|Year : 2020 | Volume
| Issue : 1 | Page : 146
Effect of educational program based on the theory of planned behavior on prostate cancer screening: A randomized clinical trial
Hesam Rezaei1, Reza Negarandeh2, Shahzad Pasheypoor1, Anoshirvan Kazemnejad3
1 Department of Community Health and Geriatric Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
|Date of Submission||17-Apr-2019|
|Date of Acceptance||14-Oct-2019|
|Date of Web Publication||10-Sep-2020|
Department of Community Health and Geriatric Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background and Aims: Prostate cancer screening applied for early diagnosis of prostate cancer. But it is not usually pursued by men. This study was conducted to determine the effect of educational program based on the Theory of Planned Behavior (TPB) on prostate cancer screening. Methods: A randomized clinical trial was carried out on 68 middle-aged men referring to community houses in Iran. Samples were selected consecutively considering the inclusion criteria. Then block randomization was used to assign the participants into two groups. Data collection included demographic characteristics, knowledge and construct of TPB (Attitude towards the behavior, Subjective norms, Perceived behavioral control, behavioral intention) and behavior. The participants in the intervention group attended a theory based program 4 session twice per week. The participants were evaluated before and two month after the intervention. P <0.05 was considered statistically significant. Results: After the 2 months intervention, the pretest-posttest changes in the intervention group compared to the control group were in the Knowledge 9.26 ± 3.5 vs. 0.03 ± 1.68, Attitude 11.46 ± 3.5 vs. -0.16 ± 1.39, Subjective norms 3.16 ± 2.6 vs. 0.29 ± 1.3, Behavioral control 6.76 ± 4 vs. 0.12 ± 1.60 and Behavioral intention 1.4 ± 1.54 vs. 0.00 ± 1.00 (P < 0.05). While none of the subjects in control group performed the prostate screening, 10 people (33.2%) performed it in the intervention group. (P < 0.001). Conclusions: Educational program based on TPB has a positive effect on prostate cancer screening. It is recommended to set up regular training programs based on TPB to encourage middle-aged men for prostate cancer screening.
Keywords: Early detection of cancer, prevention and control, prostate neoplasms
|How to cite this article:|
Rezaei H, Negarandeh R, Pasheypoor S, Kazemnejad A. Effect of educational program based on the theory of planned behavior on prostate cancer screening: A randomized clinical trial. Int J Prev Med 2020;11:146
|How to cite this URL:|
Rezaei H, Negarandeh R, Pasheypoor S, Kazemnejad A. Effect of educational program based on the theory of planned behavior on prostate cancer screening: A randomized clinical trial. Int J Prev Med [serial online] 2020 [cited 2021 Jan 24];11:146. Available from: https://www.ijpvmjournal.net/text.asp?2020/11/1/146/294695
| Introduction|| |
Prostate cancer is one of the leading causes of cancer related death in men. Prostate cancer is the 8th cause of death due to cancer in Iran. The incidence and mortality of prostate cancer have had an increasing trend in men.,, Factors such as increased age, genetics, low physical activity and obesity, environmental factors, ethnicity, family history, diet, unhealthy lifestyle, chronic prostatic inflammation or infection, behavioral factors like alcohol consumption, UV exposure, and occupational exposures may contribute to the progression of this cancer.,,,
Evidence showed that prostate cancer lowers the quality of life and causes tension for patients and their families and places a huge financial burden on the patients and health care system.,, Therefore, screening tests should be applied for early diagnosis and management of prostate cancer since early diagnosis is associated with increased odds of survival in prostate cancer patients.,, The goal of screening for prostate cancer is to increase the chance of treatment through diagnosis of new cases in early stages.,, Center for Disease Control and Prevention (2018) has found that many men with prostate cancer never have experienced symptoms and, without screening, would never know they had the disease. Evidence shows that screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened.
Behavioral, psychological, biological, social, and cultural factors may facilitate participation in prostate cancer screening. According to the findings, the frequency rates of performing PSA and DRE are 21.6% and 5.7%, respectively, in Iran, showing an inappropriate condition. Prostate cancer screening is not usually pursued by men due to males are traditionally viewed as the stronger gender., The effectiveness of health education for change behavior depends on the skills of benefiting from appropriate theories.
The results of current interventions based on theories show that theories can positively affect prostate cancer preventive behaviors of individuals by improving their knowledge level and leaving positive effects on perceived susceptibility and severity as well as considering the perceived barriers, benefits and health motivations and self-efficacy, but the intention to behavior and engagement in that behavior is not clear.,, Therefore there is a need for the interventions based on theories that, in addition to promoting knowledge and attitude, can lead to tangible change in behavior. The theory of planned behavior (TPB), an extension of the theory of reasoned action, is widely applied to predict adoption of health behaviors.,, According to TPB, the intention to behavior is a direct predictor of engagement in that behavior. Intention in turn is predicted by a person's attitude towards the behavior, subjective norms, and perceived behavioral control. The attitude toward behavior is defined as the degree to which the person treats the behavior as positive or negative. The subjective norms means social perceived pressure to engage or not to behave. Finally, perceived behavioral control means perceived ability to conduct a successful behavior., The TPB has been used successfully to predict and explain a wide range of health behaviors and intentions. The TPB states that behavioral achievement depends on both motivation (intention) and ability (behavioral control).
Many studies have used TPB as a theoretical framework in order to behavioral change that led to effective change in their participant's behavior.,,,, However, studies that show the effect of educational interventions based on theories for changing behavior in screening prostate cancer were not observed.
Considering the increasing trend of prostate cancer in the world and the effective role of correct screening in early detection and management of these patients, it is necessary to reflect on this problem and design educational interventions based on appropriate models. Therefore, this study was conducted to determine the effect of educational program based on the TPB on prostate cancer screening behavior in middle-aged men.
| Methods|| |
This randomized clinical trial was of pre-test-post-test design, conducted to determine the effect of education based on the theory of planned behavior on prostate cancer screening behavior in middle-aged men.
Participants and randomization
The research population was all middle-aged men (30-59 years of age) referring to community houses in Tehran. Community houses is a place where the neighbors are gathered there for education, recreation and social activity. It was located in the center of the neighborhood and was easily accessed by all residents.
The sample size was calculated using the difference between two proportions formula, with 95% confidence level, 90% statistical power, and P1-P2 = 0.35; Considering 10% attrition rate the sample size was 34 men per group. In current study, doing Prostate Cancer Screening was primary outcome and other variables (Knowledge, Attitude, Subjective norms, behavioral control, and behavioral intention) were secondary outcome. Therefore, the sample size was calculated based of difference in proportion.
Of the 75 eligible participants, 6 participants declined and one of them excluded due to relocation. Sixty-eight individuals were selected consecutively considering the inclusion and exclusion criteria. The selected samples were randomly assigned to intervention (n = 34) and control groups (n = 34) using blocked randomization with a block size of 4 until the required sample size was achieved. The inclusion criteria were age 45-59 years, lack of a history of participation in similar educational programs; no having a history of screening for prostate cancer until now; lack of severe mental and physical disorders and exclusion criteria were non-participation in two consecutive sessions and withdrawal from the study.
Data collection tools were demographic characteristics, knowledge of prostate screening and questionnaire with TPB constructs (Attitude towards the behavior, Subjective norms, Perceived behavioral control, behavioral intention) and behavior.
- Demographic characteristics questionnaire: It includes age, the education level, income, and number of family members, diseases, history of medication, general health status and history of prostate cancer in family
- Knowledge of prostate cancer and screening questionnaire: The 2nd questionnaire was applied to assess the knowledge of prostate cancer and screening for it (12 questions). A correct answer scored 2 and an incorrect answer scored 0. Score 1 was assigned to “I don't know”. The total score of the questionnaire ranged from 0 to 24, with higher scores indicating higher levels of knowledge.
- TPB constructs questionnaire: The 3rd questionnaire contained questions on TPB constructs, including attitude (13 Item), Subjective norms (6 Item), behavioral control (9 Item) and behavioral intention (2 item), Performing the behavior was 1 Item. The score of the sections of attitude, subjective norms, behavioral control, and behavioral intention ranged from 0 to 52, 0 to 24, 0 to 36, and 0 to 8, respectively, with higher scores indicating higher levels of attitude, subjective norms, behavioral control, and behavioral intention. This scale was scored from 0 (strongly disagree) to 4 (strongly agree). A yes-no answered question was developed to measure prostate screening in the last two months (I did screening tests for prostate cancer.).
Face and content validity of the tool was evaluated by 10 faculty members and experts in the field of TPB and S-CVI (Scale-Content Validity Index) was determined 0.98. For reliability according to the test-retest method, the score of knowledge questionnaire and attitude, subjective norms, behavioral control, and behavioral intention (TPB constructs) was 0.83, 0.95, 0.88, 0.95, and 0.9, respectively, which were acceptable. The Cronbach's alpha of the knowledge, attitude, subjective norms, behavioral control, and behavioral intention was 0.7, 0.84, 0.85, 0.84, and 0.9, respectively, which were satisfactory and acceptable.
After obtaining written informed consent, a pre-test was first administered in the both groups. The participants in the intervention group attended a theory based program include 4 session about 120-minute twice per week. Intervention were information about anatomy and structure of prostate gland, its function, common diseases, symptoms and complication of it, risk factors, prevention strategies of prostate cancer, screening exams, cost of it and how to do a screening test. All sessions were conducted based on improvement of knowledge and based on TPB constructs (attitude, subjective norms, behavioral control and behavioral intention). Educational methods were selected according to model constructs. Small groups were formed, group discussions and question and answer were conducted to promote knowledge and attitudes. Participants actively expressed their experiences and discussed their beliefs in these program. To intervention for subjective norms, since it was not possible to access a large number of key relatives of the participants in person, telephone calls were used to contact them two times during the intervention. Of the 30 participants, 10 key relatives (Significant others) were not willing to be involved in a conversation regularly or were not available. Of 20 key relatives, 15 were wives and 5 were children who participated regularly in telephone conversations. Each conversation was about 15 minutes. They were taught about the importance of prostate cancer screening, and they were asked to encourage participants to cancer screening. After intervention, Posttest was applied two months after the last interventional session. At this stage, it was asked about performing prostate screening in the last two months. Conforming to research ethics, at the end of research, the participants of both groups were given an educational booklet about prostate cancer and importance of screening it.
The Ethics Committee of Tehran University of Medical Sciences approved the study (ethics code: IR.TUMS.FNM.REC.1395.1124) and the study was registered in the Iranian Registry of Clinical Trials (IRCT2016112631118N1). They were also assured of the data confidentiality. Informed consent was obtained from all participants prior to the study.
Descriptive statistics, including frequency distribution, mean, standard deviation, median, and interquartile range, and inferential statistics such as chi square, independent t test, Mann-Whitney test, paired t test and Fisher's exact test were applied to analyze the data. The normality of the quantitative variables was checked using the Kolmogorov-Smirnov test. Some variables (Attitude, behavioral control and behavioral intention in the before intervention and knowledge, behavioral intention after intervention) were not normally distributed (P < 0.05). Therefore, we used median and interquartile range instead of mean and standard deviation. P <0.05 were considered statistically significant. All statistical analyses conducted using the Statistical Package for Social Science version 18 (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
The number of samples in each group was 34 subjects. But 4 subjects of the intervention group and 3 subjects of the control group were excluded because they were very busy and unwillingness to continue the study. Finally, data analysis was done with 61 subjects [Figure 1].
The distribution of demographic variables in the study population shows in [Table 1]. There was no significant difference in demographic variables between intervention and control groups and two groups were homogeneous.
|Table 1: Comparison of demographic variables in the intervention (n=30) and control (n=31) groups.|
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There was no significant difference between the two groups before the intervention. However, a significant difference in the score of these variables was observed between groups after the intervention (P < 0.05). After the 2 months intervention, compared with the control, Knowledge (42 ± 7.25 vs. 28 ± 13, P < 0.001), Attitude (41.6 ± 5.12 vs. 30.06 ± 7.6, P < 0.001), Subjective norms (14.9 ± 3.1 vs. 10.94 ± 4.1, P < 0.001), Behavioral control (25.33 ± 5.4 vs. 18.19 ± 6.2, P < 0.001) and Behavioral intention (6 ± 4 vs. 4 ± 3, P < 0.019) (Knowledge and Behavioral intention are based on median ± IQR). Also, the pretest-posttest changes in the intervention group compared to the control group were in the Knowledge 9.26 ± 3.5 vs. 0.03 ± 1.68, Attitude 11.46 ± 3.5 vs. -0.16 ± 1.39, Subjective norms 3.16 ± 2.6 vs. 0.29 ± 1.3, Behavioral control 6.76 ± 4 vs. 0.12 ± 1.60 and Behavioral intention 1.4 ± 1.54 vs. 0.00 ± 1.00 (P < 0.05) [Table 2].
|Table 2: Comparison of the mean/median and interquartile range score of the middle-aged men's knowledge, attitude, subjective norms, behavioral control and behavioral intention before and after intervention in the intervention and control groups.|
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According to [Table 3], there was no change in performing the behavioral in the control group after the intervention while it have done by 10 subjects (33.2%) in the intervention group. Fisher's test showed a significant difference in performing the behavior between intervention and control groups after the intervention (P < 0.001).
|Table 3: Comparison of the frequency (%) score of the middle-aged men's behavior (Prostate Cancer Screening) after intervention in the intervention and control groups.|
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| Discussion|| |
This study was conducted to evaluate the effect of education based on the theory of planned behavior on prostate cancer screening in middle-aged men. The results showed that education based on TPB has a positive effect on the constructs of this model, enhancing prostate cancer screening, and performing these tests in middle-aged men.
A significant change in the median score of knowledge in the intervention group indicated the effectiveness of intervention in knowledge improvement. Many studied showed the impact of an intervention based on TPB on knowledge of behavioral.,,, Implementation of a health education intervention as an effective way to enhance levels of knowledge and promote positive health perceptions regarding colorectal cancer and screening recommendations.
In present study, the educational intervention could improve the attitude towards screening and diagnostic tests. The results of a some studies showed same results.,
We found significant difference in the mean score of subjective norms between intervention and control groups after the intervention (P < 0.001). Although access to key persons was not satisfactory and their participation in the educational sessions was not possible, it was tried to contact them by telephone and distribute educational pamphlets for family members and relatives to modify subjective norms. Moreover, the researcher, as an influential person (health care provider) had a direct effect on subjective norms through education and improved this construct via encouraging the participants to take informed actions. In this regard, the results of a study by Williams et al. (2015) on promoting walking through education based on the TPB showed significant difference in the mean score of subjective norms between the two groups immediately, 6 weeks, and 6 months after the intervention. Motivation and education by healthcare workers are important factors for increasing cancer screening rates. The association between education and cancer screening behavior may be moderated by social support. Practitioners and researchers should focus on interventions that activate social support networks as they may help increase cancer screening compliance.
The results showed a significant increase in the mean score of behavioral control in the intervention group. It seems that the intention to perform screening behaviors becomes stronger in men when they have more knowledge about prostate cancer and its screening, develop a positive attitude towards controllability of cancers upon early detection, feel capable of doing these behaviors, and believe they can control environmental factors, which results in improved health-seeking behaviors. Different methods were used to improve behavioral control in men, including education about screening and diagnostic tests, costs of examinations and tests, guidelines of credible organizations and associations on screening for prostate cancer, facilitative and preventive factors (economic, cultural, and social barriers). Duangpunmat et al. (2013) also reported similar findings. Perceived behavioral control depend on society and culture. So, culturally-tailored education program is effective in improving knowledge, attitudes about and intentions to participate in cancer screening. It is important that culturally-tailored programs are developed in conjunction with communities to improve health outcomes.,,
The results of our study also showed a significant increase in the mean score of intention in the intervention group. According to the structure of theory of planned behavior, an educational program affecting the constructs before intention will eventually leave its effects on intention, as well. According to TPB, a behavior occurs following intention, and intention to do a behavior has the highest correlation with performing the behavior. In present research, subjects who had the strongest intention performed the behavior (cancer screening), indicating that performing a behavior is most probable in subjects who have the highest intention. Education based on TPB improves behaviors related to prostate cancer screening, including counselling, examinations, and diagnostic tests for early detection of prostate cancer (like physical examination and blood test). This finding is consistent with the results of many studies.,,, When educated individuals are better informed, they are more likely to incorporate variation in risk factors. when they report their personal cancer risk, and as risk varies, the better educated will react more strongly by adopting preventive behaviors such as cancer screening. Therefore, change behavior theories can be used as an interventional program to improve cancer screening.
But limitations of this study include low level of literacy and lack of completeness of questionnaires by some of the participants, as well as behavioral evaluation by self-report method, which can be a factor in misrepresentation of data. The main limitation of the study was the lack of placebo in control group. But, one of the strengths of the study is the study design that has been done according to the CONSORT Statement. The study also focused on current men's need for prevention of prostate cancer, which is now one of the health priorities. Also, the theory-based interventions can help assess the theory in solving health problems.
| Conclusions|| |
Proper education about prostate cancer screening, a prevalent cancer in men, in a planned manner can result in many positive outcomes, correct and develop positive attitude and beliefs, and facilitate decision-making in ambiguous situations. Health care providers as key members in the education and health services system are in a good position to address this issue through interventions. Hence it is recommended that nurses and primary health care providers set up regular training programs to encourage middle-aged men for cancer screening. Health policy-makers can take an important step in promoting awareness and behaviors through modeling these outcomes and developing theory-based programs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
The results presented herein were extracted from the thesis written by Hesam Rezaei (ethics code: IR.TUMS.FNM.REC.1395.1124).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brawley OW. Prostate cancer epidemiology in the United States. World J Urol 2012;30:195-200.
Almasi A, Shamsi M, Eshrati B, Javaheri J, Salimi Alast S, Ghasemi Z, et al
. Epidemiology of prostate cancer in Markazi province in 2005-2010. J Neyshabur Univ Med Sci 2014;2:1-8.
Rafiemanesh H, Enayatrad M, Salehiniya H. Epidemiology and trends of mortality from prostate cancer in Iran. J Isfahan Med Sch 2015;33:515-21.
Rafiemanesh H, Ghoncheh M, Salehiniya H, Mohammadian HA. Epidemiology of prostate cancer and its incidence trends in Iran. J Sabzevar Univ Med Sci 2016;23:320-7.
Blocker DE, Romocki LS, Thomas KB, Jones BL, Jackson EJ, Reid L, et al
. Knowledge, beliefs and barriers associated with prostate cancer prevention and screening behaviors among African-American men. J Natl Med Assoc 2006;98:1286-95.
Leitzmann MF, Rohrmann S. Risk factors for the onset of prostatic cancer: Age, location, and behavioral correlates. Clin Epidemiol 2012;4:1-11.
Pakzad R, Mohammadian-Hafshejani A, Ghoncheh M, Pakzad I, Salehiniya H. The incidence and mortality of prostate cancer and its relationship with development in Asia. Prostate Int 2015;3:135-40.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7-30.
Di Sarra L, Ghezzi V, Eastland TY, Antonini F, Scialó G, Zega M, et al
. Applying the theory of planned behavior to explain women's role in prostate cancer screening. Res Theory Nurs Pract 2015;29:200-13.
Hosseini M, Jahani Y, Mahmoudi M, Eshraghian M, Yahyapour Y, Keshtkar AA. The assessment of risk factors for prostate cancer in Mazandaran province, Iran. J Gorgan Univ Med Sci 2008;10:58-64.
Kenerson D. Use of the theory of planned behavior to assess prostate cancer screening intent among African American Men (Doctoral dissertation, Vanderbilt University). Vanderbilt University; 2010.
Sieverding M, Matterne U, Ciccarello L. What role do social norms play in the context of men's cancer screening intention and behavior? Application of an extended theory of planned behavior. Health Psychol 2010;29:72-81.
Moyer VA. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. Ann Intern Medi 2012;157:120-34.
Centers for Disease Control and Prevention, Prostate Cancer Screening; 2018.
Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J. Prostate-specific antigen-based screening for prostate cancer: A systematic evidence review for the US preventive services task force. JAMA 2018;319:1914-31.
Odedina FT, Campbell ES, LaRose-Pierre M, Scrivens J, Hill A. Personal factors affecting African-American men's prostate cancer screening behavior. J Natl Med Assoc 2008;100:724-33.
Khosravi V, Barati M, Moeini B, Mohammadi Y. Prostate cancer screening behaviors and the related beliefs among 50-to 70-year-old men in Hamadan: Appraisal of threats and coping. J Educ Community Health 2018;4:20-31.
Friedman DB, Corwin SJ, Dominick GM, Rose ID. African American men's understanding and perceptions about prostate cancer: Why multiple dimensions of health literacy are important in cancer communication. J Community Health 2009;34:449-60.
Ilic D. Educating men about prostate cancer in the workplace. Am J Mens Health 2013;7:285-94.
Soorand AH, Miri MR, Sharifzadeh G. Effect of curriculum based on theory of planned behavior, on components of theory in patients with hypertension. J Birjand Univ Med Sci 2015;22:199-208.
Zare M, Ghodsbin F, Jahanbin I, Ariafar A, Keshavarzi S, Izadi T. The effect of health belief model-based education on knowledge and prostate cancer screening behaviors: A randomized controlled trial. Int J Community Based Nurs Midwifery 2016;4:57-68.
Marashi T, Razaghi M, Khodakarim S, Balvayeh M. Surveying the awareness of male hospital staffs about prostate cancer screening in selected hospitals of Shahid Beheshti university of medical sciences in 2017. Paramed Sci Mil Health 2018;12:54-61.
Jeihooni AK, Kashfi SM, Hatami M, Avand A, Bazrafshan MR. The effect of educational program based on PRECEDE model in promoting prostate cancer screening in a sample of Iranian men. J Cancer Educ 2019;34:161-72.
Roncancio AM, Ward KK, Sanchez IA, Cano MA, Byrd TL, Vernon SW, et al
. Using the theory of planned behavior to understand cervical cancer screening among Latinas. Health Educ Behav 2015;42:621-6.
Ajzen I. Theory of planned behaviour questionnaire. Measurement instrument database for the social science. 2013:1-9. Retrieved from: www.midss.org.
Zhang J, Shi L, Chen D, Wang J, Wang Y. Using the theory of planned behavior to examine effectiveness of an educational intervention on infant feeding in China. Preventive medicine 2009;49:529-34.
Duangpunmat U, Kalampakorn S, Pichayapinyo P. An effect of walking exercise applying the theory of planned behavior in people at risk of hypertension. J Med Assoc Thai 2013;96(Suppl 5):S122-30.
Shakerinejad G, Baji Z, Tehrani M, Hajinajaf S, Jarvandi F. Effectiveness of an educational intervention based on the theory of planned behavior on the physical activities of high school female students. Payesh J 2017;16:511-20.
Williams SL, Michie S, Dale J, Stallard N, French DP. The effects of a brief intervention to promote walking on theory of planned behavior constructs: A cluster randomized controlled trial in general practice. Patient Educ Couns 2015;98:651-9.
Mirzaei-Alavijeh M, Ghorbani P, Jalilian F. Socio-cognitive determinants of the mammography screening uptake among Iranian women. Asian Pac J Cancer Prev 2018;19:1351-5.
Polit DF, Beck CT. The content validity index: Are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 2006;29:489-97.
Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence For Nursing Practice. Philadelphia: Lippincott Williams and Wilkins; 2012.
Hassanpour M, Delshad A, Alemi A. Effect of an educational intervention based on empowerment model on awareness, attitudes, self-esteem and self-efficacy of men in preventing prostate cancer. Prev Care Nurs Midwifery J 2014;4:9-18.
Zhu Y, Zhang Z, Ling Y, Wan H. Impact of intervention on breastfeeding outcomes and determinants based on theory of planned behavior. Women Birth 2017;30:146-52.
Abuadas FH, Petro-Nustas WJ, Abuadas MH. The effect of a health education intervention on Jordanian participants' colorectal cancer knowledge, health perceptions, and screening practices. Cancer Nurs 2018;41:226-37.
Compaore S, Ouedraogo CMR, Koanda S, Haynatzki G, Chamberlain RM, Soliman AS. Barriers to cervical cancer screening in Burkina Faso: Needs for patient and professional education. J Cancer Educ 2016;31:760-6.
Documet P, Bear TM, Flatt JD, Macia L, Trauth J, Ricci EM. The association of social support and education with breast and cervical cancer screening. Health Educ Behav 2015;42:55-64.
Cullerton K, Gallegos D, Ashley E, Do H, Voloschenko A, Fleming M, et al
. Cancer screening education: Can it change knowledge and attitudes among culturally and linguistically diverse communities in Queensland, Australia? Health Promot J Austr 2016;27:140-7.
Lee SY. Cultural factors associated with breast and cervical cancer screening in Korean American Women in the US: An integrative literature review. Asian Nurs Res (Korean Soc Nurs Sci) 2015;9:81-90.
Kwok C, Lim D. Evaluation of a culturally tailored education to promote breast and cervical cancer screening among Chinese-Australian Women. J Cancer Educ 2016;31:595-601.
Lange F. The role of education in complex health decisions: Evidence from cancer screening. J Health Econ 2011;30:43-54.
[Table 1], [Table 2], [Table 3]