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Effect of Health Education on Female Teachers’ Knowledge and Practices Regarding Early Breast Cancer Detection and Screening in the Jazan Area: a Quasi-Experimental Study

Effect of Health Education on Female Teachers’ Knowledge and Practices Regarding Early Breast... Educational programs are important tools for breast cancer prevention. The purpose of this study was to assess the effectiveness of health education in improving the knowledge and practices of female teachers regarding screening tools and the early detection of breast cancer. A two-group quasi-experimental design was conducted among 150 female teachers, who were selected from 75 schools of the Jazan General Administration of Education. Schools were chosen by a simple cluster randomization method and non-randomly assigned to either the intervention or control group. Eligible participants were recruited by a simple randomization method, proportional to the total number of teachers at each school. Those in the intervention group (n = 75) were compared to the control group (n = 75) at baseline, as well as at 6 weeks and 3 months post-intervention. Knowledge of breast cancer screening tools was measured using a modified version of the Breast Cancer Knowledge test. Breast self-examination, clinical breast examination, and mammography practices were also measured. Compared to the control group, the intervention group showed a statistically significant increase in knowledge and practice levels at both 6 weeks and 3 months post-intervention. Thus, the results of this study provide evidence that group health education programs are effective in improving breast cancer knowledge and practices in female teachers. Clinical Trial Registration number: NCT03398057. . . . . Keywords Breast cancer screening Health education Breast self-examination Clinical breast examination Mammography Introduction which in turn will represent a huge economic burden in the KSA [3]. Unfortunately, most BC cases in Saudi Arabia are Breast cancer (BC) is common in developed and developing detected in late and advanced stages with very poor prognosis. countries, and it represents 23% of all cancers in women Most studies have attributed this to low awareness levels worldwide [1]. As of 2014, BC has accounted for about among Saudi women regarding various aspects of BC, espe- 28.7% of all newly diagnosed cancer in Saudi women, making cially early detection and screening tools [2, 4–8]. it the most common cancer in this population [2]. BC inci- Early detection of BC is an important step to decrease the dence is expected to increase to 350% by the end of 2025, morbidity and mortality of this disease. BC screening tools include breast self-examination (BSE), clinical breast exami- nation (CBE), and mammography. Cooperation between BC Electronic supplementary material The online version of this article screening tools is the best way to efficiently reduce disease (https://doi.org/10.1007/s13187-018-1386-9) contains supplementary burden [9, 10]. material, which is available to authorized users. Several studies of Saudi women have revealed very low levels of knowledge and usage of BC screening tools. * Anwar Alameer Alameeranwar@hotmail.com Clearly, there is major defect in health education programs, which have so far failed to change women’s behavioral habits, even though BC screening tools have been provided free of Jazan Health Directorate, Ministry of Health, P.O. Box 1121, Abu Arish 45911, Jazan, Saudi Arabia charge [4, 5, 7, 8]. Health education is a practical, effective method to increase Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia women’s awareness of the importance of early BC detection and its associated tools [11–16]. Group health education has Health Education and Promotion Department, Faculty of Public health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia proven to be effective in this field [12–14, 16], and such 866 J Canc Educ (2019) 34:865–870 programs are commonly based on the health belief model group after an assumed 25% attrition rate after the 3- (HBM) [12, 14–16]. Several studies worldwide have proven the month follow-up. Accordingly, 75 participants were re- effectiveness of HBM-based education programs in increasing cruited for each group. BC awareness of, but few such studies have been performed in Saudi Arabia [12, 14–16]. The main objective of this study is Intervention to assess the effectiveness of a health education program in improving the knowledge and usage of screening tools for the Participants in the intervention group underwent a HBM- early detection of BC, among a cohort of female teachers in based standardized health education program (SHEP) de- Jazan, Saudi Arabia. veloped by the Heath Education Committee of the Health Education and Promotion Department, Faculty of Public Health and Tropical Medicine, Jazan University Material and Methods (Supplementary Material 1). SHEP included a comprehen- sive lecture about BC, with a deep focus on detection and Study Design screening tools, illustrated with a PowerPoint presentation containing pictures and videos. The program also includ- This was a quasi-experimental study carried from November ed a practical BSE session. Each educational session 2017 to February 2018. It was registered in the Clinical Trials lasted 60 min. At the end of SHEP, a focused group dis- Registry in December 2017 (http://www.ClinicalTrials.gov). cussion was conducted to answer participants’ questions, and to discuss important barriers regarding BSE practice Participants and Setting and visiting primary health care centers or clinics to un- dergo CBE and mammography. Several scientific and ad- This study was conducted in the city of Jazan, in south- ministrative solutions were discussed, with a concentra- west Saudi Arabia. The targeted population included all tion on the benefits of screening tools, both to overcome female teachers (approximately 1400) among 75 schools those barriers and to motivate the participants to utilize belonging to the middle education office of the Jazan breast cancer screening tools. The interventions were con- General Administration of Education, Ministry of ducted by three health care assistants who were trained by Education. Teachers were chosen according to the follow- the Health Education Committee and the primary investi- ing eligibility criteria: age ≥ 20 years, no history of BC gator. Participants in the control group were educated (personally or in a first-degree relative), and not pregnant through pamphlets that included general information or breast feeding. Participants were excluded if they re- about BC, without any interaction with our defined mea- fused to give informed consent, or if any severe medical sured variables. At the end of the data collection period, problem prevented participation. This study evaluated the SHEP was presented to the control group participants and effectiveness of health education in improving partici- the educational material was distributed. pants’ knowledge of BC screening tools and relevant practices, by comparing a health education group with a Measures control group at three time points (baseline, 6 weeks, and 3 months). The dependent variables were the level of The modified questionnaire used in this study comprised knowledge of BC detection and screening tools, and the four parts assessing knowledge of BC screening tools and practice thereof, including BSE, CBE, and mammogra- practice. The first part of the questionnaire collected phy. The independent variables were the type of interven- sociodemographic information. The second part was a tion, age, and social status. modified version of the Breast Cancer Knowledge (BCK) test developed by McCance in 1989, and assessed the par- Sampling Procedures ticipant’s knowledge of BC screening tools [17, 18]. The third part of the questionnaire assessed each participant’s Eight schools were chosen randomly according to the de- BSE practices using the scale described by Champion in sired sample size (150 participants) and the average num- 1990 [19]. The fourth part of the questionnaire assessed the ber of teachers per school (23.6). First, four schools were participant’s CBE and mammography practices, based on non-randomly allocated to the health education group, and questionnaires by de Oliveira et al. and Wang J.H. et al. other four were allocated to the control group. Eligible [15, 20]. In total, the questionnaire included 38 items, with participants were recruited by a simple randomization a mix of multiple-choice and yes/no questions in addition method proportional to the number of teachers per school. to demographic data. Each part of the instrument has been The study sample size was estimated based on a similar rigorously tested for reliability and validity (see studybyHeydari et al.[14], with 60 participants in each Supplementary Material 2). J Canc Educ (2019) 34:865–870 867 Data Collection Procedure recommended by Saudi Arabian guidelines. On the other hand, 85.3% (n = 128) knew about the increasing risk of BC Data were collected using the same self-administered ques- with age. Only 26.7 and 22.7% of participants in the interven- tionnaire at the three time points. On average, it took 20 min tion and control groups, respectively, were aware of abnormal- to finish the questionnaire. Data for the first time point was ities in nipple discharge. In contrast, 60% of participants in collected from all participants within 4 weeks. The 6-week both groups understood the symptoms of BC. data was collected within 2 weeks with a 100% response rate The differences between participants in the intervention in both groups. The 3-month data was also collected within and control groups at baseline were not statistically significant 2 weeks, with response rates of 98.7 and 97.3% in the inter- for any knowledge items related to BC detection and screen- vention and control groups, respectively. The losses to follow ing tools. The overall knowledge scores of both groups before up were due to either the inability to make contact or refusal to intervention were similar (P = 0.419). In contrast, the knowl- participate. edge scores significantly differed between the groups, both 6weeks and3monthsafter intervention(P <0.001) Statistical Analysis (Table 2). The knowledge scores were increased in the inter- vention group post intervention (P < 0.001, odds ratio [OR] = Data were analyzed using the Statistical Package for the Social 29.5, 95% confidence interval [CI] = 11.49–75.70). The pre- Sciences, version 23 (SPSS). Descriptive statistics, the inde- and post-intervention knowledge scores in the control group pendent t test, the chi-squared test, the Mann–Whitney U test, were not significantly different (P =0.692) (Table 2). the Wilcoxon signed-rank test, McNemar’s test, the Friedman test, and logistic regression were used for data analysis. Breast Self-Examination Scale Of the entire study sample, 57.3% (n = 86) practiced BSE Results before health education, and the BSE scores of the two groups were similar (P = 0.722). On the other hand, the BSE scores Demographic Information were significantly different between groups 6 weeks and 3 months after intervention (P <0.001). Three months after The participants in the intervention and the control groups had health education, 93.2% (n = 69) of the intervention group similar demographic characteristics, with no statistically sig- and 58.9% (n = 43) of the control group practiced BSE (P < nificant differences (Table 1). 0.001). Overall, the BSE score was significantly increased in the intervention group (P < 0.001, OR = 26.25, 95% CI = Breast Cancer Knowledge Test 8.26–83.42) (Tables 2 and 3). Most of the participants (n = 142, 94.7%) stated that mam- Clinical Breast Exam and Mammography mography can detect unfelt lumps easily, and 89.3% (n = 134) viewed BSE as effective for detecting breast cancer. In Compared to the control group, there was a significant in- contrast, a minority of the participants (28%, n = 42) realized crease in the level of CBE and mammography practice among the importance of practicing BSE in conjunction with under- the teachers in the intervention group at 6 weeks and 3 months going CBE and mammography. Only 20.7% (n = 31) knew after health education program (P < 0.001 and P = 0.001, the recommended age to undergo mammography as respectively; Tables 3 and 4). Table 1 Sociodemographic Demographic Intervention group Control group Statistic P characteristics in the intervention and control groups at baseline n % n % Age (M ± SD) 39.03 ± 4.96 75 38.97 ± 4.43 75 0.069 0.945 < 40 35.3 ± 3.1 39 52 35.8 ± 2.8 41 54.7 ≥ 40 43.3 ± 3.1 36 48 42.7 ± 2.70 34 45.3 ** Marital status Single 10 13.3 10 13.3 1.444 0.780 Married 60 80 63 84 Widowed 3 4 1 1.3 Divorced 2 2.7 1 1.3 M,mean; SD, standard deviation. *Independent t test; **Fisher’s exact test 868 J Canc Educ (2019) 34:865–870 Table 2 Between- and within- Item Score group comparisons of knowledge and practice scores for breast Time Intervention group, Control group, P cancer screening tools for the median ± IQR median ± IQR intervention (IG) and control groups (CG) Overall knowledge Before intervention 9 (3) 10 (5) P =0.419 score 6 weeks after 15 (3) 9.5 (5) P <0.001 intervention 3 months after 15 (2.5) 9.5 (5) P <0.001 intervention ** P P <0.001 P =0.747 BSE score Before intervention 18 (8.25) 17 (7) P =0.722 6 weeks after 38.5 (9.25) 18 (12) P <0.001 intervention 3 months after 37.5 (8.25) 17 (14) P <0.001 intervention ** P P <0.001 P <0.001 Overall knowledge score was calculated by summing the number of correct responses, with possible scores ranging from 0 to 19. Each correct response was worth one point. BSE, breast self-examination. The BSE score was calculated by summing the number of correct responses, with possible values ranging from 0 to 45. Each completely correct response was worth three points Statistical tests: *Mann–Whitney U test (between IG and CG pre-intervention, 6 weeks and 3 months post- intervention), **Freidman test (within-groups comparison). IQR, interquartile range Discussion those of previous studies and support the role of HBM- guided interventions in this area [12, 14–16]. This is one of the few studies in Saudi Arabia to assess the Improved knowledge levels had a positive impact on be- benefits of a group health education program on improving havioral change by increasing self-confidence among targeted female teachers’ knowledge and utilization of screening tools women. High confidence levels lead to improved usage of BC for the early detection of breast cancer. screening tools and ensure the sustained value of screening Group health education has proven to be effective in tools, especially with close monitoring of participants, as pre- increasing the knowledge and practice of breast cancer viously demonstrated by a study in Sri Lanka [12, 13]. screening tools in different populations [12–14, 16]. The The present study’s results demonstrated the effectiveness results of the present study imply that our group health of group health education on increasing BSE practices among education program was effective in improving knowledge female teachers, especially with its comprehensive practical and breast cancer screening practices among female session using a silicone breast model to simulate how to dis- teachers in the Jazan area. These results are consistent with cover a lump and to enable a deep understanding of abnormal Table 3 Pre- and post-intervention comparison of practices regarding breast cancer screening tools between female teachers in the intervention (IG) and control groups (CG) Practice item Pre-intervention 6 weeks post-intervention 3 months post-intervention IG CG Significance IG CG Significance IG CG Significance (N =75) (N =75) (N =75) (N =75) (N =74) (N =73) Practicing BSE 2 2= 2= Yes 43 (57.3%) 43 (57.3%) χ = 0.000 69 (92%) 43 (57.3%) χ 23.825 69 (93.2%) 43 (58.9%) χ 23.887 No 32 (42.7%) 32 (42.7%) P =1.000 6 (8%) 32 (42.7%) P < 0.001 5 (6.8%) 30 (41.1%) P <0.001 ** Underwent CBE without feeling anything 2 2 2 Yes 14 (18.7%) 15 (20.0%) χ = 0.043 53 (70.7%) 16 (21.3%) χ = 36.742 55 (74.3%) 16 (21.9%) χ = 40.418 No 61 (81.3%) 60 (80.0%) P = 0.836 22 (29.3%) 59 (78.7%) P < 0.001 19 (25.7%) 57 (78.1%) P <0.001 ** Underwent an annual CBE 2 2 2 Yes 14 (18.7%) 13 (17.3%) χ = 0.045 53 (70.7%) 14 (18.7%) χ = 41.027 55 (74.3%) 15 (20.5%) χ = 42.606 No 61 (81.3%) 62 (82.7%) P = 0.832 22 (29.3%) 61 (81.3%) P < 0.001 19 (25.7%) 58 (79.5%) P <0.001 *Breast self-examination, **Clinical breast examination, χ Chi-square test J Canc Educ (2019) 34:865–870 869 Table 4 Pre- and post-intervention comparison of BC screening tools between female teachers in the intervention (IG) and control groups (CG) Practice Items Pre-intervention 6 weeks post-intervention 3 months post-intervention IG CG Significance IG CG Significance IG CG Significance (N =36) (N =34) (N =36) (N =34) (N =36) (N =32) Underwent a mammogram, for women ≥ 40 years 2 2 2 Yes 14 (38.9%) 11 (32.4%) χ = 0.325 25 (69.4%) 11 (32.4%) χ = 9.630 27 (75.0%) 11 (34.4%) χ = 11.341 No 22 (61.1%) 23 (67.6%) P = 0.568 11 (30.6%) 23 (67.6%) P = 0.002 9 (25.0%) 21 (65.6%) P =0.001 Last mammogram 2* 2* 2* Less than 1 year 1 (7.1%) 2 (18.2%) χ =2.083 17 (68.0%) 2 (18.2%) χ =13.147 21 (77.8%) 3 (27.3%) χ = 12.574 P =0.603 P =0.003 P =0.003 2 2* χ Chi-square test, χ Fisher’s exact test breast changes [12]. Focused group discussion has been dem- can enable more women to undergo CBE and mammography onstrated to change women’s health beliefs regarding the ben- and would provide enough time to test the sustainability of efits of BC screening tools, and to motivate them to apply BSE practices. It could also provide an excellent chance to these tools, as shown in previous studies of populations in evaluate intermediate and long-term outcomes among wom- Malaysia and Turkey [12, 16]. en. Moreover, close monitoring would allow for the effective- We also confirmed the effectiveness of health education ness of this health education program to be more precisely based on HBM in overcoming several barriers mentioned in evaluated in the long term. Finally, the current study was con- previous studies of Saudi women. Of the study participants, ducted only in female teachers, which is an important limita- 74.3% underwent CBE after the group health education pro- tion that reduces the generalizability of the results to the gen- gram, compared to 18.7% before it. Moreover, 75% of the eral population in Saudi Arabia. subjects ≥ 40 years of age underwent mammography after the group health education program, compared with 38.9% before. These results regarding mammograms are consistent Conclusion with those of a similar study in Iran [14]. Finally, although group health education is more cost- Our group health education program, based on HBM, was effective and less time-consuming than individual health effective in improving knowledge and practices regarding education methods [11, 14], evidence suggests that group BC screening tools among female teachers in Jazan area and individual health education programs are equally ef- schools. There is great opportunity for researchers in Saudi fective [21]. In contrast, multimedia health education is an Arabia to study a variety of health education methods, behav- even more time- and cost-effective method than group ioral change models, and various targeted populations in this health education. While group health education was more field. Moreover, qualitative research should be performed to effective than multimedia health education in improving gain an in-depth understanding of the perception, awareness, knowledge and practice levels of mammography among and attitudes regarding breast cancer screening tools in target female teachers in an Iranian study, multimedia programs populations. Such findings would be valuable for exploring have the advantages of simplicity, flexibility, and repro- the various barriers hindering the use of breast cancer screen- ducibility [14]. The current study only demonstrated the ing tools at the community level. effectiveness of group health education in achieving Acknowledgements The authors gratefully acknowledge the female short-term outcomes. Intermediate and long-term out- teachers who consented to participate in the study, the leaders of the comes must be tested in future research by using longer schools that served as data collection sites, and the directorate of Jazan follow-up periods. Moreover, logical program models need General Administration of Education, Ministry of Education. We also to be applied to optimize the achievement of intermediate gratefully acknowledge the female team that helped with data collection. and long-term outcomes among targeted populations, re- quiring strong governmental support to have a significant Compliance with Ethical Standards effect at the population level [22]. This research protocol was reviewed and approved by the Research Ethics Committee of the Medicine College at King Khalid University Limitations (REF #2017-05-15). The whole study was conducted according to the guidelines of Saudi Committee of Bioethics Research and the Declaration The short follow-up period and lack of close monitoring were of Helsinki. Written informed consent was obtained from each participant. important limitations of this study. Longer follow-up periods 870 J Canc Educ (2019) 34:865–870 Conflict of Interest The authors declare that they have no conflict of 9. Himes DO, Root AE, Gammon A, Luthy KE (2016) Breast cancer interest. risk assessment: calculating lifetime risk using the Tyrer-Cuzick model. JNP 12:581–592 10. Ministry of Health (2018) Breast cancer. https://www.moh.gov.sa/ Abbreviations BCK, breast cancer knowledge; BSE, breast self-exam- en/Pages/Default.aspx Accessed 7 April 2018 ination; CBE, clinical breast examination; BC, breast cancer; HBM, 11. Taha H, Nyström L, Al-Qutob R, Berggren V, Esmaily H, health belief model; SHEP, standardized health education program Wahlström R (2014) Home visits to improve breast health knowl- Open Access This article is distributed under the terms of the Creative edge and screening practices in a less privileged area in Jordan. Commons Attribution 4.0 International License (http:// BMC Public Health 14:428 creativecommons.org/licenses/by/4.0/), which permits unrestricted use, 12. Akhtari-Zavare M, Juni MH, Said SM, Ismail IZ, Latiff LA, distribution, and reproduction in any medium, provided you give Eshkoor SA (2016) Result of randomized control trial to increase appropriate credit to the original author(s) and the source, provide a link breast health awareness among young females in Malaysia. BMC to the Creative Commons license, and indicate if changes were made. Public Health 16:738 13. Vithana PC, Ariyaratne M, Jayawardana PL (2015) Educational intervention on breast cancer early detection: effectiveness among target group women in the district of Gampaha, Sri Lanka. Asian Pac J Cancer Prev 16:2547–2553 14. Heydari E, Noroozi A (2015) Comparison of two different educa- References tional methods for teachers’ mammography based on the health belief model. Asian Pac J Cancer Prev 16:6981–6986 15. Wang JH, Schwartz MD, Luta G, Maxwell AE, Mandelblatt JS 1. World Health Organization (2018) Breast cancer: prevention and (2012) Intervention tailoring for Chinese American women: com- control. http://www.who.int/cancer/detection/breastcancer/en/ paring the effects of two videos on knowledge, attitudes and inten- Accessed 7 April 2018 tions to obtain a mammogram. Health Educ Res 27:523–536 2. Saudi Cancer Registry (2014) Cancer registry report. http://www. 16. Avci IA, Gozum S (2009) Comparison of two different educational chs.gov.sa/En/HealthRecords/CancerRegistry/Pages/ Accessed 7 methods on teachers’ knowledge, beliefs and behaviors regarding April 2018 breast cancer screening. Eur J Oncol Nurs 13:94–101 3. Ibrahim EM, Zeeneldin AA, Sadiq BB, Ezzat AA (2008) The pres- ent and the future of breast cancer burden in the Kingdom of Saudi 17. McCance KL, Mooney KH, Smith KR, Field R (1990) Validity and Arabia. Med Oncol 25:387–393 reliability of a breast cancer knowledge test. Am J Prev Med 6:93– 4. Abolfotouh MA, BaniMustafa AA, Mahfouz AA, Al-Assiri MH, 98 Al-Juhani AF, Alaskar AS (2015) Using the health belief model to 18. Guilford K (2011) Breast cancer knowledge, beliefs, and screening predict breast self examination among Saudi women. BMC Public behaviors of college women: utilization of the health belief model. Health 15:1163 Dissertation. The University of Alabama 5. El Bcheraoui C, Basulaiman M, Wilson S, Daoud F, Tuffaha M, 19. Champion VL (1990) Breast self-examination in women 35 and AlMazroa MA, Memish ZA, Al Saeedi M, Mokdad AH (2015) older: a prospective study. J Behav Med 13:523–539 Breast cancer screening in Saudi Arabia: free but almost no takers. 20. de Oliveira RDP, Santos MCL, Moreira CB, Fernandes AFC (2017) PLoS One 10:e0119051 Detection of breast cancer: knowledge, attitude, and practice of 6. Alam AA (2006) Knowledge of breast cancer and its risk and pro- family health strategy women. J Cancer Educ. https://doi.org/10. tective factors among women in Riyadh. Ann Saudi Med 26:272– 1007/s13187-017-1209-4 21. Rickheim PL, Weaver TW, Flader JL, Kendall DM (2002) 7. Amin TT, Al Mulhim AR, Al Meqihwi A (2009) Breast cancer Assessment of group versus individual diabetes education: a ran- knowledge, risk factors and screening among adult Saudi women domized study. Diabetes Care 25:269–274 in a primary health care setting. Asian Pac J Cancer Prev 10:133– 22. Centers for Disease Control and Prevention (2018) Infrastructure Development Tools: Logic Models. https://www.cdc.gov/ 8. Kashgari RH, Ibrahim AM (1996) Breast cancer: attitude, knowl- oralhealth/state_programs/pdf/logic_models.pdf Accessed 7 April edge and practice of breast self examination of 157 Saudi women. J Family Community Med 3:10–13 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Effect of Health Education on Female Teachers’ Knowledge and Practices Regarding Early Breast Cancer Detection and Screening in the Jazan Area: a Quasi-Experimental Study

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Springer Journals
Copyright
Copyright © 2018 by The Author(s)
Subject
Biomedicine; Cancer Research; Pharmacology/Toxicology
ISSN
0885-8195
eISSN
1543-0154
DOI
10.1007/s13187-018-1386-9
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Abstract

Educational programs are important tools for breast cancer prevention. The purpose of this study was to assess the effectiveness of health education in improving the knowledge and practices of female teachers regarding screening tools and the early detection of breast cancer. A two-group quasi-experimental design was conducted among 150 female teachers, who were selected from 75 schools of the Jazan General Administration of Education. Schools were chosen by a simple cluster randomization method and non-randomly assigned to either the intervention or control group. Eligible participants were recruited by a simple randomization method, proportional to the total number of teachers at each school. Those in the intervention group (n = 75) were compared to the control group (n = 75) at baseline, as well as at 6 weeks and 3 months post-intervention. Knowledge of breast cancer screening tools was measured using a modified version of the Breast Cancer Knowledge test. Breast self-examination, clinical breast examination, and mammography practices were also measured. Compared to the control group, the intervention group showed a statistically significant increase in knowledge and practice levels at both 6 weeks and 3 months post-intervention. Thus, the results of this study provide evidence that group health education programs are effective in improving breast cancer knowledge and practices in female teachers. Clinical Trial Registration number: NCT03398057. . . . . Keywords Breast cancer screening Health education Breast self-examination Clinical breast examination Mammography Introduction which in turn will represent a huge economic burden in the KSA [3]. Unfortunately, most BC cases in Saudi Arabia are Breast cancer (BC) is common in developed and developing detected in late and advanced stages with very poor prognosis. countries, and it represents 23% of all cancers in women Most studies have attributed this to low awareness levels worldwide [1]. As of 2014, BC has accounted for about among Saudi women regarding various aspects of BC, espe- 28.7% of all newly diagnosed cancer in Saudi women, making cially early detection and screening tools [2, 4–8]. it the most common cancer in this population [2]. BC inci- Early detection of BC is an important step to decrease the dence is expected to increase to 350% by the end of 2025, morbidity and mortality of this disease. BC screening tools include breast self-examination (BSE), clinical breast exami- nation (CBE), and mammography. Cooperation between BC Electronic supplementary material The online version of this article screening tools is the best way to efficiently reduce disease (https://doi.org/10.1007/s13187-018-1386-9) contains supplementary burden [9, 10]. material, which is available to authorized users. Several studies of Saudi women have revealed very low levels of knowledge and usage of BC screening tools. * Anwar Alameer Alameeranwar@hotmail.com Clearly, there is major defect in health education programs, which have so far failed to change women’s behavioral habits, even though BC screening tools have been provided free of Jazan Health Directorate, Ministry of Health, P.O. Box 1121, Abu Arish 45911, Jazan, Saudi Arabia charge [4, 5, 7, 8]. Health education is a practical, effective method to increase Family and Community Medicine Department, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia women’s awareness of the importance of early BC detection and its associated tools [11–16]. Group health education has Health Education and Promotion Department, Faculty of Public health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia proven to be effective in this field [12–14, 16], and such 866 J Canc Educ (2019) 34:865–870 programs are commonly based on the health belief model group after an assumed 25% attrition rate after the 3- (HBM) [12, 14–16]. Several studies worldwide have proven the month follow-up. Accordingly, 75 participants were re- effectiveness of HBM-based education programs in increasing cruited for each group. BC awareness of, but few such studies have been performed in Saudi Arabia [12, 14–16]. The main objective of this study is Intervention to assess the effectiveness of a health education program in improving the knowledge and usage of screening tools for the Participants in the intervention group underwent a HBM- early detection of BC, among a cohort of female teachers in based standardized health education program (SHEP) de- Jazan, Saudi Arabia. veloped by the Heath Education Committee of the Health Education and Promotion Department, Faculty of Public Health and Tropical Medicine, Jazan University Material and Methods (Supplementary Material 1). SHEP included a comprehen- sive lecture about BC, with a deep focus on detection and Study Design screening tools, illustrated with a PowerPoint presentation containing pictures and videos. The program also includ- This was a quasi-experimental study carried from November ed a practical BSE session. Each educational session 2017 to February 2018. It was registered in the Clinical Trials lasted 60 min. At the end of SHEP, a focused group dis- Registry in December 2017 (http://www.ClinicalTrials.gov). cussion was conducted to answer participants’ questions, and to discuss important barriers regarding BSE practice Participants and Setting and visiting primary health care centers or clinics to un- dergo CBE and mammography. Several scientific and ad- This study was conducted in the city of Jazan, in south- ministrative solutions were discussed, with a concentra- west Saudi Arabia. The targeted population included all tion on the benefits of screening tools, both to overcome female teachers (approximately 1400) among 75 schools those barriers and to motivate the participants to utilize belonging to the middle education office of the Jazan breast cancer screening tools. The interventions were con- General Administration of Education, Ministry of ducted by three health care assistants who were trained by Education. Teachers were chosen according to the follow- the Health Education Committee and the primary investi- ing eligibility criteria: age ≥ 20 years, no history of BC gator. Participants in the control group were educated (personally or in a first-degree relative), and not pregnant through pamphlets that included general information or breast feeding. Participants were excluded if they re- about BC, without any interaction with our defined mea- fused to give informed consent, or if any severe medical sured variables. At the end of the data collection period, problem prevented participation. This study evaluated the SHEP was presented to the control group participants and effectiveness of health education in improving partici- the educational material was distributed. pants’ knowledge of BC screening tools and relevant practices, by comparing a health education group with a Measures control group at three time points (baseline, 6 weeks, and 3 months). The dependent variables were the level of The modified questionnaire used in this study comprised knowledge of BC detection and screening tools, and the four parts assessing knowledge of BC screening tools and practice thereof, including BSE, CBE, and mammogra- practice. The first part of the questionnaire collected phy. The independent variables were the type of interven- sociodemographic information. The second part was a tion, age, and social status. modified version of the Breast Cancer Knowledge (BCK) test developed by McCance in 1989, and assessed the par- Sampling Procedures ticipant’s knowledge of BC screening tools [17, 18]. The third part of the questionnaire assessed each participant’s Eight schools were chosen randomly according to the de- BSE practices using the scale described by Champion in sired sample size (150 participants) and the average num- 1990 [19]. The fourth part of the questionnaire assessed the ber of teachers per school (23.6). First, four schools were participant’s CBE and mammography practices, based on non-randomly allocated to the health education group, and questionnaires by de Oliveira et al. and Wang J.H. et al. other four were allocated to the control group. Eligible [15, 20]. In total, the questionnaire included 38 items, with participants were recruited by a simple randomization a mix of multiple-choice and yes/no questions in addition method proportional to the number of teachers per school. to demographic data. Each part of the instrument has been The study sample size was estimated based on a similar rigorously tested for reliability and validity (see studybyHeydari et al.[14], with 60 participants in each Supplementary Material 2). J Canc Educ (2019) 34:865–870 867 Data Collection Procedure recommended by Saudi Arabian guidelines. On the other hand, 85.3% (n = 128) knew about the increasing risk of BC Data were collected using the same self-administered ques- with age. Only 26.7 and 22.7% of participants in the interven- tionnaire at the three time points. On average, it took 20 min tion and control groups, respectively, were aware of abnormal- to finish the questionnaire. Data for the first time point was ities in nipple discharge. In contrast, 60% of participants in collected from all participants within 4 weeks. The 6-week both groups understood the symptoms of BC. data was collected within 2 weeks with a 100% response rate The differences between participants in the intervention in both groups. The 3-month data was also collected within and control groups at baseline were not statistically significant 2 weeks, with response rates of 98.7 and 97.3% in the inter- for any knowledge items related to BC detection and screen- vention and control groups, respectively. The losses to follow ing tools. The overall knowledge scores of both groups before up were due to either the inability to make contact or refusal to intervention were similar (P = 0.419). In contrast, the knowl- participate. edge scores significantly differed between the groups, both 6weeks and3monthsafter intervention(P <0.001) Statistical Analysis (Table 2). The knowledge scores were increased in the inter- vention group post intervention (P < 0.001, odds ratio [OR] = Data were analyzed using the Statistical Package for the Social 29.5, 95% confidence interval [CI] = 11.49–75.70). The pre- Sciences, version 23 (SPSS). Descriptive statistics, the inde- and post-intervention knowledge scores in the control group pendent t test, the chi-squared test, the Mann–Whitney U test, were not significantly different (P =0.692) (Table 2). the Wilcoxon signed-rank test, McNemar’s test, the Friedman test, and logistic regression were used for data analysis. Breast Self-Examination Scale Of the entire study sample, 57.3% (n = 86) practiced BSE Results before health education, and the BSE scores of the two groups were similar (P = 0.722). On the other hand, the BSE scores Demographic Information were significantly different between groups 6 weeks and 3 months after intervention (P <0.001). Three months after The participants in the intervention and the control groups had health education, 93.2% (n = 69) of the intervention group similar demographic characteristics, with no statistically sig- and 58.9% (n = 43) of the control group practiced BSE (P < nificant differences (Table 1). 0.001). Overall, the BSE score was significantly increased in the intervention group (P < 0.001, OR = 26.25, 95% CI = Breast Cancer Knowledge Test 8.26–83.42) (Tables 2 and 3). Most of the participants (n = 142, 94.7%) stated that mam- Clinical Breast Exam and Mammography mography can detect unfelt lumps easily, and 89.3% (n = 134) viewed BSE as effective for detecting breast cancer. In Compared to the control group, there was a significant in- contrast, a minority of the participants (28%, n = 42) realized crease in the level of CBE and mammography practice among the importance of practicing BSE in conjunction with under- the teachers in the intervention group at 6 weeks and 3 months going CBE and mammography. Only 20.7% (n = 31) knew after health education program (P < 0.001 and P = 0.001, the recommended age to undergo mammography as respectively; Tables 3 and 4). Table 1 Sociodemographic Demographic Intervention group Control group Statistic P characteristics in the intervention and control groups at baseline n % n % Age (M ± SD) 39.03 ± 4.96 75 38.97 ± 4.43 75 0.069 0.945 < 40 35.3 ± 3.1 39 52 35.8 ± 2.8 41 54.7 ≥ 40 43.3 ± 3.1 36 48 42.7 ± 2.70 34 45.3 ** Marital status Single 10 13.3 10 13.3 1.444 0.780 Married 60 80 63 84 Widowed 3 4 1 1.3 Divorced 2 2.7 1 1.3 M,mean; SD, standard deviation. *Independent t test; **Fisher’s exact test 868 J Canc Educ (2019) 34:865–870 Table 2 Between- and within- Item Score group comparisons of knowledge and practice scores for breast Time Intervention group, Control group, P cancer screening tools for the median ± IQR median ± IQR intervention (IG) and control groups (CG) Overall knowledge Before intervention 9 (3) 10 (5) P =0.419 score 6 weeks after 15 (3) 9.5 (5) P <0.001 intervention 3 months after 15 (2.5) 9.5 (5) P <0.001 intervention ** P P <0.001 P =0.747 BSE score Before intervention 18 (8.25) 17 (7) P =0.722 6 weeks after 38.5 (9.25) 18 (12) P <0.001 intervention 3 months after 37.5 (8.25) 17 (14) P <0.001 intervention ** P P <0.001 P <0.001 Overall knowledge score was calculated by summing the number of correct responses, with possible scores ranging from 0 to 19. Each correct response was worth one point. BSE, breast self-examination. The BSE score was calculated by summing the number of correct responses, with possible values ranging from 0 to 45. Each completely correct response was worth three points Statistical tests: *Mann–Whitney U test (between IG and CG pre-intervention, 6 weeks and 3 months post- intervention), **Freidman test (within-groups comparison). IQR, interquartile range Discussion those of previous studies and support the role of HBM- guided interventions in this area [12, 14–16]. This is one of the few studies in Saudi Arabia to assess the Improved knowledge levels had a positive impact on be- benefits of a group health education program on improving havioral change by increasing self-confidence among targeted female teachers’ knowledge and utilization of screening tools women. High confidence levels lead to improved usage of BC for the early detection of breast cancer. screening tools and ensure the sustained value of screening Group health education has proven to be effective in tools, especially with close monitoring of participants, as pre- increasing the knowledge and practice of breast cancer viously demonstrated by a study in Sri Lanka [12, 13]. screening tools in different populations [12–14, 16]. The The present study’s results demonstrated the effectiveness results of the present study imply that our group health of group health education on increasing BSE practices among education program was effective in improving knowledge female teachers, especially with its comprehensive practical and breast cancer screening practices among female session using a silicone breast model to simulate how to dis- teachers in the Jazan area. These results are consistent with cover a lump and to enable a deep understanding of abnormal Table 3 Pre- and post-intervention comparison of practices regarding breast cancer screening tools between female teachers in the intervention (IG) and control groups (CG) Practice item Pre-intervention 6 weeks post-intervention 3 months post-intervention IG CG Significance IG CG Significance IG CG Significance (N =75) (N =75) (N =75) (N =75) (N =74) (N =73) Practicing BSE 2 2= 2= Yes 43 (57.3%) 43 (57.3%) χ = 0.000 69 (92%) 43 (57.3%) χ 23.825 69 (93.2%) 43 (58.9%) χ 23.887 No 32 (42.7%) 32 (42.7%) P =1.000 6 (8%) 32 (42.7%) P < 0.001 5 (6.8%) 30 (41.1%) P <0.001 ** Underwent CBE without feeling anything 2 2 2 Yes 14 (18.7%) 15 (20.0%) χ = 0.043 53 (70.7%) 16 (21.3%) χ = 36.742 55 (74.3%) 16 (21.9%) χ = 40.418 No 61 (81.3%) 60 (80.0%) P = 0.836 22 (29.3%) 59 (78.7%) P < 0.001 19 (25.7%) 57 (78.1%) P <0.001 ** Underwent an annual CBE 2 2 2 Yes 14 (18.7%) 13 (17.3%) χ = 0.045 53 (70.7%) 14 (18.7%) χ = 41.027 55 (74.3%) 15 (20.5%) χ = 42.606 No 61 (81.3%) 62 (82.7%) P = 0.832 22 (29.3%) 61 (81.3%) P < 0.001 19 (25.7%) 58 (79.5%) P <0.001 *Breast self-examination, **Clinical breast examination, χ Chi-square test J Canc Educ (2019) 34:865–870 869 Table 4 Pre- and post-intervention comparison of BC screening tools between female teachers in the intervention (IG) and control groups (CG) Practice Items Pre-intervention 6 weeks post-intervention 3 months post-intervention IG CG Significance IG CG Significance IG CG Significance (N =36) (N =34) (N =36) (N =34) (N =36) (N =32) Underwent a mammogram, for women ≥ 40 years 2 2 2 Yes 14 (38.9%) 11 (32.4%) χ = 0.325 25 (69.4%) 11 (32.4%) χ = 9.630 27 (75.0%) 11 (34.4%) χ = 11.341 No 22 (61.1%) 23 (67.6%) P = 0.568 11 (30.6%) 23 (67.6%) P = 0.002 9 (25.0%) 21 (65.6%) P =0.001 Last mammogram 2* 2* 2* Less than 1 year 1 (7.1%) 2 (18.2%) χ =2.083 17 (68.0%) 2 (18.2%) χ =13.147 21 (77.8%) 3 (27.3%) χ = 12.574 P =0.603 P =0.003 P =0.003 2 2* χ Chi-square test, χ Fisher’s exact test breast changes [12]. Focused group discussion has been dem- can enable more women to undergo CBE and mammography onstrated to change women’s health beliefs regarding the ben- and would provide enough time to test the sustainability of efits of BC screening tools, and to motivate them to apply BSE practices. It could also provide an excellent chance to these tools, as shown in previous studies of populations in evaluate intermediate and long-term outcomes among wom- Malaysia and Turkey [12, 16]. en. Moreover, close monitoring would allow for the effective- We also confirmed the effectiveness of health education ness of this health education program to be more precisely based on HBM in overcoming several barriers mentioned in evaluated in the long term. Finally, the current study was con- previous studies of Saudi women. Of the study participants, ducted only in female teachers, which is an important limita- 74.3% underwent CBE after the group health education pro- tion that reduces the generalizability of the results to the gen- gram, compared to 18.7% before it. Moreover, 75% of the eral population in Saudi Arabia. subjects ≥ 40 years of age underwent mammography after the group health education program, compared with 38.9% before. These results regarding mammograms are consistent Conclusion with those of a similar study in Iran [14]. Finally, although group health education is more cost- Our group health education program, based on HBM, was effective and less time-consuming than individual health effective in improving knowledge and practices regarding education methods [11, 14], evidence suggests that group BC screening tools among female teachers in Jazan area and individual health education programs are equally ef- schools. There is great opportunity for researchers in Saudi fective [21]. In contrast, multimedia health education is an Arabia to study a variety of health education methods, behav- even more time- and cost-effective method than group ioral change models, and various targeted populations in this health education. While group health education was more field. Moreover, qualitative research should be performed to effective than multimedia health education in improving gain an in-depth understanding of the perception, awareness, knowledge and practice levels of mammography among and attitudes regarding breast cancer screening tools in target female teachers in an Iranian study, multimedia programs populations. Such findings would be valuable for exploring have the advantages of simplicity, flexibility, and repro- the various barriers hindering the use of breast cancer screen- ducibility [14]. The current study only demonstrated the ing tools at the community level. effectiveness of group health education in achieving Acknowledgements The authors gratefully acknowledge the female short-term outcomes. Intermediate and long-term out- teachers who consented to participate in the study, the leaders of the comes must be tested in future research by using longer schools that served as data collection sites, and the directorate of Jazan follow-up periods. Moreover, logical program models need General Administration of Education, Ministry of Education. We also to be applied to optimize the achievement of intermediate gratefully acknowledge the female team that helped with data collection. and long-term outcomes among targeted populations, re- quiring strong governmental support to have a significant Compliance with Ethical Standards effect at the population level [22]. This research protocol was reviewed and approved by the Research Ethics Committee of the Medicine College at King Khalid University Limitations (REF #2017-05-15). The whole study was conducted according to the guidelines of Saudi Committee of Bioethics Research and the Declaration The short follow-up period and lack of close monitoring were of Helsinki. Written informed consent was obtained from each participant. important limitations of this study. Longer follow-up periods 870 J Canc Educ (2019) 34:865–870 Conflict of Interest The authors declare that they have no conflict of 9. Himes DO, Root AE, Gammon A, Luthy KE (2016) Breast cancer interest. risk assessment: calculating lifetime risk using the Tyrer-Cuzick model. JNP 12:581–592 10. Ministry of Health (2018) Breast cancer. https://www.moh.gov.sa/ Abbreviations BCK, breast cancer knowledge; BSE, breast self-exam- en/Pages/Default.aspx Accessed 7 April 2018 ination; CBE, clinical breast examination; BC, breast cancer; HBM, 11. Taha H, Nyström L, Al-Qutob R, Berggren V, Esmaily H, health belief model; SHEP, standardized health education program Wahlström R (2014) Home visits to improve breast health knowl- Open Access This article is distributed under the terms of the Creative edge and screening practices in a less privileged area in Jordan. Commons Attribution 4.0 International License (http:// BMC Public Health 14:428 creativecommons.org/licenses/by/4.0/), which permits unrestricted use, 12. Akhtari-Zavare M, Juni MH, Said SM, Ismail IZ, Latiff LA, distribution, and reproduction in any medium, provided you give Eshkoor SA (2016) Result of randomized control trial to increase appropriate credit to the original author(s) and the source, provide a link breast health awareness among young females in Malaysia. BMC to the Creative Commons license, and indicate if changes were made. Public Health 16:738 13. Vithana PC, Ariyaratne M, Jayawardana PL (2015) Educational intervention on breast cancer early detection: effectiveness among target group women in the district of Gampaha, Sri Lanka. Asian Pac J Cancer Prev 16:2547–2553 14. Heydari E, Noroozi A (2015) Comparison of two different educa- References tional methods for teachers’ mammography based on the health belief model. Asian Pac J Cancer Prev 16:6981–6986 15. Wang JH, Schwartz MD, Luta G, Maxwell AE, Mandelblatt JS 1. World Health Organization (2018) Breast cancer: prevention and (2012) Intervention tailoring for Chinese American women: com- control. http://www.who.int/cancer/detection/breastcancer/en/ paring the effects of two videos on knowledge, attitudes and inten- Accessed 7 April 2018 tions to obtain a mammogram. Health Educ Res 27:523–536 2. Saudi Cancer Registry (2014) Cancer registry report. http://www. 16. Avci IA, Gozum S (2009) Comparison of two different educational chs.gov.sa/En/HealthRecords/CancerRegistry/Pages/ Accessed 7 methods on teachers’ knowledge, beliefs and behaviors regarding April 2018 breast cancer screening. Eur J Oncol Nurs 13:94–101 3. Ibrahim EM, Zeeneldin AA, Sadiq BB, Ezzat AA (2008) The pres- ent and the future of breast cancer burden in the Kingdom of Saudi 17. McCance KL, Mooney KH, Smith KR, Field R (1990) Validity and Arabia. Med Oncol 25:387–393 reliability of a breast cancer knowledge test. Am J Prev Med 6:93– 4. Abolfotouh MA, BaniMustafa AA, Mahfouz AA, Al-Assiri MH, 98 Al-Juhani AF, Alaskar AS (2015) Using the health belief model to 18. Guilford K (2011) Breast cancer knowledge, beliefs, and screening predict breast self examination among Saudi women. BMC Public behaviors of college women: utilization of the health belief model. Health 15:1163 Dissertation. The University of Alabama 5. El Bcheraoui C, Basulaiman M, Wilson S, Daoud F, Tuffaha M, 19. Champion VL (1990) Breast self-examination in women 35 and AlMazroa MA, Memish ZA, Al Saeedi M, Mokdad AH (2015) older: a prospective study. J Behav Med 13:523–539 Breast cancer screening in Saudi Arabia: free but almost no takers. 20. de Oliveira RDP, Santos MCL, Moreira CB, Fernandes AFC (2017) PLoS One 10:e0119051 Detection of breast cancer: knowledge, attitude, and practice of 6. Alam AA (2006) Knowledge of breast cancer and its risk and pro- family health strategy women. J Cancer Educ. https://doi.org/10. tective factors among women in Riyadh. Ann Saudi Med 26:272– 1007/s13187-017-1209-4 21. Rickheim PL, Weaver TW, Flader JL, Kendall DM (2002) 7. Amin TT, Al Mulhim AR, Al Meqihwi A (2009) Breast cancer Assessment of group versus individual diabetes education: a ran- knowledge, risk factors and screening among adult Saudi women domized study. Diabetes Care 25:269–274 in a primary health care setting. Asian Pac J Cancer Prev 10:133– 22. Centers for Disease Control and Prevention (2018) Infrastructure Development Tools: Logic Models. https://www.cdc.gov/ 8. Kashgari RH, Ibrahim AM (1996) Breast cancer: attitude, knowl- oralhealth/state_programs/pdf/logic_models.pdf Accessed 7 April edge and practice of breast self examination of 157 Saudi women. J Family Community Med 3:10–13

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Journal of Cancer EducationSpringer Journals

Published: Jun 27, 2018

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