Akhtari-Zavare et al.

BMC Public Health (2016) 16:738

DOI 10.1186/s12889-016-3414-1

RESEARCH ARTICLE Open Access

Result of randomized control trial to

increase breast health awareness among
young females in Malaysia
Mehrnoosh Akhtari-Zavare1, Muhamad Hanafiah Juni2*, Salmiah Md Said2, Irmi Zarina Ismail3,
Latiffah A. Latiff2,1 and Sima Ataollahi Eshkoor4

Abstract
Background: Breast cancer is the most common cancer and the second principal cause of cancer deaths in women
worldwide as well as in Malaysia. Breast self-examination (BSE) has a role in raising breast cancer awareness among
women and educational programs play an important role in breast cancer preventive behavior. The aim of this study is to
develop, implement and evaluate the effectiveness of Breast Health Awareness program based on health belief model on
knowledge of breast cancer and breast-selfexamination and BSE practice among female students in Malaysia.
Methods: A single-blind randomized controlled trial was carried out among 370 female undergraduate students from
January 2011 to April 2012 in two selected public universities in Malaysia. Participants were randomized to either the
intervention group or the control group. The educational program was delivered to the intervention group. The outcome
measures were assessed at baseline, 6, and 12 months after implementing the health educational program. Chi-square,
independent samples t-test and two-way repeated measures ANOVA (GLM) were conducted in the course of the data
analyses.
Results: Mean scores of knowledge on breast cancer (p<0.003), knowledge on breast self examination (p<0.001), benefits
of BSE (p<0.00), barrier of BSE (0.01) and confidence of BSE practice (p<0.00) in the intervention group had significant
differences in comparison with those of the control group 6 and 12 months after the intervention. Also, among those
who never practiced BSE at baseline, frequency of BSE practice increased 6 and 12 months after the intervention (p<0.05).
Conclusion: The Breast Health Awareness program based on health the belief model had a positive effect on knowledge
of breast cancer and breast self-examination and practice of BSE among females in Malaysia.
Trial registration: The ANZCTR clinical trial registry (ACTRN12616000831482), retrospectively registered on Jun 23, 2016 in
ANZCTR.org.au.
Keyword: Breast cancer, Breast self-examination, Health education, Belief, Malaysia

Background female breast cancer cases, accounting for 31.3 % of all

Despite extensive progress and effort in treatment, cancer cases registered [2].
breast cancer remains one of the most life- threatening A significant number of Malaysian women present
conditions among women worldwide [1]. Similarly, in with advanced stages of the breast cancer due to limited
Malaysia, breast cancer is the most common type of can- knowledge of breast cancer, breast cancer screening, and
cer among females regardless of their ethnic groups from breast self-examination, which is considered as the main
the age of 15 years onwards [2]. The National Cancer barrier among Malaysian women [3–5]. According to
Registry (2008) reported that there are 11,952 registered the Third National Health Morbidity Survey [6], the
prevalence rate for breast examination in Malaysia was
* Correspondence: [email protected] 70.35 %, where the highest was for breast self-
2
Department of Community Health, Faculty of Medicine & Health Science, examination (57.14 %), followed by clinical breast exam-
Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
Full list of author information is available at the end of the article
ination (51.77 %) and mammography (7.57 %) [6]. Based

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 2 of 11

on the results of another studies, low percentages of benefits and barriers of BSE practice and other screening
clinical breast examination (23.3 %), breast self- methods [21]. One of the most widely used conceptual
examination (19.6 %), and intention to perform breast frameworks, which is often used as an educational pro-
self-examination (18.5 %) were observed among Malay- gram, is the Health Belief Model (HBM) [22, 23].
sian women [7–9]. Such results clearly show the need Health belief plays an important role in an individual’s
for awareness campaigns that raise the knowledge of interest in the health protection behaviour, which leads
young women about breast cancer and the need for the to screening practices in different countries and cultures
involvement of social media in promoting public breast [21, 24]. In this theoretical framework, women’s breast
health [6–9]. cancer screening practices such as BSE, clinical breast
Early detection of breast cancer can reduce the mor- examination, and mammography are influenced by their
tality rate and is also important for its effective treat- health belief model [25]. This model emphasizes that
ment [10]. Reportedly at an early stage (stage I-II), its 5- health behaviour is affected by threats from health prob-
year survival rate reached 100–93 %, whereas its later lems; for example, women perceiving susceptibility to
detection (stages III–IV) decreased the survival rate to breast cancer risk or believing that breast cancer is a
72–22 % [11]. Mammography, clinical breast examin- serious disease are more likely to do the BSE practice.
ation, and breast self-examination are tools for early de- Women with higher health motivation, who perceive
tection of breast cancer [10]. There are arguments greater benefits and feel fewer barriers to breast examin-
surrounding the efficacy of BSE. Based on the large ran- ation, are more likely to perform BSE [26]. The model
domized trials in Shanghai, breast self-examination was also suggests that, in addition to the health beliefs, the
not an effective screening tool for breast cancer [12]. knowledge of BSE and sociodemographic background
Likewise, the US Preventive Service Task Force and the are positively related to the increase in the chances of per-
Canadian Task Force on Preventive Health Care reported forming BSE [27]. Figure 1 shows the components of health
that breast self-examinations are no more beneficial for belief model and how it is implemented in this study.
women [5, 13].
Although BSE alone is not sufficient for early detection
Purpose
of breast cancer, it is an effective tool for raising breast
The aim of this study was to determine the effective-
cancer awareness and the opportunity to educate women
ness of a Breast Health Awareness program based on
about breast cancer in developing countries [14, 15].
the Health Belief Model (HBM) among female under-
Moreover, the BSE training and adherence is a gateway to
graduate students in public universities in Malaysia.
health promotion behavior that gives women knowledge
We assumed that female students who participated in
and sets for adherence to clinical breast examination
the Breast Health Awareness program would demon-
(CBE) and mammography screening guideline later in life
strate significant differences in knowledge and beliefs
[16, 17].
towards breast cancer and breast self-examination
Many interventions have been done to increase breast
practice compared to students who did not participate
cancer screening and BSE practice among women world-
in the program.
wide. For instance, Beydağ et al. [18] evaluated the effect
of BSE brochures among 103 Turkish female college stu-
dents at Halic University and showed that the BSE Methods
knowledge score was 43.2 ± 10.6 before education, which Study design
increased to 68.4 ± 10.5 after education (p < 0.05). Also, A single-blinded randomized controlled trial was carried
they found that more than half (53.4 %) of the female out from January 2011 until April 2012 in two selected
students, who did not perform BSE, did not have any public universities (Universiti Putra Malaysia and Uni-
knowledge about BSE. However, there is no randomized versiti Teknologi MARA) in the Klang Valley in
controlled trial done to increase the awareness of breast Malaysia. The data entry and analysis were carried out
cancer and BSE practice among young females in by an independent team led by a statistician. Approval
Malaysia. Young women believe that they are not at risk from the Ministry of Higher Education in Malaysia (Ref
of getting breast cancer [19]; however, the higher stages No. KPT.R.620-1/1/1 JId.15(9)) as well as the vice chan-
breast cancer presented among young women were cellors of the selected public universities and the Med-
more aggressive than those of older women [20]. ical Research Ethics Committee of the Faculty of
To increase breast cancer awareness among women Medicine and Health Sciences, UPM (Ref No. UPM/
and build their confidence in the BSE practice, we must FPSK/PADS/T7-MJKEtikaPer/F01(JKK_NOV(09)12)
understand what women may or may not know about were obtained before the commencement of the study.
breast cancer. Also, we must understand how they feel A written consent was taken from each respondent
about breast cancer and its early detection, as well as the before conducting the study.
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 3 of 11

Fig. 1 Conceptual framework of study based on Health Belief Model (HBM)

Recruitment and randomization Society [2, 28]. The content of the education module in-
Malaysian female students aged 20 years old and above cludes the normal breast, breast health awareness, breast
were recqruited. The purpose of study, date and places cancer, and other screening methods. In addition to this
of screening were sent via email to the eligible students. information, participants were trained on how to prac-
Those who were pregnant, breastfeeding, in the final se- tice BSE on a silicon breast model with multiple im-
mester of their study, and/or students from the Medi- planted lumps.
cine or Health Faculties were excluded. The module was developed based on the objective of
The list of all female undergraduate students in De- this study and peer reviewed through a series of meet-
partment of Communication and Malay Language as ings with members of the project team. The final con-
well as Physical Education from the two public univer- tent of the educational module and steps of the BSE
sities in the Klang Valley, Malaysia, served as the sam- practice on a silicon breast model were tested among
pling frame. The eligible participants were assigned the 30 female students other than the actual study par-
randomly into control and intervention groups from the ticipants for acceptability and comprehension. Table 1
sampling frame by using the random number table. Ma- summarises the topics covered in the educational mod-
triculation numbers were used to identify the partici- ule on breast health awareness.
pants in our sampling frame and unique code numbers
were given to each participant in both groups and used Intervention
by them in the questionnaire in order to maintain confi- To enhance the participation rate in the intervention
dentiality. Figure 2 shows the flow diagram of the study group, 16, 2-h workshops were offered, as well as a brief
participants in the control and intervention groups. description of the educational module with group of 12–
13 students in each.
Development of intervention The intervention group participated in a one-hour lec-
The educational module on breast health awareness was ture which covered all contents of the “educational mod-
developed based on the Clinical Guidelines of Malaysia ule on breast health awareness” in the form of slide
for breast cancer screening and American Cancer presentation. Also, the intervention group received
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 4 of 11

Fig. 2 Flow chart of study participants in control and intervention groups

another one-hour training on breast silicon model to on the breast silicon model to ensure they can do it cor-
learn how to do the BSE practice. After the training, rectly. At the end of the workshop, each participant was
each participant was asked to duplicate the BSE practice given a copy of the educational module.
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 5 of 11

Table 1 Summary of content in educational module on breast (1) Socio-demographic data form: Socio-demographic
health awareness data consisted of age, race, religious, marital status,
Unit Content and family monthly income.
Overview (2) Knowledge data form: Participants’ breast cancer
• Introduction to content of booklet knowledge was assessed using 35 items concerning
• The overall learning objectives their knowledge of BSE (10 items) and breast cancer
• Target Population (25 items). The 25 items on the knowledge of breast
Unit 1 Breast health awareness cancer included general facts of breast cancer (5
• Knowledge of breast cancer items), knowledge of symptoms of breast cancer (6
• Breast self examination (BSE) items), risk factors (10 items), as well as CBE and
Unit 2 Normal breast mammography (4 items). The items were derived
• Anatomy of breast from the literature (25, 29, 20). Responses were
• Physiology of breast measured using the nominal scale of “True”, “False”
Unit 3 Breast cancer and “I do not know”. Respondents were given one
• Symptoms of breast cancer point for each correct answer and zero for each
• Risk Factors for Breast Cancer wrong or unsure response. For the current study,
• Treatment of breast cancer the kappa value for categorical data was ranged
Unit 4 Other screening methods between general facts of breast cancer (0.70–0.80),
• Clinical Breast-Examination (CBE) risk factors in breast cancer (0.52–0.97), symptom
• Mammography of breast cancer (0.70–0.97), CBE and
GLOSSARY OF TERMS mammography (0.80–0.90) and knowledge of BSE
REFERENCES (0.70–0.87).
(3) Champion’s Health Belief Model Scale: The third
part evaluated health beliefs of the participants by
The control group participants did not receive any using the Champion’s Health Belief Model Scale
education during the study period but the usual treat- [30]. It consists of 40 questions related to the
ment from the health centres of each university or any seriousness and susceptibility of breast cancer,
campaign for breast cancer provided by the Ministry of barrier-BSE, benefit-BSE, the confidence of doing
Health Malaysia. However, they received the educational BSE and health motivation using a five-point Likert
module and a training of the BSE practice on a silicon scale ranging from “strongly disagree” (1) to
breast model after the data collection. All participants in “strongly agree” (5) responses. Acceptable intra-class
the intervention and control groups responded to a vali- correlation coefficient (ICC) values were recorded
dated and pretested questionnaire at baseline, as well as for seriousness (0.89–0.96), susceptibility (0.79–
6 and 12 months after the intervention. 0.86), benefit (0.85–0.98), barrier (0.70–0.80), confi-
dence (0.88–0.97) and motivation (0.92–0.98).
Outcome measure These values were consistent with the previous
The primary outcome of this study was the BSE practice. studies in Malaysia [31] and Turkish [32].
The secondary outcomes were knowledge of BSE and (4) BSE practice and frequency: The last part of the
breast cancer as well as the health belief model scales. questionnaire assessed the BSE practice by self-
To evaluate these outcomes, data were collected via a reported responses to two questions which included
self-administrative dual-language (English and Malay) whether they had ever carried out BSE (yes/no) and
questionnaire which was developed by the researchers the frequency of doing BSE (“once a month”, “occa-
based on the previous research publications [20, 25, 29]. sionally”, “others” and “never”). A woman who per-
The content validity was evaluated by five experts from formed BSE once a month was categorized as
the Community Health Department at Universiti Putra practicing “regular BSE” while a woman who per-
Malaysia to examine each item for congruence by esti- formed occasionally or others was categorized as
mating the Content Validity Index (CVI) as being over practicing “irregular BSE”. The Kappa value for the
0.80 (acceptable), while face validity was verified by dis- current study ranged from 0.82–0.85 [BSE practice
cussing the items individually with 10 students. The reli- (K = 0.82) and frequency of BSE (K = 0.85)].
ability of the questionnaire was determined by using the
test-retest reliability conducted among 80 female under- Sample size estimation
graduate students at Universiti Putra Malaysia that were The sample size of this study was estimated using the
not included in the main study. Data were collected Rosner’ formula (n = [zα√pq(1 + 1/k) + zβ √p1q1 + p2q2/
using the following questionnaires: k]2/Δ2) [33]. In order to achieve 80 % power to detect a
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 6 of 11

group difference of 13 % [34] with a two-sided 5 % sig- regularly was 15 (8.1 %) in the intervention group and 5
nificance level, 165 female students in each arm were re- (2.7 %) in the control group. At baseline, no significant
quired. On the basis of a predicted attrition rate of 20 %, differences in the BSE practices (p = 0.10) and BSE fre-
the goal was to randomly assign 198 female students in quency (p = 0.06) were found between the intervention
each intervention and control groups. Of those who ini- and control group. At 6 and 12 months after the inter-
tially agreed to participate in the study, 26 dropped out vention, the two groups differred significantly in terms
for variety of reasons (e.g. medical illness, unwillingness of their BSE practice and frequency.
to participate, moving and schedule conflict). As a result, Table 4 shows changes in the BSE practice and fre-
186 female students in the intervention group and 184 quency among those who never practiced BSE at base-
female students in the control group completed the line between groups over the period of study. Based on
study in 12 months (Fig. 2). the results, among those who never practiced BSE at
baseline, 22 (15.5 %) in the intervention group and 10
Statistical analysis (6.5 %) in the control group practiced BSE at 6 months,
The data were analyzed using the Statistical Package for while 21 (14.8 %) in the intervention group and 11
Social Science (SPSS) version 22.0. The outcome of interest (7.2 %) in the control group practiced BSE 12 months
was the BSE practice, and knowledge of breast cancer, BSE after the intervention. Likewise, 15 (10.6 %) in the inter-
and health beliefs. The Socio-demographic characteristics vention group, and 2 (1.3 %) in the control group per-
of the intervention and control groups were described by formed regular BSE 12 months after the intervention.
using frequency, percentage, mean and standard deviation. The control and intervention groups differred signifi-
The comparison at baseline between the intervention and cantly in the BSE practice at 6 and 12-month follow-ups
control groups was made by using the appropriate inferen- (p < 0.05).
tial tests such as the Chi-square and independent samples
t-test. The two-way repeated measures ANOVA (GLM) Change in the knowledge of breast cancer and self-
was used to evaluate the changes in the mean score of examination
breast cancer and BSE knowledge and belief between the Table 5 compares the mean scores for the knowledge of
control and intervention groups at baseline, as well as 6 breast cancer and self-examination between the interven-
and 12 months after the intervention. The cut-off level for tion and control groups at baseline, 6 months and
alpha was set at 0.05. 12 months after the intervention. At baseline, there were
no significant differences between the knowledge score of
Results breast cancer (p = 0.66) and knowledge of breast self-
Baseline data examination (p = 0.69) between the intervention and con-
The female students (n = 370) who participated in this trol groups. However, the knowledge score of breast can-
study were assined to the intervention (n = 186) and cer and self-examination for the intervention group was
control (n = 184) groups. The majority of the partici- significantly higher compared to the control group with
pants (349, 94.3 %) were Malays, whereas 21 (5.7 %) mean differences of 0.83 (95%CI 0.27–1.38; p = 0.003) and
were non-Malays. The proportion of Muslims was 0.67 (95%CI 0.29–1.05;p = 0.001), respectively. Also, re-
higher than non-Muslims, 352 (95.1 %) vs. 18 (4.9 %). peated measures ANOVA results revealed that the inter-
With regards to marital status, 357 (96.5 %) of the par- vention group had statistically significant increase in the
ticipants were single and 13 (3.5 %) were married. The knowledge of breast cancer (F = 5.24; p = 0.005) and
average age of the respondents was 22 years (mean = knowledge of BSE (F = 13.64;p = 0.000) over time.
21.79 ± 1.24; 95 % CI = 21.66, 21.91) and the average
monthly income was about RM5300 (mean = 4000 ± Changes in champion health belief model scales
2129.63; 95 % CI = 4511.74- 4947.17). At baseline, no Table 6 presents the changes in mean scores of champion
significant difference was found between the study health belief model scales between the intervention and
groups regarding participant characteristics (p < 0.05) control groups. Based on the result, we found that in the
(Table 2). intervention group, significant changes were seen from the
baseline to 6 and 12 months after the intervention in the
Change in the BSE practice and frequency benefits of BSE (mean differences:1.09; 95 % CI 0.32–1.89;
Table 3 shows the BSE practice and frequency among all p = 0.006), barriers of BSE (mean differences: 0.95; 95 % CI
participants at baseline, and 6 and 12 months after the -1.74 – -0.15; p = 0.019), confidence of BSE (mean differ-
intervention. Based on the results, 44 (23.7 %) of the ences: 1.66; 95%CI 0.55–2.77; p = 0.003) and total health
participants in the intervention group practiced BSE belief model score (mean differences: 2.62; 95 % CI 0.03–
whereas in the control group 31 (16.8 %) practiced BSE 5.21; p = 0.04) compared to the control group. No signifi-
at the baseline. The rate of those who practiced BSE cant differences were found between the intervention and
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 7 of 11

Table 2 Sociodemographic characteristics of the respondents

Characteristics Total participants Intervention group Control group Statistics
n (%) n (%) 186 n (%) 184
Age
(Mean ± SD) 21.79 ± 1.24 21.81 ± 1.38 21.76 ± 1.09 t = 0.39
p = 0.69
Race
Malay 349 (94.3) 174 (93.5) 175 (95.1) χ2 = 0.42, p = 0.51
Non-malay 21 (5.7) 12 (6.5) 9 (4.9)
Religious
Muslim 352 (95.1) 174 (93.5) 178 (96.7) χ2 = 2.03, p = 0.15
Non-muslim 18 (4.9) 12 (6.5) 6 (3.3)
Marital Status
Married 13 (3.5) 7 (3.8) 6 (3.3) χ2 = 0.06, p = 0.79
Single 357 (96.5) 179 (96.2) 178 (96.7)
Family Monthly Income
(Mean ± SD) 4000 ± 2129.63 4540.86 ± 2013.23 4920.10 ± 2230.45 t = -1.71
p = 0.08
SD standard deviation

control groups for the rest of the components. In addition, program may be appropriate to increase both BSE prac-
there were no baseline differences in any component of the tice and frequency of doing BSE for further samples with
health belief model between the two groups. similar demographic characteristics.

Discussion Knowledge of BSE

One of the important challenges and investments in the One of the hypotheses of this study was that there is a
health of future generations of women is educating and significant difference in the level of BSE knowledge
informing youth about breast cancer [35]. Based on the among women in the intervention and control groups at
Health Belief Model (HBM), this study assessed the effect 6 and 12 months post-intervention. Our results highlight
of breast health education intervention on BSE practice, the importance of health education in increasing
knowledge of breast cancer and BSE as well as health be- women’s level of BSE knowledge. In accordance with the
liefs of female undergraduate students in the Klang Valley, present study, other two studies carried out in Turkey
Malaysia. Our results highlighted the importance of health [23] and Iran [37] showed that educational intervention
education in increasing the level of knowledge among had a positive impact on increasing the level of know-
women about BSE and breast cancer, beliefs related to ledge of BSE. The findings of this and previous studies
breast cancer and BSE, as well as BSE practice. demonstrate that health promotion education teaches
young women to increase their knowledge and aware-
BSE practice ness on BSE, which is the first important step in breast
The results of the study showed that teaching BSE prac- cancer screening [23].
tice increases its rate and the frequency of doing BSE
among those who did not practice BSE before the health Knowledge of breast cancer
education program. This shows that the Breast Health After education, the breast cancer knowledge of partici-
Awareness program successfully motivated the women pants in the intervention group significantly differed
towards BSE practice. The results are in line with those from that of the control group at all post-tests. This sig-
of several earlier studies reporting that BSE training in- nificant difference showed that educational intervention
creases the frequency of BSE practice and performing of had a positive impact on increasing breast cancer know-
BSE [14, 36]. Secginli et al. [36] similarly reported that ledge among the participants. This finding is consistent
those learning BSE practice on breast silicon models with those of the previous studies in Iran [38], Egypt
comprising lumps displayed more frequent BSE practice [39], India [40], Taiwan [41] which showed that educa-
than those who learned BSE practice through film or tional intervention significantly increased awareness re-
pamphlets. Therefore, the Breast Health Awareness garding breast cancer as well as the frequency of
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 8 of 11

Table 3 Changes in BSE practice and BSE frequency between Table 4 Changes in BSE practice and BSE frequency between
intervention and control group at baseline, 6-months and 12- intervention and control group at 6-months and 12-months
months after intervention after intervention among those who never practice BSE at
Variable Intervention group Control group Statistics baseline
n = 186 n = 184 Variable Intervention group Control group Statistics

n (%) n (%) n (%) n (%)

BSE practice (Baseline) BSE practice (6 months)

Yes 44 (23.7) 31 (16.8) χ = 2.65, p = 0.06

2 Yes 22 (15.5) 10 (6.5) χ2 = 6.11, p = 0.01*

No 142 (76.3) 153 (83.2) df = 1 No 120 (84.5) 143 (93.5) df = 1

BSE practice (6 months) BSE practice (12 months)

Yes 66 (35.5) 36 (19.6) χ2 = 11.73, p = 0.001* Yes 21 (14.8) 11 (7.2) χ2 = 4.39, p = 0.03*

No 120 (64.5) 148 (80.4) df = 1 No 121 (85.2) 142 (92.8) df = 1

BSE practice (12 months)

Variable Intervention group Control group Statistics
Yes 65 (34.9) 30 (16.3) χ2 = 16.84, p = 0.0001*
BSE Frequency (6 months)
No 121 (65.1) 154 (83.7) df = 1
Regular 13 (9.2) 5 (3.3) χ2 = 6.30, p = 0.04*

Variable Intervention group Control group Statistics Irregular 9 (6.3) 5 (3.3)

BSE Frequency (Baseline) None 120 (84.5) 143 (93.5) df = 2

Regular 15 (8.1) 5 (2.7) χ = 5.56, p = 0.62

2 BSE Frequency (12 months)

Irregular 29 (15.6) 26 (14.2) Regular 15 (10.6) 2 (1.3) χ2 = 11.82, p = 0.003*

None 142 (76.3) 153 (83.2) df = 2 Irregular 6 (4.2) 9 (5.9)

BSE Frequency (6 months) None 121 (85.2) 142 (92.8) df = 2

BSE Breast self-examination
Regular 29 (15.6) 9 (4.9) χ = 15.00, p = 0.001*
2
*
Significant at p < 0.05
Irregular 37 (19.9) 27 (14.6)
None 120 (64.5) 148 (80.4) df = 2 BC, and health motivation did not change over times,
BSE Frequency (12 months) which is in line with studies done in Turkey [14] and
Regular 31 (16.7) 5 (2.7) χ2 = 24.10, p = 0.000* Malaysia [43]. This may be because this study involved
younger women, who believed that older women were
Irregular 34 (18.3) 25 (13.6)
more likely to get breast cancer; thus, they did not feel
None 121 (65.1) 154 (83.7) df = 2
obliged to gain knowledge about breast cancer and BSE
BSE Breast self-examination independently [44].
*Significant at p < 0.05
The participants’ confidence level and frequency of
doing BSE practice increased over time in the current
performing breast self-examination. Therefore, a study. According to Selda Secginli [36] and Ceber [14],
community-oriented educational intervention which em- people with higher level of BSE knowledge have higher
phasizes proper techniques can bring a desirable change perceived confidence. Additionally, confidence in BSE is
among women. positively related to the frequency of BSE practice [43].
Consequently, promoting breast health awareness
HBM Model through educating women about breast cancer and
In the literature, it was reported that health education is teaching them how to practice BSE correctly is import-
effective in increasing the breast cancer knowledge and ant. The health education methods which are used in
BSE practice. However, it is difficult and complex to this breast health awareness program, such as practice
achieve behavioral change. In this study, positive beliefs on breast silicon model and providing information about
about benefits of BSE and confidence of doing BSE were breast cancer via module may have fostered confidence
increased after health education while beliefs related to of doing BSE and its benefit. The findings of this study
barriers of BSE decreased. This result shows that the are supported by Park [45] who reported that women’s
health education intervention was effective in terms of confidence in performing proper BSE was improved by
increasing accurate perception, providing further sup- teaching breast awareness and BSE.
port for the results of the previous literature [23, 35, 42]. The significant difference in mean scores of perceived
However, the other components of health belief model benefits of BSE after training in the intervention group
such as perceived susceptibility to BC, seriousness of agrees with the results of the previous studies [46, 47].
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 9 of 11

Table 5 Mean scores of knowledge of breast cancer and knowledge of breast self-examination between intervention and control
group at baseline, 6-months and 12-months after intervention
Outcome Baseline 6-months 12-months Eefect of intervention p-
value
Mean ± SD Mean differences (95 % CI)
Knowledge of BC
Intervention Group 11.32 (2.89) 12.38 (3.29) 12.41 (2.74) 0.83, (0.27–1.38) 0.003*
Control Group 11.53 (3.17) 11.41 (3.71) 10.69 (2.98) 0.0
Knowledge BSE
Intervention Group 6.29 (2.16) 6.86 (2.58) 7.79 (2.18) 0.67, (0.29–1.05) 0.001*
Control Group 6.39 (2.25) 6.29 (2.37) 6.23 (2.56) 0.0
SD standard deviation, CI confidence interval
*
Significant at p < 0.05

Perceived benefits of a behavior are indicative of the per- Strengths and limitations
son’s understanding of benefits gained from conducting a The strengths of this study include the use of RCT,
behaviour [48]. The more people understand the benefits of adequate sample size, low attrition rate, appropriate statis-
a preventive behavior, the more they have that behaviour. tical tests and its generalizability to the college and univer-
Another studied psychological factor is perceived bar- sity students in Malaysia. To the best of our knowledge,
riers, which points out the person’s perception of intrin- before this study no previous research is available on RCT
sic and extrinsic obstacles in performing a behaviour. among young female students in Malaysia; consequently,
Significant differences between groups were found in the result of this study can be used as the foundamental
line with studies done in Turkey [46] and Iran [47]. data for further study. Along with the numerous strengths,

Table 6 Mean scores of health belief model scales between intervention and control group at baseline, 6-months and 12 months
after intervention
Outcome Baseline 6-months 12-months Eefect of intervention p-value
Mean ± SD Mean differences (95 % CI)
Susceptibility to BC
Intervention Group 9.98 (3.92) 10.58 (3.62) 11.20 (3.62) 0.42 (-0.26–1.10) 0.22
Control Group 10.10 (3.84) 10.19 (3.24) 10.21 (3.76) 0.0
Seriousness of BC
Intervention Group 19.60 (4.93) 19.94 (4.50) 20.04 (4.73) 0.34 (-0.54–1.23) 0.44
Control Group 19.50 (4.33) 19.54 (4.31) 19.51 (4.14) 0.0
Benefits of BSE
Intervention Group 21.89 (4.19) 23.56 (3.41) 24.68 (3.74) 1.09 (0.32–1.89) 0.00*
Control Group 22.22 (4.58) 22.34 (4.34) 22.30 (4.23) 0.0
Barriers of BSE
Intervention Group 15.16 (4.69) 12.89 (3.85) 12.81 (3.95) 0.95 (-1.74–-0.15) 0.01*
Control Group 14.56 (4.13) 14.55 (4.28) 14.60 (4.20) 0.0
Confidence
Intervention Group 28.78 (7.27) 32.41 (5.48) 32.80 (7.55) 1.66 (-0.55–2.77) 0.00*
Control Group 29.65 (6.10) 29.71 (5.87) 29.64 (5.62) 0.0
Health Motivation
Intervention Group 26.52 (4.36) 26.98 (3.67) 27.67 (3.98) 0.40 (-0.41–1.21) 0.33
Control Group 26.62 (4.69) 26.70 (4.18) 26.65 (4.10) 0.0
Total HBM score
Intervention Group 121.64 (14.34) 126.15 (11.49) 128.88 (12.74) 2.62 (0.03–5.21) 0.04*
Control Group 122.72 (14.07) 123.07 (12.79) 123.01 (12.92) 0.0
Significant at p < 0.05
*
Akhtari-Zavare et al. BMC Public Health (2016) 16:738 Page 10 of 11

our study had some limitations. First of all, the result of this Abbreviations
study cannot be generalized among all young women in CBE, clinical breast examination; BSE, breast self-examination; BC, breast cancer;
HBM, health belief model; RCT, randomized control trial, CVI, content validity
Malaysia, because it focused on young educated women index; ICC, intra-class correlation coefficient
and was only done in public universities. It is suggested that
future intervention studies should be extended to different Acknowledgments
The authors would like to thank the participants of the study.
parts and workplaces in Malaysia and among low-literate
rather than educated women. Another limitation of this Funding
study is that all collected data were self-reported with no This research was funded by the Graduate Research Fellowship (GRF),
objective measures to evaluate the women. In this study, re- Universiti Putra Malaysia, Grant #GS23943. The funding body was involved in
the design of the study, collection, analysis, and interpretation of data and
searchers did not implement any education program for writing the articles.
the control group until the end of study. Nonetheless, the
control group may have been exposed to other information Availability of data and materials
sources, such as media, printed material and any campaign A request for the data and material may be made to the corresponding
author of the article.
for breast cancer provided by the Ministry of Health during
the study period which could not be controlled. In this Authors’ contributions
study, although BSE practice was significantly improved MA-Z, MHJ and IZI designed the study. MA-Z collected the data. SMS led
data analysis. MA-Z, LAL and SAE wrote the manuscript and critically edit it.
after the intervention, the change was in a small number, All authors read and approved the final manuscript.
indicating future studies should find the barriers of BSE
practice and use others methods of intervention, like so- Competing interests
cial media, which is more attractive for this particular The authors declare that they have no competing interests.
group of participants.
Consent for publication
There are no details on individual participants within the manuscript.
Implication for practice
Although there is no evidence that BSE lowers mortality Ethics approval and consent to participate
This study was approved by Medical Research Ethics Committee of the
from breast cancer, it should not be promoted to detect Faculty of Medicine and Health Sciences, UPM (Ref No. UPM/FPSK/PADS/T7-
breast cancer tumors in women effectively. Women are MJKEtikaPer/F01(JKK_NOV(09)12). A written consent was taken from each
at risk of harm from BSE including unnecessary breast respondent before conducting the study.
biopsies, imaging tests and emotional duress [49]. Author details
Breast self-examination (BSE) might still be an import- 1
Cancer Resource & Education Center, Universiti Putra Malaysia, 43400
ant tool to improve breast awareness. Women are encour- Serdang, Selangor, Malaysia. 2Department of Community Health, Faculty of
Medicine & Health Science, Universiti Putra Malaysia, 43400 Serdang,
aged to take responsibility for their own health by Selangor, Malaysia. 3Department of Family Medicine, Faculty of Medicine &
examining themselves during bathing or dressing and to Health Science, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
4
become familiar with their breasts at different times of the Malaysian Research Institute on Ageing (MyAgeing), Universiti Putra
Malaysia, 43400 Serdang, Selangor, Malaysia.
month and with age, looking and feeling for any changes
from normal, and reporting any obvious changes Received: 4 December 2015 Accepted: 29 July 2016
promptly. Therefore, appropriate educational interven-
tions are needed to encourage women to engage in regular
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