Menopause is a process that occurs when ovarian follicular functions cease, and menstruation ceases permanently for one year [1–3]. While the early phases of menopause involve vasomotor, psychological, sexual, and urinary symptoms, late phases involve cardiovascular diseases, stroke, osteoporosis, and breast cancer [4, 5]. One out of every four women worldwide is diagnosed with breast cancer, while one every six women dies from breast cancer [6]. The prevenance of breast cancer is highest in New Zeeland, North America, North Africa countries respectively, while it is lowest in East Africa, South Asia, and Central Africa countries [6]. The prevalence of breast cancer is 43.4% in women in Türkiye [7]. While the prevalence of breast cancer is 54.1% in menopausal women, it is 30.8% in women of childbearing age [6]. Breast cancer could have negative effects on women’s quality of life, sleep patterns, and overall health [8, 9]. Therefore, early diagnosis of breast cancer is highly important. Self-examination, clinical breast examination, mammography, and ultrasound are some methods recommended for early detection of cancer [10–12]. Early detection methods enable a 97% survival rate of breast cancer within five years [13]. Implementation of early diagnosis methods, which has this much effects on women’s chances of survival, increases with the increase in women’ awareness level, education level, socio-economic condition, and access to information about breast cancer [14]. The literature recommends education interventions to increase women’s implementation of early diagnosis methods [15–17]. Gamal et al. (2025) found that education based on the Health Belief Model increased the level of knowledge about breast cancer 15 times and breast cancer prevention behaviors five times [18]. On the other hand, considering factors such as forgetting, loss of motivation, and the difficult process in the transformation of knowledge into behavior, there seems to be a need to support education with different methos, rather than providing it through direct instruction [19, 20]. The literature has documented the use of education supported with video short messages [20–22], simulation-based education [23], Health Belief Model-based education [24, 25], and education practices based on animation [22, 26] for coping with breast cancer.

The animation technique includes characters’ mutual conversations, gestures and facial expressions, and nonverbal communication [27]. When supported with appropriate materials, animation could increase the efficiency of education [28–30]. Animation was detected to increase individuals’ self-confidence, creativity, and coping strategies and enable to focus attention and strengthen memory [31, 32]. Animation was reported to decrease individuals’ stress, anxiety and depression levels and increase cognition levels [33, 34]. In the health sector, animation is used to reduce pain, psychological health problems, sleep disorders, etc. [35–37]. The literature includes studies that used animation to teach breast cancer early screening tests [18, 21]. Idrees et al., 2023 reported that animation-based practices were effective in women’s learning breast self-examination [38]. Hansen et al. (2024) found that animation-based education increased the retention and comprehensibility of health information [39].

The Organization for Economic Cooperation and Development (OECD) data indicate that while the number of doctors per 1000 people is 3.7 in the world, this ratio is 2.2 in Türkiye [40]. Similarly, while the number of nurses per 1000 is 9.2 in OECD countries, this ratio is 2.8 in Türkiye, indicating the high workload of health personnel in our country [40]. This situation makes it necessary to investigate the effect of animation, which enables health personnel’s multidisciplinary work, on menopausal women’s breast cancer attitudes, behaviors, and screening test uptake. No studies in the literature were found to have investigated the effect of animation-based education on breast cancer attitudes, behaviors and screening test uptake of menopausal women in Türkiye. In this regard, this study aims to determine the effect of animation-based education on breast cancer attitudes, behaviors and screening test uptake of menopausal women in Türkiye.

Hypotheses of the Study

H1: Animation-based education increases screening test uptake of menopausal women.

H2: Animation-based education increases breast cancer attitudes and behaviors in menopausal women.

Primary Outcome: Difference between the experimental and control group menopausal women in terms of screening test uptake at mid-test and post-test after the animation-based education.

Secondary outcome: Difference between the experimental and control group menopausal women in terms of breast cancer attitudes and behaviors at mid-test and post-test after the animation-based education.

The study was conducted with menopausal women aged 49–65 who were registered in Orduyeri and Kırtepe FHCs. Both FHCs have similar socioeconomic and cultural characteristics. The sample size of the study was determined using G*Power software (Version 3.1 9.3). Power analysis calculation was performed based on the t-test in the analysis of two independent groups and with reference to a study that used the primary outcome, the Champion Health Belief Model Scale, and the education application [41]. With an effect size of 0.63, 95% confidence interval determined with 0.05 margin of error, and 95% representative power, the sample of the study was determined as 134 menopausal women, 67 women in each group. Considering any potential losses, it was decided to include 20 menopausal women for each group. At the beginning, the study included 174 menopausal women, 87 women in the experimental group and 87 women in the control group. In the experimental group, two women changed their place of residence, four women did not participate in the post-test, one woman filled in the data collection forms incompletely, and two women did not complete the education given, so they were excluded. As for the control group, seven women could not be reached in the mid-test, five women could not be reached in the post-test, two women died, six women filled in the data collection forms incompletely, so they were excluded. The study was completed with 145 women, 78 women in the experimental group and 67 women in the control group (Fig. 1). The power analysis performed at the end of the study indicated α:0.05, β:0.035, and the power of the study was determined as 96%.

To decrease the contamination of the animation-based education provided to the experimental group, the FHCs in the study were divided into experimental and control groups. Including Orduyeri and Kırtepe FHC to the experimental and control groups was performed by the third researcher using opaque, double sided adhesive envelopes by drawing lots. Hence, while Orduyeri FHC was determined as the experimental group, Kırtepe FHC was determined as the control group. The fourth and fifth researchers listed menopausal women who came to the FHC and met the inclusion criteria according to the order or application and assigned them to the groups using a web site (www.random.org) through simple randomization at 1:1. Assignment was performed at an individual level; no clustering method was used. The process was performed under the supervision of the first researcher. Since the experimental group was provided with animation-based education, blinding of the researchers was not possible. Data analysis was performed by an independent statistician who was not involved in the study.

The inclusion criteria of the study were as follows: having no psychological, physiological and gynecological diseases, being aged between 49 and 65, reading and understanding Turkish, being accessible by e-mail, telephone, or social media accounts, having an internet access, not being in the pregnancy or postpartum periods, not having been diagnosed with breast cancer, not performing regular breast self-examination, and agreeing to participate in the study. The exclusion criteria of the study were as follows: not filling in the data collection forms, never experiencing menopausal symptoms, experiencing a surgical menopause, receiving chemotherapy or radiotherapy, having a history of breast cancer, having undergone a surgery related to the breast, dying, changing place of residence during the study period, and not completing the education given.

Data were collected through the Personal Information Form, the Menopause Rating Scale, the Champion Health Belief Model Scale, and the Breast Cancer Awareness Scale.

The scale was developed by Schneider et al. (1992) and its Turkish reliability and validity were performed by Gürkan (2005) [44]. The 11-item scale has three sub-scales, which includes somatic complaints, psychological complaints and urogenital complaints. The scale is responded on a 5-point scale and total scores range between 0 and 44. Cronbach’s alpha reliability coefficient of the total scale score was 0.84, while Cronbach’s alpha reliability coefficient of the sub-scales range between 0.65 and 0.72 [44]. In this study, Cronbach’s alpha coefficient was determined 0.95 for the Menopause Rating Scale total. Cronbach’s alpha values range between 0.94 and 0.96 for the sub-scales of the scale.

The Breast Cancer Awareness Scale was developed by Linsel et al. (2010) to measure awareness about breast cancer. Turkish validity and reliability of the scale was performed by Altundağ et al. (2021) [45]. The scale has 13 items including symptoms to determine breast cancer awareness (11 items), frequency of breast examination (1 item) and age of breast cancer (13 items). The scale has no cut-off point. The participants receive 1 point when they mark 5 of the symptoms correctly, 1 point when they mark the oldest age of breast cancer (70), and 1 point when they mark the frequency of breast examination as once a month. Higher scores indicate higher awareness about breast cancer [45]. In this study, Cronbach’s alpha coefficient of the total score was determined as 0.73.

The results of the study showed that the women in the experimental and control groups demonstrated no significant differences in terms of their age, body mass index (BMI), age of menopause, education level, employment status, marital status, and income level (Table 1, p > 0.05). The experimental and control groups also indicated no differences in terms of receiving information about breast cancer, receiving clinical breast examination, having regular BSE, knowing when to do BSE, and knowing how often BSE is done (Table 1; p < 0.05). These results indicate that the groups are homogenous.

Table 2 presents the comparison of MRS scores of the experimental and control group in the pre-test and mid-test. No significant differences were detected between the experimental and control groups in the MRS total score somatic, urogenital, psychological sub-scales in the pre-test and mid-test (p > 0.05). Post-test MRS total score was found to be significantly lower in the experimental group women (20.92 ± 10.39) compared to the control group women (24.06 ± 7.75) (p < 0.05). Besides, MRS psychological sub-scale score was significantly lower in the experimental group women (8.09 ± 4.26) compared to the control group women (9.78 ± 3.50) (Table 2; p < 0.05).

Table 3 presents the comparison of pre-test, mid-test and post-test BCAS scores of the women in the experimental and control group. BCAS total scores indicated no significant differences between the experimental and control groups in the pre-test and post-test (p > 0.05). BCAS total score of the experimental group was significantly higher in the mid-test (9.56 ± 3.88) compared to the control group (7.06 ± 5.00) (Table 3; p < 0.05).

In the pre-test, the Champion Health Belief Scale health motivation sub-scale score was significantly lower in the experimental group (18.22 ± 5.27) than the control group (20.03 ± 3.74) (Table 4; p < 0.05). In the mid-test, the Champion Health Beliefs Scale BSE self-efficacy sub-scale score was significantly higher in the experimental group women (35.10 ± 7.90) compared to the control group women 30.24 ± 10.19) (p < 0.05). In the post-test, the Champion Health Belief Scale susceptibility, health motivation, BSE benefits, BSE self-efficacy, and mammography benefits sub-scale scores were significantly higher in the experimental group women compared to the control group women (p < 0.05). Besides, the Champion Health Beliefs Scale BSE barriers and mammography barriers sub-scale scores were significantly lower in the experimental group compared to the control group (Table 4; p < 0.05).

In the pre-test, the Champion Health Belief Scale health motivation sub-scale score was found to be significantly lower in the experimental group women (18.22 ± 5.27) compared to the control group women (20.03 ± 3.74) (p < 0.05). In the mid-test, the Champion Health Belief Scale BSE self-efficacy sub-scale score was significantly higher in the experimental group women (35.10 ± 7.90) compared to the control group women (30.24 ± 10.19) (p < 0.05). In the post-test, the Champion Health Beliefs Scale perceived susceptibility, health motivation, BSE benefits, BSE self-efficacy, and mammography benefits sub-scale scores were significantly higher in the experimental group women compared to the control group women (p < 0.05). Besides, the Champion Health Belief Scale BSE barriers and mammography barriers sub-scale scores were significantly lower in the experimental group women compared to the control group women (Table 4; p < 0.05).

Mid-test and post-test BCAS mean scores of the experimental and control groups were significantly lower compared to the pre-test (Table 5; p < 0.001). Pre-test, mid-test and post-test Champion Health Belief Scale perceived susceptibility sub-scale scores of the control group were found to indicate statistically significant differences (p < 0.05). The difference in the control group was found to be between the third measurement and pre-test and mid-test (p < 0.01)

Pre-test, mid-test and post-test Champion Health Belief Scale perceived seriousness sub-scale scores of the experimental and control group women indicated statistically significant differences (Table 5; p < 0.05). The difference in the experimental group was found to be between the pre-test and mid-test. (p < 0.05). The difference in the control group was found to be between the mid-test and post-test and pre-test (p < 0.01).

Pre-test, mid-test and post-test Champion Health Beliefs Scale health motivation sub-scale scores of the experimental group women demonstrated statistically significant differences (Table 5; p < 0.001). The difference in the experimental group was found to be between the pre-test and mid-test and the post-test (p < 0.05). Besides, the women in the experimental group were found to have lower scores in the mid-test Champion Health Belief Scale health motivation sub-scale compared to the post-test.

Pre-test, mid-test and post-test Champion Health Beliefs Scale BSE benefits sub-scale scores of the experimental and control group women were found to have statistically significant differences (p < 0.001; p < 0.05). The difference in the experimental group was found to be between the pre-test and post-test (p < 0.05). Besides, the Champion Health Belief Scale BSE benefits sub-scale score was found to be lower compared to the mid-test and post-test. The difference in the control group was found to be between the mid-test and post-test (p < 0.05).

Pre-test, mid-test and post-test Champion Health Belief Scale BSE barriers sub-scale scores of the experimental group women were found to have statistically significant differences (p < 0.001). The difference in the experimental group was found to be between the pre-test and mid-test and post-test (p < 0.05).

Pre-test, mid-test and post-test Champion Health Belief Scale BSE self-efficacy sub-scale scores were found to have statistically significant differences between the experimental and control group women (p < 0.001; p < 0.001). The difference in the experimental grup was found to be between the pre-test and post-test (p < 0.05). Besides, the Champion Health Belief Scale BSE self-efficacy sub-scale score of the experimental group women was found to be lower compared to mid-test and post-test. The difference in the control group was found to be between pre-test and post-test and mid-test (p < 0.05).

Experimental and control group women’s pre-test, mid-test and post-test Champion Health Belief Scale mammography benefits sub-scale scores were found to have statistically significant differences (p < 0.001; p < 0.05). The difference in the experimental group was found to be between the pre-test and mid-test and post-test (p < 0.05). Besides, the experimental group women’s Champion Health Belief Scale mammography benefits sub-scale score was found to be lower compared to mid-test and post-test. The difference in the control group was found to be between the pre-test and mid-test (p < 0.05).

Experimental group women’s pre-test, mid-test and post-test Champion Health Belief Scale mammography barriers sub-scale scores were found to have statistically significant differences (p < 0.001). The difference in the experimental group was found to be between the mid-test and post-test and pre-test (p < 0.05; Table 5).

Although breast cancer awareness increases with women’s education levels and age, and it is commonly encountered, especially in the menopause period [49]. In this study, six out of every 10 women in the experimental group and five out of every 10 women in the control group reported to know how to perform BSE. Besides, five out of every 10 women in the experimental group and five out of every 10 women in the control group reportedly performed BSE (Table 1). In their study that investigated performing BSE through short messages sent to women monthly, Alkan & Akyıldız (2024) reported that the ratio of performing BSE was 69% before education, and it increased up to 85% after the education [15]. Therefore, using education in screening tests is of great importance [50]. Various education methods could be effective in breast cancer screening methods [16, 25, 51, 52]. Nurses have highly important roles in teaching, performing and consulting for the early screening tests for the prevention of breast cancer. Therefore, this study aims to investigate the effect of animation-based education on menopausal women’s breast cancer attitudes, behaviors, and early screening test uptake.

This study found that animation-based education decreased overall and psychological menopause symptoms (Table 2). Six et al. (2025) reported that animation-based education decreased stress and depression levels [27]. Hammarberg et al. (2024) detected that the education given to middle-age women increased women’s cognition, improved their health behaviors, and increased their heath perception because the videos were short [53]. The findings of this study are in line with the findings reported by Six et al. and Hammarberg et al., which is considered to result from the cartoons, conversation techniques, and gestures and mimics involved in animations. With these effects, animation is recommended to be used in menopausal women.

This study found that animation-based education increased experimental group women’s breast cancer awareness compared to the control group in the mid-test (Table 3). Taşhan et al. (2020) reported that theory-based education increased performing BSE in the first and sixth month, but had no effects in the third month after education [42]. Payán et al. (2020) reported that the education given to women aged 40 and over through brochures increased women’s breast cancer knowledge levels right after and three months after the education [51]. Wondmu et al. (2022) reported that education given to women through PowerPoint presentations increased women’s performing breast self-examination every month approximately three times more [52]. Ghaffari et al. (2018) detected that education based on the Health Belief Model increased women’s BSE knowledge level, having mammography, and performing BSE behaviors [54]. Ahmed & Shrief (2019) reported that education for breast cancer increased the importance given to BSE, frequency of BSE, and performing BSE in an appropriate position [50]. This finding indicates that women’s early screening test uptake increases with the increase in their level of knowledge.

This study found that compared to the women in the control group, the women in the experimental group increased their Champion Health Belief Model Scale BSE self-efficacy scores in the mid-test, but other sub-scale scores were not affected. Besides, it was found that their perceived susceptibility, BSE benefits, BSE self-efficacy, mammography benefits mean scores increased but BSE barriers and mammography barriers mean scores decreased in the post-test (Table 4). Similar to the results of the present study, Arrab et al. (2018) found that education given through visual materials increased women’s Champion Health Belief Model Scale perceived susceptibility, perceived seriousness, perceived benefits, self-efficacy, and cues to action sub-scale scores [41]. Mohammadnabizadeh and Mohammadi (2025) found that the education given to the women in the premenopausal period increased women’s breast cancer perceived susceptibility, perceived benefits, self-efficacy, screening methods uptake, controlling behaviors, intention to demonstrate positive behaviors and decrease barriers to screening [55]. Kocaöz et al. (2018) found that the education based on the Health Belief Model did not affect the Champion Health Belief Model Scale BSE benefits sub-scale scores, increased self-efficacy and mammography benefits sub-scale scores, and decreased mammography barriers sub-scale scores [25]. Ştefănuţ and Vintila (2022) reported that the psychotherapy based on the Health Belief Model increased women’s BSE perceived benefits and breast examination self-efficacy. Breast cancer education given to women could increase their level of knowledge [56]. However, education should continue in long periods so that knowledge can turn into behavior [56]. This finding supports the findings showing that Champion Health Belief Model sub-scale mid-test indicated no differences 14 days after education but increased in the 3-month post-test, when the education continued.

This study found that the women in the experimental group increased their breast cancer awareness and Champion Health Belief Model Scale perceived benefit and self-efficacy sub-scale mean scores and decreased their barriers in the post-test compared to the pre-test (Table 5; p < 0.05). On the other hand, control group women’s breast cancer awareness, Champion Health Belief Model Scale BSE perceived benefits sub-scale score increased and perceived susceptibility, perceived seriousness sub-scale scores decreased in the post-test compared to the pre-test (Table 5; p < 0.05). Ali et al. (2025) reported that women used social media sites such as Facebook and YouTube to receive information about breast cancer [57]. The study found that the use of social media increased knowledge about breast cancer, yet it had no effects on screening test uptake [57]. Meer et al. (2020) found that public service announcements increased women’s breast cancer knowledge level[58]. This study found that women who did not have breast cancer symptoms, although they are exposed to these announcements, did not have the screening tests[58]. The findings of this study are in line with those of Ali et al. (2025) and Meer et al. (2020). In this study, both groups were found to have increased breast cancer awareness and positive beliefs about breast cancer in the post-test compared to the pre-test; when the sources of knowledge about breast cancer are analyzed in both groups, it was found that 2 in every 10 women received information from media rather than health personnel, which is considered to associated with this result.