Knowledge, and Screening Behaviours of Saudi Female Teachers Towards Breast Cancer in Description Buraydah, Saudi Arabia

Backgroun Breast cancer is the second commonest cause of cancer-related deaths in Saudi Arabia and the commonest type of female cancer. However, unfortunately several women bypass early discovery and management possibilities related to the shortage of data, knowledge, and recognition of breast cancer, as well as cancer screening manners in general. This study aims to assess the knowledge, and screening behaviour of female teacher regarding breast cancer. Methods This cross-sectional study was conducted in the governmental secondary girls’ schools in Buraydah city, Saudi Arabia, during the period 2018–2019. A cluster multistage random sampling technique was used to recruit female teacher. The data were collected through a self-administered questionnaire. Results The study included 316 female teachers. The age of 55.4% of them was below 40 years. The total breast cancer knowledge score was abnormally distributed, as evidenced by significant Shapiro-Wilk test, p < 0.001. The mean ± SD score was 10.66 ± 3.73 (maximum possible score was 15) and the median (IQR) was 11 (8–13). Less than half (42.7%) of the teachers reported performing BSE while only 9.5% went to a clinic for clinical breast examination. BSE was performed on monthly basis by only 14.8% of those practiced it. Ignorance of the examination and fear to discover a tumour were mentioned by 24.9% for each as a reason for not performing BSE whereas 42.5% of those who did not practice it had no reason for that. Mammogram was ever practiced by 22.5% of the female teachers. About one-third of the participants (33.5%) claimed that they will perform mammogram in the coming year. Older teachers (40–50) reported higher rates of performing mammogram compared to those aged < 40, p = 0.012. Also, teachers who had friends with breast cancer were practiced mammogram at higher rated than their counterparts, p = 0.025. Conclusions The study indicates that breast cancer knowledge among governmental female secondary school teachers in Buraydah city, Saudi Arabia is overall insufficient, regarding risk factors and clinical presentation. Performance of breast cancer screening techniques is not enough. Improving knowledge regarding breast cancer risk factors, presentation and screening tools as BSE and mammogram


Background
Breast cancer (BC) is the commonest cancer of women worldwide with nearly1.7 million new cases of BC were diagnosed in 2012 which represents 25% of all women cancers and fifth most common cause of death in women 1 .The worldwide rate for mortality from BC ranged between 6 per 100,000 in Eastern Asia to 20 per 100,000 in Western Africa 2 .
Breast cancer is the second commonest cause of cancer-related deaths in Saudi Arabia and the commonest type of female cancer [3][4][5] . In Saudi Arabia, the incidence rate of breast cancer was 1% according to the Saudi Cancer Registry (2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008) 6 , and the overall survival rate was lower than those reported in United Kingdom and United States of America 7 ; mostly this attributed to due to the non-existence of a standard nationwide breast screening program in the kingdom and low uptake of screening 8 .
According to the recommendations from the Society of Breast Imaging and the ACR, 9 women have a sense to recognize and describe any breast abnormalities immediately to their healthcare providers through breast self-examination (BSE). In order to slow down the rising incidence of breast cancer, hindering of the increasing prevalence of its risk factors accompany improving economic conditions is recommended. The most effective method that can control this is the early detection of breast cancer. Early detection was seen as one of the most promising long-term strategies for preventing disease-related deaths 10 .
In Saudi, primary healthcare centers are the primary centers communicate with the patient and providing free public healthcare. However, unfortunately several women bypass early discovery and management possibilities related to the shortage of data, knowledge, and recognition of breast cancer, as well as cancer screening manners in general 11 .
Among local published health literacy studies. Few studies were found that examined the knowledge of female teachers in Saudi Arabia particular Buraydah. Therefore, our objectives are to assess the knowledge and screening behaviour of female teacher regarding breast cancer Methods, Study Design And Setting Study setting A cross-sectional study was conducted using a self-administered questionnaire among female teacher working at governmental secondary girls' school in Buraydah, Saudi Arabia, during the period from September 2018 to March 2019.
According to the database of the Menstrual of education in Buraydah, approximately 1739 female teacher work in 40 governmental secondary girls' school in the city of Buraydah. All female teacher working at governmental secondary girls' school primary in Buraydah were eligible for inclusion. All female teacher who were on an extended leave of duty, and teachers who declined to participate were excluded.
A cluster multistage random sampling technique was employed. For the purpose of the study, governmental secondary girls' school were clustered according to the city's geographic divisions into tow region (southern and northern), with 25-15 secondary girls' school in each region. Of these secondary girls' school, 10 schools' in each region were randomly chosen. Therefore, 20 secondary girls' school were included in the study.

Sample size
The sample size was calculated using a standard sample size equation "n = z 2 p(1-p)/e 2 " and an assumed proportion of 50% (proportion of high school females' teacher who had correct knowledge, and recognition of breast cancer, as well as cancer screening). Using a 95% confidence interval and a 5% margin of error, the sample size was estimated to be 316 and was adjusted to 378 to compensate for the non-response rate.

Participants and survey instrument
All females' teacher present at the time of data collection in the selected schools were included; hard copies of the questionnaires were delivered to the available teacher. Without seeing it first, the teachers were asked to complete the anonymous self-administered survey in Arabic in order to assess their basic background knowledge.
The data were collected using a valid pretested structured self-administered questionnaire, adopted from a similar study carried out by Al-Zalabani et al. 2018 12 . The questionnaire is divided into three parts with a total of 39 questions. The first part includes socio-demographic data covered age, marital situation and family or friend's history of breast cancer. The second part assesses breast cancer knowledge and information associated to the practice based on 21 questions, including questions regarding the breast cancer risk factors (16 questions) and its clinical presentation (5 questions). The final question inquiries about the best time to perform BSE. The source of information about breast cancer was added. A score of "1" was assigned to correct answers while a score of "0" was assigned to wrong or don`t know answers. The total score was computed for each participant and tested for normality using Shapiro-Wilk statistical test. The third part includes questions about participants practice concern such as BSE, clinical breast examination and mammogram. At the end of this part, barriers towards performing mammography were identified in 11 questions which marked as: 1 as totally disagree; 2 as disagree; 3 as neutral; 4 as agree; and 5 as totally agree. Their responses were re-coded as follows: totally agree and agree = 1, whereas totally disagree, disagree, and neutral = 0.

Data management and analysis plan
Data were coded and entered using SPSS 25.0 version statistical software. Descriptive statistics (mean, standard deviation, frequencies and percentages) were used to describe the quantitative and categorical variables. Pearson's Chi-square test was used to assess the association between the categorical variables. Non-parametric statistical tests (Mann-Whitney and Kruskal-Wallis) were applied to compare groups since the knowledge about breast cancer score was abnormally distributed as evidenced by significant Shapiro-Wilk test. A p-value of ≤ 0.05 was used to report the statistical significance and precision of the results.

Ethical considerations
Approval for the study was obtained from the Institutional research committee, College of Medicine, Qassim University (no. 20180615), AL Qassim, Saudi Arabia. Official approval letters were obtained from the minister of education in AL Qassim. Each participant received the questionnaire and was informed about the objective of the present study. The Institutional research committee has agreed that completing the questionnaire will imply consent.

Sample characteristics
Three hundred and sixteen of female teachers completed the questionnaires (response rate of 100%).  Table 2).
The main source of information about breast cancer was the internet (42.7%), followed by educational lectures (23.1%). The total knowledge score was abnormally distributed, as evidenced by significant Shapiro-Wilk test, p < 0.001. The mean ± SD score was 10.66 ± 3.73 (maximum possible score was 15) and the median (IQR) was 11 (8-13), (Fig. 1). Table 3 demonstrate a statistically significant association between non-married teachers and low breast cancer knowledge in compare to others, p = 0. 047.Other studied factors (age, family and friend history of breast cancer) were not significantly associated with knowledge score.    The Participant's barriers toward breast screening are illustrated in Table 5. Most of them strongly agreed with the following statements: fear to discover something abnormal; being busy, don`t know how to arrange to perform it; exposed to more unneeded radiation (22.1%, 20.5%, 13.6%, 13.6%; respectively). Table 6   Table 6 Participant's barriers toward breast screening (N = 316) Strong agreement toward the following statement No. %

Discussion
The purpose of this study was to assess the knowledge, and screening behaviour of female teacher regarding breast cancer.
The majority of participants in this study have a moderate knowledge of breast cancer risk factors and clinical presentation as the median score (IQR) was 11 (8)(9)(10)(11)(12)(13) 18 , in Jordon (37.5%) 19 and in Uganda (76.5%) 15 . The difference in rates between various studies could be attributed to variation in nature of the studied population, the cultural and religious background of the community. In the current study, the commonest reported barriers of breast cancer screening were fear to discover something abnormal (50.9%), being busy (49.4%), they don't know how to arrange to perform it (40.8%) and they don't know how it will be performed (37.3%). In a study carried out in Al-Madinah among primary healthcare centers attendees, 12 incorrect beliefs about mammography as being a painful procedure and the exposure of women to more unneeded radiation were the main barriers, However, also, bad communication with mammography personnel and the perception of mammography as being shameful were also important barriers in that study. The difference between results of the two studies is expected due to difference in the characteristics of the target population.

Conclusions
This study indicates that breast cancer knowledge among governmental female secondary school teachers in Buraydah city, Saudi Arabia is overall insufficient, regarding risk factors and clinical presentation. Performance of breast cancer screening techniques is not enough. Therefore, according to this conclusion, improving knowledge regarding breast cancer risk factors, presentation and screening tools as BSE and mammogram through educational programs is highly recommended for prevention and early detection. Primary health care professionals should have a role in conveying correct information regarding breast cancer and its early detection during regular physician office visits for other health problems. Encouraging practice of BSE through the audio-visual media, lectures and symposia is needed.

Conflict of interest
The authors have declared no competing interests.

Authors' contributions
Sharifa Khalid Alduraibi was responsible for the conception of the research idea and the study design, data collection, analysis, interpretation, and drafting of the manuscript.

Sources of Funding
There was no funding for this study. Distribution of the total breast cancer knowledge score among governmental secondary girls' schools' female teachers, in Buraydah city, Saudi Arabia