Original Article

Health Belief Model‑based Intervention on

Women’s Knowledge and Perceived Beliefs
about Warning Signs of Cancer
Iman Sharifikia1, Camelia Rohani2, Fatemeh Estebsari2, Mahsa Matbouei2, Fatemeh Salmani3,
Azam Hossein‑Nejad4
1
Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences,
2
Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical
Sciences, Tehran, 3Department of Epidemiology and Biostatistics, Faculty of Health, Birjand University of Medical Sciences,
Birjand, 4Department of Nursing, School of Nursing and Midwifery, Bushehr University of Medical Sciences, Bushehr,
Iran

Corresponding author: Camelia Rohani, PhD

Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti
University of Medical Sciences, Tehran, Iran

Tel: +98‑2188655367 (330); Fax: +98‑2188202518

E‑mail: [email protected]

Received: January 31, 2019, Accepted: June 15, 2019

ABSTRACT
Objective: Early detection of cancers essentially depends on cancer warning signs” improved after HBM‑based educational
knowledge of the warning signs. This study, therefore, aimed intervention in the intervention group, compared to the controls
at investigating the effect of Health Belief Model (HBM)‑based over time. Thus, the “level of knowledge” and perceived beliefs
educational intervention on the knowledge and perceived beliefs of the women in the intervention group compared to the controls
of women about the warning signs of cancer. Methods: This increased, in terms of perceived “sensitivity,” “severity,”
experimental study with intervention (n = 80) and control (n = 80) “benefits,” “barriers,” “cue to action,” and “self‑efficacy”
groups was performed at four urban health centers affiliated to over time (P < 0.001). Conclusions: It could be hoped that this
the university. Data collection was done in two phases, before intervention would be effective for improving the performance
and one month after the educational intervention, using three of women in health‑promoting behaviors of cancer prevention. It
instruments, a demographic‑clinical information questionnaire, is recommended that health‑care providers plan for HBM‑based
the awareness questionnaire on cancer warning signs, and the educational interventions, based on educational needs of the
cancer warning signs‑HBM questionnaire. Results: The results target groups at different community levels.
of the multivariate repeated‑measures analyses of variance
indicated that the hypothesis of this study was confirmed. It Key words: Education, health belief model, intervention,
means that “women’s knowledge and their perceived beliefs of warning signs of cancer, women

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Cite this article as: Sharifikia I, Rohani C, Estebsari F, Matbouei M,

DOI: Salmani F, Hossein-Nejad A. Health Belief Model-based Intervention
10.4103/apjon.apjon_32_19 on Women's Knowledge and Perceived Beliefs about Warning Signs
of Cancer. Asia Pac J Oncol Nurs 2019;6:431-9.

© 2019 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer - Medknow 431
 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

Introduction of this risk and the seriousness of its different complications

on physical, mental, social, and economic aspects (perceived
Despite the implementation of multiple cancer control
severity). They should see the positive signs that they
strategies, the disease prevalence is still rising worldwide and
receive from their surroundings (cue to action), believe in
has not been significantly reduced.[1] Cancer is one of the
the usefulness and applicability of the cancer prevention
leading causes of death worldwide. It is the second and third
program (perceived benefits), and also find the preventive
most common cause of death in developed and developing
factors of cue to action less costly than its benefits (perceived
countries, after cardiovascular diseases.[2] It is estimated
barriers) to ultimately adopt cancer prevention measures.[15]
that more than one‑third of cancers can be prevented,
A literature review shows that numerous studies have
and one‑third of them can be cured if diagnosed early.[3]
been conducted on the proportion of total cancer deaths
In Iran, cancer deaths account for the highest number of
attributable to the risk factors at the international level,
deaths after cardiovascular diseases and accidents.[4] A
but there are few studies on the level of knowledge and
total of 112,131 new cases were registered in the Iranian
beliefs of the general public toward cancer warning
National Population‑based Cancer Registry for 2014. Of
signs.[16] The results of an international study show that
these cases, 53.9% were men and 46.1% were women. The
the general public’s knowledge of cancer warning signs
age‑standardized incidence rates per 100,000 of all cancers
has been low in countries, such as India, Britain, Scotland,
were 177.44 and 141.18 in men and women, respectively. Ireland, and France.[17] A review of previous studies in
The three most prominent places of cancers in men were Iran also shows that there are a few studies on the general
stomach, prostate, and colorectum and in women were public’s knowledge and beliefs about the warning signs of
breast, colorectum, and stomach.[5] cancers.[4,18] Therefore, investigating the level of perceived
The World Health Organization (WHO) emphasizes the knowledge and beliefs of the people about cancer warning
prevention of cancer and the promotion of people’s quality signs can play an important role in disease prevention at the
of life.  WHO  predicts that between 30%‑50% of cancers community level. Since women’s health is considered a basis
can be prevented by avoiding risk factors, and early detection for the health of the population, families, and society, as
and management of patients. There is a high chance of cure well as a development indicator in countries,[19] HBM‑based
for many cancers, if they timely diagnosed and treated.[6] In educational intervention was designed for a group of
many cancers, survival and longevity are more pronounced women at urban health centers. Considering the important
if diagnosed early. Success in early detection is mainly role of nurses and other health‑care team members at the
dependent on an individuals’ knowledge of cancer warning first level of prevention, this study aimed to “determine
signs.[7] Most researchers agree on ten cancer warning the effect of HBM‑based educational intervention on
signs. These include changes in bowel and urinary habits, knowledge and perceived beliefs of women about cancer
wounds that do not heal for ≥ 3 weeks, unusual bleeding or warning signs.” Therefore, this hypothesis was formulated
secretion, presence of thickening and formation of lump in this study as “HBM‑based educational intervention has
or mass in the breast or other organs of the body, difficulty an influence on women’s knowledge and their perceived
in swallowing, digestion problems (indigestion), significant beliefs about cancer warning signs.”
changes in moles and warts, nagging cough or hoarseness,
sudden weight loss, and severe and resistant pain.[8‑10] Methods
Assessing the level of general knowledge about cancer This is a randomized experimental study with two groups
warning signs, identifying effective factors, and avoiding (intervention and control groups) by pretest–posttest design.
exposure to predisposing factors can play an important The study was conducted at four urban health centers
role in controlling and preventing disease at the community affiliated with the Bushehr University of Medical Sciences
level.[11] The Health Belief Model (HBM)‑based education in Bushehr, Iran, from 2015 to 2016.
is an efficient way to raise people’s knowledge and
subsequent behavioral change.[12] The HBM is a model Ethical approval
mostly used in the prevention programs and relatively The research project was approved by the Research Ethics
short‑term interventions to change behavior.[13] Using this Committee of the two universities, Shahid Beheshti and
model, based on six constituent constructs, one can lead Bushehr Universities of Medical Sciences, Iran (Approval
the individuals to the point of reaching the belief that they No. IR.SBMU.PHNM.1299.339). Besides, the research
are vulnerable to the disease, and hence, they should apply project was registered in the Iranian Registry of Clinical
risk‑reducing behaviors.[14] To take preventive measures Trials (IRCT2015090723937N1). The purpose of the study
based on this model, individuals should first feel threatened was explained to all participants, and informed written
by cancer (perceived sensitivity) and then perceive the depth consent was taken. All participants were informed about

432 Asia‑Pacific Journal of Oncology Nursing • Volume 6 • Issue 4 • October-December 2019

 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

the anonymity and confidentiality of the questionnaires of the educational intervention by focus on ten warning signs
and of voluntary participation in the study. The participants of cancers, high ranked cancers in the Iranian population,
were free to withdraw from the study at any time without risk factors, and healthy lifestyle behaviors was developed
consequences. in the form of an educational package. This educational
package was prepared by studying new textbooks and
Sampling and data collection procedures
articles, searching in reliable databases, and concentrating on
This experimental study was performed on 160 women, the HBM model constructs. For assessment of the validity
who came to four university health centers in two groups of the educational package, it was reviewed by an expert
as intervention (n = 80) and control (n = 80). The inclusion panel, consisting of two specialists in medical‑surgical
criteria included women having family health records in
and community health nursing and one specialist in health
those centers, having the ability to answer the Persian version
education, all of them with doctoral degrees. After this
of the questionnaires, and being cancer‑free during the study.
review and applying the necessary changes by the research
The absence of  ≥1 educational session was considered an
team, this package was again returned to the expert panel,
exclusion criterion. To determine the sample size, according
and the qualitative content validity of it was confirmed. In
to the sampling formula, around 64 samples were selected
this package, the main aims and objectives of each session
per each group (effect size 0.4, power 90%, and Type I error
together with the necessary media were explained (pamphlet,
of 0.05). Expecting a 30% dropout rate, a sample size of 83
booklet, and cancer pictures gallery. Pictures were shown
women was calculated for each group (n = 166).
in PowerPoint slides by a projector and computer). The
2σ 2 ( Z α + Z1− β ) 2 educational intervention was planned for five sessions of
1−
n= 2
2
≈ 64 30–45 min for 5 weeks (one session per week). Educational
d
intervention sessions were held with lectures, questions
For selection of the health centers, at first, all 11 urban and answers, and group discussion. Educational materials,
health centers affiliated with the Bushehr University of
including a booklet and a summary which was delivered in
Medical Sciences were divided into four clusters. Three
the form of a pamphlet (according to the HBM constructs
clusters included three health centers from the northern,
as a cue to action), were provided to the participants at the
eastern, and western parts of Bushehr city, and one cluster
end of each session. It is worth noting that the educational
included two health centers from the suburbs. Then, one
materials were fully provided to the participants in the
health center was randomly selected from each of the
control group after posttest and the completion of the
clusters, meaning that a total of four urban health centers
study, to meet the research ethics and to protect the rights
were used in the study. To select the samples for the
of participants in the control group.
intervention and control groups, two health centers were
The first session was an orientation and introduction
randomly assigned to each of them. Inside the centers, the
phase. A lecture about the research and its objectives was
samples were randomly selected from women who came to
given, and then, a pretest was done. Afterward, a lecture and
the centers, based on the inclusion criteria (41–42 women for
discussion were held about cancers, statistics in the world
each health center). Sampling began at these health centers
and Iran, and warning sign of cancers (perceived sensitivity
after obtaining the ethics permission from two universities
and severity). The importance of having a healthy lifestyle
of medical sciences and urban health centers, as well as
obtaining oral and written consent from the participants and was also discussed (perceived benefits).
coordination with the authorities. The data were collected Sessions 2–5 focused on ten cancer warning signs and
in two stages: before the intervention (pretest) and 1 month symptoms and their relationships with specific cancers,
after the intervention (posttest) using three questionnaires. according to the highest incidence ranking of cancers
In the first phase, 166 questionnaires were distributed among in Iran. These sessions had two important objectives:
the participants and 162 questionnaires were collected. In improving cancer prevention knowledge (perceived
the second phase, 162 questionnaires were distributed sensitivity, severity, and benefits) and improving cancer
among the participants, but only 160 questionnaires were preventive behaviors (perceived benefits, barriers, and
collected. Two incomplete questionnaires were removed self‑efficacy) based on the HBM constructs.
from the control group in this phase. The second session was about “thickening or lump
in the breast or other parts of the body” as one of the
Designing health belief model‑based educational warning signs of cancer in the breast or other parts of the
intervention body (testicle, lymph nodes, or glands). The focus was on
Based on the pretest phase, a need assessment process was increasing the knowledge about “breast cancer” (perceived
conducted in the intervention group. After that, the content sensitivity, severity, and benefits) and improving self‑efficacy.

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 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

The third session was focused on “changes in bowel cancer warning signs, and cancer warning signs‑HBM
habits and bladder function.” Long‑term constipation, questionnaire.
diarrhea, or a change in the stool size may be a sign of
Demographic‑clinical information questionnaire
colorectum cancer. Pain during urination, blood in the
This questionnaire included 13 questions about the
urine, or a change in the bladder function habits could be
demographic information of women participating in the
related to cancer in the bladder or prostate. “Indigestion”
study, including age, marital status, educational level, and
and “trouble swallowing” are also two warning signs of
employment status, previous information about cancer
cancers. Indigestion or trouble swallowing over a long
warning signs, cancer history among family relations,
time can be signs of cancer in the stomach, esophagus, or
having a chronic disease, present health status, and
pharynx. The focus was on increasing the knowledge about
observance of a healthy lifestyle.
“colorectum, stomach, and prostate cancer” (perceived
sensitivity, severity, and benefits) and improving self‑efficacy. Awareness questionnaire on cancer warning signs
The fourth session was focused on “unusual bleeding or This questionnaire included ten questions about the
discharge.” Coughing with blood may be a sign of cancer knowledge of cancer warning signs with three options: yes,
in lung; blood in stool which can look very dark or black no, and I do not know. Options yes, no, and I don’t know
stool could be a sign of colorectum cancer. Blood in the were assigned scores 2, 1, and 0, respectively (score range
urine may be a sign of cancer in the bladder or kidney. of 0–20). The questions in this section were prepared based
A bloody discharge from the nipple may be a sign of breast on ten cancer warning signs. The total score was obtained by
cancer. Abnormal vaginal bleeding can be related to uterus the mean calculation. The validity of this researcher‑made
cancer. Furthermore, a warning sign of “nagging cough or questionnaire was verified through determining the content
hoarseness” or a cough that does not go away may be a sign validity, i.e. the qualitative content validity, the content
of lung cancer. Hoarseness can be a sign of larynx or thyroid validity ratio (CVR), and the content validity index (CVI)
gland. The focus was on increasing the knowledge about by ten experts from the School of Nursing and Midwifery
“lung and bladder cancer” (perceived sensitivity, severity, and the School of Health. The results showed that the CVR
and benefits) and improving self‑efficacy. and the CVI values were at least 80% and 96%, respectively,
The fifth session was focused on four cancer warning signs for the questionnaire. The face validity was also confirmed
of “severe and resistant pain,” “unexplained weight loss,” by a sample independent of the original sample (n = 10),
“recent change in a wart or mole or any new skin change,” but similar to its characteristics. The reliability of
and “sores that do not heal for more than 3 weeks.” Pain the questionnaire was confirmed using a split‑half
can be an early symptom of cancer in bones or testicular. A method and calculating the Spearman–Brown correlation
headache that does not disappear or get better with treatment coefficient (r = 0.76). Consistency of the questionnaire was
may be a symptom of tumor in the brain. Back pain can be also calculated using the test–retest method and calculating
a symptom of cancer in the colorectum or ovary. Mostly, intraclass correlation coefficient (ICC = 0.99).
pain related to cancer means it has spread (metastasis). An
Cancer warning signs‑health belief model questionnaire
unexplained weight loss of 10 pounds or more may be a sign
of cancer in the pancreas, stomach, esophagus, or lung. Any This questionnaire comprised 34 questions based on six
wart, mole, or freckle that shows a change in color, size, or HBM constructs, i.e. “perceived sensitivity” (five questions
shape or losing sharp borders may be related to cancer in the with a score range of 5–25), “perceived severity”
skin. Skin cancers may bleed and appear like sores that do (five questions with a score range of 5–25), “perceived
not heal, especially in individuals who smoke, chew tobacco, benefits” (six questions with score range of 6–30),
or drink alcohol. A long‑lasting sore in the mouth could “perceived barriers” (seven questions with score range
be related to oral cancer. Sores on the penis or vagina may of 7–35), “cue to action” (four questions with a score
be a sign of early cancer. The focus was on increasing the range of 4–20), and “self‑efficacy” (five questions with
knowledge about “healthy lifestyle” (perceived sensitivity, a score range of 5–25). Appropriate questions in this
severity, and benefits) and improving self‑efficacy. section were designed by studying textbooks, articles, and
One month later, posttest was done in both, intervention available guides for each of the HBM constructs using a
and control groups. 5‑point Likert scale, ranging from “completely agree” to
“completely disagree” (score range of 1–5). For example,
Measurements one of the “perceived sensitivity” items is “attention to
The data collection was performed using three researcher- cancer warning signs reduces the chance of developing
made questionnaires, including demographic‑clinical cancer in the future.” Examples of other model constructs
information questionnaire, awareness questionnaire on include the “perceived severity” construct: “many people

434 Asia‑Pacific Journal of Oncology Nursing • Volume 6 • Issue 4 • October-December 2019

 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

who have cancer neglected cancer warning signs;” (P = 0.100), employment status (P = 0.396), previous
“perceived benefit” construct: “paying attention to cancer knowledge of cancer warning signs (P = 0.751), and a family
warning signs reduces treatment costs;” “perceived barriers” history of cancer in first‑degree relatives (P = 0.329). The
construct: “conducting diagnostic tests and diagnosis of mean age of women in this study was 29.9 ± 7.1 years. Other
cancer are costly;” “cue to action” construct: “physicians demographic and clinical characteristic of the women are
and other staff at the health‑care center can help me identify shown in Table 1.
and diagnose cancer warning signs;” and “self‑efficacy” Wilcoxon signed‑rank tests for within‑group comparison
construct: “I can overcome my fear and embarrassment of mean changes in outcome variables of the study are
to perform tests for cancer warning signs.” The score of presented in Table 2. The figures in Table 2 show that there
these constructs was estimated by the mean calculation. were significant changes in the mean scores obtained by
The validity of this questionnaire was confirmed by the participants in the intervention group for knowledge
determining the qualitative content validity, the CVR, and and all the HBM constructs from the pretest to posttest
the CVI. The results showed that the range of the CVR and
the CVI for all parts of the questionnaire was equal to at Table 1: Demographic and clinical characteristics of women in
least 80% and about 96%, respectively. The face validity of the control (n=80) and intervention groups (n=80)
this questionnaire was confirmed by a sample, independent Variable* Group Control, Intervention,
of the original sample (n = 10). The reliability of this n (%) n (%)
questionnaire was confirmed by determining Cronbach’s Age (years) <20 4 (5.0) 8 (10.0)
alpha coefficient (Cronbach’s alpha range of 0.78–0.80 for 20‑29 35 (43.7) 34 (42.4)
the constructs of the model) and the ICC (range: ≥0.92). 30‑39 32 (40.0) 31 (38.8)
≥40 9 (11.3) 7 (8.8)
Statistical analysis Marital status Single 6 (7.5) 14 (17.3)
Divorced 5 (6.2) 4 (5.0)
All statistical analyses were conducted using the SPSS
Widowed 1 (1.3) 1 (1.4)
version 20 (IBM Corporation, Armonk, NY, USA). For Married 68 (85.0) 61 (76.3)
data analysis, the descriptive and inferential statistics Education Primary school 2 (2.5) 5 (6.2)
were used in this study. Differences between two groups Secondary school 6 (7.5) 15 (18.8)
based on the six main variables of age, education, marital High school 6 (7.5) 2 (2.5)
status, job status, previous knowledge of cancer warning College 27 (33.7) 20 (25.0)
University 39 (48.8) 38 (47.5)
signs, and family history of cancer in first‑degree relatives
Employment status Employed 28 (35.0) 23 (28.7)
were examined by a primary analysis with Chi‑square and Housewife 52 (65.0) 57 (71.3)
Fisher’s exact tests. The outcome variables containing Sufficient monthly family Yes 24 (30.0) 28 (35.0)
knowledge and the HBM constructs were evaluated by the income No 56 (70.0) 52 (65.0)
Kolmogorov–Smirnov test, and the normality assumption Family history of cancer Yes 19 (23.8) 14 (17.5)
of the variables revealed a violation. To evaluate the changes No 61 (76.2) 66 (82.5)
Previous knowledge about Yes 38 (47.5) 36 (45.0)
in the knowledge and the HBM constructs before and after
cancer warning signs No 42 (52.5) 44 (55.0)
the intervention and answer to the study hypothesis, due to
Adherence to nutritional Yes 75 (93.8) 70 (87.5)
nonnormality data, the nonparametric tests including the advice No 5 (6.2) 10 (12.5)
Wilcoxon signed‑rank test for within‑group comparisons Smoking Yes 8 (10.0) 17 (21.2)
and the Mann–Whitney U‑test for between‑group No 72 (90.0) 63 (78.8)
comparisons were used. Multivariate repeated‑measures Daily exercise Yes 53 (66.2) 53 (66.2)
analysis of variance (ANOVA) was applied to show No 27 (33.8) 27 (33.8)
Alcohol consumption Yes 6 (7.5) 12 (15.0)
changes in the groups over time and interaction effects
No 74 (92.5) 68 (85.0)
between time and group from pretest to posttest phase. The Health status Bad 1 (1.3) 0 (0.0)
significance level was set at P < 0.05. Missing data in this Average 6 (7.5) 8 (10.0)
study were <5%. Good 31 (38.8) 33 (41.3)
Very good 27 (38.8) 25 (31.3)
Results Excellent 15 (18.8) 14 (17.5)
Chronic disease Yes 7 (8.7) 5 (6.3)
The results of Chi‑square and Fisher’s exact tests
No 73 (91.3) 75 (93.7)
showed that there was no difference between the two *Differences between two groups based on the six main variables of age, education,
marital status, employment status, family history of cancer in first‑degree relatives, and
intervention and control groups, based on six variables previous knowledge of cancer warning signs were examined and showed there are no
of age (P = 0.656), education (P = 0.130), marital status differences (P>0.05)

Asia‑Pacific Journal of Oncology Nursing • Volume 6 • Issue 4 • October-December 2019 435

 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

phases (P = 0.001). Table 2 also shows a significant increase Table 3 also shows significant differences in mean scores
in mean scores obtained in the control group from the obtained by the intervention group compared with
pretest to posttest phases in five constructs of the HBM, the control group concerning three HBM constructs,
including perceived susceptibility (P = 0.001), perceived including perceived benefits (P = 0.003), perceived barriers
severity (P = 0.012), perceived barriers (P = 0.006), cue to (P = 0.003), and cue to action (P = 0.015), before the
action (P = 0.003), and self‑efficacy (P = 0.001). educational intervention in the pretest phase.
Mann–Whitney U‑tests for between‑group comparison The results of multivariate repeated‑measures ANOVA
of mean changes in outcome variables of the study are showed that there was an interactive effect between time
presented in Table 3. The figures in Table 3 show that there and group in all the outcome variables. Moreover, changes
were significant changes in the mean scores obtained by the concerning the knowledge and the HBM constructs in the
participants in the intervention group compared with the intervention group, compared to the control group, are
control group for knowledge and all the HBM constructs significant over time (P < 0.001) [Table 4].
1 month after the educational intervention (P = 0.001).
Discussion
Table 2: Changes of the mean in the knowledge and the HBM This experimental study was conducted based on the
constructs within the intervention (n=80) and control groups pretest–posttest design with intervention and control group
(n=80) of women before and after the educational intervention
to determine the effect of the HBM‑based educational
Variable Group Mean±SD P intervention on knowledge and perceived beliefs of women
Before One‑month after about cancer warning signs at the health centers affiliated to
education education
the university. The results showed that the study hypothesis
Knowledge Control 7.99±3.71 7.64± 2.76 0.134
Intervention 7.50±4.18 16.68±1.98 0.001 was confirmed. It means that women’s knowledge and
Perceived Control 16.68±1.99 15.96±1.87 0.001 their perceived beliefs about warning signs of cancer
sensitivity Intervention 16.75±2.51 20.86±1.46 0.001 improved after HBM‑based educational intervention in the
Perceived Control 16.49±1.87 16.18±1.88 0.012 intervention group compared to the controls.
severity Intervention 16.22±1.91 21.16±1.71 0.001
The comparison of the intragroup means shows that
Perceived Control 20.83±2.30 20.86±2.30 0.128
benefits the mean scores in the intervention group increased seven
Intervention 21.85±1.79 26.50±2.14 0.001
Perceived Control 22.36±2.34 21.94±2.54 0.006 scores in knowledge and all of the HBM constructs, 1 month
barriers Intervention 21.40±2.68 30.26±2.13 0.001 after the educational intervention, except for the “perceived
Cue to action Control 11.99±2.04 21.94±2.54 0.003 barriers,” which increased only three scores. These results
Intervention 12.10±1.67 17.46±1.60 0.001 are in line with previous studies.[17,18] However, in our study,
Perceived Control 15.56±5.00 16.00±2.38 0.001
self‑efficacy
there was a significant increase in the mean scores obtained
Intervention 15.80±5.89 22.01±1.91 0.001
by the participants in the control group, 1 month after
the pretest in five HBM constructs, including “perceived
Table 3: Changes of the mean in the knowledge and the HBM susceptibility,” “perceived severity,” “perceived barriers,”
constructs between the intervention (n=80) and control “cue to action,” and “perceived self‑efficacy.” It can be said
(n=80) groups of women before and after educational that although the control group had not gone through any
intervention
education program, this slight increase might have been due
Variable Time of Mean±SD P
to the retention of some information after completing the
the test Control group Intervention group
questionnaires, gathering of information from the media,
Knowledge Before 7.99±3.71 7.50±4.18 0.490
and also women’s tendency to obtain information about
After 7.64±2.76 16.68±1.98 0.001
Perceived Before 16.68±1.99 16.75±2.51 0.155
cancer warning signs after participation in the study.
sensitivity After 15.96±1.87 20.86±1.46 0.001 An intergroup comparison of the means shows an
Perceived Before 16.49±1.87 16.22±1.91 0.155 increase of 4–9 scores, 1 month after the educational
severity After 16.18±1.88 21.16±1.71 0.001 intervention in knowledge and all the HBM constructs in the
Perceived Before 20.83±2.30 21.85±1.79 0.003 intervention group, compared to the control group. These
benefits After 20.86±2.30 26.50±2.14 0.001
findings are similar to previous studies in populations.[17,18]
Perceived Before 22.36±2.34 21.40±2.68 0.003
barriers After 21.94±2.54 30.26±2.13 0.001
However, in our study, before the educational intervention,
Cue to Before 11.99±2.04 12.10±1.67 0.015 there was a significant difference between the mean scores
action After 12.10±1.67 17.46±1.60 0.001 of the participants in the intervention group compared
Perceived Before 15.56±5.00 15.80±5.89 0.671 to the control group in the three constructs of the
self‑efficacy After 16.00±2.38 22.01±1.91 0.001 HBM – “perceived benefits,” “perceived barriers,” and

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 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

inadequate focus of the country’s current health system on

Table 4: The results of multivariate repeated measures
analysis of variance in the control (n=80) and intervention cancer prevention programs at the first level of prevention,
(n=80) groups based on the knowledge and the health belief though an increasing public knowledge of cancer and
model constructs over time from the preintervention to education about cancer‑risk factors is of great importance
postintervention phase in controlling the disease. Studies in developing countries
Variable Sum of squares Interactional effect F P show that individuals’ level of knowledge varies from low
Knowledge Intercept 31,680.80 2068.29 0.000 to moderate, whereas it was assessed to be high in most
Time × group 1814.51 295.93 0.000 developed countries.[20] The findings of this study are similar
Perceived Intercept 567.11 196.20 0.000
sensitivity
to those of previous studies on various cancers.[21,22] In these
Time × group 10,011.25 196,119.00 0.000
Perceived Intercept 551.25 267.22 0.000
studies, most of the participants reported a low or moderate
severity Time × group 98,140.05 20,553.23 0.000 level of knowledge before the education, but their level of
Perceived Intercept 422.01 188.51 0.000 knowledge increased in the postintervention phase.
benefits Time × group 161,085.86 22,960.46 0.000 Our findings on “perceived susceptibility” of women
Perceived Intercept 1725.15 409.67 0.000 participating in the study of cancer warning signs show that
barriers Time × group 184,176.03 22,073.01 0.000 although the average “perceived susceptibility” of cancer
Cue to Intercept 482.65 283.34 0.000
action
warning signs in the two groups was approximately the
Time × group 58,293.00 10,878.92 0.000
Perceived Intercept 96,257.81 5351.54 0.000
same in the preintervention phase, it increased as much
self‑efficacy Time × group 667.01 40.14 0.000 as four scores in the intervention group 1 month after the
educational intervention. This finding is similar to that
“cue to action.” Since the results of primary analyses in of Gammage et  al.’s study.[23] However, in our study, the
the beginning of the study showed that the intervention preintervention “perceived sensitivity” mean score was
higher than the mean score of the questionnaire, which
and control groups did not differ in terms of educational
could be due to the type of the disease and its importance
levels and previous knowledge of cancer warning signs, this
in the public’s mind. Findings on “perceived severity” of
difference could be attributed to individual personality or
cancer warning signs in women participating in the study
environmental factors, such as access to resources. Therefore,
indicate that although the average “perceived severity” of
in this study, multivariate repeated‑measures ANOVAs
cancer warning signs in the two groups was approximately
were used to investigate the genuine effectiveness of
the same in the preintervention phase, it increased as much
educational intervention. The results showed an interaction
as five scores in the intervention group 1 month after the
effect between time and group so that the mean scores
educational intervention. In our study, preintervention
for “knowledge,” “perceived susceptibility,” “severity,”
“perceived sensitivity” mean score of cancer warning signs
“benefits,” “barriers,” “self‑efficacy,” and “cue to action”
was higher than the mean score of the questionnaire, which
in the control group were slightly greater than or equal to
could indicate the severity of the disease and the subsequent
the intervention group in the pretest phase. However, these consequences of the disease in the public mind. Muthoni
findings confirmed our previous results and indicated that and Miller[24] in their study showed an improvement in all
although there was a significant difference between the two attitudinal components, including “perceived severity”
groups before educational intervention, the mean scores after the educational intervention. Findings on “perceived
of women for “knowledge,” “perceived susceptibility,” benefits” of cancer warning signs in women participating
“severity,” “benefits,” “barriers,” “self‑efficacy,” and “cue to in this study indicate that although the average score
action” in the intervention group, compared to the control of “perceived benefits” of cancer warning signs in the
group, increased significantly over time. intervention group was slightly higher than in the control
A discussion in detail on the changes in the level of group, it increased as much as six scores in the intervention
knowledge and the HBM constructs during intergroup group 1 month after the educational intervention. In our
comparisons shows that although the average knowledge of study, preintervention “perceived benefits” mean score was
cancer warning signs in the two groups was approximately approximately equal to the mean score of the questionnaire.
the same in the preintervention phase, it increased as much It should be noted that one’s perception of the benefits paves
as nine scores in the intervention group 1 month after the the way for the adoption of effective measures, and there is
educational intervention. In addition, in the preintervention a strong correlation between “perceived benefits” and the
phase, none of the groups had a good knowledge of adoption of “preventive behaviors.”[25] Gammage et al. also
cancer warning signs, and their average score was around showed in their study that the average score of “perceived
3 scores less than the average score of the questionnaire. benefits” in the intervention group had increased compared
Perhaps, one of the reasons for this can be attributed to an to the controls after the educational intervention.[23] The

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 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

effect of education on the creation of positive motivation and all the HBM constructs in the intervention group were
depends on its efficiency and an elevated understanding of significantly higher than the control group, 1 month after the
individuals on its benefits. Findings on “perceived barriers” educational intervention. Therefore, HBM‑based education
to cancer warning signs in women participating in the showed an effective influence on knowledge and perceived
study show that although the average score of “perceived beliefs of women about cancer warning signs over time.
barriers” to cancer warning signs in the control group
was slightly higher than the intervention group in the Limitations
preintervention phase, it increased as much as nine scores The use of self‑reported questionnaires and the
in the intervention group 1 month after the educational impossibility of direct monitoring of women’s performance
intervention. In our study, the preintervention mean score about cancer warning signs and prevention methods after
for “perceived barriers” was higher than the mean score of HBM‑based education in the home environment, may limit
the questionnaire. This finding is similar to a study carried the external validity of the study. The educational package
out to investigate the effects of an education program on was prepared for participants in the study, according to
women’s knowledge and beliefs about breast cancer in the pretest results. Thus, it cannot be used directly in
Spain.[26] In our study, the preintervention mean score for other studies. However, it can be a good guide for other
the “cue to action” was approximately equal to the mean researchers in parallel studies.
score of the questionnaire. In the present study, the most
important source of information for cancer warning signs in Conclusion
the intervention and control groups included media (books, The results showed that the hypothesis of the study
newspapers, magazines, Internet, radio, television, and was confirmed. It means that HBM‑based educational
satellite). However, the participants stated that physicians intervention caused an increase in the level of women’s
and health‑care personnel played a less significant role knowledge and their perceived beliefs of cancer warning
in this regard. This seems to be a serious warning to the signs in the intervention group, compared to the controls
health‑care system, underscoring the need for planning to over time. The education affected “knowledge” and
provide the ground for a more active role of this group and perceived beliefs of women referred to the health centers
their greater participation in cancer prevention educational in terms of perceived “sensitivity,” “severity,” “benefits,”
programs. In addition, findings on the “cue to action” on “barriers,” “cue to action,” and “self‑efficacy.” It could be
cancer warning signs in women participating in the study hoped that it would be effective for improving women’s
show that although the average score of “cue to action” to health‑promoting behaviors in cancer prevention. Moreover,
cancer warning signs in the intervention group was slightly
the low mean score of women’s knowledge about cancer
higher than the control group in the preintervention phase,
warning signs in the preintervention phase of our study
it increased as much as five scores in the intervention
could be an alarm for health‑care providers and health‑care
group 1 month after the intervention. This finding is similar
policymakers in the community. It is recommended that
to the previous studies.[27] Although the “self‑efficacy” mean
health‑care providers plan for HBM‑based educational
score is not a direct indicator of individual performance,
interventions based on educational needs of the target
it can be a reflection of how women will perform in the
groups at different community levels.
future. Although the average score of women’s “perceived
self‑efficacy” of cancer warning signs was the same in Acknowledgments
the two groups in the preintervention phase, it increased We appreciate all the women who participating in the
as much as six scores in the intervention group 1 month project. We would like to thank all the people who assisted
after the educational intervention. This means there in conducting this study in the Shahid Beheshti University
was an increase in women’s understanding of how they of Medical Sciences and the Bushehr University of Medical
could detect and prevent cancer with the help of warning
Sciences.
signs and make others aware of the reasons of common
cancers. This finding is consistent with the studies of other Financial support and sponsorship
researchers.[26,28,29] In our study, “perceived self‑efficacy” The project was partially funded by the School of
mean scores in both groups were somewhat higher than Nursing and Midwifery of the Shahid Beheshti University
the mean score of the questionnaire in the preintervention of Medical Sciences.
phase.
In summary, a comparison of average scores between Conflicts of interest
the groups showed that average scores in the knowledge There are no conflicts of interest.

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 Sharifikia, et al.: Effect of HBM on Women’s Beliefs about Cancer Warning Signs

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