1Al-Akdhar Health Centre, 2Head of Research Section, 3Head of School Health Section, Directorate General of Health Services of Al-Dhahira Governorate, Ministry of Health, Ibri, Oman; 4Deanship of Research, University of Nizwa, Nizwa, Oman *Corresponding Author’s e-mail: ashukaily@hotmail.com الوعي بعوامل خطر اإلصابة بسرطان الثدي واألعراض والفحص الذايت للثدي بني املعلمات العمانيات دراسة مقطعية زوينة الإ�شماعيلية، خالد النا�رصي، اأمل اليعقوبية، اأحمد ال�شكيلي abstract: Objectives: This study aimed to assess knowledge of breast cancer (BC) risk factors, warning signs and symptoms and breast self-examination (BSE) practice among Omani female teachers in Al-Dhahira Governorate. Methods: A cross-sectional sample of female teachers aged 20–50 years was collected from January to December 2018 from three wilayats (provinces) in Al-Dhahira—Ibri, Dhank and Yunqal. A questionnaire that included the Breast Cancer Awareness Scale and demographic characteristics was administered. Data were analysed using descriptive statistics, regression analysis and Pearson’s Chi-square test. Results: A total of 478 female teachers were included in the study (response rate: 72.4%). The majority of participants (60.5%) had good overall knowledge about BC while 19.9% of participants had excellent overall knowledge. Only 9% of participants demonstrating excellent knowledge of BC risk factors. More than half of the participants (56.1%) reported excellent knowledge in screening methods. Unfortunately, only 57% of the female teachers indicated practising BSE. Knowledge of BC symptoms was closely divided between excellent and good levels (45.8 and 42.5%, respectively). BSE practice was significantly (P <0.05) correlated with overall knowledge of BC and its symptoms and screening methods, but not with knowledge of BC risk factors. Conclusion: This study revealed unsatisfactory overall knowledge of BC risk factors, symptoms, screening methods and BSE practice among female Omani teachers in Al-Dhahira Governorate. These findings constitute a challenge to healthcare providers to continue developing awareness of BC and providing health information to the public. Keywords: Breast Cancer; Awareness; Knowledge; Breast Self-Examination; Risk factors; Signs and Symptoms; Oman. امللخ�ص: الهدف: هدفت هذه الدرا�شة اإىل تقييم معرفة عوامل خطر الإ�شابة ب�رصطان الثدي، وعالمات التحذير والأعرا�ص وممار�شة الفح�ص الذاتي للثدي بني املعلمات العمانيات يف حمافظة الظاهرة. الطريقة: مت جمع عينة م�شتعر�شة من معلمات ترتاوح اأعمارهن بني 20 و 50 �شنة يف الفرتة من يناير اإىل دي�شمرب 2018 من ثالث وليات يف الظاهرة-عربي، �شنك وينقل. مت اإجراء ا�شتبيان يت�شمن مقيا�ص التوعية ب�رصطان الثدي واخل�شائ�ص الدميوغرافية. مت حتليل البيانات با�شتخدام الإح�شائيات الو�شفية، وحتليل النحدار واختبار مربع كاي بري�شون. النتائج: �شملت الدرا�شة 478 معلمة )معدل ال�شتجابة = %72.4(. كان لدى اأغلبية امل�شاركات )%60.5( معرفة �شاملة جيدة عن �رصطان الثدي قي حني كان لدى %19.9 من امل�شاركات معرفة �شاملة ممتازة باملر�ص. كانت معرفة عوامل اخلطر غري مر�شية، حيث اأظهرت النتائج اأن %9 فقط من امل�شاركات لديهن معرفة ممتازة. وتبني اأن اأكرث من ن�شف امل�شاركات )%56.1( لديهن معرفة ممتازة باأ�شاليب الفح�ص. لالأ�شغ، اأ�شارت 57% فقط من املعلمات اإىل ممار�شة الفح�ص الذاتي للثدي. مت تق�شيم معرفة اأعرا�ص �رصطان الثدي بني امل�شتوى املمتاز واجليد )%42.5 و 45.8% على التوايل(. ارتبطت ممار�شة الفح�ص الذاتي للثدي ب�شكل ملحوظ )P >0.05( باملعرفة الكلية لـ�رصطان الثدي واأعرا�شه وطرق الفح�ص، ولكن لي�ص مع معرفة عوامل خطر �رصطان الثدي. اخلال�صة: ك�شفت هذه الدرا�شة عن معرفة عامة غري مر�شية بعوامل اخلطر والأعرا�ص وطرق الفح�ص وممار�شة الفح�ص الذاتي للثدي لدى املدر�شات العمانيات يف حمافظة الظاهرة. ت�شكل هذه النتائج حتديا ملقدمي الرعاية ال�شحية ملوا�شلة تطوير الوعي ب�رصطان الثدي وتوفري املعلومات ال�شحية لعامة النا�ص. الكلمات املفتاحية: �رصطان الثدي. الوعي؛ املعرفه؛ الفح�ص الذاتي للثدي؛ عوامل اخلطر؛ العالمات والأعرا�ص؛ �شلطنة عمان. Awareness of Breast Cancer Risk Factors, Symptoms and Breast Self-Examination Among Omani Female Teachers A cross-sectional study Zuweina Al-Ismaili,1 Khalid Al-Nasri,2 Amal Al-Yaqoobi,3 *Ahmed Al-Shukaili4 Sultan Qaboos University Med J, May 2020, Vol. 20, Iss. 2, pp. e194–201, Epub. 28 Jun 20 Submitted 9 Sep 19 Revision Req. 14 Nov 19; Revision Recd. 25 Dec 19 Accepted 29 Jan 20 Advances in Knowledge - This is the first study to assess breast cancer (BC) awareness in rural areas in Oman. - The study revealed insufficient overall BC knowledge among female Omani teachers. Application to Patient Care - Increased public awareness of BC’s signs, symptoms and risk factors and breast self-examination (BSE) practice has a substantial impact on the incidence and outcomes of the disease. This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2020.20.02.010 clinical & basic research https://creativecommons.org/licenses/by-nd/4.0/ Zuweina Al-Ismaili, Khalid Al-Nasri, Amal Al-Yaqoobi and Ahmed Al-Shukaili Clinical and Basic Research | e195 - Early detection of BC leads to better response to therapy and subsequently improves survival rates. - The World Health Organization stresses promoting awareness of BC in the community and encourages early diagnosis of the disease in the primary care setting. Breast cancer (bc) is the second most common cancer worldwide and the most frequently diagnosed life-threatening cancer in women. In 2018, more than two million cases of BC were newly diagnosed among women.1,2 Case fatality rates from BC are higher in low- and middle-income countries than in most high-income countries.3–6 These observations have been attributed partially to a lack of awareness of BC risk factors and symptoms and a lack of practice of breast self-examination (BSE).4–6 Increased public awareness of BC is an important factor that has a substantial impact on early detection of the disease. Delayed BC diagnosis in developing countries has been associated with poor BC awareness and barriers to access healthcare services. Cancer that is diagnosed at an early stage is more likely to be treated successfully.7–9 In Oman, BC is the most common cancer in women, with a median age at diagnosis of 48 years, followed by thyroid cancer and colorectal cancer.10,11 In 2018, a total of 454 cases of BC were reported, representing 34.15% of total cancers in Omani women.1,2 This figure indicates a significant rise in BC cases in comparison to previous reports.1,11 According to several studies, increasing incidents of BC are associated with a combination of several risk factors including delayed childbirth, reduced incidence of breastfeeding, obesity, increased consumption of alcohol and a fatty diet, sedentary lifestyle, environ- mental pollution, long-term use of hormone replace- ment therapy (HRT) containing estrogen and progestin and contraceptive use.12–14 Other risk factors for BC have been attributed to molecular and genetic deter- minates.15 BC screening can be done by BSE, clinical breast examination (CBE) and mammography.16 The effect- iveness of BSE in reducing BC mortality remains controversial. Several studies have shown that trained women practising BSE does not reduce BC mortality.17,18 Other studies show that BSE may have a substantial effect in increasing BC awareness and could encourage women to seek CBE, thus leading to earlier detection.19–21 The effectiveness of CBE is considered higher than BSE; however, the sensitivity of CBE is dependent on the amount of time taken to do an examination.22 Mammography is used as a sensitive screening method, particularly for women older than 40 years, but it is less effective for younger women.23 Studies to assess knowledge of BC and BSE practice are limited in Oman. Only two studies related to BC awareness to Oman have been published focusing on Muscat Governorate.24,25 Therefore, further studies are needed. This study aimed to ascertain the knowledge of risk factors, warning signs and symptoms of BC, including BSE practice among Omani female teachers in Al-Dhahira Governorate. Methods In this cross-sectional study, stratified random sampling was used to select participants from a total of 22 governmental female schools in Al-Dhahira Governorate, Oman. The schools were selected according to the population size of each wilayat (province). Most of Al-Dhahira’s population (75%) are concentrated in Ibri, whereas Yanqul and Dhank represent only 25% of the governorate’s population. Questionnaires were distributed to 22 schools according to the proportion of population in each area (14 schools in Ibri, four schools in Yanqul and four schools in Dhank). The sample size was calculated using online Sample Size Calculator.26 The needed sample size was estimated to be 675 female teachers. Schools were selected randomly from each stratum. The study cohort was selected because they were easily accessible and deemed to be educated. All the participants were female teachers aged between 20–50 years old. The study was conducted from January to December 2018. Non-Omani female teachers, women with a personal history of BC and incomplete questionnaires were excluded. All participants were involved in the National Health Educational and Screening Programme initiated in 2010 by the Ministry of Health. School teachers were included in this programme through the School Health Section of the Directorate General of Health Services in Al-Dhahira Governorate. Regrettably, the success of this programme has not been assessed yet. The findings of this study may contribute to understanding the effectiveness of this programme. Data were collected using a self-administered questionnaire which contained seven parts: (1) demo- graphic data; (2) general BC knowledge; (3) presence of family history of BC and personal history of breast lump; (4–6) overall knowledge of BC (i.e. knowledge of risk factors, screening methods and symptoms of BC); and (7) practice of BSE. The questionnaire was adapted from previously validated breast cancer aware- ness surveys.7,25,27 Awareness of Breast Cancer Risk Factors, Symptoms and Breast Self-Examination Among Omani Female Teachers A cross-sectional study e196 | SQU Medical Journal, May 2020, Volume 20, Issue 2 Risk factors for BC were assessed according to age, family history, having a personal history of BC, early menarche, late menopause, having the first child after the age of 30, not breastfeeding, recent use of combined oral contraceptive (COC) or HRT, exposure to radiation, obesity, following a sedentary lifestyle, eating a diet high in fat, alcohol consumption or smoking and exposure to environmental pollution. The questionnaire was scored according to awareness of BC risk factors, with 0–6 items considered reflective of poor awareness, 7–12 considered indicative of good awareness and 13–16 items considered excellent awareness. Women’s knowledge about screening methods (i.e. CBE, BSE and mammography) was assessed by asking three separate questions associated with these methods. Poor awareness was reflected in a score of 0–1 items, good awareness was reflected in a score of two items and excellent awareness was reflected in a score of three items. Additionally, the questionnaire included eight questions about BC symptoms in relation to breast pain, painless or painful breast lumps, a change in the size of the breast, nipple or skin colour, bloody nipple discharge and a loss of weight and appetite. Levels of awareness of symptoms were classified as poor (aware of 0–3 items), good (aware of 4–6 items) and excellent (aware of 7–8 items). Overall knowledge was calculated by adding the score of the three subscales (i.e. risk factors, symptoms and screening methods) and was interpreted as poor (aware of 0–11 items), good (aware of 12–20 items) and excellent (aware of 21–27 items). Statistical Package for the Social Sciences (SPSS), Version 20 (IBM, Corp., Armonk, New York, USA) was used to analyse the data. Participants’ demographic characteristics were summarised using means and standard deviation (SD) for continuous variables, and frequencies and percentages were used for categorical data. Inferential analyses (Pearson’s Chi-square test and correlation and regression analyses) were also used to analyse the data. Descriptive statistics, including percentages, means and SD, were calculated. To find the most important predictors of having better BC and BSE knowledge, a logistic regression analysis was used. Positive knowledge and practice of BSE were considered dependent variables, whereas age, educational level, income, family history of BC, previous history of breast lump, knowledge of general facts about BC and geographical location were considered independent variables. The study was approved by the Research and Ethics Committee at the Directorate General of Health Services of Al-Dhahira Governorate, Oman. Informed consent was obtained from all participants. Results A total of 478 female teachers completed the quest- ionnaire (response rate: 72.4%). The mean age of the participants was 33.3 ± 5.5 years old. As shown in Table 1, the majority of participants (58.8%) were 30–39 years old, and most had a bachelor’s degree (88.1%). Most participants (72.3%) were from Ibri, while 17.4% were from Dhank and 10.3% were from Yanqul. More than half of the women (54.4%) had a monthly income of 1,001–1,500 Omani rials (OMR), followed by an income of 500–1,000 OMR per month (39.1%), and only 6.5% of the participants had an income >1,500 OMR per month. In total, 10.5% of participants had a positive family history of BC and 3.5% had a history of a breast lump [Table 1]. Table 1: Demographic characteristics of the included female teachers from Al-Dhahira Governorate (N = 478) Variable n (%) Age (years) 20–29 131 (27.4) 30–39 281 (58.8) >40 66 (13.8) Educational level Diploma 46 (9.6) Bachelor’s degree 421 (88.1) Masters 10 (2.1) PhD 1 (0.2) Wilayat Ibri 346 (72.3) Dhank 83 (17.4) Yanqul 49 (10.3) Income (OMR) 500–1000 187 (39.1) 1001–1500 260 (54.4) >1500 31 (6.5) Family history of BC Yes 50 (10.5) No 418 (87.4) Unknown 10 (2.1) Personal history of breast lump Yes 17 (3.5) No 454 (95) Unknown 7 (1.5) OMR = Omani riyal; BC = breast cancer. Zuweina Al-Ismaili, Khalid Al-Nasri, Amal Al-Yaqoobi and Ahmed Al-Shukaili Clinical and Basic Research | e197 Most participants believed that BC is the most common cancer in females and that early detection and treatment will lead to a favourable outcome (86.2% and 94%, respectively). The most reported risk factor was exposure to a high dose of radiation (80.5%), followed by a family history (71.5%) and personal history of BC (68.8%). Smoking and environmental pollution were reported by 67.4% and 62.3% of the participants, respectively, as risk factors for BC. Some participants reported hormonal factors as a risk factor including recent use of HRT (48.5%), late menopause (36.6%) and the use of COC (32.2%). Not breastfeeding (5.6%) was the least identified risk factor [Table 2]. Regarding the knowledge of screening methods, BSE was the most familiar method (88.1%), followed by CBE (71.1%) and mammography (68%). The most reported symptoms of BC were a painless breast lump (82.2%), changes in breast size (82%) and changes in the nipple (80.8%). The least reported symptoms were breast pain (70.9%), a painful breast lump (69.9%) and loss of weight and appetite (50.2%) [Table 3]. The latter are considered symptoms of metastasis that appear at the end stage of the disease. Overall knowledge of BC was calculated by adding the scores for knowledge of risk factors, screening methods and symptoms of BC. The majority of participants (60.5%) had good overall knowledge about BC, while 19.9% had an excellent overall knowledge. The rest of the participants (19.7%) were categorised as having poor overall knowledge. About half of the participants (49.6%) had good knowledge of BC risk factors, whereas 9% had scores reflective of excellent knowledge of risk factors. More than half of the participants (56.1%) reported excellent knowledge of screening methods. Knowledge of BC symptoms (i.e., a painless breast lump; bloody nipple discharge; changes in breast skin colour, breast size or the nipple; breast pain; a painful lump; and loss of weight and appetite) was closely divided between excellent and good levels (45.8 and 42.5%, respectively) [Table 4]. The main source of information about BC was received from health institutions (64.7%) followed by the media (31.6%); however, only 3.7% of the participants had obtained information from relatives and friends. Table 2: Knowledge of risk factors for breast cancer among the included female teachers from Al-Dhahira Governorate (N = 478) Risk factor n (%) Yes No I don’t know Exposure to high doses of radiation 385 (80.5) 19 (4) 74 (15.5) Family history of BC 342 (71.5) 53 (11.1) 83 (17.4) Personal history of BC 329 (68.8) 43 (9) 106 (22.2) Smoking 322 (67.4) 43 (9) 113 (23.6) Environmental pollution 298 (62.3) 50 (10.5) 130 (27.2) Alcohol 281 (58.8) 38 (7.9) 159 (33.3) No physical exercise 271 (56.7) 65 (13.6) 142 (29.7) High fat intake 246 (51.5) 51 (10.7) 181 (37.9) Obesity 237 (49.6) 67 (14) 174 (36.4) Use of HRT 232 (48.5) 30 (6.3) 216 (45.2) Late menopause (ending periods after the age of 55 years) 175 (36.6) 67 (14) 236 (49.4) Use of COC 154 (32.2) 67 (14) 257 (53.8) Delivery of first child after 30 years of age 118 (24.7) 123 (25.7) 237 (49.6) Old age 101 (21.1) 174 (36.4) 203 (42.5) Early menarche (before 12 years old) 76 (15.9) 121 (25.3) 281 (58.8%) Not breastfeeding 27 (5.6) 411 (86) 40 (8.4) BC = breast cancer; HRT = hormone replacement therapy; COC = comb- ined oral contraceptive. Table 3: Knowledge of screening methods and symptoms of breast cancer among the included female teachers from Al-Dhahira Governorate (N = 478) Variable n (%) Yes No I don't know Knowledge of screening methods BSE 421 (88.1) 22 (4.6) 35 (7.3) CBE 340 (71.1) 34 (7.1) 104 (21.8) Mammography 329 (68) 43 (9) 106 (22.2) BC symptoms Painless breast lump 393 (82.2) 44 (9.2) 41 (8.6) Change in the size of the breast 392 (82) 32 (6.7) 54 (11.3) Change in the nipple 386 (80.8) 33 (6.9) 59 (12.3) Change in skin colour 366 (76.6) 37 (7.7) 75 (15.7) Bloody nipple discharge 364 (76.2) 37 (7.7) 77 (16.1) Breast pain 339 (70.9) 89 (18.6) 50 (10.5) Painful breast lump 334 (69.9) 93 (19.5) 51 (10.7) Loss of weight and appetite 240 (50.2) 74 (15.5) 164 (34.3) BSE = breast self-examination ; CBE = clinical breast examination ; BC = breast cancer. Awareness of Breast Cancer Risk Factors, Symptoms and Breast Self-Examination Among Omani Female Teachers A cross-sectional study e198 | SQU Medical Journal, May 2020, Volume 20, Issue 2 Multiple regression analysis using backward elim- ination method for overall knowledge of BC indicated a significant association with knowledge of the fact that early BC detection can lead to successful treatment (P = 0.001) and that BC is the commonest cancer among females (P = 0.001). Among the participants, 57.5% indicated practicing BSE. The best timing for practicing BSE was assessed among participants. In total, 55.2% of them believed that the best time for practicing BSE was after menstr- uation while 18% replied that any time was a good time, 13.6% responded when a woman feels breast pain and 13.2% said before menstruation. The majority of participants (54.2%) attributed not practicing BSE to a lack of time, while 30.5% did not know how to perform BSE. Only 8.2% considered BSE embarrassing and 7.1% of participants had a fear of finding BC if they practiced BSE. BSE was significantly correlated with overall knowl- edge of BC (P <0.05), screening methods (P <0.001) and knowledge of symptoms (P = 0.014), but not with knowledge of risk factors (P = 0.23). The logistic regression model for practicing BSE showed the most powerful associations with knowledge of BC screening methods (P = 0.001), age (P = 0.023), having a personal history of a breast lump (P = 0.042), and geographical location (P = 0.031) [Table 5]. Among demographic characteristics, age and geo- graphical location were significantly associated with BSE (P = 0.026 and 0.037, respectively) [Table 6]. General knowledge of BC as the most common cancer among females and having a personal history of breast lumps were significantly associated with practicing BSE (P = 0.016 and 0.015, respectively). Knowledge of general facts about BC were significantly associated with overall knowledge of BC (P = 0.001). Discussion This study confirms Omani women’s unsatisfactory overall knowledge about BC risk factors and screening methods.24,25 Similar observations have previously been made in developed and developing countries, with participants showing poor understanding of major BC risk factors.27–32 Because the majority of female teachers involved in the current study had only good- to-poor knowledge of BC, the results indicate that an educational programme is needed to increase awareness of BC risk factors. Table 6: Variables associated with overall knowledge and practice of breast self-examination among the included female teachers from Al-Dhahira Governorate (N = 478) Variables Overall BC knowledge Practice of BSE Chi- square value P value Chi- square value P value Demographic characteristic Age 3.11 0.540 7.27 0.026* Educational level 12.55 0.051 1.68 0.64 Province 5.45 0.244 6.61 0.037* Income 6.08 0.193 2.09 0.35 Experience with BC Family history of BC 1.1 0.881 3.29 0.193 Personal history of breast lump 9.07 0.059 7.34 0.015* Knowledge of general facts about BC BC is the commonest cancer among females 21.6 0.001* 5.79 0.016* Early detection of BC can lead to successful treatment 21.57 0.001* 0.015 0.903 BSE = breast self-examination; BC = breast cancer. *Statistically significant. Table 4: Overall knowledge of breast cancer among the included female teachers from Al-Dhahira Governorate (N = 478) Variable n (%) Excellent Good Poor Overall knowledge 95 (19.9) 289 (60.5) 94 (19.7) Knowledge of risk factors 43 (9) 237 (49.6) 198 (41.4) Knowledge of screening 268 (56.1) 97 (20.5) 113 (23.4) Knowledge of symptoms 219 (45.8) 203 (42.5) 56 (11.7) Table 5: Logistic regression analysis for the practice of breast self-examination among the included female teachers from Al-Dhahira Governorate (N = 478) Variable Wald test P value Knowledge of BC screening methods 14.327 0.001* Age 5.39 0.023* Personal history of breast lump 6.34 0.042* Wilayat 6.97 0.031* BC = breast cancer. *Statistically significant. Zuweina Al-Ismaili, Khalid Al-Nasri, Amal Al-Yaqoobi and Ahmed Al-Shukaili Clinical and Basic Research | e199 Unsatisfactory knowledge of BC risk factors was observed with risk factors such as non-breastfeeding, being overweight, having their first pregnancy after 30 years of age, having menopause after the age of 50 and doing less physical activity. This finding agrees with those reported by other studies.28,33 Moreover, knowledge of BC risk factors among Omani female teachers is different from that reported in previous studies conducted in the region. For instance, the current study showed that most participants (80%) identified exposure to radiation as the highest risk factor for BC, whereas a previous study conducted in Muscat showed that only 24% of participants identified exposure to radiation as a risk factor.24 This observation also contrasted with a previous study done in Saudi Arabia, which showed that participants most often identified not breastfeeding as a BC risk factor, whereas it was the least reported risk factor in the current study.28 Similarly, contradictory findings were observed with overall knowledge of BC. Overall knowledge in Al-Dhahira Governorate was much higher than in the Muscat region.24 This difference may be attributed to differences in the study cohort and ongoing campaigns under the National Health Educational and Screening Programme in recent years. This programme may also have had a positive effect on knowledge of screening methods, since the majority of the current participants recognised the most common methods of BC screening (i.e., BSE, CBE and mammography). Participants’ knowledge related to BSE was also satisfactory; most participants were aware of the importance of BSE. This finding is much higher than knowledge rates for BSE seen in some other studies.24,27–34 Nevertheless, Omani women’s attitudes towards BSE need improvement, since only 57% of participants indicated practicing BSE. Other studies in Saudi Arabia reported 67.6% of participants had never tried BSE.28 In contrast, a study in Uganda revealed that 76.5% of participants practiced BSE.29 On questioning current participants about reasons for not practicing BSE, 54.2% reported not having time, 30.5% of participants stated that they did not know how to do it and a few reported fear of having BC and embarrassment at the process (8.2% and 7.1% respectively). These findings may be attributed to unawareness of practicing BSE. Although the usefulness of BSE as an appropriate method for early BC detection has been debated in recent years, the awareness of the importance of practicing BSE should be encouraged via an intensive health education programme.15,18–22 Income and level of education had no association with the level of knowledge or the practice of BSE. However, practicing BSE, knowledge of BC risk factors and symptoms were significantly correlated (P <0.05) with knowledge of screening methods. This finding may be attributable to increased general awareness of BC and BSE among participants through healthcare providers. A similar study conducted in Iran revealed an association between educational level and knowledge of BC.31 The sources of information about BC in the current study included health institutions, followed by the media (i.e. TV, radio, and the Internet). This finding was inconsistent with previous studies conducted in Saudi Arabia, the United Arab Emirates, Egypt and Yemen, which showed that mass media (i.e. TV and radio) were the main sources of information about BC.28,33–36 Therefore, this study suggests that creating awareness of BC through media and campaigns needs to be strengthened in order to raise awareness of BC in the community. The main limitations of this study are that the findings cannot be generalised to all females in the country because the female teachers included in this study were only from Al-Dhahira Governorate and mainly from Ibri Wilayat (72.4%). Such a cohort may not be representative of all females in Oman and, to a lesser extent, from Al-Dhahira Governorate. In addition, the response rate of this study (72.4%) should be considered a limitation because in survey research a response rate of ≥80% is expected. Conclusion The study revealed insufficient overall BC knowledge (especially knowledge of risk factors and BSE practice) among female Omani teachers. This finding signals a need for prompt interventions to raise awareness about BC and BSE among females. Healthcare providers need to continue educating the community about BC. The media, including TV and newspapers, also need to be involved in raising BC awareness. In addition, BC awareness should be included as a part of teacher training programmes at schools and colleges. Further studies involving a larger sample size and participants from different sectors are recommended. a c k n o w l e d g e m e n t s The authors would like to thank all participating teachers in this study and research assistants for data collection during the study. We are thankful to the Directorate General of Education in Al Al- Dhahira Governorate and all school principals for their cooperation during the study. We also thank the Oman Cancer Association Al-Dhahira Branch for their support during the study. We extend our sincere gratitude to Ms Elena Filimonova, Dr Joseph J. Moore Awareness of Breast Cancer Risk Factors, Symptoms and Breast Self-Examination Among Omani Female Teachers A cross-sectional study e200 | SQU Medical Journal, May 2020, Volume 20, Issue 2 Jr. and Ms Anna Snellen, for their excellent editing of the manuscript. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. f u n d i n g No funding was received for this study. References 1. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer. From: https://gco.iarc.fr/today Accessed: Dec 2019. 2. Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. 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