Determinants of Breast Self-Examination Practice amongst Iraqi/ Sulaimani Women using Champion Health Belief Model and Breast CAM

Abstract

Breast cancer (BC) is one of the major threat to females health in Iraq which can be easily prevented through Breast self-examination (BSE). This study aims to find out the level of awareness and practice of BSE among women and investigates the relation of socio-demographic factors, other comorbid conditions, knowledge, and belief with the BSE practices. This cross-sectional study conducted on 750 women using predesigned questionnaires and two scales, Breast cancer awareness measure (BCAM) and Champion health belief model (CHBM). The findings indicate that 75.2% of women were aware regarding BSE and 49.7% knew that BSE should be done monthly. 31.7% of participants never practiced BSE, 51.8% and 18.0% of participants practiced BSE rarely and regularly respectively. Education, employment status, family history, past breast disorders, knowledge, lactation status, perceived seriousness, health motivation, confidence, perceived benefits and barriers for BSE were significantly associated with the regular practice of BSE. Increase in women's health motivation and sensitization of women about the benefits of BSE is suggested to increase the adoption and practice of BSE.

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International Journal of Medical Research &
Health Sciences, 2019, 8(9): 51-59
51
ISSN No: 2319-5886
ABSTRACT
Breast cancer (BC) is one of the major threat to females health in Iraq which can be easily prevented through Breast
self-examination (BSE). This study aims to nd out the level of awareness and practice of BSE among women and
investigates the relation of socio-demographic factors, other comorbid conditions, knowledge, and belief with the
BSE practices. This cross-sectional study conducted on 750 women using predesigned questionnaires and two scales,
Breast cancer awareness measure (BCAM) and Champion health belief model (CHBM). The ndings indicate that
75.2% of women were aware regarding BSE and 49.7% knew that BSE should be done monthly. 31.7% of participants
never practiced BSE, 51.8% and 18.0% of participants practiced BSE rarely and regularly respectively. Education,
employment status, family history, past breast disorders, knowledge, lactation status, perceived seriousness, health
motivation, condence, perceived benets and barriers for BSE were signicantly associated with the regular practice
of BSE. Increase in women’s health motivation and sensitization of women about the benets of BSE is suggested to
increase the adoption and practice of BSE.
Keywords: Breast cancer, Breast self-examination, Breast cancer, Health belief model (HBM)
Determinants of Breast Self-Examination Practice amongst Iraqi/
Sulaimani Women using Champion Health Belief Model and Breast CAM
Jamal K. Shakor1*, Atiya K. Mohammed2 and Deepika Karotia3
1 Department of Nursing, Darbandikhan Technical Institute, Sulaimani Polytechnic University,
Sulaimani, Qrga, Iraq
2 College of Nursing, University of Sulaimani, Sulaimani, Qrga, Iraq
3 National Leprosy Eradication Programme, Central Leprosy Division, Directorate General of
Health Services, Government of India, Maulana Azad Road, New Delhi
*Corresponding e-mail: jamal.shakor@spu.edu.iq
INTRODUCTION
Breast cancer is a leading public health problem in Iraq and worldwide with reporting of nearly 1.5 million new BC
annually giving a large burden to health system in term of morbidity and mortality. In the year 2015, only around
5,70,000 deaths occur due to BC worldwide [1]. In Iraq, during last decade, 23,792 new cases were registered,
accounted for 33.8% of all cancers reported during the time period [2]. In Iraq the incidence of this health condition is
mostly in early age with mean age of diagnosis from 47 to 52 years old [3,4]. However, it is diagnosed in later stage,
for instance, two different studies have shown that most cases of BC (26% and 34.1%) were diagnosed at stage 3 or 4 [4,5].
The reporting of BC in study area may be related to the implementation of early detection program in Iraq which was
introduced in health system, in 2000 which has majorly inuenced the BC reporting statistics. Data indicates that
women who practice Breast self-examination (BSE) were diagnosed in early-stage as compared to the women who do
not practice BSE [6-8]. Tumor of smaller size is also detected when women practice BSE [9-11].
In developed country such as United Kingdom (UK), the study showed that almost half of participants perform BSE
regularly [12]. In Greek, 91.5% of participants knew about BSE and 71.3% had performed it [13]. However, it has
been noted that this screening method is not advocated well by health system in developing countries leading to low
awareness and low practice/irregular practice of BSE in public. The regular practice of BSE was much low, 7.6% and
14% in two different settings in Iran [11,14]. In Qatar, 24.9% of women recognized BSE as screening method and
18.7% of women practiced BSE [15]. In Saudi Arabia 43.4% identied BSE as a screening method but 67.6% never
practiced BSE [16]. However, in Iraq, under the program, monthly practice of BSE has been recommended for women

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Kadhim, et al.
aged more than 20 years hence better observations were found 69.1% of participants aware about BSE and 42.6% had
practiced BSE occasionally regular practice of BSE was not found [10,11,17].
In addition to low awareness about BSE, various factors i.e., sociodemographic, medical background and knowledge
about BC, inuence the practice of BSE. Many studies observed that young, educated women and women who had
family history of BC practice BSE monthly [7,8,13]. Other factors inuence practice of BSE were parity, contraceptive
use, age at menarche and breast disorder [18-20]. Further, a study of UK indicated that the Information, Education,
and Communication (IEC) for signs, symptoms and risk factors of BC increased the practice of BSE by 15% [12].
Another factor associated with practice of BSE is women’s individual belief about BC and screening behavior.
The Health belief model (HBM) has been widely used to investigate women’s belief regarding practice of the BSE
[21,22]. This model, women’s study various factors i.e., women’s perceived seriousness and susceptibility to the
disease, women’s motivation and condence towards health, perceived benets and barriers of BSE and determine the
women’s beliefs and attitude about BC and practice of the BC screening behaviors such as BSE [11,14].
The present study aims to nd out the awareness regarding BSE and practice of same among Iraqi/Sulaimani women.
It also assess the association of various factors i.e., sociodemographic, health, knowledge/awareness etc. with practice
of BSE. In addition, by using the health belief model, it assess the individual belief and attitude regarding BSE.
MATERIALS AND METHODOLOGY
Study Area
The study was conducted on visitors of Breast disease treatment center (BDTC) and other two health centers from
Urban and Suburban area, North Iraq, Sulaimani province inhabited by population of around 2 million, mostly resided
in the center of the city and suburban area. BDTC is the only center in city providing services for early detection and
treatment of BC and other related diseases. In BDTC, screening of normal women and women with minor breast
disorder done diagnosis, and further treatment.
Study Design and Sampling
The cross-sectional study designs wherein non-probability (purposive) sample of 750 women drawn from women
visiting the BDTC (273) and other two health centers (477). As recommended in the screening model of Iraq, women
aged >20 years are supposed to practice BSE monthly. Hence, any women of age >20 year visiting selected health
centers during our study period from 13th December 2016 to 12th June 2017, were eligible to participate in the study
after provision of oral consent.
Tools
The questionnaire designed to get information on socio-demographic and medical background. Content of the
questionnaire was validated by 13 experts of different expertise, based on their opinion and suggestions. Two scales
i.e., Breast Cancer Awareness Measure (Breast CAM) and Champion health belief model (CHBM) were utilized.
Breast CAM used to measure women’s knowledge about BC and screening [23,24]. It consists of 4 subscales and 33
questions with various themes i.e., screening method (5 questions), breast cancer (5 questions), warning signs and
symptoms (7 questions) and risk factors and health behaviors (12 questions). It was 3 Likert scale answer (yes, no, I
don’t know), knowledge in this scale is scored based on the number of true answers.
Champion health belief model (CHBM) is a standard instrument widely used in many different cultures. It is translated
to many languages [23,25,26]. CHBMs in this study was consisted of 6 subscales and 26 items, (perceived seriousness:
5 items), (perceived susceptibility: 3 items), (health motivation: 5 items), (condent self-efcacy to practice BSE: 6
items), (perceived benets of BSE: 4 items), (perceived barriers of BSE: 4 items). This scale is 5-point Likert scale
ranging from 1 (strongly disagree) to 5 (strongly agree). Women’s attitude was measured by addition of each item
score in each subscale. High score of each item indicated the strong attitude of concepts (subscale) except barriers
subscale which was scored inversely. Reliability test for both the scales was performed through a pilot study on 50
women and Croanbach Alpha was calculated to assess the internal consistency. Alpha value for various subscale of
CHBM was as below Seriousness: 84%, Susceptibility: 83%, Health motivation: 81%, Condence: 83.1%, BSE
benets: 82%, BSE barriers: 82.5%. Alpha value for breast CAM was 78%.

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Kadhim, et al.
Statistical Analysis
The data compilation, management, and analysis were done by using Statistical Package for the social sciences (SPSS)
program version 21.0 [22]. Descriptive and inferential statistics tests were applied to data. The frequency, percentage,
mean and standard deviation (SD) were calculated using SPSS. The inferential diagnosis was made based on the
test of signicance, Chi-square test, Analysis of variance (ANOVA). Binary logistic regression was done to make a
prediction of the regular practice of BSE vs. never practiced.
RESULTS
Table 1 indicated that although 564 (75.2%) of women knew how to perform the BSE, but only 373 (49.7%) knew
that BSE should be done monthly.
Table 1 Frequency of awareness regarding to BSE
Frequency of true answer regarding to screening method Frequency (%)
Do you know how to perform BSE 564 (75.2%)
BSE should be done monthly 373 (49.7%)
Table 2 showed the BSE practice in women with respect to socio-demographic characteristics. More than half of study
participants were of more than 40 years old, 426 (56.8%), 89 (11.8%) participants were uneducated, 586 (78.2%) of
participants live in urban area, 598 (79.85%) participants were married, 493 (65.75%) participants were unemployed,
and barely self-perceived the economic status 383 (51%). Among the participants 238 (31.7%) of women had never
practiced BSE, and 377 (50.3%), 135 (18.0%) of women were doing BSE rarely and regularly respectively. Among
socio-demographic variables, secondary level of education 57 (21.5%) and having a job (employed) 57 (22.2%) were
signicantly associated with practice of BSE regularly, statistic value were (Χ2=6.7, p=0.04), (Χ2=6.29, p=0.04)
respectively.
Table 2 The association of practice BSE vs. Socio-deomographic characteristics
Variables Frequency (%)
Practice of breast self-examination
Chi-Squre p-value
Never n (%) Rarely n (%) Regularly n
(%)
Age group
Age 20-29 years 89 (11.8%) 31 (34.8%) 44 (49.4%) 14 (15.7%)
6.7 0.193
Age 30-39 years 235 (31.3%) 83 (35.3%) 104 (44.3%) 48 (20.4%)
Age 40 and above 426 (56.8%) 124 (29.1%) 229 (53.8%) 73 (17.1%)
Total 750 (100%) 238 (31.7%) 377 (50.3%) 135 (18.0%)
Education levels
Uneducated 89 (11.8%) 36 (40.4%) 48 (53.9%) 5 (5.6%)
16.1 0.041
Primary 218 (29%) 64 (29.4%) 114 (52.3%) 40 (18.3%)
Secondary 265 (34.1%) 89 (33.6%) 119 (44.9%) 57 (21.5%)
Diploma 108 (14.4%) 31 (28.7%) 56 (51.9%) 21 (19.4%)
Bachelor and above 70 (9.3%) 18 (25.7%) 40 (57.1%) 12 (17.1%)
Place of residence
Urban (Sulaimani) 586 (78.2%) 189 (32.3%) 297 (50.7%) 100 (17.1%) 1.28 0.526
Sub urban (District) 163 (21.7%) 49 (30.1%) 80 (49.1%) 34 (20.9%)
Marital Status
Married 598 (79.8%) 185 (30.9%) 303 (50.7%) 110 (18.4%)
2.87 0.82
Widowed 39 (5.2%) 12 (30.8%) 20 (51.3%) 7 (17.9%)
Single 84 (11.2%) 32 (38.1%) 38 (45.2%) 14 (16.7%)
Divorce 28 (3.7%) 9 (32.1%) 16 (57.1%) 3 (10.7%)
Occupation
Employed 257 (34.2%) 70 (27.2%) 130 (50.6%) 57 (22.2%) 6.29 0.043
Un employed 493 (65.7%) 168 (34.1%) 247 (50.1%) 78 (15.8%)
Perceived self-economic status

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Kadhim, et al.
Insufcient 181 (24.1%) 56 (30.9%) 95 (52.5%) 30 (16.6%)
4.3 0.36
Barely Sufcient 383 (51%) 113 (29.5%) 201 (52.5%) 69 (18.0%)
Sufcient 184 (24.5%) 67 (36.4%) 81 (44.0%) 36 (19.6%)
Table 3 illustrate the association of medical and health condition with the practice of BSE. Most women had 3 children,
160 (21.3%), 541 (72.1%) participants used a contraceptive, 552 (73.6%) participants were in lactation phase, 353
(47%) participants had participated in early diagnosis program and 317 (42.2%) participants had past history of minor
breast disorders. 108 (14.4%) of participants had history of BC in family and 46 (6.4%) were smokers.
Table 3 The association of practice BSE vs. health conditions
Variables Frequency (%)
Practice of breast self-examination Chi-
squre p-value
Never
n (%)
Rarely
n (%) Regularly n (%)
Women parity
Nulpara 133 (17.7%) 48 (36.1%) 62 (46.6%) 23 (17.3%)
8.7 0.55
1 para 62 (8.2%) 22 (35.5%) 29 (46.8%) 11 (17.7%)
2 para 141 (18.8%) 47 (33.3%) 73 (51.8%) 21 (14.9%)
3 para 160 (21.3%) 44 (27.5%) 81 (50.6%) 35 (21.9%)
4 para 114 (15.2%) 29 (25.4%) 60 (52.6%) 25 (21.9%)
5 and more 140 (18.7%) 48 (34.3%) 72 (51.4%) 20 (14.3%)
Contraceptive use
Yes 541 (72.1%) 162 (29.9%) 282 (52.1%) 97 (17.9%) 3.2 0.19
No 209 (27.7%) 76 (36.4%) 95 (45.5%) 38 (18.2%)
Family history of Breast Cancer
Yes 108 (14.4%) 17 (15.7%) 57 (52.8%) 34 (31.5%) 23 0
No 642 (85.6%) 221 (34.4%) 320 (49.8%) 101 (15.7%)
Lactation
Yes 552 (73.6%) 161 (29.2%) 289 (52.4%) 102 (18.5%) 6.4 0.04
No 198 (25.7%) 77 (38.9%) 88 (44.4%) 33 (16.7%)
Smoker
Yes 46 (6.4%) 6 (13.0%) 21 (45.7%) 19 (41.3%) 20.1 0
No 701 (93.5%) 230 (32.8%) 355 (50.6%) 116 (16.5%)
Purpose of visting the screening center
Not visited 288 (38.4%) 142 (49.3%) 122 (42.4%) 24 (8.3%)
85.8 0
For screening 109 (14.5%) 15 (13.8%) 57 (52.3%) 37 (33.9%)
For diagnosis 353 (47%) 81 (22.9%) 198 (56.1%) 74 (21.0%)
Minor disorder past history
Yes 317 (42.2%) 65 (20.5%) 178 (56.2%) 74 (23.3%) 34.3 0
No 433 (27.7%) 173 (40.0%) 199 (46.0%) 61 (14.1%)
In this study a signicant association was found between the BC family history (X2=23.0, p=0.00), women in
lactation phase (X2=6.4, p=0.04), smoking (X2=20.1, p=0.00), undergoing Clinical breast examination (CBE) either
for screening or early diagnosis (X2=85.6, p=0.00), and having past minor disorder (X2=34.3, p=0.00) with the regular
practice of BSE. Regular practice of BSE was found more in women who had BC family history 9 (25%), lactating
mothers 102 (18.5%), smokers 19 (41.3%), undergone the CBE 37 (33.9%), have past minor breast disorder 74
(23.3%).
Table 4 the means of breast CAM and CHBM subscales with respect to the practice of BSE. The study found that there
is a signicant association between BC knowledge and practice of BSE (F=86.05, p=0.000). The breast CAM mean
was signicantly higher among those women who practice BSE regularly (23.25 ± 2.85) in respect to rarely (20.86 ±
3.52) or never practice (18.15 ± 4.39).

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Kadhim, et al.
Table 4 Mean of (breast CAM) and (CHBM) sub-scales vs. practice Of BSE
Practice BSE BC
Knowledge
Perceived
Seriousness
Perceived
Susceptible
Perceived
Motivation
Perceived Perceived Perceived
Condent Benet of
BSE
Barrie of
BSE
Never practice 18.15 ± 4.3 19.02 ± 5.7 7.92 ± 1.6 17.22 ± 3.3 17.63 ± 4.1 14.22 ± 2.3 9.82 ± 2.2
Rarely practice 20.86 ± 3.5 19.79 ± 5.2 8.18 ± 1.8 19.17 ± 3.4 20.93 ± 3.9 15.67 ± 2.2 8.16 ± 2.0
Regular practice 23.25 ± 2.8 18.22 ± 5.1 8.31 ± 1.8 20.95 ± 2.4 23.13 ± 3.9 16.70 ± 1.8 7.01 ± 2.0
Total 20.43 ± 4.1 19.26 ± 5.3 8.12 ± 1.7 18.87 ± 3.5 20.28 ± 4.4 15.40 ± 2.3 8.48 ± 2.3
F-test 86.053 4.589 2.48 58.911 90.254 59.044 82.454
p-value 0.000 0.010 0.084 0.000 0.000 0.000 0.000
Mean of perceived seriousness (18.22 ± 5.11) was signicantly lower in those women who regularly practice BSE
(F=4.589, p=0.010). However, perceived susceptibility of BC was higher in women who regularly practice BSE (8.31
± 1.86) compared to those who rarely practice or not practice, but, this relationship was not statistically signicant.
The high value of mean for health motivation (20.95 ± 2.46) was observed as signicant in women who regularly
practice BSE, (F=58.911, p=0.000). Similarly, the high value of mean for self-condent (23.13 ± 3.94) was observed
as signicant in women who regularly practice BSE (F=90.254, p=0.000).
The study found that mean of perceived benet of practicing BSE regularly was increased with regularity/ frequency
of practicing of BSE (F=59.044, p=0.000), the mean of never practice, rarely practice and regular practice of BSE
were (14.22 ± 2.33), (15.67 ± 2.29), and 16.70 ± 1.8 respectively. Similarly, the mean of women perceived the barriers
of practicing BSE was regularly decrease with the regularity of practicing of BSE (F=82.454, p=0.000), the mean of
never practice, rarely practice and regular practice of BSE was (9.82 ± 2.27), (8.16 ± 2.08), (7.01 ± 2.06) respectively.
DISCUSSION
One aim of this study was to nd out the awareness and practice frequency of BSE in women in Iraq/Sulaimani. While
practice and awareness about this screening behavior vary worldwide, a review study indicated that the practice of the
BSE ranged from 2.6% to 84.7% [27-29]. Regarding awareness in this study, high BSE awareness was observed as
compared to many countries of the region however they did not recognize the BSE as regular screening practice, only
half of women (49.7%) knew that BSE should be done monthly. Regarding practice, this study found that only one-
third of women, 31.7% never practiced BSE, 50.3% of women practiced rarely and only 18.0% of women practiced
BSE regularly which is higher than 30.3% found in Iraq but lower than 51.1% ndings from UAE study [30-33].
While another study among health worker in Iran shown the high percentage of the BSE, 73.2% of participants
performed BSE and 26.9% of them performed it regularly, indicating BSE was only introduced among the health staff.
In this study, however, more women were aware of the BSE, but advocacy for screening is low only 49.7% of women
were aware of regular practice of BSE. This nding is in cognizance of another Iraqi study which illustrated that out
of participants of study who were aware of BSE only 57.4% perform the BSE [17]. A similar nding was observed in
Arabi Saudia, wherein 57% of participants performed BSE [28].
Further, with respect to the association of various factors with BSE it was found that Low regular practice of BSE
may be related to low education level of women and status of un-employment. Among socio-demographic variables,
education and employment were signicantly associated with practice of BSE regularly, statistic shows (X2=6.7,
p=0.04), (X2=6.29, p=0.04) respectively. The positive association of education and employment status has been
concluded in many studies [7,8,30,34,35]. They never practice of BSE was signicantly high among illiterate (40.4%)
and unemployed (34.1%). High practice of BSE in employed and educated women could be explained by health
belief model. The study indicated that high perceived benets of BSE, self-efcacy, health motivation were higher
in employed women and gradually increases with level of education [36]. Additionally educated women would
have good knowledge about BC early symptoms and benets of early detection [37]. Regarding other variables,
however regular practice BSE was more among women age 30-39 years, sub-urban resident, married, sufcient self-
perceived economic status, but signicant association could not be found. Although, some other studies have found
the signicant association of marital status, resident and age with practice of BSE [20,30,34,37]. Regarding medical
and health condition, signicant association was found between the positive BC history (X2=23.0, p=0.00), women in
lactation phase (X2=6.4, p=0.04), smoking (X2=20.1, p=0.00), utilizing CBE (X2=85.6, p=0.00) and having past minor
disorder (X2=34.3, p=0.00) with practice of BSE regularly.

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Kadhim, et al.
In the present study, almost half of women utilized the CBE and only two-third practiced the BSE. Marital status and
parity were not signicantly related with practice of BSE, although lactation was signicant. Signicant relation of
marital status with practice of BSE was indicated in some studies [11,34], but relation of lactation with practice of
BSE was not studied yet. Smoking is negative health behavior which is adversely associated with practice of BSE
while our nding was controversial with this consisting nding [20,32].
This study found that there was a signicant association between BC knowledge and practice of BSE (F=86.05,
p=0.000). Breast CAM mean was signicantly high among those women who practice BSE regularly in respect
to those practices BSE rarely or never practice. The knowledge about early signs of BC and early detection would
increase the positive attitude toward BC and increase the seeking for positive health behavior and practice BSE [37-
39]. Many studies have revealed the signicant improvement in the practice of screening behavior (BSE) by providing
knowledge [33,40] as improved knowledge about BC would enhance the women’s perceived seriousness about BC
and susceptibility of BC. This, in turn, improve the women health motivation and self-efcacy, increase perceived
benet towards practice of BSE and decrease perceived barrier of BSE [41,42].
According to the health belief model, women attitude regarding BC and women’s perceived benets regarding the
practice of BSE and barriers of screening methods would directly relate to screening behavior and practice of BSE
[11,33,36]. Similar ndings were found in current study, perceived benets of practicing BSE was signicantly high
in women who regularly practice BSE as compared to rarely practice and never practice, (F=59.044, p=0.000). As
well as, current study found perceived of barriers of practicing BSE was decline regularly in never practice (9.82 ±
2.27) to rarely practice (8.16 ± 2.08) and regular practice of BSE (7.01 ± 2.06). Signicant value was (F=82.454,
p=0.000).
There is not a signicant nding regarding Perceived susceptibility in the study. In this study, the regular practice of
BSE was high in women who perceived high susceptibility, but a signicant difference was not found. The greater
susceptibility of BC was observed in women who perform BSE in two studies while other studies in Iran found out
the negative relation [11,13,14,39]. Similarly, in the Turkish study, perceived susceptibility and perceived barriers
were low among those who performed BSE [39]. The high mean of health motivation (F=58.911, p=0.000) and
condence (self-efcacy to practice BSE) (F=90.254, p=0.000) were signicantly associated with regular practice of
BSE which is in cognizance with other studies [11,14,33]. The study found that women’s perception of seriousness
was signicantly low in those women who regularly practice BSE (F=4.589, p=0.010).
In an Iranian study, some socio-demographic and health-related variables were determined as the predictors for
BSE practice. Age, IEC, having a family history of BC, current marital status, years of education, menarche,and
menopausal status also predicted BSE performance [11,18,43]. Similarly, in this study, the logistic analysis model was
constructed for predicting regular practice of BSE (Table 5). All variable regarding sociodemographic, medical and
health condition, knowledge and sub-scales of CHBM were included in this analysis. The model accounted for 58%
of the variance in performing BSE. In this study, eleven variables could predict the regular practice of BSE with a
signicant odds ratio. The non-lactating women were over 10 times more likely to practice BSE regularly (OR=10.23,
p=0.009), and those women who got pregnant rst time in high age,had practiced BSE regularly (OR=1.151, p=0.009).
Women who have good knowledge about BC (OR=1.241, p=0.002), perceived susceptibility (OR=1.721, p=0.001),
high health motivation (OR=1.340, p=0.001), high self-condent (OR=1.211, p=0.001), and perceived benets of
BSE (OR=1.332, p=0.001) were over one time more likely practice BSE regularly. Meanwhile, women perceived
barrier of BSE were more like to never practice BSE (OR=0.514, p=0.000).
Table 5 Logistic regression dening the predictors of regular practice of BSE
Variables B Sig. Odd ratio 95% C.I. for EXP (B)
Lower Upper
Address (sub urban) -1.493 0.009 0.225 0.073 0.693
Age at delivery 0.141 0.004 1.151 1.045 1.268
Not history of BC -2.677 0.000 0.069 0.015 0.31
Not lactation 2.326 0.009 10.23 1.766 59.331
Good knowledge of BC 0.216 0.002 1.241 1.083 1.423
Perceive seriousness -0.121 0.031 0.886 0.794 0.989

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Kadhim, et al.
Perceive susceptibility 0.543 0.001 1.721 1.245 2.38
Health motivation 0.292 0.001 1.34 1.122 1.599
Perceive condent 0.191 0.004 1.211 1.064 1.378
Perceive benet (BSE) 0.286 0.035 1.332 1.021 1.737
Perceive barrier (BSE) -0.666 0.000 0.514 0.379 0.695
Constant -17.39 0.000 0.000
CONCLUSION
Awareness and regular practice of BSE among participants was considerably high with respect to other studies of the
region. The results of this study illustrated that although women have awareness about BSE, only a few of them knew
that this screening exercise is to be done monthly as it was found that more than two-third participants performed BSE
but only few performed BSE regularly. Education, employment status, family history, past history of breast disease,
lactation was signicantly associated with regular practice of BSE. In addition various factors i.e., nonlactating phase,
pregnancy in high age,good knowledge, perceived susceptibility, self-efcacy, health motivation, awareness regarding
benet of BSE and low barrier of breast self-examination were found associated with regular practice of BSE.
DECLARATIONS
Ethical Clearance
Ethical clearance was taken by the ethical committee of the University of Sulaimani.
Conict of Interest
The authors declared no potential conicts of interest with respect to the research, authorship, and/or publication of
this article.
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