Knowledge , Perception , Practice and Barriers of Breast Cancer Health Promotion Activities among Community Pharmacists in Two Districts of Selangor State , Malaysia

Breast cancer is the commonest cancer in women in most parts of the world and across all ethnic groups in Malaysia. According to the statistics reported by the National Cancer Patient Registry (NCPR) of Malaysia, 1 in 20 women will develop the disease in their life time (Yip et al., 2006). Early detection is a key to reduce the morbidity and mortality associated with breast cancer. However, most of the patients in Malaysia present with advanced stage of the disease on their initial visit to the public hospitals (Hisham and Yip, 2004; Nur et al., 2007). Hence, there is a need to facilitate the early breast cancer detection (Hadi et al., 2010). Community pharmacists could play a vital role to educate the public about breast cancer and the importance of early detection (El Hajj and Hamid, 2011). As reported by Anderson (2000) and Krass et al. (2003), community


Introduction
Breast cancer is the commonest cancer in women in most parts of the world and across all ethnic groups in Malaysia. According to the statistics reported by the National Cancer Patient Registry (NCPR) of Malaysia, 1 in 20 women will develop the disease in their life time (Yip et al., 2006).
Early detection is a key to reduce the morbidity and mortality associated with breast cancer. However, most of the patients in Malaysia present with advanced stage of the disease on their initial visit to the public hospitals (Hisham and Yip, 2004;Nur et al., 2007). Hence, there is a need to facilitate the early breast cancer detection (Hadi  pharmacists are well suited to offer health promotion services due to their accessibility and credibility. They could provide reliable up-to date information, offer advice and counseling, display leaflets and refer women to special breast cancer screening programs. The involvement of community pharmacists in health promotion activities on the other hand is anticipated to effectively position the profession in the 21 st century (Hassali et al., 2009).
So far there is no study that assessed these potential roles of community pharmacists on breast cancer health promotion in Malaysia. Therefore, this study was set to examine knowledge, perception and barriers of community pharmacists in provision of breast cancer health promotion services.

Materials and Methods
A face to face interview, using structured questionnaire, was carried out with pharmacists working in community pharmacies in district of Hulu Langat and Sepang, Selangor. Fifty-two registered community pharmacists working in these districts were approached to take part in the study. The consent to participate was obtained after the community pharmacists were presented with a cover letter explaining the purpose of the study. A total of 35 out of 52 community pharmacists (67% response rate) agreed to participate in the study.

Data analysis
Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0. Rate and proportions were used to summarize community pharmacists' response in this study. A P-value of less than 0.05 was considered as statistically significant.

Results
The average age of the community pharmacists who took part in this study was 34.7±5.9 years. The majority of the respondents are female and graduated from local universities ( Table 1). Most of these pharmacists work in independent community pharmacies. The reported average working hours per week is 47.2 hrs which is about 6.7 hrs/day and 33 out of 35 respondents work alone in shift. According to the findings, 23 community pharmacists see more than 30 female clients per day.
Breast cancer knowledge was evaluated using 7 questions to be answered as yes, no or uncertain. More than half (50%) of the participants answered general questions related to breast cancer and its risk factors correctly. The mean percent score of correct answers was 72.6%±11.
Pharmacists' perception regarding breast cancer health promotion was assessed using 8 lickert scale type questions. As indicated in Table 3 the mean percent score for the pharmacists who strongly agree or agree with all the given statements is 90%±8.07. Hence, the  health promotion services were lack of enough time, lack of breast cancer education materials, lack of training, lack of personnel, lack of profit, lack of budget and gender barrier.  majority of these community pharmacists either agree or strongly agree that they should be involved in breast cancer health promotion by counseling, distributing breast cancer education materials, and inviting other healthcare professionals to provide breast cancer education. In addition, most of these pharmacists strongly agree or agree that integrating breast cancer health promotion into community pharmacists' daily practice is important.

Discussion
An increased interest is observed in broadening community pharmacists' role in public health. Pharmacists are easily accessible and recognized as experts in matters of health; therefore, they could offer public health interventions more conveniently than other health care providers (Wiedenmayer et al., 2006). Furthermore, community pharmacies are the ideal site for credible counseling for a large segment of the population because pharmacists have frequent contact with the public, have extended opening hours, and are widely distributed geographically. However, pharmacists working in noninstitutionalized settings, such as pharmacies are not being fully utilized (Chandra et al., 2003). Similarly, none of the community pharmacists who work in district of Hulu Langat and Sepang claimed that they were involved in offering breast cancer health promotion services to the community.
A recent systematic review on the beliefs and attitudes of pharmacists regarding pharmaceutical public health showed that, although most view public-health services as important and part of their role, various organizational barriers limit their involvement (Eades et al., 2011). Similarly, community pharmacists who took part in this study demonstrated a positive outlook regarding taking part in breast cancer health promotion activities despite their actual poor involvement. As shown by the findings, more than 90% of the community pharmacists strongly agree or agree that they should be involved by providing counseling, distributing breast cancer education materials, and inviting healthcare professional to provide breast cancer education. Furthermore, they view involvement in breast cancer health promotion as their responsibility and as an opportunity to improve their professional status. Besides, 91.4% strongly agree or agree that there is a need to integrate breast cancer health promotion activities in to their daily practice and about 71.4% strongly agree or agree that there is a demand from the community to get advice on breast cancer screening and early detection.
It is crucial to better understand the barriers and facilitators of greater involvement of pharmacists in public health activities in order to integrate community pharmacists into public-health programs to optimize population health (Laliberté et al., 2012). The community pharmacists cite lack of time (80%), lack of breast cancer education materials (77.1%), and training (62.9%) as major barriers that limit their involvement in breast cancer health promotion activities. Lack of time is an obstacle that stands against the provision of cognitive services by pharmacists' worldwide (Keene et al., 1994;Anderson, 1998;Dunlop and Shaw, 2002;Aquilino et al., 2003;Uema et al., 2008;Awad, 2010). Time constraints reported in this study might have been associated with the fact that 94.2% (33) respondents work alone in a given shift. Other reported obstacles include gender barrier (37.1%), lack of personnel (25.7%), lack of profit (5.71%) and lack of budget (2.85%).
Overcoming these barriers will require reorganizing not only community-pharmacy practice but also the health care system in order to better integrate pharmacists into the provision of preventive services. This reorganization will doubtless require agreement, commitment and engagement by all pharmacy stakeholders in addition to financial investments.
Government policy, remuneration for service delivery, communication and teamwork; leadership, task delegation, external support or assistance, reorganization of the structure and function of the pharmacy, professional satisfaction or competitiveness, communication and collaboration with physicians, and patient expectations regarding the services to be offered could serve as facilitators for change in community pharmacy (Roberts et al., 2005(Roberts et al., : 2008. The cross-sectional survey was confined to community pharmacists in district of Hulu Langat and Sepang in the state of Selangor (Malaysia), hence the results could not be generalized to all community pharmacists in Malaysia. However, this study was the first of its kind in that it attempted to specifically examine the actual breast cancer health promotion practice of community pharmacists and their perception and perceived barriers.
In conclusion, to date, little information has been gathered in Malaysia on involvement of community pharmacist in provision of breast cancer health promotion services. Although the results indicated that none of these community pharmacists are involved in any breast cancer health promotion activities, the majority view breast cancer health promotion as a part of their responsibility. However, low breast cancer knowledge in addition to other identified barriers can prevent actualizing pharmacist's role in breast cancer education. Therefore, further work should focus on providing these pharmacists with high quality breast cancer continuous education and overcoming all identified barriers to enable these pharmacists to make an important contribution to breast cancer education in this country.