|Year : 2019 | Volume
| Issue : 2 | Page : 108-112
Barriers to breast self-examination among Iranian women
Fariba Taleghani1, Maryam Kianpour1, Maryam Tabatabaiyan2
1 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Surgery, Seyed Al-Shohada Hospital, Focal Point of Breast Cancer at Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||15-Feb-2019|
Prof. Fariba Taleghani
Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Breast cancer is a very common cancer in women which is diagnosable using inexpensive, accessible, and easy screening programs in the early stages of the disease. Culture, beliefs, and opinions of women affect adoption of screening techniques. Nursing professionals are supposed to be aware of such influencing factors. Therefore, this study was conducted to investigate barriers to breast self-examination (BSE) among women in Isfahan province. Materials and Methods: During a cross-sectional descriptive and correlational study in 2017, 1509 women in rural and urban areas of Isfahan province were selected using multistage sampling method. Data were collected by visiting homes, using a questionnaire, and conducting interviews and were analyzed using descriptive and analytical statistics. Results: The results showed that barriers consisted of lack of awareness about breast examination (p = 0.006), lack of awareness about BSE techniques (p < 0.001), and lack of training by personnel of healthcare centers (p = 0.016), which were significantly associated with residency areas (i.e., urban and rural areas). Moreover, women's educational level was significantly associated with 5 of 10 barriers and their occupation was significantly associated with 2 of 10 barriers to BSE. Conclusions: Among the several factors that may affect BSE, a part of them in Isfahan women act as obstacle that they are moderated by some demographic factors such as residency areas, education level, and occupation. Therefore, nursing plans and interventions aimed at developing BSE should be tailored to suit the unique demographic characteristics of women.
Keywords: Barriers, breast self-examination, women
|How to cite this article:|
Taleghani F, Kianpour M, Tabatabaiyan M. Barriers to breast self-examination among Iranian women. Iranian J Nursing Midwifery Res 2019;24:108-12
| Introduction|| |
Breast cancer is one of the most important health problems. It is the most common cancer among women in developed and developing countries. However, its incidence is highly variable in different geographical regions in the world. In Iran, breast cancer has the highest rate of incidence in women, compared with other malignancies. Because of an increase in life expectancy of Iranian population, the incidence of this disease among Iranian women will increase in the coming years. Besides, an increased trend of breast cancer mortality in Iran has challenged the health system, which indicates a need for prevention and early detection of disease. Health professionals and particularly nurses have a great role in promoting women's health by enhancing prevention and early detection of breast cancer.
The relationships between early detection (i.e., screening) and outcomes of disease have been highlighted in the literature., Evidences suggested that standard screening techniques including mammography and clinical breast examination can be effective in reducing the death rates., In addition, breast self-examination (BSE) has also been suggested as a valuable technique for early diagnosis of breast cancer. However, evidences suggested a weakness in screening and early detection of this disease particularly in Iran., Therefore, identifying barriers to breast cancer screening is significantly important in preventing the disease progression, through shedding more insight into essential activities by nursing and other health professionals. This study was conducted to determine barriers to BSE and their associations with some related demographic factors among women living in urban and rural areas of Isfahan province.
| Materials and Methods|| |
This cross-sectional descriptive study was conducted from January 2016 to December 2017. The study population consisted of women between 20 and 65 years of age, living in Isfahan province. Krejcie and Morgan's formula based on population size up to 500,000, confidence of 95%, and margin of error of 2.5% was used to determine the required sample size. More than 1500 subjects were required. Hence, in this study, 1509 women were enrolled. Inclusion criteria included willingness to participate in the study, Iranian nationality, living in Isfahan province, and aging between 20 and 65 years. Based on the number of cities in Isfahan province and the population of 20–65 years old women living in each city, initially the share of each city was determined using multistage sampling method in which the number of clusters in each city was determined using random number table and based on the serial number of the list of health centers. Cluster heads were also randomly selected using numbers registered in the Cancer Prevention Services Office in selected villages' health houses and health centers in each city and the first address was selected as the reference of each cluster. Then, based on the right-hand rule, 10 families were interviewed. The first family was the reference family and the other nine families had a member who had a woman between 20 and 69 years old.
Data were collected using a questionnaire and through conducting interviews to fill the questionnaire. The questionnaire consisted of two parts: (1) demographic characteristics including education level, occupation, residency areas (i.e., urban or rural), and age and (2) barriers to cancer screening including forgetfulness and negligence, lack of awareness about breast examination techniques, lack of awareness about BSE techniques, lack of time (being too much busy), lack of training by personnel of healthcare centers, fear of doing a biopsy to diagnosis the disease, fear of diagnosis, lack of enough time to perform the examination, touching a lot of lumps during examination, and worrying and fear of feeling pain during examination. The instrument was developed through literature review and reviewing the existing documents. It contained 10 items and a dummy response options (i.e., yes and no). The content validity was censured by the experts and the reliability was supported through a 2-week test–retest examination with a pilot sample (n = 20) drawn from the study population (r coefficient ≥0.7 for all items).
The interviewers were trained to complete the questionnaire. Fifteen interviewers were selected among people with associate and bachelor's degree in family health and midwifery. To coordinate and monitor the data collection process, a supervisor was selected in each city to organize the interviewers, to monitor data collection process, and to review and send questionnaires to the provincial health centers. ID cards were issued for interviewers, and after conducting coordination with the police chief and provincial police intelligence (Agahi police), the names and information of interviewers were declared to these organizations. Interviewers visited families, and after obtaining verbal consent of participation in the study, they completed the questionnaire by conducting structured interviews using instrument.
Data were analyzed using descriptive (i.e., mean and standard deviation) and analytical (i.e., chi-squire test) statistics using SPSS software version 19 (SPSS Inc., Chicago, IL, USA) and considering the significance level of less than 0.05.
Approval of the ethics of the study was obtained by regional committee of ethics in medical studies in Isfahan University of Medical Sciences. The major ethical considerations of this study included obtaining the subjects' informed consents and ensuring their anonymity and their right to withdraw from the study at any time.
| Results|| |
In this study, 1509 women, including 1307 women living in urban areas and 202 women living in rural areas, were enrolled. The frequency distribution of age, education, and occupation in rural and urban areas among women in Isfahan province is presented and compared in [Table 1]. The frequency distribution of barriers to BSE among women in Isfahan province in urban and rural areas is presented and compared in [Table 2]. As shown in [Table 2], forgetfulness and negligence, lack of awareness about breast examination techniques, lack of awareness about BSE techniques and lack of time were above the first quartile (i.e., 25%) and considered as being important barriers to the BSE. Moreover, the relationships among barriers to BSE and some other demographic and characteristics (i.e., age, education level, and occupation) were investigated and presented in [Table 3]. It was revealed that 5 of 10 barriers to BSE had significant relationship with education level (p < 0.01), and 2 of 10 barriers had significant relationship with the subjects' occupation (p < 0.5).
|Table 1: Frequency distribution of age, education, and occupation in rural and urban areas among women in Isfahan province|
Click here to view
|Table 2: Frequency distribution and comparison of barriers to BSE based on residing areas (i.e., urban and rural areas)|
Click here to view
|Table 3: Relationships among barriers to BSE and education level as well as occupation|
Click here to view
| Discussion|| |
This study was conducted to investigate barriers to BSE among women in Isfahan province. The results showed that forgetfulness and negligence, lack of awareness about breast examination techniques, lack of awareness about BSE techniques, and lack of time are the main barriers to BSE in Isfahan province.
Some other studies also support the results of this study. For example, in a study by Ferrat et al., negligence was identified as a barrier to breast cancer screening in France. In line with our study results, much attention has internationally been paid to lack of awareness about breast examination and self-examination techniques as the main barriers to BSE.,,, Moreover, this study revealed that lack of time is another barrier to BSE among Iranian women living in Isfahan. This finding is consistent with Tavafian et al. that they found that from the perspective of women requiring too much time to do regular self-examination was a main barrier to BSE. Some other studies have reported inconsistent results. For example, in some other studies, the main barriers to BSE were reported as observing no clinical symptom, considering oneself not at risk and the absence of doctor advice, perceived benefits, self-efficacy, and the perceived barriers as the predictors of BSE.
Despite inconsistencies about the main barriers to BSE in the world, lack of awareness stands at the top of the barriers indicating a need for improving the community awareness of importance and techniques of BSE by nurses and other health professionals.
The study results also showed that women's educational level, residency areas, and their occupation were significantly associated with some kinds of barriers to BSE. Such findings were supported by Al-Dubai et al., who reported that having a high education level was more likely to practice BSE, and by Yavari and Pourhoseingholi who suggested that the knowledge and practices of women toward breast cancer early detection were inadequate in women with a lower level of education. Moreover, they are consistent with the results from Madubogwu et al. who reported that the level of education and occupation had significant correlations with the knowledge and practice of breast cancer screening methods.
Among demographic variables, age had no significant relationship with barriers to BSE. This finding is inconsistent with that of Akhtari-Zavare et al. who found a significant relationship between age and practice of BSE.
This study has shed more insight into the barriers to BSE in Iranian women living in Isfahan province. Moreover, it sheds more insights into essential nursing professional activities and may help health managers and nursing professionals to consider significant barriers at the time of planning and practicing relevant interventions. In addition, the findings have noticed nursing and other health professionals about the potential modifying role of demographic variables in obstacles to BSE.
Findings of the study need to be considered along with its limitations. Few personal characteristics and demographic variables included in the study limit the strong inferences from the results of the study. Future researches are needed to include most of the personal characteristics and demographic variables to capture the complexities as well as interactions among barriers and other determinants of health behaviors.
| Conclusion|| |
BSE in Isfahan women was faced with some kinds of obstacles that they further were moderated by some demographic factors such as residency areas, education level, and occupation. Therefore, nursing plans and interventions aimed at developing BSE should be tailored to suit the unique demographic characteristics of women. Moreover, training the personnel of healthcare centers and improving women's readiness (i.e., knowledge and attitudes) to BSE is suggested.
The authors wish to express their gratitude to all participants who contributed to this research. This study is part of a research project approved by Isfahan University of Medical Sciences (grant no. 292195).
Financial support and sponsorship
Isfahan University of Medical Sciences (IUMS), Iran
Conflicts of interest
Nothing to declare.
| References|| |
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al.
Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86.
Mousavi SM, Montazeri A, Mohagheghi MA, Jarrahi AM, Harirchi I, Najafi M, et al.
Breast cancer in Iran: An epidemiological review. Breast J 2007;13:383-91.
Taghavi A, Fazeli Z, Vahedi M, Baghestani AR, Pourhoseingholi A, Barzegar F, et al.
Increased trend of breast cancer mortality in Iran. Asian Pac J Cancer Prev 2012;13:367-70.
Teixeira MS, Goldman RE, Gonçalves VC, Gutiérrez MG, Figueiredo EN. Primary care nurses' role in the control of breast cancer. Acta Paulista de Enfermagem 2017;30:1-7.
Smith RA, Caleffi M, Albert US, Chen TH, Duffy SW, Franceschi D, et al.
Breast cancer in limited-resource countries: Early detection and access to care. Breast J 2006;12:S16-26.
Yip CH, Smith RA, Anderson BO, Miller AB, Thomas DB, Ang ES, et al.
Guideline implementation for breast healthcare in low-and middle-income countries: Early detection resource allocation. Cancer 2008;113:2244-56.
Todd A, Stuifbergen A. Breast cancer screening barriers and disability. Rehabil Nurs 2012;37:74-9.
Marmot MG, Altman D, Cameron D, Dewar J, Thompson S, Wilcox M. The benefits and harms of breast cancer screening: An independent review. Br J Cancer 2013;108:2205.
Armin J, Torres CH, Vivian J, Vergara C, Shaw SJ. Breast Self-Examination Beliefs and Practices, Ethnicity, and Health Literacy: Implications for Health Education to Reduce Disparities. Sage; 2014.
Nissan A, Spira RM, Hamburger T, Badrriyah M, Prus D, Cohen T, et al.
Clinical profile of breast cancer in Arab and Jewish women in the Jerusalem area. Am J Surg 2004;188:62-7.
Ebrahimi M, Vahdaninia M, Montazeri A. Risk factors for breast cancer in Iran: A case-control study. Breast Cancer Res 2002;4:R10.
Azami-Aghdash S, Ghojazadeh M, Gareh Sheyklo S, Daemi A, Kolahdouzan K, Mohseni M, et al.
Breast cancer screening barriers from the womans perspective: A meta-synthesis. Asian Pac J Cancer Prev 2015;16:3463-71.
Nichols M. The nurse's role in self–breast examination education. Plast Surg Nurs 2012;32:143-5.
Krejcie RV, Morgan DW. Determining sample size for research activities. Educ Psychol Measure 1970;30:607-10.
Ferrat E, Le Breton J, Djassibel M, Veerabudun K, Brixi Z, Attali C, et al.
Understanding barriers to organized breast cancer screening in France: Women's perceptions, attitudes, and knowledge. Family Pract 2013;30:445-51.
Al-Naggar RA, Bobryshev YV. Practice and barriers of mammography among Malaysian women in the general population. Asian Pac J Cancer Prev 2012;13:3595-600.
Rezaee Ghazdehi M, Amini L, Parvizi S, Hoseyni AF. Attitudinal barriers to mammography screening among women in Tehran. J Mazandaran Univ Med Sci 2013;23:69-75.
Al-Sharbatti SS, Shaikh RB, Mathew E, Al-Biate MA. Breast self examination practice and breast cancer risk perception among female university students in Ajman. Asian Pac J Cancer Prev 2013;14:4919-23.
Rosmawati N. Knowledge, attitudes and practice of breast self-examination among women in a suburban area in Terengganu, Malaysia. Asian Pac J Cancer Prev 2010;11:1503-8.
Tavafian SS, Hasani L, Aghamolaei T, Zare S, Gregory D. Prediction of breast self-examination in a sample of Iranian women: An application of the Health Belief Model. BMC Women's Health 2009;9:37.
Ghazdehi MR, Amini L, Parvizi S, Hoseyni AF. Attitudinal barriers to mammography screening among women in Tehran, 2010. J Mazandaran Univ Med Sci 2013;23.
Darvishpour A, Vajari SM, Noroozi S. Can health belief model predict breast cancer screening behaviors? Open access Maced J Med Sci 2018;6:949.
Al-Dubai SA, Ganasegeran K, Alabsi AM, Manaf MR, Ijaz S, Kassim S. Exploration of barriers to breast-self examination among urban women in Shah Alam, Malaysia: A cross sectional study. Asian Pac J Cancer Prev 2012;13:1627-32.
Yavari P, Pourhoseingholi MA. Socioeconomic factors association with knowledge and practice of breast self-examination among Iranian women. Asian Pac J Cancer Prev 2007;8:618-22.
Madubogwu CI, Egwuonwu AO, Madubogwu NU, Njelita IA. Breast cancer screening practices amongst female tertiary health worker in Nnewi. J Cancer Res Ther 2017;13:268-75.
Akhtari-Zavare M, Juni MH, Ismail IZ, Said SM, Latiff LA. Barriers to breast self examination practice among Malaysian female students: A cross sectional study. Springerplus 2015;4:692.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||The effect of self-care training programs on lifestyle and breast self-examination of immigrant Afghan women
| ||Elaha Jafari, Mahnaz Zarshenas, Monireh Toosi, Azar Nematollahi, Mehrab Sayadi |
| ||Journal of Education and Health Promotion. 2023; 12(1): 14 |
|[Pubmed] | [DOI]|
||Evaluation of Knowledge, Practice, and Barriers Towards Breast Self-Examination (BSE)
| ||Siti Nur Anis Ismail, Nurul Dizyana Nor Azman, Ann Eryyna Lema Thomas Sudin, Nurul Saadiah Shamsuddin |
| ||Malaysian Journal of Medicine and Health Sciences. 2022; 18(s15): 190 |
|[Pubmed] | [DOI]|
||Design, implementation, and evaluation of self-care program in the prevention of breast cancer among women in Isfahan: a community-based participatory action research protocol
| ||Maryam Kianpour, Fariba Taleghani, Mahnaz Noroozi, Mitra Savabi-Esfahani, Zahra Boroumandfar, Tahereh Changiz, Zahra Ravankhah, Shaghayegh Haghjooy Javanmard, Maryam Sadat Hashemi |
| ||Women's Midlife Health. 2022; 8(1) |
|[Pubmed] | [DOI]|
||Breast Self-examination Among AKHA Women (Hill Tribe Group) in Chiang Rai, Thailand
| ||Sirinan Suwannaporn,Montakarn Chuemchit |
| ||Journal of Immigrant and Minority Health. 2021; |
|[Pubmed] | [DOI]|
||A Qualitative Focus Group Study for the Exploration of Knowledge and Attitudes of Informal Caregivers Toward Breast Cancer: Perceptions of Informal Caregivers and Healthcare Professionals in Three European Countries
| ||Theologia Tsitsi, Andri Christou, Maria Christodoulou-Fella, Sara Beccati, Licia Boccaletti, Alessia Palermo, José Alves, Ana Teixeira, Andreas Charalambous |
| ||INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2021; 58: 0046958021 |
|[Pubmed] | [DOI]|
||Determinant of breast self-examination with health belief model approach in student of 17 high school Makassar in 2019
| ||Mohammad Jumiati,Ummu Salmah,Ummu Indar |
| ||Enfermería Clínica. 2020; 30: 308 |
|[Pubmed] | [DOI]|
||Assessment of knowledge and practice of breast self-examination among reproductive age women in Akatsi South district of Volta region of Ghana
| ||Rita Dadzi,Awolu Adam,Carmella August |
| ||PLOS ONE. 2019; 14(12): e0226925 |
|[Pubmed] | [DOI]|