INTRODUCTION:

Breast cancer is the most common cancer as well as the primary cause of cancer deaths in women worldwide¹. Breast cancer in Korea is the second most popular cancer among women, accounting for approximately 20% of all women with cancer in Korea².

Younger women tend to have a shorter interval between malignancies as well⁴. It is known that 20%–30% of women with breast cancer (WWBC) in Korea experience recurrence within two to three years after surgery², despite the administration of preventive therapies such as Tamoxifen. Thus, it is very important to detect secondary or metastatic breast cancer early in WWBC. Awareness of the early signs and symptoms of breast cancer is necessary to detect it early. It is reported that eighty percent of WWBC older than 40 self-detected breast abnormality in their breast⁵. Kontosand colleagues likewise found that the majority of instances of contralateral recurrence in WWBC were detected by the combination of mammography with breast self-examination (BSE)⁶. Thus, WWBC should be guided to perform BSE in order to detect breast abnormalities early. Nurses could play an important role in educating WWBC on the importance of BSE and how to perform it correctly. However, Chung et al. reported that only 14.5% of Korean WWBC performed BSE monthly⁷. So far, most studies about BSE education have been conducted in healthy women, with the goal of detecting primary breast cancer and raising their awareness about breast cancer. Therefore, it is necessary to conduct studies characterizing the effect of BSE education among WWBC. In addition, WWBC tend to have poor quality of life^8,9. Thus, it is important to improve their quality of life by developing and providing effective nursing interventions.

Self-efficacy theory has been known to be suitable in BSE education^10,11. The breast health education program described in this study drew upon self-efficacy theory. Self-efficacy means the ability of person to organize and execute a series of action to accomplish a designated task¹². Four kinds of resources increase self-efficacy in health behavior: enactive attainment, indirect experience, verbal persuasion, and physiological feedback. In the context of BSE, enactive attainment is the most powerful factor in increasing self-efficacy, meaning touching lumps in silicone breast model and performing BSE on one’s own breasts. Indirect experience is seeing other women performing BSE successfully. Verbal persuasion and feedback can also enhance self-efficacy related to breast cancer and BSE. Self-efficacy is known to be predictive of actual BSE performance ¹³. It is therefore necessary to enhance self-efficacy relating to the performance of BSE in WWBC.

In addition to self-efficacy theory, we encouraged WWBC to tell and share their own illness stories in the breast health education program. Narrative can be defined as any description of incidents experienced by the narrator ¹⁴, and it is known to be useful in increasing resilience¹⁵. By articulating their own experience clearly and by transforming their illness stories into more positive stories, people with illness will acquire resilience¹⁵, which is defined to be a personal quality that enables one to prosper in the face of adversity¹⁶. Resilience is known to protect people from depression, anxiety, fear, helplessness, and other negative emotions that they experience in their everyday life¹⁷.

Narrative is also known to empower people to explore the meaning of their experiences ¹⁸. Cancer usually disrupts the meaning and purpose in life, requiring people to create new meaning in life. By narrating major life events, such as breast cancer, the narrator feels catharsis and finds insight and reconstructs the meaning of his or her life¹⁹. Evans and colleagues suggested that narrative expression had a therapeutic role in cancer patients by contributing to the meaning-making process²⁰. Based upon the literature review, we assumed that narrating their illness stories would be helpful enhancing resilience and meaning and purpose in life in WWBC.

Therefore, this study investigated the effects of the breast health education using self-efficacy theory and narratives on knowledge and self-efficacy about breast cancer and BSE, resilience, and meaning and purpose in life among WWBC in Korea.

2. METHODS:

2.1. Samples:

G*Power 3 with alpha of .05, a power of .80, and an effect size of .86 ²²was used with a t-test design to calculate an appropriate sample size ²¹, 36 participants were estimated to be necessary. The inclusion criteria for the treatment group were as follows: WWBC under 60 years of age who had completed operation, chemotherapy, and/or radiation therapy for the treatment of breast cancer and were able to communicate and agreed to participate voluntarily. Twenty-five patients enrolled in the program and 20 patients were recruited. The control group was collected separately. In order to assemble the control group, we visited a breast cancer self-help group at a university hospital in Seoul and another one in Gwangju. The inclusion criteria for the control group were identical to those of the treatment group, with the additional stipulation that they should have had no prior experience with this education program. Twenty-one participants were recruited into the control group, resulting in a total sample of 41 WWBC.

2.2. Breast health education program:

Twenty-four hours of education were provided in February 2014, comprising two consecutive days per week for two weeks. The lectures were given in seminar rooms in Seoul National University in Korea. Three oncology nursing professors, one medical doctor, and one graduate nursing student were involved in the lectures. Table 1 shows the composition of the 24-hour program. All lectures used PowerPoint slides, and written materials were provided before the program began. A lump-implemented silicone breast model and wooden marbles to represent cancer size were used to increase self-efficacy. Additionally, all participants watched a DVD about BSE and they practiced BSE in the institution’s Fundamental Nursing Lab with a nursing professor and a graduate nursing student. Each participant was asked to write out their personal illness experiences as homework and to present their experience for about 15 minutes in order to share their experience of breast cancer with other women in the program. Most of them wrote their illness story chronologically from the time they first noticed something unusual to their breasts to the present. On the last day, they took the written exam and the performance exam. After the exam, they met experienced instructors and heard their teaching experiences and what they learned from their volunteering experiences. They were encouraged to join them to do meaningful activities, which raise breast cancer awareness and how to do BSE in general public. Then the certificate was given for those who successfully completed this program and they can give lectures about breast cancer and BSE to the general public after a few more training sessions with experienced instructors.

Table 1. Breast health education program

Day 1	Time	Content	Education method	Lecturers and goals	Sources of self-efficacy
	10:00–11:00	Opening announcement	Introduction to program and self-introduction	Nursing professor Increase group cohesiveness
	11:00–12:00	Risk factors and prevention strategies of breast cancer	Lecture Question and answer	Nursing professor Improve knowledge about breast cancer	Verbal persuasion
	13:00–15:00	The structure and function of breast and breast self- examination (BSE)	Lecture and demonstration	Nursing professor Improve knowledge about the breast Identify differences between normal and abnormal breasts	Verbal persuasion Indirect experience
	15:00–17:00	Diagnosis and treatment of breast cancer	Lecture Question and answer	Medical doctor Improve knowledge about breast cancer	Indirect experience
Day 2	10:00–12:00	How to prevent lymphatic edema and secondary breast cancer	Lecture Question and answer	Nursing professor Enhance knowledge	Indirect experience
Day 2	13:00–18:00	Narratives: Sharing one’s own breast cancer experience	Listening and talking about breast cancer experiences	Nursing professors Honoring the stories of patients’ own illness	Indirect experience
Day 3	10:00–12:00	BSE practice	Lecture Question and answer Practice BSE using silicone breast models and mirrors.	Nursing professor Improve BSE knowledge and skills	Enactive attainment Indirect experiences Verbal persuasion
	13:00–15:00	Sexual life in women with breast cancer	Lecture & narrative Question and answer Sharing own experience	Nursing professors Improve understanding about sexual intimacy	Verbal persuasion Indirect experience
	15:00-17:00	Strategies on how to educate the general public to prevent breast cancer	Lecture Question and answer	Nursing professor Improve teaching skills by using self-exposure	Verbal persuasion
Day 4	10:00–11:00	Written exam		Nursing professor
	11:00–12:00	Performance test		Nursing professor
	13:00–15:00	Plans for the future	Sharing experienced breast health educators’ teaching experiences Introduction to Korean Breast Health Educators and their role	Experienced breast cancer prevention instructors Encourage participation in Korean Breast Health Educators	Indirect experience Verbal persuasion
	15:00–16:00	Closing remarks		Nursing professor Program evaluation

2.3. Data Collection Procedures:

After institutional research board approval, an advertisement was posted on the Korean Breast Health Educators website (www.huyk.co.kr) to collect participants two months before the program. Convenience sampling, in particular the snowballing method, was used to recruit participants. Immediately before the first day of the education program started, questionnaires were given to the treatment group participants who signed the consent form. For the control group participants, we visited two self-help group activity sites and the questionnaires were distributed to those signed the informed consent form. The 24-hour education program was administered to the treatment group, whereas BSE information leaflets were provided to the control group after the second round of data collection. Immediately after the program was completed, questionnaires were given to the participants in the treatment group. For the control group, survey questionnaires with a return envelope and stamp were mailed to each participant and each was called to increase response rate.

2.4. Measures:

Self-reported questionnaires were used to measure each variable. Permission to use each instrument was obtained before the questionnaires were distributed to the participants.

2.4.1. Knowledge:

Questionnaire presented by Choi was used to measure knowledge²³. It comprises 17 yes/no items, including nine items dealing with breast cancer and its symptoms and eight items about BSE. The scores range from 0 to 17 and higher score indicates more knowledge. The Kuder-Richardson reliability was found to be 0.86 in Choi’s study ²³ and 0.58 (pre-education) and 0.71 (post-education) in this study.

2.4.2. Self-efficacy:

Self-efficacy was measured using the questionnaire ²⁴, which was originally developed by Champion ²⁵. This scale has 12 items. Higher scores mean higher levels of self-efficacy. The internal reliability was 0.88 ²⁴ and 0.93 (pre-education) and 0.97 (post-education) in this study.

2.4.3. Resilience:

Resilience was measured using the Korean version ²⁶of the Connor-Davidson Resilience Scale-10²⁷. It is composed of 10 items, ranging from 0 to 40 points. Higher score indicate higher levels of resilience. Cronbach’s alpha coefficient was 0.85 at the time of development²⁷ and 0.92 (pre-education) and 0.95 (post-education) in this study.

2.4.4. Meaning and purpose in life:

The Purpose in Life instrument was used to measure how much their life is meaningful and purposeful ^28,29. Park and Lee translated and validated the Korean version of this instrument and it showed good reliability and validity ³⁰. It is a 20-item scale. Total scores range from 20 to 140 and greater scores mean higher degree of meaning and purpose in life. The Cronbach’s alpha was 0.91 in Park and Lee’s study³⁰ and 0.94 (pre-education) and 0.96 (post-education) in this study.

2.5. Ethical considerations:

Approval for the study was obtained by the Institutional Review Board of College of Nursing at Seoul National University in Korea. The authors informed the participants that they could withdraw their participation any time without negative consequences. We emphasized that information they provided would be coded and only used for research. After a discussion of the above points, patients signed the informed consent if they agree to participate. A gift card for 10,000 won in Korean currency (approximately 8.66 USD) was given to all participants for their contribution.

2.6. Data analysis:

The data were analyzed using IBM SPSS Statistics version 22.0 ³¹. The chi-square test, Fisher’s exact test were used to compare the categorical variables in both groups. The pre-intervention data showed a normal distribution and equal variation. Thus, the independent t-test was conducted for homogeneity of continuous variables. The two groups were not homogeneous in terms of education level, employment, and meaning and purpose in life before the education program. After the intervention, all dependent variables in the treatment group showed a negatively skewed distribution. Therefore, generalized linear model (GLM) with gamma family and log link was used to analyze differences between the two groups ³². A p-value below 0.05 was regarded as statistically significant.

3. RESULTS:

3.1. Characteristics of the participants and homogeneity tests:

The mean (SD) age of the participants was 51.56(5.37) years and 92.7% were married. All reported a religious affiliation, with Protestantism being the most common. Thirty nine percent had graduated from college and 19.5% were employed. Three-quarters of them regarded their economic status as middle-class. The mean (SD) time since diagnosis was 47.83(33.53) months. At the time of diagnosis, 46.3% had stage II breast cancer, followed by stage I breast cancer among 29.3% of the participants. A total of 78.0% and 75.6% of the participants underwent chemotherapy and radiation therapy, respectively. Approximately 59% underwent lumpectomy. Only 39.0% of the participants had received BSE education before this program, and 22.0% had performed BSE every month. In contrast, 24.4% of the participants had not performed BSE in the previous year. Table 2 shows participants' characteristics. When the baseline demographic and illness-related data of the treatment and control groups were compared, education level, employment status, and meaning and purpose in life were found to be significantly different. Table 3 shows the results of homogeneity of two groups before the intervention.

GLM with gamma family and log link was used to test between-group differences in knowledge, self-efficacy, resilience, and meaning and purpose in life, controlling for baseline education, employment, and meaning and purpose in life.

Table 2. Characteristics of the participants and homogeneity test. (N=41)

Characteristics

Categories

Treatment group(n=20) n(%)

Control group(n=21)

N (%)

Total (N=41)

N (%)

χ²or t

Age (yr)

Mean (SD)

30s

40s

50s

50.35(6.17)

1(5.0)

7(35.0)

12(60.0)

52.71(4.33)

0(0.0)

5(23.8)

16(76.2)

51.56 (5.37)

1(2.4)

12(29.3)

28(68.7)

-1.427

.162

Marital status

Single

Married

2 (10.0)

18(90.0)

1(4.8)

20(95.2)

3(7.3)

38(92.7)

.414

.606*

Religion

Protestantism

Catholicism

Buddhism

Other

7(35.0)

3(15.0)

6(30.0)

4(20.0)

7(33.4)

4(19.0)

5(23.8)

14(34.1)

7(17.1)

11(26.8)

9(22.0)

.481

1.000^†

Education

Middle school

High school

College

1(6.4)

8(40.0)

11(55.6)

0(0.0)

16(76.2)

5(23.8)

1(2.4)

24 (58.6)

16(39.0)

5.717

.037^†

Employment

Yes

7(35.0)

13(65.0)

1(4.8)

20(95.2)

8(19.5)

33(80.5)

5.964

.020*

Economic status

Upper

Middle

Lower

1(5.0)

17(85.0)

2(10.0)

2(9.5)

14(66.7)

5(23.8)

3(7.3)

31(75.6)

7(17.1)

1.892

.474^†

Time since diagnosis

(N=40)

Mean(±SD) (months)

Less than 1 year

1-5 years

More than 5 years

55.95(40.24)

0(0.0)

14(73.7)

5(26.3)

40.48(24.82)

2(9.5)

16(76.2)

3(14.3)

47.83(33.53)

2(5.0)

30(75.0)

8(20.0)

1.479

.147

Stage

III

1(5.0)

7(35.0)

5(25.0)

0(0.0)

1(4.8)

5(23.8)

12(57.1)

2(9.5)

1 (4.8)

2(4.9)

12(29.3)

19(46.3)

7(17.1)

1(2.4)

3.999

.408^†

Received treatment^‡

Chemotherapy

Radiation therapy

Hormone therapy

15(75.0)

17(85.0)

11(55.0)

17(81.0)

14(66.7)

13(61.9)

32(78.0)

31(75.6)

24(58.5)

.212

1.867

.201

.719*

.277*

.756

Surgery type^‡

Lumpectomy

Mastectomy

Breast reconstruction

13(65.0)

7(35.0)

2(10.0)

11(52.4)

10(47.6)

2(9.5)

24(58.5)

17(41.5)

4(9.8)

.672

.003

.530^†

1.000

Recurrence or metastasis

Yes

1(5.0)

19(93.7)

1(4.8)

20 (95.0)

2(4.9)

39(95.1)

.001

1.000*

BSE education

Yes

6(30.0)

14(70.0)

10(47.6)

11(52.4)

16(39.0)

25(61.0)

1.336

.341*

BSE^§ performance

Monthly

Irregular

Never

3(15.0)

12(60.0)

5(25.0)

6(28.6)

10(47.6)

5(23.8)

9(22.0)

19(53.7)

10(24.3)

1.178

.644^†

^*Fisher exact test ^†Fisher-Freeman-Halton Test

^‡More than one item can be chosen ^§Breast Self-Examination

Table 3. Homogeneity test of dependent variables (N=41)

Dependent Variables	Treatment (n=20) Mean(SD)	Control (n=21) Mean(SD)	t	p
Knowledge	11.10(2.49)	10.57(2.98)	.615	.542
Self-efficacy	37.15(10.42)	39.52(9.27)	-.771	.445
Resilience	28.90(7.37)	25.29(6.40)	1.680	.101
Meaning/purpose of life	116.05(13.74)	96.67(23.65)	3.187	.003

Table 4. The effects of the breast health education (N=41)

Variables	Parameter estimates(β)	Standard error	95% Wald Confidence Interval		Wald Chi-square	Exp(β)	p
Variables	Parameter estimates(β)	Standard error	Lower	Upper	Wald Chi-square	Exp(β)	p
Knowledge
Intercept	2.563	.131	2.306	2.821	380.692		<.001
Group	.287	.044	.201	.373	42.560	1.332	<.001
Education	-.054	.038	-.130	.021	2.011		.156
Employment	.034	.053	-.071	.138	.400		.527
Self-efficacy
Intercept	3.651	.232	3.196	4.106	247.568		<.001
Group	.402	.079	.246	.557	25.748	1.494	<.001
Education	-.007	.068	-.141	.128	.009		.923
Employment	-.008	.096	-.197	.182	.006		.937
Resilience
Intercept	3.396	.209	2.986	3.806	263.466		<.001
Group	.269	.068	.135	.402	15.548	1.308	<.001
Education	-.014	.060	-.132	.104	.054		.816
Employment	-.038	.084	-.203	.127	.204		.651
Meaning and purpose in life
Intercept	4.335	.155	4.031	4.640	777.472		<.001
Group	.102	.047	.010	.194	4.750	1.107	.029
Education	.008	.037	-.065	.082	.050		.824
Employment	-.064	.051	-.166	.038	1.527		.217
Pre-meaning and purpose of life	.004	.001	.002	.006	18.526		<.001

4. DISCUSSION:

This study investigated effects of breast health education in WWBC using self-efficacy theory and narratives. The education program was helpful improving knowledge and self-efficacy regarding breast cancer and BSE, resilience, and meaning and purpose in life. Most previous studies of BSE have focused on healthy women, while this study was performed in WWBC.

The significant increases in knowledge and self-efficacy in the treatment group after the intervention were consistent with the findings of other BSE studies using self-efficacy theory for healthy women^10,11. It clearly indicates that self-efficacy theory is a suitable framework for BSE education not only for healthy women but also for WWBC.

This study showed only 39.0% of the participants had experienced BSE education before and the baseline monthly BSE rate was only 22.0%. Shin and her colleagues ³⁴ reported that 27% of a sample of 2,186 female university students in Korea performed BSE. It indicates that the baseline BSE performance rate of the participants was similar to those of university students. Thus, it is necessary to help them perform regular BSE, considering that WWBC are at higher risk of having secondary or metastatic cancer. Shin ³⁴ found that knowledge of breast cancer was a predictor of BSE performance. Yoo et al.³⁵ also found that lack of knowledge about proper BSE technique leads not to practice BSE. As this study demonstrates effectiveness in improving knowledge and self-efficacy about breast cancer and BSE, this program using self-efficacy theory and narratives can be utilized in educating WWBC to improve BSE performance.

Levels of resilience increased significantly in the treatment group after education. This is supported by Heiney in nursing who addressed the therapeutic benefits of story, such as cognitive, affective, and interpersonal and personal growth ³⁶. This is also consistent with the work of Holloway et al.that have suggested that the stories of those who experience illness and disability should be told more frequently because doing so helps them shape their own world and identity ³⁷. Cepeda and colleagues further reported that cancer patients whose narratives had high levels of emotional disclosure showed significantly less pain and a greater degree of well-being than those with less emotional narratives ³⁸. Thus, narrative can be used as a nursing intervention for not only traumatized people but also people with cancer or other chronic diseases. Nurses must pay more attention to patients’ stories and encourage them to narrate their experiences with illness in a clinical setting in addition to a research setting.

Meaning-making is important when adapting to a life-threatening experience such as cancer²⁰. The meaning and purpose in life showed significant increase in the treatment group. This is in agreement with Carlick and Biley, who argued that narratives can help patients cope with cancer by providing distance from the situation, allowing them to find meaning, empowering them to obtain greater self-awareness, and relieving psychological distress¹⁹. This is also consistent with the report by Fredriksson and Eriksson that a narrative approach in a caring conversation enabled patients to understand and find meaning in suffering and to achieve a new sense of wholeness³⁹. Cancer patients' illness stories provide cues and information about supportive care needs and also contributed to a personal meaning-making process²⁰. This is also supported by Gilbert ⁴⁰ who addressed that a narrative approach can be a useful tool for coping with grief by contributing to the creation of stories and enabling people to find meaning in the meaningless. Thus, oncology nurses need to actively employ narratives to find the supportive care needs and promote self-knowledge and personal growth of people with cancer during their illness journey.

In this study, the participants in the treatment group stated that they registering for the education to learn more about their disease to maintain their own health and to educate others about how to prevent breast cancer and the importance of regular BSE. When they first noticed a lump in their breast, they did not know what it was and what to do, so some of them ignored it. They felt they had an obligation to tell others about their experiences. The focus of these WWBC moved from relieving their own suffering to helping others. Participants were also introduced to former graduates of this program who actively volunteered as breast health educators. These experienced educators served as role models for the newcomers. Their stories stimulated higher levels of motivation in the program participants and are thought to have played a key role in increasing participants’ resilience and meaning and purpose in life. This education program empowered the participants and broadened their vision from themselves as cancer patients to seeing themselves as a bridge connecting the rest of the population with cancer patients. Unlike previous studies, we not only provided WWBC knowledge and skills about breast cancer and BSE, but also elicited patient narratives, so that the participants were able to acquire knowledge and self-efficacy and to increase their resilience and meaning and purpose in life.

This study has some limitations. First, its generalizability is limited because this study was conducted in Korea, so applying its results to other countries may not be valid. Second, we recruited participants in the control group separately, meaning that we could not control for exogenous variables such as selection bias. A randomized controlled trial with a larger population sample is needed.

5. CONCLUSION:

Self-efficacy theory and narratives can be a useful framework in educational program for people with cancer. They can be effective in improving knowledge and self-efficacy and in promoting resilience and meaning and purpose in life. We recommend that oncology nurses utilize these kinds of program for people with cancer not only to improve knowledge about disease but also to promote personal growth and healing. Further studies are needed to determine whether similar programs would be effective for people with other types of disease.

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Received on 22.06.2017 Modified on 30.06.2017

Research J. Pharm. and Tech. 2017; 10(7): 2295-2302.

DOI: 10.5958/0974-360X.2017.00407.3