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              ~Kumaraswamy~M,
              ~Robin~George}
\def\citetitle{Development and Validation of Breast cancer and Breast self-examination scale to assess the Knowledge and attitude towards Breast cancer and Breast self-examination}
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\def\RunningAuthor{Chandana B et al.}
\firstPage{406}
\articleType{Original Article}
\receivedDate{10 Aug 2023}
\acceptedDate{29 Aug 2023}
\revisedDate{28 Aug 2023}
\journalVolume{3}
\journalIssue{4}
\copyrightYear{2023}
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\def\journalTitle{Future Journal of Pharmaceuticals and Health Sciences}

\title{Development and Validation of Breast cancer and Breast self-examination scale to assess the Knowledge and attitude towards Breast cancer and Breast self-examination}
\author{Chandana~B\textsuperscript{*},  
            Thanushree~D~R,  
            Kumaraswamy~M, 
            Robin~George~\\[5pt]{Department of pharmacy practice,  Sri Adhichuchanagiri College of pharmacy,  Adhichuchanagiri University, B G Nagara, Mandya, India}}

\begin{abstract}
The second most prevalent type of cancer after lung cancer, breast cancer affects women more frequently than any other type.BSE is a screening method that women can use at home to find breast cancer early on. Whether female college students are sufficiently informed about breast cancer. They can aid in reducing the prevalence of breast cancer in their neighbourhood and assist in cancer prevention for themselves. As the nation's future mothers, they ought to be at least somewhat knowledgeable about breast cancer. The secondary objective was to perform its reliability and validity. Apart from referring to previous existing scales, were also considered while developing the scale. The scale was administered to a total of 1006 participants, from pharmacy, medical, nursing, and BSC \&MSC with ages ranging from 18-33 years. The participants did not report any difficulty in understanding the questions. The final scale consists of (21-items development and validation of breast cancer and breast self-examination scale) with a content validity index (CVI=1), Pearson's 'r' value (0.96), Cronbach's Alpha (0.923). Hence (21-items development and validation of breast cancer and breast self-examination scale) turned out to be a reliable and valid tool in assessing knowledge, attitude about breast cancer and breast self-examination among female college students. The (21-items development and validation of breast cancer and breast self-examination scale) is expected to aid in the clinical evaluation and research the field.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Breast cancer,\newline Content Validity Index,\newline reliability,\newline validation,\newline scale
\end{keywords}
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\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Chandana~B~\\ Phone:\ 9980755064~\\  Email:\ Chandanababu63@gmail.com
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\section{INTRODUCTION}
The second most prevalent type of cancer after lung cancer, breast cancer affects women more frequently than any other type \unskip~\cite{2050697:28837212}. Globally, the incidence of breast cancer increased by 3.1\% annually from 641000 cases in 1980 to 1643000 cases in 2010 \unskip~\cite{2050697:28837211}. The 15{\textendash}20 "lobes" on each breast make up the breast. The tissues of the breast are where breast cancer first develops. Breast cancer can come in two main forms. The majority of breast cancers are Ductal Carcinomas, which begin in the milk-transporting tubes (ducts) between the breast and the nipple. The breast's lobules, which produce milk, are where lobular carcinomas first appear \unskip~\cite{2050697:28837223}. We still struggle to comprehend the precise causes of breast cancer. But multiple studies have identified several predictors that can increase a person's risk for acquiring breast cancer. Risk factors included individual and familial history of breast cancer, late menopause ({\textgreater}55 years), premature menstruation (12 years), older age initial full-term pregnancy ({\textgreater}30 years), consumption of alcohol, ageing, do not breastfeeding a child, misuse of  contraceptives, smoking, high fat diet, being obese (postmenopausal), latest and prolonged use of hormonal replacement therapy, a lack of activity and high-dose chest x-rays \unskip~\cite{2050697:28837215}. The most typical warning signs of breast cancer are a lump in the breast or under the armpit, pulling in the breast, discomfort in the breast or nipple, wrinkling or dimpling of the breast skin, bleeding or release from the nipple, breakouts in the nipple or breast skin, redness of the breast skin, and an alteration in the breast's size as a result of swelling \unskip~\cite{2050697:28837224,2050697:28837216}. The most frequently recommended methods for detection are breast self-examination (BSE), medical breast examination, and mammography \unskip~\cite{2050697:28837218}. Women can use the BSE screening method at home to detect breast cancer early. Women can check their breast tissue for any physical or visible changes using this quick, easy, affordable, and simple technique. BSE improves the likelihood that women will receive treatment, which raises the percentage of women who survive \unskip~\cite{2050697:28837217}. BSE can be used to check for tumours, cysts, and other breast abnormalities.  BSE is something that all women should prioritise because breast cancer can be treated in its early stages if discovered early \unskip~\cite{2050697:28837222}. There are numerous misconceptions about breast cancer treatment. One widespread myth is that breast cancer can be cured by immediate total breast removal, followed by chemotherapy and radiation treatment. In fact, those with early-stage breast cancer who choose to have breast conserving surgery, in which only the cancerous portion of the breast is removed, have a higher rate of survival.  Furthermore, not every case of breast cancer necessitates surgery, chemotherapy, and radiation. The complexity of each individual's cancer cells is one of many variables that affect how a patient is treated.  Overtreatment{\textemdash}the practise of receiving more medical care than is required for a given type of cancer{\textemdash}has grown to be a serious problem \unskip~\cite{2050697:28837210}. The standard of breast cancer understanding among female university students. In along with assisting in cancer prevention, they can help shorten the prevalence of breast cancer in their neighborhood. They ought to have some basic knowledge of breast cancer since they will be the nation's future mothers. Our aim is to evaluate female college students' knowledge, attitudes on breast cancer and breast self-examination techniques. Commonly used existing scales till now were (SESSM-B), HBMS for BSE, HBM questionnaire for promoting breast self-examination and screening mammogram. 

Development and validation of self-efficacy scale for self-management of breast cancer (SESSM-B): (SESSM-B) was devised in the year 2012 which is of 13 items. This questionnaire was based on self-management of breast cancer \unskip~\cite{2050697:28837219}. HBMS for BSE: It was devised in the year 2020 which is of A total of 42 questions are used for assessing each of the six HBM dimensions: susceptibility (5 questions), seriousness (7 questions), benefits (6 questions), barriers (6 questions), health motivation (7 questions), and self-efficacy (11 questions). On a 5-point Likert scale, the response was given \unskip~\cite{2050697:28837220}. The HBM questionnaire, which has 67 items and a 5-point Likert scale, was developed in 2019 to encourage breast self-examination and screening mammography \unskip~\cite{2050697:28837213}.  

\textbf{Need for the study }

Proactively the second most prevalent cancer among women after lung cancer, breast cancer is an important medical issue. The standard of breast cancer understanding among female university students. In along with assisting in cancer prevention, they can help shorten the prevalence of breast cancer in their neighborhood. The existing scales for evaluating knowledge, attitude towards breast cancer, and breast self-examination were developed decades ago, but they still seem extensive. Our primary objective was to develop a novel 21- item, a brief assessing scale for knowledge, attitude on breast cancer and breast self{\textendash}examination to being simple and concise. The secondary objective was to perform its reliability and validity.
    
\section{METHODOLOGY}
\textbf{Questionnaire development overview}

Self {\textendash}An administered scale for assessing knowledge, attitude towards breast cancer and breast self{\textendash}examination was formed and validated in five steps. First, a comprehensive investigation of the literature was conducted before a panel of experts was invited for discussion. The draught instrument's face validity (an evaluation of a questionnaire's clarity, compressibility, and understanding of target groups) and content validity (an assessment of how well an instrument (like a test) covers every pertinent aspect of the construct it aims to measure) had been evaluated on a small sample of participants (27), and these tests were followed by a group discussion with the expert panel separately. Third, in the creation of a self-administered scale for evaluating knowledge, attitude towards breast cancer and breast self-examination. Consists of 21 items that were subjected to a pilot study with 200 participants in order to conduct an exploratory factor analysis (EFA) to determine reliability and factor structure. 21 items for a self-administered scale to assess knowledge, attitude, and breast self-examination were used in the fourth main study to test reliability and factor loading.

\textbf{Construction of Scale}

First, a thorough review of the literature was conducted using literature-based questionnaires created by Emaediong I. Akpanekpo \unskip~\cite{2050697:28837214}, Hadi MA et al. \unskip~\cite{2050697:28837221}, and FM Aldhafeeri \unskip~\cite{2050697:28837225}. A review of the literature led to the development of 35 likely items, which were then evaluated by a panel of five experts (three gynaecologists, one surgeon, and one pharmacy practise department) throughout five rounds of expert discussions. The experts only suggested a small number of changes to the scales. 28 items that had been shortlisted were examined for content validity. The degree to which assessment item elements are pertinent to and reflect the target construct is indicated by the term "content validity."The evaluation of each item's relevance and representativeness to the content domain is done by a panel of experts who then rate each item's content validity. Using the ratings provided for each item by five experts, the content validity index (I-CVI) and content validity ratio (CVR) are computed. An I-CVI of more than 0.87 and a CVR of less than 0.67 indicate that the content is valid. Which resulted in 26 items (Table~\ref{tw-85540ecd7442}). In discussions with experts, it was proposed that the development and validation of breast cancer and breast self-examination scale be formulated as 3 point scale, with correct answer one score 1(= YES), 0(= NO),0(=DON'T KNOW). Finally, a novel 21-items based self -diagnostic scale to assess knowledge, attitude towards breast cancer and breast self-examination among female students.

\textbf{Participants and Procedures}

Prior to the start of the research, this study acquired ethical clearance from the Institutional Ethical Committee of AH\&RC, Adhichuchanagiri Hospital and Research Centre (IECAH\&RCAC0112022). The current study had been carried out in three stages to establish concurrent validity and reliability: a pilot study, a main study, and a study of face and content validity. Cluster random sampling was used to choose 1 pharmacy, 1 nursing, 1 paramedical, 1 medical, 1 BSc \& MSc college and 1 medical college located on the Adhichuchanagiri campus. Students were further randomized from each college by stratified randomized sampling based on age (18-21 years, 22-25 years, 26-29 years, and 30-33 years). Prior to the study, we obtained the principals' approval from reputable colleges, went to each college to collect data, and then gave out questionnaires to students during a pre-test and education session while using a presentation, patient information leaflets about breast cancer, and breast self-examination. After a two-week post-education period, a questionnaire test was administered to evaluate participants' knowledge, attitudes towards breast cancer and breast self-examination methods. First, 27 individuals randomly chosen from 1 pharmacy college and 1 MBBS institution participated in a face validity and content validity study for 35 shortlisted items. After that, focus group discussions (FGDs) with experts and participants were held to assess the initial questionnaire's content and challenges that respondents had to overcome. The respondents favored the scale format and offered some comments regarding the specifics of the items and specific wordings. The recommended adjustments were made, the I-CVI and CVR scores were calculated, and the breast self-examination scale, which comprised 26 items at that point, was used in the development and validation of breast cancer. The 21-item scale for breast cancer and breast self-examination has been retested in a pilot study for CVI, internal coherence (Cronbach's alpha), and EFA, leading to factorial domains and model alterations. 200 participants who were randomly selected have been chosen for the study from 1 Pharmacy College, 1 MBBS College, and 1 nursing, BSC, and MSC institution. Finally, the main study was performed among 1007 subjects (1 Pharmacy college, 1 MBBS, 1 Nursing, 1 BSc \& MSc college at Adhichuchanagiri campus) with the objective to assess the CVI, reliability (Cronbach's alpha), and factor loadings of a 21-item scale constructed and verified for the assessment of knowledge, attitude, and breast self-examination among female college students.

\textbf{Statistical analysis}

Using SPSS 25.0, statistical calculations were performed. Using a panel of experts and CVI scores, the content validity of the scale was determined. To gauge the scale's reliability throughout tests, the Pearson correlation coefficient was used. Then, Pearson's correlation coefficient was determined for each item on the two instruments of both the pre- and post-tests to examine concurrent validity between the development and validation of the breast cancer and breast self-examination scales.
    
\section{RESULTS}
\textbf{Participants demographics}

The characteristics of the respondents are shown in Table~\ref{tw-158210bf3f4e} for all three study stages. Participants were chosen at random for the face and content validity study, the pilot study, and the main study; there were 27 participants for the face and content validity study, 200 for the pilot study, and 1007 for the main study.


\begin{table*}[!htbp]
\caption{\boldmath {Socio-demographic characteristics of research subjects} }
\label{tw-158210bf3f4e}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.18150000000000002\linewidth-2\tabcolsep}p{\dimexpr.25039999999999996\linewidth-2\tabcolsep}p{\dimexpr.16810000000000002\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{2}{p{\dimexpr(.4319\linewidth-2\tabcolsep)}}{Variable} & Face validation n (\%) & Pilot study n (\%) & Main study n (\%)\\
\tblmidrule 
AGE &
  18-21 &
  27 (100\%) &
  97(48.5\%) &
  799(79.9\%)\\
\multicolumn{1}{p{\dimexpr(.18150000000000002\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{}} &
  22-25 &
  0(0\%) &
  103(51.5\%) &
  201(20.1\%)\\
 &
  26-29 &
  0(0\%) &
  0(0\%) &
  4(0.4\%)\\
 &
  30-33 &
  0(0\%) &
  0(0\%) &
  0(0\%)\\
\multicolumn{1}{p{\dimexpr(.18150000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{STUDY COURSE}} &
  Pharmacy &
  27(100\%) &
  50(25\%) &
  357(35.4\%)\\
 &
  Medical &
  0(0\%) &
  50(25\%) &
  367(36.4\%)\\
 &
  Nursing &
  0(0\%) &
  50(25\%) &
  207(20.5\%)\\
 &
  BSC \& MSC &
  0(0\%) &
  50(25\%) &
  76(7.5\%)\\
\multicolumn{1}{p{\dimexpr(.18150000000000002\linewidth-2\tabcolsep)}}{\multirow{6}{\linewidth}{ACADEMIC YEAR}} &
  1ST YEAR &
  27(100\%) &
  58(29\%) &
  389(38.5\%)\\
 &
  2ND YEAR &
  0(0\%) &
  47(23.5\%) &
  326(32.3\%)\\
 &
  3RD YEAR &
  0(0\%) &
  35(17.5\%) &
  220(21.8\%)\\
 &
  4TH YEAR &
  0(0\%) &
  59(29.5\%) &
  32(3.1\%)\\
 &
  5TH YEAR  &
  0(0\%) &
  0(0\%) &
  25(2.4\%)\\
 &
  6TH YEAR &
  0(0\%) &
  0(0\%) &
  15(1.4\%)\\
\multicolumn{1}{p{\dimexpr(.18150000000000002\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{MARITAL STATUS}} &
    SINGLE &
  27(100\%) &
  200(100\%) &
  986(97.8\%)\\
 &
  MARRIED &
  0(0\%) &
  0(0\%) &
  20(1.9\%)\\
FAMILY HISTORY OF BREAST CANCER &
  YES &
  0(0\%) &
  4(2\%) &
  76(7.5\%)\\
 &
  NO &
  27(100\%) &
  196(98\%) &
  930(92.4\%)\\
\multicolumn{1}{p{\dimexpr(.18150000000000002\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{INFORMATIONAL \mbox{}\protect\newline SOURCE}} &
  HEALTH &
  8(29\%) &
  12(6\%) &
  161(15.9\%)\\
 &
  BOOK &
  2(7\%) &
  17(8.5\%) &
  225(22.3\%\\
 &
  LECTURE &
  0(0\%) &
  35(17.5\%) &
  227(22.5\%)\\
 &
  SOCIAL MEDIA &
  17(62\%) &
  136(68\%) \mbox{}\protect\newline  &
  391(38.8\%) \mbox{}\protect\newline \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Content Validity Index of a Scale} }
\label{tw-a1d6ac04ac5b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1279\linewidth-2\tabcolsep}p{\dimexpr.0814\linewidth-2\tabcolsep}p{\dimexpr.0907\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}p{\dimexpr.1186\linewidth-2\tabcolsep}p{\dimexpr.0814\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{6}{p{\dimexpr(.60\linewidth-2\tabcolsep)}}{\cAlignHack Content Validation} & \multicolumn{4}{p{\dimexpr(.40\linewidth-2\tabcolsep)}}{}\\
\rowcolor{kwdboxcolor}Questions & Expert1 & Expert2 & Expert3 & Experts4 & Experts 5 & Average & Experts in Agreement & I-CVI & UA\\
\tblmidrule 
1 to 21  &
  1 &
  1 &
  1 &
  1 &
  1 &
  1 &
  5 &
  1 &
  1\\
Population Relevance &
  1 &
  1 &
  1 &
  1 &
  1 &
  1 &
  S-CVI/Ave &
  \multicolumn{2}{p{\dimexpr(.1814\linewidth-2\tabcolsep)}}{1}\\
\multicolumn{6}{p{\dimexpr(.60\linewidth-2\tabcolsep)}}{Average proportion of items judged as relevance \mbox{}\protect\newline } &
  1 &
  S-CVI/UA &
  \multicolumn{2}{p{\dimexpr(.1814\linewidth-2\tabcolsep)}}{1}\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.2334\linewidth-2\tabcolsep}p{\dimexpr.25009999999999998\linewidth-2\tabcolsep}p{\dimexpr.25980000000000004\linewidth-2\tabcolsep}p{\dimexpr.2567\linewidth-2\tabcolsep}}
\caption{\boldmath {Reliability and exploratory factor analysis offinal (21-items development and validation of breast cancer and breast self-examination scale)} }
\label{tw-0d4c00f13680}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
\tbltoprule \rowcolor{kwdboxcolor}Factors & Item No. & Corrected Items-Total Correlation & Squared Multiple Correlation\\
\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}Factors & Item No. & Corrected Items-Total Correlation & Squared Multiple Correlation\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.2334\linewidth-2\tabcolsep)}}{\multirow{8}{\linewidth}{}} &
  1. Do you think breast cancer is an inherited condition? \mbox{}\protect\newline  &
  0.876 &
  0.816\\
 &
  2. Do you think early detection of breast cancer improve survival rates? &
  0.735 &
  0.648\\
 &
  3. Do you think breast cancer is curable? &
  0.613 &
  0.576\\
 &
  4. Do you think breast cancer may be fatal? &
  0.711 &
  0.584\\
 &
  5. Do you think breast cancer patients should be isolated? \mbox{}\protect\newline  &
  0.652 &
  0.597\\
 &
  6. Do you think breast cancer patients should be permitted to live unrestrictedly in the neighborhood? \mbox{}\protect\newline  &
  0.612 &
  0.698\\
 &
  7. Do you think the public should offer assistance and home care to those with breast cancer? &
  0.803 &
  0.672\\
 &
  8. Do you think breastfeeding should be prohibited in cases of breast cancer? &
  0.849 &
  0.722\\
\multicolumn{1}{p{\dimexpr(.2334\linewidth-2\tabcolsep)}}{\multirow{13}{\linewidth}{F1(Cronbach's Alpha=0.87) \mbox{}\protect\newline F2(Cronbach's Alpha=0.85) \mbox{}\protect\newline }} &
  9. Do you think the risk of breast cancer increases with age? &
  0.597 &
  0.561\\
 &
  10. Do you think breast cancer risk is lesser in breastfeeding female? \mbox{}\protect\newline  &
  0.695 &
  0.570\\
 &
  11. Do you think prolonged use of HRT raise the risk of breast cancer? \mbox{}\protect\newline  &
  0.644 &
  0.529\\
 &
  12. Do you think breast cancer risk higher at late menopause and early menarche? \mbox{}\protect\newline  &
  0.570 &
  0.510\\
 &
  13. Do you think breast cancer symptoms include a painless breast lump? &
  0.781 &
  0.755\\
 &
  14. Do you think breast cancer symptoms include a lump under the armpit? \mbox{}\protect\newline  &
  0.642 &
  0.595\\
 &
  15. Do you think breast cancer symptoms include a nipple discharge? \mbox{}\protect\newline  &
  0.612 &
  0.698\\
 &
  16. Do you think is breast cancer symptomized by altered breast shape? &
  0.876 &
  0.816\\
 &
  17. Do you know what breast self-examination is? \mbox{}\protect\newline  &
  0.711 &
  0.584\\
 &
  18. Do you think every month BSE testing is advised? &
  0.652 &
  0.597\\
 &
  19. Do you think BSE should be performed on 7th day after menstruation begins? &
  0.849 &
  0.722\\
 &
  20. Do you think, BSE is done in front of the mirror? \mbox{}\protect\newline  &
  0.735 &
  0.648\\
 &
  21. Do you think while performing BSE, the pad of the fingers should be used? &
  0.894 &
  0.725\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 

\begin{table*}[!htbp]
\caption{\boldmath {21-items development and validation of breast cancer and breast self-examination scale} }
\label{tw-984260318e92}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.09650000000000002\linewidth-2\tabcolsep}p{\dimexpr.6166\linewidth-2\tabcolsep}p{\dimexpr.09639999999999999\linewidth-2\tabcolsep}p{\dimexpr.0913\linewidth-2\tabcolsep}p{\dimexpr.0992\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Item no & QUESTIONS & YES & NO & DON'T KNOW\\
\tblmidrule 
1 &
  Do you think breast cancer is an inherited condition? &
  1 &
  0 &
  0\\
2 &
  Do you think early detection of breast cancer improve survival rates? &
  1 &
  0 &
  0\\
3 &
  Do you think breast cancer is curable? &
  1 &
  0 &
  0\\
4 &
  Do you think breast cancer may be fatal? &
  1 &
  0 &
  0\\
5 &
  Do you think breast cancer patients should be isolated? &
  0 &
  1 &
  0\\
6 &
  Do you think breast cancer patients should be permitted to live unrestrictedly in the neighborhood? &
  1 &
  0 &
  0\\
7 &
  Do you think the public should offer assistance and home care to those with breast cancer? &
  1 &
  0 &
  0\\
8. &
  Do you think breastfeeding should be prohibited in cases of breast cancer? &
  1 &
  0 &
  0\\
9. &
  Do you think the risk of breast cancer increases with age? &
  1 &
  0 &
  0\\
10. &
  Do you think breast cancer risk is lesser in breastfeeding female? &
  1 &
  0 &
  0\\
11. &
    Do you think prolonged use of HRT raise the risk of breast cancer? &
  1 &
  0 &
  0\\
12. &
  Do you think breast cancer risk higher at late menopause and early menarche? &
  1 &
  0 &
  0\\
13. &
  Do you think breast cancer symptoms include a painless breast lump? &
  1 &
  0 &
  0\\
14. &
    Do you think breast cancer symptoms include a lump under the armpit? &
  1 &
  0 &
  0\\
15. &
  Do you think breast cancer symptoms include a nipple discharge? &
  1 &
  0 &
  0\\
16 &
  Do you think is breast cancer symptomized by altered breast shape? &
  1 &
  0 &
  0\\
17. &
  Do you know what breast self-examination is? &
  1 &
  0 &
  0\\
18. &
  Do you think every month BSE testing is advised? &
  1 &
  0 &
  0\\
19. &
  Do you think BSE should be performed on 7th day after menstruation begins? &
  1 &
  0 &
  0\\
20 &
  Do you think, BSE is done in front of the mirror? &
  1 &
  0 &
  0\\
21 &
  Do you think while performing BSE, the pad of the fingers should be used? &
  1 &
  0 &
  0\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Methods used in 3 phases: face and content validity, pilot and main studies} }
\label{tw-84524883cb33}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.27349999999999994\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}p{\dimexpr.3865\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Face and Content Validity (35 Items) & Pilot study (26 Items) & Main study(21 Items)\\
\tblmidrule 
\ensuremath{\cdot} S-CVI{\tt\string\ \unskip}Ave=0.792 \mbox{}\protect\newline \ensuremath{\cdot} S-CVI{\tt\string\ \unskip}UA=0.615 &
  \ensuremath{\cdot} S-CVI{\tt\string\ \unskip}Ave=0.895 \mbox{}\protect\newline \ensuremath{\cdot} S-CVI{\tt\string\ \unskip}UA=0.835 &
  \ensuremath{\cdot} S-CVI{\tt\string\ \unskip}Ave=1 \mbox{}\protect\newline \ensuremath{\cdot} S-CVI{\tt\string\ \unskip}UA=1\\
 &
  Internal consistency: \mbox{}\protect\newline Cronbach's Alpha(\ensuremath{\alpha } = 0.89) \mbox{}\protect\newline  &
  Internal consistency: \mbox{}\protect\newline Cronbach's Alpha(\ensuremath{\alpha } = 0.923) \mbox{}\protect\newline \\
 &
  EFA: \mbox{}\protect\newline 3 factors \mbox{}\protect\newline \ensuremath{\cdot} Kaiser-Meier {\textendash}Olkin normalization(0.612) &
  EFA: \mbox{}\protect\newline 2 factors \mbox{}\protect\newline \ensuremath{\cdot} Kaiser-Meier {\textendash}Olkin normalization(0.923) \mbox{}\protect\newline \ensuremath{\cdot} Factor reliability (\ensuremath{\alpha } = 0.87) \mbox{}\protect\newline \ensuremath{\cdot} Factor reliability (\ensuremath{\alpha } = 0.85) \mbox{}\protect\newline \\
 &
   &
  Pearson's correlation coefficient : (r=0.96)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/e96f2a46-07ce-4ffb-9ccb-4ac603d68bc0-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/e96f2a46-07ce-4ffb-9ccb-4ac603d68bc0-upicture1.png}{\includegraphics{images/e96f2a46-07ce-4ffb-9ccb-4ac603d68bc0-upicture1.png}}{\includegraphics{e96f2a46-07ce-4ffb-9ccb-4ac603d68bc0-upicture1.png}}
\makeatother 
\caption{\boldmath {Pearson's Correlation of Test{\textendash}retest reliability}}
\label{f-9c9f1ae85e51}
\end{figure}
\egroup
A small group of individuals were selected for the face and content validity study; they were all from the pharmacy (100\%), had been employed for 1 year (100\%), were between the ages of 18 and 21, were single (100\%), and had no known relatives who had breast cancer. They had also all heard of breast cancer and had used social media (17\%), books (2\%) and 8 (29\%) as informational sources about the disease.

200 people participated in the pilot project, of whom 50 (or 25\%) were from the pharmacy, 50 (25\%), from the medical field, 50 (25\%), from the nursing field, and 50 (25\%), from the BSC and MSC fields. 97 (48.5\%) of those in the (18{\textendash}21) and 103 (51\%) age groups. Academic year from 1st year 58 (29\%) to 4th year 59 (29.5\%), 2nd year 47 (23.5\%), 3rd year 35 (17.5\%), and so on. All of them were unmarried, 196 (98\%) had no prior family history, and 4 (2\%). The topic of breast cancer was discussed with all participants. The participants' informational sources were health 12 (6\%), books 17, lectures 35, and social media 136 (68\%).

Main study: In this phase of the study, which had the largest participant pool, there were students in the 18{\textendash}21, 22{\textendash}25, 26{\textendash}29, and 30-33 age groups who totalled 799 (79.9\%), 201 (20.1\%), and 4 (0.4\%). 

Participants were distributed according to study course as follows: medical (367, 36.4\%), pharmacy (357, 35.41\%), nursing (207, 20.53\%), and BSC \& MSC (76, 7.53\%). 

According to academic year, the participants were distributed as follows: first year, 389 (38.59\%), second year, 326 (32.34\%), third year, 220 (21.82\%), fourth year, 326 (3.14\%), fifth year, 25, and sixth year, 15, respectively. 

In terms of participant distribution by marital status, there are 986 participants who are single (97.81\%) and 20 individuals (1.98\%) who are married. 76 people (7.5\%) of the 930 people studied (92.44\%) had a breast cancer family history. 

Breast cancer is discussed with all attendees. Social media was utilized as an informational source by 391 (31.82\%), lectures were used by 227 (22.54\%), books were used by 225 (22.34\%), and health was used as an informational source by 161 (15.98\%), respectively.

\textbf{Content validity index of development and validation of breast cancer and breast self-examination scale}

Five experts used content validity analysis (CVI) to condense the initial development and validation of the breast cancer and breast self-examination measure. In the initial CVI analysis, 26 of the 35 items were determined to match the CVI criteria, while 9 items with I-CVI 0.6 and CVR 0.51 were eliminated. S-CVIAve=0.895 and S-CVIUA=0.835, which were valid for a scale, were shown in the second round CVI analysis of 26 items. The 21-item, final version of the breast cancer and breast self-examination scale-21 produced a very high content validity index with S-CVIAve=1 and S-CVIUA=1.

\textbf{Reliability}

The 26-item survey had a pilot study, and a reliability test was conducted on it. The initial version of the 26-item scale for assessing breast self-examination and breast cancer had an internal consistency score of 0.89, with 5 items scoring poorly and being eliminated. Reevaluation of reliability for the (21-item) formulation and validation of breast cancer and breast self-examination scale revealed a Cronbach's alpha of 0.923 and an appropriate inter-item correlation, ranging from 0.45 to 0.754. The final evaluation of the main study's results led to the development and validation of a 21-item scale for assessing breast cancer and self-examination, which had a very high level of internal coherence (Cronbach's alpha of 0.923). Factor 1 showed a higher reliability within the factors (=0.87), while Factor 2 had a lower reliability (=0.85). Table~\ref{tw-0d4c00f13680}  lists the complete outcomes for each factor and item. 27 participants' Test-Rest dependability showed a very significant Pearson's correlation with an 'r' value of 0.96 during a 20-day period (Figure~\ref{f-9c9f1ae85e51}).

\textbf{Exploratory factor analysis}

The 26-item breast cancer and self-examination measure was used to the pilot study population and validated with EFA using principal axis factoring and constricting factors orthogonal (varimax) rotation. It generated a kaiser-Meier-Olkin normalisation of 0.695, and there were 3 factors with 5 items inside factor 3 that had a factor loading of less than 0.4 and were eliminated. EFA on the 21-item scale for developing and validating breast cancer and self-examination led to a kaiser-meier-olkin normalisation of 0.923, Bartlett's test of sphericityP{\textless}0.001, and the identification of two factors that explained 70.034\% of the total variance. Tables~\ref{tw-984260318e92} and~\ref{tw-84524883cb33}  displays the complete EFA results.

\textbf{Concurrent validity}

An inter-item Pearson correlation test was performed between the development and validation of breast cancer and breast self-examination scale's 21 items and earlier literature scales to ascertain the scale's concurrent validity. The findings point to a statistically significant association between all of the items (P{\textless}0.001).

\textbf{The total score ranging from:}

\textbf{Knowledge of breast cancer 12 items:}


  
  \begin{enumerate}
  \item \relax 9 to 12 indicates high knowledge.
  \item \relax 5 to 8 indicates moderate knowledge.
  \item \relax 4 below indicates poor knowledge.
  \end{enumerate}
  \textbf{Attitude of breast cancer 4 items:}


  
  \begin{enumerate}
  \item \relax 3 to 4 indicates positive attitude.
  \item \relax \ensuremath{\leq }2 indicates negative attitude.
  \end{enumerate}
  \textbf{Knowledge of breast self-examination 5 items:}
  
  \begin{enumerate}
  \item \relax 4 to 5 indicates high knowledge.
  \item \relax 2 to 3 indicates moderate knowledge.
  \item \relax {\textless}2 indicates poor knowledge.
  \end{enumerate}
  
    
\section{CONCLUSION}
The 21-item breast cancer and self-examination development and validation scale is a trustworthy and valid tool for assessing knowledge and attitude towards breast cancer and self-examination. It is a self-administered instrument that is succinct and simple to use. The 21-item breast cancer and breast self-examination scale, which was developed and validated, appears to hold promise for helping with the field's major clinical evaluations and research.

\textbf{Conflict of Interest}

The authors declare no conflict of Interest.

\textbf{Funding}

There was no dedicated grant for the evaluation from any public, commercial, or non- profit organization.
    

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