The Impact of a Hospital-Based Awareness Program on the Knowledge of Patients About Breast Cancer and Cancer Cervix

Background: Breast cancer and cancer cervix contribute to high morbidity and mortality rates among women worldwide. Appropriate knowledge of both cancers can help in early detection and management. Aim: This study aimed to assess the effect of a hospital-based awareness program on the knowledge of patients attending some outpatient clinics in Sohag University Hospital regarding the 2 cancers. Subjects and Methods: The program was held in Sohag University Hospital on 150 female patients during the period between August and October 2018. The knowledge of the patients about the risk factors, symptoms, screening, and management of both cancers was first assessed using an interview questionnaire. Then, the awareness program included 4 sessions and every session discussed only 1 aspect of knowledge regarding both cancers. Later, patients were assessed again using the same questionnaire and the improvement was determined. Results: The mean age of the participating patients was 29.6 ± 6.7 years, 74.7% could read and write, and 85.3% were married. Only education was associated with better knowledge about breast cancer (p = 0.002) and cancer cervix (p = 0.007). Thanks to the program, the percent of patients with optimal knowledge of breast cancer improved from 14.7% to 50% (p < 0.001). This percent distributed as follows; risk factors 10% to 50% (p < 0.001), manifestations 20% to 60% (p < 0.001), screening 4% to 7% (р < 0.001), and management 24.8% to 63% (p < 0.001). Regarding cancer cervix, the improvement was as follows; total knowledge 13.3% to 46.2% (p < 0.001), risk factors 8% to 50% (p < 0.001), manifestations 12.2% to 50% (р < 0.001), screening 15% to 40% (р < 0.001), and management 18.2% to 44.8% (р < 0.001). Conclusion and Recommendations: Patients had suboptimal knowledge about breast cancer and cancer cervix. However, the program achieved remarkable successes in improving the knowledge of patients. Future programs on a wider scale and different populations should be considered.


Introduction
[3] In the USA more than 40.5 thousand deaths attributed to breast cancer were recorded during 2017. [4]Nationally, breast cancer represented more than a third of all cancers affecting women in 2011 with high incidence and prevalence rates. [5,6] n Egypt, recently WHO in 2014 had announced that ƁC is the most common cancer among Egyptian women with the mean age at diagnosis is ten years lower than in the United States and Europe. [7]It represents for 32.0% of cancer cases among Egyptian women with high dominated frequency in Upper, Middle, and Lower Egypt (38.7%, 33.8%, and 26.8%, respectively).However, a study in 2014 reported that Breast cancer was diagnosed in 19105 Egyptian women. [8]east cancer is considered the most horrible cancer for women. [9,10] t is а heterogeneous disease with unknown causes.Yet it has multidimensional risk factors specifically; genetic predisposition, family history, personal history, female sex and increasing age.[13] However, what is noisy about diagnosis of breast cancer is that it has almost no symptoms during its early stages which makes its early detection challenging.This is although early detection of the cancer can provide higher cure and survival rates.Meanwhile, screening for breast cancer is important for its detection in early stages. [14,15] HO delineated that 30%-50% of cancers can be inhibited through avoidance of risk factors and screening measures. [11]This screening can be done at home or at special clinics via breast self-examination, clinical breast examination, and/or mammography. [8,9] ast self-examination (ƁSE) is the most healthful monthly performed protective behavior that is recommended for all women at any age starting from 20 years along their life span.[18] Breast self-examination is recommended by World Health Organization as an individual measure for raising women's awareness about ƁC risks and its early detection.However, overutilization of ƁSE and improper performance can lead to misleading or false results.Thus, the American Cancer Society screening guidelines for ƁC in 2015 further suggested that women should be informed about the possible advantages, disadvantages of ƁSE and the value of immediate reporting of any discovered breast changes to health professionals. [11,16] the other hand, cancer cervix, however less common than breast cancer, can be life-threating as well. [19,20] e morbidity rates of cancer cervix differ widely among studies due to many social, ethnic, and behavioral reasons. [1,2] n Egypt, cancer cervix is 20 times less common than breast cancer and its mortality rates are inconsistence. [6]ke breast cancer, early diagnosis of cancer cervix is crucial for its treatment and could improve the cure and survival rates. [7]The widely-known Papanicolaou test (Pаp smear test) is heavily used to screen for the cancer.2][23][24] Previous literature spoke about the pivotal role of nurses; directly by participation in the screening programs and indirectly by raising the awareness of women about the necessity of screening for cancers. [25]Meanwhile, the investigators in this study explored the impact of a hospital-based awareness program given by nurses on the knowledge of patients about breast cancer and cancer cervix.

Significance of the Study
[28][29] However, little is known about the knowledge of patients about the risk factors, symptoms, screening, and management of both cancers and whether awareness programs could be effective in improving their knowledge or not.We believe that knowledgeable people can spread the awareness among their relatives and could benefit from the awareness in early detection of breast cancer and cancer cervix that might affect them.

Aim of the Study
The aim of this study was to evaluate the effect of a hospital-based program on the knowledge of patients attending the outpatient clinics of Sohag University Hospital about risk factors, manifestations, screening, and management of breast cancer and cancer cervix.

Research Hypothesis
We hypothesized that the program would improve the knowledge of patients about breast cancer and cancer cervix.

Study Design
Α quasi-experimental design was adopted.

Setting and Time Frame
The awareness program was held in Sohag University Hospital over 4 sessions; 90 minutes each and continued for 2 days.However, the inclusion of the patients was continuous, so the same program using the same educators and materials was repeated over 2 months between August and October 2018.The assessment of the patients' knowledge was done before and after the program.

Sampling
The sample size was calculated using the program; Epi-Info version 7 Stat Calc, [Center for Disease Control (СDС), World Health Organization (WΗΟ)], an improvement of the optimal knowledge with 25%, a confidence level of 95%, and a margin of error of 5%.
A total of 200 patients attending the outpatient clinics of Gynecology and Obstetrics in Sohag University Hospital were chosen randomly over 1 week in a consecutive manner.Of the 200 patients, 150 accepted to participate and attended the awareness giving us a response rate of 75%.

Fieldwork and Data Collection
The authors prepared an Arabic questionnaire for the sake of data collection.The questionnaire comprised of 3 sections.Section I included questions about the demographic characters of the patients; name, age, residence, education.Marital status, family history of breast cancer or cancer cervix, and history of attending awareness programs about the same topics.
Section II evaluated the knowledge of patients about breast cancer using 16 statements and patients were asked to show to what extent they agreed or disagreed with these statement on a Likert scale from 1 to 5 in which 1 referred to strongly disagree and 5 to strongly agree.Reverse questions had inverse scores.The 16 statements were equally divided on 4 subdivisions; risk factors, manifestations, screening, and management of breast cancer.The score of each division was 20 and the total score was the average of the 4 subdivisions.Patients with scores higher than 60% of the division score or the total score were considered of optimal knowledge regarding this division and/or the total knowledge.Alike, section III included the same number of questions divided on the same 4 aspects but to assess the knowledge about cancer cervix.The same scoring system was applied.
For more details, the risk factors division of breast cancer evaluated the knowledge of patients about the effect of diet, family history, different traits of metabolic syndrome, and gynecological disorders on the occurrence of breast cancer.The manifestations division included 2 statements about the local symptoms and 2 statements about the general symptoms of breast cancer.The screening division included statements about the age of first screening, methods of screening (2 statements), and spacing between screening.The management division evaluated the knowledge of patients about 4 procedures of treatment; chemotherapy, radiotherapy, surgery, and hormonal therapy.
Regarding cancer cervix, the division of risk factors evaluated the knowledge of patients about the effect of age, sexually transmitted infections, contraception, and obesity on the development of cancer cervix.The division of manifestations was like that of breast cancer (2 local and 2 general symptoms).The screening division included statements about the age of first screening, methods, times, and accuracy of screening.The management division assessed knowledge of patients about chemotherapy, radiotherapy, surgery, and psychological rehabilitation.
The investigators interviewed the patients twice, 1 time before the start of the program and 1 time immediately after the last session.

Pilot Study
Before putting the questionnaire in practice a pilot study on 10 patients were conducted to test the validity and reliability of the questionnaire.

Validity & Reliability
The Cronbach's alpha for reliability was 0.77, while the content validity was assessed by a professor of public health and 3 professors of maternity, obstetrics & gynecologic nursing.

Program Sessions
The awareness program, designed by the investigators, included 4 sessions; 90 minutes each, on 2 consecutive days.Session 1 included information about the familial, nutritional, lifestyles (e.g.inactivity, poor dietary habits, smoking, and alcohol intake) and medical risk factors associated with both cancers.The second session discussed the possible manifestations associated with the cancers.Session 3 discussed the pivotal role of screening in detecting early cases, age of screening, times of screening, and its accuracy.The last session covered cancer's preventive measures and discussed the possible treatment procedures based on the type and grade of cancer (surgical, chemotherapy, radiotherapy).We adopted problem-solving approach in the awareness sessions.This approach allowed patients to participate and discuss their concerns.During the awareness sessions, presentations, short films, and group discussion were held.At the end of each session, the investigators summarized the important points of this session and the participants were encouraged to ask and show their personal experience.Booklets, brochures and leaflets, supported by illustrated figures, were distributed as take-home notes.Patients who missed 1 or more sessions during the program were given wrap-ups of what they have missed.

Ethical Considerations
The study was conducted in full accordance with the guidelines for the Declaration of Helsinki, and data for each participant were collected only after obtaining informed consent.The research ethics committee of Sohag University gave its approval to the protocol.

Data Analysis
Data were analyzed using the software, Statistical Package for Social Science (SРSS Inc.Released 2009, РΑSW Statistics for Windows, version 18.0: SPSS Inc., Chicаgo, Illinois, USΑ).Frequency distribution and descriptive statistics were calculated.Chi-square and t-test were done whenever needed.P values of less than 0.05 were considered significant.The graphical presentation included 3-D Clustered Column and Pie chart diagram.

A total of 150 patients attending different outpatient clinics in Sohag University
Hospital participated in this study.The age of the patients was 29.6±6.7 years.Most of the patients 70.7% were residing in rural areas, 74.7% were literate, and 85.3% were married.Only 3.3% had a positive history of any of the 2 cancers and 4% reported attending previous awareness programs (Table 2).
When the 22 patients with baseline optimal knowledge about breast cancer were compared to their 128 counterparts with suboptimal baseline knowledge, only education associated with better knowledge (р = 0.002) (Table 3).
The same finding was detected also among the 20 patients with baseline optimal knowledge about cancer cervix in comparison to the 130 patients with suboptimal baseline knowledge (р = 0.007) (Table 4).

Discussion
Breast/Cervical cancer is considered as а public health emergency issue and one of the chief causes of increased mortality/disability among women despite its preventable nature through early detection.Thus, Healthy People 2020 highlighted a chief delineated goal to decrease the new diagnosed cases.2][33] Evidently, in 2015, Egypt Demographic Health Survey (EDΗЅ) reported that only 11.0% of, aged 15-59 years, women were aware of how to conduct ƁSE to recognize signs of BC and only 6% of them were actually had performed ƁSE in the previous year. [33]Therefore, the current study was conducted with the aim of evaluate the effect of a hospital-based program on the knowledge of patients attending the outpatient clinics of Sohag University Hospital about risk factors, manifestations, screening, and management of breast cancer and cancer cervix.
The morbidities and mortalities attributed to different cancers constitute a huge burden on underdeveloped countries.However, screening for cancers can help in early detection and appropriate treatment.The awareness of people about cancer and the importance of screening will increase their chance to screen for the disease regularly. [34]The current study evaluated the knowledge of patients about 2 important cancers; breast cancer and cancer cervix and assessed the impact of a hospital-based awareness program on their knowledge about both cancers.
The baseline results of this study showed that our patients had suboptimal knowledge about all aspects of breast cancer.Similar limitations were recorded in studies from Brazil [35,36] , Ethiopia [37] , Turkey [38,39] , Singapore [40] , Pakistan [41], the USA [42] , and Egypt [43] It should be noted that the cited studies were conducted on different population samples using different study designs and data collecting methods.However, the common finding was the suboptimal knowledge of the surveyed people.
Our results showed that education associated with better knowledge scores.This finding seems reasonable because educated people have more sources of knowledge.Yet, we did not find an association between the positive family history and knowledge which contradicted previous findings. [11,12] evertheless, only 5 patients reported a positive family history of breast cancer or cancer cervix.This low number is not enough for the statistical analyses to show significant differences.
Alike, we recorded low baseline knowledge among our patients regarding cancer cervix.Our results agreed with previous findings on populations from Singapore [40] , India [44,45] , Nepal and Sri Lanka [46] , and the USA [42,47] which found low knowledge about cancer cervix.Like the studies of breast cancer, these studies investigated different populations using different research methods and data collecting tools.Again, educated patients in our study showed better knowledge about cancer cervix compared to their illiterate counterparts.
Moving to the crucial part of this study, our program led to remarkable improvements in the knowledge of patients about breast cancer and cancer cervix.These improvements included all aspects of knowledge; risk factors, manifestations, screening, and management.
Many interventional studies targeted improving the knowledge of women about breast cancer and cancer cervix.These programs were performed on women from Iran [48] , Saudi Arabia [49] , Turkey [50] , Malaysia [51] and the USA [52] and recorded some achievements.Many differences regarding the used materials, assessment tools, and duration of the program were noted, however, most studies showed various improvements.This highlights the value of the educational intervention on improving knowledge level.
The positive effect of our hospital-based awareness program could be attributed to many factors.First, the program was divided on 4 sessions and each session discussed only 1 aspect of knowledge about both cancers.This offered patients а chance to fully understand all aspects of knowledge.We also allowed patients who missed 1 or 2 sessions to complete the program and attend the remaining sessions after giving them the summary of the sessions they missed.
Further, our awareness program was designed to be suitable for patients with low educational levels through using simple definitions, direct phrases, and illustrating figures.Moreover, the investigators encouraged the participants to ask, discuss their concerns, and narrate their personal experiences.
Another advantage was conducting the program in Sohag University Hospital where patients were seeking healthcare.This encouraged patients to complete the program and created an appropriate environment for the success of the program.

Conclusion and Recommendations
In conclusion, the knowledge of the patients about breast cancer and cancer cervix was unsatisfactory, especially, regarding the screening division.However, the hospital-based awareness program achieved remarkable successes in improving the knowledge.

Recommendations
Further awareness programs should be conducted regularly and on a wider scale for all women's in all different ages in Egypt.

Figure 1 .
Figure 1.Improvement of knowledge of the patients about breast cancer after the program, Sohag University Hospital, 2018 (p<0.001each)

Table 1 .
Overview of the elements in the program about women's' knowledge regarding breast cancer and cancer cervix (duration 3 months)

Table 2 .
Demographic characteristics of the patients, Sohag University Hospital, 2018

Table 3 .
Relation between the demographic characteristics of the patients and their baseline knowledge about breast cancer, Sohag University Hospital, 2018

Table 4 .
Relation between the demographic characteristics of the patients and their baseline knowledge about cancer cervix, Sohag University Hospital, 2018