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The accepted absorption is amid the aboriginal to appraise if the capability of theory-based interventions in convalescent mammography screening is due to changes in targeted constructs. Women in the HBM-based accumulation appeared to accept added screening about to women in the CON accumulation due to greater susceptibility, self-efficacy, and perceived control. Nonetheless, barriers appeared to be an basal confounder in the mediating aftereffect of self-efficacy for this set of absorption arm differences. Women in the TPB-based accumulation appeared to accept greater allowance of accepting mammograms about to women in the CON accumulation due to greater reductions in barriers and added self-efficacy. These basic allegation accept important implications apropos which constructs should be targeted in approaching HBM- and TPB-based interventions in Iran. They added accommodate a abstract belvedere by which added theory-based interventions may be evaluated.

Similar to our antecedent assignment in accession burghal of Iran [30], the accepted absorption begin that women accommodating in action accoutrements able cogent changes in targeted abstract constructs. There were about some differences. Aural the Sanandaj study, women beyond both action accoutrements able decidedly greater increases in susceptibility, severity, benefits, abstract norms, and perceived ascendancy as able-bodied as a cogent abridgement in barriers about to women in the ascendancy group. Aural the accepted study, the HBM action appeared to assignment analogously in agreement of cogent changes in abstract constructs about to women in the ascendancy group. Nonetheless, women in the TPB action did not acquaintance cogent changes with attention to susceptibility, severity, and allowances about to women in the ascendancy group. These differences may be due to differences in absorption architecture (e.g., randomized controlled balloon against quasi-experimental design) or absolute differences in how these concepts are able beyond audible regions in Iran. Our allegation highlight the accent of archetype in adjustment to characterize action capability beyond altered populations and to access acceptable abstracts to appraise mediators and moderators basal aberration in effectiveness.

Across absorption arms, added susceptibility, self-efficacy and perceived ascendancy was associated with greater allowance of accepting mammograms, afterwards adjusting for conjugal status. In addition, a abridgement in perceived barriers was associated with greater allowance of accepting mammograms. Our assignment is circumstantial with empiric studies in Iran and added countries that advance mammography affairs and practices are accompanying to beneath barriers [41–43], greater self-efficacy [44–46], and greater perceived ascendancy [30]. Our allegation added adjust with some assignment suggesting added susceptibility is associated with greater guideline-concordant mammography screening [47, 48], although added assignment has adumbrated that over-elevated susceptibility ability be associated with non-adherence [49, 50]. It is added advantageous to accede that our absorption did not acquisition benefits, severity, or abstract norms to be associated with mammography screening, adverse to HBM and TPB frameworks. One abeyant estimation is that these factors acerb overlap with added abstract constructs, which may act as confounders or mediators. For example, the relationships of abstract norms and amusing factors added broadly with mammography screening may be advised or ashamed by self-efficacy and/or perceived ascendancy [44].

We begin important cogent differences in mediators of screening. Specifically, bargain barriers and added self-efficacy did not consistently arbitrate screening differences amid women in the CON and HBM arms, but did decidedly arbitrate differences amid women in the CON and TPB arms. Conversely, changes in susceptibility appeared to arbitrate differences in screening amid CON and HBM arms, but not amid CON and TPB arms. Such allegation arise to be counterintuitive, accustomed both HBM and TPB accoutrements able the aforementioned HBM materials, except for Week 20. Simultaneously, perceived ascendancy appeared to arbitrate differences in affiliation to the HBM-based group, but not the TPB-based group, admitting a abridgement of action agreeable that was pertinent to this construct. It is advantageous to accede that the relationships amid the abstract constructs may abash and arbitrate not alone bivariate associations, but additionally mediating effects. Our acuteness analyses appear such a book for self-efficacy as a advocate in the ambience of HBM-CON differences, wherein admittance of barriers in the archetypal attenuated its role as a mediator. This may be because barriers serve as mediators or confounders in this three-variable relationship.

Our allegation present a circuitous picture. On the one hand, the accepted absorption was motivated by the absorption that arbitration models can analyze the abstract constructs that serve as mechanisms basal action efficacy. Such models may aftereffect in affirmation to advance that interventions can be aesthetic to be beneath and targeted against beneath abstract constructs. On the added hand, however, our allegation announce that targeted constructs are not alone interconnected, but may serve as confounders and mediators in bivariate and multivariable associations. Specifically, participants’ acknowledgment to action abstracts apropos some constructs may accidentally aftereffect in changes in added constructs as able-bodied as the accord amid added constructs and screening. Such allegation advance that interventions’ agreeable should abide to focus on all abstract constructs, as action abstracts may affect not alone the targeted abstract constructs, but additionally commutual abstract constructs and their associations with screening. An accessible aing footfall is to administer structural blueprint clay in adjustment to accept added the cast of targeted constructs basal action efficacy.

There are a cardinal of limitations that charge be noted. First, although this assignment was longitudinal, appraisal of mediators and the aftereffect of absorption occurred at the aforementioned time. Accustomed this, causal relationships should not be inferred. Second, our arbitration models do not annual for all accidental factors to women’s screening practices, but alone the constructs that were targeted in the interventions (i.e., intrapersonal and perceived ecology factors). Nonetheless, absolute ecology factors acceptable accord to the alarmingly low ante of approved screening. Approaching assignment should accommodate these factors in analyses and appraise their about contributions aural the ambience of psychosocial interventions that abode predominantly intrapersonal and perceived ecology factors. A third limitation apropos the role of altitude for our analyses. Specifically, we acclimated both single- and multiple-item measures, which may accept afflicted our findings. Our accommodation to use single-item measures for abstract norms and perceived ascendancy was based on the availability of evidence-based scales that abstinent absolute forms of these perceived constructs [1, 18, 28, 29, 44, 51]. Approaching studies should advance and use multiple-item instruments that anon admeasurement both abstract norms and perceived ascendancy to affirm our findings. Accession important limitation commendations our operationalization of perceived behavioral control. Conceptually, this assemble is actual agnate to self-efficacy, but focuses on ecology and systemic factors [28, 29]. Our single-item apparatus did not about anon admeasurement women’s perceived ascendancy about to specific ecology and systemic factors, which may accept afflicted our allegation back including both measures (e.g., abeyant for multicollinearity). This bound blazon of operationalization has been discussed by advisers such as Ajzen, who accept adumbrated that these constructs may be the aforementioned and differences may be a aftereffect of altitude absurdity [27]. Our absorption appropriately is not able to accord to this dialogue. Nonetheless, our counterintuitive allegation from arbitration models aural the ambience of altered interventions highlight its accent and the charge for accurate appraisal and allegory of assemble authority for these two abstract constructs. Approaching studies are acceptable that advance and accommodate multiple-item measures that specify women’s perceived ascendancy about to specific constructs (e.g., in the face of no civic screening program) in adjustment to affirm our findings. Fourth, TPB capacity were continuously presented last, in adjustment to ascendancy for adjustment furnishings beyond absorption arms. Ordering furnishings may accept afflicted which factors appeared to be the mechanisms basal action success. Approaching studies should carbon our allegation back comparing three adaptations of the HBM   TPB intervention, wherein TPB interventions are presented aboriginal and aftermost as able-bodied as interspersed. Fifth, women who absitively to participate throughout the action may accept been added motivated to access a mammogram than women who were absent to aftereffect and women who absitively to not participate at all. Sixth, our absorption is a archetype of a antecedent randomized controlled trial. A above aberration in designs apropos the use of assorted healthcare centers and individual-level randomization in the Sanandaj absorption [30] compared to a quasi-experimental architecture that administered interventions at three abstracted hospitals, which may appulse the generalizability of this study. Our absorption allegation may added not be applicative in Western societies, added non-Western societies, or alike added regions of Iran. Accession above limitation apropos our altitude of mammography above-mentioned to the trial. In adjustment to be eligible, women had to self-report their appliance of mammography at some point aural their able and abridgement of mammography screening aural the able 2–3 years. We did not about aggregate specific dates and abundant history about the time that had able back the aftermost mammogram. This is a limitation, accustomed mammography history may be a confounder in associations found. Further, these abstracts are self-report, which are generally ambiguous in agreement of altitude absurdity [52]. Approaching trials should affirm our findings, wherein lifetime as able-bodied as post-intervention mammography history are adjourned based on medical almanac abstraction. In addition, we focused on echo mammography utilization; notably, however, women who access at atomic one mammogram are added acceptable to access mammograms in the approaching [53]. Our action may be decidedly bare by women with no lifetime history of mammography. Simultaneously, we agenda that echo mammography is decidedly low in Iran [54]. Appropriately there is a charge for these types of interventions in the ambience of both mammography behavior admission and maintenance.

In accession to its limitations as a analysis study, there are important apropos apropos our after-effects can construe to accepted care. There are several abeyant venues for practitioners to explore. First, approaching accomplishing efforts may analyze the about amount capability of relying on in-person accumulation sessions only, phone-based abundant sessions, or the aboriginal accumulated approach. Added options may accommodate added modes of communication, including use of e-mail and the Internet for the abundant apparatus of our program. Accession abeyant way to apparatus this action may be through hospital-based navigators, who can facilitate interactions amid women and their providers in a agnate appearance as able by our absorption staff. Indeed, such accommodating apprenticeship and counseling while acclamation systemic and ecology factors are accepted apparatus of aeronautics programs [55, 56].

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