The Effect of Education Based on Systematic Comprehensive Health Education and Promotion Model to Health Volunteers on Their Female Clients' Knowledge Regarding Breast Cancer Screening

Document Type : Original Research Article

Authors

1 Associate Professor, Department of Midwifery, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

2 MSc Student of Counselling Midwifery, Department of Midwifery, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

3 Assistant Professor, Department of Midwifery, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

4 Professor, Department of Biostatistics and Epidemiology, Faculty of Public Health, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background & aim: Despite the importance of screening for early diagnosis of breast cancer, few women have adequate knowledge in this regard. This study was performed to determine the effect of education based on comprehensive systematic health education and promotion model (SHEP model) on breast cancer screening knowledge of women referred to Mashhad health centers.
Methods: This quasi-experimental study with two groups of trainers and audiences was performed at Ab-o-Bargh and Shahid Najafi Health Centers that were randomly assigned to experimental and control centers. The study subjects were 12 health volunteers and 120 audiences (women referred to the health centers). In the case group, the health volunteers received training based on the SHEP model during two four-hour sessions. The control group received the routine training program. In both centers, ten women were randomly allocated to each health volunteer. The trainers of each group held a two-hour training session for the women covered by the health centers. The women's knowledge was assessed before, as well as immediately and four weeks after the intervention using a self-made questionnaire. To analyze the data, Mann Whitney, Friedman, Chi-squared, and Fisher’s exact tests were run in SPSS, version 20.
Results: Before the intervention, mean knowledge scores of the experimental and control groups were 16.52 and 16.53, respectively, which were not significantly different (P>0.05). Immediately and four weeks after the intervention, mean scores of knowledge in the experimental group were significantly higher than in the control group (43.13 and 42.38 vs 23.28 and 22.83; P<0.05). In both groups, there were significant differences in mean scores of knowledge at the three time points of before, immediately after, and four weeks post-intervention, but these disparities were greater in the experimental group compared to the control group.
Conclusion: Our outcomes confirmed the effectiveness of training based on SHEP model by matched trainers on women’s short- and long-term knowledge promotion as to breast cancer screening.

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Introduction

Globally, breast cancer is the most common type of cancer among female population, such that approximately one million new cases of the disease are reported annually. About 23% of new cases diagnosed as cancer and 14% of deaths are due to breast cancer (1). In Iran, breast cancer is suggested as the most common type of cancer among women (2). The incidence of breast cancer in Iranian women is estimated to annually increase by three times until 2030 (3).

Breast diseases, especially breast cancer, which may lead to loss of breast, not only cause mental health problems in women, but also in some cases lead to severe social and family problems and compromise women’s normal life (4).

If remained untreated, breast cancer can cause a wide range of problems for patients and their families, but in case of early diagnosis and prompt treatment this disease is curable. Awareness regarding the signs and symptoms of breast cancer is of utmost importance in early detection and timely treatment. With increasing public awareness on early detection and screening methods, especially in high-risk individuals, the risk of mortality due to breast cancer can be diminished (5).

Secondary prevention, such as participation in screening tests, is of great significance in breast cancer and leads to diagnosis of the disease in early stages (6).

Today, in developed countries, promoting women's awareness regarding breast cancer screening methods has led to increased health center referrals for performing diagnostic procedures, and in turn, a reduction in mortality due to breast cancer. Nonetheless, in developing countries such as Iran, the disease is still diagnosed in more advanced stages due to poor knowledge and attitudes of people (4).

Health literacy is a concept often ignored in the realm of cancer awareness (7). Results of studies performed in Iran showed the fact that the level of health literacy is low in Iran and 71.9% of Iranians have inadequate health literacy. Furthermore, women with low health literacy are less likely to perform breast examination than others, which might be due to the fact that those with higher health literacy have greater awareness of screening tests and feel the need to do it (8). In order to improve the level of health literacy, health information should be presented proportional to the health literacy and level of understand of the audience (9).

Currently, most training content in the health system is presented in written form (10). However, the use of media such as pictures is an effective way to deliver health messages to those who have low health literacy, even those who simply prefer non-textual messages (11). These facts pinpoint the need for appropriate training in conjunction with cultural background (12). Accordingly, comprehensive systematic health education and promotion model (SHEP) was developed to enhance health literacy using the strategy of training matched educators. Two important features of this model are its comprehensiveness and systematicity.

Comprehensive means that all the health concepts that play a role in increasing health literacy are involved in the model and the trainer presents the content to the audience according to the characteristics of the target group. Systematic denotes that the program is implemented based on a flowchart characterizing all parts of the model including evaluation, research, developing educational packages, workshops until the stages of monitoring and evaluation.

Training packages are designed in such a way that in addition to health care workers, target groups, especially peer groups, can use them. This model consists of three main stages of evaluation (i.e., literature review, selection of research topics, and providing educational content), implementation (i.e., designing visual training tool, educating the trainer, and training the target audience), and assessment (short-, medium-, and long-term).

As of yet, SHEP model educational packages have been prepared for five health topics of AIDS, diabetes, influenza, cholera, and oral hygiene. Despite multiple reports by health centers of different provinces in Iran regarding increased awareness of trainees using these educational packages (13), few studies were conducted using this model. The only study using this model is the one by Soufizadeh et al. (2013) that aimed to evaluate the effectiveness of SHEP model in training on prevention and control of diabetes and emphasized on the efficiency of this model in promoting the knowledge and modifying the attitude of audience (14).

Given the importance of early detection of breast cancer in promotion of physical and mental health of women and the effective role of health volunteers as matched trainers in raising awareness of families, interventional training programs held by health volunteers can be of great help. Since so far no study has been performed using this model, we sought to determine the effect of training breast cancer screening based on comprehensive SHEP model on breast cancer screening knowledge in women referred to Mashhad health centers to use these results in developing educational programs. 

Materials and Methods

This quasi-experimental, interventional study was performed on 12 health volunteers and 120 women covered by Mashhad health centers who were randomly divided into experimental and control groups. The sample size for the target audience was determined using the sample size formula and according to previous studies (15). Considering the power of 0.80, mean difference of 1.05, standard deviations of 1.75 and 2.1, and the confidence level of 0.95, the standard sample size was estimated 52 cases for each group, and regarding the possibility of subject attrition, the final sample size was considered 60 cases in each group. Since each health volunteer trained 10 cases in each group, six health volunteers were assigned to each group.

To select the study setting, health center No. 1 was first-rated in five healthcare centers of Mashhad since it covers a larger number of healthcare centers and has appropriate educational facilities and adequate space. Afterwards, two urban health centers (Shahid Najafi and Ab-o-Barq) were selected as the research environment via convenience sampling and randomly assigned to the experimental and control groups. These health centers offer proper equipment and educational environments and are at an acceptable distance from each other in order to prevent information exchange during the study. After selecting the health centers, we presented at the health centers and records of the health volunteers and the referred women were evaluated and the eligible individuals were identified. Sampling was performed in two stages at both health centers (first for health volunteers, then for female clients). Simple random sampling without assignment and systematic random sampling were employed to select the health volunteers and women covered by these health centers, respectively.

The inclusion criteria for the health volunteers comprised of a minimum age of 20 years, at least high school education, active participation in training sessions of the selected center within one year before the beginning of the study, completion of the training program for health volunteers, and willingness to participate in the study. Furthermore, the inclusion criteria for the target audience were having Iranian nationality, minimum age of 20 years at the time of the study, having basic education, having active family records in the selected healthcare centers since the beginning of 2015, non-participation in educational programs related to the subject of the study during the six months prior to the study, and willingness to participate in the study.

The exclusion criteria were unwillingness to continue participation in the study, lack of participation in any of the tests, failure to respond to all items of the questionnaire, and absence or attending less than 30 minutes in the training sessions. After selecting the eligible individuals, they were contacted through telephone call, the research objectives were explained to them, and they were invited to refer to the health center at a set time.

Data collection tool was a researcher-made questionnaire designed based the questionnaires used in other studies (2, 16, 17). The ques-tionnaire consisted of two parts: 1) Personal information, including 14 items on age, educational level, occupation, marital status, number of children, personal and family history of breast diseases, contraceptive methods, awareness of breast cancer screening methods and source of knowledge, history of self-examination, clinical breast examination, mammography, close relationship with a person with breast cancer, and duration of cooperation as a health volunteer and 2) knowledge assessment, assessing the subjects’ knowledge in four dimensions (breast cancer [four items], risk factors for breast cancer [15 items], signs and symptoms of breast cancer [nine items], and breast cancer screening methods [17 items]).

The questionnaire items were rated using a 3-point Likert scale (agree, disagree, and no idea). For each correct answer, one score and for wrong answers or do not know, zero scores were assigned. The knowledge scores ranged from 0 to 45. Content validity of the questionnaire was established by a panel of experts and its reliability was confirmed after performing a pilot study on 30 cases using Kuder-Richardson coefficient (α=0.76).

The study was conducted in two stages. In the first stage, the educational intervention was implemented at the selected centers based on SHEP model in the form of workshops during two 4-hour sessions (a total of eight hours) for 12 health volunteers by the researcher. In the first session