In Jordan, cancer is the second leading cause of death after cardiovascular disease, with breast cancer being the most common form of cancer among women. 1 In 1997, breast cancer among women in Jordan constituted 14.2% of all newly diagnosed cancer cases among women with a crude incidence rate of 21.3 per 100,000. 1 This rate is much lower than in other places of the world, such as the United States, where in the same year breast cancer represented 30% of newly diagnosed cases, with a crude incidence rate of 137.2 per 100,000 women. 2,3 Nevertheless, the frequency of this disease makes it an important public health issue.
The level of breast cancer awareness among women in Jordan has not previously been evaluated; however, breast cancer education programs began in the country in 1996 when the first cancer center was established. 1 Although not focused on breast cancer, one study did evaluate the awareness and attitudes of Jordanians toward cancer in general and revealed that most people were aware of common cancer risk factors, such as smoking, exposure to sun or radiation, and diet. 4 The lack of previous assessment limits the development and effectiveness of breast cancer prevention efforts. Provision of baseline information about the level of breast cancer awareness among women in Jordan may assist health educators to target and tailor prevention programs. It can also serve as a reference for evaluating future breast cancer education efforts.
The purpose of this study is to describe the level of breast cancer awareness among women nurses and teachers according to select demographic variables, such as education, age, religion, insurance, and family history of breast cancer. Nurses and teachers are the population of interest because of the important role they play in cancer education and prevention. Nurses can combine their knowledge of the health of their women clients and the available health services to educate women about breast cancer risk factors (eg, reproductive and lifestyle) and available breast cancer screening services and practices. 5–7 Teachers may also be in a position to effectively educate young people about breast cancer risk factors, types of screening practices, and influence behaviors that reduce the risk of breast cancer incidence and death. However, this assumes they are aware of breast cancer risk factors and recommended screening guidelines.
Analysis was based on a sample of 341 women aged 18 years and older employed as nurses and teachers in select private hospitals and schools in Amman, Jordan. Private hospitals and schools were chosen because they are more accessible than those in the public sector. In Jordan, nurses do not specialize in a certain field, thus participants were general nurses working in various units of the hospital. Emergency room nurses were excluded. The teachers chosen for analysis taught various school subjects in grades 7 through 12. Health is taught in these grades in Amman. Although the curriculum does not necessarily focus on breast cancer, basic health behaviors that may be linked to breast cancer (poor diet, physical inactivity, obesity, and alcohol consumption) are emphasized.
Amman is the capital of Jordan and comprises approximately 40% of the country’s population. 8 Sixty-two percent of all private hospitals and 51% percent of all private schools in Jordan are located in Amman. 9–10 Four main regions throughout the city of Amman were identified, and the largest private hospital in each region was selected for assessment. Private schools were chosen based on their proximity to the private hospitals contacted to minimize potential confounding due to geographic variation. After receiving approval from the administrators of the hospitals and schools to conduct the survey, all women nurses and teachers were given the questionnaire through the hospital and school administrators. These administrators supervised the administration of the questionnaire to their employees. To ensure that they were carrying out the survey, periodic contact was made with the key administrators during the 6-week period of data collection. A cross-sectional design assessed cancer awareness among nurses and teachers. Participants included all women nurses and teachers, not just Jordanians.
Instruments and Procedures
The questionnaire consisted of 2 previously validated breast cancer knowledge-based published surveys. 11–12 The first part contained general breast cancer awareness questions, which would reflect the participants’ knowledge of breast cancer risk factors and myths associated with the disease, while the second part contained breast cancer screening awareness questions, which would reflect the participants’ knowledge of methods, recommended ages, and frequency of breast self-examination and mammography.
We also added to the questionnaire basic demographic variables, such as age, religion, and family history of breast cancer. Information on family history of breast cancer was collected by asking the respondents whether they had a mother, sister, daughter, grandmother, aunt, or other woman relative with a history of breast cancer. Information on personal chronic disease history was collected for specific conditions by asking whether they had experienced the following: cancer, heart disease, diabetes mellitus, glaucoma, arthritis, lung disease, or other chronic diseases. Two additional variables were created to reflect general breast cancer awareness and screening awareness. These questions were scored according to percentage correct. A correct response was based on the breast cancer risk factors, myths, and screening techniques found in the literature.
Ten of the general awareness questions were obtained from Stager’s questionnaire. 12 Stager’s questionnaire contained 12 general breast cancer awareness questions. We excluded 2 of those questions because one was specific to women in the United States and the other could not be translated without creating confusion. Stager’s questionnaire was based on the Breast Cancer Knowledge Test by McCance et al. 11–12 The Kudar-Richardson (KR) 20 score, a measure of internal consistency, found by Stager was modest for general knowledge, 0.60. 11 We added 3 additional questions because diet, exercise, and hormone replacement therapy have been more recently identified as risk factors of breast cancer. 13–18
Breast cancer screening awareness questions were all obtained from the 1990 Breast Cancer Knowledge Test by McCance et al. 12 This instrument is an expansion of Stillman’s 1977 general health beliefs questionnaire. 19 The Breast Cancer Knowledge Test included 18 screening awareness questions. Internal consistency for the 18-item scale was KR20 = 0.810. 12 Fifteen of the 18 screening awareness questions were used in our questionnaire. One question was oriented toward postmenopausal women and was dropped because we anticipated that our population would be primarily premenopausal. Four of the 18 questions were combined into 2 questions to minimize redundancy in the questions.
Validity and Reliability
The adopted questions from the previous two instruments established content validity by using experts in the area of breast cancer screening and control, including nursing and medical oncologists. Stager chose not to include questions involving controversial risk factors, such as diet and exercise. 12 We chose to include these questions, however, based on more supportive evidence in the literature. Face validity of the instrument in Arabic and English was based on consensus among 3 health educators experienced with survey sampling and 3 native Jordanians fluent in Arabic.
Items answered correctly were coded as 1, and items answered incorrectly or didn’t know were coded as 0. To identify the items that do not discriminate between people who score high versus those who score low on the total for all items, biserial correlations were computed. Internal consistency reliability was also established for general breast cancer knowledge and screening awareness subscales using the KR20 statistic.
The questionnaire was distributed by hospital and school administrators and provided in Arabic and English, because many Jordanian nurses and teachers were more comfortable answering the survey in Arabic and foreign nurses and teachers required English. The cover page of the questionnaire briefly described the purpose of the study and indicated that by returning the questionnaire they were consenting to participate in the study.
The survey was administered between August 15 and September 30, 2000. The response rate was 78%, with 341 completed questionnaires, and no question had more than 3 missing responses.
Data were analyzed using the SAS system for personal computers, release 8.0. Frequency distributions and multiple regression techniques were employed to summarize and describe the data. Because of small numbers in any one category, family history and chronic disease variables were each recoded into whether a family history of breast cancer was present or whether the person had a history of chronic disease. Significance was based on either the Pearson Chi-square or the Fisher’s exact test. Analysis of covariance was used to evaluate the influence of the demographic variables on general breast cancer awareness and breast cancer screening. The average percentage of correct responses adjusted for covariates (called adjusted means) were also computed. Cases with missing observations were removed from the analysis. All tests of significance were based on the 0.05 level.
Table 1 presents the number and percentage of nurses and teachers aged 18 years and older according to select demographic variables. Nurses and teachers were mainly from Jordan, with a minority from the Philippines and other countries (16.7% and 2.8%, respectively). Nurses were mainly Muslim, and teachers were primarily Christian. Educational differences were also observed. Teachers had a higher level of education than nurses. Teachers were also more likely to be married, have health insurance, and have a family history of breast cancer. The mean age of nurses was 32.1 years (range 19 to 63 years), while that of teachers was 34.8 years (range 18 to 58 years).
The number and percentage of correct answers to general breast cancer awareness questions for both nurses and teachers are presented in Table 2. Overall there was no difference in the adjusted mean general awareness score between nurses and teachers. Nevertheless, mean differences were observed between nurses and teachers for 6 of the 13 general awareness questions. Table 3 presents the number and percentage of correct answers to breast cancer screening awareness questions for both nurses and teachers.
Table 4 shows the biserial correlation coefficients of the items for both subscales. Ten of 13 general awareness items had correlation coefficients greater than 0.40, which is the level typically used for retaining an item. Thirteen of the 15 screening awareness items had correlation coefficients satisfying the automatic criteria for retention. Only item 12 in the screening awareness subscale had a correlation coefficient less than 0.20, which is the level typically used for automatically dropping an item. Items with correlation coefficients between 0.20 and 0.40 may be retained based on determination of clinical significance. The KR20 for internal consistency reliability was calculated for all the items. The KR20 for the general breast cancer knowledge subscale was 0.26 and for breast cancer screening awareness subscale was 0.52. Deleting item 12 from the screening awareness items and recalculating KR20 for this subscale gave 0.57.
Next we assessed models involving mean percentage of correct responses related to (1) general breast cancer knowledge and mean percentage of correct responses to (2) breast cancer screening awareness and profession. Item 12 in the screening awareness subscale was dropped and not included in the mean percentage of correct responses related to screening awareness. Independent variables included profession, religion, nationality, race, education, marital status, health insurance, family history of breast cancer, personal chronic disease history, and age. Both models were determined using stepwise regression. Profession was not statistically significant in model 1 (P = .8470). Only family history of breast cancer was related to general breast cancer knowledge (P = .0447). Those women with a family history of breast cancer were more knowledgeable than those without a family history of breast cancer about breast cancer risk factors and myths associated with the disease. The mean general breast cancer knowledge score was 66.1% for those with a family history of breast cancer compared with 62.4% for those without a family history of breast cancer.
The final model for breast cancer screening knowledge included profession (P < .0001), family history of breast cancer (P = .0272), and age (P = .0003). With increasing age, breast cancer screening awareness of nurses and teachers significantly decreased. Those with a family history of breast cancer were more aware of the importance of screening and more knowledgeable about screening methods. The adjusted mean screening awareness score was 79.1% for those with a family history of breast cancer compared with 74.3% for those without a family history of breast cancer. Nurses were more aware of the importance of screening than teachers. The adjusted mean screening awareness score was 88.3% for nurses and 73.1% for teachers.
Significant differences were observed between nurses and teachers on 6 of 13 the general awareness questions and 8 of the 15 screening awareness questions. Differences regarding general awareness were in questions related to breast risk factors as opposed to myths about breast cancer. In the multivariate analysis involving the overall mean percentage of correct responses as the dependent variable, profession was not significant in the first model (general breast cancer awareness) but was significant in the second model (breast cancer screening awareness). Profession was not significantly related to the mean percentage of correct responses in the first model but was related in the second model. Superior screening knowledge among nurses versus teachers may be consistent with the fact that nurses work with individuals who are more likely to benefit from screening. In addition, women with a family history of breast cancer had significantly better general breast cancer knowledge and awareness about breast cancer screening. Those with a family history of breast cancer may have had better general breast cancer knowledge and awareness about screening because they have had to consider the disease. Finally, age was inversely related to breast cancer screening knowledge, possibly due to younger nurses having more current screening knowledge because continuing education is not required of nurses in Jordan.
These results provide important baseline information about breast cancer awareness. Such information may be used to develop tailored breast cancer education programs, increase primary and secondary prevention efforts, and evaluate the effectiveness of prevention programs. In Jordan, nurses are mainly involved with secondary prevention efforts. For breast cancer, primary prevention includes educating women on breast cancer risk factors and influencing behavior change, whereas secondary prevention includes screening for and early detection of the disease. Previous studies have shown that knowledge is directly associated with prevention efforts. For example, lack of breast cancer screening knowledge among nurses has been found to be an obstacle in encouraging patients to obtain screening. 20–21
Guidelines and Recommendations
It has been well documented that needs assessment is helpful in directing prevention efforts of various diseases. 22–25 The information obtained from this study may assist in planning intervention and prevention strategies. For example, nurses were found to have better awareness of screening practices compared to knowledge about breast cancer risk factors. Only 29.8% of nurses knew that in some women being overweight may increase the risk of breast cancer, and only 35.0% recognized that cancer was more common in 65-year-old women than in 40-year-old women. When planning an education program for nurses, breast cancer risk factors should be emphasized. The mean scores before and after an education program would also help to evaluate the effectiveness of these programs. Based on the lack of breast cancer knowledge among the nurses surveyed in this study, the promotion of future health policies, such as mandatory continuing education, which involves breast cancer screening guidelines and general breast cancer awareness, may be justified.
The generalizability of this study should be limited to nurses and teachers working in the private sector of Jordan. Future studies may assess women in the public sector and evaluate similarities and differences between the two groups.
Despite only one item having very low biserial correlation, internal consistency reliability (item intercorrelations) of the two subscales was low for general breast cancer knowledge and moderate for breast cancer screening awareness. The low internal consistency among the items related to general breast cancer knowledge may be because questions were related to both risk factors and myths about the disease. Also, cultural differences between Amman, Jordan, and the United States, where the questions for this study were developed and validated, may further explain the disappointing KR 20 scores. The 22% failure rate to respond to the survey may have further limited the generalization of the study. We could not determine whether failure to respond was associated with the general breast cancer knowledge or screening awareness of these women.
Future studies may focus on other healthcare professionals, such as physicians in both the public and the private sectors. In addition, emphasis should also be placed on the relation between breast cancer awareness and screening practices. This relation would help clarify whether educating Jordanian women would actually improve their screening practices. Some studies have shown that a positive correlation exists between breast cancer awareness and screening practices among different groups. 11–12,26 If this relation holds among the Jordanian population, more education programs would increase the early detection of breast cancer, reducing the public health burden of the disease.
1. National Cancer Registry and Ministry of Health’s 1997 annual report.
Amman, The Hashemite Kingdom of Jordan; 1999.
2. Parker SL, Tong T, Bolden S, Wingo PA. Cancer statistics 1997. CA Cancer J Clin. 1997; 47:5–27.
3. SEER*Stat 3.0 [database online]. SEER Cancer Incidence Public Use database. Bethesda, MD: US Department of Health and Human Services; 1973–1997. Updated.
4. Jadalla A, Sharaya H. A Jordanian view about cancer knowledge and attitudes. Cancer Nurs. 1998; 21:269–273.
5. Vogel VG. Breast cancer prevention
: a review of current evidence. CA Cancer J Clin. 2000; 50:156–170.
6. Leslie NS. Role of the nurse practitioner in breast and cervical cancer prevention
. Cancer Nurs. 1995; 18( 4):251–257.
7. Baron RH, Borgen PI. Genetic susceptibility for breast cancer: testing and primary prevention
options. Oncol Nurs Forum. 1997; 24( 3):461–468.
10. General Directorate of Planning. Statistics and Information Division. The distribution of schools, students, teachers, and sections in the ministry of education
according to the municipalities for the school year 2000/2001; Amman, Jordan: Ministry of Education
11. McCance KL, Mooney KH, Smith KR, Field R. Validity and reliability of a breast cancer knowledge test. Am J Prev Med. 1990; 6:93–98.
12. Stager JL. The comprehensive breast cancer knowledge test: validity and reliability. J Adv Nurs. 1993; 18:1133–1140.
13. Mezzetti M, La Vecchia C, Decarli A, Boyle P, Talamini R, Franceschi S. Population attributable risk for breast cancer: diet, nutrition, and physical exercise. J Natl Cancer Inst. 1998; 90:389–394.
14. Clavel-Chapelon F, Niravong M, Joseph RR. Diet and breast cancer: review of the epidemiologic literature. Cancer Detect Prev. 1997; 21:426–440.
15. McCredie M, Hopper JL, Cawson JN. Risk factors
and preventive strategies for breast cancer. Med J Aust. 1995; 163:435–440.
16. Pujol P, Galtier-Dereure F, Bringer J. Obesity and breast cancer risk. Hum Reprod. 1997; 12(suppl 1):116–125.
17. von Schoultz B. HRT and breast cancer risk, what to advise. Eur J Obstet Gynecol Reprod Biol. 1997; 71:205–208.
18. Colditz GA. Hormone replacement therapy increases the risk of breast cancer. Ann NY Acad Sci. 1997; 833:129–136.
19. Stillman M. Women
’s health beliefs about breast cancer and breast self-examination. Nurs Res. 1977; 26:121–127
20. Lillington LB, Padilla GV, Sayre JW, Chlebowski RT. Factors influencing nurses’ breast cancer control activity. Cancer Pract. 1993; 1:307–314.
21. Tessaro I, Herman C. Changes in public health nurses’ knowledge and perception of counseling and clinical skills for breast and cervical cancer control. Cancer Nurs. 2000; 23:401–405.
22. McLennan JD. Knowledge and practices of preventing diarrhoea in malnourished children. J Diarrhoeal Dis Res. 1998; 16:235–240.
23. Jemmott LS, Maula EC, Bush E. Hearing our voices: assessing HIV prevention
needs among Asian and Pacific Islander women
. J Transcult Nurs. 1999; 10:102–111.
24. Brassard P, Smeja C, Valverde C. Needs assessment for an urban native HIV and AIDS Prevention
program. AIDS Educ Prev. 1996; 8:343–351.
25. Singla N, Sharma PP, Jain RC. Awareness about tuberculosis among nurses working in a tuberculosis hospital and in a general hospital in Delhi, India. Int J Tuberc Lung Dis. 1998; 2:1005–1010.
26. Mamon JA, Zapka JG. Breast self-examination by young women
: characteristics associated with frequency. Am J Prev Med. 1986; 2:61–69.
Keywords:© 2002 Lippincott Williams & Wilkins, Inc.
Cross-sectional; Education; Risk factors; Prevention; Women