Health Promoting Behavior and Its Influencing Factors in Iranian Breast Cancer SurvivorsRESEARCH ARTICLEHealth Promoting Behavior and Influencing Factors in IranianBreast Cancer SurvivorsFatemeh Moghaddam TabriziAbstractBackground: The purpose of this study was to investigate the associations among the internal health locus ofcontrol, depression, perceived health status, self efficacy, social support, and health-promoting behavior in Iranianbreast cancer survivors and to determine influential variables. Materials and Methods: A predictive design wasadopted. By convenient sampling the data of 262 breast cancer survivors in Iran were collected by questionnairesduring 2014. Data were analyzed applying descriptive statistics, t-tests, one-way ANOVA, Pearson’s correlationcoefficients, and stepwise multiple regression. Results: The internal health locus of control, depression, perceivedhealth status, self efficacy, social support and undergoing chemotherapy all correlated significantly with thehealth-promoting lifestyle. Stepwise multiple regression analysis revealed that social internal health locus ofcontrol, depression, perceived health status, self efficacy and social support and chemotherapy accounted forabout 39.8% of the variance in health promoting lifestyle. The strongest influence was social support, followedby self efficacy, perceived health status, chemotherapy and depression. Conclusions: The results of the studyclarifed the seriousness of social support, self efficacy, perceived health status and depression in determiningthe health-promoting lifestyle among Iranian breast cancer survivors. Health professionals should concentrateon these variables in designing plans to promoting a healthy lifestyle.Keywords: Health promotion behavior - internal control - self efficacy - perceived health status social supportAsian Pac J Cancer Prev, 16 (5), 1729-1736IntroductionBreast cancer is the primary cause of cancer deathamong women universally. It is predicted that over 508,000 women globally died in 2011 due to breast cancer.Although breast cancer is thought to be a disease of theadvanced world, nearly 50% of breast cancer cases and58% of deaths happen in less developed countries (WorldHealth Organization, 2014). Breast cancer survival ratesdiffer greatly throughout the world, ranging from 80%or over in North America, Sweden and Japan to around60% in middle-income countries and below 40%in lowincome countries. The low survival rates in less developedcountries can be described mainly by the lack of earlydiagnosed projects, resulting in a high prevalence ofwomen existing with late-stage disease, as well as by thelack of adequate detection and treatment facilities (WorldHealth Organization, 2014). According to the most recentIranian cancer registry report, breast cancer is the mostprevalent cancer among Iranian women (Mousavi et al.,2009).Iranian women are affected by breast cancer atleast 10 years earlier than their counterparts in developedcountries (Chon et al., 2001).Mammography lead to decrease mortality in breastcancer up to 16% and even 29% in 40-49 age group withearly detection (Hellquist et al., 2011). Thus, in spiteof high occurrence, detection and treatment in primarystages elevates the portion of survivors (Rızalar and Altay,2010). Since the survived individuals are grown, healthpolicy makers have started to concentrate to their life timeevents (Fallowfield and Jenkins, 2015). Diabetes, heartdisease and obesity are the complications that threatencancer survivors more than those other population incomparison (Aleman et al., 2014; Naughton and Weaver,2014; Rugbjerg et al., 2014; Travier et al., 2014). In thisline Ashing et al. (2014) demonstrated, 75% of breastcancer survivors revealed at least one comorbidity witharthritis (37%), high blood pressure (37%), psychologicalcomplications (29%), and diabetes (19%). These comorbidsituations are mostly link with diminish total survivaland elevates mortality (Phillips and McAuley, 2015).Consequently, shifting to a health-promoting lifestyle isvital to cancer survivors, both for health status promotionand preventing (Mishra et al., 2015; Schiavon et al., 2015).It is established that adjusting with healthy life styleis a major barrier to cancer survivors (Moon et al., 2013;Hauken et al., 2015). Greater risks of comorbidity incancer survivors and other proofs that cancer survivorsNursing and Midwifery Department, Reproductive Health Research Center, Urmia University of Medical Sciences, Urmia, Iran*For correspondence: [email protected] Pacific Journal of Cancer Prevention, Vol 16, 20151729

Fatemeh Moghaddam Tabriziare at higher risks of other cancers and chronic diseases,interventional programs to make aware of theses groupregarding their health problems are mostly essential.Since the process of cancer treatment is complicatedand the outcome of the cure is ambiguous, it is critical fora person to pursue health promotion lifestyles.It is shown that undertaking health behaviors after acancer detection will be beneficial effort to strengthenthe sense of control regarding their health in individuals(Meraviglia and Stuifbergen, 2011). Studies have shownthat influential factors such as health locus of control,depression, self-efficacy, perceived health status andsocial support are affecting on health-promoting lifestyles.Health locus of control (HLC) has been investigatedin relation to health attitudes and health behaviors(Falzon et al., 2012; Berglund et al., 2014; Gururatanaet al., 2014; Iskandarsyah et al., 2014). For breast cancersurvivors, achieve to a supportive surroundings can avoidpsychological complications and sustain her well being(Lagana et al., 2014; Nazik et al., 2014). Depression hasrecognized as a negative predisposing variable for cancer,such as breast cancer (Sahin et al., 2013; Sotelo et al.,2014). When individuals are self assessed as having highself-efficacy, they will energetically cooperate in healthbehaviors or lifestyles and then they empower to performhealthy behaviors (Hanson, 2014). Low level of perceivedhealth has been related with various physical symptomssuch as tiredness, headaches, musculoskeletal problems,mastitis, perineal pain, dysuria, stomachaches, and nausea(Schytt et al., 2005). So exploring the influential factorsand variables on health-promoting behaviors, empowerthe researchers to give authority in following a healthpromoting lifestyle.The research questions in this study include (1)what are the relationships among demographic andillness-related characteristics, IHLC, depression, socialsupport, self-efficacy, perceived health status, of healthbehaviors, and health-promoting behaviors? (2) whatare the predictors of health promoting lifestyles in breastcancer survivors?Materials and MethodsThis research used a predictive design to examinerelationships among IHLC, depression, social support,self-efficacy, perceived health status, and healthpromoting behaviors in Iranian breast cancer survivors andto identify factors influencing health-promoting behaviors.Included in this study were Iranian breast cancer survivorswho had finished treatment by surgery, chemotherapy, and/or radiation but not necessarily hormone therapy.Data collection proceduresInitially, the researchers approached the leaders ofoncology wards, explaining the purpose of the studyand asking for a list of potential subjects with telephonenumbers to contact. The leaders then recruited the potentialsubjects who were willing to participate in the study ona voluntary basis. A list of 391potential subjects wasobtained by leaders of oncology wards. The potentialsubjects, then, were approached by the researchers by1730Asian Pacific Journal of Cancer Prevention, Vol 16, 2015phone to make sure whether they wanted to participatein the study. Among 391 potential subjects, 346 answeredthe phone and 45 did not. Among the 346 subjectswho answered the phone, 18 refused to participate,explaining that they were too busy or without providingany explanation. Once questionnaires were sent to the328 subjects who agreed to participate voluntarily in thestudy, 283 subjects returned the questionnaires. Twentyone questionnaires were not complete enough for theanalysis; thus, in the end 262 questionnaires were used.Ethical considerationsBefore collecting the data, the proposal for the studywas approved by the Institutional Review Board wherethe study was carried out. All potential subjects wereinformed about: the purpose of the study; what being inthe study would involve; anonymity and confidentialityissues; and, the right to withdraw from the study, at anytime, without repercussions. In addition, each potentialsubject was given the primary investigator’s (PI) contactinformation and encouraged to contact her if they hadquestions or concerns. After the verbal consent wasobtained initially by phone, the written consent form andthe questionnaires with a stamped envelope to return themailed questionnaire were mailed.Internal health locus of controlThe C form of the Multidimensional Health Locus ofControl (MHLC) scales (Wallston et al., 1994) was usedto assess participants’ feelings of control over their illnessor disease. It was designed as a generic medical conditionspecific measurement of locus of control that could easilybe adapted for use with any medical condition. It consistsof one Internal scale and three External scales: (1) chance,(2) doctors, and (3) powerful others. In this study, the word‘condition’ was substituted with ‘cancer’ for the patients.This instrument consists of 18 items using a 6-point Likertformat, ranging from 1 ‘strongly disagree’ to 6 ‘stronglyagree’. Alpha reliabilities of the MHLC subscales rangedfrom 0.673 to 0.767 when it was developed (Wallston etal., 1978). When it was used in the Iranian version, thealpha reliabilities of each subscale were 0.61 for IHLC,0.68 for PHLC, and 0.8 for CHLC (Hashemian et al.,JPMA). The scores of IHLC were used for the analysis.The higher the IHLC score, the more likely it is that anindividual believes he/she has control over his/her health.Social supportTo measure social support, the Personal ResourceQuestionnaire II (PRQ-II) developed by Weinert (Weinert,1988) was used. It is a self administered norm-referencedinstrument measuring the social support perceived bysubjects. It has 25 items with three dimensions. It is a fourpoint scale with total scores ranging from 25 to 100, wherehigher scores indicate better social support. In the studyof Baheiraei et al (2012) in Iran, the Cronbach’s α and theintra-class correlation coefficient (ICC) were established0.84 and 0.9, respectively (Baheiraei et al., 2012).Health-promoting lifestyleThe Health-Promoting Lifestyle Profile II developed

Health Promoting Behavior and Its Influencing Factors in Iranian Breast Cancer Survivorsby Walker et al. (1987) was used to measure healthpromoting lifestyle. It is an instrument with a 52-itemsummated behavior rating scale. It employs a four-pointresponse format to measure frequency of self reportedhealth-promoting behaviors with 1 never, 2 sometimes,3 often, and 4 routinely. It consists of the domains ofhealth responsibility, physical activity, nutrition, spiritualgrowth, interpersonal relations, and stress management(Walker et al., 1987). Thus, health responsibility has 8items, physical activity 8, nutrition 9, spiritual growth 9,interpersonal relations 8, and stress management 8. Thetotal scores of the HPLP II range from 50 to 200 with ahigher score indicating a better health-promoting lifestyle.For this study, the Health-Promoting Lifestyle Profile IIwas translated into Persian using to the following steps:(i) the original English instrument was translated intoIranian by the researcher, (ii) the Iranian version wastranslated back into English by a bilingual professionalperson who had not seen the original English versionand (iii) the three versions were then compared. Unclearor incorrect translations were discussed between theresearcher and the professional translator until agreementwas obtained. Thus, the translation process followed therecommendations provided by the California AcademicPress and according (White and Elander, 1992). Forpresent study alpha reliability coefficient for the total scaleis 0.89. The alpha coefficients for the subscales range from0.699 to 0.898.DepressionThe Center for Epidemiologic Studies-Depression(CES-D) scale is a self-report scale designed to measuredepressive symptomatology in the general population(Radloff, 1977) and is commonly used to measuredepression in cancer patients. Hann et al. (1999) validatedits reliability and validity for women with breast cancer inparticular (Hann et al., 1999). To measure the degree ofdepression for this study, the persian version of the CES-Dscale translated and validated by researcher was used. Itconsists of 20 items with a four point scale, with higherscores indicating more depression. Item numbers 4, 8,12, 16 were coded in reverse because they were positivesentences. The total score of depression ranged from 0 atthe lowest to 60 at the highest. In the study of Chon et al.(2001), the alpha reliability coefficient was 0.91 (Chon etal., 2001). For this study, it was 0.83. In this study scoreshigher than 15 on the CES-D are considered indicativeof clinical depression as Chon et al. (2001) suggested(Chon et al., 2001).Perceived health statusThe women’s subjective rating of their own healthcondition by a one-item Short Form Health Survey withan 11-point numerical rating scale developed by Stewartet al. (1998) was measured (Stewart et al., 1998) . Scoresranged from zero (“I do not feel at all healthy”) to 10 (“Ifeel that I could not be healthier”). Higher scores indicatehigher levels of subjective health status. An 11-pointsingle item numerical rating scale is widely used tomeasure subjective feeling (Kim, 2009) and the validityof this subjective rating scale was reported in a previousstudy in Korea (Son et al.,2009). Before using this scale,three professors of women’s health nursing confirmed theappropriateness and applicability of the scale for breastcancer survivors.Perceived self-efficacyPerceived self-efficacy was measured by way of the10-item General Self Efficacy Scale (GSES). The itemswere rated on a 4-point Likert-type scale ranging from1 “not at all true” to 4 “exactly true.” An example of anitem on the GSES was “I can manage everything in mylife.” A total score, which could range from 10 to 40, wascalculated by summing response scores across all items. Ahigher score indicated greater perceived self-efficacy. Theperceived self-efficacy questionnaire was found to havea Cronbach’s alpha coefficient of 0.878 (Bandura, 1997).Data analysisThe Statistical Package for the Social Sciences (SPSS,SPSS Inc., Chicago, IL, U.S.A.), release version 10.0,was used for data analysis. First descriptive statistics wasapplied to analyze demographic and illness related factorsof the samples as well as the variables IHLC, depression,social support, self efficacy and health promotingbehaviour. Then one way ANOVA and t-tests were usedto investigate differences in health promoting lifestylebased on the demographic and illness related factors.Pearson’s correlation was used to determine associationsamong IHLC, depression, self efficacy social support, andhealth promoting lifestyle. At the end stepwise multipleregression analysis was used applying IHLC, depression,self efficacy and social support, to identify the significantpredictors which committed to health-promoting lifestylesin Iranian breast cancer survivors and to identify therelative contribution of each variable.ResultsDemographic factorsThe demographic factors of the sample are picturedin Table 1. The mean age of the samples was 47.9(SD 11.4), ranging from 25-72. Most of them (n 239)were married and 59% had attended high school andabove, and about 71% of the sample were not employed.Regarding financial situation only 20% of the sampledemonstrated that they had no money problem. Most ofthem were living in a city. A summary of the demographiccharacteristics of the participants is presented in Table 1.When differences of health-promoting behaviors referredto demographic characteristics were investigated, nosignificant differences were shown.Illness linked factorsRegarding illness-related characteristics, almost 77%of the samples had equal or less than stage II of breastcancer when they were detected (Table 2). Most of thesamples (n 228) had encountered mastectomy. Most ofthem (n 231) had earned chemotherapy. Investigatingdifferences of health-promoting behaviors referring toillness-related factors, no significant differences wererevealed exempting for enduring chemotherapy (t -3.01,Asian Pacific Journal of Cancer Prevention, Vol 16, 20151731

Fatemeh Moghaddam TabriziTable 1. Health Promotion Behavior by Demographic Characteristics N (262)Characteristicsn(%)Mean SDT or FpAge 4055(21)143.04 19.871.950.36240-60170(65)135.98 32.75 6037(14)140.34 21.89Range (25-72)Mean SD (47.9 11.4)Marital statusSingle23(9)141.46 12.760.550.622Married239(91)140.23 32.45EducationIilitrated34(13)136.45 42.120.590.532Primary73(28)137.21 23.62High school105(40)139.34 61.12Above college50(19)140.32 11.02EmploymentHousewife186(71)139.23 61.120.450.399Employed34(13)136.54 73.18Retired42(16)140.65 12.97Financial situationNo money problem39(20)140.45 21.460.950.331Fair147(51)136.23 51.08Not enough76(29)135.64 16.90Area of residenceBig city126(48)140.56 13.560.650.501Small city113(43)141.23 37.35Urban23(9)138.25 45.12Number of Children0-142(16)139.21 43.720.740.603297(37)140.53 23.50357(22)136.21 03.22 466(25)138.01 63.41Table 2. Health Promotion Behaviors by Illness Related Characteristics (N 262)Characteristicsn(%)Mean SDStage of disease at diagnosis05(2)139.26 10.36116(6)138.13 72.052181(69)139.40 12.80344(17)137.31 43.61Unknown16(6)136.34 51.12Type of surgeryMastectomy228(87)140.62 41.32Lumpectomy26(10)139.63 51.18Mastectomy and Lumpectomy8(3)136.24 53.70ChemotherapyYes231(88)141.95 16.37No31(12)130.05 11.06RadiotherapyYes152(58)139.46 22.76No110(42)138.73 92.45Hormone therapyYes149(57)139.35 46.13No113(43)137.51 73.42Years since diagnosis 1 yr52(20)138.34 61.121-3 yrs105(40)140.72 18.063-5 yrs60(23)138.83 69.12 5 yrs45(17)136.54 73.18Family history of breast canceryes65(25)139.55 16.77No197(75)140.35 51.46Other diseaseYes52(20)138.65 16.07No210(80)140.25 31.16*p 0.051732Asian Pacific Journal of Cancer Prevention, Vol 16, 2015T or F1.241.32-3.01*0.650.550.750.850.75

Health Promoting Behavior and Its Influencing Factors in Iranian Breast Cancer SurvivorsTable 3. Scores for IHLC, Depression, Social Support,and Health-Promoting Lifestyle (N 262Table 5. Stepwise Multiple Regression Analysis ofBreast Cancer Survivors’ Health promoting LifestylesVariable (actual range of scors)VariablesMean SDIHLC (6-36)Perceived health status (4-8)Depression(0-57)Social support(37-100)Self efficacy(13-40)Health-promoting lifestyle(71-190)Health responsibility(9-31)Physical activity(8-32)Nutrition(15-35)Spiritual growth(12-36)Interpersonal relations(8-32)Stress management(11-32)βPartialR2 Model R2withvariableadd25.16 4.246.58 1.8416.78 6.5480.34 11.4229.11 6.97139.87 66.2121.20 11.3219.32 22.3125.21 15.3528.11 13.6523.22 15.3520.30 17.22Social d health statusIHLC*P 0.05, **p 0.001p 0.030) (Table 2). Other pertinent illness-related factorsof the samples are also illustrated in Table 2.Scores for social support, self efficacy, depression, IHLC,and health-promoting lifestyleTable 3 shows that the mean score of IHLC was 25.16(SD 4.24). The mean score for depression was16.78(SD 6.54). The number of subjects who had scores higherthan 15, the cutoff point for clinical depression, was146 (55.9%). The mean score for social support, healthpromoting lifestyle were 80.34 (SD 11.42) and 139.87(SD 66.21) respectively. Among the six domains of ahealth promoting lifestyle, spiritual growth had the highestscore (28.11 13.65), while physical activity showed thelowest (19.32 22.31).Relationships among IHLC, depression, self efficacy,social support, and health promoting lifestyleTable 4 shows correlations among IHLC, depression,self efficacy, social support and a health-promotinglifestyle. Significant negative relationships were identifiedbetween IHLC and depression (r -0.1968, p 0.05),depression and social support (r -0.621, p 0.001),perceived health status and health-promoting lifestyle(-0. 1732, p 0.01) and depression and health-promotinglifestyle (r -0.1968, p 0.001). Significant positiverelationships were detected between IHLC and healthpromoting lifestyle (r 0.1301, p 0.05), and social supportand health-promoting lifestyle (r 0.6450, p 0.001).Predictors of health promoting lifestyles for breast cancersurvivorsResults of stepwise multiple regression analysisdemonstrated that 39.8% of the variance (p 0.001) inhealth-promoting lifestyles was elucidated by a 3810.3950.398of six predictors, social support, self-efficacy, depression,IHLC, perceived health status, and chemotherapy (Table4). The strongest predictor was social support (R2 0.309),followed by self-efficacy, chemotherapy, perceiveddepression and IHLC (Table 4). This revealed that thebreast cancer survivors had a higher prevalence of healthpromoting lifestyles if they experienced a strongerDiscussionTo investigate influential factors on health-promotingbehaviors, using a correlational, cross-sectional researchdesign with convenience sampling in 262 Iranian breastcancer survivors, we realized that the combined effectson health-promoting lifestyles, as the dependent variable,from a conjunction of five predictors, IHLC, depression,self efficacy social support, and chemotherapy asindependent variables, were higher than the effect of anysingle predictor by itself. All five variables elucidated39.8% of the variance in health promoting lifestyles inbreast cancer survivors. This shows that Iranian breastcancer survivors were more possibly to fallow a healthpromoting lifestyle if they had experience strong socialsupport, had higher self efficacy, had chemotherapy, hadIHLC and had lower depression. In summary, the fivepredictors of breast cancer survivors’ health promotinglifestyles established in this research could be emphasizesources on consultation needs for individuals with breastcancer. The variance of this study is higher than the workof Yi and Kim (2013) and Frank-Stromborg et al. (1990),which reported that 34.98 and 23.52 percent variance inhealth-promoting lifestyle among respectively.Consistent with the study of Yi and Kim (2013), Socialsupport, was the most important predictor of healthpromoting lifestyle in this study. It seems the admiring,supporting and appreciations the women, in this study,experienced from their family members and friends mayTable 4. Correlation among IHLC, Depression, Self Efficacy, Social Support, and Health-Promoting Lifestyle(N 262)VariableHealth-promoting lifestyleSocial supportSelf efficacyDepressionPerceived health 301*0.05620.1437*-0.1165*Asian Pacific Journal of Cancer Prevention, Vol 16, 2015IHLC11733

have improved their encouragement for better life style.The results of the current study are similar with otherstudies in other women which revealed powerful relationbetween social support and health-promoting behaviors(Lin et al., 2009; Thaewpia et al., 2012). The results ofthe study show that sociocultural construction of Iranianfamilies made people be responsible and awareness of theirfamilies and introduce a sense of belonging, depending,intimacy, and social unity. So with the result of this study,we can contemplate that social support is an importanttruth of conductive or in a society in which individualsinteractions are more dependent close on each other. Asa result, Iranian cancer survivors might have been hugelyinfluenced by the support of their family and friends inadjustment with health life style and fallowing healthybehavior. Consequently, in Iran having concentrationon family members and communities as well as cancersurvivors themselves is essential to establish healthy lifestyles so it should be the cornerstone of planning theprogram for health care makers.The findings of this study found that women witha higher self efficacy were revealed to empower forperusing health promoting lifestyles. This is consistentwith the results of other studies on cancer survivors(Pongthavornkamol et al., 2014), which found selfefficacy as a predisposing factor. In this line Pender’sHealth Promotion Model (Pender and Murdaugh, 2006)demonstrates that experienced self-efficacy affects actionby influencing perceived barriers to health heighteningbehaviors and statue of responsibility for fallowing aprogram in practice. People with high perceived selfefficacy have been realized to have assurance in theirability to implement special behaviors (Bandura, 1997). Ina result, people who have higher self-efficacy are mostlyto acquire knowledge to convert high risk behaviors tohealthy life style., and peruse appropriate and proper selfcare once the symptoms are revealed comparing those withlower self efficacy (Korpershoek and Bijl, 2011). Studiesin pregnant and obese women found that self efficacy as astrong predictor in health-promoting behaviors (Armitageet al., 2014; Thaewpia et al., 2012). In consequence, theresults indicate that for promoting health-promoting lifestyle in breast cancer survivors the consultations should befocused to receiving the self efficacy in health behaviors.The current study explored depression as a negativepredisposing factor. It demonstrates that depressionmust be assessed before fulfilling health-promotinginterventional programs. This is consistent with the resultsof other studies on cancer survivors (Yi and Kim, 2013).The present study showed that perceived health statushad an inverse effect on health promoting lifestyles inbreast cancer survivors. In consistent with our study, thestudy of Rottenberge et al (2014) showed poor self-ratedhealth was associated with increased risk of death in cancersurvivors. Christian et al. (2011) also demonstrated thatpoorer self-rated health was associated with both poorersleep and lower physical activity. Thus in providingintervention programs a picture of health status shouldbe clarify for patients to show them a real view of theirhealth situation for encouraging them to follow the healthybehaviors.1734Asian Pacific Journal of Cancer Prevention, Vol 16, 2015In this study IHLC describes ignorable amount ofvariance which shows that IHLC to be a small portion ofthe prediction of a health-promoting behavior. Swinneyet al. (2002) found similar results in their study withAfrican American people with cancer. Iskandarsyah et al.(2014) found that of women with breast cancer incline toattach their complications and illness to external sourcesof control, such as: physicians, significant others, chanceand God. One probable reason for these phenomena isassociated to the humor of cancer and its difficulties in100.0treatment process. The belief of unmanageable natureof cancer and the ambiguity and unpredictability ofits treatment might cause negative attitudes in patientsregarding personal control to overcome their illness.75.0This circumstance may lead to an expanded attitudes inexternal forces among individuals and low motivation andencouragement to improve health behavior.The mean score for a health-promoting lifestyle was50.0139.87 (SD 66.21) in the possible rage of 50-200. Thisis similar to that (Mean 135.93, SD 22.53) of breastcancer survivors in Korea (Yi and Kim, 2013). In the25.0study of Bahar et al (2014), the score was inconsiderablyhigher comparing with middle-aged healthy women(Mean 2.5 0.36).It could be speculate that people attempt to adjust 0a higher health promoting lifestyle after a cancerdetection (Mann et al., 2013). When each domain ofhealth-promoting behaviors was compared, the score ofspiritual growth was the highest among the six domainsin the current study. This is consistent with the work ofFrank-Stromborg et al. (1990) in the U.S in breast cancersurvivors, which indicated the score of self-actualizationwas the highest. On the other hand, the score of physicalactivity was the lowest in the present study, similar to theworks of Frank-Stromborg et al. (1990) which showed thatthe exercise was the lowest. This suggests that a feasibleapproach would be to promote light intensity activities asa way of ameliorating a sedentary life-style. Thus exerciseshould be emphasized in developing interventions for ahealthy lifestyle, although more studies are required toidentify which domain is in dominant and main role tohealth promotion.The mean score for depression was 16.78 (SD 6.54),and a considerable amount (55.9%) of the sampleemphesized depressive symptoms at a status related withclinically serious category of depression ( 15 on theCES-D) in this study. when compared with Korean breastcancer survivors, these are noticable (Yoo et al., 2009; Yiand Kim, 2013). So oncology professionals must considerspecialized observation to determine depression symptomsin Iranian breast cancer survivors, and to try to help themto overcome to it before fulfilling interventional projectsfor a healthy lifestyle.The mean score for IHLC was 25.16 (SD 4.24) witha possible range from 6 to 36 in this study. This is lessthan for those of individuals in Korea 29.62 (SD 4.96)(Yi and Kim, 2013). A review study about religion an

recommendations provided by the California Academic Press and according (White and Elander, 1992). For present study alpha reliability coefficient for the total scale is 0.89. The alpha coefficients for the subscales range from 0.699 to 0.898. Depression The Center for Epidemiologic Studies-Depression