breast cancer is the most common cancer in women worldwide . because of the lack of formal cancer registration in iran , there are no valid and reliable statistics about the incidence and mortality from breast cancer . however , informal statistics show the incidence rate is about 24 and prevalence rate 120 per 100,000 women per year . considering the population of 35 million women in iran it is realized that factors like age , race , ethnicity , and socioeconomic status can influence the incidence and mortality.[35 ] one of the most basic factors that can affect mortality from breast cancer is the stage of cancer disease that women are in when they present for medical care . results of a study in iran showed that among 1500 women , 78.3% were at stage 2 or more at the first visit , which means they had at least one involved lymph node . the most common reason that brought patients under medical attention was masses discovered in the breast . another study found that among 2946 females with breast cancer , 76.8% were t2 or higher and 65.3% had positive lymph nodes and were in the last phase . these findings indicate the vast majority of breast cancer patients in iran are diagnosed in advanced stages of the disease . while the chance of developing breast cancer increases as a woman gets older in western countries , raafat 's study revealed the mean age of iranian patients was about 49 years and 15% were under 40 years . mean age at the time of disease emergence in iran is lower than in western countries . this low age presentation of breast cancer among iranian women is likely related to race or low age at menarche and having an overall younger population than in developed countries . breast cancer survival varies by the stage at diagnosis ; the later the stage of the disease at diagnosis , the lower the survival rate . because of improvements in treatment , more women with breast cancer have been cured and the number of women dying due to breast cancer is decreasing . however , many iranian women with breast cancer delay their first visit to a medical professional . there is also lower compliance among iranian women for regular breast cancer testing and a lack of specific national breast cancer screening programs . all of these factors result in often late breast cancer detection and subsequent increased mortality rate in this population . it is therefore necessary to create interventions aimed at increasing adherence to breast cancer screening among iranian women . when undertaking breast cancer screening behaviors , it is important that theoretically based factors are employed to maximize the impact of the intervention . the health belief model ( hbm ) has been used to explain factors influencing breast cancer screening behaviors and to plan and implement breast cancer screening programs in various populations.[41719 ] the hbm is based on the theory that a person 's willingness to change a health behavior is primarily due to the following factors : ( 1 ) perceived susceptibility ( i.e. , women 's opinion of the chances of getting breast cancer ) , ( 2 ) perceived severity ( i.e. , a person 's opinion of the seriousness of the condition ) , ( 3 ) perceived benefits ( i.e. , the opinion of the effectiveness of some advised action to reduce the risk , such as mammography ) , and ( 4 ) perceived barriers to having a mammography . another model that can be applied to this research area is the stage of change model ( scm ) which includes the stages of change that a person moves through when adopting a behavior . the scm framework proposes that individuals move through a temporal sequence of five stages : pre - contemplation ( never having a mammogram and not planning to get one within the next 12 years ) , contemplation ( never having a mammogram but intends to get one within the next 12 years ) , action ( having one mammogram on schedule and intends to get another on schedule ) , maintenance ( having at least two mammograms and intends to get another on schedule ) , and relapse ( having one or more mammograms but is now off schedule and does not plan to have a mammogram in the next 12 years ) . many researchers have applied the scm to identify and promote breast cancer screening.[2125 ] although both these models offer unique theoretical strengths for studying breast cancer screening behaviors , few researchers have conducted theoretically based studies of iranian women 's participation in breast cancer screening behaviors such as mammography . therefore , the aims of the current study were to use hbm and scm constructs to examine : 1 ) associations between individual characteristics and stages of mammography behavior ; 2 ) relationships between the related beliefs ( perceived susceptibility , severity , benefits and barriers ) while controlling for socio - demographic factors and stages of mammography behavior associations ; and 3 ) socio - demographic factors and the health beliefs that predict stages of mammography behavior among a cluster random sample of iranian women . we hypothesized that 1 ) there will be significant socio - demographic and belief differences in the women in each of the scm stages related to mammography and 2 ) the socio - demographic factors will predict stages of mammography behavior . participants were from sanandaj , iran , which is a city with diverse socioeconomic status with 28 primary health care centers . all health care centers were considered as clusters and 30 women were randomly selected from each . if they were interested in participating , they were asked to sign an enclosed consent form and return it to the study investigators . a total of 810 women had agreed to participate and a questionnaire was sent to them . seventy - five women were excluded because they did not meet these criteria . of these 712 participants , 23 cases with incomplete or missing data were deleted , yielding a final sample size of 689 . the socio - demographic items included in the survey were age , marital status , employment status , educational status , family history of breast cancer , and health insurance . the questionnaire used in the current study was based on champion 's revised health belief model scale ( chbms ) . the chbms was tested in a previous study to assess perceived severity and susceptibility to mammography , with the cronbach 's alpha reliability coefficients 0.82 and 0.84 , respectively , in iranian women . further , the cronbach 's alpha coefficients were 0.72 and 0.73 for the perceived benefits and barriers , respectively . belief statements were rated on a 5-point scale ( 1=not at all sure to 5=very true ) and scored by calculating the means of all item scores . perceived benefits of mammography are defined as positive or reinforcing aspects of getting mammography and were measured on 6-items scale . perceived barriers refer to real or imagined impediments that prevent , or make participation in mammography difficult and were measured by a 10-item instrument . perceived susceptibility reflects individuals feeling of personal vulnerability to chances of a specific health problem . stage of mammography ( som ) adoption was assessed by an adapted measure recommended by rakowski et al . the test  retest reliability of the staging algorithm in the current study within a 2-week interval was 0.94 ( n=48 ) . the women were classified based on frequency and regularity of current screening behavior and future intention to get mammography as follows : pre - contemplation : never had a mammogram and not planning to get one within the next 12 years . contemplation : never had a mammogram but intends to get one within the next 12 years . action : had one mammogram on schedule and intends to get another on a time frame that will keep the women on schedule . maintenance : had at least two mammograms on schedule and intends to get another on a time frame that will keep the women on schedule . relapse : had one or more mammograms in the past but is now off schedule and does not plan to have a mammogram within 12 years . the statistical package for the social sciences ( spss ) version 16 was used for all statistical analyses . in order to test hypothesis 1 , chi - square tests were used to examine associations between stage of mammography adoption and socio - demographic factors . one - way analysis of covariance ( ancova ) which considered socio - demographic variables as covariates was used to assess differences in the outcome variables ( perceived severity , susceptibility , benefits , and barriers ) across the stages with tukey kramer tests to identify the stage differences of the outcome variables . to test multivariate relationships , we used the pre - contemplation stage as the reference group to compare separately with contemplation , relapse , action , and maintenance stages . outcome variables and socio - demographic factors were entered independently into the multinomial logistic regression . participants were from sanandaj , iran , which is a city with diverse socioeconomic status with 28 primary health care centers . all health care centers were considered as clusters and 30 women were randomly selected from each . if they were interested in participating , they were asked to sign an enclosed consent form and return it to the study investigators . a total of 810 women had agreed to participate and a questionnaire was sent to them . seventy - five women were excluded because they did not meet these criteria . of these 712 participants , 23 cases with incomplete or missing data were deleted , yielding a final sample size of 689 . the socio - demographic items included in the survey were age , marital status , employment status , educational status , family history of breast cancer , and health insurance . the questionnaire used in the current study was based on champion 's revised health belief model scale ( chbms ) . the chbms was tested in a previous study to assess perceived severity and susceptibility to mammography , with the cronbach 's alpha reliability coefficients 0.82 and 0.84 , respectively , in iranian women . further , the cronbach 's alpha coefficients were 0.72 and 0.73 for the perceived benefits and barriers , respectively . belief statements were rated on a 5-point scale ( 1=not at all sure to 5=very true ) and scored by calculating the means of all item scores . perceived benefits of mammography are defined as positive or reinforcing aspects of getting mammography and were measured on 6-items scale . perceived barriers refer to real or imagined impediments that prevent , or make participation in mammography difficult and were measured by a 10-item instrument . perceived susceptibility reflects individuals feeling of personal vulnerability to chances of a specific health problem . stage of mammography ( som ) adoption was assessed by an adapted measure recommended by rakowski et al . the test  retest reliability of the staging algorithm in the current study within a 2-week interval was 0.94 ( n=48 ) . the women were classified based on frequency and regularity of current screening behavior and future intention to get mammography as follows : pre - contemplation : never had a mammogram and not planning to get one within the next 12 years . contemplation : never had a mammogram but intends to get one within the next 12 years . action : had one mammogram on schedule and intends to get another on a time frame that will keep the women on schedule . maintenance : had at least two mammograms on schedule and intends to get another on a time frame that will keep the women on schedule . relapse : had one or more mammograms in the past but is now off schedule and does not plan to have a mammogram within 12 years . the statistical package for the social sciences ( spss ) version 16 was used for all statistical analyses . in order to test hypothesis 1 , chi - square tests were used to examine associations between stage of mammography adoption and socio - demographic factors . one - way analysis of covariance ( ancova ) which considered socio - demographic variables as covariates was used to assess differences in the outcome variables ( perceived severity , susceptibility , benefits , and barriers ) across the stages with tukey kramer tests to identify the stage differences of the outcome variables . to test multivariate relationships , we used the pre - contemplation stage as the reference group to compare separately with contemplation , relapse , action , and maintenance stages . outcome variables and socio - demographic factors were entered independently into the multinomial logistic regression . participants had a mean age of 55.72 ( sd=7.42 ) years ( range=4072 years ) ; 46.9% were single and 53.1% were married ( divorced or common - law is not an option in iran ) ; 53.6% did not work outside of the home ; 48.2% had less than a high school education , 32.7% had a high school education , and 19.2% had attended university . in terms of income , 10.45% perceived their income as bad or very bad , 23.8% as middle , and 65.75% as good or very good . 94.8% of the participants reported no history of family breast cancer and 18.4% were uninsured . among the 689 participants , 40.1% were in pre - contemplation stage , 34.7% in contemplation , 7.5% in relapse , 12% in action , and 5.7% in maintenance stage of mammography adoption age groups , marital status , and health insurance were significantly associated with the stage of adoption ( p<0.001 ) . there were more number of older women in the pre - contemplation stage ( 44.5% ) and action stage ( 16.7% ) compared with those in the other age groups . the middle - aged ( 5059 ) women were more than the other two age groups in the maintenance stage ( 9.4% ) . the youngest women were most likely to be in the relapse stage ( 19% ) . bivariate relationships between participants socio - demographic factors and stage of mammography married women were more likely to be in the action stage compared to single women . because age , marital status , and health insurance were significantly associated with the stage of mammography adoption , these variables were included as covariates in the ancova . differences between stages of adoption were found for all psychosocial factors ( all p<0.001 ) . the results of the ancova are presented in table 2 . as hypothesized , among the health beliefs variables , perceived susceptibility , severity , and benefits were positively associated with the stage of adoption while perceived barriers were negatively associated with the stage of adoption . it was found that the women in the relapse group had the lowest scores for perceived barriers , followed by the women in the maintenance group . adjusted marginal means ( sd ) on perceived benefits , barriers , susceptibility , and severity for the five stages of mammography in addition , the relationships between demographic factors as covariates and health beliefs were examined . health insurance was associated with higher perceived susceptibility , greater benefits , and lower barriers ( p<0.030.001 ) . age and marital status were associated with higher perceived benefits , greater susceptibility , and fewer perceived barriers ( p<0.010.001 ) . results of the multinomial logistic regression and pair - wise comparison across stages of mammography adoption on socio - demographic variables and the health beliefs are reported in tables 3 and 4 , respectively . women were more likely to be in the maintenance stage than in the pre - adoption stage if they were in the middle age group ( 5059 years ) [ or=4.96 , 95% confidence interval ( ci)=1.8513.33 ] , than in the youngest age group ( or=1.98 , 95% ci=0.566.80 ) . the younger women ( < 50 years ) compared to older women were about 26 times more likely to be in the relapse stage and the odds for middle age were about 9 times compared to women more than 60 years old . married women had higher odds of being in the action group than in the pre - contemplation stage compared with single women ( 96% vs. 0.4% ) , although the odds of being in the maintenance stage were lower for married women ( 37% vs. 63% ) . no significant differences were found across the stages of mammography adoption on employment status , education level , income level , family history of breast cancer , and health insurance except for those women with a family history of breast cancer , who were more likely in the maintenance than in the pre - contemplation stage ( 99% ) compared with those not having this family history . odds of being in stage of mammography screening by socio - demographic factors odds of being in stage of mammography screening by health beliefs among the health beliefs examined , all were significantly different between stages ( p<0.040.001 ) . those who were in relapse , action , and maintenance stages had higher perceived benefits and susceptibility scores than those in pre - adoption stages . women in pre - adoption stages were 4 times in maintenance stage if they had lower perceived susceptibility ( p<0.001 ) . women in maintenance , action , and relapse stages had lower barriers to mammography and were less likely to be in pre - contemplation stage . interestingly , the odds of being in adoption stages ( action and maintenance ) were no different than of women being in the relapse stage ( or=0.06 ) . it means the odds of being in adoption or relapse stages compared to being in pre - adoption stages ( pre - contemplation , contemplation ) were higher for women with fewer barriers compared with those who had higher barriers to mammogram . results of the multinomial logistic regression and pair - wise comparison across stages of mammography adoption on socio - demographic variables and the health beliefs are reported in tables 3 and 4 , respectively . women were more likely to be in the maintenance stage than in the pre - adoption stage if they were in the middle age group ( 5059 years ) [ or=4.96 , 95% confidence interval ( ci)=1.8513.33 ] , than in the youngest age group ( or=1.98 , 95% ci=0.566.80 ) . the younger women ( < 50 years ) compared to older women were about 26 times more likely to be in the relapse stage and the odds for middle age were about 9 times compared to women more than 60 years old . married women had higher odds of being in the action group than in the pre - contemplation stage compared with single women ( 96% vs. 0.4% ) , although the odds of being in the maintenance stage were lower for married women ( 37% vs. 63% ) . no significant differences were found across the stages of mammography adoption on employment status , education level , income level , family history of breast cancer , and health insurance except for those women with a family history of breast cancer , who were more likely in the maintenance than in the pre - contemplation stage ( 99% ) compared with those not having this family history . odds of being in stage of mammography screening by socio - demographic factors odds of being in stage of mammography screening by health beliefs among the health beliefs examined , all were significantly different between stages ( p<0.040.001 ) . those who were in relapse , action , and maintenance stages had higher perceived benefits and susceptibility scores than those in pre - adoption stages . women in pre - adoption stages were 4 times in maintenance stage if they had lower perceived susceptibility ( p<0.001 ) . women in maintenance , action , and relapse stages had lower barriers to mammography and were less likely to be in pre - contemplation stage . interestingly , the odds of being in adoption stages ( action and maintenance ) were no different than of women being in the relapse stage ( or=0.06 ) . it means the odds of being in adoption or relapse stages compared to being in pre - adoption stages ( pre - contemplation , contemplation ) were higher for women with fewer barriers compared with those who had higher barriers to mammogram . among the 689 participants , 75% were in pre - contemplation and contemplation stages of mammography adoption compared with only 17.5% in action and maintenance stages , leaving 7.5% in the relapse stage . the low rate of mammography adoption behavior is consistent with previous research with iranian women . aalvi found that even among female iranian gynecologists , only 27% had regularly mammogram testing . another study showed 12% of women had gotten a mammogram within the previous 3 years . low adherence to recommended screening behaviors has similarly been demonstrated in iranian women . when compared to other studies , iranian women were found to be less likely to be in maintenance and action stages than asian american , indian and filipino , cambodian , chinese , or chinese and filipino women . this likely reflects greater acculturation to regular -mammography -testing than is found among iranian women . we found that the stage distribution varied by age , marital status , and health insurance coverage . the largest group in the pre - contemplation stage was the oldest women , which is likely to be due to cultural beliefs like not needing a routine mammogram done if one is old and related health beliefs to getting a mammogram done . although older women were the most likely to be in the action stage , they also formed the lowest numbers in the maintenance stage . the odds of being in the maintenance stage were more likely in the middle age , followed by the youngest women ( or=4.96 and 1.96 , respectively ) . these findings could help with the creation of interventions tailored to encourage older women to progress toward maintenance stage . the normative belief among iranians is that older women should spend more time on family issues rather than on themselves . so , it would be helpful if other family members , such as husbands , were informed about the risk of developing breast cancer and the importance of regular mammogram screening to detect early diagnosis . our results are similar to those reported for cambodian , korean , chinese , filipino american , and swiss women , but inconsistent with studies on chinese and korean immigrants who were not found to differ across stages by marital status . considering the high percent of married women in the action stage , our results again suggest that spouses may be a useful source of social support . the number of married women in the action stage dropped from 21 to 5% in the maintenance stage . there is a need to motivate married women and their family members to adhere to regular mammography . women with a history of breast cancer in their families compared to those without such history were more likely to be in the maintenance stage than in the pre - contemplation stage . however , sometimes family history can create fear and apprehension to impede getting a mammogram done and it can become a barrier rather than a facilitator , although our findings do not support this idea . there is a need to further explore the cultural beliefs to find out why despite the positive perceived outcomes when breast cancer is diagnosed in an early stage , having a history becomes a barrier in some women . unlike other findings , health insurance did not predict the stage of adoption for mammography.[222328 ] these results may be related to the difference in insurance coverage in iran compared to other countries . there are several different types of insurance in iran that provide rather similar services , so we integrated them into one category . further , even with insurance coverage , one must pay a high cost to visit a physician , so this issue may influence regular physician visits which will subsequently result in not receiving a physician 's recommendation for regular mammography . in addition , insurance pays only a small part of mammography costs , so there is not a salient difference between insured and uninsured women in this regard . the results proved our hypothesis that health beliefs will be related to the stage of adoption of mammography . for women in the relapse stage , it seems that they retained their beliefs regarding mammography but did not act accordingly . it is not clear if when one recycles to pre - adoption stages , beliefs undergo salient changes such as decreasing perceived threats and increasing barriers or if there are other factors influencing the health behaviors . contrary to results from previous studies conducted in rural korea and on korean immigrants to the usa which reported that perceived susceptibility predicted the stage of mammography or recent mammogram , our findings were more similar to those of kathleen that there is not greater likelihood of being in action than in relapse stage due to perceived susceptibility . it must be noted that perceived threat about developing breast cancer is an overall concept while risk appraisal goes beyond the perceived threat . this may be a reason for there not being different perceived severity for women in the different stages . there is a need to further explore the risk appraisal according to normative beliefs , characteristic culture , socio - demographic status , and access to effective screening and treatment services related to breast cancer among iranian women . hbm and scm postulate that people will take action for healthy behavior if they believe in the efficacy of action and if the barriers are outweighed by perceived positive outcomes . contrary to these hypotheses , our results did not show any significant differences between those who were in relapse and action stages given perceived benefits , but differed between pre - adoption and adoption stages as reported by other researchers.[17283335 ] the women in the maintenance stage even had lower benefits than those in the relapse and action stages . according to scm , all beliefs will not differ by stage , as supported by our results ; women in the relapse stage reported the highest perceived benefits to getting a mammogram done than the women in all other stages . there is the possibility that despite someone not acting on a recommended health behavior , they still may acknowledge and express the benefits of that behavior . the odds were greater in the adoption than in the pre - adoption stages when adding the perceived benefits , as reported in other studies . women in the relapse stage had the lowest barriers compared to those who were in action and maintenance stages . the prior experiences with getting a mammogram done may have influenced the current and future intentions and attitudes related to breast cancer screening . it may be that women in the relapse stage experienced some barriers like pain , embarrassment , or fear . these feelings may have been normalized explaining why women in the relapse stage had lower perceived barriers than those in the adoption stages . except those who were in the relapse stage , there were important differences between pre - contemplators and those in the adoption stages related to perceived barriers to getting a mammogram done . similar to other findings , our results revealed that when stages progress from early to advanced , perceived barriers decreased . the findings of the current study indicate that women in the relapse stage reported the highest perceived benefits , rather higher perceived susceptibility , severity , and the lowest barriers . it is a unique finding that needs further research to detect the other factors that may impact having a regular mammogram . for example , interpersonal influences including social support , exposure to models , and interpersonal norms are likely to be important correlates , particularly within the iranian cultural context . it must be realized which specific changes at an item level regarding perceived beliefs predict progress across stages . for example , if a woman in the pre - adoption stages declares that getting a mammogram done is painful , it means this belief is influenced by vicarious learning rather than her own prior experience . exploring item - level beliefs would help to plan and conduct effective interventions tailored to the stage of mammography adoption . this study provides the first test of the associations between stages of mammography adoption based on scm combined with selected aspects of the hpm among iranian women . results indicate differences across stages of change were found for related beliefs , and also for current and future intentions for all participants , except for those in the relapse stage . thus , iranian women in the relapse stage of mammography do not significantly differ in beliefs , but in their intention to getting a mammogram done compared to women in the action and maintenance stages . given the lack of population - based mammography and clinical breast exam screening programs , the rate of relapse as well as the low adherence to regular screening behavior for breast cancer among the women in this sample and other iranian women , there is a need to conduct further research in theoretically based interventions designed to decrease relapse , especially in younger iranian women . if the intervention programs achieve success to keep the same number in the adoption stages and prevent relapse , it is worth it . further , it is important to understand why older women are less likely to maintain the behavior . it is important that the distinction between perceived related beliefs to mammography according to age is better understood . therefore , intervention programs aimed at increasing mammogram behavior must be tailored to the stage of change , age , and other socioeconomic factors .