, there are studies stating the achievement of peer education in different branches of health (among adult women, nurses, and mid-wives) (Lurie et al., 2006; Gill et al., 2008). The hypothesis of the current study answers positively the question whether using different education methods through peer training has any effect on BSE knowledge and performance. The astounding result was that students instructed in groups showed improvement in their BSE knowledge compared with those instructed individually. Other studies using both individual and group methods proved that education increases BSE knowledge and performance before and after the program (Engels et al., 2003; Alkaya et al., 2007). The previous findings were in a similar vein with the present study.

Different studies, utilizing both individual and group techniques completely through companion instruction demonstrated that training builds BSE learning fulfillment and implementation sufficiency in group education than individual education (Alkaya et al., 2007). The previous result was in parallel with the present study. In our study, we identified that there was an absence of learning regarding breast growth and BSE practice for caretakers, and furthermore, insufficient knowledge and practices, before the BSE educational program implementation.

Concerning the kind of associate training strategy, another study affirmed that it has a low effect on BSE information fulfillment and practice adequacy after the instruction (Gursoy et al., 2009), which was in contradiction to the present study. In our perspective, the educational program that was carried out in their study may be an insufficient wellspring of learning and practice.

In another study carried out on nursing undergraduates, the learning level and practices of undergraduates regarding BSE enhanced after peer instruction program, which demonstrates the adequacy of the training program on knowledge and practices of group education than individual one, which supplemented their knowledge with right and attractive data. It is of significance to better instruct the undergraduates, as they have a key part in demonstrating the importance of preventive well-being measures, including BSE, to society and other college undergraduates as colleagues (Yucel et al., 2014). This was in congruity with the present study. In our view, it is vital that efforts to utilizing media should be enhanced to make BSE mindfulness and underline its significance in early discovery of breast growth, as this has all the earmarks of being better, as media reach to a more extensive group of onlookers.

In a preceding study done on 538 nursing students in a single Higher Technological Educational Institute in Greece by Lavdaniti (2014), it was found that nursing students had insufficient knowledge and practice about BSE. After peer education program, more than half of the group education students showed fulfillment of knowledge and adequate practice than individual education students, with statistical difference between pre–post-educational program. This study supports the current study. This could be due to a long time that students worn-out with each other. Besides, the students who did not have BSE training before health education program believed that it was not necessary. It is clear from previous results that the health education program for younger women is necessary toward better breast cancer prevention efforts, develop self-assurance in BSE skill as well as precise information about BSE and breast cancer, and reduce apprehensions in women. In addition, the team work is better than the individual work.

Moreover, an intervention study conducted by Mohamed et al. (2013) on 37 adolescent girls in Al Noor Institute for Blind Girls in Qena Governorate, Egypt, showed similar findings to the current study. Their findings showed a statistical difference between the level of BSE knowledge and education of mothers of girls, a statistical difference between educated and uneducated mothers of girls and the level of BSE performance, and also a statistical difference between group education and individual education groups in relation to satisfaction of knowledge and practices of BSE. In addition, a statistical difference was found between rural and urban residents and the level of knowledge and performance of BSE. The agreement between the studies could be credited to more health alertness of girls with educated mothers and enhancement of health attentiveness among urban residents than rural one.

Regarding the relation between female student’s mother’s education, residence of students, and their knowledge and performance of BSE, the current study showed that knowledge and performance of BSE were higher in female students with educated mother and in students who lived in urban areas, which were as predictable. In a further study regarding knowledge and practice of Jordanian students regarding BSE, participants having mothers who finished high school levels of education were found to be more well-informed in practicing BSE than those with other lower levels of education (Akel et al., 2011). In another different study, the higher knowledge of practicing BSE screening was seen in those who had mothers having completed university education or more; moreover, group education students had higher knowledge and performance of BSE than individual education students regarding having educated mothers (Lam et al., 2008). The previous study was consistent with the current study. The similarity in the results may be because educated mothers would pass on the gained education to their daughters, who would be more eager to learn and discover normal structures of their breasts, allowing them to identify any collection or differences in their breasts that may become detectable, and therefore revealing early signs of breast cancer, in comparison with other students having mothers with low education, and so, the students with educated mothers should be more knowledgeable than other students.

Another contrasting study found no association between knowledge and practice satisfaction of BSE and the level of education or residence (Yucel et al., 2005). This finding was in contrast with the current study. This finding may be related to the fact that the type or the source of information may not differ according to areas of residence. Moreover, regarding the education of mothers and its relation to satisfaction in knowledge and practice of BSE, the knowledge imparted may differ on the type of relationships between mothers and their girls.


  Conclusion Top


The satisfactory knowledge level after intervention was reported more frequently among the students in the group education than in the individual group. Moreover, after intervention, the frequency of adequate performance of BSE was significantly higher in the students in the group education.

Recommendations

It is recommended to conduct additional studies using study samples from a variety of institutions in Egypt. Moreover, peer educational programs based on BSE should be conducted for various age groups (reproductive age and menopausal women) to raise community awareness and achieve generality about breast cancer prevention. In addition, BSE should be included in all nursing curriculum.[31]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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