The association between health beliefs and breast self-examination among healthcare providers: A cross-sectional study.

Introduction
After lung cancer, breast cancer is the second most common cause of cancer-related deaths in women and makes up nearly one-third of all cancer cases. It is estimated that more than a million new cases of breast cancer will arise globally each year. Epidemiological studies based on the age-specific incidence in Iraq indicate that the cancer is most common in women between the ages 45–55.[1] These studies show that, like in other developing countries, breast cancer tends to accumulate, among younger women in our community. Although every woman in the West can receive a breast cancer diagnosis a few months prior to the disease’s clinical onset, in Iraq, almost 65% of cases resulted in death within a few months of beginning treatment because of the delayed diagnosis.[2] In the United States, the incidence rate of breast cancer increased by 3% between 2000 and 2020, but the death rate from breast cancer decreased during the same time.[3] “Breast self-examination (BSE), clinical breast examination (CBE), and mammography” are the main methods for an early diagnosis of breast cancer. The BSE process is simple, quick, and free. A woman, who practices BSE may identify and assess any changes in her body and get the care and therapy she needs early on. These days, women are typically the first to use BSE to discover a breast lump, despite conflicting opinions regarding the impact of BSE on life expectancy.[4] BSE is a straightforward, inexpensive, and non-invasive way to screen for breast cancer.[5] Despite these benefits and BSE’s well-established effectiveness, research shows that its monthly performance is less than (15%).[6] Iraq’s BSE procedures are also unsatisfactory.[78] Completing BSE and mammography appears to be linked to several traits, such as awareness of breast cancer, educational attainment, family history of the disease, lack of a doctor’s referral, and unfavorable attitudes and health perceptions regarding this condition[9]. In accordance with the HBM, people who engage in preventive behavior must perceive that they are at risk from the health issue “perceived susceptibility” comprehend the extent of the problem’s physical, mental, economic, and social effects “perceived severity” receive positive cues from their internal or external environment “cues of action” and believe that the advantages of the health behavior “perceived benefits” outweigh the obstacles to engaging in the behavior “perceived barriers,” as well as relying on their own judgment and competence “self-efficacy.”[10] Breast cancer preventive initiatives prioritize early identification and screening to lower death rates, taking into account the risk factors for breast cancer.[11] There is insufficient evidence regarding the predictive determinants of breast cancer screening behaviors, particularly in northern Iraq, and prior research indicates that health behaviors, involving clinical examination, self-examination, and mammography are low.[12] Thus, to forecast the behavior of BSE among the medical professionals in Mosul, the researchers in this study chose to employ HBM. The aim of the paper to identify the associations between healthcare providers’ health beliefs and breast self-examination.

Materials and Methods

Study design and setting
A cross-sectional study was on healthcare providers of hospitals Mosul city, Iraq. The sample collection period lasted over 2 months, from February 1, 2025 to April 2, 2025. The study sample was collected from four teaching hospitals “Al-Batoul Hospital, Al-Bahshi Hospital, Al-Khansa Hospital, and Al-Salam Hospital.”

Studying participants and sampling
The healthcare workers at four teaching hospitals in Mosul City: (Al-Batoul Hospital, Al-Bahshi Hospital, Al-Khansa Hospital, and Al-Salam Hospital) were the subjects of a cross-sectional study. There were 225 health workers among the participants. Direct interviews with healthcare professionals were used to gather the sample, guaranteeing representation of both genders and a range of educational backgrounds. One of the requirements for participation was that hospital healthcare workers be eligible. One of the exclusion criteria was that participants who refused to participate would be disqualified.

Data collection tools and technique
Demographic information such as age, marital status, hospital and healthcare provider types, family history of breast cancer, and BSE performance were all covered in the questionnaire. The main objective of the HBM is to investigate the relationship between breast self-examination and the Health Beliefs. This model also states that knowledge of “perceived susceptibility, perceived sensitivity, perceived benefit, perceived barriers, cue to action, and perceived self-efficacy” must be developed. The source of information on breast self-examination was also identified through a set of primary sources related to the study. Numerous studies conducted in Iraq have proven the validity and reliability of this scale. The HBM’s prior test-retest results ranged from 0.84 to 0.93.

Statistical analysis
The data was statistically analyzed using “SPSS Version-28.” For continuous data, the standard deviation was employed, and for mean data, descriptive statistics such as frequency and percentage were employed.

Ethics consideration
The Institutional Review Board (IRB), the University of Mosul College of Nursing, and the scientific committee of the community health nursing department all examined and approved the study proposal. (Nu 2456/5195 in 2//2/2025). It adhered to the Declaration of the Helsinki’s ethical guidelines. In accordance with order No. (198767/231NM), approval was also received from the Iraqi Ministry of Health and the Nineveh health directorate.

Results
The study sample showed that most participants were under the age of 25 (61.77%), with an average age of 22.32 years. This indicates that most participants were young. The largest number were nurses (37.78%), followed by female doctors (20.44%) and pharmacists (16.89%). Given their significant contribution to the research sample and their initiative for health education and learning, this emphasizes the significance of nursing staff participation. There is a need for more education and training because 55.56% of healthcare professionals, especially nurses, reported not doing breast self-examination. In line with research demonstrating low adherence to breast self-examination among healthcare workers, only 10.67% regularly performed breast self-examination.

Discussion
The study’s main objective was to investigate the connections between healthcare providers’ BSE and their health beliefs. According to preliminary findings in the study sample’s demographic characteristics tables, most participants (61.77%) were under 25 years, with an average age of 22.32 years. This indicates that most participants were young. The largest number were nurses (37.78%), followed by female doctors (20.44%) and pharmacists (16.89%). This highlights the importance of nursing staff in participating, as they played a key role in the research sample and provided the initiative for health education and learning. Regarding breast self-examination, 55.56% of healthcare workers, particularly nurses, reported not performing it, indicating a need for further education and training. Only 10.67% practiced breast self-examination regularly, consistent with studies showing low adherence to the breast self-examination among healthcare workers.[13] Marital status revealed that 54.22% were single and only 6.67%, were divorced or separated, perhaps reflecting the young average age of healthcare workers in hospitals. It is worth noting that only 9.78% reported a family history of breast cancer, which may have influenced their habits and shifted their health beliefs toward a more positive direction [Table 1]. The Table 2 shows the source of information obtained by health workers in the application of breast self-examination. The results showed that the scientific aspect had the largest role as information during the study period amounted to (45.78%), followed by scientific books (23.12%). In the 1950s, Hochbaum, and others developed the (HBM) to characterize behaviors linked to health and identify the associated. The factors influencing the decision to perform breast self-examination were examined using the HBM. Among other things, the results showed no significant relationship between frequency and a wellness conception of health, according to the Health Belief Models Instrument. Except for “the perceived severity,” all health belief subscales showed a significant relationship with regular BSE. Additionally, all health belief sub-scales except “the perceived severity” showed a significant relationship with irregular BSE [Table 3]. It has also been suggested that healthcare providers be encouraged to perform BSE, despite the lack of evidence that it reduces the death rate from breast cancer.[141516] BSE empowers women to take control of their own health, understand their breasts at different stages, notice and feel changes as they age, and promptly report any abnormal changes.[17] Promoting young women’s involvement in health-promoting behaviors and educating them about breast cancer are two of the biggest obstacles in this area.[181920] The frequency of BSE reported at the one-year follow-up had decreased, despite the fact that the study’s findings, which examined the effects of HBM-based education on healthcare providers’ health beliefs and BSE practices, demonstrate improvements in their understanding of breast cancer, health beliefs, and BSE skills. The results summarized that there is a need for urgent and necessary interventions, especially among young women, as they are more vulnerable to the risk, to improve clinical practices for breast self-examination as the primary prevention of the risk of fatal breast cancer.

Limitations and recommendation
One of the most significant barriers to academic achievement was that most medical staff, especially female doctors and nurses, were committed to work in operating rooms and wards. Therefore, the study recommends encouraging all healthcare workers in governmental and non-governmental institutions, as well as universities, to organize programs and workshops on breast self-examination to detect any breast-related problems early.

Conclusion
According to the study, performing breast self-examination was statistically significantly correlated with the health beliefs of the healthcare providers. There was no obvious correlation, except for perceived seriousness.

Ethics consideration
The Institutional Review Board (IRB), the University of Mosul College of Nursing, and the scientific committee of the community health nursing department all examined and approved the study proposal. (Nu 2456/5195 in 2//2/2025). It adhered to the Declaration of Helsinki’s ethical guidelines. In accordance with order No. (198767/231NM), approval was also received from the Iraqi Ministry of Health and the Nineveh health directorate.

Conflicts of interest
There are no conflicts of interest.