Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Abstract

Screening plays an essential role in the reduction of mortality and morbidity of breast cancer, which is one of the most common cancers in women worldwide. The aim of this study was to find out whether the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior. Applying different search strategies, we searched electronic databases including PubMed, ScienceDirect, Web of Science, and Scopus without time limit from January 12 to March 11, 2017. Keywords included “Breast neoplasm,” Screening,” “Women,” and “Health Education.” First, screening was conducted based on title, abstract, and full text. Then, the studies were screened according to the selection criteria of our study. The relevant and eligible studies were critically appraised by Delphi checklist. In addition, a meta-analysis of eligible studies was conducted with the random-effect approach. Twenty-six of 8,620 initial studies (with sample size of 10,681 in the intervention group and 8,854 in the control group) were included in the final analysis. The results of the meta-analysis showed that the probability of screening behavior in the intervention group is 1.4 times of that in the control group. Furthermore, subgroup analysis by the type of screening behavior indicates that the probabilities of conducting breast self-examination and mammography in the intervention group are 1.9 and 1.4 times of those in the control group. The health education program has a significant impact on breast cancer screening behaviors, particularly breast self-examination. Thus, given the positive effects of the educational screening programs in women, it is suggested that these programs must be continuously pursued with long-term follow-up and increasing rates of screening behaviors should be monitored.

Keywords

screening breast neoplasm’s health behavior women meta-analysis

Introduction

Breast cancer is the most common cancer and the main cause of cancer death in women globally.¹ It is responsible for 23% of all cancers in women so that the annual incidence of breast cancer is 38.1 million cases worldwide.² In addition, 502,000 women in the world die from breast cancer every year.³ According to the American Cancer Society, in the United States, 252,710 new cases of breast cancer were diagnosed in 2017 and 40,610 of them died.⁴ Breast cancer had a substantially higher incidence (43.3 per 100,000) and the highest mortality rate (12.9 per 100,000) than any other cancer.⁵ The high mortality rate is due to late diagnosis of this disease. If this cancer be diagnosed at an early stage, it can be treated and the screening can be used for its diagnosis.⁶ Screening methods include mammography, clinical breast examination, and breast self-examination (BSE).⁷ Screening consists of testing women to identify cancers before the appearance of any symptoms.⁸ Screening and early diagnosis play a vital role in reducing the mortality of breast cancer.⁹ The consequences of delayed or unavailable cancer care are a lower likelihood of survival, greater morbidity of treatment, and higher costs of care, resulting in avoidable deaths from cancer. Early detection improves cancer outcomes by providing care at the first possible step and is consequently a significant public health strategy in all settings.

According to breast cancer screening guideline, BSE every month after the age of 20 years, clinical breast examinations every 3 years at the age of 20 to 39 years, clinical breast examinations and an annual mammogram every year after the age of 40 years are recommended.¹⁰

Studies have revealed that the mortality of women who participated in breast cancer screening programs was reduced to 40%. Despite the importance of screening, a very low percentage of the population do attend the breast cancer screening programs.^11,12

Women experience barriers to breast cancer screening. These barriers included fear of breast cancer detection, lower income, fatalistic view of cancer, poor cancer knowledge, lack of time, absence of symptoms, lower perceived susceptibility to breast cancer, embarrassment, and lack of screening recommendation.^13–15 Hence, women have to be empowered regarding screening, and educational measures should be taken to promote this behavior among women. An important step is to motivate women to protect themselves against breast cancer, and an important factor for motivation is the health promotion programs, which focus on health education and health behaviors.¹⁶ Therefore, an educational model plays a major role in identifying and addressing educational requirements, starting the program in the right direction, and reducing the unclear and vague parts that may be present in the main content of an educational intervention.¹⁷

Considering that different studies have applied one or more interventions to assess the impact of screening on breast cancer prevention, the purpose of the study is to determine the most effective type of theory-based interventions in this field. Moreover, by this systematic meta-analysis, we will be able to find out if the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior.

Materials and Methods

Search Strategy

The electronic search of databases including PubMed, ScienceDirect, Web of Science, and Scopus was conducted without time limit from January 12 to March 11, 2017. The search strategy included key terms: “Breast cancer,” “Breast neoplasm,” “Breast cancers,” “Screening,” “Training Breast self-examination,” “Breast self-examination,” “Clinical Breast Examination,” “Mammography,” “Female,” “Screening,” “Breast Tumor,” “Breast Carcinoma,” “Breast Malignant Tumor,” “Neoplasm,” “Breast,” “Screening behavior,” “Mass screening,” “Cancer early Detection,” “Women,” and “Prevention.” The search strategy for databases is presented in Appendix. This article is designed according to a Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Selection of Studies

After extracting the full text of the articles and removing duplicate studies, according to the selection criteria of our study, the articles were reviewed based on the title, abstract, and full text. In addition, the references of all eligible articles were investigated to identify additional relevant studies. The process of selecting articles was done by two independent researchers. Furthermore, the Google Scholar search engine was applied for gray or additional literature.

The PICOTS-based inclusion criteria to select appropriate articles were as follows:

Types of Studies

We included studies with randomized controlled trials that (a) aimed for behavioral interventions based on theory and model and (b) focused on screening behaviors, including BSE, physician breast examination, and mammography.

Types of Participants

Studies with participants who were 20 years and older, who were without breast cancer, and whose history of breast cancer that apparently was healthy.

Types of Interventions

Behavioral interventions based on the model and theory, focusing on screening behaviors.

Types of Outcomes

The final outcomes were self-examination behavior, clinical examinations, and mammography.

Time

There was no time limitation in our study.

Language

The searches were conducted for the articles that were written in English.

Quality Assessment

After reading full-text articles, two researchers assessed the quality of each study independently using the Delphi checklist.¹⁸

Exclusion Criteria Studies

Exclusion criteria were the studies that have been conducted to screening for breast cancer along with other cancers; studies that have been conducted on women with a history of breast cancer; studies that did not report the outcomes of behavior; and the studies that were aimed to assess the knowledge, attitude, and behavioral intention.

Data Extraction

Data were extracted from each study based on the title, author name, time and place of study, target group, sample size, follow-up, theory or model, study variables, intervention method, and intervention results. Two researchers extracted data independently.

Statistical Analysis

The data analysis was done using the meta-analysis with the random-effect approach. In addition, the results were presented as forest plot and tables, and heterogeneity was evaluated by χ² test. In addition, the presence of publication bias was assessed by funnel plot.

Results

From the initial search, 8,620 articles were retrieved. Among these articles, 7,972 studies were excluded, as they were duplicates or irrelevant. The remaining 648 articles were reviewed, of which380 studies were excluded because they did not contain intervention. In the next step, 268 articles were carefully reviewed. In the subsequent step, 180 articles were excluded because they did not cover theory base, and only 88 articles were selected theory base. Eventually, 62 studies were excluded because these were not fulfilling the purpose of the study. Thus, a total of 26 studies^{12,14,19–42} were selected for meta-analysis (Figure 1). Characteristics of the included studies are presented in Table 1.

Figure 1.

Flow chart of the systematic review process.

Table 1.

Characteristics of Studies Included in Review.

References	Time and place of study	Title	Target group	Sample size	Follow-up	Theory/model	Study variables	Intervention method	Intervention results
Lee et al.¹⁵	August 2008 to September 2010, United States	The effect of a couples intervention to increase breast cancer screening among Korean Americans	Women 40 years of age or older	428 Married (217 couples= group intervention, 211 couples = group control)	6 and 15 months	HBM	Sociodemographic variables and mammography uptake	Showing a project team designed 30-min Korean language DVD on breast cancer screening to change health beliefs and improve spousal support, holding a brief group discussion session immediately after the video, and requiring each couple to complete a discussion activity at home to enhance spousal support.	Significant increase in mammography uptake over the control group at 6 and 15 months postintervention (p = .004)
Sheppard et al.²⁰	2013, United States	Promoting mammography adherence in underserved women: The telephone coaching adherence study	Black women and Latinos 40 years of age or older	37 Women (group control, n = 15) (group intervention, n = 22).	12 months	Social cognitive theory	Knowledge, attitudes, skills, self-efficacy, outcome expectancies, mammography appointments	-Motivational telephone intervention -Tailor intervention messages Psychosocial issues discussed in the focus group included fear of pain during mammography and perceived risk of breast cancer	Appointments for mammography in the intervention group (54%) were higher than that in the control group (46%).
Aghamolaei et al.¹²	Iran, 2010	Improving breast self examination: An educational intervention based on health belief model	Eligible women at health centers	240 Women (group control, n = 120) (group intervention, n = 120)	4 months	HBM	Susceptibility, seriousness, benefits, barriers, health motivation, perform BSE	-Lecture breast cancer importance, its risk factors, its severity, the value of early diagnosis, what BSE is, why, how, and when BSE -Printed materials with guidelines regarding BSE -Practiced BSE	Statistical differences BSE rate (p<.001)
Champion²¹	United States, 1994	Effect of interventions on stage of mammography adoption	Women aged 40–88 years	301 Women (group control, n = 78) (group intervention, n = 222)	12 months	HBM/theory of reasoned action	HBM variables, mammography compliance	Belief intervention, received individually tailored messages and provider information related to mammography screening.	Women in the combined belief/information group were over 2 times more likely to have been compliant with mammography
Paskett et al.²²	1998–2002, United States	Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women	Poor and minority women aged 40 years or older	851 Women (group control, n = 433) (group intervention, n = 418)	12–14 months	PRECEDE—PROCEED social learning theory communication—behavior change model “TTM”	Demographics, risk factors, barriers, beliefs, knowledge about mammography, mammography utilization	First home visit: lay health education provided educational materials about individual cancer risk and ways to overcome barriers for mammography and BSE. Second home visit (30–45 min, 2–3 weeks after first visit): teach and reinforce BSE Phone calls and mailings (months 3–9): provide information on other important health topics, determine stage of readiness to change. Mailings addressed women’s readiness to obtain a mammogram. Final visit (months 10–14). The LHA asked about screening received and the participant’s ability to do BSE	42.5% of the women in the intervention group and 27.3% of those in the control group had had a mammogram
Taymoori et al.²³	Iran, 2014	Effects of a randomized controlled trial to increase repeat mammography screening in Iranian women	Women aged 50 years or older	184 Women (group control, n = 61) (group intervention, n = 123)	6 months	HBM/theory of planned behavior	HBM and TPB variables, mammography screening	Eight sessions for the HBM and TPB interventions that focused on perceived threat. -Multimodal lectures with educational resources (films, slides pamphlets) -Individual counseling sessions -Contact for 5 important relatives and invited them to participate in a 60-min public session that included different ways to talk to family members about mammography use, including short phone messages as well as reminders about the need to obtain a mammogram -Obtain a physician recommendation for a mammogram	Significantly increased mammography screening rates (p <.001)
Lee-Lin et al.¹⁴	United States, April 2010 to September 2011	A longitudinal examination of stages of change model applied to mammography screening	Immigrant women aged 40 years or older	300 Women (group control, n = 147) (group intervention, n = 153)	3, 6, and 12 months	HBM/TTM	Beliefs and demographics, having a mammogram, perceived barriers, stage of change	-Group teaching with targeted messages followed by an individual counseling session within 10 days. -Targeted breast health educational program messages were targeted to the participants’ stages of change.	Significantly increased mammography screening rates after 12 months 71/4% in intervention group and 42/5% in control group (p < .001)
Hegenscheid et al.²⁴	Germany, 2008	Telephone counseling and attendance in a National Mammography-Screening Program: A randomized controlled trial	Women aged 50 to 69 years	5,477 Women (group control, n = 2,952) (group intervention, n = 2,455)	3 months	HBM/TTM conflict model of decision-making	Mammography screening	-Eligible women living in a predefıned region receive mailed invitation letters biennially for each screening round. -After 6 weeks, nonresponders are sent written reminders, again. -During the 2 weeks between the mailing of the reminder, the counselor obtained the mailing addresses and retrieved the telephone numbers for TC. -The counselor provided a brief description of mammography and tried to identify and overcome the woman’s individual barriers to screening	Comparison of screening attendance revealed a significantly higher attendance rate in the intervention group compared with controls (29.7% vs. 26.1%, p = .0035)
King et al.²⁵	United States, 1989–1990	Mammography interventions for 65- to 74-year-old HMO women	Women aged 65–74 years	1,316 women (group control, n = 190) (group intervention TC and a letter, n = 171) (group intervention TC, n = 187)	4 months	HBM/TTM	Sociodemographic, knowledge, attitude, HBM Scale, use mammography	Ninety days after the referral mailing, women were randomized to receive (a) a survey, (b) a survey in addition to telephone mammography counseling, or (c) a survey, TC, and a letter	13% of control group women compared with 27% who received phone counseling and 32% who received counseling and a letter obtained a mammogram (p < .000)
Akhtari-Zavare et al.26	Malaysia, January 2011 to April 2012	Result of randomized control trial to increase breast health awareness among young females in Malaysia	Students average age 22 years	370 Female (group control, n = 198) (group intervention, n = 198)	6 and 12 months	HBM	Sociodemographic knowledge HBM Scale, BSE practice, and frequency	One-hour lecture which covered all contents of the educational module on “breast health awareness” in the form of slide presentation -Received another 1-hr training on breast silicon model to learn how to do the BSE practice. After the training, each participant was asked to duplicate the BSE practice on the breast silicon model	The rate of BSE was 15.5% after 6 months and 14.8% after 12 months in the intervention group and in the control group 6.5% and 7.2% (p < .00)
Champion et al.²⁷	United States	A tailored intervention for mammography among low-income African-American women	Low-income African-American women aged 45 to 64 years	329 Women (group control, n = 159) (group intervention, n = 170)	12 months	HBM/TTM stage of change	Sociodemographic, stage of compliance regarding, adoption of mammography	-Present messages regarding perceived susceptibility, benefits, and barriers -The brochures given to women were developed with culturally relevant pictures. -Messages also were tailored according to an individual’s cognitive stage at baseline. -Discussed and strategies were suggested to overcome those barriers	Compliance with mammography in the intervention group increased 17% (from 59.0% to 75.7%), whereas compliance in the control group increased only 7% (from 63.8% to 71.1%) (p < .000)
Champion et al.²⁸	(1996–2000), United States	Comparison of tailored interventions to increase mammography screening in nonadherent older women	Elderly women aged 74–65 years	773 Women (group control, n = 134) (group intervention, n = 639)	6 months	HBM/TTM stage of change	Stage of change, adoption of mammography	Tailored interventions delivered by five different methods, i.e., TC, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter.	Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in group control achieved 48% adherence compared with 50%–70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%. (p < .001)
Mishra et al.²⁹	Samoan, United States	Results of a randomized trial to increase mammogram usage among Samoan women	Women aged 42 years and older	776 Women (group control, n = 403) (group intervention, n = 406)	8 months	The health behavior framework and Freire’s empowerment pedagogy	Sociodemographic, knowledge, health beliefs, social norms, past health behaviors, adoption of mammography	The intervention was designed around four modules. The first session (breast cancer: myths and facts) focused on the sessions’ procedural rules, reasons for staying healthy, what each learner already knew about breast cancer, and myths and facts regarding the disease. The second session (breast cancer risk factors and symptoms). The third session (mammograms and follow-up) and role-playing for requesting mammograms; This session also included a discussion on screening barriers (cost, fear of radiation, embarrassment, pain), The fourth session (review) summarized the information presented in the prior sessions.	There was no statistically significant intervention effect, although the odds of self-reported mammogram use were higher in the intervention than the control group (p = .39)
Wu and Lin³⁰	From March 2010 to July 2011, United States	Developing and evaluating an individually-tailored intervention to increase mammography adherence among Chinese American women	Chinese American women aged 40 years and older	193 Women (group control, n = 97) (group intervention, n = 96)	4 months	HBM	Sociodemographics, knowledge, mammography-related cognition variables (perceived benefits, barriers, and self-efficacy)	-Tailored telephone intervention -The counseling content provided individualized messages that are pertinent to the individual participant based on her responses at baseline assessment.	40% of the women (n = 34) in the intervention group compared with 33% of the women in control (n = 27) went to obtain mammograms
Crane et al.³¹	United States, 1994–1997	Effectiveness of a telephone outcall intervention to promote screening mammography among low-income Women	Women aged 50 years and older	2,185 Women (group control, n = 695) (group intervention, n = 1,490)	6 months– 2 years	TTM	Demographic information, decisional balance, intention to get a mammogram. To get a CBE and to practice BSE and assessment of mammography stage of change	Three study groups: (a) control, (^b) out call only, and (^c) advance card + outcall. The intervention tailored to the stage of change of the woman and included (^a) the provision of basic Information about mammography (particularly emphasized for precontemplators); (^b) barriers or concerns about mammography and counseling directed at those barriers; (^c) positive reinforcement to prevent; (^d) information about transportation and cost; (^e) encouragement to talk to their doctors about getting a mammogram, as well as to get a CBE and to practice BSE	Neither intervention had a significant effect on the main outcome, receipt of mammography in the 6-month follow-up period. The 2-year follow-up indicates a small increase in mammography adherence attributable to the advance invitation + outcall.
Secginli and Nahcivan³²	Turkey, 2009	The effectiveness of a nurse-delivered breast health promotion program on breast cancer screening behaviors in non-adherent Turkish women: A randomized controlled trial	Women aged 41 years and older	190 women (group control, n = 93) (group intervention, n = 97)	3 and 6 months	HBM	Demographic information, knowledge and health belief, To get a CBE and to practice BSE, mammography	The intervention group received a 120-min breast health promotion program based on HBM including a breast health education, film, BSE instruction, and a booklet, a calendar, a card designed specifically for the study .	The breast health promotion program significantly increased BSE frequency and proficiency and breast health knowledge. No significant differences existed in mammography and clinical breast examination rates between the two groups at 6 months. (p = .94)
Bodurtha et al.³³	2003 to 2005, United States	Mammography screening after risk-tailored messages: The women improving screening through education and risk assessment (WISER) randomized, controlled trial	Women aged 40 years and older	899 women (group control, n = 450) (group intervention, n = 449)	18 months	HBM	Sociodemographic variables, get a CBE and to practice BSE, mammography intention, relevant theoretical constructs	Barriers to mammography, breast cancer seriousness, individual risk for breast cancer, and the benefits of a yearly mammogram. Twenty five nutrition and physical activity recommendations were also included. Follow-up surveys were conducted through phone interviews whenever possible. Participants who could not be reached by telephone within 3 weeks of the scheduled follow-up date were mailed a survey to be completed and mailed back.	CBE was available for 773 (84%) subjects, and BSE and mammography intentions were available for approximately 74% (p = .48)
Farhadifar et al.³⁴	Iran, 2015	Mediators of repeat mammography in two tailored interventions for Iranian women	Women aged 50 years and older	176 women (group control, n = 56) (group intervention, n = 120)	6 months	HBM/theory of planned behavior	Demographic information, obtain mammography, relevant theoretical constructs	HBM and TPB arms participated in HBM-oriented group and individual counseling sessions focused on the perceived threat of breast cancer, the benefits of obtaining mammograms, the barriers to obtaining mammograms, and self-efficacy. Participants then received a 10–15 min individual counseling session. Women in the TPB group, however, received four group and individual counseling sessions focused on subjective norms and perceived behavioral. Small groups were formed to promote peer support and increase exposure to positive subjective norms. Concerning mammography use during individual counseling sessions to identify and provide contact information for five important relatives, they thought might help remind them about scheduling a mammogram.	63% of the women in the intervention group compared with 21% of the women in control group went to obtain mammograms
Goel and O’Conor³⁵	Spain, 2015	Increasing screening mammography among predominantly Spanish speakers at a federally qualified health center using a brief previsit video	Women aged 40 years or older	97 women (group control, n = 48) (group intervention, n = 49)	12 months	Social cognition theory	Demographic information, obtain mammography, relevant theoretical constructs	The video explains the importance of mammography and demonstrates the experience of undergoing mammography. The video shows how breast cancer grows and spreads if undetected and how a mammogram can detect breast cancer. After developing a video prototype, a bicultural research assistant conducted both focus groups and one-on-one interviews	The proportion of mammogram referrals in the intervention group was significantly higher than the control group, 37% vs. 15%, respectively (p < .01). The intervention group had a higher proportion of completed mammograms, 33% vs. 13% (p < .02).
Gathirua-Mwangi et al.³⁶	United States, 2015	Mammography adherence in African-American women: Results of a randomized controlled trial	Women aged 41–65 years	244 women (group control, n = 72) (group intervention, n = 172)	6 months	HBM/TTM stage of change	Demographic information, obtain mammography, relevant theoretical constructs	The messages contained in both the DVD and phone counseling were tailored on (^a) perceived and actual risk, (^b) perceived benefits, (^c) barriers, (^d) self-efficacy, and (^e) knowledge	Mammography uptake increased similarly among all three groups—41% for DVD, 42% for TC,and 35% for usual care (p= .6491)
Janz et al.³⁷	United States, 1997	A two-step intervention to increase mammography among women aged 65 and older	Women aged 65 years and older	460 women (group control, n = 237) (group intervention, n = 223)	12 months	HBM	Demographic information, obtain mammography, relevant theoretical constructs	The two-step intervention consisted of (^a) a personal letter from the primary care physician with a coupon incentive and (^b) for women who did not respond to the letter within 2 months, a TC session conducted by a community peer.	Over the 12 months of the study, 38% of the women in the intervention group compared with 16% of the women in control group obtain mammograms
Partin et al.³⁸	Minnesota, 1998–2000	Randomized controlled trial of a repeat mammography intervention: Effect of adherence definitions on results	Women aged 40–63 years	1,558 women (group control, n = 496) (group intervention, n = 1,062). First group intervention =560. Second group intervention = 502	24 months	TTM stage of change	Repeat mammography	Mailed reminder (minimum group); mailed thank you card, newsletters, and reminder (maximum group); no mailings (control)	The first group was 54%, the second group was 52%, and the control group was 47%, the mammogram increased
Rimer et al.⁴⁰	United States, 1997–2000	Effects of a mammography decision-making intervention at 12 and 24 months	Women aged 40 to 44 years and 50 to 54 years	1,278 women (group control, n = 378) (group intervention, n = 713). First group intervention = 374. Second group intervention = 339	12 and 14 months	TTM and PAPM	Sociodemographic information, knowledge about mammography, use mammography, pros and cons about mammography screening	Tailored print intervention mailed to women following their 12-month follow-up interview was a newsletter designed to reinforce and, where appropriate, update content in the booklet. Trained health advisors called women in the TP_TC group to conduct tailored TC	At both 12 and 24 months, 18% to 20% of the UC group, 13% to 16% of the TP group, and 22% to 24% of the TP+TC group had mammograms (p = .031 to .016)
Rimer et al.³⁹	United States, 1997–2000	The short term impact of tailored mammography decision making interventions	Women aged 40 to 44 years and 50 to 54 years	1,127 women (group control, n = 412) (group intervention, n = 715). First group intervention = 392. Second group intervention = 323	12 and 15 months	TTM and PAPM	Sociodemographic information, knowledge about mammography, use mammography, pros and cons about mammography screening	Tailored print booklets alone (TP), or TP plus TC (TP+TC). Reminder letter on the woman’s birthday, letters to providers identifying their patients in need of mammograms, and a physician training manual about mammography for all providers in the plan. The TP group received a tailored booklet within about 2 weeks after completing the interview. The TP+ TC group received TC call 2 weeks after receiving the tailored print booklets.	63% of group control, 61% of the TP group, and 69% of the TP+TC group reported having had a mammogram in the past 15 months (p = .066)
Sadler et al.⁴¹	United States, 2011	A cluster randomized controlled trial to increase breast cancer screening among African American women: The Black cosmetologists promoting health program	Women aged 20 years or older	928 women (group control, n = 503) (group intervention, n = 481)	6 months	HBM	Sociodemographic information, knowledge about breast cancer screening, use mammography	The cosmetologists’ verbally delivered health messages were reinforced by posters, pamphlets, and booklets placed strategically throughout the salon.	46% of the women in the intervention group compared with 30% of the women in control group went to obtain mammograms (p < .001)
Zhu et al.⁴²	United States, 1997	An intervention study on screening for breast cancer among single African-American women aged 65 and older	women aged 65 years and older	325 women (group control, n = 163) (group intervention, n = 162)	24 months	HBM, precede–proceed model, theory of reasoned action, social support theory	Demographic characteristics, knowledge, attitudes, and beliefs on breast health, use of breast cancer screening	Intervention used two strategies, coping and social support, to improve single women’s psychological health. Three intervention aspects: cognitive barriers, psychological barriers related to single status, and social network barriers	72% of women in the intervention group had had a clinical breast examination compared with 59% of the women in control group (p = .23)

Abbreviations: HBM, health belief model; TTM, transtheoretical model; PAPM, precaution adoption process model; BSE, breast self-examination; TP, tailored print booklets alone; TC, telephone counseling.

Quality Assessment Results

After determining the related articles, the quality of the articles was evaluated using the Delphi checklist. This checklist evaluated articles based on nine criteria (randomization, allocation concealed, similar in the baseline, eligibility criteria specified, outcome assessor blinded, care provider blinded, patient blinded, variability outcome measures, and intention-to-treat) and considered the maximum score of 9.

Meta-Analysis Results

The results of the meta-analysis show that the probability of screening behavior in the intervention group is 1.4 (95% CI: [1.30, 1.59]) times of that in the control group. In addition, subgroup analysis by the type of screening behavior indicates that probabilities of conducting BSE and mammography in the interventional group are 1.9 (95% CI: [1.06, 3.68]) and 1.4 (95% CI: [1.29, 1.58]) times of those in control group (Figures 2 and 3).

Figure 2.

Effectiveness of training mammograms in women.

Figure 3.

Effectiveness of training breast self-examination in women.

In this study, the overall effect of educational interventions was evaluated in terms of three periods: less than 6 months, 6 to 12 months, and over 12 months. Subgroup analysis of the follow-up period shows that the most effective screening behavior was reported in the period of 6 to 12 months.

Discussion

This study included 26 randomized controlled trial studies, which indicated that educational interventions increased screening behaviors significantly. Health education focuses on influencing and changing individual behavior.⁴³ Moreover, training plays an important role in raising awareness and consequently promoting screening behavior.

Theoretically-based interventions may be appropriate by identifying key concepts for the target group for behavior change. The positive effects in objective and subjective outcomes may be that while theoretical constructs are targeted in the intervention, theory and model facilitate determining the components of intervention techniques.⁴⁴

Our study confirms that behavioral theory-based interventions increase breast cancer screening behaviors.

Among the three methods of screening—mammography, clinical breast examination, and self-breast examination—the most effective method was self-breast examination. In addition, other methods are costly and time-consuming and hence would be the barriers for women to test screening behaviors especially mammography. The BSE is the inexpensive, simplest, and most available method to detect the breast cancer in the earlier stages. In the study by Secginli and Nahcivan,³² among the three methods of screening, increased behavior was observed for BSE, because other methods required to overcome perceived barriers such as getting a referral from a physician, going to a separate site for the screening, and paying for the procedure.

Subgroup analysis by follow-up period shows that the screening behavior is effective for the period of 6 to 12 months. Therefore, it is recommended that this program must be continuously pursued with long-term follow-up. It seems that in the 6-month follow-up, behavior change has not occurred, and in the 12-month follow-up, the sensitivity of individual has decreased and the behavior will also be disremembered.

To plan the effective intervention programs to promote breast cancer screening, many investigators have attempted to find out the agents that influence women’s behavior for breast cancer screening. The most used model in this survey was the health belief model (HBM). The HBM has been used in many studies as the theoretical framework for understanding breast cancer diagnosis behaviors. According to the HBM, if individuals perceive the disease as a risk for themselves, believe in the consequence regarding the severity of the diseases, and are aware of benefits and barriers of screenings, then the health behavior is expected to appear.⁴⁵

In a study by Crane et al. using transtheoretical model, although there were significant differences in attitude and intention, no significant difference was obtained by mammography. This result can indicate that every intention does not lead to behavior, and this relationship depends upon barrier elimination and attracting support on different levels.

Differences were observed among the studies reviewed. One of the most important differences was the sample size, which can affect the results.

Subgroup analysis by the type of screening behavior indicates that BSE was more prevalent than mammography. Moreover, mammography screening has been utilized in more developed countries. One of the reasons for this difference is the cost, and cost elimination resulted in a modest increase in the rate of mammography screening.⁴⁶

With any systematic review study, there are a number of sources of bias that impact the results of the meta-analyses. The first one is whether all relevant articles were identified. Although this is unknown, we believe that we have identified the key published articles.

The second source of bias is publication bias. This is a major concern in all of the meta-analysis because studies reporting significant or positive findings are more possible to be published.⁴⁷The third source of bias is heterogeneity. The heterogeneity of the studies was evaluated using the χ² test. Given the differences in study groups, sample size, ethnicity, and culture distribution of cases, some degrees of heterogeneity are to be expected.

Limitations and Strengths

This systematic review study provides strong evidence on the effectiveness of the theory-based interventions to promote breast cancer screening behavior, especially BSE behavior because this behavior is a skill that does not require cost and equipment.

Thus, it can be promoted through education and increasing the self-efficacy of women. Our review focused on studies that designed to help women to decide and encourage them in participation and adherence to screening.

Our review has several limitations. First, we cannot prevent publication bias, although we performed a comprehensive and complete literature search. The studies that had a low sample size and with meaningless results were to impact our results. Second, several studies had an open intervention design and used unblinded clinical conclusion assessments, which caused lower scores for trial quality. Third, there was a lack of access to full-text articles. Fourth, the evaluation of published articles was only in English. Fourth, in this study, we did not compare the studies that were performed without model and theory. Therefore, it is suggested that this goal should be considered in future studies.

Conclusion

The health education program has an important impact on breast cancer screening behaviors, especially BSE. Training and consulting to the women in the line with encouragement and increasing their skill in performing the self- examination are important stages toward the diagnosis of breast cancer in the earlier stages of the disease. For this reason, informing women about breast cancer, promoting breast awareness, and teaching them how to perform BSE correctly are important. Therefore, considering the positive effect of the educational screening programs in women, it is proposed that these programs must be continually pursued with long-term follow-up and the increasing screening behaviors should be monitored.

Supplemental Material

Supplemental material for Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Supplemental Material for Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis by Saeed Bashirian, Younes Mohammadi, Majid Barati, Leila Moaddabshoar and Mitra Dogonchi in International Quarterly of Community Health Education

Footnotes

Appendix: Search Strategy for All Databases

Breast cancer	“breast cancer” OR “Breast Neoplasm” OR “Breast Neoplasm's” OR “Breast Tumors” OR “Breast Tumor” OR “Malignant Neoplasm of Breast” OR “Malignant Tumor of Breast” OR “Breast Malignant Tumor” OR “Breast Malignant Tumors” OR “Breast Carcinoma” OR “Breast Carcinomas” OR “Human Mammary Neoplasm's” OR “Cancer of the Breast”
Screening	Mammography OR “Breast Self-Examination” OR “Screening behavior” OR “Screening Tests” OR “Mass Screening” OR “training Breast self-examination” OR “Clinical Breast Examination” OR “BSE (Breast Self Examination)” OR “Screening Mammogram” OR “Screening Mammograms” OR diagnosis OR “Mammogram repeat” OR “Cancer Early Detection”
Target group	Woman OR women OR female OR Girl OR “Women Group”
The intervention section and the program	effect* OR control* OR evaluation* OR program* OR “Health education” OR “health promotion” OR “Community Health Education” OR outcome OR “impact training” OR “behavior modification” OR “self care” OR promoting OR promotion OR counseling
Type of study	“randomized controlled trial” OR “controlled clinical trial” OR “randomized controlled trials” OR “random allocation” OR “double-blind method” OR “single-blind method” OR “clinical trial” OR “clinical trials” OR singl* OR doubl* OR tripl* OR mask* OR blind* OR placebo* OR random* OR “research design” OR “comparative study” OR “evaluation studies” OR “prospective studies” OR control* OR volunteer* NOT animal

Implications for Future Research

Our study proposes that effective planning and interventions tailored to the audience’s characteristics can be effective through removing perceived barriers and increasing participation and encouragement of women for performing screening methods. By raising public awareness and early detection of cancer through screening methods, they can play a key role in the reduction of incidence and mortality of cancer.

Acknowledgments

This project has been approved by the Research and Technology Deputy of Hamadan University of Medical Sciences. The authors wish to thank all the interviewers who worked in this study.

Author Contributions

Saeed Bashirian and Majid Barati were involved in conception and design. Mitra Dogonchi and Leila Moaddabshoar contributed to collection and assembly of data. Younes Mohammadi performed data analysis and interpretation. Mitra Dogonchi was involved in Manuscript writing. All authors approved final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Hamadan University of Medical Sciences (Grant Number: 9603091553).

Author Biographies

Saeed Bashirian, PhD, is an associate professor of in the Department of Public Health at Hamadan University of Medical Sciences. He teaches in the areas of health behavior Bashirian et al. 7 change and health communication and has scholarly interests in predicting and changing health behavior.

Younes Mohammadi, PhD, is an assistant professor of Epidemiology, Department of Epidemiology, School of Health, Modeling of Noncommunicable Diseases Research Center, Hamadan University of Medical Sciences.

Majid Barati, PhD, is an assistant professor of Health Education and Health Promotion at Hamadan University of Medical Sciences. Her research interests are in psychosocial aspects related to health beliefs and behavior, and the role of social determinants of health in influencing health and wellbeing.

Leila Moaddabshoar, radiotherapy specialist oncology Activities in the field of cancer treatment and also writing national guidelines for treatment and early diagnosis of cancer and the development of radiation therapy and palliative care.

Mitra Dogonchi, is Ms Health Education and Health Promotion and PhD, is a researcher in the field of Health Education, chronic disease prevention.

References

Birhane

Alemayehu

Anawte

, et al. Practices of breast self-examination and associated factors among female Debre Berhan University students. Int J Breast Cancer 2017; 2017: 8026297.

Kutlu

Biçer

Ü.

Evaluation of breast cancer risk levels and its relation with breast self-examination practices in women. J Breast Health 2017; 13: 34.

Ayran

Fırat

Kucukakca

, et al. The effect of peer education upon breast self-examination behaviors and self-esteem among university students. Eur J Breast Health 2017; 13: 138.

Rebecca

Kimberly

Ahmedin

Cancer statistics. CA Cancer J Clin 2017; 67: 7–30.

Bernard

Wild

PSaC.

World cancer report 2014. Lyon, France: International Agency for Research on Cancer, 2014.

Hajian-Tilaki

Auladi

Health belief model and practice of breast self-examination and breast cancer screening in Iranian women. Breast Cancer 2014; 21: 429–434.

World Health Organization, Cancer Prevention. http://www.who.int/cancer/prevention/diagnosis-screening/en/ (2017, accessed 24 June 2019).

http://www.who.int/cancer/prevention/diagnosis-screening/breast-cancer/en/ (2017, accessed 24 June 2019).

Savabi-Esfahani

Taleghani

Noroozi

, et al. Role playing for improving women’s knowledge of breast cancer screening and performance of breast self-examination. Asian Pac J Cancer Prev 2017; 18: 2501.

10.

Aminisani

Fattahpour

Dastgiri

, et al. Determinants of breast cancer screening uptake in Kurdish women of Iran. Health Promot Perspect 2016; 6: 42.

11.

Khalili

Shahnazi

Breast cancer screening (breast self-examination, clinical breast exam, and mammography) in women referred to health centers in Tabriz, Iran. Indian J Med Sci 2010; 64: 149.

12.

Aghamolaei

Hasani

Tavafian

, et al. Improving breast self-examination: an educational intervention based on health belief model. Iran J Cancer Prev 2011; 4: 82–87.

13.

Russell

Champion

Monahan

, et al. Randomized trial of a lay health advisor and computer intervention to increase mammography screening in African American women. Cancer Epidemiol Prev Biomarkers 2010; 19: 201–210.

14.

Lee-Lin

Nguyen

Pedhiwala

, et al. A breast health educational program for Chinese-American women: 3-to 12-month postintervention effect. Am J Health Promot 2015; 29: 173–181.

15.

Abu-Helalah

Alshraideh

Al-Serhan

, et al. Knowledge, barriers and attitudes towards breast cancer mammography screening in Jordan. Asian Pac J Cancer Prev 2015; 16: 3981–3990.

16.

Merakou

Papagiannopoulou

Chania

, et al. Effectiveness of a brief health education intervention for breast cancer prevention in Greece under economic crisis. International Journal of Caring Sciences 2013; 6: 170.

17.

Glanz

Rimer

Viswanath

Health behavior and health education: theory, research, and practice. Hoboken, NJ: John Wiley & Sons, 2008.

18.

Verhagen

de Vet

de Bie

, et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998; 51: 1235–1241.

19.

Lee

Menon

Nandy

, et al.

The effect of couples intervention to increase breast cancer screening among Korean Americans.

Oncol Nurs Forum 2014; 41: E185–E193.

20.

Sheppard

Wang

JH-y

Eng-Wong

, et al. Promoting mammography adherence in underserved women: The telephone coaching adherence study. Contemp Clin Trials 2013; 35: 35–42.

21.

Champion

VL.

Strategies to increase mammography utilization. Med Care 1994; 32: 118–129.

22.

Paskett

Tatum

Rushing

, et al. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. J Natl Cancer Inst 2006; 98: 1226–1237.

23.

Taymoori

Molina

Roshani

Effects of a randomized controlled trial to increase repeat mammography screening in Iranian women. Cancer Nurs 2015; 38: 288.

24.

Hegenscheid

Hoffmann

Fochler

, et al. Telephone counseling and attendance in a national mammography-screening program: a randomized controlled trial. Am J Prev Med 2011; 41: 421–427.

25.

King

Ross

Seay

, et al. Mammography interventions for 65-to 74-year-old HMO women: Program effectiveness and predictors of use. J Aging Health 1995; 7: 529–551.

26.

Akhtari-Zavare

Juni

Said

, et al. Result of randomized control trial to increase breast health awareness among young females in Malaysia. BMC Public Health 2016; 16: 738.

27.

Champion

Ray

Heilman

, et al. A tailored intervention for mammography among low-income African-American women. J Psychosoc Oncol 2000; 18: 1–13.

28.

Champion

Maraj

Hui

, et al. Comparison of tailored interventions to increase mammography screening in nonadherent older women. Prev Med 2003; 36: 150–158.

29.

Mishra

Bastani

Crespi

, et al. Results of a randomized trial to increase mammogram usage among Samoan women. Cancer Epidemiol Prev Biomarkers 2007; 16: 2594–2604.

30.

T-Y

Lin

Developing and evaluating an individually-tailored intervention to increase mammography adherence among Chinese American women. Cancer Nurs 2015; 38: 40.

31.

Crane

Leakey

Rimer

, et al. Effectiveness of a telephone outcall intervention to promote screening mammography among low-income women. Prev Med 1998; 27: S39–S49.

32.

Secginli

Nahcivan

NO.

The effectiveness of a nurse-delivered breast health promotion program on breast cancer screening behaviours in non-adherent Turkish women: A randomized controlled trial. Int J Nurs Stud 2011; 48: 24–36.

33.

Bodurtha

Quillin

Tracy

, et al. Mammography screening after risk-tailored messages: The Women Improving Screening through Education and Risk Assessment (WISER) randomized, controlled trial. J Women's Health 2009; 18: 41–47.

34.

Farhadifar

Molina

Taymoori

, et al. Mediators of repeat mammography in two tailored interventions for Iranian women. BMC Public Health 2016; 16: 149.

35.

Goel

O’Conor

Increasing screening mammography among predominantly Spanish speakers at a federally qualified health center using a brief previsit video. Patient Education and Counseling 2016; 99: 408–413.

36.

Gathirua-Mwangi

Monahan

Stump

, et al. Mammography adherence in African-American women: Results of a randomized controlled trial. Ann Behav Med 2015; 50: 70–78.

37.

Janz

Schottenfeld

Doerr

, et al. A two-step intervention of increase mammography among women aged 65 and older. Am J Public Health 1997; 87: 1683–1686.

38.

Partin

Slater

Caplan

Randomized controlled trial of a repeat mammography intervention: effect of adherence definitions on results. Prev Med 2005; 41: 734–740.

39.

Rimer

Halabi

Skinner

, et al. The short-term impact of tailored mammography decision-making interventions. Patient Educ Counsel 2001; 43: 271–287.

40.

Rimer

Halabi

Skinner

, et al. Effects of a mammography decision-making intervention at 12 and 24 months. Am J Prev Med 2002; 22: 247–257.

41.

Sadler

, et al. A cluster randomized controlled trial to increase breast cancer screening among African American women: the black cosmetologists promoting health program. J Natl Med Assoc 2011; 103: 735–745.

42.

Zhu

Hunter

Bernard

, et al. An intervention study on screening for breast cancer among single African-American women aged 65 and older. Prev Med 2002; 34: 536–545.

43.

Koelen

Van den Ban

Health education and health promotion. Wageningen, the Netherlands: Wageningen Academic Publishers, 2004.

44.

Zhao

Suhonen

Koskinen

, et al. Theory‐based self‐management educational interventions on patients with type 2 diabetes: a systematic review and meta‐analysis of randomized controlled trials. J Adv Nurs 2017; 73: 812–833.

45.

Tuzcu

Bahar

Gözüm

Effects of interventions based on health behavior models on breast cancer screening behaviors of migrant women in Turkey. Cancer Nursing 2016; 39: E40–E50.

46.

Jena

Huang

Fireman

, et al. Screening mammography for free: impact of eliminating cost sharing on cancer screening rates. Health Serv Res 2017; 52: 191–206.

47.

Johns

Houlston

RS.

A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol 2001; 96: 2992–3003.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.37 MB