Mammography-Specific Self-Efficacy Scale – Arabic Version

1. Abstract

Breast cancer remains one of the most diagnosed malignancies and leading causes of cancer-related mortality among women worldwide, including in the Middle East. While clinical screening via routine mammography is effective for early detection and mortality reduction, adherence to screening guidelines across Arab populations has historically lagged behind international targets. This disparity is influenced not only by logistical or socio-demographic barriers, but fundamentally by underlying health-related cognitive constructs. Central among these is self-efficacy, defined within Albert Bandura’s Social Cognitive Theory as an individual’s belief in their capability to execute courses of action required to achieve specific behavioral attainments.

The Mammography-Specific Self-Efficacy Scale – Arabic Version (MSSE-Ar) was adapted and psychometrically validated by Abdulmohsen Hamdan Al-Zalabani (2019) to address the need for a culturally attuned, linguistically valid instrument for clinical research and preventive healthcare screening. Derived from established Western operationalizations of cancer screening confidence, the MSSE-Ar comprises 10 items administered via a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”), yielding a total summative score between 10 and 50 points.

Psychometric evaluation conducted with 221 women aged 30 years and older recruited from primary healthcare centers in Al-Madinah Al-Munawarah, Saudi Arabia, revealed that the instrument has a stable unidimensional factor structure. Confirmatory factor analysis (CFA) demonstrated good model fit after correlating redundant error terms (Comparative Fit Index [CFI] = 0.961, Tucker-Lewis Index [TLI] = 0.943, Root Mean Square Error of Approximation [RMSEA] = 0.076, and Standardized Root Mean Square Residual [SRMR] = 0.045), with standardized factor loadings ranging from 0.42 to 0.85. The scale demonstrated high internal consistency reliability (Cronbach’s alpha = 0.88; corrected item-total correlations between 0.44 and 0.74). Construct and known-groups validity were supported by the scale’s ability to statistically differentiate women with a prior history of mammography within the preceding two years (mean = 39.00) from those who had never been screened (mean = 35.88), as well as aligning with the action stages of the Transtheoretical Model. The MSSE-Ar provides a reliable assessment tool for epidemiological inquiries, public health surveillance, and the formulation of targeted educational interventions across Arabic-speaking demographics.

2. Keywords

Mammography, Self-Efficacy, Breast Cancer Screening, Psychometrics, Arabic Validation, Health Behavior, Preventative Medicine, Social Cognitive Theory, Confirmatory Factor Analysis, Transtheoretical Model

3. Authors

The cultural adaptation and empirical psychometric validation of the Arabic version of the scale was executed by:

• Abdulmohsen Hamdan Al-Zalabani, MD, SBFM, ABFM, FFPH
  Department of Family and Community Medicine, College of Medicine, Taibah University, Al-Madinah Al-Munawarah, Kingdom of Saudi Arabia.
  Email: [email protected]

The conceptual foundation of mammography-specific self-efficacy measurement originates from early operationalizations by Victoria L. Champion and colleagues in health psychology and behavioral oncology.

4. Purpose

In preventive oncology, reducing breast cancer mortality depends directly upon secondary prevention through population-level screening mammography. Despite state-sponsored initiatives, widespread availability of diagnostic infrastructure, and fully subsidized healthcare access in countries such as the Kingdom of Saudi Arabia, screening compliance remains lower than recommended public health thresholds. Many eligible women present with advanced-stage, metastatic disease at initial diagnosis. Research into health behavior indicates that structural determinants—such as geographical distance, financial expenditure, or clinic accessibility—do not fully account for screening avoidance. Psychological, emotional, and cognitive barriers, notably procedural apprehension, fatalistic health beliefs, modesty concerns, and low perceived competence, play a central role.

The primary purpose of the Mammography-Specific Self-Efficacy Scale – Arabic Version (MSSE-Ar) is to provide an empirical instrument calibrated to assess an Arabic-speaking woman’s perceived self-efficacy in scheduling, organizing, and completing a screening mammogram. In clinical contexts, measuring general health locus of control or broad generalized self-efficacy frequently lacks the diagnostic granularity required to predict specific health actions. By localizing self-efficacy directly to the procedural, emotional, and logistical sequence of acquiring a mammogram, the MSSE-Ar bridges an important assessment gap in Middle Eastern clinical psychology and preventive oncology.

For health educators, epidemiologists, and behavioral researchers, the MSSE-Ar serves several applied functions:

• Targeted Risk Stratification: It identifies individuals or sub-populations exhibiting diminished screening-related self-efficacy, allowing primary healthcare professionals to intervene prior to non-attendance.
• Intervention Formulation: By elucidating specific areas of low confidence (e.g., handling procedural discomfort, managing negative affective states regarding diagnostic results, navigating appointment logistics), public health programs can develop targeted educational messaging rather than generic reminders.
• Outcome Evaluation: It functions as a standardized pre- and post-intervention outcome measure to evaluate the efficacy of psychological, educational, and motivational interventions designed to increase breast cancer screening rates.
• Theoretical Integration: The instrument facilitates the empirical investigation of behavioral models, such as the Health Belief Model (HBM) and the Transtheoretical Model (TTM), within non-Western linguistic and sociocultural environments.

5. Psychological Construct

The psychological construct evaluated by the MSSE-Ar is domain-specific perceived self-efficacy. Conceptualized within social-cognitive frameworks, self-efficacy is not an omnibus personality trait or global optimism; rather, it represents a dynamic generative capacity whereby individuals integrate cognitive, social, emotional, and behavioral sub-skills to manage situational demands.

Within cancer screening adherence, mammography-specific self-efficacy represents a woman’s cognitive appraisal of her capacity to initiate and maintain the actions required to obtain a mammogram, particularly when encountering personal, systemic, or affective obstacles. The MSSE-Ar operationalizes this as a unidimensional construct that encompasses several practical dimensions:

• Logistical and Temporal Self-Efficacy: Confidence in managing scheduling demands, coordinating household or familial responsibilities, securing appropriate transportation, and committing dedicated time to attend a dedicated radiology or primary care facility.
• Affective and Anxiety Regulation: The perceived ability to confront, modulate, and overcome fears associated with procedural pain, physical compression of breast tissue, anticipation of diagnostic uncertainty, or potential malignant findings.
• Interpersonal and Sociocultural Navigation: Confidence in communicating personal health requirements within the familial unit, requesting support or permission if culturally expected, and interacting with healthcare personnel despite feelings of modesty or apprehension.
• Procedural Continuance: Self-belief in navigating the medical environment, completing registration requirements, interacting with clinical and technical staff, and tolerating the test protocol to completion.

The scale models these operational facets as manifestations of an underlying single latent trait of screening-specific confidence. Elevated scores represent an integrated perception of self-mastery over screening barriers, whereas lower scores reflect susceptibility to behavioral abandonment when confronted with minor hurdles.

6. Theoretical Framework

The structural design and conceptual validation of the MSSE-Ar are grounded in Albert Bandura’s Social Cognitive Theory (SCT), supplemented by behavioral decision-making constructs from the Transtheoretical Model of Behavior Change developed by Prochaska and DiClemente.

According to Social Cognitive Theory, human functioning is sustained through triadic reciprocal determinism—the continuous interaction between personal cognitive factors, behavioral patterns, and environmental influences. Bandura proposed that outcome expectancies alone (e.g., understanding that a mammogram can identify tumors early) are insufficient to motivate action if an individual doubts their capacity to perform the prerequisite behaviors. Self-efficacy beliefs influence whether health behavior change will be initiated, the amount of effort expended, and the duration of persistence in the face of impediments.

Bandura postulated four primary informational sources that govern the formation and evolution of self-efficacy judgments, each relevant to mammography screening:

• Mastery Experiences: Successful execution of a target behavior serves as the strongest catalyst for high self-efficacy. In the validation of the MSSE-Ar, women who had previously completed a screening appointment showed significantly elevated scores, as their personal experiential history diminished anticipatory dread.
• Vicarious Experiences: Observing peers, relatives, or community members successfully undergo screening without debilitating distress enhances an observer’s confidence in their own capability.
• Verbal and Social Persuasion: Encouragement from primary care clinicians, family members, and health campaigns can bolster self-belief, provided the target challenges remain within manageable bounds.
• Somatic and Emotional States: Individuals interpret physiological arousal, such as acute autonomic tachycardia or visceral tension, as signs of vulnerability. Elevated self-efficacy allows individuals to reframe physiological arousal during appointments as normal anticipatory reactions rather than reasons to abort the procedure.

The Transtheoretical Model further underpins the instrument’s construct validity. The TTM posits that health behavior change is achieved across sequential stages: Precontemplation (no intent to screen within six months), Contemplation (considering screening within six months), Preparation (intending to screen within 30 days), Action (actively undergoing screening or compliant within current interval guidelines), and Maintenance (regular adherence over years). In empirical assessments of the MSSE-Ar, self-efficacy systematically climbed as individuals progressed along these discrete stages, supporting the construct that self-efficacy serves as a primary cognitive driver of stage transitions.

7. Validity

The validation study by Al-Zalabani (2019) in Saudi Arabia examined several forms of construct validity for the MSSE-Ar, including face, content, known-groups, and structural validity.

Content and Cultural Adaptation Validity: The translation followed international standards for cross-cultural health research, employing rigorous forward- and back-translation protocols. An expert panel in family medicine, community health, and behavioral epidemiology examined the translated items to verify linguistic accuracy, semantic equivalency, and cultural appropriateness within the Saudi context, ensuring that concepts aligned with regional healthcare interactions.

Known-Groups Validity: A primary method for demonstrating construct validity is establishing that an instrument can discriminate between groups known to differ on the underlying attribute. Al-Zalabani evaluated differences across mammography screening histories:

• Women who had obtained a mammogram within the preceding two years demonstrated a statistically significant higher mean self-efficacy score (mean = 39.00, standard deviation [SD] = 6.47) compared to women who had never undergone a mammogram (mean = 35.88, SD = 7.14; p < 0.05).
• When analyzed using the Transtheoretical Model, self-efficacy scores differed significantly across stages of change: women in the Action/Maintenance stage reported higher scores compared to those in the Precontemplation or Contemplation phases, confirming predictive validity regarding clinical screening participation.

Item Discrimination and Metric Association: Corrected item-total correlations across the 10 items ranged from 0.44 to 0.74. These indices confirm that all items contribute meaningfully to the target construct without falling below acceptable discriminatory thresholds (>0.30), while remaining distinct enough to prevent measurement redundancy.

8. Reliability

The MSSE-Ar demonstrated strong internal consistency reliability in its primary target population. Psychometric analyses conducted on the complete validation sample (N = 221) produced an overall scale Cronbach’s alpha of 0.88. This value exceeds the conventional 0.70 benchmark for research instruments and aligns with the 0.80 standard recommended for screening measures in clinical practice.

This level of internal consistency indicates strong homogeneity among the items, showing they reliably capture the single overarching dimension of mammography self-efficacy. Analysis of alpha-if-item-deleted statistics indicated that removing any single item failed to yield an increase in the composite coefficient, confirming that each item contributes positively to the overall variance captured. The consistency matches figures reported for the original English-language versions developed by Victoria Champion and colleagues, which typically report Cronbach’s alpha values between 0.87 and 0.90.

9. Factor Analysis

To verify the internal structural validity of the translated and culturally adapted MSSE-Ar, a Confirmatory Factor Analysis (CFA) was conducted to test the hypothesized unidimensional model.

The initial specification of an unconstrained single-factor model produced marginal goodness-of-fit indices, attributable to localized residual covariance across items sharing semantic and procedural similarities. To address this, the model was refined by allowing correlated measurement error terms between theoretically linked item pairs. This adjustment resulted in strong model fit across standard indices:

• Comparative Fit Index (CFI): 0.961 (exceeding the ≥0.95 criterion for superior fit)
• Tucker-Lewis Index (TLI): 0.943 (exceeding the standard ≥0.90 threshold)
• Root Mean Square Error of Approximation (RMSEA): 0.076 (falling below the upper acceptable threshold of ≤0.08, with a satisfactory 90% confidence interval)
• Standardized Root Mean Square Residual (SRMR): 0.045 (well within the acceptable range of ≤0.08)

Standardized factor loadings for the 10 items were statistically significant (p < 0.001), ranging from 0.42 to 0.85. The presence of moderate to strong factor loadings across all items confirms that the unidimensional structure is sustained in the Arabic-speaking population, indicating that mammography self-efficacy functions as a unified psychological attribute.

10. Instrument / Measurement Tool

• Instrument Name: Mammography-Specific Self-Efficacy Scale – Arabic Version (MSSE-Ar)
• Test Type: Structured interview-administered psychometric assessment; can also be completed as a self-report survey where appropriate
• Intended Population: Arabic-speaking adult women eligible for breast cancer screening (typically aged 30 years and older)
• Number of Items: 10 items
• Response Format: 10 items, 5-point Likert scale (1 = strongly disagree to 5 = strongly agree)
• Administration Modality: Administered as a structured interview by trained female nursing or clinical research staff, helping minimize misinterpretations stemming from health literacy variations
• Completion Duration: Approximately 5 to 10 minutes
• Scoring Instructions: Total score is calculated as the sum of all individual item responses. With 10 items scored from 1 to 5, total possible scores range from 10 to 50. Higher scores indicate greater perceived self-efficacy in obtaining a screening mammogram.
• Normative Reference Data: In the validation cohort of 221 Saudi women (mean age = 39.6 years), the sample mean score was 36.5 with a standard deviation of 7.1.

11. Permissions & Fee and Test Year

• Year of Adaptation Publication: 2019
• Primary Author: Abdulmohsen Hamdan Al-Zalabani
• Academic Affiliation: Taibah University, College of Medicine, Al-Madinah Al-Munawarah, Saudi Arabia
• Original Publication Journal: Saudi Medical Journal
• Accessibility and Licensing: The study is published under an open-access model. However, researchers planning to implement the MSSE-Ar for academic, public health, or clinical purposes must request access to the scale and verify licensing terms directly with the corresponding author ([email protected]) or via Taibah University.
• Fee: Generally available free of charge for non-commercial academic research and clinical audits, subject to formal author notification and institutional review board approval.

12. References

• Al-Zalabani, A. H. (2019). Adaptation and validation of the Arabic version of self-efficacy scale for mammography. A report on psychometric properties. Saudi Medical Journal, 40(7), 691–697. https://doi.org/10.15537/smj.2019.7.23938
• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Champion, V. L. (1999). Revised susceptibility, benefits, and barriers scale for mammography screening. Research in Nursing & Health, 22(4), 341–348. https://doi.org/10.1002/nur.20088
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390

13. Items of the Scale