Knowledge
and
Practice of Breast Cancer Screening Among Egyptian Nurses
Karima
F.
Elshamy DNSc1, Ashraf M. Shoma
MD2
1Adult
Nursing,
Faculty of Nursing, Mansoura University, Egypt.
2General
Surgery,
Faculty of Medicine, Mansoura University, Egypt.
Corresponding
author:
Dr. K Elshamy, Adult Nursing Department, Faculty of Nursing, Mansoura
University, P.O. Box 12557, Mansoura University, Egypt. E-mail: Karima_elshamy2002@yahoo.com
Afr J Haematol Oncol 2010;1(4):122-128
ABSTRACT
AIM
To describe
the levels of knowledge about breast cancer and its early detection,
determine
the extent of breast self-examination (BSE) practice, and assess
barriers for
not practicing BSE among Mansoura nurses.
METHODS
This was a cross-sectional descriptive study
carried out
among female nurses working in different healthcare settings in
Mansoura
University Hospitals during five months from June to October 2008. A
convenience sample of 133 eligible nurses aged 30-48 years was
recruited for the
study. Two questionnaires were used for data collection: one for breast
cancer
risk factors and early detection; and the other for the practice of and
barriers to BSE.
RESULTS
The total percent of correct answers for all
knowledge items
about different breast cancer risk factors and early detection was
39.9%.
Nurses’ knowledge about early-detection methods was limited, the
highest score
was that an early detection of breast cancer can help with successful
treatment
of breast cancer (60.2%), followed by knowledge that every woman who is
20
years or older should perform breast self-examination once every month
(52.6%),
56.4% nurses reported performing BSE during their lifetime, only 18.8%
of the
nurses practiced BSE on a monthly basis.
CONCLUSION
Nurses had limited levels of knowledge about breast cancer risk factors
and
methods of early detection; few nurses practiced BSE monthly.
Continuing
education programs for nurses are urgently needed to improve
nurses’ knowledge
about breast cancer and BSE. There is also very urgent need for
updating the
various curricular of these nurses to include courses in screening
methods for
early detection of breast cancer. Regular update courses for nurses on
health
maintenance practices are also recommended.
Keywords:
Breast Cancer; Early Detection of Cancer;
Cancer Screening; Early Diagnosis of Cancer; Nurses; Self-Examination.
INTRODUCTION
Breast
cancer is
an important public health problem in Egypt and studies have reported
low
levels of awareness and practice of breast self examination (BSE) as an
important method of prevention. BSE is a cost-effective method for
early
detection of cancer of the breast especially in resource poor countries.
1
In
Egypt,
mammograms are not requested or conducted on a regular basis.
Mammograms are
not easily available to a high proportion of Egyptian women, especially
those
of low socioeconomic status, who are the majority of the population.
Mammography is not incorporated into clinical checkups in governmental
health
clinics, where the majority of women receive their health care. Many
women have
to pay for the procedure out of pocket. 1
BSE
and clinical breast examination (CBE) are the only early detection
techniques
that could be recommended to women in populations that are economically
less
privileged. BSE is even more important because even CBE might not be
accessible
to these women due to economic or other reasons. In studies relating
BSE
practice to tumor stage, most of the evidence is in favor of better
survival. 2
Competence
of performance has been shown to affect the efficacy of
self-examination. Most
studies on BSE value, however, did not assess the examiner's
competence.
Because data obtained elsewhere show that most women performing BSE do
not
perform it competently, the significance of the positive evidence on
BSE value
is likely higher in reality. Most breast tumors are self-discovered,
and
encouraging competent BSE performance will give more women better means
to
discover tumors earlier.
A
study on BSE practice and its impact on breast cancer diagnosis in
Alexandria,
Egypt, showed that BSE was practiced in 10.4% of cases. 3 There
was
significant association between failure to practice BSE and diagnostic
delay.
This emphasized the need for breast self-examination awareness
campaigns as a
key measure for ensuring earlier diagnosis and hence better prognoses
for
breast cancer patients in Egypt. Recent reports suggest that BSE is
also a
reliable screening tool when used as an adjunct to CBE and imaging
studies 4-6
Nurses
play a
crucial role in health care delivery. Literature shows a significant
relationship between nurses’ confidence in performing BSE and
their
recommendation of BSE to their clients .7-8 Female
healthcare
providers, such as nurses and physicians, constitute the primary source
of
information about breast cancer for a large number of women. Female
nurses, who
make up the majority of nurses in Egypt, and other female healthcare
providers
could play a significant role in identifying and bridging barriers to
early-detection practices among women, 9 and in alerting
women to
the early detection of breast cancer as they usually have the closest
contacts
with female patients 4,10-11
A
study in
Jordan, reported that women who have learned about breast
self-examination have
positive attitudes toward breast cancer and practice breast
self-examination
more frequently, and that nurses who teach their clients about methods
of early
detection and breast self-examination are more knowledgeable about
breast
cancer screening and breast self-examination techniques than those who
do not. 12
Therefore, it is important to understand nurses' knowledge about
breast
cancer and its early detection. For
these reasons, we set out to describe the levels of knowledge of,
competency in
and barriers to BSE among Mansoura nurses.
METHODS
This
was a cross-sectional
descriptive study carried out among female nurses working in different
healthcare settings in Mansoura University Hospitals during five months
from
June to October 2008. A convenience sample of 160 nurses was recruited
for the
study. Eligible nurses were those with three-year diplomas, technical
and
health institute (2 years nursing studies after secondary school) and
baccalaureate degrees. Nurses with previous diagnosis of breast cancer
were excluded.
Out of this sample, 27 nurses refused to participate with a response
rate of
83%. The main reasons for refusal were lack of time or fear of talking
about
breast cancer. The sample retained for study and analysis was 133
nurses aged
30-48 years working in medical, surgical, maternity, and intensive care
units.
None of them had received special education in oncology.
Two
questionnaires
were used for data collection: one on knowledge of breast cancer risk
factors
and early detection (knowledge questionnaire); and another one on the
practice
of and barriers to BSE (BSE practice and barriers questionnaire). These
were
developed by the researchers based on literature review. Content
validity and
reliability were checked. A pilot study
test
was done on 10 nurses who were excluded from the final study.
The
knowledge
questionnaire included 28 questions in four parts : strong risk factors
(increasing
age, family history, and personal history of breast cancer); moderate risk factors (exposure to radiation
and chemicals); other risk factors (age at time of reproductive events,
pregnancy and breastfeeding, hormone replacement therapy, height and
weight,
presence of other cancers); and miscellaneous factors. Subjects
responded
“yes,” “no,” or “I don’t
know.” Total knowledge scores were computed by adding
the questions answered correctly.
The
BSE practice
and barriers questionnaire consisted of two parts. The first included
two
questions measuring the practice of BSE: one asked whether nurses had
ever
practiced BSE previously, and the second asked them to list the number
of times
they had practiced BSE in the previous 12 months. Available answers
ranged from
once per 12 months, once every 6 months, once every 2–3 months,
and once every
month. The second included questions about reasons for not practicing
BSE, and
the practice and barriers to CBE.
Permission
was
obtained from administrators of all areas of study. The questionnaires
and a
cover letter were given to each nurse administrator at each area. The
researcher left the questionnaires with the head nurse for distribution
among
nurses on different shifts. All participants gave an informed consent
to
participate. Questionnaires were
answered anonymously.
Categorical
variables
studied were represented by numbers and percentages. For each correct
knowledge
item, a score of 1 was given and the numbers of correct answers were
expressed
as percent of the total sample. The total knowledge score is the sum of
all
correct answers expressed as percent of the number of items multiplied
by the
sample size.
Comparison
of
frequencies was achieved by the chi square test at the 5% threshold of
significance.
RESULTS
The
participants’ ages ranged from 30-48 years, 88% of the nurses
were 35 or
younger, 70% of the nurses had 11 years’ or less clinical
experience and 62%
were married. Ninety-one percent of the nurses did not have a relative
with
breast cancer. Eighty-eight percent of them had three-year diplomas
from a nursing,
technical and health institute (2 years nursing studies after secondary
school),
12% had baccalaureate degrees in nursing. Nurses received information
about
breast cancer during undergraduate studies; 69% received information
about BSE
during undergraduate studies, and 55% received information about
different early-detection
methods during their studies. None of the nurses received any training
on
methods of conducting CBE or BSE. Eighty one percent of the nurses had
heard
about mammograms during their clinical experience.
KNOWLEDGE
OF BREAST CANCER RISK FACTORS AND EARLY DETECTION
Knowledge
about different breast cancer risk factors and early detection ranged
from 32.5%
to 73.4% correct answers (Table 1). Total
correct answers for all knowledge
items were 39.9%. However, knowledge score for strong risk factors was
73.4%
followed by knowledge about moderate risk factors (69.2%). The
difference was
not statistically significant. Knowledge scores of other and
miscellaneous risk
factors were 39.3% and 32.5% respectively, which was statistically
significantly
lower than knowledge about strong and moderate risk factors (P, 0.01)
Ninety
point two percent of the nurses knew that a woman's risk of breast
cancer is
higher if her mother, sister, or daughter had breast cancer and the
risk is
higher if her family member got breast cancer before age 40, and that
women who
have been diagnosed with other cancers are more likely to develop
breast cancer
than women who do not have these cancers. Second in frequency was
knowledge
that physical activity can decrease the risk of breast cancer (82.7%).
Knowledge
about early-detection methods was limited. The highest scores were that
early
detection of breast cancer can help with successful treatment of breast
cancer
(60.2%), and that every woman who is 20 years or older should perform
breast
self-examination once every month (52.6%). Although 60.2% of nurses
knew that
early detection can result in more effective treatment, only 25.6% knew
that
every woman aged 20-39 years should have a clinical breast examination
every
three years. The lowest knowledge reported by nurses was that high-fat
diet can
increase the risk of breast cancer (22.6%). Other correct answers about
knowledge
of breast cancer risk factors and early detection ranged from 25.6%
-68.4% (Table
1).
BSE
AND CBE PRACTICE AND BARRIERS
Although
75
nurses (56.4%) reported performing BSE during their lifetime, only
18.8% of them
practiced BSE on a monthly basis. Fifty one nurses (68.0%) of those who
practiced BSE were married. Forty six (79.3%)
nurses
reported
that they did not practice BSE because they did not have a breast
problem, and
40 (68.9%) of them were not convinced that BSE is important. Thirty one
(53.4%)
of the nurses reported that they did not know how to practice BSE. Only
10
nurses (17.2%) reported that they did not practice BSE because they are
lazy.
Forty
three (32.3%) of the nurses reported that they practiced CBE, 61.1%
reported
that they did not practice CBE because they did not have breast
problems, and 58.9%
mentioned that they do not feel well when thinking or talking about
breast
cancer and 55.6% of the nurses reported that they do not want to expose
their
breasts to strangers. The least frequent reason for not practicing
clinical
breast examination was lack of free time to go for checkup (11.1%), Table 2.
|
Table 1. Knowledge of Breast Cancer Risk Factors
and Early Detection (N=133) |
|
Table 2. Description of the Practice of Breast
Self- Examination (BSE) (N=133) |
DISCUSSION
The
findings in
our study indicate that 56.4% nurses reported performing BSE. However,
only 18.8%
of them reported practicing BSE on a regular monthly basis. Alkhasawneh IM
reported
that although 83.5% of nurses reported performing BSE during their
lifetime,
only 18% of the nurses practiced BSE on a monthly basis. 13 Akhigbe
and Omuemu reported
that the practice of BSE was
about 77.6% in their study 14 while
studies among Nigerian nurses in Lagos from a general hospital reported
89% 15-16
Onwere et
al. studied knowledge
and practice of BSE as a method of early detection of breast
cancer among antenatal clinic attendees in South Eastern Nigeria. They
reported
that 78% of the respondents practiced breast self-examination
regularly, only
34% of whom knew the reason for practicing breast self-examination, and
that
breast self-examination practice was mostly ineffective in their
community so
they recommend the establishment of public health programs that teach
women to
regularly examine their breasts and to seek early treatment for any
detected
lesions through the mass media, seminars, conferences, workshops at the
grassroots level and health education at health facilities. 17 G Ertem and A Kocer
studied
BSE among nurses and midwives in Odemis
health
district in Turkey. The study indicated that 52% of the participants
performed
BSE.18
The
low rate of BSE practices among our nurses could
be attributed to absence of feeling of breast problems and a negative
attitude
towards the importance of BSE as an early detection method. Some of the
nurses
reported that they do not know how to perform BSE. The majority of our
nurses
who did not practice CBE reported that they do not have breast problems
and do
not want to expose their breasts to strangers. Moreover they do not
feel at
ease when thinking or talking about breast cancer.
The
findings of
our study revealed that the total percentage of correct answers of
knowledge
about breast cancer risk factors and early detection was 39.9% which is
far
below any satisfactory level. The scores were higher for strong and
moderate
factors; dropping to very low levels for the multitude of other and
miscellaneous risk factors.
Alkhasawneh
found that
respondents’ knowledge about breast cancer risk factors and early
detection was 51%.
13 Akhigbe and Omuemu
reported
that the majority of female health worker respondents in a Nigerian
urban city
had very poor knowledge (55.0%) about breast cancer screening. 14
Seif and Aziz studied the effect of
BSE training programs
on knowledge, attitudes and practice of a group of working women in
Egypt. The
study revealed that knowledge and BSE level of the participants were
10.1% and
11.5% respectively 19
In
our study, years
of education were not associated with increased knowledge. Although 90%
of the
nurses knew that early detection can improve treatment of breast
cancer, only
18.8% practiced BSE on a monthly basis. Of those who practiced BSE
regularly,
13.3% were younger than 40 years old. Knowledge
is a very
important controllable risk factor for cancer prevention, and can be
increased
through educational awareness and training programs.
Findings
of our study are consistent with those of other studies that
report nurses’ limited knowledge about risk factors and
early-detection methods.
Although 90% of nurses know that early detection can result in more
effective
treatment, only 10% know that prognosis of the disease differs with
stage at
diagnosis. Thirty-eight percent of nurses believe that breast cancer is
a fatal
disease regardless of its stage at diagnosis.13 In
order
to function as effective promoters
of breast cancer control through early detection, health workers must
possess
the relevant knowledge as well as appropriate attitude and belief
concerning
the disease and its early detection .20 Akhigbe and Omuemu reported that if health workers are to be
included as role models for creating awareness about breast cancer
screening,
an enlightenment program must be introduced as part of the general
health maintenance
knowledge for them.14 Abd El
Aziz et al.
enforce the continuing need for more breast cancer education programs
that are
intended to attract the attention of women with low literacy skills.
1
CONCLUSION
Nurses
had limited levels of knowledge about breast cancer risk factors
and methods of early detection. Few nurses practiced BSE regularly. Intervention studies that aim to increase
nurses’ knowledge of breast cancer and their practice of
early-detection
methods should be encouraged. Continuing education programs for nurses
are
urgently needed to improve nurses’ knowledge about breast cancer
and early
detection and change misconceptions about risk factors and attitude
towards
cancer screening even among the apparently normal woman. This should
run in
parallel to and in preparation for well studied screening programs
through
mammographic examination which hopefully will become the preferred
technique in
the near future.
FOOTNOTES
Conflicts
of
interest:
The authors declare no competing conflicts of interest.
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