Knowledge, attitude, and practices of women attending primary health care centers toward breast self-examination in Al-Karkh baghdad, 2018

Breast cancer (BC) is the most prevalent form of cancer in Iraq, accounting for 21% of all female cancers. It is considered to be a progressive disease with a poor prognosis if detected late. The low level of knowledge and practice of breast self-examination is an important method of prevention. The objective of this study to assess knowledge of Iraqi women at Baghdad-Alkarkh about breast cancer risk factor and their practices of breast self-examination. The aim of the study to assess knowledge of a sample of Iraqi women at Baghdad-Alkarkh about breast cancer risk factors and their practices of breast self-examination, clinical breast examination and mammography, to assess the attitude and practices of breast cancer screening methods. Across-sectional study was conducted using interviewer-administered questionnaires. Samples of 400 females were systematic randomly selected from women attending primary health care centers at Baghdad-Alkarkh sector. Statistical package for social sciences (SPSS) version 25 was used to study the statistical association between variables. This study showed that two third of participants had knowledge of BSE and poor practicing for BSE. The main source of information among all participants via PHCCs. In conclusion, good knowledge was noticed among women attending primary health care centers. Practicing of breast self-examination was poor .


Introduction
Breast cancer is the glandular breast tissue.It's the most common malignancy among women in most developed and developing regions of the world with nearly million new cases each year.It accounts for nearly 21% of all cancers and is considered the leading cause of cancer mortality among women worldwide [1].In Iraq, it is ranked first among female cancers.The incidence rate among Iraqi Women was increased from 2000-2009 as shown in figure-1-reaching to 18.46/100000 female population in 2009 and the highest incidence rate (99.23/100000) was recorded among 45-49 age group [2].The aim of the breast selfexamination method is to find cancer early and in a curable phase in order to decrease mortality caused by breast cancer.
The ideal result for a screening program is reduced suffering for the affected individual at the minimum cost for society.High coverage and regular attendance are necessary to achieve this aim and can only be obtained by trust and acceptance among the targeted populations [3].Therefore, there is need to assess current level of knowledge of breast cancer risk factors and practice of screening methods among female populations.This would help in determining the need for continuing health education programs that could improve knowledge of the disease and adoption of early detection measures among this targeted population.
Objectives of this study is to assess knowledge of a sample of Iraqi women at Baghdad/AlKarkh about breast cancer risk factors and their practices of breast selfexamination, clinical breast examination and mammography, to assess the attitude and practices of breast cancer screening methods.

Materials and Methods
A cross sectional study was conducted to assess the breast cancer related knowledge, attitude, and practice of breast self-examination.All females who attended selected primary health care center (three selected by systematic random method).Primary health care centers of family medicine which include: The Target population comprised all females attending selected primary health care center.
Criteria for eligibility included females twenty or more years old and who don't have previous history of breast cancer.Using interviewer-administered questionnaires manuscript in Arabic language.These questionnaires divided into four parts: -First part is to elicit socio-demographic data on age, profession, marital status, education.
Questions relating to knowledge of breast cancer risk factors were included in second part, which consisted of many factors with different levels of relative risk for breast cancer as: age, late menopause, early menopause, family history, and obesity in menopause, contraceptive pills, hormonal replacement therapy, no breast feeding and smoking.In third part, question was asked on their knowledge related to early detection method and their practicing of BSE.
The last part concentrated on the main source of their knowledge, a participant's awareness of breast cancer and early detection methods.The participants answered most questions by choosing from given answers.Systemic random sampling technique was applied to select 400 female attending to primary health care centers.

Results
A total of 400 women was enrolled in this study with a mean age of 36.6 ± 12.7 (range: 17-78) years.A majority of the studied group (81%) aged less than 50 years.Vast majority (94%) of the studied group were married.Eighty-one of them had secondary or higher level of education, 71.5% were housewives, 84.3% were physically active.The mean body mass index (BMI) of the studied group was 28.9 ± 5.6 (range: 18.6 -47.7) kg/m 2 on the other hand, 29% of the women had normal BMI Normal (BMI: 18.6 -24.9 kg/m²), 33.5% were overweight (BMI: 25 -29.9 kg/m²) and 37.5% were Obese (BMI ≥ 30 kg/m²).These findings are shown in (table 1).  2 and 3).Knowledge about breast self-examination (BSE) among the studied group, 269 women (67.25%) claimed that they were learned about BSE (Figure 1).Additionally, 122/269 women (45.4%) mentioned that their learning about BSE was obtained from the PHCCs, 76 (28.3%) from TV, 62 (15.5%) from the internet and 48 (12%) from other sources, (Table 5).To assess the relationship between the characteristics of the women in the study and their learning about BSE, cross tabulation was performed between learning about BSE and these characteristics, (Table 8), a significant relationship had been found between age and learned BSE; women at age (< 30 years) and those at (≤ 60 years) were less likely heard and learned about BSE, (P = 0.001), furthermore a significant higher proportion of women who were overweight, had Secondary school or higher level of education, employed, practiced sports, premenopausal and with positive family history of breast cancer were heard and learned about BSE, in all comparisons, (P<0.05),other variables showed insignificant relationship.
For the practicing of BSE, it had been significantly found that higher proportion of women practiced BSE among those aged 30 -49 years, with secondary school or higher level of education and among employed women, in all comparisons, (P<0.05),other variables showed insignificant correlation with practicing BSE, (Table 9).Further analysis was conducted between leaning about BSE and practicing BSE which significantly revealed a that women who were heard or learned about BSE were more likely to practice BSE than those who did not, (P<0.05),(Table 10).
On the other hand, women heard about BSE tend to regularly practice BSE, (46.1%), then those who did not heard or informed (5.3%) about BSE, (P< 0.001), also higher proportion of women heard about BSE checked their breasts at the PHCC than those who did not heard, 13.4% vs. 3.1%, respectively.Additionally, 11.2 % of these women performed X-ray of the breast previously compared to only 2.3% of those who did not hear about BSE, (P=0.002),(Table 11).

Discussion
This cross-sectional study examined Iraqi women's breast cancer awareness and screening behavior (BSE, CBE and mammography).In other developed and developing nations, women's breast cancer knowledge was low [4,5].Most research participants were unaware of key breast cancer risk factors.Non-breastfeeding, hormone therapy, and family history of breast cancer were the biggest risk factors.
The health education in PHCC, media, and community leaders' breast-feeding efforts are congruent with Saudi Arabia's results [6].Early menarche, late menopause, and early childbirth were not risk factors in examined populations.It matches Kuwaiti news (7).
Hameed just reported the same in Iraq [8].Nurses, pharmacists, physiotherapists, and laboratory workers had intermediate breast cancer risk factor knowledge.31% knew well.
Other female healthcare practitioner research has comparable findings [9].
In Lagos, Nigeria, nurses have poor breast cancer risk factor knowledge [10].In the UK, more than half of general practitioners could properly identify breast cancer risk factors [11,12].However, Australian research found that GPs knew little about breast cancer risk factors Country-specific breast cancer risk factor knowledge appears.This study found that women knew more about breast cancer than PHCC attendees.Breast cancer information did not affect BSE practice (p= 0.02).
This may be because or maneuver are unrelated to knowledge.Due to their frequent contact with patients and family members, nurses are crucial to breast cancer knowledge, dissemination, and care.Specialist breast care nurses in advanced nations have extended this position [13].Nurses said they might dispel breast cancer misconceptions [14].Many characteristics were related with higher knowledge in this study.Over-40s have poorer knowledge.Knowledge ratings decreased with ageing in another research [15].
The study also found that educational status considerably (p=0.001)affects knowledge level, which is consistent with a study of educated Iraqis [16] and the National American survey on cancer risk [17].Many studies have linked late breast cancer diagnosis to inadequate breast self-examination, either because women have never heard of it or don't know how to conduct it, and they don't use mammography for screening [16].More than 67.25% of participants knew about BSE, which is comparable with prior Iraqi studies [16].It is lower than Pakistan (83%) [18] and greater than India (56%) [19], Iran (64%), and Saudi Arabia (30.3%) [20].
Poor BSE female attendance at PHCC 5.3% was lower than prior research in Iraq [4,16].
The findings showed poor BSE practice among health professionals (18%), lower than a cross-sectional research of female healthcare workers in Tehran (6%) [21] and Turkey (87%) (22).40% of Korean nurses did BSE [23].Health workers practiced BSE more than medical and law students.Health directorate intensive seminars may explain these outcomes.Workshops teach health.
The findings may emphasize small group education and face-to-face techniques.This supports another research [24].This research found lower monthly BSE than prior Iraqi studies [4,16].BSE practice is consistent with Saudi Arabia (20) and higher than Iran (4.5%) [25].Iraq's cancer screening process may explain the stated number.Lack of national programmer may explain Iran's low rate [25].In Egypt, 10.4% was found [5,26].The study centered on newly diagnosed breast cancer patients.In developed nations, 58.1% Korean American women [27] and 90.3% Sao Paulo women [28] had higher rates, suggesting that breast cancer awareness is higher in developed countries [29].In this study, those who did not conduct BSE did not know how.
Iraqi research found this knowledge gap [4,16].This study found an age-BSE knowledge correlation.This conclusion matches another Iraqi research [30] and contradicts Chennai's [31].Even among breast cancer risk-aware women, BSE, CBE, and mammography screening rates were low.Clinical examination, mammography, and other services may be inaccessible.This matches other reports [27].The early detection section/MOH reported that BSE quadrupled in Iraq in 2010 [32].This research revealed a substantial correlation between knowledge and age, comparable to earlier studies, but unlike studies in the United Arab Emirates, which found no correlation [33].

Conclusion
Two thirds of females were studying a good knowledge on breast cancer.Weak practicing screening methods.Knowledge of health worker about breast cancer was weak.
Educational level was a factor for good knowledge.Age was a determinant of a good knowledge.

1 .
Al-Mansour PHC, 2. Al-Yarmouk PHC, 3. AL-Dakhlia PHC two days per week.Collection of data was extended from the beginning of March 2018 till the end of May 2018.

Figure 1 .
Figure 1.Distribution of the studied group according to the Knowledge about Breast Self-Examination (BSE) (N = 400)

Table 1 .
Demographic characteristics of the studied group

Table 2
shows the Obstetrical characteristics of the studied group, where 144 women (36%) had started their menarche at age less than 12 years, 221 (55.3%) at 12 -14 years and 35 (8.8%) of women at age of more than 14 years.Regarding parity, parous women were 364 women (91%) while only 36 women (9%) were nulliparous, and the mean age at first pregnancy was 23 ± 4.6 (range: 14 -41) years, additionally, among the parous women, 253 (69.5%) mentioned that they feed their child normally.Regarding menopausal status, 75 women (18.8%) were menopause, and the mean age of menopause was 49 ± 3.8 (range: 40 -55) years, on the other hand, almost in two third of menopause women, (50/75), the body weight raised after menopausal, (Tables

Table 2 .
Obstetrical characteristics of the studied group

Table 3 .
Distribution of age at first pregnancy and mean at menopause (75 menopause women)

Table 4 .
Breast cancer related factors

Table 5 .
Source of knowledge of 269 women who were learned about BSE of the 400, (10%) checked their breast at the PHCC and only 33 (8.3%) performed x-ray of the breast (Table7) .

Table 6 .
Timing of examination of 178 women who were practiced BSE

Table 7 .
History of Breast checking at PHCC and performed breast X-ray (N = 400).

Table 8 .
Cross-tabulation of the relationship between knowledge about BSE and characteristics of participant women.

Table 9 .
Cross-tabulation of the relationship between practicing BSE and characteristics of

Table 10 .
Cross-tabulation of the relationship between practicing knowledge and practicing of BSE

Table 11 .
Cross-tabulation of the relationship of Knowledge about BSE with regularity of BSE and clinical examination of breast.