Assessment of knowledge attitude and practice regarding breast cancer among women attending a tertiary hospital in Kabul Afghanistan 2023

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Early diagnosis helps early detection and helps long survival and also reduces the mortality rate. The aim of this study was to assess KAP and identify factors associated with them among women attending a tertiary hospital in Kabul, Afghanistan. Materials and Methods This cross-sectional study was conducted (2023) in Cure tertiary hospital, surveying 268 females aged 15–49 years. Data was a structured questionnaire on sociodemographic characteristics, reproductive history, and KAP toward breast cancer. Participants were selected through non-random convenience sampling. Binary and multivariate logistic regression analyses were used to identify factors associated with KAP. Results Overall, knowledge about breast cancer was found to be limited, while attitudes were generally positive, and practices were inadequate. In the multivariable model, no sociodemographic or reproductive variables were independently associated with knowledge. However, age and educational status significantly predicted attitudes: literate women (AOR = 4.84, 95% CI: 2.62–8.92, p < 0.001) and women with a history of lactation (AOR = 2.58, 95% CI: 1.12–5.94, p = 0.02) were more likely to have positive attitudes. Regarding practice, education was the strongest determinant; literate women were more than twice as likely to show good practice (AOR = 2.32, 95% CI: 1.11–4.85, p = 0.02). Conclusion Educational status was a consistent predictor across domains; therefore, it highlights the effect of educational programs with specific emphasis on increasing breast cancer knowledge, attitude, and practice among women as a cost-effective way to confront the second cause of death, cancer, in Afghanistan. Clinical trail number: Not applicable Knowledge Attitude Practice Breast Cancer Afghan women Afghanistan Figures Figure 1 Introduction Breast cancer is a condition characterized by the uncontrolled growth of abnormal cells in the breast, which can lead to tumor formation. If not managed properly, these tumors can metastasize and potentially become life-threatening ( 1 ). It is the most common malignant tumor among women worldwide, with 2.26 million new cases diagnosed and nearly 686,000 deaths in 2020 ( 2 ), and it ranks as the second leading cause of cancer-related deaths ( 3 ). The rising number of breast cancer cases in South America, Africa, and the Asia-Pacific region underscores the urgent need for early detection to decrease mortality rates ( 4 ). About 60% of cancer-related deaths among women in Low- and Middle-Income Countries (LMICs) are due to breast cancer ( 5 ). While the projected incidence of female breast cancer in underdeveloped and developing Asian nations is lower than in Western countries, the mortality rate is significantly higher ( 4 ), largely due to late diagnoses and limited access to timely medical care. Following the global pattern, breast cancer is the second leading cause of the cancer-related deaths in Afghanistan, following stomach cancer ( 6 ). A recent Afghan study highlighted the growing burden of breast cancer and emphasized that most patients present with late-stage disease due to low awareness, cultural stigma, and inadequate screening infrastructure ( 7 ). The World Health Organization ( 8 ) has stated that, while population-based mammography screening is the best way to address this health issue, which may not be practical in lower-income countries ( 9 ). Evidence suggests that increased awareness of breast cancer symptoms and better access to healthcare services lead to earlier diagnosis and better treatment outcomes ( 10 – 12 ). In this context, breast self-examination is an important practice in lower-income settings ( 13 ). However, it is precisely in these environments that knowledge about BSE tends to be lacking ( 14 , 15 ). A study in Afghanistan found that only a small number of female students had adequate knowledge of or practiced BSE, even though they had heard of it before ( 16 ). Additionally, a systematic review of Afghan women’s awareness of breast cancer, which included nearly 3.085 individuals, highlighted low levels of awareness regarding BSE. This was accompanied by low screening rates and unmanaged risk factors ( 17 ). The Knowledge, Attitude, and Practice framework in understanding how awareness, beliefs, and behaviors influence health outcomes (Fig. 1). The dramatic increase in the breast cancer cases in Afghanistan raised concerns about its management and prevention. Issues surrounding breast cancer are made worse by a weak health system and low screening practices. The literature clearly shows a lack of awareness regarding breast cancer and BSE, even among educated women, highlighting the significant challenges. However, as evidence suggests, there is only one study ( 18 ) exploring the knowledge and practice of diagnosed women with breast cancer. Therefore, this study aims to explore factors affecting knowledge, attitude, and practice of breast cancer among women who are attendant in healthcare, and there is potential their knowledge, attitude, and practice may be different from the general population. Hence, this study aims to contribute further to the existing literature on breast cancer by examining the sociodemographic factors that predict knowledge, attitude, and practice levels among women. Materials and Methods Study design and setting: A cross-sectional Knowledge, Attitudes, and Practices study was conducted between March 2023 and September 2023 at Cure Hospital, Kabul, Afghanistan. This tertiary hospital serves a diverse patient characteristic from all regions of Afghanistan. It should be noted that a significant proportion of the patients attending this tertiary hospital are women, who often face unique healthcare challenges and barriers. Therefore, we examined women’s knowledge, attitude, and practice regarding breast cancer as a health issue. Study Participants and Sampling: The study population included female patients and their attendants visiting the hospital during the study period. The inclusion criteria were as follows:(і) female patients and their attendants aged 18 years and older; (іі) women with or without a personal history of breast cancer; (ііі) participants who could provide informed consent. Women who were unable to provide consent for any reason and women who were too unwell to participate were excluded from the study. We selected our participants through non-random convenience sampling, due to the nature of our study setting at Cure Hospital, where female patients and their attendants were approached for participation as they visited the hospital for care. Data collection tool and technique: Data were collected using a researcher-developed questionnaire, adapted from previous KAP studies on breast cancer ( 19 – 22 ). Women and their attendants who met the inclusion criteria were included in the study via convenient sampling. Six nurses and doctors working in the hospital were recruited as data collectors for this study. The data collectors received training firsthand on the structure, data collection, and error-checking strategies during data collection to minimize the potential sampling bias. The data collection form consisted of four sections: socio-demographic and reproductive information, a Knowledge section, an attitude section, and a practice section. Firstly, the objective of the study was explained to the participants. Afterward, written informed consent was obtained from the participants. Consequently, data collectors gathered data from the study participants based on the study questionnaire (Additional File 1). The questionnaire included demographic and reproductive characteristics such as age, marital status, educational level, pregnancy history, and lactation history. Moreover, it comprised 29 awareness items regarding signs, risk factors, prevention, and early diagnosis of breast cancer. It also included 16 attitude items related to breast self-examination and mammography, as well as 6 practice items regarding breast examination. Correct answers in the knowledge section were scored as 1 point, while unanswered or incorrectly answered items received a score of 0. Based on the total knowledge score (maximum: 29), participants were categorized into two groups: adequate (17.5–29, ≥ 60%) and inadequate (0-17.4, < 60%). A 3-point Likert scale was used to score the attitudes; participants were classified into positive (9.6–16, ≥ 60%) and negative (0-9.5, < 60%) attitude groups based on their scores (out of 16). In the practice section, correct answers were scored as 1 point, while unanswered and incorrect answers scored 0. Based on the practice score (maximum: 5), participants were divided into poor/low (0–2, < 60%) and good (3–5, ≥ 60%) practice groups. Ethical consideration Before data collection, we obtained permission from the administrative board of Cure Hospital in Kabul, Afghanistan. Although a formal ethical approval code was not issued, we tried to consider all procedures of ethical research standards. Data collectors informed all participants about the study’s purpose, objective, and voluntary nature. This study followed the ethical principles outlined in the Declaration of Helsinki. We obtained written informed consent from all participants before enrollment. Throughout the study, we maintained the confidentiality and anonymity of participants. No personal identity information was recorded. Participants were assured of their right to withdraw from the study at any time without any consequences to their medical care. Statistical analysis method: The collected data were analyzed using SPSS software (version 21). Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated to summarize participant characteristics and KAP levels. Pearson’s correlation coefficient assessed relationships between knowledge, attitude, and practice scores. Bivariate logistic regression analysis explored the predictive effects of contextual variables on participants’ knowledge, attitudes, and practices. A p-value of less than 0.05 was considered statistically significant. Results During the study period, 268 females referring to the hospital were enrolled with the mean age of 33.5 ± 9.26 years. The majority (84.7%, n = 227) of participants were married, and over half of the participants were illiterate or low-educated (53.7%, n = 144). Most of the participants had a history of pregnancy (81.7%, n = 219), and 60% of participants had a history of breastfeeding (Table 1 ). Table 1 Frequency distribution of study population regarding demographic and reproductive characteristics (N = 268). Variable Classification N (%) Age > 25 years 51 ( 19 ) 25–34 years 102 (37.9) 35–44 years 53 (19.7) ≤ 45 years 41 (15.2) Not reported 22 (8.2) Marital Status Single 41 ( 15.3) Married 227 (84.7) Educational Status Illiterate 144 (53.7) literate 124 (46.3) History of pregnancy Yes 219 (81.7) No 49 (18.3) History of Lactation Yes 163 (60.8) No 105 (39.2) The mean scores for knowledge, attitude, and practice regarding breast cancer among the participants were reported as 11.95 ± 4.42, 10.57 ± 2.57, and 0.92 ± 1.28, respectively. In total, 69.4%, 59%, and 71.6% of the participants had moderate knowledge, negative attitudes, and poor practice regarding breast cancer, respectively. (Table 2 ). Table 2 Frequency distribution of KAP levels Variable N (%) Knowledge (0–29) Adequate (≥ 60%) 28 (10.4 ) Inadequate (< 60%) 240 (89.6) Attitude ( 0–16) Negative (< 60%) 100 ( 37.3) Positive (≥ 60%) 168 (62.7) Practice ( 0–5) Poor (< 60%) 225 (84) Good (≥ 60%) 53 ( 16 ) We used binary logistic regression to examine factors associated with breast cancer knowledge, attitude, and practice among women regarding breast cancer. In Table 3 the results of the study is presented. The results of the study showed there is no statistically significant association between sociodemographic and reproductive variables with knowledge. In contrast, there was a statistically significant association between attitude and age, education, and history of lactation. A significant association was shown between good practice and educational status (more details in Table 3 ). Table 3 Bivariate logistic regression: factors associated with knowledge, Attitude, and practice Characteristics Knowledge Attitude Practice Crude odds ratio (95%CI) P-Value Crude odds ratio (95%CI) P-Value Crude odds ratio (95%CI) P-Value Age Less than 25 058 (0.14–2.33) 0.09 3.61 (1.56–8.34) 0.003 1.1 (0.35–3.44) 0.87 25–34 0.72 (0.20–2.49) 0.6 4.25 (1.92–9.43) 0.0001 1.3 (0.45–3.8) 0.62 35–44 2.05 (0.58–7.16) 0.26 2.56 (1.05–6.22) 0.037 1.21 (0.36–4.06) 0.75 ≥ 45 reference reference reference Marital status Single reference reference reference Married 0.81 (0.29–2.27) 0.69 0.42 (0.19–9.22) 0.31 1.13 (0.44–2.89) 0.78 Education Illiterate reference reference reference Literate 0.15 (0.22–1.18) 0.11 5.96 (3.36–10.56) 0.08 1.22 (0.54–2.75) 0.62 History of pregnancy Yes 1.24 (0.47–3.26) 0.65 1.87 (0.91–3.63) 0.08 1.22 (0.54–2.75) 0.62 No reference reference reference History of lactation Yes 0.71 (0.3–1.63) 0.42 3.46 (1.97–6.07) 0.0001 1.79 (0.93–3.45) 0.081 No reference reference reference In the multivariable model (Table 4 ), which adjusted for confounders, the factors that were independently associated with knowledge, attitude, and practice were age, educational status, history of pregnancy, and history of lactation. Knowledge In the multivariable logistic regression, adjustments were done to identify potential confounders, and none of the independent variables was significantly associated with knowledge. Attitude Age and literacy status emerged as important predictors of attitude in this adjusted model. Women aged 35–44 years had borderline higher odds of a positive attitude compared with those ≥ 45 years (AOR = 2.54, 95% CI: 0.97–6.63, p = 0.05), while those aged 25–34 years showed a non-significant trend (AOR = 2.27, 95% CI: 0.93–5.54, p = 0.06). Literate women were about five times more likely to report a positive attitude compared to illiterate women (AOR = 4.84, 95% CI: 2.62–8.92, p < 0.001). Women with a history of lactation also had significantly greater odds of a positive attitude than those without (AOR = 2.58, 95% CI: 1.12–5.94, p = 0.02). The results of the study did not show a significant association with attitude and history of pregnancy. Practice The analysis showed education remained a significant determinant of practice. Literate women were more than twice as likely to demonstrate good practice compared with illiterate women (AOR = 2.32, 95% CI: 1.11–4.85, p = 0.02). No significant associations were observed with age, marital status, history of pregnancy, or history of lactation. Table 4 Multivariate logistic regression: factors associated with knowledge, Attitude, and practice Characteristics Knowledge Attitude Practice Adjusted odds ratio (95%CI) P-Value Adjusted odds ratio (95%CI) P-Value Adjusted odds ratio (95%CI) P-Value Age Less than 25 0.48 (0.13–2.56) 0.48 2.16 (0.84–5.55) 0.1 0.75 (0.22–2.52) 0.64 25–34 0.87 (0.24–3.35) 0.89 2.27 (0.93–5.54) 0.06 0.79 (0.25–2.51) 0.69 35–44 2.26 (0.63-8) 0.20 2.54 (0.97–6.63) 0.05 1.11 (0.32–3.82) 0.86 ≥ 45 reference reference reference Education Illiterate reference reference reference Literate 0.55 (0.22–1.38) 0.2 4.84 (2.62–8.92) 0.0001 2.32 (1.11–4.85) 0.02 History of pregnancy Yes 2.38 (0.59–9.64) 0.22 0.69 (0.25–1.91) 0.48 0.79 (0.3–2.12) 0.65 No reference reference reference History of lactation Yes 0.79 (0.21–2.94) 0.72 2.58 (1.12–5.94) 0.02 1.69 (0.71–4.01) 0.23 No reference reference reference Discussion Breast cancer is a global threat for women, claiming the lives of hundreds of thousands of females annually, and Afghanistan is no exception to this phenomenon ( 14 ). In our study sample, the overall level of knowledge about breast cancer was low. Many women did not have enough awareness of symptoms and early detection methods. In contrast, most participants had a generally positive attitude toward breast cancer prevention and treatment, especially among younger and literate women. However, the use of preventive measures, such as breast self-examination, was low. This shows the gap between awareness and practice. Knowledge This study found that 89% of the participants had inadequate knowledge about breast cancer. This finding is consistent with a systematic review by Hewad Mal et.al ( 17 ), which showed that 40% of 3.085 Afghan women were aware of breast clinical screening methods or self-examination. Similarly, studies conducted among undergraduate students at Ethiopia, Addis Ababa University, and Malesia, where poor knowledge was reported at 52.9%, 50.1%, and 55%, respectively ( 23 – 25 ). Given these alarming statistics, it is crucial to explore the underlying factors contributing to such limited understanding of breast cancer in this study may stem from a lack of awareness, insufficient health literacy ( 26 ), and limited access to healthcare services. Also, obstacles to promote seeking health behaviors included deficiencies in infrastructure due to conflict, and gender norms that limit women’s involvement in healthcare decision-making ( 17 ). The results of the study indicate that age does not significantly affect knowledge about breast cancer (p > 0.05). This finding aligns with previous studies by Alanazi, and Zhu, which also reported no significant link between age and breast cancer awareness ( 27 , 28 ). Therefore, it is important to share information with people regardless of their ages. This is might because of societal norms in Afghanistan that cause-limited access to information. Traditional beliefs often influence health-seeking behaviors regardless of women’s age. Other sociodemographic or reproductive factors did not have a significant association with knowledge, which aligns with reports from similar low-resource settings, where knowledge levels are generally low and influenced by broader community awareness rather than individual characteristics. This suggests that knowledge gaps are widespread across different groups, underscoring the urgent need for mass education and awareness interventions. Attitude In our study, the overall attitude of participants regarding breast cancer was 62.8%, and it was more positive compared with their level of knowledge and practice. Additionally, two key factors were significantly associated with women’s attitudes towards breast cancer: education level, and a history of lactation. Age was found to have a significant inverse relationship with positive attitudes toward breast cancer awareness and screening. Some studies in Asia ( 29 ) and Pakistan ( 30 ) are consistent with that older participants were less likely to exhibit favorable attitudes, whereas younger women demonstrated more awareness and proactive attitudes toward breast health and early detection strategies ( 31 ). This may reflect differences in health education, media access, or cultural openness regarding discussions about women’s health issues. Educational level showed a strong connection to attitudes toward breast cancer. Women who were illiterate had significantly lower odds of having a positive attitude compared to those who were literate. This connection agrees with global evidence indicating that higher education improves awareness, risk perception, and motivation for early screening practices ( 32 ). In Afghanistan, a study has shown that illiterate women have lack of awareness regarding breast cancer and its primary signs and symptoms, leading to delayed in diagnosis ( 33 ). A study by Coughlin found that lack of education and health literacy may limit access to information or the ability to understand health messages ( 34 ). This underlines the need for targeted educational programs in low-literacy populations. It is also important to note that since Afghanistan’s political transition in 2021, women’s access to health facilities, educational institutions, and public awareness regarding breast cancer has been severely restricted. It can be a warning sign for the need to improve women’s health outcomes. Interestingly, a history of breastfeeding was also linked to attitudes. Women who had breastfed were much less likely to have a positive attitude toward breast cancer. This surprising finding contrasts with studies in the UK ( 35 ) and India ( 36 ), which discovered that breastfeeding mothers often showed better knowledge and attitudes, likely due to their regular contact with healthcare services. However, breastfeeding is culturally encouraged in Afghanistan; the lack of comprehensive postnatal care may result in insufficient education about the potential risks associated with breast cancer. If healthcare providers do not discuss breast health during routine visits, mothers may miss out on crucial information that could shape their attitudes toward breast cancer. The negative relationship observed in our setting could be attributed to cultural misconceptions, and low rates of counseling during postnatal care. In contrast, a history of pregnancy did not show a statistically significant link to attitudes. While the odds ratio suggested a negative trend, the wide confidence interval and p-value > 0.05 imply that this relationship might be due to chance or influenced by other unmeasured variables. Practice One of the important findings of this study is the overall poor level of practice (16%) among women in relation to breast cancer, despite relatively better levels of knowledge and attitude reported in the same population. This low level practice aligns with low practice rates in Ethiopia from 13% to 21% ( 37 – 39 ), Nepal 12% ( 40 ), Cameron 15% ( 39 ), and a recent study in Afghanistan 19% ( 41 ). This low level of BSE practice may be due to a lack of BSE knowledge, traditional cultural influences, and lower levels of education. This highlights an important public health concern, as inadequate practice directly undermines the potential benefits of awareness in the presentation of breast cancer. The level of education was significantly associated with better breast cancer-related practices. Women with no formal education or lower levels of schooling were substantially less likely to engage in preventive behaviors compared to those with higher education. For instance, literate women had 2.32 higher odds of good practice (p = 0.02). In contrast, illiterate women or those with only primary education had a noticeably lower likelihood. This finding agrees with a new study in Afghanistan ( 41 ) and other studies from Southwest Ethiopia ( 37 , 38 ), Northwest Ethiopia ( 42 ), and Nigeria ( 43 ). These studies showed that women with more education were more likely to perform breast self-examinations, so it is important to improve educational level to improve awareness, attitude and ultimately practice. In our study, age wasn’t a significant factor influencing practice. While Tilaki et al. showed in their study that older women are more motivated to perform breast cancer screening due to increased perceived risk ( 44 ). The lack of association in our findings suggests that maternal and reproductive health services in Afghanistan may not be adequate to send the preventive messages into routine counseling. Furthermore, lower access to antenatal and postnatal care among Afghan women and the absence of pregnant women’s health education programs on the severity of breast cancer may contribute to our findings. Overall, our findings emphasize that knowledge and attitude alone are insufficient to drive preventive practices. Low health literacy, lack of access to healthcare facilities, and cultural barriers may contribute to low preventive practices against breast cancer. With the recent regulations on the closure of schools and higher education institutions for women in Afghanistan, lower knowledge and practice of women towards breast cancer may be exacerbate, reducing the intervention points for improving these indicators, hence leading to a dramatic increase in the breast cancer incidence. Limitations The authors of this study acknowledge several limitations in this survey. Firstly, the study was conducted in a single center, and despite the attendance of the general population from Kabul at this hospital, the generalization of the findings should still be made with caution. Moreover, the current study lacked some variables in the socio-demographic and reproductive health sections, such as the economic status of the participants, number of parities, and breastfeeding approach (exclusive or mixed with powdered milk), which could help the authors in furthering the analysis and providing expanded insights into the predicting factors of knowledge, attitude, and practice. Finally, a mixed-method approach with a qualitative component would have improved the depth of results and provided new and underexplored areas of concern and consideration. Conclusion This study concludes that majority of the participants had inadequate knowledge of BSE, over half of the participants had positive attitude and only 16% of the participants had good practice. The study also include education was the most influential predictors of BC. The findings indicate that education is the most influential predictor of breast cancer attitude and practice. Despite current policies in Afghanistan restricting women’s access to education, the results highlight the need for educational programs on breast cancer. These programs should be aligned with health policy that prioritize women’s health education and promoting awareness and ultimately improving health outcomes in Afghanistan. Declarations Acknowledgment We would like to thank the director of the hospital where we conducted the research. We would like to extend our thanks to the efforts and mentorship of Areta Aramak Research Services, and Afghanistan Center for Translation Medicine and Public Health. We are grateful to all those who contributed to the data collection for this study (sahar Ghafoori, Yasamin Andkhoy Sadat, Nilofar Farooq, Qadria Bakhtiari, Arezo Azimi, Fahima Zia). We would also like to thanks to the participants of the study. Author’s contributions MOM, MSF, and ASM led the study, conducted the data collection, data quality, and wrote the first draft. ZE and SN contributed to the data analysis and writing the first draft, review and revision of the manuscript. SMSH and AK contributed to review of the manuscript. All authors read and approved the final manuscript. Ethics statement The study has received permission from Cure Hospital in accordance with the Declaration of Helsinki. The study has received the permission from educational directorate and committee members, which are responsible for the ethical issues as well. Consent to participate Consent forms were signed by all the participants before being included in the study. 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Niazi A-u-R, Jami AA, Shams AZ, Mahmoodi AS, Krapfl E, Falk S, et al. Establishing a breast cancer center in Herat, Afghanistan: an implementation study. Global Health J. 2021;5(4):204–8. Coughlin SS, Vernon M, Hatzigeorgiou C, George V. Health Literacy, Social Determinants of Health, and Disease Prevention and Control. J Environ health Sci. 2020;6(1). Stordal B. Breastfeeding reduces the risk of breast cancer: A call for action in high-income countries with low rates of breastfeeding. Cancer Med. 2023;12(4):4616–25. Babita, Kumar N, Singh M, Malik JS, Kalhan M. Breastfeeding reduces breast cancer risk: a case-control study in north India. Int J Prev Med. 2014;5(6):791–5. Hussen A, Kumbi M, Bedewi J, Lette A, Nuriye S. Breast self-examination practice and associated factors among women of reproductive age in southeast Ethiopia. Front Oncol. 2023;13:1176022. Urga Workineh M, Alem Lake E, Asmare Adella G. Breast Self-Examination Practice and Associated Factors Among Women Attending Family Planning Service in Modjo Public Health Facilities Southwest Ethiopia. Volume 13. Breast cancer (Dove Medical; 2021. pp. 459–69. Mihret MS, Gudayu TW, Abebe AS, Tarekegn EG, Abebe SK, Abduselam MA, et al. Knowledge and Practice on Breast Self-Examination and Associated Factors among Summer Class Social Science Undergraduate Female Students in the University of Gondar, Northwest Ethiopia. J cancer Epidemiol. 2021;2021:8162047. Gyawali P, Gautam SJIJoHS. Research. Breast self-examination practice and its associated factor among the women of reproductive age of Rapti Sonari rural municipality. Banke District. 2021;11(4):75–82. Ahmadi M, Nemat A, Sakhi R, Ahmadi A, Massoud M, Ebadi E, et al. Knowledge and practice of breast self-examination and associated factors among women with breast cancer in Kabul. Afghanistan. 2025;20(10):e0335460. Yazew BG, Alemu BW, Walle TAJFO. Factors associated with knowledge and practice of breast self-examination among female governmental school teachers in Gondar Town, Northwest Ethiopia, 2019. 2024;14:1481714. Oladimeji KE, Tsoka-Gwegweni JM, Igbodekwe FC, Twomey M, Akolo C, Balarabe HS, et al. Knowledge and Beliefs of Breast Self-Examination and Breast Cancer among Market Women in Ibadan, South West, Nigeria. PLoS ONE. 2015;10(11):e0140904. Hajian Tilaki K, Auladi S. Awareness, Attitude, and Practice of Breast Cancer Screening Women, and the Associated Socio-Demographic Characteristics, in Northern Iran. Iran J cancer Prev. 2015;8(4):e3429. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8892604","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623149119,"identity":"d655ebe4-9847-49d0-9486-1b8b62911f26","order_by":0,"name":"Mohammad Omer Malikzai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYLACxgYGBjb2HjCbh494LTxnGBgOALWwEa2FQSIHrIWBoBZ+scPHPn7dYZPPJ/n24OOPOXYybAzMDx/dwKNFcnZa8mzZM2mWbdJ5yQYHtyUDHcZmbJyDR4vB7RxjZsm2wwZs0jlmEge3MQO18ADZeLXkf4ZokTwD0lJPjJYcZsaPIC0SPCAthwlrAfrFmJmxLc2AjSfH2ODstuM8bMwE/MIvnfyY8WebjYF8+xnDB5Xbqu352ZsfPsanBQSYeVC5BJSDAOMPIhSNglEwCkbBCAYAFg5AvwR94nMAAAAASUVORK5CYII=","orcid":"","institution":"cure hospital","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Omer","lastName":"Malikzai","suffix":""},{"id":623149120,"identity":"2cebc35b-b794-46b4-8fe9-d817c07c3f2c","order_by":1,"name":"Mohammad Samim Fahmi","email":"","orcid":"","institution":"cure hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Samim","lastName":"Fahmi","suffix":""},{"id":623149121,"identity":"12981451-67e6-4556-b02f-6963917881c4","order_by":2,"name":"Aqil Shah Mohmand","email":"","orcid":"","institution":"cure hospital","correspondingAuthor":false,"prefix":"","firstName":"Aqil","middleName":"Shah","lastName":"Mohmand","suffix":""},{"id":623149123,"identity":"374c24ef-9efd-4087-b9ef-a2358b1c640f","order_by":3,"name":"Zainab ezadi","email":"","orcid":"","institution":"cure hospital","correspondingAuthor":false,"prefix":"","firstName":"Zainab","middleName":"","lastName":"ezadi","suffix":""},{"id":623149125,"identity":"80e4d8b7-aae6-475e-8f3d-6a9f5d4efe12","order_by":4,"name":"Sayed Murtaza Sadat Hofiani","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sayed","middleName":"Murtaza Sadat","lastName":"Hofiani","suffix":""},{"id":623149129,"identity":"8d286914-dea6-4f1a-8eec-72e645a2c8ba","order_by":5,"name":"Shoaib Naeemi","email":"","orcid":"","institution":"Eastern Mediterranean Public Health Network (EMPHNET)","correspondingAuthor":false,"prefix":"","firstName":"Shoaib","middleName":"","lastName":"Naeemi","suffix":""},{"id":623149132,"identity":"7c21ff89-c38a-4e00-86e8-b5d03a423d1e","order_by":6,"name":"Ahmad Komail Frogh","email":"","orcid":"","institution":"Action Against Hunger (AAH), Kabul, Afghanistan,","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"Komail","lastName":"Frogh","suffix":""}],"badges":[],"createdAt":"2026-02-16 11:10:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8892604/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8892604/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107243063,"identity":"835f2312-5e69-48d2-ac34-24330da1ab1a","added_by":"auto","created_at":"2026-04-19 07:48:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4493,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"fig.png","url":"https://assets-eu.researchsquare.com/files/rs-8892604/v1/e9cb0bf8304e1ef75be08af3.png"},{"id":107484616,"identity":"efb20ee6-288d-45b8-8210-8bf91ee908b1","added_by":"auto","created_at":"2026-04-22 02:32:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":481891,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8892604/v1/258dc9a7-7b41-49c5-99c3-71d8952a8d60.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of knowledge attitude and practice regarding breast cancer among women attending a tertiary hospital in Kabul Afghanistan 2023","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is a condition characterized by the uncontrolled growth of abnormal cells in the breast, which can lead to tumor formation. If not managed properly, these tumors can metastasize and potentially become life-threatening (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is the most common malignant tumor among women worldwide, with 2.26\u0026nbsp;million new cases diagnosed and nearly 686,000 deaths in 2020 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and it ranks as the second leading cause of cancer-related deaths (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The rising number of breast cancer cases in South America, Africa, and the Asia-Pacific region underscores the urgent need for early detection to decrease mortality rates (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). About 60% of cancer-related deaths among women in Low- and Middle-Income Countries (LMICs) are due to breast cancer (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While the projected incidence of female breast cancer in underdeveloped and developing Asian nations is lower than in Western countries, the mortality rate is significantly higher (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), largely due to late diagnoses and limited access to timely medical care.\u003c/p\u003e \u003cp\u003eFollowing the global pattern, breast cancer is the second leading cause of the cancer-related deaths in Afghanistan, following stomach cancer (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A recent Afghan study highlighted the growing burden of breast cancer and emphasized that most patients present with late-stage disease due to low awareness, cultural stigma, and inadequate screening infrastructure (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The World Health Organization (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) has stated that, while population-based mammography screening is the best way to address this health issue, which may not be practical in lower-income countries (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidence suggests that increased awareness of breast cancer symptoms and better access to healthcare services lead to earlier diagnosis and better treatment outcomes (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In this context, breast self-examination is an important practice in lower-income settings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, it is precisely in these environments that knowledge about BSE tends to be lacking (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A study in Afghanistan found that only a small number of female students had adequate knowledge of or practiced BSE, even though they had heard of it before (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Additionally, a systematic review of Afghan women\u0026rsquo;s awareness of breast cancer, which included nearly 3.085 individuals, highlighted low levels of awareness regarding BSE. This was accompanied by low screening rates and unmanaged risk factors (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The Knowledge, Attitude, and Practice framework in understanding how awareness, beliefs, and behaviors influence health outcomes (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eThe dramatic increase in the breast cancer cases in Afghanistan raised concerns about its management and prevention. Issues surrounding breast cancer are made worse by a weak health system and low screening practices. The literature clearly shows a lack of awareness regarding breast cancer and BSE, even among educated women, highlighting the significant challenges. However, as evidence suggests, there is only one study (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) exploring the knowledge and practice of diagnosed women with breast cancer. Therefore, this study aims to explore factors affecting knowledge, attitude, and practice of breast cancer among women who are attendant in healthcare, and there is potential their knowledge, attitude, and practice may be different from the general population.\u003c/p\u003e \u003cp\u003eHence, this study aims to contribute further to the existing literature on breast cancer by examining the sociodemographic factors that predict knowledge, attitude, and practice levels among women.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eA cross-sectional Knowledge, Attitudes, and Practices study was conducted between March 2023 and September 2023 at Cure Hospital, Kabul, Afghanistan. This tertiary hospital serves a diverse patient characteristic from all regions of Afghanistan. It should be noted that a significant proportion of the patients attending this tertiary hospital are women, who often face unique healthcare challenges and barriers. Therefore, we examined women\u0026rsquo;s knowledge, attitude, and practice regarding breast cancer as a health issue.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Participants and Sampling:\u003c/h3\u003e\n\u003cp\u003eThe study population included female patients and their attendants visiting the hospital during the study period. The inclusion criteria were as follows:(і) female patients and their attendants aged 18 years and older; (іі) women with or without a personal history of breast cancer; (ііі) participants who could provide informed consent. Women who were unable to provide consent for any reason and women who were too unwell to participate were excluded from the study. We selected our participants through non-random convenience sampling, due to the nature of our study setting at Cure Hospital, where female patients and their attendants were approached for participation as they visited the hospital for care.\u003c/p\u003e\n\u003ch3\u003eData collection tool and technique:\u003c/h3\u003e\n\u003cp\u003eData were collected using a researcher-developed questionnaire, adapted from previous KAP studies on breast cancer (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Women and their attendants who met the inclusion criteria were included in the study via convenient sampling. Six nurses and doctors working in the hospital were recruited as data collectors for this study. The data collectors received training firsthand on the structure, data collection, and error-checking strategies during data collection to minimize the potential sampling bias. The data collection form consisted of four sections: socio-demographic and reproductive information, a Knowledge section, an attitude section, and a practice section. Firstly, the objective of the study was explained to the participants. Afterward, written informed consent was obtained from the participants. Consequently, data collectors gathered data from the study participants based on the study questionnaire (Additional File 1).\u003c/p\u003e \u003cp\u003eThe questionnaire included demographic and reproductive characteristics such as age, marital status, educational level, pregnancy history, and lactation history. Moreover, it comprised 29 awareness items regarding signs, risk factors, prevention, and early diagnosis of breast cancer. It also included 16 attitude items related to breast self-examination and mammography, as well as 6 practice items regarding breast examination.\u003c/p\u003e \u003cp\u003eCorrect answers in the knowledge section were scored as 1 point, while unanswered or incorrectly answered items received a score of 0. Based on the total knowledge score (maximum: 29), participants were categorized into two groups: adequate (17.5\u0026ndash;29, \u0026ge;\u0026thinsp;60%) and inadequate (0-17.4, \u0026lt;\u0026thinsp;60%). A 3-point Likert scale was used to score the attitudes; participants were classified into positive (9.6\u0026ndash;16, \u0026ge;\u0026thinsp;60%) and negative (0-9.5, \u0026lt;\u0026thinsp;60%) attitude groups based on their scores (out of 16). In the practice section, correct answers were scored as 1 point, while unanswered and incorrect answers scored 0. Based on the practice score (maximum: 5), participants were divided into poor/low (0\u0026ndash;2, \u0026lt;\u0026thinsp;60%) and good (3\u0026ndash;5, \u0026ge;\u0026thinsp;60%) practice groups.\u003c/p\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003eBefore data collection, we obtained permission from the administrative board of Cure Hospital in Kabul, Afghanistan. Although a formal ethical approval code was not issued, we tried to consider all procedures of ethical research standards. Data collectors informed all participants about the study\u0026rsquo;s purpose, objective, and voluntary nature.\u003c/p\u003e \u003cp\u003e This study followed the ethical principles outlined in the Declaration of Helsinki. We obtained written informed consent from all participants before enrollment. Throughout the study, we maintained the confidentiality and anonymity of participants. No personal identity information was recorded. Participants were assured of their right to withdraw from the study at any time without any consequences to their medical care.\u003c/p\u003e\n\u003ch3\u003eStatistical analysis method:\u003c/h3\u003e\n\u003cp\u003eThe collected data were analyzed using SPSS software (version 21). Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated to summarize participant characteristics and KAP levels. Pearson\u0026rsquo;s correlation coefficient assessed relationships between knowledge, attitude, and practice scores. Bivariate logistic regression analysis explored the predictive effects of contextual variables on participants\u0026rsquo; knowledge, attitudes, and practices. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, 268 females referring to the hospital were enrolled with the mean age of 33.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.26 years. The majority (84.7%, n\u0026thinsp;=\u0026thinsp;227) of participants were married, and over half of the participants were illiterate or low-educated (53.7%, n\u0026thinsp;=\u0026thinsp;144). Most of the participants had a history of pregnancy (81.7%, n\u0026thinsp;=\u0026thinsp;219), and 60% of participants had a history of breastfeeding (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency distribution of study population regarding demographic and reproductive characteristics (N\u0026thinsp;=\u0026thinsp;268).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (37.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;45 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 ( 15.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e227 (84.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEducational Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144 (53.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124 (46.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e219 (81.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistory of Lactation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (60.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (39.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean scores for knowledge, attitude, and practice regarding breast cancer among the participants were reported as 11.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42, 10.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57, and 0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28, respectively.\u003c/p\u003e \u003cp\u003eIn total, 69.4%, 59%, and 71.6% of the participants had moderate knowledge, negative attitudes, and poor practice regarding breast cancer, respectively.\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency distribution of KAP levels\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKnowledge (0\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate (\u0026ge;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (10.4 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInadequate (\u0026lt;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240 (89.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAttitude ( 0\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative (\u0026lt;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 ( 37.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive (\u0026ge;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168 (62.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePractice ( 0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor (\u0026lt;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e225 (84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood (\u0026ge;\u0026thinsp;60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe used binary logistic regression to examine factors associated with breast cancer knowledge, attitude, and practice among women regarding breast cancer. In Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e the results of the study is presented.\u003c/p\u003e \u003cp\u003eThe results of the study showed there is no statistically significant association between sociodemographic and reproductive variables with knowledge.\u003c/p\u003e \u003cp\u003eIn contrast, there was a statistically significant association between attitude and age, education, and history of lactation.\u003c/p\u003e \u003cp\u003eA significant association was shown between good practice and educational status (more details in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate logistic regression: factors associated with knowledge, Attitude, and practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrude odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCrude odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e058 (0.14\u0026ndash;2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.61 (1.56\u0026ndash;8.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1 (0.35\u0026ndash;3.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.20\u0026ndash;2.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.25 (1.92\u0026ndash;9.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3 (0.45\u0026ndash;3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.05 (0.58\u0026ndash;7.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.56 (1.05\u0026ndash;6.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.21 (0.36\u0026ndash;4.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81 (0.29\u0026ndash;2.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42 (0.19\u0026ndash;9.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13 (0.44\u0026ndash;2.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15 (0.22\u0026ndash;1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.96 (3.36\u0026ndash;10.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.22 (0.54\u0026ndash;2.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eHistory of pregnancy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.24 (0.47\u0026ndash;3.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.87 (0.91\u0026ndash;3.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.22 (0.54\u0026ndash;2.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eHistory of lactation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.71 (0.3\u0026ndash;1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.46 (1.97\u0026ndash;6.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.79 (0.93\u0026ndash;3.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the multivariable model (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), which adjusted for confounders, the factors that were independently associated with knowledge, attitude, and practice were age, educational status, history of pregnancy, and history of lactation.\u003c/p\u003e\n\u003ch3\u003eKnowledge\u003c/h3\u003e\n\u003cp\u003eIn the multivariable logistic regression, adjustments were done to identify potential confounders, and none of the independent variables was significantly associated with knowledge.\u003c/p\u003e\n\u003ch3\u003eAttitude\u003c/h3\u003e\n\u003cp\u003eAge and literacy status emerged as important predictors of attitude in this adjusted model. Women aged 35\u0026ndash;44 years had borderline higher odds of a positive attitude compared with those\u0026thinsp;\u0026ge;\u0026thinsp;45 years (AOR\u0026thinsp;=\u0026thinsp;2.54, 95% CI: 0.97\u0026ndash;6.63, p\u0026thinsp;=\u0026thinsp;0.05), while those aged 25\u0026ndash;34 years showed a non-significant trend (AOR\u0026thinsp;=\u0026thinsp;2.27, 95% CI: 0.93\u0026ndash;5.54, p\u0026thinsp;=\u0026thinsp;0.06). Literate women were about five times more likely to report a positive attitude compared to illiterate women (AOR\u0026thinsp;=\u0026thinsp;4.84, 95% CI: 2.62\u0026ndash;8.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Women with a history of lactation also had significantly greater odds of a positive attitude than those without (AOR\u0026thinsp;=\u0026thinsp;2.58, 95% CI: 1.12\u0026ndash;5.94, p\u0026thinsp;=\u0026thinsp;0.02). The results of the study did not show a significant association with attitude and history of pregnancy.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePractice\u003c/h2\u003e \u003cp\u003eThe analysis showed education remained a significant determinant of practice. Literate women were more than twice as likely to demonstrate good practice compared with illiterate women (AOR\u0026thinsp;=\u0026thinsp;2.32, 95% CI: 1.11\u0026ndash;4.85, p\u0026thinsp;=\u0026thinsp;0.02). No significant associations were observed with age, marital status, history of pregnancy, or history of lactation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression: factors associated with knowledge, Attitude, and practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAttitude\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ePractice\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.48 (0.13\u0026ndash;2.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.16 (0.84\u0026ndash;5.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.75 (0.22\u0026ndash;2.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87 (0.24\u0026ndash;3.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.27 (0.93\u0026ndash;5.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.79 (0.25\u0026ndash;2.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.26 (0.63-8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.54 (0.97\u0026ndash;6.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.11 (0.32\u0026ndash;3.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.55 (0.22\u0026ndash;1.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.84 (2.62\u0026ndash;8.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.32 (1.11\u0026ndash;4.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eHistory of pregnancy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.38 (0.59\u0026ndash;9.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69 (0.25\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.79 (0.3\u0026ndash;2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eHistory of lactation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79 (0.21\u0026ndash;2.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.58 (1.12\u0026ndash;5.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.69 (0.71\u0026ndash;4.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBreast cancer is a global threat for women, claiming the lives of hundreds of thousands of females annually, and Afghanistan is no exception to this phenomenon (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In our study sample, the overall level of knowledge about breast cancer was low. Many women did not have enough awareness of symptoms and early detection methods. In contrast, most participants had a generally positive attitude toward breast cancer prevention and treatment, especially among younger and literate women. However, the use of preventive measures, such as breast self-examination, was low. This shows the gap between awareness and practice.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge\u003c/h2\u003e \u003cp\u003eThis study found that 89% of the participants had inadequate knowledge about breast cancer. This finding is consistent with a systematic review by Hewad Mal et.al (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), which showed that 40% of 3.085 Afghan women were aware of breast clinical screening methods or self-examination. Similarly, studies conducted among undergraduate students at Ethiopia, Addis Ababa University, and Malesia, where poor knowledge was reported at 52.9%, 50.1%, and 55%, respectively (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Given these alarming statistics, it is crucial to explore the underlying factors contributing to such limited understanding of breast cancer in this study may stem from a lack of awareness, insufficient health literacy (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and limited access to healthcare services. Also, obstacles to promote seeking health behaviors included deficiencies in infrastructure due to conflict, and gender norms that limit women\u0026rsquo;s involvement in healthcare decision-making (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of the study indicate that age does not significantly affect knowledge about breast cancer (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This finding aligns with previous studies by Alanazi, and Zhu, which also reported no significant link between age and breast cancer awareness (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Therefore, it is important to share information with people regardless of their ages. This is might because of societal norms in Afghanistan that cause-limited access to information. Traditional beliefs often influence health-seeking behaviors regardless of women\u0026rsquo;s age.\u003c/p\u003e \u003cp\u003eOther sociodemographic or reproductive factors did not have a significant association with knowledge, which aligns with reports from similar low-resource settings, where knowledge levels are generally low and influenced by broader community awareness rather than individual characteristics. This suggests that knowledge gaps are widespread across different groups, underscoring the urgent need for mass education and awareness interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAttitude\u003c/h2\u003e \u003cp\u003eIn our study, the overall attitude of participants regarding breast cancer was 62.8%, and it was more positive compared with their level of knowledge and practice.\u003c/p\u003e \u003cp\u003eAdditionally, two key factors were significantly associated with women\u0026rsquo;s attitudes towards breast cancer: education level, and a history of lactation.\u003c/p\u003e \u003cp\u003eAge was found to have a significant inverse relationship with positive attitudes toward breast cancer awareness and screening. Some studies in Asia (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and Pakistan (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) are consistent with that older participants were less likely to exhibit favorable attitudes, whereas younger women demonstrated more awareness and proactive attitudes toward breast health and early detection strategies (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This may reflect differences in health education, media access, or cultural openness regarding discussions about women\u0026rsquo;s health issues.\u003c/p\u003e \u003cp\u003eEducational level showed a strong connection to attitudes toward breast cancer. Women who were illiterate had significantly lower odds of having a positive attitude compared to those who were literate. This connection agrees with global evidence indicating that higher education improves awareness, risk perception, and motivation for early screening practices (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In Afghanistan, a study has shown that illiterate women have lack of awareness regarding breast cancer and its primary signs and symptoms, leading to delayed in diagnosis (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). A study by Coughlin found that lack of education and health literacy may limit access to information or the ability to understand health messages (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This underlines the need for targeted educational programs in low-literacy populations. It is also important to note that since Afghanistan\u0026rsquo;s political transition in 2021, women\u0026rsquo;s access to health facilities, educational institutions, and public awareness regarding breast cancer has been severely restricted. It can be a warning sign for the need to improve women\u0026rsquo;s health outcomes.\u003c/p\u003e \u003cp\u003eInterestingly, a history of breastfeeding was also linked to attitudes. Women who had breastfed were much less likely to have a positive attitude toward breast cancer. This surprising finding contrasts with studies in the UK (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and India (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), which discovered that breastfeeding mothers often showed better knowledge and attitudes, likely due to their regular contact with healthcare services. However, breastfeeding is culturally encouraged in Afghanistan; the lack of comprehensive postnatal care may result in insufficient education about the potential risks associated with breast cancer. If healthcare providers do not discuss breast health during routine visits, mothers may miss out on crucial information that could shape their attitudes toward breast cancer. The negative relationship observed in our setting could be attributed to cultural misconceptions, and low rates of counseling during postnatal care.\u003c/p\u003e \u003cp\u003eIn contrast, a history of pregnancy did not show a statistically significant link to attitudes. While the odds ratio suggested a negative trend, the wide confidence interval and p-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05 imply that this relationship might be due to chance or influenced by other unmeasured variables.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePractice\u003c/h2\u003e \u003cp\u003eOne of the important findings of this study is the overall poor level of practice (16%) among women in relation to breast cancer, despite relatively better levels of knowledge and attitude reported in the same population. This low level practice aligns with low practice rates in Ethiopia from 13% to 21% (\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), Nepal 12% (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), Cameron 15% (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), and a recent study in Afghanistan 19% (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This low level of BSE practice may be due to a lack of BSE knowledge, traditional cultural influences, and lower levels of education. This highlights an important public health concern, as inadequate practice directly undermines the potential benefits of awareness in the presentation of breast cancer.\u003c/p\u003e \u003cp\u003eThe level of education was significantly associated with better breast cancer-related practices. Women with no formal education or lower levels of schooling were substantially less likely to engage in preventive behaviors compared to those with higher education. For instance, literate women had 2.32 higher odds of good practice (p\u0026thinsp;=\u0026thinsp;0.02). In contrast, illiterate women or those with only primary education had a noticeably lower likelihood. This finding agrees with a new study in Afghanistan (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and other studies from Southwest Ethiopia (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), Northwest Ethiopia (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), and Nigeria (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). These studies showed that women with more education were more likely to perform breast self-examinations, so it is important to improve educational level to improve awareness, attitude and ultimately practice.\u003c/p\u003e \u003cp\u003eIn our study, age wasn\u0026rsquo;t a significant factor influencing practice. While Tilaki et al. showed in their study that older women are more motivated to perform breast cancer screening due to increased perceived risk (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The lack of association in our findings suggests that maternal and reproductive health services in Afghanistan may not be adequate to send the preventive messages into routine counseling. Furthermore, lower access to antenatal and postnatal care among Afghan women and the absence of pregnant women\u0026rsquo;s health education programs on the severity of breast cancer may contribute to our findings.\u003c/p\u003e \u003cp\u003eOverall, our findings emphasize that knowledge and attitude alone are insufficient to drive preventive practices. Low health literacy, lack of access to healthcare facilities, and cultural barriers may contribute to low preventive practices against breast cancer. With the recent regulations on the closure of schools and higher education institutions for women in Afghanistan, lower knowledge and practice of women towards breast cancer may be exacerbate, reducing the intervention points for improving these indicators, hence leading to a dramatic increase in the breast cancer incidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe authors of this study acknowledge several limitations in this survey. Firstly, the study was conducted in a single center, and despite the attendance of the general population from Kabul at this hospital, the generalization of the findings should still be made with caution. Moreover, the current study lacked some variables in the socio-demographic and reproductive health sections, such as the economic status of the participants, number of parities, and breastfeeding approach (exclusive or mixed with powdered milk), which could help the authors in furthering the analysis and providing expanded insights into the predicting factors of knowledge, attitude, and practice. Finally, a mixed-method approach with a qualitative component would have improved the depth of results and provided new and underexplored areas of concern and consideration.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study concludes that majority of the participants had inadequate knowledge of BSE, over half of the participants had positive attitude and only 16% of the participants had good practice. The study also include education was the most influential predictors of BC. The findings indicate that education is the most influential predictor of breast cancer attitude and practice.\u003c/p\u003e \u003cp\u003eDespite current policies in Afghanistan restricting women\u0026rsquo;s access to education, the results highlight the need for educational programs on breast cancer. These programs should be aligned with health policy that prioritize women\u0026rsquo;s health education and promoting awareness and ultimately improving health outcomes in Afghanistan.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the director of the hospital where we conducted the research. We would like to extend our thanks to the efforts and mentorship of Areta Aramak Research Services, and Afghanistan Center for Translation Medicine and Public Health. We are grateful to all those who contributed to the data collection for this study (sahar Ghafoori, Yasamin Andkhoy Sadat, Nilofar Farooq, Qadria Bakhtiari, Arezo Azimi, Fahima Zia). We would also like to thanks to the participants of the study. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMOM, MSF, and ASM led the study, conducted the data collection, data quality, and wrote the first draft. ZE and SN contributed to the data analysis and writing the first draft, review and revision of the manuscript. SMSH and AK contributed to review of the manuscript. All authors read and approved the final manuscript. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has received permission from Cure Hospital in accordance with the Declaration of Helsinki. The study has received the permission from educational directorate and committee members, which are responsible for the ethical issues as well.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent forms were signed by all the participants before being included in the study. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the study are not publicly available due to participant confidentiality and institutional restrictions but are available from the corresponding author on reasonable request. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding support. \u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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PLoS ONE. 2019;14(12):e0226925.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakhi R, Muhammadi FA, Ahmadi M, Sadat SAW, Noori N, Fazili I et al. Knowledge, Attitude and Performance Regarding Breast Self-examination among Students of Medical Institutes. Indian Cancer Aware J.0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHewad Mal MR, Sen L. Breast Cancer in Afghan Women: A Systematic Review of Awareness, Screening Practices, and Risk Factors. J Epidemiol global health. 2025;15(1):91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMudaber MJ, Mehmet NJIJRMS. Breast cancer screening practices among Afghan women visiting Istiqlal and Jumhuriat hospitals in Kabul city. Afghanistan. 2020;8(6):1973.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalid A, Hassnain S, Gakhar H, Khalid B, Zulfiqar F, Wahaj A. Breast cancer among young girls: a KAP study conducted in Lahore. Int J Sci Rep. 2018;4(6):166\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlwan NA, Al-Attar WM, Eliessa RA, Madfaie ZA, Tawfeeq FN. Knowledge, attitude and practice regarding breast cancer and breast self-examination among a sample of the educated population in Iraq. Eastern Mediterranean health journal\u0026thinsp;=\u0026thinsp;La revue de sante de la Mediterranee orientale\u0026thinsp;=\u0026thinsp;al-Majallah al-sihhiyah li-sharq al-mutawassit. 2012;18(4):337\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilani SI, Khurram M, Mazhar T, Mir ST, Ali S, Tariq S, et al. Knowledge, attitude and practice of a Pakistani female cohort towards breast cancer. JPMA J Pakistan Med Association. 2010;60(3):205\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrani M, Nosrati SF, Sardasht FG, Fasanghari M, Najmabadi KMJJM, Knowledge HR. Attitude, and Practice of Women Regarding Breast Cancer Screening Behaviors in Mashhad. Iran. 2021;9(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmagneneh T, Daniel T, Nega AT, Tsegaye D. Knowledge, attitudes, and practices regarding breast cancer screening and associated factors among female undergraduate students at Bonga University, Ethiopia. Sci Rep. 2025;15(1):31638.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGetu MA, Kassaw MW, Tlaye KG, Gebrekiristos AFJBCT, Therapy. Assessment of breast self-examination practice and its associated factors among female undergraduate students in Addis Ababa University, Addis Ababa, Ethiopia, 2016. 2018:21\u0026thinsp;\u0026ndash;\u0026thinsp;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkhtari-Zavare M, Latiff LA, Juni MH, Said SM, Ismail IZJAPJCP. Knowledge of female undergraduate students on breast cancer and breast self-examination in Klang Valley. Malaysia. 2015;16(15):6231\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeherali S, Punjani NS, Mevawala A. Health Literacy Interventions to Improve Health Outcomes in Low- and Middle-Income Countries. Health Lit Res Pract. 2020;4(4):e251\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlanazi WN, Mohamed GM, Alosaimi NS, Alosaimi LM. Breast cancer awareness, knowledge and self-screening intention among females in Northern Border of Saudi Arabia, Arar City. BMC Public Health. 2025;25(1):964.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu L, Zhou Q, Huang Z, Yang Y, Yang Y, Du Y, et al. Factors Influencing Breast Cancer Awareness in Rural Southwest China: A Cross-Sectional Study. Int J women's health. 2024;16:509\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAslam A, Mustafa AG, Hussnain A, Saeed H, Nazar F, Amjad M, et al. Assessing Awareness, Attitude, and Practices of Breast Cancer Screening and Prevention Among General Public and Physicians in Pakistan: A Nation With the Highest Breast Cancer Incidence in Asia. Int J breast cancer. 2024;2024:2128388.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehmood Q, Rafay A, Qurat Ul Ain H, Junaid Tahir M, Saeed A, Hanan A, et al. Knowledge, attitude, and perception of Pakistani women regarding breast cancer and mammography screening: A cross-sectional study. Medicine. 2025;104(23):e42806.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToan DTT, Son DT, Hung LX, Minh LN, Mai DL, Hoat LN. Knowledge, Attitude, and Practice Regarding Breast Cancer Early Detection Among Women in a Mountainous Area in Northern Vietnam. Cancer control: J Moffitt Cancer Cent. 2019;26(1):1073274819863777.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAuletto A, Kim T, Marias RJCICE. Educational Attainment and Egalitarian Attitudes Toward Women in the MENA Region: Insights from the Arab Barometer. 2017;20(1):45\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiazi A-u-R, Jami AA, Shams AZ, Mahmoodi AS, Krapfl E, Falk S, et al. Establishing a breast cancer center in Herat, Afghanistan: an implementation study. Global Health J. 2021;5(4):204\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoughlin SS, Vernon M, Hatzigeorgiou C, George V. Health Literacy, Social Determinants of Health, and Disease Prevention and Control. J Environ health Sci. 2020;6(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStordal B. Breastfeeding reduces the risk of breast cancer: A call for action in high-income countries with low rates of breastfeeding. Cancer Med. 2023;12(4):4616\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBabita, Kumar N, Singh M, Malik JS, Kalhan M. Breastfeeding reduces breast cancer risk: a case-control study in north India. Int J Prev Med. 2014;5(6):791\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussen A, Kumbi M, Bedewi J, Lette A, Nuriye S. Breast self-examination practice and associated factors among women of reproductive age in southeast Ethiopia. Front Oncol. 2023;13:1176022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrga Workineh M, Alem Lake E, Asmare Adella G. Breast Self-Examination Practice and Associated Factors Among Women Attending Family Planning Service in Modjo Public Health Facilities Southwest Ethiopia. Volume 13. Breast cancer (Dove Medical; 2021. pp. 459\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMihret MS, Gudayu TW, Abebe AS, Tarekegn EG, Abebe SK, Abduselam MA, et al. Knowledge and Practice on Breast Self-Examination and Associated Factors among Summer Class Social Science Undergraduate Female Students in the University of Gondar, Northwest Ethiopia. J cancer Epidemiol. 2021;2021:8162047.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGyawali P, Gautam SJIJoHS. Research. Breast self-examination practice and its associated factor among the women of reproductive age of Rapti Sonari rural municipality. Banke District. 2021;11(4):75\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmadi M, Nemat A, Sakhi R, Ahmadi A, Massoud M, Ebadi E, et al. Knowledge and practice of breast self-examination and associated factors among women with breast cancer in Kabul. Afghanistan. 2025;20(10):e0335460.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYazew BG, Alemu BW, Walle TAJFO. Factors associated with knowledge and practice of breast self-examination among female governmental school teachers in Gondar Town, Northwest Ethiopia, 2019. 2024;14:1481714.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOladimeji KE, Tsoka-Gwegweni JM, Igbodekwe FC, Twomey M, Akolo C, Balarabe HS, et al. Knowledge and Beliefs of Breast Self-Examination and Breast Cancer among Market Women in Ibadan, South West, Nigeria. PLoS ONE. 2015;10(11):e0140904.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHajian Tilaki K, Auladi S. Awareness, Attitude, and Practice of Breast Cancer Screening Women, and the Associated Socio-Demographic Characteristics, in Northern Iran. Iran J cancer Prev. 2015;8(4):e3429.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Knowledge, Attitude, Practice, Breast Cancer, Afghan women, Afghanistan","lastPublishedDoi":"10.21203/rs.3.rs-8892604/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8892604/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eBreast cancer is among the leading causes of death worldwide and also in Afghanistan; meanwhile, it\u0026rsquo;s the most common cancer among women worldwide. Early diagnosis helps early detection and helps long survival and also reduces the mortality rate. The aim of this study was to assess KAP and identify factors associated with them among women attending a tertiary hospital in Kabul, Afghanistan.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted (2023) in Cure tertiary hospital, surveying 268 females aged 15\u0026ndash;49 years. Data was a structured questionnaire on sociodemographic characteristics, reproductive history, and KAP toward breast cancer. Participants were selected through non-random convenience sampling. Binary and multivariate logistic regression analyses were used to identify factors associated with KAP.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, knowledge about breast cancer was found to be limited, while attitudes were generally positive, and practices were inadequate. In the multivariable model, no sociodemographic or reproductive variables were independently associated with knowledge. However, age and educational status significantly predicted attitudes: literate women (AOR\u0026thinsp;=\u0026thinsp;4.84, 95% CI: 2.62\u0026ndash;8.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and women with a history of lactation (AOR\u0026thinsp;=\u0026thinsp;2.58, 95% CI: 1.12\u0026ndash;5.94, p\u0026thinsp;=\u0026thinsp;0.02) were more likely to have positive attitudes. Regarding practice, education was the strongest determinant; literate women were more than twice as likely to show good practice (AOR\u0026thinsp;=\u0026thinsp;2.32, 95% CI: 1.11\u0026ndash;4.85, p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEducational status was a consistent predictor across domains; therefore, it highlights the effect of educational programs with specific emphasis on increasing breast cancer knowledge, attitude, and practice among women as a cost-effective way to confront the second cause of death, cancer, in Afghanistan.\u003c/p\u003e\u003ch2\u003eClinical trail number:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Assessment of knowledge attitude and practice regarding breast cancer among women attending a tertiary hospital in Kabul Afghanistan 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:48:30","doi":"10.21203/rs.3.rs-8892604/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-14T08:10:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T13:58:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T18:43:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T19:51:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T07:32:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T17:52:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201379368974619807257389745617696777769","date":"2026-04-13T09:47:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108849384985879138565591464934258518221","date":"2026-04-12T17:06:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243159928298277503569862757776317629420","date":"2026-04-10T15:27:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68544723317849014307493447619838501596","date":"2026-04-10T08:36:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136473765894516657089508174031519139004","date":"2026-04-10T08:21:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T07:00:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-19T04:43:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-11T19:32:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-11T13:02:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-03-11T08:46:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ca18c95-333e-44fe-b32c-1e2a0c4b3ba2","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-14T08:10:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T13:58:35+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T08:23:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:48:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8892604","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8892604","identity":"rs-8892604","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}