Breast Cancer, Breast Self-Examination Knowledge among Female High School Students in Riyadh City

(

Kholoud M. Al-Haji (1) Salma A.Moawed (2) (1) Demonstrator, Department of Maternal & Child Health Nursing, College of Nursing , King Saud University, Riyadh, Kingdom of Saudi Arabia (2) Professor, Doctor, Department of Maternal & Child Health Nursing, College of Nursing , King Saud University, Riyadh, Kingdom of Saudi Arabia . Correspondence: Kholoud M.Al-Haji , Department of Maternal & Child Health Nursing, College of Nursing , King Saud University, PO Box 1155149, Riyadh 11758, Kingdom of Saudi Arabia Email: Kalhaji@ksu.edu.sa

Abstract Breast cancer (BC) is the most prevalent form of cancer in the Kingdom of Saudi Arabia, accounting for 11% 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 study was aimed at assessing the knowledge of breast cancer and practice of Breast Self-Examination (BSE) among female secondary school students in Riyadh city. Material & Methods : A cross-sectional descriptive correlation design was used in this study. A representative probability sample was recruited (Sample Size = 917 Students). A self-administered questionnaire was prepared by the researcher. It consists of four parts. Data was analyzed using the SPSS software package (version 16) for data entry and analysis. Results: The results of the study indicated that none of the secondary school students had an excellent knowledge regarding breast cancer; 98.8% of the participants had a fair level of knowledge about breast cancer. The mass media was the most common source of information about breast cancer. The majority of participants did not perform breast self-examination 80.8%; only 3.4% perform (BSE) on monthly basis . There was a statistically significant relation between level of breast cancer knowledge and secondary school type, nationality, family history of breast cancer and secondary school levels but there was no significant relation between knowledge of breast cancer and age groups, marital status and family income level. Logistic regression analysis revealed that a negative family history of breast cancer was a significant predictor for lower scores on the level of knowledge of breast cancer. However, age group, family history of breast cancer were significant predictors of performance of breast self-examination. Conclusions : This study revealed that most of the female secondary school students in Riyadh, Saudi Arabia had very low knowledge about breast cancer. We recommended developing a health educational program about breast cancer for students, teachers and the community, to raise awareness. Key words : Breast cancer, Knowledge & Practice, Secondary school.

Introduction
Breast cancer is the most common cancer among Arab women. Breast cancer incidence rates in Arab women have increased during the last 24 years, and women are now being diagnosed with breast cancer at more advanced stages of the disease(1). In 2008, the Saudi Ministry of Health reported that BC among females constituted the highest percentage of cancers, 26.9% of total number of malignant tumors in Riyadh and 31.9% in Jeddah (2).

Young breast cancer patients have a lower rate of survival than older breast cancer patients due to being diagnosed at an advanced stage, but if discovered early breast cancer can usually be cured, however, early detection through screening is the only way to reduce mortality (3). The women who are in the process of transitioning from adolescence to adulthood offer a unique, critical window of opportunity for change in (or impact on) health behavior.

Students in secondary schools, mainly teenagers, are considered a vulnerable group passing through a critical period of physiological and mental development that requires special health care. The adolescent period is a time of rapid change that provides teaching opportunities for shaping health behaviors into adulthood. Teaching breast self-care may encourage positive behaviors such as performing breast self-examination and seeking regular professional breast examinations (5,6,7). Health behaviors such as BSE can help empower women to take some control and responsibility over their health promotion (4). For younger women, BSE education and adherence to clinical breast examination and mammography screening later in life provides for early detection.

Educating young women about early diagnostic methods of breast cancer is critically important to increase their breast cancer awareness. Acquiring the behavior and practice of BSE at an early age will also increase the probability of continuing it later (8,9).

Regular performance of BSE does not mean that breast cancer is necessarily self-detected. BSE increases body awareness, so that there is heightened awareness of changes that may be detected during BSE or at some other time. Although the American Cancer Society, 2007 recommended that women beginning in their 20s should be told about the benefits and limitations of BSE, this procedure is not considered the best method for early detection but the best option for interval screening among women of all ages(8,10). The poor knowledge and wrong beliefs about breast cancer prevention among teenagers are responsible for a negative perception of the curability of a cancer detected early and of the efficacy of the screening tests.

Many studies have shown that nurses have positive influence on women's breast cancer knowledge and BSE practice (11). Women who were advised about BSE by health care providers demonstrated greater knowledge, and confidence and were likely to practice it routinely . Although there were a lot of studies about knowledge of breast cancer and practice of BSE in female university students (3,14,15 ), there were few studies about the knowledge of breast cancer and practice of BSE in the age group of 15-20 years (5,12). The role of the nurse ,therefore, is to empower women by providing information, advice and support. Breast cancer awareness includes knowledge of breast cancer risk factors, signs, symptoms, and screening methods(12,13).

The objective of this study was to assess the knowledge of breast cancer and Practice of Breast Self-Examination (BSE) among female high school students in Riyadh city.

Material & Methods

Study design: Cross-sectional descriptive correlation design was used in this study.
Settings : The study was conducted at secondary girls' schools, both governmental
and private in Riyadh city.
Study subjects : A representative probability sample of secondary school girls, both Governmental and private in Riyadh city was recruited for conducting this study. The total number of the study subjects was 917 female students.
Sample criteria :
1- Inclusion criteria : Female secondary school students in Riyadh city.
2- Exclusion criteria: Those who were absent or couldn't complete the questionnaire for any reason.
Tools for data collection :
A self-administered questionnaire prepared by the researcher after the review of literature was used. It consists of four parts as following;

Part I :
1- Socio-demographic characteristics such as age, secondary school type, marital status ….etc.
2- Personal and family history for breast cancer: It is composed of 4 questions; the answers are ?Yes, No, or I don't know.

Part II:
Knowledge of students about breast cancer composed of 5 questions :

1- General knowledge about breast cancer: It is composed of 4 questions; the answers are ?Yes, No, or I don't know.
2- Knowledge about the risk factors of breast cancer was assessed by 11 questions, the answers were ?Yes, No, or I don't know?. This part assesses the presence of breast cancer risk factors with reference to guidelines of the American Cancer Society (2008)(40).
3- Knowledge about the signs &symptoms of breast cancer, it consists of 7 questions, the answers are ?Yes, No, or I don't know..
4- Knowledge about the methods of early detection of breast cancer, it consists of 5 questions, the answers are ?Yes, No, or I don't know.
5- Knowledge about the methods of breast cancer treatment, it consists of 5 questions, the answers are ?Yes, No, or I don't know.

Part III:
Knowledge about breast self-examination practice, it is composed of 4 questions; the students were asked whether they performed breast self-examination and if they answered ?yes, they were asked some skills performed during their examination.

Part IV :
About source of information about breast cancer.

Ethical Consideration :
Permission was obtained from the Director of School Education affiliating with the Ministry of Education after asking for permission to carry out this study in 12 schools throughout the academic year (2013/2014). The students who were given information about the study and who accepted to participate in the study were included. They were informed about the aim and potential benefits of the study and their consent was taken and their confidentiality was ensured.

Statistical analysis :
Data was analyzed using the SPSS software package (version 16) for data entry and analysis. Descriptive statistics with cross -tabulations were performed. The Chi-squared test, was used to examine the association between variables. Linear regression models were used to assess the relation between the demographic variables and level of knowledge.

Scores on knowledge level were predicted from the following variables (7 predictors): school type (coded 1 = private, 2 = governmental), age groups (coded 1 = 15-16 yrs., 2 = 17-18 yrs., 3 = 19-20 yrs., 4 = more than 20 yrs.), nationality (coded 1 = Saudi, 2 = non-Saudi), marital status (coded 1 = single, 2= married), secondary level (coded 1 = first, 2 = second, 3 = third), family income (coded 1 = good, 2 = medium, 3 = poor), family history (coded 1 = yes, 2 = No). The total N was 917. The significance level used was being with p< 0.05.

For the total knowledge of breast cancer, the total score was 38. A score of 0- 25 was considered a fair level of knowledge; 26-29 was considered a good level of knowledge, 30-33 was considered a very good level of knowledge, while 34-38 was considered an excellent level of knowledge. A score of 1 was assigned to each correct answer while zero was assigned to incorrect answer.

Results
Out of the 1000 questionnaires administered to the respondents, 917 were fully completed giving a response rate of (91.7%). Table 1 shows the sociodemographic characteristics of the participants. Most participants, 491 (53.5%), were aged between 17 and 18 years old. A majority of female secondary school participants were from governmental secondary schools, (67.1%). A greater percentage of secondary school participants were Saudi citizens, (81.7%), while (18.3%) were non-Saudi participants. A majority of female secondary school participants were single, (98%). Little more than one half of the participants,(58.9%) considered their financial status as medium between (5000-8000 SR).

Table 1: Distribution of the female students according to their Socio-demographic Characteristics


Table 2: Distribution of the female students according to their total degree of Knowledge about Breast Cancer


The personal and family history related to breast cancer was summarized in four questions. The first question was about any previous problems in the breast; the majority of participants did not complain of any breast problems. Only (8%) participants complained of a breast problem. The second question was about the history of breast surgery; the majority of the participants, had no breast surgery. The third question was about family history of breast cancer; the majority of participants have a negative family history of breast cancer and only (6%) participants had a positive family history of breast cancer. The fourth question was about having a family history of other kinds of cancers; (79%) had negative family history of other types of cancers. while (12%) had positive family history of other types of cancers.

Regarding general knowledge about breast cancer nearly half of the samples (53.3%) answered not all breast tumors are cancer while more than half of samples they did not know of Metastasis (57%) and the causes of breast cancer(52.2%), and if it can be prevented completely(43.3%).

Regarding the risk factors of breast cancer, the most widely known risk factors for breast cancer was exposure to radiation (41.9%), smoking (49.4%), but most of them didn't know the association between breast cancer and late menopause (70.9%), late age at first pregnancy (more than 30 years )(69.7%) early menarche (less than 12 years.) (51%) , use of OCP (58.5%) woman who do not breast feed 48.6% and eating fatty food 48.4%, increasing age (47.5%) , obesity (44.3%).

Regarding knowledge about the signs and symptoms of breast cancer, when they were asked about the symptoms the samples answered correctly, the presence of a mass in the breast (66.6%), sense of mass under the armpit (48.4%), pain in the breast area (64%) are the warning signs of breast cancer, while more than half of the sample did not know the warning signs of breast cancer such as bloody discharge(50%), wrinkling in the skin of the breast(57%) and inverted nipples (71.4%).

Concerning the screening methods for detection of breast cancer, more than two thirds of the sample mentioned that blood test (64%), breast exam by the doctor (78.3%), and breast self-examination (70.4%) are the methods used for early detection of breast cancer, while one third of the participants have information about mammography (38.5%) and magnetic resonance imaging of the breast (38.3%).

Regarding the line of treatment of breast cancer, more than half of the samples (52.1%) mentioned that surgical treatment is only the method of treatment and less than half of sample (48.4%) mentioned chemotherapy is the treatment while more than two -thirds did not know that radiotherapy (64.3%) hormonal therapy(67.3%), and immunotherapy(67.4%) are methods of treatment of breast cancer.

Regarding the knowledge of breast self-examination practice, Table 3, the majority of samples (86%) don't know how to do BSE . Only (2.3%) participants were doing breast self-examination on a regular basis and (16.9%) performing it on a non-regular basis, while (80.8%) did not perform breast self-examination. (3.4%) participants were doing breast self-examination once per month. A small percentage of the students had knowledge about appropriate time for BSE (5.1%).

Table 3: Distribution of the female students according to their Knowledge about Breast Self-Examination Practice

Table 4: Results of Chi-square test significance for variables with degree of knowledge with breast cancer


The association between demographic variables and degree of knowledge of breast cancer for female students
A chi-square test was used to test the association of breast cancer knowledge level with secondary school type, age group, nationality, marital status, secondary school levels, and family income Table 4. The variable of secondary school type (private school) (x2=10.04, P=.007) was significantly associated with level of knowledge of breast cancer. The variable of nationality (Saudi) (x2=40.82, P=.001) was significantly associated with level of knowledge of breast cancer. The variable of secondary school level (first) (x2=21.10, P=.001) was significantly associated with level of knowledge of breast cancer. The variable of family history of breast cancer (x2=45, P=.001) was significantly associated with level of knowledge of breast cancer. The variable of family income (x2=8.3, P=.016) was significantly associated with breast self-examination practice. Logistic regression analysis revealed that one of seven predictors was significantly predictive of level of knowledge scores; this was family history of breast cancer, (b = - 0.079 , p < 0.05); the negative of family history indicated that higher scores on family history (e.g., no history of breast cancer) predicted lower scores on the level of knowledge Table 5.

Table 5: Linear Regression Model of Demographic Variables and Level of Knowledge


One of seven predictors were significantly predictive of performance of self-examination scores; these included age groups; (B = 0.33, p < 0.05) the higher scores on age group (e.g., 20 yrs. or more) predicted higher scores on the performance of breast self-exam ( e.g., Yes I perform breast self-exam) Table 6.

Click here for Table 6 :Binary Logistic Regression Model for Performance of Breast Self-Exam with Demographic Variables


Discussion
A study conducted in Saudi Arabia by Ibrahim et al estimated that the future burden of breast cancer in Saudi Arabia is expected to increase by approximately 350% by 2025(13).

The results of the study show that students had low knowledge score in relation to breast self-examination; this reflects the needs for targeting educational programs for female secondary schools. This finding was consistent with several studies in Saudi Arabia and in Malaysia (16,17) .

Concerning the risk factors about breast cancer, the present study showed that most of the students had low knowledge of breast cancer risk factors. The most widely known risk factors by the students was smoking 49.4% followed by repeated exposure to radiation on the breast (41.9%). This finding is similar to that reported in Saudi Arabia (18) but most subjects didn't know the association between breast cancer and age, using oral contraceptive pills, avoiding breast feeding, obesity and increased fatty food intake, previous history in the family. However some studies have shown that the incidence of breast cancer is said to be slightly higher in persons that have a first degree relative with a history of breast cancer, persons that have early menarche and late menopause, those that use oral contraceptives, persons who do not breast feed and those women having their first birth after age 35 or in nulliparous women, the incidence is also increased with increasing age of the patient, smoking, obesity, physical inactivity, radiation exposure, intake of alcohol and high fat diet (16,19,20, 21 ). These breast cancer risk factors can be changed with health education. So health care professionals can play an important role in educating students, to enhance their awareness of breast cancer risk factors and influence their behavior. Slightly more than half of the samples (52.2%) did not know the cause of breast cancer. Similar results have been reported in previous studies (19,22).

Regarding to the symptoms of breast cancer, most of the respondents in this study did not know other warning signs of breast cancer such as bloody discharge from nipple (49.6%), dimpling or wrinkling in the skin of the breast (57%) and inverted nipple (71.4%). This observation was also reported in other studies (21,23 ). This reflects their lack of knowledge regarding early symptoms of the disease, which is very important from the point of view of better prognosis.

Concerning the screening methods for detecting the disease, the participants in this study did not know about the use of mammography and magnetic resonance imaging (MRI) as a screening tool for early detection of breast cancer. This finding has also been documented in previous studies (14,19,24,25 )MRI(16). Health education about the benefits of mammography screening for detection of breast cancer should be encouraged. Therefore maternity nurses she have great influence on female students to develop positive perceptions of breast cancer and motivation to practice screening methods for early detection of the disease.

Regarding treatment, the respondents knowledge about the treatment options of breast cancer showed that some of the respondents were aware of treatment modalities of breast cancer the majority of the respondent 52.1%, 48.4% knew that surgery and chemotherapy respectively are the treatment options of breast cancer. This result is similar to a study done by (Tiengo J.2011, Ibrahim N .2009 )(21,26 ).

Regarding knowledge of practice of breast self-examination, in this study about 2.3% of the students who heard about BSE reported having performed it. From this only 3.4% performed BSE monthly and the majority of the students performed BSE irregularly (16.9%). Students knowledge about BSE might have affected their monthly BSE performance. However, only a small number of students who had knowledge about the BSE procedure were performing BSE monthly. This may be due to insufficiency of education programs organized to increase breast health awareness. In this study, the findings regarding regular BSE are different from a previous study done in Turkey which showed that 20% of the students reported that they performed BSE irregularly and only 6.7% of those who practice BSE performed it regularly every month(27 ). The study done in Kuwait revealed that only 14.0% perform BSE irregularly and only 7.1 % of participants perform BSE monthly(19). In other studies the percentage of monthly BSE performance has been found to be 3.4% among teenagers(28). This observation was also reported in other studies (19,29).

A significant association was seen between family history of breast cancer and overall level of breast cancer knowledge. This finding was relatively consistent with findings in previous research studies (24,30 ), while two studies showed a relation between family history of breast cancer and regular BSE performance (27,29). Another three studies revealed no relation between family history of breast cancer and BSE performance (18,31,32 ). This finding was consistent with conclusions drawn in earlier studies, which found known breast cancer family history influenced women's attitudes about breast cancer and their willingness to engage in breast cancer screening behaviors (33). A negative family history was found to be a significant lower predictor on the level of breast cancer knowledge. But this result is in contraindication with the findings of some other studies that have found a positive family history of breast cancer tends to show better awareness and functions and affected women do more regular breast screening compared with the other women (34,35).

Family income in this result was not significantly associated with level of breast cancer, however family income was significantly associated with BSE practice. In similar studies by (Alsaif A ,2004 ; Dundar E ,2006)(31,36) showed no significant association between family income with level of breast cancerknowledge and BSE practice, unlike the findings of the present study withfindings of a previous study by (Dandash K,2007) which found a significant
relation between family income with level of breast cancer knowledge and BSE practice (18).
Linear regression analysis reveals age group was significantly predictive of performance of self-examination. The findings of this study are consistent with those of other studies, as many studies have found age was the most important predictor for BSE practice (37,38,39). The findings of the present study are contrary to the findings of some studies which found that marital status, level of education, positive family history of breast cancer, menarche and menopausal status were predictors for BSE performance (34,37,38).

Conclusion
It is concluded that most of the female secondary school students in Riyadh, Saudi Arabia had very low knowledge about breast cancer. Recommendations are suggested to raise students' level of knowledge toward breast cancer and practice of breast self-examination among female students through the following activities; Developing a health education programme that should be built into school curricula, regarding breast cancer and BSE practice starting from their secondary school. Developing educational programmes for teachers. School health unit, mass media and Ministry of Health should plan to raise awareness about breast cancer in the community.

References
1- Glanz, K., Rimer, B & Lewis F. (2002). Health Behavior and Health Education, 3rd ed. San Francisco: Jossey-Bass.
2- Gaballah I.(2011). Awareness, Knowledge and Practice of Breast Self-Examination Among Saudi Women. Med. J. Cairo Univ; 79(2): 81 86. Available at : www.medicaljournalofcairouniversity.com
3- Beydag K, Karaoglan H. (2007). Effect of Training for self breast examination on Knowledge and Attitude to University Student. Preventive Medicine Bulletin of Turkish Armed Forces;6:106-111.
4- Jeber E, Soyer M, Ciceklioglu M&Climat S. (2006). Breast cancer risk assessment and risk perception on nurses and midwives in Bornova Health District in Turkey. Cancer Nurs; 29:224-249.
5- Esam Murshidy 19 June 2009, 1-37. Available at: http://www.oncology.org.sa
6- Ogletree R, Hamming B, Drolet J& Birch D.(2004). Knowledge and intentions of ninth - grade girls after a breast self examination program. Sch Health J ;74:365-369.
7- Rashidi A, Rajarom S. (2000). Middle Eastern Asian Islamic Woman and breast self -examination. Cancer Nurs ; 23:64-70.
8- Gürsoy A, Y?lmaz F, Bulut H, Mumcu H, Ye?ilçiçek K, Kahriman I& Hindistan S. (2009). The effect of peer education on university students knowledge of breast self examination and health beliefs. The Journal of Breast Health ; 5 (3 ).
9- Ogletree J, Hammig B, Drolet C & Birch A.(2004). Knowledge and intentions of ninth-grade girls after a breast self-examinations program. Journal of School Health; 74(9): 365-369.
10- American Cancer Society .Breast Cancer Facts &Figures (2006-2007).
11- Baig S &Ali S.(2006). Evaluation of efficacy of self-breast examination for breast cancer prevention: a cost effective screening tool. Asian Pac J Cancer Prev ; 7(1): 154- 156.
12- Yarbro H.(2003). International nursing and breast cancer. Breast J; 9( 2): 98- 100.
13- Yousuf S.(2010). Breast Cancer Awareness among Saudi Nursing Students. Med. Sci.; 17 (3): 67-78 .
14- Maurer F. (1997). A peer education model for teaching breast self-examination to undergraduate college woman. Cancer Nurs; 20:49-61.
15- American Cancer Society: Cancer facts and figure 2009). Available at: http:// www.cancer.org
16- Habib F, Salman S, Safwat M& Shalaby S .(2010). Awareness and Knowledge of Breast Cancer Among University Students in Al Madina Al Munawara Region. Middle East Journal of Cancer ; 1(4): 159-166.
17- Zavare M ,Joni M& Manaf R .( 2011). Knowledge on breast cancer and practice of breast self-examination among selected female university students in Malaysia. Medical and Health Science Journal, MHSJ; 7:49-56 . Available at :www.academicpublishingplatforms.com .
18- Dandash K & Al- Mohaimeed A. Knowledge, Attitudes, and Practices Surrounding Breast Cancer and Screening in Female Teachers of Buraidah, Saudi Arabia. International Journal of Health Sciences, Qassim University ; 1(1) (January 2007/Muharram 1428H).
19- Alharbi N, Alshammari M, Almutairi B, Makboul G & El-Shazly M.(2012). Knowledge, awareness, and practices concerning breast cancer among Kuwaiti female school teachers. Alexandria Journal of Medicine ;48:75-82.
20- Vahabi M.(2010). Knowledge of Breast Cancer and Screening Practices Among Iranian Immigrant Women in Toronto J Community Health ;36:265-273.
21- Tiengo J & Peltzer K .(2011). Knowledge attitude and practice of breast cancer examination among women attending a health facility in Gaborone ,Botswana. Gender & Behaviour; 9(1).
22- Ertem G& Koçer A .(2009). Breast self-examination among nurses and midwives in Odemis health district in Turkey. Indian Journal of Cancer; 46 (3).
23- Sambanje M,&, Mafuvadze B .(2012). Breast cancer knowledge and awareness among university students in Angola. Pan African Medical Journal; 11:70 .This article is available online at: http://www.panafricanmedjournal.com/content/article/11/70/full/
24- Charkazi A, Samimi A, Razzaghi K, Kouchaki G&Moodi M. Adherence to recommended breast cancer screening in Iranian Turkmen women : the role of knowledge and beliefs . ISRN Preventive Medicine ,Volume 2013, Article ID 581027, 8 pages .available at : http://dx.doi.org/10.5402/2013/581027
25- Olowokere A, Onibokun A & Oluwatosin A.(2012). Breast cancer knowledge and screening practices among women in selected rural communities of Nigeria. Journal of Public Health and Epidemiology ;4(9): 238-245.
26- Ibrahim N& Odusanya O.(2009). Knowledge of risk factors, beliefs and practices of female healthcare professionals towards breast cancer in a tertiary institution in Lagos, Nigeria. BMC Cancer; 9(76).
27- Karayurt O , Özmen D & Çetinkaya A .(2008). Awareness of breast cancer risk factors and practice of breast self examination among high school students in Turkey. BMC Public Health ; 8:359 .Available at :http://www.biomedcentral.com/1471-2458/8/359.
28- Ludwick R & Gaczkowski S.(2001). Breast self- exams by teenagers. Cancer Nurs; 24:315-319.
29- Al-Naggar R, Al-Naggar D, Bobryshev Y, Chen R& Assabri A .(2011). Practice and Barriers Toward Breast Self Examination Among Young Malaysian Women. Asian Pacific J Cancer Prev;12: 1173-1178.
30- Royse D. & Dignan M.(2009). Improving cancer knowledge and screening awareness: test of a telephone interviewer intervention. Journal of Cancer Education; 24: 315-318.
31- Alsaif A.(2004). Breast self-examination among Saudi female nursing students in Saudi Arabia. Saudi Med J; 25 (11): 1574-1578.
32- Jirojwong S & MacLennan R.(2003). Health beliefs, perceived self-efficacy, and breast self-examination among Thai migrants in Brisbane. Journal of Advanced Nursing ;41:241-249.
33- Bird Y., Moraros J & Banegas P.(2010). Breast cancer knowledge and early detection Among Hispanic women with a family history of breast cancer along the U.S.- Mexico border. Journal of Health Care for the Poor and Underserved; 21 (2): 475-488.
34- Hajian S, Vakilian K, Najabadi K, Hosseini J& Mirzaei H.(2011). Effects of Education Based on the Health Belief Model on Screening Behavior in High Risk Women for Breast Cancer, Tehran, Iran. Asian Pacific J Cancer Prev; 12: 49-54.
35- Ceber E, Yücel U, Mermer G, et. al (2009). Health beliefs and breast self-examination in a sample of Turkish women academicians in a university. Asian Pac J Cancer Prev; 10, 213-8.
36-Dündar E, Ozmen D, Ozturk B, Haspolat G, Akyildiz F & Colan G. (2006). The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey. BMC Cancer; 6, 43.
37- Avci IA .(2008). Factors associated with breast self-examination practices and beliefs in female workers at a Muslim community. Eur J Oncol Nurs; 12: 127-133.
38- Noroozi A, Jomand T& Tahmasebi R.(2010). Determinants of Breast Self-Examination Performance Among Iranian Women: An Application of the Health Belief Model, J Canc Educ ,DOI 10.1007/s13187-010-0158-y
39- Parsa P, Kandiah M& Abdul Rahman H.(2006). Barriers for Breast Cancer Screening Among Asian Women: A Mini Literature Review. Asian Pacific J Cancer Prev;7: 509-514
40- American Cancer Society: Breast Cancer Fact and Figures.2008 http://www.cancer.org/downloads/STT/CAFF2005BrFacspdf2005pdf