Introduction

Cancer is a generic term for a large group of diseases that can affect any part of the body. Currently, cancer is one of the major reasons of morbidity and mortality. Annually more than 10 million new cases of cancer and more than 6 million deaths due to cancer occur around the globe (3).

By 2020, world population is estimated to be 7.5 billion, 15 million of whom would suffer from cancer and 12 million of them would die of cancer (4-5). Despite the new treatment methods, cancer mortality rate is appraised to remain high (over 11 million) in 2030 (6). The most cases of death occur in the economically developing countries. At present, the third cause of mortality in Iran is cancer, and each year 30,000 people die of cancer in Iran (7).

Although the cause of all cancers is multiple mutations, most mutations are the result of interaction with the environment; therefore, more than half of cancers are preventable (5). Taking timely measures can prevent cancer incidence and mortality in numerous cases. Management and prevention of cancer have been reported as primary or secondary prevention. The chief goal of primary prevention is promoting awareness regarding carcinogenic agents, while in secondary prevention the objective is essentially set as cancer screening (8).

In the medical world today, cancer screening is important for reducing mortality and morbidity due to cancer. These methods are easy, cost-effective, and available and can result in reduction of cancer statistics and diminish the severity of cancer at diagnosis (2, 4).

Based on the GLOBOCAN 2012 estimates, breast, cervical, and colorectal cancers (CRC) are the most frequently diagnosed types of cancer and the most important causes of death due to cancer among female population (9). In developing countries, the maximum incidence rates of breast cancer occur within the 45-54 age group, while in developed countries, the highest incidence rates are observed in older ages (10).

Breast cancer is the most common type of cancer among Iranian women (9). An epidemiological review on breast cancer in Iran revealed that this type of cancer is most frequently observed in the 40-49 age group. Age of breast cancer in Iran is 10 years lower than in other nations. The incidence and prevalence rates of breast cancer in women were 22 and 120 per 100,000 cases, respectively, and 57% of the cases were diagnosed while in stage II (11).

According to the GLOBOCAN 2012, CRC is estimated to be a major cause of mortality due to cancer and the third most common type of cancer worldwide (9). Considering the latest evidence, screening tests can reduce mortality from CRC, and guidelines from several major professional groups propose that anyone aged over 50 should receive regular screening for colorectal polyps and cancer. Although the current guidelines do not unanimously agree on the type and frequency of cancer screening for high-risk population, all emphasize on adherence to a regular screening program that includes annual fecal occult blood test (FOBT) (12-14). FOBT is a cheap and simple test recommended in national guidelines for CRC screening (15). Experts have estimated that with widespread adoption of screening practices, as many as 30,000 lives can be saved each year (14).

Cancer survival rate is lower in developing countries, which is most likely due to diagnosis in the late stages and limited access to timely and standard treatments. A significant portion of the worldwide burden of cancer might be reduced through the use of existing knowledge on cancer management and implementation of cancer screening programs (16).

Although cervical cancer is the 12^th most common type of cancer among Iranian female population, it has high mortality rates due to advanced stage diagnosis; this disease accounts for almost 2% of female cancer deaths (9).

Based on studies performed in Iran and Asia, a large number of women never receive screening for cancer (e.g., breast, cervix, or colorectal) or do not adhere to regular screening due to various reasons (17-20). Regular screening for these types of cancer might remarkably diminish mortality rates. Several studies have separately examined cancer screening for all types of cancer among Iranian women (18, 20-22). Given the high risk of breast, cervix, and colorectal cancers with advancing age, in this study, we aimed to evaluate cancer screening behavior among middle-aged women in Yazd, Iran. Moreover, we compared the characteristics of women performing regular screening with those who never received any screening test and identified the main obstacles and motivators of cancer screening practice.

 Materials and Methods

Using a sequential mixed method approach, this cross-sectional study was performed during spring 2010 on middle-age women in Yazd, Iran. To select the participants, cluster random sampling method was applied. In the beginning, 500 middle-age women were selected from 10 chosen areas of Yazd (50 participants from each area). In general, 15 of the subjects rejected to participate and two questionnaires were not filled-out completely. Ultimately, 483 women were recruited in the study.

Questionnaires were distributed and the interviews were conducted by the researcher. Due to low level education of participants, the questionnaires were completed via personal interviews. The inclusion criteria comprised of being aged 40-60 years, voluntary participation, and no previous history of breast, cervical, or colorectal cancer.

In the current study, data were collected using a self-designed questionnaire, which was validated by a panel of experts. The reliability of the questionnaire was confirmed using Cron-bach's alpha (α=0.85). The questionnaire includes predisposing factors such as age, educational level, marital status, occupation, number of children, weight, height, perceived health status-related factors including health insurance status, perceived adequacy of income, and history of cancer screening. Perceived health status and perceived adequacy of income were evaluated based on self report (1= weak, 2= intermediate, and 3= good or enough).

History of cancer screening for breast cancer (i.e., monthly breast self examination [BSE], annual clinical breast exam [CBE], and annual mammogram), cervical cancer (Pap test, first annually for three years and then every three years), and colorectal cancer (annual fecal occult blood tests [FOBT]) was based on self report; the questionnaire was rated using regular=3, irregular=2, and never=1. Body mass index (BMI) was calculated, as well.

To identify the screening behavior deter-minants, the qualitative part was performed. Semi-structured interviews were conducted with 21 women chosen through purposeful sampling. Suitable candidates were selected and contacted via telephone calls, and the aim of the study was explained and time and place were arranged with them.

The scientific research committee of Yazd University of Medical Sciences approved the study (1184). The ethical procedures of the study assured confidentiality of the data. All the participants were informed of the purposes of the study, and informed consent was obtained from them. Immersion in research, member check, and the peer reviewing were used to rigor of data analysis.

 For data analysis, descriptive statistics including frequency, percentile, and mean were used. Spearman product-moment correlation test, Chi-squared, and One-way ANOVA tests were performed to evaluated associations between demographic factors and cancer screening prac-tice, using SPSS version 10. P-value less than 0.05 was considered statistically significant. Qualitative data was analyzed manually by content analysis.

 Results

The demographic characteristics of the participants (n=483) are presented in Table 1. The mean age of the subjects was 48.51±6 years (age

*(Mean±SD, range)

range: 40-60 years), most of whom (93%) were married, and about one-third of them had less than high school education; 25% of the subjects had high school diploma or an academic degree. In general, only 27% of the subjects expressed adequate income and 8.3% were working full-time. The majority of the participants (93.6%) reported having health insurance.

Regarding cancer screening history, the majority of the samples (64%, 67.3%, and 87.7%) had never been screened for breast cancer by BSE, CBE, and mammogram, respectively. Only 4.3% of the participants received annual mammogram and 11% monthly BSE. Moreover, 8.3% of the participants performed regular Pap test and 64.2% of them did not have history of Pap test. FOBT was performed in 1% of women and 89.8% of them did not have history of this test and had never heard about it (Figure 1).

The data were analyzed to identify any significant associations between cancer screening behavior and correlating factors. Pearson product-moment correlation test reflected a positive significant correlation between cancer screening and educational level (P<0.001) and a negative significant correlation between the number of children and FOBT (P<0.006; Table 2).

Chi-squared test demonstrated a significant relationship between cancer screening practice (except for FOBT) and perceived adequacy of income (P<0.05). According to ANOVA, there was a significant link between cancer screening practice and occupation and educational level, as screening practice was more commonly observed among retired women than those who were housewives or employees. Table 2 exhibits the study findings.

In the qualitative part of the study, the data were obtained from semi-structured interviews with 21 participants, who had never received screening cancer procedures on a regular basis. Sampling was tried to have maximum diversity. Six participants in this study were in menopausal and 15 were in postmenopausal periods. In terms of educational level, 10 participants had primary, eight high school or diploma, and three academic education. In addition, 16 participants were housewives, four employees, and one retired.

Directed content analysis was carried out, and codes were extracted after analyzing each interview. After summarizing and comparing the data, these codes were classified considering their similarity. The codes were sited under subcategories of the main theme of obstacles and motivators for cancer screening.

 Seven main obstacles and two major motivators for cancer screening were found among the middle-aged women. The obstacles were lack of knowledge, cost of screening examination, lack of financial independence, negligence of spouse, fear of cancer, embarrassment, and belief in destiny. The major motivators of cancer screening were knowledge and observation of cancer among acquaintances and relatives.