ISSN 2449-8866 Current

Life Sciences Research Article

Current Life Sciences 2016; 2 (2): 27-35

Breast cancer educational program and breast

self-examination in Sana'a, Yemen

Gawad M. A. Alwabr

Sana'a Community College, Sana'a, P.O. Box 5695, Yemen; Phone: 00967 777160932; Email: alwabr2000@yahoo.com

ABSTRACT Breast cancer is one of the most common cancer in women, constituting 22% of all cancer cases worldwide. One of the methods of breast cancer screening is breast self-examination. This study aimed to assess the impact of education on breast cancer and breast self-examination on female workers' knowledge, attitude, and practice. The study concerned to 103 females as a control group and 103 females as a case group. Intervention health education program was administrated to individual females of the case group. The results showed an improvement in knowledge of breast cancer risk factors, between control and case groups of parti-cipant females. Females' knowledge and attitude about breast self-examination factors clarify a high improvement in all answers of case group parti-cipants. In the control group 83.5% of women not practiced breast self-examination compared to 66% practicing it in the case group after the intervention. Radio and TV showed the highest percentage (41.7%) in the control group participants as a source of knowledge about breast cancer and breast self-examination. While health education program, represents the highest percentage (46.6%) in the case group participants as a source of knowledge for both breast cancer and breast self-examination. Correlation tests revealed a significant difference between knowledge and behavior scores in the control group participants (P = 0.019). This study results concluded that education can significantly

improve the level of females' knowledge, attitude, and behavior of breast cancer and breast self-examination. This study recommended that educa-tional programs used to improve females' know-ledge of breast cancer and advantages of breast self-examination are an effective method for early recognition of this disease. Keywords: Breast cancer; Breast self-examination; Knowledge; Attitude; Practice. 1. INTRODUCTION Cancer is one of the most important diseases which threaten human health nowadays [1]. Because of abnormal cell growth, malignant cells can invade and spread to adjacent tissues and even distant organs. While the tumor reaches advanced stages, it can lead to patient death [2]. Among different types of cancers, breast cancer is one of the most common cancer in women worldwide; constituting 22% of all cases worldwide [3-5]. In Yemen, in 2008, the prevalence rate of breast cancer between years 2001-2005 estimated to be 42.4 per 100,000 women. At 2009, an average of breast incidence rate in Yemen was 20.9 (1261 cases) according to World-wide Breast Cancer 2011 [6]. The most common age group affected in Yemen was women aged 41-50 years, with (35%) of cases occurring in this age [7]. Yemen's patients with late inoperable stages represented 67.0% of the total staged breast cancer patients, indicating the need for increased

Received: 21 January 2016; Revised submission: 23 February 2016; Accepted: 2 March 2016 Copyright: © The Author(s) 2016. Current Life Sciences © T.M.Karpiński 2016. This is an open access article licensed under the

terms of the Creative Commons Attribution Non-Commercial International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

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community awareness and early detection of the disease [8]. In Arabic countries in general, women currently face a significant risk of high mortality rate from breast cancer due to late diagnosis [9]. So early detection must be considered the best second choice for reducing mortality [11]. The breast self-examination has a major role in early detection of breast cancer (48%), compared with annual mammography and clinical breast examination (41% and 11%, respectively) [12]. Breast self-examination is recommended to be performed routinely on a monthly basis in all the women aged above 20 years and the importance of raising awareness on breast cancer via BSE is noted [1]. In addition, breast self-examination is easy and can be done by anyone without any special equipment. Furthermore, it is also an economic, secure and noninvasive process [13]. This study aimed to evaluate the effect of the educational program regarding breast cancer and breast self-examination on knowledge, attitude, and behavior of female workers in Sana'a city institutes. 2. MATERIALS AND METHODS 2.1. Research design

This study was an interventional educational program and was conducted on a sample of 103 female workers as a case group who are attended educational program regarding breast cancer and breast self-examination, under coverage of the National Oncology Centers' health team in Sana'a city. And a sample of 103 female workers as a control group who have not attended the educational program. All individuals of the both groups were selected among female workers from the different institutes of government and private sectors in Sana'a city, Yemen, through systematic sampling on the list of their working institutes. All females (age 20-70 years) were considered the target population. Data collection for the study was carried out in the period from March to June 2011. 2.2. Tools of the study

Data gathering tool was a standard question-naire developed by the investigator based on the related literature to assess the level of knowledge,

attitude, and practice of female workers about breast cancer and breast self-examination. The validity of the research tool was ensured through a review by 3 experts who hold a Ph.D. in Oncology and the necessary modification was made. A pilot study was conducted on 20 females to ensure the visibility of the tool.

The questionnaire consisted of two parts: demographic characteristics (4 questions), namely are; age, marital status, educational level and monthly income. And questions about individuals’ knowledge (14 questions) to identify the knowledge regarding breast cancer and breast self-examination, included items regarding general knowledge of cancer, causes, symptoms, examination, treatment, prevention of breast cancer and knowledge of breast self-examination. An attitude and behavior (13 questions) for assessing females practice about breast self-examination. Included items related to breast self-examination practice. Both groups' indi-viduals filled in the questionnaire.

The study tool was used for individuals of the control group to get a baseline data of participants’ knowledge of breast cancer and their level of breast self-examination practice. The same tool was used for individuals of the case group to test if there is any difference in participants’ knowledge, attitude, and practice, compare to the control group.

The awareness program was offered for a case group. The methods of teaching used were a lecture followed by focus group discussion and demonstration for practices. Posters were also used to provide and view more information and each female is provided a copy. The post-test questionnaire was given to the respondents after a period of three months of the program was offered. This period of time was given for them to familiarize themselves with the feel and appearance of their breasts so that they can notice any difference or change in the way their breasts looked and felt. 2.3. Data analysis

All data were coded, tabulated and subjected to statistical analysis. Statistical analysis is perfor-med using SPSS version 12. Quantitative and quali-tative variables are described by proportions and percentages. Descriptive statistics are used to analyze

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the response to individual items and the respondents' characteristics. A correlation test was used to test differences between the different groups. 3. RESULTS 3.1. Socio-demographic factors

Among 103 of case group participants, 49 (47.57%) were married and 49 (47.57%) were single while 5 (4.86%) were divorced. 50 (48.5%) of individuals age were less than30 years and 43 (41.7%) were between 30-39 years while 10 (9.8%) were more than 39 years. Regarding their literacy levels, 77 (74.7%) had university degrees, 21 (20.3%) were the secondary school, 2 (1.9%) had the primary school and 3 (2.9%) were illiterate.

Among 103 of control group participants, 40 (38.8%) were married and 56 (54.3%) were single while 7 (6.9%) were divorced. 57 (55.3%) of individuals age were less than30 years and 38 (36.9%) were between 30-39 years while 8 (7.8%) were more than 39 years. Regarding their literacy levels, 63 (61.1%) had university degrees, 24 (23.3%) were a secondary school, 8 (7.7%) had the primary school and 8 (7.7%) were illiterate. There were no significant differences in these variables between two groups.

3.2. Impact of the intervention program

As shown in Table 1, there was an impro-vement in all intervention items regards knowledge of breast cancer risk factors, between control and case groups of participant females. The highest percent change to the correct answer between the control and the case groups were reported for the items of "childlessness after the age of 35, genetic factors and previous benign tumors" (27.2%, 24.3%, and 22.3%) respectively. On the other hand, the lowest percent change to the correct answer (7.7%) was reported for an item of "breast cancer is the most common tumors between women". Concerning level of the knowledge about the breast cancer's signs, the percent change of correct answers ranged from 5.8% for the item of "difference in the shape and position of the nipples", to 27.2% for the item of "change the shape of the breast" (Table 2).

Table 3 showed that the females' knowledge and attitude about breast self-examination factors clarifies a highly improvement in all answers of case group participants, concerning: use the palm of the hand, place of another hand, appropriate time and frequency of breast self-examination, (46.9, 38.8, 38.8 and 33) respectively.

Table 1. Comparison of the control and case group intervention knowledge about risk factors for breast cancer among females' participating.

Correct answer No. (%) Risk factors for breast cancer Control group

n= 103 Case group n= 103

No. (%) of change

Breast cancer is the most common tumors among women 84(81.6) 92(89.3) 8 (7.7)

Previous benign tumors increase breast cancer risk 27(26.2) 50 (48.5) 23(22.3)

Early menarche and late menopause increase the probability of incidence

4(3.9) 21 (20.4) 17(16.5)

Increase the incidence of breast cancer with age 26(25.2) 41(39.8) 15(14.6)

Genetic factors affect the incidence of breast cancer 26(25.2) 51(49.5) 25(24.3)

Users of oral contraceptives from factors breast cancer incidence 19(18.4) 38(36.9) 19(18.5)

Obesity has strong relationship with breast cancer occurrence 26(25.2) 37(35.9) 11(10.7)

Feeding a key role in the prevention of breast cancer 42(40.8) 54(52.4) 12(11.6)

Breastfeeding causes of breast cancer prevention 76(73.8) 87(84.5) 11(10.7)

Childlessness or having children after the age of 35 factors that may increase the incidence of breast cancer

16(15.5) 44(42.7) 28(27.2)

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Table 2. The knowledge's level about symptoms and signs of breast cancer incidence.

No. (%) of change Case group Control group Answers Breast cancer's signs

15(14.6) 89(86.4) 74(71.8) Correct

6(5.8) 7(6.8) False

8(7.6) 22(21.4) Don't know

Exit means of nipple without pressure

28 (27.2) 75 (72.8) 47 (45.6) Correct

22 (21.4) 21 (20) False

6 (5.8) 35 (34) Don't know

Change the shape of the breast may be a sign of breast cancer

18 (17.5) 85 (82.5) 67 (65) Correct

4 (4) 5 (5) False

14 (13.6) 31 (30) Don't know

The presence of mass under the armpit evidence of the breast tumors

6 (5.8) 76 (73.8) 70 (68) Correct

20 (19.4) 14 (13.6) False

7 (6.8) 19 (18.4) Don't know

Difference in the shape and position of the nipples refers to the existence of the breast tumors

8 (7.4) 23 (22) 15 (14.6) Correct

71 (69) 56 (54.4) False

9 (7.8) 32 (31) Don't know

The presence of pain in the breast during the scan

19 (18.2) 96 (93) 77 (74.8) Correct

4 (3.9) 4 (3.9) False

3 (2.9) 22 (21.4) Don't know

Change the color of skin of the breast and the increased thickness is evidence of cancerous tumors of the breast

Table 3. The knowledge and attitude level about breast self-examination.

No. (%) of change Case group Control group Answers Breast self-examination factors

40 (38.8) 48(46.6) 8(7.8) Correct

24(23.3) 13(12.7) False

31(30) 82(79.6) Don't know

Appropriate time for performing breast self-examination

34 (33) 70 (68) 36 (35) Correct

31 30) 59 (57) False

2 (1.9) 8 (7.8) Don't know

Frequency of breast self-examination practice

24 (23.3) 50 (48.5) 26 (25.2) Correct

27 (26.3) 23 (22.4) False

26 (25.2) 54 (52.4) Don't know

Appropriate age for start a breast self-examination

48 (46.9) 73 (70.9) 25 (24) Correct

13 (12.6) 3 (2.9) False

17 (16.5) 75 (72.8) Don't know

Use the palm of hand when breast examination

40 (38.8) 52 (50.2) 12 (11.7) Correct

30 (29) 18 (17.5) False

21 (20.4) 73 (70.9) Don't know

Place of another hand during breast self-examination

25 (24.2) 97 (94.2) 72(70) Correct

1 (1) 2 (1.9) False

5 (4.9) 28 (27.2) Don't know

Breast self-examination is the most important means of early detection of breast cancer

4 (3.9) 96(93) 92 (89) Correct

2 (1.9) 2 (3.9) False

4 (3.9) 7 (6.8) Don't know

Early diagnosis improves treatment outcomes

8 (7.8) 89(86.4) 81(78.6) Correct

4 (3.9) 7 (6.8) False

10 (9.7) 14 (13.6) Don't know

The discovery and treatment of breast cancer early often lead to full recovery

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99 (96.1%) of the control group participants, has heard about breast cancer and 102 (99%) of the case group participants, heard about breast cancer. Only, 21 (20.4%) of the control group participants, know about breast self-examination procedure, while 102 (99%) of the case group participants, know about breast self-examination procedure. In addition, 83.5% did not practice breast self-examination in the control group compared to 66% practicing it in the case group after the intervention. Furthermore, the main reason for not practicing breast self-examination in the control group was not knowing how to perform it (58.1%), while in the case group the main reason given for not practicing breast self-examination was forgetting (48.6%).

Almost of the case group and the control group participants together agreed that there is no

adequate awareness by the authorities concerned about breast self-examination. And almost of the case group and the control group participants, together agreed that awareness about the importance of self-examination may help in early detection of breast cancer. Also, almost of the case group and the control group participants, together encourage awareness campaigns about breast self-examination.

Radio and TV media were the highest percentages (41.7%), as a source of knowledge about breast cancer and breast self-examination in the control group participants. While health education programs, represents the highest percen-tages (46.6%), as a source of knowledge for both breast cancer and breast self-examination in the case group participants. (Table 4).

Table 4. The practice and other factors of breast cancer and breast self-examination.

No. (%) of change

Case group No. (%)

Control group No. (%)

Answers Factors

3 (2.9) 102(99) 99 (96.1) Yes

1(1) 4(3.9) No Heard of breast cancer

81 (78.6) 102 (99) 21 (20.4) Yes

1 (1) 82 (79.6) No

Know about breast self-examination procedure

51 (49.5) 68 (66) 17 (16.5) Yes

35 (34) 86 (83.5) No Practice breast self-examination

2 (5.7) 50 (58.1) I do not know how

9 (25.7) 16 (18.6) Fear of discovery of something unnatural

7 (20) 7 (8.1) Pain

17 (48.6) 13 (15.1) Forgetting

35 (100) 86 (100) Total

Causes of didn't practice breast self-examination

0 (0) 16 (15.5) 16 (15.1) Yes

87 (84.5) 87 (84.5) No

Is there adequate awareness by the authorities concerned about breast self-examination

0 (0) 102 (99) 102 (99) Yes

1 (1) 1 (1) No

Is awareness of the importance of self-examination may help in early detection of breast cancer

3 (2.9) 101(98.1) 99 (96.1) Yes

2 (1.9) 4 (3.9) No

Do you encourage awareness campaigns about breast self-examination

21 (20.4) 43 (41.7) Radio and TV

0 (0) 3 (2.9) Internet

48 (46.6) 2 (1.9) Education program

10 (9.7) 30 (29.1) Family and friends

23 (22.3) 21 (20.4) Journals and posters

Source of breast cancer knowledge

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Table 5. The correlation between knowledge and behavior of individuals control and case groups participants.

Case group Knowledge Behavior Control group Knowledge Behavior Case group Pearson Correlation Sig. (2-tailed) N

.(a) . 103

.(a) . 103

.(a) . 102

.(a) . 103

.(a) . 103

.(a) . 39

Knowledge Pearson correlation Sig. (2-tailed) N

.(a) . 103

1 . 103

.(a) . 102

.(a) . 103

.052 .605 103

.(a) . 39

Behavior Pearson correlation Sig. (2-tailed) N

.(a) . 102

.(a) . 102

1 . 102

.(a) . 102

.025 .806 102

.428(**) .007 39

Control group Pearson correlation Sig. (2-tailed) N

.(a) . 103

.(a) . 103

.(a) . 102

.(a) . 103

.(a) . 103

.(a) . 39

Knowledge Pearson correlation Sig. (2-tailed) N

.(a) . 103

.052 .605 103

.025 .806 102

.(a) . 103

1 . 103

.373(*) .019 39

Behavior Pearson correlation Sig. (2-tailed) N

.(a) . 39

.(a) . 39

.428(**) .007 39

.(a) . 39

.373(*) .019 39

1 . 39

** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed). a Cannot be computed because at least one of the variables is constant.

The correlation tests revealed a significant difference between knowledge and behavior scores in the control group participants (P= 0.019). And it was a significant difference in the behavior scores of the control and case group participants (P= 0.007) as shown in Table 5. 4. DISCUSSION The analysis of the present study revealed that breast cancer and breast self-examination awareness program provided during the study had a great impact on the responses of the case group. Also, results of our study demonstrated that education can improve individuals’ level of knowledge, attitude, and behavior about breast cancer and breast self-examination. This is similar to findings of previous studies conducted in different countries. A study conducted in Egypt reported that there was a highly significant improvement in all the knowledge items

of the intervention group from pre to post-test [11]. Other study conducted in Egypt reported that there was a significant improvement in the studied women regarding general knowledge of breast cancer and breast self-examination through-out the educational program in all items and in total score [14]. A study conducted in the Kingdom of Saudi Arabia reported that there was a significant impro-vement in studied women's regarding general knowledge of breast cancer and breast self-examination after implementation of the interven-tion program [9]. Other study conducted in the Kingdom of Saudi Arabia reported that the total mean knowledge scores of the participants increased significantly after the educational program [15]. A study conducted in Turkey reported that the difference between their knowledge before and after the training sessions was exceptionally significant [13]. A study conducted in Iran reported that the mean knowledge and behavior score related to

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breast cancer and breast self-examination were increased after education [2].

As regards to knowledge of risk factors for breast cancer, this study results showed that the recognition of childlessness after the age of 35, genetic factor and previous benign tumors as risk factors increased significantly among of case group participants. The recognition of oral contraceptives users, early menarche, late menopause, and women's age, as risk factors also increased in the present study among the case group participants. This is agreed with findings previous study conducted in Egypt reported that the highest percent change to correct answer between pre and post test was reported for women's age and early age of menarche [11].

In relation to the average of the percentage change in knowledge of breast cancer signs between the control group and case group was low something (15.1%), that because of the control group had high knowledge about most of breast cancer signs' items. This agreed with findings of other studies. A study conducted in Egypt reported that there was 27.1% increase in the percentage of correct answer regarding knowledge of the breast cancer's signs [11]. Other study conducted in the Kingdom of Saudi Arabia reported that there was an improvement in the knowledge and knowing the dangerous signs and symptoms between studied groups [9]. Another study conducted in the Kingdom of Saudi Arabia reported that after the intervention program, there were statistically signi-ficant improvements in knowledge in relation to breast cancer signs and symptoms [15].

Regarding to knowledge and attitude of breast self-examination, this study results showed that, the education program showed an impact on the remarkable increase in the use the palm of hand when breast examination from 24% to 70.9%, place of other hand during breast self-examination from 11.7% to 50.2%, appropriate time for perform breast self-examination from 7.8% to 46.6% and frequency of breast self-examination practice from 35% to 68%. This agreed with findings of other study conducted in Egypt and reported that the women's knowledge about breast self-examination clarifies also a highly significant improvement in all answers concerning procedure, frequency and appropriate time from pre to post-test [11]. Study conducted in

Iran reported that the average point of positive attitude about breast self-examination has increased after intervention [16].

Results of this study showed that the knowledge and practice ratios of breast self-examination were increased from 20.4% to 99% and from 16.5% to 66% respectively. This agreed with findings of other studies. A study conducted in Egypt reported that 75% practiced breast self-examination in post-test compared to 70% who did not practice it in pre-test [11]. Other study conduc-ted in Egypt reported that before the program all students don't practice breast self-examination, after the program a significant was observed in the students' practice in relation to methods and techniques and total practice score [14]. A study conducted in the Kingdom of Saudi Arabia repor-ted that 83.3% of women successfully performed breast self-examination after implementation of the program compared to 25% pre-program [9]. A study conducted in Western Turkey reported that the difference was statistically important when com-pared the breast self-examination practices of the women who participated in the study before and after the training program [1].

This study results also showed that the main reason for not practicing breast self-examination among control group participants was that they did not know how to perform it (58.1%), while the forgetting was the main reason for not practicing breast self-examination among case group parti-cipants (48.6%). This agrees with findings of other studies. A study conducted in Egypt reported that the main reason for nonpracticing breast self-examination prior to the program was that they did not know how to perform it [14]. Other study conducted in the Kingdom of Saudi Arabia reported that the reason for not performing breast self-examination regularly was forgetfulness [15].

As regards the main source of females' knowledge of breast cancer and breast self-examination, it changed from the media (Radio and TV) in the control group respondents to the intervention program in the case group respondents. This agreed with findings of other studies. A study conducted in Egypt reported that media was the highest percentage in the pre-test as a source of knowledge about breast cancer and breast self-examination while the intervention program rated

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high as a source of knowledge of the post-test individuals [11]. Other study conducted in the Kingdom of Saudi Arabia reported that TV and doctor throw intervention program were high as a source of information about breast cancer [9].

Based on results of this study, the correlation tests revealed that the control group individuals’ knowledge and behavior are significantly related to each other (P = 0.019). Also, the correlation tests revealed that there is a statistical relationship between behavior level between the control and case group individuals (P = 0.007). This agreed with findings of other studies. A study conducted in Egypt reported that women's education and knowledge score were significantly associated with the practice of breast self-examination [11]. Other study conducted in Egypt reported that women's knowledge score was significantly associated with the practice of breast self-examination [14]. A study conducted in Iran reported that a significant stati-stical correlation was seen between knowledge level and attitude (p = 0.001) [5]. Another study con-ducted in Iran reported that the correlation test revealed that after education there was a signifi- cant relationship between knowledge and behavior (P = 0.005) [2]. 5. CONCLUSIONS

This study was conducted in order to evaluate

the effects of interventions for increasing breast cancer and breast self-examination awareness. The study results indicate that females who received intervention program had the higher level of knowledge, attitude, and behavior regarding breast cancer and breast self-examination. As mentioned, education can significantly improve individuals’ levels of knowledge, attitude, and behavior about breast cancer and breast self-examination. Recommendations: According to aforementioned points, we suggest to considering comprehensive educational programs to improve females' know-ledge about breast cancer and advantages of breast self-examination as an effective method for early recognition of the disease.

ACKNOWLEDGEMENT We would like to thank the team of this work (Mujahed Al-Jawfi, Abdulkader Al-Mihrab, Mohsen Al-Sultan, Yahia Al-Soday, Jamal Al-Azab, Radhiah Al-Mahakeri, Almntaser Ali Saeed, Sadiah Al-daboush, Abdulrahman Khargain, Abdulbaset Al-Zomer and Anisa Al-Omari), for them assistance in implementation of the educational program and collection of this work's data. Also many thanks to Dr. Nada Alsyed Hassan Ahmad and Dr. Ahmad Al-Wadaf for their assistance. TRANSPARENCY DECLARATION The authors declare no conflicts of interest. REFERENCES

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