|Year : 2019 | Volume
| Issue : 1 | Page : 25-35
The effect of health promotion program on female breast self-examination knowledge and practice
Shereen Abd El-Moneam Ahmed1, Sheren Elsayed Shrief2
1 Department of Medical-Surgical Nursing, Faculty of Nursing, Suez Canal University, Suez Canal, Egypt
2 Department of Medical-Surgical Nursing, Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt
|Date of Submission||30-Sep-2018|
|Date of Acceptance||29-Oct-2018|
|Date of Web Publication||10-May-2019|
Shereen Abd El-Moneam Ahmed
Department of Mrdical-Surgical Nursing, Suez Canal University, Suez Canal
Source of Support: None, Conflict of Interest: None
Background Breast self-examination (BSE) is a screening method that should be taught at early ages to make women aware about the importance of early detection of breast cancer. It can be performed without the assistance of health professionals after effective education and requires no special equipment.
Aim The aim was to evaluate the effect of a health promotion program on female BSE knowledge and practice.
Participants and methods A quasi-experimental pretest/post-test was used to implement the current study, at the surgical outpatient departments affiliated to Suez Canal University Hospitals and Beni-Suef University Hospitals, on a convenience sample of 80 women from September 2017 to December 2017. Two tools were used for data collection: A structured interview questionnaire to evaluate the participants’ sociodemographic data, BSE knowledge, barriers to practice BSE, and an observational checklist to assess the BSE practice among the studied female.
Results There was a high significant relationship between sociodemographic variables and women’s knowledge and practice on BSE with an increase in their scores after implementation of the health promotion program.
Conclusion and recommendations This study concluded that the designed health promotion program could improve BSE among the studied women. The current study recommended implementing health promotion programs and educational instructions to provide more information based on scientific knowledge about BSE to female patients at the hospitals.
Keywords: breast self-examination, health promotion program
|How to cite this article:|
Ahmed SA, Shrief SE. The effect of health promotion program on female breast self-examination knowledge and practice. Egypt Nurs J 2019;16:25-35
|How to cite this URL:|
Ahmed SA, Shrief SE. The effect of health promotion program on female breast self-examination knowledge and practice. Egypt Nurs J [serial online] 2019 [cited 2019 Aug 25];16:25-35. Available from: http://www.enj.eg.net/text.asp?2019/16/1/25/257966
| Introduction|| |
Breast self-examination (BSE) is a self-inspection of the breasts. During a breast exam, eyes are used to observe the appearance, and hands are used to feel the breast. BSE gives a greater awareness of the condition of breasts and helps identify potential breast problems. Because many women experience tenderness and lumpiness in their breasts before menstruation, many healthcare providers advise women to perform BSE regularly every month, 5–7 days after menses (Hinkle and Cheever, 2014).
There are only three methods for early detection of breast cancer (BC), including mammography, clinical examination, and BSE (Fikry et al., 2012). There is no evidence about the effects of BSE on early detection of BC, but different organizations recommend regular self-examination in women over 20 years of age in the promotion of self-awareness and risk control (Ceber et al., 2010).
In fact, regular BSE has been suggested as part of the overall health promotion concept (WHO, 2016). BSE depends on knowledge and attitude towards BSE practice among women. Its effectiveness is dependent upon the skills of healthcare providers and available facilities. It is considered a simple, noninvasive, inexpensive, and accessible method for younger and high-risk women to discover early changes and abnormalities in their breasts (El-Hay and Mohamed, 2015).
The American Cancer Society supports the BSE as an early detection behavior. Research suggests that women who receive personal instruction on BSE from a healthcare professional demonstrate greater knowledge and confidence and are more likely to practice routine BSE than those who become aware of the method from other sources (Rezaee et al., 2018).
There are some obstacles that prevent female individuals from practicing BSE, as reported by El-lassy and Abd Elaziz (2015), which include not having time and being too busy, forgetting, not believing that it is beneficial, thinking it is wrong to touch the breast, anxiety about the possibility of recognizing a breast mass, and embarrassing procedures.
Tsangari et al. (2014) conducted a study to compare the beliefs and practices of BSE between Cypriot and Egyptian women. They found that about 65% of Cypriot women had practiced BSE at least once in the past year, as opposed to 35% for Egyptian women. Therefore, they recommended the need for introducing proper and correct information about BC and BSE for Egyptian women who have lack of confidence in the correct performance of BSE. Therefore, the researchers are interested to implement this study to introduce accurate information through a health promotion program and touch on the effect of female knowledge and practice with regard to BSE.
Health promotion is a process, which purposes to strengthen the capabilities and skills of individuals to help them take action; it also increases the capacity of groups or communities to exert control over the determinants of health. Effective health promotion requires the development of professional skills, organizational structures, resources, and commitment to health improvement in health sectors (Kumar and Preetha, 2012; WHO, 2016).
Nurses play a unique role in alerting the people to BSE, and early detection of BC, as they usually have the closest and effective contacts with female patients. The nurses play a highly important role in educating women through specially designed health promotion programs in the healthcare settings, as well as through community outreach strategies (Oza et al., 2011).
Significance of the study
Approximately one million new cases of BC are diagnosed each year worldwide. It is the commonest malignancy in women and comprises 18% of all female cancers; it accounts for nearly one in four cases of cancer among all women (Moodi et al., 2011; Loh and Chew, 2011). It is the most common cause of cancer morbidity and mortality among women in low-income and middle-income countries, as most women who have BC are diagnosed in late stages due to lack of awareness on early detection and BSE. Therefore, WHO (2016) recommended the use of BSE as an early screening method to detect BC in low-income and middle-income countries.
Early diagnosis affords a better chance of survival and better prognosis in the absence of an etiological agent for BC; the most appropriate way of controlling it will be early detection and treatment. Regular BSE can identify any abnormal changes in the breast to establish good prognosis. The baseline data provided in this study will be used to develop strategies to increase the efficacy of BSE among women, and hence help in early screening of cancer with effective treatment, which in turn is useful to the nursing profession and the community. Reduced cost of cancer treatment will be a significant effect of the current study to the community and will give an opportunity to nursing staff to develop educational programs to teach female individuals about BSE. For research purpose, the results of the current study give indicators about female individual’s awareness, and thus can help in investigating barriers to implement the procedure, and make an improvement plan for nursing staff and female inividuals to maximize the effect of BSE.
| Participants and methods|| |
The present study aims to evaluate the effect of health promotion programs on female BSE knowledge and practice.
H1: BSE knowledge score of the studied participants will be higher after implementing the health promotion program than before.
H2: BSE practice will improve among the studied participants after implementing the health promotion program.
A quasi-experimental before/immediately after/and after 1-month post-test model was used to implement the current study.
The present study was implemented at two sites including the surgical outpatient department affiliated to Suez Canal University Hospitals, Ismailia city, Egypt, and the surgical outpatient department affiliated to Beni-Suef University Hospitals.
A convenience adult female individuals’ sample of 80 women came for follow-up at the surgical outpatient department from September 2017 to December 2017 was included in this study. The inclusion criteria were as follows: being an adult nonpregnant female individual, aged more than 20 years, but not more than 40 years, either married or not married, does not breastfeed, had no breast surgery, had no visual or auditory disabilities, and agreed to participate in this study.
Tools for data collection
A structured interview questionnaire, designed by the researchers, after reviewing the related literature. It includes the following:
- Sociodemographic and related data: included items such as age, marital status, education, occupation, number of family members, family history of BC and personal history of a breast lump.
- BSE knowledge questionnaire based on Phungula (2011), which involves nine multiple choices questions covering the following: importance of BSE, reason for doing it, source of information about BC and BSE, methods of early screening of BC, appropriate time for performing BSE, frequency of BSE, previous practice of BSE, and position used to perform the procedure. The scoring system was as follows: the right answer was given a score of two, score one for the wrong answer, and 0 for do not know the answer, with a total score of 18. The total score of knowledge greater than or equal to 75% was considered as satisfactory.
- Barriers to practice BSE: This includes 10 options for the participants to report their barriers to practice BSE as no source of information, no need for the practice, anxiety, forgetfulness, absence of symptoms, the pressure of studies or work, embarrassment, painful, time-consuming, and interferes with activities. Adopted from Champion’s Health Belief Model Scale (CHBMS, 1997). The participants were allowed to choose more than one barrier.
- BSE observational checklist: This was designed and revised by the researchers with reference to Abeloffet al.(2008) to assess the participants’ practice of BSE. It included 12 items such as position used to examine the breast, abnormalities seen with the examination, and how to perform BSE. The scoring for the procedure was two for the accurately practiced step, one for incomplete or moderately practiced step, and the not practiced one was given a 0; with a total score of 24. The total score of practice greater than or equal to 75% was considered as good.
Eight patients participated in the pilot study and were excluded from the study sample resulting in a total number of the study sample after exclusion of 80.
Tool validity and reliability
The tools were reviewed by five experts in the Medical-Surgical Department to assure their validity, and the needed modifications were made. A pilot study was implemented on eight women to test the feasibility of tools and time needed to complete. Test reliability of the tools was carried out by Cronbach’s α=0.86.
The procedure of data collection in the current study was implemented through the following phases:
The preparation phase
- The researchers reviewed the related literature and prepared the used instruments to collect data. In addition, permission was taken from the college and the hospital administration to start the study.
The implementation phase
(1) Data were collected during the period spanning from September to December 2017. The researchers visited the surgical outpatient department in the previously mentioned settings two times a week, using different sessions.
(2) During the first session, the researchers explained the nature and purpose of the study and took oral consent from participants who fulfilled the study criteria, and divided them into two groups each of 8 to 10 participants for each session.
(3) The study tools were given to the participants to be completed as a pretest. If the participants could not read or write; the researchers asked them and noted their response in their sheets. The time consumed in this session was 20–25 min.
(4) During the same session, the researchers explained the health promotion program, which takes about 70–90 min to implement, including knowledge about BSE and with regard to practice. The researchers asked the participants to describe how they practice BSE, then the researchers make check on the right step throughout the observational checklist as follows:
(5) Teaching methods for the program included lecture and group discussion for the theoretical part, and demonstration and redemonstration using the breast model ‘normal and abnormal one’ for the practical part.
(6) The researchers allowed the participants to practice during the redemonstration using the checklist individually.
(7) Data show, pictures, and posters used to facilitate teaching and provide more information.
(8) Every participant was provided the booklet that was developed on the basis of Hinkle and Cheever (2014) with detailed information on knowledge and practice about BSE and barriers to practice at the end of the interview.
- Each group tested for knowledge before and immediately after following the program by one of the researchers.
- The evaluation was implemented after 1 month from the pretest period using the same tools to identify the change in the level of knowledge and practice.
Oral consent was obtained from the participants after explaining the aim of the study, and participants were assured about the confidentiality of their response. The researchers explained to the participants that they were free to withdraw from the study at any time.
Statistical analysis was implemented using SPSS version 21. Descriptive data were presented using percentage, and differences of data through the program phases were tested using the χ2-test and t-test, with the significant level preset at P less than 0.05.
| Results|| |
[Table 1] shows that 75.00% of the study participants were aged from 30 to 40 years, 85.00% were married, and the same percentage (62.5%) of the study participants were university educated, did not work and their number of family members ranged between six and nine persons.
|Table 1 Distribution of the study participants according to their sociodemographic data and history (N=80)|
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It also shows that 25.00% of the study participants had a family history of BC; 50.00% of their relatives had BC and 30% of their mothers had BC. Moreover, 87.5% had no personal history of the breast lump.
[Table 2] shows that there is a statistically significant difference in the studied participants’ knowledge about BSE throughout all phases of the study, 75% of the study participants have correct knowledge about the importance of BSE, and 80% know that it helps early detection of BC, immediately after the program implementation. An overall 30.00% know the appropriate time of performing BSE before the program implementation, but, after the program, 90% know the right time. Only 30% of the study participants know the frequency of BSE before the program, and 87.5% immediately after the program, 85% of the study participants did not perform BSE before the program but, at the follow-up phase 75%, they perform it. With regard to the position used for BSE, only 37.5% of the study sample did not know the suitable position before implementation of the program, but, after implementation of the program, the studied sample’s level of knowledge increased (χ2=22.13, P=0.001**).
|Table 2 Distribution of the study participants according to their knowledge score about breast self-examination throughout all the program phases (N=80)|
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[Figure 1] shows that in the preprogram phase, the level of satisfactory total knowledge about BSE is 20%, while immediately after the program it is 90%, and after 1 month of the program it is 80%, with statistically significant differences (χ2=22.13, P=0.001**; χ2=34.16, P=0.001*).
|Figure 1 Percentage distribution of satisfactory breast self-examination total knowledge among the studied sample along the program phases. N=80.|
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[Figure 2] shows that there is a statistically significant difference in the studied sample’s knowledge about the source of information with regard to BC and BSE throughout the phases of the study. The highest percentage of the respondents 50%, 75%, and 67.5% respectively their source of information throughout the program phases is from the social media.
|Figure 2 Percentage distribution of the source of information about breast cancer and breast self-examination among the studied participants. N=80.|
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[Table 3] shows that barriers to practice BSE before the program; a perceived 90% of the study sample do not know about BSE, 87.5% feel anxious from the procedure, 75% reported absence of symptoms as well as forgetfulness, followed with 62.5% seeing that there is no need for practicing BSE, as well as admitting to the embarrassment. An overall 12.5% of the studied sample said the barrier to practice BSE was the stress of study/or work, while after the program, all the percentages reduced, as the greatest barrier from the studied sample point of view was that BSE is time-consuming and interferes with activities; this was reported by 25%, 20% of the studied sample, respectively, with a statistically significant difference between before and one month after the program.
|Table 3 Percentage distribution of breast self-examination practice barriers among the studied participants (N=80)|
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[Figure 3] shows that, during the preprogram phase, the level of accurately carrying out the practice of BSE is 37.50%, immediately after the program, the level of accurately carried out practice is 87.5%, and, after the program, within 1 month, the level of accurately carried out practice is 82.5%, with statistically significant differences (χ2=11.13, P=0.12**).
|Figure 3 Percentage distribution of satisfactory breast self-examination practice score among the studied sample along the program phases. N=80.|
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[Table 4] shows a highly significant relationship between sociodemographic variables and women’s knowledge on BSE, as the more knowledgeable women immediately after implementation of the health promotion program are the women aged from 20 to 30 years old (82.5%), the not married female (85%), and the employed female (90%). [Table 5] shows a highly significant relationship between sociodemographic variables and women’s practice of BSE immediately after the program implementation, with most of the respondents (90%) aged 30–40 years old practicing good BSE. An overall 92.5% of the unmarried sample practice BSE; 90% of the employed female individuals practice BSE. An overall 82.5% of the university participants practice BSE.
|Table 4 Sociodemographic variables and breast self-examination knowledge among the studied participants (N=80)|
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|Table 5 Sociodemographic variables and the breast self-examination satisfactory practice among the studied participants (N=80)|
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[Table 6] shows a highly statistically significant relationship between the mean total score of knowledge and mean total score of practice of BSE among the studied female participants, with P less than 0.000.
|Table 6 Relation between breast self-examination total knowledge scores and total practice scores along the program phases (N=80)|
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| Discussion|| |
Breast screening is an essential health maintenance activity, is very important in reducing mortality, and helps to detect BC at an earlier stage. Women who are familiar with their own normal breast characteristics can easily discover any abnormalities early and can be effectively treated. Each woman and girl should be aware of her own risk factors for BC (Aghamolaei et al., 2011).
The present study was implemented with the aim of evaluating the effect of health promotion program on female BSE knowledge and practice. The results of the current study fulfilled the predetermined goal and are expressed as follows.
The sociodemographic data of studied participants in the current study shows that three-quarters of the study participants were aged 31–40 years. The majority of the study participants are married, university educated, do not have work and the number of family members ranged between six and nine persons, but slightly more than one-third of the studied sample work. From the researcher’s point of view, this could express the Egyptian female status.
In the same line, El-Hay and Mohamed (2015) studied the effect of educational program on building accurate information and behavior among women about BC knowledge and BSE, and found that slightly less than half of the participants were in the age group of 35–45 years; the majority had university education and were married. The results of the current study contradict with Güçlü and Tabak (2013) who studied the impact of health education on improving women’s knowledge and awareness of BC and BSE in Turkey. They found that the average studied women’s age ranged between 15 and 49 years, the majority of participating women had only primary school education, and only one-third of the women had high school or high-level education.
According to the family history, the present study shows that one-quarter of the study participants have a family history of BC, half of their relatives have BC and one-third of their mothers have BC. Moreover, most of the studied sample has no personal history of a breast lump. The results of the current study are consistent with El-lassy and Abd Elaziz (2015) who studied the impact of education program with regard to BSE on female employees in Damanhour University, and they found that the majority of the studied sample had no history of BC, and most had no previous breast problems or lump.
The present study shows that there is a statistically significant difference in the study participants’ total knowledge about BSE along phases of the program, as the level of knowledge increased immediately after implementation of the program in the majority of the respondents, and decreased slightly after one month from the program implementation. From the researchers’ point of view, these results could relate to the effect of education on the human being, as education improves the level of knowledge, especially if it is continued.
The results of the current study are in the same line with Masso-Calderón et al. (2016) who studied the effect of educational intervention on BSE, BC prevention-related knowledge, and healthy lifestyles in scholars from a low-income area in Bogota, Colombia, and found that knowledge of the BSE technique significantly increases across all measurements with P less than 0.0001. Moreover, Gupta et al. (2009), who studied the impact of educational program on BSE by women in a semiurban area in India, found significant improvement in knowledge with regard to all aspects of BSE of the intervention group from before the test to after the test, as, after the program, more than half of the studied women had good knowledge, and most of them practiced BSE compared with no one before the test.
The results of the current study showed that during the preprogram, three-quarters of the study participants have correct knowledge about the importance of BSE, and most of the participants know that it helps early detection of BC, and know the appropriate time and frequency of performing BSE immediately after the program implementation. The highest percentage of the respondents obtained their source of information throughout the program phases from the social media. In the same line, a study by Ahmed et al. (2017), who studied the effect of BSE training program on knowledge and practice of adolescent girls at Kafr-El Sheikh, revealed that more than two-fifths of adolescent girls received their knowledge from television; more than one-quarter from the internet, one-fifth from their friends, while a low percentage mentioned that their mothers were the main source of knowledge.
A study carried out by Anakwenze et al. (2015), who studied the effect of theory-based intervention to improve BC awareness and screening in Jamaica, contradicted with the results of the current study, and reported that most of the participants reported that doctors and nurses were the sources of their knowledge, with media being the second source by more than half of the participants. These results could be related to elevated and recurrent use of the internet and wide range of programs on the social media and TV, in addition to embarrassment from the healthcare workers who ask questions related to the practice of BSE.
With regard to the position used for BSE, the current study showed that slightly more than one-third of the study sample do not know the suitable position, and that most of the sample did not know the appropriate time of performing BSE before the program implementation, but, after the program, the majority of the sample know the right time and position. From the researchers’ point of view, these results could be related to an inappropriate source of knowledge with contradicting information that confused the participants, but clarification by the researchers make the participants well informed.
In the same line, AbdElgaffar and Atia (2015), who studied the impact of educational program with regard to BSE on knowledge and practices of female students of the nursing technical institute at Menoufia University, stated that there was a statistically significant improvement in the participants’ knowledge with regard to suitable time of implementing BSE after implementation of the program. Furthermore, a study carried out by Moustafa et al. (2015), who studied the effect of a BSE educational intervention among female university students at Zagazig City, found that there was a significant improvement in the participants’ level of knowledge about the right time and position of practicing BSE.
According to barriers that prevent women from practicing BSE, the current study shows that, before the program, slightly less than the entire studied sample reported that their main barrier to carry out BSE was deficient knowledge. While, after the program, the higher barrier from the female point of view was that BSE is time-consuming, with a statistically significant difference between before and after the program. These results could be related to the reduced perception of BSE importance in early screening of BC among the participants, and women are busy in their jobs and household routines.
The results of the present study are consistent with that of Alwabr (2016) at Yemen and revealed that the main barrier to practice BSE among control group participants was the lack of knowledge, while forgetfulness was the main reason for not practicing BSE among case group participants. Moreover, a study by Moussa and Shalaby (2014), who studied the effect of BSE education program on knowledge, attitude, and practice of nursing students at Port Said University, Egypt, stated that the most common barriers for not practicing BSE among the study participants were lack of knowledge, forgetfulness, fear of finding breast mass, dislike of touching the breasts, and no time, respectively.
With regard to the level of practice among the studied sample, the current study shows significant improvement in the participants’ level of BSE practicing. From the researchers’ point of view, this could be related to effect of knowledge on practice, as with an increased level of knowledge, the level of self-confidence also increases, and the individual can practice more accurately.
These results are consistent with El-Hay and Mohamed (2015), who revealed that there was a significant improvement in the level of women’s practice of BSE after the program implementation. Furthermore, a study performed by Moussa and Shalaby (2014), who stated that the educational program had a significant effect in increasing level of practice on BSE from no one to almost all of the participants performing BSE correctly. The main reason for not practicing BSE before the program was that they did not know the right way to perform it.
The current study shows that there was a high statistically significant relationship between sociodemographic variables and women’s knowledge on BSE, as the highly knowledgeable women immediately after the program were found to be the following: women aged between 20 and 30 years, not married, employed, and university educated. In the same line, a study by Ayed et al. (2015) on BSE, in terms of knowledge, attitude, and practice among nursing students of Arab American University/Jenin, revealed that there was a high statistically significant relation between age groups and academic level with total mean knowledge of BSE (P>0.000). These results contradict with Moussa and Shalaby (2014) who found that there was no statistically significant relationship between age, marital status and knowledge level, whereas the older and the married students had high knowledge level.
The current study shows a highly significant relationship between sociodemographic variables and women’s practice of BSE immediately after the program implementation; most of the respondents were aged between 30 and 40 years, were unmarried, employed, and university educated, and had satisfactory BSE practice. These results are consistent with Gaballah (2011) who studied awareness, knowledge, and practice of BSE among Saudi women and found that the knowledge and performance with regard to BSE were significantly associated with age, marital status, employment status, and educational level of participants with the same results of this study. However, these results contradict with Moussa and Shalaby (2014) who found that there was no statistically significant relationship between age, marital status and level of practice on BSE, with the married students having a satisfactory performance level, 3 months after the test.
The current study shows a highly significant relation between the mean total score of knowledge and the mean total score of practice of BSE among the study participants, with P less than 0.000. In the same line, AbdElgaffar and Atia (2015) revealed a statistically significant relation between total knowledge and practice, with P less than 0.048. This result could be related to the effective relation between the level of knowledge and practice, as well as, when knowledge increases, the level of practice also increases.
| Conclusion and recommendations|| |
The present study revealed that knowledge and practice with regard to BSE were significantly associated with age, marital status, employment status, and educational level of participants. The study findings confirm the need to improve knowledge and practice of BSE. This study recommended that youngsters in their 20 s and 30 s should have a clinical breast examination as a part of periodic health examination by a health professional at least every 3 years. Educational programs and mass media should provide more information based on scientific knowledge about BSE to female individuals. In addition, further studies are needed to identify reasons for not practicing breast self-examination.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]