Research Article Assistance based on research to encourage women who are concerned about breast can - cer to get screened Jesim Yksoy, Puba AcarII Department of Women’s Health and Illness, Faculty of Nursing, In- önü Üniversitesi, Malatya, Turkey. *Corresponding Author : Jesim Yksoy, Department of Women’s Health and Illness, Facul- ty of Nursing, Inönü Üniversitesi, Malatya, Turkey. Received : August 19, 2023 Accepted: August 20, 2023 Published : Septmber 22, 2023 Abstract

BACKGROUND : Concerns about breast cancer play a significant role in determining behaviour that supports breast cancer screening. OBJECTIVE : To ascertain the impact of theory-based training on wom- en with varying degrees of breast cancer anxiety towards breast cancer screening. DESIGN AND SETTING : Conducted two family health centres as part of a randomised controlled experiment. METHODS: 285 women in all were enlisted. Women with low levels of concern about breast cancer be- longed to the first intervention group, which consisted of 112. Women with high levels of concern were part of the second intervention group, which consisted of 37 women, and the second control group, which consisted of 43 women. The groups receiving intervention received instruction based on theory to encourage breast cancer screening. At one, three, and six months, the women’s readiness to have a breast cancer screening as well as their anxiety ratings regarding the disease were assessed. RESULTS : Following the training, women in the low cancer-worry in- tervention group self-examined their breasts more in months 1 and 6, while women in the high cancer-worry control group self-examined their breasts more in month 3 (P < 0.05). Regarding breast self-exam- ination, clinical breast examination, or mammography, there was no difference between the women with low or high levels of breast cancer fears (P > 0.05). CONCLUSION : The effectiveness of theory-based training was not im- pacted by anxiety level, and it had a partial positive impact on partici- pants’ willingness to get screened for breast cancer. CLINICAL TRIAL REGISTRATION : NCT04225741. INTRODUCTION Among gynaecological cancers, breast cancer is the most com- mon type of cancer and the leading cause of cancer-related deaths. Breast cancer affects one in four cancer-stricken wom- en worldwide. According to data from the International Cancer Agency, 626,679 people died from breast cancer globally in 2018 and there were around 2,088,849 new cases.1. While the inci- dence of breast cancer is higher in developed than in develop- ing nations, fewer people die from breast cancer in developed than in developing nations. It is well recognised that mammog- raphy, clinical breast examinations, and breast self-examina- tions are crucial in the early detection of breast cancer. Because mammography is an expensive procedure and not everyone has health insurance and governmental funding is insufficient, particularly in developing nations, the uptake rate for this pro- cedure is low. Therefore, clinical breast examination (which only has a minimal cost) and breast self-examination (which is free) continue to be crucial diagnostic techniques. Additionally, med- ical professionals have the chance to provide advice on breast cancer, risk factors, preventative strategies, and screening tech- niques during a clinical breast examination. It’s critical to understand the obstacles that prevent women from voluntarily undergoing breast cancer screening. Accord- ing to Azami-Aghdash et al., fear, difficulties with transitioning to the clinic, and a lack of knowledge were the main obstacles preventing people from participating in breast cancer screening programmes, in that order.7. Tuzcu and Bahar’s study in Tur- key revealed that the main barrier inhibiting willingness to get screened for breast cancer is ignorance.8 Numerous scholarly investigations have examined the impact of education in sur- mounting the obstacle of inadequate knowledge about breast cancer screening. www.directivepublications.org Page - 1 Journal of Clinical Breast Cancer

Research Article The idea of cancer can be unsettling or frightening. Fear is the third most obstacle to getting screened for breast cancer and can influence women’s decisions to get screened. Women who are afraid or anxious about developing cancer may be more in- clined to seek an early diagnosis in some cases, but in other cas- es, they may be discouraged.11 Research has shown that unfa- vourable feelings like anxiety and concern about health issues might actually cause people to put off getting an early cancer di- agnosis.13–16 The main focus of cancer-related personal edu- cation should be on examining women’s concerns about breast cancer and their behavioural choices throughout follow-up. Thus far, there has been little discussion of how women’s fear and anxieties about cancer affect their behaviour and learning process when it comes to breast cancer screening. It is antic- ipated that the current study will significantly advance our knowledge of women’s attitudes and behaviours about breast cancer screening. OBJECTIVE The purpose of this study was to evaluate the impact of theo- ry-based training on women who are concerned about breast cancer in order to encourage screening for the disease. Further- more, women with varying degrees of concern about breast cancer were compared in terms of their screening habits. METHODS Study design, setting, participants and ethics Two family health centres in eastern Turkey that offered prima- ry healthcare services were the sites of a randomised controlled study. 3,900 women between the ages of 20 and 65 who were registered at these family health centres made up the study’s population. The sample size was calculated by a power analysis using OpenEpi, version 3, a statistical programme that is available to the general public. A significance threshold of 5%, an effect size of 22%, and an 80% power to represent the population were used in this research. Research demonstrated that each group required a minimum of 105 women in the sample size (i.e., 105 in the intervention group and 105 in the control group). In terms of randomization and allocation concealment, women were chosen from Başharık family health centre for the control groups and Sıtmapınarı family health centre for the intervention groups. Using basic random selection, these women were cho- sen from both family health centres. Each family health centre employed a random number table, which made it possible to enrol 1,530 women. For the 420 women who fulfilled the inclu- sion criteria, the Breast Cancer Worry Scale (BCWS) was admin- istered. Participants in the first intervention group and the first control group were women who had been determined to have low levels of breast cancer anxiety, while participants in the second intervention group and the second control group were women who had high levels of breast cancer anxiety. Based on their BCWS scores, 305 women (intervention 182; control 123) with low levels of breast cancer anxiety and 115 women (inter- vention 55; control 60) with high levels of breast cancer anxiety were found. Blinding for group assignment was not feasible for the re- searchers or the participants after allocation. This occurred as a result of follow-up interviews that were done with the ladies and researchers. A total of 285 women completed the study protocol: 37 women completed it in the high breast cancer-wor- ry intervention group and 43 women completed it in the high breast cancer-worry control group. Similarly, 173 women in the low breast cancer-worry intervention group and 112 women in the low breast cancer-worry control group completed the study. These lower numbers resulted from women changing their ad- dresses (n = 33) and wanting to withdraw from the study (n = 22) during the data collection phase (Figure 1). The following were the inclusion criteria. The participants were literate, not pregnant or nursing, had not previously had a mammogram, had not previously had a clinical breast exam- ination, had not been diagnosed with breast cancer, and had not been performing monthly breast self-examinations. The Turkish breast cancer screening programme states that women 20 years of age and older should do a monthly breast self-ex- amination; women 20 years of age and older should have a clinical breast examination every two years; women 40 years of age and older should have a clinical breast examination annually; and women 40-69 years of age should have a mam- mogram annually.21 Consequently, ladies who had been per- forming monthly breast self-examinations were approved. as conducting a self-examination of the breasts. Women who were 40 years of age or older were considered to have undergone clinical breast examination and mammography if they had at least one clinical breast examination within the first six months following training. The largest populations around the Malatya provincial border are served by the Sıtmapınarı and Başharık family health centres (2,500 women served by Sıtmapınarı and www.directivepublications.org Page - 2 Journal of Clinical Breast Cancer

Research Article 1,400 by Başharık), and these populations are homogeneous in terms of sociodemographics. Ethics Under approval number 2014/44, the Internal Review Board (Ethics Committee) of Inönü Üniversitesi gave its blessing to this work on April 16, 2014. The Clinical Trial Registry has this trial listed as NCT04225741. Measurements Between January 2015 and August 2017, information was gath- ered via a personal information form, the BCWS, and the Breast Cancer Screening Behaviour Questionnaire (BCSBQ). Form for personal information: The questionnaire, which was created by the researchers, asked questions about the sociodemographic characteristics of the women. Questionnaire on Breast Cancer Screening Behaviour: The re- searchers created this questionnaire, which included inquiries about mammography procedures, clinical breast examinations, and self-examination of the breast.19 In Turkey, there was no approved instrument for evaluating breast cancer screening behaviour. According to the national guidelines that must be adhered to during studies on breast cancer screening pro- grammes carried out by the Turkish Ministry of Health, the BCSBQ was created. Breast Cancer Worry Scale: This three-item measure was created by Lerman et al. (20) to assess the degree of anxiety about breast cancer and how it affects daily activ- ities and mood. Subsequently, Lerman expanded the scale’s scope beyond breast cancer to include general cancer and in- cluded six new questions.20 Timur Taşhan et al. then adapted Lerman’s six-item cancer worry scale to evaluate just breast cancer fears, and a Turkish validity and reliability study on the BCWS was carried out. The five-item Likert-type scale used in this Turkish-language validated version of the BCWS requires respondents to select one of the following answers for each question: never = 0, seldom = 1, sometimes = 2, frequently = 3, or always = 4. Consequently, the lowest possible overall score is achieved is zero, and 24 is the maximum. A total score below 12 implies minimal concern about cancer, whereas a total score above 12 indicates significant concern.21 The Turkish-language validated version of the BCWS had a Cronbach’s alpha reliability coefficient of 0.78. Procedure The Public Health Institution of Turkey as well as the family health centres in Sıtmapınarı and Başharık gave written con- sent for the study to be conducted. The Inonu University Health Sciences Scientific Research and Publication Ethics Committee also granted approval (April 16, 2014, under number 44). All participating ladies gave verbal agreement prior to the study commencing. Data from the intervention group and the control group were gathered at the same time. The researchers sched- uled phone consultations with the ladies and used in-person interviews to gather data in four phases at the women’s resi- dences. During the first interview, the women who had been chosen to form the two control groups were given the BCWS and the per- sonal information form to complete in order to assess their lev- els of concern about breast cancer. One, three, and six months after the initial interview, follow-up interviews were held, and the BCSBQ was given out at each visit. After distributing the BCWS and the personal information form to the women who were chosen to form the two intervention groups (a high breast cancer worry group and a low breast can- cer worry group) during the initial interview, the researchers provided both intervention groups with breast cancer screen- ing training in the form of group training (8–12 women) in the training room of the Sıtmapınarı family health centre under equal conditions. The women in the intervention groups re- ceived follow-up consultations through home visits in months 1, 3, and 6 after completing this training. The BCSBQ was given out by the researchers at these intervals. The effectiveness of the theory-based training on breast cancer screening behaviour served as the study’s main outcome measure.Changes in the behaviour of screening for breast cancer were the secondary outcome measures. The intervention The 40- to 45-minute single-session training was held in the Sıt- mapınarı Family Health Center’s training room, which served as an appropriate setting. The health belief model explains the low involvement in disease prevention and screening programmes as well as the predictors of the determinants of preventive health behaviours.22, 23 Moreover, this model assesses the cognitive elements that support health-promoting behaviours in addition to explaining screening behaviour. Numerous earlier studies have looked at the health belief model and screening behaviour for breast cancer at the same time.22, 25, and 28 Consequently, this model was applied in the training that was given as part of the current study in order to improve www.directivepublications.org Page - 3 Journal of Clinical Breast Cancer

Research Article participant comprehension of the significance of breast cancer screening. According to the health belief model, participants would learn how to properly do breast self-examination and comprehend the value of clinical breast examination and mam- mography through this training. The concepts listed below were discussed: • Sensitivity perception: Information about the disease, its epidemiology, the anatomy of the breast, and risk factors for breast cancer were given to women in an ef- fort to raise their perception of their own vulnerability to the disease. • Severity perception: The features of breast lumps as identified in early and late breast cancer, as well as the variations in treatment protocols, were elucidated to women in order to enhance their perception of the se- verity of breast cancer. • Perceived benefit: The treatment benefit of early diag- nosis of breast cancer, the role of alternative treatment methods, such as lumpectomy instead of radical mas- tectomy, and the impact of routine examinations on the breast cancer mortality rate were explained in or- der to improve women’s perceptions of breast cancer screening. • Perceived trust: The proper way to perform a self-ex- amination of the breast, the components of a clinical breast examination, the purpose of mammography, and the duration of the mammography procedure were all discussed. • felt barrier: The factors preventing women from per- forming breast self-examination, from having clinical breast exams, and from having mammograms were thoroughly addressed in order to lessen the women’s felt hurdles against getting breast cancer screenings. The control group received none of the above-discussed inter- ventions. Statistical analysis The Statistical Package for the Social Sciences, version 16.0, was used to analyse the data. Percentages, means, Fisher’s exact tests, chi-square tests, independent-sample t tests, and repeat- ed-measurement analysis of variance (ANOVA) tests were em- ployed in the data assessment. The chi-square test and Fisher’s exact test were used to compare the groups with respect to categorical variables. To compare the intervention and control groups, an independent t test was employed. Repeated-mea- surement ANOVA was utilised to look for a significant change in means over time. The threshold for statistical significance was determined to be P < 0.05. RESULTS The control group’s and the intervention group’s age, marital status, work position, educational attainment, and economic standing were identical. Regarding sociodemographic traits, there was no statistically significant difference between the in- tervention and control groups (Table 1). From the pre-intervention test to the tests in months 1, 3, and 6, the mean BCWS scores of the women in the intervention group with low levels of cancer fears climbed progressively, and the changes in the scores were statistically significant (P = 0.001). Among the women in the control group with low levels of can- cer fears, there was no difference in the mean BCWS scores be- tween the pre-test and the tests in months 1, 3, and 6 (P = 0.096). Among the women in the intervention group with high levels of cancer fears, there was no difference in the mean BCWS scores between the pre-test and the tests in months 1, 3, and 6 (P = 0.263).From the pre-test to the tests in months 1, 3, and 6, the mean BCWS scores of the women in the control group who had high levels of cancer fears steadily declined, and the differences in the scores were statistically significant (P = 0.001) (Table 2). In the first month following the theory-based training, it was discovered that 41.6% of the women in the intervention group and 20.5% of the women in the matching control group con- ducted breast self-examination, indicating that these women had low levels of concern about breast cancer. P = 0.001 indi- cates that there was a statistically significant difference in the usage of breast self-examination. Additionally, there was a statistically significant difference (P = 0.021) in the number of women who did breast self-examination in month six between the intervention group (56.1%) and the control group (42%). Be- tween the women in the intervention and control groups, there were no differences in the rates of breast self-examination in the third month or of clinical breast examination and mammog- raphy during the first six months following training (Table 3). In the third month following training, 45.9% of the intervention group’s women and 79.1% of the control group’s women per- formed breast self-examinations, indicating that these women had significant levels of concern about breast cancer. There was a statistically significant difference in the usage of breast www.directivepublications.org Page - 4 Journal of Clinical Breast Cancer

Research Article self-examination (P = 0.020). There were no differences seen between the women in the intervention and control groups on the frequencies of breast self-examination in months 1 and 6, or between having a clinical breast examination and mammog- raphy within the first six months (Table 4). DISCUSSION In order to combat breast cancer, it is crucial that women are encouraged to undergo cancer screening exams on a regular basis. On the other hand, a range of psychosocial factors in- fluence behaviours, including the willingness to participate in cancer screening tests.3. Anxiety, worry, and despair are just a few of the negative emotions that can arise from thinking about cancer.11,29 Of these psychological factors, cancer fear or wor- ry is the most common.In this context, research is needed to de- termine the kinds of disparities that psychosocial factors exhibit in relation to cultural structures and the readiness to seek early diagnosis.The goal of the current study was to ascertain how women’s attitudes about breast cancer screening were affect- ed by theory-based training, based on their degree of concern about breast cancer. The low breast cancer worry intervention group’s women’s con- cerns about breast cancer increased gradually and dramatically, according to the results of follow-ups conducted in months 1, 3, and 6. On the other hand, the women in the control group with high breast cancer worries experienced a steady and significant decline in their anxieties (P < 0.05).According to Janz et al., peo- ple’s anxiety over cancer recurrence caused them to enquire more during doctor visits. It has also been said that people are quite likely to heed the advice of those who have a great deal of faith in, including clergy and medical professionals.According to Çaman et al., women were effectively encouraged to frequent cancer screening centres by the recommendations of physi- cians. These authors also disclosed that women’s concern levels were significantly influenced by the conduct of healthcare pro- viders. According to the fundamental components of the health belief model, the present study’s explanation of breast cancer risk factors, lump characteristics, and treatment regimen vari- ations based on an early or late diagnosis were categorised under the headings of perceived susceptibility and perceived severity.18, 25 It was believed that this information would raise the anxiety levels of the women in the low cancer-worry inter- vention group while lowering the worry levels of the women in the high breast cancer-worry control group. It was suggested that gradually losing the information was the cause of the rise in anxiety in this intervention group. There was a discernible difference in the breast self-examina- tion between the low cancer-worry intervention group and the other groups in months 1 and 6. In contrast, the high can- cer-worry control group did better in month three when it came to self-examination of the breasts. Kim et al.33 discovered that women who worried about cancer a lot were irrationally pessi- mistic. Their behaviour in getting an early cancer diagnosis may be negatively impacted by unfavourable ideas about cancer treatment or survival, which may indicate that they do not want to know about the cancer beforehand. Gasalberti demonstrat- ed that concerns about breast cancer prevented women from doing breast self-examinations,34 while Arts-de Jong et al.35 discovered a link between cancer fears and demoralisation. The current study’s findings are consistent with those of these ear- lier investigations. Other studies have demonstrated that training significantly affects women’s willingness to perform breast self-examina- tion9,10, undergo clinical breast examination, and undergo mammography, despite some earlier research on the effects of training on women’s willingness to undergo breast cancer screening suggesting that this training had no effect in relation to clinical breast examination9 or mammography8,9.10 Ngua et al.’s study on cervical cancer (36) revealed that the training pro- vided had no impact after month six. The instruction provided had a short-term impact on the women’s behaviour, primari- ly with regard to breast self-examination, as demonstrated by the results of the current study. It was noted that the degree of cancer anxiety and the instruction provided had no impact on the willingness to undergo the most valuable diagnostic proce- dures, a clinical breast examination and a mammography. The hypothesis that “theory-based training does not affect women’s acquisition of behaviour favouring breast cancer screening” is partially supported by this finding. In this sense, the current study’s findings are consistent with earlier research. Concerns about acquiring cancer and the impression of one’s own cancer risk are two significant variables that interact with each other, according to numerous research.3,37–39 Within this frame- work, research has examined the impact of breast cancer fears and perceptions of breast cancer risk on the willingness to get screened for the disease. While some research indicated that screening behaviour for breast cancer increased with worry or perceived risk,38,40–44 another research revealed no differenc- es.45 According to Baysal and Gozum46, a lower risk of breast www.directivepublications.org Page - 5 Journal of Clinical Breast Cancer

Research Article cancer was linked to a higher mammography uptake rate. The frequencies of clinical breast examinations, mammography procedures, and breast self-examination did not alter between the low and high cancer fear intervention groups. The hypoth- esis that “the level of breast cancer worry among women does not affect the acquisition of behaviour favouring breast cancer screening” is supported by the results of this study. According to Amuta et al.47, this concern had a transient impact on behaviour linked to health, and that behaviour also changed when there was no emotion involved in making health-related decisions. Furthermore, these investigators discovered that anxiety about cancer had no effect on how frequently people attended cancer screenings. In the Early Diagnosis, Screening and Education Centre for Cancer of Turkey, Çaman et al.32 con- ducted a study and discovered that there was no statistically significant correlation between the frequency of breast self-ex- aminations and the perception of cancer risk. Furthermore, there was no discernible correlation discovered between the perception of cancer risk and the consideration of taking part in breast cancer screening programmes in the future. According to Seven et al.39, there was no relationship between women’s perceptions of their risk of developing breast cancer and their knowledge of the disease, breast self-examination techniques, or mammography procedures. The current study’s findings align with those published by Amuta et al., 32 Çaman et al., 39, and Seven et al. The first study restriction was the small percentage of women who were enrolled and who worried a lot about breast cancer. The second was that the ladies in the experimental group re- ceived instruction that was portrayed as group-based instruc- tion. Finally, there was no assessment of these women’s true breast cancer risks or their pre- and post-training knowledge levels.

CONCLUSIONS The current study discovered that theory-based training had no influence on willingness to undergo clinical breast examination and mammography, but it did have a partial effect on willing- ness to perform breast self-examination. Furthermore, it was noted that the women’s degree of worry had no bearing on the effectiveness of theory-based training aimed at promoting breast cancer screening. It is believed that these women wor- ried after learning about the risk factors for developing breast cancer screening behaviours, but their anxiety had little effect on their behaviour. Instead, it sent them more encouraging messages; as a result, research into how this strategy affects breast cancer screening behaviour is necessary. REFERENCES 1. GLOBOCAN 2018: Data visualization tools for exploring the global cancer burden in 2018. Available from: https:// gco.iarc.fr. Accessed in 2019 (May 9). 2. Ministry of Health. National standards of breast cancer screening program of Turkey. Available from: https:// hsgm.saglik.gov.tr/tr/. Accessed in 2017 (Aug 9). 3. Naivar Sen CK, Baruh L, Kumkale GT. Beyond a Paycheck: The influence of workforce participation on women’s can- cer screening in Turkey. Sex Roles. 2016;75(11-12):599– 611. doi: 10.1007/s11199-016-0611-4. 4. American Cancer Society 2016. Breast Cancer Facts & Fig- ures 2015-2016. Available from: https://www.cancer.org/ content/dam/cancer-org/ research/cancer-facts-and-sta- tistics/breast-cancer-facts-and-figures/ breast-cancer- facts-and-figures-2015-2016.pdf Accessed in 2017 (Aug 9). 5. Uğraş GA, Akyolcu N. Breast Self-Examination: How im- portant is it in early diagnosis? The Journal of Breast Health. 2011;7(1):10-14. Available from: http://www.the- journalofbreasthealth.com/en/breast-self-examination- how-important-is-it-in-early-diagnosis-13217. Accessed in 2020 (Mar 19). 6. Bueno ATP, Capelasso VL, Pacheco RL, et al. What do Co- chrane systematic reviews say about the clinical effective- ness of screening and diagnostic tests for cancer? Sao Paulo Med J. 2017;135(4):401-10. PMID: 28813112; doi: 10.1590/1516-3180.2017.0171110717. 7. Azami-Aghdash S, Ghojazadeh M, Sheyklo SG, et al. Breast cancer screening barriers from the woman’s perspective: A meta-synthesis. Asian Pac J Cancer Prev. 2015;16(8):3463- 71. PMID: 25921163. 8. Tuzcu A, Bahar Z. Barriers and facilitators to breast can- cer screening among migrant women within Turkey. J Transcult Nurs. 2015;26(1):47- 56. PMID: 24692336; doi: 10.1177/1043659614526245. www.directivepublications.org Page - 6 Journal of Clinical Breast Cancer

Research Article 9. Wu TY, Lin C. Developing and evaluating an individu- ally tailored intervention to increase mammography adherence among Chinese American women. Cancer Nurs. 2015;38(1):40-9. PMID: 24621965; doi:10.1097/ NCC.0000000000000126. 10. Mermer G, Turk M. Assessment of the effects of breast cancer training on women between the ages of 50 and 70 in Kemalpasa, Turkey. Asian Pac J Cancer Prev. 2014;15(24):10749-55. PMID: 25605170. 11. Tuzcu A, Bahar Z, Gözüm S. Effects of interventions based on health behavior models on breast cancer screen- ing behaviors of migrant women in Turkey. Cancer Nurs. 2016:39(2):E40-50. PMID: 26018817; doi: 10.1097/ NCC.0000000000000268. 12. Vrinten C, McGregor LM, Heinrick M, et al. What do people fear about cancer? A systematic review and meta-synthe- sis of cancer fears in the general population. Psychooncol- ogy. 2017;26(8):1070-9. PMID: 27643482; doi: 10.1002/ pon.4287. 13. Greiner KA, James AS, Born W, et al. Predictors of fecal occult blood test (FOBT) completion among low income adults. Prev Med. 2005;41(2):676- 84. PMID: 15917068; doi: 10.1016/j.ypmed.2004.12.010. 14. McQueen A, Vernon SW, Meisner HI, et al. Risk perceptions and worry about cancer: does gender make a difference. J Health Commun. 2008;13(1):56-79. PMID: 18307136; doi: 10.1080/10810730701807076. 15. Skinner CS, Champion V, Menon U, et al. Racial and educa- tional differences in mammography-related perceptions among 1,336 nonadherent women. J Psychosoc Oncol. 2002;20(1):1-18. doi: 10.1300/ J077v20n03_01. 16. Lerman C, Hughes C, Trock BJ, et al. Genetic testing in families with hereditary nonpolyposis colon cancer. JAMA. 1999;281(17):1618-22. PMID: 10235155; doi: 10.1001/ jama.281.17.1618. 17. Gooding HC, Organista K, Burack J, Biesecker BB. Genetic susceptibility testing from a stress and coping perspec- tive. Soc Sci Med. 2006;62(8):1880- 90. PMID: 16198036; doi: 10.1016/j.socscimed.2005.08.041. 18. Seçginli S. Mammography self-efficacy scale and breast cancer fear scale. Cancer Nurs. 2012;35(5):365-73. PMID: 21946901; doi: 10.1097/ NCC.0b013e3182331a9a. 19. Ministry of Health. Breast cancer screening programs in the world and in Turkey. Available from: https://hsgm. saglik.gov.tr/ tr/kanser-tarama-standartlari/listesi/485- meme-kanseri-tarama- program%C4%B1-ulusal-standar- tlar%C4%B1.html. Accessed in 2018 (Aug 9). 20. Lerman C, Trock B, Rimer BK. Psychological side effects of breast cancer screening. Health Psychol. 1991;10(4):259- 67. PMID: 1915212; doi: 10.1037//0278-6133.10.4.259. 21. Timur Taşhan S, Uçar T, Aksoy Derya Y, Nacar G, Erci B. Validity and reliability of the Turkish version of the Mod- ified Breast Cancer Worry Scale. Iran J Public Health. 2018;47(11):1681-7. PMID: 30581784. 22. Champion VL, Skinner CS. The health belief model. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: Theories, research and practice. San Francisco, CA: Jossey-Bass; 2008. p. 46-65. 23. Janz NK, Champion VL, Strecher VJ. The health belief mod- el. In: Glanz K, Rimer BK, Lewis FM, editors. Health be- havior and health education. San Francisco: Jossey-Bass; 2002. p. 45-66. 24. Shiloh S, Ilan S. To test or not to test? Moderators of the relationship between risk perceptions and interest in pre- dictive genetic testing. J Behav Med. 2005;28(5):467-79. PMID: 16195820; doi: 10.1007/s10865- 005-9017-4 . 25. Çenesiz E, Atak N. Türkiye’de Sağlık İnanç Modeli ile Yapilmiş Araştirmalarin Değerlendirilmesi [The Evaluation of the Researchers in the Health Belief Model in Turkey]. Kor Hek. 2007;6(6):427-34. Available from: https:// www. researchgate.net/publication/317196908_Turkiye’de_ Saglik_ Inanc_Modeli_ile_Yapilmis_Arastirmalarin_De- gerlendirilmesi. Accessed in 2019 (Sep 30). 26. Dündar PE, Özmen D. Öztürk B, et al. The knowledge and attitudes of breast self-examination and mammography in www.directivepublications.org Page - 7 Journal of Clinical Breast Cancer

Research Article a group of women in a rural area in western Turkey. BMC Cancer. 2006;6:43 PMID: 16504119; doi: 10.1186/1471- 2407-6-43. 27. Karayurt O, Dramalı A. Adaptation of Champion’s health belief model scale for Turkish women and evaluation of the selected variables associated with breast self-exam- ination. Cancer Nurs. 2007;30(1):69-77. PMID: 17235224. 28. Schwartz K, Fakhouri M, Bartoces M, et al. Mammography screening among Arab American women in metropolitan Detroit. J Immigr Minor Health. 2008;10(6):541-9. PMID: 18392934; doi: 10.1007/s10903-008- 9140-8. 29. Croyle RT, Lerman C. Risk communication in genetic test- ing for cancer susceptibility. J Natl Cancer Inst Monogr. 1999;(25):59-66. PMID: 10854459. 30. Freund A, Cohen M, Azaiza F. The doctor is just a messenger: Beliefs of ultraorthodox Jewish women in regard to breast cancer and screening. J Relig Health. 2014;53(4):1075-90. PMID: 23543095; doi: 10.1007/ s10943-013-9695-0. 31. Hillen MA, de Haes HC, Stalpers LJ, et al. How attachment style and locus of control influence patients’ trust in their oncologist. J Psychosom Res. 2014;76(3):221-6. PMID: 24529041; doi: 10.1016/j.jpsychores.2013.11.014. 32. Çaman ÖK, Bilir N, Özcebe H. Are family history of cancer and perceived cancer risk associated with cancer preven- tive behaviors? Firat Med J. 2014;19(2):95-100. 33. Kim J, Huh BY, Han HR. Correlates of misperception of breast cancer risk among Korean-American Women. Women’s Health. 2016;56(6):634-49. PMID: 26580449; doi: 10.1080/03630242.2015.1118722. 34. Gasalberti D. Early detection of breast cancer by self-ex- amination: the influence of perceived barriers and health conception. Oncol Nurs Forum. 2002;29(9):1341–7. PMID: 12370704; doi: 10.1188/02.ONF.1341- 1347. 35. Arts-de Jong M, DeJong CAJ, Hermens RP, et al. High de- moralization in a minority of oophorectomized BRCA1/2 mutation carriers influences quality of life. J Psychosom Obstet Gynaecol. 2018;39(2):96-104. PMID: 28279121; doi: 10.1080/0167482X.2017.1296429. 36. Ngu SF, Wei N, Kwan TTC, et al. Impact of different educa- tional interventions on psychosocial well-being of wom- en with a positive high-risk human papilloma virus and normal cervical cytology: A randomised trial. J Psychosom Obstet Gynaecol. 2018;39:146-55. PMID: 28391730; doi: 10.1080/0167482X.2017.1312335. 37. April-Sanders A, Oskar S, Shelton RC, et al. Predictors of breast cancer worry in a Hispanic and predominantly im- migrant mammography screening population. Women’s Health Issues. 2017;27(2):237-44. PMID: 27863982; doi: 10.1016/j.whi.2016.10.003. 38. Rondanina G, Puntoni M, Guerrieri-Gonzaga A, et al. Wor- ry and risk perception of breast cancer in a prevention trial of low dose tamoxifen in midlife postmenopausal hormone users. Breast. 2017;34:108-14. PMID: 28570956; doi: 10.1016/j.breast.2017.05.008. 39. Seven M, Bağcivan G, Akyüz A, Bölükbaş F. Women with family history of breast cancer: How much are they aware of their risk? J Cancer Educ. 2018;33(4):915-21. PMID: 28474221; doi: 10.1007/s13187-017-1226-3. 40. Bennett P, Parsons E, Brain K, et al. Long-term cohort study of women at intermediate risk of familial breast cancer: experiences of living at risk. Psychooncolo- gy. 2010;19(4):390-8. PMID: 19514016; doi: 10.1002/ pon.1588. 41. Caruso A, Vigna C, Gremigni P. The cancer worry scale revised for breast cancer genetic counseling. Cancer Nurs. 2018;41(4):311-9. PMID: 28538002; doi: 10.1097/ NCC.0000000000000511. 42. Norouznıa S. Meme kanseri korkusunun kadınların erken tanı davranışları üzerinde etkisinin incelenmesi [Tezi]. Turkey: Dokuz Eylül Üniversitesi Sağlık Bilimleri Enstitüsü; 2014. 43. Yavan T, Akyüz A, Tosun N, IyigUn E. Women’s breast can- cer risk perception and attitudes toward screening tests. www.directivepublications.org Page - 8 Journal of Clinical Breast Cancer

Research Article J Psychosoc Oncol. 2010;28(2):189-201. PMID: 20391075; doi: 10.1080/07347330903570453. 44. Yüksel S, Altun Uğraş G, Çavdar İ, et al. A Risk Assessment comparison of breast cancer and factors affected to risk perception of women in Turkey: A cross-sectional study. Iran J Public Health. 2017;46(3):308-17. PMID: 28435816. 45. Ersin F, Bahar Z. Effects of health belief models on breast cancer early detection behaviors: A literature review. Asian Pac J Cancer Prev. 2011;12(10)2555-62. PMID: 22320955. 46. Baysal HY, Gözüm S. Effects of health beliefs about mam- mography and breast cancer and telephone remind - ers on re-screening in Turkey. Asian Pac J Cancer Prev. 2011;12(6):1445-50. PMID: 22126479. 47. Amuta AO, Mkuu RS, Jacobs W, Ejembi AZ. Influence of cancer worry on four cancer related health protec- tive behaviors among a nationally representative sam- ple: Implications for health promotion efforts. J Cancer Educ. 2018;33(5):1002-10. PMID: 28251521; doi: 10.1007/ s13187- 017-1195-6. www.directivepublications.org Page - 9 Journal of Clinical Breast Cancer