Educational interventions on breast cancer in men and women: a necessity in primary healthcare

Breast cancer (BC) is one of the most common diseases in the global population. It most commonly presents in women; however, there has been an increase in the number of men diagnosed with the disease, although at a lower rate. Its specific characteristics and associated risk factors mean that preventative measures are considered to be one of the most important methods of avoiding BC. Therefore, education is a fundamental part of this process. The objective of this study is to report on the educational interventions on BC carried out in healthcare between 2016 and 2021. To this end, an integrative review was carried out using the following databases: PubMed (NCBI), Science Direct, Scopus, SciELO and Google Scholar, using the keywords ‘breast cancer’, ‘intervention education’, ‘prevention’ and the Boolean operator ‘AND’. Quantitative, full-text articles in English, Spanish or Portuguese were included. Finally, 19 articles were selected for analysis and it was found that, with regard to educational interventions on BC carried out in healthcare, one article included men and women and the remaining 18 included only women, with interventions carried out in sessions, workshops, in stages and using dynamic techniques. Therefore, there is a pressing need for educational interventions on BC for men and women at all stages of life; however, priority should be given to the young population in order to allow for early prevention. These interventions do not generate costs for the health sector, but they have a positive effect by increasing knowledge and promoting self-care.


Introduction
Breast cancer (BC) is a malignant disease where the rapid, abnormal and uncontrolled spread of cells in the different tissue types found in the mammary gland, such as epithelial cells of the mammary ducts or lobules, form a tumour that invades neighbouring tissues and metastasises to other organs in the body [1].
Another modifiable risk factor is the tendency not to undertake self-examination, as indicated in a study conducted in Lima, Peru, which reports that 62.5% of women do not know the frequency with which self-examination should be undertaken and 78.8% is not aware of its usefulness for early detection of cancer [22].
Breast self-examination should be performed by all women from the age of 20, between the 5th and 7th day, after the menstrual cycle, since this is when the breasts are softer. Women who no longer have their period will have to do it on a specific day of each month, this is to create a habit and try to improve the detection technique [23].
The risk factors found suggest that it would be beneficial to develop actions that promote HL [24]. Thus, it should be oriented at all stages of a person's life, and in particular it should be started in early childhood to encourage them to take responsibility for self-care of health, to reduce risk factors where possible and promote HL. In addition, promoting health in order to detect BC should include self-examination, clinical examination and mammography.
It is based on the assumption that the main ways to foster understanding about the prevention and characteristics of BC are through educational measures, through teaching in a friendly way to this community and at a low cost; which can have a positive impact on the early identification of cancer.
Studies associated with the effectiveness of measures carried out in this area show that educational interventions for the prevention and early detection of BC in women of childbearing age are effective, and that more than 60% of women gained sufficient knowledge about the prevention and early detection of BC [25].
On the other hand, in a study carried out in Mexico City that had the objective of assessing the impact of the syllabus on modifying behaviour and attitudes related to BC in teenagers, the results showed that the programme was successful, since the sessions included in the programme were adequate for improving the adolescents' level of knowledge about BC [26].
Educational interventions have been recommended as an effective public health approach in the comprehensive control of BC, especially among young people.
At the same time, the importance of preventive BC health education interventions, in all stages of life, is reiterated, in order to develop health-promoting behaviours that allow the detection and timely control of risks in the development of BC. Its effectiveness has been demonstrated, but the need to have the knowledge, skills and competencies necessary to be able to transmit relevant and updated education on the subject is highlighted [27].
That is why a review of the bibliography referring to health interventions in BC in men and women at any stage of their lives has been undertaken, in order to show the work done in this regard, highlighting its need and importance for society as a whole. This enhances the possibility of adopting, adapting and improving it, in order to develop a primary prevention programme in effective health associated with this pathology.

Approach
For the development of the study, a search of scientific documents was carried out in databases PubMed (NCBI ), SciELO, Scopus and the Google Scholar search engine, using the descriptors 'breast cancer', 'intervention education', 'prevention', 'primary' and the Boolean operators 'AND'.
The articles included quantitative and qualitative studies, full texts, written in English, Spanish or Portuguese, published from 2016 to 2021.
For the inclusion criteria, to be considered articles needed to be full-text, published in the aforementioned databases and in the search engine, products of primary research carried out in English, Spanish or Portuguese where the concept of educational interventions in BC is addressed, focused in primary prevention applied to men, women or both in all stages of life, with the publication date 2016-2021 and based on quantitative, qualitative or mixed-focus studies.
During the period from 2019 to 2020, an exhaustive search was made in the scientific literature for articles describing educational interventions in BC, through which 137 articles were found; with 19 articles remaining to be analysed ( Figure 1).

Results
In the present literature review, predominantly articles in English and Spanish were used, finding the following; eleven in PubMed, five in Sci-ELO, zero in Scopus and three in the Google Scholar search engine, obtaining a total of 19 selected for the development of this bibliographic review.
Of the 19 articles, all of them on educational interventions of BC, one included men and women and the remaining 18 included women only. Of these articles found, the types of study in the order of predominance were: those of an experimental cut from a quantitative methodology. Of these, six of the selected papers are classified as quasi-experimental; one responds to an experimental design; two claim to be preexperimental studies; two are trials. In addition, a pilot test, a descriptive and a prospective study were carried out. Only three of them were classified as mixed studies, and in two this fact is not mentioned.
Amongst the main topics addressed, we find a predominance of work aimed at promoting, in some way, knowledge about BC, especially linked to self-examination and the prevention of risk factors. Other studies, in order of appearance, respond to awareness/education work. To a lesser extent, there are more specific approaches linked to beliefs, attitudes, behaviours. All studies, however, are aimed at prevention, and it is important to note that in one of them they use technologies as tools to mediate the process of learning.
The countries most represented in these studies are: Colombia, in four; Mexico and Cuba in two studies each. Next, countries that appear in one study such as Peru, Saudi Arabia, Malaysia, Iran, India, Spain Brazil, Ethiopia and England, and two studies that do not contextualise their results. The largest scientific production/publication is associated with the years 2019-2020, with 10 of the publications concentrated in that period.
We observe that 13 of the studies consider interventions in the population of adolescents and young people, whilst 2 of them include also those over 20 years old (up to 60); 5 of them focus only on adults and 1 does not specify the data.
On the other hand, it is observed that, in the studies presented, there is a tendency to use educational strategies where information/discussion/practical exemplification is weighted, rather than active participation in the preventive educational process.
The summary of the particularities of the studies found on educational interventions in BC is presented in Table 1.

Discussion
Within the studies found, health education is addressed in a general sense, being considered as a dynamic and continuous process that includes self-care behaviours, compliance with healthcare requirements, recommendations, satisfaction in caring for health and adjustments in the person's quality of life [28].
Prevention activities include educational communication with the public to create awareness of risk factors and to promote HL which can contribute to reducing BC morbidity, as well as promoting demand for early detection in order to improve opportunities for diagnosis and treatment [29,30]. Furthermore, consideration is given to the need to establish BC detection strategies and define methods to improve prevention based on educational intervention [31], as well as preventative methods for modifiable risk factors.
One of the modifiable risk factors most often cited in this bibliographical review is regular breast examination. The tendency cited is towards nonexistent or inadequate self-examination. It is noted that women are unaware of how often self-examination should be done or of its usefulness in early detection of cancer [32,33]. It is important to emphasise the need for breast self-examination within a community and to make that need visible, as a means of promoting women's health and as a primary method of preventing BC. This practice needs to be one of the priorities within primary healthcare [34,35].
The strategies which have been provided at international and national levels in terms of prevention and promotion of health include: breast examination, mammography and early detection [36].
In this context, it was found that interventions addressing awareness, attitudes and practices relating to breast self-examination in adolescent women provide positive results [34], other studies in young people state that breast self-examination should be carried out from the age of 20 onwards. However, a percentage of the population surveyed is unaware of this and there is considerable ignorance about the age at which breast examination should start [32]. Other studies in young people mention that those who managed to acquire a level of awareness of risk factors and BC did not put this into practice in their daily life [28,[37][38][39].
With respect to people's knowledge of and attitudes towards BC, they indicate that these vary depending on age and marital status, with a pronounced lack of awareness of preventive measures and risk factors for BC among young and single people [5,40].
Another noteworthy element in relation to breast self-examination is failure to take the menstrual cycle into account, as a factor for consideration in good practice, which indicates a persistent failing in this aspect, showing the need to educate all age groups [41].
It was found that in interventions in the 30-65 years age range, there is insufficient knowledge about BC. However, after the educational intervention, there was generally a very good level and following the intervention no women were found to have a poor level of knowledge [42,43].
Mention was made of the need to implement health promotion and education strategies to tackle non-transmissible diseases and other health conditions. Particular emphasis was placed on working to reduce premature mortality due to BC. In this respect, it is essential to address BC from an epidemiological-preventive and social perspective, instead of merely placing it within a curative care paradigm [44].
Several studies have been carried out in which education and health are structured as connecting axes in preventing the appearance of BC, including basic information on cancer facts and figures, BC epidemiology, risk factors for developing cancer, signs and symptoms, etc., [28,45].
After analysing the data, it can be said that the level of awareness in individuals who participated in the studies contained in the research shown increased significantly [43] as a result of the various educational interventions on BC, particularly in aspects concerning new information and early detection methods. This indicates that the educational interventions are effective, managing to significantly increase the level of awareness in all their variants, leading to future quality of life through timely detection, linked with prevention and control of the disease and with improvements in life styles [33,37,[46][47][48][49][50][51][52][53][54][55][56][57][58][59][60].
These results corroborate the need to develop policies that guide the development of information, education and counselling programmes in order to strengthen awareness of risk factors, and the signs and symptoms that require immediate health care, in connection with BC [36,38].
It is therefore necessary to design new teaching methods based on these educational interventions in order to increase the efficiency of the teaching/learning process in health education, and its relationship with BC, since the government has not so far managed to make an impact in early detection of this condition [34,61,62].
In this light, educational initiatives have been recommended as effective public measures for the integrated control of BC, particularly among young people [28,33,37].
It should be stressed that lack of health education is a predisposing factor that prevents women and men of all ages from obtaining precise information about what they need to do to prevent BC, and to detect it at an early stage. Self-examination of the breasts is considered one of the core aspects of such education, as it enables timely detection of changes such as benign nodules, cysts, etc.
In the context of these searches, there is evidence about educational interventions to prevent BC in the under 20s, so emphasis is placed on the need to ensure successful intervention from an early age [28,47].
On the other hand, it can be seen that the male population barely participates in this learning process, demonstrating the urgent need to develop educational interventions that include not only women, but also men, since according to these figures 98% of cases in males are diagnosed at an advanced stage of the disease, worsening their prognosis compared to women [63]. For example, in the present study, only one research project was found that covered both sexes.
It is therefore necessary for educational programmes to be designed and implemented with an emphasis on a change in attitudes towards health promotion [42].
It is recommended that providers of information on BC make use of educational interventions to reduce mortalities and promote women's health [64]. It will be necessary to expand the intervention to more people and other health areas in order to more precisely demonstrate its reliability. It would also be advisable to make a technical assessment of the viability of interventions that have been designed, and measure their impact on early diagnosis of this type of cancer [28].
Certain characteristics have been identified which increase the effectiveness of educational interventions. These findings points to the development of programmes designed with integrated interventions. These should include aspects linked to quality of life, social and family support. The may be periodic or include follow-up over time, mix teaching approaches, make use of those that involve greater participation by attendees. They will need to be assessed using experimental methods, validated and reliable instruments that take into account process indicators, and quality of care results from attendees [28,65].

Conclusions
BC education interventions are effective, low-cost strategies, which can encourage their implementation in health policies. Nevertheless, they should be addressed to men and women, at all stages of life, encouraging self-care through prevention and health promotion. They should look at dietary factors, physical activity, Body Mass Index, alcohol consumption, hormonal factors, breast self-examination, thus helping to develop HL. Although incidence is very low in males compared to females, the diagnosis has a higher mortality rate due to late detection. All of this calls for multidisciplinary health interventions, not forgetting that in order to achieve the desired impact, there needs to be long-term follow-up, to verify whether the aims of the intervention are being met.

Conflicts of interest and funding
Funded by the University of Guanajuato.