Abstract: Breast cancer is the most common and most preventable cancer in women and early detection has the important role in reducing its morbidity and mortality, so increase 95% survival time. The present study conducted to compare the effects of two educational methods on knowledge, attitude and practices of Arak physicians. An interventional study after randomized allocation of each 64 physician to any of two different educational methods (video and systematic review) used to compare knowledge; attitude and practices score variation about breast cancer screening skills. Data collection carried out with structured questionnaire and entered to SPSS software. Data analyzed by t-test, paired t-test and Man-Whitney test in significant level of 0.05. Mean of total score of knowledge, attitude and practices (KAP) showed a significant difference before and after training and the total score of KAP increase (p<0.05). But KAP score variation and their subscales were same in two groups and didn’t show any significant difference (p>0.05). Although KAP in Arak physician is appropriate and any educational program increase their KAP level, but continuing and repetition of educational courses seems to be necessary.
INTRODUCTION
Cancer is the second leading cause of death in worldwide (Harirchi et al., 2010) and the third cause of death after cardiovascular diseases and accidents and injuries in Iran (Mousavi et al., 2009). Among cancers, breast cancer is the most common cancer among women in world (Rabia and Sebahat, 2008; Parkin et al., 2005) and in Iran (Mousavi et al., 2009; Sadjadi et al., 2002). Since, involves 24.4% of all cancers and it is the most fatal form of malignancy among 35 to 50 years old women accounting for 16-18% of all cancer deaths (Avci and Gozum, 2009; Nejla and Ozge, 2008; McCready et al., 2005). Crude incidence rate of breast cancer is 17.81 and an Age Standardized Rate (ASR) is 23.65 per 100,000 in the year of 2006 , according to a report of the Ministry of Health and Medical Education in Iran (Harirchi et al., 2010).
Early detection of breast cancer plays an important role in reducing its morbidity and mortality. Theoretically, a 95% survival rate could be achieved if this cancer was diagnosed at an early stage (Tavafian et al., 2009). Breast Self Examination (BSE), mammography and clinical breast examination are the secondary preventive tools that considered as screening methods for early detection breast cancer (Tavafian et al., 2009; Dundar et al., 2006; Avci, 2008), these methods cause 24% mortality reduction in women aged 40 and older (Nejla and Ozge, 2008).
There was some studies about Knowledge, Attitude and Practice (KAP) about breast cancer, that their result showed knowledge of women about breast cancer, screening and treatment is moderate but attitude and practices is low (Dundar et al., 2006; Secginli and Nahcivan, 2006; Simi et al., 2009), also attitude and practice in health workers (physicians, nurses and midwifes) were not adequate although their knowledge were high (Nejla and Ozge, 2008; Ibrahim and Odusanya, 2009). But interventional studies can increase in knowledge, belief and perceptions of women and nurses (Rabia and Sebahat, 2008; Avci and Gozum, 2009). Therefore it is hoped, to improve the overall survival rates by early detection of disease with educational efforts and programs for health workers such as physicians to increase the numbers diagnosed at an early stage.
With considering to high incidence and mortality rate of BC in developing countries (Shibuya et al., 2002) such as Iran (Saidi et al., 1995), epidemiologic evaluations and educational programs for people and work staffs is necessary. Because physicians must be diagnosed and treatment the breast cancer cases and increase of knowledge in this group is necessary rather other groups of health workers. Based on these documents current study designed and conducted to evaluate Physician KAP about breast cancer and comparison of two educational methods in increasing of Physician KAP in Arak, Iran.
MATERIALS AND METHODS
The current study is an interventional study that assesses KAP of Arak city physicians in Iran about screening, diagnosis and treatment of breast cancer, in the baseline and after an educational Intervention. Employed physicians were the study population involves 140 physicians that have been sampled by random sampling method after a pilot study from all 262 physicians. Then the study purposes have described and after taking the informed consent, 128 physicians remained in the sample.
Randomization carried out based on KAP scores in the baseline. After collection data in the baseline and calculating the KAP scores for participants, half of physicians that acquired score above of mean and half of them that acquired score bellow of mean assign to one intervention group by chance and so for other group. So participants divided in two groups by stratified random allocation and each group contains 64 physicians.
Based on randomization, one group assign to video training intervention and other group assign to systematic review article training intervention. Educational content of two groups was similar and include sections about histology, anatomy, epidemiology, examination and history, screening methods and diagnosis of breast cancer, but educational procedure was different. In the first group, a 30 min video and a power point that contain educational sections used and for second group training fulfill by a systematic review article that printed and give to them. In addition to video or article that gives to any participants, a questionnaire and a guideline about using the tools and answering to questions give too.
Data gathering conducted by a structured questionnaire in before and after of educational intervention. In questionnaire designing first prepared a question bank and test in pilot study. Questions entered to the main questionnaire that have reliability coefficient higher than 0.8. Final questionnaire involve 12 demographic questions, 10 knowledge questions, 20 attitude questions and 8 practice questions. The Final questionnaire acquired reliability coefficient higher than 0.8 in all dimensions. In the current study had taken informed consent from all participants and Arak medical University ethical committee approved this research.
After data gathering and entering to SPSS software version 16, data checked for any outlier and incorrect value. In the data analysis has been used from independent t-test, paired t-test, Man Whitney and levene tests. Significant level considered as 0.05.
RESULTS
From all 128 participated physicians in the study 68% (87 physicians) were male and 84.4% were married. Most of participants (60.9%) were in 20-30 years old range and 68.8% employed in private clinic. 74.2% reported that educated about cancer case finding in student period. Also, 27.3% reported that don’t self-confident in diagnosis of breast cancer.
Result of statistical test according to Table 1 showed that total score mean of attitude, practice and their subscales and also total score mean of knowledge have significant difference before and after of training and the total score of KAP increase (p<0.05).
| Table 1: | Comparison mean score of KAP and their subsets before and after of training |
| Table 2: | Comparison of mean KAP scores and their subsets after of training between two groups |
But knowledge in epidemiology, practice in history and diagnosis of breast cancer didn’t show any significant difference before and after intervention (p>0.05).
Table 2 showed that KAP score variation and their subscales were same in two groups and didn’t show any significant difference after educational intervention (p>0.05).
DISCUSSION
Life time risk of breast cancer equal to one per nine women and one million new cases of the disease occurs annually in the world. Breast cancer is the most common cancer among women and included 18% of all female cancers. Since, the natural history of disease is largely unknown and is difficult to prevent from disease (McCready et al., 2005) a lot of emphasis has been to the diagnosis and treatment of breast cancer, but this requires high level knowledge of health workers and people, especially in women.
Several studies in women indicated low performance for their diagnosis through breast self-examination and mammography. Secginli and Nahcivan (2006) and Marinho et al. (2003) studies showed that knowledge and practice of women referred to health centers in Brazil was insufficient but there was a good attitude towards breast cancer screening. Since, the knowledge causes better attitude and practice, most studies have been considered increasing the awareness as one of the solutions.
The mean total score of knowledge, attitude and peractice before the intervention in the baseline measurement was above of average. In a study on the Nigerian female doctors the knowledge was adequate (74% of total score) and 86% of them have good belief to diagnosis (Ibrahim and Odusanya, 2009). Another study in Colorado Health care staffs indicated high level of knowledge about instruction of diagnosis and treatment of breast cancer (Bakemeier et al., 1995). These results are same to present study, but a study on health personnel in Tehran showed that low levels of knowledge and need for excess training (Haji-Mahmoodi et al., 2002) that conflict to our results. Since, the health workers such as nurses, modifies and physicians are in direct contact to patients in all studies in these people emphases for increasing knowledge by educational interventions.
The mean total score of knowledge, attitude and performance before and after the intervention showed significant difference, so that the total score in all three scopes of knowledge, attitude and practice has been increased. Other studies have shown rising in knowledge, attitude and practice after educational and training interventions too. A study on the Egyptian students about risk factors for breast cancer showed significant increase in knowledge, attitude and practice (Fatohy et al.,1998). In Ngelangel et al. (1997) study, the mean changes of knowledge, attitude and practice before and after training intervention was significant too. These finding is same to my results in current study.
Changes in KAP and their subsets showed no statistically significant difference in two groups that indicating equality of two educational methods in improving physician’s KAP. In a study with the aim of the training effect in two individual and group educations on female employees showed that attitude and belief of them in individual education have significant differences before and after intervention, but knowledge on the subjects in any two technique was not shown significant difference (Brailey, 1986). These results show that probably any educational intervention caused increase in KAP score and it is a educational benefits of these studies.
In a Avci and Gozum (2009) study in Turkey in order to compare two educational videos and attend educational class on teachers didn’t observe significant differences between two study groups, but increase in attitude score was similar in two groups. This finding is consistent with the results of this study. As well as their knowledge before and after the intervention was showed a significant difference, but was not found significant difference in practice of video group. The results of other studies were considered that education intervention is effective in increasing knowledge and performance of the subjects (Leight et al., 2000; Zhu et al., 2002; Lu, 1998).
Knowledge and awareness about breast cancer is varying in different population groups and communities around the world. Studies on Women indicating an acceptable level of knowledge among them in some population (Ibrahim and Odusanya, 2009; Grunfeld et al., 2002; McMenamin et al., 2005) but reports of other elsewhere, especially in developing countries like Nigeria and Iran indicate insufficient knowledge about the disease (Haji-Mahmoodi et al., 2002; Okobia et al., 2006). Two studies in Saudi women showed low knowledge about risk factors, screening and breast self examination (Jahan et al., 2006; Dandash and Mohaimeed, 2007). Also, specified that in communities where awareness of the disease is high, patients diagnose in the early stages of the disease (Ibrahim and Odusanya, 2009).
One of the goals of reducing burden of cancer depends on the public health education and implementation of effective screening programs in primary care services. In breast cancer having a good understanding of behaviors associated with breast cancer screening and its risk factors is crucial. So, for health workers, especially nurses that have the most contact with the patients and physicians that responsible for diagnose and screening it is essential to aware about the disease and factors affecting breast cancer screening behaviors (Secginli and Nahcivan, 2006).
It would be considered that although educational intervention increase knowledge, attitude and practice but based the results of other studies, such interventions is necessary to remember the compulsion of screening and early diagnosis and in order to study subjects including medical health workers doing screening procedure correctly (Avci and Gozum, 2009; Leight et al., 2000; Zhu et al., 2002).
Authors suggested that further studies conducted about other educational methods with a longer time duration gap between intervention and final measurement about physician’s skills.
CONCLUSION
Although, based on the results of this study KAP scores in the Arak physicians were in acceptable range at the baseline and two educational methods were improved the KAP score. Also since medical educational programs in any form can lead to increased knowledge, better understanding and better performance for the diagnosis and treatment of disease but of course continuous and regular training and retraining to upgrade skills and take up more medical knowledge is necessary.
ACKNOWLEDGMENT
We thanks from research vice-chancellor and ethical committee of Arak University of Medical Sciences for funding and approving this research.