The Effect of the Nurse Navigation Program Applied to Immigrant Syrian Women on their Beliefs on Breast Cancer Screening Behaviors, Mammography Self-Efficacy, and Breast Cancer Fears: A Randomized Controlled Trial

The Effect of the Nurse Navigation Program Applied to Immigrant Syrian Women on their Beliefs on Breast Cancer Screening Behaviors, Mammography Self-Efficacy, and Breast Cancer Fears: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of the Nurse Navigation Program Applied to Immigrant Syrian Women on their Beliefs on Breast Cancer Screening Behaviors, Mammography Self-Efficacy, and Breast Cancer Fears: A Randomized Controlled Trial Tuba YILMAZ BULUT, Birsen ALTAY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4298638/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study was conducted to determine the effect of the nurse navigation program immigrant Syrian women on their beliefs about breast cancer screening behaviors, their mammography self-efficacy, breast cancer fears and their knowledge levels about BSE. Methods This single-blind randomized controlled study was conducted in June-October 2021 with the pretest-posttest control group design. This research, which was carried out in accordance with randomized pre-test-post-test control group, with a total of 150 Syrian women, 75 in the experimental group and 75 in the control group. As data collection tools; "Descriptive Questionnaire", "Health Belief Model Scale", "Mammography Self-efficacy Scale", "Champion Breast Cancer Fear Scale", "Breast Self-Examination Checklist Form" and "Telephone Interview Form" were used. The study has a Clinical Trials registry with the number ……. Results According to the post-tests, there is a statistically significant difference in rate of having mammography between the experimental and control groups. After applying the Nurse Navigation Program based on the Health Belief Model to the Syrian women in the mammography self-efficacy scale score levels of the women in the experimental group increased after the experiment compared to before the experiment. Conclision Results of the study, it was determined that the Nurse Navigation Program applied according to the Health Belief Model (HBM) increased the breast cancer screening behaviors, self-efficacy and knowledge levels of Syrian women, and decreased their fear of breast cancer. Breast cancer Screening Health promotion Women’s health Transcultural nursing Telenursing Figures Figure 1 Figure 2 Introduction Breast cancer is the most common type of cancer in the world. It is also the most common type of cancer among Syrian women [ 1 ]. The incidence of breast cancer is 46.3 per hundred thousand worldwide, while it is 45.6 per hundred thousand in Turkey, the country hosting the highest number of Syrian refugees [ 2 ]. It is also observed that the incidence of breast cancer is continuously and epidemiologically increasing among the migrant Arab women [ 3 ]. Despite the high prevalence of breast cancer, it is reported that the ethnocultural group with the lowest incidence of breast cancer screening programs is Arabic-speaking immigrants, including the Syrians [ 4 , 5 ]. Although breast cancer is very common throughout the world, it can be diagnosed at an early stage when early diagnostic practices against cancer are taught to individuals [ 2 ]. Cultural factors and exceptional circumstances such as war affect the cancer process by creating barriers to early diagnosis practices. Although national cancer screening in Turkey is free and accessible for all citizens, disadvantaged groups cannot benefit from this service. Studies have shown that Syrian women do not practice clinical breast examination (CBE) in the countries they migrated to because of their religious beliefs and cultural perceptions [ 6 , 5 ], and mammography rates were also found to be quite low among Syrian women [ 5 , 7 , 8 ]. There are various models to ensure the feasibility of breast cancer early diagnosis screening against such barriers. One of these models is the Health Belief Model (HBM), which is used to determine the beliefs of individuals about a health behavior and take the necessary measures in case of negative beliefs [ 9 ]. Another practice that may increase the prevalence of breast cancer screening is the nurse navigation program (NNP). Barriers to screening can be eliminated with the help of a navigator nurse serving individuals from different cultures [ 10 ]. This system aims to reduce racial, ethnic and financial inequalities in care [ 11 ]. Studies have shown that the NNP to be applied for the early diagnosis of cancer increases the early diagnostic practices of individuals for breast cancer [ 12 , 13 , 14 ]. The NNP is a life-saving model especially for disadvantaged individuals. The HBM is also one of the most effective models that can be applied to develop self-efficacy and beliefs about early breast cancer diagnostic practices, to diagnose breast cancer at an early stage and start treatment, and to have mammography, CBE, and breast self-examination (BSE). Fear is thought to have an effect on breast cancer screening. It has been reported in some studies that thoughts such as catching the disease, pain, the idea of ​​losing the breast, and death emerge due to fear, which prevents breast cancer screening [ 15 , 16 ]. Individuals do not want to adopt early diagnostic practices due to the fear of being diagnosed with breast cancer. It is significant for nurses to provide training and counseling services with the NNP so that women adopt early diagnostic practices for cancer [ 17 , 18 ]. Our literature review revealed that studies on the breast cancer early diagnostic practices of Syrian women based on the HBM are quite limited in Turkey. Studies conducted abroad revealed that the NNP is used in both the diagnosis and treatment phases of breast cancer. This study is thought to contribute to the field of nursing as it includes the application of the NNP to the Syrian women living in Turkey based on the HBM. It aims to investigate the effect of the NNP administered to the Syrian women living in Turkey based on the HBM on their beliefs on breast cancer screening behaviors, mammography self-efficacy, and breast cancer fears. Hypothesis 0: The Nurse Navigation Program applied based on the HBM does not affect the breast cancer screening behaviors, beliefs about the breast cancer screening methods, mammography self-efficacy, and breast cancer fear levels of the Syrian women in the experimental and control groups. Hypothesis 1a: Following the nursing interventions, the breast cancer screening behavior of the women in the experimental group will increase compared to the control group. Hypothesis 1b: Following the nursing interventions, a positive difference will occur in the health beliefs of the women in the experimental group about early diagnostic practices compared to the women in the control group. Hypothesis 1c: Following the nursing interventions, the mammography self-efficacy scores of the women in the experimental group will increase compared to the women in the control group. Hypothesis 1d: Following the nursing interventions, the breast cancer fear scores of the women in the experimental group will decrease compared to the women in the control group. Materials and Methods Study Design This single-blind randomized controlled study was conducted in June-October 2021 with the pretest-posttest control group design. Participants and Setting The study was carried out between June-October 2021 in Sultanbeyli district of Istanbul. The target population of the study consisted of Syrian women aged 40–69 who were under temporary protection and were admitted to the Migrant Health Center. Clinical breast examination is performed free of charge in this center. However, there is no mammography device. The inclusion criteria were as follows: (a) being between the ages of 40–69 (Ministry of Health, 2020), (b) being a Syrian immigrant woman, (c) not having been diagnosed with breast cancer, (d) not being pregnant, not breastfeeding, and not being in the postpartum period, (e) not having received training on breast cancer, (f) volunteering to participate in the study, (g) being literate, accessible, and ready to communicate and (h) having immigrated to Turkey at least one year ago. The exclusion criteria are as follows: (a) having experienced breast cancer before, (b) performing BSE every month (c) having a mammography every two years, (d) having CBE once a year, and (e) having had mastectomy. Ethic Approval Statement Prior to the study, Ethics Committee approval (No: 220/132) was obtained from the Presidency of XXXX Social and Human Sciences Ethics Committee and the Department of Migration Policies and Projects of the General Directorate of Migration Management (No: 62103649000E.20374). Then, an institutional approval was obtained from XXXX Provincial Directorate of Health (E-15916306-604.01.01) in order to conduct the study at the Migrant Health Center. The participants were informed about the purpose of the study prior to the intervention, and their written consent was obtained. The research conforms to the provisions of the Declaration of Helsinki (as revised in Brazil 2013). All participants gave informed consent for the research, and that their anonymity was preserved. Sample Size and Randomization Power analysis was performed using the G*Power 3.1 program to calculate sample size. Considering the the Health Belief Model Scale [ 19 ], Champion Breast Cancer Fear Scale [ 20 ] and Mammography Self-Efficacy Scale [ 21 ] mean scores, the required sample size was determined as 134 at 95% confidence interval, 5% margin of error, 0.63 effect size, and 95% power. A total of 150 participants (75 participants in the experimental group and 75 participants in the control group) were recruited for the study with approximately 12% (16 people) extra participants, taking a possible data loss into account. The research sample was selected using the simple random sampling method. Recruitment and retention Participants were recruited from among the women who applied to the Migrant Health Center Family Medicine Polyclinic for any complaint. Those who met the inclusion criteria were given a pseudonmy and number. The participants in the sample pool were assigned to the experimental group and the control group using the Research Randomizer program. Each group consisted of 75 participants. During the research period, none of the participants withdrew from the study. In the study, blinding was ensured by randomly assigning the Syrian women to the experimental and control groups. It was also ensured that the participants did not know which group they were in. Following the data collection process, the data was entered into the IBM SPSS V23 program in the form of “first group” and “second group”. Data analysis was performed by a statistician who did not know which set of data belonged to which group. The results pertaining to the groups were reported when the statistical analysis was completed. Interventions The intelligibility of the Personal Information Form was tested by piloting the form on 10 Syrian women with the same characteristics as the Syrian women in the study. The NNP program (early diagnostic practices against cancer, cancer screening consultancy, motivational interviews, reminder phone calls, nurse-based call guidance) was applied to the women in the experimental group based on the HBM over a four-month period. The training content of the NNP program was prepared based on the HBM. 75 women in the experimental group were divided into groups of 5 people, and in the first month of the study, they were informed about the purpose and the content of the study and were asked to sign the informed consent form. Following the first interaction with the participants, the ‘Nurse-led Screening Consultancy Telephone Support Line’ was established for the Syrian women within the scope of the NNP. The participants were administered the pre-tests in the second month. The pre-tests were the Personal Information Form, the Health Belief Model Scale-Arabic Form, the Mammography Self-Efficacy Scale-Arabic Form, and the Champion Breast Cancer Fear Scale-Arabic Form. These pre-tests were administered by the researcher using the face-to-face interview technique. In addition, the participants were given a BSE calendar. Following the administration of the pre-tests, the participants in the experimental group were given training on the early diagnosis of breast cancer during the third month. The training sessions included information on the early breast cancer screening practices and the demonstration of BSE on a model. All trainings were given by the principal investigator with professional translators who received medical training. Breast cancer case presentations were also made. The women in the experimental group were distributed the “Training Booklet on Increasing Breast Cancer Screening Behaviors of Migrant Women” prepared according to the HBM. The booklet includes the content of the training. Then, face-to-face motivational interviews were held with women for breast cancer early screening practices, and first reminder phone calls were made. Motivational interviews were conducted by the principal researcher with the support of professional translators. The use of an interpreter in motivational interviews did not have a negative effect on the research. In the last month, all participants were called by phone every week, 4 times in total, and reminders were made within the scope of the reminder telephone counseling. At the end of the 4th month, the data collection forms and scales were administered again as post-tests and also the Post-Training Screening Behavior Follow-up Form was administered. The pre and post-test scores of the participants were used to evaluate the effectiveness of the training. After the research was completed, all trainings given to the experimental group were also given to the individuals in the control group and the training booklet was distributed. Insert Fig. 1 . Outcome Measures Personal Information Form The form was developed by the researchers and consists of 31 questions on participants’ socio-demographic characteristics, beliefs on early diagnostic practices, genetic characteristics, and early diagnostic practices for cancer. The form was prepared in Turkish and translated into Arabic by two expert linguists who know both languages very well. Health Belief Model Scale : The scale is used to reveal the beliefs and attitudes of individuals towards breast cancer, BSE, CBE, and mammography. It was developed in 1984 and revised in 1999 [ 22 ]. The Cronbach’s alpha of the original scale varies between .65-.90, and the test- retest correlations vary between .40-.68 [ 22 ]. The Arabic validity and reliability study of the scale was conducted by Mikhail and Petro-Nustas (2001) [ 23 ]. The items are on a five-point Likert type scale and the items under the factors are as follows: perceived severity (8–40), perceived BSE benefits (6–30), perceived barriers to BSE (7–35), perceived susceptibility (5–25), perceived health motivation (6–30), perceived BSE self-efficacy (9–45), perceived CBE benefits (5–25), perceived barriers to CBE (4–20), perceived mammography benefits (2–10), and perceived barriers to mammography (10–50). Higher scores indicate increasing perception of susceptibility and severity, and higher levels of perceived health motivation, benefits, barriers, and self-efficacy. In this study, all subdimensions of the scale were investigated. The items under the perceived barriers sub-dimension are reverse-coded. Written permission was obtained from the author to use the scale in the study. In this study, the Cronbach’s alpha values of the factors of the HBM varied between .70 and .95 for the pre-test and between .74 and .98 for the post-test. Mammography Self-Efficacy Scale The scale was developed by Champion et al. in 2005. The Cronbach’s alpha of the original scale is .87 [ 24 ]. Al-Zalabani (2019) conducted the Arabic validity-reliability study of the scale [ 25 ]. The scale consists of 10 items to evaluate the perceived self-efficacy of women for mammography screening. The items are rated on a five-point Likert type scale. The total score that can be obtained from the scale varies between 10 and 50 points, and higher total scores indicate higher levels of self-efficacy. Al-Zalabani (2019) found the Cronbach’s alpha of the scale as .88 [ 25 ]. The Cronbach’s alpha of the scale in this study is .87 for the pre -test and .95 for the post-test. Champion Breast Cancer Fear Scale (CBCFS) : The scale consists of eight items. It was translated into Arabic by Alyami et al. in 2019. The validity and reliability study was conducted and published in 2021. The items in the scale are rated on a five-point Likert type scale [ 26 ]. The lowest score to be obtained from the scale is 8 and the highest score is 40. Based on the score, the levels of fear about breast cancer are as follows: Low fear (8–15 points), moderate fear (16–23 points), and high fear (24–40 points). For the Arabic version of the scale, the Cronbach's alpha is .94, and the corrected item total correlations vary between .74 and .81 for each item [ 26 ]. The Cronbach’s alpha in the current study is .94 for the pre -test and .95 for the post-test. Development of the Training Materials Colored and illustrated training booklets were distributed to the participants both in Arabic and in Turkish to increase the effectiveness of the practices. Insert Fig. 2 Statistical Analysis The data were analyzed using the IBM SPSS V23 package program. Compliance with normal distribution was examined with the Kolmogorov-Smirnov test. Chi-square and Fisher’s Exact tests were used to compare the categorical variables according to groups. The McNemar test was performed to compare the categorical variables with two states according to the in-group pre-test and post-test. The Wilcoxon test was used to compare the categorical variables with three or more states according to the in-group pre-test and post-test. The Friedman test was performed to reveal the differences between groups across pre and post-tests. The Mann-Whitney U test was conducted to compare the data that did not show normal distribution across groups. The Wilcoxon test was also performed to compare the pre and post-test scores that did not show normal distribution within the group. The results of the analyses were presented as mean ± standard deviation and median (minimum - maximum) for quantitative data and as frequency (percentage) for categorical data. The level of significance was set at p < .050. Research Budget Financial support was received from XXXX University Scientific Research Projects Unit under 1904-B- PhD Thesis Projects (Project No: PYO.SBF.1904.21.001). Results In the research, 90.7% of the participants in the experimental group were married, 44% were primary school graduates, 82.7% had three or more children, 49.3% worked, and 70.7% smoked. 89.3% of the participants in the control group were married, 49.3% were primary school graduates, 66.7% had three or more children, and 72% smoked. Table 1. Comparison of the Frequency of BSE, CBE and Mammography Application of Women in the Experimental and Control Groups Before and After the İntervention (n=150) Experimental Group Control Group Total Statistics p n (%) n (%) n (%) pre -test Frequency of BSE With irregular intervals 3 (4) 6 (8) 9 (6) --- .494 F Who never did 72 (96) 69 (92) 141 (94) Post-test Frequency of BSE Once a month 57 (76)a 1 (1.3)b 58 (38.7) =130.417 <.001 With irregular intervals 18 (24)a 5 (6.7)b 23 (15.3) Who never did 0 (0)a 69 (92)b 69 (46) Statistics Z=-7.918 Z=-0.302 p <.001 .763 Pre -test CBE status With irregular intervals 2 (2.7) 2 (2.7) 4 (2.7) --- 1.000 F Never done 73 (97.3) 73 (97.3) 146 (97.3) Post-test CBE status With irregular intervals 5 (6.7) 3 (4) 8 (5.3) =50.370 <.001 Once made 38 (50.7)a 1 (1.3)b 39 (26) Never done 32 (42.7)a 71(94.7)b 103 (68.7) Statistics Z=-6.166 Z=-1.000 p <.001 .317 Pre -test Mammography status Had mammography 2 (2.7) 3 (4) 5 (3.3) --- 1.000 F Had’t mammography 73 (97.3) 72 (96) 145 (96.7) Post-test Mammography status Had mammography 61 (81.3) 5 (6.7) 66 (44) =84.848 <.001 Had’t mammography 14 (18.7) 70 (93.3) 84 (56) Statistics c --- --- p <.001 .500 X 2 : Ki-kare test statistics, F: Fisher Exact test, Z: Wilcoxon test statistics, c McNemar test, a-b : There is no difference between groups with the same letter Abbreviations: BSE, breast self-examination; CBE, clinical breast examination. Insert Table 1 . In the experimental group, a statistically significant difference was found between the pre-test and post-test frequency of having BSE scores (p < .001). While 96% of the participants in the experimental group stated that they never had BSE in the pre-test, this rate decreased to 0% in the post-test (Table 1 ). In the experimental group, a statistically significant difference was found between the pre-test and post-test frequency of having CBE and mammography scores (p < .001). After the intervention, 81.3% of the participants in the experimental group and 6.7% of the participants in the control group had mammography. Before the intervention, only 2.7% of the participants reported that they had mammography, while this rate increased to 81.3% after the intervention (Table 1 ). No statistically significant difference was found between the pre-intervention median scores of the experimental and control groups (p > .050) Insert Table 2 . Table 2 Distribution of Medians of HBM Scale Sub-Dimensions for Pre-Intervention and Post-Intervention Breast Cancer Among Women in The Experimental and Control Groups Experimental Group Control Group Statistics p Ortanca (Min - Max) Ortanca (Min - Max) Perceived susceptibility (Pre -test) 15 (5–20) 15 (5–25) U = 2662 .485 Perceived susceptibility (Post-test) 19 (7–25) 15 (5–22) U = 1197.5 < .001 Statistics Z=-6.315 Z=-0.401 p < .001 .689 Perceived severity (Pre -test) 22 (8–37) 20 (8–39) 22 (8–32) 22 (8–38) U = 2802 .968 Perceived severity (Post-test) U = 2008 .002 Statistics p Z=-1.247 .212 Z=-1.388 .165 Perceived health motivation (Pre -test) 22 (6–27) 22 (9–30) U = 2300 .051 Perceived health motivation (Post-test) 24 (9–30) 22 (12–30) U = 1995 .002 Statistics Z=-4.958 Z=-1.267 p < .001 .205 Perceived BSE benefit (Pre -test) 22 (9–30) 23 (6–30) U = 2513.5 .253 Perceived BSE benefit (Post-test) 30 (6–30) 24 (6–30) U = 646 < .001 Statistics Z=-6.781 Z=-0.808 p < .001 .419 Perceived BSE self-efficacy (Pre -test) 27 (9–45) 27 (9–45) U = 2774.5 .882 Perceived BSE self-efficacy (Post-test) 45 (9–45) 27 (9–34) U = 434.5 < .001 Statistics Z=-6.5 Z = 1.232 p < .001 .218 Perceived CBE benefit (Pre -test) 18 (5–25) 18 (10–25) U = 2531 .269 Perceived CBE benefit (Post-test) 23 (13–25) 18 (5–22) U = 387.5 < .001 Statistics Z=-6.792 Z=-0.967 p < .001 .334 Perceived mammography benefit (Pre -test) 6 (2–10) 6 (3–8) U = 2695.5 .615 Perceived mammography benefit (Post-test) 9(2–10) 6 (4–8) U = 275 < .001 Statistics Z=-7.02 Z=-1.861 p < .001 .063 Perceived barriers to BSE (Pre -test) 20 (7–35) 19 (7–28) U = 2757 .833 Perceived barriers to BSE (Post-test) 7 (7–29) 19 (7–27) U = 283.5 < .001 Statistics Z=-7.192 Z=-0.571 p < .001 .568 Perceived barriers to CBE (Pre -test) 10 (4–20) 9 (4–20) U = 2484.5 .204 Perceived barriers to CBE (Post-test) 7 (4–16) 9 (4–16) U = 1689 < .001 Statistics Z=-4.455 Z=-0.496 p < .001 .620 Perceived barriers to mammography(Pre -test) 30 (16–50) 28 (22–40) U = 2469 .192 Perceived barriers to mammography(Post-test) 18 (10–39) 30 (11–40) U = 489 < .001 Statistics Z=-7.026 Z=-0.314 p < .001 .754 U: Mann-Whitney U test statistics, Z: Wilcoxon test statistics Abbreviations: BSE, breast self-examination; CBE, clinical breast examination; HBM, Health Belief Model When the results for the groups were compared, a statistically significant difference was found in terms of median post-test health motivation and perceived severity scores ​​(p = .002). The comparison of the post-test scores of the groups revealed a statistically significant difference between the perceived susceptibility, perceived BSE benefits, perceived BSE self-efficacy, perceived CBE benefits, perceived mammography benefits, perceived barriers to BSE, and perceived barriers to mammography scores of the experimental group and those of the control group (p < .001). The perceived susceptibility, perceived health motivation, perceived BSE benefits, perceived BSE self-efficacy, perceived CBE benefits, and perceived mammography benefits post-test median scores of the experimental group increased after the intervention compared to the pre-test scores. This increase was found to be statistically significant (p < .001). After the intervention, the participants in the experimental group were found to have lower median scores for the sub-dimensions of perceived barriers to BSE, perceived barriers to CBE, and perceived barriers to mammography. The decrease was found to be statistically significant (p < .001) Insert Table 3 . Table 3 Comparison of Pre-Intervention and Post-Intervention Mammography Self-Efficacy Scale, CBCFS and BSE Knowledge Test Medians of Women in the Experimental and Control Groups Experimental Group Control Group Statistics p Median (Min - Max) Median (Min - Max) Mammography self-efficacy(Pre -test) 20 (10–40) 20 (10–50) U = 2802.5 .970 Mammography self-efficacy(Post-test) 40 (21–50) 21 (10–40) U = 172.5 < .001 Statistics Z=-7.401 Z=-1.517 p < .001 .129 CBCFS (Pre -test) 28 (8–40) 23 (8–40) U = 2304 .055 CBCFS (Post-test) 15 (8–40) 23 (8–40) U = 1199.5 < .001 Statistics Z=-5.586 Z=-0.207 p < .001 .836 U: Mann-Whitney U test statistics, Z: Wilcoxon test statistics Abbreviations: BSE, breast self-examination; CBCFS, Champion Breast Cancer Fear Scale A statistically significant difference was found in the experimental group between mammography self-efficacy and CBCFS median pre-test and post-test scores (p < .001). A statistically significant difference was found between the groups in terms of post-test mammography self-efficacy and CBCFS median scores ​(p < .001). Insert Table 4 . Table 4 Comparison of The Mammography Status of the Experimental Group After the Nursing İnterventions According to The Motivational Phone Calls Made Within the Scope of NNP Mammography after nursing interventions Statistics p Had mammography Appointment taker Who wıll have Had’t mammography n (%) n (%) n (%) n (%) Telephone call 1 7 (9.3) a 7 (9.3) 10 (13.3) 51 (68) \({\chi }^{2}\) =116.388 < .001 Telephone call 2 20 (26.7) a 4 (5.3) 14 (18.7) 37 (49.3) Telephone call 3 39 (52) b 2 (2.7) 17 (22.7) 17 (22.7) Telephone call 4 60 (80) b 0 (0) 2 (2.7) 13 (17.3) X 2 : Friedman test statistics, a-b: There is no difference between groups with the same letter Abbreviations: NNP, nurse navigation program. The motivational phone calls within the scope of the NNP caused an increase in the mammography screening scores of the experimental group. A statistically significant difference was found between the motivational telephone calls (p < .001), which was due to the difference between call 1 and calls 3 and 4 and between call 2 and calls 3 and 4. 9.3% of the participants were found to have mammography after call 1, 26.7% after call 2, 52% after call 3, and 80% after call 4. With the help of the BSE reminder calendar, 85.3% of the women in the experimental group stated that they now have BSE once a month. Discussion The study revealed that the participants in the experimental group had an increased tendency to have BSE. In Turkey, the Ministry of Health recommends regular BSE every month as it is thought that individuals will have increased awareness of breast cancer with BSE. Previous studies found that different nursing practices have increased the rates of BSE [ 27 , 28 ]. Research has shown that when women have higher levels of knowledge about breast cancer, their BSE behavior increases [ 29 , 30 , 31 , 32 ]. Thus, the change in the rates of BSE in the women in the experimental group is an expected finding. Our findings further revealed that the rate of CBE increased in the experimental group, which received the NNP. Previous studies including the HBM also reported an increase in the CBE rates of the participants [ 27 , 30 ]. In addition, the post-test results revealed that the participants in the experimental group had higher mammography scores than those in the control group. Similar studies which applied the HBM reported that the mammography screening behaviors of women increased after the intervention [ 27 , 32 , 28 ]. One study conducted with refugee women showed that the patients who had the NNP intervention had higher mammography rates [ 12 ]. The higher mammography scores in the experimental group in our study can be attributed to the fact that, based on the National Cancer Screening Standards, the age limit in the study was minimum 40, and that there was a mobile mammography truck where the research was conducted and all the participants were accompanied to this mobile unit one by one. The mobile mammography unit facilitated access to the mammography device, which is thought to contribute to the high rate of mammography among the participants at the end of the study. Based on the findings, the H 1a hypothesis (Following the nursing attempts, the breast cancer screening behavior of the women in the experimental group will increase compared to the control group) has been accepted (Table 1 ). After the intervention, the participants in the experimental group were found to have higher levels of perceived susceptibility sub-dimension median score. One study conducted with Syrian refugees in Jordan reported that low levels of perceived susceptibility affect women's breast cancer screening practices [ 33 ]. Previous studies also revealed that following the interventions based on the HBM, a significant increase was observed in the perceived susceptibility towards cancer [ 19 , 27 , 34 , 35 , 36 , 37 , 38 ]. Our study also revealed that the participants in the experimental group had higher levels of perceived susceptibility towards breast cancer after the intervention. The median perceived severity score of the control group was found to be higher than that of the experimental group after the intervention. Previous studies conducted with Syrian immigrants revealed that perceived severity has an effect on women's breast cancer screening practices [ 8 , 33 ]. On the other hand, some studies reported that perceived severity does not affect the beliefs of individuals regarding breast cancer early diagnostic practices [ 19 , 37 , 39 ]. It can be stated that the present study helped increase women’s practices for early diagnosis of breast cancer; however, women should be supported in terms of belief development. The post-test health motivation median score of the experimental group was found to be higher compared to the pre-test score. Similar findings were obtained in the literature [ 5 , 27 , 40 ]. It can be stated that the NNP was very effective in raising the health motivation of the women about breast cancer, which is one of the goals of the NNP, and thus it can be widely used to increase the health motivation of immigrant women who are considered to be in the disadvantaged group. The post-test results revealed that the Syrian women in the experimental group had higher perceived BSE benefits median score even in the fourth month after the intervention. Previous studies which applied various nursing interventions based on the HBM reported an increase in perceived BSE benefits scores of participants [ 34 , 35 ]. One study conducted with immigrant Syrian women based on the HBM found that perceived BSE benefits decreased as the perceived barriers to BSE increased [ 5 ]. Our findings coincide with those in the literature and it can be stated that the NNP is effective in increasing the perceived BSE benefits. The study revealed that after the intervention, the participants in the experimental group had a higher perceived BSE self-efficacy median score. Previous studies also showed that the participants in the experimental group had higher levels of BSE self-efficacy after the interventions based on the HBM [ 34 , 35 ]. Our findings revealed that the NNP positively affected perceived BSE self-efficacy and attitudes of women in the experimental group. Furthermore, the experimental group was found to have a higher perceived CBE benefits median score after the intervention. Previous studies conducted using the HBM revealed an increase in the perceived CBE benefits after the intervention [ 35 , 37 ]. It can be stated that following the intervention, the beliefs and attitudes of women in the experimental group toward CBE were more positive than the control group. It was found that the participants in the experimental group had a higher perceived mammography benefits median score after the intervention. It was revealed that perceived benefits directly supported the behavior of having mammography. This finding coincides with those in previous studies [ 39 ]. Studies revealed that following the HBM interventions, participants in the experimental group obtained a higher perceived mammography benefit score compared to the control group [ 19 , 34 , 35 , 36 , 41 , 42 ]. A study conducted in Brazil showed that the NNP helped fill the time gap between encouraging patients to have mammography and following up patients until diagnosis [ 43 ]. Our findings coincide with those in the literature. The results suggest that individuals have more control over their own health with the HBM, and thus, public health nurses can safely use this model to protect the health of individuals. Another finding of the study is that the participants in the experimental group had a lower perceived barriers to BSE median score after the intervention, while there was no change in the control group. This finding can be attributed to the fact that the NNP focuses on eliminating various barriers such as selection of screening methods and timing of screening in early diagnostic practices for cancer [ 44 ]. In addition, previous studies revealed that as a result of the HBM-based interventions, the mean perceived barriers to BSE score of the women in the experimental group decreased compared to the control group [ 5 , 19 , 37 ]. Our study also revealed that the NNP positively supported participants’ perceived barriers to BSE. The inter-group analyses further revealed that the perceived barriers to CBE median score of the experimental group was lower than that of the control group. Studies which applied some nursing interventions based on the HBM within the scope of breast cancer screening revealed a significant decrease in the perceived barriers to early diagnostic practices score [ 19 , 45 ]. It is thought that in our study, the NNP was effective in reducing perceived barriers to CBE in the experimental group. In addition, the perceived barriers to mammography score of the experimental group decreased after the intervention. Similar to our study, previous studies also reported a significant decrease in the perceived barriers to mammography score in the experimental group [ 4 , 5 , 39 , 42 , 45 ]. Our study found that perceived barriers prevent people from having mammography. Based on these results, the H 1b hypothesis (Following the nursing interventions, a positive difference will occur in the health beliefs of the women in the experimental group about early diagnostic practices compared to the women in the control group) was accepted (Tables 2 and 3 ). In the experimental group, mammography self-efficacy median score increased after the intervention. Similar results were obtained in previous studies conducted based on the HBM [ 19 , 30 , 38 , 41 ]. Mammography is important in breast cancer screening. The increase in mammography self-efficacy levels may make it easier for nurses to detect breast cancer cases earlier. Thus, it is thought that it will both ensure the diagnosis of the disease before it progresses and contribute to minimizing the psychological and material damage. Considering this finding of the study, the H 1c hypothesis (Following the nursing interventions, the mammography self-efficacy scores of the women in the experimental group will increase compared to the women in the control group) was accepted (Table 4 ). The median CBCFS score of the participants in the experimental group decreased after the intervention. Studies define fear as one of the factors that prevent early diagnostic practices for breast cancer [ 15 , 16 , 46 ]. However, some studies define fear as a convincing factor that promotes motivation and self-protection in breast cancer [ 47 ]. Kayar (2019) found that breast cancer fear scale scores increased in the experimental group following the intervention [ 32 ]. In this study, the decrease in the CBCFS scores contributed to the increase in women's breast cancer early diagnostic practices. Based on this finding, the H 1d hypothesis (Following the nursing interventions, the breast cancer fear scores of the women in the experimental group will decrease compared to the women in the control group) was accepted (Table 4 ). The motivational telephone calls within the scope of the NNP led to an increase in the mammography scores of the experimental group. Studies have shown that in breast cancer, interventions including a training program integrated with patient reminders or motivational interviews increase early diagnostic practices of individuals such as mammography, CBE, and BSE [ 13 , 14 ]. Some studies found that early diagnostic practices against cancer and navigation services such as phone calls, follow-up, and trainings increase the quality of comprehensive breast cancer care [ 48 , 49 ]. The findings of our research support those in the literature. It is thought that when motivational interviewing is used by public health nurses in their initiatives, it can contribute to increasing healthy lifestyle behaviors of individuals. Limitations and Recommendations During the interventions, an interpreter helped the researchers since the research sample included Syrian women who did not know Turkish. Due to the COVID-19 pandemic, the study, which was planned to be conducted in the Migrant Health Center, was conducted in groups of 3–5 participants in an open environment using personal protection in accordance with the social distance rules. Another limitation of the study is the small sample size. Implications for Nursing Practice Providing care to individuals from different cultures is a challenging task for nurses, especially if cultural factors prevent healthcare practices of individuals. The NNP may help protect individuals against life-threatening diseases such as cancer. It can be used by nurses together with the HBM to understand what motivates all individuals, including immigrants, to have health screenings for early detection of breast cancer and how they take action to keep their disease under control by taking the responsibility for their own health. Conclusion The NNP applied in the study led to an increase in the rate of breast cancer diagnosis practices and the rate of having BSE, CBE, and mammography in the experimental group. It was found that the women in the experimental group had a positive change in the perceived benefits, perceived barriers, CBCFS, and mammography self-efficacy scores compared to those in the control group. Based on the research findings, it is recommended that immigrant Syrian women should be supported in terms of breast cancer screening behaviors and the NNP should also be used for other disadvantaged women. It is also recommended that breast cancer screening training should be given to immigrant women with the support of an interpreter. Furthermore, supportive programs such as the NNP are recommended to be integrated into the practices of public health nurses. Declarations Funding Financial support was received from Samsun Ondokuz Mayıs University Scientific Research Projects Unit under 1904-B- PhD Thesis Projects (Project No: PYO.SBF.1904.21.001). Author Contribution All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by TYB and BA. The frst draft of the manuscript was written by TYB and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgement We would like to thank the institutions that allowed and supported us to conduct the study, and all the Syrian women who agreed to participate in the study. References World Health Organization (WHO) (2020) Cancer. https://www.who.int/news-room/fact-sheets/detail/cancer . Accessed 16 May 2022 Ministry of Health (2021) Türkiye public health institution. Breast Cancer Screening Program National Standards. Republic of Turkiye Ministry of Health General Directorate of Public Health Cancer Department. https://hsgm.saglik.gov.tr/tr/kanser-taramalari . Accessed 20 April 2022 Hashim MJ, Al-Shamsi FA, Al-Marzooqi NA et al (2018) The burden of breast cancer in the Arab world: Findings from global burden of disease. J Epidemiol Global Health 8(1–2):54–58 Kwok C, Endrawes G, Lee C (2016) Cultural Beliefs and Attitudes About Breast Cancer and Screening Practices Among Arabic Women in Australia. Cancer Nurs 39(5):367–374 Racine L, Andsoy I, Maposa S et al (2021) Examination of Breast Cancer Screening Knowledge, Attitudes, and Beliefs among Syrian Refugee Women in a Western Canadian Province. Can J Nurs Res 1–13 Alatrash M (2020) Prevalence, perceived benefits, and perceived barriers regarding breast cancer screening among three Arab American women subgroups. J Transcultural Nursing: Official J Transcultural Nurs Soc 31(3):242–249 Lofters AK, McBride ML, Li D et al (2019) Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study. BMC Cancer 19(42):1–11 Sacca L, Markham C, Fares J (2020) Using Intervention Mapping to Develop Health Education and Health Policy Components to Increase Breast Cancer Screening and Chemotherapy Adherence Among Syrian and Iraqi Refugee Women in Beirut, Lebanon. Front Public Health 8(101):1–25 Rollins L, Sy A, Crowell N et al (2018) Learning and action in community health: Using the Health Belief Model to assess and educate African American community residents about participation in clinical research. Int J Environ Res Public Health 15:1862 Mailloux C, Halesey E (2018) Patient navigators as essential members of the healthcare team: a review of the literature. J Nurs Patient 3(1):1–5 Hopkins J, Mumber MP (2009) Patient navigation through the cancer care continuum: An overview. J Oncol Pract 5(4):150–152 Percac-Lima S, Ashburner JM, Bond B et al (2013) Decreasing Disparities in Breast Cancer Screening in Refugee Women Using Culturally Tailored Patient Navigation. J Gen Intern Med 28:1463–1468 Saei Ghare Naz M, Simbar M, Rashidi Fakari F et al (2018) Effects of model-based interventions on breast cancer screening behavior of women: a systematic review. Asian Pac J Cancer Prev 19(8):2031–2041 Priaulx J, Turnbull E, Heijnsdijk E et al (2020) The influence of health systems on breast, cervical and colorectal cancer screening: an overview of systematic reviews using health systems and implementation research framework. J Health Serv Res Policy 25(1):49–58 Illaboya D, Gibson L, Musoke D (2018) Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach. Global Health 14(9):1–10 Sayed S, Ngugi AK, Mahoney MR et al (2019) Breast Cancer knowledge, perceptions and practices in a rural Community in Coastal Kenya. BMC Public Health 19:180 Grossman DC, Curry SJ, Owens DK et al (2018) Behavioral counseling to prevent skin cancer: us preventive services task force recommendation statement. JAMA 319(11):1134–1142 Roussi P, Miller SM, Giri VN et al (2018) Effects of a randomized trial comparing standard and enhanced counseling for men at high risk of prostate cancer as a function of race and monitoring style. J Health Psychol 23(14):1800–1809 Ghaffari M, Esfahani SN, Rakhshanderou S et al (2019) Evaluation of Health Belief Model-Based Intervention on Breast Cancer Screening Behaviors Among Health Volunteers. J Canc Educ 34:904–912 Taylan S, Çelik GK (2020) Breast cancer diagnostic behaviors in women with and without a family history of breast cancer. Cukurova Med J 45(4):1467–1475 Erdoğan E (2018) Comparison of mammography behaviors, health beliefs and fear levels of women with and without a family history of breast cancer. Unpublished Master Thesis. Akdeniz University Institute of Health Sciences, Department of Nursing, Antalya Champion VL (1999) Revised Susuceptibility, Benefits, and Barriers Scale for Mammography Screening. Res Nurs Health 22:341–348 Mikhail BI, Petro-Nustas W (2001) Transcultural adaptation of Champion’s Health Belief Model Scales. J Nurs Scholarsh 33(2):173–179 Champion V, Skinner CS, Menon U (2005) Development of a self-efficacy scale for mammography. Res Nurs Health 28:329–336 Al-Zalabani AH (2019) Adaptation and validation of the Arabic version of selfefficacy scale for mammography. Saudi Med J 40(7):707–713 Alyami M, Al-Sharef A, Al-Aseri M et al (2021) Mammography Self-efficacy Scale and Breast Cancer Fear Scale: Psychometric Properties of the Arabic Versions Among Saudi Women. Cancer Nurs 44(2):163–170 Masoudiyekta L, Rezaei-Bayatiyani H, Dashtbozorgi B et al (2018) Effect of Education Based on Health Belief Model on the Behavior of Breast Cancer Screening in Women. Asia Pac J Oncol Nurs 5(1):114–120 Kısa İ, Özkan G, Er F (2020) The Effect of Video Training on Breast Screening Methods and Follow-up on Awareness Level. J Kesit Acad 6(24):67–77 Kolutek R, Aydın Avci İ (2015) The effects of education and home follow-up on the knowledge and practices of married women about breast and cervical cancer. J Breast Health 11:155–162 Khiyali Z, Aliyan F, Kashfi SH et al (2017) Educational Intervention on Breast Self-Examination Behavior in Women Referred to Health Centers: Application of Health Belief Model. Asian Pac J Cancer Prev 18(10):2833–2838 Mahmoud MH, Sayed SH, İbrahim HA et al (2018) ) Effect of Health Belief Model-Based Educational Intervention About Breast Cancer on Nursing Students' Knowledge, Health Beliefs and Breast Self-Examination Practice. Int J Stud Nurs 3(3):77–90 Kayar N (2019) The effect of education about breast cancer and self-breast examination on breast cancer fear and health beliefs. Unpublished Master Thesis. Ordu University Health Sciences Institute, Department of Nursing El Saghir NS, de Celis ESP, Fares JE et al (2018) Cancer care for refugees and displaced populations: middle east conflicts and global natural disasters. Am Soc Clin Oncol Educ Book 38:433–438 Tuzcu A, Bahar Z, Gozum S (2016) Effects of interventions based on health behavior models on breast cancer screening behaviors of migrant women in Turkey. Cancer Nurs 39(2):E40–50 Ersin F, Bahar Z (2017) Effects of nursing interventions planned with the health promotion models on the breast and cervical cancer early detection behaviors of the women. Int J Caring Sci 10(1):421–432 Ma H, Ursin G, Xu X et al (2017) Reproductive factors and the risk of triple-negative breast cancer in white women and African-American women: a pooled analysis. Breast Cancer Res 19(1):6 Sharifikia I, Rohani C, Estebsari F et al (2019) Health Belief Model-based Intervention on Women's Knowledge and Perceived Beliefs about Warning Signs of Cancer. Asia-Pacific J Oncol Nurs 6(4):431–439 Khorsandi B, Khakbazan Z, Mahmoodzadeh HA et al (2020) Self-efficacy of the First-degree Relatives of Patients with Breast Cancer in the Prevention of Cancer: Using the Health Belief Model. J Canc Educ 35:977–982 Darvishpour A, Vajari SM, Noroozi S (2018) Can Health Belief Model Predict Breast Cancer Screening Behaviors? Open Access Maced J Med Sci 6(5):949–953 Grimley CE, Kato PM, Grunfeld EA (2019) Health and health belief factors associated with screening and help-seeking behaviours for breast cancer: A systematic review and meta-analysis of the European evidence. Br J Health Psychol 25(1):107–128 Khazir Z, Morrowati Sharifabad MA, Vaezi AA et al (2019) Predictors of mammography based on Health Belief Model in Khorramabad women. J Educ health promotion 8:180. https://doi.org/10.4103/jehp.jehp_63_19 Temuçin E, Nahcivan NO (2020) The effects of the nurse navigation program in promoting colorectal cancer screening behaviors: a randomized controlled trial. J Cancer Educ 35(1):112–124 Tomazelli JG, Silva GAE (2017) Breast cancer screening in Brazil: An assessment of supply and use of Brazilian National Health System health care network for the period 2010–2012. Epidemiol Serv Saude 26(4):713–724 Li C, Liu Y, Xue D et al (2020) Effects of nurse-led interventions on early detection of cancer: A systematic review and meta-analysis. Int J Nurs Stud 110:103684 Taymoori P, Habibi S (2014) Application of a health belief model for explaining mammography behavior by using structural equation model in women in Sanandaj. Sci J Kurdistan Univ Med Sci 19:103–115 Joffe M, Ayeni O, Norris SH et al (2018) Barriers to early presentation of breast cancer among women in Soweto, South Africa. PLoS ONE 13(2) Ruiter AC, Kessels LTE, Peters GY et al (2014) Sixty years of fear appeal research: current state of the evidence. Int J Psych 49(2):63–70 Riley S, Riley C (2016) The role of patient navigation in improving the value of oncology care. J Clin Pathways 2(1):41–47 Shockney LD (2016) The value of patient navigators as members of the multidisciplinary oncology care team. ASCO Daily News-The value of patient navigators Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies 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-4298638","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298477643,"identity":"5238cc55-dd5a-4c16-90df-2686f082b726","order_by":0,"name":"Tuba YILMAZ BULUT","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIie3QMUvDQBTA8RcC6XLS9Q0lfgLhpBAyCH6Vk4BZjDiVTEWXZLDi6uCHuE3cLgTpcrZrQhdF6FQkY4cUvEvWJK6C9x8eIcmPdwmAyfQnI3rgRE9RxejS5i71B0BL9LSyJ+lPKdia4G+kmXZ+lMQXvCHQT84xyior8clJuvxQBMOX0eMb398gjNN71rkFrwO0EiSeZCx7XmH0usidcqEOhvKdd5Mr2hLBhNjNMOJF4BREEaque8h035D1560gDoZUkbIeJl67pQggIwkyTTaDW+T3pQ8rTbagfjKecpl7mwlF0vctozTKC5jNXW8dflVVPD+my7ttuavP3HH60El09sHp2t/3els9/NhkMpn+eT9dJWHUNGWGoQAAAABJRU5ErkJggg==","orcid":"","institution":"Kocaeli University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Tuba","middleName":"YILMAZ","lastName":"BULUT","suffix":""},{"id":298477644,"identity":"36fdd4ea-5208-4748-a29a-2372f8b7dee6","order_by":1,"name":"Birsen ALTAY","email":"","orcid":"","institution":"Ondokuz Mayıs University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Birsen","middleName":"","lastName":"ALTAY","suffix":""}],"badges":[],"createdAt":"2024-04-20 19:39:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4298638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4298638/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55991781,"identity":"dd0b2464-566e-4be6-a015-439523b864cb","added_by":"auto","created_at":"2024-05-07 09:29:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48861,"visible":true,"origin":"","legend":"\u003cp\u003eNurse Navigation Program for Early Diagnosis of Breast Cancer by Health Belief Model\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4298638/v1/e7683b224246c6ec9d45147c.png"},{"id":55991782,"identity":"e28b3dd2-38da-4fc8-a439-770969ef1644","added_by":"auto","created_at":"2024-05-07 09:29:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38507,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT 2010 Patient Flow Diagram.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4298638/v1/b0cb6bd7f492fe86e22173af.png"},{"id":100159091,"identity":"09df96c7-f5dc-47dd-b971-58a8f3d8618f","added_by":"auto","created_at":"2026-01-13 14:39:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1807096,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4298638/v1/37c68335-7094-4ee3-842d-5ce8a294f480.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of the Nurse Navigation Program Applied to Immigrant Syrian Women on their Beliefs on Breast Cancer Screening Behaviors, Mammography Self-Efficacy, and Breast Cancer Fears: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common type of cancer in the world. It is also the most common type of cancer among Syrian women [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The incidence of breast cancer is 46.3 per hundred thousand worldwide, while it is 45.6 per hundred thousand in Turkey, the country hosting the highest number of Syrian refugees [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is also observed that the incidence of breast cancer is continuously and epidemiologically increasing among the migrant Arab women [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite the high prevalence of breast cancer, it is reported that the ethnocultural group with the lowest incidence of breast cancer screening programs is Arabic-speaking immigrants, including the Syrians [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although breast cancer is very common throughout the world, it can be diagnosed at an early stage when early diagnostic practices against cancer are taught to individuals [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCultural factors and exceptional circumstances such as war affect the cancer process by creating barriers to early diagnosis practices. Although national cancer screening in Turkey is free and accessible for all citizens, disadvantaged groups cannot benefit from this service. Studies have shown that Syrian women do not practice clinical breast examination (CBE) in the countries they migrated to because of their religious beliefs and cultural perceptions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and mammography rates were also found to be quite low among Syrian women [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There are various models to ensure the feasibility of breast cancer early diagnosis screening against such barriers. One of these models is the Health Belief Model (HBM), which is used to determine the beliefs of individuals about a health behavior and take the necessary measures in case of negative beliefs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother practice that may increase the prevalence of breast cancer screening is the nurse navigation program (NNP). Barriers to screening can be eliminated with the help of a navigator nurse serving individuals from different cultures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This system aims to reduce racial, ethnic and financial inequalities in care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies have shown that the NNP to be applied for the early diagnosis of cancer increases the early diagnostic practices of individuals for breast cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The NNP is a life-saving model especially for disadvantaged individuals. The HBM is also one of the most effective models that can be applied to develop self-efficacy and beliefs about early breast cancer diagnostic practices, to diagnose breast cancer at an early stage and start treatment, and to have mammography, CBE, and breast self-examination (BSE).\u003c/p\u003e \u003cp\u003eFear is thought to have an effect on breast cancer screening. It has been reported in some studies that thoughts such as catching the disease, pain, the idea of ​​losing the breast, and death emerge due to fear, which prevents breast cancer screening [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Individuals do not want to adopt early diagnostic practices due to the fear of being diagnosed with breast cancer. It is significant for nurses to provide training and counseling services with the NNP so that women adopt early diagnostic practices for cancer [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur literature review revealed that studies on the breast cancer early diagnostic practices of Syrian women based on the HBM are quite limited in Turkey. Studies conducted abroad revealed that the NNP is used in both the diagnosis and treatment phases of breast cancer. This study is thought to contribute to the field of nursing as it includes the application of the NNP to the Syrian women living in Turkey based on the HBM. It aims to investigate the effect of the NNP administered to the Syrian women living in Turkey based on the HBM on their beliefs on breast cancer screening behaviors, mammography self-efficacy, and breast cancer fears.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eHypothesis 0:\u003c/strong\u003e The Nurse Navigation Program applied based on the HBM does not affect the breast cancer screening behaviors, beliefs about the breast cancer screening methods, mammography self-efficacy, and breast cancer fear levels of the Syrian women in the experimental and control groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 1a:\u003c/strong\u003e Following the nursing interventions, the breast cancer screening behavior of the women in the experimental group will increase compared to the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 1b:\u003c/strong\u003e Following the nursing interventions, a positive difference will occur in the health beliefs of the women in the experimental group about early diagnostic practices compared to the women in the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 1c:\u003c/strong\u003e Following the nursing interventions, the mammography self-efficacy scores of the women in the experimental group will increase compared to the women in the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis 1d:\u003c/strong\u003e Following the nursing interventions, the breast cancer fear scores of the women in the experimental group will decrease compared to the women in the control group.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis single-blind randomized controlled study was conducted in June-October 2021 with the pretest-posttest control group design.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Setting\u003c/h2\u003e \u003cp\u003eThe study was carried out between June-October 2021 in Sultanbeyli district of Istanbul. The target population of the study consisted of Syrian women aged 40\u0026ndash;69 who were under temporary protection and were admitted to the Migrant Health Center. Clinical breast examination is performed free of charge in this center. However, there is no mammography device.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: (a) being between the ages of 40\u0026ndash;69 (Ministry of Health, 2020), (b) being a Syrian immigrant woman, (c) not having been diagnosed with breast cancer, (d) not being pregnant, not breastfeeding, and not being in the postpartum period, (e) not having received training on breast cancer, (f) volunteering to participate in the study, (g) being literate, accessible, and ready to communicate and (h) having immigrated to Turkey at least one year ago.\u003c/p\u003e \u003cp\u003eThe exclusion criteria are as follows: (a) having experienced breast cancer before, (b) performing BSE every month (c) having a mammography every two years, (d) having CBE once a year, and (e) having had mastectomy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEthic Approval Statement\u003c/h2\u003e \u003cp\u003ePrior to the study, Ethics Committee approval (No: 220/132) was obtained from the Presidency of XXXX Social and Human Sciences Ethics Committee and the Department of Migration Policies and Projects of the General Directorate of Migration Management (No: 62103649000E.20374). Then, an institutional approval was obtained from XXXX Provincial Directorate of Health (E-15916306-604.01.01) in order to conduct the study at the Migrant Health Center. The participants were informed about the purpose of the study prior to the intervention, and their written consent was obtained. The research conforms to the provisions of the Declaration of Helsinki (as revised in Brazil 2013). All participants gave informed consent for the research, and that their anonymity was preserved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSample Size and Randomization\u003c/h2\u003e \u003cp\u003ePower analysis was performed using the G*Power 3.1 program to calculate sample size. Considering the the Health Belief Model Scale [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], Champion Breast Cancer Fear Scale [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and Mammography Self-Efficacy Scale [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] mean scores, the required sample size was determined as 134 at 95% confidence interval, 5% margin of error, 0.63 effect size, and 95% power. A total of 150 participants (75 participants in the experimental group and 75 participants in the control group) were recruited for the study with approximately 12% (16 people) extra participants, taking a possible data loss into account. The research sample was selected using the simple random sampling method.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and retention\u003c/h2\u003e \u003cp\u003eParticipants were recruited from among the women who applied to the Migrant Health Center Family Medicine Polyclinic for any complaint. Those who met the inclusion criteria were given a pseudonmy and number. The participants in the sample pool were assigned to the experimental group and the control group using the Research Randomizer program. Each group consisted of 75 participants. During the research period, none of the participants withdrew from the study.\u003c/p\u003e \u003cp\u003eIn the study, blinding was ensured by randomly assigning the Syrian women to the experimental and control groups. It was also ensured that the participants did not know which group they were in. Following the data collection process, the data was entered into the IBM SPSS V23 program in the form of \u0026ldquo;first group\u0026rdquo; and \u0026ldquo;second group\u0026rdquo;. Data analysis was performed by a statistician who did not know which set of data belonged to which group. The results pertaining to the groups were reported when the statistical analysis was completed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInterventions\u003c/h2\u003e \u003cp\u003eThe intelligibility of the Personal Information Form was tested by piloting the form on 10 Syrian women with the same characteristics as the Syrian women in the study.\u003c/p\u003e \u003cp\u003eThe NNP program (early diagnostic practices against cancer, cancer screening consultancy, motivational interviews, reminder phone calls, nurse-based call guidance) was applied to the women in the experimental group based on the HBM over a four-month period. The training content of the NNP program was prepared based on the HBM. 75 women in the experimental group were divided into groups of 5 people, and in the first month of the study, they were informed about the purpose and the content of the study and were asked to sign the informed consent form. Following the first interaction with the participants, the \u0026lsquo;Nurse-led Screening Consultancy Telephone Support Line\u0026rsquo; was established for the Syrian women within the scope of the NNP. The participants were administered the pre-tests in the second month. The pre-tests were the Personal Information Form, the Health Belief Model Scale-Arabic Form, the Mammography Self-Efficacy Scale-Arabic Form, and the Champion Breast Cancer Fear Scale-Arabic Form. These pre-tests were administered by the researcher using the face-to-face interview technique. In addition, the participants were given a BSE calendar. Following the administration of the pre-tests, the participants in the experimental group were given training on the early diagnosis of breast cancer during the third month. The training sessions included information on the early breast cancer screening practices and the demonstration of BSE on a model. All trainings were given by the principal investigator with professional translators who received medical training. Breast cancer case presentations were also made. The women in the experimental group were distributed the \u0026ldquo;Training Booklet on Increasing Breast Cancer Screening Behaviors of Migrant Women\u0026rdquo; prepared according to the HBM. The booklet includes the content of the training. Then, face-to-face motivational interviews were held with women for breast cancer early screening practices, and first reminder phone calls were made. Motivational interviews were conducted by the principal researcher with the support of professional translators. The use of an interpreter in motivational interviews did not have a negative effect on the research. In the last month, all participants were called by phone every week, 4 times in total, and reminders were made within the scope of the reminder telephone counseling.\u003c/p\u003e \u003cp\u003eAt the end of the 4th month, the data collection forms and scales were administered again as post-tests and also the Post-Training Screening Behavior Follow-up Form was administered. The pre and post-test scores of the participants were used to evaluate the effectiveness of the training. After the research was completed, all trainings given to the experimental group were also given to the individuals in the control group and the training booklet was distributed.\u003c/p\u003e \u003cp\u003eInsert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003ePersonal Information Form\u003c/strong\u003e \u003cp\u003eThe form was developed by the researchers and consists of 31 questions on participants\u0026rsquo; socio-demographic characteristics, beliefs on early diagnostic practices, genetic characteristics, and early diagnostic practices for cancer. The form was prepared in Turkish and translated into Arabic by two expert linguists who know both languages very well.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth Belief Model Scale\u003c/b\u003e: The scale is used to reveal the beliefs and attitudes of individuals towards breast cancer, BSE, CBE, and mammography. It was developed in 1984 and revised in 1999 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Cronbach\u0026rsquo;s alpha of the original scale varies between .65-.90, and the test- retest correlations vary between .40-.68 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Arabic validity and reliability study of the scale was conducted by Mikhail and Petro-Nustas (2001) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The items are on a five-point Likert type scale and the items under the factors are as follows: perceived severity (8\u0026ndash;40), perceived BSE benefits (6\u0026ndash;30), perceived barriers to BSE (7\u0026ndash;35), perceived susceptibility (5\u0026ndash;25), perceived health motivation (6\u0026ndash;30), perceived BSE self-efficacy (9\u0026ndash;45), perceived CBE benefits (5\u0026ndash;25), perceived barriers to CBE (4\u0026ndash;20), perceived mammography benefits (2\u0026ndash;10), and perceived barriers to mammography (10\u0026ndash;50). Higher scores indicate increasing perception of susceptibility and severity, and higher levels of perceived health motivation, benefits, barriers, and self-efficacy. In this study, all subdimensions of the scale were investigated. The items under the perceived barriers sub-dimension are reverse-coded. Written permission was obtained from the author to use the scale in the study. In this study, the Cronbach\u0026rsquo;s alpha values of the factors of the HBM varied between .70 and .95 for the pre-test and between .74 and .98 for the post-test.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMammography Self-Efficacy Scale\u003c/strong\u003e \u003cp\u003eThe scale was developed by Champion et al. in 2005. The Cronbach\u0026rsquo;s alpha of the original scale is .87 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Al-Zalabani (2019) conducted the Arabic validity-reliability study of the scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The scale consists of 10 items to evaluate the perceived self-efficacy of women for mammography screening. The items are rated on a five-point Likert type scale. The total score that can be obtained from the scale varies between 10 and 50 points, and higher total scores indicate higher levels of self-efficacy. Al-Zalabani (2019) found the Cronbach\u0026rsquo;s alpha of the scale as .88 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The Cronbach\u0026rsquo;s alpha of the scale in this study is .87 for the pre -test and .95 for the post-test.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eChampion Breast Cancer Fear Scale (CBCFS)\u003c/b\u003e: The scale consists of eight items. It was translated into Arabic by Alyami et al. in 2019. The validity and reliability study was conducted and published in 2021. The items in the scale are rated on a five-point Likert type scale [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The lowest score to be obtained from the scale is 8 and the highest score is 40. Based on the score, the levels of fear about breast cancer are as follows: Low fear (8\u0026ndash;15 points), moderate fear (16\u0026ndash;23 points), and high fear (24\u0026ndash;40 points). For the Arabic version of the scale, the Cronbach's alpha is .94, and the corrected item total correlations vary between .74 and .81 for each item [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The Cronbach\u0026rsquo;s alpha in the current study is .94 for the pre -test and .95 for the post-test.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDevelopment of the Training Materials\u003c/strong\u003e \u003cp\u003eColored and illustrated training booklets were distributed to the participants both in Arabic and in Turkish to increase the effectiveness of the practices.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eInsert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using the IBM SPSS V23 package program. Compliance with normal distribution was examined with the Kolmogorov-Smirnov test. Chi-square and Fisher\u0026rsquo;s Exact tests were used to compare the categorical variables according to groups. The McNemar test was performed to compare the categorical variables with two states according to the in-group pre-test and post-test. The Wilcoxon test was used to compare the categorical variables with three or more states according to the in-group pre-test and post-test. The Friedman test was performed to reveal the differences between groups across pre and post-tests. The Mann-Whitney U test was conducted to compare the data that did not show normal distribution across groups. The Wilcoxon test was also performed to compare the pre and post-test scores that did not show normal distribution within the group. The results of the analyses were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median (minimum - maximum) for quantitative data and as frequency (percentage) for categorical data. The level of significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.050.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResearch Budget\u003c/h2\u003e \u003cp\u003eFinancial support was received from XXXX University Scientific Research Projects Unit under 1904-B- PhD Thesis Projects (Project No: PYO.SBF.1904.21.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the research, 90.7% of the participants in the experimental group were married, 44% were primary school graduates, 82.7% had three or more children, 49.3% worked, and 70.7% smoked. 89.3% of the participants in the control group were married, 49.3% were primary school graduates, 66.7% had three or more children, and 72% smoked.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Comparison of the Frequency of BSE, CBE and Mammography Application of Women in the Experimental and Control Groups Before and After the İntervention (n=150)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.295081967213115%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.147540983606557%\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperimental Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.540983606557376%\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.672131147540984%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.967213114754099%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.091653027823241%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.495908346972175%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.566284779050736%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.857610474631752%\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.783960720130933%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.947626841243862%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.2569558101473%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003epre -test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.131147540983605%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of BSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.475409836065573%\" colspan=\"3\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.504273504273506%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eWith irregular intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.965811965811966%\" colspan=\"3\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068376068376068%\" colspan=\"6\"\u003e\n \u003cp\u003e6 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.598290598290598%\" colspan=\"2\"\u003e\n \u003cp\u003e9 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.017094017094017%\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" rowspan=\"2\"\u003e\n \u003cp\u003e.494\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.44549763033175%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eWho never did\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.587677725118482%\" colspan=\"3\"\u003e\n \u003cp\u003e72 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.274881516587676%\" colspan=\"6\"\u003e\n \u003cp\u003e69 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.691943127962086%\" colspan=\"2\"\u003e\n \u003cp\u003e141 (94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.131147540983605%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of BSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.475409836065573%\" colspan=\"3\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.504273504273506%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eOnce a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.965811965811966%\" colspan=\"3\"\u003e\n \u003cp\u003e57 (76)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.068376068376068%\" colspan=\"6\"\u003e\n \u003cp\u003e1 (1.3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.598290598290598%\" colspan=\"2\"\u003e\n \u003cp\u003e58 (38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.017094017094017%\" colspan=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003e=130.417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.44549763033175%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eWith irregular intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.587677725118482%\" colspan=\"3\"\u003e\n \u003cp\u003e18 (24)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.274881516587676%\" colspan=\"6\"\u003e\n \u003cp\u003e5 (6.7)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.691943127962086%\" colspan=\"2\"\u003e\n \u003cp\u003e23 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"46.44549763033175%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eWho never did\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.587677725118482%\" colspan=\"3\"\u003e\n \u003cp\u003e0 (0)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.274881516587676%\" colspan=\"6\"\u003e\n \u003cp\u003e69 (92)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.691943127962086%\" colspan=\"2\"\u003e\n \u003cp\u003e69 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.016393442622952%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.59016393442623%\" colspan=\"5\"\u003e\n \u003cp\u003eZ=-7.918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\n \u003cp\u003eZ=-0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.016393442622952%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.59016393442623%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\n \u003cp\u003e.763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre -test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.60655737704918%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBE status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.114754098360656%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.504273504273506%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eWith irregular intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.017094017094017%\" colspan=\"4\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" colspan=\"5\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.307692307692308%\" colspan=\"3\"\u003e\n \u003cp\u003e4 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.478632478632479%\" rowspan=\"2\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" rowspan=\"2\"\u003e\n \u003cp\u003e1.000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.475638051044086%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003eNever done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.02552204176334%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e73 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.79350348027842%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e73 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.705336426914155%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e146 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.60655737704918%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBE status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.114754098360656%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.163934426229508%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.442622950819672%\" colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.98293515358362%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003eWith irregular intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.651877133105803%\" colspan=\"4\"\u003e\n \u003cp\u003e5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.79863481228669%\" colspan=\"4\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.286689419795222%\" colspan=\"3\"\u003e\n \u003cp\u003e8 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.457337883959044%\" rowspan=\"3\"\u003e\n \u003cp\u003e=50.370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.822525597269625%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.4537037037037%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003eOnce made\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\" colspan=\"4\"\u003e\n \u003cp\u003e38 (50.7)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.36111111111111%\" colspan=\"4\"\u003e\n \u003cp\u003e1 (1.3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" colspan=\"3\"\u003e\n \u003cp\u003e39 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.4537037037037%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003eNever done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.51851851851852%\" colspan=\"4\"\u003e\n \u003cp\u003e32 (42.7)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.36111111111111%\" colspan=\"4\"\u003e\n \u003cp\u003e71(94.7)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" colspan=\"3\"\u003e\n \u003cp\u003e103 (68.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.105090311986864%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.541871921182267%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.091954022988507%\" colspan=\"6\"\u003e\n \u003cp\u003eZ=-6.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31527093596059%\" colspan=\"4\"\u003e\n \u003cp\u003eZ=-1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.180623973727421%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.464696223316913%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.300492610837438%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.105090311986864%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.541871921182267%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.091954022988507%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.31527093596059%\" colspan=\"4\"\u003e\n \u003cp\u003e.317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.180623973727421%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.464696223316913%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.300492610837438%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.105090311986864%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre -test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.541871921182267%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMammography status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.97208538587849%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" colspan=\"3\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.748768472906406%\" colspan=\"6\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.986863711001641%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.300492610837438%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.794871794871796%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eHad mammography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.726495726495726%\" colspan=\"5\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.282051282051283%\" colspan=\"3\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.871794871794872%\" colspan=\"5\"\u003e\n \u003cp\u003e5 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.478632478632479%\" rowspan=\"2\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" rowspan=\"2\"\u003e\n \u003cp\u003e1.000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.15545243619489%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eHad\u0026rsquo;t mammography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.34570765661253%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e73 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.31322505800464%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e72 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.185614849187935%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e145 (96.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.105090311986864%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.541871921182267%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMammography status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.97208538587849%\" colspan=\"4\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" colspan=\"3\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.748768472906406%\" colspan=\"6\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.986863711001641%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.300492610837438%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.794871794871796%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eHad mammography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.726495726495726%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e61 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.991452991452991%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.162393162393162%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e66 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.478632478632479%\" rowspan=\"2\"\u003e\n \u003cp\u003e=84.848\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.846153846153847%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.15545243619489%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eHad\u0026rsquo;t mammography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.34570765661253%\" colspan=\"5\"\u003e\n \u003cp\u003e14 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.633410672853827%\" colspan=\"4\"\u003e\n \u003cp\u003e70 (93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.865429234338748%\" colspan=\"4\"\u003e\n \u003cp\u003e84 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.491803278688526%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistics\u003csup\u003ec\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.950819672131148%\" colspan=\"4\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.80327868852459%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.967213114754099%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.098360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.491803278688526%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.950819672131148%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.40983606557377%\" colspan=\"6\"\u003e\n \u003cp\u003e.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.80327868852459%\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.967213114754099%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.278688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e: Ki-kare test statistics, F: Fisher Exact test, Z: Wilcoxon test statistics,\u0026nbsp;\u003csup\u003ec\u003c/sup\u003eMcNemar test, \u0026nbsp;\u003csup\u003ea-b\u003c/sup\u003e: There is no difference between groups with the same letter\u003c/p\u003e\n\u003cp\u003eAbbreviations: BSE, breast self-examination; CBE, clinical breast examination.\u003c/p\u003e\n \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn the experimental group, a statistically significant difference was found between the pre-test and post-test frequency of having BSE scores (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). While 96% of the participants in the experimental group stated that they never had BSE in the pre-test, this rate decreased to 0% in the post-test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the experimental group, a statistically significant difference was found between the pre-test and post-test frequency of having CBE and mammography scores (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). After the intervention, 81.3% of the participants in the experimental group and 6.7% of the participants in the control group had mammography. Before the intervention, only 2.7% of the participants reported that they had mammography, while this rate increased to 81.3% after the intervention (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo statistically significant difference was found between the pre-intervention median scores of the experimental and control groups (p\u0026thinsp;\u0026gt;\u0026thinsp;.050)\u003c/p\u003e \u003cp\u003eInsert 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\u003eDistribution of Medians of HBM Scale Sub-Dimensions for Pre-Intervention and Post-Intervention Breast Cancer Among Women in The Experimental and Control Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eOrtanca (Min - Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eOrtanca (Min - Max)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived susceptibility (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e15 (5\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.485\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived susceptibility (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e19 (7\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;1197.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-6.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.401\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived severity (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c4\" namest=\"c3\" rowspan=\"2\"\u003e \u003cp\u003e22 (8\u0026ndash;37)\u003c/p\u003e \u003cp\u003e20 (8\u0026ndash;39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e22 (8\u0026ndash;32)\u003c/p\u003e \u003cp\u003e22 (8\u0026ndash;38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.968\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived severity (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-1.247\u003c/p\u003e \u003cp\u003e.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-1.388\u003c/p\u003e \u003cp\u003e.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived health motivation (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22 (6\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (9\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived health motivation (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e24 (9\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 (12\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-4.958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-1.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived BSE benefit (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22 (9\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (6\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2513.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived BSE benefit (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30 (6\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (6\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;646\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-6.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.808\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived BSE self-efficacy (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e27 (9\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (9\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2774.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.882\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived BSE self-efficacy (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e45 (9\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (9\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;434.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ\u0026thinsp;=\u0026thinsp;1.232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived CBE benefit (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e18 (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (10\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived CBE benefit (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e23 (13\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;387.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-6.792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.334\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived mammography benefit (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (2\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (3\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2695.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.615\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived mammography benefit (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9(2\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-7.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-1.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to BSE (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e20 (7\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (7\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2757\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to BSE (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (7\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (7\u0026ndash;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;283.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-7.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to CBE (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e10 (4\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (4\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2484.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to CBE (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7 (4\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (4\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;1689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-4.455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.620\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to mammography(Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e30 (16\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (22\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived barriers to mammography(Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e18 (10\u0026ndash;39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (11\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eZ=-7.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-0.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.754\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eU: Mann-Whitney U test statistics, Z: Wilcoxon test statistics\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eAbbreviations: BSE, breast self-examination; CBE, clinical breast examination; HBM, Health Belief Model\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen the results for the groups were compared, a statistically significant difference was found in terms of median post-test health motivation and perceived severity scores ​​(p\u0026thinsp;=\u0026thinsp;.002).\u003c/p\u003e \u003cp\u003eThe comparison of the post-test scores of the groups revealed a statistically significant difference between the perceived susceptibility, perceived BSE benefits, perceived BSE self-efficacy, perceived CBE benefits, perceived mammography benefits, perceived barriers to BSE, and perceived barriers to mammography scores of the experimental group and those of the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eThe perceived susceptibility, perceived health motivation, perceived BSE benefits, perceived BSE self-efficacy, perceived CBE benefits, and perceived mammography benefits post-test median scores of the experimental group increased after the intervention compared to the pre-test scores. This increase was found to be statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003e After the intervention, the participants in the experimental group were found to have lower median scores for the sub-dimensions of perceived barriers to BSE, perceived barriers to CBE, and perceived barriers to mammography. The decrease was found to be statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.001)\u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\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\u003eComparison of Pre-Intervention and Post-Intervention Mammography Self-Efficacy Scale, CBCFS and BSE Knowledge Test Medians of Women in the Experimental and Control Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMedian (Min - Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian (Min - Max)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMammography self-efficacy(Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (10\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (10\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2802.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.970\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMammography self-efficacy(Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (21\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (10\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;172.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ=-7.401\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ=-1.517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCBCFS (Pre -test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (8\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (8\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;2304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCBCFS (Post-test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (8\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (8\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;1199.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ=-5.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ=-0.207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eU: Mann-Whitney U test statistics, Z: Wilcoxon test statistics\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations: BSE, breast self-examination; CBCFS, Champion Breast Cancer Fear Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA statistically significant difference was found in the experimental group between mammography self-efficacy and CBCFS median pre-test and post-test scores (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). A statistically significant difference was found between the groups in terms of post-test mammography self-efficacy and CBCFS median scores ​(p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\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\u003eComparison of The Mammography Status of the Experimental Group After the Nursing İnterventions According to The Motivational Phone Calls Made Within the Scope of NNP\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 \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eMammography after nursing interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHad mammography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAppointment taker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eWho wıll have\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eHad\u0026rsquo;t mammography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTelephone call 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9.3)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\chi }^{2}\\)\u003c/span\u003e\u003c/span\u003e=116.388\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTelephone call 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (26.7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (18.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37 (49.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTelephone call 3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (52)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (22.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTelephone call 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (80)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (17.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003e\u003cem\u003eX\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e: Friedman test statistics, a-b: There is no difference between groups with the same letter\u003c/p\u003e\n\u003cp\u003eAbbreviations: NNP, nurse navigation program.\u003c/p\u003e\n\u003cp\u003eThe motivational phone calls within the scope of the NNP caused an increase in the mammography screening scores of the experimental group. A statistically significant difference was found between the motivational telephone calls (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), which was due to the difference between call 1 and calls 3 and 4 and between call 2 and calls 3 and 4. 9.3% of the participants were found to have mammography after call 1, 26.7% after call 2, 52% after call 3, and 80% after call 4.\u003c/p\u003e \u003cp\u003eWith the help of the BSE reminder calendar, 85.3% of the women in the experimental group stated that they now have BSE once a month.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study revealed that the participants in the experimental group had an increased tendency to have BSE. In Turkey, the Ministry of Health recommends regular BSE every month as it is thought that individuals will have increased awareness of breast cancer with BSE. Previous studies found that different nursing practices have increased the rates of BSE [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Research has shown that when women have higher levels of knowledge about breast cancer, their BSE behavior increases [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Thus, the change in the rates of BSE in the women in the experimental group is an expected finding.\u003c/p\u003e \u003cp\u003eOur findings further revealed that the rate of CBE increased in the experimental group, which received the NNP. Previous studies including the HBM also reported an increase in the CBE rates of the participants [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, the post-test results revealed that the participants in the experimental group had higher mammography scores than those in the control group. Similar studies which applied the HBM reported that the mammography screening behaviors of women increased after the intervention [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. One study conducted with refugee women showed that the patients who had the NNP intervention had higher mammography rates [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The higher mammography scores in the experimental group in our study can be attributed to the fact that, based on the National Cancer Screening Standards, the age limit in the study was minimum 40, and that there was a mobile mammography truck where the research was conducted and all the participants were accompanied to this mobile unit one by one. The mobile mammography unit facilitated access to the mammography device, which is thought to contribute to the high rate of mammography among the participants at the end of the study.\u003c/p\u003e \u003cp\u003eBased on the findings, the \u003cb\u003eH\u003c/b\u003e\u003csub\u003e\u003cb\u003e1a\u003c/b\u003e\u003c/sub\u003e \u003cb\u003ehypothesis\u003c/b\u003e (Following the nursing attempts, the breast cancer screening behavior of the women in the experimental group will increase compared to the control group) has been accepted (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter the intervention, the participants in the experimental group were found to have higher levels of perceived susceptibility sub-dimension median score. One study conducted with Syrian refugees in Jordan reported that low levels of perceived susceptibility affect women's breast cancer screening practices [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Previous studies also revealed that following the interventions based on the HBM, a significant increase was observed in the perceived susceptibility towards cancer [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Our study also revealed that the participants in the experimental group had higher levels of perceived susceptibility towards breast cancer after the intervention.\u003c/p\u003e \u003cp\u003eThe median perceived severity score of the control group was found to be higher than that of the experimental group after the intervention. Previous studies conducted with Syrian immigrants revealed that perceived severity has an effect on women's breast cancer screening practices [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. On the other hand, some studies reported that perceived severity does not affect the beliefs of individuals regarding breast cancer early diagnostic practices [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. It can be stated that the present study helped increase women\u0026rsquo;s practices for early diagnosis of breast cancer; however, women should be supported in terms of belief development.\u003c/p\u003e \u003cp\u003eThe post-test health motivation median score of the experimental group was found to be higher compared to the pre-test score. Similar findings were obtained in the literature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. It can be stated that the NNP was very effective in raising the health motivation of the women about breast cancer, which is one of the goals of the NNP, and thus it can be widely used to increase the health motivation of immigrant women who are considered to be in the disadvantaged group.\u003c/p\u003e \u003cp\u003eThe post-test results revealed that the Syrian women in the experimental group had higher perceived BSE benefits median score even in the fourth month after the intervention. Previous studies which applied various nursing interventions based on the HBM reported an increase in perceived BSE benefits scores of participants [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. One study conducted with immigrant Syrian women based on the HBM found that perceived BSE benefits decreased as the perceived barriers to BSE increased [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our findings coincide with those in the literature and it can be stated that the NNP is effective in increasing the perceived BSE benefits.\u003c/p\u003e \u003cp\u003eThe study revealed that after the intervention, the participants in the experimental group had a higher perceived BSE self-efficacy median score. Previous studies also showed that the participants in the experimental group had higher levels of BSE self-efficacy after the interventions based on the HBM [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Our findings revealed that the NNP positively affected perceived BSE self-efficacy and attitudes of women in the experimental group.\u003c/p\u003e \u003cp\u003eFurthermore, the experimental group was found to have a higher perceived CBE benefits median score after the intervention. Previous studies conducted using the HBM revealed an increase in the perceived CBE benefits after the intervention [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. It can be stated that following the intervention, the beliefs and attitudes of women in the experimental group toward CBE were more positive than the control group.\u003c/p\u003e \u003cp\u003e It was found that the participants in the experimental group had a higher perceived mammography benefits median score after the intervention. It was revealed that perceived benefits directly supported the behavior of having mammography. This finding coincides with those in previous studies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Studies revealed that following the HBM interventions, participants in the experimental group obtained a higher perceived mammography benefit score compared to the control group [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A study conducted in Brazil showed that the NNP helped fill the time gap between encouraging patients to have mammography and following up patients until diagnosis [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our findings coincide with those in the literature. The results suggest that individuals have more control over their own health with the HBM, and thus, public health nurses can safely use this model to protect the health of individuals.\u003c/p\u003e \u003cp\u003eAnother finding of the study is that the participants in the experimental group had a lower perceived barriers to BSE median score after the intervention, while there was no change in the control group. This finding can be attributed to the fact that the NNP focuses on eliminating various barriers such as selection of screening methods and timing of screening in early diagnostic practices for cancer [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In addition, previous studies revealed that as a result of the HBM-based interventions, the mean perceived barriers to BSE score of the women in the experimental group decreased compared to the control group [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our study also revealed that the NNP positively supported participants\u0026rsquo; perceived barriers to BSE.\u003c/p\u003e \u003cp\u003eThe inter-group analyses further revealed that the perceived barriers to CBE median score of the experimental group was lower than that of the control group. Studies which applied some nursing interventions based on the HBM within the scope of breast cancer screening revealed a significant decrease in the perceived barriers to early diagnostic practices score [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. It is thought that in our study, the NNP was effective in reducing perceived barriers to CBE in the experimental group.\u003c/p\u003e \u003cp\u003eIn addition, the perceived barriers to mammography score of the experimental group decreased after the intervention. Similar to our study, previous studies also reported a significant decrease in the perceived barriers to mammography score in the experimental group [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Our study found that perceived barriers prevent people from having mammography.\u003c/p\u003e \u003cp\u003eBased on these results, the \u003cb\u003eH\u003c/b\u003e\u003csub\u003e\u003cb\u003e1b\u003c/b\u003e\u003c/sub\u003e \u003cb\u003ehypothesis\u003c/b\u003e (Following the nursing interventions, a positive difference will occur in the health beliefs of the women in the experimental group about early diagnostic practices compared to the women in the control group) was accepted (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the experimental group, mammography self-efficacy median score increased after the intervention. Similar results were obtained in previous studies conducted based on the HBM [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Mammography is important in breast cancer screening. The increase in mammography self-efficacy levels may make it easier for nurses to detect breast cancer cases earlier. Thus, it is thought that it will both ensure the diagnosis of the disease before it progresses and contribute to minimizing the psychological and material damage.\u003c/p\u003e \u003cp\u003eConsidering this finding of the study, the \u003cb\u003eH\u003c/b\u003e\u003csub\u003e\u003cb\u003e1c\u003c/b\u003e\u003c/sub\u003e \u003cb\u003ehypothesis\u003c/b\u003e (Following the nursing interventions, the mammography self-efficacy scores of the women in the experimental group will increase compared to the women in the control group) was accepted (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe median CBCFS score of the participants in the experimental group decreased after the intervention. Studies define fear as one of the factors that prevent early diagnostic practices for breast cancer [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, some studies define fear as a convincing factor that promotes motivation and self-protection in breast cancer [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Kayar (2019) found that breast cancer fear scale scores increased in the experimental group following the intervention [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In this study, the decrease in the CBCFS scores contributed to the increase in women's breast cancer early diagnostic practices.\u003c/p\u003e \u003cp\u003eBased on this finding, the \u003cb\u003eH\u003c/b\u003e\u003csub\u003e\u003cb\u003e1d\u003c/b\u003e\u003c/sub\u003e \u003cb\u003ehypothesis\u003c/b\u003e (Following the nursing interventions, the breast cancer fear scores of the women in the experimental group will decrease compared to the women in the control group) was accepted (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe motivational telephone calls within the scope of the NNP led to an increase in the mammography scores of the experimental group. Studies have shown that in breast cancer, interventions including a training program integrated with patient reminders or motivational interviews increase early diagnostic practices of individuals such as mammography, CBE, and BSE [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Some studies found that early diagnostic practices against cancer and navigation services such as phone calls, follow-up, and trainings increase the quality of comprehensive breast cancer care [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The findings of our research support those in the literature. It is thought that when motivational interviewing is used by public health nurses in their initiatives, it can contribute to increasing healthy lifestyle behaviors of individuals.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Recommendations\u003c/h2\u003e \u003cp\u003eDuring the interventions, an interpreter helped the researchers since the research sample included Syrian women who did not know Turkish. Due to the COVID-19 pandemic, the study, which was planned to be conducted in the Migrant Health Center, was conducted in groups of 3\u0026ndash;5 participants in an open environment using personal protection in accordance with the social distance rules. Another limitation of the study is the small sample size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Nursing Practice\u003c/h2\u003e \u003cp\u003eProviding care to individuals from different cultures is a challenging task for nurses, especially if cultural factors prevent healthcare practices of individuals. The NNP may help protect individuals against life-threatening diseases such as cancer. It can be used by nurses together with the HBM to understand what motivates all individuals, including immigrants, to have health screenings for early detection of breast cancer and how they take action to keep their disease under control by taking the responsibility for their own health.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe NNP applied in the study led to an increase in the rate of breast cancer diagnosis practices and the rate of having BSE, CBE, and mammography in the experimental group. It was found that the women in the experimental group had a positive change in the perceived benefits, perceived barriers, CBCFS, and mammography self-efficacy scores compared to those in the control group.\u003c/p\u003e \u003cp\u003eBased on the research findings, it is recommended that immigrant Syrian women should be supported in terms of breast cancer screening behaviors and the NNP should also be used for other disadvantaged women. It is also recommended that breast cancer screening training should be given to immigrant women with the support of an interpreter. Furthermore, supportive programs such as the NNP are recommended to be integrated into the practices of public health nurses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eFinancial support was received from Samsun Ondokuz Mayıs University Scientific Research Projects Unit under 1904-B- PhD Thesis Projects (Project No: PYO.SBF.1904.21.001).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by TYB and BA. The frst draft of the manuscript was written by TYB and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eWe would like to thank the institutions that allowed and supported us to conduct the study, and all the Syrian women who agreed to participate in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO) (2020) Cancer. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/cancer\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/cancer\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 16 May 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health (2021) T\u0026uuml;rkiye public health institution. Breast Cancer Screening Program National Standards. Republic of Turkiye Ministry of Health General Directorate of Public Health Cancer Department. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hsgm.saglik.gov.tr/tr/kanser-taramalari\u003c/span\u003e\u003cspan address=\"https://hsgm.saglik.gov.tr/tr/kanser-taramalari\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 April 2022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashim MJ, Al-Shamsi FA, Al-Marzooqi NA et al (2018) The burden of breast cancer in the Arab world: Findings from global burden of disease. J Epidemiol Global Health 8(1\u0026ndash;2):54\u0026ndash;58\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwok C, Endrawes G, Lee C (2016) Cultural Beliefs and Attitudes About Breast Cancer and Screening Practices Among Arabic Women in Australia. Cancer Nurs 39(5):367\u0026ndash;374\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRacine L, Andsoy I, Maposa S et al (2021) Examination of Breast Cancer Screening Knowledge, Attitudes, and Beliefs among Syrian Refugee Women in a Western Canadian Province. Can J Nurs Res 1\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlatrash M (2020) Prevalence, perceived benefits, and perceived barriers regarding breast cancer screening among three Arab American women subgroups. J Transcultural Nursing: Official J Transcultural Nurs Soc 31(3):242\u0026ndash;249\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLofters AK, McBride ML, Li D et al (2019) Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study. BMC Cancer 19(42):1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSacca L, Markham C, Fares J (2020) Using Intervention Mapping to Develop Health Education and Health Policy Components to Increase Breast Cancer Screening and Chemotherapy Adherence Among Syrian and Iraqi Refugee Women in Beirut, Lebanon. Front Public Health 8(101):1\u0026ndash;25\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRollins L, Sy A, Crowell N et al (2018) Learning and action in community health: Using the Health Belief Model to assess and educate African American community residents about participation in clinical research. Int J Environ Res Public Health 15:1862\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMailloux C, Halesey E (2018) Patient navigators as essential members of the healthcare team: a review of the literature. J Nurs Patient 3(1):1\u0026ndash;5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHopkins J, Mumber MP (2009) Patient navigation through the cancer care continuum: An overview. J Oncol Pract 5(4):150\u0026ndash;152\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePercac-Lima S, Ashburner JM, Bond B et al (2013) Decreasing Disparities in Breast Cancer Screening in Refugee Women Using Culturally Tailored Patient Navigation. J Gen Intern Med 28:1463\u0026ndash;1468\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaei Ghare Naz M, Simbar M, Rashidi Fakari F et al (2018) Effects of model-based interventions on breast cancer screening behavior of women: a systematic review. Asian Pac J Cancer Prev 19(8):2031\u0026ndash;2041\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriaulx J, Turnbull E, Heijnsdijk E et al (2020) The influence of health systems on breast, cervical and colorectal cancer screening: an overview of systematic reviews using health systems and implementation research framework. J Health Serv Res Policy 25(1):49\u0026ndash;58\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIllaboya D, Gibson L, Musoke D (2018) Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach. Global Health 14(9):1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSayed S, Ngugi AK, Mahoney MR et al (2019) Breast Cancer knowledge, perceptions and practices in a rural Community in Coastal Kenya. BMC Public Health 19:180\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrossman DC, Curry SJ, Owens DK et al (2018) Behavioral counseling to prevent skin cancer: us preventive services task force recommendation statement. JAMA 319(11):1134\u0026ndash;1142\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoussi P, Miller SM, Giri VN et al (2018) Effects of a randomized trial comparing standard and enhanced counseling for men at high risk of prostate cancer as a function of race and monitoring style. J Health Psychol 23(14):1800\u0026ndash;1809\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhaffari M, Esfahani SN, Rakhshanderou S et al (2019) Evaluation of Health Belief Model-Based Intervention on Breast Cancer Screening Behaviors Among Health Volunteers. J Canc Educ 34:904\u0026ndash;912\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylan S, \u0026Ccedil;elik GK (2020) Breast cancer diagnostic behaviors in women with and without a family history of breast cancer. Cukurova Med J 45(4):1467\u0026ndash;1475\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErdoğan E (2018) Comparison of mammography behaviors, health beliefs and fear levels of women with and without a family history of breast cancer. Unpublished Master Thesis. Akdeniz University Institute of Health Sciences, Department of Nursing, Antalya\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChampion VL (1999) Revised Susuceptibility, Benefits, and Barriers Scale for Mammography Screening. Res Nurs Health 22:341\u0026ndash;348\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikhail BI, Petro-Nustas W (2001) Transcultural adaptation of Champion\u0026rsquo;s Health Belief Model Scales. J Nurs Scholarsh 33(2):173\u0026ndash;179\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChampion V, Skinner CS, Menon U (2005) Development of a self-efficacy scale for mammography. Res Nurs Health 28:329\u0026ndash;336\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Zalabani AH (2019) Adaptation and validation of the Arabic version of selfefficacy scale for mammography. Saudi Med J 40(7):707\u0026ndash;713\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlyami M, Al-Sharef A, Al-Aseri M et al (2021) Mammography Self-efficacy Scale and Breast Cancer Fear Scale: Psychometric Properties of the Arabic Versions Among Saudi Women. Cancer Nurs 44(2):163\u0026ndash;170\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasoudiyekta L, Rezaei-Bayatiyani H, Dashtbozorgi B et al (2018) Effect of Education Based on Health Belief Model on the Behavior of Breast Cancer Screening in Women. Asia Pac J Oncol Nurs 5(1):114\u0026ndash;120\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKısa İ, \u0026Ouml;zkan G, Er F (2020) The Effect of Video Training on Breast Screening Methods and Follow-up on Awareness Level. J Kesit Acad 6(24):67\u0026ndash;77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolutek R, Aydın Avci İ (2015) The effects of education and home follow-up on the knowledge and practices of married women about breast and cervical cancer. J Breast Health 11:155\u0026ndash;162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhiyali Z, Aliyan F, Kashfi SH et al (2017) Educational Intervention on Breast Self-Examination Behavior in Women Referred to Health Centers: Application of Health Belief Model. Asian Pac J Cancer Prev 18(10):2833\u0026ndash;2838\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoud MH, Sayed SH, İbrahim HA et al (2018) ) Effect of Health Belief Model-Based Educational Intervention About Breast Cancer on Nursing Students' Knowledge, Health Beliefs and Breast Self-Examination Practice. Int J Stud Nurs 3(3):77\u0026ndash;90\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayar N (2019) The effect of education about breast cancer and self-breast examination on breast cancer fear and health beliefs. Unpublished Master Thesis. Ordu University Health Sciences Institute, Department of Nursing\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Saghir NS, de Celis ESP, Fares JE et al (2018) Cancer care for refugees and displaced populations: middle east conflicts and global natural disasters. Am Soc Clin Oncol Educ Book 38:433\u0026ndash;438\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuzcu A, Bahar Z, Gozum S (2016) Effects of interventions based on health behavior models on breast cancer screening behaviors of migrant women in Turkey. Cancer Nurs 39(2):E40\u0026ndash;50\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErsin F, Bahar Z (2017) Effects of nursing interventions planned with the health promotion models on the breast and cervical cancer early detection behaviors of the women. Int J Caring Sci 10(1):421\u0026ndash;432\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa H, Ursin G, Xu X et al (2017) Reproductive factors and the risk of triple-negative breast cancer in white women and African-American women: a pooled analysis. Breast Cancer Res 19(1):6\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharifikia I, Rohani C, Estebsari F et al (2019) Health Belief Model-based Intervention on Women's Knowledge and Perceived Beliefs about Warning Signs of Cancer. Asia-Pacific J Oncol Nurs 6(4):431\u0026ndash;439\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhorsandi B, Khakbazan Z, Mahmoodzadeh HA et al (2020) Self-efficacy of the First-degree Relatives of Patients with Breast Cancer in the Prevention of Cancer: Using the Health Belief Model. J Canc Educ 35:977\u0026ndash;982\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarvishpour A, Vajari SM, Noroozi S (2018) Can Health Belief Model Predict Breast Cancer Screening Behaviors? Open Access Maced J Med Sci 6(5):949\u0026ndash;953\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrimley CE, Kato PM, Grunfeld EA (2019) Health and health belief factors associated with screening and help-seeking behaviours for breast cancer: A systematic review and meta-analysis of the European evidence. Br J Health Psychol 25(1):107\u0026ndash;128\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhazir Z, Morrowati Sharifabad MA, Vaezi AA et al (2019) Predictors of mammography based on Health Belief Model in Khorramabad women. J Educ health promotion 8:180. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/jehp.jehp_63_19\u003c/span\u003e\u003cspan address=\"10.4103/jehp.jehp_63_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemu\u0026ccedil;in E, Nahcivan NO (2020) The effects of the nurse navigation program in promoting colorectal cancer screening behaviors: a randomized controlled trial. J Cancer Educ 35(1):112\u0026ndash;124\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomazelli JG, Silva GAE (2017) Breast cancer screening in Brazil: An assessment of supply and use of Brazilian National Health System health care network for the period 2010\u0026ndash;2012. Epidemiol Serv Saude 26(4):713\u0026ndash;724\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Liu Y, Xue D et al (2020) Effects of nurse-led interventions on early detection of cancer: A systematic review and meta-analysis. Int J Nurs Stud 110:103684\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaymoori P, Habibi S (2014) Application of a health belief model for explaining mammography behavior by using structural equation model in women in Sanandaj. Sci J Kurdistan Univ Med Sci 19:103\u0026ndash;115\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoffe M, Ayeni O, Norris SH et al (2018) Barriers to early presentation of breast cancer among women in Soweto, South Africa. PLoS ONE 13(2)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuiter AC, Kessels LTE, Peters GY et al (2014) Sixty years of fear appeal research: current state of the evidence. Int J Psych 49(2):63\u0026ndash;70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiley S, Riley C (2016) The role of patient navigation in improving the value of oncology care. J Clin Pathways 2(1):41\u0026ndash;47\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShockney LD (2016) The value of patient navigators as members of the multidisciplinary oncology care team. ASCO Daily News-The value of patient navigators\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast cancer, Screening, Health promotion, Women’s health, Transcultural nursing, Telenursing","lastPublishedDoi":"10.21203/rs.3.rs-4298638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4298638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study was conducted to determine the effect of the nurse navigation program immigrant Syrian women on their beliefs about breast cancer screening behaviors, their mammography self-efficacy, breast cancer fears and their knowledge levels about BSE.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis single-blind randomized controlled study was conducted in June-October 2021 with the pretest-posttest control group design. This research, which was carried out in accordance with randomized pre-test-post-test control group, with a total of 150 Syrian women, 75 in the experimental group and 75 in the control group. As data collection tools; \"Descriptive Questionnaire\", \"Health Belief Model Scale\", \"Mammography Self-efficacy Scale\", \"Champion Breast Cancer Fear Scale\", \"Breast Self-Examination Checklist Form\" and \"Telephone Interview Form\" were used. The study has a Clinical Trials registry with the number \u0026hellip;\u0026hellip;.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAccording to the post-tests, there is a statistically significant difference in rate of having mammography between the experimental and control groups. After applying the Nurse Navigation Program based on the Health Belief Model to the Syrian women in the mammography self-efficacy scale score levels of the women in the experimental group increased after the experiment compared to before the experiment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclision\u003c/b\u003e\u003c/p\u003e \u003cp\u003eResults of the study, it was determined that the Nurse Navigation Program applied according to the Health Belief Model (HBM) increased the breast cancer screening behaviors, self-efficacy and knowledge levels of Syrian women, and decreased their fear of breast cancer.\u003c/p\u003e","manuscriptTitle":"The Effect of the Nurse Navigation Program Applied to Immigrant Syrian Women on their Beliefs on Breast Cancer Screening Behaviors, Mammography Self-Efficacy, and Breast Cancer Fears: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-07 09:29:42","doi":"10.21203/rs.3.rs-4298638/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79c87789-5cc1-40d1-9dca-0f6976950462","owner":[],"postedDate":"May 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-13T14:39:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-07 09:29:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4298638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4298638","identity":"rs-4298638","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}