Breast cancer is a major killer disease of women both globally and regionally. It is the most common cancer among women, and the second cause of deaths among women worldwide (World Health Organization WHO, 2010). The incidence of breast cancer in women remains high. It is estimated that 1,000,000 women develops breast cancer each year and Approximately 519,000 women deaths are related to breast cancer (WHO, 2010; McPherson, Steel, & Dixon, 2000). According to Manning-Walsh (2004) breast cancer incidence has increased and it is alarming for women affecting all ages. As a result, interpersonal relationships such as marital or sexual relationship are negatively affected. Stephen (2009) described breast cancer as “a malignant (cancerous) growth that begins in the tissues of the breast, cancer is a disease in which abnormal cells grow in an uncontrolled way” (p.1). Moreover there is no known cause for breast cancer but there are risk factors that are closely linked to development and progression of breast cancer. Breast cancer is classified into four stages. According to The American Joint Committee on Cancer (AJCC) revise the four stages are based on tumor size, the degree of lymph node involvement, the presence of inflammatory signs, and evidence of metastasis (Singletary at el. 2002). Stage (I) breast cancer involves primarily small tumors (less than or equal to 2 cm) with no known lymph node involvement and no metastases to other organs, in Egypt few women present at this stage. stage (II) breast cancers are characterized by either slightly larger primary tumor than stage (I) (between 2 and 5 cm) or if there is lymph node involvement. stage (III) consists of large tumors (greater than 5 cm) with signs of inflammatory breast cancer, also if ipsilateral nodes are involved where the tumor has caused the node to be fixed to another node or to other structures it is designated stage (III), high percent of women present in this stage which treatment option are limited. Stage 4 means any metastatic breast cancer no matter what size the tumor or if there is nodal involvement or not. If it is metastatic, it is stage (IV), in general stage (IV) is not considered curable (Singletary at el. 2002). The occurrence of breast cancer creates psychosocial stress for both the patient and her family, due to threat to the patient’s life and other consequences of breast cancer such as metastasis to other body organs and parts. In addition studies have shown that middle aged women (40-60) are most likely to develop breast cancer, and most patients with breast cancer present for the first time at stages two and three (Khatib, Modjtabai, 2006). Breast cancer has high incidence among women during productive period and has effect on financial as breast cancer treatment is very costly.
Breast cancer account for 37% of all types of cancer globally, moreover incidence of breast cancer varies from one country to another (WHO, 2010). In United State of America (USA) around 20 women will develop breast cancer each hour, moreover and around 5 women will die with breast cancer each hour (Lancaster, 2005). Studies have established that the rate of breast cancer is highest in USA and Canada, one out of nine women are expected to develop breast cancer and it is most common among women age 47-73 years old, leading to epidemic proportions in USA and Canada (McPherson, Steel & Dixon, 2000; George, 2000; Naeem at el., 2008). 182,460 cases developed breast cancer in USA in 2008 (Jemal at el., 2008).
Breast cancer incidence in developing country is high almost as high as in developed countries. One out of nine Pakistani women are expected to developed breast cancer (50 per 100,000), which is high compared to Indian women (19 per 100,000) (Kumar, Imam, Manzoor, & Masood, 2009). In Iran, one of the Arabic Country, in 2005 prevalence of breast cancer among women was (22 per 100,000) (Tavafian, Hasani, Aghamolaei, Zareand, & Gregory, 2009). Breast cancer is a major health alarms for many countries in the Mediterranean Region such as Bahrain represents 38.4% of all female cancers and in Jordan its represents 28% of all female cancers (Khatib, Modjtabai, 2006; Center for Arab Genomic Studies, 2003).
Likewise, breast cancer is the most common cancer among Egyptian women. According to the Egypt National Cancer Institute (NCI) in Egypt, breast cancer represents 18.9% of all cancers cases (35.1% in women and 2.2 % in men) (Omar, et al. 2003). Incidence of breast cancer is not different comparing with other countries which represented (24 per100, 000) and mortality rate related to breast cancer is 9.3% of all cancers (Seif, & Aziz, 2000). According to Khatib and Modjtabai (2006) Egyptian women under the age of 50 are more likely to develop breast cancer, where women aged 50 years and older are the most commonly affected group. In Egypt breast cancer is usually detected at late stages (around 60% of cases detected in third stage of breast cancer), when treatment options are limited therefore breast cancer is high fetal (Bender et al. 2005; Ibrahim at el., 2010).
In Aswan, breast cancer is most frequent cancer among both males and females (Ibrahim at el. 2010). Moreover it is presents 63.9% of all cancer cases among Aswan females, and most women aged (40-59) are the most commonly affected group. According to Ibrahim at el. (2010) “after the age of 20 years, breast cancer became the most frequent cancer with a peak in the age group 40-59 years” (p.72). In addition most cases are diagnosed in late stages only 3.1% cases are diagnosed in first stage, on the other hand around 96.2% of breast cancer cases are diagnosed in second and third stage when treatment options are limited making breast cancer is high fetal. As a result it is important to understand Aswan females experience about breast self examination and early detection of breast cancer. Moreover the high incidence and mortality rates of breast cancer, as well as the high cost of treatment and limited resources available, require that it should continue to be a focus of attention for health care providers. The benefits of fighting breast cancer, including the positive impact that early detection and screening can have, need to be carefully addressed.
The early detection of breast cancer is the most important and beneficial area of protection techniques. Diagnosis of breast cancer during the early stages of disease has been positively linked to a decrease in the mortality and morbidity of the illness (Budden, 1998; Gray 1990; Mele, Archer, & Pusch, 2005). Early detection of breast cancer is very important to decrease the morbidity and mortality of breast cancer outcome; ‘mammography and breast self examination’ have been used as strategies for this purpose (Budden, 1998; Gray 1990; Mele, Archer, & Pusch, 2005). Moreover there are a number of approaches to the screening of breast cancer such as Breast self-examination (BSE), clinical breast examination and mammography (Khatib, Modjtabai, 2006). (I) BSE is effective, cheap and less painful; however, it is dependent on knowledge, attitude towards BSE practice among women. (II) Clinical breast examination is one of the primary modes of screening for breast cancer. Its effectiveness is dependent upon the skills of the health care providers and the facilities available. (III) Mammography is known to reduce breast cancer mortality among women, but its benefits are dependent upon several factors such as the equipment used, the skills of the technician and it is expensive as well (Khatib, Modjtabai, 2006; Budden, 1998; Gray 1990; Mele, Archer, & Pusch, 2005).
Breast Self examination
BSE should be preformed every month starting at age 20 (ACS, 2009). The purpose of BSE is for a woman to learn the natural features of her breast, know how her breasts normally feel, thus easier for her to identify and report any new changes to the physician. (Gray, 1990; Highton, 2002). There is strong evidence that BSE can reduce mortality from breast cancer, around 90% of breast cancer are detected by BSE. (Smith, 2002; Wilson &Ayers, 2007). However the studies showed that BSE practice is very low. Therefore women should be aware of BSE tool. Consequently there seems to be general agreement on the importance to empower women with BSE knowledge and skill to promote BSE practice. Several studies have shown that there is a gap in knowledge about BSE and practice among women. (Al Qattan, Alsaleh, Al Musallam, &Masoud, 2008; Alkhasawneh, Akhu-Zaheya, & Suleiman, 2009; Wilson &Ayers, 2007).
George (2000) the barrier to breast cancer screening could be classified to personal, caregiver or demographic barriers, personal barriers included attitude and lack of information. At caregiver level, the assumption is lack of knowledge, skills, attitude, and consistency. For demographic it could be related to age, education level or culture. A fear of detecting any lump is also considered one of breast cancer screening barrier. The WHO (2010) suggested that to decrease the incidence of breast cancer in developing countries, breast cancer screening programs should be emphasized. The way this phenomenon is perceived by women influenced by many factors such as women’s socio cultural beliefs, values, geographical environment, personal knowledge and so on. Women face many challenges in rural areas which may affect their quality of life. To enhance the quality of life of middle age women in rural areas, it is important to have in depth understanding about their BSE perception.
Breast self examination practice
Knowledge and practice rate of BSE is varies from one country to another. According to Coleman (1991) around 96% of the American women had heard about BSE, however only 19-40% of them practice BSE every month. In the other hand 37% of the Kuwaiti women are practice BSE (Al Qattan, Al Saleh, Al Musallam & Masoud, 2008). In literature review only two studies were founded that were conducted in Egypt about BSE one was on Evaluation of “effect of breast self examination training program on knowledge, attitude and practice” (Seif & Aziz, 2000; p. 105), among 122 worker women in Ain Shams University- Lower Egypt. The result showed that around 25% of the participants have knowledge about breast cancer and BSE, however only 10.6% and 11.5% of the total sample practiced BSE. In addition the participant asserted that caregiver teams have an important role to provide the knowledge, skills and practice about BSE (Seif & Aziz). The second study is “Breast self-examination practice and its impact on breast cancer diagnosis in Alexandria, Egypt” (Abdel-Fattah, Zaki, Bassili, El-Shazly, & Tognoni, 2000, p.34). The result showed that 10. 4% of breast cancer patient practiced BSE after being diagnosed with breast cancer as study was focused on breast cancer patients, to monitor for spread of the cancer to the unaffected breast (Abdel-Fattah, Zaki, Bassili, El-Shazly, & Tognoni, 2000).
The gap in the two finding, (I) they focused only on percentage of knowledge and practice of BSE. (II) Both studies recommended follow up for studies to assess BSE knowledge and positive attitude and level of practice among women. (III) There is BSE negative attitude among women (72.1%) without explain the reasons. (IV) Both studies show the importance of attitude and perception of women related to BSE practice. Limitations of the two studies as one published in 2000 and the other one in 2003 and both are quantitative research. Usually people’ life style knowledge, attitude and behavior changes can be meaningfully captured through qualitative studies. In addition this data could be too old and no longer valid. Most of the studies on this subject were quantitative, and were designed to describe the demographic variables associated with BSE practice, increase the compliance or proficiency of women, or evaluate it as a screening technique. However there were recommendations for further studies to explore women beliefs and attitude about BSE.
The purpose of this study is to understand the perception of BSE among middle age women, and explore barriers to practice of BSE among Egyptian women. Furthermore, it will help identify knowledge, skills and practice gaps and recommend strategies to address the gap in BSE.
What is the perception related to knowledge, attitude and practices of middle age women regarding breast self examination in rural areas of Aswan, Egypt?
To explore the perception of middle age women related to breast self examination (BSE).
To understand Egyptian women’s experience about BSE.
To assess BSE knowledge and its sources among middle age women.
To assess if nurses teach women in community about BSE.
To evaluate whether women practice BSE in rural areas.
Significance of Proposed Study to Nursing
Incidence of breast cancer has increased and it seems that it will continue to rise, as predicted by scientists, physicians and previous studies. To decrease breast cancer morbidity and mortality rate, early detection is important. BSE is an important tool and should be practice to help in early diagnosis breast cancer. This study will enable researcher to understand perception of BSE among middle age women. Nurses who are working in the hospital or other health institute should be aware of breast cancer’s knowledge, altitude and practice among women. Hence, help them in early detection and intervention. In addition the findings of this study will enhance awareness among health professionals about BSE perception related to knowledge, practice and attitude among women. It also will provide need to plan intervention program about aware of breast cancer’s early detection knowledge, altitude and practice. As patient education is an integral component of nursing role. (Saarmann, Daugherty & Riegel, 2002). So those who are working in different areas in different status, nurses, health workers, lady health visitor and nurse practitioner should be able to provide health education according to their socio-cultural and arrange sessions on sharing the women experience, perception of BSE and guide in understanding early detection techniques. Moreover can expand the research and may help other in further research if they want to search more information on BSE in relation to specific aspects such as cultural and religion.
Qualitative descriptive-exploratory design will be used for this study. This design is selected science, little is known about BSE experience among women, as the majority of studies carried out on women’s knowledge, beliefs, attitudes, and practices related to BSE have been quantitative (Kearney, 2006). Which are chiefly designed to describe the demographic variables associated with its practice, increase the compliance or proficiency of women, or evaluate it as a screening technique. According to Polit and Beck (2008) qualitative approach is conducting the study within naturalistic pattern. A qualitative method deals with experiences of human being in real life by exploring it directly. It helps to understand the phenomenon in- deeply, by giving rich and most appropriate information. In addition according to Pope and Mays (1995) suggested that qualitative research helps to understand complex behaviors and attitude. The purpose of exploratory study is to examine a specific concept about which little is known (Burns and Grove, 2007). It emphasizes on identification of factors related to a phenomenon of interest. As this study aims to explore perception related to BES Knowledge, attitude and practice of middle age women in Egypt, therefore, a qualitative exploratory descriptive design is best suited to this study.
The purpose of this study is to understand the perceptionrelated to knowledage , attitude and practice of BSE among middle age women, and explore barriers to practice BSE among Egyptian women. Furthermore, it will help identify knowledge, skills and practice gaps and recommend strategies to address the gap in BSE.
What is the perception related to knowledge, attitude and practices of middle age women regarding Breast self examination in rural areas of Aswan, Egypt?
Study Setting and Population
Health care clinics in rural areas in Aswan- Egypt will be selected as setting for recruiting participant. The study population would be middle aged (40-60 years) women, coming to the health care clinics. The target population will be all the middle age women who will meet the following inclusion criteria: (I) aged women between 40-60 years. (II) the women who have not been diagnosed with breast cancer. (III) They are living in rural area. (IV) They can speak Arabic or English. (V) They are willing to participate in the study and use audiotape. Women will be excluded if they have any mental illness, as this may affect their judgment, or are not willing to participate in the study.
Study Sample and Size
The sampling method would be used is purposive sample. This type of sampling is often use by qualitative researcher because the aim is to contact participants who can give in-depth, rich information about the study phenomenon (Polit & Beck, 2008). The study samples comprise of 8-12 women who are in middle age or to the point at which data saturation is achieved.
Health care clinics’ director, physicians and nurses will be met and discuss about the study and request them to identify potential participants. The women who will come to the health care clinic and who meet the inclusion criteria for the study, nurses will give them invitation and consent letter. The women who will be willing to participate will be asked for informed written and oral consent. Then discuss and agree on the date, time and venue of one to one interview according to the woman’s convenience. The interview will be held in noise free setting either at health care clinic or at participant’s house/ convenient place.
Polit and Beck (2008) Polit study help to assess “adequacy of the study and quality of instruments” (p. 214). Prior to collecting the data, the pilot testing of interview guide would be done on 1-2 middle age women who would be coming to the health care clinic of Aswan, Egypt, after taking the participants’ consent. The objectives of Polit study: to evaluate the understanding of the semi structure questions, to assess the comfort level of the women, to identify the amount of time required by the participants and to determine the time of the day that suits best for the interview to be conducted. The data collected from pilot testing will be used as part of the data collection.
Data will be collected from April 2011 to June 2011 in Aswan, Egypt. For this study, the data will be collected using semi structured questions to guide an in-depth interview. The time for interview is approximately 50-70 minutes. Individual interview will help to explore individual perception in detail and while maintaining confidentially. It is assumed that the participants may feel more comfortable and free while expressing and sharing their experiences in privacy. Audiotape will be used to record the interview. Notes will be taken for observation made onthings might be relevant to the study, such as participant’s non verbal communication (facial expressions, posture and other body language). At the end of the session the data will be verified/ cross checked with participants for clarity consistency. After audio taping the interview, the data would be transcribed and will be checked for matching.
The written consent will be taken from the participants prior to the interview. Interview will be conducted in Arabic as it is participants ease; so the data will be understood well and bias would be reduced in this way. Probes would be used to explore more information and will provide direction to the participant. Field notes will be taken; observation would be noted such as non verbal communication of the patient. Does the non verbal and verbal communication matches or not and observation related to the environment that provides and clue related to the data or experience. The data analysis will be proceeded by guidelines (unrau& coleman, 1997) (a) the transcribed interview of the participants will be coded for analyzing data, (b) identifying emerging themes in the data, (c) labeling the themes with significant code words, (d) codes will be clustered and labeled using broader themes and sub themes throughout analytic process, (e) the thematic strands will be weaved together into an integrated picture of phenomena under investigation. Data analysis will be carried out manually. The researcher will read the data over and over in search of meaning and deeper understanding, carefully reading the interviews to obtain a general sense of the experience.
Data Analysis Plan
Data analysis in qualitative research is actually begins when data collection begins (Polit & Beck, 2008) therefore, the researcher will start analyzing the data after taking the first interview. The qualitative data analysis involves four cognitive processes: comprehension- identifying the themes; synthesis- merging of the themes to make a composite pattern; theorizing- connecting the findings with the larger body of knowledge; re-contextualization- applying the findings to other setting or the context in which the findings fit (Morse, 1994). Therefore, these processes will be applied to the data analysis of this study. (a) for analyzing data, the transcribed interview will be coded (b) identifying emerging themes in the data, (c) labeling the themes with significant code words, (d) codes will be clustered and labeled using broader themes and sub themes throughout analytic process, (e) the thematic strands will be weaved together into an integrated picture of phenomena under investigation.
Data analysis will be carried out manually. The researcher will read the data over and over in search of meaning and deeper understanding, carefully reading the interviews to obtain a general sense of the experience. According to Morse and Field (2005), gathering the responses according to the question is a significant procedure for semi structured interviews. Therefore, the researcher will read the transcripts and gather the responses to each question in a separate file. The gathered responses to each question will be organized in a text that will have three columns. The centre column will contain the participants responses, the left column will show the coding and the right column will include my comments and thoughts concerning the text. The qualitative content analysis will be used as analytic method, while for content analysis the form which is referred by Morse and Field (1995) will be utilized. The form divided into manifest and latent content analysis. In manifest analysis, the researcher search for specific words, phrases or ideas used in the content of interview. In latent analysis, the researcher search for the underlying meaning of the message showed in the text. The latent content analysis has greater validity than manifest analysis as it permits for the coding of the meaning and not just the words of the participants (Morse & Field, 1995). Therefore, the researcher will use both analysis methods. For coding, the researcher will reread the text and underline words or phrases and will copy them into the left hand column of the document. At the same time, the researcher also aggregate codes into relevant categories in a separate document. Pseudonyms and identification number to each individual text will be given.
The pseudonyms will help to imagine the respondent and to make sense of it, whereas, identification number will facilitate to identify patterns during coding and categorization exercises. The codes with each category will be identified from its origin through identification number. The short form of category will also be assign to a code as well. Each category will be compared and contrast that may help to create sub categories. After sorting the major categories into smaller ones, the researcher will look for atypical and representative cases that will help to explain the significant experience found in the research. The researcher will also look for the relationships among categories to find common themes. The researcher will also refer to the notes that have non verbal expressions of the participants and her own feelings in the analysis process. The researcher will be involving the committee members and supervisor throughout the analysis process.
The proposal will be sent to the University’s “Ethical review committee” (ERC) which will give a written permission for the study. Informed consent and Permission will be obtained from Aswan Directors of Health. The principle of autonomy will be followed which means that Participants will be approached to consent for voluntary participation. Complete information about the study will be provided to the participants. The participant will be informed about the study purpose, risks and benefits of participating. Participants will be approached to consent for voluntary participation and will have freedom to choose or to terminate their participation at any time during the study. No potential physical or psychological harm is expected. Those willing to participate will sign a consent form and a copy of the consent form will be provided to the participants. Confidentiality refers to the researcher’s assurance to the participants that the shared information will not be publicized (Burkhardt & Nathaniel, 2002). Thus, confidentiality in this study will be maintained by not sharing the participant’s data with any other participant and will be observed throughout the study. Anonymity and confidentially is the key principle to maintain privacy (Burkhardt & Nathaniel, 2002). The participant’s identity will not be revealed in the study. Codes will be used instead of the name. The researcher will assure the participants of their confidentiality. The data will not be utilized for any other purpose, there being aneed for secondary analysis of the data permission will be obtained from relevant bodies. This study will help middle age women to verbalize their perceptions, feelings and experience about BSE. Women might get emotionally upset in the process of sharing their experience. In these instances break would be provided during the interview. The researcher will answer all the participant’s queries in order to provide complete information regarding the study to easy tension and promte comfort.
Trustworthiness is the term used in the qualitative research to show rigor (Poilt and Beck, 2008). In this study the rigor will be maintained throughout by utilizing Lincoln and Guba (1985) guidelines. Lincoln and Guba identified four criteria for maintaining trustworthiness of a qualitative research (i) credibility, or (Truth value), (ii) dependability, reliability or Auditability, (iii) confirmability or Neutrality, and (iv) Transferability, Fittingness. The research will be described clearly; the procedures will be used to ensure that the data will be recorded accurately. The researcher will ensure that findings and the themes will be logical and reflective of the data. Credibility, dependability, conformability, and transferability will be maintained.
Lincoln and Guba (1985) credibility presented “such faithful descriptions or interpretations of a human experience that the people having that experience would immediately recognize it . . .” (p. 30). Also when others can recognize the experience by reading about it. To confirm the credibility of the findings, the researcher will share the outcomes with women, who recognized the findings and conformed that they were true to their experiences and perception, this establishes the credibility. One technique to improve credibility is to give out sufficient time for data collection activities to gain an in-depth understanding of the individuals’ experience.
it could be maintained when another researcher can clearly follow the “decision trail” used by the investigator. In addition, another researcher could arrive at the same or comparable but not contradictory conclusions given the researcher’s data, perspective, and situation.To provide dependability, the researcher applied and recorded the audit trial. Lincoln and Guba (1985), state, “Conformability is termed as a process to provide the study records in order to maintain the objectivity; and to verify the quality and adequacy of the results and interpretation”. (Lincoln & Guba, 1985).In this study the audit trail and research plan will be shared with the thesis supervisor and to the committee members so that they would verify its dependability. Dependability relies on three factors and should be ensured by the researcher: the sample size, the analysis approach, and the dissemination of the research result. The sample size will be sufficient for the research design as the researcher will achieved saturation, and the researcher plans to disseminate the study findings through publication of articles and presentations at the national and international level.
when auditability, fittingness, and credibility have been established by an audit trail, conformability could be achieved. Audit trail consist of raw data, memos, communications, records of gestures, etc. the researcher applied an audit trail to meet these conditions by constructing and maintaining a record of unrefined data, data reduction and reconstruction, synthesis products and consequent analysis (Lincoln & Guba, 1985).
It will be achieved when study findings “fit” into contexts outside the study situation and when the audience views the findings as meaningful and transferable to the rest of the potential users. Lincoln and Guba (1985) termed transferability as the way of presenting adequate data such that external conclusions may be made about the findings. These in-depth interviews, with rich descriptions about menopause experience allow the readers to decide about its transferability. Through rich and extensive description, the researcher will provide with in-depth information about the contexts, the data, and the participants.
Limitations of the study includes: (I) the data collection plan is limited to three months only as it is a part of master’s programme that may affect the quality of the study. (II) The researcher’s own experiences and opinion there is a chance of biasness. (III) The transferability of the study findings will be limited to Aswan’s population; as each community has specific culture. (IV) Because of the culture and the topic some of the participant will not share full information about their experience.
Finding Dissemination Plan
Results will be presented to nurses and nurse leaders of Aswan Directors of Health. The researcher will give recommendations and will work with Aswan nurse and their leaders to achieve the recommendations. The study will be presented at national scientific conferences and seminars, as well as published in local and international journal.
Abdel-Fattah, M., Zaki, A., Bassili, A., El-Shazly, M., & Tognoni, G. (2000). Breast self- examination practice and its impact on breast cancer diagnosis in Alexandria, Egypt. Eastern Mediterranean Health Journal, 6(1), 34-40.
Al Qattan, M. M., Al Saleh, K. A., AlMusallam, S. S., & Masoud, G. M. (2008). Knowledge and factors affecting breast self examination among Kuwaiti women. Kuwait Medical Journal, 40 (2), 103-110.
Alkhasawneh, I. M., Akhu-Zaheya, L. M