Impact of Web-Based Educational Intervention on Preventive Behaviors of Breast Cancer among Damanhour University Female Students

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Original(Article
Impact of Web-Based Educational Intervention on
Preventive Behaviors of Breast Cancer among
Damanhour University Female Students
Asmaa Hamed Mohamed 1, Enas Mohamed Ibrahim Hassan 2, Abeer Abd El-Aziz Madian 3, &
Amel Attia Abd Elghaffar Moustafa 4.
1.Assistant lecturer at Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt.
2. Professor of Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt.
3. Professor of Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt.
4. Lecturer of Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt.
ABSTRACT
Background: Breast cancer, the most typical cancer in women, is a significant global health concern.
Unhealthy habits that may influence students' health and way of life as adults usually accompany the
university years. Following these health-promoting behaviors is one of the best strategies for university
students to protect and regulate their health against breast cancer because they are closely linked to
health promotion and illness prevention. Aims: to evaluate the impact of web-based educational
intervention on preventive behaviors of breast cancer among Damanhour University female students.
Design: A Randomized educational intervention trial (pre- post& follow up) design. Subjects: fourth
grade female university students. Tools: four tools; tool (I) online breast cancer knowledge assessment
structured questionnaire. Tool (II) online Healthy Promoting Life-Style Behaviors Profile Scale
(HPLP). Tool (III) online behaviors questionnaire sheet toward Breast self-examination, and tool (IV):
web-based educational intervention satisfaction scale. Results: There was a positive correlation
between students’ attitude toward BSE, level of knowledge, level of BC prevention practices and level
of HPLP behaviors respectively as the students’ attitude toward BSE improved, the level of BC
knowledge, BSE practices and total score of HPLP scale improved and vice versa. Conclusion: In
order to improve university female students' BC preventative & screening practices (BSE), the study
found that the research hypothesis is validated and that the HBM-based preventive educational website
was a useful and effective way to do so. Recommendations: Researchers should repeat this study with
an observational checklist of breast self-examination (BSE) to address BSE practices skills objectively.
Key words: Web-based, Educational intervention, Preventive behavior, Breast cancer & Female
students.
*Corresponding author: Asmaa Hamed Mohamed, Assistant lecturer at Community
Health Nursing, Faculty of Nursing, Damanhour University.

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INTRODUCTION
The young adult period, which starts at age 18 and lasts until age 25, is typically the time when people are studying
at universities and is therefore the most valuable resource in the world. It is a stage of life with specific health and
developmental needs and rights. (1) Additionally, this is a period for knowledge and skill development, relationship
management skills, and acquiring traits and skills that will be crucial for maintaining adult health. (2) During this time,
people develop their independence in making lifestyle and health-related decisions, therefore education and preventive
behaviors are crucial. (1, 2)
University life has a significant impact on how sensitive a group of adults are to developing morbidity as adults.
(3) Young adults, especially females, are more likely to develop breast cancer and other cancers because of risky behaviors
that have been linked to cancer's later start, such as being overweight and physically inactive, eating poorly, smoking,
and alcohol drinking excessively. (4)
The second leading cause of mortality worldwide and the main factor in cancer-related fatalities among women,
cancer affects 2.1 million women annually. World Health Organization, 2018 (5) stated that, the most common form of
cancer in women that causes death worldwide is breast cancer (BC), creating an issue for global public health. According
to estimates, 627,000 women, or 15% of all women who died from cancer, did so as a result of breast cancer. Although
rates are rising in almost every region worldwide, breast cancer rates are greater among women in more developed
regions. 1.67 million new instances of breast cancer (about 25% of all malignancies) were discovered in 2012. In 2018,
this number rose to 2.09 million new cases, or 11.6% of all malignancies. A lifetime diagnosis of invasive breast cancer
will occur in 1 in 8 women (13%) and 1 in 39 women (3%) will pass away from the disease. (6-9)
Primary preventive strategies for BC are currently scarce, and they tend to underestimate the importance of early
detection in raising women's quality of life and reducing mortality associated with it. Therefore, the most important
secondary preventative intervention for achieving such aims is screening. Notably, WHO stated in 2020 that risk factor
avoidance and screening procedures might prevent 30 to 50 percent of malignancies. Mammography, clinical breast
examinations, and breast self-examination (BSE) are suggested screening techniques for BC. Even though mammography
screening is the best way to find breast cancer early, it is painful, has a high rate of false positive or false negative results
because of dense breast tissue, and is only available once a year to women over the age of 45. (4-8)
One of the key behaviors change models is the Health Belief Model (HBM), has been often used to measure
attitudes towards preventative health behaviors like BSE, eating well, and exercising. Although it is crucial to assist
women in their attempts to lower their cancer risk and improve their breast health behaviors, the HBM will benefit this
age group the most. A psychosocial model for behavior modification is called the Health Belief Model (HBM), that looks
at health behaviors to identify elements that may influence people's beliefs, which may then influence how they decide
to engage in preventative health behaviors. Six constructions centered around the main tenet of the paradigm, which was
changed over time to incorporate HBM. (10, 11)
Among the applications (apps) that could be used in interventions for health education, web-based stands out.
Users using the group communication feature of this instant messaging service for desktops and smartphones can
communicate audio, text, video, or locations. Clients and healthcare professionals’ benefit from computerized health
behavior interventions. Web-based applications (apps) provide a successful method for changing women's behavior in
order to avoid breast cancer. This involves educating people about how to manage their weight, eat healthily, drink in
moderation, exercise, breastfeed, and steer clear of things that can cause cancer, such smoking and using mixed estrogen
and progestin hormones. (12)
The process of testing for breast cancer is crucial, and community health nurses play a variety of responsibilities
in the early cancer identification and prevention. The most typical function of community health professionals is
awareness and information raising. Home visits were done to increase neighborhood awareness of breast cancer by going
door to door. Other activities included giving educational talks in public places (like schools and youth centers) and
community health centers, distributing informational leaflets and pamphlets, playing motivational videos on mobile
phones and instructing women in BSE. Due to a lack of research, community health nurses are adopting web-based
applications to improve breast cancer prevention strategies and encourage women to lead healthy lives to stave against
the illness later in life. (13) The purpose of this study is to assess the impact of web-based educational intervention on
preventive behaviors of breast cancer among Damanhour university female students.

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SIGNIFICANT OF STUDY
Breast cancer (BC) is the most lethal malignancy for women in the world. The early stages of this disease's
combat should focus on females. Breast cancer (BC) is regarded as the most prevalent malignancy among women that
results in death worldwide, creating an issue for global public health. (6)
In Egypt, WHO, 2018 (7) stated that an important public health issue is breast cancer, accounting for 35.1% of
cases of newly diagnosed cancer. Because of interplay between genes and health behaviors, early onset breast cancer
incidence has changed so quickly that it cannot be completely attributed to genetics. (8) Prevention has been suggested as
an effective strategy to lessen the burden of breast cancer because many behavioral risk factors are changeable.
Additionally, a healthy habit has been suggested for preventing breast cancer. (9)
Early detection is very important and even more crucial to increase breast cancer awareness among young girls
using efficient and preferred learning channels because breast cancer in young age is typically more aggressive and may
result in worse survival rates. In order to improve university female students' knowledge of breast cancer risk reduction
and early detection, this study aims to provide evidence for its utility and effectiveness. It also seeks to assess the effects
of a social interaction channel on key knowledge about breast cancer through a web-based app. (10)
AIM OF THE STUDY
This study was conducted to evaluate the impact of Web-based educational intervention on preventive
behaviors of breast cancer among Damanhour University female students.
RESEARCH HYPOTHSIS
Damanhour University female students who receive education regarding preventive behaviors of breast cancer
using Web-based educational intervention will exhibit higher knowledge, and preventive behaviors than those who are
not.
MATERIALS AND METHODS
Materials
Study design:
Randomized educational intervention trial (pre- post) design was adopted to conduct this study.
Study setting:
The study was carried out at Damanhour University, El-Beheira Governorate {it includes eleven faculties that
divided into 2 groups 5 scientific faculties and 6 literature faculties}.
Study subjects:
Six hundred and forty (640) fourth grade female students at previously selected faculties at academic year
(2020- 2021) were taken as research subjects, because fourth grade students were mature enough to understand and
practice effective breast self-examination.
Sample size:
The sample size was determined by applying a proportional allocation of 25% to the overall number of female students
in each group of randomly chosen instructors. As a consequence, 640 female students met the minimum sample size
requirement (320 in the intervention group and 320 in the control group).
Sampling technique:
Every odd number was assigned to the intervention group (n=320 students), and every even number was assigned to the
control group (n=320 students). Students were chosen at random from a list. A web-based educational program for

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preventing breast cancer was given to the intervention group before it was given to the control group at the conclusion
of the program and assessment phase.
Inclusion criteria
§
Girls who were not pregnant or breast fed.
§
had access to the internet and a smart phone.
§
There are no disabilities or chronic illnesses present.
§
Never had breast cancer.
§
Willing to participate in the study.
Study tools:
Data was acquired using the following study tools:
Tool (I): Online Breast Cancer knowledge assessment structured questionnaire:
This questionnaire was used in order to assess female student knowledge of breast cancer with different categories, and
it included four parts as the following:
Part I: knowledge of breast cancer risk factors that contained 9 (yes/no) questions, was adopted from the Breast CAM
(Breast Cancer Awareness Measure) (14) that received support for its validation from breast cancer care and breakthrough
breast cancer. (15) For the total of 9 questions, each knowledge scored as follows: Correct response = 1, incorrect response
= 0, and no response = 1. So, the total range of points was from (0-9). The score of the items summed-up and converted
into percent score to be categorized to three levels as:
o < 50% (less than 4) = Poor level of knowledge.
o 50 % -75% (4 to 7) = Fair level of knowledge.
o >75% (greater than 7) = Good level of knowledge.
Part II: Knowledge of breast cancer warning signs and symptoms that contained 11 (yes/no) questions, was
adopted from the Breast Cancer Awareness Measure (Breast CAM). (14) For the total of 11 questions, each
knowledge was scored as following: Correct response = 1, incorrect response = 0, and no response = 1. So, the total
range of points was from (0-11). The score of the items was summed-up and converted into percent score to be
categorized to three levels as:
o < 50% (less than 5) = Poor level of knowledge.
o 50 % -75% (5 to 8) = Fair level of knowledge.
o >75% (greater than 8) = Good level of knowledge.
Part III: Knowledge of Breast Self-Examination (BSE) that contained 15 (yes/no) questions, was taken from
Rosmawati N's (2010) work. (16) For the total of 15 questions, each knowledge was scored as follows: Correct
response = 1, incorrect response = 0, and no response = 1. So, the total range of points was from (0-15). The sore of
the items was summed-up and converted into percent score to be categorized to three levels as:
o < 50% (less than 7) = Poor level of knowledge.
o 50 % -75% (7 to 11) = Fair level of knowledge.
o >75% (greater than 11) = Good level of knowledge.
Part IV: Student personal data was assessed from students; it included data as age, faculty name, residence, marital
status, family history of breast cancer, parents’ education and occupation.
In addition to these:
§
Source of student knowledge regarding prevention of breast cancer was assessed.

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§
Anthropometric measurements: weight and height were reported by students, and body mass index was calculated
according to WHO standards.
Tool (II): Online Healthy Promoting Life-Style Behaviors Profile Scale (HPLP):
Healthy Promoting Life-Style Behavior Scale (HPLP), that was developed by Walker et al in 1987 (17) to
measure the behavior improving one’s health in relation to their healthy lifestyle was adopted and used by the researcher;
additionally, validity and reliability of the scale which included 52 items was made by Esin in 1997. (18) All items of the
scale were prepared in 4-point Likert type. Each item is scored with the numbers as following:
• Never = 1
• Often = 3
• Sometimes = 2
• Regularly = 4
The scale includes six sub-scales:
1. Self-actualization sub-group (9 items) determined one’s purpose of life, their individual ability to actualize
themselves, how much they knew about themselves and how much they could satisfy themselves.
2. Health responsibility sub-group (9 items) determined the level of responsibility one has for their health and how
much they take care of their health.
3. Exercise sub-group (8 items) determined how much one carries out exercises which are indispensable for a healthy
life.
4. Nutrition sub-group (9 items) determined one’s values in selecting and arranging their meals and food selection.
5. Interpersonal support sub-group (9 items) determined the level of one’s communication with those with whom
they had intimate relations and the continuity of this communication.
6. Stress management (8 items) determined the level of one’s familiarization with sources of stress and stress control
mechanisms.
Tool (III): Online behaviors questionnaire sheet toward Breast self-examination:
This questionnaire was used to assess attitudes and practices of female students adopted from the previous work of
Rosmawati N (2010) (16) and included two parts:
Part I: from this tool included 13 five- point Likert scales to assess participants’ attitudes towards breast self-examination
(BSE) such as asking them if BSE made them laugh while practicing it, BSE would be embarrassed for them, BSE wasted
their time. It was ranging from 0 (strongly disagree) to 4 (strongly agree), with a total range of score was from (0-52),
and was at three levels:
Part II: of this tool included 7 five- point Likert scales to evaluate participants’ practices of BSE, such as asking them if
BSE is practiced once a month and if friends advise to do a BSE. On a 5-point Likert scale, where 4 is for "always" and
0 is for "rarely,". Three levels and a total score range of 0 to 28 were used.
• < 50% (less than 14)
Poor level of practicing Breast Self-Examination.
• 50 % -75% (14 to 21)
Fair level of practicing Breast Self-Examination.
• >75% (greater than 21)
Good level of practicing Breast Self-Examination.
Tool (IV): Web-based educational intervention Satisfaction scale:
This tool was created after evaluating recent literature in order to gauge how satisfied female students were
with the online learning environment. (overall web site design, structure, content, font typography and font size, graphics
and photographs, prototype, knowledge presentation, usability and functionality) as (Do the objectives of that training
were clear or not? – Do the training program content was introduced in attractive manner or not? – Were the content
introduced in an organized manner or not?). The items were graded using a 5-point Likert scale, with 4 being the strongest
• < 50 % (< 26)
Negative attitude
• 50 %-75% (26-39)
Neutral attitude
• >75 > ( 39)
Positive attitude

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agreement and 0 being the strongest disagreement. The total range of scores was 0–20, and they were divided into three
levels as follows:
Methods
Administrative process
§
The Damanhour University department of learning and students' affairs received an official letter from the dean of
the nursing faculty informing them of the study's objectives and requesting their consent to carry it out in the chosen
faculties.
§
After explaining the purpose of the study, permission was gained to perform it in the chosen location.
Development of study tools
§ Tools I, II, and III have been translated into Arabic as:
§ Tool (I) Online Breast Cancer knowledge assessment structured questionnaire that was adopted from the Breast
Cancer Awareness Measure (Breast CAM) and employed to test the comprehension of breast cancer information
among female students using various categories (risk factors, warning signs and symptoms, breast self-examination).
§ Tool (II): Online Healthy Promoting Life-Style Behaviors Profile Scale (HPLP) that was created in 1987 by Walker
et al. (17) to measure the behavior improving one’s health in relation to their healthy lifestyle and was included six
sub-scales; namely, self-actualization, health responsibility, exercises, nutrition, interpersonal support, and stress
management.
§ Tool (III): Online behaviors questionnaire sheet toward Breast self-examination that was adopted from the previous
work of Rosmawati N (2010) (16) and used to assess attitudes and practices of female students, participants’ attitudes
towards breast self-examination (BSE), and evaluate participants’ practices of BSE.
§ After examining recent literature, the researcher created Tool IV to gather information from the research subjects.
Pilot study
The researcher conducted a pilot study with 64 university female students, or 10% of the total study population, in order
to assess the tools' clarity, applicability, and comprehension, identify potential barriers to data collection, and gauge the
required time.
Data collection
§ Assessment phase started in January 2021 and ended in Mars 2021.
§ Program development began in April 2021 and became available and valid from the start of August 2021. During
this period, the pretest was done for both intervention and control group.
§ The fieldwork of preventive web site was accomplished in 6 months during the period from 1/8/2021 to 31/1/2022.
§
The posttest was done 3 months after closing the web site.
Developing the program:
Web-based breast cancer preventive educational program was applied according to the following phases:
1. Assessment phase:
§ Students University Emails were obtained from the department of learning and students' affairs in each selected
faculty.
§ Permission E-mail message to all students of the selected faculties to obtain their acceptance for sharing in research
and to determine the way for receiving the program.
§ Two Telegram application groups; one for intervention group and another for control group were done to facilitate
communication with them.
• < 50 % (less than 10)
Dissatisfied
• 50 % -75% (10- 15)
Neutral
• >75% (greater than 15)
Satisfied

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§ Every odd number will be assigned to the intervention group (n=320 students), and every even number will be
assigned to the control group (n=320 students). This allocation of students to each group was done at random from
faculty student lists.
§ The learning environment, as well as the learner's prior knowledge and skills, were recognized, and the instructional
difficulty of the thesis was made clear.
§ All students were instructed to measure their weight and height before filling in the study form.
§ Before starting the program, Tools I, II, and III were given to every student in both Telegram application groups in
order to execute the pretest phase and gather baseline data.
2. Planning phase:
Ø Determining the website program objectives: The general objective of the website program was to enhance
the female student's understanding of and behavior towards BC prevention.
Ø Determining the content of the website program:
The information on the page is based on the Health Belief Model (HBM), one of the most significant behavior
modification models that has been used extensively to look at attitudes about preventative health behaviors like BSE.
Three key content categories on the website were information about breast cancer, prevention, and early detection.
A. The breast cancer category, which provided details on the disease and its risk.
B. The preventative category, which provided details on weight management, exercise, and a balanced diet.
C. Information on breast self-examination, clinical breast exams, and mammography were included in the early
detection category.
3. Designing and development phase:
§ The design phase of the website was systematic and specific.
§ The website also had a responsive, mobile friendly design that means a website's design was automatically resized
to fit the screen size on which it's being viewed.
§ Website was created to run in any web browser and mobile android.
§ Several web pages were created. Content was displayed through written information accompanied by info-graphs,
images, and videos. The windows pages were consisted of the following: (Fig. 1, 2)
§ Main Page: this page includes three main icons for moving to other page, namely (main, connect with us, and life
stories), as the home page banner shows the program title “pinky step for healthy life” accompanied by visual effects.
Figure (1): Screen shot for main page of the educational program.
§ Menue’s page: contains the subject headings of the preventive health education Website,
and when the students press the title of the subject it moves directly to the main screen of
the content of the subject, and through it begins to involve within its elements which
contains 8 topics.
1) Breast cancer statistics.
2) Overview about breast cancer.
3) Types of breast cancer.
4) Diagnosis of breast cancer.
5) Prevention and treatment.
6) Ways of Breast Self-Examination.
7) False perceptions about breast cancer.

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8) Most common queries on breast cancer.
Figure (2): Screen shot for topics page of the educational program.
§ A group of programs has been used for graphic design of website as Adobe Illustrator , photo shop, coding by
HTML5, in addition to video editing by Camtasia Studio application.
§ The development of website was conducted by the developers through creating and assemble the content assets.
§ For the Expert Consultations, three members of the community health nursing department at faculty of Nursing from
different University provided their insights.
§ The website premiered in April 2021 and reopened with password after edit and improvement on August 1st, 2021,
providing information to the students who signed up in the study. Finally, in October 2021, the website link became
accessible to study students without the login password (http://aibcancer.com/index.html) to overcome the login
problems that happened when using password.
4. Field work implementation phase:
§ The breast cancer preventive website was implemented for the intervention students in the form of eight topics in
addition to life stories menu, interaction menu and link for referral system, each topic takes around 10-15 minutes to
read effectively.
§ Any problems related to website link password and form link were encountered to make sure that the links were running,
and students were guided for what to do to open the links effectively.
§ Daily Short health messages were sent to all students of the intervention group through Telegram application. These
messages included important Breast Self-Examination skills, and healthy lifestyle instruction.
§ Every week, one topic of health education content was appeared to studied students in website and was discussed with
them through Telegram chat.
§ One life story about breast cancer was delivered each week on the main page of the educational website as a motivator
for implementation of breast cancer prevention practices.
§ Participants had access to the latest breast cancer news and information through link for breast cancer pages on the
bottom of main page which they could press on it and refer them to various pages as WHO breast cancer statistics,
Breast Cancer Foundation of Egypt (BCFE) affiliated from ministry of social solidarity, and Baheya hospital website.
5. Evaluation phase:
§ Two posttests were used for the intervention group's evaluation, immediate post intervention and follow up after 3
months of intervention of website education (using tools: I, II, and III).
§ Satisfaction of students regarding web-based preventive educational program was evaluated for evaluation group using
tool (IV).
§ A posttest was conducted utilizing the same tools (I, II, and III) through the Telegram application for the control group
and intervention group at the same time.
Statistical analysis:

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§ After data gathering, the obtained data was coded and converted into a format that was specifically created to be fed
into a computer.
§ The SPSS version 20 statistical program of social science (SPSS) was used to enter and analyse the data.
§ After data entry, it was reviewed and corrected manually, through cross-tabulation and frequency analysis.
§ Standard deviation (SD), range (minimum and maximum), arithmetic mean, and percentages were used to analyze the
variables.
§ The study's level of significance was set at p 0.05.
§ In order to examine the association between categorical variables, the Chi square test (version 2) was applied.
§ The difference between two linked variables was assessed using a paired sample T-test.
§ The strength between variables was assessed using the Pearson correlation coefficient (r-test).
§ Graphs were created to visualize the data.
Ethical considerations:
§ Every Dean of the chosen faculties was informed of the day and time of the data collection.
§ After explaining the purpose of the study and assuring the participants that the data collected would only be used
for the purpose of the study, online informed consent was obtained from the selected female students in the
selected faculty involved in the study.
§ Using university emails and phone numbers in place of names ensured the confidentiality and anonymity of each
response.
§ After the post test, the control group received the website's preventative health education content by being sent
the link via the Telegram app.
RESULTS
Table (1): shows how the examined students were distributed across the intervention and control groups in
terms of their personal characteristics. The study sample consisted of 640 participants, which was drawn from the
population of Damanhour female university students who met the inclusion criteria. As seen in Table 1, the age of the
studied students ranged from 20 to 23 years old with a mean (23±1.2years and 22.0±1.3years) among intervention and
control groups respectively, as well as more than three quarters (80.9% &75.3%) of them respectively were single, while
the minority (3.8%, 4.7%) of them respectively had children.
According to students' parents' level of education, in excess of one third (37.2%) of intervention group and
more than two fifths (42.2%) of control group respectively had fathers with high level of education, while more than one
quarters (30.6%, 25.9%) of them respectively had mothers with high level of education. Regarding students' parents'
occupation, more than three quarters (88.4%) of intervention group and more than two thirds (70.0%) of control group
their fathers were work; on the other hand, more than two thirds (70.0%) of intervention group and more than three
quarters (75.3%) of control group their mothers were housewives.
In terms of students' family history of breast cancer, the majority (93.7%, 94.7%) of intervention and control
groups respectively reported that they had no family history of breast cancer, while only (6.3%, 5.3%) of both groups
respectively reported that they had family history of breast cancer, with a p value of 0.01 indicating a statistically
significant difference between the two groups.
Pertaining to the relationship between the students and the breast cancer affected family member, two fifths
(40.0%) of the intervention group and more than one third (35.3%) of the control group stated that their grandmothers
had breast cancer diagnoses, however there was no statistically significant difference between the two groups.

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Table (1): Distribution of the studied students (intervention and control groups) according to their personal
characteristics. (N=640)
Personal characteristics
Intervention group (n=320)
Control group
(n=320)
Test
No
%
No
%
Age/ years
20< 21
21< 22
> 22
62
104
154
19.4
32.5
48.1
41
168
111
12.8
52.5
34.7
t= 0.8
P=0.044*
Min. – Max.
20-23 years
20-23 years
Mean ± SD
23±1.2 years
22.0±1.3 years
Marital state
Single
259
80.9
241
75.3
χ2=
1.8
P=
0.64
Married
49
15.3
64
20.0
Have Children
12
3.8
15
4.7
Father Educational level
Not read and write
22
6.9
31
9.7
χ2=
3.24
P=
0.76
Certificate of illiteracy
52
16.3
63
19.7
Secondary education
127
39.6
91
28.4
High education
119
37.2
135
42.2
Father Occupation
Work
283
88.4
224
70.0
χ2=
3.16
P=
1.31
Not Work
22
6.9
59
18.4
Dead
15
4.7
37
11.6
Mother Educational level
Not read and write
19
5.9
23
7.2
χ2=
3.16
P=
0.68
Certificate of illiteracy
28
8.8
12
3.8
Secondary education
175
54.7
202
63.1
High education
98
30.6
83
25.9

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Mother occupation
Work
75
23.4
68
21.3
χ2=
3.74
P=
0.10
Housewife
224
70.0
241
75.3
Dead
21
6.6
11
3.4
Family history of breast cancer
No
300
93.7
303
94.7
χ2=
17.49
P=
<0.01*
Yes
20
6.3
17
5.3
------------------------------------------------------------------------------------
The relationship (n=20)
(n=17)
Mother
4
20
5
29.4
χ2=
1.02
P=
0.08
Sister
2
10
1
5.9
Aunt
6
30
5
29.4
Grandmother
8
40
6
35.3
Figure (1): displays the student distribution under study (intervention and control groups) according to their
residence. It was found that less than two thirds (60.3%, 62.8%) of intervention and control groups respectively were
rural residents, while just more than one third (39.7%, 37.2%) of them respectively were urban areas residents.
Figure (1): Distribution of the studied students (intervention and control groups) according to their residence.
Intervention group
Control group
0
10
20
30
40
50
60
70
Urban Rural
Urban, 39.7
Rural, 60.3
Urban, 37.2
Rural, 62.8
Intervention group
Control group

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Table (2): clarifies the distribution of the studied students (intervention and control groups) according to their
total level of knowledge about BC throughout the program phases. The table shows that, most of intervention group
(88.7%) had poor total level of knowledge about BC pre-program where, more than half (61.2%) and more than three
quarters (75.4%) of them had strong understanding of the post-implementation of the follow-up program, respectively.
On the other hand, the majority (93.7%, 74.7%) of control group pre and post program respectively had poor total level
of knowledge about BC. There was a statistically significant difference between intervention students’ total level of
knowledge about BC post and follow up program implementation at (P2 <0.01, P3 <0.01) respectively.
Table (2): Distribution of the studied students (intervention and control groups) according to their total level of
knowledge about BC throughout the program phases. (N=640)
Total
level
of
knowledge
Pre
Post
Follow-up
P1
P2
P3
Interventio
n Group
(n=320)
Control
Group
(n=320)
Interventio
n Group
(n=320)
Control
Group
(n=320)
Interventio
n Group
(n=320)
Control
Group
(n=320)
χ2
p-
valu
e
χ2
p-
valu
e
χ2
p-
valu
e
%
%
%
%
%
%
Good
(>75%)
3.9
0.0
75.4
1.0
61.2
1.0
0.22
>0.0
3
98.3
<0.0
1*
97.2
<0.0
1*
Average
(50 -
75%)
7.4
6.3
22.7
24.3
23.7
13.7
Poor
(<50%)
88.7
93.7
1.9
74.7
15.1
85.3
Figure (2) illustrates the distribution of the studied students (intervention and control groups) according to
their source of information regarding BC. This figure shows that less than half (40.6%, 49.7%) of intervention and control
groups respectively reported that the mass media and the internet were the most common sources of information about
breast cancer, with parents and friends and training courses coming in second and third (10.7% and 9.6%, respectively)
and third and fourth (20.6% and 18.8%), respectively.
Figure (2): Distribution of the studied students (intervention and control groups) according to their
source of information regarding Breast Cancer. (N=640)
10
40.6
20.6
18.1
10.7
9.4
49.7
18.8
12.5
9.6
010 20 30 40 50 60
DOCTORS/HEATH CENTERS
MASS MEDIA&INTERNET
PARENTS/FRIENDS
PREVIOUS STUDIES
TRAINING COURSES
Source of information among both groups
Control group Intervention group

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Table (3): represents the distribution of the studied students (intervention and control groups) according to
their total subscales of Health Promoting Lifestyle Behaviors Profile (HPLP) throughout the program phases. It was
found that the highest mean ± SD score at post and follow up program implementation was (35.9±9.3) & (31.8±13.3)
respectively for intervention group regarding their nutritional habits compared to its value (6.6±6.2) at preprogram that
was very low which indicated the effectiveness of educational intervention. On contrary, it was no obvious improvement
of HPLP for control group regarding nutritional habits as the mean ± SD score was (8.6±7.7) preprogram and became
(13.8±7.1) & (11.6±9.2) at post and follow up program implementation respectively, with a highly statistically significant
difference between both groups at (P <0.01). At pre, post, and follow up of the program implementation at (P1, P2), a
highly statistically significant difference was seen between the total score for each of the six subscales of the (HPLP) for
both examined groups regarding breast cancer.
Table (3): Distribution of the studied students (intervention and control groups) according to their total subscales
of Health Promoting Lifestyle Behaviors Profile (HPLP) scale throughout the program phases. (N=640)
Total score
for each of
the
six subscales
of
HPLP scale
Pre-Test
Post- Test
Follow up Test
Paired t
test (1)
p-value
Paired t
test (2)
p-value
interventi
on Group
(n=320)
Contro
l
Group
(n=320
)
interventio
n Group
(n=320)
Control
Group
(n=320)
interventio
n Group
(n=320)
Control
Group
(n=320)
Mean ±SD
Mean ±SD
Mean ±SD
1. Health
responsibility
6.4±2.8
5.9±2.1
9.5±2.7
9.9±2.7
10.8±3.3
6.5±2.4
15.682
<0.001*
*
12.876
<0.001*
*
2. Physical
exercises
7.7±5.7
9.9±6.1
24.5±5.6
12.1±5
20.7±4.9
10.2±7.
7
12.898
<0.001*
*
10.342
<0.001*
*
3. Nutrition
6.6±6.2
8.6±7.7
35.9±9.3
13.8±7.
1
31.8±13.3
11.6±9.
2
6.564
<0.001*
*
9.651
<0.001*
*
4. self-
actualization
6.7±4
6.2±3.9
10.9±2.3
7.1±3.5
11.8±1.1
9.3±3.6
10.245
<0.001*
*
7.374
<0.001*
*
5.
Interpersonal
support
6.3±3.7
8.6±7.7
14.4±1.3
4.5±4.6
13.5±3.4
5.6±1.5
16.675
<0.001*
*
6.421
<0.001*
*

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6. Stress
management
7.8±5.7
6.2±3.9
21.3±4.5
12.6±6.
1
23±3.4
14.6±8.
2
12.765
<0.001*
*
10.032
<0.001*
*
Table (4): illustrates the distribution of the studied students (intervention and control groups) according to their
score for overall Health Promoting Lifestyle Behaviors Profile (HPLP) scale throughout the program phases. It can be
seen from this table that, the majority (83.7%, 93.7%) of intervention and control groups had poor level of HPLP
behaviors at preprogram phase, with no statistically significant difference between both groups (χ2 = 0.27, P1>0.04). On
the other hand, the table clarifies drastic improvement among intervention group at post and follow up program
implementation, while less than three quarters (73.1%, 65.6%) among them had good level of HPLP behaviors at post
and follow up program implementation. On contrast, the majority (73.4%, 81.6%) among control group had poor score
of HPLP behaviors at post and follow up program phases respectively. Meanwhile, there was a statistically significance
difference at (P1, P2< 0.01) between both groups regarding HPLP behaviors at post and follow up program
implementation phases.
Table (4): Distribution of the studied students (intervention and control groups) according to their score for
overall Health Promoting Lifestyle Behaviors Profile (HPLP) scale throughout the program phases. (N=640)
Score
for
overall
HPLP
scale
Pre
Post
Follow-up
P1
P2
P3
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
χ2
p-
value
χ2
p-
value
χ2
p-
value
%
%
%
%
%
%
Good
(>75%)
6.9
0.0
73.1
6.6
65.6
2.8
0.27
>0.04
96.7
<0.01*
72.1
<0.01*
Average
(50 -
75%)
9.4
6.3
21.9
20.0
18.8
15.6
Poor
(<50%)
83.7
93.7
5.0
73.4
15.6
81.6
Table (5): depicts the distribution of the studied students (intervention and control groups) according to their
attitudes towards Breast Self-Examination (BSE) throughout the program phases. This table clarified that more than
half (51.5%, 58.8%) among both groups had negative attitude toward BSE at preprogram phase. On the other hand,
three quarters (75.0%) and more than half (51.6%) of intervention group post and follow up program phase
respectively had positive attitude towards BSE, compared to only (22.8%, 13.4%) among control group. So, it was
evidenced that there was no statistical significance at pre-program between intervention and control group (P1>0.05),
while there was a highly statistically significant difference at post and follow up program between intervention and
control group at (P1<0.01, P2<0.001).

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Table (5): Distribution of the studied students (intervention and control groups) according to their attitudes
towards Breast Self-Examination (BSE) throughout the program phases. (N=640)
Table (6): demonstrates the distribution of the studied students (intervention and control groups) according to
their BSE practices throughout the program phases. The table reveals that, less than three quarters (71.6%) of intervention
group had poor score of total BSE practices preprogram compared to more than three quarters (76.6%) and more than
half (58.8%) of them had good score post and follow up program implementation respectively, while around two thirds
(64.0%, 71.9%) of control group had poor score of total BSE practices post and follow up program implementation
respectively with a statistically significant difference between both groups at post and follow up tests only (P2, P3<0.01).
Table (6): Distribution of the studied students (intervention and control groups) according to their Breast Self-
Examination (BSE) practices throughout the program phases. (N= 640)
BSE
practices
Pre-test
Post-Test
Follow-up
P1
P2
P3
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
χ2
p-
value
χ2
p-value
χ2
p-value
%
%
%
%
%
%
χ2
p-
value
χ2
p-value
χ2
p-value
Good
(>75%)
10.0
9.4
76.6
14.1
58.8
11.3
0.15
98.2
92.1
Attitudes
towards
BSE
Pre
Post
Follow-up
P1
P2
P3
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
Intervention
Group
(n=320)
Control
Group
(n=320)
χ2
p-
value
χ2
p-value
χ2
p-value
%
%
%
%
%
%
%
%
%
%
%
%
χ2
p-value
Negative
attitude
(<50%)
51.5
58.8
9.7
35.0
17.8
46.0
0.19
>0.05
83.2
<0.01**
67
<0.001**
Neutral
attitude
(50 - 75%)
33.5
28.1
15.3
42.2
30.6
40.6
Positive
attitude
(>75%)
15.0
13.1
75.0
22.8
51.6
13.4

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Fair (50
- 75%)
18.4
12.5
20.0
21.9
27.8
16.8
>0.05
<0.01*
<0.01*
Poor
(<50%)
71.6
78.1
3.4
64.0
13.4
71.9
Table (7): presents the relation and paired difference between the mean of Health Promoting Lifestyle
Behaviors Profile (HPLP) scale and BSE practices in intervention students throughout the program phases. The table
shows that, the mean students' total HPLP score related to students' BSE practices was (22,795±20.970) before the
educational website intervention which increased significantly to (86.434±18.314) after the intervention, and
(56.711±20.942) follow up 3 months after the program implementation with a highly statistically significant correlation
at all three stages of program (P-value<0.001). Furthermore, this table shows highly significant improvement in students'
BSE practices accompanied with significant improvement of their scores of HPLP scale post implementation of web
based educational program with highly statistically significant differences between pre, post, and follow-up tests at
(P<0.001) at all relations.
Table (7): Relation and paired difference between the mean of Health Promoting Lifestyle Behaviors Profile
(HPLP) scale and BSE practices in intervention students throughout the program phases. (N=320)
Total
HPLP
BSE Practices
Comp.
Paired Differences
Paired t-test
Mean
±
SD
Mean
±
SD
t
P-value
Total
Pre
22.795
±
20.970
Pre –
Post
-63.639
±
33.154
-17.487
<0.001**
Post
86.434
±
18.314
Pre –
Follow up
-33.916
±
22.017
-14.034
<0.001**
Follow
Up
56.711
±
20.942
Post -
Follow up
29.723
±
34.709
7.802
<0.001**
Table (8): reveals the relation between intervention students' total score of HPLP scale, BC knowledge, BSE
practices and their attitudes toward BSE. It was noticed that there was a positive correlation (0.769, 0.875, 0.597) between
intervention students' level of BC knowledge and their (BSE practices, attitudes toward BSE, total score of HPLP
behaviors) respectively, as Pearson Correlation Coefficient (r-test) had a positive value between -1 and 1, which indicates
a perfectly strong linear relationship where a change in students’ knowledge is accompanied by a perfectly consistent
change in their attitudes toward BSE, their BSE practices and their total score of HPLP scale, as while there was a positive
direction when one variable increase, the other would increase and vice versa, with a highly statistically significant
difference between them as p-value =0.000.

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Table (8): Relation between intervention students' total score of HPLP scale, BC knowledge, BSE practices and
their attitudes toward BSE. (N=320)
Items
Total score of
knowledge
Total score of
practice
Total score of
attitudes
Total score of
HPLP
Total score of
knowledge
R
--------
0.769**
0.875**
0.597**
p-value
--------
0.000
0.000
0.000
Total score of
attitudes
R
0.597**
0.687**
--------
0.586**
p-value
0.000
0.000
--------
0.000
Total score of
practices
R
0.893**
--------
0.689**
0.896**
p-value
0.000
--------
0.000
0.000
Total score of
HPLP
R
0.996**
0.687**
0.472**
--------
p-value
0.000
0.000
0.000
--------
Figure (3): clarifies the distribution of intervention students according to their total satisfaction regarding web-based
educational intervention. It was found that, (86.3%, 62.5%) of intervention group were satisfied with the educational
website at post and follow up program implementation respectively, compared to the minority (3.4%, 9.4%) of them who
were dissatisfied at post and follow up program implementation respectively, with a statistically significant difference at
P<0.01. Overall, the result revealed that the website preventive educational program was satisfied for majority of
intervention students.
Figure (3): Distribution of intervention students according to their total satisfaction regarding web-based
educational intervention. (N=320)
3.4
10.3
86.3
9.4
28.1
62.5
0
10
20
30
40
50
60
70
80
90
100
Dissatisfied Neutral Satisfied
post test follow up test

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DISCUSSION
Despite being preventable by early detection, breast cancer is the most prevalent disease in women globally and
its incidence is rising in many countries. It is one of the major reasons of increased death and disability among women.
(19) WHO, fact sheet 2020 (20) stated that Every eighth woman born today will experience a breast cancer diagnosis at
some point in her life. In emerging nations, the prevalence of breast cancer is quickly rising as a result of longer life
expectancies, expanding urbanization, and the adoption of western lifestyles, particularly among younger women.
The present study gives a clear picture of 640 participants, who were driven from the population of Damanhour
fourth grade female university students. It was found that the age of the studied students ranged from 20 up to 23 years
old with a mean (23±1.2 years) among intervention group and (22±1.3 years) among control group. Out of all respondents
recruited in this study, more than three quarters of them were single, more than half of them had Body Mass Index (BMI)
values within normal range; this goes in line with the study conducted in Bangladesh by Sarker et al., (2022) (21) to
evaluate how an educational intervention program affected young female university students' knowledge of breast cancer
and their use of BSE.
All human being are motivated to take action when they are aware of what is happening with their bodies. Due
to this reality, screening programs will assist female students in examining their bodies and become completely aware of
what is happening inside them. Therefore, any public program must address these women's prior experiences and work
to raise their level of understanding of BC disease. It is crucial to arm these women, whether they are younger or older,
with a strong degree of knowledge and practice skills regarding this lethal condition since a motivated woman adheres
better to public activities.(22)
Based on this fact, the current study attempted to determine your level of knowledge among studied sample and
indicated that, majority of them had poor level of knowledge about breast cancer. This result was in accordance with the
study performed by Anuwe et al., (2020), (23) Qasim et al., (2020) (24) and Ahmed H et al., (2018) (25) who found that
around half of university students had poor level of knowledge about breast cancer and its early symptoms. The lack of
health information sources for students during the study years, combined with the increased academic demands and
adjusting to new life circumstances at the university level, may be the cause of this. These circumstances had an impact
on the students' motivation to learn any health information.
On the other hand, this result disagreed with study carried out by Negi et al., (2017) (26) who carried out a study
about breast cancer awareness and attitude among nurses of a tertiary care center and found that half of them had average
level of knowledge about breast cancer, This outcome could be explained by the fact that BC illness is typically covered
in nursing curricula.
To learn more about BC, sources of information are required. The participants in this study most frequently cited
the internet and mass media as information sources. Various published articles were also indicated TV or internet as the
most common source of information about BC as Alsowiyan AA el al., (2020), (27) Manzour A.F et al., (2019), (28) Kan'an
A et al., (2018) (29) and Hassan EE et al., (2017). (30) The majority of people, however, chose to learn about BC via family,
friends, healthcare professionals, and educational training programs, according to the other researches as Al-Suroj HR et
al., (2018), (31) Dinegde NG et al., (2017). (32) These findings demonstrate that one of the most significant sources of
knowledge regarding BC and BSE is the media, and they also highlight the media's role in working with healthcare
educators to disseminate accurate information about BC to young adults.
The Health Promoting Lifestyle Behaviors Profile (HPLP) mean score and its characteristics for the intervention
group considerably improved both immediately and three months later when compared to the preprogram phase,
according to the findings of the current study., but there was no significant difference found in the control group, which
was consistent with those found in a study conducted by kacan Y et al., (2019). (33) This finding was consistent with the
study done in Iran (2020) by Solhi M et al. (34) who found that intervention groups' HPLP significantly improved after
the implementation of the instructional program. Therefore, behavioral changes connected to a lifestyle that promotes
health and its dimensions can be made with the help of educational interventions.
A set of feelings, thoughts, and behaviors towards a particular person, thing, or event is referred to as an attitude
in psychology. Experiences frequently have an impact on attitudes. People's reactions can be strongly impacted by it, and

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depending on the situation, they might act differently. (35) Therefore, it was important to assess how female students felt
about BC and the concerns that it is related with. Moreover, half of the participants in the current study had unfavorable
sentiments towards BSE during the preprogram phase.
This outcome can be a result of the students' unfavorable perceptions of the BC disease that affects children their
age. This is in line with research results from Darawad (2020), (36) which discovered that more than two thirds of the
students under investigation had poor attitudes about breast self-examination. However, a contrasting image was found
in the study conducted in Jordan by Alsaraireh et al., (2018) (37) and claimed that two thirds of them agreed about how
easier it is to treat cancer when it is caught early.
The BSE practices rate was disappointing, showing that slightly less than three-quarters of them had a poor degree
of practice regarding self-examination. This finding was in addition to the current study's finding that the attitude was
demoralizing. These findings were matching with the study conducted by Ayed et al., (2015) (38) who found low level of
BSE practices among female health science students in Ethiopia. These findings might be the result of the younger age
of the study population, which is typically not projected to be a breast cancer patient and hence does not report practicing
BSE, may have contributed to these findings. Aside from the potential that they lacked breast cancer knowledge, training
materials, and curricular information pertaining to breast cancer.
Over 75% of the intervention group had good BSE practices after the teaching program was put into place, which
was a significant and obvious improvement. Similar improvement was reported in other studies done by Esfahani MS, et
al., (2018) (39) Abd El Salam et al., (2020). (40) As opposed to, a study by Ceber et al., (2010) (41) found that there were no
significant differences in the BSE practices between the two groups. This discrepancy may be caused by the fact that the
study participants did not major in health sciences, they never had the opportunity to receive training on breast cancer
screening techniques, and that nurses and other healthcare professionals who made up the sample of the contrasted study
were typically more knowledgeable about BSE than the study participants.
According to a study by Jabeen Z et al., (2021), (42) Regarding the knowledge, attitude, and practices of female
university students, there was a statistically significant difference between the overall knowledge score and the practices
of BSE. at Jinnah Sindh Medical University. This finding is consistent with that study's findings. A different study
conducted by Ali A et al. (2020) (43) found a substantial correlation between BSE knowledge and practices. However,
this contrasts with a study conducted by Azemfac K et al., (2019), (44) who observed that there was a significant disparity
between knowledge of BSE and practices of BSE, with just 15% of their respondents practicing BSE while only 25%
knew about BSE.
According to the aforementioned studies, a web-based educational intervention among female undergraduate
students at Damanhour University had a substantial impact on their BC knowledge, attitudes about BSE, practices related
to BSE, and HPLP level. All participants were reconnected with three months after the start of the educational website
intervention in order to complete an online posttest survey. Given that all study participants were university-based fourth-
grade dropouts who resided in their own dorms for the length of the study, the full response rate for the posttest looked
reasonable.
In summary, breast cancer is a significant public health problem that has had a significant impact on women's
health as well as the health of their families, communities, and offspring. Community health nurses must explain to their
patients the advantages of online training programs, including the possibility of reducing learning time, self-paced
learning, limitless access to training resources, the elimination of travel requirements, minimal interruption of university
schedules, and the elimination of trip requirements. Education systems are increasingly working to modernize their
information technology infrastructure as more schools adopt e-learning practices. The introduction of instructional
programs for the web can be facilitated by this infrastructure. Community health nurses must offer sufficient services
that benefit female students' educational experiences and may enhance future generations' comprehension of public health
messaging. Therefore, numerous initiatives should be taken to protect female university students from breast cancer.

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CONNCLUSION AND RECOMMENDATIONS
Given how frequently it happens, breast cancer is a serious health problem. The most expensive type of medical
treatment for breast cancer is acknowledged on a global scale. Nursing is a great professional resource that can help
encourage positive changes through health education programs.
The study concluded that the research hypothesis is supported and that the HBM-based preventive educational
website is an effective and efficient method in enhancing university female students' BC preventive & screening practises
(BSE) and improving their knowledge level about BC. The findings gave the researcher baseline information about the
level of breast cancer awareness among fourth-year undergraduate female students at Damanhour University.
This knowledge could help nurse educators target and customize educational initiatives to give students the
knowledge and abilities they need to be successful breast cancer preventers. It can also be used as a guide for assessing
upcoming campaigns to educate people about breast cancer. Thus, this study recommended that:
§ The development of policies to institutionalize a healthier campus and create health promotion programs
encouraging healthy choices among university students should involve faculty administrators, curriculum planners,
and health educators.
§ Make the most of the internet, social networks, and pertinent support groups, especially for educated women, to
raise their level of understanding of the condition and available preventative treatments.
§ Campaigns to raise awareness of BC prevention techniques and therapies are being launched, and they are aimed at
a wider audience, including men, community and religious leaders, and medical professionals.
§ Creating educational pamphlets on BC based on HBM to enhance screening practices, health beliefs, and knowledge.
Acknowledgment:
Our sincere appreciation goes out to the study participants who participated and provided us with all the necessary data.
Last but not least, we appreciate the collaboration and assistance of the corresponding Damanhour University Faculty
Deans during the data collection process.
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