Knowledge and Attitude towards Breast Cancer among Female School Teachers in El-Sharkia , Egypt

Background: Breast cancer is the most prevalent cancer among Egyptian women. Aim: To determine the knowledge and attitude of female school teachers towards breast cancer in Ibrahemia district, El-Sharkia Governorate, Egypt. Subjects and Methods: A descriptive study design was used. The study sample amounted to 200 female teachers from Ibrahemia schools. Two types of tools were used for data collection: a questionnaire sheet which was designed to collect information on the socio-demographic characteristics of the studied female school teachers, and their knowledge about prevention of breast cancer and a three point likert scale was used to assess the attitude of the female school teachers towards breast cancer. Results: More than half (51.5%) of the school teachers had low level of knowledge about breast cancer and only 8.5% had high level of knowledge. The majority of them expressed positive attitude towards breast cancer (86.5%). Twenty nine percent of female teachers were practicing breast-self-examination (BSE) but only 5.0% of them used the correct procedure of BSE. Recommendations: Findings of this work highlight the need for increasing awareness of female school teachers about breast cancer through heath education programs which to provide them with information about breast cancer and teach them the correct technique for BSE. Booklets about breast cancer, BSE and healthy lifestyles should be available at school libraries in Arabic language.

The early BC lesions are detected by mammograms.Lumps found in lymph nodes located in the armpits can also indicate BC. (8) Indications of BC other than a lump may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge.Pain ("mastodynia") is an unreliable tool in determining the presence or absence of BC, but may be indicative of other breast health issues.(9)   Numerous risk factors are associated with BC.One major risk factor is increasing age.(10)   Other factors that augment the risks of developing BC are: early menarche and late menopause, obesity after menopause, use of iatrogenic hormones (both oral contraceptives and postmenopausal hormone therapy have been implicated), nulliparity or having the first child after the age of 30, certain ethnical features, radiation, or intake of alcohol on daily basis.(11,10)   Factors that decrease BC risks include breastfeeding, physical activity, and maintenance of a healthy body weight.(11)   Mammography, clinical breast examination (CBE) and breast self-examination (BSE) are the secondary preventive methods used for investigation in the early detection of BC. (12)   According to The American Cancer Society health care providers.BSE is an option for women starting from the early 20s. (13)Women in their 20s and 30s should have a CBE as part of a periodic health examination by health professionals preferably every 3 years.After the age of 40, women should have a CBE and a mammogram every year, as recommended by The American Cancer Society. ( Long term survival rates for BC have a direct correlation to early detection of a disease. Poor adherence to routine screening examinations can put the client at risk of severe illnesses a result of failed early detection.Considering the fact that BC is the most common major cancer in developed countries as well as in Egypt with a steadily increasing incidence, (15,16) the nurses' role in educating female clients about BSE is becoming extremely important.
Meanwhile, teachers can play an effective role in communication with and motivation of young students, assessment of their knowledge, attitudes and behaviors that is essential to reduce the risk of BC among future young generations. (17)

Aim of The Study:
The aim of the study was to determine the knowledge and attitude of female school teachers towards BC in Ibrahemia district, El-Sharkia Governorate, Egypt.

Research questions:
-Do female school teachers have knowledge and attitude about BC?
-What are female school teachers' responses to attitude statements about BC?
-Is there a relationship between female school teachers' qualification, specialization and their knowledge about BC?

SUBJECTS AND METHODS: Study design:
A descriptive design was used in conducting the current study.

Study setting and population:
All schools with preparatory and secondary classes in the same building (8   schools) in Ibrahemia district, El-Sharkia, Bull High Inst Public Health Vol.41 No. 4 [2011]   Egypt were included in the study.All females working at the above mentioned school setting during the study period (academic year 2009 -2010) were invited to participate in the study (200 teachers).

Data collection tools:
Two tools were utilized for data collection.The questionnaires were filled by the female teachers at the studied schools.

Scoring system:
A scoring system for knowledge about BC risk factors consisted of giving one for correct answer and zero for wrong answer or "I don't know".A scoring was given to each question and the maximum total knowledge score was 20 points.Female teachers' total scores were classified as follows: high level of knowledge (16-20), medium level of knowledge (10-15) and low level of knowledge (<10).
A scoring system for methods of and ease of implementation.Accordingly, modifications were applied.

Fieldwork:
The data collection procedures of this study were executed in one month (May,   2010).Distribution of the questionnaire sheet was subsequently done till the required number of female school teachers was obtained.

Ethical considerations:
A written permission was taken from the directors of the chosen schools.
Subjects' consent to participate in the study was taken orally after explaining the purpose of the study briefly to female teachers during the break time between lessons.

Statistical analysis:
Data entry and statistical analysis were done using statistical software package (SPSS) version 14.0.Data were presented using descriptive statistics in the form of frequencies and percentages.Chi-square test (X

2
) was used for comparing quantitative categorical variables.Statistical significance was considered at P-value of < 0.05.

RESULTS:
The Correct answer Wrong answer or I don't know 174

Figure 1a. Female school teachers' level of general knowledge about (BC)
51.5% 40.0%practices, and they influence behaviors that will reduce the risk of future BC morbidity and mortality.(20)   Therefore the purpose of this study was to determine the knowledge and attitude towards BC among female school teachers in Ibrahemia district, El-Sharkia Governorate.
The present study revealed that the majority of female teachers were working in secondary schools.More than three quarters of them were aged between 30 and more than 40 years.These results agree with study conducted in Egypt (21) among working women who reported that most of the studied women were in the age group 35 to less than 45, which is the age of rise of BC risk.In this regard, Hoskin P (22) stated that age was by far the most important risk factor for BC, and the risk increases ten folds between 30 and 50 years.And disagree with the National Cancer Institute (23) which reported that all women are at risk for developing BC.The older a woman is, the greater her chances of developing BC.
The current study results revealed that nearly two thirds of the participants reported that BC is the commonest cancer in Egypt and in Arab countries among women and about half of them mentioned that it is the second cause of death after lung cancer among women (table 2).
These findings agree with a study done in Egypt (15) which mentioned that carcinoma of the breast is the most prevalent cancer among Egyptian women.This result agrees with the results of other studies which reported that BC is about 100 times more common in women than in men, although males tend to have poorer outcomes due to delays in diagnosis.Also, the results of this study reveal that less than half of female teachers were aware that BC occurs among nullipara and primipara after 35 years.These two groups are more vulnerable to BC.About one quarter of participants reported that a woman who had early menarche is more susceptible to BC and about one third of

Abd E El l--G Gh ha an ny y & & M
Mo oh ha am me ed d 258 them were aware that oral contraceptives for long period result in being more prone to BC.The results also showed that about two thirds of female teachers reported that breast feeding for long period reduces the incidence of BC and one third of them reported that increased incidence of BC is related to its presence in first degree relatives.Also nipple withdrawal is a risk factor for BC and BC usually does not begin with severe pain while, about two thirds of the participants´ in the current study mentioned that a hard lump of breast denotes BC and also, less than half of female teachers mentioned that bloody discharge from the breast indicates BC and that some masses were not palpable by physicians, while about third of them reported that the enlargement of one breast denotes BC.These results agree with a study done in Yew York (25) which claimed that the risk of BC increased among women who have had no children and those who did not breast feed their babies.Also the American Cancer society (24) added that breast feeding might slightly lower BC risk, especially if breast feeding is continued for 1.5 to 2 years and the risk of a positive family history has been previously confirmed by Yip CH et al (26) who mentioned that BC risk was higher among women whose close relatives have this disease and agree with Suzanne C et al These results also agree with a study done in Yemen (32) among university students which found that despite that the majority of the participants heard about BSE, a minority of them were performing it.More than half of them mentioned that lack of knowledge about the technique of BSE was a barrier for not practicing BSE.These findings also agree with a study done in Malaysia (20)  The current study revealed that nearly half of female teachers mentioned that radio and TV were considered the most common methods that provide them with information about BC (Table 4).These results come in agreement with a study done in Turkey (37) which mentioned that nearly half of the students reported that their main source of information about BC and BSE was media.This result is consistent with the results of the study conducted in Saudi Arabia (17) which findings indicated that media continued to be one of the most important sources of information about BC and BSE and highlighted the cooperation between public health educators and the media in dissemination of BC information and BSE.
These findings agree with a study done in Iran (18) which reported that the main sources of information about BC were 'mass media' followed by friends and in agree with the results of a study done among African American women (38) which reported that women most frequently listed the media as their best source of BC information.Since the public spends considerably more time exposed to the media than to their health care providers, the media represent an important partner for the dissemination of health information.which reported slightly better results regarding the definition of cancer breast, its signs and symptoms, and the diagnostic methods.
In the current study, the majority of female teachers had expressed a positive attitude towards BC and three quarters of them had expressed a neutral behavior towards practices if they had been affected with BC (figure 2).These results disagree with a study done among African American women (41) which reported that the poor  7).These results agree with a study done in Saudi Arabia (43)   which reported that the level of education plays a role in the ease of delivering health education; however, it can also be an obstacle if some misconceptions exist.In a previous study, the participants, who were highly educated, had a higher erroneous response regarding the outcome of BC, the potential risk factors, and the importance of mammography than the general population.These results also agree with a study done in Alexandria The present study illustrated that the age influenced the level of knowledge about BC in general and the methods of prevention among female teachers (Table 8).The study showed that the majority of participants aged 40 and more had a positive attitude towards BC.These findings agree with Chamot et al (45) who reported that the participants aged 40 years and over showed the best level of knowledge.

CONCLUSION
In the light with the main study findings, it might be concluded that the majority of the studied respondents reported that they did not

(
ACS) recommendations, women should know how their breasts normally feel and report any breast changes promptly to their Abd E El l--G Gh ha an ny y & & M Mo oh ha am me ed d 240

( 1 )
A questionnaire was developed by the researchers to collect data about sociodemographic characteristics as age, marital status, residence, qualifications, specialization, and mass media available at home.Receiving training concerning BSE was also inquired.In addition, the tool assessed female teachers' knowledge regarding risk factors (20 items) and methods of prevention of BC (17 items).

Bull
Figure 1a and 1b illustrates that only 8.5% of female teachers had high level of knowledge about BC in general and more than half (51.5%) of them had low level of knowledge.Meanwhile, only 4.0% of them

Figure 3a and b show
Figure 3a and b show that 65.7% of specialist literature teachers compared to 37.6% specialist sciences teachers had low level of knowledge score about BC in general and 16.8% of the literature teachers had high level of knowledge compared to none of those of

Figure 3 .
Figure 3. Distribution of the studied female teachers by speciality and general knowledge about BC

Figure 4
Figure 4 shows the residence influence on female teachers' knowledge about BC in

Figure ( 4 )
Figure (4): Distribution of the study sample by their residence and their general knowledge about BC

Knowledge 1 :
general knowledge & Knowledge 2: prevention measures of BC D DI IS SC CU US SS SI IO ON N BC remains an important public health problem and is one of the most common cancers among females worldwide.

( 18 )
School teachers play an important role in health education, helping young people to develop healthy behaviors including BSE.In health education, students gain an understanding and appreciation of healthy lifestyles that promote lifelong wellbeing.

( 19 )
Women constitute 90% of the teaching profession.Considering the important role teachers have in education, they are in a position to educate young people about BC risk factors, types of screening Bull High Inst Public Health Vol.41 No.4 [2011] knowledge and wrong beliefs about cancer breast prevention among women are responsible for a negative perception of the curability of a cancer detected early and of the efficacy of the screening tests and agree with a study done in Ajman And United Arab Emirates (42) which mentioned that the majority of nurses have a positive attitude in providing knowledge regarding risk factors of BC and purposes of performing BSE.The majority of the nurses had a positive attitude towards providing information about BSE to all females who Bull High Inst Public Health Vol.41 No.4 [2011] come to the hospital irrespective of their demand.The current study showed about two thirds of female teachers having middle education and nearly half of those having university education had low level of knowledge about BC in general and methods of prevention and the majority of female teachers with university education had a positive attitude towards BC and have a neutral behavior towards practices about BC (table the practice of early detection was positively associated with the educational level.The lack of association in the present study could be attributed to the fact that the majority of the sample had university or above education, and were not exposed to any source of training about this topic.

RECOMMENDATIONBased on the findings of the current study, it is recommended to: 1 . 2 . 3 .
receive any training courses about BSE.More than half of the studied female teachers had deficient knowledge about BC.Despite that Abd E El l--G Gh ha an ny y & & M Mo oh ha am me ed d 264 the majority of them had a positive attitude towards BC, a minority of them practiced BSE.There was an association between some sociodemographic characteristics and the knowledge and attitude towards BC.The researchers developed a guideline booklet about the factors that decrease or increase BC risks, signs and symptoms of BC and correct practice of BSE and gave it to each participant in the present study.Increase knowledge of female school teachers about BC through heath education programs to provide them with information about BC and to teach them the correct technique of BSE conducted at school based clinic.Make booklets about BC, BSE and healthier lifestyles available in school libraries in Arabic language.Develop a booklet guideline containing knowledge about BC, and method of prevention, as well as how to practice BSE.(Appendix I)

Table 3
displays knowledge about methods for preventing BC among the studied female teachers.Only 5.5% and 12.5% of the participants reported ''No'' and ''I do not know'' respectively regarding routine BSE benefit or its role in early detection of the disease, while most of them (82.0%) reported "yes".Regarding practicing BSE, only 10.0% reported that they did not know how to practice BSE, while 29.0% reported that they practice BSE.Concerning correct procedure of BSE, only 5.0% of the participants practiced the correct procedure of BSE and 21% of them answered correctly the timing of BSE.

Table 4
reveals that nearly two thirds of the studied sample (63.5%) mentioned that mass media did not cover knowledge about BC.Meanwhile, 40.5% and 22.0% of them mentioned that radio and T.V and women meetings are the main sources that raise awareness about BC respectively.

Table 5
illustrates the response of school teachers to attitude statements about BC.The general attitude mean score toward BC was 2.860 ± 0.362.Concerning attitude

Table 5 . Attitude towards BC among the studied school teachers (n= 200) A At tt ti it tu ud de e t to ow wa ar rd
Abd E El l--G Gh ha an ny y & & M Mo oh ha am me ed d 250 Figure 2. Female school teachers' attitude towards BCTable 6 shows that the overall ratings for knowledge score were high for 8.5% of female teachers, medium for 40% and low for 51.5%.

Table 6 . Relation between female school teachers' level of knowledge and attitude towards BC
* Significant at p < 0.05 ** Significant at p<0.001

Table ( 8): Relation between participants' age and their knowledge, attitude and behavior towards BC
*

Significant at (P < 0.05) Knowledge 1: general knowledge about BC & Knowledge 2: measures of prevention The table 9 shows
that the mass media at home did not influence the level of knowledge among female teachers about BC as general.