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Faludi Vargáné E, Ghanem AS, Nguyen CM, Pataki J, Szőllősi GJ, Nagy AC. Influencing factors on attendance in cervical cancer screening among women with diabetes in Hungary: a cross-sectional study using European Health Interview Surveys 2009-2019. Front Oncol 2025; 15:1501654. [PMID: 40365342 PMCID: PMC12069032 DOI: 10.3389/fonc.2025.1501654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 04/07/2025] [Indexed: 05/15/2025] Open
Abstract
Introduction With this study, we examined the participation in cervical cancer screening among women with diabetes and the influencing factors of attendance. Methods Data from the European Health Interview Surveys in Hungary (2009, 2014, 2019) were analyzed with multivariate and multiple logistic regressions. Results A higher level of education (OR=2.56, 95% CI: 1.03-6.33 in the case of secondary level in 2014; and OR=3.09, 95% CI: 1.17-8.13 in the case of tertiary level in 2019, OR= 2.24, 95% CI: 1.12-4.46 in the case of tertiary level in the pooled data), a perceived good economic situation (OR=2.31, 95% CI: 1.30-4.09 in the pooled data), participation in breast cancer screening (OR= 5.41, 95% CI: 3.49-8.38 in the pooled data), and social support (OR= 2.04 95% CI: 1.03-4.03 in 2019) have a positive effect on participation in screening. Taking prescription drugs (OR= 0.31 95% CI: 0.12-0.83, in the pooled data), lower economic status (OR=0.25 95% CI:0.07-0.88, in 2009) and worse perceived health (OR= 0.20, 95% CI: 0.06-0.64 in 2014) can be considered factors with a negative effect. Conclusion This study identified groups with low participation rates and made it clear that those groups with unfavorable health factors (bad financial status, bad perceived health, taking prescription drugs) participate the least in screening.
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Affiliation(s)
- Eszter Faludi Vargáné
- Department of Integrative Health Sciences, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Amr Sayed Ghanem
- Department of Health Informatics, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Chau Minh Nguyen
- Department of Health Informatics, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Jenifer Pataki
- Department of Integrative Health Sciences, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Gergő József Szőllősi
- Coordination Center for Research in Social Sciences, Faculty of Economics and Business, University of Debrecen, Debrecen, Hungary
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Attila Csaba Nagy
- Department of Health Informatics, Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
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Subramanian SS, Bhaskarapillai B, Jayakrishnan R. Female cancer screening in India: Results from the National Family Health Survey (NFHS-5) and the way forward. J Family Med Prim Care 2024; 13:4552-4559. [PMID: 39629359 PMCID: PMC11610822 DOI: 10.4103/jfmpc.jfmpc_2037_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 12/07/2024] Open
Abstract
The incidence of cancer is increasing in India, reflecting global trends. This study attempts to identify various socioeconomic factors associated with breast and cervical cancer screening in females aged 30-49 years using the National Family Health Survey-5 (NFHS-5) data. Data focused on sociodemographic variables, cancer awareness, and information on breast and cervical cancer screening. Poisson regression was used to identify factors and reported adjusted prevalence ratio (APR) and 95% confidence intervals (CI). The proportion of women who had undergone breast and cervical cancer screening all over India was 0.9% and 1.9%, respectively. Socioeconomic factors seem to play a role as the poor and middle wealth index groups were less likely to undertake breast (APR = 0.60; 95%CI: 0.37, 0.99) and cervical cancer (APR = 0.68; 95%CI: 0.51, 0.92) screening compared to the wealthier groups. Moreover, 43% of participants in the poor wealth index category had not undergone cervical cancer screening (APR = 0.57; 95%CI: 0.33, 0.96). Further, women who watched messages on visual media were more likely to undergo screening for breast (APR = 2.00; 95%CI: 1.12, 3.57) and cervical cancer (APR = 1.46; 95%CI: 1.18, 1.82) within a week. In conclusion, screening for cancer among Indian females is remarkably low, which highlights the need for a uniform protocol for message dissemination on cancer and to collect information based on risk assessment. Furthermore, the negligible community participation in cancer screening points to the potential role of sociodemographic characteristics in taking up cancer screening, which was reflected in less participation among socioeconomically disadvantaged groups.
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Bhandari AKC, Htay ZW, Parvin R, Murakami M, Krull Abe S. Prevalence of Breast Cancer Screening in Asia: Systematic Review and Meta-Analysis. Asian Pac J Cancer Prev 2024; 25:3379-3391. [PMID: 39471004 PMCID: PMC11711340 DOI: 10.31557/apjcp.2024.25.10.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 10/13/2024] [Indexed: 11/01/2024] Open
Abstract
BACKGROUND Breast cancer is one of the leading causes of cancer-related mortality among women above 50 years of age. This systematic review and meta-analysis aimed at identifying the prevalence and trend of breast cancer screening among selected Asian countries. METHODS We searched three databases including, PubMed, Web of Science, and Scopus using our search terms. Two independent reviewers screened titles and abstracts applying the inclusion and exclusion criteria specified in the PROSPERO (registration ID: CRD42023401516) and any conflicts were resolved through discussion. Two independent reviewers and conflicts also completed the full-text screening, which was solved. Relevant information was extracted in an Excel sheet and random effects meta-analysis was performed to identify the pooled estimate of breast cancer screening in Asia using Stata 17. RESULTS We identified 41 studies from 14 selected Asian countries reporting breast cancer screening rates from 2012-2023. The pooled estimate of four countries (China, Iran, Japan, and Korea) with more than three data points on clinical breast examination and mammographic screening showed a screening rate of 24% (95% CI: 0.20 - 0.27) and 18% (95% CI: (0.14 - 0.21) in the last ten years respectively. CONCLUSION Most Asian countries do not have sufficient data on breast cancer screening due to a lack of nationally representative surveys or national-level cancer registries. Therefore, it is crucial to strengthen cancer control policies including breast cancer screening programs.
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Affiliation(s)
- Aliza K C Bhandari
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan.
- St. Luke’s International University, Graduate School of Public Health, Tokyo, Japan.
| | - Zin Wai Htay
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rokshana Parvin
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan.
| | - Mutsumi Murakami
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan.
- Department of Cancer Epidemiology, Division of Social Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Sarah Krull Abe
- Division of Prevention, National Cancer Center Institute for Cancer Control, Tokyo, Japan.
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Kim SH, Park HE. Investigating Factors Influencing the National Cancer Screening Program among Older Individuals in Republic of Korea-Data from the Korea National Health and Nutrition Examination Survey VIII. Healthcare (Basel) 2024; 12:1237. [PMID: 38921351 PMCID: PMC11203246 DOI: 10.3390/healthcare12121237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/27/2024] Open
Abstract
This study aims to determine the influencing factors of the participation of older individuals aged 65 years and above in South Korea's National Cancer Screening Program (NCSP) using data from the eighth wave (2019-2021) of the Korea National Health and Nutrition Examination Survey (KNHANES VIII), and discuss potential problems and coping strategies. Variables were selected based on Andersen's healthcare utilization model. "Participation in the NSCP" was considered the dependent variable, with independent variables including sociodemographic characteristics (sex, marital status, residence, education level, income level, economic activity, medical coverage type, and private insurance), health conditions (subjective health status, hypertension, and diabetes), and health behaviors (physical activity, monthly alcohol consumption, and current smoking status). The analysis revealed that higher participation rates correlated with being married, having an education level beyond elementary school, being employed, subscribing to private insurance, perceiving oneself as having average or poor health, engaging in physical activity, and not smoking. Sex, residence, income, medical coverage type, hypertension, diabetes, and monthly alcohol consumption were found to be insignificantly correlated. These findings underscore the importance of tailored promotion and health education for older individuals to boost NCSP participation rates, which could ultimately elevate public health standards.
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Affiliation(s)
- Seok Hwan Kim
- Department of Health Information, Dongguk University Wise Campus, 123 Dongdae-ro, Gyeongju-si 38066, Gyeongsangbuk-do, Republic of Korea;
| | - Hyo Eun Park
- Department of Nursing, Suwon Women’s University, 72 Onjeong-ro, Gwonseon-gu, Suwon-si 16632, Gyeonggi-do, Republic of Korea
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Liu S, Zheng S, Qin M, Xie Y, Yang K, Liu X. Knowledge, attitude, and practice toward ultrasound screening for breast cancer among women. Front Public Health 2024; 12:1309797. [PMID: 38855455 PMCID: PMC11160319 DOI: 10.3389/fpubh.2024.1309797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Background Several obstacles can hinder breast cancer screening. This study aimed to investigate the knowledge, attitude, and practice (KAP) toward ultrasound screening for breast cancer in women. Methods This cross-sectional study recruited women who visited the breast specialist clinic of Zhongshan City People's Hospital (a tertiary hospital) between August 2022 and April 2023 through convenience sampling. KAP scores ≥70% were considered adequate. Results This study enrolled 501 participants. The mean knowledge, attitude, and practice levels were 8.56 ± 1.81/12 (possible range 0-12, 71.33%), 29.80 ± 2.71 (possible range 8-40, 74.50%), and 32.04 ± 3.09 (possible range 8-40, 80.10%). Senior high school education (vs. junior high school and below, coefficient = 1.531, 95%CI: 1.013-2.312, p = 0.044), bachelor's education and above (vs. junior high school and below, coefficient = 5.315, 95%CI: 3.546-7.966, p < 0.001), housewife or unemployed (vs. employed, coefficient = 0.671, 95%CI: 0.466-0.966, p = 0.032), and a history of breast ultrasound (vs. no, coefficient = 1.466, 95%CI: 1.121-1.917, p = 0.005) were independently and positively associated with knowledge. Knowledge (coefficient = 1.303, 95%CI: 1.100-1.544, p = 0.002) and monthly income >10,000 (vs. <5,000, coefficient = 4.364, 95%CI: 1.738-10.956, p = 0.002) were independently and positively associated with attitude. Only attitude (coefficient = 1.212, 95%CI: 1.096-1.340, p < 0.001) was independently and positively associated with the practice. A structural equation modeling (SEM) analysis was used to estimate causality among KAP dimensions, showing that knowledge directly influenced attitude (β = -1.090, p = 0.015), knowledge did not directly influence practice (β = -0.117, p = 0.681) but had an indirect influence (β = 0.826, p = 0.028), and attitude directly influenced practice (β = -0.757, p = 0.016). Conclusion Women in Zhongshan City had good knowledge, favorable attitudes, and active practice toward breast ultrasound screening for breast cancer. Women's characteristics associated with a poorer KAP were identified, allowing for more targeted interventions.
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Affiliation(s)
- Shaozhong Liu
- Department of Ultrasound Imaging, Zhongshan City People’s Hospital, Zhongshan, China
| | - Shukai Zheng
- Department of Breast Surgery, Zhongshan City People’s Hospital, Zhongshan, China
| | - Mengzhen Qin
- Department of Ultrasound Imaging, Zhongshan City People’s Hospital, Zhongshan, China
| | - Yifeng Xie
- Department of Ultrasound Imaging, Zhongshan City People’s Hospital, Zhongshan, China
| | - Kun Yang
- Department of Ultrasound Imaging, Zhongshan City People’s Hospital, Zhongshan, China
| | - Xiaozhen Liu
- Department of Ultrasound Imaging, Zhongshan City People’s Hospital, Zhongshan, China
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Park KH, Loibl S, Sohn J, Park YH, Jiang Z, Tadjoedin H, Nag S, Saji S, Md Yusof M, Villegas EMB, Lim EH, Lu YS, Ithimakin S, Tseng LM, Dejthevaporn T, Chen TWW, Lee SC, Galvez C, Malwinder S, Kogawa T, Bajpai J, Brahma B, Wang S, Curigliano G, Yoshino T, Kim SB, Pentheroudakis G, Im SA, Andre F, Ahn JB, Harbeck N. Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer. ESMO Open 2024; 9:102974. [PMID: 38796284 PMCID: PMC11145753 DOI: 10.1016/j.esmoop.2024.102974] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 05/28/2024] Open
Abstract
The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer were updated and published online in 2023, and adapted, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with early breast cancer. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with breast cancer representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), co-ordinated by ESMO and KSMO. The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with early breast cancer across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling, as well as the age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.
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Affiliation(s)
- K H Park
- Division of Medical Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.
| | - S Loibl
- German Breast Group, Neu-Isenburg, Goethe University Centre for Haematology and Oncology, Bethanien, Frankfurt, Germany
| | - J Sohn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul
| | - Y H Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Z Jiang
- Department of Oncology, The Fifth Medical Center of PLA General Hospital, Bejing, China
| | - H Tadjoedin
- Department of Internal Medicine, Division of Hematology-Medical Oncology, Dharmais Hospital, National Cancer Center, Jakarta, Indonesia
| | - S Nag
- Department of Medical Oncology, Sahyadri Speciality Hospitals, Pune, Maharashtra, India
| | - S Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - M Md Yusof
- Cancer Centre at PHKL, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - E M B Villegas
- Cebu Cancer Institute, Perpertual Succour Hospital, Cebu Doctors' University Hospital, Cho-ing Hua Hospital, Cebu City, Philippines
| | - E H Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Y-S Lu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - S Ithimakin
- Division of Medical Oncology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - L-M Tseng
- Department of Surgery, Taipei-Veterans General Hospital, and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - T Dejthevaporn
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T W-W Chen
- Department of Oncology, National Taiwan University Hospital and Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S C Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore (NCIS), Singapore, Singapore
| | - C Galvez
- St. Luke's Medical Center Global City, Taguig City, Philippines
| | - S Malwinder
- Cancer Centre at PHKL, Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - T Kogawa
- Advanced Medical Development, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - J Bajpai
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - B Brahma
- Department of Surgical Oncology, Dharmais Hospital, National Cancer Center, Jakarta, Indonesia
| | - S Wang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - G Curigliano
- Istituto Europeo di Oncologia, IRCCS, Milan, Italy; Department of Oncology and Haematology, University of Milano, Milan, Italy
| | - T Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - S-B Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - S-A Im
- Department of Internal Medicine, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - F Andre
- Breast Cancer Unit, Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - J B Ahn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul
| | - N Harbeck
- Breast Center, Department of Obstetrics and Gynaecology and Comprehensive Cancer Center Munich, LMU University Hospital, Munich, Germany
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Jeong S, Choi YJ. Association between Socioecological Status, Nutrient Intake, and Cancer Screening Behaviors in Adults Aged 40 and Over: Insights from the Eighth Korea National Health and Nutrition Examination Survey (KNHANES, 2019). Nutrients 2024; 16:1048. [PMID: 38613081 PMCID: PMC11013844 DOI: 10.3390/nu16071048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Cancer screening is pivotal for early detection and improved survival rates. While socio-ecological factors are known to influence screening uptake, the role of lifestyle, dietary habits, and general health in shaping these decisions remains underexplored. Utilizing the 2019 Korea National Health and Nutrition Examination Survey (KNHANES), this study examined the myriad of factors impacting cancer screening utilization. Data from 274,872 adults aged 40 years or older were scrutinized, highlighting demographics, income, lifestyle behaviors, health-related variables, nutrient intake, and dietary quality. A combination of descriptive statistics and logistic regression helped us ascertain influential determinants. Higher educational attainment and income quartiles were positively correlated with cancer screening rates. Regular walkers, those engaged in moderate physical activity, and individuals with a previous cancer diagnosis were more likely to get screened. High-risk drinkers and smokers were less inclined towards screening. Dietary habits also influenced screening decisions. Notably, participants with healthier eating behaviors, indicated by factors such as regular breakfasts and fewer meals out, were more likely to undergo screening. Additionally, nutrient intake analysis revealed that those who had undergone screening consumed greater quantities of most nutrients, bar a few exceptions. For individuals aged 50-64, nutritional assessment indicators highlighted a higher mean adequacy ratio (MAR) and index of nutritional quality (INQ) value among those who participated in screening, suggesting better nutritional quality. This study elucidates the complex socio-ecological and nutritional landscape influencing cancer screening decisions. The results underscore the importance of a holistic approach, emphasizing lifestyle, dietary habits, and socio-economic considerations. It provides a roadmap for policymakers to craft more inclusive screening programs, ensuring equal access and promoting early detection.
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Affiliation(s)
- Seungpil Jeong
- Department of Medical Informatics, College of Medicine, Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Yean-Jung Choi
- Department of Food and Nutrition, Sahmyook University, Seoul 01795, Republic of Korea
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Joulaei H, Delshad MH, Pourhaji F. The Correlation of Social Support and Fear of Breast Cancer among Women in Northeast of Iran: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2023; 11:210-221. [PMID: 37489226 PMCID: PMC10363265 DOI: 10.30476/ijcbnm.2023.98094.2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
Background Breast cancer (BC) is the most commonly diagnosed cancer worldwide. Screening programs are the most common prevention methods. Perceived social support and fear are two important factors affecting women's participation in breast cancer screening. This study aimed to determine the relationship between fear of BC and perceived social support among women in Torbat Heydarieh, northeast of Iran. Methods This study is an online cross-sectional survey that was conducted on 352 women in Torbat Heydarieh city of Northeast Iran, from October 26th, 2021 to December 26th, 2022. Along with collecting sociodemographic characteristics, the Breast Cancer Fear Scale (BCFS), and the Multidimensional Scale of Perceived Social Support were electronically administered to participants. Data were analyzed through SPSS software version 25, using independent samples t-tests, one-way analysis, Pearson's correlation coefficient, and multiple linear regression models. The statistical significance level was set at P<0.05. Results The mean score for the BCFS was 20.67±1.03 which was in the moderate range for the total score of 40. Assessment of perceived social support indicated a moderate level of perceived support for all dimensions. Also, a significant correlation was found between the women's BCFS scores and perceived social support (r=-0.29, P<0.001). Conclusion We found that there was a negative statistically significant correlation between the BCF and social support. Therefore, this study suggests that healthcare providers pay attention to these factors. Moreover, further research is needed to explore the long-term effects of BCF due to low social support.
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Affiliation(s)
- Hassan Joulaei
- Health Policy Research Center, Institute for Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Delshad
- Health Policy Research Center, Institute for Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Public Health, School of Health, Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Fatemeh Pourhaji
- Health Policy Research Center, Institute for Health, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Public Health, School of Health, Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
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