Assessment Of Breast Cancer Early Detection Program's Activities In Primary Health Care Centers In Baghdad City.

: Objective: To assess early detection program for breast cancer by evaluating the structure of the regulatory process (any activities performed by health personnel) and the outcome. Methodology: descriptive study was conducted for the period from April 15 - May 31/2012. And such a study has selected a random sample (simple) which its frame was (220) and as a result of the different demographics of the sample studied, and their diversity which has the need for the work of three questionnaires distributed as follows: first questionnaire is to study the structure of management and the building that provide the service for tests of early breast cancer to the beneficiaries; and which may include two health central sector of all primary health care in the city of Baghdad and the total count for this sample is (20) centers for primary health care. The second questionnaire is to examine the services; activities performed by health personnel in the field of this program by their units and were answered by officials of this program in primary health care centers. The third questionnaire is to study the segment benefited from the services of the program of early detection of breast cancer which has included the study of the qualities of demographic and social services for them; their review to primary health care center, their satisfaction, their acceptance and their participation in the activities of the health center, beside that attending the awareness seminars and health education so the total of such sample, reaches (200) of the beneficiaries of care. The data analyzed by using of SPSS, and performed the data analysis process through the use of statistical methods of descriptive analysis method (Recurring, and percentages) and the arithmetic mean and standard deviation and deductive analysis (Chi square, sufficiency ratio percentage. Result: The early detection program for breast cancer has experienced some limitations in its implementation that include the process which is concerned with registration by health personnel and the documentation, The program's outcome indicates that beneficiaries are satisfied with health services; the program is high effective; and most of the beneficiaries is ranging between non-morbid and those who have completed the treatment and moving toward recovery, Conclusion: The program overall assessment shows that the program has a capacity to achieve less than two third of its anticipated performance. Recommendations: The follow up for the implementation of the vocabulary of the program by the Ministry of Health officials about the program at the health centers to address the imbalance in this implementation.

0 are a number of risk factors (1) . It will remain a major cause of worldwide cancer deaths in the 21st century (2). Cancer is an important factor in the global burden of disease. The estimated number of new cases each year is expected to rise from 10 million in 2002 to 15 million by 2025, with 60% of those cases occurring in developing countries. Breast cancer is the most common cancer in women in the Eastern Mediterranean Region and the leading cause of cancer mortality worldwide. There is geographic variation, with the standardized age incidence rate being lower in developing than industrialized countries. Although the etiology of breast cancer is unknown, numerous risk factors may influence the development of this disease including genetic, hormonal, environmental, socio-biological and physiological factors. Over the past few decades, while the risk of developing breast cancer has increased in both industrialized and developing countries by 1%-2% annually, the death rate from breast cancer has fallen slightly. Researchers believe that lifestyle changes and advances in technology, especially in detection and therapeutic measures, are in part responsible for this decrease. Breast cancer does not strike an individual alone but the whole family unit. Despite considerable social changes, women continue to be the focus of family life. The impact of breast cancer is therefore profound on both the woman diagnosed with the disease and her family. Their fear and anxiety over the eventual outcome of the illness may manifest itself through behavioral changes. The high incidence and mortality rates of breast cancer, as well as the high cost of treatment and limited resources available, require that it should continue to be a focus of attention for public health authorities and policy-makers. The costs and benefits of fighting breast cancer, including the positive impact that early detection and screening can have, need to be carefully weighed against other competing health needs (3) .And another oddity of cancer and not the latter is injured girls breast cancer, which is known for it affects women between the ages of 40-80 years of age of women but strange that this disease afflicting girls at the age of eleven or twelve or thirteen years of age and this means this disease has become more lethal and aggressive and resistant to immunity physical enjoyed by rights at an early age and resistance to these diseases, especially since this disease that attack on his victims at the age unknown became today attacked and successfully animate the early ages of age  in the case stopped at Medicine is incapable of reasoning and to address this disease, which is tampering with those small buds Iraqi and such cases are almost nonexistent in the Western states or even countries near Iraq (4) .In Iraq, the numbers of cases of breast cancer among Iraqi women were 2726 cases according to information published by the Iraqi Council of cancer in 2008.
The council points out that among the reasons for the increasing number of cases the disease is alarming due to the events witnessed by Iraq during the last decades of environmental pollution and exposure to radiation, and an increase in rates human growth, and many women use drugs to prevent pregnancy, affecting Physiologically and hormonally on breast cells, in addition to non-compliance with regulations healthy diet and exercise (5) .The goal of screening exams for early breast cancer detection is to find cancers before they start to cause symptoms. Screening refers to tests and exams used to find a disease, such as cancer, in people who do not have any symptoms. Early detection is an approach that lets breast cancer get diagnosed earlier than otherwise might have occurred. Breast cancers that are found because they are causing symptoms tend to be larger and are more likely to have already spread beyond the breast. In contrast, breast cancers found during screening exams are more likely to be smaller and still confined to the breast. The size of a breast cancer and how far it has spread are some of the most important factors in predicting the prognosis of a woman with this disease. (6). Although incidence, mortality, and survival rates vary fourfold in the world's regions, in the world as a whole, the incidence of breast cancer is increasing, and in regions without early detection programs, mortality is also increasing. The growing burden of breast cancer in low-resource countries demands adaptive strategies that can improve on 1 the too common pattern of disease presentation at a stage when prognosis is very poor. In January 2005, the Breast Health Global Initiative (BHGI) held its second summit in Bethesda, Maryland, USA.
The Early Detection and Access to Care Panel reaffirmed the core principle that a requirement at all resource levels is that women should be supported in seeking care and should have access to appropriate, affordable diagnostic tests and treatment. In terms of earlier diagnosis, the panel recommended that breast health awareness should be promoted to all women. Enhancements to basic facilities might include the following, in order of resources: effective training of relevant staff in clinical breast examination (CBE) both for symptomatic and asymptomatic women; opportunistic screening with CBE; demonstration projects or trials of organized screening using CBE or breast self-examination; and finally, feasibility studies of mammographic screening. Ideally, for complete evaluation, such projects require notification of deaths among breast cancer cases and staging of diagnosed tumors (7) .

OBJECTIVE:
To assess early detection program for breast cancer by evaluating the structure of the regulatory process (any activities performed by health personnel) and the outcome .

METHODOLOGY:
A descriptive study is conducted on (20) main primary health care centers in Baghdad city. The study aims at assessing the implementation of the Early Detection Program of Breast Cancer in primary health care centers, for the period from December 1st 2011 to July 3rd 2012. The study is carried out at the breast cancer early detection units in the primary health care centers of Baghdad City, as being divided into (2) sectors; AL-Karkh and Al-Rusafa health sector Directorate. A total of (20) main primary health care centers are selected from (10) health sectors in Baghdad City for the purpose of the study.
A simple random sample of (220) subject, it is selected throughout the use of probability sampling approach The sample of study is divided into three categories which include: 1. Early detection units for breast cancer in (20) Primary Health Centers to assess their organizational structure which are covered by (15) items from the study tool (questionnaires). 2. Essential services that are provided by their units, which are covered by (45) items from the questionnaires. 3. A sample of (200) beneficiary woman to assess their satisfaction with essential primary health care services of the breast cancer early detection program at the time of the study which are presented by (22) item in the questionnaires. Instrument: Through an extensive review of relevant literature, questionnaires are constructed by the researcher depending on standards, which are designed by Ministry of Health with the technical support from World Health Organization, for the purpose of the study to the essential primary health care services to measure the underlying concepts in the present study. The instruments comprised four questionnaires and overall items included in these questionnaires are (100) item. Data Collection: Data are collected through the utilization of the developed questionnaires and the interview technique as data collection methods and keeping records of all available contacts that facilitate the access to the study sample. Interviews are conducted with the directors of the main primary health care centers. Each interview takes approximately (10) minutes. The data collection is carried out from April 15 -May 31/2012. Statistical Analysis: Data are analyzed through the use of SPSS (Statistical Process for Social Sciences) version 10.0 application Statistical analysis system and Excel application. The following statistical data analysis approaches were used in order to analyze and assess the results of the study: Descriptive Data Analysis and Inferential data analysis .  This table, results showed that this event; according " Registration: The registration is done by" the responding of the study sample are within the "Failure" assessment and accounted for (30%) of the sample, Regarding to the "Steps of the clinical examination of the breast ", the responding of the study sample are within the "Pass" assessment and accounted for (55%) of the sample, With respect to the "Health Education ", the responding of the study sample are within the "Pass" assessment and accounted for (75%) of the sample, Regarding to the "Epidemiological monitoring ", the responding of the study sample are within the "Pass" assessment and accounted for (60%) of the sample, Regarding to the "Follow-up ", the responding of the study sample are within the "Pass" assessment and accounted for (100%) of the sample, finally, with respect to the "Activities of Health Personnel ", the responding of the study sample are within the "Pass" assessment and accounted for (58%) of the sample.

Figure 1. Assessment of the Main Domains of the Units' Activities for Breast Cancer Early Detection Program
This figure represents graphically the mean of score values of sampling surveyed responding throughout the Process: activities performed by health personnel, and overall assessment of the program's process. This results showed that this event; according " Registration: The registration is done by" and accounted for (33.3%) of the sample, regarding to" Steps of the clinical examination of the breast" and accounted for (58.3%) of the sample, with respect to" Health Education" and accounted for (75%) of the sample, regarding to" Epidemiological monitoring" and accounted for (60%) of the sample, finally, with respect to" Follow-up" and accounted for (100%) of the sample.

Figure3: The presence and absence of the Clinical Examination's Steps for breast Cancer
This figure: Bar chart for the presence and absence of the steps of the clinical examination of the breast assessment for the system of the early screening unit for breast cancer, represented graphically the present (success) and absent (shortage) of the applicable program due to the respondents consideration, and accounted for (55%) of the sample. (success) and absent (shortage) of the applicable program due to the respondents consideration, and accounted for (66.67%) of the sample.

Figure5: The Presence and Absence of Epidemiological Monitoring for Breast Cancer in the Early Detection
This figure: Bar chart for the presence and absence of the epidemiological monitoring assessment for the system of the early screening unit for breast cancer, represented graphically the present (success) and absent (shortage) of the applicable program due to the respondents consideration, and accounted for (60%) the sample.

Figure 6: The Presence and Absence of Follow-up Process in the Early Detection Units for Breast Cancer
This figure: Bar chart for the presence and absence of the follow-up assessment for the system of the early screening unit for breast cancer,) represented graphically the present (success) and absent (shortage) of the applicable program due to the respondents consideration, and accounted for (100%) of the sample.

Figure 7: The Presence and Absence of the Whole Process Components for the Breast Cancer Early Detection Program
This figure: Bar chart for the presence and absence of the activities of health personnel assessment for the system of the early screening unit for breast cancer, represented graphically the present (success) and absent (shortage) of the applicable program due to the respondents consideration, and accounted for (58%) of the sample.
That mean; Present that the domains of registration in the Activities of the early detection program for breast cancer experienced Failure which is accounted for (30%) and the remaining domains experienced Pass.

Demographical Characteristics Variables:
This results has reported that the Breast Cancer Early Detection Program's Implementation in Primary Health Care Centers had no relationship with their socio-demographical characteristics and that concluded that the studied program can be amend for all individuals of the population of the beneficiary's women's whatever a differences with their (demographical characteristics) factors would be! (Table 1).

Assessment of Breast Cancer Early Detection Program's Activities:
The overall assessment of the program's process has revealed that almost fifty eight percent of its performance has passed the standard of the program's process ( Table 2; Figure 1 -5).Building a special information system research program; for research on cancer to cover all data related to patients, and organize a database of knowledge and practices towards the early detection of breast cancer in Iraqi women is crucial (8) .Finding relatives to the steps of the clinical examination of the breast cancer have indicated that almost half of the steps have been experiencing failure in their implementation. Such steps include performing of the examination by the nurse, measuring pulse, measuring the blood pressure, measuring the height and weight (Table 3; Figure 4).The domains of health education has become at the second next to that of follow-up. Most of its components have been appropriately implemented except that of the use of videos, television for advertisement and health letters (Table3, and Figure7). For epidemiological monitoring, almost sixty percent of its components has been implemented appropriately except that of follow-up of the visit of the beneficiary to the health center and that of visiting the organizers of the health education services at home for the monitoring of the recipient for detection always (Table 3; Figure 5). This study by ( Donald Maxwell Parkin, 2008 ) Cancer control aims to reduce the incidence, morbidity, and mortality of cancer and to improve the quality of life of cancer patients through the systematic implementation of evidence-based interventions in prevention, early diagnosis, treatment, and palliative care. In the context of a national cancer control program (NCCP), cancer surveillance program (CSP), built around a population-based cancer registry, is an essential element.
Data on the size and evolution of the cancer burden in the population are essential to evaluation of the current situation, to setting objectives for cancer control, and defining priorities. Cancer data are essential in monitoring the progress of the implementation of an NCCP, as well as providing an evaluation of the many individual cancer control activities. In the context of an NCCP, the CSP should provide a focus of epidemiological expertise, not only for providing statistical data on incidence, mortality, stage distribution, treatment patterns, and survival but also for conducting studies into the important causes of cancer in the local situation, and for providing information about the prevalence of exposure to these factors in the population. Cancer surveillance via the population-based registry therefore plays a crucial role in formulating cancer control plans, as well as in monitoring their success (9) . The current media landscape is vast and includes traditional media channels such as television, newspapers, magazines and radio, as well as new media conduits like blogs and social networks. Preparing for Media Outreach Developing a well-honed media strategy is essential to conducting successful outreach, as it helps determine who to reach, what they should know, and how to best reach them (10) . Through the data analysis of the main domains for the breast cancer early detection program's process, the findings reveal that follow-up domain has presented the higher level of performance through out the program's implementation by virtue that all of its components are early implemented (Table 3; Figure 2, 3, 4, 5, 6, 7).

CONCLUSIONS:
After the discussion of the results complete we can conclude that8 1. The early detection program for breast cancer has experienced some limitations in its implementation that include the process which is concerned with registration by health personnel and the documentation. 2. The program overall assessment shows that the program has a capacity to achieve less than two third of its anticipated performance.

RECOMMENDATIONS:
Based on the early stated conclusion; we can recommend that: 1. Regular review of the program can assist to maintain its capacity in term of the process and outcome. 2. Special attention can be forwarded to the limitation of the program's performance. 3. Creation of new standards can benefit the evaluation of the program on a regular base. 4. Further research can be carried out on a national large scale for program assessment and evaluation.