Evaluating the Knowledge and Attitude of Menopaused Women for Breast Cancer Screening: A Cross Sectional Study in Iran

authors:

avatar Vahid Kohpeima Jahromi ORCID 1 , avatar Nader Sharifi ORCID 1 , *

Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran

how to cite: Kohpeima Jahromi V, Sharifi N. Evaluating the Knowledge and Attitude of Menopaused Women for Breast Cancer Screening: A Cross Sectional Study in Iran. Jundishapur J Chronic Dis Care. 2021;10(3):e113340. https://doi.org/10.5812/jjcdc.113340.

Abstract

Background:

Breast cancer (BC) is a major public health problem worldwide. Considering the high prevalence and mortality of BC in postmenopausal women, and since the population of Iran is aging, this study aimed to investigate the knowledge and attitude of postmenopausal women in Jahrom, Iran regarding BC screening.

Methods:

This cross-sectional study was performed on postmenopausal women referred to Honari Clinic of Jahrom in 2019. To select the samples, 120 women were randomly selected from the existing medical files. Data collection tools included a demographic information questionnaire and the knowledge and attitude questionnaire on BC screening behavior. After explaining the objectives of the research to the participants and obtaining a consent form, the questionnaire was answered by them. The data were entered into SPSS software version 21 and tested by descriptive statistics, chi-square, Kruskal-Wallis, and one-way ANOVA tests. Descriptive statistics were used to examine demographic data.

Results:

The level of knowledge of most participants (49.2%) was moderate, and the majority of them (94.2%) had a positive attitude. There was a significant association between the mean score of knowledge and attitude in postmenopausal women with source of information (P = 0.004). Most information came from radio and television, physician, health system staff, and friends and relatives. There was no significant association between the mean score of knowledge and attitude of postmenopausal women with breast-related diseases and family history of BC.

Conclusions:

The mass media, especially radio and television, as well as physician and health system staff, play an important role in raising women's awareness to increase their participation in BC screening programs.

1. Background

Breast cancer (BC), a major public health problem worldwide, is the second most common cancer and a prime reason for death in women worldwide (1). The prevalence of BC in developing countries has been increasing in recent years due to increased life expectancy, urbanization growth, and poor lifestyle (2).

The incidence of BC varies widely, from 25 per 100,000 in Central Africa and East Asia to 92 per 100,000 in Western Europe. Incidence is projected to increase by 46.5% worldwide by 2040 (3). BC is on the rise in the Middle East and is rapidly approaching the level of the disease in Western countries (4). The rate of BC is expected to double in 2030 compared to 2012 in the Middle East, which is the highest relative increase compared to other parts of the world (5). The mortality rate from BC in the Eastern Mediterranean countries is 70%, which is higher than the mortality rate in developed countries (6). BC accounts for 32% of all types of cancer among Iranian women (7).

Early detection plays a key role in preventing BC mortality and increases the 5-year survival rate of patients from 56 to 85% (8). Studies have shown that low levels of knowledge, fear, and psychosocial barriers are the main reasons for women not participating in BC screening programs (9-11).

Women in the Middle East face a number of psychosocial, cultural, and doctrinal challenges that lead to a negative attitude toward screening, resulting in delays in the diagnosis of BC and an increased risk of death (12). A closer look at women's knowledge and attitudes is useful to better understand how they decide whether or not to participate in BC screening (13).

Kalliguddi et al.'s study in India showed that the level of knowledge and attitude of women about breast self-examination is very low (8). Naqvi's study showed that Pakistani women's knowledge and attitude about BC screening is inadequate (14). A systematic review of the results of various studies in Iran showed that women's attitude toward BC screening is inappropriate (6). Considering the high prevalence and mortality of BC in postmenopausal women (15) and given that the population of Iran is aging (16) and considering the contradictory results of previous research in this field in Iran (17-19) and the fact that women in Jahrom have special religious and cultural characteristics that can affect their participation in BC screening programs, this study was conducted to investigate the knowledge and attitude of postmenopausal women in Jahrom regarding BC screening.

2. Methods

This cross-sectional study was performed on postmenopausal women referred to Honari Clinic of Jahrom, Iran, in 2019. Considering the minimum value of correlation coefficient as 0.25, Type I error (α) as 0.05, and power of 80%, the sample size was determined as 120 individuals.

The inclusion criteria were women aged 45 to 89 (to cover all menopausal women) referring to Honari Clinic in Jahrom. The exclusion criteria included dissatisfaction with the study and a history of malignant breast disease.

To select the samples, 120 women who met the inclusion criteria were randomly selected from 532 health files. To randomly select the participants, the files were numbered, and the samples were selected using the Random Number Since Since seven women were not eligible to participate in the study, they were randomly replaced by other individuals.

Data collection tools included a demographic information questionnaire and the knowledge and attitude questionnaire on BC screening behavior, the reliability of which were confirmed by calculating Cronbach's alpha coefficient (0.86) and face and content validity by providing tools to health education professionals (20). The questionnaire had four sections, including demographic characteristics (four questions), history of breast diseases (three questions), knowledge questions (24 questions), and attitude questions (42 questions). To rank the level of knowledge, the total questions of this section were given 72 points (three points for correct answers and two points for wrong answers), and individuals were divided into three categories according to the score: weak knowledge (score between 55 - 48), moderate knowledge (score between 56 - 63), and good knowledge (score between 64 - 72). Attitude questions were set as a Likert score of 1 - 3 points (3 points for agreeing, 2 points for neither agreeing nor disagreeing, 1 point for disagreeing). A total of 126 points were given to the questions in this section, and the individuals were divided into two categories according to the score: positive attitude (score between 84 - 126) and negative attitude (score between 42 - 83). Negative attitude indicates reluctance, and positive attitude indicates inclination to BC screening behavior.

In the present study, the reliability of the questionnaire with the participation of 30 postmenopausal women was measured by Cronbach's alpha method, which was 0.72 for the knowledge section and 0.79 for the attitude section.

After explaining the research objectives to the participants and obtaining a consent letter, the questionnaire was answered by the participants in the presence of researcher. For illiterate women, the questionnaires were completed with the help of the researcher. All participants answered the questionnaire completely. Then, the data were entered into SPSS software version 21, and the data distribution was checked by Kolmogorov-Smirnov test. Demographic variables were analyzed using descriptive statistics and chi-square test. Knowledge question data had no normal distribution and was tested by Kruskal-Wallis tests. The data of attitude questions had a normal distribution and were tested by one-way ANOVA test. Descriptive statistics were used to examine demographic data.

3. Results

A total of 120 postmenopausal women participated in this study, with the highest frequency being 56 (46.7%) in the age group of 50 - 59 years. In terms of education level, the majority of participants were under diploma [57 (47.5%)] and illiterate [18 (15%)]. Moreover, the majority of participants were married [98 (81.7%)]. Regarding the source of information, radio and television [68 (56.7%)], physician and health system staff [33 (27.5%)], friends and relatives [32 (26.7%)], and newspapers, magazines, and books [8 (6.7%)] had the highest frequency. Also, the level of knowledge of most participants (49.2%) was moderate, and the majority of them (94.2%) had a positive attitude (Table 1).

Table 1. Demographic Variables and Frequency of Level of Knowledge and Attitude of Postmenopausal Women
Variables No. (%)
Age
40 - 4923 (19.2)
50 - 5956 (46.7)
60 - 6922 (18.3)
70 - 796 (5)
80 - 892 (1.7)
Education
Illiterate18 (15)
Under diploma57 (47.5)
Diploma30 (25)
College education15 (12.5)
Marital status
Single4 (3.3)
Married98 (81.7)
Divorced3 (2.5)
Widow15 (12.5)
Level of knowledge
Weak35 (29.1)
Moderate52 (49.2)
Good26 (21.7)
Level of attitude
Negative7 (5.8)
Positive113 (94.2)

There was a significant association between the mean score of knowledge and attitude in postmenopausal women with source of information (P = 0.004). Most information came from radio and television, physician and health system staff, and friends and relatives, respectively. There was no significant association between the mean score of knowledge and attitude of postmenopausal women with a history of breast diseases (Table 2).

Table 2. Association of Knowledge and Attitude with the Source of Information and History of Breast Diseases
VariablesNo. (%)P a
Knowledge
Source of information0.004
Radio and television68 (56.6)
Newspapers, magazines, and books8 (6.6)
Friends and relatives32 (26.6)
Physician and health system staff33 (27.5)
History of breast diseases0.11
History of breast pain10 (8.3)
Benign breast diseases14 (11.6)
Malignant diseases of the breast4 (3.3)
Attitude
Source of information0.004
Radio and television68 (56.6)
Newspapers, magazines, and books8 (6.6)
Friends and relatives32 (26.6)
Physician and health system staff33 (27.5)
History of breast diseases0.11
History of breast pain10 (8.3)
Benign breast diseases14 (11.6)
Malignant diseases of the breast4 (3.3)

There was no significant association between the mean score of knowledge and attitude of postmenopausal women with breast-related diseases and family history of BC (Table 3).

Table 3. Association of Knowledge and Attitude with Breast-Related Diseases and Family History of BC
VariablesNMeanFP
Knowledgea
Breast-related diseases0.29
Yes
Referred to health centers1765.76
Not referred to health centers1371.27
No8957.25
Family history of BC0.63
Yes
Mother, sister, and daughter1168.55
Farther, relatives, and acquaintances2163.1
No8858.88
Attitude b
Breast-related diseases0.460.63
Yes
Referred to health centers 17103.23
Not referred to health centers13103.61
No89101.05
Family history of BC0.660.51
Yes
Mother, sister, and daughter11105.36
Farther, relatives, and acquaintances21101
No88101.13

4. Discussion

The knowledge of the majority of participants about BC screening was poor and moderate. Thomas' study found that most Iranian women have little knowledge of BC risk and do not play an active role in BC screening (17). Asgharnia’s study showed that a low percentage of Iranian women have a good knowledge about BC screening (21). However, in Hassanzadeh's study, women's knowledge was at a desirable level, though they had a poor practice in this field (18). The results of a meta-analysis by Ahmadi in Iran showed that women's awareness of BC screening in various studies was between 5 and 79.8% (22). Considering the findings of the present study and some contradictory results of other studies in Iran, it seems that there is no coherent plan to involve women in the BC screening program. It also seems that cultural and social differences in different regions of the country can affect the awareness and participation of women in BC screening program.

In Alshahrani et al.'s study of Saudi women, the majority of participants had a low knowledge of BC and its various screening methods (23). Findings from a study in India showed that more than half of women were aware of BC, but most of them had poor knowledge about early diagnosis (24). According to the results of these studies, there are differences in the level of awareness of women about BC screening in other countries in the West Asian region. Based on the findings of one of the mentioned studies, although the people's information about BC is somewhat desirable, knowledge about BC screening is not at the desired level as an effective way to prevent complications.

The present study showed that the main sources of information for women about BC screening were the mass media (radio and television) and physicians and healthcare workers. In Alshahrani’s study, the main source of information was social media, while the source of information for a small number of people was healthcare workers and mass media such as television and magazines (23). In Eyvanbagha et al.'s study of women working in medical school, print media was the main source of information on BC screening (25). In Hajian Tilaki and Auladi's study, the main source of information was health personnel (26). Also, in Ng’ida et al.'s study on rural women in Tanzania, the main sources of information were radio and television, colleagues, and health workers, respectively (27). It seems that the choice of media type is influenced by the level of literacy and the level of access to different media. In the present study, since the level of literacy of women was low (62.5% of people were illiterate or under diploma), radio and television, and health workers had the greatest impact on raising knowledge about BC and its screening. Meanwhile, in studies conducted on educated women, print media was reported as the main source of information.

While the majority of women had a positive attitude towards BC screening in the present study, the majority of women in the study by Al-Azri et al. in Oman did not have a positive attitude towards BC screening (12). In Heena et al.'s study, more than half of the participants believed that they could not be diagnosed by BC screening (28). In Andegiorgish et al.'s study of female nurses in Eritrea, the majority of participants had a positive attitude towards BC screening, although many of them considered the disease to be specific to the elderly (29). This discrepancy may be due to the fact that various studies have addressed different aspects of women's beliefs about the importance of BC and its screening. For example, Heena et al.'s study focused on women's attitudes about perceived sensitivity to the disease and the ability of the experiment to diagnose it, while in the present study, different aspects of women's attitudes toward BC screening were considered (28).

People's attitudes were significantly related to obtaining information from physician and health system staff. The studies by Jensen et al. (30) and Price et al. (31) showed that women's participation in BC screening was strongly related to general practitioners' attitudes toward BC screening. In Ghanouni et al.'s study of women's attitudes towards risk-stratified BC screening among women, general practitioners and cancer specialists were preferred as a source of information in high-risk individuals (32). Women consider physician and health system staff as a reference for health information. Physicians and healthcare personnel can play an important role in attracting women's attention and confidence in the BC screening program.

The limitation of the present study was the lack of cyberspace as a new communication medium among the sources of information about BC screening. The standard questionnaire used had its drawbacks; for example, there was no ‘I do not know’ option in knowledge questions. The strength of this study is the selection of the study sample from a wide range of postmenopausal women in terms of age, which allows the results to be generalized to a wide range of postmenopausal women. Also, the research was conducted with the desired quality due to full access to the participants.

4.1. Conclusions

The majority of women had moderate knowledge and a positive attitude towards BC screening. The mass media, especially radio and television, as well as physician and health system staff play an important role in raising women's awareness to increase their participation in BC screening programs. It is suggested to plan for the cooperation of mass media and health system personnel to encourage women, especially the elderly, to participate in BC screening.

Acknowledgements

References

  • 1.

    Mitra S, Dash R. Natural products for the management and prevention of breast cancer. Evid Based Complement Alternat Med. 2018;2018:8324696. doi: 10.1155/2018/8324696. [PubMed: 29681985]. [PubMed Central: PMC5846366].

  • 2.

    Sauter ER. Breast cancer prevention: Current approaches and future directions. Eur J Breast Health. 2018;14(2):64-71. doi: 10.5152/ejbh.2018.3978. [PubMed: 29774312]. [PubMed Central: PMC5939980].

  • 3.

    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424. doi: 10.3322/caac.21492. [PubMed: 30207593].

  • 4.

    Ginsburg O, Bray F, Coleman MP, Vanderpuye V, Eniu A, Kotha SR, et al. The global burden of women's cancers: A grand challenge in global health. Lancet. 2017;389(10071):847-60. doi: 10.1016/S0140-6736(16)31392-7. [PubMed: 27814965]. [PubMed Central: PMC6191029].

  • 5.

    Naja F, Nasreddine L, Awada S, El Sayed Ahmad R, Hwalla N. Nutrition in the prevention of breast cancer: A middle eastern perspective. Front Public Health. 2019;7:316. doi: 10.3389/fpubh.2019.00316. [PubMed: 31788465]. [PubMed Central: PMC6856137].

  • 6.

    Badakhsh M, Balouchi A, Taheri S, Bouya S, Ahmadidarehsima S, Aminifard M. Attitude and practice regarding breast cancer early detection among Iranian women: A systematic review. Asian Pac J Cancer Prev. 2018;19(1):9-16. doi: 10.22034/APJCP.2018.19.1.9. [PubMed: 29373873]. [PubMed Central: PMC5844641].

  • 7.

    Rahimzadeh M, Pourhoseingholi MA, Kavehie B. Survival rates for breast cancer in Iranian patients: A meta- analysis. Asian Pac J Cancer Prev. 2016;17(4):2223-7. doi: 10.7314/apjcp.2016.17.4.2223. [PubMed: 27221922].

  • 8.

    Kalliguddi S, Sharma S, Gore CA. Knowledge, attitude, and practice of breast self-examination amongst female IT professionals in Silicon Valley of India. J Family Med Prim Care. 2019;8(2):568-72. doi: 10.4103/jfmpc.jfmpc_315_18. [PubMed: 30984674]. [PubMed Central: PMC6436306].

  • 9.

    Gupta A, Shridhar K, Dhillon PK. A review of breast cancer awareness among women in India: Cancer literate or awareness deficit? Eur J Cancer. 2015;51(14):2058-66. doi: 10.1016/j.ejca.2015.07.008. [PubMed: 26232859]. [PubMed Central: PMC4571924].

  • 10.

    Chidyaonga-Maseko F, Chirwa ML, Muula AS. Underutilization of cervical cancer prevention services in low and middle income countries: a review of contributing factors. Pan Afr Med J. 2015;21:231. doi: 10.11604/pamj.2015.21.231.6350. [PubMed: 26523173]. [PubMed Central: PMC4607967].

  • 11.

    Nyblade L, Stockton M, Travasso S, Krishnan S. A qualitative exploration of cervical and breast cancer stigma in Karnataka, India. BMC Womens Health. 2017;17(1):58. doi: 10.1186/s12905-017-0407-x. [PubMed: 28768506]. [PubMed Central: PMC5541646].

  • 12.

    Al-Azri M, Al-Rubaie K, Al-Ghafri S, Al-Hinai M, Murthi Panchatcharam S. Barriers and attitudes toward breast cancer screening among Omani women. Asian Pac J Cancer Prev. 2020;21(5):1339-47. doi: 10.31557/APJCP.2020.21.5.1339. [PubMed: 32458642]. [PubMed Central: PMC7541873].

  • 13.

    Kregting LM, van Ravesteyn NT, Spijker W, Dierks T, Aitken CA, Geuzinge HA, et al. Effects of a leaflet on breast cancer screening knowledge, explicit attitudes, and implicit associations. Patient Educ Couns. 2020. doi: 10.1016/j.pec.2020.06.032. [PubMed: 32732022].

  • 14.

    Naqvi AA, Zehra F, Ahmad R, Ahmad R, Ahmad N, Yazdani N, et al. Awareness, knowledge and attitude towards breast cancer, breast screening and early detection techniques among women in Pakistan. J Pak Med Assoc. 2018;68(4):576-86. [PubMed: 29808048].

  • 15.

    Heer E, Harper A, Escandor N, Sung H, McCormack V, Fidler-Benaoudia MM. Global burden and trends in premenopausal and postmenopausal breast cancer: A population-based study. Lancet Glob Health. 2020;8(8):e1027-37. doi: 10.1016/S2214-109X(20)30215-1. [PubMed: 32710860].

  • 16.

    Hosseini FS, Sharifi N, Jamali S. Correlation anxiety, stress, and depression with perceived social support among the elderly: A cross-sectional study in Iran. Ageing Int. 2020;46(1):108-14. doi: 10.1007/s12126-020-09376-9.

  • 17.

    Thomas E, Escandón S, Lamyian M, Ahmadi F, Setoode S, Golkho S. Exploring Iranian women's perceptions regarding control and prevention of breast cancer. Qual Rep. 2011;16(5):1214-29.

  • 18.

    Hassanzadeh R, Rahimi R, Ranjbar M, Heidarzadeh M. [Health beliefs in screening for breast cancer among women referring to Bonab Health Centers in 2014]. J Rafsanjan Univ Med Sci. 2015;14(7):575-86. Persian.

  • 19.

    Rakhshani T, Asadi ZS, Taravatmanesh S, Kashfi SM, Ebrahimi MR. [Study of the women’s breast cancer screening behavior in Shiraz, 2016]. Iran J Obstet Gynecol Infertil. 2018;21(8):39-46. Persian.

  • 20.

    khodayarian M. [Assessment of awareness and attitude of women about breast cancer screening behavior in Yazd city, Iran in 1391]. Iran Q J Breast Dis. 2014;6(4):41-51. Persian.

  • 21.

    Asgharnia M, Faraji R, Zahiri Z, Salamat F, Mosavi Chahardah SM, Sefati S. [A study of knowledge and practice of woman about breast cancer and its screening, in the case of women who referred to Alzahra Hospital in Rasht during 2010-2011]. Iranian Journal of Surgery. 2013;21(1). Persian.

  • 22.

    Bouya S, Balouchi A, Ahmadidarehsima S, Badakhsh M. Knowledge and source of information about early detection techniques of breast cancer among women in Iran: A systematic review. J Cancer Prev. 2018;23(1):51-60. doi: 10.15430/JCP.2018.23.1.51. [PubMed: 29629349]. [PubMed Central: PMC5886495].

  • 23.

    Alshahrani M, Alhammam SYM, Al Munyif HAS, Alwadei AMA, Alwadei AMA, Alzamanan SSM, et al. Knowledge, attitudes, and practices of breast cancer screening methods among female patients in primary healthcare centers in Najran, Saudi Arabia. J Cancer Educ. 2019;34(6):1167-72. doi: 10.1007/s13187-018-1423-8. [PubMed: 30191519]. [PubMed Central: PMC6882780].

  • 24.

    Somdatta P, Baridalyne N. Awareness of breast cancer in women of an urban resettlement colony. Indian J Cancer. 2008;45(4):149-53. doi: 10.4103/0019-509x.44662. [PubMed: 19112202].

  • 25.

    Eyvanbagha R, Kamran A, Nasiri K, Habibi A, Mozafari P, Shamkhali R. [Knowledge, attitude and practice of female employees in Khalkhal Faculty of Medical Sciences of breast self-examination and its relationship with some individual characteristics]. Depiction of Health. 2015;6(3):41-7. Persian.

  • 26.

    Hajian Tilaki K, Auladi S. Awareness, attitude, and practice of breast cancer screening women, and the associated socio-demographic characteristics, in Northern Iran. Iran J Cancer Prev. 2015;8(4). e3429. doi: 10.17795/ijcp.3429. [PubMed: 26478790]. [PubMed Central: PMC4606374].

  • 27.

    Ng'ida FD, Kotoroi GL, Mwangi R, Mabelele MM, Kitau J, Mahande MJ. Knowledge and practices on breast cancer detection and associated challenges among women aged 35 years and above in Tanzania: A case in Morogoro Rural district. Breast Cancer (Dove Med Press). 2019;11:191-7. doi: 10.2147/BCTT.S199889. [PubMed: 31239761]. [PubMed Central: PMC6554511].

  • 28.

    Heena H, Durrani S, Riaz M, AlFayyad I, Tabasim R, Parvez G, et al. Knowledge, attitudes, and practices related to breast cancer screening among female health care professionals: A cross sectional study. BMC Womens Health. 2019;19(1):122. doi: 10.1186/s12905-019-0819-x. [PubMed: 31640681]. [PubMed Central: PMC6806575].

  • 29.

    Andegiorgish AK, Kidane EA, Gebrezgi MT. Knowledge, attitude, and practice of breast Cancer among nurses in hospitals in Asmara, Eritrea. BMC Nurs. 2018;17:33. doi: 10.1186/s12912-018-0300-4. [PubMed: 30083079]. [PubMed Central: PMC6069844].

  • 30.

    Jensen LF, Mukai TO, Andersen B, Vedsted P. The association between general practitioners' attitudes towards breast cancer screening and women's screening participation. BMC Cancer. 2012;12:254. doi: 10.1186/1471-2407-12-254. [PubMed: 22708828]. [PubMed Central: PMC3413538].

  • 31.

    Price MA, Butow PN, Charles M, Bullen T, Meiser B, McKinley JM, et al. Predictors of breast cancer screening behavior in women with a strong family history of the disease. Breast Cancer Res Treat. 2010;124(2):509-19. doi: 10.1007/s10549-010-0868-1. [PubMed: 20364401].

  • 32.

    Ghanouni A, Sanderson SC, Pashayan N, Renzi C, von Wagner C, Waller J. Attitudes towards risk-stratified breast cancer screening among women in England: A cross-sectional survey. J Med Screen. 2020;27(3):138-45. doi: 10.1177/0969141319883662. [PubMed: 31701797].

Copyright © 2021, Jundishapur Journal of Chronic Disease Care. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.