Effect of Mobile Based Educational Program through WhatsApp on Self-Efficacy and Psychological Distress among Female Geriatric Patients with breast cancer Undergoing Chemotherapy.

Background: Breast cancer diagnosis and its treatment act as a life-threatening negative stressor seriously affecting the physical and psychological wellbeing of the female geriatric patients. Although there are many evidences that support the value of patient education in the management of breast cancer and consecutive treatment side effects, few studies determine the effect of applying mobile based education on self-efficacy and psychological distress among female geriatric patients with breast cancer who undergo chemotherapy. Aim of the study : To determine the effect of mobile based educational program through WhatsApp on self-efficacy and psychological distress among female geriatric patients with breast cancer undergoing chemotherapy. Setting: The study was conducted in the chemotherapy outpatient clinics of Damanhour Oncology Institute in El-Behaira Governorate, Egypt . Subjects: A convenience sample of sixty female geriatric patients with breast cancer was randomly divided into two equal groups. Design: The study followed a quasi-experimental research design (study and control groups). Tools : Four tools were used for data collection:1) Socio-demographic and Clinical Data Structured Interview Schedule,2) Cancer Treatment Survey (CaTS), 3) The Side effects-Management Self-Efficacy Scale-Breast Cancer (SMSES-BC) Related to Chemotherapy Questionnaire, and 4) National Comprehensive Cancer Network Distress Thermometer (NCCN-DT) Results : After the interventions, the mean scores of side effect management self-efficacy were increased from (27.07 ± 34.89) to (172.47 ± 64.05) with a statistically significant difference between pre and post interventions in the study group (P= 0.000). As well, psychological distress mean scores were reduced from (6.600 ± 2.343) to (1.370 ± 1.752) with a statistically significant difference between pre and post interventions in the study group (P= 0.000).A statistically significant differences were found between the study and control groups post interventions regarding side effect management self-efficacy and psychological distress (P=0.000). Conclusion : Implementing the mobile based educational program through WhatsApp significantly improves self-efficacy and reduces psychological distress among female geriatric patients with breast cancer undergoing chemotherapy. Recommendations : The oncology nurses should implement mobile based educational sessions for female geriatric patients with breast cancer undergoing chemotherapy to improve their self-efficacy in managing chemotherapy side effects and enhance their psychological status.

about 50% of all new breast cancer diagnosis occur in women aged 65 years and more. In 2040, the number of breast cancer cases is estimated to rise to 26 million with 53% of them expected to need chemotherapy. In the USA, each year there is more than 200,000 patients are diagnosed with breast cancer and 73% of them are older women (American Cancer Society, 2022). In Egypt, the National Cancer Institute reported that the incidence of breast cancer is about 35.5 cases per 100,000 women each year and most of them are over the age of 50 years (El-Moselhy et al., 2017).
Breast cancer diagnosis and treatment acts as a life-threatening negative stressor seriously affecting the physical and psychological wellbeing of the female geriatric patients (Li et al., 2018).
Chemotherapy is frequently prescribed for female geriatric patients with breast cancer to eradicate cancer cells. However, its benefits come with many side effects including physiological effects such as fatigue, insomnia, pain, infection, bruising, and gastrointestinal disturbances as well as psychological effects including fear, worry, anxiety, depression, and sadness. (De Martel et al., 2016). Female older adults are at greater risk for increased toxicity and poor tolerance to chemotherapy because of alterations in drug pharmacodynamics caused by increased susceptibility of organs with age. Chemotherapy side effects can be overwhelming and very distressing for geriatric patients especially when chemotherapy is given for the first time in life.
These side effects can influence the patients' selfcare abilities and treatment compliance resulting in poor physiological and psychological outcomes (Viveiros, 2020). Therefore, nursing interventions for female geriatric patients receiving chemotherapy should focus on improving their self-efficacy in managing chemotherapy side effects and reducing their psychological distress (Wagland et al., 2016).
Self-efficacy (SE) is defined as the person's belief in their ability to produce a desired outcome through their own actions using their own skills and abilities (Lopez-Garrido, 2023  Being able to use smart phones, read sent messages, and deal with related applications alone or with assistance of a family member.

Tools of the study:
In order to collect the study data, four tools were used.

III-Evaluation phase:
After two weeks from the end of the received chemotherapy regimen, the researchers met each patient in the study and control groups at the chemotherapy outpatient clinics during their scheduled follow up visit to evaluate the effect of the program by using the tools II, III, and IV.
-Following program evaluation, the educational sessions' content and brochure were given to the control subjects via WhatsApp groups meeting done thereafter to avoid interfering with the study results and ensuring that all study subjects were treated fairly.
-The data collection started from the beginning of November 2022 to the end of March 2023.
-The evaluation of the effectiveness of the educational program was determined through using the proper statistical analysis.

Ethical considerations:
All study subjects were informed about the purpose of the study and an informed consent was obtained. Study subjects' privacy and anonymity were assured, and confidentiality of the collected data was maintained. The researchers informed the study subjects that they have the right to withdraw from the study at any time without penalty.

Statistical analysis:
The collected data were coded and entered in a special format to be suitable for computer feeding. Following data entry, checking and verification process were done to avoid any errors.   Furthermore, a statistically significant difference was found between the study and control groups post interventions regarding chemotherapy related concerns (P=0.000), and its dimensions including sensory-psychological concerns (P=0.000), as well as procedural concerns (P=0.000).

Sensory-psychological concerns
Square test X 2 comparison in the same before and after intervention Xa 2 comparison between the study and control group before intervention X b2 comparison between the study and control group after intervention * Significant at p ≤0.05 NA= Not applicable t= Paired t test t a ,t b = student t test t a comparison between the study and control group before intervention t b comparison between the study and control group after intervention  28.23 ± 38.11 34.03 ± 37.56 t a = 0.015 P= 0.902 t b = 104.29 P= 0.000* t= 119.23 P= 0.000* t= 0.353 P= 0.555 X 2 = Chi Square test X 2 comparison in the same group before and after intervention Xa 2 comparison between the study and control group before intervention X b2 comparison between the study and control group after intervention * Significant at p ≤0.05 t= Paired t test t a ,t b = student t test t a comparison between the study and control group before intervention t b comparison between the between the study and control group after intervention Square test X 2 comparison in the same group before and after intervention Xa 2 comparison between the study and control group before intervention X b2 comparison between the study and control group after intervention t= Paired t test t a ,t b = student t test t a comparison between the study and control group before intervention t b comparison between the between the study and control group after intervention * Significant at p ≤0.05 Figure (1

Conclusion:
The study hypothesis is supported by the current study findings; thus, it can be concluded that implementing the mobile based educational program through WhatsApp significantly improves chemotherapy management self-efficacy and reduces psychological distress among female geriatric patients with breast cancer undergoing chemotherapy.

Recommendations:
Based on the findings of the present study, the following recommendations are suggested: