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International Journal of Nursing Practice 2015; 21: 882–888
RESEARCH PAPER
Perceptions and health beliefs of Greek nursing students about breast self-examination: A descriptive study Maria Lavdaniti BSc MSc PhD RN Assistant Professor, Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece
Accepted for publication October 2013 Lavdaniti M. International Journal of Nursing Practice 2015; 21: 882–888 Perceptions and health beliefs of Greek nursing students about breast self-examination: A descriptive study Breast self-examination is a screening option for young women. Among students, knowledge about breast selfexamination ranges from insufficient to average. This descriptive study was planned in order to determine the health beliefs and perceptions of nursing students regarding breast self-examinations. We recruited 538 nursing students in a single Higher Technological Educational Institute in Greece. Data were collected using the Champion’s Health Belief Model Scale. Parametric tests were used in the data analysis. We found significant differences in the results of the subscales of Champion’s Health Belief Model Scale on comparing people with respect to nationality, previous education about breast self-examination, smoking status and semester in which they were studying. The ‘confidence’ subscale was positively associated with the frequency of breast self-examination. The results of the present study demonstrated that nursing students have knowledge about breast-self examination but inadequate practice. Key words: breast cancer, breast self-examination, health behavior, nursing, perceptions.
INTRODUCTION Breast cancer is the most common type of cancer among women in both developed and developing countries. Worldwide, an estimated 1.38 million (≈23% of all diagnosed cancers) new breast cancer cases were diagnosed in 2008.1 According to the Organisation for Economic Co-operation and Development, breast cancer accounted for 30% of cancer incidence among women and 15% of cancer deaths in 2009. In Greece, it is the most common cancer in women, with an estimated age-standardized
Correspondence: Maria Lavdaniti, Nursing Department, Technological Educational Institute of Thessaloniki, Thessaloniki, Thessaloniki 57400, Greece. Email: [email protected] doi:10.1111/ijn.12323
incidence rate of 27.2% and a mortality rate of 18.2% among Greek women.2 Mammography, clinical breast examination and breast self-examination (BSE) are the recommended methods of breast cancer screening.3 However, although the BSE is simple, quick and cost-free,4 its effectiveness remains controversial.5,6 The American Cancer Society recommends that women undergo mammography or clinical breast examinations for early breast cancer detection but also recommends that women start performing BSEs as a screening option, starting in their 20s. Women who regularly perform BSEs have greater awareness of their breasts, and if they detect any changes in their breasts, they should immediately report it to a health-care professional. In addition, women should be informed about the © 2014 Wiley Publishing Asia Pty Ltd
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benefits and limitations of BSE.7 The Ministry of Health in Greece recommends that women perform a BSE monthly and accepts the guidelines of the World Health Organization for breast cancer screening.8 Numerous studies have investigated knowledge of breast cancer and BSE in women between 14 and 19 years of age.5,9,10 Knowledge of BSE in these ages has been found to range from insufficient5,9 to average.1 Furthermore, a low percentage of secondary college students reported having performed a BSE at some point in their lives.9,10 All of the above researchers agree that there is a great need to promote knowledge of breast cancer and BSEs, and adequate health education in general, among young women. Several studies have evaluated the effectiveness of BSE education programs for university students.11,12 The majority of these studies indicated that BSE knowledge increased after such education programs.12,13 Moreover, these education programs appear to contribute to an increased frequency of BSEs in midwifery students13 and improved the accuracy of BSEs in nursing and midwifery students in Turkey.11 Furthermore, some studies assessed the health beliefs about, and the knowledge and practice of BSE among nursing students.14–17 The majority of these studies were comparative, focusing on how knowledge of BSE differed between nursing and midwifery students, and how health beliefs differed between nursing students and their mothers,16 and between nursing students of two countries.15 These studies reported that nursing students performed BSEs regularly14–17 and had sufficient information about them.14,17 Kara & Acikel,16 in a comparative study of health beliefs between nursing students and their mothers, found that nursing students scored higher on health motivation, benefits of BSE and confidence about performing BSE, whereas their mothers scored high on perceived susceptibility to breast cancer and barriers to BSE. They concluded that the frequency of BSE depended on the level of education. Other studies indicated that there is a correlation between students level of academic experience and BSE practice.14,17 Chouliara et al.,15 in a study conducted on nursing students in Scotland and Greece, found that BSE practice did not differ significantly between the two samples, but there was difference in their knowledge and attitudes towards BSE and healthrelated personality traits. However, studies assessing BSE had average samples consisting of different aged group,16 and some researchers used questionnaires © 2014 Wiley Publishing Asia Pty Ltd
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specifically developed for those studies from the current literature.14,17 Although the body of evidence regarding knowledge, beliefs and attitudes about BSE is growing worldwide, the existing literature in Greece is limited to differences in knowledge of BSE between breast cancer patients and healthy women,18 and health behaviors related to BSE in the general population of women.19 Furthermore, only one study examined knowledge of breast cancer screening in midwifery students.20 To our knowledge, there is no prior research on health beliefs and knowledge about BSE in Greece. Therefore, the aim of the present study was to determine the health beliefs and perceptions of nursing students regarding BSE and to establish baseline data for further research about BSE in Greece. The Health Belief Model (HBM)21 was used as a theoretical framework underlying this study. The HBM consists of four dimensions: susceptibility, seriousness, benefits and barriers. Later, Rosenstrock et al. (1988)22 added health motivation and confidence in the model. By applying the HBM to breast cancer and BSE, we created the following model: women who believe that they are susceptible to breast cancer and that breast cancer is a serious disease, but they perceive more benefits of and fewer barriers in performing BSE are more likely to perform BSEs. Moreover, women who are motivated to promote their health and are confident in their ability to perform BSE are more likely to perform BSEs.23
METHODS Setting and sample The study was descriptive and nonexperimental and was conducted in the Nursing Department of higher technological educational institute in a major city in Northern Greece. We used a convenience sampling method to select nursing students enrolled in this institute. A total of 538 nursing students completed the questionnaire (response rate: 92%). The inclusion criteria were (i) female; (ii) not pregnant or breastfeeding; (iii) attending classes at the institute during the period of research; and (iv) over 18 years old.
Procedure Ethical approval for this study was obtained from the Research Committee of the higher technological educational institute. The first author approached students who were present in classes on the day when data were
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collected and explained to them the purpose of the study. A questionnaire was then distributed to students who met the inclusion criteria mentioned above. Each questionnaire contained a letter that explained the study purpose and the respondent’s rights as research participants. Potential participants were informed that participation was voluntary and posed no known risks to them and that they could withdraw from the study at any time. Subsequently, participants who agreed to participate in the study voluntarily completed the questionnaire, which took about 15 min to complete. Data collection was carried out between February and December 2009.
Instrument Data were collected through a self-administered questionnaire that included questions on sociodemographic characteristics and the revised Champion’s Health Belief Model Scale (CHBMS). Sociodemographic characteristics included age, marital status, current semester at the institute and various questions about BSE practice. The CHBMS was developed in 198424 and has been revised since then.24,25 It is the most commonly used instrument for measuring the HBM variables of susceptibility, seriousness, benefits, barriers, confidence and health motivation related to breast cancer screening.25 All the items are rated on Likert-type scale ranging from ‘strongly disagree’ to ‘strongly agree’. Higher scores indicated stronger feelings related to that construct. All the scales were found to be positively related to screening behavior, except for barriers, which was negatively related.26 The permission to use the CHBMS was obtained from Victoria Champion in 2007 through personal communication. Before data collection, the scale was translated into Greek using a back-translation technique. Two bilingual individuals independently translated the English version of the scale into Greek. Experts oncology professionals then met and reviewed the Greek translation for inconsistencies with the original form and made minor revisions. The Greek version of the CHMBS was then back-translated into English by a bilingual individual working at the higher technological educational institute. The two forms of the scale were compared and were found to be highly similar. The content validity of the translated CHMBS was determined by an expert panel consisting of an oncologist and two nurses specialized in oncology.27 Before the completion of the questionnaire, a pilot study was conducted28 on nursing students selected via purposive sampling. This
study allowed us to revise and modify some of the items. This corrected version was then used in the study. The Cronbach’s α, of the translated CHMBS in the present sample, ranged from 0.70 to 0.87, which was consistent with previous studies.24,29
Data analysis All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 15.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were used to describe participants’ sociodemographic and general health characteristics. Parametric tests were used to compare health beliefs and knowledge (and breast cancer screening behavior) among participants. In addition, a linear regression analysis was conducted. Statistical significance was set at P ≤ 0.05
RESULTS The participant characteristics are presented in Table 1. Participants’ age ranged between 18 and 25 years of age, and their mean age was M = 20.83, SD = 2.28. Most Table 1 Demographic characteristics of the sample
Age (year) Mean 20.83 ± 2.28 18–20 21–24 > 24 Nationality Greek Other Family status Married Married with children Divorced Cohabitation Unmarried Semester First Second Third Fourth Fifth Sixth Seventh
Frequency (n)
%
— 282 205 50
— 52.5 38.2 9.3
517 21
96.1 3.9
9 22 2 23 480
1.7 4.1 0.4 4.3 89.6
136 67 53 18 98 42 73
25.3 12.5 9.9 3.3 18.2 7.8 23.1
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participants were Greek (96.1%), aged < 20 years (52.5%), and were unmarried (89.6%). Almost a quarter of the participants were in their first semester at the institute (n = 136, 25.3%) and another quarter in their seventh, or final, semester (n = 73, 23.1%). In addition, 65.1% of participants consumed alcohol and 60.5% were smokers. Only 12.7% (n = 68) of participants reported having a family history of breast cancer. The average frequency of BSEs per month during the last year was 4.14 ± 3.54. Furthermore, about 54.4% (n = 291) had performed BSE at least once, 52.8% (n = 284) had learned about BSE previously, out of which 63.2% (n = 198) had learned about BSE from a health professional. When asked their opinion on the usefulness of learning BSE, almost all participants (97.6%, n = 523) answered positively. The comparisons of the subscales of the CHBMS by nationality, previous education about BSE and smoking habits are presented in Table 2. We observed no significant differences with respect to the subscales except for perceived susceptibility to breast cancer that was significantly lower in nationalities other than Greek (P < 0.001). Confidence (P < 0.001) and health motivation (P = 0.008) were significantly higher in students who had not been previously educated about BSE than in students who had been educated about BSE. The average scores for seriousness and barriers regarding BSE were significantly higher in students previously educated about BSE than in students who were not educated (P = 0.024 and P = 0.012, respectively). We also noted that health
motivation was significantly higher in smokers than in nonsmokers (P < 0.001). Furthermore, we found that last/seventh semester students scored significantly higher on the scores subscale for health motivation and confidence than those in first semester students (P < 0.001 and P = 0.036, respectively). We also found that the average score for the barriers subscale for the first semester students was significantly higher than that for seventh semester students (P < 0.001). Table 3 presents the results of a linear regression analysis for each subscale score with the frequency of BSE practice in the last year. As can be seen from the table, the only statistically significant factor was confidence (P < 0.001). The model for the linear regression analysis was built on the following equation: Frequency of BSE = 1.984×confidence score − 4.174. The coefficient β = 1.984 indicated that when confidence increases by one unit and the other factors are constant, the frequency of BSE practice increases by almost 2 units—in other words, it was conducted more frequently.
DISCUSSION This study assessed perceptions of breast cancer and BSE among female nursing students according to the HBM. In this study, 54.4% had performed BSE in the past. This percentage is rather low although it is consistent with previous research.14,15,17 Furthermore, the mean frequency of BSE was 4.14 per month in the last year, and this low frequency might reflect students’ lack of knowledge about the purpose of BSE and how to perform it.30
Table 2 Mean total scores for Health Belief Model scales according to the participants’ characteristics Nationality
Previous education on breast self-examination
Smoking
Mean ± SD
Mean ± SD
Mean ± SD
Variable
Greek
Other
P†
Yes
No
P†
Yes
No
P†
Confidence Health motivation Susceptibility Seriousness Benefits of BSE Barriers to BSE
2.99 ± 0.63 3.71 ± 0.48 2.69 ± 0.69 3.29 ± 0.69 3.74 ± 0.55 2.46 ± 0.66
2.95 ± 0.75 3.80 ± 0.57 2.30 ± 0.83 3.37 ± 0.70 3.57 ± 0.64 2.41 ± 0.58
0.799 0.422 0.014 0.636 0.219 0.750
2.94 ± 0.63 3.68 ± 0.49 2.67 ± 0.69 3.33 ± 0.66 3.71 ± 0.56 2.50 ± 0.63
3.15 ± 0.64 3.81 ± 0.47 2.67 ± 0.74 3.16 ± 0.77 3.81 ± 0.52 2.32 ± 0.72
0.001 0.008 0.995 0.024 0.053 0.012
2.96 ± 0.63 3.77 ± 0.46 2.64 ± 0.74 3.30 ± 0.68 3.75 ± 0.55 2.44 ± 0.66
3.02 ± 0.65 3.60 ± 0.50 2.72 ± 0.65 3.32 ± 0.66 3.68 ± 0.56 2.50 ± 0.63
0.299 0.000 0.193 0.815 0.175 0.323
†
t-test. BSE, breast self-examination; SD, standard deviation.
© 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Simple linear regression analysis of Health Belief Model variables on the frequency of breast self-examination practice in the last year Coefficients β
(Constant) Confidence Health motivation Seriousness Benefits Barriers
−4.174 1.984 0.441 −0.466 0.473 2.315 × 10−3
t
−1.493 4.937 0.891 −1.331 1.101 0.005
In the present study, more than half of students who had received some prior education about BSE had received it from health-care professionals. Studies from other countries reported conflicting results regarding the source of information regarding BSE. Budden30 found that first-year Australian nursing students obtained BSE information mostly from media (e.g. newspaper, radio and TV), whereas nursing students in Turkey were informed through their school curricula (midwifery and nursing) as well as written materials (books, materials and brochures). A possible explanation is that nursing schools in different countries have different curricula. Memis et al.17 emphasized the importance of information gained from the curricula as contributing factor. An interesting result was that the susceptibility subscale had the highest values among Greek students. One explanation for this finding is the differences in health beliefs between cultures—in other words, women of different cultures might view health differently.31 However, it is worth mentioning that the percentage of participants of nationalities other than Greek was small, and hence the findings are not robust, and warrants further research. In this study, students with no previous education about BSE had higher scores on the confidence and health motivation subscales of the CHBMS. These results were surprising, but it might be explained by the fact that in this study a high percentage of students (47.2%) had received no prior information on BSE. In addition, this result showed that in Greece, it would be necessary to include courses on BSE in the nursing curriculum, so that students can be educated and motivated to practice BSE. In addition, we observed no significant difference in the perceived seriousness of breast cancer between students who
P
0.137 0.000 0.374 0.184 0.272 0.996
95% confidence interval for β Upper bound
Lower bound
−9.678 1.192 −0.534 −1.155 −0.374 −0.878
1.331 2.775 1.416 0.223 1.320 0.883
had been previously educated on BSE and those who had not been educated. This was an expected outcome and supported the claim that seriousness was not a relevant predictor for BSE performance as breast cancer was almost universally regarded as a serious condition by most women.24,32 Although educated students perceived breast cancer as serious, most of them reported high barriers toward practicing BSE. The high scores on the perceived barriers subscale were inconsistent with other studies,16 which showed that nursing students perceived fewer barriers. This difference might be explained by the fact that Turkish nursing students, in a previous study, were well informed about BSE, whereas Greek students are not. This might also be a result of cultural differences. Additionally, Chouliara et al.15 suggested that ‘Greek women tend to believe that their health is a matter of chance and it is the responsibility of health professionals’, and this belief affects their perceptions about the benefits of early detection methods. Further research is needed to identify the barriers to BSE for young Greek students, which will help in planning and implementing appropriate interventions to reduce perceived barriers. The students in their final semester had more confidence and health motivation, and lower scores on the barriers to BSE, than did students in their first semester. This was an expected outcome and was consistent with similar studies in nursing students14,30 and female university students in general.33 In addition, this result supports the assertion of Kara & Acikel (2009)16 that ‘nursing students receive training about breast cancer and BSE practice during their education and the care offered to women with breast cancer could have affected their own health beliefs regarding BSE’. © 2014 Wiley Publishing Asia Pty Ltd
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According to the logistic regression analysis, women who were confident in their ability to conduct BSE were more likely to perform it. This finding is consistent with the HBM, particularly in relation to confidence and BSE practice24,29 and is also consistent with the findings of other studies.34,35 Our study highlights the importance of education to increase women’s confidence and ability to perform BSE. Thus, it is important for the Greek Health Ministry to organize educational programs in universities and other educational institutions in order to increase BSE practice among female Greek students.
Limitations This study had several limitations. First, the study was conducted in just one technological educational institute in Greece, and thus, generalizability of these results to all Greek female nursing students is limited. Additional research is needed in several educational institutes and other universities in order to improve the generalization of these findings. Another limitation was that due to the lack of previous similar studies in Greece that investigated the health beliefs and perceptions of nursing students concerning BSE, we were unable to compare our results with many other previous ones.
Conclusions and implications for nursing practice The results of the present study demonstrated that nursing students have knowledge about BSE but inadequate practice. In addition, health beliefs differed significantly by nationality, previous education about BSE, students’ semester and whether they smoked. Furthermore, confidence significantly predicted BSE behavior. It is essential that nursing students receive adequate training about BSE and practice it efficiently. In addition, it is important that they transfer this information to their relatives, thus contributing to public health. Furthermore, the findings of this study might be of great interest among nursing educators in Greece, as they have the potential to enrich the nursing curriculum with BSE practice. Furthermore, these trained students, once fully fledged nurses, will go on to educate women in the community. Further research should examine the barriers to BSE practice and specify the health beliefs about breast cancer screening in women, which could add useful information to the Greek nursing literature and to the Greek National Health System. © 2014 Wiley Publishing Asia Pty Ltd
REFERENCES 1 Ferlay J, Shin HR, Bray F et al. Estimates of worldwide burden of cancer in 2008. International Journal of Cancer 2010; 127: 2893–2917. 2 GLOBOCAN (IARC). Section of Cancer Information. Fast Stats, 2008. Available from URL: http://www.globocan .iarc.fr/factsheets/populations/factsheet.asp. Accessed 30 August 2012. 3 World Health Organization. Breast Cancer: Prevention and Control, 2008. [Updated 2012] Available from URL: http:// www.who.int/cancer/detection/breastcancer/en/index3 .html. Accessed 30 August 2012. 4 Doshi D, Reddy BS, Kulkarni S, Karunakar P. Breast selfexamination: Knowledge, attitude, and practice among female dental students in Hyderabad City, India. Indian Journal of Palliative Care 2012; 18: 68–73. 5 Karayurt O, Ozmen D, Cetinkaya AC. Awareness of breast cancer risk factors and practice of breast self-examination among high school students in Turkey. BMC Public Health 2008; 8: 359. 6 Sarvazyan A, Egorov V, Son JS, Kaufman CS. Cost-effective screening for breast cancer worldwide: Current state and future directions. Breast Cancer (Aukl) 2008; 1: 91–99. 7 American Cancer Society. How Is Breast Cancer Diagnosed?, 2010. Available from URL: http://www.cancer.org. Accessed 30 August 2012. 8 National Plan Action for Public Health. Greek Ministry Health and Social Help, 2008–2012. Available from URL: http:// www.yyka.gov.gr. Accessed 30 August 2012. 9 Isara AR, Ojedokun CI. Knowledge of breast cancer and practice of breast self-examination among female senior secondary school students in Abuja, Nigeria. Journal of Preventive Medicine and Hygiene 2011; 52: 186–190. 10 Shalini Varghese D, Nayak M. Awareness and impact of education on breast self-examination among college going girls. Indian Journal of Palliative Care 2011; 17: 150–154. 11 Balkaya NA, Memis S, Demirkiran F. The effects of breast self-exam education on the performance of nursing and midwifery students: A 6-month follow-up study. Journal of Cancer Education 2007; 22: 77–79. 12 Gursoy AA, Yig˘itbas¸ C, Yilmaz F et al. The effects of peer education on university students’ knowledge of breast selfexamination and health beliefs. Journal of Cancer Education 2009; 24: 331–333. 13 Beydag˘ KD, Yürügen B. The effect of breast selfexamination (BSE) education given to midwifery students on their knowledge and attitudes. Asian Pacific Journal of Cancer Prevention 2010; 11: 1761–1764. 14 Alsaif AA. Breast self-examination among Saudi female nursing students in Saudi-Arabia. Saudi Medical Journal 2004; 25: 1574–1578. 15 Chouliara Z, Papadioti-Athanasiou V, Power KG, Swanson V. Practice of and attitudes toward breast self-examination
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17
18
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21 22 23 24 25
(BSE): A cross-cultural comparison between younger women in Scotland and Greece. Health Care for Women International 2004; 25: 311–333. Kara B, Acikel CH. Health beliefs and breast selfexamination in a sample of Turkish nursing students and their mothers. Journal of Clinical Nursing 2009; 18: 1412– 1421. Memis S, Balkaya NA, Demirkian F. Knowledge, attitudes, and behaviors of nursing and midwifery students regarding breast self-examination in Turkey. Oncology Nursing Forum 2009; 36: E39–E46. Roupa Z, Sapountzi-Krepia D, Gourni M et al. Breast self-examination (BSE) among Greek women living in the greater area of Athens. ICUs and Nursing Web Journal 2000; 12: 1–6. Deltsidou A. Behaviors models and breast self-examination. Review of Clinical Pharmacology and Pharmacokinetics, International Edition 2008; 26: 193–201. Tigka M, Gourounti K, Bilatis I, Lykeridou K. Knowledge of breast cancer screening of Greek and Italian student midwives. A comparative study. Health Science Journal 2009; 3: 72–78. Rosenstock IM. Why people use health services. Milbank Memorial Fund Quarterly 1996; 44 (Suppl.): 94–127. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Education Quarterly 1988; 15: 175–183. Champion VL. Instrument development for health belief model constructs. ANS Advanced Nursing Science 1984; 6: 73–85. Champion VL. Instrument refinement for breast cancer screening behaviors. Nursing Research 1993; 42: 138–143. Champion VL, Scott CR. Reliability and validity of breast cancer screening belief scales in African American women. Nursing Research 1997; 46: 331–337.
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26 Champion VL. Revised Susceptibility, benefits, and barriers scale for mammography screening. Research in Nursing Health 1999; 22: 341–348. 27 Polit DF, Hungler BP. Nursing Research: Principles and Methods. Philadelphia: JB Lippinicot Company, 1995. 28 Lavdaniti M, Deltsidou A, Kourkouta L, Avramika M, Sapountzi-Krepia D. The knowledge of nursing students regarding breast self-examination: A pilot study in Northern Greece. Nosileftiki 2010; 49: 418–425. 29 Mikhail BI, Petro-Nustas WI. Transcultural adaptation of Champion’s Health Belief Model Scales. Journal of Nursing Scholarship 2001; 33: 159–165. 30 Budden L. Student nurses’ breast self-examination health beliefs, attitudes, knowledge, and performance during the first year of preregistration degree program. Cancer Nursing 1999; 22: 430–437. 31 Parsa P, Kandiah M, Mohd Nasir MT, Hejar AR, Nor Afiah MZ. Reliability and validity of Champion’s Health Belief Model Scale for breast cancer screening among Malaysian women. Singapore Medical Journal 2008; 49: 897–903. 32 Canbulat N, Uzun O. Health beliefs and breast cancer screening behaviors among female health workers in Turkey. European Journal of Oncology Nursing 2008; 12: 148– 156. 33 Moodi M, Mood MB, Sharifirad GR, Shahnazi H, Sharifzadeh G. Evaluation of breast self-examination program using Health Belief Model in female students. Journal of Research in Medical Science 2001; 16: 316–322. 34 Petro-Nustas W, Mikhail BI. Factors associated with breast self-examination among Jordanian women. Public Health Nursing 2002; 19: 263–271. 35 Tavafian SS, Hasani L, Aghamolaei T, Zare S, Gregory D. Prediction of breast self-examination in a sample of Iranian women: An application of the Health Belief Model. BMC Women’s Health 2009; 29: 37.
© 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21: 882–888
RESEARCH PAPER
Perceptions and health beliefs of Greek nursing students about breast self-examination: A descriptive study Maria Lavdaniti BSc MSc PhD RN Assistant Professor, Nursing Department, Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece
Accepted for publication October 2013 Lavdaniti M. International Journal of Nursing Practice 2015; 21: 882–888 Perceptions and health beliefs of Greek nursing students about breast self-examination: A descriptive study Breast self-examination is a screening option for young women. Among students, knowledge about breast selfexamination ranges from insufficient to average. This descriptive study was planned in order to determine the health beliefs and perceptions of nursing students regarding breast self-examinations. We recruited 538 nursing students in a single Higher Technological Educational Institute in Greece. Data were collected using the Champion’s Health Belief Model Scale. Parametric tests were used in the data analysis. We found significant differences in the results of the subscales of Champion’s Health Belief Model Scale on comparing people with respect to nationality, previous education about breast self-examination, smoking status and semester in which they were studying. The ‘confidence’ subscale was positively associated with the frequency of breast self-examination. The results of the present study demonstrated that nursing students have knowledge about breast-self examination but inadequate practice. Key words: breast cancer, breast self-examination, health behavior, nursing, perceptions.
INTRODUCTION Breast cancer is the most common type of cancer among women in both developed and developing countries. Worldwide, an estimated 1.38 million (≈23% of all diagnosed cancers) new breast cancer cases were diagnosed in 2008.1 According to the Organisation for Economic Co-operation and Development, breast cancer accounted for 30% of cancer incidence among women and 15% of cancer deaths in 2009. In Greece, it is the most common cancer in women, with an estimated age-standardized
Correspondence: Maria Lavdaniti, Nursing Department, Technological Educational Institute of Thessaloniki, Thessaloniki, Thessaloniki 57400, Greece. Email: [email protected] doi:10.1111/ijn.12323
incidence rate of 27.2% and a mortality rate of 18.2% among Greek women.2 Mammography, clinical breast examination and breast self-examination (BSE) are the recommended methods of breast cancer screening.3 However, although the BSE is simple, quick and cost-free,4 its effectiveness remains controversial.5,6 The American Cancer Society recommends that women undergo mammography or clinical breast examinations for early breast cancer detection but also recommends that women start performing BSEs as a screening option, starting in their 20s. Women who regularly perform BSEs have greater awareness of their breasts, and if they detect any changes in their breasts, they should immediately report it to a health-care professional. In addition, women should be informed about the © 2014 Wiley Publishing Asia Pty Ltd
883
benefits and limitations of BSE.7 The Ministry of Health in Greece recommends that women perform a BSE monthly and accepts the guidelines of the World Health Organization for breast cancer screening.8 Numerous studies have investigated knowledge of breast cancer and BSE in women between 14 and 19 years of age.5,9,10 Knowledge of BSE in these ages has been found to range from insufficient5,9 to average.1 Furthermore, a low percentage of secondary college students reported having performed a BSE at some point in their lives.9,10 All of the above researchers agree that there is a great need to promote knowledge of breast cancer and BSEs, and adequate health education in general, among young women. Several studies have evaluated the effectiveness of BSE education programs for university students.11,12 The majority of these studies indicated that BSE knowledge increased after such education programs.12,13 Moreover, these education programs appear to contribute to an increased frequency of BSEs in midwifery students13 and improved the accuracy of BSEs in nursing and midwifery students in Turkey.11 Furthermore, some studies assessed the health beliefs about, and the knowledge and practice of BSE among nursing students.14–17 The majority of these studies were comparative, focusing on how knowledge of BSE differed between nursing and midwifery students, and how health beliefs differed between nursing students and their mothers,16 and between nursing students of two countries.15 These studies reported that nursing students performed BSEs regularly14–17 and had sufficient information about them.14,17 Kara & Acikel,16 in a comparative study of health beliefs between nursing students and their mothers, found that nursing students scored higher on health motivation, benefits of BSE and confidence about performing BSE, whereas their mothers scored high on perceived susceptibility to breast cancer and barriers to BSE. They concluded that the frequency of BSE depended on the level of education. Other studies indicated that there is a correlation between students level of academic experience and BSE practice.14,17 Chouliara et al.,15 in a study conducted on nursing students in Scotland and Greece, found that BSE practice did not differ significantly between the two samples, but there was difference in their knowledge and attitudes towards BSE and healthrelated personality traits. However, studies assessing BSE had average samples consisting of different aged group,16 and some researchers used questionnaires © 2014 Wiley Publishing Asia Pty Ltd
M Lavdaniti
specifically developed for those studies from the current literature.14,17 Although the body of evidence regarding knowledge, beliefs and attitudes about BSE is growing worldwide, the existing literature in Greece is limited to differences in knowledge of BSE between breast cancer patients and healthy women,18 and health behaviors related to BSE in the general population of women.19 Furthermore, only one study examined knowledge of breast cancer screening in midwifery students.20 To our knowledge, there is no prior research on health beliefs and knowledge about BSE in Greece. Therefore, the aim of the present study was to determine the health beliefs and perceptions of nursing students regarding BSE and to establish baseline data for further research about BSE in Greece. The Health Belief Model (HBM)21 was used as a theoretical framework underlying this study. The HBM consists of four dimensions: susceptibility, seriousness, benefits and barriers. Later, Rosenstrock et al. (1988)22 added health motivation and confidence in the model. By applying the HBM to breast cancer and BSE, we created the following model: women who believe that they are susceptible to breast cancer and that breast cancer is a serious disease, but they perceive more benefits of and fewer barriers in performing BSE are more likely to perform BSEs. Moreover, women who are motivated to promote their health and are confident in their ability to perform BSE are more likely to perform BSEs.23
METHODS Setting and sample The study was descriptive and nonexperimental and was conducted in the Nursing Department of higher technological educational institute in a major city in Northern Greece. We used a convenience sampling method to select nursing students enrolled in this institute. A total of 538 nursing students completed the questionnaire (response rate: 92%). The inclusion criteria were (i) female; (ii) not pregnant or breastfeeding; (iii) attending classes at the institute during the period of research; and (iv) over 18 years old.
Procedure Ethical approval for this study was obtained from the Research Committee of the higher technological educational institute. The first author approached students who were present in classes on the day when data were
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collected and explained to them the purpose of the study. A questionnaire was then distributed to students who met the inclusion criteria mentioned above. Each questionnaire contained a letter that explained the study purpose and the respondent’s rights as research participants. Potential participants were informed that participation was voluntary and posed no known risks to them and that they could withdraw from the study at any time. Subsequently, participants who agreed to participate in the study voluntarily completed the questionnaire, which took about 15 min to complete. Data collection was carried out between February and December 2009.
Instrument Data were collected through a self-administered questionnaire that included questions on sociodemographic characteristics and the revised Champion’s Health Belief Model Scale (CHBMS). Sociodemographic characteristics included age, marital status, current semester at the institute and various questions about BSE practice. The CHBMS was developed in 198424 and has been revised since then.24,25 It is the most commonly used instrument for measuring the HBM variables of susceptibility, seriousness, benefits, barriers, confidence and health motivation related to breast cancer screening.25 All the items are rated on Likert-type scale ranging from ‘strongly disagree’ to ‘strongly agree’. Higher scores indicated stronger feelings related to that construct. All the scales were found to be positively related to screening behavior, except for barriers, which was negatively related.26 The permission to use the CHBMS was obtained from Victoria Champion in 2007 through personal communication. Before data collection, the scale was translated into Greek using a back-translation technique. Two bilingual individuals independently translated the English version of the scale into Greek. Experts oncology professionals then met and reviewed the Greek translation for inconsistencies with the original form and made minor revisions. The Greek version of the CHMBS was then back-translated into English by a bilingual individual working at the higher technological educational institute. The two forms of the scale were compared and were found to be highly similar. The content validity of the translated CHMBS was determined by an expert panel consisting of an oncologist and two nurses specialized in oncology.27 Before the completion of the questionnaire, a pilot study was conducted28 on nursing students selected via purposive sampling. This
study allowed us to revise and modify some of the items. This corrected version was then used in the study. The Cronbach’s α, of the translated CHMBS in the present sample, ranged from 0.70 to 0.87, which was consistent with previous studies.24,29
Data analysis All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 15.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were used to describe participants’ sociodemographic and general health characteristics. Parametric tests were used to compare health beliefs and knowledge (and breast cancer screening behavior) among participants. In addition, a linear regression analysis was conducted. Statistical significance was set at P ≤ 0.05
RESULTS The participant characteristics are presented in Table 1. Participants’ age ranged between 18 and 25 years of age, and their mean age was M = 20.83, SD = 2.28. Most Table 1 Demographic characteristics of the sample
Age (year) Mean 20.83 ± 2.28 18–20 21–24 > 24 Nationality Greek Other Family status Married Married with children Divorced Cohabitation Unmarried Semester First Second Third Fourth Fifth Sixth Seventh
Frequency (n)
%
— 282 205 50
— 52.5 38.2 9.3
517 21
96.1 3.9
9 22 2 23 480
1.7 4.1 0.4 4.3 89.6
136 67 53 18 98 42 73
25.3 12.5 9.9 3.3 18.2 7.8 23.1
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participants were Greek (96.1%), aged < 20 years (52.5%), and were unmarried (89.6%). Almost a quarter of the participants were in their first semester at the institute (n = 136, 25.3%) and another quarter in their seventh, or final, semester (n = 73, 23.1%). In addition, 65.1% of participants consumed alcohol and 60.5% were smokers. Only 12.7% (n = 68) of participants reported having a family history of breast cancer. The average frequency of BSEs per month during the last year was 4.14 ± 3.54. Furthermore, about 54.4% (n = 291) had performed BSE at least once, 52.8% (n = 284) had learned about BSE previously, out of which 63.2% (n = 198) had learned about BSE from a health professional. When asked their opinion on the usefulness of learning BSE, almost all participants (97.6%, n = 523) answered positively. The comparisons of the subscales of the CHBMS by nationality, previous education about BSE and smoking habits are presented in Table 2. We observed no significant differences with respect to the subscales except for perceived susceptibility to breast cancer that was significantly lower in nationalities other than Greek (P < 0.001). Confidence (P < 0.001) and health motivation (P = 0.008) were significantly higher in students who had not been previously educated about BSE than in students who had been educated about BSE. The average scores for seriousness and barriers regarding BSE were significantly higher in students previously educated about BSE than in students who were not educated (P = 0.024 and P = 0.012, respectively). We also noted that health
motivation was significantly higher in smokers than in nonsmokers (P < 0.001). Furthermore, we found that last/seventh semester students scored significantly higher on the scores subscale for health motivation and confidence than those in first semester students (P < 0.001 and P = 0.036, respectively). We also found that the average score for the barriers subscale for the first semester students was significantly higher than that for seventh semester students (P < 0.001). Table 3 presents the results of a linear regression analysis for each subscale score with the frequency of BSE practice in the last year. As can be seen from the table, the only statistically significant factor was confidence (P < 0.001). The model for the linear regression analysis was built on the following equation: Frequency of BSE = 1.984×confidence score − 4.174. The coefficient β = 1.984 indicated that when confidence increases by one unit and the other factors are constant, the frequency of BSE practice increases by almost 2 units—in other words, it was conducted more frequently.
DISCUSSION This study assessed perceptions of breast cancer and BSE among female nursing students according to the HBM. In this study, 54.4% had performed BSE in the past. This percentage is rather low although it is consistent with previous research.14,15,17 Furthermore, the mean frequency of BSE was 4.14 per month in the last year, and this low frequency might reflect students’ lack of knowledge about the purpose of BSE and how to perform it.30
Table 2 Mean total scores for Health Belief Model scales according to the participants’ characteristics Nationality
Previous education on breast self-examination
Smoking
Mean ± SD
Mean ± SD
Mean ± SD
Variable
Greek
Other
P†
Yes
No
P†
Yes
No
P†
Confidence Health motivation Susceptibility Seriousness Benefits of BSE Barriers to BSE
2.99 ± 0.63 3.71 ± 0.48 2.69 ± 0.69 3.29 ± 0.69 3.74 ± 0.55 2.46 ± 0.66
2.95 ± 0.75 3.80 ± 0.57 2.30 ± 0.83 3.37 ± 0.70 3.57 ± 0.64 2.41 ± 0.58
0.799 0.422 0.014 0.636 0.219 0.750
2.94 ± 0.63 3.68 ± 0.49 2.67 ± 0.69 3.33 ± 0.66 3.71 ± 0.56 2.50 ± 0.63
3.15 ± 0.64 3.81 ± 0.47 2.67 ± 0.74 3.16 ± 0.77 3.81 ± 0.52 2.32 ± 0.72
0.001 0.008 0.995 0.024 0.053 0.012
2.96 ± 0.63 3.77 ± 0.46 2.64 ± 0.74 3.30 ± 0.68 3.75 ± 0.55 2.44 ± 0.66
3.02 ± 0.65 3.60 ± 0.50 2.72 ± 0.65 3.32 ± 0.66 3.68 ± 0.56 2.50 ± 0.63
0.299 0.000 0.193 0.815 0.175 0.323
†
t-test. BSE, breast self-examination; SD, standard deviation.
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Table 3 Simple linear regression analysis of Health Belief Model variables on the frequency of breast self-examination practice in the last year Coefficients β
(Constant) Confidence Health motivation Seriousness Benefits Barriers
−4.174 1.984 0.441 −0.466 0.473 2.315 × 10−3
t
−1.493 4.937 0.891 −1.331 1.101 0.005
In the present study, more than half of students who had received some prior education about BSE had received it from health-care professionals. Studies from other countries reported conflicting results regarding the source of information regarding BSE. Budden30 found that first-year Australian nursing students obtained BSE information mostly from media (e.g. newspaper, radio and TV), whereas nursing students in Turkey were informed through their school curricula (midwifery and nursing) as well as written materials (books, materials and brochures). A possible explanation is that nursing schools in different countries have different curricula. Memis et al.17 emphasized the importance of information gained from the curricula as contributing factor. An interesting result was that the susceptibility subscale had the highest values among Greek students. One explanation for this finding is the differences in health beliefs between cultures—in other words, women of different cultures might view health differently.31 However, it is worth mentioning that the percentage of participants of nationalities other than Greek was small, and hence the findings are not robust, and warrants further research. In this study, students with no previous education about BSE had higher scores on the confidence and health motivation subscales of the CHBMS. These results were surprising, but it might be explained by the fact that in this study a high percentage of students (47.2%) had received no prior information on BSE. In addition, this result showed that in Greece, it would be necessary to include courses on BSE in the nursing curriculum, so that students can be educated and motivated to practice BSE. In addition, we observed no significant difference in the perceived seriousness of breast cancer between students who
P
0.137 0.000 0.374 0.184 0.272 0.996
95% confidence interval for β Upper bound
Lower bound
−9.678 1.192 −0.534 −1.155 −0.374 −0.878
1.331 2.775 1.416 0.223 1.320 0.883
had been previously educated on BSE and those who had not been educated. This was an expected outcome and supported the claim that seriousness was not a relevant predictor for BSE performance as breast cancer was almost universally regarded as a serious condition by most women.24,32 Although educated students perceived breast cancer as serious, most of them reported high barriers toward practicing BSE. The high scores on the perceived barriers subscale were inconsistent with other studies,16 which showed that nursing students perceived fewer barriers. This difference might be explained by the fact that Turkish nursing students, in a previous study, were well informed about BSE, whereas Greek students are not. This might also be a result of cultural differences. Additionally, Chouliara et al.15 suggested that ‘Greek women tend to believe that their health is a matter of chance and it is the responsibility of health professionals’, and this belief affects their perceptions about the benefits of early detection methods. Further research is needed to identify the barriers to BSE for young Greek students, which will help in planning and implementing appropriate interventions to reduce perceived barriers. The students in their final semester had more confidence and health motivation, and lower scores on the barriers to BSE, than did students in their first semester. This was an expected outcome and was consistent with similar studies in nursing students14,30 and female university students in general.33 In addition, this result supports the assertion of Kara & Acikel (2009)16 that ‘nursing students receive training about breast cancer and BSE practice during their education and the care offered to women with breast cancer could have affected their own health beliefs regarding BSE’. © 2014 Wiley Publishing Asia Pty Ltd
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According to the logistic regression analysis, women who were confident in their ability to conduct BSE were more likely to perform it. This finding is consistent with the HBM, particularly in relation to confidence and BSE practice24,29 and is also consistent with the findings of other studies.34,35 Our study highlights the importance of education to increase women’s confidence and ability to perform BSE. Thus, it is important for the Greek Health Ministry to organize educational programs in universities and other educational institutions in order to increase BSE practice among female Greek students.
Limitations This study had several limitations. First, the study was conducted in just one technological educational institute in Greece, and thus, generalizability of these results to all Greek female nursing students is limited. Additional research is needed in several educational institutes and other universities in order to improve the generalization of these findings. Another limitation was that due to the lack of previous similar studies in Greece that investigated the health beliefs and perceptions of nursing students concerning BSE, we were unable to compare our results with many other previous ones.
Conclusions and implications for nursing practice The results of the present study demonstrated that nursing students have knowledge about BSE but inadequate practice. In addition, health beliefs differed significantly by nationality, previous education about BSE, students’ semester and whether they smoked. Furthermore, confidence significantly predicted BSE behavior. It is essential that nursing students receive adequate training about BSE and practice it efficiently. In addition, it is important that they transfer this information to their relatives, thus contributing to public health. Furthermore, the findings of this study might be of great interest among nursing educators in Greece, as they have the potential to enrich the nursing curriculum with BSE practice. Furthermore, these trained students, once fully fledged nurses, will go on to educate women in the community. Further research should examine the barriers to BSE practice and specify the health beliefs about breast cancer screening in women, which could add useful information to the Greek nursing literature and to the Greek National Health System. © 2014 Wiley Publishing Asia Pty Ltd
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