Life Science Journal http://www.lifesciencesite.

com
2016;13(5)

Application of the Health Belief Model for Breast Cancer Screening and Implementation of Breast
Self- Examination Educational Program for Female Students of Selected Medical and Non-Medical
Faculties at Umm al Qura University"
Hoda Abed El-Azim Mohamed 1,2, Youssreya Mohammed Ibrahim 1,3
, Sahar Mansour Lamadah1,4 and Manal
Hassan Abo El-Magd1,5
1
Faculty of Nursing, Umm Al Qura University, Makkah Al- Mukarramah, KSA
2
Obstetrics and Gynecological Nursing Department, Faculty of Nursing, El Minia University, Egypt
3
Critical Care Nursing Department, Faculty of Nursing, Mansoura University, Egypt
4
Obstetric And Gynecological Nursing Department, Faculty of Nursing, Alexandria University,
Egypt Mental and Psychiatric Health Nursing Department, Faculty of Nursing, El Minia
5

University, Egypt
[email protected]
Abstract: Background: Breast cancer has been considered as a major health problem among females because
of its high incidence in recent years. BSE is one of the most important methods for early diagnosis of
breast cancer. More than 90% of all breast cancers can be diagnosed in the early stage by BSE. The aim of
this study was to identify female college students' breast cancer screening beliefs and practice based on the
Health Belief Model, evaluate their compliance with breast cancer screening behaviors and implement a breast
self-examination educational program for female college students. Subjects and methods: Quasi
experimental research design was used. A convenient sample consisted of 600 students in the age group
(18-21 years) were recruited from three medical and three non- medical faculties at Umm Al Qura University. A
self-administered questionnaire, Champion’s Health Belief Model Constructs Scale (CHBMS) and an
observation competency checklist for BSE were used to collect the data. Results: The present study revealed
that there was no statistically significant difference between medical and non-medical students regarding
perceived susceptibility and perceived severity (P =0.30 and 0.75 respectively). However, there was a
statistically significant difference between medical and non-medical students regarding perceived benefits,
perceived barriers, cues to action (motivation) and self-efficacy. In addition the study revealed that more than
three quarters of students don’t perform breast self-examination. Statistically significant improvements in
students’ knowledge and practice regarding breast self- examination were recorded in the post test. Good
practice with positive attitudes regarding all domains of Health Believe Model increased after students had
attended the educational program. Conclusion: The present study concluded that, there was a high percentage
of students from each group that had unsatisfactory knowledge, negative attitude and poor practice regarding
breast self-examination and breast cancer at pretest. The results of the present study also confirmed the
positive effects of an educational program according to HBM on females’ knowledge, beliefs and practice
regarding breast self-examination and breast cancer. The present study recommends that: Breast cancer
awareness programs should be developed in universities on a regular basis and should focus on removing
perceived barriers to screening and enhancing self- efficacy among female students. Policy makers should
integrate breast cancer awareness programs in the routine programs provided in all healthcare centers.
Attention should be paid to barriers to women undergoing mammography, such as costs, shame and
accessibility. Target population awareness and positive attitudes towards benefits of early breast cancer
screening should be increased.
[Hoda Abed El-Azim Mohamed, Youssreya Mohammed Ibrahim, Sahar Mansour Lamadah and Manal
Hassan Abo El-Magd. Application of the Health Belief Model for Breast Cancer Screening and
Implementation of Breast Self-Examination Educational Program for Female Students of Selected
Medical and Non-Medical Faculties at Umm al Qura University. Life Sci J 2016;13(5):21-33]. ISSN:
1097-8135 (Print) / ISSN: 2372-613X (Online). http://www.lifesciencesite.com. 3.
doi:10.7537/marslsj13051603.
Key words: Breast Cancer– Breast Self-Examination- Health Belief Model.

1. Introduction Cancer Society report, breast cancer is diagnosed

Cancer is a pan societal problem that affects in about 1.3 million women annually worldwide
two thirds of the world population. Breast cancer and around 465,000 will die from the disease.(2)
is the most common type of cancer diagnosed The burden of the disease is increasing in both
among women both in developing and developed developed and developing countries (2)and if no
countries.(1)
It is the second cause of death in the action is taken it will go out of control.
world. A proximately one out of eight women
(1)
Breast cancer (BC) is the most common
worldwide develops breast cancer. According to cancer among Saudi females and accounted for
the American more than
24% of all newly diagnosed cancer among them(3). screening procedures, their application remains very low
Breast cancer was the ninth leading cause of death in the Kingdom(10)of Saudi Arabia, a country with free
for females in the Kingdom of Saudi Arabia (KSA) health services.
in 2010. (4,5) It is expected that the incidence of Furthermore, a lack of belief regarding the
breast cancer will increase over the coming necessity of regular BSE has an impact on the
decades(6,7)in KSA due to population growth and screening behavior. Understanding women's beliefs
ageing. Early detection of breast cancer plays regarding BSE can be used to design appropriate
an important role in reducing its morbidity and educational interventions which promote the desired
mortality. Theoretically, a 95% survival rate could screening behavior.(11) In order to improve the
be achieved(8) if this cancer was diagnosed at an awareness and knowledge of women about breast
early stage. cancer, it is important to initiate interventions that
One of the screening methods for early provide health education and to encourage preventive
detection of breast cancer is breast self- health care behaviors. One of the best models that
examination (BSE). A woman who performs proved to be efficient in studying preventive behaviors in
regular BSE may be more motivated to seek cancer is the Health Belief Model (HBM) (12)
medical attention, including mammography and The Health Belief Model (HBM) is a psychosocial
clinical breast exams if available.(9) Despite the model that accounts for health behaviors by identifying
relative benefits of BSE and breast cancer factors associated with individuals' beliefs which
1
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
influence their behaviors(13). The Champion's
Health Belief Model Scale (CHBMS) is a valid and consequences may include effects on work, family
reliable tool to measure (12)
beliefs about breast cancer life, and social relations.
and screening methods. The components of this The third component of HBM is perceived
model are perceived susceptibility, perceived benefits which is one’s belief in the efficacy of the
severity, perceived benefits, perceived barriers, cues advised action to reduce health risks. (16).
to action and self-efficacy(14). Perceived benefits of breast cancer screening
The first component of the HBM, is perceived behaviors include BSE and CBE for early detection
susceptibility. It is defined as a subjective of breast diseases. People tend to adopt healthier
perception of the risk of an illness. In the context behaviors when they believe the new behavior will
of breast cancer, perceived susceptibility may decrease their chances of developing a disease.
include the risk of a breast cancer diagnosis in the Perceived benefits play an important role in the
long term or immediate future. Individuals will seek adoption of secondary prevention behaviors such as
preventive care if they believe they are personally screening. Perceived barriers is the fourth
at risk. It is one of the more powerful perceptions component of HBM. It refers to the potential
in promoting people to adopt healthier behaviors.(15) negative aspects or obstructions to take a
Perceived severity is the second construct of the recommended health action. This is the belief
HBM. Perceived severity is one’s belief about the about physical and psychological costs of taking
seriousness of a medical condition, the sequence health action. Perceived barriers to exhibiting
of events after diagnosis and feelings resulting from breast cancer screening behaviors can be
the consequences of a specific medical condition(15). emotional, social and physical. Potential barriers
Possible medical consequences may include death, may include financial expenses, danger of the
disability, and pain. Possible social procedure, pain, feeling upset, inconvenience, and
time-consumption (16).
Cues to action are the strategies taken to
activate one’s readiness to take health action. Cues
to action, formerly known as motivation, refer to
internal incentives to live a healthy lifestyle. Cues
to action for exhibiting breast cancer screening
behaviors encourage people to undergo BSE,
CBE, and mammography. Cues to action include
health education or recommendations by a
physician. The self-efficacy construct states that
confidence in lifestyle alteration is essential
before successful change is possible. Individuals
must also feel able or self-efficacious to(17,18)
overcome
perceived barriers to taking action . The
health Belief Model (HBM) was developed to show
that a persons' response to their own health
problems is directly related to their perceptions
about the actual threat to their health and about
whether or not any action they take regarding
such (18)
problems worth it and whether it will benefit
them .
1.1. Significance of the problem
Breast cancer has been considered as a
major health problem among females because of
its high incidence in recent years. BSE is one of
the most important methods for early diagnosis of
breast cancer. 95% of all breast cancers can be
diagnosed in the primary stage by BSE.(19)
Unfortunately, despite the relative benefits of
regular BSE, few women actually examine
themselves. In fact, the majority does not even
know how to do a BSE (20). A cross- sectional
study was carried out among 262 female
undergraduate students in Putra University in
Malaysia. The study showed that only 36.6% of
girls performed BSE monthly(21). All university
students were at a stage where it was important
to carry out BSE on a regular basis to feel any
changes early. (22)
The study focused on medical students as they are examination educational program for female college
the future health care providers. They will play students.
animportant role in raising awareness of the 1.2. Aim of the study: This study aims to:
community about the early detection of breast  Identify female college students' breast cancer
cancer as they usually(23)have the closet contacts screening beliefs and practices based on the
with female patients . Also positive attitudes Health Belief Model.
can be developed by the young adults towards  Evaluate female college students' compliance
breast self-examination. This contributes in early (self-efficacy) with breast cancer screening
breast cancer detection as well as reducing late behaviors.
breast cancer presentation. Thus, not only should  Implement a breast self-examination educational
young students learn more about BSE, but they also program for female college students.
play an important role in teaching their mothers,
sisters and friends to examine their breasts 2. Subjects and Methods
In KSA, studies related to knowledge, 2.1. Research design:
attitudes and practices around breast cancer are A quasi -experimental research design was
scarce(7). So, the aims of this study is to identify utilized.
female college students' breast cancer screening
beliefs and practices based on the Health Belief
Model, evaluate compliance (self-efficacy) with 2.2. Research setting:
breast cancer screening behaviors of female The study was conducted in selected medical and
college students and implement a breast self- non-medical faculties, Umm Al Qura University in
2
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
Makkah Al Mukkaramah.
2.3. Research subjects: It was designed by the researchers after
reviewing relevant literatures and it consisted of
A convenient sample consisted of 600 two parts.
students enrolled in the above mentioned setting Part 1 was concerned with student's socio-
in the age group 18-21 years. From each of the demographic characteristics such as their age,
selected faculty, 100 students participated in this college enrollment, family history of breast cancer.
study. Part II was concerned with students' knowledge
Sampling technique: regarding breast cancer and breast self-examination
The following sampling technique was and sources of breast cancer information. Questions
applied. Three medical and three non-medical varied between open and close. It took 20 – 25
faculties at Umm Al Qura University were selected minutes to fill out the questionnaire.
randomly. In each of the selected faculties, 100 Scoring system
students who accepted to participate in the study Part II of the questioner consisted of 22
were recruited. items that assessed students' knowledge related to
breast cancer and 13 items that assessed students'
2.4 Tools of data collection knowledge regarding breast self-examination.
The following tools were used for data Answers obtained from the students related to
collection: their knowledge were scored and calculated. Each
Tool I: A self-administered questionnaire correct response is scored by one grade and each
(pre/post educational program): wrong or "don’t know" response is scored by zero.
The total score of the students' knowledge
regarding breast cancer was 22 grades (equal
100%) while the total score of the students'
knowledge regarding breast self-examination was 13
grades (equal 100%). Accordingly the students'
answers were classified as satisfactory
knowledge (50% and more) or unsatisfactory
knowledge (less than 50%). Pre designed key
answers were used to check whether the obtained
answers can be regarded as satisfactory or
unsatisfactory knowledge.
Tool II: Champion’s Health (24)Belief Model
Constructs Scale (CHBMS) (pre/post
educational program)
Tool II was used to assess students ‘beliefs
and attitude regarding breast cancer and breast
self- examination. The Champion Health Belief
Model Scale (CHBMS) was utilized to measure
HBM components. It is a self-report questionnaire
adapted to measure perceived susceptibility,
perceived seriousness, perceived benefits,
perceived barriers, cues to action and self-efficacy
related to frequency of breast self-examination. It
is a method used to evaluate and explain
individual differences in preventative health
behavior. It consists of 65- statements classified
as follows into six dimensions.
Susceptibility: A six-item scale was used to
assess perceived susceptibility to breast cancer.
Severity (seriousness): A 12-item scale was used
to assess perceived seriousness of breast
cancer.
Benefits: A five -item scale of CHBMS was used to
assess perceived benefits of performing BSE.
Another five items were adapted from BSE model
and used to assess perceived benefits of
performing CBE. Barriers: An eight -item scale was
used to assess perceived barriers to performing
BSE. Another nine
items were adapted from the BSE model to examination. This checklist consists of 7 practical
assess perceived barriers to performing CBE. steps. All steps were scored from (0-2). Each correct
Cues to Action (Motivation): An eight-item scale and complete practical step was scored as two grades,
was used to assess the motivation of living a each correct but incomplete step was scored as one
healthy lifestyle. grade while each incorrect step was scored as zero.
Self-Efficacy: Twelve items were used to assess The total practical scores were 14 divided into two
self- efficacy in performing BSE and getting CBE. categories. Scores from 8- 14 referred to good practice
Scoring system while scores < 8 referred to poor practice.
A three-point Likert Scale was used to
measure responses. All statements were scored on 2.4. Validity and reliability
a scale from 1-3. Students' responses were scored Tool I & II of the present study were submitted to
as follows: agree were scored as three, neither three academic nursing staff in the Obstetric and
agree nor disagree were scored as two, while Gynecological Nursing field to test the content validity
disagree were scored as one. The total attitudinal of the tools. All recommended modifications were
scores was195 divided into two categories. performed according to the academic nursing experts'
Scores from 98 - 195 referred to positive judgment on clarity of sentences and the
attitudes while scores (<98) referred to negative appropriateness of the content. Internal consistency of
attitudes. tool I was calculated using Cronbach alpha and the
Tool III: An observation competency checklist for degree of reliability alpha precision equaled 0.82
BSE (pre/post educational program). which indicates an accepted reliability of the tool.
A checklist was designed by the researchers 2.5. Pilot study:
to evaluate students’ performance of breast self-

3
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
A pilot study was carried out on 10% of
students at the previously mentioned settings to data collection lasted over two months starting
test the study tools for clarity, feasibility, from the beginning of September to the end of
applicability and time required to fill out the October 2015. The researchers held meetings with
questionnaires. The necessary modifications were the students during their free classes time and
done through omission of unneeded or repeated during breaks. They briefly explained the nature
questions and improvements were made prior to and the purposes of the study. All students were
data collection according to the pilot study informed that participation is voluntary. After
results. The sample of the students who obtaining the acceptance of students to participate
participated in the pilot study was excluded from in the present study, the self- administered
the main study sample. question naires and the Champion’s Health Belief
2.6. Procedure: Model Constructs Scale (HBM)(tools I &II)were
distributed to each student to assess their socio-
Assessment phase: demographic data, and their knowledge, beliefs and
The researchers attended the selected attitudes regarding breast cancer and breast self-
faculties two days per week, from 9.00 a.m. to examination (pretest). Explanations and
2.00 p.m. The clarifications were provided according to students'
questions. The data collectors ensured that all
information pertaining to the sheet was complete.
The average time needed to fill out the
questionnaires was 30-40 minutes. For non-
medical students the questionnaire was translated
using a back-translation technique with the help
of a panel of 3 experts and interpreters to
translate the items from the source language
(English) to the target language (Arabic) and then
back-translation of it to the source language.
Implementation phase
A comprehensive health educational program
was prepared and implemented for 184 medical
students and 200non-medical students who had
finished filling out tool I &II. The educational
program was proceeded by observing students'
performance of BSE (pretest) using the
observational checklist (tool III).After assessing
the students' knowledge and performance, the
total sample was divided into small groups.
Medical students were divided into 8 groups,
each group ranged from 20-23 students. Non-
Medical students were divided into 8 groups,
each group consisted of 25 students. The health
education was organized in two sessions. The
researchers allocated one hour to cover the
theoretical session and one hour to cover the
practical session on two consecutive days for each
group.
In the first session (theoretical part), the
researchers used short interactive lectures and
group discussions followed by interactive sessions
with the students to clarify doubts using audio-
visual aids. An additional 10 minutes were assigned
at the end of each session for an open discussion
with the students about this topic. Brochures
containing brief points about breast cancer and
BSE were distributed to students at the end of the
session. In the second session, the researchers
instructed the students on how to perform BSE
through demonstration and re-demonstration on a
breast model and with the aid of posters, printed
materials handouts (brochure containing steps of
breast self-examination) and educational video.
The educational content included the breast breast cancer and breast self- examination. An
anatomy, prevalence of breast cancer among observational competency checklist of BSE (Tool III) was
women, its morbidity and mortality rate, definition, used to evaluate students' performance of breast self-
risk factors, signs and symptoms of breast examination immediately after finishing education
cancer, the importance of breast cancer screening program (practical sessions).
methods in early detection, breast self- 2.7. Ethical and administrative considerations:
examination and how to perform BSE at home. In All official permissions to carry out the study
addition to this information, students received were secured from pertinent authorities at the
specific messages related to health motivation, previously mentioned settings after explanation of the
susceptibility to breast cancer, the perceived purpose of the study. An informed oral consent was
benefits and barriers to undergoing obtained from all the participants before collecting
mammography and perceived self-efficacy based data. All students were informed that their
on HBM. participation is voluntary and that the collected data
Evaluation Phase: would be only used for the purpose of the current
The researchers used the same questionnaires study, as well as for their benefit.
of the pretest (Tools I& II) one week after 2.8. Statistical analysis:
implementing the educational sessions with the The data was analyzed using the Statistical
same students that received the educational Package for Social Sciences (SPSS) Version 20.
program in order to evaluate the effect of the Descriptive statistics was used to calculate
comprehensive health educational program on the percentages and frequencies. Chi square (X2) and Z
level of students' knowledge and beliefs about test was used to estimate the statistically significant
4
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
differences. P. value was considered significant
when it was ˂0.05 and highly significant when P Table (2) shows the percent distribution of
value was the students according to their knowledge about
breast cancer risk factors. The most widely known
<0.01. risk factors to medical students were family
history of breast cancer and smoking (72.0 % and
3. Results 65.0% respectively). For non-medical students the
Table (1) illustrates the distribution of the percentage were (46.7% and 58.0%) respectively.
students according to their socio-demographic A statistically significant difference was found
characteristics. It can be observed that, the age of between medical and non-medical students
around three quarters (73.9%) of the students' (p<0.05). Knowledge of the students regarding
ranged between 20 – and 25 years. 44.2% of the breast cancer warning signs was illustrated in
students were in their third year of study. Most of table (3). Warning signs of breast cancer which
the students (84.2%) were single. Moreover, more were known to more than two thirds of the
than three quarters of the students (79.5%) lived in medical students were breast lump (83.7%),
an urban area compared to (20.5%) lived in a rural bloody nipple discharge (72.0%), pain in breast
area. Most of the students (83.6%) had no family (70.7%) and change in breast shape and/or size
history of breast cancer. (83.0%). For no medical students the percentage
were (76.0 %, 65.0%, 61.7%, and 72.3%)
respectively. Regarding students' knowledge about
breast cancer screening methods it can be
observed that, more than one half of the medical
students know that mammogram is a method of
early detection (56.3%) and that mammogram
could discover a lump earlier than clinical breast
examination (63.0%). For no medical students the
percentage were (30.3%, and 39.7%) respectively.
A statistically significant difference was found
between medical and non-medical students
(P<0.001).
Regarding the students' sources of
information about breast cancer and breast self-
examination, figure
(1) reveals that audio visual media is the most
common source of information (76.6%) followed
by social media (55.83%).
Table (4) reveals medical and non-medical
student’s attitude towards breast self-
examination according the Health Believe Model
HBM. It was found that there was no statistically
significant difference between medical and non-
medical students regarding perceived susceptibility
and perceived severity (P= 0.30 and 0.75
respectively). However, there was a statistically
significant difference between medical and non-
medical students regarding perceived benefits (P=
0.05), perceived barriers (P= 0.00), cues to action
(motivation) (P= 0.03) and self-efficacy (P=0.02).
Concerning, students' compliance with BSE
screening behaviors, figure (2) illustrates that
more than three quarters of medical and non-
medical students (77% and 85% respectively)
didn't perform breast self-exam. Less than one
fifth of medical (13.0%) and non-medical students
(8.5%) performed breast self-exam the past year.
In addition, a minority of medical (7.0%) and non-
medical students (4.5%) performed BSE in the
past three months. Table (5) illustrates marked
deficiency in students’ knowledge among medical
and non-medical students before the intervention.
The implementation of the program was
associated with statistically significant
improvements
in students’ knowledge regarding breast self- attitude has increased after the test. This applies to
examination (P =0.03) for medical students and both groups in the perceived susceptibility, perceived
P=0.001 for non-medical students. The same severity, perceived benefits, perceived barriers,
table indicates statistically significant improvements perceived cues of action (motivation) and efficacy
in the students' practice (P = 0.002 among medical domains of the Health Believe Model. There was a
students and P= 0.01 among non-medical statistically significant difference (P< 0.001). Table
students). (8) shows the relationship between students' total
Concerning students' knowledge regarding knowledge and practice according to socio-
breast self- examination by using HBM before and demographic characteristics. It can be observed that
after attending the educational program, table (6) satisfactory knowledge increased among 47.39% of the
shows that there is a statistically significant age group 20-25 years, 29.94% of third year students
improvement in both medical and non-medical and 62.24% of students living in an urban area. There
students' knowledge in all the HBM domains, was
perceived susceptibility (P= 0.02), perceived
severity (P= 0.00), perceived benefits (P= 0.00),
perceived barriers (P= 0.05), cues to action
(motivation) (P= 0.00), and self-efficacy (P= 0.00).
Marked improvement of students' practice
and attitude after the educational program was
observed in table (7). Good practice with a positive
5
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
a statistically significant difference (P= 0.053
0.029, 0.00 and 0.027 respectively). In
addition, good practice increased among and 0.267 respectively).
51.56% of the age group 20-25 years, 42.44
% of third year students and 70.57% of Table (1): Distribution of the students according
students living in an urban area. There was a to their socio-demographic characteristics
statistically significant difference (P= 0.016, (n=600)

6
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)
Item No. %
Age (by years)
< 20 year 157 26.2
20 - 25 443 73.9
Academic year
Second year 219 36.5
Third year 265 44.2
Fourth year 116 19.3
Marital status
Single 505 84.2
Married 195 15.8
Place of residence
Urban 477 79.5
Rural 123 20.5
Family history of breast cancer
Yes 98 16.4
No 502 83.6
Table (2): Percent distribution of the students according to their knowledge about breast cancer risk factors
Medical (n=300) Non -medical (n=300)
Risk factors of breast cancer Yes No Don’t Yes No Don’t Z Sig
know know
% % % % % %
1. Advanced age: 47.7 25 27.3 36.7 37 26.3 1.692 0.09
2. Family history of breast 72 20.3 7.7 46.7 28.3 25 6.812 0.00*
cancer
3. Early menarche<12 23.3 33.7 43 18 43 39 .006 0.995
4. Late menopause 24.3 24.7 51 20.3 41.7 38 1.79 0.07
5. Obesity 36.7 40.7 22.7 35 38 27 .912 0.362
6. Smoking 65.3 19.7 15 58 20.3 21.7 2.08 .037*
7. Never breast fed 47.3 24.3 28.3 47.3 30 22.7 .683 0.494
8. Lack of physical exercise 33.7 35.7 30.7 25.7 35.7 38.7 2.443 0.015*
9. Larger breast size 23.7 55.7 20.7 27 46.7 26.3 .390 0.697
10. Eating food rich in fat 42 30 28 43 22.7 34.3 .669 0.503
11. Use of HRT for a long 22.7 15 62.3 48 15 37 6.77 0.00*
duration
12. Hormonal Contraceptive 47 14.7 38.3 46.3 15.7 38 .054 0.957
methods

7
 Life Science Journal http://www.lifesciencesite.com
2016;13(5)

*: Significance

8
 77%
80%
56%
60% 42%
40%
24%
20%
11.0%
0%

Audio Social LectureFriends Health care

visual media media providers

Figure (1): Percent distribution of the students according to their sources of information regarding breast
cancer and breast self- examination (n=600)
Table (3): Percent distribution of the students according to their knowledge about breast cancer warning
signs and screening methods
Medical Non-medical
Warning signs of breast cancer (n. =300) (n =300) Z Sig.
Yes No Don’t Yes No% Don’t
% % know% % know%
Warning signs of breast cancer
1. Breast lump 83.7 2.3 14 76 11.7 12.3 1.91 0.05*
2. Bloody nipple discharge 72 14.7 13.3 65 10 25 2.41 0.01*
3. Nipple retraction 57.3 15 27.7 57.3 13 29.7 .204 0.83
4. Pain in breast 70.7 13.7 15.6 61.7 14.7 23.6 10.17 0.006*
5. Change in breast shape and/or 83 8.7 8.3 72.3 10 17.7 3.31 0.001*
size
6. Redness of breast skin 59.7 14.7 25.7 57.7 10.3 32 .97 0.330
Screening methods of breast cancer
1. Mammogram is a method of early 56.3 11.7 32 30.3 8.3 61.3 7.15 0.00*
detection
*:
2. Significance
Clinical breast examination is a 75.2 9.3 15.5 66.7 10 23.3 2.37 0.01*
Table (4):method of early
Student’s detection
breast self- examination attitude among medical and non-medical students' by using
3. belief
health Mammogram
model HBMcould(n=600)
discover a 63 17 20 39.7 14 46.3 6.63 0.00*
lump earlier than Clinical breast
examination
HBM Medical(n =300) Non-Medical (n =300) X2 (p. value)
4. dimensions
Mammogram recommended Positive
to Negative
31.7 45.7
Positive
22.7 30
Negative
15.7 54.3 5.16 0.00*
start No. % No. % No. % No. %
 Susceptibility 167 55.7 133 44.3 154 51.4 146 48.6 1.04 (0.307)
 Severity 252 84 48 16 250 83.3 50 16.7 0.09 (0.75)
 Benefits 289 96.3 11 3.7 210 70 90 30 1.37 (0.05*)
 Barriers 72 24 228 76 41 13.7 259 86.3 10.47 (0.00*)
*: Significance
 Cues to action 27 9 273 91 14 4.7 286 95.3 4.24 (0.03*)
 Self-Efficacy 232 77.3 68 22.7 207 69 93 31 5.30 (0.02*)
Total 290 96.7 10 3.3 289 96.3 11 3.7 0.049 (0.824)
 85%
90% 77%
80%
70% Medical Students
60% Non Medical Students
50%
40%
30%
13% 8.5%
20% 7% 4.5% 3% 2%
10%
0%
Didn’t performedSince one year3 Since the pastScince the past
monthsmonth

Figure (2): Distribution of the study sample according to their compliance (self-efficacy) of BSE
Table (5): Distribution of the students according to their total knowledge and practice pre & post educational
program regarding breast self- examination (n=384)
Medical Non -medical Total
Items (n = (n = 200) (n=384)
184)
Pre Post Pre Post Pre Post
No. % No. % No. % No. % No. % No. %
Total Knowledge
Satisfactory 60 32.6 174 94.6 43 21.5 170 85 103 26.8 344 89.59
Un satisfactory 124 67.4 10 5.4 157 78.5 30 15 281 73.2 40 10.42
X2 (P)
*: Significance 5.11 (0.03*) 9.66 (0.001*) 16.36 (0.00*)
Total practice
Table (6): Percent
Good distribution
35 of19.0
the students'
175 knowledge
95.1 17 about
8.5 breast
176cancer
88 and 52breast self- examination
13.5 351 91.4
by using HBMPoorpre& post educational
149 81 program(n=384)
9 4.9 183 91.5 24 12 332 86.5 33 8.6
X2 (P) 9.06 (0.002*)
Pre. 6.16 (0.01*) Post. 5.65 (0.007*)
HBM Medical Non-medical Medical Non-medical P. value
(n=184) (n=200) (n=184) (n=200)
S. Un S. Un. S. Un. S. Un.
Susceptibility
Positive 21.2 4.34 14 5.5 88.59 1.63 82.5 3 2.29 (0.02*)
Negative 11.41 63.04 7.5 73 5.98 3.8 2.5 12
Severity
Positive 28.80 5.43 21.5 2.5 93.48 00 76 00 283.1 (0.00*)
Negative 3.80 61.96 00 76 1.09 5.43 9 15
Benefits
Positive 27.72 9.24 21.5 9 88.59 3.81 78.5 4.5 3.92 (0.00*)
Negative 4.89 58.15 00 69.5 5.98 1.63 6.5 10.5
Barriers
Positive 27.72 9.24 6.5 3.5 88.59 00 80.5 2.5 1.89 (0.05*)
Negative 4.89 58.15 15
S: Satisfactory knowledge / Un: Unsatisfactory knowledge 75 5.98 5.43 4.5 12.5
Cues to action
Positive 22.83 11.96 18 9 88.59 3.8 70 4.5 133.8 (0.00*)
Negative 9.78 55.43 3.5 69.5 5.98 1.63 15 10.5
Self -Efficacy
Positive 20.65 9.24 11.5 6.5 76.09 1.63 69.5 10 98.24 (0.00*)
Negative 11.96 58.15 10 72 18.48 3.8 15.5 5
Table (7): Percent distribution of the students according to breast self-examination practice by using HBM
pre & post educational program (n=384)
Pre. Post.
HBM P. value
Medical Non-medical Medical Non-medical
(n=184) (n=200) (n=184) (n=200)
Good Poor Good Poor Good Poor Good Poor
Susceptibility 125.9
Positive 19.02 6.52 8.5 11 89.13 1.09 85.5 0 (0.00*)
Negative 00 74.45 00 80.5 5.98 3.80 2.5 12
Severity 72.83
Positive 15.76 15.21 4.5 15.5 88.04 00 76 00 (0.00*)
Negative 3.26 65.76 4 76 7.07 4.89 12 12
Benefits
Positive 16.85 9.24 8.5 10 89.13 3.26 81.5 1.5 17.18
Negative 2.18 71.74 00 81.5 5.98 1.63 6.5 10.5 (0.00*)
Barriers 154.9
Positive 19.02 17.93 6 4 88.59 0 81.5 1.5 (0.00*)
*: Significance
Negative 00 63.04 2.5 87.5 6.52 4.89 6.5 10.5
TableCues
(8): to
Distribution
action of the students according to their total knowledge and practice of BSE with socio
demographic characteristics (n=384).
Positive 9.23 25.54 8.5 18.5 89.13 3.26 73 1.5 33.9
NegativeItems 9.78 Age (%) 00
55.43 73 Academic
5.98 year 1.63(%) 15 Residence
10.5 (%)
(0.00*)
Self –Efficacy <20 20-25 Second Third Fourth Urban Rural
Total
Positiveknowledge 19.02 14.13 2 16 76.63 1.09 72.5 7 78.8
Satisfactory
Negative 00 32.29
66.84 47.39 6.5 25.26 18.49
75.5 29.94 3.80 29.16 15.5 62.24
5 17.44
(0.00*)
Unsatisfactory 5.72 14.58 4.16 3.12 13.02 13.54 6.77
X2 (p. value) 4.002 (0.029*) 21.11 (0.00*) 4.431 (0.027*)
Total practices
*:
Good Significance 42.187 51.56 27.6 42.44 23.69 70.57 23.18
Poor
4.2 Discussion 1.30 4.94 2.34 1.30 2.60 5.20 1.04
X (p.Breast
value)cancer has been5.347 (0.016*) identify
5.858 female
(0.053*) college students'.796
breast cancer
(0.267)
the most frequent screening beliefs and practice based on the
cancer among females. It accounted for 21% of all Health Belief Model, evaluate their compliance
cancer sites (The National Cancer Registry2005) with breast cancer screening behaviors and
(3)
. Breast cancer is commonly presented at a implement a breast self-examination educational
relatively young age and with an advanced stage of program for female college students.
disease. This could be due to lack of awareness, The results of the present study revealed that
and knowledge and due to certain beliefs about the most widely known risk factors among both
breast cancer and its management among females. medical and non-medical students were family
Breast health awareness appears to be a pragmatic history of breast cancer and smoking. This is
and simple tool which can play an important role consistent with the results of a study done by
in the detection of early breast cancers with a Boulos and Ghali (2014)(27) who indicated that the
favorable prognosis (Agarwal et al. 2007) (25).
In widely known risk factors by the students were
addition, performing breast self- examination smoking (66.9%), radiation to the chest (63.7%),
(BSE) (26)
can detect 40% of breast lesions (Gupta genetic factors (63.7%) and family history of
2009) . The aim of the present study was to breast cancer (47.5%). The results of the
present study are also in line with a study carried of the respondents were unable to recognize early onset
out to determine the awareness of breast cancer of menses as a complex risk factor of breast cancer.
risk factors and practice of breast self-examination Having knowledge about breast cancer symptoms
among female students of the University of Nigeria is essential for early diagnosis and treatment of the
Enugu Campus. It showed that the only risk factor disease. Results of the present study revealed that the
that is widely known is family history of (28) breast most common symptoms reported by the students were
cancer (50%) (Iheanacho et al., 2013(29) . In breast lump, bloody nipple discharge, pain in breast
addition, Al Junaibiand Khan (2011) who and change in breast shape and/or size which are
studied the knowledge and awareness of breast consistent with the(29)results of study done by Al Junaib
cancer among university female students in Muscat, iand Khan (2011) who revealed that the majority of
reported that the majority of participants knew the participants considered breast pain and breast
about genetics or family history of breast cancer as lump as the most common presenting symptoms. This
established risk factors for the disease. The results percentages were higher than the results of other similar
of the present study are incongruent with the studies done in UK (Ba’Amer, 2010)(31). This increased
results of a study conducted in Saudi Arabia awareness about early signs, symptoms and risk factors
which reported that the most commonly known of breast cancer among female students could be
risk factor among respondents was absence of attributed to their age and educational level especially
breast feeding (52.7%) (Danash and Al- among the medical group. However, the results of the
Mohaimeed, 2007)(30). In the present study, more present study are incongruent with (32) the results of a
than one third of the students did not know that study done by Habib et al (2010) who reported
early menarche<12 is one of the risk factors for that “swelling in the breast or axilla” was the most
breast cancer. This finding is in accordance with frequently identified symptom of breast cancer. Also,
the results of a study done by Al Junaibi and Sambanje1 and Mafuvadze (2012)(33) reported that
Khan (2011)(29) who reported that more than 50 % the majority of participants were not aware of early
signs of breast cancer such as changes in color or
shape of the nipple. (2014)(27), Iheanacho et al (2013)(28) and Habib
Regarding the students' sources of et al (2010)(32) who reported that the main
information about breast cancer and breast self- sources of information about breast cancer and
examination, the present study indicated that the breast self- examination were television and radio.
audio visual media was the most common source However, these results are not on line with the
of information about breast cancer and breast results of Rizwan and Saadullah (2009)(34) who
self-examination. These results are in line with found friends and colleagues to be the main
the results of Boulos and Ghali sources of information. The results of the present
study reinforced the fact that mass media is a
very beneficial and effective way to disseminate
knowledge among the population at large. It plays a
major role in shaping the development of future
generations.
Knowledge is a basic requirement for any
individual to maintain proper health. In the greater
attempt to disseminate knowledge and increase
awareness about a given health-related issue such
as breast cancer, the researchers of the present
study developed and delivered an educational
program to the selected group of students. The
present study assessed students' knowledge and
practice regarding breast self- examination (BSE)
and breast cancer before the educational
program. It was evident that a large percentage of
both medical and non-medical group had
unsatisfactory knowledge and poor practice. These
results are congruent with the results of Boulos and
Ghali (2014)(27) who showed that female university
students may not have adequate knowledge about
BSE. However, the results are not on line with the
results of Al Junaibi and Khan (2011)(29) who
indicated that only 23% of respondents did not
know the correct procedure to perform BSE. They
wrongly believed that it should be performed either
annually or occasionally while 61% of all
participants knew the appropriate time to perform
BSE.
According to the finding of the present study,
a large percentage of medical and non-medical
students did not perform BSE. This may be due to
their lack of knowledge about(35) this issue. Study
done by El Saghir et al (2007) that 90% of the
participants heard about BSE and only 19% stated
that they performed it on a(36)
regular monthly basis.
Also, Yelda et al (2012) found that 97% of
women heard about breast self-examination but only
36.7% of respondents performed it.
Attitude is a more important factor in
preventive behaviors including cancer control
behavior than just knowledge about BSE. The
Health Belief Model has been used in several
studies as a theoretical framework to study BSE
and other breast cancer (37) detection behaviors.
(Cohen and Azaiza, 2005) . The present study
examined breast cancer beliefs and screening
behaviors in relation to each domain of the Health
Belief Model. Results from the present study
indicate that a large percentage of the students
from both groups have a negative attitude
towards perceived susceptibility, perceived barriers
and cues to
action (motivation). There was a statistically susceptibility (P<0.01), higher cancer worries (P<0.05),
significant difference between medical and non- and fewer barriers to mammography (P<0.05).
medical students regarding perceived benefits, Moreover, the health education program used in the
perceived barriers, cues to action (motivation) and present study had positive effects on knowledge and
self-efficacy. beliefs of student from both groups regarding breast
It is very important to note that the cancer and breast self-examination in all domains of
educational curriculum played a very important the Health Believe Model. These results are consistent
role in sending messages about this topic for with the results of a study done by Mood et al (2011)
medical students. Thus, it is important to give the (41)
who indicated that the HBM mean scores were
right information through different channels to increased in all components (perceived susceptibility,
cover this area of knowledge about breast cancer perceived severity, perceived benefits and perceived
and to change wrong beliefs. Furthermore, Hajian barriers) after educational intervention.
et al (2011)(38) concluded that we need to pay In addition, student’s practice of breast self-
attention to barriers for women undergoing examination has also improved after attending
mammography such as costs, shame and educational program. According to HBM, women's
accessibility, and increase the target population perception of their susceptibility to breast cancer and
awareness and positive attitudes towards the the severity of the disease were associated (42)
with their
benefits of early breast cancer screening. The knowledge about the disease (Farmer 2007) . So for
findings of the present study are inconsistent with women who received the educational intervention, the
the results of a(40)
study done by Radi (2013)(39) and perceived susceptibility of having breast cancer
Ahmed (2010) who reported higher perceived increased. These results are in line with the findings of
Rezaeian (2014)(43) who indicated that the
educational intervention increased perceived years, third year students and those living in an
benefits and decreased perceived barriers urban area. These results are supported by Hadi
significantly in the intervention group compared to et al (2010)(45) who reported that the age,
control group. In a study from Turkey, peer educational level and social status significantly
education increased perceived benefits of influenced breast cancer knowledge. Results of a
mammography and lowered the perceived barriers study done by Guilford, (2011)(46) revealed however
to undergoing mammography (Gozum 2010) (44). that there is no significant influence of the grade
This improvement in students' attitude related to average and level of knowledge.
knowledge acquired from education program also
reflected on the students practice. 5. Conclusions:
Regarding the relationship between students
total knowledge and practice levels according to Based on the findings of the present study, it
their socio-demographic characteristics it can be can be concluded that, there was a high
observed that satisfactory knowledge and good percentage of students from each group that had
practice increased among students of the age unsatisfactory knowledge, negative attitude and
group 20-25 poor practice regarding breast self-examination and
breast cancer at pretest. The results of the present
study also confirmed the positive effects of an
educational program according to HBM on
females’ knowledge, beliefs and practice regarding
breast self-examination and breast cancer.

Recommendations
 Breast cancer awareness programs should
be developed in universities on a regular
basis and should focus on removing
perceived barriers to screening and
enhancing self-efficacy among female
students.
 Policy makers should integrate breast cancer
awareness programs in the routine programs
provided in all healthcare centers.
 Attention should be paid to barriers to
women undergoing mammography, such as
costs, shame and accessibility.
 Target population awareness and positive
attitudes towards benefits of early breast
cancer screening should be increased.

Acknowledgements
The authors would like to thank Deanship of
Scientific Research at Umm Al-Qura University
(project No 43409029) for the financial support.

Reference
1. Jamal A, Siegel R, Xu J, Ward E. (2010):
Cancer statistics. CA Cancer J
Clin.2010;60(5):277–300.
2. American Cancer Society; (2010): Cancer
facts & figures. Atlanta. American Cancer
Society 2010; 9–10.
3. The National Cancer Registry, (2005): Cancer
Incidence Report Saudi Arabia. Available
from: http://www. kfshrc.edu.sa/NCR/. Ann
Afr Med 2008 7: 192-7.
Available: from:
http://www.annalsafrmed.org/text.asp?
2008/7/4/192/55654.
4. Mokdad H, Jaber S, Aziz M, Al Buhairan F, Al
Ghaithi A, Al Hamad M et al.. (2010): The
state of health in the Arab world, 1990–
2010: an
analysis of the burden of diseases, injuries, Arabia. Med Oncol (Northwood Lond Engl) 2008;
and risk factors. Lancet 2014; 383: 309– 25: 387–393. doi: 10.1007/s12032-008-9051-5.
320. doi: 10.1016/S0140-6736(13)62189-3. 7. Bcheraoui C, Basulaiman M, Wilson S, Daoud F,
pmid: Tuffaha M, AlMazroa M et al,. (2015): Breast
24452042. Cancer Screening in Saudi Arabia: Free but
5. Lozano R, Naghavi M, Foreman K, Lim S, Almost No Takers. PLoS ONE 2015; 10(4). doi:
Shibuya K, Aboyans K, et al.. (2010): Global 10.1371/journal.pone.0124850
and regional mortality from 235 causes of 8. Yarbrough SS, Braden CJ. (2001): Utility of
death for 20 age groups in 1990 and 2010: health belief model as a guide for explaining or
a systematic analysis for the Global Burden predicting breast cancer screening behaviors. J
of Disease Study 2010. The Lancet 2012; Adv Nurs 2001, 33(5):677-688.
380: 2095–2128. doi: 10.1016/S0140- 9. Gozum S, Aydin I (2004): Validation evidence for
6736(12)61728-0. pmid: Turkish adaptation of Champion's health belief
23245604. model scales. Cancer Nurs 2004, 27(6):491-
6. Ibrahim M, Zeeneldin A, Sadiq B, Ezzat A 498.
(2008) The present and the future of breast 10. Canbulat N, Uzun O (2008): Health beliefs and
cancer burden in the Kingdom of Saudi breast cancer screening behaviors among female
 health workers in Turkey. Eur J Oncol. Nurs
2008, 12:148-156. 16. Dündar PE, Özmen D, Öztürk B, Haspolat G,
11. Avci IA (2008): Factors associated with Akyıldız F, Çoban S, (2006) The knowledge
breast self-examination practices and beliefs in and attitudes of breast self-examination and
female workers at a Muslim community. Eur J mammography in a group of women in a rural
Oncol Nurs 2008, 12(2):127-133. area in western Turkey. BMC Cancer. 2006;
12. Parsa P, Kandiah M, Mohd Nasir MT, Hejar 6:43.
AR, Nor Afiah MZ (2008): Reliability and 17. Hajian K, Auladi S. (2014): Health belief
validity of Champion's Health Belief Model model and practice of breast self-
Scale for breast cancer screening among examination and breast cancer screening in
Malaysian women, Singapore Med. J., 2008 Iranian women. Breast cancer 2014
Nov;49(11):897-903. Jul;21(4):429-34. doi: 10.1007/s12282-012-
13. Champion VL, Scott CR (1997): Reliability 0409-3. Epub 2012 Sep 1.
and validity of breast cancer screening belief 18. Frankenfield K. (2009): Health Belief Model
scales in African American women. Nurs Res of Breast Cancer Screening for Female
1997, 46(6):331-337. College Students. Master's Theses and
14. Sharifirad GR, Entezari MR, Kamran A, Doctoral Dissertations submitted to the
Azadbakht L 2009). The effectiveness of School of Health Promotion and Human
nutritional education on the knowledge of Performance Eastern Michigan University.
diabetic patients using the health belief model. 19. Sørensen J, Hertz A, Gudex C. (2005):
J Res Med Sci. 2009;14(1):1–6. Evaluation of a Danish teaching program in
15. Janz, KN., Champion, V., and Stretcher VJ. breast self-examination. Cancer Nurs.
(2002): The Health Belief Model, health 2005;28(2):141–7.
Behavior and Health Education (2002): 2 (3): 20. Mazloomy SS, Zare M, Feisal M, Maleki F,
45- 66. Servat F, and Ahmadieh MH. (2006): Effects
of health education on knowledge, attitude
and practice of female teachers in Yazd
intermediate schools on breast cancer.
Journal of Brigand University of Medical
Sciences. 2006;13(1):12– 8.
21. Akhtari-Zavare M., Juni H M, Said S, and
Ismail Z I, (2013): Beliefs and Behavior of
Malaysia Undergraduate Female Students in
a Public University Toward Breast Self-
examination Practice, Asian Pacific J Cancer
Prev, 14 (1), 57- 61.
22. Mason TE, White KM. (2008): The role of
behavioral, normative and control beliefs in
breast self-examination. Women Health
2008, 47(3):39-56.
23. Al-Naggar RA, Al-Naggar DH, Bobryshev YV,
Chen R, Assabri A. (2011): Practice and
barriers toward breast self-examination
among young Malaysian women. Asian Pac J
Cancer Prev. 2011;12(5):1173–8.
24. Champion, V. L. (1984). Instrument
development for health belief model constructs.
Advances in Nursing Science, 73-87.
25. Agarwal G, Pradeep PV, Aggarwal V, Yip CH,
Cheung PS. (2007): Spectrum of breast cancer
in Asian women. World J Surg
2007;31:1031-41.
26. Gupta SK. (2009): Impact of a health
education intervention program regarding
breast self- examination by women in a semi-
urban area of Madhya Pradesh, India. Asian
Pac J Cancer Prev. 2009;10(6):1113-7.
27. Boulos DN., & Ghali R R. (2014): Awareness
of Breast Cancer among Female Students at
Ain
Shams, University, Egypt, Global Journal of students. Asian Pacific Journal of Cancer
Health Science; Vol. 6, No. 1; 2014. Prevention. 2010; 11:101-105.
28. Iheanacho, P., Ndu, A., & Emenike, A. D. 32. Habib F., Salman S Safwat M., Shalaby S.,
(2013). Awareness of breast cancer risk factors (2010): Awareness and Knowledge of Breast
and practice of breast self-examination Cancer Among University Students in Al Madina
among female undergraduates in university Al Munawara Region, Middle East Journal of
of Nigeria Enugu campus. Open Journal of Cancer 2010; 1(4): 159-166.
Nursing, 3, 147- 152. 33. Sambanje1 MN., & Mafuvadze B., (2012): Breast
http://dx.doi.org/10.4236/ojn.2013.31019. cancer knowledge and awareness among university
29. Al Junaibi M R., and Khan AS.,(2011): students in Angola, Pan Afr Med J. 2012; 11: 70.
Knowledge and Awareness of breast cancer 34. Rizwan MM, Saadullah M. (2009): Lack of
among university female students in Muscat, awareness about breast cancer and its screening in
Sultanate of Oman- A pilot study, Journal of developed countries. Indian J Cancer
Applied Pharmaceutical Science 01 (10); 2011: 2009;46:252-3.
146-149. 35. El Saghir N, Khalil M, Eid T., El Kinge A.,
30. Danash K.F, Al-Mohaimeed A. (2007): Charafeddine M., Seoud M., & Shamseddine A
Knowledge, attitude, and practice (2007): Trends in epidemiology and management of
surrounding BC and screening in female breast cancer in developing Arab countries: A
teachers of Buraidah, Saudi Arabia. literature and registry analysis, International
International Journal of Health Sciences. Journal of Surgery, Volume 5, Issue 4, August
2007; 1: 75-85. 2007, Pages 225 233.
31. Ba’Amer A. (2010): Awareness of breast http://www.sciencedirect.com/science/article/pii/
cancer and BSE among Yemeni university S0960977605001773.
36. Yelda C D, Eda D, & Meryem (2012): Breast
Self-examination Practices and the Effect of Asian Pacific Journal of Cancer Prevention,
a Planned Training Program in Western 13 (12), 6159- 616.
Turkey, 37. Cohen, M. & Azaiza, F. 2005). Early breast
cancer detection practices, health beliefs,
and cancer worries in Jewish and Arab
women. Preventive Medicine, 41(5-6) 852-
858.
38. Hajian S1, Vakilian K, Najabadi KM, Hosseini
J, Mirzaei HR. (2011): Effects of education
based on the health belief model on screening
behavior in high risk women for breast cancer,
Tehran, Iran. Asian Pac J Cancer Prev.
2011;12(1):49-54.
39. Radi SM (2013): Breast Cancer awareness
among Saudi females in Jeddah. Asian Pac J
Cancer Prev. 2013;14(7):4307-12.
40. Ahmed, B. A. (2010). Awareness and
practice of breast cancer and breast-self-
examination among university students in
Yemen. Asian Pacific Journal of Cancer
Prevention, 11(1), 101-105.
41. Mood M, Sharifirad, G R., Hossein S., and
Sharifzadehe G., (2011): Evaluation of breast
self-examination program using Health Belief
Model in female students, J Res Med Sci.
Mar 2011; 16(3): 316–322.
42. Farmer D, Reddick B, D’Agostino R, Jackson
SA. (2007): Psychosocial correlates of
mammography screening in older African
American women. Oncol Nurs Forum.
2007;34:117–23.
43. Rezaeian, M. Sharifirad, G., Mostafavi, F,
Moodi, M., and Abbasi1 M., (2014): The
effects of breast cancer educational
intervention on knowledge and health beliefs of
women 40 years and older, Isfahan, Iran, J
Educ Health Promot. 2014; 3: 43.
44. Gozum S, Karayurt O, Kav S, Platin N.
(2010): Effectiveness of peer education for
breast cancer screening and health beliefs in
eastern Turkey. Cancer Nurs. 2010;33:213–
20.
45. Hadi MA, Hassali MA, Shafie AA, Awaisu A.
(2010): Evaluation of Breast cancer awareness
among female university students in
Malaysia. Pharmacy Practice. 2010; 8(1):29-
34.
46. Guilford K., (2011): Breast cancer
knowledge, beliefs, and screening behaviors
of college women: utilization of the health
belief model, a dissertation, department of
health science in the graduate school of the
university of Alabama Tuscaloosa, Alabama
2011.

4/13/2016