CSIRO PUBLISHING

Australian Journal of Primary Health, 2013, 19, 68–73

Research
http://dx.doi.org/10.1071/PY11123

Women’s knowledge, attitudes and practice about breast

cancer screening in the region of Monastir (Tunisia)

Sana El Mhamdi A,C, Ines Bouanene A, Amel Mhirsi B, Asma Sriha A, Kamel Ben Salem A
and Mohamed Soussi Soltani A
A
Department of Epidemiology and Public Health, Faculty of Medicine, University of Monastir,
Avicenne Street, 5000, Monastir, Tunisia.
B
Direction of Primary Health Care, Hedi Chaker Street, Monastir, Tunisia.
C
Corresponding author. Email: sanaelmhamdi@yahoo.fr

Abstract. Breast cancer remains a worldwide public health problem. In Tunisia, it is considered to be the primary women’s
cancer and causes high morbidity and mortality. This study aimed to investigate female knowledge, attitudes and practice of
breast cancer screening in the region of Monastir (Tunisia). We conducted a descriptive cross-sectional design exploring
knowledge, attitudes and practices of women in the region of Monastir on breast cancer screening. The study was conducted
in health centres of this region from 1 March 2009 to 30 June 2009. Data were collected via a structured questionnaire
containing 15 items on demographic status, knowledge of risk factors and screening methods and attitudes towards the
relevance and effectiveness of breast cancer screening. A scoring scheme was used to score women’s responses. A total of
900 women agreed to take part in the study. Their mean age was 41.6  12.4 years and 64% did not exceed the primary level
of education. According to the constructed scores, 92% of participants had poor knowledge of the specific risk factors for
breast cancer and 63.2% had poor knowledge of the screening methods. Proper practice of breast cancer screening was
observed in 14.3% of cases. Multiple logistic regression analysis showed that good knowledge of risk factors and screening
methods, higher level of education and positive family history of breast cancer were independently correlated with breast
cancer screening practice. This study revealed poor knowledge of breast cancer and the screening methods as well as low
levels of practice of breast cancer screening among women in the region of Monastir. Results justify educational programs to
raise women’s adherence to breast cancer screening programs in Tunisia.

Additional keywords: breast neoplasm, early detection, health knowledge attitudes and practice.

Received 29 September 2011, accepted 20 January 2012, published online 5 March 2012

Introduction
Breast cancer is the most common malignancy in women
worldwide, with a steadily increase of its incidence (Parkin et al.
2001; Mauad et al. 2009). In fact, breast cancer comprises
~16% of all cases of cancer in women (American Cancer
Society 2010). It has been estimated that one out of every
nine women living in western countries is likely to be afflicted
by breast cancer in her lifetime (American Cancer Society
2010).
Although this cancer was thought to be a disease of the
developed world, the majority of deaths occur in developing
countries. These deaths were generally related to detection of
neoplasm in advanced stages reducing the opportunity for
efficient treatment (World Health Organization 2006).
In Tunisia, like other developing countries, breast cancer is
the primary cancer in women, with an incidence of 21.5 cases
per 100 000 women per year (Ben Abdallah et al. 2009). In
40.2% of cases, breast cancer was diagnosed for the first time at
stage two or three (Boussen et al. 2010). These findings indicate
the need for increased community awareness and early detection
of these diseases.
Several studies found that regular breast cancer screening
(BCS) interventions can facilitate early detection and reduce its
morbidity and mortality (Bonfill et al. 2001). The success of
screening programs depends not only on women’s attitude and
perception but also on commitment of health care professionals
(Jefferies 2009).
The objective of this study was to assess the knowledge,
attitude and practice of BCS among women and health care
professionals in the region of Monastir.
Methods
Setting and sampling
We performed a cross-sectional study in 15 health centres in
the Monastir region of Tunisia from March to June 2009. The

Journal compilation
La Trobe University 2013 www.publish.csiro.au/journals/py

Screening of breast cancer in Tunisia Australian Journal of Primary Health 69

region’s population was equally dispersed around each centre *

and the sample size of each centre was the same.
Each health centre provided many preventive and curative
services, such as family planning, immunisation, child
development assessment and breast and cervical cancer
screening. In-house doctors or midwives educate women to
perform breast self-examination, they also ensure clinical
breast examination. If needed, doctors refer patients to a
mammography facility.
Among women referred to the 15 health centres, we targeted
those aged 25 years and older who had not previously been
diagnosed with breast cancer. The minimum sample size required
for the study was 865 women based on 0.05 probability of a type
1 error (a), a precision of 2% and assuming screening rates of
10% according to literature (Bouchlaka et al. 2009).
We conducted stratified simple random sampling and
questionnaires to determine women’s knowledge, attitudes
and practices (KAP) for breast cancer early detection. In each
health centre, 60 women 25 years and older were recruited.
Mammography had been practiced once every two years from
45 years and over and for younger women with positive family
history of breast cancer.
Data analysis
Data analysis was carried out in SPSS version 15.0 and P-values
<0.05 were considered statistically significant. Univariate
analysis was performed using Chi-squared test. Women’s age
was divided into two categories (<45 years and 45 years)
referring to literature showing that the median age of women with
breast cancer was 45 years (Missaoui et al. 2011).
A multivariate stepwise logistic regression was used to
identify factors associated with the practice of BSE. In this case,
‘proper’ BSE was our dependant variable. Explicative variables
with a univariate test value 0.25 were included. The final
retuned variables were those significant at the level of 5%.
Ethical consideration
Informed consent was obtained before conducting the interviews.

Measures Results
After sampling procedure, data were collected via a structured In total, 900 women agreed to take part in the study. Their mean
questionnaire derived from the literature (Montazeri et al. 2008) age was 41.6  12.4 years and more than half were married
and the decision of the study group. Four trained investigators (68%). Among the participants, 64% did not exceed the primary
interviewed each respondent. level of education and 53% were housewives. A family history of
The questionnaire consisted of 15 items on demographic breast cancer was reported by 11% of women (Table 1).
characteristics (age, level of education, marital status and family According to the constructed scores, most of the participants
history of breast cancer), knowledge about breast cancer and its (92%) had poor knowledge of the specific risk factors for breast
risk factors, screening methods (Appendix 1) and practice of cancer and 63.2% (n = 569) had poor knowledge of the screening
breast self-examination (BSE). methods (Table 2).
Attitudes and cultural barriers towards the relevance and Overall, the study findings indicated that 85% (n = 765) of the
effectiveness of BCS were also collected. The practice of BSE respondents had positive attitudes towards BCS and 14.3%
and mammography, from 45 year and over, were identified by the (n = 229) of women had a proper practice of BCS (Table 2).
questionnaire. Univariate analysis factors shown to be associated with proper
BCS were educational level, family history of breast cancer,
knowledge of risk factors and knowledge of screening methods
Scoring scheme (Table 3).
Women’s knowledge of risk factors was assessed by requesting When the variables were identified by univariate analysis, they
that the respondents identify them from the following list: were combined in a multiple logistic regression analysis. Results
tobacco use, lack of breastfeeding, obesity, positive family
history and pregnancy in later age. Each correct response was Table 1. Demographic characteristics of the study sample (n = 900)
scored one (1) point and each wrong response was scored zero (0).
Characteristics Number %
The total score ranged from 0 to 5. Women with scores of 3 to 5
were considered to have good knowledge. Age
Knowledge of screening methods was assessed by seven 25–44 years 566 63
questions related to BSE and mammography. The total score 45 years and over 334 37
Marital status
ranged from 0 to 7. Respondents with scores of 0 to 3 were
Married 612 68
considered to have poor knowledge and those with 4 to 7 points
Not married 288 32
good knowledge. Educational level
Attitudes and cultural barriers were also measured by five Elementary/primary education 576 64
questions. In this case, favourable attitude was scored (1) and Secondary education 243 27
unfavourable attitude was scored (0). Women with scores of 0 University/higher education 81 9
to 2 were considered to have negative attitudes and those with 3 Career
to 5 points positive attitudes towards BCS. Housewives 477 53
If practiced, BCS was considered ‘proper’ if the two following Others occupations 423 47
conditions were satisfied: Family history of breast cancer
Yes 99 11
*
BSE had been performed at least once a month and outside the
No 801 89
menstrual period for women from 25 to 44 years.
70 Australian Journal of Primary Health S. E. Mhamdi et al.

Table 2. Knowledge, attitudes and practices of women towards breast Table 4. Factors associated with breast cancer screening practice in
cancer screening (n = 900) multivariate analysis (n = 900)
CI, confidence interval; OR, odds ratio
Characteristics Number %
Characteristics OR 95% CI P-value
Knowledge of risk factors
Poor knowledge 828 92 Knowledge of risk factors 0.008
Good knowledge 72 8 Poor knowledge – –
Knowledge of screening methods Good knowledge 1.65 1.17–2.33
Poor knowledge 569 63.2 Educational level <0.001
Good knowledge 331 36.8 Elementary/primary education – –
Attitudes towards screening Secondary education 1.48 1.01–2.20
Positive attitude 765 85 University/higher education 1.78 1.08–3.94
Negative attitude 135 15 Knowledge of screening methods <0.001
Practice of breast cancer screening Poor knowledge – –
Proper practice 229 14.3 Good knowledge 2.31 1.59–3.37
Improper practice 771 85.7 Family history of breast cancer <0.001
Negative – –
Positive 2.67 1.70–4.21

Table 3. Factors associated with breast cancer screening (BCS) practice

in univariate analysis (n = 900) BCS compared with women with poor knowledge (aOR = 2.31;
CI, confidence interval; OR, odds ratio 95% CI = 1.59–3.37). Women with a family history of breast
Characteristics Proper OR 95% CI P-value
cancer were also more likely to undergo BCS compared with
BCS (%) those without family history (aOR = 2.67; 95% CI = 1.70–4.21).

Age 0.09
25–44 years 23.3 – – Discussion
45 years and over 28.0 1.30 0.95–1.76 This study was carried out to investigate female knowledge of
Marital status 0.18 breast cancer and their BCS practices in the region of Monastir,
Married 24.0 – – Tunisia. Although BCS programs in Tunisia target women aged
Not married 28.1 1.20 0.86–3.36
35 and over, we included women 25 years and older in accordance
Educational level 0.04
with studies of the epidemiological profile of breast cancer in
Elementary/primary education 23.0 – –
Secondary education 29.0 1.40 0.91–1.97 Tunisia, which showed a higher rate among younger women
University/higher education 30.8 1.56 1.04–3.66 (Ben Abdallah et al. 2009). The study was performed in the
Career 0.18 region of Monastir, the demographic structure of which was not
Housewives 25.1 – – different to other Tunisian regions (Republic of Tunisia 2005).
Others occupations 27.4 1.24 0.81–1.88 Thus, we can consider our study results as representative of the
Family history of breast cancer <0.001 situation of Tunisian women.
No 23.4 – – We selected participants from public health care centres. This
Yes 49.0 3.20 2.06–4.96 exclusion of the private health sector may have introduced a
Knowledge of risk factors <0.001
selection bias into our study leading to an underestimation of
Poor knowledge 8.2 – –
the proper practice of BCS. However, to avoid this bias we
Good knowledge 43.0 2.33 1.10–4.92
Knowledge of screening methods <0.001 included women who consulted for any curative or preventive
Poor knowledge 15.5 – – reason, especially women who take their children for vaccination,
Good knowledge 31.9 2.65 1.13–4.78 which is carried out mainly in primary health care centres
Attitudes towards screening 0.10 (public health sector).
Negative attitude 17.4 – – Results showed that participants have a lower rate of BCS
Positive attitude 20.8 1.44 0.79–3.78 practice (14.3%). Lower rates of adherence to BCS have been
reported in other developing countries (Anderson and Jakesz
2008). In fact, the reported rate of BCS ranges from 9.1%
of the latter showed that four of the following factors were in Nigeria (Okobia et al. 2006) to 18.7% in Saudi Arabia (Jahan
significant (Table 4). Women with good knowledge of risk et al. 2006). This low adherence to screening methods was
factors (adjusted odds ratio [aOR] = 1.65; 95% CI = 1.17–2.33) manifested by higher rates of breast cancer diagnosis at later
were more likely to undergo breast screening compared with stages, with higher mortality in these countries (Maalej et al.
those in the reference category (poor knowledge). Women who 2008; Knaul et al. 2009). In contrast, developed countries show a
had graduated from secondary school (aOR = 1.48; 95% significant increase in breast cancer diagnosis in earlier stages,
CI = 1.01–2.20) or university or other higher education institutes with a significant decrease in mortality rates (Fontenoy et al.
(aOR = 1.78; 95% CI = 1.08–3.94) were more likely to undergo 2010). Results from developing countries were related to the
BCS compared with women who had received elementary or application of organised screening programs aimed at early
primary education. Based on the aOR, women with good detection, before the disease has spread, which permitted less
knowledge of screening methods were more likely to undergo invasive and more effective therapy (Humphrey et al. 2002;
Screening of breast cancer in Tunisia
Holleczek et al. 2011). To detect breast cancer earlier and reduce
women’s mortality, BSE seems to be effective (Harmer 2011).
In fact, stimulating women’s awareness about breast cancer and
regular practice of BSE can be an important way to detect breast
cancer early (Dahlui et al. 2011). Others studies confirmed that an
appropriate practice of BSE is a useful tool for early detection of
breast cancer (Shalini et al. 2011).
This study’s findings underscore the positive correlation
between BCS and good knowledge of risk factors, higher levels of
education, good knowledge of screening methods and a family
history of breast cancer. Multivariate analysis did not identify the
age of a woman or her attitudes towards screening to be associated
with the practice of BCS.
Knowledge of risk factors and screening methods were
identified by the literature as predictors of BCS (Sim et al. 2009).
In fact, this knowledge increases women’s awareness and
adherence to screening programs (Gözüm et al. 2010). In many
studies, higher levels of education have also been positively
associated with screening (Abdul Hadi et al. 2010). Indeed,
highly educated women were more likely to get information and
more receptive to health education (Oran et al. 2008).
We identified a positive family history of breast cancer as a
determinant of screening practice. However, in others studies,
neither positive family history nor perceived relative risk of breast
cancer was associated with either increased or decreased early
detection practices (West et al. 2003). Other studies suggest that
practices of women with a positive family history of breast cancer
increase when knowledge improvement is targeted (Bird et al.
2010).
Conclusion
This study has revealed poor knowledge of breast cancer and
screening methods as well as low levels of practice of BCS
among women in the region of Monastir. There is very urgent
need for updating health education to raise women’s adherence to
BCS programs in Tunisia.
Conflicts of interest
None declared.
Acknowledgements
We thank all health workers in the participating health care centres for their
help and study investment.
References
Abdul Hadi M, Hassali MA, Shafie AA, Awaisu A (2010) Knowledge and
perception of breast cancer among women of various ethnic groups in the
state of Penang: a cross-sectional survey. Medical Principles and Practice
19(1), 61–67. doi:10.1159/000252837
American Cancer Society (2010) The breast cancer resource center: 2000.
Available at http://www.cancer.org/cancerinfo/load [Verified 10 May
2011]
Anderson BO, Jakesz R (2008) Breast cancer issues in developing countries:
an overview of the Breast Health Global Initiative. World Journal of
Surgery 32(12), 2578–2585. doi:10.1007/s00268-007-9454-z
Ben Abdallah M, Zehani S, Maalej M, Hsairi M, Hechiche M, Ben Romdhane
K, Boussen H, Saadi A, Achour N, Ben Ayed F (2009) Breast cancer in
Tunisia: epidemiologic characteristics and trends in incidence. La Tunisie
Medicale 87(7), 417–425.
Australian Journal of Primary Health 71
Bird Y, Moraros J, Banegas MP, King S, Prapasiri S, Thompson B (2010)
Breast cancer knowledge and early detection among Hispanic women with
a family history of breast cancer along the U.S.–Mexico border. Journal of
Health Care for the Poor and Underserved 21(2), 475–488. doi:10.1353/
hpu.0.0292
Bonfill X, Marzo M, Pladevall M, Martí J, Emparanza JI (2001) Strategies for
increasing women participation in community breast cancer screening.
Cochrane Database of Systematic Reviews (1), CD002943.
Bouchlaka A, Ben Abdallah M, Ben Aissa R, Zaanouni E, Kribi L, Smida S,
M’barek F, Ben Hamida A, Boussen H, Gueddana N (2009) Results
and evaluation of 3 years of a large scale mammography program in the
Ariana area of Tunisia. La Tunisie Medicale 87(7), 438–442.
Boussen H, Bouzaiene H, Hassouna JB, Dhiab T, Khomsi F, Benna F,
Gamoudi A, Mourali N, Hechiche M, Rahal K, Levine PH (2010)
Inflammatory breast cancer in Tunisia: epidemiological and clinical
trends. Cancer 116(Suppl. 11), 2730–2735. doi:10.1002/cncr.25175
Dahlui M, Ng C, Al-Sadat N, Ismail S, Bulgiba A (2011) Is breast self
examination (BSE) still relevant? A study on BSE performance among
female staff of University of Malaya. Asian Pacific Journal of Cancer
Prevention 12(2), 369–372.
Fontenoy AM, Leux C, Delacour-Billon S, Allioux C, Frenel JS, Campone M,
Molinié F (2010) Recent trends in breast cancer incidence rates in the
Loire-Atlantique, France: a decline since 2003. Cancer Epidemiology
34(3), 238–243. doi:10.1016/j.canep.2010.03.007
Gözüm S, Karayurt O, Kav S, Platin N (2010) Effectiveness of peer education
for breast cancer screening and health beliefs in eastern Turkey. Cancer
Nursing 33(3), 213–220. doi:10.1097/NCC.0b013e3181cb40a8
Harmer V (2011) Breast awareness and screening. Nursing Times 107(25),
21–23.
Holleczek B, Arndt V, Stegmaier C, Brenner H (2011) Trends in breast
cancer survival in Germany from 1976 to 2008 – a period analysis by age
and stage. Cancer Epidemiology 35(5), 399–406. doi:10.1016/j.canep.
2011.01.008
Humphrey LL, Helfand M, Chan BK, Woolf SH (2002) Breast cancer
screening: a summary of the evidence for the U.S. Preventive Services
Task Force. Annals of Internal Medicine 137(5 Part 1), 347–360.
Jahan S, Al-Saigul AM, Abdelgadir MH (2006) Breast cancer. Knowledge,
attitudes and practices of breast self examination among women in Qassim
region of Saudi Arabia. Saudi Medical Journal 27(11), 1737–1741.
Jefferies H (2009) Women must be given better cancer screening advice.
Nursing Times 105(8), 13.
Knaul FM, Nigenda G, Lozano R, Arreola-Ornelas H, Langer A, Frenk J
(2009) Breast cancer in Mexico: an urgent priority. Salud Publica Mex
51(Suppl. 2), s335–s344. doi:10.1590/S0036-36342009000800026
Maalej M, Hentati D, Messai T, Kochbati L, El May A, Mrad K, Romdhane
KB, Ben Abdallah M, Zouari B (2008) Breast cancer in Tunisia in 2004:
a comparative clinical and epidemiological study. Bulletin du Cancer
95(2), E5–E9.
Mauad EC, Nicolau SM, Moreira LF, Haikel RL, Jr, Longatto-Filho A,
Baracat EC (2009) Adherence to cervical and breast cancer programs is
crucial to improving screening performance. Rural and Remote Health
9(3), 1241.
Missaoui N, Jaidene L, Abdelkrim SB, Abdelkader AB, Beizig N, Yaacoub
LB, Yaacoubi MT, Hmissa S (2011) Breast cancer in Tunisia: clinical and
pathological findings. Asian Pacific Journal of Cancer Prevention 12(1),
169–172.
Montazeri A, Vahdaninia M, Harirchi I, Harirchi AM, Sajadian A, Khaleghi F,
Ebrahimi M, Haghighat S, Jarvandi S (2008) Breast cancer in Iran: need
for greater women awareness of warning signs and effective screening
methods. Asia Pacific Family Medicine 7(1), 6. doi:10.1186/1447-056X-
7-6
Okobia MN, Bunker CH, Okonofua FE, Osime U (2006) Knowledge, attitude
and practice of Nigerian women towards breast cancer: a cross-sectional
study. World Journal of Surgical Oncology 4, 11. doi:10.1186/1477-
7819-4-11
72 Australian Journal of Primary Health
Oran NT, Can HO, Senuzun F, Aylaz RD (2008) Health promotion lifestyle
and cancer screening behavior: a survey among academician women.
Asian Pacific Journal of Cancer Prevention 9(3), 515–518.
Parkin DM, Bray FI, Devesa SS (2001) Cancer burden in the year 2000. The
global picture. European Journal of Cancer 37(Suppl. 8), S4–S66.
doi:10.1016/S0959-8049(01)00267-2
Republic of Tunisia (2005) National Institute of Statistics. Tunisian
population and housing Census (2004). Available at http://www.ins.nat.
tn/indexfr.php [Verified 29 December 2011]
Shalini, Varghese D, Nayak M (2011) Awareness and impact of education
on breast self examination among college going girls. Indian Journal of
Palliative Care 17(2), 150–154. doi:10.4103/0973-1075.84538
S. E. Mhamdi et al.
Sim HL, Seah M, Tan SM (2009) Breast cancer knowledge and screening
practices: a survey of 1,000 Asian women. Singapore Medical Journal
50(2), 132–138.
West DS, Greene PG, Kratt PP, Pulley L, Weiss HL, Siegfried N, et al. (2003)
The impact of a family history of breast cancer on screening practices
and attitudes in low-income, rural, African American women. Journal of
Women’s Health 12(8), 779–787. doi:10.1089/154099903322447747
World Health Organization (2006) EMRO technical publications. Guidelines
for the early detection and screening of breast cancer: October 2002.
Available at http://www.emro.who.int/dsaf/dsa696.pdf [Verified 12 June
2011]
Screening of breast cancer in Tunisia Australian Journal of Primary Health 73

Appendix 1

Agree Disagree I do not know

n (%) n (%) n (%)
Knowledge of risk factors
What are risk factors of breast cancer?
Lack of breastfeeding 47 (5.2) 610 (67.8) 243 (27.0)
Tobacco use 21 (2.3) 681 (75.7) 198 (22.0)
Obesity 4 (0.5) 676 (75.1) 220 (24.4)
Family history of breast cancer 67 (7.4) 695 (77.3) 138 (15.3)
Pregnancy in later age 51 (5.7) 468 (52.0) 381 (42.3)
Knowledge of screening methods
Do you have any idea about breast self-examination (BSE) and effectiveness of breast cancer prevention? 290 (32.2) 610 (67.8) –
When should a woman practice BSE?
Usually one week after your menstrual period begins 187 (20.8) 614 (68.2) 99 (11.0)
At any day of the month 353 (39.2) 424 (47.1) 123 (13.7)
A stopped menstruating woman (menopause or hysterectomy)
At the same day each month 193 (21.4) 447 (49.7) 260 (28.9)
Women who are pregnant or breast-feeding
Can continue the BSE 211 (23.4) 335 (37.3) 354 (39.3)
Do you have any idea about mammography and its benefits? 319 (35.4) 581 (64.6) –
Can mammography detect early stage breast cancer before it is palpable? 139 (15.5) 259 (28.7) 502 (55.8)
How often should mammography be done?
Once in a woman’s life 530 (58.8) 258 (28.7) 112 (12.5)
Once every two years 236 (26.2) 620 (68.8) 44 (5)
Attitudes towards breast cancer screening
Do you feel embarrassed when you are facing a male doctor? 558 (62.0) 342 (38.0) –
Do you feel that breast cancer can be detected at home? 335 (37.2) 450 (50.0) 115 (12.8)
Are you discouraged by partner or others? 199 (22.1) 701 (77.9) –
Have you a fatalistic attitude? (when we get cancer only God can help us and screening tests have no interest) 298 (33.2) 602 (66.8) –
Do you feel that the problem of breast cancer does not concern you? (I’m not ill so it’s not necessary) 180 (20.0) 720 (80.0) –

www.publish.csiro.au/journals/py