Application of the Health Action Process Approach Model in Predicting Mammography among Iranian Women

Background: This aim of this study was examining the application of the Health Action Process Approach Model (HAPA) in predicting diagnostic mammography among women over 40 years old in Iran. Methods: This was a cross-sectional study that was performed on four hundred women over 40 years old in health centers in Tehran between May to September 2017. The multi-stage cluster sampling were selected for sample research. The instrument was designed on based literature review about Health Action Process Approach (HAPA). Data were collected by self-report questionnaires and analyzed using statistical tests, t-test, correlation regression analysis. The predictors of diagnostic mammography were determined by the structures of the HAPA model. Results: The result regression analysis showed the diagnostic mammography behavior prediction rate, using the structures of the HAPA model was generally 60%. Conclusions: This study showed the effectiveness of the HAPA to predict diagnostic mammography in women over 40 years old. So, it seems examining mammography behavior and individuals' beliefs about breast cancer based on HAPA model is important in order to development of training programs and effectiveness interventions for breast cancer prevention.


Background
Breast cancer is one of the most prevalent disease with high incidence in recent years. It is an important health problem across the word, especially in Iran (1,2) and the latest national databases showed the age-standardized rate for breast cancer is 33.21 per 100,000 (2). In study of Akbari and et al (3) the means of age morbidity in Iranian women is 5 years earlier compared to women from developed countries and the fth leading cause of death from cancer disease is breast cancer in Iran (14.2% of death) (2). The early detection strategies for breast cancer in women, include performing clinical examination and mammography. The most effective screening method for breast cancer among asymptomatic women is mammography (4). The researches have shown mammography decreases the rate of deaths from breast cancer about 20-30% in women 40 years and older (5). It seems factors such as lack of participation in the breast cancer screening programs, late presentation for diagnosis and treatment, insu cient diagnostic and treatment facilities are causing high mortality rate in these regions. In order to effective breast cancer screening programs in decreasing the mortality rate, It has to capture both high participation and detection rate of breast lesions (6).
The results of previous literature showed despite the possible advantages of mammography screening for breast cancer prevention, there is a low level of implementation and ethnic and familial variations in breast cancer screening among women (less than 1-44%) (7,8). Since the mammography can be a very early diagnosis of breast cancer, allows on time treatment and it can enhance women's chance of survival and promoting their quality of life (9).
Various studies have shown that suitable educational intervention can be a predisposing factor for mammography practice, and can increase the level of women's knowledge, attiudes and practice about breast cancer and early detection. In health education; using theories of health behavior to interventions is recommended (10) because they can lead to effective health education programs. In fact, the models offer a framework for understanding how people learn and how they practice and why people practice as they provide (11). The health action process approach (HAPA) is a universal theory was developed for assessing the health promoting behaviors in 1992, especially those pertaining to breast cancer. This theory has two phase change behavior that may make different social cognitive predictors (12).
According to the views of Schwazer the HAPA has two layers: a continuum and stage layer. The HAPA model suggested a difference between pre-intentional motivation processes that leads to a behavioral intention and post-intentional volition process the leads to the real health behavior. There are different patterns of social-cognitive predictors in this model (Fig. 1). In the rst motivation phase assumed to be a person extend an intention to act, and this phase risk perception is seen as a distal antecedent. They are important during the motivation phase when a person balances the advantages and disadvantages (pros and cons) of certain behavioral outcomes. In addition, one needs to task self-e cacy that it is the belief's individual about one's ability to perform a behavior. Task self-e cacy in adapting with positive outcome expectancies signi cantly contribute to the formation of an intention. This structure is intended to preintender category. After organizing an intention has entered the volitional phase. In this phase, a person has 'good intention' to be transformed into detailed instructions on how to accomplish the desired practice. The post-intentional phase included planning, action control, recovery self-e cacy.The HAPA model provides a better behavior prediction and re ects a causal mechanism of behavior change (13).
Therefore, this paper aims to report application of the HAPA model in predicting diagnostic mammography among women over 40 years old in Iran.

Method
This was a cross-sectional study that was performed on four hundred women over 40 years old in health centers in Tehran between May to September 2017. The participants were registered women 40 years and older in urban health centers. In total, 410 questionnaires were distributed, but the nal sample consisted of 400 women (response rate = 97.56%). The sampling method was the multi-stage cluster. In the rst step, three health networks (North, East, Shemiranat) were randomly selected from 10 health networks at Shahid Beheshti University of Medical Sciences of Iran (SBMUS). Next, for each network were randomly selected ve urban health centers). Then, 400 women over 40 years old were randomly selected according to the inclusion and exclusion criteria in this study. The subjects informed regarding the risks and bene ts of the study, and completed consent form. The instrument was included a demographic information and self-reported questionnaire based on structures of HAPA in mammography behavior. It was consisted 48 items using a 5-point Likert-type response scale anchored by 1, de nitely disagree, and 5, de nitely agree where higher scores indicate the better status of responder in that scale toward mammography. Items speci cally devised to assess mammography related perception (Table 1).  (28)  Maintenance self-e cacy The con dence of the individuals regarding their ability to undergo mammography even if they were blocked by some barriers was measured (30,31). The participants' convictions were measured to see if they could recover by themselves after failing in mammography behavior (14).
Recovery selfe cacy The participants' convictions were measured to see if they could recover by themselves after failing in mammography behavior. The women were asked to respond to the following statement regarding their con dence about the ability to return to mammography even after quitting this behavior.

Results
The women's age range was 40-65 years with a mean age of 45.6 years (SD = 5.45 years). The educational background of 37.2% women was less than high school. The majority (88%) women were married. Overall, 20% of the participants had positive history breast cancer in the family. The other characteristics of participants are displayed in Table 2 and Table 3 shows mean ± SD of HAPA structure.
The result of Pearson correlation indicated there is no signi cant correlation between people's age, risk perception, outcome expectancies, action control, coping planning, maintenance self-e cacy and recovery self-e cacy; However, Pearson correlation coe cient showed a signi cant correlation between the means of people's age and task self-e cacy (r = 0.17, p < 0.01) and this variable and action planning (r = 0.16, p < 0.01). In order to examine the structures of HAPA in mammography behavior used Pearson correlated. The nding showed there was a signi cant and strong correlation between action and coping planning (r = 0.75, p < 0.01). Also, there was signi cant correlation between action planning (r = 0.33, p < 0.01) and coping planning (r = 0.25, p < 0.01) and mammography behavior (Table 4).   Table 4 The correlation matrix of the structures of (HAPA) in the mammography behavior of participants The regression analysis showed the structures of HAPA_ risk perception, outcome expectancies, task selfe cacy, action control, action planning, recovery self-e cacy_ were predictors of mammography behavior. The estimated regression analysis indicated that HAPA model accounted for 60% of the variance in mammography behavior (Table 5).

Discussion
In this study, was applied the health action process approach (HAPA) using the concept of Schwarzer's model (14) to understand mammography behavior among women over 40 years old. There is a little research that used HAPA model to explain mammography behavior in women and it seems this study is the initial research on the application of HAPA in Iranian women and provides new evidence about using behavioral theories in breast cancer research in this country and other developing countries. This current study suggested mammography intention and recent mammography were related to HAPA factors. The nding of our study is consistent with a number of related studies (13)(14)(15). According to HAPA theory perceiving greater risk perception and outcome expectancies to health risks, and having more task selfe cacy and action control and action planning, encourage intentions and/or behaviors.
The results showed that 97% of subjects had no information about mammography while 3% of them had appropriate knowledge. In other studies conducted in Iran, there are low levels of knowledge about breast cancer and detection methods (16). In our study, the reason for the lack of knowledge was the low education levels in the most participants. The results showed there was no signi cant relationship between education levels and mammography practice in contrast, in the study of Doqham and et.al (17) there was a signi cant relationship between education level and mammography behavior.
The results indicated 93% of participants have not intention for mammography doing and the fear of breast cancer was the most important reason for not having a mammography. In this study, there was the negative and signi cant association between age and mammography behavior; so that younger women did more mammograms (r= -0.1, p < 0.01). This nding con rmed by Sadatjediarani and et.al study (18) and study by Victoria Champion (19). It seems younger women had a lower barrier to mammography.
Our ndings suggested task self-e cacy, risk perception and outcome expectancies had different predictors and effects.While in the study by Murphy (10) barriers were factors that had different predictors and effects. Overally, understanding of mammography in this study was about 3% which in research of Aminisani and et.al (7) reported 17%. Furthermore, it reported lower in other study (20,21). In this study, mammography behavior was not higher among women with positive history of breast cancer in family, while other study reported opposite ndings (22). Consistent with other studies (23), task selfe cacy was related to individual's motivation to predict mammography and it suggested self-e cacy can be arranged by the care provided to increase women's participation in mammography screening program.
In the current study, risk perception was an effective factor in mammography behavior. This result con rmed in the study by Nichole A.Morman and et.al (24) so that women's risk perception about cancer was signi cantly associated with more remember of recommendation for breast health care. In other research, risk perception affects the application of early diagnostic methods, personality high risk perception increases the frequency of mammography (25,26).
The ndings indicated mammography behavior is low in women of Tehran, and signalized the need for performing a comprehensive educational intervention and it should be considered as an important priority for health policy makers and providers.
Another barrier for doing mammography is the lack of facilitators, which need to be included in the process of developing breast cancer screening program as the essential and basic foundation. In the present study, some in uential factors identi ed that may help to design and provide an appropriate educational intervention for target women. We recommend more research to identify potential barriers to participating in screening in such areas. Finally, it must be noted that one of the issues concerned with breast cancer detection behavior is the concept of health in different cultures.
There are several limitations of this study. First, as regards the data were gathered by cross-sectional and self-report, in which participants may report practice higher than the real amount. Secondary, applying convenient sampling causes ndings of this study not to be generalized to all Iranian women. This study provides why it is believed that determining the effects of the HAPA on mammography must be multifaceted. Despite these limitations, this study was the rst application HAPA as a theoretical framework to predict mammography behavior in Iran.

Conclusion
Page 10/13 The ndings of this study supported from theory-based interventions to encourage women's breast cancer screening. Lastly, the strength of this research is that it may be used as a guide to examine mammography behavior in women in other countries.

Declarations
Ethics approval and consent to participate  Figure 1 The Diagram of Health Action Process Approach (32). The HAPA framework builds on social cognitive theory (SCT), It is distinguished two stages of behavior change: motivation, and maintenance phase. The basic assumption HAPA is that motivation is a necessary position for behavior change, but goal-setting and action planning are needed for the change to actually occur. The self-e cacy play a key role throughout the process of behavior change.