CLIMACTERIC 2015;18:99–100

Letters to the Editors

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Health knowledge, attitude, practice: the missing circle of breast cancer screening programs in Iran Yip and Taib have described well the barriers of early detection of breast cancer in developing countries1. This critical fact applies in Iran. During the last decades, breast cancer incidence has doubled and is seen in most countries around the world. Breast cancer is one of the most common cancers among women in Iran. Previous studies in Iran have revealed that the majority of patients were diagnosed with advanced disease2. This important health problem caused the Ministry of Health and Medical Education in Iran to officially recommend the following screening measures: mammography, clinical breast examination, and breast self-examination (BSE). The goal of such a program was the early diagnosis of the disease with effective treatment to decrease morbidity and mortality rates3. However, regular screening in developing countries including Iran remains low4. Results from a study reported that most Iranian women were not familiar with warning signs of breast cancer and how to perform BSE and that knowledge regarding routine screening methods including clinical examination and mammography was very inadequate5. Yip and Taib have described well the barriers to early detection of breast cancer in developing countries1, and they specifically mentioned several associated factors as ‘barriers to early detection’ such as geographical isolation, financial limitations, lack of education, and lack of autonomous decision-making1. However, there are other important factors including religion and spirituality that play a role in screening delay in developing countries6. There are many patients who avoid attending the clinic early only because of their embarrassment of being examined. For example, in Iran, radiologic assessments such as sonography and mammography are available in most of the urban areas in the country, but people’s knowledge of breast assessment tools is poor. This might be the major explanation for the growing number of mastectomy and end-stage breast cancers in the past years in Iran, in contrast to the situation in developed countries where the incidence of breast cancer has been steadily controlled. In Iran, most patients do not follow the routine screening program. To manage and enhance the screening programs nationwide, it seems vital to conduct knowledge, attitude and practice (KAP) studies for evaluating the current situation and then to make a program for the current inquiries

of this issue. Primary health-care centers need to integrate more effective and feasible programs in order to emphasize screening, despite the absence of symptoms. Previous studies in Iran supported the efficacy of the health belief model to increase the knowledge of women regarding the benefits of mammography in the early detection of breast cancer7. But still, the approach of policymakers on this issue seem to be ambiguous. As we achieve better implementation of educational programs in target populations, we are capable of prompting these women to be conscious of their own health status. Health-care providers should raise the knowledge and awareness of breast health among the women and the educational programs need to be implemented widely by educated family physicians in this issue.  Student Research Committee, A. Zarghami Babol University of Medical Sciences,   Babol, Iran; E-mail: [email protected]

References 1. Yip CH, Taib NA. Breast health in developing countries. Climacteric 2014;17(Suppl 2):54–9 2. Mousavi SM, Mohagheghi MA, Mousavi-Jerrahi A, Nahvijou A, Seddighi Z. Outcome of breast cancer in Iran: a study of Tehran Cancer Registry data. Asian Pac J Cancer Prev 2008;9:275–8 3. Moodi M, Rezaeian M, Mostafavi F, Sharifirad GR. Determinants of mammography screening behavior in Iranian women: A population-based study. J Res Med Sci 2012;17:750–9 4. Taymoori P, Molina Y, Roshani D. Effects of a randomized controlled trial to increase repeat mammography screening in Iranian women. Cancer Nurs 2014 Aug 13. Epub ahead of print 5. Montazeri A, Vahdaninia M, Harirchi I, et al. Breast cancer in Iran: need for greater women awareness of warning signs and effective screening methods. Asia Pac Fam Med 2008;7:6 6. Gullate M. The influence of spirituality and religiosity on breast cancer screening delay in African American women: application of the Theory of Reasoned Action and Planned Behavior (TRA/TPB). ABNF J 2006;17:89–94 7. Rezaeian M, Sharifirad G, Mostafavi F, Moodi M, Abbasi MH. The effects of breast cancer educational intervention on know­ ledge and health beliefs of women 40 years and older, Isfahan, Iran. J Educ Health Promot 2014;3:43

Author’s reply In his recent letter1, Dr Zarghami described the situation in Iran where the majority of women with breast cancer present with advanced disease, and one of the barriers the author identified is religion and spirituality. While religion and  © 2015 International Menopause Society DOI: 10.3109/13697137.2014.974532

spirituality have been well studied as a coping strategy after a diagnosis of breast cancer2, their role in screening and early detection is not so well studied, although the role of ethnicity and culture in screening practices has been studied. Ethnicity,

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Letters to the Editors  culture and religion are so intertwined that the differencs become blurred. A woman with a strong belief in God may not go for screening or even see a doctor if she feels a breast lump, because she will feel that it is due to God’s will, and only God can cure cancer3. In Islamic cultures, a woman’s decision-making power may be limited and male family members often have the primary say in matters related to healthseeking behavior. Hence, a women needs sanction from her husband or male relatives to see a doctor. She may not have autonomous decision-making, as seen in a study done in Malaysia, a predominantly Muslim country4. Dr Zarghami also alluded to embarrassment in being examined as a barrier to seeking treatment. However, in many parts of the world, there are more female doctors being trained compared to male doctors, and hence a culturally sensitive approach, with women health-care workers being involved in the primary care of these women, will overcome this barrier. A woman’s decision-making journey is complex and why she presents late, whether at a personal or societal level, needs more study and only then can we design intervention programs to promote diagnosis at earlier stages where cure is possible5.


Yip Consultant Breast Surgeon,  Breast Centre, Sime Darby Medical Centre, Subang Jaya, Selangor, Malaysia; E-mail: [email protected]

C.-H. Yip

References 1. Zarghami A. Health knowledge, attitude, practice: the missing circle of breast cancer screening programs in Iran. Climacteric 2015;18:99 2. Choumanova I, Wanat S, Barrett R, Koopman C. Religion and spirituality in coping with breast cancer: perspectives of Chilean women. Breast J 2006;12:349–52 3. Mitchell J, Lannin DR, Mathews HF, Swanson MS. Religious beliefs and breast cancer screening. J Women’s Health 2002;11:907–15 4. Taib NA, Yip CH, Low WY. A grounded explanation of why women present with advanced breast cancer. World J Surg 2014; 38:1676–84 5. Abdullah A, Abdullah KL, Yip CH, Teo SH, Taib NA, Ng CJ. The decision-making journey of Malaysian women with early breast cancer: a qualitative study. Asian Pacific J Cancer Prev 2013;14: 7143–7


Health knowledge, attitude, practice: the missing circle of breast cancer screening programs in Iran.

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