epidemiologic researches in the united states reveal that one out of four deaths is due to cancer ( 1 , 2 ) . breast cancer ( bc ) is the most common type of cancer among women worldwide , which accounts for approximately one - fifth of all deaths in women aged 40 to 50 years ( 2 , 3 ) . the most common and fatal cancer in women is bc while the most common cancer in men is lung cancer ( 1 ) . over one million new cases of bc are diagnosed each year and more than 600000 of them would lead to death . it is a worldwide - growing public health problem , specially in developing countries so that its incidence has increased to 5% per year ( 5 ) . the proportion of death because of bc in developing countries is higher than developed countries . although just half of the cases of bc occur in developing countries , two - thirds of deaths due to bc occur in these countries ( 6 ) . regardless of their age , all of the women are at risk for bc ; however , aging increases its risk . bc prevalence in the world is increasing and it has had a concerning incremental trend in iran ( 7 ) , where its incidence was estimated at 20 per 105 women , and one of every ten women would develop bc during her life ( 8 , 9 ) . since all cases of bc are not registered in iran , we can not comment on its prevalence , incidence , and fatality . nonetheless , bc rate in iran is estimated at 20 new cases in 100000 female ( 10 ) . moreover , although bc is not preventable , we can increase patient s survival by more than 90% through early diagnosis ( 11 ) . there are different ways for early diagnosis of bc including breast self - examination ( bse ) , physical exam by a physician , and mammography ; however , unfortunately , it is not diagnosed in early stages of the disease in many patients when they are mostly curable . in developed countries , most of women use screening tests and it has caused a reduction in bc mortality rates . nevertheless , the condition is not the same in developing countries ( 12 ) . in many countries , mammography is the best screening test for diagnosis of bc at early stages ( 13 ) . in iran , with regard to growing rate of bc and referring of patients in advanced stages of the disease , it is necessary to improve patient s attitude towards bc by performing behavior remodeling programs ( 14 ) among which bse is available and inexpensive and women show tendency to perform it ( 15 ) . by means of monthly correct bse , women become familiar with their breast s characteristics and can distinguish abnormal changes in future and in case of any unnatural changes , it would be diagnosed at early stages . if all of the women examine their breasts monthly and refer to the physician for further physical exam and mammography on time , it would be possible to prevent bc s progression to high stages of the disease in 95% of cases ( 16 ) . the sooner the cancer is diagnosed , the lower the needed radiotherapy would be and hence , the higher the patient s quality of life would be . the reasons that prevent women from performing regular bse include disorientation about exam importance , fear and anxiety , and unawareness of correct way of performing exam ( 17 - 19 ) . studies showed that women with higher information about bse would perform it correctly and regularly ( 16 ) . a study on awareness and attitude of female employees of education ministry toward bc in shahrekord city in 2008 showed that the attitude was very good in 15.53% , good in 17% , and poor in 10.95% ( 20 ) . in a similar study in kashan city in 2001 , 42% had poor attitude and 5.5% had negative and apathetic attitude toward bse ( 21 ) . bc is the most common cancer and the most common cause of death from cancer in women ( 1 ) . a study about women s awareness of mammography , bse , and other diagnostic methods in at - risk women has not been done in dezful city yet . our study aimed to evaluate the awareness of and attitude toward bse , which is one of the most simple diagnostic methods , among women in dezful city , iran , in 2013 health policymakers would use the results to design training programs on bse and provide information on correct performance of the examination . this descriptive cross - sectional study included 1020 women over 15 years of age and was performed in 2013 . simple random cluster of accessible women was used to recruit participants . sampling communities included women referred to medical centers ( rural and urban ) , students of dezful university of medicine , students of dezful islamic azad university , students of jundishapour engineering university , students of rural and urban high schools in dezful city and homemakers in five dezful city municipal districts . sample size was calculated by the following formula : 
 n = [ ( z + z  ) /(1 - 0 ) ] 
  educated females were evaluated through questionnaire and illiterates through face - to - face interview . questionnaire included five sections : first section was the form of giving consent ; second section included sample s demographic characteristics ; third section included sample s awareness of bc , which according to standard protocols , consisted of prevalence , risk factors , sign and symptoms , bse , clinical breast exam , and mammography ( 22 ) ; fourth section included women awareness of and attitude toward bse questionnaire ; fifth section included assessment of bc risk factors in samples . the responses to 20 questions of questionnaires were calculated as follows : correct , 1 ; false , -1 ; and " i do nt know " , 0 . then the sum of them was classified to four levels , which was adjusted by likert scale ( good , 11 - 20 ; moderate , 1 - 10 ; and bad , 0 to -10 ) . validity questionnaire was validated using content validity method by five internal medicine specialists , endocrinologist , and immunologist in dezful university of medical sciences . reliability of this questionnaire was obtained by test - retest in which by a pilot study on 60 persons cronbach s alpha of 0.86 was obtained . chicago , il , usa ) using mean , absolute , and relative frequencies . in order to assess parameter s association , we used independent - samples t test and chi square test . the ethics committee of dezful university of medical sciences approved the study protocol ( code of ethical approval , durs104 ) . in this study , sampling strategy and inability to generalized finding to target population was one of the basic limitation . study about women s awareness of mammography , bse , and other diagnostic ways has not been done in dezful yet . in this study , we had 1020 participants with mean age of 37.1  1.3 years ( range , 15 - 79 ) . in this study , 195 women ( 19.1% ) were single and the rest were married . the education level was under high school diploma in 385 women ( 37.7% ) , high school diploma in 295 ( 28.9% ) , and academic education in 340 ( 33.3% ) . among the participants , 630 women ( 61.8% ) were housekeeper , 170 ( 16.7% ) were employed , and 220 ( 21.6% ) were students . the history of bc in family members ( mother , aunt , and grandmother ) was reported by 7.8% of women and 10.8%of women had history of bc in distant relatives ( table 2 ) . most of participants ( 72% ) believed that breast physical exam and mammography are efficient medical diagnostic ways . although 685 women ( 67.2% ) knew that monthly bse was necessary , only 426 ( 41.8% ) knew its proper time . the results of this study showed that the mean score of women 's knowledge 51.24  7.12 ( median , 53.17 ; interquartile range [ iqr ] , 17.43 ) . participants knowledge about bc and its screening tests was good in 206 women ( 20.2% ) , moderate in 783 ( 76.8% ) , and poor in 31 ( 3% ) . the positive therapeutic effects of early diagnosis were acknowledged by 715 women ( 70.1% ) . although 525 women ( 51.5% ) performed bse , only 400 ( 39.2% ) knew how to do it correctly . the results of this study showed that the mean score of women 's attitude was 74.12  11.83 ( median , 67.71 ; iqr , 25.03 ) . overall , 83.3% of participants believed that bse would have positive effects in early diagnosis of bc , 82.4% believed that bse was not unpleasant , 47.1% believed that bse was an appropriate way of bc diagnosis , and 72.5% believed that it is necessary to train all of the women on performing bse correctly . only 37% of participants were trained on examining their breasts themselves and among training sources , healthcare staff were the most important sources ( 38.2% ) . among the reasons of not doing bse , the most important ones were consecutively  not knowing how to do it  and  not having breast problems  . although 51.5% of women performed bse , only 33.3% of women over 40 years of age performed it and 31.8% of them knew how to do it correctly ( p < 0.001 ) . table 5 shows participant s bse proportions in different age ranges and shows whether they were trained how to do it . chi - square test showed statistically significant association between participant s awareness of and attitude toward bse . it showed that the higher the level of awareness was , the more positive the attitude would be ( p < 0.001 ) . it means that those who had a more positive attitude did the exam more frequently ( p < 0.001 ) . there was statistically significant association between participant s awareness with age ( odds ratio [ or ] = 1.58 ; p < 0.001 ) , marital status ( or = 1.3 ; p = 0.021 ) , education ( or = 2.2 ; p = 0.001 ) , a positive family history ( or = 3.45 , p < 0.001 ) . there was a statistically significant correlation between participant s attitude with age ( or = 2.70 ; p < 0.001 ) , marital status ( or = 1.6 ; p = 0.040 ) , education level ( or = 1.9 ; p = 0.001 ) , previous training history ( or = 3.4 ; p < 0.001 ) , and positive family history ( or = 2.4 ; p < 0.001 ) . there was an statistically significant relation between doing bse with age ( or = 2.4 , p < 0.001 ) , marital status ( or = 2.01 , p < 0.001 ) , education ( or = 1.5 , p = 0.015 ) , previous training ( or = 1.08 , p < 0.001 ) , positive family history ( or = 2.6 , p < 0.001 ) and participant s attitude to do the test ( or = 1.12 , p = 0.004 ) , but it does not have significant relation with test unpleasantness ( p = 0.682 ) . there was a statistically significant correlation between education level and knowing to do the test ( p = 0.009 ) . in addition , those who were trained on performing the test , did it more frequently ( p < 0.001 ) . doing the test properly had a direct correlation with level of education ( p < 0.001 ) . our study evaluated the degree of awareness and attitude of women about bc and bse in dezful city for the first time . we tried to study the association of women s attitude toward bse with parameters such as age , marital status , education , occupation , and family history ( bc grade 1 , 2 ) . the results of this study approved results of other studies on the positive effects of elevating women s awareness of and attitude toward bc on their participation in screening programs . the responses to the questionnaire about bc and its preventive routes in women in dezful city showed that only 20.2% of participants had a good level of knowledge and the rest had moderate to poor knowledge of this issue . a survey by jokar and ghiasi in 1997 about women 's awareness of and attitude toward bc in ilam province showed that most of them ( 57.3% ) had poor awareness and only 11.9% had good awareness ( 22 ) . moreover its screening tests showed that 42% of kashan city s women did not know about bc screening tests and only 22% were informed ( 23 ) . in a study by jokar and ghiasi the women 's awareness of and attitude toward bc was good in 28.5% , moderate in 67.3% , and poor in 4.2% . the women s awareness of positive effects of early diagnosis of bc was 89% but this proportion was reduced to 70.1% in dezful city 's women in our study . nevertheless , our research shows that dezful city women s information has not increased with the same anticipated rate . according to our results , 51.5% of dezful city 's women performed bse , 82.4% of them had a positive attitude toward the test , and 83.3% believed that the test has a positive effect in early diagnosis of bc . in a study by jokar and ghiasi in 1998 , 64% of women had positive attitude toward breast screening tests and 35% of them did the bse ( 22 ) . a study by abedzadeh et al . showed that 94.5% of women had a positive attitude toward bse , 42.7% of them perform it , and 19.7% were referred to healthcare staff to do it for them ( 23 ) . a study by banaiyan et al . on women 's awareness of and attitude toward bc screening tests in brijen city in 2004 , showed that only 16.7% of women had a positive attitude towards screening tests , 67.7% had moderate attitude , and 15.6% had negative attitude . women s attitude toward bse was only positive in 23% and only 47.1% performed the exam ( 24 ) . a study by vietri et al . in the united states in 1997 showed that 58% of women performed bse ( 25 ) , which was higher than the rate by dezful women . this result showed that women s culture has an important role in this difference and more efforts are needed to inform women and make bse important for them in developing countries . this issue showed us that to design training programs , we should consider two important points : providing appropriate bse training programs to diagnose it earlier ; and explaining its benefits to women . parameters such as age , education , marital status , and family history would affect the knowledge level of participants . women over 20 years of age with higher education and positive family history of bc had better information about bc preventing programs ( p > 0.001 ) . these results were in parallel with many researches performed until now ( 23 , 24 ) . with regard to the higher level of education in iranian women than women in central asia , middle east , caucasus , africa , and south america , it seems that designation and performing training interventional health programs on cancers , especially bc , would improve establishment of bc screening tests in iranian women in comparison with above countries . in other words , interventional health training programs increase women s awareness of and attitude toward cancers , specially bc , and their screening and early diagnostic tests . in women with higher education level , there is a higher awareness of this issue . studied healthcare staff with high level of education and appropriate knowledge about bc and its screening tests . the results showed that their tendency toward participating in bc screening tests was higher than was in general population ( 26 ) . according to this survey , most of these women prefer bse in comparison with other screening tests . a survey by levshin et al . on 1500 cases of bc showed that 81% of them had noticed its symptoms themselves first ( 27 ) . in conclusion , if women learn bc s sign and symptoms and perform bse monthly , it would be possible to diagnose bc in early stages , which would provide a better diagnosis . with regard to high prevalence of bc in iran and considering the positive awareness of dezful city 's women about bse , which was shown in our study , and paying attention to the fact that our target population lacked information about bc , we need interventional health training programs and regular screening tests in iran . we suggest the following ways in order to reduce mortality rate of bc : regular interventional health training programs performance to elevate awareness and attitude of women over 15 years toward cancers , especially bc . establishment of nongovernmental organizations ( ngo ) and support them to inform the people .   establishing cancer clinics in each city . active screening tests and clinical breast exam and mammography by physicians in rural and urban health centers for women over 40 years . health policymakers of dezful city can establish bse training programs to elevate women 's awareness of and attitude toward early diagnosis of bc and bse .
background : over one million new cases of breast cancer ( bc ) are diagnosed each year with a mortality rate of more than 600 thousand women per year . 
 breast self - examination ( bse ) is a patient - centered , inexpensive , and noninvasive diagnostic test . 
 we focused on the role of screening in bc in early diagnosis.objectives:the purpose of this study was to evaluate awareness and attitude of women toward bse in dezful city , iran , in 2013.patients and methods : this descriptive cross - sectional study included 1020 women over 15 years of age in dezful city , in 2013 . 
 simple random clustering was used to enroll accessible women . 
 we have applied the available pieces of software for statistical analysis.results:the mean age of recruited women was 37.1  1.3 and 23.6% of participants had a history of bc in themselves or in their relatives ( mother , sister , aunt , and grandmother ) . 
 in addition , 70.1% of participants benefited from early diagnosis of bc , 83.3% of participants considered bse necessary and useful for early diagnosis of bc , and 51% of them performed bse . 
 there was a statistically significant correlation between being married and doing bse ( p = 0.034 ) and between womens level of education and awareness to perform bse ( p = 0.009).conclusions : with regard to high prevalence of bc in iran , this study showed a positive attitude of women in dezful city toward bse . 
 health policymakers in dezful city can establish training programs to increase women s awareness of bse and to instruct them to perform it properly .