This study used the grounded theory approach by Strauss and Corbin [18] and adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to ensure rigor [19]. Grounded theory is a qualitative research method aimed at developing a theory that is firmly based on data that are collected and analyzed systematically. This approach is especially effective for examining intricate social processes, such as BSE practice, as it seeks to understand how people develop and sustain behaviors about a specific health issue.

The data were gathered between August 2024 and April 2025. The researchers applied both purposive and theoretical sampling to select data sources and participants. Oncology nurses asked 11 high-risk women to participate in the study, and no one declined to take part in the interviews. The timing and date were arranged based on the availability of the participants, and the researchers provided thorough explanations about the study. At first, purposive sampling was used to identify participants who met certain eligibility criteria: (1) female participants with mothers diagnosed with BC, (2) proficiency in the Urdu language, and (3) willingness to take part. When the investigation advanced, theoretical sampling was used to enhance evolving theory. Theoretical sampling is an iterative process in which data collection and analysis are conducted simultaneously, using the emerging analysis to guide the selection of subsequent data to collect. Collected data were coded and analyzed to form initial concepts, categories, and themes. The selection of new participants was based on their marital status (unmarried, married, or widowed) and level of education (primary school, middle school, tenth grade, or higher) to understand the concepts, fill the gaps, refine categories, and expand the theory. Theoretical sampling persisted until data saturation was reached, when no further relevant data or insights were produced. The aforementioned 11 high-risk participants from diverse communities took part in the study (Table 1).

The Research Ethics Committee of the Institute of Allied Health Sciences associated with the hospital provided ethics approval for this study, with reference IAHS/WMC/786/008-02. All participants provided informed consent, and information was provided on their right to leave the study at any point without facing repercussions. Participant data were anonymized to ensure confidentiality, and all research materials were securely stored. Participants were not provided any compensation for their participation.

Data were gathered through semistructured interviews (Table 2). These interviews were conducted in person, with audio recordings made of participants, along with observations and verbatim transcriptions. Each interview lasted approximately 35 to 50 minutes. Field notes were kept providing contextual details. Several participants were interviewed more than once, with 81.8% (9/11) taking part in a second interview to enhance the data and facilitate clarification, deeper exploration, and a richer understanding of emerging themes. Data were gathered until data saturation was achieved, which is defined as the point at which no new themes or insights arise. Due to logistical constraints and participant preferences, transcripts were not returned to participants for member verification. Nonetheless, to maintain ethical standards and ensure the accuracy of the transcriptions, a method of double transcription and validation was used [20,21].

Analysis of the data was conducted following the grounded theory approach by Strauss and Corbin [18], which involved open, axial, and selective coding (Figure 1).

Coding of interview transcripts was done using verbatim data. Conceptual sensitivity to achieve reflexivity and analytic consensus was maintained by using multiple coders in discussion, where codes were reached through ongoing discussions and adjustments to the coding framework. The coding tree (Table 3) shows that the initial codes were organized into 5 subcategories under a single main category and were subsequently combined to create the final thematic model. Constant comparative analysis was used for the development of themes, in which new data were continually assessed against existing codes and categories. This approach allowed for the refinement of the emerging theory and affirmed its applicability across diverse participant experiences [22,23], directed at identifying repeated patterns and connections within the data [20,24,25]. The process resulted in the documentation of the key themes: the desire for breast health awareness, family support, change in perceptions and attitude, and early diagnosis of BC (Figure 2).

The reliability and credibility of this study were maintained through implementation of several approaches as suggested by recognized qualitative research guidelines [26]. These included (1) member checking, in which initial interpretations and findings were shared with high-risk participants to check the accuracy and authenticity; (2) triangulation, which involved comparing various data sources—such as interview transcripts and field notes—to enhance the validity of the results; (3) investigator triangulation through ongoing team discussions during the data analysis phase to confirm consistency and individual bias reduction; and (4) an audit trail by keeping thorough documentation, such as coding decisions, to facilitate external review and transparency.

Understanding the mother’s BC situation and being aware of BC symptoms such as pain or hair loss, fear of rejection from society, and stress creates the need for breast health maintenance and can inspire participants to take part in screening activities such as BSEs for early detection and instill hope for improved health. Family support, especially support from mothers who realized their own situation and understood their daughters’ need for breast health, motivated participants to change their perceptions of health care choices and the way in which they sought health services and build a positive attitude to engage in health-seeking behaviors such as BSE practice.

The objective of BSE practice is to facilitate the early identification of BC through health education, thereby enhancing quality of life and promoting better living. Early diagnosis of BC significantly increases the likelihood of survival for patients.

This core category emerged in various driving themes, such as the realization of breast health issues, the change in participants’ perceptions and attitude, and participants’ need for BSE practice for identification of any breast change that would lead to early BC diagnosis (Table 4).

The results of this research highlight the importance of health education in encouraging BSE practice among Pakistani high-risk women. This research adds to the grounded theory concerning BSE practice by demonstrating how health education influences various elements of preventive and promotional health care, such as perceptual change, attitudinal change, and familial support for BSE. The primary theme, breast health education as a motivator, emerged as a key factor influencing behaviors related to BSE practice. This observation is consistent with the health belief model, which suggests that people are likely to engage in health-promoting behavior when they recognize a significant degree of susceptibility to a health issue [27]. The findings of this study on BC symptoms served as a trigger for embracing BSE practice, underpinning the idea that awareness of potential health risks fosters change in behavior [28].

This research emphasizes that educating individuals about breast health plays a critical role in encouraging them to perform BSE. Those with greater knowledge about BC were found to be more motivated to engage in practices that promote breast health. This highlights the significance of educational programs aimed at improving people’s understanding of BC, the misperceptions about it and its associated risks, and the advantages of different screening strategies [29].

Knowledge affects an individual’s views and interpretations of sociocultural contexts, as well as their ability to foresee results and make choices. Greater awareness and a favorable change in perceptions of BC and the taboos of BSEs can greatly enhance BSE practice [30]. This aligns with the principles of social cognitive theory. According to social cognitive theory, knowledge affects perception by influencing how people decode social situations and anticipate outcomes [31].

Education about breast health can alleviate feelings of embarrassment and fear, resulting in a more favorable outlook on BSEs and the pursuit of medical consultations due to cultural impact [32]. These conclusions correspond with the change theory and the stages of change model by Lewin [33], which can be used to foster more constructive attitudes toward change. Individuals and groups adjust to new circumstances, handle resistance, and reinforce new behaviors [33].

Cultural context affects behavior change. The PEN-3 cultural model has also already demonstrated how cultural context matters in interventions, such as those for cancer awareness and screening [34]. Naturally occurring support from family members has been shown to increase healthy lifestyle behaviors such as BC screening measures (eg, BSE) through providing information and role-modeling. Family members have an impact on women’s decisions and actions throughout their BC journey, such as (1) confirming breast changes, (2) managing personal emotions, (3) seeking the information, (4) seeking alternative forms of treatment, and (5) advocating for conventional treatment [35]. Family support, especially from mothers, acts as a significant environmental factor that plays an important role in influencing BSE practice. Respectable family support increases a woman’s awareness of and interest in undergoing early cancer screening. If a woman receives good emotional support, then she is more likely to behave well for her health [36].

The influence of culture on perception, attitude, and family support, especially from mothers, regarding BSE practice is a core observation of this study. The participants’ ability to adopt cultural practices such as family support and change in perception of and attitude toward women’s breast health in response to health needs determines the importance of culturally sensitive interventions [37]. This study highlighted the need for BSE practices that are culturally and contextually relevant, such as breast health education targeting participant negative cultural beliefs related to BC and BSE (eg, the taboo of touching oneself) by fostering positive perceptions of this body part, such as the fact that it is a woman’s body part, which means that it is also a part of health and not only a part of sexuality, and fostering a positive attitude about BC and its screening measures (eg, BSE) by encouraging women to talk about BC with their family members (eg, with their mothers). Family support motivates women regarding the fact that BSE is not a wrong concept. The breast is a part of their body, which they have a responsibility to be aware of. All these efforts will lead toward behavior change and the promotion of preventive behaviors.

This study was carried out at a single hospital, representing a limited group of high-risk women in the area. Grounded theory seeks to create theories based on contexts and data, which might restrict the applicability of the results to different populations.

This study offers convincing evidence underscoring the vital role of breast health education in promoting BSE practices among high-risk women in Punjab, Pakistan. The findings provide essential insights into how improved breast health education can bring about positive changes in attitudes, perceptions, and the involvement of family support systems. This research marks the first effort to develop a grounded theory that presents a new conceptual model to understand the processes related to effective breast health management in similar culture-bound communities.