Maltese Translation and Adaptation of Champion’s Health Belief Model Scale and the Revised Illness Perception Questionnaire for Breast Screening Among Maltese Women

Background and Purpose: Translating, adapting, and piloting Champion’s Health Belief Model Scale for Mammography Screening (CHBMS-MS) and Revised Illness Perception Questionnaire (IPQ-R) among Maltese women. Methods: The Maltese questionnaire (Maltese Breast Screening Questionnaire [MBSQ]) was developed through 9 steps. Bilingual women (n = 15) completed MBSQ at 2 time points. Results: During forward-backward translations (Steps 1–4), 4 English controversial terms were raised. Twelve experts agreed on terminologies during adaptation process (Step 5). Following face validity (n = 6; Step 6), 3 items were deleted. Following reconciliation (Step 7) and proofreading (Step 8), MBSQ consisted of 121 items. Pilot testing (Step 9) showed positive correlation (CHBMS-MS = .87, IPQ-R = .85; p < .001); high Cronbach’s alpha (CHBMS-MS = .93, IPQ-R = .92); overall acceptable internal consistency (CHBMS-MS = .69–.83, IPQ-R = .75–.93); and acceptable test–retest reliability correlations: CHBMS-MS (Maltese = .62–.76; English = .61–.84), IPQ-R (Maltese = .63–.82; English = .61–.91; p < .001). Conclusions: Maltese and English scale items demonstrated high reliability and validity preliminary values.

B reast cancer is the primary site of cancer in Maltese women (Malta National Cancer Registry, 2015). Over the last decade, an average of 280 women were diagnosed yearly with breast cancer in Malta (Malta National Cancer Registry, 2015). Breast screening (BS) by mammography has shown to decrease breast cancer mortality rates in women aged 50-69 years by 25%-30% (Greif, 2010). By the end of Malta's first BS round, the rates of participation were below European benchmarks (i.e., acceptable participation [.70%] or higher desirable level [.75%] specified in European guidelines; Eurostat, 2014), such that less than 60% of women aged 50-60 years had accepted their invitation (Marmarà, Curtis, & Marmarà, 2015). BS uptake is influenced by a multitude of factors (Mamdouh et al., 2014). In particular, studies have demonstrated that beliefs about breast cancer and screening (Huaman, Kamimura-Nishimura, Kanamori, Siu, & Lescano, 2011) as well as illness perceptions (Anagnostopoulos et al., 2012) are important predictors of mammography compliance (Anagnostopoulos et al., 2012). However, little is known why Maltese women are less likely to have a screening mammogram than their European counterparts. This is because a gap exists in our understanding of factors impacting Maltese women's decisions to undergo BS, partly because of the lack of instruments locally validated for this aim. The instruments chosen for translation and adaptation were selected from the extent literature, which shows that health beliefs and illness perceptions are key determinants of BS behavior (Anagnostopoulos et al., 2012;Champion et al., 2008;Moss-Morris et al., 2002).
The aims of our study were threefold: (a) to translate and adapt existing scales, that is, Champion's Health Belief Model Scale for Mammography Screening (CHBMS-MS) and the Illness Perception Questionnaire (IPQ-R) from English to Maltese (CHBMS-MS-M 1 IPQ-R-M 5 MBSQ) so that these could subsequently be used to examine why women in Malta attend/do not attend BS when invited; (b) to determine whether Maltese women interpret consistently the meaning of questions in Maltese and English; and (c) to pilot test the reliability and validity of the Maltese and English versions of CHBMS-MS and IPQ-R. Because the English language is an official language but not our national and sole mother tongue language, we aimed to pretest not only the Maltese version but also the English version because some Maltese women may opt to respond in the language they prefer.

History and Development of the Champion's Health Belief Model Scale
The health belief model (HBM), developed in the early 1950s, is a behavior prediction model, comprising six fundamental constructs: perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, cues to action, and self-efficacy (Jahanlou, Lotfizade, & Karami, 2013). Champion developed and validated a scale in 1984 (Champion's Health Belief Model Scale [CHBMS]), consisting of 36 items to measure perceived susceptibility to breast cancer as well as perceived benefits and barriers to BS (Champion, 1984). In 1999, CHBMS-MS, excluding the breast self-examination used in the original studies, showing significant correlation between mammography compliance and high scores in the Susceptibility and Benefit subscales, whereas perceived barriers were associated with lower screening compliance (Huaman et al., 2011).
Because HBM is widely cited (Noar & Zimmerman, 2005), we used CHBMS-MS (Champion, 1999) to translate, adapt, and test among Maltese women. HBM, however, only explains some of the variation in BS behavior such that it does not consider the impact of emotions (such as fear; Norman & Brain, 2005), nor does it accommodate social and environmental influences of past behavior (Lunt et al., 2005) which is why other models have been incorporated in studies to understand BS uptake (Cameron, 2008). In response to HBM's limitations, an instrument associated with the common-sense model (CSM) of health and illness behavior (Cameron, 2008) was also translated, adapted, and tested.

History and Development of the Revised Illness Perception Questionnaire
In the late 1960s and early 1970s, Leventhal explored how fear messages in relatively acute situations might lead individuals to respond to the health threat communication by taking health-promoting actions (Broadbent et al., 2015), such as wearing seat belts or giving up smoking (Leventhal, Hudson, & Robitaille, 1997). Subsequent research by Leventhal and colleagues in 1980s led to the development of the CSM of self-regulation, which proposes that individuals develop two parallel, yet interrelated, representations of the stimulus (cognitive and emotional) in response to a perceived threat (Leventhal et al., 1997). Hence, CSM provides a framework for understanding how individual symptoms and emotions experienced during the health threat or diagnosis influence illness perceptions and guide subsequent coping behavior (Diefenbach & Leventhal, 1996). This model was later used to understand illness prevention and preventive behavior intentions (Figueiras & Alves, 2007).
The Illness Perception Questionnaire (IPQ; Weinman, Petrie, Moss-Morris, & Horne, 1996) was developed in light of self-regulation theory to provide a quantitative assessment of the five components of illness representation-identity, cause, timeline, consequences, and control/cure in Leventhal's self-regulation model (Moss-Morris et al., 2002). These five dimensions have been studied in breast (Anagnostopoulos et al., 2012) and colorectal screening (Orbell et al., 2008).
Subsequent measures include the Brief Illness Perception Questionnaire (B-IPQ; Broadbent et al., 2015), the Revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002), which examines illness beliefs and behaviors within specific groups of patients, or groups at risk from an illness, and an adapted version of the IPQ-R for "healthy" individuals (IPQ-RH) in recognition of the unique characteristics of asymptomatic populations (Figueiras & Alves, 2007). To remedy shortcomings in the original IPQ scale, the IPQ-R was developed by Moss-Morris et al. (2002) as a more comprehensive, psychometrically acceptable, quantitative measure to include measures of perceptions of illness duration ("acute/chronic timeline"), fluctuation in illness over time ("cyclical timeline"), perceptions of "treatment control" and "personal control" over illness, "illness coherence" (how clear and comprehensive an individual feels her illness to be), and "emotional representations" (feelings of depression, upset, anger, worry, and anxiety). Subsequently, the IPQ-R has been validated for use in diverse diseases or healthy populations (Chen, Tsai, & Lee, 2008), with language-specific validated IPQ measures, such as Italian (Giardini, Majani, Pierobon, Gremigni, & Catapano, 2007), Swedish (Brink, Alsén, & Cliffordson, 2011), Greek (Giannousi, Manaras, Georgoulias, & Samonis, 2010), Croatian and Lebanese (Petrak, Sherman, & Fitness, 2015), and Portuguese (Figueiras & Alves, 2007) versions. However, it has not yet been adapted and validated for Maltese asymptomatic and/or symptomatic women. Hence, we adapted the IPQ-R in this study to make it appropriate for both healthy women and those with cancer.

Data Sources and Study Design
The study was conducted during June 2015, as part of a larger cross-sectional study about BS in Malta. The parent study was approved by the School Research Ethics Committee at the School of Health Sciences, University of Stirling (SREC14/15-Paper No. 18v4), and by the Maltese Health Ethics Committee (HEC 02/2015). Permission to use the scales (CHBMS-MS and IPQ-R) was sought from the respective authors (Prof. Victoria Champion in 2013 for CHBMS-MS use and Prof. Rona Moss-Morris in 2014 for IPQ-R use). Permissions were also received from the chief medical officer, the chief executive officer (Primary Health Care Department), and the health data protection officers in primary and secondary care in Malta.

Sample and Procedures
Four translators were recruited for the translation pathway as follows: two translators (i.e., a European translator working in Brussels who was also a bilingual native speaker of both Maltese and English languages and a Maltese expert translator) translated the instrument from English to Maltese (Steps 2-3) and two different bilingual translators (i.e., a bilingual expert from the Health Ministry and an expert interpreter at the University of Malta) backtranslated the instrument from Maltese to English (Step 4). 1 An expert panel (n 5 12) was set up to ascertain content validity and to verify that it is clinically meaningful to experts in the clinical area (Anagnostopoulos, Dimitrakaki, Niakas, & Tountas, 2013). The 12 members comprised the lead researcher for this study, the 4 expert translators/interpreters, a statistician with 10 years' experience in statistical research and analysis, 2 mammographers (Maltese and Scottish radiographers), a BS client, a breast cancer survivor, a consultant, and a clinician.
A focus group was conducted with a convenience sample of asymptomatic women (n 5 6) to pilot test the adapted Maltese version of the instrument. Three of the women were housewives (53, 55, 58 years, respectively) who had attended BS, two were public employees (59, 60 years, respectively) who had not attended BS, and the other was a retired 62-year-old midwife who had also not attended BS when invited.
A convenience sample of 15 women (n 5 15) participated in structured face-to-face interviews to assess comprehensibility and suitability of the research instrument and to ensure understanding of all scale items in both languages. Women were recruited from the BS center and were BS attendees, aged 50-60 years. The convenience sample was recruited because it was felt that such women would be interested in engaging with such a topic (Creswell & Plano Clark, 2011), thereby giving access to a range of women with different backgrounds (Kaltsa, Holloway, & Cox, 2013). Women with prior history of breast cancer or breast surgery, those who sought breast cancer treatment, as well as nonbilingual women were excluded.
Participants were assured that they had no obligation to participate, that their participation was voluntary, and that they could withdraw from the study at any time without the need to give any reason. The cover letter provided information to the women on how the researcher would protect their anonymity and confidentiality through coding. Following explanation on the nature of the research, informed consent was obtained from the participants. Figure 1 illustrates the pathway in which the translation and adaptation of the mentioned scales was undertaken, based on published methods (Champion, 1984(Champion, , 1999Yilmaz & Sayin, 2014).

Steps 1-2: Identification of Scales and Forward Translation
Following the identification of validated scales by the researcher, initial translation of the questionnaire from English (original) to Maltese (target) languages was performed by two expert translators. This bilingual team first prepared their own translated versions; they Step 1: Identification of English-validated scales (Original versions: v1) Step 2: Forward translation from English to Maltese by two translators (v2) Step 3: Reconciliation meeting to decide on one translated version (v3) Step 4: Back-translation of reconciled version from Maltese to English (two translators) (v4) Step 5: Adaptation process: Both language versions examined for conceptual equivalence (v5) Step 6: Face validity testing with target population to check that the translation of v5 (Maltese version) and v1 (English version) are equivalent (v6) Step 7: Reconciliation session-comparison of latest versions in a meeting between researcher and two professional translators (v7) Step 8: Proof reading and final Maltese version produced (v8) then gave their versions to each other to verify each other's work and finally came up with collaborative decisions about the translation.

Step 3: Reconciliation Session
The two experts met up with the researcher in a "reconciliation session" in Malta and reviewed the translation together for inconsistencies with the original English scale and to ensure that the language was kept simple to be understood by Maltese women.
Step 4: Back-Translation Into English The adequacy of the Maltese translated instrument was evaluated using the back-translation technique. The Maltese version was back-translated into English (original language) by another team of experts (i.e., not the original translators in Steps 2-3). Step

5: Adaptation Process
Both language versions were examined for conceptual equivalence by the expert panel (n 5 12) which included the lead researcher and statistician for this study, the four translators (Steps 2-4), screening/medical professionals, and lay women. The backtranslation and the original English instrument version were compared with attention given to grammar and the meaning conveyed by the words. In this "adaptation" process, the cultural and social characteristics of the translation are protected as much as possible (Kulis, Arnott, Greimel, Bottomley, & Koller, 2011).
Step 6: Face Validity Testing A focus group was conducted with a convenience sample of asymptomatic women (n 5 6) to pilot test the adapted Maltese instrument version. This cognitive debriefing procedure (Wild et al., 2005) was followed to ascertain face validity of the instrument, to ensure clarity and comprehensibility of the items, to highlight inappropriate items or response options, and to identify and test translation alternatives and modifications. This ensures that conceptual equivalence and cultural appropriateness are achieved (Anagnostopoulos et al., 2013). This group of screened/nonscreened women tested the instrument's face validity and determined its cultural appropriateness and the accuracy of the translation, similar to the undertaken Turkish process (Yilmaz & Sayin, 2014). The researcher read the translated text aloud to the participants, following which each item was scored on a 5-point scale.
Step 7: Reconciliation Session The scales were modified in a "reconciliation session" so that they could be administered by an interviewer, where two translators met up with the researcher in Malta to review the final version.
Step 8: Proofreading Following proofreading, the final Maltese version was produced and entitled the Maltese Breast Screening Questionnaire (MBSQ). The following procedures were used to test the MBSQ: Test-Retest Reliability. The final version (MBSQ) from Step 8 was then tested for reliability (Step 9). An estimation of stability is commonly assessed by a test-retest reliability analysis, where the questionnaire is given to the same person or set of respondents, in the same way, on two different occasions, usually with an interval of 2-6 weeks (Yilmaz & Sayin, 2014). In this study, a convenience sample of 15 bilingual women, aged 50-60 years, were recruited by the researcher from the BS center to assess test-retest reliability of the Maltese and English subscales, respectively. Participants responded to the questionnaire through face-to-face interviews on two occasions separated by a 2-week interval, a test-retest period considered appropriate (Streiner, Norman, & Cairney, 2014). These women were contacted by a research assistant and two convenient times were arranged with each participant. The interviews were conducted in the participants' homes. Participants were informed that they were free to choose only one language. However, all participants were willing to complete the survey in both languages and opted to complete the survey first in Maltese followed by the English language at both time points (Day 1, Day 14) to test and retest for stability and reliability of responses in the same language. The scores were then correlated.
Approaches to Reliability and Validity Assessments. Reliability was evaluated by Cronbach's alpha for internal consistency (reliability) and test-retest correlation. In terms of reliability, lower values indicate no internal consistency of the tool (.00  a , .40 not reliable, .40  a , .60 low reliability, .60  a .80 high reliability, .80  a , 1 very high reliability; Buyukozturk, 2012;Tekindal, 2009;Yilmaz & Sayin, 2014). If Cronbach's alpha score is low, then the corrected item-total correlations for values of ,.30 are considered (minimum acceptable item-total correlation is .30; Yilmaz & Sayin, 2014). Such low values might be considered satisfactory if item deletion does not improve the overall alpha value (Buyukozturk, 2012). Test-retest scores for each dimension were computed for the Maltese and English measures, respectively, using Pearson's correlations at both time points (T1, T2) for an estimation of reliability over time. Test-retest reliability refers to the correlation coefficient which should be at least .6 (Balci, 2011;Buyukozturk, 2012;Huaman et al., 2011;Tekindal, 2009). Construct validity, a measure that confirms the extent to which inferences can be made from scale scores in relation to the latent, theoretical construct of interest (Pruitt et al., 2010), was supported through Pearson's correlations to test the associations between subscales for each measure. Quantitative data analysis was performed using the SPSS Version 21.

Translation and Adaptation
Four queries of subcultural word comprehension were raised by the bilingual translators, which required consensus. The term breast lumps in the original instrument was translated to boċoċ f'sidrek. The second controversial term was mammogram, for which two panel members argued that some women in the target population may not be aware of early diagnostic breast tests. Although mammografija in the translated instrument was acceptable, the general known term was mammogram. Following this debate, the panel decided that both words were suitable and could be used interchangeably (i.e., mammogram, mammografija). A third controversial term was thickening of the breast. Following discussion, the panel decided on the phrase h xuna tat-tessuti tas-sider. Another word discussed by all group members was nipple. Several controversies arose on whether to use the word nipple as is, nippla, or the pure technical phrase ras il-biżla. Most members argued that some women in the target population are not aware of the technical phrase but are familiar with the English term. This was then literally translated to nipil.
Because most women perceive breast cancer as a serious threat (Lagerlund, Sparén, Thurfjell, Ekbom, & Lambe, 2000), it was decided that the construct "perceived severity" would not be measured using HBM (Anagnostopoulos et al., 2012). Further removal of the item in the HBM-related scale would also avoid duplication because the seriousness of breast cancer was addressed in the IPQ-R scale. Moreover, because the use of both HBM and CSM often fails to address contextual constraints such as low income and education level that may influence women's screening behavior, sociodemographic and socioeconomic factors as well as lifetime mammography use were added because of the acknowledgement of their contributions as BS determinants (Anagnostopoulos et al., 2012;Jepson et al., 2000;Lagerlund et al., 2000). The panel further added cues to action (such as physician recommendations and family history), which are often omitted from empirical studies through HBM use (Anagnostopoulos et al., 2012). Finally, based on these conclusions, the original version of the instrument consisted of 124 items and was presented to the focus group (n 5 6) for testing.

Face Validity
From the original 50-item IPQ-R, two items were removed from the cancer timeline domain ("Breast cancer will last for a long time"; "I expect to have breast cancer for the rest of my life") because they were found to confuse the women and cause consistent heightened anxiety in responders, resulting in a 48-item Maltese (M) version (entitled IPQ-R-M). Participants were asked to report their personal views about breast cancer rather than their perceptions of an illness personally affecting them. For example, "My illness has serious economic and financial consequences" was replaced with "Breast cancer has serious economic and financial consequences"; "My illness will last for a long time" was replaced with "Breast cancer will last for a long time" following which reverse scoring was eliminated for this item to read "Breast cancer will last for a short time" because of the misunderstanding, confusion, and anxiety experienced by all women. The IPQ-R risk factors domain title were also amended to read "Risk/Lifestyle Factors," whereas the sections "personal" and "treatment" control were categorized under the heading "Curability/Controllability." For the lifetime mammography use domain, 1 item was deleted to avoid overlap ("a mammogram prior to breast screening" yes/no). Hence, the final Maltese instrument (MBSQ), comprising the Maltese (M) scales CHBMS-MS-M and IPQ-R-M, consisted of 121 items that were clustered into 11 subscales for sociodemographic and health status (20 items), 4 subscales for lifetime mammography use (17 items), 5 subscales for health beliefs (36 items), and 7 subscales for illness perceptions (48 items).
The earlier-mentioned method found the instrument to be acceptable and ready for use in psychometric testing among the target population. Of the convenience sample of 15 women (n 5 15), the mean age was 54.5 years 6 3.2 years (SD); 6 women were from below-average-income families (lower than €16,113), 11 women were housewives, and 12 women had up to a secondary education level.

Instrument Scoring
For the scope of preliminary mean instrument scoring, the mean values at Time 1 in Maltese were analyzed (refer to mean Maltese T1 in Table 2). Subscale scores were retrieved as the mean of items (following reverse scoring [r] for only one item "There is no possibility of getting breast cancer" in the Perceived Susceptibility subscale). Higher scores for Health Belief subscales, for instance, indicate more susceptibility, benefits, barriers, cues to action and self-efficacy (Champion, 1999). Maltese women scored highest for perceived benefits and lowest for perceived barriers, and highest for cyclical timeline and lowest for acute/chronic timeline.  5 .96). These values showed that the scale items measured similar features with high reliability because each dimension was expected to have an alpha of at least .7 (Huaman et al., 2011). Hence, preliminary high Cronbach's alpha values indicated that the Maltese instrument had internal consistency.

Reliability Over Time
The .74, respectively (Table 3). Hence, all of the subscale items met the criteria of reliability and were retained.

Construct Validity
When applying correlation analysis between the English and the Maltese versions (Table 1), the Pearson correlation values for CHBMS-MS and IPQ-R were .87 and .89, respectively. All correlation values exceeded .6 and showed a significant correlation between the items of both versions (p , .001). The Pearson correlation values were tested at the .05 level of significance. When applying a Pearson correlation between the two time points, the Pearson correlation value was .778, showing a strong positive correlation between the two time points. Such an association was found to be significantly different (p , .001).

DISCUSSION
This study focused on translating, adapting, and pilot testing the validity and reliability of two existing scales for use among Maltese women. We found that it was feasible to translate and adapt these scales and that the translated instrument shows promise of acceptable validity and reliability. The high correlation values obtained are suggestive of strong validity of scale items. Moreover, completeness was high (100% of participants answered all the questions), thereby indicating that the instrument was easy and simple to administer. Results of the translation and adaptation pathway and focus group analysis provided useful information on the understanding of items. Evidence suggests that although measures may be valid and reliable across diverse cultures, researchers are encouraged to modify and reword subscale items, taking into account cultural settings and any linguistic origins of their populations under exploration (Abubakari et al., 2012). This led to some items being omitted from the original scales because they either duplicated other items or failed to convey a clear expression of the intended objectives.
Overall positive and high correlation of the total inter-item correlation (Pearson) was obtained in our study for health beliefs (.87) and illness perceptions (.85) and high Cronbach's alpha (CHBMS-MS 5 .93, IPQ-R 5 .92) denoting overall acceptable internal consistency. In our study, internal consistency ranged from .69 to .83 for health beliefs. Similarly, internal consistency reliability ranged from .69 to .83 in Gözüm and Aydin's (2004) study, from .64 to .79 in Hashemian and colleagues' (2013) study, and was above .73 for all scales in Champion and colleagues' (2008) study among African American women. A high consistency was observed in our study between the three perceived susceptibility scale items. Champion similarly reported high internal consistency of items for this subscale and observed a proper fit (.82) using confirmatory factor analysis (Champion, 1999). However, we could not confirm our subscales through confirmatory factor analysis because our reported findings were limited to our small sample in comparison, although our aim was not to elicit the most important factors that explain health beliefs and illness perceptions. Therefore, our findings can only be considered as preliminary values for the instrument's internal consistency.
In our study, test-retest reliability correlations were from .62 to .76 for CHBMS-MS-M (Maltese) and ranged from .61 to .84 for CHBMS-MS (English). In Hashemian and colleagues' (2013) study, test-retest reliability correlation ranged from .67 to .92 for health belief subscales and ranged from .67 to .92 for the Persian scale version among Iranian women (Hashemian et al., 2013). Our test-retest data for the health beliefs dimensions shows that perceived susceptibility and perceived benefits appear to remain the most consistent over the 2-week time period. This may suggest that women will take action to screen for or control illness if they believe they are susceptible to it, especially if the illness is viewed to potentially have serious personal consequences and if they believe that the benefits of screening outweigh the barriers for doing so.
In Medina-Shepherd and Kleier's (2010) study, test-retest correlations for control group women (n 5 20) were perceived susceptibility (Spearman's rho: r 5 .57), perceived benefits (r 5 .63) and perceived barriers (r 5 .83). In Champion's original validation study in an American city (Champion, 1999), test-retest scores were .62 (susceptibility), .61 (benefits), and .71 (barriers). Our findings were similarly significant for test-retest correlation (.76,.62,.67,respectively,for Maltese version;.75,.71,.70,respectively,for English version), whereas all five CHBMS-MS subscales in our study show similar psychometric properties to more recent findings (Medina-Shepherd & Kleier, 2010;Yilmaz & Sayin, 2014). A test-retest score ,.80 indicates that women did not reply in the same way at the second time point (Yilmaz & Sayin, 2014), which could mean that women did not read the scale items in the same way at both time points. However, according to the test-retest results, women answered the scale items similarly in both sessions, indicating that the scale has strong stability over time. Our test-retest results were generally higher than those reported in the Medina-Shepherd and Kleier's (2010) study and Champion's (2010) study. This difference may be attributed to the small sample in our study.
Our preliminary findings for Cronbach's alpha coefficients were .91 (susceptibility), .88 (barriers), .75 (benefits), .86 (cues to action), and .90 (self-efficacy). Similarly, Cronbach's alpha coefficient for Champion's subscales were also reported between .77 and .90 among Chinese American women (Wu & Yu, 2003), and were found to be equal to .88 (barriers) and .93 (benefits) in a Malaysian study (Parsa et al., 2008), .89 and .73, respectively, among African American women (Champion et al., 2008) but lower (.63 for benefits) in Medina-Shepherd and Kleier's (2010) study. Among Iranian women with family history of breast cancer, Cronbach's alpha coefficients were .72 (susceptibility), .75 (seriousness), .82 (benefits), and .76 (barriers), although a limitation in the Iranian study is that all participants had a family history of breast cancer which can be considered to guide further prevention and increase women's susceptibility for this disease (Hashemian et al., 2013). A controversial HBM subscale is perceived barriers (Hashemian et al., 2013) because of the diverse individual and environmental barriers present in different communities (Park et al., 2011). However, none of the items of this subscale in the original version of the questionnaire were omitted because women considered all items to be equally important.
The original IPQ-R demonstrates higher internal consistency (Cronbach's alphas range from .75 to .89) than the original IPQ and good test-retest reliability ranging from .46 to .88 over 3 weeks (Moss-Morris et al., 2002). In our study, the IPQ-R scale similarly demonstrated a relatively high degree of internal consistency (Cronbach's alpha 5 .75-.93), with overall Cronbach's alpha ..70 (a 5 .86 [Maltese] and .85 [English]). Our test-retest data of the IPQ-R dimensions is homogeneous with the original IPQ and IPQ-R versions (Moss-Morris et al., 2002;Weinman et al., 1996) and show that the IPQ-R has acceptable levels of stability over 2 weeks. Test-retest reliability (Pearson's) correlations were computed between the IPQ-R completed at the two time points with correlations above .6, that is, .63-.82 (Maltese) and .61-.91 (English). Breast cancer identity, causes, and emotional representations appear to remain the most consistent over this time period for the Maltese language. This suggests that patients possibly attribute a relatively high or low number of symptoms to their illness and experience a wide range of emotional issues. As for the English version, treatment control and emotional representations remain most consistent. These findings provide evidence toward the validity and reliability of the IPQ-R as a suitable measure of illness perceptions in the context of BS. IPQ-R dimensions prove to be useful measures on how the illness "makes sense" holistically to symptomatic or asymptomatic women and may play an important role in longer term adjustment and symptom response. The IPQ-R also allows researchers to investigate how emotional representations affect coping behaviors and illness outcomes (Moss-Morris et al., 2002). Moreover, cognitive beliefs that the illness has severe consequences is cyclical in nature and out of one's personal control seem to strongly affect women's emotional responses.

Implications
The Maltese and English versions of the CHBMS-MS and IPQ-R can be used by nurses and other health care professionals as measures to assess Maltese women's health beliefs and illness perceptions concerning breast cancer and screening. Nurses have frequent patient contact in various health care settings and are known to be valuable change agents and patient advocates (Arabi, Rafii, Cheraghi, & Ghiyasvandian, 2014). An important breast health promotion opportunity for public health nurses is raising public awareness on breast cancer by educating women about the importance of practicing screening. Likewise, nurses and health care professionals can structure patient education and counseling sessions guided by the conceptual theoretical framework proposed in this study to ensure comprehensiveness of approach and content. For instance, information on breast cancer risks, susceptibility to breast cancer, signs and symptoms of breast cancer, and its consequences, as operationalized by different HBM and CSM constructs, can increase patients' knowledge to improve screening use (Noar & Zimmerman, 2005). Moreover, health care providers can use the HBM and CSM to understand patients' needs, employing constructs of the models to guide patient interviewing. For instance, a BS invitation may be based on factors that influence BS behavior such as existing perceptions of benefits and barriers and on psychological and social factors (Kaltsa et al., 2013). Nurses can therefore assess women's level of perceived risk and target their teaching about health-promoting behaviors to reduce risk perception by educating women about the risk factors for breast cancer. If women are aware they may be at risk for developing breast cancer, they may perceive themselves at risk and participate in screening. Counseling may be required to increase the likelihood that a woman attends for screening by increasing women's confidence. Particular focus on the appointment related to screening could provide an opportunity for targeted interventions to increase BS uptake, such as assisting women with scheduling an appointment, ensuring that guidelines and information is provided about the recommended intervals between mammograms and addressing the importance of regular screening. This will ultimately affect the quality of an individual's life and reduce the allocation of resources needed to treat those who develop breast cancer.
Because individuals possess multifaceted cognitive representations of various diseases (Lykins et al., 2008), nurses can support patients to explore beliefs and perceptions by helping them to relate personal accounts about their families, their culture, and their illness perceptions, including causal attributions for the disease (Richer & Ezer, 2000). Achieving this may be more attainable if nurses and health care providers are knowledgeable, competent, and feel supported in providing education and counseling in the clinical setting. This presents a challenge for all health care disciplines considering that health implications span the entire health care continuum. Furthermore, the gap in competency includes lack of recognition of the relevancy of screening to nursing practice which may impact the uptake of continuing education in this area. To overcome these challenges, robust interventions are needed with reliable measures that can adequately assess the outcomes of these strategies. Validated instruments for nursing and patient assessment should be made available in clinical settings as a priority. With reliable measures to inform the required interventions and outcomes associated with their implementation, nurse-led interventions make it possible to design cost-effective strategies focused on reducing disparities across diverse populations and increasing quality within health care systems.

Limitations
Although our preliminary internal consistency and test-retest reliability correlation scores were relatively similar or higher to those reported in prior validation studies of the CHBMS and IPQ-R research, we recognize this study's limitations. First, the reported findings cannot be generalized because these are limited to a convenience sample. Our goal was not to obtain a representative sample but rather to obtain an indication of the instrument's reliability and validity among women with varied backgrounds and diverse perspectives. For greater applicability, it is recommended that this instrument be tested among a larger sample. Second, recruitment of these women may have led to a biased sample of women with no socioeconomic inequalities. We acknowledge that those who participated may have been more interested in and knowledgeable about screening as compared with those who would not attend for screening. Third, for those who participated in this study, the formal consent to participate sets them apart from those who would refuse such an invitation. Moreover, although women were asked to express their true feelings, they may have responded in a way that is considered socially acceptable. Despite these limitations, our rigorous approach to translating and adapting the instrument gives us confidence in the instrument's acceptability and readiness for use to collect data from the target population.

CONCLUSION
The translation, adaptation, and preliminary evidence of the psychometric properties assessment of the MBSQ shows promise of being a valid and reliable instrument that can be used among Maltese women to assess their health beliefs and illness perceptions toward breast cancer and screening practices and provides insights for the planning of effective interventions. Because these are preliminary findings, further psychometric testing of these scales is recommended to include diverse socioeconomic strata, educational levels, and geographic location. Future studies should include factor analyses on the current scale items using a larger sample size. Further research to measure women's health beliefs and illness perceptions on breast cancer and screening is also warranted.