THE RELATIONSHIP BETWEEN GYNECOLOGIC CANCER AND REPRODUCTIVE HEALTH AWARENESS AND OBESITY IN WOMEN:A CROSS-SECTION STUDY

Purpose: This study was conducted to determine the effect of obesity awareness on gynecological cancer and reproductive health awareness in women. Materials and Methods: This study is a cross-sectıonal study. The sample of the study consisted of overweight and obese women. Data were collected using the introductory information form, obesity awareness scale, and gynecological cancers awareness scale via a Google form. Results: Obesity was found to have a statistically significant association with reproductive health, including the risk for pregnancy and baby, uterus, ovary and breast cancer, menstrual irregularity, age of first menstruation, polycystic ovary syndrome, cesarean section risk, preeclampsia, gestational diabetes, stillbirth risk, birth defects, the chance of conception, the success of fertility treatment, early menopause, osteoporosis, baby weight, and iron deficiency anemia. The total mean score Obesity Awareness Scale and Gynecologic Cancer Awareness Scale was significantly higher among those who believed in this association. A highly significant positive correlation was observed between total and sub-dimension mean scores of women's Obesity Awareness Scale and Gynecologic Awareness Scale. Conclusion: It has been determined that obesity awareness in women is related to reproductive health and gynecological cancer awareness.


INTRODUCTION
Obesity is characterized by the abnormal or excessive accumulation of fat in the body, posing a significant health risk. It is a substantial global public health issue that is on the rise (1). According to the World Health Organization (WHO), people with a body mass index of 25 kg/m 2 and above are overweight, while those with a body mass index of 30 kg/m 2 and above are obese. In 2016, 13% of the world's adult population (15% for women; 11% for men) were obese (2). According to the Turkish Statistical Institute (TSI, 2019), one in five people (21.1%) in Turkey is obese (24.8% for women; 17.3% for men) (3). Obesity is more common in women than in men because of increased fat tissue, metabolic rate, mood swings, and sedentary life resulting from hormonal fluctuations (such as pregnancy, childbirth, and menopause) (4,5,6). Obesity in women causes cycle irregularities, polycystic ovary syndrome, infertility, risky pregnancy, and problems related to the birth process, adversely affecting reproductive health (7-10). Furthermore, obesity is associated with an increased risk of gynecologic cancers. Research shows that obesity is positively correlated with breast, endometrial, and ovarian cancer (11)(12)(13)(14). We need to raise women's awareness of obesity to prevent gynecologic cancers and reduce its adverse effects on reproductive health (15). Women who are aware of the impact of obesity on gynecologic cancers and reproductive health may be more likely to reach and maintain a healthy weight. Research suggests that people with high awareness of obesity are better at managing body weight and improving their quality of life (16,17). However, most women are unaware of the impact of obesity on reproductive health (18,19). Therefore, all health professionals should counsel women regarding the consequences of obesity on reproductive health (18). While there has been a growing body of awareness-based research in recent years, there is no research focusing on the effect of obesity awareness on gynecologic cancer and reproductive health awareness. Hence, this study aims to determine the effect of obesity awareness on gynecologic cancer and reproductive health awareness. This study will fill a gap in the literature, help us make a societal assessment, and guide health professionals in planning training and consultancy programs.

Study Design and Participants
This cross-sectional and descriptive study aimed to evaluate the effect of obesity awareness on gynecologic cancer and reproductive health awareness in women. The study sample comprised women residing in a southern province of Turkey diagnosed with obesity. Data collection took place in the province of Osmaniye from July to March 2021. Simple, random sampling was employed to recruit participants, ensuring an equal opportunity for all individuals in the population to be selected. A power analysis was conducted to determine the appropriate sample size, revealing that a sample of 420 participants would be sufficient to detect significant differences. Inclusion criteria: comprised a total of 35 items, with 13 items assessing sociodemographic characteristics and 22 items focusing on knowledge pertaining to the impacts of obesity on reproductive health. Obesity Awareness Scale (OAS); The Obesity Awareness Scale (OAS) was developed by Allen and adapted to Turkish by Kafkas and Özen (20,21). The scale consists of 21 items and three subscales: obesity awareness (8 items), nutrition (7 items), and physical activity (8 items). The scale has a Cronbach's alpha of 0.872, which was 0.863 in this study. Gynecologic Cancer Awareness Scale (GCAS); The Gynecologic Cancer Awareness Scale (GCAS) was developed by Dal and Ertem (22). The scale consists of 41 items and four subscales: (1) routine control of gynecologic cancers and awareness of serious illness perception, (2) awareness of gynecologic cancer risks, (3) awareness of prevention of gynecologic cancers, and (4) early diagnosis and information awareness in gynecologic cancers. The total score ranges from 41 to 205, with higher scores indicating higher awareness of gynecologic cancers. The scale demonstrated high internal consistency, with a Cronbach's alpha coefficient of 0.944 (22), which was found to be 0.936 in the present study. Reproductive Health Awareness Form; The Reproductive Health Awareness Form was developed by the researchers through an extensive review of the relevant literature. The form encompassed 22 items, focusing on women's knowledge, attitudes, and perceptions regarding reproductive health. The data were collected online (Google Docs) by the researchers between April 2021 and September 2021. Women who met the inclusion criteria were reached through social media platforms. Prior to data collection, participants were provided with detailed information regarding the research objectives and procedures. Each participant was given approximately 20-25 minutes to complete the data collection forms.

P a p e r A c c e p t e d
Statistical Package for Social Sciences (SPSS) 25 program was used in the analysis of the data. Normality was tested using skewness and kurtosis values. Number, percentage, mean, standard deviation, median, and minimum-maximum values were used for descriptive data. The data were analyzed using the Mann-Whitney U test, independent samples t-test, One Way ANOVA test, Welch test, Kruskal-Wallis test, Chi-Square test, and Pearson Correlation. Cronbach's alpha analysis was also used. Table 1 shows the participants' sociodemographic characteristics.

RESULTS
There was a significant difference in sociodemographic characteristics (marital status, education, pap smear test, age, body mass index, number of pregnancies, and number of children) between overweight and obese participants (p<0.05). Obese participants were older than overweight participants. More obese participants had pap smear tests than overweight participants. More obese participants were married than overweight participants. Obese participants were less educated than overweight participants. The statistical difference between the two groups was due to the difference between the groups with primary school and bachelor's degrees. The two groups did not significantly differ by income, employment, family type, place of residence, and training in obesity (p>0.05).
Participants had a mean OAS and GCAS score of 60.94 ± 6.23 and 155.39 ± 18.63, respectively (p>0.05). Overweight participants had a significantly higher OAS "nutrition" subscale score than obese participants (p<0.05). Overweight participants had significantly higher GCAS "awareness of prevention of gynecologic cancers" and "early diagnosis and information awareness in gynecologic cancers" subscale scores than obese participants (p<0.05) ( Table 2). Table 3 shows the distribution of scale scores by sociodemographic characteristics. Income, education, and training in obesity significantly affected participants' OAS scores (p<0.05). Participants with a positive income (income > expense), those with bachelor's degrees, and those who had received training in obesity before had significantly higher OAS scores. Participants' GCAS scores significantly differed by income, education, employment, family type, pap smear test, training in obesity, and the number of children (p<0.05). Participants with a positive income, those with bachelor's degrees, those with jobs, those with nuclear families, those who had a pap smear test, those who had received training in obesity, and those with 1-3 children had higher GCAS scores. Table 4 shows the participants' OAS and GCAS scores by their answers to questions about reproductive health awareness. The two groups had similar levels of awareness of reproductive health. The groups significantly differed in their answers to the question, "Does obesity affect the risk of gestational diabetes during pregnancy?" More overweight participants responded "yes" to the question than obese participants (p<0.05). Participants who believed that obesity was associated with reproductive health, risky birth, uterine, ovarian, and breast cancer, menstrual irregularity, polycystic ovary syndrome, cesarean delivery, preeclampsia, gestational diabetes, stillbirth, congenital disabilities, fertility treatment success, early menopause, O N L I N E F I R S T P a p e r A c c e p t e d osteoporosis, baby weight, and iron deficiency anemia had higher OAS and GCAS scores (p<0.05). Participants who thought that obesity affected the protectiveness of hormonal birth control methods had a statistically higher GCAS score (p<0.05). Table 5 shows the mean scale scores. A statistically significant positive correlation was observed between the total scores and subscale scores of OAS and GCAS (p<0.05).

DISCUSSION
Obesity is associated with many obstetric and gynecological problems in terms of reproductive health. Participants were highly aware of the effects of obesity on reproductive health. More overweight participants responded "yes" to the question "Does obesity affect the risk of gestational diabetes during pregnancy?" than obese participants.
It was found that Polish women with high BMI knew more about gestational diabetes (23). Ersoy et al. conducted a study on women with obesity and reported two results (24). First, women were adequately aware of the effects of obesity on pregnancy. Second, women who regarded obesity as a high-risk factor for gestational diabetes had significantly higher BMI values than those who did not. Overweight participants had higher GCAS "awareness of prevention of gynecologic cancers" and "early diagnosis and information awareness in gynecologic cancers" subscale scores than obese participants. Research also shows that women with higher BMI are less aware of gynecologic cancers (28).
Obese women are less likely to participate in cervical cancer screening (32,33). However, some studies show that obese women attend screenings more often (34). Participants with a positive income, those with bachelor's degrees, and those who had received training in obesity had higher awareness of obesity. Evaluated the awareness of women of reproductive age about the risks of obesity and found that low-income women knew less about the risks of obesity evaluated overweight and obese people's attitudes towards obesity and found that those with higher education levels were more aware of the effects of obesity on health (35, 36). İnvestigated how much pregnant women knew about obesity and determined that women with higher levels of education knew more about the risks of obesity looked into the impact of a public education campaign for obesity and reported that education was associated with obesity awareness (37, 38).

P a p e r A c c e p t e d
Employed participants with a positive income, bachelor's degrees, and nuclear families were more aware of gynecologic cancers. Found that self-employed and highly educated low-income women had lower awareness of gynecologic cancers than other groups (29). Gözüyeşil et al. determined that high-income women had higher awareness of gynecologic cancers (31). Reported no significant relationship between income, employment status, and gynecologic cancer awareness (28,30). Stated that women with primary school degrees were less aware of gynecologic cancers than others (29). Although earlier studies have reported different results, high-income working women are likely to be more aware of cancer because they are likely to have higher education and more access to information. Most working women in Turkey live in nuclear families and have higher education and more access to information, which may explain why they are more aware of gynecologic cancers.
The pap smear test is the most effective method for the early diagnosis of cervical cancer (39). Our participants who took pap smear tests were more aware of gynecologic cancers than those who did not. Also found that women who took pap smear tests were more aware of gynecologic cancers than those who did not (40).
Participants with 1-3 children were more aware of gynecologic cancers than those with more than three children. Evaluated the awareness of women of reproductive age and postmenopausal period about gynecological cancers and determined that women with 1-3 children were more aware of gynecologic cancers than those with more than three children (30).
Participants who were aware of the effects of obesity on reproductive health were also more aware of obesity than those who were not. Reported that women knew enough about obesity and its effects on health (41). Investigated how much women of reproductive age knew about the effects of obesity on reproductive health and found that most women had a positive tendency towards obesity and did not know enough about its effects on reproductive health (42).
Screening and early detection are critical to reducing cancer-related death rates (43). However, women apply to healthcare institutions too late because they do not know enough about health risks and ignore their health problems (28).
We must raise women's awareness to protect them from cancer and cancer-related deaths. Our results showed that women who were aware of the effects of obesity on reproductive health were more aware of gynecological cancers than those who were not.

CONCLUSION
Our results indicate that overweight and obese women who are more aware of obesity are also more aware of reproductive health and gynecological cancers. Income, education, and training in obesity affect women's awareness of obesity. Income, education, employment status, family type, pap smear test, training in obesity, and the number of children affect women's awareness of gynecologic cancers. Healthcare professionals should consider the sociodemographic characteristics of women to solve the problem of obesity. They should provide women with training to raise their awareness of obesity and its adverse effects on reproductive health.

P a p e r A c c e p t e d
Therefore, authorities should provide healthcare professionals with in-service training programs to raise their awareness of the effects of obesity on women's health. In addition, researchers should focus on obesity awareness in large samples.

Ethical Approval
The study received approval from the Scientific Research and Publication Ethics Committee of a state university. The initial page of the online questionnaire served as the electronic informed consent form. All participants were provided with comprehensive information about the study's purpose and procedure, and they were explicitly informed that their participation was entirely voluntary, with the freedom to withdraw from the study at any point.