|Ahead of print publication
Knowledge, awareness, and practice of breast self-examination among females in Mosul city, Iraq
Harith Khalid Al-Qazaz1, Noralhuda A Yahya2, Doaa Kh Ibrahim2
1 Department of Clinical Pharmacy, College of Pharmacy, University of Mosul, Ninevah, Iraq
2 Department of Pharmacology and Toxicology, College of Pharmacy, University of Mosul, Ninevah, Iraq
|Date of Submission||10-Sep-2019|
|Date of Decision||12-Jan-2020|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||09-Oct-2020|
Harith Khalid Al-Qazaz,
Department of Clinical Pharmacy, College of Pharmacy, University of Mosul, Ninevah 81011
Source of Support: None, Conflict of Interest: None
Aims: This study is carried out to report on the knowledge and practice regarding breast self-examination (BSE) among women from the city of Mosul in Iraq and to evaluate the prevalence of performing clinical breast examination (CBE) and mammography among them.
Settings and Design: A descriptive, cross-sectional survey carried out among females working in the University of Mosul, as a sample of the female population of Mosul city.
Subjects and Methods: The sample was collected conveniently, and the data were collected from July to November 2018. Data were collected by interviews with 405 participants. Knowledge answers were scored and categorized into two groups: good and poor level of knowledge.
Results: A final sample of 384 participants were included in the analysis, with a mean age of 42.58 ± 8.9. Only 39 (10.1%) and 37 (9.6%) participants performed mammographic examination and CBE of their breasts, respectively. Just 100 (30.3%) of the 330 females who knew BSE performed BSE routinely or intermittently. The mean knowledge score was 4.22 ± 1.66, and only 141 females (42.7%) were found to have a good level of knowledge. A statistically significant association of knowledge level with marital status (P = 0.015), perceived benefit of BSE (P = 0.001), previous gain of instructions of BSE (P < 0.05), and the provider (P < 0.05) was found.
Conclusions: The performance results of BSE were poor as well as for CBE and mammography among the study participants. There is a need for educational programs to create awareness and improve knowledge about routine breast cancer screening behavior.
Keywords: Breast self-examination, Iraq, knowledge, practice
| > Introduction|| |
Cancer is the most malicious disease that can affect people since it can increase people suffering. Cancers have a negative effect on the quality of life and can finally lead to death in disastrous, tragic manner. Cancers are ranked as the fourth cause of death globally and as the second cause of death after cerebrovascular disease in Iraq. Developing countries have the highest incidence, and there is an estimation that by the year 2020, up to 70% of newly diagnosed cases will be in the third world or people in low socioeconomic development.
Breast cancer is the most common malignancy that affects women worldwide, and Iraq is not different., According to the Iraqi Cancer Registry, breast cancer is accounting to one-third of the cancerous female population. The incidence of breast cancer in Iraqi females of all ages has been increasing, and the most susceptible age group is 60–69 years. In the past three decades, it was found that 19.4% of all newly diagnosed cancers, 34.7% of female's cancers, and 22.5% of malignancy-related deaths in Iraq were breast cancer.
Screening and early detection of breast cancer with appropriate therapy will lead to reduction in breast cancer mortality rate.,,, The lack of public health awareness programs is considered one of the reasons that the early diagnosis of breast cancer is difficult in Iraq and other middle- and low-income countries. Currently, in many developing countries like India, higher attention is paid for breast cancer screening that resulted from a distinct rise in the incidence rates among females of younger ages and the late diagnosis of cancer.
Three means which are approved to be cost effective are available as screening tests for breast cancer that include breast self-examination (BSE), clinical breast examination (CBE), and mammography. These means help to detect the asymptomatic condition.,,, BSE is one of the vital and easily performed techniques for the early detection of breast cancer which can be performed by females themselves. Some studies show that up to 90% of breast cancers can be detected by females themselves, although performing BSE regularly in women does not necessitate the discovery of the illness., Other diagnostic and preventive techniques are CBE and mammography; both require equipment and a visit to the clinic. In relation to CBE, it is the best way by which health workers can give advice to women about breast cancer risks and early detection methods. CBE can be performed by doctors, but there is also CBE performed by nurse. Females should start having CBE at their 20s, and the test should be performed every 3 years, then the frequency increases in 40s to one test every year. Regarding mammography, the results from many studies proved the influence of screening with mammography in reducing the mortality rates and improving the treatment in women with breast cancer., However, it is not recommended for all ages. In comparison between CBE and mammography, CBE has an advantage of lower cost, and hence, it may be considered a better screening test than mammography.
Level of knowledge, attitude, and practice among population with regard to breast cancer detection techniques are varied., In Iran, a study conducted at health centers in Tabriz in 2012 found that about 18.8% of women perform BSE monthly, and 19.1% had CBE yearly by referral of health workers and 3.3% did mammograms. A Saudi study performed by an online questionnaire has shown that about 20.8% of women practiced BSE, 19.8% had CBE, and 13% had mammogram. In Sulaimani (North of Iraq), it was found that 39.8% of women know BSE and the correct way to perform it, 35% practice BSE, 45.6% have knowledge about CBE, and only 4.4% knew that mammography is a screening test for BC. This study is carried out to report on the knowledge and practice regarding BSE among women from the city of Mosul in Iraq and to evaluate the prevalence of performing CBE and mammography among them.
| > Subjects and Methods|| |
Approval from the Central Ethics Committee at the Mosul Directorate of Health was obtained in addition to the approval from the Scientific Committee of the Department of Clinical Pharmacy and College of Pharmacy/University of Mosul. All participants were informed that their personal information would be confidential. Written consent was also obtained from the participants before the commencement of the study.
Participants and setting
This study is a descriptive, cross-sectional survey carried out among females working in the University of Mosul, as a sample of the female population of Mosul city. The sample was collected as nonprobability convenience sample. The data were collected from July to November 2018. Almost all nonmedical colleges at the main campus of Mosul University were included in the study. The inclusion criteria include general officers, laboratory scientists, lecturers, and temporary employees. The required sample size was 378 which was calculated by the online Epi-info program considering a confidence level of 95% and population size of 20,000. The exclusion criteria include males, medical staff, students, and females <20 years old.
Instruments and data collection
The questionnaire used in this study was adapted from previous studies, and consisted of five domains: first was about sociodemographic information followed by questions on the knowledge of breast cancer and family history. The third, fourth, and fifth domains assessed the knowledge of BSE technique, practicing the clinical examination and mammography, respectively. The third domain contained details about the knowledge of ideal frequency and the correct way of performing BSE, also participants' attitude, and their level of practicing the tests.
This questionnaire was adapted and translated from English to Arabic and then the translation was validated by professional linguist and the questionnaire was assessed by two specialized doctors in the Woman Care Center at Al-Khansaa Hospital. After that, the questionnaire social compatibility was validated by performing a pilot study on 30 participants.
Questionnaires were filled by two female pharmacists according to the results of face-to-face interviews with 405 participants. Seven participants refused to enter the study due to their negative concept about these screening tests. In addition, 14 participants could not continue with the interview. Data were analyzed using the SPSS software version 23. The Chi-square test was used for the categorical variables. The questionnaire was pretested by validity and reliability test (Cronbach's alpha test).
| > Results|| |
For the 10-item knowledge test, Cronbach's alpha test of internal consistency was 0.798 which was within the suggested satisfactory result for reliability. A final sample of 384 participants was included in the analysis, and the basic sociodemographic characteristics are shown in [Table 1]. The mean age was 42.58 ± 8.9, with a minimum age of 20 and maximum of 62. All the females were government employed.
Knowledge about breast cancer
The vast majority of the females in this study (99.5%) have heard about the disease, and only 2 respondents (0.5%) explored that they did not hear about the disease. The participants expressed that breast cancer information and knowledge were gathered from different sources, including books (12.5%), media (71.1%), hospital posters (16.1%), lectures and conferences (38.5%), in addition to friends and relatives (26.6%). Out of the study participants, 139 (36.1%) indicated that one of their family members or relatives was affected by breast cancer. Only 39 (10.1%) performed mammographic examination of their breasts as a routine screening behavior and 37 (9.6%) preformed CBE.
Knowledge and practice concerning self-examination of the breast
With regard to BSE, 330 (85.9%) participants heard about a self-examination practice of the breast and 310 (93.9) knew that BSE is useful in the early detection of breast cancer. A total of 243 (63.3%) females explained that they were taught about practicing BSE. However, only 100 (30.3%) out of the 330 females who knew BSE, performed BSE routinely or intermittently, and this is equivalent to 26.0% of the total sample of females. [Table 2] is a summary of the above basic information regarding the BSE.
A small number (58) of the females (17.6%) knew the recommended age to start BSE and 156 (47.3%) knew the appropriate time to perform the BSE. However, only 54 (16.4%) correctly answer how the BSE performed. [Table 3] shows the knowledge of the study participants toward BSE variables studied.
Association between knowledge and relevant variables
Knowledge answers were scored and categorized into two groups: good and poor level of knowledge, while the mean knowledge score was 4.22 ± 1.66 (median = 4) with a cutoff point of 4 (good knowledge ≥4 and poor below 4). Out of the 330 females who heard about breast cancer, only 141 females (42.7%) were found to have a good level of knowledge, whereas the remaining 189 (57.3%) had low or poor level of knowledge. [Table 4] shows the results of association examination between demographic characteristics, basics of self-examination, and knowledge level. Significant association between marital status and BSE knowledge level was found. In addition, significant association between BSE level of knowledge and perceived benefit of BSE, females taught about the BSE, and also with the knowledge provider was also found.
|Table 4: Association between knowledge level of the participants and relevant variables*|
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| > Discussion|| |
Breast cancer is on the peak of malignancies affecting females in Iraq, and around 900 females death from that disease are registered annually., The findings of this study showed that 36.1% of the participants indicated that at least one family member was diagnosed with breast cancer, and this is consistent with the incidence of the disease in Iraq (34.7%) of female malignancies., The findings of this study showed that 93.9% of the females knew that BSE is useful for the early detection of breast cancer which is compatible with the findings from other studies., This finding indicates that females are aware about the disease and the role of BSE in its detection which could be considered as a positive motivating point if the systematic program is intended to be held. Such a program is needed and this is confirmed in this study by the small proportions of females who performed BSE (30.3%) and mammography (10.1%), indicate that there are still some barriers to perform BSE such as lack of knowledge and low level of belief about the risk of late detection of the disease. These results are to some extent was in accordance with the findings in Africa, but they are far from a study result in Iran. Inadequate knowledge and awareness about the real risk of developing breast cancer might be the reason.
The source of knowledge and information about breast cancer and the importance of BSE were from the media (71.1%), which is a sign of inadequate contribution of health-care providers to deliver the essential knowledge. With regard to knowing about BSE, it was found that 85.9% of the participants have heard about BSE which is than what has been recorded from Saudi Arabia (30%) and Egypt (10.4%)., This could be attributed to the level of education of the sample participated in this study, mostly being females with university-level education.
BSE practicing results in this study (26.0%) were higher than those from Malaysia (14.8%) and Iran (18.8%),, but, to some extent, comparable to others such as Nigeria (32.1%), Pakistan (28.3%), and Turkey (28%).,, More interest in the last few years concerning the issue of breast cancer could be the reason for the higher frequency of practicing BSE in Iraq compared to Malaysia and Iran. In this study, the proportion of those who have heard about BSE and were aware of the correct timing (17.6%), correct frequency (50.3%), and practical steps of BSE (16.4%) were all considerably low. These findings strongly recommend the need for an interventional program for exploring both importance and correct practices of BSE.
The analysis of the knowledge scale used in this study showed that 17.6% of participants knew the recommended age to start performing BSE routinely which is low and needs to be considered in further interventional works. In addition to that, 50.3% of participants indicated that the BSE should be repeated on a monthly basis which is in accordance with the study in Iran, but not with others' findings., The overall BSE knowledge in this study is considered poor (poor knowledge percent = 57.3%) which is an indication for the need to an essential public education program concerning breast cancer. Significant association of knowledge level and marital status of the female were found, confirming the incorrect belief that breast cancer is a disease of married ladies and this belief is not affected by the level of education of the females. Significant association was also found between the knowledge level and perceived benefit of BSE as a useful tool for the early detection of breast cancer. Perceived benefits of BSE play an important role in gaining correct knowledge about breast cancer, behavior change, and routine practice of BSE.,, In this study, significant association between previous gain of instructions of BSE and knowledge was found. Moreover, significant association between the provider (the doctor was the best) and level of knowledge was also found. Providing the knowledge to promote BSE is essential for correct BSE practice and the provider should be well trained for the task., There is a high chance that increasing awareness, knowledge, and perceived benefits of BSE may have contribution to decrease the mortality for breast cancer as noted in some other nations.
This study has several limitations that could be acknowledged. First is the self-reporting method of data collection and the cultural barriers to explore information in this type of study from the females; however, there was no pressure on the participants to report increased or decreased performance of BSE. This study was carried out among apparently well-educated university employees who are considered open-minded participants to explore correct information. The convenient sampling method does not represent all the females in the city and cannot be generalized, so conducting a randomized data collection would increase our understanding of the objectives to improve the breast self-care.
| > Conclusions|| |
The performance results of BSE were poor as well as for CBE and mammography among the study participants. There is a need for educational programs to create awareness and improve knowledge about routine breast cancer screening behavior. In this sample of females, most of the participants obtained information from media; therefore, it is vital to start well-designed programs controlled by the Ministry of Health and medical colleges with important health issues.
The authors would like to thank the participants who involved in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]