Hindawi

International Journal of Breast Cancer

Volume 2022, Article ID 5697739, 8 pages
https://doi.org/10.1155/2022/5697739

Research Article
The Effect of Educational Intervention on Knowledge, Attitude,
and Practice of Women towards Breast Cancer Screening

Tayebeh Rakhshani,1 Maryam Dada,2 Seyyed Mansour Kashfi,2 Amirhossein Kamyab,3

and Ali Khani Jeihooni 1
1
Nutrition Research Center, Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
2
Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
3
Department of Community Medicine, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran

Correspondence should be addressed to Ali Khani Jeihooni; [email protected]

Received 8 January 2022; Accepted 12 May 2022; Published 26 May 2022

Academic Editor: Pranshu Sahgal

Copyright © 2022 Tayebeh Rakhshani et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. Early identification of breast cancer may result in earlier treatment and a lower mortality rate. This fact has resulted
in the development of screening programs to detect breast cancer in its early stages; thus, the current study sought to investigate
the influence of educational intervention on knowledge, attitude, and practice about breast cancer screening in Izeh, Khozestan
Province, Iran. Materials and Methods. This experiment was carried out on the women of Izeh city in 2019. This study
included 120 women who were randomized into the experimental and control groups at random (60 in the experimental and
60 in the control groups). Before and two months after the intervention, data were collected using a researcher-created
questionnaire by the control and education groups. The intervention program for the intervention group included eight
educational sessions over the course of two months. The SPSS 20 statistical program was used to examine the data, as well as
the paired t-test, independent t-test, and Chi-square. Results. There was no significant difference between the experimental and
control groups’ mean scores of knowledge, attitude, and practice prior to the educational intervention, but a significant
difference was observed after the intervention, with the experimental group obtaining significantly higher mean scores of
knowledge, attitude, and practice (P = 0:05).Conclusion. In the present study, the educational intervention on the knowledge,
attitude, and practice towards breast cancer screening led to the increased scores of the experimental group compared to
control group.

1. Introduction According to the most recent estimates, 1383500 persons

were diagnosed with breast cancer in 2010, with 458400
The World Health Organization reported 7.6 million deaths dying as a result of the condition. Thus, in past years, breast
from cancer in 2005 [1]. Breast cancer is the second most cancer was the most frequent malignancy among women
frequent malignancy in women, after skin cancer. It is also and the second largest cause of death. However, with
the second most frequent cancer of all forms and the leading 458400 fatalities per year, cancer presently ranks first in can-
cause of death in both developed and developing countries cer mortality among women worldwide, with lung cancer
for women [1]. coming in second with 427400 deaths per year [4].
According to global statistics, 80000 persons per 100000 The disease rate has been rising in Iran in recent years,
are afflicted with the disease [2], and 519000 women die and it has been the most prevalent cancer among Iranian
from breast cancer each year, with more than 70% occurring women since 1998, with the annual rate increasing by 2%
in low-income nations [3]. between 2002 and 2007 [3]. The average age of development
2 International Journal of Breast Cancer

of breast cancer in Iran is estimated to be 48.8, with the the mean scores of cancer awareness, breast self-examina-
highest incidence of malignancy observed in the age group tion, risk factors, and symptoms were 2:10 ± 0:67, 34:10 ±
of 40-49 years [4]. 0:77, 8:05 ± 3:1, and 6:80 ± 2:73, respectively. Their results
The risk factors for this cancer include family history, indicated a low level of women’s awareness of screening [21].
age of first pregnancy, early onset of menstruation, late men- Women make up half of the population of any society
opause, obesity after menopause, alcohol consumption, and meanwhile nurture all members of the society. In the
smoking, physical inactivity, body mass index, hormone current Iranian health system, women with health records
therapy, breast density, and exposure to chest radiography. in health centers can be examined for free, but due to the
However, job stress, women’s night work shifts, and lifestyle lack of regular visits and the low level of their knowledge
are definitely influential [5–8]. and attitude towards breast cancer, this program has faced
Despite the reduction in breast cancer mortality, espe- problems. On the other hand, since there is no systematic
cially in developed countries, the disease is still a major program to teach and learn breast cancer screening methods
challenge for health policy makers in developing countries, in the country, even in urban communities, and as breast
including Iran [9, 10]. Hence, early detection of cancer is cancer is the most common cancer among women and a
critical. It is estimated that more than a third of cancers major problem in health priorities at the national and
are preventable [11], and breast cancer is one of the few regional levels, the present study entitled the effect of in-
cancers that can be diagnosed early [12]. Early detection of person education on knowledge, attitude, and practice
breast cancer may lead to early treatment and reduced mor- towards breast cancer screening was conducted in Izeh city
tality. This fact has led to the emergence of screening pro- in 2019.
grams to detect breast cancer in the early stages in which
treatment has the greatest impact on clinical outcomes [7]. 2. Materials and Methods
About half of the patients with early diagnosis of breast
cancer spend the rest of their lives without recurrence, and 2.1. Study Design and Participants. This experimental study
a third die from the disease. Thus, it is obvious that breast was carried out in 2019 in Izeh city, Khozestan Province,
cancer prevention and early diagnosis are among the vital Iran. The study population consisted of the women who
factors in controlling the disease and increasing the patients’ referred to Izeh community health centers in 2019.
survival [13]. 2.1.1. Inclusion and Exclusion Criteria. The inclusion criteria
Screening methods can reduce mortality by over 25%. were as follows: having a health record in a health center, not
Prompt diagnosis has a great impact on the treatment pro- having a special disease (such as a history of cancer and
cess and the patients’ survival as well. Experts believe that depression, cardiovascular disease), and not having cancer.
if cancer is diagnosed at an early stage, the survival of the The exclusion criteria were unwillingness to participate at
patients in the first 5 years will be 97%. They suggest that any time of the study, more than two absences from the
women undergo regular and monthly screening methods training sessions, and changing the dwelling place.
[14]. There are three screening methods for early detection
of breast cancer including mammography, clinical breast 2.2. Sample Size. The sample size was estimated to be 47 for
examination, and breast self-examination, in the order of each group, using the comparison of two means and taking
importance [15, 16]. Breast self-examination is a screening into account the dropout rate of 20% as well as the alpha
method that does not require specialized equipment and of 0.05 and 80% study power. However, 60 people per group
staff due to its simplicity, cost-effectiveness, and efficiency were examined in the final analysis due to the sample drop-
and is performed by the person herself after being trained. out [22]. The 120 participants were divided into two groups
If the person performs breast self-examination regularly and using the semirandom sampling method (60 individuals in
accurately, she can detect even smaller-than-1 cm glands the intervention group and 60 in the control group).
[17]. According to the findings of several research, the world
as a whole has a low rate of regular and monthly breast self-  2

examination. Although 82% and 61% of women in Saudi Z 1−ðα/2Þ + Z 1−β 3:22 + 3:372
Arabia were aware of the benefits of breast self-examination n= : ð1Þ
and mammography, respectively, only 41.2 percent and ð18:1 − 16:2Þ2
18.2 percent had performed breast self-examination and
nondiagnostic mammography, respectively [18]. Despite 2.3. Sampling Method. In this investigation, the cluster sam-
the benefits of breast self-examination, few women do it pling method was used. Izeh city had 5 comprehensive
and some do not even know how to do it. There is evidence health centers and 12 attached and unattached health homes
that women trained by BSE physicians or nurses are more and centers; each health home and center was designated a
likely to do breast self-examination [19]. Given that breast cluster.
cancer can be detected by the individual through breast Then, two health centers and two health homes were
self-examination, informing women about it and teaching chosen at random, with one center and one health home
them how to do breast examination properly seem necessary serving as the experimental group and one center and one
[19]. Studies show that one of the most important factors in health home serving as the control group.
promoting breast cancer screening awareness and practices Then, among the selected health homes and centers, 60
is education [20]. In their study, Taha et al. reported that women were randomly chosen from one health home and
International Journal of Breast Cancer 3

one health center for the experimental group; then, 60 2.9. Results. The demographic and background information
women were also chosen from the remaining health home of the participants is shown in Table 2. The mean and stan-
and health center serving as the control group of the study. dard deviation of the age of the participants in the interven-
tion and control groups were 33:65 ± 8:56 and 33:65 ± 8:25,
2.4. The Data Collection Tools. To gather information for respectively; the independent t-test showed no significant
this study, the researchers used a questionnaire to gather difference between the experimental and control groups in
demographic information about the women (such as their terms of age (P = 0:22).
occupation, education, and economic status), as well as a The Chi-square test indicated that there was no signifi-
researcher-made questionnaire to elicit information about cant difference between the experimental and control groups
the women’s breastfeeding history and any underlying dis- in terms of education (P = 0:56), economic status (P = 0:07),
eases (such as diabetes, cardiovascular disease, and another occupation (P = 0:24), number of deliveries (P = 0:22), type
cancer). of previous delivery (P = 0:22), history of breastfeeding
(P = 0:22), and underlying disease (P = 0:27) and history of
2.5. Knowledge, Attitude, and Practice Questionnaire. On the breast self-examination (P = 0:32).
knowledge level, there were 18 questions (related to breast The independent t-test showed that prior to the educa-
cancer screening, including the information about its neces- tional intervention, there was no significant difference
sity, as well as the time of onset, frequency, location, and between the two groups in terms of their mean scores of
ways of doing breast self-examination in each cycle, and knowledge, attitude, and practice, but the result completely
the time of onset and frequency of clinical examinations reversed after the intervention, and the experimental group
and mammography). The Likert scale was used to score obtained higher mean scores of knowledge, attitude, and
the responses (1 = severely disagree, 2 = disagree, 3 = no practice. The difference was statistically significant (P <
idea, 4 = agree, and 5 = highly agree). The lowest and highest 0:05) (Table 3).
scores obtained were 18 and 90, respectively. The results of the paired t-test indicated a significant dif-
There were 20 attitude questions, all of which were about ference in the experimental group in terms of the mean
screening for early detection and treatment of cancer and its scores of knowledge, attitude, and practice before and after
implications. The Likert scale was used for scoring (1 = the intervention (P < 0:05) (Table 4).
severely disagree, 2 = disagree, 3 = no idea, 4 = agree, and According to the results of the paired t-test, no signifi-
5 = highly agree). The lowest and highest scores were 20 cant difference was observed in the control group in terms
and 100, respectively. of the mean scores of knowledge, attitude, and practice
There were seven practice-related questions, separated before and after the intervention (P > 0:05) (Table 5).
into three categories: breast self-examination, clinical breast
examination, and mammography. The Likert scale was used
to score the responses (1 = severely disagree, 2 = disagree, 3 3. Discussion
= no idea, 4 = agree, and 5 = highly agree). The lowest and In the present study, educational intervention led to an
highest possible scores were 7 and 35, respectively. The ques- increase in the mean knowledge of the experimental group
tionnaire’s reliability and validity were assessed in this study, compared to that of the control group. This finding is con-
and its Cronbach’s alpha was 0.82 percent (Supplementary sistent with the results of the studies conducted by Awwad
Files-Research Project Questionnaire). et al., Noman et al., Ibitoye et al., and Dadsetan et al. and
2.6. Educational Intervention Program. In the experimental on learning knowledge from longitudinal data of mammo-
group, knowledge, attitude, and practice were the foci of the grams to improving breast cancer risk prediction [22–25].
educational intervention. It consisted of eight 60-minute It is consonant with another study by Mohsenipouya et al.,
sessions held weekly over the course of two months for the who aimed at investigating the use of educational interven-
experimental group. The details of the training sessions are tion in breast cancer screening in northern Iran [26]. Also,
presented in Table 1. The Breast Cancer Screening Guide pub- it was consistent with the studies by Heidari et al., Sabeg
lished by the Ministry of Health was used to provide educa- et al., and Sadeghi et al. [27–29].
tional information in the training sessions [9]. The finding of this study was also in line with those of
In the control group, no intervention was performed. the studies by Noman et al. on effect of educational interven-
tion of screening practices on the knowledge and attitude of
2.7. Statistical Analysis. The SPSS 20 software was used to primary school teachers in Malaysia [30], and Alomair et al.
analyze the data, and the normality of the data was first deter- on the effect of educational intervention on screening prac-
mined using the Kolmogorov-Smirnov test. The data was tices of the Saudi women [31].
also described using frequency, mean, and standard devia- The possibility of reason of increase acknowledges was
tion indices, and data was analyzed using the paired t-test, the educational program, because the educational program
independent t-test, and Chi-square test. In all tests, the sig- was necessary to increase knowledge and create proper
nificance threshold was set at 0.05. health attitudes and beliefs and to perform breast self-
examination accurately and correctly. However, acquiring
2.8. Ethics Approval Code. This study was approved by the necessary skills was also essential. On the other hand, the
ethics committee of Shiraz University of Medical Sciences high mean score of knowledge in our study could be due
as the project number (IR.SUMS.REC. 97-01-04-19005). to the fact that in general, in Iran and other developing
4 International Journal of Breast Cancer

Table 1: The educational intervention program was as follows.

Time duration
Session Objective Subject Training method Educator
(minute)
Acquainting the group members
with each other and with the
The aim of educational Lectures as well as Expert group and
1st psychologist expressing objectives 60
sessions Q&A midwifery expert
Familiarity with different types of
cancers and breast cancer
Training on breast cancer screening Lectures, group
Psychiatrist and
2nd Screening types of screening and advantages and 60 discussions, and
midwifery expert
disadvantages of each Q&A
Definition of knowledge, attitude, and
Consulting expert
Knowledge, attitude, practice—assessing the levels of Educational videos
3rd & 4th 60 and midwifery
and practice knowledge, attitude and practice and posters
expert
of the participants
Role of knowledge, Determining the advantages and Lectures, group
Expert group and
5th & 6th attitude, and practice in benefits of screening in early cancer 60 discussions, and
midwifery expert
screening diagnosis Q&A
Lectures, group
Review of previous contents and
7th & 8th 60 discussions and Midwifery expert
summary and final evaluation
Q&A

Table 2: Comparison of frequency distribution of primary variables of the participants in two groups.

Variable Control group (%) Experimental group (%) P value

Under diploma 11 (18.3) 9 (15)
Education Diploma 29 (48.4) 31 (51.7) 0.56
University degree 20 (33.3) 20 (33.3)
1-2 million 14 (23.3) 6 (10)
Economic status 2-4 million 32 (53.3) 43 (71.7) 0.07
More than 4 million 14 (23.3) 11 (18.3)
Housewife 53 (88.3) 57 (95)
Occupation 0.24
Employee 7 (11.7) 3 (5)
No delivery 14 (23.3) 8 (13.3)
Number of deliveries One delivery 8 (13.3) 13 (21.7) 0.27
More than one delivery 38 (36.6) 39 (65)
No history of delivery 14 (23.3) 8 (13.3)
Type of previous delivery Natural delivery 30 (50) 31 (51.7) 0.31
Cesarean section 16 (26.7) 21 (35)
Yes 48 (80) 52 (86.7)
History of breastfeeding 0.31
No 12 (20) 8 (13.3)
Yes 12 (20) 5 (8.3)
Underlying disease 0.1
No 48 (80) 55 (91.7)
Yes 14 (23.3) 3 (5)
Has a history of breast self-examination 0.32
No 46 (76.7) 57 (95)
∗
Chi-square test.

countries, women’s increased information and desire for In the present study, the educational intervention led to
acquiring knowledge have led to some practice for early an increase in the mean attitude of the experimental group
diagnosis of breast cancer, and, as a result, they are more compared to the control group. Possibly, the reason for the
aware of this disease than before. increase in attitude was the training program which justifies
International Journal of Breast Cancer 5

Table 3: Comparison of mean knowledge, attitude, and practice scores of the two groups before and after the intervention.

Preintervention Postintervention
P value∗ Control Experimental P value∗ Control Experimental Variable
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
0.001 59:78 ± 6:13 83:48 ± 4:47 0.12 59:21 ± 7:06 53:51 ± 6:85 Knowledge
0.001 64:13 ± 5:64 79:53 ± 4:47 0.26 65:46 ± 6:18 64:8 ± 7:31 Attitude
0.001 20:93 ± 3:01 27:86 ± 4:03 0.31 20:66 ± 4:50 15:46 ± 4:14 Practice
∗
Independent t-test.

Table 4: Comparison of mean knowledge, attitude, and practice in

Also, the results of the present study are consistent with
the experimental group before and after the intervention.
the results of the study by Godfrey et al. who assessed breast
Postintervention Preintervention cancer knowledge and breast self-examination on 204 female
P value∗ Variable students of Kampala, Uganda [40]. However, it was not con-
Mean ± SD Mean ± SD
0.001 83:48 ± 4:47 53:51 ± 6:85 Knowledge
sistent with the results of the study by Sargazi et al. on the
effect of educational intervention on early breast cancer
0.001 79:53 ± 4:47 64:8 ± 7:31 Attitude screening in Zahedan [41].
0.001 27:86 ± 4:03 15:46 ± 4:14 Practice According to the results, the mean scores of knowledge
∗
Paired t-test. in the experimental group before and after the educational
intervention, respectively, showing a significant increase.
That is, knowledge-focused interventions were effective on
screening. This is consistent with the results of a study by
Table 5: Comparison of mean knowledge, attitude, and practice Tuna et al. entitled Online Education in Teaching Breast
before and after the intervention in the control group.
Self-Examination [42]. In their study, Tuna et al. examined
Postintervention Preintervention 1679 women and reported that the mean scores of the par-
P value∗ Variable ticipants’ knowledge of breast self-examination was 46.5
Mean ± SD Mean ± SD
0.50 59:78 ± 6:13 59:21 ± 7:06 Knowledge
(14%) before the education, 77.4 (11%) one month after
the education, and 76.7 (9.52%) six months later.
0.17 64:13 ± 5:64 65:46 ± 6:18 Attitude The results of the present study showed that the mean
0.70 20:93 ± 3:01 20:66 ± 4:50 Practice scores of attitude in the experimental group were 64:08 ±
7:31 before the educational intervention and 79:53 ± 4:47
after it, showing a significant increase. In other words,
attitude-focused interventions could lead to increased atti-
the result, that is to say, the level of knowledge directly tudes toward breast cancer screening. This finding is in line
affected the formation of correct attitudes in women. In with the results of the study by Ghasemi and Kheivani
the present study, women’s high levels of knowledge chan- (2014). They randomly examined 50 women working in uni-
ged their attitudes, and that, in turn, had a positive effect versities and reported that the mean attitude score had chan-
on breast self-examination, consistent with the results of ged from 74:5 ± 14:7 to 82:2 ± 10:2 [43].
the studies conducted by Sadoh et al., Samami et al., and According to the results of this study, the mean score
Maheri et al. [32–34], and also in line with another study of practice in the experimental group significantly
by Alsaraireh and Darawad on the impact of breast cancer increased after the educational intervention (27:86 ± 4:03)
educational intervention on the women’s knowledge, atti- compared to the preintervention score (15:46 ± 4:14). In
tude, and performance in Jordan [35]. However, the findings other words, practice-focused interventions could lead to
of our study are not consistent with those of the study by an increase in screening practices, consistent with the
Khani Jeihooni et al. who examined the effect of educational results of the study by Tuna et al. entitled Online Educa-
intervention on breast cancer screening in Iranian women tion in Teaching Breast Self-Examination [42]. They exam-
[36]. They found out that the mean score of attitude ined 1679 women and reported that the rate of systematic
increased in the experimental group after the intervention, breast self-examination among the women increased from
but it was not statistically significant [36]. Attitude is one 30.8% to 47.8% after the education program, which was
of the issues that requires a long time to change and is rooted significantly different [42].
in the person’s beliefs and understanding. To change atti- The results of the present study indicated that before the
tudes, the person’s root beliefs must be identified and educational intervention, the mean score of knowledge in
corrected. the control group (59:21 ± 7:06) was higher than in the
The possible positive effect of educational program in experimental group (53:51 ± 6:85), and the mean score of
the experimental group is also consistent with the results practice was also higher in the control (20:66 ± 4:50) than
of the studies conducted by Dieli-Conwright et al., Abo Al- the experiment group (15:46 ± 4:14). This could be partly
Shiekh et al., and Prusty et al. [37–39]. due to the difference between the two groups in terms of
6 International Journal of Breast Cancer

their education levels, as the control group had higher edu- Supplementary Materials
cation than the other group, and the results of many studies
have shown that higher education would lead to increased Research project questionnaire. (Supplementary Materials)
knowledge and practice towards breast cancer screening. In
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