Assessment of knowledge and practice of mammography and breast self-examination among the general female population in Asir region of KSA

Abstract

OBJECTIVE: Breast cancer is the most common malignancy in Kingdom of Saudi Arabia (KSA) and an increasing burden in terms of incidence, morbidity and mortali- ty. It accounts for about 28.7% of all new can- cers in women. In 2015, the Saudi cancer reg- istry shows that breast cancer was graded first among women and it accounts for 16.7% of all cancers reported among Saudi nationals. This study was designed to assess breast cancer screening knowledge and practices among women in the Asir region, Kingdom of Saudi Arabia.
MATERIALS AND METHODS: A cross-sec- tional study recruiting 1,021 female partici- pants was performed. The variables included breast cancer knowledge, socio-demograph- ic features, breast self-examination knowledge and practice. Descriptive statistics was used to compare and analyze the collected data while chi-square test was used to check the statistical significance among the selected variables. Sau- di married women from Asir region were the par- ticipants of this cross-sectional study.
RESULTS: Our findings suggested that par- ticipants had a satisfactory level of knowledge about breast self-examination and mammo- grams at a rate of > 90% and 44.76% respective- ly. Over 90% of participants had good breast self-exam knowledge, however, only 6.37% was always performed breast self-examination. Simi- larly, nearly 40% of participants performed mam- mograms, while 40.5% were unaware. Leaflets and doctors were the primary sources of infor- mation for participants regarding the informa- tion of breast cancer screening.
CONCLUSIONS: Breast self-examination is a crucial approach to the timely detection of breast cancer and is subsequently critical for ef- fective treatment. From the findings of this study we concluded that most women in the Asir region have a good awareness of breast cancer screening methods. However, either screening of self-examination or mammogram for breast cancer was not carried out thoroughly and regularly. This means that we must continue to emphasize the importance of primary health care in the earliest stages of breast cancer.

Full text

7231
gion have a good awareness of breast cancer
screening methods. However, either screening
of self-examination or mammogram for breast
cancer was not carried out thoroughly and reg-
ularly. This means that we must continue to em-
phasize the importance of primary health care in
the earliest stages of breast cancer.
Key Words:
Breast cancer, Breast self-exam, Mammogram, Asir
region, Saudi Arabia.
Introduction
Literature shows that there is an increasing
burden of breast cancer in terms of incidence,
morbidity and mortality related to breast cancer
world-wide. Breast cancer is a most common ma-
lignancy in Kingdom of Saudi Arabia1. It accounts
for about 28.7% of all new cancers in women. In
2015, the Saudi cancer registry shows that breast
cancer was graded rst among women and it ac-
counts for 16.7% of all cancers reported among
Saudi nationals2.
In the United States, 50% of new breast cancer
cases occur in women over the age of 65 years,
while in the Arab countries, including Saudi Ara-
bia, it usually occurs in women at the age of 52
years. Numbers between the United States and
KSA are not varying, but the difference is appar-
ent in the age of patient and the stage of disease
when it is diagnosed (MOH). According to stud-
ies in Europe and America, 1 in 8 women will
develop breast cancer over the course of her life-
time3. In the KSA, breast cancer usually presents
Abstract. – OBJEC TIVE: Breast cancer is
the most common malignancy in Kingdom of
Saudi Arabia (KSA) and an increasing burden
in terms of incidence, morbidity and mortali-
ty. It accounts for about 28.7% of all new can-
cers in women. In 2015, the Saudi cancer reg-
istry shows that breast cancer was graded rst
among women and it accounts for 16.7% of all
cancers reported among Saudi nationals. This
study was designed to assess breast cancer
screening knowledge and practices among
women in the Asir region, Kingdom of Saudi
Arabia.
MATERIALS AND M ETHODS : A cross-sec-
tional study recruiting 1,021 female partici-
pants was performed. The variables included
breast cancer knowledge, socio-demograph-
ic features, breast self-examination knowledge
and practice. Descriptive statistics was used to
compare and analyze the collected data while
chi-square test was used to check the statistical
signicance among the selected variables. Sau-
di married women from Asir region were the par-
ticipants of this cross-sectional study.
RE S ULT S : Our ndings suggested that par
-
ticipants had a satisfactory level of knowledge
about breast self-examination and mammo-
grams at a rate of > 90% and 44.76% respective-
ly. Over 90% of participants had good breast
self-exam knowledge, however, only 6.37% was
always performed breast self-examination. Simi-
larly, nearly 40% of participants performed mam-
mograms, while 40.5% were unaware. Leaets
and doctors were the primary sources of infor-
mation for participants regarding the informa-
tion of breast cancer screening.
CONCLUSIONS: Breast self-examination is
a crucial approach to the timely detection of
breast cancer and is subsequently critical for ef-
fective treatment. From the ndings of this study
we concluded that most women in the Asir re-
European Review for Medical and Pharmacological Sciences 2021; 25: 7231-7237
T. ALQAHTANI1, A.M. ALQAHTANI1, S.M. ALSHAHRANI2, K. ORAYJ2,
M. ALMANASEF2, A.H. ALAMRI3, V. EASWARAN2, N.A. KHAN2
1Department of Pharmacology, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
2Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
3Department of Pharmaceutics, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
Corresponding Author: Ali Alqahtani, Ph.D; e-mail: amsfr@kku.edu.sa
Assessment of knowledge and practice
of mammography and breast self-examination
among the general female population
in Asir region of KSA

T. Alqahtani, A.M. Alqahtani, S.M. Alshahrani, K. Orayj, M. Almanasef, A.H. Alamri, et al
7232
at advanced stage than western countries. Yet, the
apparent barriers to late presentation is not prop-
erly evaluated4. Mammography ensures early
diagnosis and a better chance for treatment and
recovery3,4.
The risk factors of this disease are numerous,
and their prevalence varies between racial and
ethnic groups as well as geographical regions5.
Several studies reported that the awareness of
breast cancer is very low and adequately of ob-
stacles have been reported among Arab women
in previous studies6. It clearly shows that there is
huge increase of incidence of breast cancer and it
is expected to grow in near future. In addition, it
brings terrible social, economic and public health
implications. Breast cancer among Saudis is usu-
ally characterised by high aggressiveness, poor
clinical pathological features and early onset5. It
has also been reported that self-efcacy and fear
of breast cancer can inuence patients’ screening
behaviour.
The Centres for Disease Control and Preven-
tion recommend mammography for breast cancer
screening at least every two years for women aged
50-74 years old. The appearance of lumps does
not necessarily mean cancer; it may be due to the
presence of cysts, abscesses, or other benign tu-
mours. Thus, it is also important to understand
the awareness on mammogram among Saudi Fe-
male population. Currently, there is no sufcient
knowledge on the causes of breast cancer, but
there is knowledge of risk factors that increase
the possibility of developing breast cancer. There-
fore, prevention and early detection of the disease
remains the cornerstone of breast cancer control7.
Therefore, the current study was designed to un-
derstand the impact of specic demographic char-
acteristics on practice of self-examination pattern
and mammogram usage.
The aim of this cross sectional (quantitative)
study was to estimate the impact of demograph-
ic characters on the self-breast examination and
usage of mammogram for the early detection of
cancer.
Materials and Methods
Study Design and Setting
This study followed a prospective cross-sec-
tional design using an online self-administered
questionnaire. The study took place in Asir re-
gion, Kingdom of Saudi Arabia using a conve-
nience sampling strategy between November
2019 to January 2020.
Study Population and Sample Size
Calculation
The study participants were female residents
with an age of 18 years or older. According to the
Saudi general authority for statistics, the total fe-
male population who are 18 years or older in Asir
region was 694,930 in mid-2019. The minimum
recommended sample size was 384 subjects. This
was estimated using Raosoft® sample size calcu-
lator based on the population size, 5% margin of
error ( p≤005), 95% condence interval and 50%
response distribution.
Study Tools and Data Collection Process
Based on various previous studies that reect
different regions of Saudi Arabia, a self-adminis-
tered, structured and closed-ended questionnaire
was designed8. The survey questionnaire was cre-
ated using Google forms as part of a cross-sec-
tional study conducted over three months. Sever-
al different social media platforms (Twitter and
WhatsApp) were used to draw upon a sample of
female participants based in the Asir Region. The
questionnaire was distributed across several fe-
males WhatsApp groups of various activities to
target the female population of the Asir region.
The survey was translated into Arabic. Initially, a
self-administered questionnaire was created and
the pilot sample was then validated to ensure its
quality and internal reliability. The Cronbach Al-
pha factor was determined as 0.799. In addition,
three experts working within this eld provided
advice regarding this process. The questionnaire
was divided into two sections. The rst sec-
tion collected demographic information, while
the second section contained closed-open and
closed-ended questions aimed at learning about
participants’ attitudes on contraception.
Ethical Considerations
Ethical approval was granted by the King Kha-
lid University Research Ethics Committee, approv-
al reference (ECM#2019-87/HAPO-06-B-001). ).
All the study participants were explained the study
method, importance of the study and other relevant
matters to obtain an informed consent. Data were
kept securely and were not used to identify respon-
dents. Protocols of Helsinki’s were followed while
conducting the research.
Statistical Analysis
The questionnaires completeness and accura-
cy were conrmed, and then, entered into SPSS

KAP and mammography in Aseer, KSA
7233
version 24 (IBM Corp., Armonk, NY, USA). The
participants demographics were represented de-
scriptively. As all variables were categorical in
natures, they reported frequencies and percentag-
es. A multiple logistic regression model (χ2) was
conducted to investigate the factors that affect the
intention to use mammogram methods in the fu-
ture. The chi-square test will be used for categori-
cal data. p-value was considered signicant if it is
less than 0.05, i.e., 5%.
Results
A total of 1021 volunteers agreed to participate
in the study and send back the questionnaire. The
majority (44.27%) of the survey participants were
between the age of 18 to 29 years, 26.35% (n=269)
aged between 30 and 40 years and the remaining
29.38% (n=300) were older than 40 years. Just be-
low 1% of the participants (n=10) had no formal
schooling, around 30% (n=296) had school edu-
cation while the majority (70%) holds a university
degree. The demographic data of the participants
are summarised in Table I.
The majority of the participants (93.93%) in all
education levels and age categories were aware
about breast self-exam. Around 40% of the par-
ticipants who had no formal schooling did not
hear about breast self-exam practice. Just below
two thirds (2/3) of those who had school educa-
tion (58.3%) and university degree (63.1%) heard
about breast self-exam from leaets. However,
around 67% (n=4) obtained this information from
their doctor. Among the different age groups, the
highest proportion of the participants (64.7% for
20-29 years age group, 62% for 30-40 years age
group, and 56% for older than 40 years) indicat-
ed that they relied on leaets to get information
about breast self-exam. Breast self-exam was not
practiced in just above half (57.69%) of the study
sample and the percentage was higher in lower
educational level and younger age groups. About
60.43% of the women who participated in this
survey were convinced about breast self-exam ef-
fectiveness. The percentage, however, was higher
among those with lower educational level and old-
er age groups as shown in Table II-V.
Just above half (55.25%) of the study partici-
pants indicated that the did not hear about breast
mammogram. The percentage was higher among
women with lower educational level and younger
age groups. Woman who heard about mammo-
gram indicated that they got the information from
leaets (48.14%), followed by doctor (30.6%),
followed by family and friends (21.2%). How-
ever, the majority of women who had no formal
schooling got information about mammogram
from their doctor. Additionally, nearly half of
those participants who had school education and
university degree got their information from leaf-
lets. The highest percentage of the participants
(55.9% for 20-29 years age group, 50.4% for 30-
40 years age group) indicated that they relied on
leaets to get information about mammogram.
However, the majority of the participants (75.8%)
who were older than 40 years old were equally
divided between leaets and doctors as a source
of information. Suspicion of breast cancer sign
and symptoms was found as the main motivation
to undergo mammogram for around 50% of the
study sample and about 40% did not know what
was their motivation for this. Higher proportion
of those participants who had no formal schooling
did not know about their motivation to do mam-
mogram. Around two thirds of the participants
who are above the age of 40 years indicated that
suspicion of breast cancer was the main motiva-
tion for them to undergo mammogram. About
40% of the study sample did not know how fre-
quent should a woman undergo a mammogram,
and a similar proportion of them thought the fre-
quency should be a yearly basis. A larger propor-
tion of those who indicated that they did not know
were in the younger age groups, i.e., 20-29 years
and 30 to 40 years. However, a larger percentage
of participants who indicated that the mammo-
gram should be done yearly were those who are
older than 40 years.
Discussion
Proper precautionary policies and strategies fo-
Table I. Demographic information of the participants (n =
1021).
n (%)
Age group
18 -29 years 452 (44.27)
30 - 40 years 269 (26.35)
> 40 years 300 (29.38)
Education Level
No formal schooling 10 (0.98)
School education 296 (28.99)
University degree 715 (70.03)

T. Alqahtani, A.M. Alqahtani, S.M. Alshahrani, K. Orayj, M. Almanasef, A.H. Alamri, et al
7234
cusing on both primary and secondary preventive
mechanisms are desirable to decrease the occur-
rence of breast cancer. One crucial strategy is to
evaluate the awareness and knowledge of breast
cancer and breast self-examination and the second
major approach is to help increase breast self-ex-
amination among vulnerable women9. This study
was conducted among women in the Asir region,
aged 18 years or older, to evaluate the knowledge
of breast cancer and explore their awareness of
breast self-examination and mammogram as a
screening strategy for the early diagnosis of can-
cer. Advancing society’s awareness of breast can-
cer will increase the chances of early diagnosis
and improve prognosis.
The most frequent breast cancer in KSA is breast
cancer, while breast cancer cases in the Middle East
are expected to increase four times in the next twenty
years. Breast cancer has early effects in Saudi women,
which imposes social and economic expenses com-
pared to developed countries. The majority of cases
are diagnosed later, resulting in poor recovery rates.
Breast cancer awareness is essential for early detection
and prevention and general healthcare facilities will
be the rst contact point for women and their families
inside that healthcare system. Increased knowledge of
the procedures for screening breast cancer will lead
to early intervention, diagnosis and survival9,10. In the
present study, the majority of the participants (70%)
have university degree, while only 0.98% holds no
formal schooling. Consequently, 93.93% are aware
of the breast self-exam, while majority of them have
educational background, which is similar to the previ-
ous study reported in Riyadh11. Additionally, 60.43%
of the participated women were convinced with the
breast self-exam effectiveness. Around half of the
participants in the earlier ndings at Najran, Saudi
Arabia, displayed low awareness about breast cancer
(54.4%) and breast self-exam (56.8%). In addition,
the study found that 35% of women who visited the
primary healthcare centres underwent breast self-ex-
aminations9. The results can be compared to previous
studies in Abha, Buraidah, and Al Hassa in Saudi
Arabia1,12,13. In addition, a study in Ain Shams Uni-
versity Hospitals, Egypt, revealed that TV (42.9%),
radio and newspapers (3.9% each) and the Internet
and health education in some primary health facili-
ties were the most prevalent sources utilized by the
participants to obtain information (23.9% and 22.6%,
respectively)14.
In the present study, 61.42% of participants took
information about breast self-exam from leaets,
while 21.58% and 16.99% from doctors and family,
respectively. However, the ndings about the breast
self-exam practices are signicantly (p< 0.001)
correlated with the age groups, whereas more than
50% of the participants were not practice breast
self-exam effectiveness. However, more than 90%
of the participants were acknowledge that they are
heard about breast self-exam. Similar type of nd-
ings observed in previous couple of study, whereas
the age groups play an important role in breast can-
Total
n=1021
No formal
schooling
n=10
School
Education
n=296
University
Degree
n=715 p-value
Heard about SE
Yes
No
959 (93.93%)
62 (6.7%)
6 (60.0%)
4 (40.0%)
276 (93.2%)
20 (6.8%)
677(94.7%)
38 (5.3%)
< 0.001
Source of info about SE
Family and friends
Doctor
Leaets
163 (16.99%)
207 (21.58%)
589 (61.42%)
1 (16.67%)
4 (66.67%)
1 (16.67%)
65 (23.6%)
50 (18.16%)
161 (58.3%)
97 (14.3%)
153 (22.6%)
427 (63.1%)
< 0.001
Practice SE
No
Rarely
Sometimes
Always
589 (57.69%)
101 (9.89%)
266 (26.05%)
65 (6.37%)
7 (70.0%)
1 (10.0%)
1 (10.0%)
1 (10.0%)
185 (62.5%)
27 (9.1%)
69 (23.3%)
15 (5.1%)
397 (55.5%)
73 (10.2%)
196 (27.4%)
49 (6.9%)
0.44
Effectiveness of SE
Don’t know
Not convincing
Convincing
334 (32.71%)
70 (6.86%)
617 (60.43)
3 (30.0%)
0 (0.0%)
7 (70.0%)
97 (32.8%)
20 (6.8%)
179 (60.5%)
234 (32.7%)
50 (7.0%)
431 (60.3%)
0.93
Table II. Level of education and breast Self-Exam (SE) practices.

KAP and mammography in Aseer, KSA
7235
cer knowledge9,14,15.
Global standard screening for early breast can-
cer detection is mammography. Regular screening
of mammograms has been associated with lower
breast cancer death rates of about 20% to 25%16,17.
In Saudi Arabia, the government has offered the
general public free mammograms via health work-
ers and others, namely the Zahra Breast Cancer
Association. Although mammograms are avail-
able free of charge by the government, most wom-
en still do not use these screenings9. In the present
study, both the age and educational groups report-
ed similar percentage regarding the knowledge of
mammogram practices, whereas half of them are
aware about mammogram. However, the motiva-
tions towards mammogram are below 50%, while
39.3% are not aware of the mammogram. Similar
low percentage also observed in previous study in
KSA1,9,18,19. In other Islamic countries, the aware-
ness about mammogram was found similarly low
Total
n=1021 20 -29 years
n=452 30 - 40 years
n=269 > 40 years
n=300 p-value
Heard about SE
Yes
No
959 (93.93%)
62 (6.7%)
422 (93.4%)
30 (6.6%)
253 (94.1%)
16 (5.9%)
284 (94.7%)
16 (5.3%)
0.76
Source of info about SE
Family and friends
Doctor
Leaets
163 (16.99%)
207 (21.58%)
589 (61.42%)
61 (14.5%)
88 (20.9%)
273 (64.7%)
46 (18.2%)
50 (19.8%)
157 (62%)
56 (19.7%)
69 (24.3%)
159 (56%)
0.3
Practice SE
No
Rarely
Sometimes
Always
589 (57.69%)
101 (9.89%)
266 (26.05%)
65 (6.37%)
281 (62.2%)
54 (11.9%)
102 (22.6%)
15 (3.3%)
156 (58.0%)
16 (5.9%)
73 (27.1%)
24 (8.9%)
152 (50.7%)
31 (10.3%)
91 (30.3%)
26 (8.7%)
< 0.001
Effectiveness of SE
Don’t know
Not convincing
Convincing
334 (32.71%)
70 (6.86%)
617 (60.43)
166 (36.7%)
33 (7.3%)
253 (56.0%)
76 (28.3%)
22 (8.2%)
171 (63.6%)
92 (30.7%)
15 (5.0%)
193 (64.3%)
0.06
Table III. Age groups and Breast Self-Exam (BSE) practices.
Total
n=1021 No formal
schooling
n=10
School
Education
n=296
University
Degree
n=715 p-value
Heard about MG
Yes
No
457 (44.76%)
564 (55.24%)
4 (40.0%)
6 (60.0%)
126 (42.6%)
170 (57.4%)
327 (45.7%)
388 (54.3%)
0.62
Source of info about MG
Family and friends
Doctor
Leaets
97 (21.23%)
140 (30.63%)
220 (48.14%)
1 (25.0%)
3 (75.0%)
0 (0.0%)
32 (25.4%)
34 (27.0%)
60 (47.6 %)
64 (19.6%)
103 (31.5%)
160 (48.9%)
0.32
Motivation to do MG
Age > 30 years
Suspicion of Breast Cancer signs
and symptoms
Don’t know
107 (10.5%)
513 (50.2%)
401 (39.3%)
0 (0.0%)
4 (40.0%)
6 (60.0%)
16 (5.4%)
148 (50.0%)
132 (44.6%)
91 (12.7%)
361 (50.5%)
263 (36.8%)
0.003
Frequency should you do MG
Monthly
Yearly
Every 2 years
Every 10 years
Don’t know
98 (9.6%)
400 (39.2%)
92 (9%)
18 (1.8%)
413 (40.5%)
2 (20.0%)
4 (40.0%)
1 (10.0%)
0 (0.0%)
3 (30.0%)
28 (9.5%)
108 (36.5%)
26 (8.8%)
3 (1.0%)
131 (44.3%)
68 (9.5%)
288 (40.3%)
65 (9.1%)
15 (2.1%)
279 (39.0%)
0.74
Table IV. Level of education and mammogram (MG) practices.

T. Alqahtani, A.M. Alqahtani, S.M. Alshahrani, K. Orayj, M. Almanasef, A.H. Alamri, et al
7236
where only 21.5% of Iranian women, 22.5% of
Qatar and 39.4% of Turkish Republic were aware
about mammogram20-22 . Mammograms at age 40
are offered by the American college of obstetri-
cians and gynaecologists and the American Can-
cer Society23. In the current study, 35% of the par-
ticipants aged older than 40 years were not aware
that they had to do the mammogram regularly,
while 44.7% considered doing it yearly. Likewise,
almost similar percentage of ndings (40.3%) was
reported for the participants who have university
degree. In a study carried out among Arab wom-
en residing in Qatar, 24.4% of respondents dis-
cussed breast cancer with their doctors24, while in
our study 30% acquired the information about the
mammogram from the doctors.
The present outcomes showed that higher ed-
ucation boosts people’s knowledge, which was
also reported in the previous study. This is clearly
because better levels of education allow people
to discover information and have a favourable
attitude towards their evaluation sources about
various diseases25,26. In this study, leaets were
the primary source of information on breast can-
cer, while some other studies reported the social
media was inuential for awareness. An annual
event to raise breast cancer awareness was orga-
nized by the Minister of Health in Saudi Arabia
during the International Breast Cancer Aware-
ness in October1,9.
Conclusions
The ndings of this study show an overall lack
of punctuality of breast self-examination among
rural women in the Asir region of KSA. It is ob-
served in the current study that most women show
a satisfactory understanding of the methods of
screening for breast cancer. However, the self-ex-
amination or mammography was not thoroughly
screened by the participants. Further attention
must be placed into raising awareness of mam-
mograms to early breast cancer identication by
women health care providers.
Acknowledgments
Authors are thankful to the university admin for the
provision of research environment.
Funding Statement
No external funding was available for this research.
Data Availability
Data will be available on demand or request.
Conflicts of interest
Question Total
n=1021 20-29 years
n=452 30-40 years
n=269 > 40 years
n=300 p-value
Heard about MG
Yes
No
457 (44.76%)
564 (55.24%)
177 (39.2%)
275 (60.8%)
119 (44.2%)
150 (55.8%)
161 (53.7%)
139 (46.3%)
<0.001
Source of info about MG
Family and friends
Doctor
Leaets
97 (21.23%)
140 (30.63%)
220 (48.14%)
30 (17.0%)
48 (27.1%)
99 (55.9%)
28 (23.5%)
31 (26.1%)
60 (50.4%)
39 (24.2%)
61 (37.9%)
61 (37.9%)
0.001
Motivation to do MG
Age > 30 years
Suspicion of Breast Cancer
signs and symptoms
Don’t know
107 (10.5%)
513 (50.2%)
401 (39.3%)
56 (12.4%)
207 (45.8%)
189 (41.8%)
28 (10.4%)
121 (45.0%)
120 (44.6%)
23 (7.7%)
185 (61.7%)
92 (30.7%)
0.001
Frequency should you do MG
Monthly
Yearly
Every 2 years
Every 10 years
Don’t know
98 (9.6%)
400 (39.2%)
92 (9%)
18 (1.8%)
413 (40.5%)
56 (12.4%)
161 (35.6%)
41 (9.1%)
9 (2.0%)
185 (40.9%)
25 (9.3%)
105 (39.0%)
13 (4.8%)
3 (1.1%)
123 (45.7%)
17 (5.7%)
134 (44.7%)
38 (12.7%)
6 (2.0%)
105 (35.0%)
0.001
Table V. Age groups and mammogram (MG) practices.

KAP and mammography in Aseer, KSA
7237
The authors declare no conicts of interest.
Authors’ Contributions
All authors contributed equally.
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