Breast cancer educational program and breast self-examination in Sana'a, Yemen Gawad M. A. Alwabr

1. ISSN 2449-8866
Current
Life Sciences
Research Article
Current Life Sciences 2016; 2 (2): 27-35
Breast cancer educational program and breast
self-examination in Sana'a, Yemen
Gawad M. A. Alwabr
Sana'a Community College, Sana'a, P.O. Box 5695, Yemen; Phone: 00967 777160932; Email: alwabr2000@yahoo.com
ABSTRACT
Breast cancer is one of the most common cancer
in women, constituting 22% of all cancer cases
worldwide. One of the methods of breast cancer
screening is breast self-examination. This study
aimed to assess the impact of education on breast
cancer and breast self-examination on female
workers' knowledge, attitude, and practice. The
study concerned to 103 females as a control group
and 103 females as a case group. Intervention health
education program was administrated to individual
females of the case group. The results showed an
improvement in knowledge of breast cancer risk
factors, between control and case groups of parti-
cipant females. Females' knowledge and attitude
about breast self-examination factors clarify a high
improvement in all answers of case group parti-
cipants. In the control group 83.5% of women not
practiced breast self-examination compared to 66%
practicing it in the case group after the intervention.
Radio and TV showed the highest percentage
(41.7%) in the control group participants as a
source of knowledge about breast cancer and breast
self-examination. While health education program,
represents the highest percentage (46.6%) in the
case group participants as a source of knowledge for
both breast cancer and breast self-examination.
Correlation tests revealed a significant difference
between knowledge and behavior scores in the
control group participants (P = 0.019). This study
results concluded that education can significantly
improve the level of females' knowledge, attitude,
and behavior of breast cancer and breast self-
examination. This study recommended that educa-
tional programs used to improve females' know-
ledge of breast cancer and advantages of breast
self-examination are an effective method for early
recognition of this disease.
Keywords: Breast cancer; Breast self-examination;
Knowledge; Attitude; Practice.
1. INTRODUCTION
Cancer is one of the most important diseases
which threaten human health nowadays [1]. Because
of abnormal cell growth, malignant cells can invade
and spread to adjacent tissues and even distant
organs. While the tumor reaches advanced stages, it
can lead to patient death [2]. Among different types
of cancers, breast cancer is one of the most common
cancer in women worldwide; constituting 22% of all
cases worldwide [3-5]. In Yemen, in 2008, the
prevalence rate of breast cancer between years
2001-2005 estimated to be 42.4 per 100,000 women.
At 2009, an average of breast incidence rate in
Yemen was 20.9 (1261 cases) according to World-
wide Breast Cancer 2011 [6]. The most common
age group affected in Yemen was women aged
41-50 years, with (35%) of cases occurring in this
age [7]. Yemen's patients with late inoperable
stages represented 67.0% of the total staged breast
cancer patients, indicating the need for increased
Received: 21 January 2016; Revised submission: 23 February 2016; Accepted: 2 March 2016
Copyright: © The Author(s) 2016. Current Life Sciences © T.M.Karpiński 2016. This is an open access article licensed under the
terms of the Creative Commons Attribution Non-Commercial International License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
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2. 28 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
community awareness and early detection of the
disease [8]. In Arabic countries in general, women
currently face a significant risk of high mortality
rate from breast cancer due to late diagnosis [9]. So
early detection must be considered the best second
choice for reducing mortality [11]. The breast self-
examination has a major role in early detection
of breast cancer (48%), compared with annual
mammography and clinical breast examination
(41% and 11%, respectively) [12]. Breast self-
examination is recommended to be performed
routinely on a monthly basis in all the women aged
above 20 years and the importance of raising
awareness on breast cancer via BSE is noted [1]. In
addition, breast self-examination is easy and can be
done by anyone without any special equipment.
Furthermore, it is also an economic, secure and
noninvasive process [13]. This study aimed to
evaluate the effect of the educational program
regarding breast cancer and breast self-examination
on knowledge, attitude, and behavior of female
workers in Sana'a city institutes.
2. MATERIALS AND METHODS
2.1. Research design
This study was an interventional educational
program and was conducted on a sample of 103
female workers as a case group who are attended
educational program regarding breast cancer and
breast self-examination, under coverage of the
National Oncology Centers' health team in Sana'a
city. And a sample of 103 female workers as a
control group who have not attended the educational
program. All individuals of the both groups were
selected among female workers from the different
institutes of government and private sectors in
Sana'a city, Yemen, through systematic sampling on
the list of their working institutes. All females (age
20-70 years) were considered the target population.
Data collection for the study was carried out in the
period from March to June 2011.
2.2. Tools of the study
Data gathering tool was a standard question-
naire developed by the investigator based on the
related literature to assess the level of knowledge,
attitude, and practice of female workers about breast
cancer and breast self-examination. The validity of
the research tool was ensured through a review by
3 experts who hold a Ph.D. in Oncology and the
necessary modification was made. A pilot study was
conducted on 20 females to ensure the visibility of
the tool.
The questionnaire consisted of two parts:
demographic characteristics (4 questions), namely
are; age, marital status, educational level and
monthly income. And questions about individuals’
knowledge (14 questions) to identify the knowledge
regarding breast cancer and breast self-examination,
included items regarding general knowledge of
cancer, causes, symptoms, examination, treatment,
prevention of breast cancer and knowledge of
breast self-examination. An attitude and behavior
(13 questions) for assessing females practice about
breast self-examination. Included items related to
breast self-examination practice. Both groups' indi-
viduals filled in the questionnaire.
The study tool was used for individuals of the
control group to get a baseline data of participants’
knowledge of breast cancer and their level of breast
self-examination practice. The same tool was used
for individuals of the case group to test if there is
any difference in participants’ knowledge, attitude,
and practice, compare to the control group.
The awareness program was offered for a
case group. The methods of teaching used were a
lecture followed by focus group discussion and
demonstration for practices. Posters were also
used to provide and view more information and
each female is provided a copy. The post-test
questionnaire was given to the respondents after a
period of three months of the program was offered.
This period of time was given for them to
familiarize themselves with the feel and appearance
of their breasts so that they can notice any
difference or change in the way their breasts looked
and felt.
2.3. Data analysis
All data were coded, tabulated and subjected
to statistical analysis. Statistical analysis is perfor-
med using SPSS version 12. Quantitative and quali-
tative variables are described by proportions and
percentages. Descriptive statistics are used to analyze

3. 29 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
the response to individual items and the respondents'
characteristics. A correlation test was used to test
differences between the different groups.
3. RESULTS
3.1. Socio-demographic factors
Among 103 of case group participants, 49
(47.57%) were married and 49 (47.57%) were single
while 5 (4.86%) were divorced. 50 (48.5%) of
individuals age were less than30 years and 43
(41.7%) were between 30-39 years while 10 (9.8%)
were more than 39 years. Regarding their literacy
levels, 77 (74.7%) had university degrees, 21
(20.3%) were the secondary school, 2 (1.9%) had
the primary school and 3 (2.9%) were illiterate.
Among 103 of control group participants, 40
(38.8%) were married and 56 (54.3%) were single
while 7 (6.9%) were divorced. 57 (55.3%) of
individuals age were less than30 years and 38
(36.9%) were between 30-39 years while 8 (7.8%)
were more than 39 years. Regarding their literacy
levels, 63 (61.1%) had university degrees, 24
(23.3%) were a secondary school, 8 (7.7%) had the
primary school and 8 (7.7%) were illiterate. There
were no significant differences in these variables
between two groups.
3.2. Impact of the intervention program
As shown in Table 1, there was an impro-
vement in all intervention items regards knowledge
of breast cancer risk factors, between control and
case groups of participant females. The highest
percent change to the correct answer between the
control and the case groups were reported for the
items of "childlessness after the age of 35, genetic
factors and previous benign tumors" (27.2%, 24.3%,
and 22.3%) respectively. On the other hand, the
lowest percent change to the correct answer (7.7%)
was reported for an item of "breast cancer is the
most common tumors between women". Concerning
level of the knowledge about the breast cancer's
signs, the percent change of correct answers ranged
from 5.8% for the item of "difference in the shape
and position of the nipples", to 27.2% for the item of
"change the shape of the breast" (Table 2).
Table 3 showed that the females' knowledge
and attitude about breast self-examination factors
clarifies a highly improvement in all answers of
case group participants, concerning: use the palm
of the hand, place of another hand, appropriate time
and frequency of breast self-examination, (46.9,
38.8, 38.8 and 33) respectively.
Table 1. Comparison of the control and case group intervention knowledge about risk factors for breast cancer among
females' participating.
Correct answer No. (%)
Risk factors for breast cancer Control group
n= 103
Case group
n= 103
No. (%)
of change
Breast cancer is the most common tumors among women 84(81.6) 92(89.3) 8 (7.7)
Previous benign tumors increase breast cancer risk 27(26.2) 50 (48.5) 23(22.3)
Early menarche and late menopause increase the probability of
incidence
4(3.9) 21 (20.4) 17(16.5)
Increase the incidence of breast cancer with age 26(25.2) 41(39.8) 15(14.6)
Genetic factors affect the incidence of breast cancer 26(25.2) 51(49.5) 25(24.3)
Users of oral contraceptives from factors breast cancer incidence 19(18.4) 38(36.9) 19(18.5)
Obesity has strong relationship with breast cancer occurrence 26(25.2) 37(35.9) 11(10.7)
Feeding a key role in the prevention of breast cancer 42(40.8) 54(52.4) 12(11.6)
Breastfeeding causes of breast cancer prevention 76(73.8) 87(84.5) 11(10.7)
Childlessness or having children after the age of 35 factors that
may increase the incidence of breast cancer
16(15.5) 44(42.7) 28(27.2)

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Current Life Sciences 2016; 2 (2): 27-35
Table 2. The knowledge's level about symptoms and signs of breast cancer incidence.
No. (%) of change
Case group
Control group
Answers
Breast cancer's signs
15(14.6)
89(86.4)
74(71.8)
Correct
6(5.8)
7(6.8)
False
8(7.6)
22(21.4)
Don't know
Exit means of nipple without pressure
28 (27.2)
75 (72.8)
47 (45.6)
Correct
22 (21.4)
21 (20)
False
6 (5.8)
35 (34)
Don't know
Change the shape of the breast may be a
sign of breast cancer
18 (17.5)
85 (82.5)
67 (65)
Correct
4 (4)
5 (5)
False
14 (13.6)
31 (30)
Don't know
The presence of mass under the armpit
evidence of the breast tumors
6 (5.8)
76 (73.8)
70 (68)
Correct
20 (19.4)
14 (13.6)
False
7 (6.8)
19 (18.4)
Don't know
Difference in the shape and position of
the nipples refers to the existence of the
breast tumors
8 (7.4)
23 (22)
15 (14.6)
Correct
71 (69)
56 (54.4)
False
9 (7.8)
32 (31)
Don't know
The presence of pain in the breast during
the scan
19 (18.2)
96 (93)
77 (74.8)
Correct
4 (3.9)
4 (3.9)
False
3 (2.9)
22 (21.4)
Don't know
Change the color of skin of the breast and
the increased thickness is evidence of
cancerous tumors of the breast
Table 3. The knowledge and attitude level about breast self-examination.
No. (%) of change
Case group
Control group
Answers
Breast self-examination factors
40 (38.8)
48(46.6)
8(7.8)
Correct
24(23.3)
13(12.7)
False
31(30)
82(79.6)
Don't know
Appropriate time for performing breast
self-examination
34 (33)
70 (68)
36 (35)
Correct
31 30)
59 (57)
False
2 (1.9)
8 (7.8)
Don't know
Frequency of breast self-examination
practice
24 (23.3)
50 (48.5)
26 (25.2)
Correct
27 (26.3)
23 (22.4)
False
26 (25.2)
54 (52.4)
Don't know
Appropriate age for start a breast self-
examination
48 (46.9)
73 (70.9)
25 (24)
Correct
13 (12.6)
3 (2.9)
False
17 (16.5)
75 (72.8)
Don't know
Use the palm of hand when breast
examination
40 (38.8)
52 (50.2)
12 (11.7)
Correct
30 (29)
18 (17.5)
False
21 (20.4)
73 (70.9)
Don't know
Place of another hand during breast self-
examination
25 (24.2)
97 (94.2)
72(70)
Correct
1 (1)
2 (1.9)
False
5 (4.9)
28 (27.2)
Don't know
Breast self-examination is the most
important means of early detection of
breast cancer
4 (3.9)
96(93)
92 (89)
Correct
2 (1.9)
2 (3.9)
False
4 (3.9)
7 (6.8)
Don't know
Early diagnosis improves treatment
outcomes
8 (7.8)
89(86.4)
81(78.6)
Correct
4 (3.9)
7 (6.8)
False
10 (9.7)
14 (13.6)
Don't know
The discovery and treatment of breast
cancer early often lead to full recovery

5. 31 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
99 (96.1%) of the control group participants,
has heard about breast cancer and 102 (99%) of the
case group participants, heard about breast cancer.
Only, 21 (20.4%) of the control group participants,
know about breast self-examination procedure,
while 102 (99%) of the case group participants,
know about breast self-examination procedure. In
addition, 83.5% did not practice breast self-
examination in the control group compared to 66%
practicing it in the case group after the intervention.
Furthermore, the main reason for not practicing
breast self-examination in the control group was not
knowing how to perform it (58.1%), while in the
case group the main reason given for not practicing
breast self-examination was forgetting (48.6%).
Almost of the case group and the control
group participants together agreed that there is no
adequate awareness by the authorities concerned
about breast self-examination. And almost of the
case group and the control group participants,
together agreed that awareness about the importance
of self-examination may help in early detection of
breast cancer. Also, almost of the case group and the
control group participants, together encourage
awareness campaigns about breast self-examination.
Radio and TV media were the highest
percentages (41.7%), as a source of knowledge
about breast cancer and breast self-examination
in the control group participants. While health
education programs, represents the highest percen-
tages (46.6%), as a source of knowledge for both
breast cancer and breast self-examination in the case
group participants. (Table 4).
Table 4. The practice and other factors of breast cancer and breast self-examination.
No. (%)
of change
Case group
No. (%)
Control group
No. (%)
Answers
Factors
3 (2.9)
102(99)
99 (96.1)
Yes
1(1)
4(3.9)
No
Heard of breast cancer
81 (78.6)
102 (99)
21 (20.4)
Yes
1 (1)
82 (79.6)
No
Know about breast self-examination
procedure
51 (49.5)
68 (66)
17 (16.5)
Yes
35 (34)
86 (83.5)
No
Practice breast self-examination
2 (5.7)
50 (58.1)
I do not know how
9 (25.7)
16 (18.6)
Fear of discovery
of something unnatural
7 (20)
7 (8.1)
Pain
17 (48.6)
13 (15.1)
Forgetting
35 (100)
86 (100)
Total
Causes of didn't practice breast self-
examination
0 (0)
16 (15.5)
16 (15.1)
Yes
87 (84.5)
87 (84.5)
No
Is there adequate awareness by the
authorities concerned about breast self-
examination
0 (0)
102 (99)
102 (99)
Yes
1 (1)
1 (1)
No
Is awareness of the importance of self-
examination may help in early detection
of breast cancer
3 (2.9)
101(98.1)
99 (96.1)
Yes
2 (1.9)
4 (3.9)
No
Do you encourage awareness campaigns
about breast self-examination
21 (20.4)
43 (41.7)
Radio and TV
0 (0)
3 (2.9)
Internet
48 (46.6)
2 (1.9)
Education program
10 (9.7)
30 (29.1)
Family and friends
23 (22.3)
21 (20.4)
Journals and posters
Source of breast cancer knowledge

6. 32 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
Table 5. The correlation between knowledge and behavior of individuals control and case groups participants.
Case group Knowledge Behavior Control group Knowledge Behavior
Case group
Pearson Correlation
Sig. (2-tailed)
N
.(a)
.
103
.(a)
.
103
.(a)
.
102
.(a)
.
103
.(a)
.
103
.(a)
.
39
Knowledge
Pearson correlation
Sig. (2-tailed)
N
.(a)
.
103
1
.
103
.(a)
.
102
.(a)
.
103
.052
.605
103
.(a)
.
39
Behavior
Pearson correlation
Sig. (2-tailed)
N
.(a)
.
102
.(a)
.
102
1
.
102
.(a)
.
102
.025
.806
102
.428(**)
.007
39
Control group
Pearson correlation
Sig. (2-tailed)
N
.(a)
.
103
.(a)
.
103
.(a)
.
102
.(a)
.
103
.(a)
.
103
.(a)
.
39
Knowledge
Pearson correlation
Sig. (2-tailed)
N
.(a)
.
103
.052
.605
103
.025
.806
102
.(a)
.
103
1
.
103
.373(*)
.019
39
Behavior
Pearson correlation
Sig. (2-tailed)
N
.(a)
.
39
.(a)
.
39
.428(**)
.007
39
.(a)
.
39
.373(*)
.019
39
1
.
39
** Correlation is significant at the 0.01 level (2-tailed).
* Correlation is significant at the 0.05 level (2-tailed).
a Cannot be computed because at least one of the variables is constant.
The correlation tests revealed a significant
difference between knowledge and behavior scores
in the control group participants (P= 0.019). And it
was a significant difference in the behavior scores of
the control and case group participants (P= 0.007) as
shown in Table 5.
4. DISCUSSION
The analysis of the present study revealed that
breast cancer and breast self-examination awareness
program provided during the study had a great
impact on the responses of the case group. Also,
results of our study demonstrated that education can
improve individuals’ level of knowledge, attitude,
and behavior about breast cancer and breast self-
examination. This is similar to findings of previous
studies conducted in different countries. A study
conducted in Egypt reported that there was a highly
significant improvement in all the knowledge items
of the intervention group from pre to post-test [11].
Other study conducted in Egypt reported that there
was a significant improvement in the studied
women regarding general knowledge of breast
cancer and breast self-examination through-out the
educational program in all items and in total score
[14]. A study conducted in the Kingdom of Saudi
Arabia reported that there was a significant impro-
vement in studied women's regarding general
knowledge of breast cancer and breast self-
examination after implementation of the interven-
tion program [9]. Other study conducted in the
Kingdom of Saudi Arabia reported that the total
mean knowledge scores of the participants increased
significantly after the educational program [15].
A study conducted in Turkey reported that the
difference between their knowledge before and after
the training sessions was exceptionally significant
[13]. A study conducted in Iran reported that the
mean knowledge and behavior score related to

7. 33 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
breast cancer and breast self-examination were
increased after education [2].
As regards to knowledge of risk factors for
breast cancer, this study results showed that the
recognition of childlessness after the age of 35,
genetic factor and previous benign tumors as risk
factors increased significantly among of case group
participants. The recognition of oral contraceptives
users, early menarche, late menopause, and women's
age, as risk factors also increased in the present
study among the case group participants. This is
agreed with findings previous study conducted in
Egypt reported that the highest percent change to
correct answer between pre and post test was
reported for women's age and early age of menarche
[11].
In relation to the average of the percentage
change in knowledge of breast cancer signs
between the control group and case group was low
something (15.1%), that because of the control
group had high knowledge about most of breast
cancer signs' items. This agreed with findings of
other studies. A study conducted in Egypt reported
that there was 27.1% increase in the percentage of
correct answer regarding knowledge of the breast
cancer's signs [11]. Other study conducted in the
Kingdom of Saudi Arabia reported that there was an
improvement in the knowledge and knowing the
dangerous signs and symptoms between studied
groups [9]. Another study conducted in the
Kingdom of Saudi Arabia reported that after the
intervention program, there were statistically signi-
ficant improvements in knowledge in relation to
breast cancer signs and symptoms [15].
Regarding to knowledge and attitude of breast
self-examination, this study results showed that,
the education program showed an impact on the
remarkable increase in the use the palm of hand
when breast examination from 24% to 70.9%, place
of other hand during breast self-examination from
11.7% to 50.2%, appropriate time for perform breast
self-examination from 7.8% to 46.6% and frequency
of breast self-examination practice from 35% to
68%. This agreed with findings of other study
conducted in Egypt and reported that the women's
knowledge about breast self-examination clarifies
also a highly significant improvement in all answers
concerning procedure, frequency and appropriate
time from pre to post-test [11]. Study conducted in
Iran reported that the average point of positive
attitude about breast self-examination has increased
after intervention [16].
Results of this study showed that the
knowledge and practice ratios of breast self-
examination were increased from 20.4% to 99% and
from 16.5% to 66% respectively. This agreed with
findings of other studies. A study conducted in
Egypt reported that 75% practiced breast self-
examination in post-test compared to 70% who did
not practice it in pre-test [11]. Other study conduc-
ted in Egypt reported that before the program all
students don't practice breast self-examination,
after the program a significant was observed in
the students' practice in relation to methods and
techniques and total practice score [14]. A study
conducted in the Kingdom of Saudi Arabia repor-
ted that 83.3% of women successfully performed
breast self-examination after implementation of the
program compared to 25% pre-program [9]. A study
conducted in Western Turkey reported that the
difference was statistically important when com-
pared the breast self-examination practices of the
women who participated in the study before and
after the training program [1].
This study results also showed that the main
reason for not practicing breast self-examination
among control group participants was that they did
not know how to perform it (58.1%), while the
forgetting was the main reason for not practicing
breast self-examination among case group parti-
cipants (48.6%). This agrees with findings of other
studies. A study conducted in Egypt reported that
the main reason for nonpracticing breast self-
examination prior to the program was that they did
not know how to perform it [14]. Other study
conducted in the Kingdom of Saudi Arabia reported
that the reason for not performing breast self-
examination regularly was forgetfulness [15].
As regards the main source of females'
knowledge of breast cancer and breast self-
examination, it changed from the media (Radio and
TV) in the control group respondents to the
intervention program in the case group respondents.
This agreed with findings of other studies. A study
conducted in Egypt reported that media was the
highest percentage in the pre-test as a source of
knowledge about breast cancer and breast self-
examination while the intervention program rated

8. 34 | Alwabr Breast cancer educational program and breast self-examination in Sana'a, Yemen
Current Life Sciences 2016; 2 (2): 27-35
high as a source of knowledge of the post-test
individuals [11]. Other study conducted in the
Kingdom of Saudi Arabia reported that TV and
doctor throw intervention program were high as a
source of information about breast cancer [9].
Based on results of this study, the correlation
tests revealed that the control group individuals’
knowledge and behavior are significantly related to
each other (P = 0.019). Also, the correlation tests
revealed that there is a statistical relationship
between behavior level between the control and case
group individuals (P = 0.007). This agreed with
findings of other studies. A study conducted in
Egypt reported that women's education and
knowledge score were significantly associated with
the practice of breast self-examination [11]. Other
study conducted in Egypt reported that women's
knowledge score was significantly associated with
the practice of breast self-examination [14]. A study
conducted in Iran reported that a significant stati-
stical correlation was seen between knowledge level
and attitude (p = 0.001) [5]. Another study con-
ducted in Iran reported that the correlation test
revealed that after education there was a signifi-
cant relationship between knowledge and behavior
(P = 0.005) [2].
5. CONCLUSIONS
This study was conducted in order to evaluate
the effects of interventions for increasing breast
cancer and breast self-examination awareness. The
study results indicate that females who received
intervention program had the higher level of
knowledge, attitude, and behavior regarding breast
cancer and breast self-examination. As mentioned,
education can significantly improve individuals’
levels of knowledge, attitude, and behavior about
breast cancer and breast self-examination.
Recommendations: According to aforementioned
points, we suggest to considering comprehensive
educational programs to improve females' know-
ledge about breast cancer and advantages of breast
self-examination as an effective method for early
recognition of the disease.
ACKNOWLEDGEMENT
We would like to thank the team of this work
(Mujahed Al-Jawfi, Abdulkader Al-Mihrab, Mohsen
Al-Sultan, Yahia Al-Soday, Jamal Al-Azab,
Radhiah Al-Mahakeri, Almntaser Ali Saeed, Sadiah
Al-daboush, Abdulrahman Khargain, Abdulbaset
Al-Zomer and Anisa Al-Omari), for them assistance
in implementation of the educational program and
collection of this work's data. Also many thanks to
Dr. Nada Alsyed Hassan Ahmad and Dr. Ahmad Al-
Wadaf for their assistance.
TRANSPARENCY DECLARATION
The authors declare no conflicts of interest.
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