Introduction

The World Health Organization (WHO), states that breast cancer is the most common type of cancer affecting women worldwide as well as the most common cause of cancer-related deaths (WHO 2023; PAHO/WHO 2023). The organization has also reported that 2.3 million women were diagnosed with breast cancer across the world in 2020, resulting in 685,000 deaths. It has also been reported that early diagnosis and treatment of breast cancer can be highly effective for the survival of individuals (WHO 2023; PAHO/WHO 2023). Among recommended screening methods are breast self-examination (BSE), clinical breast examination, and mammography. BSE, is a simple, inexpensive, easy, and effective early diagnosis screening technique that allows women to examine their breast tissues to observe any physical and visual changes (Rahman et al. 2019). It has been pointed out that when breast cancer is diagnosed early, mortality rates are reduced and women’s overall quality of life can be improved (Didarloo et al. 2017). BSE also encourages women to receive treatment and increases survival rates (Rahman et al. 2019). This is because BSE will enable women to recognize normal breast tissues and make them more willing to receive definitive diagnosis by increasing their awareness (Gençtürk et al. 2017). With the Turkish Breast Cancer Screening Program, women over the age of 20 are recommended to perform breast self-examination once a month (Republic of Türkiye Ministry of Health 2023). It is reported that many women do not take recommended screening tests despite their reported benefits in detecting breast cancer. Therefore, the importance of understanding the factors that have an impact on behaviors related to breast cancer screening tests has been emphasized (Didarloo et al. 2017). It has been pointed out that women’s health beliefs may affect their behaviors of BSE practice (Ahmad et al. 2022). The Health Belief Model argues that individuals are affected by susceptibility to the health problem, their perception concerning the problem, and their health motivation, as well as perceived benefits and threats when adopting a certain behavior (Yurt et al. 2019). Individuals’ awareness of breast cancer is also a key factor for the outcomes of the disease (Rahman et al. 2019). However, it is suggested that women do not have adequate knowledge about BSE (Yurt et al. 2019). One study uncovered that breast cancer knowledge levels and practicing BSE were the factors affecting health beliefs (Erbil and Bolukbas 2014).

Nurses and midwives in health care have a fundamental role in referring women to early diagnosis programs, as they are in constant contact with female patients. Thus, considering the effects of individuals’ health beliefs and knowledge levels in breast cancer on the outcomes of the disease, we believe that it is important to investigate the BSE behaviors of female nursing and midwifery students with regard to their own situation and their contribution to society. The present study was conducted to inspect the relationship between health beliefs and breast cancer knowledge levels and the behavior of performing BSE among undergraduate students of midwifery and nursing departments.

Methods

The type of study

This study was conducted in a cross-sectional research design in a Web environment.

Variables

Independent variables:

  • Students’ socio-demographic characteristics.

  • Students’ characteristics related to their medical history.

  • Students’ characteristics with regard to clinical breast examination.

  • Scores of subscales in Champion’s Health Belief Model Scale (perceived susceptibility, perceived severity/seriousness, health motivation, obstacle perception, perceived benefits, and confidence/self-efficacy).

  • Total score and scores of the subscales (general knowledge and curability score) of the comprehensive breast cancer knowledge test.

Dependent variable:

  • BSE behavior (yes/no).

Population and sample

The research population consists of 3rd- and 4th-year female students studying at midwifery and nursing departments of a private and state university in Konya in the fall-spring semester of the 2020–2021 academic year. Nursing students receive information about breast cancer and breast examination in the spring semester of the 2nd year and in the fall semester of the 3rd year. Midwifery students are provided with this information in the fall and spring semesters of the 2nd year. The research sample comprises 3rd- and 4th-year female students of midwifery and nursing departments who are members of social media groups between December 2020 and May 2021 and who meet the inclusion criteria. All students who meet the inclusion criteria are contacted.

Inclusion criteria

  • Being a 3rd- or 4th-year midwifery and nursing student.

  • Having taken the “Obstetrics and Gynecology Nursing” course in the fall semester (5th semester) in the 3rd year of the nursing department.

  • Being 20 years of age or older.

Exclusion criteria

  • Being a 1st- or 2nd-year nursing and midwifery student.

  • Not having taken the “Obstetrics and Gynecology Nursing” course in the 3rd year of the nursing department.

  • Being a foreign national.

  • Breastfeeding or being pregnant.

Data collection tools and procedures

Various data collection tools were used for collecting research data, which are as follows: the Introductory Information Form prepared by the researchers in line with the literature (Gençtürk et al. 2017; Güzel and Bayraktar 2019; Kıssal et al. 2017), the Champion’s Health Belief Model Scale (CHBMS), and the Comprehensive Breast Cancer Knowledge Test (CBCKT), which were adapted to Turkish upon validity and reliability analyses.

Introductory information form

The form is made up of 26 questions in total, which includes socio-demographic, medical-history, and breast-examination characteristics of the students included in the study in accordance with the literature.

Champion’s Health Belief Model Scale (CHBMS)

The scale was developed by Victoria Champion in 1984 to measure women’s health beliefs about breast cancer and the status of practicing BSE (Champion 1984). It was revised in later studies (1993, 1997, 1999) by Victoria Champion (Champion 1993, 1999; Champion and Scott 1997). The scale was adapted into Turkish by Karayurt and Dramalı (2003, 2007). The CHBMS has six subscales and 42 items: perceived susceptibility (three items), perceived severity (seven items), perceived benefits (four items), perceived obstacle perception (11 items), confidence (ten items), and health motivation (seven items). Accordingly, the present study made use of a 5-point Likert scale used by Karayurt and Dramalı (2003) in their Turkish validity and reliability study. The total score of each subscale is calculated independently (Karayurt and Dramalı 2007). In the Turkish validity and reliability study of the scale by Karayurt and Dramalı (2003), Cronbach’s alpha reliability coefficient for each subscale was between 0.58 to 0.89 and the test–retest reliability was between 0.89 to 0.99. In the current study, Cronbach’s alpha coefficient was 0.798 and 0.847 for the perceived susceptibility and the perceived severity subscales about breast cancer respectively. Regarding performing BSE, it was 0.883 for the perceived benefits, 0.859 for the obstacle perception, 0.934 for the confidence subscales, and 0.827 for the health motivation subscale.

Comprehensive Breast Cancer Knowledge Test (CBCKT)

The test was developed by Stager (1993) to measure women’s knowledge levels about breast cancer (Stager 1993). The Turkish validity and reliability study was conducted by Başak and Tosun (2015). The scale consists of two subscales, which are general knowledge and curability, including 20 questions in total. Eight questions out of 20 questions were correct (questions 3, 4, 7, 8, 9, 10, 13, and 16) and 12 were incorrect (questions 1, 2, 5, 6, 11, 12, 14, 15, 17, 18, 19, and 20). Correctly answered questions are scored as “1 point”, while incorrectly answered questions and unanswered questions are scored as “0 point”. The lowest score that can be obtained from the test is “0” and the highest score is “20” (Başak and Tosun 2015). The KR-20 reliability coefficient that was used to determine internal consistency in the original test was found to be 0.60 for the general knowledge subscale, 0.62 for the curability subscale, and 0.71 for the total scale (Stager 1993). Since the KR-20 reliability coefficient values are higher than 0.50, the reliability of the scale is high (Alpar 2014). In the Turkish version of the CBCKT, the Cronbach’s Alpha reliability coefficient is 0.49 for the general knowledge subscale, 0.80 for the curability subscale, and 0.90 for the whole knowledge test (Başak and Tosun 2015). In the present study, the KR-20 reliability coefficient is 0.691 for the total scale, 0.499 for the general knowledge subscale, and 0.660 for the curability subscale.

Data collection

The data were collected between December 28, 2020 and January 15, 2021. In order to collect the data, institutional permissions were first obtained. Afterwards, through e-mail and WhatsApp groups over the internet, the survey questions created with an online survey system were shared with the students who agreed to participate in the study. At the top section of the survey form, participants were provided with information about the voluntary participation and the inclusion criteria. In order for them to indicate their voluntary participation in the study, the survey form was preceded by the statements “I want to participate in the study voluntarily” and “I do not want to participate”. In order to prevent data loss, answering all questions in the online survey system was made compulsory. In addition, the online survey system prevented moving on to the next page before each page was completed. To prevent the same participants from filling out the survey more than once, the multiple participation prevention feature was used that was provided by the survey system.

Ethics of the study

Ethics committee approval was obtained to carry out the present study (date: 15/12/2020, decision number: 2020/025). Institutional permission was received from both universities for conducting the study. Upon giving the necessary information about the research to the nursing and midwifery students who volunteered to participate in the study and met the inclusion criteria, their informed consent was obtained.

Data analysis

Research data were analyzed in IBM’s SPSS statistical package version 25. First, descriptive statistics (number, percentage, mean, standard deviation, median, minimum, and maximum) were uncovered. Afterwards, parametric (t-test), nonparametric analyses (Mann–Whitney U test), and chi-square test analyses were performed according to the results of normality analysis. Multi-factor analysis was conducted using binary logistic regression (backward: Wald method). Variables associated with BSE application status in univariate analyzes (p < 0.05) were included in the binary logistic regression analysis. The criterion for not including independent variables in the logistic regression analysis was p > 0.20 (Bayman and Dexter 2021). As a result of binary logistic regression, odds ratio (OR) values and 95% confidence intervals (CI) were presented. The level of statistical significance was taken as p < 0.05.

Findings

The mean age of the students was found to be 21.47 and their weighted grade point average was 3.13; 57.8% of the students were in nursing and 42.2% in midwifery. Among them, 55.6% were in the 3rd year and 87.5% graduated from a high school other than a medical vocational high school. Further, 99.1% were single, 65.8% lived in the city, 75.9% had a medium income perception, and 86.6% lived in a nuclear family. In addition, 92% of them had no history of breast cancer in their family, and 92.2% had had a clinical breast examination at least once in their lives. The rate of performing BSE was higher among those living in a nuclear family (90.2%) and those who had had a clinical breast examination (9.5%) (Table 1, p < 0.05).

Table 1 BSE application situations of nursing and midwifery students according to the introductory characteristics
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It was revealed that 75% of the students had practiced BSE, but only 52.7% of them performed the examination on a regular basis (Table 2).

Table 2 The BSE application situations of nursing and midwifery students (n = 448)
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The mean score of the perceived susceptibility subscale of the CHBMS related to breast cancer was 6.79 ± 2.18 and the mean score of the perceived severity/seriousness subscale was 20.85 ± 5.54. With regard to performing BSE, the mean score of the perceived benefits subscale was 17.16 ± 3.37, the mean score of the obstacle perception subscale was 21.16 ± 6.76, the mean score of the confidence/self-efficacy subscale was 38.72 ± 7.42, and the mean score of the health motivation subscale was 26.31 ± 4.89. The mean total score of the CBCKT was 9.73 ± 3.25, the mean score of the general knowledge subscale was 7.12 ± 2.12, and the mean score of the curability subscale was 2.60 ± 1.68. In terms of performing BSE, there was no statistically significant difference between the mean scores of the total scale score of CBCKT and its subscales (p > 0,05). Moreover, no statistical difference was found between the mean scores of the perceived susceptibility and perceived severity/seriousness subscales of the CHBMS (p > 0,05). However, there was a statistically significant difference between the mean scores of the perceived benefits, obstacle perception, confidence/self-efficacy, and health motivation subscales of CHBMS (Table 3, p < 0.05).

Table 3 CHBMS and CBCKT scores of nursing and midwifery students according to the BSE application situations
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Multivariate binary logistic regression analysis (backward: Wald) given in Table 4 was performed to determine the risk factors associated with students’ BSE application situations. Accordingly, to the model; age, weighted GPA, grade, income perception, family type, insurance social, health status perception, family history of breast cancer, history of clinical breast examination, CHBMS’s perception of sensitivity sub-dimension score, benefit perception sub-dimension score, obstacle perception sub-dimension score, confidence/self-efficacy about BSE application sub-dimension score and health motivation sub-dimension score were taken as independent variables. Among the independent variables that contribute significantly to the model, having an extended family is 3.29 (OR = 3.29, CI = 1.73–6.26), not having a clinical breast examination is 6.53 (OR = 6.53, CI = 1.84–23.14), and a 1-unit increase in weighted GPA is 2.18 (OR = 2.18, CI = 1.11–4.29) and a 1-unit increase in the obstacle perception sub-dimensional score related to BSE practice increased the risk of not performing BSE in students by 1.11 times (OR = 1.11, CI = 1.06–1.15). A 1-unit increase in the confidence/self-efficacy about BSE application sub-dimension score reduced the risk of not performing BSE by 0.94 times (OR = 0.94, CI = 0.90–0.97). In this study, the independent variables that contribute significantly to the model explain 26% of the non-practice of BSE (Table 4).

Table 4 Risk factors associated with the BSE application situations of students
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Discussion

The present study aimed to inspect the relationship between midwifery and nursing undergraduate students’ health beliefs and breast-cancer knowledge levels, and performing BSE. In accordance with the literature, this section discusses the significant findings concerning the behaviors of students performing BSE.

The current study revealed that only 52.7% of the students performed BSE on a regular basis. Considering the relevant studies in the literature, it is seen that Koç et al. (2019) found that 33.3% of female university students regularly performed BSE (Koc et al. 2019). In one study conducted with female university students, 31.4% of them practiced BSE on a regular basis (Abo Al-Shiekh et al. 2021), and the figure was 28.8% in another study (Rahman et al. 2019). Carrying out a study with female nursing students, Kıssal et al. (2017) found out that 14.8% of the students regularly practiced BSE (Kıssal et al. 2017). In one study conducted with midwifery students, only 14.4% of them performed BSE every month on a regular basis (Gençtürk et al. 2017). The above-mentioned study findings indicate that the awareness levels about BSE and its practice by students differ and that there may be a global need for raising awareness about breast cancer among female university students.

A 1-unit increase in the weighted GPA increased the risk of not performing BSE by 1.11 times. It is stated in the literature that this may be due to the fact that the process of BSE practice is not internalized, even though the students’ theoretical knowledge is at a good level (Dinas et al. 2018; Karadag et al. 2014). This can be interpreted as the fact that it takes time for knowledge to transform into attitude and behavior.

In this study, the rate of performing BSE was higher among the students who had clinical breast examination (9.5%). Additionally, not having a clinical breast examination increased the risk of not having a breast exam by 6.53 times. In their study with female nursing students, Kıssal et al. (2017) revealed that there was no significant difference between performing BSE and having a clinical breast examination (Kıssal et al. 2017). Likewise, a statistically significant difference was found in a study that evaluated the rate of women’s practice of BSE according to whether or not they had had a mammography within 1 year (Ertem et al. 2017). These findings may suggest that women who underwent clinical breast examination and had mammography had a high level of awareness about BSE which contributed positively to their practice of BSE.

The rate of BSE was higher among those living in nuclear families. Additionally, the risk of not applying BSE increased by 3.29 times in those with large families. It is believed that this may be due to the difficulties in finding a suitable environment and appropriate time for performing BSE and thus privacy problems in extended families.

The present study found a significant difference between the mean scores of the perceived benefits, obstacle perception, confidence/self-efficacy, and health motivation subscales of the CHBMS and performing BSE. While a 1-unit increase in the obstacle perception subdimension score concerning BSE application increased the risk of students not applying BSE by 1.11 times, a 1-unit increase in the confidence/self-efficacy about BSE application sub-dimension score reduced the risk of not performing BSE by 0.94 times. Darvishpour et al. (2018) uncovered that women with more self-efficacy, perceived benefits, and fewer obstacle perceptions were more likely to practice BSE (Darvishpour et al. 2018). Ertem et al. (2017) also found a statistically significant difference between the mean scores of perceived benefits, obstacle perception, health motivation, and self-efficacy subscales based on doing BSE (Ertem et al. 2017). In one study carried out with 3rd- and 4th-year nursing students, the predisposition and obstacle perception scores for BSE were higher in 3rd-year students and self-efficacy scores were higher in 4th-year students, and a statistically significant difference was found (Kıssal et al. 2017). In their study with midwifery students, Gençtürk et al. (2017) found that scores of perceived benefits, obstacle perception, and confidence subscales were positively associated with regular practice of BSE (Gençtürk et al. 2017). In line with all these results, it becomes quite essential to implement model-supported training classes for women to perform BSE on a regular basis, to increase their health motivation, to be aware of the risk factors that contribute to the development of breast cancer, to increase their awareness of early diagnosis methods, and to make these attitudes and behaviors continuous (Ertem et al. 2017).

Implications for nursing

In order for nurses and midwives to be role models for preventive health care practices in the society, their health beliefs, attitudes, and behaviors related to breast cancer and the importance of performing BSE should be improved throughout their education.

Conclusion and recommendations

The present study uncovered that nearly half of the students practiced BSE regularly, had a high level of general knowledge about breast cancer, and yet a low level of knowledge about its curability. In general, susceptibility and severity about breast cancer, perceived benefits, perceived self-efficacy, and health motivation about practicing BSE, especially among those who practiced BSE, were found to be at a high level, while obstacle perception were low. To sum up, in order for nurses and midwives to be role models for preventive health care practices in the society, their health beliefs, attitudes, and behaviors related to breast cancer and the importance of performing BSE should be improved throughout their education.