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Assessment Awareness of Public About Breast Cancer and its Screening Measurements in Asir Region, KSA

  • Safar M. AlshahraniEmail author
  • Khalid A. Fayi
  • Saeed H. Alshahrani
  • Dhafer S. Alahmari
  • Khaled M. Al Bejadi
  • Dhafer M. Alahmari
  • Talal M. Alshahrani
  • Motaz N. Alsharif
Open Access
Original Article
  • 72 Downloads

Abstract

Breast cancer (BC) has a major impact on women’s health worldwide. The Kingdom of Saudi Arabia is no exception, where it is considered the most common malignancy, embodying the second leading cause of cancer deaths after lung cancer. In today’s world, people are more health conscious and more aware of different medical specialties. Despite the tremendous advancements in education, there seems to be a limited knowledge among the public regarding this issue. Various studies have been conducted in many regions to determine the perception/awareness about breast cancer. The present study is of the first of its type in our region, assessing the awareness of the public about breast cancer and its screening measurements. As per our knowledge, there is no study that estimated the awareness of breast cancer and its screening measurements among the public in the Asir region. Therefore, this study aims to estimate the awareness of breast cancer and its screening measurements among public and assess the knowledge about Breast Self-Examination (BSE) and their opinion about its effectiveness in early diagnosis of breast cancer to detect the relationship between awareness and socioeconomic status. This study is a cross-sectional prospective study, with a sample of 1046 participants aged between 12 and 80 years (male and female) from the Asir region evaluated by questionnaire after attaining consent. The selection of participants was based on the simple random sampling method. The majority of participants were of age 20 to less than 30 years (56.9%). About half of them were males (52.7%). The majority was single (61.2%). Most of them (74.0%) have a high education level (University and more). About one-third of the participants (32.7%) worked in the medical field, and most of them worked in the non-medical field (46.6%). Regarding general knowledge, the score was 60.2%, which represented a relatively good knowledge. The overall knowledge regarding breast cancer as recorded by our population reported that only 18.8% had good knowledge. Participants of this resettlement colony have poor knowledge about breast cancer, be it about risk factors, signs, and symptoms, or early detection procedures, where the overall knowledge score was only 18.8%.

Keywords

Breast Cancer Awareness Assessment Knowledge Breast self-examination Screening Asir Region Saudi Arabia 

Introduction

Breast cancer (BC) is a serious disease and a leading cause of deaths among females worldwide [1]. Approximately 1.67 million new cases of breast cancer, representing 25% of all cancers, were diagnosed among women in 2012 [2]. Its incidence is the highest in developed countries, with rates as high as 92 per 100,000 people in North America compared with 27 per 100,000 people in Middle Africa and Eastern Asia [2].

In 2010, breast cancer was the ninth leading cause of death for females in the Kingdom of Saudi Arabia (KSA) [3, 4]. Moreover, 1308 new breast cancer cases were reported in 2009, and about 25% of all new cancer cases were registered among Saudi women [5]. The incidence of breast cancer, it is expected, will increase in the coming decades in KSA due to the population’s growth and aging [6].

A breast lump, one of the most common presentations of breast lesion, can be detected through breast self-examination (BSE), clinical breast examination (CBE), and mammography. Early detection and prompt treatment offer the greatest chance of long-term survival in breast cancer patients [7, 8]. Mammography, CBE, and BSE are the secondary preventive methods used for screening in the early detection of breast cancer [7]. Cancer-screening tests play a pivotal role in reducing breast cancer-related mortalities [7]. The American Cancer Society (ACS) recommends CBE and mammography for the early detection of breast cancer [9]. According to ACS recommendations, women should know how their breasts normally feel and report any changes promptly to their health care providers. BSE is an option for women starting from the early 20s [7, 9, 10, 11].

Many women miss early detection and treatment opportunities owing to lack of information, knowledge, breast cancer awareness, and cancer-screening practices [12]. A significant number of women have advanced stages of the disease due to lack of information, knowledge, and awareness of early detection measures. Two previous studies showed limited knowledge about breast cancer screening, and few women performed screening for early detection purposes [13, 14, 15].

This study aims to assess breast cancer knowledge, beliefs, and practices among Saudi women and men related to (i) disease-associated risk factors, (ii) causes (including myths and folklore), (iii) early detection, and (iv) existing and preferred sources of information. The ultimate goal of the work is to inform the development of effective breast cancer educational resources for Saudi women aimed at removing barriers to evidence-based prevention and early detection interventions. Hence, we undertook this study with an aim to ascertain awareness among the public about breast cancer.

Materials and Methods

This study is a cross-sectional prospective study, with a sample of 1046 participants aged between 12 and 80 years (male and female) from the Asir region evaluated by a questionnaire after taking their consent. The participants were selected based on the simple random sampling method. The consent form was given to participants after the purpose and method of the study was explained to each one of them. Participants who refused were excluded. We invited them to participate in a 31-question survey to assess their attitude, knowledge, perception, and understanding of breast cancer and its screening measurements. The information sought in the questionnaire also included demographics of the participants. The personal information about the students was kept confidential. The study was performed from Nov. 2018 to Mar. 2019. The study protocol was approved by the Ethics Committee of King Khalid University, and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Statistical Analysis

The collected data was revised, coded, and fed to the statistical software IBM SPSS version 20. The given graphs were constructed using Microsoft Excel. All statistical analysis was done using two-tailed tests and with an alpha error of 0.05. A p value less than or equal to 0.05 was considered to be statistically significant. For knowledge domains, each correct answer was given one point score, and the total domain score was assessed by summing the discrete scores for each item. The score was then transferred into score percent of maximum by dividing over the total score and multiplying it by 100. The score percentage was then categorized into poor level if it was less than 60% of the maximum score and good if more. Chi-square/Mont Carlo exact test and Fisher’s exact test were used to test for the association between different patients’ factors and knowledge level. Exact tests were used if there were small frequencies where chi-square was invalid. Multiple logistic regression models were used to estimate the adjusted effect of different participants’ data on their knowledge level.

Results

Table 1 shows the distribution of 1046 participants according to some of their socio-demographic characteristics. The majority of them were of age 20 to less than 30 years (56.9%). About half of them were males (52.7%). The majority was single (61.2%). Most of them (74.0%) have a high education level (University and more). About one-third (32.7%) worked in the medical field, and most of them worked in non-medical fields (46.6%). Approximately, all of them were from Saudi (98.6%), and one-half belonged to intermediate monthly income families of 5000–15,000 Saudi Riyals (51.9%). Almost all of them have no breast cancer history (98.1%). Breast cancer in their family history was reported by 13.4% of the participants.
Table 1

Personal and family data of general population participants from the Asir region, Saudi Arabia, 2018

Personal data

No.

%

Age in years

< 20 years

124

11.9

20−

595

56.9

30−

168

16.1

40+

159

15.2

Gender

Male

551

52.7

Female

495

47.3

Marital status

Single

639

61.1

Married

391

37.4

Divorced/widow

16

1.5

Educational level

Below university

272

26.0

University/more

774

74.0

Work field

Not working

217

20.7

Non-medical field

487

46.6

Medical field

342

32.7

Nationality

Saudi

1031

98.6

Non-Saudi

15

1.4

Monthly income

Less than 5000 S.R

199

19.0

5000–15,000 S.R

543

51.9

15,000–30,000 S.R

243

23.2

More than 30,000 S.R

61

5.8

History of breast cancer

Yes

11

1.1

No

1035

98.9

Family history of breast cancer

Yes

140

13.4

No

906

86.6

Table 2 shows the distribution of participants according to knowledge and BSE issues of breast cancer. Regarding general knowledge, the score was 60.2%, representing a relatively good knowledge. With regard to knowledge of signs and symptoms, risk factors, and BSE. The scores were 51.4%, 31.8%, and 49.8% respectively, reflecting poor knowledge.
Table 2

Breast cancer knowledge domains as recorded by the general population in the Asir region, Saudi Arabia, 2018

Knowledge domain

Poor

Good

Score (%)

No.

%

No.

%

General knowledge

592

56.6%

454

43.4

60.2

Knowledge about signs and symptoms

539

51.5%

507

48.5

51.4

Knowledge about risk factors

944

90.2%

102

9.8

31.8

Knowledge about BSE

688

65.8%

358

34.2

49.8

Poor: score % < 60%.

Good: score % 60–100%.

BSE breast self-examination.

Fig. 1 illustrates the overall knowledge regarding breast cancer as recorded by our population; as reported, only 18.8% had good knowledge.
Fig. 1

Overall knowledge regarding breast cancer as recorded by the general population in the Asir region, Saudi Arabia, 2018

The associations between socio-demographic characteristics and BC knowledge scores are illustrated in Table 3. Knowledge of BC was significantly associated with age, gender, educational level, the field of work, and monthly income (p value = 0.001, 0.002, 0.002, 0.001, and 0.018 respectively). The good knowledge scores were lowest among participants whose age was less than 20 years (8.1%), male gender (15.2%), participants with below university educational level (12.5%), non-medical field workers (12.5%), and participants whose income was less than 5000 SR (13.6%). Conversely, the good knowledge scores were highest among participants of age 20 to less than 30 years (27.4%), female gender (22.8%), participants with university or more educational level (21.1%), medical field workers (28.9%), and participants whose income was more than 30,000 SR (27.9%).
Table 3

Distribution of breast cancer knowledge of the general population by their personal and family data, Asir region, Saudi Arabia, 2018

Factors

Overall knowledge

p

Poor

Good

No.

%

No.

%

Age in years

< 20 years

114

91.9

10

8.1

.001*

20−

448

75.3

147

24.7

30−

147

87.5

21

12.5

40+

140

88.1

19

11.9

Gender

Male

467

84.8

84

15.2

.002*

Female

382

77.2

113

22.8

Marital status

Single

508

79.5

131

20.5

.208

Married

327

83.6

64

16.4

Divorced/widow

14

87.5

2

12.5

Educational level

Below university

238

87.5

34

12.5

.002*

University/more

611

78.9

163

21.1

Work field

Not working

180

82.9

37

17.1

.001*

Non-medical field

426

87.5

61

12.5

Medical field

243

71.1

99

28.9

Monthly income

less than 5000 S.R

172

86.4

27

13.6

.018*

5000-15,000 S.R

446

82.1

97

17.9

15,000–30,000 S.R

187

77.0

56

23.0

More than 30,000 S.R

44

72.1

17

27.9

History of breast cancer

Yes

8

72.7

3

27.3

FEP = .472

No

841

81.3

194

18.7

Family history of breast cancer

Yes

106

75.7

34

24.3

.076

No

743

82.0

163

18.0

P Pearson χ2 test, FEP Fisher exact probability

*p < 0.05 (significant)

Table 4 shows the logistic regression analysis of breast cancer knowledge among participants with some independent variables. After adjusting for all possible confounders, the significant predictors to breast cancer were found to be positive females (p = 0.000), high education (p = 0.040), medical field workers (p = 0.000), income (p = 0.017), and lower PMS of barrier domain (p = 0.046).
Table 4

Multiple logistic regression model for predictors of breast cancer knowledge among the general population in the Asir region, Saudi Arabia, 2018

Factor

B

SE

P

AOR

95% C.I. for OR

Lower

Upper

Age in years

− .267

.144

.064

.766

.58

1.02

Female

1.013

.185

.000

2.76

1.92

3.96

Married

.111

.254

.661

1.12

.68

1.8

High education

.089

.043

.040

1.09

1.01

1.19

Medical field work

.666

.141

.000

1.95

1.48

2.56

Income

.249

.104

.017

1.28

1.05

1.57

History of BC

.785

.727

.281

2.17

0.52

9.09

Family history of BC

.389

.228

.088

2.33

0.94

2.42

Constant

− 2.696

1.536

.079

.068

  

Model pseudo R2; significance

12.3%; .003*

Model fit

81.5%

SE standard error, AOR adjusted odds ratio, CI confidence interval

Regarding sources of BC knowledge among our population, more than half of them received their knowledge from mass media, 18.4% from relatives, 17.1% from conferences, 7.2% from books, and 1.3% from physicians (Fig. 2).
Fig. 2

Sources of breast cancer knowledge among the general population in the Asir region, Saudi Arabia, 2018

Table 5 shows the BSE practice recorded among our population. About half of the participants (52.5%) had previously undergone BSE. Regarding the frequency of BSE among participants who had undergone it, only 4.2% had undergone it weekly, and 17.3% monthly; the remaining were varied nearly equally between rarely and sometimes (39.6% and 38.8% respectively). Among those who had undergone BSE, 14.2% found changes in their breast.
Table 5

Breast self-examination practice recorded among the general population in the Asir region, Saudi Arabia, 2018

Practice regarding BSE

No.

%

Previously undergone BSE

  Yes

260

52.5

  No

235

47.5

If yes, frequency (n = 260)

  Rarely

103

39.6

  Sometimes

101

38.8

  Weekly

11

4.2

  Monthly

45

17.3

Did you find breast changes (n = 260)

  Yes

37

14.2

  No

223

85.8

BSE breast self-examination

Regarding risk factor awareness among our population, the following factors were thought to have risk for occurrence of BC: advancing age (56.1%), exposure to radiation (39.3%), avoiding breastfeeding (57.6%), previous precancerous lesion on breast (49.4%), old primipara (above age of 30 years) (60.0%), breast injuries (40.5%), late menopause (42.4%), obesity (47.2%), smoking (34.3%), wearing of tight brassiere (50.2%), inactivity and sedentary lifestyle (39.7%), and underweight (47.4%) (Table 6).
Table 6

Risk factor awareness among the general population in the Asir region, Saudi Arabia, 2018

 

Yes

No

Do not know

Count

Row N %

Count

Row N %

Count

Row N %

Positive family history

139

13.3

331

31.6

576

55.1

Advancing age

587

56.1

257

24.6

202

19.3

Race/ethnicity

310

29.6

417

39.9

319

30.5

Exposure to radiation

411

39.3

294

28.1

341

32.6

Avoiding breast feeding

603

57.6

158

15.1

285

27.2

Previous precancerous lesion on breast

517

49.4

223

21.3

306

29.3

Old primipara (above age of 30 years)

628

60.0

100

9.6

318

30.4

Multiparity and gravidity

203

19.4

342

32.7

501

47.9

Null parity

118

11.3

534

51.1

394

37.7

Early menarche (below age of 11 years)

174

16.6

430

41.1

442

42.3

Recurrent oral contraceptives use

158

15.1

375

35.9

513

49.0

Breast injuries

424

40.5

164

15.7

458

43.8

Late menopause

443

42.4

196

18.7

407

38.9

Hormonal replacement therapy

228

21.8

319

30.5

499

47.7

Obesity

494

47.2

128

12.2

424

40.5

Smoking

359

34.3

239

22.8

448

42.8

Wearing of tight brassiere

525

50.2

189

18.1

332

31.7

Inactivity and sedentary lifestyle

415

39.7

238

22.8

393

37.6

Witchcraft

281

26.9

304

29.1

461

44.1

Underweight

496

47.4

247

23.6

303

29.0

Table 7 illustrates the level of general knowledge among our population. Almost all of them (95.8%) had heard of breast cancer. Most of them (59.8%) thought that breast cancer was somewhat prevalent and 12.0% thought breast cancer for once prevent subsequent cancer.
Table 7

General knowledge among the general population in the Asir region, Saudi Arabia, 2018

 

Count

Column N %

Have you heard of breast cancer?

Yes

1002

95.8

No

44

4.2

What do you think about breast cancer?

Rare

52

5.0

Somewhat prevalent

625

59.8

Highly prevalent

369

35.3

Breast cancer for once prevent subsequent cancer

Yes

125

12.0

No

447

42.7

Do not know

474

45.3

Discussion

According to this study, 95.9% of its participants had heard about breast cancer. This is higher than the percentage observed in a group of Ghana [16], Malaysian [17], and Iranian [18] women: 95%, 81.2%, and 64% respectively. It is, however, much lower than the 100% among the female medical students in Harar, Ethiopia [19], and the 98.7% among the female students in the University of Ibadan, Nigeria [20].

Knowledge and awareness of early detection measures of breast cancer, such as the BSE, is also considerable. About half of the participants, as shown by the findings, knew about BSE as an early detection measure, but very few participants practiced it. This results differed from Somdatta et al. [21], results which reported that knowledge and awareness of BSE are low and only a few women practiced it.

Our findings reveal poor understanding and misperceptions of the risk factors for breast cancer. More than half of the respondents identified advancing age, avoiding breastfeeding, old primipara (above age of 30 years), and wearing tight brassier as potential risk factors, while more than one-third identified exposure to radiation, previous precancerous lesion on breast, breast injuries, late menopause, obesity, smoking, inactivity, sedentary lifestyle, and underweight as potential risk factors for breast cancer. Only less than one-third of them identified positive family history, race/ethnicity, multiparity and gravidity, null parity, early menarche (below the age of 11 years), recurrent oral contraceptives use, hormonal replacement therapy, and witchcraft as potential risk factors of breast cancer. These results could be compared with those of Sama et al. [22], which revealed a poor understanding and misperceptions of the risk factors, signs/symptoms, prevention, and treatment. More than two-thirds of the respondents did not identify gender, increasing age, race/ethnicity and positive family history, first child at a late age, early menarche, late menopause, positive personal history, and nulliparity as potential risk factors. Knowledge gaps about risk factors have also been reported elsewhere among the general population [17, 23]: university students in Angola [24], female medical students in Saudi Arabia [25], nurses in Pakistan [26], and female teachers in Malaysia [27] and Kuwait [28].

With regard to misperceptions, 26.9% of participants cited witchcraft as a risk factor of breast cancer. This is in line with a community survey in semi-urban Cameroon [29], studies on rural women [30] and market women [31] in Ibadan, Nigeria, and female medical students in Ethiopia [19], suggesting that women still attribute the occurrence of breast cancer to a mystical origin. Among others, they considered it “a spiritual attack”, “God’s curse”, and “attack from the enemy”. This observation was not that different from reports in a more developed setting: female teachers in Saudi Arabia attributed breast cancer to God and a belief in the evil eye [32], while 96.8% of Arab-speaking women in Qatar attributed its occurrence to fate/destiny, and less than one-fifth to Gods’ punishment and bad luck [33].

The major contribution of media in educating the public regarding breast cancer observed in this study has also been reported by other researchers from Saudi Arabia [32], Lebanon [34], Nigeria [35], and Iran [18]. This demonstrates the need to pay greater attention to this source of information to ensure that the correct information reaches the target population.

Conclusion

In conclusion, this study has shown that participants of this resettlement colony have poor knowledge about breast cancer, be it about risk factors, signs, and symptoms, or early detection procedures, where the overall knowledge score was only 18.8%. Therefore, it is important to create awareness, educate the community, and remove the misconceptions associated with ignorance through community-based educational/awareness campaigns. Educating health care workers is also a very important aspect. We also have to keep in mind that media exclusively will not be enough; information needs to be disseminated in a form which is appealing to the community.

Notes

Compliance with Ethical Standards

Ethical Considerations

The official ethical clearance was obtained from the King Khalid University Ethical Committee; the private information of the students was used for research only.

Administrative Considerations

The researchers fulfilled all the required official approvals.

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© The Author(s) 2019

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Safar M. Alshahrani
    • 1
    Email author
  • Khalid A. Fayi
    • 1
  • Saeed H. Alshahrani
    • 1
  • Dhafer S. Alahmari
    • 1
  • Khaled M. Al Bejadi
    • 1
  • Dhafer M. Alahmari
    • 1
  • Talal M. Alshahrani
    • 1
  • Motaz N. Alsharif
    • 2
  1. 1.College of MedicineKing Khalid UniversityAbhaSaudi Arabia
  2. 2.Department of General SurgeryAssir Central HospitalAbhaSaudi Arabia

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