https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Nurses’ Awareness toward Risk Factors of Breast Cancer in Kirkuk City Hospitals ABSTRACT INTRODUCTION Breast cancer, the proliferation of cells in breast tissue, is a deadly malignancy world- wide. This disorder is characterized by lumps in the breast, persistent pain in the breast or armpit, dimpling of the skin, shift- ing the location of the nipples, rashes on the nipple and swelling under the armpit. This condition is not limited to women on- ly. In both developed and developing countries, it is the most common form of cancer diagnosed in women around the world, with more than one million cases Background and objectives: In women worldwide, breast cancer is the most common can- cer. It is one of the leading causes of cancer death in women, accounting for 15% of all cancer deaths in the female population. In most countries, breast cancer incidence rates are higher than they have ever been at an early age. This study aimed to identify the level of nurses’ awareness towards risk factors of breast cancer. Methods: A cross-sectional study was carried out among 341 nurses from different de- partments in three Kirkuk city hospitals (Azadi Teaching Hospital, Kirkuk General Hospital, and Pediatric Hospital) from 25 February to 25 June 2021. A non-probability/convenient sampling technique was utilized to collect data. A socio-demographic characteristics data form and awareness of breast cancer risk factors form were used to collect data through face-to-face interviews. Data were analyzed using Statistical Package for the Social Scienc- es, version 21, presenting descriptive and inferential statistics comprising frequency, per- centage and chi-square test. Results: Out of the 341 nurses, 44.9% were from Azadi Teaching Hospital, while more than one-third (38.1%) were from Kirkuk General Hospital, and 17% were from Pediatric Hospi- tal. Most of the nurses, 38.4%, were between the ages of 21 and 25, 64.8% were female, and 66.9% were married. About 36.1% of nurses report acceptable level of awareness and 5.9% report being with good level of awareness about risk factors associated with breast cancer. Conclusion: The awareness level of breast cancer risk factors among nurses working in Kirkuk city hospitals was generally high. Younger age was associated with higher level of awareness of risk factors. Regarding to the gender was highly significant differences be- tween the nurses’ awareness of breast cancer risk factors. Keywords: Breast cancer, Risk factors, Nurses, Awareness. Burhan Qader Saadoon; Department of Nursing, College of Nursing, Sulaimani University, Sulamani, Iraq. (Correspondence: borhanqader@gmail.com ) Salih Ahmed Abdulla; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 105 Erbil Journal of Nursing & Midwifery Received: 14/09/2021 Accepted: 18/11/2021 Published: 30/11/2021 mailto:borhanqader@gmail.com https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article occurring annually [1]. Breast cancer devel- opment can be categorized by genetic, life- style and environmental factors. Genetic factors include age, race, familial/personal history of breast cancer, early menstrua- tion (before age 12), late menstruation (after age 51), genetic influences, and dense breast tissue. Lifestyle and environ- mental factors include parity, contracep- tive use, hormone replacement therapy after menopause, breastfeeding, tobacco use, obesity or overweight, and poor diet and exercise [2]. In most countries, breast cancer incidence rates are higher than they have ever been at an early age, and these results are generally highest where histori- cally low rates have been reported [3]. The first and most common symptom of breast cancer is a painless lump or thickening in the breast. Breast pain or heaviness, changes in breast size and form, swelling, and nipple defects, such as spontaneous discharge (especially if bloody), erosion, or retraction, are other signs and symptoms [4]. On mammograms, the first symptoms of breast cancer are typically seen, even before lumps can be felt [5]. Breast cancer is a big health issue for women and society. Community and general nurses are the pri- mary teams of health care professionals who are easily approachable and can serve as the future health educator. The preven- tive services provided by nurses in the form of health evaluation, screening, and thera- py can be incorporated into systematic health promotion and safety programs at the community level. The optimal initial step for the community health nurse is to evaluate women’s history awareness and attitudes prior to the planning and involve- ment in conducting breast cancer teaching programs [6]. Breast cancer compensates one-tenth of all newly diagnosed cancer cases worldwide. Five percent of new breast cancer diagnoses occur in women less than 40 years of age. This may contribute to higher rates of mortality from breast cancer in younger women. The 5-year relative survival rate of young wom- en who are 40 years of age or younger is significantly lower compared to women who are 40 and older. Screening for early detection and having awareness about risk reduction is important for young people [7]. The presence of a lump in the breast that progressively enlarges over time is usually an early sign. If these symptoms are identified, it is better to obtain imme- diate medical advice [8]. The purpose of this study is to evaluate nurse’s level of awareness about breast cancer risk factors and explain how that may influence their ability to provide information and care for their patients. A cross-sectional study was carried out among 341 nurses at different depart- ments in three Kirkuk city hospitals from 25 February to 25 June 2021. A non- probability/convenient sampling technique was utilized to collect data. The inclusion criteria were male and female nurses wor- king morning, evening, and night shifts who agree to participate in this study. Exclusion criteria are those who refused participation or absent during the period of data collection, and nurses who work in managerial role. The sample size was de- termined by K = components (K-items or test lets). σ2X = The variance of the ob- served total test scores. σ 2 Yi = The vari- ance of component i for the current sam- ple of persons [9] Reliability was deter- mined using the Cronbach’s alpha (0.82) values. In order to collect the proper infor- mation of the study, the questionnaire was designed and constructed by the research- er to measure the variables underlying the present study. The researcher prepared a questionnaire for collecting data based on the review literature. The questionnaire 106 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article social science (SPSS) version 21 and the following statistical test were used in data analysis: descriptive statistical data analy- sis: This approach applied through the meas- urement of the following: a. Frequencies (f): n. of samples b. Percentages (%): c. Means: d. Standard Deviation (SD): SD Inferential statistical data analysis: For the abbreviations of the Comparative Signifi- cance (CS), we used the following: NS: Not significant at p. value ≥ 0.05 S: significant at p. value < 0.05 HS: Highly significant at p. value < 0.01 Analysis of Variance (ANOVA) test: A para- metric statistical test used to compare the differences between the means of two or more groups by comparing the variability between groups and within groups. This test was used to determine the differences in the means of nurses' awareness level about the risk factors for breast cancer to different subject variables. Table 1 shows the socio-demographic characteristics of the sample. Nearly half of the sample (44.9%) were from Azadi Teaching Hospital, more than a third (38.1%) were from Kirkuk General Hospi- tal, and about 17% were from Pediatric Hospital. 38.4% of the sample were aged 21-25 years old, 64.8% were female, and 66.9% were married. Less than half (41%) of the population were institute graduates. About 18.8% of the population worked in medical wards, and 14.7% worked in surgi- cal wards. 47.8% of the population had 1-5 years of experience. 94.4% of the popula- tion reported they had not had breast can- cer, and 61.3% reported not caring for breast cancer patients. Finally, based on participation in the trainings, the non- participated sample made the majority consists of two parts: 1) socio demographic characteristics section, and 2) observation checklist with information related to level awareness about breast cancer risk factors, each questionnaire item regarding level of awareness had 3 responses: Yes rated as (1), No is rated as (2) and, I don't know rat- ed as (3). The level of awareness is scored by calculating the lowest total of the incor- rect answers "Yes" or "No". A value of "0- 15.5" indicated poor level of awareness, a value of "16-20" indicated an acceptable level, a value of "21-25" indicated an inter- mediate level, and a value of "26-31" indi- cated a good level. Face-to-face interviews of 30 minutes was also used to collect data. All participants were informed that the in- formation will be kept confidential and use for scientific purposes only. The question- naire was verified by a panel of experts who have extensive experience from differ- ent specialties. Based on their comments, the questionnaire was corrected and modi- fied for appropriate data collection. Before conducting interviews, the researchers ex- plained the purpose to all participants and acquired their oral consent, with ethical permission from the University of Sulaima- ni/College of Medicine and its ethics com- mittee the No: 112 and date of the approv- al 25/5/2021. The hospital's director gave approval prior to data collection, and the unit's nurse in charge were informed. A pilot study was carried out on 30 nurses through the period from 16-24 February in 2021. The pilot study was beneficial to de- termine the reliability of the study instru- ment. The result of the pilot study revealed that the items of the questionnaire were clear and understandable to the partici- pants and required some modification in the "socio-demographic characteristics" section. Each questionnaire took approxi- mately 30 minutes to complete. The data was summarized and analyzed through us- ing the application statistical package for 107 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article percentage (65.1%) of whole sample. Table 2 shows the levels of awareness about breast cancer risk factors for the study sample. As shown in this table, most of the study sample (36.1%) have an acceptable level of awareness about breast cancer risk fac- tors. 108 Table 1: Distribution of the Socio-demographical data characteristics of the Study Sample (No.: 341). The Socio-demographical Characteristics Subgroups f. (%) Hospital Name Azadi Teaching Hospital 153 (44.9) Kirkuk General Hospital 130 (38.1) Pediatric Hospital 58 (17) Age Groups/Years 21 – 25 131 (38.4) 26 – 30 101 (29.6) 31 – 35 21 (6.2) 36 – 40 29 (8.5) 41 – 45 30 (8.8) 46 – 50 16 (4.7) More than 50 13 (3.8) Gender Male 120 (35.2) Female 221 (64.8) Marital Status Single 111 (32.5) Married 228 (66.9) Separated 1 (0.3) Divorced 1 (0.3) Education Level Preparatory Graduated 92 (27) Institute Graduated 140 (41) College Graduated 105 (30.8) Post-graduate 4 (1.2) Departments Surgical Ward 50 (14.7) Medical Ward 64 (18.8) Pediatric Ward 15 (4.4) Gynecology & Obstetric Ward 34 (10) Consultant Clinics 26 (7.6) Emergency Room 33 (9.7) Operation Theater 34 (10) CCU 24 (7) RCU 19 (5.6) Premature Unit 27 (7.9) Mammography Unit 5 (1.5) Dialysis Unit (Artificial Kidney) 10 (2.9) The Socio-demographical Characteristics Subgroups f. (%) Years of experience Less than 1 Year 47 (13.8) 1 – 5 163 (47.8) 6 – 10 54 (15.8) 11 – 15 25 (7.3) 16 – 20 21 (6.2) 21 – 25 15 (4.4) 26 – 30 10 (2.9) 31 Years + more 6 (1.8) Suffered from BC Yes 19 (5.6) No 322 (94.4) Cared of BC Patients Yes 132 (38.7) No 209 (61.3) Participating in Trainings Non-Participated 222 (65.1) Yes - One Training 119 (34.9) Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Table 4 shows highly significant differences between the study sample responses re- garding gender (p-value < 0.001). 109 Erbil Journal of Nursing & Midwifery Table 3 shows no significant differences between the study samples regarding their age groups (p-value = 0.978). Table 2: Distribution of the levels of the awareness about breast cancer risk factors for the study sample (No.: 341) Awareness levels about breast cancer risk factors f. % Mean S.D. Poor Level 106 31 2.08 0.901 Acceptable Level 123 36.1 Intermediate Level 92 27 Good Level 20 5.9 Total 341 100 Table 3: Comparisons the levels of the awareness about breast cancer risk factors regarding to the age group of the study sample by One-Way ANOVA test. Awareness Age Groups f. % Mean ± SD F. value Sig. value Awareness levels about breast cancer risk factors 21-25 Y. 131 38.42 2.11 ±0.897 0.195 0.978 N.S. 26-30Y. 101 29.62 2.10 ±0.911 31-35 Y. 21 6.16 2.05 ±1.024 36-40 Y. 29 8.50 1.97 ±0.865 41-45 Y. 30 8.8 2.10 ±0.960 46-50 Y. 16 4.69 2.00 ±0.894 More than 50 Y. 13 3.81 1.92 ±0.760 Total 341 100 2.08 ±0.901 F. value: ANOVA test value. Table 4: Comparisons the levels of the awareness about breast cancer risk factors regarding to the sex of the study sample by Chi-Square test. Awareness Sex f. % Mean ± SD F. value Sig. value Awareness levels about breast cancer risk factors Male 120 35.19 2.07 ±0.914 72.243 0.001 H.S. Female 221 64.81 2.08 ±0.896 F. value: Chi-Square test. https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article Table 5 shows a significant difference between the study sample responses A high percentage of the sample (38.4%) were between the ages of 21-25, and those over 50 contributed to the lower percent- age (3.8%). This result agrees with the re- sult of the study [10] in their research “Assessment of Knowledge of Breast Can- cer and Screening Methods among Nurses in University Hospitals in Addis Ababa, Ethi- opia, 2011”. This might be explained be- cause of the need for new staff nurses to work at all hospital departments, and these ages were capable of bearing and toler- ating the burdens of working with patients. The majority of sample were female (643.8%) which is in agreement with the result of a study with the higher percent- age of the population (89%) were female [11]. The majority of sample in the study were married (66.9%), a finding which is in disagreement with the result of the study [12] which mentions that most of the nurs- es (51.2%) are single. Which is in agree- ment with the study done in Jordanian nurses [13] which mentions that most of the nurses (51.8%) are married. Concern- ing graduation level, most of the sample study (41%) had a degree in nursing, and 1.2% had higher studies of nursing science regarding marital status at (p-value 0.041). degree. A higher proportion of the sample (18.88%) worked in medical wards, and 14.7% worked in surgical wards. This find- ing was similar with the finding of another study [11]. There are separate wards for men and women in the medicine and sur- gery departments in Kirkuk City Hospitals. Regarding the years of experience in de- partments, it has been noted that 47.8% of nurses had 1 to 5 years, while 1.8% of nurses had more than 31 years of experi- ence. This result in agreement with the result of the study among nurses in Univer- sity Hospitals in Addis Ababa, Ethiopia, 2011 which reported 61.1% of nurses had below 5 years of experience, while 1.5 of nurses had more than 31 years of experi- ence [10]. 94.4% of the sample reported they had not had breast cancer ad, 61.3% reported not caring for any breast cancer patients. This finding was similar with the finding of another study which reported 99.3% of the sample had not had breast cancer and, 54.1% not caring for any breast cancer patients [11]. Training cours- es are necessary to improve nurses’ aware- ness of breast cancer in all hospital depart- ments. Based on participation in the 110 Erbil Journal of Nursing & Midwifery DISCUSSION Table 5: Comparisons the levels of the awareness about breast cancer risk factors regarding to the marital status of the study sample by One-Way ANOVA test. Awareness Marital Status f. % Mean ± SD F. value Sig. value Awareness levels about breast cancer risk factors Single 111 32.6 2.26 ±0.922 2.779 0.041 S. Married 228 66.8 1.98 ±0.880 Separated 1 0.3 2.00 ±.000 Divorced 1 0.3 3.00 ± .000 Total 341 100 2.08 ±0.901 https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article differences in level of awareness about breast cancer risk factors due to age groups as indicated by p-value =0.294) [15]. The level of awareness of breast cancer risk factors was generally high among nurs- es working in Kirkuk City hospitals. The lower the age group the higher awareness on breast cancer risk factors. The study findings report highly significant differ- ences between the nurses’ awareness of breast cancer risk factors by gender. Based on the findings of this study, the promotion of future health policies, such as mandatory continuing education is high- ly recommended to improve awareness levels of breast cancer risk factors among nurses. There is a need for the Ministry of Health, hospital management, training in- stitutions to improve breast cancer con- tent in the nursing curriculum. As the im- plementation of the revised curriculum may take some time, workplace training courses for the nurses can be introduced relatively earlier. Nurses are encouraged to disseminate this knowledge effectively and appropriately within the general popula- tion. The author declares no competing inter- ests. trainings, the non-participated sample made the majority proportion (65.1%) of whole sample, and the participated sam- ple (34.9%) made the lowest percentage of the sample. Continuing education is the best way to update the nurses’ awareness of breast cancer regarding risk factors. Concerning awareness levels about breast cancer risk factors items have a mean score of 2.08 and a standard deviation of .901. This indicates that total average of breast cancer risk factors events that occur in the workplace per- ceived by nursing staff in many hospital departments. Nurses in Kirkuk City Hospi- tal had poor level of awareness (31%) which is in agreement with the study re- sults among nurses in teaching hospitals of Karachi, Pakistan reporting 25% of nurses had poor level of awareness of breast cancer risk factors [14]. The over- all level of awareness towards this breast cancer was similar among male and fe- male nurses, single and married nurses, younger and older nurses, and among nurses with different educational levels. The level of awareness was also not influ- enced by years of experience, previous history of breast cancer, or a history of caring for a breast cancer patient. The results of present study disagree with the study among nurses and midwives in Mu- lago Hospital which reports 91.11% of the sample had poor level of awareness of breast cancer risk factors [11]. This could be explained by the lack training programs and sensitization workshops for the health care professionals in the hospital. The finding indicated that there were no statistical significant differences between the study samples regarding their age groups (p-value=0.978). The outcome of the study agrees with the result of a study among a cohort of nurs- es in Iran that showed there were no sta- tistically significant statistically 111 Erbil Journal of Nursing & Midwifery CONCLUSION RECOMMENDATION COMPETING INTERESTS https://doi.org/10.15218/ejnm.2021.12 Erbil j. nurs. midwifery, Vol. 4, No. (2), Nov 2021 Original Article [11] Ekong, O. Awareness of breast cancer risk factors and early detection measures and associated factors among nurses and mid- wives at mulago hospital. 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