The study revealed that the participants in the experimental group had an increased tendency to have BSE. In Turkey, the Ministry of Health recommends regular BSE every month as it is thought that individuals will have increased awareness of breast cancer with BSE. Previous studies found that different nursing practices have increased the rates of BSE [27, 28]. Research has shown that when women have higher levels of knowledge about breast cancer, their BSE behavior increases [29, 30, 31, 32]. Thus, the change in the rates of BSE in the women in the experimental group is an expected finding.
Our findings further revealed that the rate of CBE increased in the experimental group, which received the NNP. Previous studies including the HBM also reported an increase in the CBE rates of the participants [27, 30].
In addition, the post-test results revealed that the participants in the experimental group had higher mammography scores than those in the control group. Similar studies which applied the HBM reported that the mammography screening behaviors of women increased after the intervention [27, 32, 28]. One study conducted with refugee women showed that the patients who had the NNP intervention had higher mammography rates [12]. The higher mammography scores in the experimental group in our study can be attributed to the fact that, based on the National Cancer Screening Standards, the age limit in the study was minimum 40, and that there was a mobile mammography truck where the research was conducted and all the participants were accompanied to this mobile unit one by one. The mobile mammography unit facilitated access to the mammography device, which is thought to contribute to the high rate of mammography among the participants at the end of the study.
Based on the findings, the H1a hypothesis (Following the nursing attempts, the breast cancer screening behavior of the women in the experimental group will increase compared to the control group) has been accepted (Table 1).
After the intervention, the participants in the experimental group were found to have higher levels of perceived susceptibility sub-dimension median score. One study conducted with Syrian refugees in Jordan reported that low levels of perceived susceptibility affect women's breast cancer screening practices [33]. Previous studies also revealed that following the interventions based on the HBM, a significant increase was observed in the perceived susceptibility towards cancer [19, 27, 34, 35, 36, 37, 38]. Our study also revealed that the participants in the experimental group had higher levels of perceived susceptibility towards breast cancer after the intervention.
The median perceived severity score of the control group was found to be higher than that of the experimental group after the intervention. Previous studies conducted with Syrian immigrants revealed that perceived severity has an effect on women's breast cancer screening practices [8, 33]. On the other hand, some studies reported that perceived severity does not affect the beliefs of individuals regarding breast cancer early diagnostic practices [19, 37, 39]. It can be stated that the present study helped increase women’s practices for early diagnosis of breast cancer; however, women should be supported in terms of belief development.
The post-test health motivation median score of the experimental group was found to be higher compared to the pre-test score. Similar findings were obtained in the literature [5, 27, 40]. It can be stated that the NNP was very effective in raising the health motivation of the women about breast cancer, which is one of the goals of the NNP, and thus it can be widely used to increase the health motivation of immigrant women who are considered to be in the disadvantaged group.
The post-test results revealed that the Syrian women in the experimental group had higher perceived BSE benefits median score even in the fourth month after the intervention. Previous studies which applied various nursing interventions based on the HBM reported an increase in perceived BSE benefits scores of participants [34, 35]. One study conducted with immigrant Syrian women based on the HBM found that perceived BSE benefits decreased as the perceived barriers to BSE increased [5]. Our findings coincide with those in the literature and it can be stated that the NNP is effective in increasing the perceived BSE benefits.
The study revealed that after the intervention, the participants in the experimental group had a higher perceived BSE self-efficacy median score. Previous studies also showed that the participants in the experimental group had higher levels of BSE self-efficacy after the interventions based on the HBM [34, 35]. Our findings revealed that the NNP positively affected perceived BSE self-efficacy and attitudes of women in the experimental group.
Furthermore, the experimental group was found to have a higher perceived CBE benefits median score after the intervention. Previous studies conducted using the HBM revealed an increase in the perceived CBE benefits after the intervention [35, 37]. It can be stated that following the intervention, the beliefs and attitudes of women in the experimental group toward CBE were more positive than the control group.
It was found that the participants in the experimental group had a higher perceived mammography benefits median score after the intervention. It was revealed that perceived benefits directly supported the behavior of having mammography. This finding coincides with those in previous studies [39]. Studies revealed that following the HBM interventions, participants in the experimental group obtained a higher perceived mammography benefit score compared to the control group [19, 34, 35, 36, 41, 42]. A study conducted in Brazil showed that the NNP helped fill the time gap between encouraging patients to have mammography and following up patients until diagnosis [43]. Our findings coincide with those in the literature. The results suggest that individuals have more control over their own health with the HBM, and thus, public health nurses can safely use this model to protect the health of individuals.
Another finding of the study is that the participants in the experimental group had a lower perceived barriers to BSE median score after the intervention, while there was no change in the control group. This finding can be attributed to the fact that the NNP focuses on eliminating various barriers such as selection of screening methods and timing of screening in early diagnostic practices for cancer [44]. In addition, previous studies revealed that as a result of the HBM-based interventions, the mean perceived barriers to BSE score of the women in the experimental group decreased compared to the control group [5, 19, 37]. Our study also revealed that the NNP positively supported participants’ perceived barriers to BSE.
The inter-group analyses further revealed that the perceived barriers to CBE median score of the experimental group was lower than that of the control group. Studies which applied some nursing interventions based on the HBM within the scope of breast cancer screening revealed a significant decrease in the perceived barriers to early diagnostic practices score [19, 45]. It is thought that in our study, the NNP was effective in reducing perceived barriers to CBE in the experimental group.
In addition, the perceived barriers to mammography score of the experimental group decreased after the intervention. Similar to our study, previous studies also reported a significant decrease in the perceived barriers to mammography score in the experimental group [4, 5, 39, 42, 45]. Our study found that perceived barriers prevent people from having mammography.
Based on these results, the H1b hypothesis (Following the nursing interventions, a positive difference will occur in the health beliefs of the women in the experimental group about early diagnostic practices compared to the women in the control group) was accepted (Tables 2 and 3).
In the experimental group, mammography self-efficacy median score increased after the intervention. Similar results were obtained in previous studies conducted based on the HBM [19, 30, 38, 41]. Mammography is important in breast cancer screening. The increase in mammography self-efficacy levels may make it easier for nurses to detect breast cancer cases earlier. Thus, it is thought that it will both ensure the diagnosis of the disease before it progresses and contribute to minimizing the psychological and material damage.
Considering this finding of the study, the H1c hypothesis (Following the nursing interventions, the mammography self-efficacy scores of the women in the experimental group will increase compared to the women in the control group) was accepted (Table 4).
The median CBCFS score of the participants in the experimental group decreased after the intervention. Studies define fear as one of the factors that prevent early diagnostic practices for breast cancer [15, 16, 46]. However, some studies define fear as a convincing factor that promotes motivation and self-protection in breast cancer [47]. Kayar (2019) found that breast cancer fear scale scores increased in the experimental group following the intervention [32]. In this study, the decrease in the CBCFS scores contributed to the increase in women's breast cancer early diagnostic practices.
Based on this finding, the H1d hypothesis (Following the nursing interventions, the breast cancer fear scores of the women in the experimental group will decrease compared to the women in the control group) was accepted (Table 4).
The motivational telephone calls within the scope of the NNP led to an increase in the mammography scores of the experimental group. Studies have shown that in breast cancer, interventions including a training program integrated with patient reminders or motivational interviews increase early diagnostic practices of individuals such as mammography, CBE, and BSE [13, 14]. Some studies found that early diagnostic practices against cancer and navigation services such as phone calls, follow-up, and trainings increase the quality of comprehensive breast cancer care [48, 49]. The findings of our research support those in the literature. It is thought that when motivational interviewing is used by public health nurses in their initiatives, it can contribute to increasing healthy lifestyle behaviors of individuals.
Limitations and Recommendations
During the interventions, an interpreter helped the researchers since the research sample included Syrian women who did not know Turkish. Due to the COVID-19 pandemic, the study, which was planned to be conducted in the Migrant Health Center, was conducted in groups of 3–5 participants in an open environment using personal protection in accordance with the social distance rules. Another limitation of the study is the small sample size.
Implications for Nursing Practice
Providing care to individuals from different cultures is a challenging task for nurses, especially if cultural factors prevent healthcare practices of individuals. The NNP may help protect individuals against life-threatening diseases such as cancer. It can be used by nurses together with the HBM to understand what motivates all individuals, including immigrants, to have health screenings for early detection of breast cancer and how they take action to keep their disease under control by taking the responsibility for their own health.