Effect of Direct Education on Breast Self Examination Awareness and Practice among Women in Bolu, Turkey

Breast cancer (BC) affects women across the world. It accounts for 14% of cancer deaths and 23% of new cancer cases. Sixty percent of cancer deaths occur in developing countries (Juan et al., 2004; Ozmen, 2011; Jamal et al., 2011). According to national data from the Ministry of Health of the government of Turkey in 2008, BC is now the most common cancer among women, with a frequency of 41.6 cases per 100,000 individuals (Republic of Turkey, 2011). Screening programs allow for early diagnosis of cancer and are crucial for better prognosis and long-term survival. The Ministry of Health recommends breast self examination (BSE) and clinical breast examination (CBE) for all women beginning at age 20 years. For at-risk women between the ages of 40 and 49 years, screening intervals are determined by the treating physician. Screening is recommended biannually for women over the age of 50 years regardless of the presence of risk factors (Republic of Turkey, 2008). However, insufficient data are available on the approach to breast health, information, behavior, and attitude of Turkish women. We evaluated the effectiveness of the designed training program by determining its effect on the BSE practices of women in our family practice office


Introduction
Breast cancer (BC) affects women across the world.It accounts for 14% of cancer deaths and 23% of new cancer cases.Sixty percent of cancer deaths occur in developing countries (Juan et al., 2004;Ozmen, 2011;Jamal et al., 2011).According to national data from the Ministry of Health of the government of Turkey in 2008, BC is now the most common cancer among women, with a frequency of 41.6 cases per 100,000 individuals (Republic of Turkey, 2011).
Screening programs allow for early diagnosis of cancer and are crucial for better prognosis and long-term survival.The Ministry of Health recommends breast self examination (BSE) and clinical breast examination (CBE) for all women beginning at age 20 years.For at-risk women between the ages of 40 and 49 years, screening intervals are determined by the treating physician.Screening is recommended biannually for women over the age of 50 years regardless of the presence of risk factors (Republic of Turkey, 2008).However, insufficient data are available on the approach to breast health, information, behavior, and attitude of Turkish women.
We evaluated the effectiveness of the designed training program by determining its effect on the BSE practices of women in our family practice office

Participants
Bolu is a city with a population of approximately 1

Effect of Direct Education on Breast Self Examination Awareness and Practice among Women in Bolu, Turkey
Sebahat Gucuk 1 *, Ummugul Uyeturk 2 140.000.The healthcare system of our city adopted a family practice model on October 16, 2006, and is amongst the cities in which the practice is carried out systematically.
We invited women between the ages of 20 and 49 years registered in our family practice clinic to participate in our case-control study.Potential participants were contacted by telephone between December 2012 and July 2013.Those who chose to participate were enrolled following completion of an informed consent document.Based on their respective order of enrollment, the female subjects were randomized into either the control or the test group.
Pregnant and breastfeeding women were excluded from the study due to concern physical distress would affect their compliance with the scheduled appointments and thus the overall outcome.Patients who missed their scheduled appointment were given one phone call and reminded of their appointment.Patients who did not complete all appointments were excluded from the study.The study was completed with 144 and 112 qualifying subjects in the test and control groups, respectively.

Procedure
The questionnaire was developed in a preliminary study at our clinic and re-reviewed with patients in our clinic to test the questions for proper clarity.The questionnaire containing 22 questions was completed for each participant by the physician at our clinic during the initial face-to-face interview (the first of three conducted to evaluate BSE practices).It consisted of two sections.The first contained questions addressing socio-demographic information and BC risks.The second section gathered information on breast health screening behaviors and the frequency of screening among respondents.
BSE training for participants was conducted in two ways: via brochures and instruction by a healthcare professional.
A 12-line BSE form was used to score interviews (in terms of evaluation performance) based on a training brochure normally given to women in our clinic (Republic of Turkey,2008).For each item, a score of two was given for full performance, one for partial performance, and zero for non-performance.Radiation examination was determined to be a more preferable evaluation method by our participants, was selected and described.

First interview
After completing the survey during the first interview, both groups were educated on the importance of breast health, factors causing BC, BC symptoms, and the importance of BSE.The control group was asked to perform BSE under the supervision of a physician.Then the participants were given a leaflet about BSE prepared by the Ministry of Health for review.The subjects were scheduled for a return visit in 2 months and dismissed.The test group was also asked to perform BSE under the supervision of a physician.The subjects were educated by the physician on the proper technique for each BSE step.Sections not understood by the participants were repeated.Participants were scheduled for a return visit in 2 months once they were fully capable to perform the evaluation.

Second interview
Two months after the first interview, the test group was asked to perform the BSE steps they remembered from the previous interview.This exam was scored and information was given a second time for reinforcement.The control group was also asked to perform a BSE and scored for performing and describing the details they read in the leaflet.Participants who had lost their leaflet for any reason were given another.Both groups were scheduled for a follow-up visit in 2 months.

Third interview
During the third appointment held 4 months after the first appointment, both groups were scored as in the second interview.Because it was the last appointment, the control group also received breast evaluation by the doctor.All participants were informed about the function of our provincial Early Cancer Diagnosis and Treatment Center.While they differed at each individual step, the duration of the interviews varied between 15 and 45 min.
Patients for whom pathology was identified in either self evaluation or our examinations were referred to the medical center and excluded from study to avoid inconsistency with the controls.

Statistical analyses
Data were evaluated using the Statistical Program for Social Sciences (SPSS 20) software package.A Mann-Whitney U Test was used to test differences across groups for abnormally distributed variables.A Kruskal-Wallis H test with Bonferroni correction was employed for abnormally distributed variables in more than two groups.The Wilcoxon signed rank test was used for the abnormally distributed variables when testing the score differences between the groups based on their arrival time.Between-groups differences were analyzed using 95% confidence intervals.

Results
The average age of the women was 34.97±7.17and 35.03±7.71 in the test and control groups, respectively.The socio-demographic information of the participants is shown in Table 1.Among all participants, 7.1% of controls and 2.8% of the test group had a family history of BC.The percentage of participants with a family history of other cancers was 16.1% and 14.1%, respectively.Having a family member diagnosed with BC or any cancer type had no impact on BSE (p>0.05) or CBE (p>0.05)behaviors.
While 39.5% of the participants obtained prior information on BSE from healthcare professionals, 25.8% of participants had no knowledge of BSE prior to enrollment in this study.The percentage of subjects who performed a BSE during the past year was 47.3% in the control and 33.3% in the test group, with 9.4% and 8.3% within each group performing regular BSEs.The status of and reasons for breast examination among participants within the past year are shown in Table 2.
None of the study participants had a history of prior breast tissue radiation exposure.The body mass index of the subjects was greater than 30 for 18.1% of the test and 29.5% of the control group.When questioned about exercise, 47.9% of subjects in the test and 29.5% in the control group said they never exercised.In the test group, 30% were smokers for greater than 10 years compared to 24% in the control group.
Growing older increased BSE ratio by a factor of 1.4 and increased CBE by a factor of 1.5 among the women.Higher education level increased BSE and CBE ratios by 3.4 times.The BSE performance ratio was 6.3 times higher in married women than single/widowed women and that of CBE was 3 times higher in married women.
While prior BSE performance during the past year was associated with a significant difference between scores for each interview, the scores for the first and second interviews of patients who previously performed BSE were significantly higher (p<0.05)than those who had not performed BSE prior to study enrollment and had no previous knowledge of BSE.
Scores increased significantly (p<0.05) with each subsequent interview.No statistically significant difference was found between the control and test groups in terms of the scores for the first and second visits.The scores for the final visit were higher for the test group than for the control group (p<0.05)(Table 3).Scores were higher amongst women who had performed BSE prior to study enrollment at each of the three interviews (p<0.05)(Table 4) The scores for the final visit were higher in subjects who performed regular BSEs throughout the study (p<0.05).BSE was performed between interviews by   63.6% of participants who retained the leaflet provided during their first and second interview compared to only 34.6% of those who did not retain the leaflet, a significant difference (p<0.05).Likewise, evaluation scores for the last interview were significantly higher for participants who retained the leaflet compared to those who did not (p<0.05).
Scores for all interviews were significantly higher in individuals who were educated about BSE by healthcare professionals or hospital awareness programs compared to participants who obtained information about BSE through other sources such as television, radio, and the Internet (p<0.05).

Discussion
The early diagnosis of BC is among the most important factors for reducting morbidity and mortality.Early diagnosis is only possible with proper screening methods.The majority of studies performed on screening programs have demonstrated that screening is able to control BC at an early stage and that the stage and the histopathological grade of cancers in women who received early screening are lower compared to the normal population (Andersson ve Janzon, 1997;Chu et al., 1988).
The selection of convenient, cost-effective methods for increased BC awareness, screening, and diagnosis is particularly important in developing countries (Mittra et al,2000).The low survival rates for BC in underdeveloped countries are associated with advanced-stage diagnosis of disease mainly due the lack of early diagnostic programs (Gupta, 2009).
BSE is a free, easily applicable method of early BC screening.Individuals who perform BSE tend to have more knowledgeable of BC (Dündar et al., 2006).However, many women refrain from using this technique due to a lack of self confidence, shortage of time, and embarrassment associated with manipulation of the breast (Lierman et al., 1994;Stillman 1997).However, regularly performed BSEs would provide reference information on the breast, thereby enabling a woman to know her breast tissue and notice any potential changes.The lack of BC awareness among young women results in BC diagnosis at progressed stages.This, again, leads to further increased mortality rates (Anders, 2008).
In our study, groups were trained using practical educational methods on BSE, and the methods were evaluated for their potential benefits.
Given the improved awareness of breast health in rural areas and developing countries with little to no access to healthcare services and the increased level of information on CBE mammography, BSE should be given importance and encouraged (Dişcigil, 2007).Although BSE awareness is 90% amongst women in developed countries, only 15-40% actually conduct the exams (Friedman, 1994).Tavafian et al. (Tavafian, 2009) found that 31.7% of women had performed BSE once, but only 7.1% were practicing it on a regular basis.Al-Dubai (Al-Dubai et al., 2012) reported that about 55.4% of respondents had performed a BSE, but only 28.5% performed the examination monthly.A study conducted in the Tekirdağ province (Gürdal et al., 2012) showed that 27.4% of women performed BSE regularly while 68.5% had performed at least one BSE.Donmez et al. (Donmez et al, 2012) reported that 61.3% of subjects were unaware of breast evaluation and while 49.2% performed BSE, only 15.4% did so once each month.In the present study, 47.3% of participants in the control group and 33.3% of participants in the test group had performed a BSE within the past year.Only 9.4% and 8.3% of these participants were performing BSE on a regular basis.The very low number of subjects regularly performing BSE indicates that a health behavior model regarding BSE could not be established among the women in our region.
Studies provided effective training increased BC awareness, knowledge of BC risk factors and BSE (Kuhns-Hastings et al., 1993;Wood et al., 2002).Not all women can perform a BSE with equal quality, and thus further training programs are required.In addition to improved levels of information among women, such training programs also increase BSE practice (Ozturk et al., 2000), and different training methods improve the quality of BSE practices (Oliver-Vázquez, 2002;Rao et al., 2005).Ozaras et al. (Ozaras, 2010) found that scores were higher after BSE training.CBEs may be associated with the education status of women (Juan et al., 2004;Achat et al., 2005;David et al., 2005).Indeed, in the present study, information scores significantly improved with the frequency of visits, and exams improved with increased education level.These results demonstrate the role of education in increasing the level of awareness and the practice of BSE among women.
Media, Internet, hospitals, primary healthcare clinics, and friends and acquaintances all assume an important role in the BSE education of society (Thomas et al., 2002), with the Internet, television, hospital, and primary healthcare institutions being the most common sources of information concerning BSE (Gürdal et al., 2012).Karayurt et al. (Karayurt et al., 2008) found that media was the primary source of information on BC for 48.6% of participants.Yoo et al. (Yoo et al., 2012) found that only 17.2% of subjects obtained BSE information from a physician or nurse.In the present study, 39.5% of the subjects obtained their information on BSE from healthcare professionals.We found that scores during all visits were significantly higher in individuals educated on proper BSE techniques by healthcare professionals and hospital programs compared to individuals who obtained this information from sources such as television, radio, and the Internet.This indicates that face-to-face patient education significantly increases BSE awareness.As a consequence, access to information provided by primary care professionals, who are in close personal contact with female patients, is essential for breast health.
Our study was conducted with women in our own service population.In our national family practice program, information is supplied via leaflets handed to patients who apply for family planning or any other reason.It is usually not possible to determine patient understanding of information contained with in these leaflets or to monitor the practice of this information by patients.There are diverse opinions on what constitutes effective BSE training.One of the restrictive aspects of our study was the selection of handouts and the breastevaluation methods taught by healthcare professionals, which were thought to be feasible for a realistic practice in a polyclinic setting with a highly busy patient population.
Considering that our study is among the first conducted at a family medical center, we believe that our results can DOI:http://dx.doi.org/10.7314/APJCP.2013.14.12.7707Effect of Direct Education on Breast Self Examination Awareness and Practice among Women in Bolu, Turkey make a difference further studies and training programs.
In conclusion, Oftentimes, a patient can notice a change in her breast.BSE establishes a reference point for an individual's knowledge of her own breast and can be key for early diagnosis.BSE information should be provided by healthcare professionals during the evaluation of female patients at family practices where healthcare services are acquired on a frequent basis.Especially in developing countries, such as our own, training courses addressing individual requirements should be organized, and the effects of such courses should be assessed by feedback.We believe that such efforts will result in increased BSE practice and BC awareness, thereby improving early diagnosis and treatment rates.

Table 2 . CBE Status of Study Subjects
*CBE:Clinical breast examination