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Knowledge and Source of Information About Early Detection Techniques of Breast Cancer Among Women in Iran: A Systematic Review
Journal of Cancer Prevention 2018;23:51-60
Published online March 30, 2018
© 2018 Korean Society of Cancer Prevention.

Salehoddin Bouya1, Abbas Balouchi2,3, Sudabeh Ahmadidarehsima4, and Mahin Badakhsh5

1Clinical Immunology Research Center, Ali-ebne Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran, 2Student Research Committee, Nursing and Midwifery School, Iran University of Medical Sciences, Tehran, Iran, 3School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran, 4Faculty of Nursing and Midwifery, Jiroft University of Medical Sciences, Jiroft, Iran, 5Midwifery Department, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Iran
Correspondence to: Mahin Badakhsh, Midwifery Department, School of Nursing and Midwifery, Zabol University of Medical Sciences, Zabol, Sistan and Baluchestan Province, Ferdowsi st, 9993139146, Iran, Tel: +98-9156786203, Fax: +98-5435223101, E-mail: badakhshmahin@gmail.com, ORCID: Mahin Badakhsh, http://orcid.org/0000-0002-2728-7991
Received February 13, 2018; Revised March 12, 2018; Accepted March 12, 2018.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Background

An increase of access to knowledge about early detection techniques of breast cancer can reduce this mortality rate. This study aimed to determine the knowledge and source of information about early detection techniques of breast cancer among Iranian women.

Methods

Both International (PubMed, Web of Science, and Google Scholar) and national (scientific information database [SID] and Magiran) databases were reviewed launching to September, 2017 to obtain related articles. Steps involving the screening, analysis of quality of the studies and extraction of papers were performed by two researchers.

Results

Of the 749 studies searched initially, 25 studies performed on 11,756 people were selected for the final stage. General knowledge for breast cancer screening among women ranged from 4.5% to 45%. The number of people with sufficient knowledge about breast self-examination in various studies was between 5% and 79.8%. The most important source of information was the Healthcare team.

Conclusions

Considering the poor knowledge and different source of information, it is suggested that educational programs be conducted around the country especially in at-risk populations.

Keywords : Breast self-examination, Early detection of cancer, Knowledge, Iran, Systematic reviews
INTRODUCTION

Worldwide, breast cancer is the second leading cause of death from cancer in women.1,2 In Iran, breast cancer is common cancer with 76% of women cancer patients suffering from this malignancy.3 The results of a study in Iran showed that 23% of breast cancers were observed in women under 40 years of age, and 70% of women died from the diagnosis of advanced disease in a short period of time. The persistence of death from breast cancer in Iranian women is partly due to the low usage of breast cancer screening and late detection.4 There is evidence that among all Iranian women, one of every four women with cancer diseases is diagnosed as advanced stages breast cancer, and this has killed more than 3,742 people by 2017.3,5,6 According to the World Health Organization, the best way to control breast cancer is early diagnosis.7 The purpose of the screening program is to diagnose the disease after it starts and before it can lead to clinical symptoms. The American Cancer Society recommends the following screening methods for early detection of cancer in asymptomatic patients including: 1) Breast self-examination (BSE); 2) Clinical breast examination (CBE); and 3) Mammography.8 In developing countries including Iran, awareness of breast cancer screening methods is low.6 In Iran, with an increase in life expectancy and aging, the incidence and mortality rate of breast cancer will increase in the coming years, so that deaths caused by breast cancer are expected to increase by more than 7,000 by 2035.1,3 Given the importance of the knowledge and determining the correct age of the early diagnosis of breast cancer in the timely treatment of the disease and reducing the resulting mortality, accurate determination of women’s awareness as an epidemiologic gap can help increase the awareness of health decision-makers and determine the suitable source of information. Therefore, this systematic study was conducted to assess the knowledge and information resources about the prevention techniques of breast cancer among women in Iran.

MATERIALS AND METHODS

1. Eligibility criteria

The methods adopted for this systematic review have been developed in accordance with the Cochrane Handbook for Systematic Reviews and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) tool.9 Quantitative observational studies were included in the present study. Case series, case reports and letter to editors were excluded. The target population was women with and without breast cancer living in Iran. The knowledge and source of information about early detection of techniques of breast cancer were measured in this study. Minimum required sample size was ≥ 25 participants.

2. Search strategy and databases

Literature review was done using the medical subject headings (MeSH) and key words related to knowledge and source of information about breast cancer screening techniques in Iran. The international (MEDLINE [PubMed interface], Google Scholar, and Web of Science [Web of Science interface]) and national (scientific information database [SID] and Magiran) and National key journal (Iranian Journal of Breast Diseases) databases were searched for relevant studies without settings and language limits from lunching to 30 December 2017. Health Sciences Librarian and PRESS standard were used for creating the search strategy.10 The MEDLINE program was adopted to search in for other databases. Moreover, PROSPERO was used to search for ongoing or recently completed systematic reviews. Boolean operators (AND, OR, and NOT), MeSH, truncation “*” and related text words were used for search in title and abstract using following keywords: Knowledge, Sources of information, Breast cancer, Breast neoplasm, Breast cancer self-examination, Mammography, Clinical breast examination, Population and Iran.

3. Study selection

Results of the Literature review were exported to Endnote. Prior to the formal screening process, a calibration exercise was undertaken to pilot and refine the screening. Formal screening process of titles and abstracts were conducted by two researchers according to the eligibility criteria, and consensus method was used for solving controversies among the two researchers. The full text was obtained for all titles that met the inclusion criteria. Additional information was retrieved from the study authors in order to resolve queries regarding the eligibility criteria. The reasons for the exclusion criteria were recorded. Neither of the review authors was blinded to the journal titles, the study authors or institutions.

4. Data extraction, quality assessment

Data form items included general information (first author, brief title, province and year of publication), study characteristics (study design, sampling method, mean of data collection, setting, sample size and risk of bias, questioner characteristics and psychometric characteristics), participants characteristics (age group) and outcome measures (knowledge and source of information). The tool of Hoy et al.11 was used to assess the quality of studies. These decisions were made independently by two review authors based on the criteria for judging the risk of bias; in case of any disagreement, the consensus method was used to resolve such controversies. Studies were tabulated in chronological order.

RESULTS

1. Study selection

A total of 749 articles were retrieved from the initial search in different databases. Out of 620 non-duplicated studies in title and abstracts screening process, 575 studies were excluded due to irrelevant titles. Of 45 studies, 25 studies met the eligibility criteria. In 20 excluded studies, two studies were review, six studies were letter to editor, three studies had no full text and nine studies were of low quality and could not be included in the study. The list of studies is available at http://uploadboy.me/verhw72hohee/List of final included studie1.pdf.html (Fig. 1).

2. Study characteristics

Final included studies were conducted on 11,756 participants; the age group range was 15 to 75 years. All the included studies used a cross-sectional design. Studies were conducted only in 16 out of 31 provinces in Iran. Of the 25 studies, three studies were from Chaharmahal and Bakhtiari,1214 two studies were from Ardabil,15,16 while in Golestan,17,18 Isfahan,19,20 Khuzestan,21,22 Mazandaran,23,24 Yazd,25,26 Razavi Khorasan,4,27 and in other provinces were conducted one study each. Most studies were conducted at outpatient clinics (n = 14), had a simple random sampling method (n = 7), date were collected through interview (n = 19) and had low risk of bias (n = 20) (Table 1).4,1235

3. Main results

1) Instruments

In general, all the instruments used in the reviewed studies were researcher-designed. The aim of the questionnaires was to assess the knowledge, attitude and practice about early detection techniques of breast cancer. The total number of items in different questionnaires ranged from 20 to 54. Of the 25 studies, only 14 studies analyzed the reliability of used instruments. The reliability of the instruments was investigated by test-retest, and results of the Cronbach alpha were between 0.6414 and 0.95.30 In nineteen studies, the validity of used instruments was approved by opinions of experts from the related disciplines.

2) Knowledge of breast self-examination, clinical brest examination, and mammography

From among the 25 included studies, 19 had reported attitudes about BSE. Knowledge about breast cancer screening methods was measured by answering whether enough awareness of breast screening techniques exists to perform the tests at the right time and with the right number of test replicates. The responses included the duality of aware/unaware, and the general knowledge for breast cancer screening among woman was classified as sufficient, moderate, and poorly informed. In Table 2,4,1235 the results of knowledge level in general aspects of BSE, CBE, and Mammography are reported as a percentage of people with adequate knowledge of breast cancer screening methods. General knowledge for breast cancer screening among woman was reported in five studies, ranging from 4.5%30 to 45%.32 Participants’ knowledge of BSE was investigated in 22 studies. The number of people with sufficient knowledge about BSE in various studies was between 5%35 and 79.8%.20

Knowledge about CBE and Mammography was only mentioned in two studies, with the awareness of CBE rated between 7.8%12 and 76%.32 The awareness of mammography was between 6%12 and 33.8%.32

3) Source of information about breast self- examination, clinical brest examination, and mammography

The information sources used by the participants were listed in 14 studies. The most important sources of information in terms of the number of studies used were the healthcare team (13 studies), TV/radio/media (10 studies), family/friends (six studies), and books (five studies) (Table 3).12,1517,19,22,23,26,2831,34,35

DISCUSSION

This study was performed aiming at determining the knowledge and source of information on breast cancer screening techniques in Iran. Twenty-five studies on 11,756 participants were included in the final stage. The instruments used in all of the studies were researcher made based on expert opinions and literature review.

The instruments used in many studies in the countries of Oman36 and Ethiopia37 were author-made. General knowledge for breast cancer screening among woman was reported in five studies, which ranged from 4.5% to 45%. In various studies in Ethiopia (57.8%),38 Uganda (61.3%)36 and the United States (76.4%),39 the knowledge rate was higher than the current study, which could be due to introduction and better implementation of breast cancer prevention programs and higher levels of community literacy in these countries.

Participants’ knowledge of BSE in this study was 30.6%, which is a low level–like Angola in which only 35% had sufficient knowledge.40 However, in countries like Iraq (38.8%)41 and Cameroon (73.5%),42 the level was higher despite the fact that Iran has a better position with regard to the level of literacy and socioeconomic status. A study by Khokher et al.43 in Pakistan showed that only 27% of participants had enough insight into BSE.

Knowledge about Mammography was between 6% and 33.8%. But in a study conducted in Nigeria, only 5.1% had adequate knowledge of mammography.44 However, in Malaysia (50%),45 it was higher than the current study, which could be due to high awareness and knowledge of Malaysian screening methods. Knowledge about CBE ranged from 7.8% to 76%; The result was almost as low as Mali (20%).46 The information sources used by the participants were listed in 14 studies. The most important information sources in terms of the number of studies used were the healthcare team, TV/radio/media, family/friends. In a study by Obajimi et al.,44 the most important information sources were newspapers and magazines. The systematic review in Nigeria revealed the most important resource as TV.2 Differences in the information resources used in various studies can be due to the availability of these resources in each country. This difference could be due to the existence of various educational programs on breast cancer in the developed world and the existence of supportive services in these countries. The strengths of this study were: According to our searches, this is the first systematic review in this area. The studies were made without any time limitations. The most important limitation was the use of researcher made instruments to determine the knowledge. Due to the lack of complete information in most studies, contact was made with the authors to gain extra information. The present systematic review conducted aimed to determine the knowledge and source of information towards breast cancer early detection among Iranian woman. The main results showed that only one of third of women had sufficient knowledge about BSE. The main source of information was healthcare team members. According to the results of this study, it is recommended that a national study is conducted to determine the real status of knowledge in Iran and provide educational materials among women, specifically in regions with poor level of literacy.

CONFLICTS OF INTEREST

No potential conflicts of interest were disclosed.

Figures
Fig. 1. Study selection process.
Tables

Summary of included studies

First authorYearProvinceTarget populationSampling methodMean of data collectionSettingSample size (n)Age group (yr)Risk of bias (quality of study)
Abedzadeh192003IsfahanHealthy housekeepersMultistage stratifiedInterviewOutpatient clinics40020–45 >45Low
Akhtari-Zavare282014HamedanHealthy housekeepersPurposiveInterviewOutpatient clinics38418–52Low
Alaei Nejad292007SemnanHealthy housekeepersSimple randomInterviewOutpatient clinics8920–57Low
Asgharnia302013GilanHealthy womenConvenienceInterviewHospital40040–71Low
Banaeian122006Chaharmahal and BakhtiariHealthy housekeepersSimple randomInterviewOutpatient clinics40031.1Moderate
Besharat172004GolestanHealthy studentsStratified randomInterviewMixed42815–65Low
Dadkhah152002ArdabilHealthy housekeepersSystematic clusterInterviewOutpatient clinics15020–50Low
Danesh132002Chaharmahal and BakhtiariHealthy staffSystematic randomSelf-reportMinistry of education34020–49 >50Low
Eyvanbagha162016ArdabilHealthy staffCensusInterviewUniversity30026–41Low
Fazel272010Razavi KhorasanHealthy womanStratified randomInterviewOutpatient clinics36420–40 >40Moderate
Ghorbani182009GolestanHealthy staffSimple randomInterview/Self-ReportMixed33022–54Moderate
Haghighi42012Razavi KhorasanHealthy teachersSimple randomInterviewMinistry of education40020–56Low
Hajian Tilaki232015MazandaranHealthy womanCluster samplingInterviewOutpatient clinics50020–65Low
Iurigh242016MazandaranRural healthy womanMultistage randomInterview/Self-reportOutpatient clinics3,04420–75Low
Lalouei312006TehranHealthy womanCensusSelf-reportHospital37619–59Moderate
Mahvari322003FarsHealthy womanRandom stratifiedInterviewOutpatient clinics1,00035–60Low
Zare Marzouni212014KhuzestanHealthy womanSimple randomInterviewOutpatient clinics1,02015–79Low
Moajhed252001YazdHealthy nurses and midwivesCensusSelf-reportHospital280>20Low
Naghibi332009West AzerbaijanHealthy healthcare professionalsCensusInterviewOutpatient clinics8920–60Moderate
Navvabi-Rigi342012Sistan and BalochistanHealthy studentsStratified randomSelf-reportUniversity385>21Low
Nourizadeh352010East AzerbaijanHealthy womanCluster randomInterview/Self-reportHealth center21930–40Low
Reisi202011IsfahanHealthy healthcare professionalsSimple randomSelf-reportOutpatient clinics11938.3Low
Shahbazi142014Chaharmahal and BakhtiariHealthy healthcare professionalsCensusSelf-reportHospital8931.95Low
Talaiezadeh222009KhuzestanHealthy womanSimple randomInterviewHealth center40020–60Low
Zadeh262016YazdPatientsPurposiveInterviewHospital25025–65Low

Knowledge and source of information about Breast cancer early detections techniques among Iranian woman

First authorBrief titleQuestioner characteristicPsychometric characteristicSufficient knowledgeaSource of information
Abedzadeh19Knowledge, attitude and practice about BC screening36 Items in four sections: demographics (9 items), knowledge (10 items), attitude (10 items), practice (7 items)
Knowledge scoring: poor (lower than 10), average (10–15), positive (16–20)
Reliability: NR
Validity: NR
  • 22%

  • NR

  • NR

  • NR

  • Radio/TV

  • Healthcare team

  • Newspaper/book

  • Family

Akhtari-Zavare28Knowledge towards BSEA two part questioner included demographics and knowledgeReliability: NR
Validity: NR
  • NR

  • 20.6%

  • NR

  • NR

  • Media

  • Brochure

  • Friends

  • Healthcare team

Alaei Nejad29Knowledge, attitude and skill about BSE50 Items in four sections: demographics (NR), knowledge (21 items), attitude (22 items), and skill (7 items)
Scoring: knowledge: poor (under 7), average (7–14), and good (above 14)
Reliability: NR
Validity: NR
  • NR

  • 78.7%

  • NR

  • NR

  • Healthcare team

Asgharnia30Knowledge and practice about BC and screening tests30 Items in three sections: demographics (13 items), knowledge (16 items), and practice (4 items)
Scoring: knowledge: poor (0–5), average (6–10), and good (11–16)
Reliability: 0.96
Validity: approved by experts in field
  • 4.5%

  • NR

  • NR

  • NR

  • TV/radio

  • Journals

  • Healthcare teams

  • Internet

  • Friends

  • Family

Banaeian12Knowledge, attitude and practice about BC screening31 Items in three sections: knowledge (11 items), attitude (16 items), practice (4 item)
Knowledge scoring: poor (under 5), good (up 5)
Reliability: NR
Validity: approved by experts in field
  • 3.7%

  • 37.8%

  • 7.8%

  • 6%

  • Healthcare team

Besharat17Knowledge towards BSEA two-part questionnaire included: demographics and knowledgeReliability: NR
Validity: approved by experts in field
  • NR

  • 17.1%

  • NR

  • NR

  • Clases

  • Media

  • Brochure

Dadkhah15Knowledge, attitude and practice about BSE36 Items in four sections: demographics (NR), knowledge (22 items), attitude (6 item), practice (10 item)
Knowledge scoring: poor (under 8), average (8–14), good (up 14)
Reliability: Cronbach’s alpha = 0.87
Validity: approved by experts in field
  • NR

  • 14%

  • NR

  • NR

  • Heath care team

  • Media

Danesh13Knowledge, attitude, practice about BSEA four-part questionnaire included: demographics, knowledge, attitude and practice
Knowledge scoring: poor (under 8), average (8–29), good (up 29).
Reliability: 0.85
Validity: approved by experts in field
  • NR

  • 17%

  • NR

  • NR

NR
Eyvanbagha16Knowledge, attitude, practice about BSE54 Items in four sections: demographics (14 item), knowledge (29 item), attitude (11 item),practice (NR)
Knowledge scoring: poor (0–9), average (10–19), and good (20–29)
Reliability: Cronbach’s alpha = 0.8
Validity: approved by experts in field
  • NR

  • 56.50%

  • NR

  • NR

  • Books

  • Healthcare team

  • Internet

  • TV/Radio

  • Seminars

Fazel27Knowledge, and performance about BSEA four-part questionnaire included: demographics, knowledge, practice and overall knowledge
Knowledge scoring: poor (under 7), average (7–14), good (up 14)
Reliability: NR
Validity: approved by experts in field
  • NR

  • 12.1%

  • NR

  • NR

NR
Ghorbani18Knowledge, attitude, practice about BSE38 Items in four sections: demographics (6 item), knowledge (15 item), attitude (12 item), practice (6 item)
Knowledge scoring: poor (11–17), average (18–46), good (37–55)
Reliability: 0.88
Validity: approved by experts in field
  • NR

  • 28.3%

  • NR

  • NR

NR
Haghighi4Knowledge, attitude, practice about BC screening67 Items in four sections: demographics (14 item), practice: (7 item), knowledge (27 item), attitude (19 item)
Knowledge scoring: poor (under 30%), average (30%–60%), good (above 60%)
Reliability: 0.72
Validity: approved by experts in field
  • NR

  • 12%

  • NR

  • NR

NR
Hajian Tilaki23Knowledge, attitude, practice about BC screeningA four-part questionnaire included: demographics, knowledge (22 items), health belief (6 items), and practice (3 items)
Knowledge scoring: poor (under 7), average (7–10), good (11–14)
Reliability: 0.8
Validity: approved by experts in field
  • 14.8%

  • NR

  • NR

  • NR

  • Healthcare team

  • Magazine

  • Books

  • Brochure

Iurigh24Knowledge, attitude, practice about BC screeningA four-part questionnaire included: demographics, knowledge, attitude and practice
Knowledge scoring: poor (−10–0), average (0–10), good (11–20)
Reliability: 0.82
Validity: approved by experts in field
  • NR

  • 8.6%

  • NR

  • NR

NR
Lalouei31KnowledgeA two-part questionnaire included: demographics and knowledge items
Scoring: NR
Reliability: NR
Validity: NR
  • NR

  • 64.4%

  • NR

  • NR

  • CDs

  • Class

  • Healthcare team

Mahvari32Knowledge and practice BC screeningA four-part questionnaire included: demographics (knowledge and practice)
Scoring: NR
Reliability: NR
Validity: by experts in field
  • 45%

  • 46.3%

  • 76%

  • 33.8%

NR
Zare Marzouni21Awareness, attitude towards BSEA three part questionnaire included: demographic, knowledge, and BC risk factors
Scoring: NR
Reliability: 0.86
Validity: approved by experts in field
  • NR

  • 20.2%

  • NR

  • NR

NR
Moajhed25Awareness, practice towards BSEA two-part questionnaire included: demographics and Knowledge, attitude and practice
Knowledge scoring: poor (0–5), average (6–9), good (10–13)
Reliability: NR
Validity: NR
  • NR

  • 13.21%

  • NR

  • NR

NR
Naghibi33Knowledge, attitude, practice towards BSE43 Items in four sections: demographics (10 items), Attitude (13 items), knowledge (10 items), practice (10 items)
Knowledge scoring: poor (≤ 8), average (9–14), good (≥14)
Reliability: 0.85
Validity: approved by experts in field
  • NR

  • 50.6%

  • NR

  • NR

NR
Navvabi-Rigi34Knowledge, attitude towards BSEA three-part questionnaire included: demographic, knowledge, and attitude.
Scoring: NR
Reliability: 0.7
Validity: approved by experts in field
  • NR

  • 33.9%

  • NR

  • NR

  • Healthcare team

  • Books

  • TV/Radio

  • Friends

Nourizadeh35KnowledgeA four-part questionnaire included: demographic, knowledge, practice attitude.
Knowledge scoring: poor (≤ 6), average (6–12), good (13–18)
Reliability: 0.77
Validity: approved by experts in field
  • NR

  • 5%

  • NR

  • NR

  • Healthcare team

  • Newpapers

  • Books

  • Journals

  • Media

  • Friends

Reisi20Knowledge, attitude, practice towards BSE42 Items in a section: demographics (6 items), knowledge (20 items), attitude (10 items), practice (6 items)
Scoring: NR
Reliability: 0.88
Validity: approved by experts in field
  • NR

  • 79.8%

  • NR

  • NR

NR
Shahbazi14Knowledge and attitude towards BSE35 Items in four sections: demographics, knowledge, attitude
Knowledge scoring: very poor (0–5), poor (6–10), average (11–15), good (16–20).
Reliability: 0.64
Validity: approved by experts in field
  • NR

  • 34.8%

  • NR

  • NR

NR
Talaiezadeh22Knowledge towards BSEA two-part questionnaire included: demographic and knowledge
Knowledge scoring: NR
Reliability: NR
Validity: NR
  • NR

  • 26%

  • NR

  • NR

  • Healthcare team

  • Media

Zadeh26Awareness and attitude towards BSE20 items in three sections: demographics, knowledge, attitude
Knowledge scoring: poor (0), average (1–3), good (4–6)
Reliability: NR
Validity: approved by experts in field
  • NR

  • 6.2%

  • NR

  • NR

  • Healthcare team

  • Media

  • Friends

NR, none reported; BC, breast cancer; BSE, breast self-examination; CBE, clinical breast examination.

*Sufficient knowledge: 1, General knowledge; 2, BSE, 3. CBE; 4, Mammography.


Sources of information about BSE, CBE, and mammography

StudySources of information

Healthcare teamBooks/brochureInternetSeminars/CDs/classesTV/radio/mediaNewspaper/journalsFamily/family
Abedzadeh et al.19
Akhtari-Zavare et al.28
Alaei Nejad et al.29
Asgharnia et al.30
Banaeian et al.12
Besharat et al.17
Dadkhah and Mohammadi15
Eyvanbagha et al.16
Hajian Tilaki and Auladi23
Lalouei and Kashani-Zadeh31
Navvabi-Rigi34
Nourizadeh et al.35
Talaiezadeh22
Zadeh26

BSE, breast self-examination; CBE, clinical breast examination.


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