The aim of the current study was to investigate breast cancer screening performance among Iranian Turkmen women along with their knowledge and beliefs. A cross-sectional study was carried out in June to December 2011. Through clustered sampling method, 1080 Iranian Turkmen women completed the questionnaire including breast cancer screening adherence, knowledge, fatalism beliefs, and perceived threat using Champions Health Belief Model Scale (CHBMS).The mean age of the participants was 43.04 (SD = 11.80) years. Compliance rate in a regular basis based on national guidelines was 13.1%, 2.5%, and 0.9% for SBE, CBE, and mammography, respectively. A mere 4% have been provided adequately with information about breast cancer. Having knowledge was the best predictor of breast cancer screening adherence along with high educated husbands for SBE performing. Susceptibility and fatalism were low and were influenced by participants’ educational level and age. In conclusion, Iranian Turkmen women had insufficient knowledge, low perceived susceptibility, high fatalistic belief, and very poor adherence to breast cancer screening. There is a need for providing breast cancer education programs among the Iranian Turkmen women to increase their adherence rate.
Breast cancer is the most common type of cancer among women and its incidence rates are increasing throughout the world [
Essential to the success of decreasing mortality, early detection and breast cancer diagnosis is logically a significant process and it could lead consequently to an increase in the survival rate up to 95% [
The Health Belief Model (HBM) has provided a useful conceptual framework to prevent health behaviors. According to HBM, threat perception and behavioral evolution are the two main components which are derived from expectancy-value theory. Threat perception included two key beliefs: perceived susceptibility and anticipated severity of contracting health conditions [
The model states internal and external cues such as body states and environmental factors which may also promote or inhibit health enhancing behavior (cues to action), the confidence that one can successfully practice the behavior required to produce the outcome (self-efficacy), and the desire to maintain good health status (health motivation) were added to the model [
Researchers have found that the fatalistic attitudes are the major barrier to recommended breast cancer screening uptake. Fatalism is identified as a doctrine of fate, a philosophical doctrine held by individuals who believe that all events are fated to happen and that human beings have no control over their futures and are unable to change their outcomes [
Turkmen people are a racial group that reside in northern and north east of the Islamic Republic of Iran and composed about 0.8% of the Iranian population. This population group has different culture, religion, and language from the most part of the country. There is not any survey that reported this racial minority with the topic of breast cancer screening behaviors. Studies indicated that along with demographic characteristics, the health belief variables such as perceived susceptibility to breast cancer, seriousness of breast cancer can influence the performance of BSE, CBE, and mammography [
A cross-sectional study was carried out in June to December 2011, simultaneously in Gonbade Qabous and Turkmen districts in Golestan province where their main residents are Turkmen people. Prior to data collection, the study was approved by the Golestan University of Medical Sciences Authorities. Women gave verbal consent to participate after being given assurances of confidentiality and anonymity, and no incentives were offered for completing the survey. The inclusion criteria for participants were 30 years of age or older, women who are Turkmen ethnic group, and capable of communicating in Turkmen language.
The perceived susceptibility and perceived severity related to breast cancer instruments were translated using the Banville method, to develop a cultural adaptation [
To recruit eligible women to participate in this study, we had recourse to a number of 10 health centers in the cities and 60 rural health houses, providing and including all family records basis on primary health cares.
Participants were a clustered randomized sample of 1080 Turkmen women. Their ages ranged between 30 and 82 years, with a mean age of
Demographic profile of the surveyed population.
Characteristics |
|
---|---|
Age ( |
|
30–39 | 522 (48.3) |
40–49 | 249 (23.1) |
50–59 | 177 (16.4) |
≥60 | 132 (12.2) |
Marital status ( |
|
Married | 921 (85.3) |
Unmarried | 63 (5.8) |
Widowed | 93 (8.6) |
Divorced | 3 (0.3) |
Educational level ( |
|
Illiterate | 399 (37) |
Less than 5 years | 355 (33) |
6–8 years | 132 (12.1) |
9–11 years | 41 (3.8) |
High school graduate | 104 (9.6) |
College level | 49 (4.5) |
Job | |
Work in home | 1030 (96) |
Out of home | 50 (4) |
Breastfeeding experience | |
Exclusive breastfeeding | 776 (70.8) |
Formula | 48 (4.4) |
Both of them | 173 (16) |
Unknown | 94 (7.8) |
Oral contraceptive use | |
Yes | 578 (53.5) |
No | 502 (46.5) |
The questionnaire consisted of four parts: (1) demographic variables included questions about age, level of education, current marital status, children’s number, job, and breast cancer risk factors such as history of oral contraceptive use, family history of breast cancer, and whether breastfed their child/children; (2) knowledge-related breast cancer screening: hearing of BSE, CBE, and mammography, periodic time of BSE, CBE, and mammography, and receiving of first mammogram time; (3) practice for breast cancer screening behaviors: recommended frequency of BSE, CBE, mammography, and regular/irregular basis; (4) susceptibility (3 items) and seriousness (7 items) to breast cancer were assessed using the Champions Health Belief Model Scales (CHBMS) [
All data were entered in the SPSS (version 15) Windows software. Descriptive statistics were used in demographic characteristics and other variables. Chi-Square test was applied to on the difference between breast cancer screening performance and selected demographic variables. One-way analysis of variances and Mann-Whitney
According to Table
Age groups and breast cancer screening behaviors in a sample of Iranian Turkmen women.
Age group | Performed BSEa |
Performed CBEb |
Performed mammogramb | ||||||
---|---|---|---|---|---|---|---|---|---|
Yes % ( |
No % ( |
Statistics | Yes % ( |
No % ( |
Statistics | Yes % ( |
No % ( |
Statistics | |
30–39 | 83 (15.9) | 439 (84.1) |
|
32 (6.1) | 490 (93.9) |
|
4 (0.8) | 518 (99.2) |
|
40–49 | 36 (14.5) | 213 (85.5) | 12 (4.8) | 237 (95.9) | 2 (0.8) | 247 (99.3) | |||
50–59 | 19 (10.7) | 158 (89.3) | 2 (1.1) | 175 (98.9) | 3 (1.7) | 174 (98.3) | |||
≥60 | 6 (4.5) | 126 (95.5) | 0 (0) | 132 (100) | 0 (0) | 132 (100) | |||
| |||||||||
Total | 144 (13.3) | 936 (86.6) | 46 (4.3) | 1034 (95.7) | 9 (0.8) | 1071 (92.2) |
aWomen of 30 years of age and older.
bWomen of 40 years of age and older.
When asked about their common barrier to participating in breast cancer educational session, they listed lack of time (47.8%), followed by transportation (20.7%), did not want to think about breast cancer (10.4%), and did not believe that breast cancer is important (2.5%), and 18.6% did not report any reasons for barriers.
When women were asked if they had heard something about BSE, CBE, and mammography, 42.2% reported that they heard about BSE, 32.7% about CBE, and 24.4% about mammography. Results regarding breast cancer screening behaviors based on national guidelines revealed that the majority of women (94.4%) did not know anything about monthly BSE. Only 1.9% correctly reported that CBE every three years should be performed between the ages of 20 and 39 years. The annual yearly mammography screening test started at the age of 40 was reported by 4.5% of the participants.
Seventy-six point eight percent of the participants had not ever performed BSE, followed by 93% for CBE, and 97.8% for mammography. Last month performance of BSE among those who have 30 years and older was 13.1%. Among those who have 40 years and older, mammogram in the past year was .9% and CBE in the past year was 2.5%. When women were asked if they were acquainted with any person who had breast cancer, they reported only one person having breast cancer themselves, 0.8%, 0.7%, 0.1%, 10.7%, and 4.2% reported that their mother, sister, daughter, close relatives (except family members), and friends have breast cancer, respectively. 42.5% delineated they have also lie with breast cancer.
The breast cancer screening behaviors were influenced by age group except for mammography (Table
Educational levels and breast cancer screening behaviors in a sample of Iranian Turkmen women.
Educational level | Performed BSEa (within last month) | Performed CBEb (within last year) | Performed mammogramb (within last year) |
||||||
---|---|---|---|---|---|---|---|---|---|
Yes % ( |
No % ( |
Statistics | Yes % ( |
No % ( |
Statistics | Yes % ( |
No % ( |
Statistics | |
Illiterate | 44 (11) | 355 (89) |
|
12 (3) | 387 (97) |
|
5 (1.3) | 394 (98.7) |
|
Less than 5 years | 47 (13.2) | 308 (86.8) | 11 (3.1) | 344 (94.9) | 2 (0.6) | 353 (99.3) | |||
6–8 years | 16 (12.1) | 116 (87.9) | 2 (1.5) | 130 (98.5) | 0 (0) | 132 (100) | |||
9–11 years | 4 (9.8) | 37 (90.2) | 1 (2.4) | 40 (97.6) | 0 (0) | 41 (100) | |||
High school graduate | 21 (20.2) | 83 (79.8) | 8 (7.7) | 96 (92.3) | 2 (1.9) | 102 (92.2) | |||
College level | 10 (20.4) | 39 (89.6) | 7 (14.3) | 42 (85.7) | 0 (0) | 49 (100) | |||
| |||||||||
Total | 142 (13.2) | 126 (86.8) | 41 (3.8) | 1039 (96.2) | 9 (0.8) | 1071 (99.2) |
aWomen of 30 years of age and older.
bWomen of 40 years of age and older.
The results described that the mean and SD of susceptibility of the women were
Beliefs related to breast cancer screening adherence and educational levels in a sample of Iranian Turkmen women.
Beliefs | Educational levels |
|
Tukey's HSDa | |||||
---|---|---|---|---|---|---|---|---|
A ( |
B ( |
C ( |
D ( |
E ( |
F ( |
|||
Susceptibility | 2.66 ± 1.11 | 2.91 ± 1.20 | 2.78 ± .95 | 2.69 ± .96 | 3.07 ± 1.10 | 3.25 ± .95 | 4.805 | A, B < C, D, E, F C, D, E < F |
Seriousness | 3.74 ± .73 | 3.82 ± .66 |
3.66 ± .67 | 3.65 ± .59 | 3.55 ± .75 | 3.57 ± .73 | 3.397 | N.S |
Fatalism | 4.02 ± .68 | 3.96 ± .76 | 3.79 ± .69 | 3.45 ± .94 | 3.49 ± .89 | 3.26 ± .87 |
18.650 | F, E, D < C, B, A, C < B, A |
A: illiterate; B: less than 5 years; C: 6–8 years; D: 9–11 years; E: high school graduate; F: college level.
aMean differences for the Tukey's HSD pairwise comparisons (
Beliefs related to breast cancer screening adherence and age groups in a sample of Iranian Turkmen women.
Beliefs | Age group |
|
Tukey's HSDa | |||
---|---|---|---|---|---|---|
A ( |
B ( |
C ( |
D ( |
|||
Susceptibility | 2.90 ± 1.10 | 2.89 ± 1.12 | 2.67 ± 1.16 | 2.57 ± 1.08 | 4.851 | A, B > C, D |
Seriousness | 3.73 ± .67 | 3.79 ± .68 | 3.65 ± .79 | 3.67 ± .73 | 1.601 | N.S |
Fatalism | 3.76 ± .81 | 3.93 ± .76 | 3.94 ± .77 | 4.03 ± .66 | 6.176 | A < B, C, D B, C < D |
A: 30–39 years; B: 40–49 years; C: 50–59 years; D: ≥60 years.
aMean differences for the Tukey's HSD pairwise comparisons (
The Mann-Whitney
Significant association was founded between exposure to the concept of perceived susceptibility (
Logistic regression results showed that women’s knowledge rate about breast cancer screening behaviors was the best predictor of BSE, CBE, and mammography adherence. Further, the husband education level was an another predictor of BSE performance (Table
Logistic regression analysis for breast cancer screening performance among Turkmen women.
|
SE | Wald |
|
Exp(B) | 95% CI | |||
---|---|---|---|---|---|---|---|---|
Lower | Upper | |||||||
SBE | Knowledge | 0.464 | 0.143 | 10.482 | 0.001 | 1.591 | 1.201 | 2.107 |
Husband education | 0.137 | 0.061 | 4.991 | 0.025 | 1.147 | 1.017 |
1.294 | |
CBE | Knowledge | 0.841 | 0.164 | 26.277 | 0.001 | 2.318 | 1.681 | 3.197 |
Mammography | Knowledge | 0.995 | 0.261 | 14.559 | 0.001 | 2.704 | 1.626 | 4.507 |
Early detection of breast cancer via adherence to current screening behaviors is a key epigram to effective treatment and prognosis of this malignancy which can reduce morbidity and mortality. In this regard, the adherence rates may be influenced by some personal and sociodemographic variables as well as the individuals’ knowledge and beliefs. The objective of the current study was to determine the SBE, CBE, and mammography performance in a sample of Iranian Turkmen women.
The results of the study indicated the participants’ knowledge and compliance with recommended screening practice is insufficient and poor. In this regard, the lack of sufficient knowledge of breast cancer reported by subjects may have influenced their low screening adherence. According to the knowledge, 96% said that their information related to breast cancer is insufficient and 71.9% were willing to receive personal education and would be willing to participate in this area by educational materials. This worthy intention for education is a good opportunity for local health care providers to implementing appropriate interventions for the enhancing breast cancer knowledge, belief, and screening compliance. In this regard, the time and transportation were the most reported barriers to participation in educational sessions, suggesting that to implementing of the interventions in women routine patterns of living and improving local transportation accessibility.
In the current study, a mere 13.1% of participants have had BSE during the last month and the vast majority of the participants (97.5%) at the age of 40 and older did not report CBE in the past year; this rate was 99.1% for mammogram. Our findings have been identical nearly to the results of other previous studies conducted in Iran, where breast cancer screening performance in accordance with national guidelines ranged from 4.5% to 42.7% for SBE, 3% to 29.5% for CBE, and 3.3% to 30.5% for mammography in different samples and varied ethnic groups [
The results demonstrated that SBE performance was impressed by age, marital status, and exposure to breast cancer. Inconsistent with our finding Avci reported marital status and familial breast cancer history were significantly associated with BSE performance, but not associated by educational levels and age [
In line with mammography among women of 40 years and older, the very poor performance was observed. Iranian Ministry of Health recommended mammogram every 1-2 year at age of 40 and thereafter. The finding of the current study related to mammogram practice is lower than other parts of Iran. In contrast, mammography practice is higher in western countries, where Wu et al. reported that compliance with recommended screening practice is 64% among Filipino, Chinese, and Asian-Indian women of ethnic group in the United States [
Mammography adherence was not significantly associated with demographic characteristics like age, education, marital status, and breast cancer family. Contrary to our findings other studies demonstrated that annual mammogram performance varied according to age, educational level, marital status, and having breast cancer exposure [
On the basis of the selected HBM subscales, only concept of susceptibility was positively associated with BSE, CBE, and mammography compliance. Women who performed BSE, CBE, and mammography perceived higher risk to breast cancer than those who did not practice BSE, CBE, and mammography. The concept of perceived severity is not significantly associated with screening behavior that is inconsistent with HBM theory. Our findings are in agreement and supported other studies, where they concluded that perceived severity may be that the breast cancer is regarded as a serious condition by most women [
In the current study, the education level and age were significantly associated with susceptibility; the younger and high educated women perceived higher risk to breast cancer. Meanwhile, the education level negatively correlated with seriousness and fatalism that poorly educated women are more likely to consider the breast cancer as severe condition and that its susceptibility is the will of God and depend on luck. In consistence with our findings, Katapodi et al. meta-analytic review demonstrated that perceived risk is weakly influenced by age and education. Seven of those studies concluded that younger women were more likely to perceive higher risk for developing breast cancer than older women [
We found that fatalism belief was higher than perceived susceptibility and seriousness which could considered as a barrier to breast cancer screening behaviors and early detection. Fatalism belief had a positive significance with age; the older women had higher perceived fatalistic belief. This result supports previous findings suggesting that fatalistic belief is an important belief in Muslim societies [
In conclusion, the results of the current study revealed Turkmen women had poor knowledge, low perceived susceptibility, high fatalistic belief, and low adherence to breast cancer screening. For increasing breast cancer screening adherence of Turkmen women, conducting a holistic and comprehensive intervention through viable strategy is imperative.
First, the study used a cross-sectional sample. Second, the self-report nature of questionnaire in spite of the anonymous nature of the questionnaires should be mentioned. Third, women's self-report in compliance with CBE and mammography screening was not validated with their medical records. Another limitation was that the concepts of perceived barriers, perceived benefits, self-efficacy, and health motivation were not survived. Thus, further studies are needed to examine these concepts in other geographic locations of Turkmen population women. In spite of this limitation, the current study demonstrated new sights for the understanding of perceived threat, fatalism, and behaviors of breast cancer screening in Iranian Turkmen women.
The authors declare that there is no conflict of interests.
The authors are very grateful to Gozel Bahalkeh for her valuable cooperation and primary health care providers of the selected centers for their help in the data collection process. Meanwhile, they thank Golestan University of Medical Science, Vice Chancellor for research for their financial support.