Volume 28, Issue 4 (9-2018)                   J Holist Nurs Midwifery 2018, 28(4): 246-251 | Back to browse issues page

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Amani M, Mirhaghjou S N, Niknami M, Kazem Nezhad Leyli E. The Status of Screening Tests for Women's Common Cancers in the Personnel of the Educational-Medical and Health Centers. J Holist Nurs Midwifery. 2018; 28 (4) :246-251
URL: http://hnmj.gums.ac.ir/article-1-586-en.html
1- Nursing (MSN), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
2- Instructor, Social Determinants of Health Research Center (SDHRC), Department of Midwifery, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
3- Instructor, Department of Midwifery, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.
4- Associate Professor, Social Determinants of Health Research Center (SDHRC), Biostatistics, Guilan University of Medical Sciences, Rasht, Iran.
Keywords: Cancer, Screening, Women
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Introduction
World statistics indicate an increase in the incidence of breast cancer and its faster growth in the developing countries [1]. Breast cancer with a prevalence of 21.40% was the most common cancer in the Iranian women [2]. The most prevalent affected age group in Iran is 45-54 years. Its mortality is 1200 deaths per year in Iran, and now about 40,000 females live with this disease [1, 3, 4]. 
According to the World Health Organization, 25% of female deaths are due to the malignant tumors, of which 18% are due to cervical cancer [4]. Cervical cancer is the fourth most common cancer among the Iranian women. The incidence of this cancer is 4.5 cases per 100000 females in a year, prevalence is 6.64%, and the mean age of the cancer is 52.20 years [4-6]. 90% women had five-year survival rate when early stage diagnosis of breast cancer while only 60% cases had the same survival rate when the disease progressed [4, 7]. Furthermore, five-year survival for a patient with cervical cancer is 70% and 10%-15% after metastasis [4]. 
Early stage diagnosis and timely treatment of cancer or pre-cancerous conditions are the best possible protection. Screening for cancer is the primary tool for its early detection [8]. Self-examination (monthly breast examination by the person after 20 years of age), clinical examination of the breast by the experts (between the age of 20 to 40 every three years, and then annually after the age of 40), sonography of the breast tissue (in women under 40) and mammography (in women over 40 years of age once in 2-3 years), are the most effective methods for early diagnosis of breast cancer [7]. Screening test for early detection of cervical cancer in women is Pap Smear test (seemingly healthy), which is considered as a primary health-promoting behavior [9]. Results obtained from some studies, on screening for the breast and cervix cancers, on the medical team group have been very weak. This plays an important role in informing the society [10, 11]. 
According to a study conducted on the obstetrics and gynecology specialty assistants, from different medical schools in Iran, 95.20% of the subjects never used the cervix and breast screening methods for themselves [10]. The results of the study on nurses and midwives in Jordan also showed that only 19.4% of the subjects regularly performed self-examination of the breast [11]. In accordance with the policies of the Ministry of Health, screening tests should be conducted in the health care centers for women aged 20-65 years, but despite the availability of the screening programs and effectiveness of the tests, the number of referrals for the testing is not favorable. 
Studies conducted in Iran and other countries suggest that numerous cultural, emotional and practical factors and their repetition at standard time intervals have rendered the screening tests ineffective [4]. Since health care centers have an important place in the education and the health teams influentially motivate and encourage the screening for common cancers in women, the current study has been designed with the aim of “determining the status of screening tests for women’s common cancers and related factors in personnel employed in educational and health care centers in the Rasht City”. It is expected that the obtained results have an effective role in spreading awareness about the screening of breast and cervical cancers and promoting the health of women in our society.
Materials and Methods
In this study, 212 females employed in the specialized hospitals and health care centers in Rasht (107 midwives, 45 nurses, 18 general practitioners, 7 obstetrician and gynecologists, 9 residents and 26 family experts) were investigated by the census method in 2014-2015. Data collection instrument was a researcher-made questionnaire having 4 sections. The first section constituted of 20 questions about individual and social factors related to the screening tests. The second part included 8 questions about the risk factors associated with performing the screening tests for breast cancer and 14 questions related to the risk factors for cervical cancer. The third part included 9 questions on the status of screening tests (Pap Smear) for cervical cancer, 3 questions related to the conditions for performed mammography and 3 questions related to the status of performed breast self-examination. The last part had 14 questions concerning the motivational factors associated with performing the screening tests for the common cancers in women. 
To determine the validity of this questionnaire, content validity method was used, and the questionnaire was provided to 10 members of the Faculty of Nursing and Midwifery for their feedback. Due to the nature of the instrument, determination of reliability was not necessary. After obtaining the code, the researcher questionnaire was distributed after providing the necessary information to the subjects, and informed consent was obtained.Statistical analysis was performed using SPSS (V. 18). To compare the individual and social variables, associated risk factors and motivational factors related to the screening tests for common female cancers, Independent t test, Chi-square and Fisher’s exact test were used. To determine the status of screening tests for cancers, descriptive statistics methods (frequency and percentage) were used. To determine the predictive factors for performing a Pap Smear test, mammography and breast self-examination in multiple analysis, the logistic regression model was used. This model was conducted with backward LR method. 
Results
In this study, 212 female employees of the hospital and health care centers in Rasht participated, of which 18 were general practitioners, 9(12.70%) were residents, 7(3.30%) were gynecologists, 45(21.20%) were nurses, 107(50.50%)were midwives and 26(12.30%) were family health experts. Investigation of the demographic and social profiles of the subjects showed that majority of the subjects were married (77.80%) had a bachelor’s degree (57.50%) with a monthly income of $170 to $340 and spouse with university education(92.60%). Most of them (93.80%) did not undergo tubectomy procedure and used the natural method to prevent pregnancy (37.30%). Their mean age was 37.79±8.79 years, the average working experience was 13.08±8.72 years, the mean age for the first menstruation was 13.1±1.50 years, the mean age for the marriage was 25.40±4.19 years, the mean of marriage times was 1.0±0.0, the mean age of the first gestation was 13.1±1.50 years, the mean number of pregnancies was 1.9±0.90, the mean number of abortions was 0.3±0.60, the mean number of live children was 1.50±0.50, the mean age of the last delivery was at 30.88±4.54 years, and the mean duration of using prevention methods was 8.52±6.13 years. The mean weight of the studied subjects was 65.06±10.72 kg, the average height was 161.22±6.00 cm and the mean BMI was 25.29±4.28 kg/m2. 
Regarding the performance of the screening tests for common female cancers, the results showed that majority of the married subjects performed Pap Smear test (87.60%). They were referred for a checkup for no particular reason and in 90.90% of cases; the result of the Pap Smear test was normal. Out of the 9.10% of the abnormal cases, 90% were the cases of infection and inflammation. Causes for the non-performing Pap Smears of the research subjects were either forgetfulness or negligence (38.50%) and not having enough time (23.10%).
About 42.20% of the studied subjects were referred irregularly, and 30.5% were referred regularly to perform the Pap Smear test. The mean visit time after the intercourse was 4.07±4.05 years, and the mean age of the first Pap Smear test was 30.02±5.16 years. Most of the subjects (57.30%) were referred for the examina

 

 

 
tion at the interval of 10-18 days of the menstrual cycle, and 98.30% did not perform the Pap Smear test during pregnancy. Only 6.8% of subjects were referred for the examination 8 weeks after the delivery.
About 50% of the subjects performed mammography. The leading cause for the failure to perform mammography was forgetfulness and negligence (43.30%). The mean age of the subjects under study at the time of the first mammography was 37.30(5.59) years, and the majority (41.30%) of those who performed the mammography were referred regularly; moreover, the majority of studied subjects (86.6%) performed the breast self-examination.
The highest percentage of causes for the non-performing breast self-examination (37.90%) was related to the forgetfulness and negligence. The mean age of the subjects at the time of their first self-examination of the breast was 26.17±6.65 years, and the majority of them performed the breast self-examination irregularly (68.60%). Individual and social factors associated with performing the mammography and the Pap Smear test are given in Table 1.
Regression model showed that the variable for the duration of the current method of contraception usage (P=0.05), having suspicious mass in the breast (P=0.004) were the predictors of mammography in such a way that, longer the use of the current contraceptive method, lower are the relative chances of performing mammography. And those subjects who were suspicious of the mass in their breast had 2.09 times chance of performing mammography, as compared to those who did not suspect the presence of mass in the breast (Table 2). Predictive factors for performing the Pap Smear test and the breast self-examination are listed in Tables 3 and 4.
Discussion
Considering the culture and traditions of the studied community, single females could not perform Pap Smear. So the researcher investigated this procedure in married women, and the results showed that the number of women who had Pap Smear was much higher as compared to the previous studies conducted on the members of the health care team in Rasht City [12] and the country of Sri Lanka [13]. In this study, half of the subjects performed the mammography test, which was higher than those reported in Nilaweera study [13]. Results of breast self-examination were higher than other studies [10, 12, 13]. It seems that different 
culture and context of conducting research might be the reasons for this disparity.
According to the responses by our subjects, out of the individual and social factors, there was a significant statistical relationship between performing the Pap Smear test and variables of age, work history, number of pregnancies, the number of live children, the duration of the current contraceptive method, height and body mass index. Based on the Sabery study results, there was a significant relationship between the Pap Smear test and the type of contraceptive method [14]. The relationship between the age and Pap Smear test has been approved in many studies [15-17]. Similar to our results, younger women perform more Pap Smear test than the older women. To the researcher’s opinion, the higher rate of performing the test in younger women is perhaps due to the fact that they refer more to health care centers to use maternal and child health care services or the fact that younger age group pay attention to their health status.
There was also a significant statistical relationship between age, work experience, duration of using the current contraceptive method and performing mammography. The study results by Shiryazdi indicate a statistically significant relationship between age, work experience and performing mammography [18]. In a study conducted by Ahmadian in Tehran, there was a significant relationship between the age and mammography [19]. According to the results, the mean age of females who did mammography was more than those who did not. The reason may be that with getting older, women find themselves at risk of developing serious illnesses and they have more frequency to do screening tests. 
Predicting factors to perform Pap Smear test are the early diagnosis of cancer, age and age of the first pregnancy. Results of the Karimi study showed that early diagnosis of cancer is one of the predictive factors for performing the Pap Smear test [20]. It seems that the fear of cancer and awareness of the effectiveness of screening tests as an early detection of cancer can be the reasons for these findings in the medical and health care staff. Based on the results of this study, the fear of having a mass in the breast and/or getting cancer has been the instigating factor for performing the mammography. 
Besides, based on the results of this study, fear of cancer was the only predictor for performing the breast self-examination. These findings are similar to those in the other studies, which confirmed that the fear of cancer has been the most important factor affecting the cancer screening [21, 22]. To explain this fear, we can say that most of the members of the health team are in contact with patients with a variety of cancers, including breast cancer or observing the disease in their family or friends, which attracted them to undergo the screening tests. Psychological state of the subjects is effective in completing the questionnaire, and this condition could not be controlled by the researcher. The time elapsed is an effective method for reminding the exact timing of screening tests for the breast and cervix cancer, recall bias may have affected the results.
It seems necessary to conduct retraining courses and repeating the importance to the subjects in order to improve the performance of the health care team and to encourage more females to perform screening tests. Paying attention to this point is important because these people are considered as role models for other females in their community. It is necessary to inform and motivate them through the provision of health services from the health care centers on the condition of performed screening tests, in-service training, training by family planning clinics to explain the function and role of screening tests in raising the levels of women’s performance.
Ethical Considerations
Compliance with ethical guidelines

This research was registered with the number 92236 and the code of ethics as 23219.
Funding
This article was extracted from Massoomeh Amani MS thesis approved by the Rasht Shahid Beheshti Faculty of Nursing and Midwifery. 
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
We express our gratitude towards Mrs. Maryam Bagheri, Social Determinents of Health Research Centers (SDHRC) and those who helped us in the conduction of this study. 


References
  1. Asgharnia M, Faraji R, Zahiri Z, Salamat F, Mosavi CS, Sefati S. [A study of knowledge and practice of woman about breast cancer and its screening, in the case of women who referred to Alzahra hospital in Rasht during 2010-2011 (Persian)]. Journal of Iran Surgery. 2013; 21(1):1-9.
  2. Khalili S, Shojaiezadeh D, Azam K, Kheirkhah Rahimabad K, Kharghani Moghadam M, Khazir Z. [The effectiveness of education on the health beliefs and practices related to breast cancer screening among women referred to Shahid Behtash Clinic, Lavizan area, Tehran, using health belief model (Persian)]. Journal of Health. 2014; 5(1):45-58.
  3. Tahergorabi Z, Moodi M, Mesbahzadeh B. [Breast cancer: A preventable disease (Persian)]. Journal of Birjand University of Medical Sciences. 2014; 21(2):126-41.
  4. Akbari H, Jaddi Arani T, Gilasi H, Moazemi-Goodarzi A, Ghalipoor Z, Alinaghi Poor A, et al. [Study of motivational factors and causes of nonparticipation to breast and cervical cancer screening tests among women attending health centers in Kashan city (Persian)]. Scientific Journal of Ilam University of Medical Sciences. 2014; 22(3):137-48.
  5. Hajializadeh K, Ahadi H, Jomehri F. [The role of health beliefs in predicting barriers to cervical cancer screening (Persian)]. Journal of Kerman University of Medical Sciences. 2014; 21(5):416-25.
  6. Mirzaei-Alavijeh M, Karami-Matin B, Jalilian F, Rakhshani F, Mahboubi M, Emdadi S. [Pap Smear test promotion among women: An educational intervention based on theory of planned behavior (Persian)]. Journal of Biology and Today's World. 2014; 3(4):100-3.
  7. Sargazi M, Mohseni M, Safar-Navadeh M, Iran-Pour A, Mirzaee M, Jahani Y. [Effect of an educational intervention based on the theory of planned behavior on behaviors leading to early diagnosis of Breast Cancer among women referred to health care centers in Zahedan in 2013 (Persian)]. Iranian Journal of Breast Diseases. 2014; 7(2):45-55.
  8. Enjezab B, Faraj khoda T, Mojahed S, Bokaee M. [Barriers and motivators related to cervical and Breast Cancer screening (Persian)]. Journal of Shahid Sadoughi University of Medical Sciences. 2004; 12(3):78-84.
  9. Morowatisharifabad M, Norouzi S, Layeghy S, Norouzi A. [Survey of Cervix Cancer screening determinants among 20-65 years old women based on health belief model in Lordegan, Chahar Mahal Bakhtiyaree, 2009 (Persian)]. The Journal of Toloo-e-Behdasht. 2013; 12(1):98-106.
  10. Alavi Gh, Hoseininejad J, Fattahi Masoom AS, Shakeri MT. [Evaluation of prevalence of Cervical and Breast Cancer screening programs between gynecologists (Persian)]. Iranian Journal of Obstetrics, Gynecology and Infertility. 2010; 13(1)1-6. 
  11. Amasha HA. Breast self-examination and risk factors of breast cancer: Awareness of Jordanian nurses. Health Science Journal. 2013; 7(3):303-14.
  12. Esmailpour N, Mirblouk F, Shodjaei Tehrani H, Poorseyad Reza A, Dalil Heirati SF. [Survey the knowledge, attitude and practice on popsmear in nurses and midwives (Persian)]. Journal of Guilan University of Medical Sciences. 2011; 20(77):81-8.
  13. Nilaweera R, Perera S, Paranagama N, Anushyanthan A. Knowledge and practices on breast and cervical cancer screening methods among female health care workers: A SriLankan experience. Asian Pacific Journal of Cancer Prevention. 2012; 13(4):1193-6. [DOI:10.7314/APJCP.2012.13.4.1193] [PMID]
  14. Saberi F, Sadat Z, Abedzadeh Kolahrodi M. [Factors related to servix cancer screening and barriers to trying it in women (Persian)]. Journal of the Iranian Institute for Health Sciences Research. 2012; 11(3):365-70.
  15. Jalilian F, Mirzaei Alavijeh M, Emdadi SH, Barati M, Nasirzadeh M, Hatamzadeh S. [Predicting factors related with Pap Smear results among women based on health belief model (Persian)]. Journal of Health System Research. 2011; 7(6):1226-34. 
  16. Farshbaf-Khalili A, Salehi-Pourmehr H, Shahnazi M, Yaghoubi S, Gahremani-Nasab P. [Cervical cancer screening in women referred to healthcare centres in Tabriz, Iran (Persian)]. Nigerian Medical Journal: Journal of the Nigeria Medical Association. 2015; 56(1):28-34.
  17. Ncube B, Bey A, Knight J, Bessler P, Jolly PE. Factors associated with the uptake of cervical cancer screening among women in Portland, Jamaica. North American Journal of Medical Sciences. 2015; 7(3):104-13. [DOI:10.4103/1947-2714.153922] [PMID] [PMCID]
  18. Shiryazdi SM, Kargar S, Farahbod AR, Neamatzadeh H, Ghasemi N, Aboueian-Jahromi M. [Knowledge, attitude, and practice of women referring to Yazd city health centers regarding breast cancer screening (Persian)]. Journal of Community Health Research. 2014; 3(2):80-95.
  19. Ahmadian M, Samah AA, Redzuan M, Emby Z. [Barriers to mammography among women attending gynecologic outpatient clinics in Tehran, Iran (Persian)]. Scientific Research and Essays. 2011; 6(27):5803-11. [DOI:10.5897/SRE11.1384]
  20. Karimi M, Shamsi M, Araban M, Gholamnia Z, Kasmaie P. [Health beliefs and performance regarding Pap Smear test in Zarandieh City women's (Persian)]. Journal of Guilan University of Medical Sciences. 2011; 20(80):42-8.
  21. Keshavarz Z, Simbar M, Ramezankhani A, Majd Alavi H. [Factors influencing the behavior of female-workers in the reproductive age regarding breast and cervical cancer screening based on the Integrated Model of Planned Behavior and Self-Efficacy: A qualitative approach (Persian)]. Journal of Health Institute and Health Surveys Institution. 2011; 9(3):23-36.
  22. Aam ES, Dma ES, El Shorbagy D, Zaid H. Knowledge, attitude and practice of female medical students of Tanta University towards Breast Cancer and its screening. Egyptian Journal of Community Medicine. 2014; 32(3):27-45. [DOI:10.12816/0011961]
Article Type : Research | Subject: General
Received: 2017/08/27 | Accepted: 2018/04/11 | Published: 2018/09/1

References
1. Asgharnia M, Faraji R, Zahiri Z, Salamat F, Mosavi CS, Sefati S. [A study of knowledge and practice of woman about breast cancer and its screening, in the case of women who referred to Alzahra hospital in Rasht during 2010-2011 (Persian)]. Journal of Iran Surgery. 2013; 21(1):1-9.
2. Khalili S, Shojaiezadeh D, Azam K, Kheirkhah Rahimabad K, Kharghani Moghadam M, Khazir Z. [The effectiveness of education on the health beliefs and practices related to breast cancer screening among women referred to Shahid Behtash Clinic, Lavizan area, Tehran, using health belief model (Persian)]. Journal of Health. 2014; 5(1):45-58.
3. Tahergorabi Z, Moodi M, Mesbahzadeh B. [Breast cancer: A preventable disease (Persian)]. Journal of Birjand University of Medical Sciences. 2014; 21(2):126-41.
4. Akbari H, Jaddi Arani T, Gilasi H, Moazemi-Goodarzi A, Ghalipoor Z, Alinaghi Poor A, et al. [Study of motivational factors and causes of nonparticipation to breast and cervical cancer screening tests among women attending health centers in Kashan city (Persian)]. Scientific Journal of Ilam University of Medical Sciences. 2014; 22(3):137-48.
5. Hajializadeh K, Ahadi H, Jomehri F. [The role of health beliefs in predicting barriers to cervical cancer screening (Persian)]. Journal of Kerman University of Medical Sciences. 2014; 21(5):416-25.
6. Mirzaei-Alavijeh M, Karami-Matin B, Jalilian F, Rakhshani F, Mahboubi M, Emdadi S. [Pap Smear test promotion among women: An educational intervention based on theory of planned behavior (Persian)]. Journal of Biology and Today's World. 2014; 3(4):100-3. [DOI:10.15412/J.JBTW.01030405]
7. Sargazi M, Mohseni M, Safar-Navadeh M, Iran-Pour A, Mirzaee M, Jahani Y. [Effect of an educational intervention based on the theory of planned behavior on behaviors leading to early diagnosis of Breast Cancer among women referred to health care centers in Zahedan in 2013 (Persian)]. Iranian Journal of Breast Diseases. 2014; 7(2):45-55.
8. Enjezab B, Faraj khoda T, Mojahed S, Bokaee M. [Barriers and motivators related to cervical and Breast Cancer screening (Persian)]. Journal of Shahid Sadoughi University of Medical Sciences. 2004; 12(3):78-84.
9. Morowatisharifabad M, Norouzi S, Layeghy S, Norouzi A. [Survey of Cervix Cancer screening determinants among 20-65 years old women based on health belief model in Lordegan, Chahar Mahal Bakhtiyaree, 2009 (Persian)]. The Journal of Toloo-e-Behdasht. 2013; 12(1):98-106.
10. Alavi Gh, Hoseininejad J, Fattahi Masoom AS, Shakeri MT. [Evaluation of prevalence of Cervical and Breast Cancer screening programs between gynecologists (Persian)]. Iranian Journal of Obstetrics, Gynecology and Infertility. 2010; 13(1)1-6.
11. Amasha HA. Breast self-examination and risk factors of breast cancer: Awareness of Jordanian nurses. Health Science Journal. 2013; 7(3):303-14.
12. Esmailpour N, Mirblouk F, Shodjaei Tehrani H, Poorseyad Reza A, Dalil Heirati SF. [Survey the knowledge, attitude and practice on popsmear in nurses and midwives (Persian)]. Journal of Guilan University of Medical Sciences. 2011; 20(77):81-8.
13. Nilaweera R, Perera S, Paranagama N, Anushyanthan A. Knowledge and practices on breast and cervical cancer screening methods among female health care workers: A SriLankan experience. Asian Pacific Journal of Cancer Prevention. 2012; 13(4):1193-6. [DOI:10.7314/APJCP.2012.13.4.1193] [PMID] [DOI:10.7314/APJCP.2012.13.4.1193]
14. Saberi F, Sadat Z, Abedzadeh Kolahrodi M. [Factors related to servix cancer screening and barriers to trying it in women (Persian)]. Journal of the Iranian Institute for Health Sciences Research. 2012; 11(3):365-70.
15. Jalilian F, Mirzaei Alavijeh M, Emdadi SH, Barati M, Nasirzadeh M, Hatamzadeh S. [Predicting factors related with Pap Smear results among women based on health belief model (Persian)]. Journal of Health System Research. 2011; 7(6):1226-34.
16. Farshbaf-Khalili A, Salehi-Pourmehr H, Shahnazi M, Yaghoubi S, Gahremani-Nasab P. [Cervical cancer screening in women referred to healthcare centres in Tabriz, Iran (Persian)]. Nigerian Medical Journal: Journal of the Nigeria Medical Association. 2015; 56(1):28-34. [DOI:10.4103/0300-1652.149167] [PMID] [PMCID]
17. Ncube B, Bey A, Knight J, Bessler P, Jolly PE. Factors associated with the uptake of cervical cancer screening among women in Portland, Jamaica. North American Journal of Medical Sciences. 2015; 7(3):104-13. [DOI:10.4103/1947-2714.153922] [PMID] [PMCID] [DOI:10.4103/1947-2714.153922]
18. Shiryazdi SM, Kargar S, Farahbod AR, Neamatzadeh H, Ghasemi N, Aboueian-Jahromi M. [Knowledge, attitude, and practice of women referring to Yazd city health centers regarding breast cancer screening (Persian)]. Journal of Community Health Research. 2014; 3(2):80-95.
19. Ahmadian M, Samah AA, Redzuan M, Emby Z. [Barriers to mammography among women attending gynecologic outpatient clinics in Tehran, Iran (Persian)]. Scientific Research and Essays. 2011; 6(27):5803-11. [DOI:10.5897/SRE11.1384] [DOI:10.5897/SRE11.1384]
20. Karimi M, Shamsi M, Araban M, Gholamnia Z, Kasmaie P. [Health beliefs and performance regarding Pap Smear test in Zarandieh City women's (Persian)]. Journal of Guilan University of Medical Sciences. 2011; 20(80):42-8.
21. Keshavarz Z, Simbar M, Ramezankhani A, Majd Alavi H. [Factors influencing the behavior of female-workers in the reproductive age regarding breast and cervical cancer screening based on the Integrated Model of Planned Behavior and Self-Efficacy: A qualitative approach (Persian)]. Journal of Health Institute and Health Surveys Institution. 2011; 9(3):23-36.
22. Aam ES, Dma ES, El Shorbagy D, Zaid H. Knowledge, attitude and practice of female medical students of Tanta University towards Breast Cancer and its screening. Egyptian Journal of Community Medicine. 2014; 32(3):27-45. [DOI:10.12816/0011961] [DOI:10.12816/0011961]

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