1School of Nursing, Badr University in Cairo, 11829, Egypt
2College of Nursing, Prince Sattam Bin Abdulaziz University, 16278 Al-Kharj, Saudi Arabia
3Faculty of Nursing, Suez Canal University, 8366004 Ismailia Governorate, Egypt
4Faculty of Nursing, Damietta University, 34511 Damietta, Egypt
5Faculty of Nursing, Cairo University, 12613 Giza Governorate, Egypt
6College of Nursing, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), 21423, Al Ahsa, Saudi Arabia 7Faculty of Nursing, Beni-Suef University, 2722165 Beni Suef Governorate, Egypt
*Corresponding Author’s Email: hemat.mostafa@buc.edu.eg
Keywords: Breast Cancer; Body Image; Self-esteem; Quality of Sexual Life
Breast Cancer (B.C.) is a prevalent malignancy in human and is the most frequently diagnosed cancer in women. Its rising incidence has become a significant public health issue today. Research on breast cancer holds crucial practical implications for women's health and well-being (Lin et al., 2023). In 2020, female breast cancer overtook lung cancer as the most common cancer globally, with approximately 2.3 million new cases, making up 11.7% of all cancer cases. It is the fifth leading cause of cancer-related deaths worldwide, with 685,000 fatalities (Sung et al., 2021). This biennial update from the American Cancer Society presents statistics on breast cancer among women, utilising high-quality data on incidence and mortality from the National Cancer Institute and the Centers for Disease Control and Prevention. Between 2012 and 2021, breast cancer incidence increased by 1% annually, primarily driven by cases in the localised stage and hormone receptor-positive disease (Giaquinto et al., 2024).
Breast cancer originates in the epithelial lining of the ducts (85%) or lobules (15%) of the glandular tissue. The malignant growth is initially confined to the duct or lobule (in situ), often without symptoms and with a low risk of metastasis. Early detection significantly improves the success of breast cancer treatment (Brajković et al., 2024). The treatment typically involves a combination of surgical removal, radiation therapy, and medication. Historically, all breast cancers were treated surgically with a mastectomy. However, most breast cancers today can be treated with a less extensive procedure called a "lumpectomy" or partial mastectomy, where only the tumour is removed. In such cases, radiation therapy to the breast is generally required to reduce the risk of recurrence (Al-Sharman et al., 2024).
Breast cancer in women: poor body image and sense of self-worth are linked. In breast cancer survivors, a negative body image includes feelings of dissatisfaction with the appearance, a sense of losing femininity and physical integrity, aversion to seeing themselves naked in mirrors, feelings of unattractiveness to men, feelings of insecurity about looks and dissatisfaction with surgical wounds (Yehia et al., 2022).
Sexuality represents one of the main aspects of the relationship between wife and husband. It also significantly affects how the mastectomy modifies one's quality of life (QoL). Sexuality, which includes sex, gender, sexual and gender identity, sexual orientation, emotional attachment/love, and reproduction, is an essential feature of being human. Sexuality encompasses more than just the ability to participate in sexual activities or conceive children; in addition, it encompasses ideas, expectations, aspirations, convictions, dispositions, principles, roles, and connections. Therefore, BC diagnosis and treatment can lead to psychological and sexual issues (King et al., 2020).
Women require guidance both before and after a mastectomy, including support in accepting the treatment procedures and adjusting to new circumstances. Consequently, nurses should address and support women in psychological, family, social, and sexual aspects following the surgery. It is crucial to consider the impact of the surgical procedure on women’s psychological well-being, especially given the high prevalence of BC and surgical removal of the breast (Savani et al., 2023).
Self-esteem refers to a person's overall feeling of self-worth and value. It's the way a person views and accepts themselves, regardless of the challenges they may face. Self-esteem is influenced by various factors, such as confidence in one's abilities, feeling safe and secure, a sense of belonging, and a sense of competence. Women who undergo mastectomy due to breast cancer often experience significant changes in their roles and responsibilities at home and in their professional lives. This can lead to relationship issues, including relationship breakdowns and changes in intimacy. They may also struggle with feelings of dependency, which can negatively impact their self-esteem and marital status. The physical changes resulting from the surgery, such as changes in appearance, can lead to a loss of self-perception and self-esteem, as they may feel unattractive and lack confidence in their appearance. This can, in turn, affect their sense of sexuality and their ability to be open and intimate with their partner (Yehia et al., 2022).
Interventions that address the women’s psychological and informational needs, encourage emotional expression, and improve coping mechanisms are essential for a first-rate educational program. Therapeutic communication is one type of educational intervention that has been successfully used to cure depression, lower stress levels, improve quality of life, and assist women with cancer during diagnosis and recovery. Interventions are designed and implemented to help women achieve specific goals based on the developmental and cultural needs. Continuous assessment is also required to ensure she receives timely and effective nursing care (Li et al., 2024).
Breast cancer is a global health issue that affects women of all ages, from puberty onwards, in every country worldwide. However, the incidence of breast cancer tends to increase with age, particularly in later life. In Egypt, breast cancer is the most prevalent type of cancer among women, making up approximately 38.8% of all female cancer cases. According to estimates, there were nearly 22,700 cases of breast cancer in 2020, and this number is expected to rise to around 46,000 by 2050. Additionally, ranking it as the second leading cause of cancer mortality, after liver cancer. The increasing incidence of breast cancer and associated detrimental effects, including the challenges associated with treatment affecting not only physical health but also psychological, social, and emotional aspects of women's lives, underscore the importance of this study. It aims to examine the quality of sexual life in affected women and develop an effective nursing educational program. This program would focus on enhancing sexual well-being, improving self-esteem, and helping women first address body image issues before learning to manage the relationships, especially with husbands.
To investigate the impact of educational nursing program on quality of sexual life, body image, and self-esteem among women with breast cancer.
A quasi-experimental design with a one-group (pretest and post-test) was used to achieve the aim of this study. For this process written approval to conduct the study was granted by the director of El- Galaa Hospital and the head nurse of the Medical Out-Patient Clinics. In addition, each breast cancer survivor participating in the study provided written informed consent. Prior to consenting, participants were thoroughly informed about the study's objectives and reassured about the confidentiality of their data and the safety of the procedures. Participants were also made aware of their right to withdraw from the study at any time without facing any penalties.
The research was carried out at the oncology outpatient clinic of a government hospital (El-Galaa Hospital) which is affiliated with the General Teaching Hospital Organisation & institutions. The hospital offers comprehensive inpatient and outpatient services. The oncology outpatient clinics are located on the second floor of the outpatient department. One room is designated for examining women, while the other is used for follow-up care, including patients receiving hormonal therapy, chemotherapy, and radiotherapy. Outpatient clinics are accessible four days per week, two days for diagnosis and two days for follow-up.
A purposive sample of 40 breast cancer women was selected and chosen based on specific inclusion and exclusion criteria.
Willingness to participate in the research Fertile women between the ages of 18 and 40.
At least six months following breast cancer diagnosis. Married with regular sexual relations.
Women who undergo additional distortion-causing surgeries. Severe mental illness.
Missing two instructional program sessions.
Four tools were used for data collection.
The researcher created this tool in Arabic and reviewed by an expert. It consists of two parts. First part included data related to demographic characteristics as women age, level of education, occupation etc. The Second part included data related to medical history such as duration of diagnosis, stage of breast cancer, types of treatment etc.
The researcher used a modified scale, originally developed by Koleck in 2002, to assess women's perceptions of their bodies and how breast cancer affects their body image. The scale consists of 16 items, with 10 original items and 6 additional items added by the researcher. The items are scored on a Likert-type scale. The higher scores indicate poorer body image. The scale categorises body image as follows: scores of 54 or higher indicate poor body image, scores of 49-53 indicate average body image, and scores of 38-48 indicate good body image.
This scale was created in 1965 by Rosenberg and updated in 2009 by Hatcher to measure women with breast cancer sense of self. There are ten items in all, 5 having negative features and five having good ones. Reactions are recorded using a Likert-type scale. A Likert-type scale with a range of 1 (not at all) to 4 (strongly agree) is used to record responses. The maximum score was (40) and minimum (10).
This scale consists of twenty-seven questions broken down into 4 categories: environment, interpersonal connections, psychology, and physical health. Likert-type scales were used to record the responses. The responses are made on a Likert -type scale. Response was as: (5) strongly satisfied,
(4) satisfied, (3) sometimes satisfied, (2) dissatisfied and (1) strongly dissatisfied. The lowest score was 27, and the highest was 135.
A pilot study was conducted on 10% (4) of the participants to evaluate the usability and clarity of the study tools before initiating the fieldwork and estimate the time required to complete each tool. The pilot data revealed that each breast cancer participant needed fifteen to twenty minutes to complete
the study tools, with no changes needed. So, the participants in the pilot study were included in the main study sample.
Five experts, comprising two psychiatrists, a professor of medical oncology, and two professors of obstetrics and gynaecological nursing, reviewed the tool's content to ensure that it was easy to use, comprehensive, relevant, and applicable.
The tool's Arabic version was tested on forty post-breast cancer women to determine its reliability. The researcher conducted a test-retest-reliability coefficient on patients with a fourteen-day time interval in the same circumstances. Its value for the 16 items was (0.93) which indicated that the Arabic version of the Body Image Scale demonstrated excellent scale reliability and its value for 10 items (Self-Esteem Scale) was (r = 0.9). The reliability of the tool (Quality of Sexual Life) was assessed through measuring their internal consistency by determining the Cronbach alpha coefficient.
The data was collected over twenty-four weeks, starting August 2023 and ending January 2024. Four phases were involved in the study's execution as follows:
After obtaining the required clearances, the researcher started the preparatory phase. Before the intended program's implementation, each participant was interviewed individually for fifteen to twenty minutes at the oncology outpatient clinic. The phase took one month to complete.
Through teaching effective coping mechanisms and problem-solving techniques, subjects can deal mentally and emotionally with the daily stressors brought on by the removal of their breast. The sample was divided into four subgroups, each with ten women. Each subgroup attended ten sessions, two weekly sessions for five weeks, each lasting between sixty and ninety minutes.
The researcher developed the program's objectives and content in ten-, sixty-, and ninety-minute sessions, employing various teaching techniques and aids.
The general objective of the program is to enhance BC women's awareness and skills regarding body image, self-esteem, and quality of sexual life.
Upon completing the educational nursing program, every woman with breast cancer can learn about breast cancer, practice problem-solving techniques, enhance their body image, boost their self- confidence, and improve their quality of sexual life.
Introductory section outlining the program's goals and overview of breast cancer, including the stages of therapy and practical advice on honing problem-solving and decision-making abilities.
Identify the concept of body image-associated signs and symptoms of breast cancer, the practical part about transforming negative thoughts into good ones.
Discuss the necessary methods to cope with peer pressure, improve social interaction, and the practical part about promoting self-esteem.
Discuss methods of improving body image and practical positive self-talk. Implement essential steps and guidelines needed for enhancing positive self-concept. Apply the importance of social interaction and pragmatism to enhance body image.
Define sexual health. Identify methods to improve sexual life, helpful in acquiring proficient communication abilities with both one and others.
Identify negative emotions. Apply methods to control and manage negative feelings associated with breast cancer.
Appreciate the value of relaxation techniques in craving prevention and pragmatic regarding meditation and relaxation methods.
Acquire the necessary instructions for getting productive work, helpful information regarding stress reduction methods, and a post-assessment exam.
Following the implementation of the session at the end of the 10th session, researchers used the same three instruments to reevaluate the women with breast cancer.
After the data was collected, it was tabulated and examined using the appropriate statistical tests (version 20 SPSS). The data were displayed as frequencies and percentages using descriptive statistics in the form of frequencies and percentages. Chi-square tests were used to compare frequencies and correlation between study variables.
The researchers obtained ethical clearance from the Research Board of the Institutional Ethical Committee of Badr University in Cairo, Egypt with reference number BUC-IACUC-231217-48 on 17th December 2023.
The sociodemographic characteristics of the study sample showed that more than half of the respondents were between the ages of 41 and 50, and only 15% were between the ages of 18 and 30, with a mean age of 39.1± 4.9 years old more than two-thirds of the women with breast cancer. in the study were childless. Less than half of the study sample complete their secondary education and were working.
Table 1: Distribution of the Study Sample According to Clinical Characteristics (N=40)
Variables | No. 40 | % | ||
Time Spent Diagnosing | ||||
Six months to less than a year | 12 | 30 | ||
From 12 to 18 months | 20 | 50 | ||
18 to 24 months | 8 | 20 | ||
Mean ±SD =16.2±2.7 | ||||
Breast Cancer Stage | ||||
First Stage | 2 | 5 | ||
Second Stage | 32 | 80 | ||
Third Stage | 6 | 15 | ||
Managements | ||||
Chemotherapy | 18 | 45 | ||
Radiation therapy | 6 | 15 | ||
Hormonal treatment | 16 | 40 | ||
Removal of the Breast | ||||
Radical breast removal | 0 | 0 | ||
Adapted radical breast removal | 18 | 45 | ||
Complete breast removal | 22 | 55 |
Table 1 reveals that more than three-fourths (80%) of the women in the study had breast cancer that was in its second stage. Additionally, less than half of them is receiving chemotherapy, and Over 50% of the participants had a complete mastectomy.
Table 2: Distribution of the Study Sample According to Levels of Body Image Concerns Before and After the Program (N=40)
Levels of Breast Cancer Body Image Concerns Before and After the Program | Educational Nursing Program | t-test | P value | |
Before | After | |||
Mean + SD | ||||
Poor concerns of body image | 33.31±0.1 | 17.87±0.34 | 22.4 | <0.001** |
Average concerns of body image | 28.60±11.27 | 38.60±11.27 | 25.8 | <0.001** |
Good concerns of body image | 34.25±4.77 | 44.25±4.77 | 29.8 | <0.001** |
** Highly statistically Significant
Table 2 indicates that all body-image scores among the examined individuals have improved statistically significantly following the educational nursing intervention.
Table 3: Levels of Self-Esteem of Subjects Pre and After the Implementation Program (N=40)
Level of Breast Cancer Women Self-Esteem | Educational Program | X2 | P value (N=40) | |||
Before | After | |||||
No. | % | No. | % | |||
Poor self-esteem | 18 | 45 | 3 | 7.5 | 22.5 | <0.001** |
Average self-esteem | 10 | 25 | 12 | 30 | 27.4 | <0.001** |
Good self-esteem | 12 | 30 | 25 | 62.5 | 26.2 | <0.001** |
** Highly statistically Significant
Table 3 demonstrated that there is a highly statistically significantly difference in self-esteem levels among women with breast cancer before and after the program implementation, with a marked increase in self-esteem following the program (p < 0.001**).
Table 4: Comparison of the Sample Overall Mean Scores in Areas of Sexual Well-Being Before and After Implementing the Program (N=40)
Areas of Sexual Well-Being | Educational Nursing Program | t-test | P value (N=40) | |
Before | After | |||
Mean + SD | Mean + SD | |||
Physical health | 31.4±6.2 | 36.23±6.9 | 23.5 | 0.001** |
Mental health | 27.15 ±6.32 | 38.26 ±7.2 | 25.8 | 0.001** |
Interpersonal relationship | 28.43±4.92 | 32.17±6.54 | 21.7 | 0.001** |
Surrounding environment | 27.81±4.76 | 31.54±6.23 | 23.3 | 0.001** |
** Highly statistically Significant
Table 4 demonstrates that the quality of sexual life domains differs significantly (p<0.001) between women with B.C. before and after the end of the program. The psychological domain had the highest mean among the women under study, with the physical, environmental, and social connection domains following closely behind.
Table 5: Relation between the Pre-and Post-Program Body Image of Women with Breast Cancer and Their Demographic Characteristics (N=40)
Degrees of Sexual well-being | Educational Program | t-test | P value (N=40) | |
Before the Program | Following the Program | |||
Mean ± SD | ||||
Poor quality of sexual life | 40.8±0.9 | 19.99±0.9 | 15.8 | <0.001** |
Average quality of sexual life | 28.63 ±2.45 | 17.33 ±4.2 | 12.9 | <0.001** |
Good quality of sexual life | 15.34±4.22 | 31.67±7.15 | 17.4 | <0.001** |
** Highly statistically Significant
Table 5 shows that the quality of the study sample sexual lives greatly improved after the program was implemented, with a high statistical difference in the two periods.
Table 6: Relations Between the Individuals' Body Image and Self-Esteem, Before and After The Program (N=40)
Items | Overall Sexual Well-Being | P- value (N=40) | ||
Pre- program | P- value | Post-program | ||
Overall self-esteem | r =0.154 | 0.05 | r =0. 362 | 0.001 |
Overall perception of one' body | r =0.190 | 0.05 | r =0.247 | 0.001 |
Table 6 shows that the quality of the subjects' self-esteem, and their body image perception before and after program implementation are positively correlated and statistically significant (p<0.001).
The result of this study will be discussed in the frame of reference of the following hypotheses: H1 Women with breast cancer who will follow an educational program will have a higher post-test score regarding sexual life. H2 Women with breast cancer who follow an educational program will have a higher post-test significant improvement in body image score than pretest. H3 Women with breast cancer who follow an educational program will have higher post-test significant improvement in their self-esteem score than pretest. The study results support these hypotheses.
The current study findings on sociodemographic characteristics showed that the researched women’s mean age was 39.1±4.9 years, with 60% of the respondents between the ages of 41 and 50 and 15% between the ages of 18 and 30. These findings suggest that most women have reached the end of their reproductive years. Hamd et al. (2019) observed that the age between forty and less than fifty years old is the most prevalent for mastectomy in Egypt.
More than two-thirds did not have children. The study sample who had given birth and had breastfeeding experience had fewer menstrual cycles, thus having a reduction of hormonal production that causes cancer. That could be the reason why having children typically lowers one's lifelong risk of BC. On the other hand, Maleki et al. (2021) found that almost two-thirds of the breast cancer study participants had one or two children.
The results revealed that most subjects under investigation had completed secondary school, one- third were literate and slightly less than one-quarter had completed higher education. The study's findings indicate that almost two-thirds of the participants had educational backgrounds, making it easy to accept and participate in the educational nursing intervention program. These results are consistent with those of Faghani and Ghaffari (2016), who discovered that fewer than 50% of the study sample in the BC study had a diploma, and under one quarter had advanced education. Of the study samples with breast cancer, more than three-quarters had jobs. This is consistent with the findings of Mohamed et al. (2017), who found that over one-third of post-mastectomies were housewives, and almost two-thirds were employed. On the other hand, Maleki et al. (2021) found that, two-thirds of the examined breast cancer women were housewives.
The study indicates that a year after receiving a breast cancer diagnosis, the study sample began to think about their sexual behaviour, self-worth, and body image. These results align with the study done by Faghani and Ghaffari (2016). On the other hand, Hamed et al. (2019) reported that women started to think about their sexual behaviour, self-worth, and body image from 1 to 5 years following a breast cancer diagnosis.
Regarding the surgical procedure, the findings showed that over half of the women underwent a total mastectomy, with over three-quarters of them having a positive family history and less than half undergoing chemotherapy. The current findings are in the same line with the findings of Maleki et al. (2021), who found that most women underwent a total mastectomy, were in the early stage (II), and had a family history of breast cancer.
Furthermore, depression, hopelessness, and anxiety are psychological symptoms experienced by nearly two-thirds of breast cancer patients. Less than one-third of the research participants who had breast cancer did not experience any psychological problems. The results of this study are in line with those of Hamed et al. (2019), who discovered that suicidal thoughts, social disengagement, negative self-esteem, feelings of guilt, worthlessness, and hopelessness can all be signs of depression.
The results of the study also showed that almost of breast cancer women experienced sexual complaints, such as vaginal dryness, pain during intercourse, and lack of desire for sexual activity. The diagnosis and treatment of BC, including hormonal treatment, radiation, and chemotherapy, may have contributed to these problems. This outcome concurs with Chang et al. (2019), who state that sexual dysfunction is frequently seen in breast cancer women, and symptoms include decreased breast sensitivity, decreased sexual pleasure, dyspareunia, libido loss, and dryness and shrinkage of the vagina.
The current study's premise is that providing women with breast cancer with an "Educational Nursing Program" will improve their quality of sexual life, sense of self, and perception of their bodies. According to the study's findings, the tables and figures presented notable variations between the subjects' test scores before and after the program. This result validates the study's hypothesis.
To enhance the body image of breast cancer women, researchers used body image scale to compare bodily perception before and after implementation. There was a significant change in every aspect of the self-image subscale before and after the implementation of the educational nursing program. This outcome was consistent with the findings of Hamed et al. (2019), who discovered that the psychoeducational program considerably improved the post-mastectomy women’s body image issues by lowering the mean score of their concerns.
The findings of the current study are contradictory with Andreis, 2018 who discovered that there was no discernible impact on body image following the educational program for individuals with mastectomies. The study also revealed that although there were significant differences in body image among the subjects within the first year after the operation, these differences eventually disappeared.
The current study's findings showed a highly statistically significant difference in the study sample levels of self-esteem pre and post utilising the educational program. This result demonstrates that the training was successful in boosting participants' self-esteem after having a mastectomy. Similarly, Richard et al. (2019) reported that following group education sessions, women’s self-esteem increased due to the combination of textbooks, lectures, and printed educational resources.
These results also demonstrated that the percentage of study participants' who are reluctant to ask their husbands for sex and who feel ashamed to ask life advice reduced following the implementation of the nursing education program. This result is consistent with that of Faghani and Ghaffari (2016), who found that the program improved the quality of sexual life for breast cancer women. However, Stabile et al. (2017) found no correlation between the educational program and the physical symptoms related to sexual life experienced by women diagnosed with BC, including discomfort during sexual activity, dryness, vaginal adhesions, lack of sex desire, and absence of orgasm.
According to the study, women who have breast cancer often rely on inaccurate information about sexual health from others, are unaware of the level of sexual health after BC and learn from each other while conversing and chatting while they wait. This result is consistent with Yan et al. (2020) claim that erroneous sexual attitudes regarding cancer could be corrected through effective patient- doctor communication regarding sexuality.
Several of the participants withdrew from the study at the beginning of the implementation phase due to discomfort discussing the quality of their sexual lives. The researchers replaced the withdrawn participants with others to maintain the sample size. This limitation highlights the potential sensitivity
of the topic, which may have influenced participant retention. Further studies could consider incorporating strategies to address these concerns to minimise dropout rates and ensure a more complete understanding of the impact of breast cancer on sexual well-being.
Findings of the current study concluded that after an educational nursing program was implemented, women with breast cancer experienced a notable enhancement in sexual life quality, self-esteem, and body image. In addition, there was a strong statistically significant correlation between the quality of sexual health, self-esteem, and body image scores between the women with breast cancer being studied, so the current study's findings are consistent with the research hypothesis.
Future studies with long-term follow-up assessments to evaluate the sustained impact of educational nursing programs on quality of life, body image, and self-esteem among women with breast cancer will enhance the understanding. Studies should include comparison groups to evaluate the effectiveness of educational nursing programs compared to standard care., conduct large-scale research among breast cancer women to explore ways to enhance sexual lives, body image, and self- esteem and replicate the study with a substantial sample across different settings to generalise the results.
A health education program must be developed to train healthcare providers to help women with breast cancer feel better about bodies, self-esteem and quality of their sexual life, create a counseling intervention focused on coping strategies for those affected by breast cancer. future studies should consider a larger and more diverse participant pool. A larger sample would enhance the statistical power and generalizability of the findings, offering more reliable insights into the impact of educational programs on a broader population.
The authors declare that they have no competing interests.
The authors sincerely thank all the women with breast cancer who participated in this study. Your bravery and openness in sharing your experiences have been essential to the success of this research. We also extend our deep appreciation to the nursing educators and healthcare professionals whose contributions were pivotal in designing and implementing the educational nursing program.
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