The literature supports the argument that regular practice of BSE influences treatment, prognosis and survival rates [21, 22]. In this study only 10.2% of the participants reported practicing BSE on a regular monthly basis while 29.5% stated that they examined themselves irregularly. Similarly, some studies have reported that less than half of their study groups actually practice BSE monthly [5, 24]. In contrast, some studies have found that the majority of older women performed breast screening activities on a regular basis [25, 26]. In this study, there was no statistically significant association between the different age groups and BSE. 27.9% of women, expressed that they had no knowledge of mammography and only 5.1% of them, had had an annual mammography over a two year period. The rate of undergoing a recommended mammography practice was lower than Secginli's study which had been performed in Istanbul, and other studies from different countries [4, 13, 14, 28, 28].
In this study it was found that 3.3% of women have CBE once a year, and 18.4% when they have a complaint. In the study of Ho, the annual CBE percentage is 45% in educated women . In this study it must be reiterated that 20.1% of our study group were illiterate women living in a rural area.
Although 76.6% of the women in this study reported having heard or read about breast cancer, our study revealed that only 56.1% of them had sufficient knowledge of breast cancer, half of whom had acquired the information from health professionals. Nearly 40% of the study group reported their main source of information on breast cancer was obtained from the TV/radio. This finding indicates the advocacy of TV/radio. Our study group consisted of under educated housewives, to whom TV/radio is readily available which makes it an important information source. It is a considerable finding that health professionals are a relatively poor information source accounting for only 23.4% of the group. Primary health care systems in Turkey is population based. Each midwife/nurse working in primary health care is responsible for a certain groups. Their main responsibilities include child care, pregnancy follow-up and reproductive health problems of women aged 15–49. In this health care system, subjects may be informed about breast cancer screening which in turn may be a solution for women living in a rural areas. According to logistic regression analysis; the odds of having insufficient knowledge about breast cancer was 2.2 (1.2–4.0) times higher in women who lived in extended families than in nuclear families, 3.7 (1.7–7.9) times higher in women who had never had a CBE than in women had had a CBE. A better understanding of the fore mentioned is made possible when taking in to account the knowledge that a majority of the women who live in extended families are more likely to be illiterate and to have a more traditional lifestyle. Champion and Miller have indicated that sociodemographic variables may influence attitudinal variables and thus indirectly influence behavioural patterns. Experiential and demographic variables have several direct paths to attitudinal variables and potential indirect paths to BSE behaviour . In this study it was found that being knowledgeable of breast cancer is the only significant variable in BSE as well as in the practice of mammography. Similarly, in Lagerlund's study, it was found that, a sufficient levels of knowledge of breast cancer had a positive effective factor on having mammography . Hyun's study also reveals that women who are taught to perform BSE have a better level of knowledge about breast cancer . That is to say, variables like age, education level, health insurance, history of breast cancer in friends and/or relatives and family type are not significant in BSE and mammography practice. Similarly, in Jirojwong's study, it was found that sociodemographic variables were not effective on BSE practice [32, 33]. Since, independent variables like education levels, women's job status, income level and type of health insurance are similar among the women of this study, they may not be significant in BSE practice as well as mammography.
As in studies of Black American, Australian, Hispanic American, Jordanian, Chinese, Vietnamese, and Asian Indian women, the results of this study indicate that the revised CHBMS is a useful framework to identify factors that influence BSE for Turkish women [4, 5, 14, 17, 18, 29, 33, 34].
In this study seriousness, susceptibility and motivation were not significant in explaining BSE performance on a regular basis, but increased confidence, BSE-benefit and reduced BSE-barriers were significantly associated with it. In other studies with Chinese, Jordanian and U.S. women, seriousness has been continuously reported as a non-significant predictor of BSE [18, 35–37]. This supports the assertion that seriousness is not a good predictor for preventive health behaviour because breast cancer may be perceived by all women as a serious event, influencing physical, psychological and social aspects of life itself .
Motivation was found to be the significant factor for mammography practice in this study. This finding was parallel to the results of Holm and Eun-Hyun [31, 38]. In BSE practice, however, motivation was not found to be a significant factor, the practice of monthly BSE was low. One explanation for low compliance is that women in the sample did not believe they were susceptible to breast cancer. Another explanation could be the lack of education in breast cancer (only 56.1% of women had a sufficient level of knowledge). There was no significant association between susceptibility and BSE-mammography practice. The present results parallel those of Eun-Hyun and Petro-Nustas [18, 31].
Benefits were a significant variable predicting BSE and mammography performance. It was supported by the findings of American studies that have reported where women who perceived more benefits from BSE behaviour were more likely to perform BSE [14, 19, 38, 39]. In contrast, in other studies with Asian women such as from Korea, Hong Kong and Jordan, benefits were not significant variables [5, 26, 40].
Confidence was found to be a significant factor for both BSE and mammography practice in this study. The confidence levels of women who perform BSE on a regular basis, and have recommended mammograms, were much higher than among non-practitioners. Research on the relationship between confidence and breast cancer screening has been reported by several researchers with varying degrees of attention to measurement issues. One research group found a positive relationship between confidence and BSE . In a study among Mexican American women, knowledge and confidence were associated with both BSE and colorectal cancer screening . In a few studies, confidence has been related to mammography behaviour. These studies found that, confidence strongly related to a subjects overall intentions to have a mammogram . Similarly, Sortet, Ashton and Foxall's study showed that, women who reported more confidence in performing BSE were significantly more likely to do so regularly [37, 44, 45].