An-Najah National University Faculty of Graduates Study Breast Cancer Screening Barriers among Women in Nablus Governorate By Dina Zayed Younes Supervised by Dr. Mariam Al -Tell This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Study of Women, Faculty of Graduates Study, An Najah National University, Nablus, Palestine . 2015 iii Dedication To my mother who learns I to believe in myself, and always encouraged me to go in every adventure, I done this with your faith and support. To my sisters, brothers, to my husband, to my son and daughter. iv Acknowledgment Would like to thank An Najah National University, Faculty of Graduates Study and coordinator of the Women Study master program. Special thank to my Supervisor Dr. Mariam Al-Tell for her guidance, support and advices to complete this work, and to all who provide help. vi List of abbreviations BSE Breast self exam CBE Clinical breast exam Mammography Breast X Ray WHO World Health Organization NCD Non communicable diseases MOH Ministry of Health GSCE General Secondary Certificate Examination (Tawjihi) vii Table of Contents No. Content Page Dedication iii Acknowledgment iv Declaration v List of abbreviations vi Table of Contents vii List of Tables ix List of Figure xi List of Annexes xii Abstract xiii Chapter One: Introduction 1 1.1 Statement of problem 4 1.2 Significance of the study 5 1.3 Purpose of the study 5 1.4 Research questions 5 1.5 Research hypotheses 6 1.6 Definition of terms 6 Chapter Two: Background 8 2.1 History of breast cancer 9 2.2 Risk factors 11 2.3 Signs and symptoms 13 2.4 Stages of breast cancer 15 2.5 Screening and early detection 16 Chapter three: Literature Review 22 Chapter four: Methodology 39 4.1 Study design 40 4.2 Setting and Site 40 4.2.1 Nablus Governorate 41 4.2.2 Nablus City 41 4.2.3 Beita Town 41 4.2.4 Beit Furik Village 42 4.2.5 Askar Refugee Camp 42 4.3 Study Population 42 4.4 Sample size and sampling method 43 4.5 Inclusion criteria 44 4.6 Data collection tool 44 4.7 Validity and reliability 46 4.8 Ethical consideration 46 4.9 The study procedure 47 viii No. Content Page 4.10 Scoring system 48 4.11 Data analysis 49 Chapter Five :Results 50 5.1 Participant’s socio-demographic data 51 Participants knowledge and their perceptions about 5.2 usefulness of breast cancer screening test for early 52 detection 5.3 Participants practice of breast cancer screening tests 53 Participants perceptions of breast cancer screening 5.4 54 barriers 5.5 Results of the hypothesis 63 Chapter sex :Discussion 70 6.1 Demographic date 71 Participant knowledge about breast cancer screening 6.2 71 tests 6.3 Participant Practice of breast cancer screening tests 73 Participants perceptions of breast cancer screening 6.4 75 barriers 6.5 Results of the hypothesis 79 Chapter Seven :conclusion and recommendation 83 7.1 Conclusion 84 7.2 Recommendation 85 7.3 Limitations of the Study 86 References 87 Annexes 98 b ﺍﻝﻤﻠﺨﺹ ix List of Tables No. Table Page Estimated risk of developing breast cancer by Table (2. 1) 12 certain age. Presenting symptoms in operable breast cancer Table (2.2) 14 patients. Table (2.3) Stages of Breast Cancer 16 Sensitivity and specificity for CBE and Table (2.4) 20 Mammography Recommendations for Breast Cancer Screening Table (2.5) 21 tests. Studies explored the barriers of breast cancer Table (3.1) 32 screening tests Barriers towards Breast Cancer Screening in the Table (3.2) 37 Arab Women Table (4.1) The distribution of study sample 43 Table (4.2) The result of chronbach alpha test 46 Distribution of the percentage of the participant Table (5.1) 51 regards their socio-demographic data Distribution of the percentage of the participant regards their knowledge of breast cancer Table (5.2) 52 screening tests and the Usefulness for early detection Distribution of the percentage of the participant Table (5.3) regards their practice of breast cancer screening 53 tests Distribution of the mean, standard deviations, level of agreement and percentage of Table (5.4) 54 participants regarding their fear of having cancer Distribution of the means, the standard deviations, the level of agreement and Table (5.5) 56 percentage regarding the general barriers of practicing breast cancer screening tests Distribution of the means, the standard Table (5.6) deviations, the level of agreement and 58 percentage of participants regard CBE barriers Distribution of the means, the standard deviations,the level of agreement and Table (5.7) 60 percentage of participants regarding barriers of performing BSE x No. Table Page Distribution of the means, the standard deviations, the level of agreement and Table (5.8) 62 percentage of participants regard barriers of performing mammography Distribution of Mean, standard deviation and significances of the relationship between Breast Table (5.9) 64 cancer screening tests barriers and demographic data Scheffe Post Hoc test, for comparing the means Table(5.10) 65 of mammography to place of residence Scheffe Post Hoc test, for comparing the means Table (5.11) 66 of barriers to level of education Mean and standard deviation of relationship Table (5.12) 67 between general barriers and demographic data Scheffe Post Hoc test, for comparing the mean Table (5.13) 68 of general barriers according to age Scheffe Post Hoc test, for comparing the mean Table (5.14) of general barriers according to level of 68 education xi List of Figure No. Figure Page Figure (3.1) Barriers to Breast Cancer Screening 33 Figure (3.2) Barriers to Breast Cancer Screening 36 xii List of Annexes No. Annex Page Annex (1) Questioner in Arabic 98 Annex (2) Consent form 107 Barriers and facilitators towered breast cancer Annex (3) 108 screening in the Arab World. xiii Breast Cancer Screening Barriers among Women in Nablus Governorate By Dina Zayed Younes Supervised by Dr. Mariam Al -Tell Abstract Introduction: Breast cancer is still one of the major health problems not only in Palestine but also all over the world. It is one of the Non Communicable Diseases (NCD) that form a biggest challenge and major public health problem that most countries especially the developing countries face. Knowing the breast cancer screening barriers that prevent women from performing breast cancer early screening can increase the chance of early detection and this can be minimize the occurrence of disease and related deaths. Objectives: The main objective was to assess the barriers that prevent women from performing breast cancer screening tests. Method: A convenient sample method including 269 women aged from 30-60 years old who lived in Nablus Governorate was used. Also a purposive sample method was used to select women’s social centers from Nablus city, two villages (Beit Furik, Beita) and Askar refugee camp. Participants filled in self-administrated questionnaire, and data analysis was done by using SPSS. xiv Results: The percentage of the participants who knew mammogram, CBE and BSE tests (59.5%), (47.6%) and (67.3%) respectively. Moreover, the percentages of participants who did not perform mammogram and CBE tests were (60.2%) and (74.0%) respectively. The most common barriers that prevented women from performing breast cancer screening tests were “fear of suffering cancer pains” and “changing physical appearance”, “financial cost”, “afraid of having cancer”, “shy of applying the tests” and “it takes time to conducting regularly” and “test may cause pain”. Also, there were a significant relationships between mammogram barriers and place of residency (P values .046), between BSE and educational status (P values .021), between the age and geographical and financial barriers (p value.012), (p value.001) respectively, and between the educational status and geographical and financial barriers (p value.002), (p value.001) respectively. Recommendation: increase women’s knowledge about breast cancer screening tests, and to have a female physician in every clinic . 1 Chapter one Introduction 2 Chapter One Introduction The non-communicable diseases (NCD) in the twenty-first century are challenge and major public health problem that most countries especially the developing countries face. Related deaths reached up to 35 million death around the world, 28 million from them in developing countries, and 14 million can be prevented, (W.H.O, 2009 ), in addition, cancer contributes to 21% of morbidity, which caused 8.2 million deaths in 2012 and 1.7 million new cases every year, (W.H.O, 2011). Globally, breast cancer considered as the major killer of women (W.H.O, 2013). The new cases were 124.6 per 100,000 women per year (National Cancer Institution, 2014). According to Goldman and Ausiello (2004) and Barakat et al. (2009) it was the second leading cause of cancer death in women after lung cancer, and more than 1, 2 million women affected yearly worldwide (Barakat et al., 2009). In USA in 2012, about 39,920 died, but the number decreased to 39,620 in 2013. In Palestine, cancer ranked the second among the diseases that leads to death. In West Bank; Mortality rates has increased from 10.3% in 2007 to 10.8 in 2010, and it reached 13.3% in 2013. The estimated rate reached up to 53.3% among women while for men, it estimated 48.5% of cases, (Palestinian Center Bureau of Statistics (P.C.B.S., 2013). Breast cancer is rated third among the factors that lead to death and occupied the first type and the most common type of cancer among 3 Palestinian women (18.3%) it represented (35.4%) of all cancers, 60% affected age group 15-60 years old (P.H.I.C, 2013).