Health Education and Health Promotion

Effect of Protection Motivation Theory-Based Training on Intention to Perform Mammography among Teachers

Authors

S. Hosseinzadeh 1
A. Bahmani 2
S. Nili 3
A. Fallahi 3

1 Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran

2 Department of Public Health, School of Health, Kurdistan University of Medical Sciences, Sanandaj, Iran

3 Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran

https://doi.org/10.58209/hehp.13.2.289
Abstract
Aims: Early detection of breast cancer through mammography is effective in reducing mortality associated with this cancer. This study aimed to determine the effect of Protection Motivation Theory-based education on the intention to undergo mammography among teachers in District 4 of Tehran.

Materials & Methods: This interventional study was conducted on 250 teachers in Tehran, who were randomly divided into an intervention group (125 participants) and a control group (125 participants) in 2024. The data collection tool was a questionnaire on women’s participation in breast cancer screening based on protection motivation theory, which included 56 items and 8 dimensions. The educational intervention based on protection motivation theory was conducted in four sessions, held bi-weekly, for the intervention group. Data were analyzed by SPSS 26 using chi-square tests, paired t-tests, and covariance analysis.

Findings: After the educational intervention, the mean scores of the constructs of protection motivation theory and the intention to undergo mammography showed a significant difference between the intervention and control groups (p<0.05).

Conclusion: The educational intervention using protection motivation theory is effective in increasing women’s intention to participate in breast cancer screening programs and undergo mammography.

Keywords

Breast Cancer
Mammography
Motivation
Subjects
Introduction
Breast cancer, as one of the significant challenges in women’s health worldwide, accounts for millions of deaths each year, representing nearly 1 in every 6 deaths [1]. Global estimates show substantial inequalities in the burden of breast cancer in relation to human development. For instance, in countries with a very high human development index, 1 in 12 women will be diagnosed with breast cancer in their lifetime, and 1 in 71 women will die from it. In contrast, in countries with a low human development index, 1 in 27 women will be diagnosed with breast cancer in their lifetime, and 1 in 48 women will die from it [2]. In Iran, breast cancer constitutes 12.9% of all common cancers and was the fifth leading cause of cancer-related deaths in 2020. The most recent age-standardized incidence rate of breast cancer in Iran was 35.8, and it is expected to rise to over 70 cases per 100,000 people by the end of 2030. The highest incidence of breast cancer in Iran was found in central provinces, while the lowest rates were reported in southeastern provinces. The peak incidence occurs in the age group of 40 to 49 years. A rapid increase in incidence among young women from various regions of the country has also been reported. Understanding the timeline from breast cancer diagnosis to recovery requires precise analysis and diagnosis [3]. Early detection and timely medical intervention can significantly improve prognosis and increase survival rates while playing a crucial role in cancer management and treatment [4].
Among the methods for breast cancer screening, breast self-examination by women is a simple, effective, and beneficial way to screen for breast cancer, suitable for all women, and it increases self-awareness [5]. However, mammography is the most effective screening method, as it aids in early diagnosis and treatment at the asymptomatic stage [6]. Despite extensive evidence regarding the importance of regular mammography [6-8], participation rates in screening are low [9] and vary greatly depending on age, region, and insurance status [10, 11]. Breast cancer screening in routine health care settings leads to a significant reduction in breast cancer mortality [12]. Psychological and practical issues, ethnic factors, the impact of socio-economic status, and issues related to screening programs are all influential factors in participation in mammography screening. Lack of awareness and ignorance about the necessity of screening present major barriers to widespread involvement in mammography [9]. Other factors affecting screening uptake include education level, occupation, personal history of breast disease, financial and time constraints, fear, and embarrassment [13, 14]. Barriers to mammography among Asian women include knowledge, demographic factors, costs and insurance, cultural factors, beliefs, attitudes, emotions, fear, pain and embarrassment, self-efficacy, religious factors, psychological issues, time constraints, fatalism, professional recommendations, communication, social support, and access to services. Awareness, attitude and belief, perceived risk, and facilitating professional and social factors are important for promoting mammography [13]. Bashirian et al. reported that using health education models and theory-based behavioral interventions affects breast cancer screening behaviors among women [15].
Education is recognized as the most fundamental and significant way to promote self-care behaviors [16]. Considering that human behavior is influenced by various factors, health researchers need to understand behavior and the factors influencing it in order to create a healthy lifestyle and design effective interventions that either change or modify existing behaviors or replace them with new ones. This emphasizes the role of models and theories in behavioral studies [17]. Utilizing theories increases the efficiency, effectiveness, and likelihood of achieving results [18]. Various motivational programs have been developed to raise public awareness regarding protective behaviors. The most successful health behavior promotion programs emerge when effective factors influencing human behavior are addressed. One such educational model is protection motivation theory (PMT) [19].
PMT is one of the most useful frameworks for predicting protective behaviors in health behavior change studies when adopting preventive behaviors [20]. Protection Motivation Theory posits that fear can enhance positive protective motivations through six constructs: self-efficacy, response efficacy, response cost, perceived susceptibility, perceived severity, and perceived rewards. This model, which contains the essential component of motivation, can be employed to change attitudes and behaviors [21]. This protective motivation ultimately stimulates health behavior [22].
Healthcare providers can utilize PMT as a framework for developing educational interventions aimed at improving breast cancer screening behaviors among women [23]. In this regard, Hakim et al. suggest that healthcare providers develop PMT-based programs for the early detection of breast cancer among women in various community settings [24].
Considering that PMT has been extensively used as one of the best theories in behavioral sciences in various studies to explain behavior and identify the most significant influencing factors, and that its validity has been empirically confirmed in many health-related studies, this theory is utilized as the conceptual framework for this research. Conducting a theory-based educational intervention and selecting teachers according to their social and cultural status, who can play an increasing role in promoting community health, are innovations of the present study. This study aimed to determine the effect of an educational intervention based on protection motivation theory on the intention to undergo mammography in female teachers in Tehran.

Materials and Methods
Research design and participants
This interventional study was conducted on 250 teachers in District 4 of Tehran in 2024. The sample size was determined based on previous studies [25], with α=0.05, β=80%, a design effect of 10%, and considering a 10% incomplete questionnaire completion rate within each group, totaling 250 participants (125 individuals in each group). Sampling was carried out in multiple phases. According to the survey, there are 64 middle school girls’ schools in District 4 of Tehran. Initially, 24 schools were randomly selected using even and odd numbers. Then, using random number tables, 125 women over 40 years old from 12 schools were chosen as the intervention group, and 125 women over 40 from another 12 schools were chosen as the control group (10 women per school).
Inclusion and exclusion criteria
Inclusion criteria included the willingness of individuals to participate, physical and mental health, no history of cancer, and employment as teachers in middle schools. Exclusion criteria included individuals over 40 years of age with breast cancer, non-participation in educational sessions, a history of breast biopsy, and pregnancy during the study. After obtaining approval for the study design and receiving an ethics code, written consent was obtained from the study participants, assuring them of the confidentiality of their information. The implementation of this research took place from early December 2024 to the end of March 2025.
Data collection tools
Data were collected using a two-part questionnaire completed through interviews and self-reporting. The first part of the questionnaire contained demographic information, while the second part consisted of the Protective Motivation Questionnaire for Iranian Women’s Participation in Preventive Breast Cancer Behaviors, developed by Khodayarian et al. [26]. The questionnaire includes 56 items across 8 dimensions, including perceived susceptibility (8 items, e.g., “Because there is no history of breast cancer in my family, my chances of developing breast cancer are lower”), perceived severity (11 items, e.g., “If I develop breast cancer and my body does not respond to chemotherapy, the likelihood of death is high”), rewards (3 items, e.g., “I do not go for diagnosis and treatment of breast cancer because I will lose my beauty”), response efficacy (7 items, e.g., “If a mass in my breast is detected early through a doctor’s examination or mammography, I can be treated sooner”), self-efficacy (5 items, e.g., “I can schedule a mammogram”), response costs (16 items, e.g., “The mammography center is too far from my residence”), fear (5 items, e.g., “I don’t want to think about breast cancer because it reminds me of death”), and protective motivation (1 item, e.g., “What is your decision regarding undergoing a mammogram in the next month?”). All items, except for the motivational one (intent), are scored on a 5-point Likert scale ranging from strongly agree to strongly disagree. In the study by Kavosi et al., the reliability and validity of the questionnaire were confirmed [26].
Intervention
The educational program was conducted over four sessions of 60 minutes each at two-week intervals (Table 1). The content of the educational program included primary prevention methods, secondary prevention methods, and factors predisposing individuals to breast cancer. The training employed methods, such as lectures, question-and-answer sessions, group discussions, and feedback. Two months after the intervention, to assess the impact, a post-test was conducted for both the intervention and control groups, and participants in both groups completed the questionnaires once again. To maintain ethical considerations, the educational materials were provided to the control group after they had completed the questionnaires.

Table 1. Schedule and content of the educational sessions provided


Statistical analysis
The data analysis was conducted using SPSS version 26, employing descriptive statistics (mean, standard deviation, frequency) and independent t-tests, paired t-tests, chi-square tests, or Fisher’s exact test. The significance level was set at 0.05.

Findings
A total of 125 individuals were assigned to the intervention group and 125 to the control group (Table 2).

Table 2. Frequency of participants' demographic information according to study groups


In terms of education, spouse’s education, spouse’s occupation, age, marital status, having children, and having supplementary insurance, both study groups were homogeneous (p>0.05).

Table 3. Mean scores of protection motivation theory constructs in the intervention and control groups before and after the intervention


Based on the independent t-test results, the mean scores of the protection motivation theory constructs for both the intervention and control groups did not differ significantly before training (p>0.05; Table 3).
To compare the averages of the protection motivation theory constructs in the studied groups, after examining the assumptions of the analysis of covariance, this analysis was used (Table 4).

Table 4. Comparison of the mean scores of the protection motivation theory constructs in the intervention and control groups using analysis of covariance


Training based on the theory of protective motivation caused changes in the theoretical constructs and the intention to undergo mammography (Table 5).

Table 5. Comparison of intention to undergo mammography in the intervention and control groups after the intervention


Discussion
The present study investigated the effect of an educational intervention based on Protection Motivation Theory on the intention to perform mammography among female teachers in Tehran. In this study, the educational intervention improved the perceived susceptibility among participants in the intervention group. Correspondingly, Zahabi et al. and Mahboobighazaani et al. reported that after the intervention, there is a significant difference in perceived susceptibility between the intervention and control groups [27, 28]. However, Lwin reported that perceived susceptibility has a minor effect on the motivation to screen for breast cancer [29]. Pirzadeh et al. and Nazari et al. also reported that perceived susceptibility after the educational intervention does not show a significant difference between the intervention and control groups [23, 30]. The differences in findings from those studies may be due to varying intervention methods and educational content. Additionally, potential differences in participants’ demographic characteristics (age, education, socioeconomic status) and cultural contexts across studies might result in discrepancies in findings. In this study, data on breast cancer incidence and mortality among Iranian women in recent years were employed, based on the constructs of Protection Motivation Theory, to enhance perceived susceptibility. Women who believe they are at risk for breast cancer are more likely to engage in breast cancer screening behaviors. Therefore, increasing beliefs about breast cancer as a motivation for undergoing mammography is promising, and it is necessary to adapt educational materials to the culture and language while focusing on enhancing support for women [31].
The educational intervention improved the perceived severity construct among participants in the intervention group. Supporting this finding, Zahabi et al. reported that group counseling based on PMT leads to increased perceived severity in the intervention group for breast self-examination [27]. Additionally, Ghaffari et al. reported that perceived severity related to self-examination and mammography increases in the intervention group [32]. However, in the studies by Pirzadeh et al. [30] and Nazari et al. [23], perceived severity after the educational intervention does not show significant differences between the intervention and control groups [30]. Perceived severity can act as a double-edged sword; in other words, when perceived severity is high, denial or non-acceptance of preventive behaviors may occur [28]. The results suggest that if individuals seriously understand the illness and its consequences, they will engage in preventive behaviors. In this study, the use of images and videos of patients with advanced breast cancer increased the perceived severity in the intervention group.
The educational intervention also improved perceived self-efficacy among participants in the intervention group. There is a direct and significant relationship between breast cancer screening behaviors and perceived self-efficacy [23]. Ghaffari et al. [32] and Pirzadeh et al. [30] also report a significant increase in self-efficacy scores among participants in the intervention group.
Response efficacy is significantly related to breast cancer screening [33]. Consistent with the findings of this study regarding the improvement of perceived efficacy, the results of Chen & Yang showed that women receiving messages containing high efficacy have the highest intention to perform breast self-examination [34].
After the educational intervention, the response cost construct was reduced among participants in the intervention group. There is an inverse statistical relationship between breast cancer screening behaviors and perceived costs [23]. In line with these findings, Ghaffari et al. reported that theory-based education for health volunteers reduces barriers to breast self-examination and mammography in the intervention group [32]. Contrary to our findings, in the study by Pirzadeh et al., participants’ perceived barriers to undergoing mammography do not decrease post-intervention [30]. This discrepancy may stem from differences in study participants regarding demographic factors and their socioeconomic status. In this regard, Pirzadeh reported that the high cost of mammography, due to the lack of free services in the health system, is often considered a barrier for individuals, for which there is unfortunately no solution. Additionally, it can be said that in this study, the strategies used in the educational sessions (question-and-answer and brainstorming) led to the articulation of barriers by participants and provided suitable solutions to overcome them.
The educational intervention significantly improved perceived rewards among participants in the intervention group. Supporting this finding, several studies have reported an increase in perceived benefits from breast cancer screening following the educational intervention among women participating in the intervention group [27, 28, 32].
Women’s fears and health beliefs impact their participation in early breast cancer detection approaches [35]. The fear construct was improved among participants in the intervention group. Additionally, according to Ghofranipour et al., women who report higher levels of fear are more likely to regularly perform breast self-examination [33]. There is also a significant relationship between self-efficacy for undergoing mammography and fear of breast cancer [36]. Multiple factors affect the effectiveness of fear appeals, including individual personality, norms, fear strength, perceived threat, and perceived response efficacy. Fear appeals can influence women’s attitudes and behavioral intentions, but not necessarily the early detection of breast cancer [37]. In the study by Emami et al., fear of breast cancer does not have a significant effect on women’s mammography screening [38]. Differences in the demographic characteristics of the study population may explain this discrepancy.
An educational intervention based on protective motivation theory significantly increased the intention to undergo mammography among female teachers. This finding is consistent with the studies by Lee et al. [39] and Ghaffari et al. [32]. Therefore, it can be concluded that interventions based on educational models promote self-care, create a foundation for improving breast cancer screening behavior in women, and increase the awareness and efforts of policymakers to enhance breast cancer screening behaviors.
One of the strengths of this study is the focus on teachers, who, as role models for students, can play an important role in promoting community health by transferring the information learned in educational sessions to students and their parents. These findings can be utilized by other researchers, especially in developing countries with similar socioeconomic statuses.
Given that self-reported information is not an objective measure for assessing individuals’ beliefs, convictions, and abilities, and is not available to the researcher, some individuals may have refused to provide truthful answers and instead given unrealistic responses. The inability to measure behavior (i.e., undergoing mammography) due to the limited follow-up time is another limitation of this study.
Our results demonstrated the pivotal role of the protective motivation theory constructs in explaining the intention to undergo mammography among female teachers. These findings, while confirming the effectiveness of this theory in health promotion research, provide a specific scientific basis for designing targeted interventions. Health planners and policymakers can use these insights to optimize breast cancer screening strategies and promote women’s active participation by strengthening protective motivational factors. This, in turn, will lead to early detection, improved treatment outcomes, and enhanced general health and quality of life for this target group. An educational intervention based on this theory is proposed for screening other diseases in different communities.

Conclusion
The educational intervention using protection motivation theory is effective in increasing women’s intention to participate in breast cancer screening programs and undergo mammography.

Acknowledgments: The authors would like to thank all participants for their cooperation and involvement throughout the study.
Ethical Permissions: This article is part of a master’s thesis in health education and promotion, approved by the Ethics Committee of Kurdistan University of Medical Sciences, Iran, under the ethics code IR.MUK.REC.1403.200. All methods were performed in accordance with the Declaration of Helsinki. After explaining the research objectives, written informed consent was obtained from all participants, who were also informed about the confidentiality of their data.
Conflicts of Interests: the authors reported no conflicts of interests.
Authors' Contribution: Hossainzadeh S (First Author), Introduction Writer/Methodologist/Main Researcher (35%); Bahmani A (Second Author), Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (35%); Nili S (Third Author), Methodologist/Assistant Researcher/Discussion Writer/Statistical Analyst (20%); Fallahi A (Fourth Author), Methodologist/Assistant Researcher/Discussion Writer (10%)
Funding/Support: No funding was received.
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Health Education and Health Promotion
Volume 13, Issue 2
Spring 2025
Pages 289-296