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This is to certify that the

thesis entitled
BARRIERS TO ADHERENCE T0 MAMMOGRAPHY GUIDELINES

AMONG EMPLOYED WOMEN AGES 42-65

presented by

Rose Mary Ross

0

has been accepted towards fulfillment
of the requirements for

matters—degree in Mn;—

AZ;

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Major professor

11-17-95

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MSU to An Affinnotivo ActionlEquol Opponuntty trunnion
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BARRIERS TO ADHERENCE TO MAMMOGRAPHY GUIDELINES
AMONG EMPLOYED WOMEN AGES 42-65

By

Rose Mary Ross

A THESIS

Submitted to
Michigan State University
in partial fulfilhnent of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

ABSTRACT

BARRIERS TO ADHERENCE TO MAMIVIOGRAPHY GUIDELINES
AMONG EMPLOYED WONIEN AGES 42-65

By

Rose Mary Ross

One of nine American women will at some time be diagnosed with
breast cancer. Early detection is directly related to increased survival rates.
Mammography is the best tool for early detection. This study examined
whether the barriers reported in the literature apply to women who have had a
mammogram but are noncompliant with guidelines of the American Cancer
Society for subsequent mammograms. Data was obtained from a
questionnaire survey, Assessment of Barriers and Facilitators to Screening for
Breast Cancer--a Worksite Approach (Given, B., Given, C.W., & Dimitrov,
N., 1991, MDPH). The sample included 179 employed women ages 42-65
who had had a mammogram but had not had their next mammogram within
screening guidelines. The sample did not agree that cost, lack of physician
referral, discomfort, fear of finding cancer, inaccessibility, and lack of
knowledge were barriers to adherence to mammography screening guidelines.
Further research is needed to discover other barriers to adherence to

screening mammography guidelines.

To my husband, Truman, for all of his love and support,
and to my children, J. T., Jennifer, Luke, and Clinton

for allowing me to pursue my dream.

ACKNOWLEDGMENTS

I would like to express my appreciation to Barbara Given PhD, RN,
F AAN , chairman of my committee for her guidance, to Patty Peek MS, RN,
PNP for her support, and to Rachel Schiffman, PhD, RN, for her
encouragement and editorial help. I would like to thank WE. Bontrager
MD. for his many years of encouragement, and many thanks to Wayne Wahl
MD. for his mentoring. I would also like to thank my Mom and Dad for a

lifetime of love and support, it has been greatly appreciated.

TABLE OF CONTENTS

LIST OF TABLES ...................................................................................... vii
LIST OF FIGURE ...................................................................................... viii
Introduction ................................................................................................... 1
Background .............................................................................................. 1
Purpose of Study ...................................................................................... 4
Review of Literature ...................................................................................... 5
Conceptual Definition of the Variables ..................................................... 5
Development of Theoretical Model ........................................................ 10
Review and Synthesis of Literature Within the Context of This Study ..... l4
Methodological and Conceptual Problems in the Literature .................... 22
Methods ...................................................................................................... 25
Research Design ..................................................................................... 25
Sample ................................................................................................... 25
Data Collection ...................................................................................... 26
Operational Definition of Variables and Scoring ..................................... 26
Instrumentation ....................................................................................... 29
Data Analysis ......................................................................................... 29
Limitations and Assumptions .................................................................. 31
Protection of Human Subjects ................................................................. 31
Findings and Interpretation .......................................................................... 32
Sociodemographic Characteristics .......................................................... 32
Barrier Variables .................................................................................... 34

Discussion ................................................................................................... 46

Limitations ............................................................................................. 46
Implications for Advanced Nursing Practice ........................................... 49
Recommendations for Further Research ................................................. 58
Summary ................................................................................................ 61
APPENDIX A Health Care Practices: A Worksite Survey ......................... 62
APPENDIX B Protection of Human Subjects Approvals ............................ 82
LIST OF REFERENCES ............................................................................. 84

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

LIST OF TABLES

Sociodemographic characteristics of noncompliant women ..........

Frequency and percent of cost hardship barrier related to

mammography .............................................................................

Frequency and percent of discomfort items related to

mammography .............................................................................

Frequency and percent of anxiety items related to

mammography .............................................................................

Frequency and percent of inaccessibility items related to

mammography .............................................................................

Frequency and percent of lack of knowledge of ACS guidelines

vii

..33

..35

..39

..41

..43

.45

LIST OF FIGURE

Figure 1 Health Belief Model and Regular Mammography Acquisition ....... 13

viii

Introduction
Bacgmund
Breast cancer is the most frequently diagnosed form of cancer and the
second major cause of cancer death in American women. The American
Cancer Society (ACS) estimated 182,000 new cases of breast cancer to be
diagnosed in 1995 (American Cancer Society [ACS], 1995). One of nine

women can expect to experience breast cancer in her lifetime (ACS, 1995).
A woman’s chances of survival are directly linked to the stage of disease at
diagnosis. Early detection prolongs survival and reduces morbidity. A
woman’s five year survival rate decreases as the tumor size increases and the
probability of nodal metastasis increases. Currently tumor size and nodal
status are reliable predictors of the outcome for breast cancer (Henson &
Ries, 1990). Only 50% of breast cancers are detected before metastasis to
the lymph nodes and 75%-90% of all breast cancers are found, not by
mammogram or clinical exam but by women themselves (N ettles-Carlson,
1989). Unfortunately, women who discover a lump in their breast by self
palpation are likely to be in the later stages of breast cancer involving
metastasis to the lymph nodes. Although there are known risk factors such as
family history of breast cancer, early menarche, nulliparity greater than age
30, and late menopause, 75% of women who develop breast cancer have no
known risk factors other than increasing age (Basset, Manjikian, & Gold,
1990)

The best prognosis for survival is when diagnosis is made when lesions
are small without axillary node metastasis. It was previously thought the

spread of breast cancer was an orderly progression from breast to axillary

nodes and then to distant sites. Now it is believed that breast cancer can be a
systemic disease early on. But there is thought to be a two to three year
preclinical phase in which breast cancer can be detected by mammography
before the cancer spreads (Hamwi, 1990).

The five year survival rate for localized breast cancer has risen from
78% in the 1940’s to 94% today. Breast cancer in situ (non-invasive) has a
five year survival rate approaching 100%. Breast cancer with regional spread
has a five year survival rate of 73% and cancer with distant metastasis has a
five year survival rate of 18% (ACS, 1995). Therefore, a woman’s five year
survival rate vastly diminishes as the breast cancer metastasizes from the
original breast lump. It is imperative for breast cancer to be detected in the
very early stages if a high survival rate is to be realized.

Breast cancer screening has three important components, monthly
breast self-exam, yearly clinical breast exam by a health care provider, and
mammography. Seventy-eight per cent of physicians are complying with
ACS recommendations for annual clinical breast exams (ACS, 1990), and
women are being taught self breast examination. The missing component is
regular mammography.

Mammography is the most sensitive screening tool available for early
detection of breast cancer. Breast lesions can be identified with
mammography several years before they can be palpated in the breast tissue.
Thirty-seven per cent of physicians are complying with ACS
recommendations for regular mammography (ACS, 1990). According to the
Michigan Department of Public Health (19903) breast cancer mortality rates
could be reduced by 30%-50% through early detection utilizing

mammography. Ifbreast cancer is detected in its early stages before
metastasis, survival rates approach 100% (MDPH, 1990a). The American
Cancer Society currently recommends a baseline mammogram by the age of
40, a mammogram every one to two years during ages 40-49, and then a
yearly mammogram at age 50 and older (ACS, 1995).

The number of women utilizing mammography has increased
significantly over the last few years. A 1990 Mammography Attitudes and
Usage study (Mortality and Morbidity Weekly Report, 1990) indicates that
64% of women aged 40 or greater reported at least one mammogram. But
only 31% were following mammography screening guidelines. A repeat
study in 1992 found 74% had had at least one mammogram and 41% were
following guidelines (Horton, Romans, & Cruess, 1992). Miller and
Champion (1993) found 81% of women had had one mammogram and only
23% of women had followed guidelines for the three preceding years.

It is not clear why so few women are following the recommended
guidelines for mammography. There are most likely barriers that
influence women and deter them from obtaining a regular mammogram.
Some of the documented barriers to screening mammography are cost,
lack of transportation, inconvenience, lack of time, lack of knowledge,
fear and distrust of radiation, fear of finding cancer, discomfort,
inaccessibility, lack of physician referral, and a belief that a
mammogram is unnecessary in the absence of symptoms (Bastini,

Marcus, & Hollatz-Brown, 1991; Glanz, Resch, Blake, Gorchov, &
Rimer, 1992; Horton et al., 1992; Miller & Champion, 1993). There

are quite a few studies evaluating barriers to mammography in the last

ten years, however very few address barriers to regular mammography.
Early studies were concerned about barriers to a single mammography
since few women ever had a mammogram. Today the percentage of
women who have had at least one mammogram is increasing and
emphasis should now be focused on identifying barriers to regular
mammography according to recommended guidelines.

Pumse of Study

At this point in time there are no definitive strategies for prevention of
breast cancer. The only line of defense against this killer disease of American
women is early detection and treatment. The best early detection tool is the
screening mammogram. However one mammogram every few years in a
sporadic fashion may not be effective. Marnmograrns must be obtained on a
regular basis such as following the recommendations of the ACS. Regular
mammography is imperative if breast cancer is to be diagnosed in the very
early stages when it is most curable. Since the technology is available, why
are women not following the guidelines for early detection especially those
who have had at least one mammogram?

The purpose of this study was to explore employed women’s barriers to
acquisition of regular mammography. Specifically, women who had one
mammogram but did not acquire the second mammogram within ACS
guidelines were studied to ascertain which selected barriers they identified.

The Health Belief Model developed by Rosenstock (197 4) and
expanded by J anz and Becker (1984) was used to guide this study. The
Health Belief Model is a psychosocial model that attempts to explain an

individual’s decision-making whether to engage or not engage in preventive

health behavior. Data from Given, Given, and Dirnitrov’s, (1991) research,
Assessment of Barriers and Facilitators to Screeningfor Breast Cancer--a
Worksite Approach, MDPH, Chronic Disease Division, was secondarily
analyzed. It is hoped that identification of barriers to regular mammography
will better equip health care workers and work sites to provide strategies to
overcome barriers and increase repeated mammography.

The specific question being studied is: Do employed women ages 4:2;
65 who h_ave had one mammogram but failed to acquire subsequent

mammograms according to ACS gm'delines identifl cost, lack of physician
referral, discomfort, fear of finding cancerjmaccessibility, or lack of

 

knowledge as barriers to mammoggaphy?

 

Review of Literature

Conceptual Definition of the Variables

The independent variables in this study are selected barriers chosen
from the literature. Barrier was defined as the perceived hindrances or
obstructions that deter a woman from following through with the suggested
screening health behavior, mammography. The barriers selected for study
were cost, lack of physician referral, discomfort, fear of finding cancer,
inaccessibility, and lack of knowledge of screening guidelines.

Cost was defined for this study as the woman’s perception of hardship
due to the amount of money involved in obtaining a mammogram. The cost
of a mammogram can vary widely from $25 to $250 and for women with low
income or no insurance, cost can be a definite hindrance or obstruction.
Many researchers (Bastini et al., 1991; Miller & Champion, 1993; MMWR,
1990; Rimer, Keintz, Engstrom, & Rosen, 1989; Stein, Fox, Murata, &

Morisky, 1992) define cost as a monetary cost. Sometimes the researchers
are referring to the actual dollar figure charged for the mammogram or
sometimes they are referring to the respondent’s out of pocket cost. Urban,
Anderson, and Peacock, (1994) speak of cost and lack of insurance as factors
influencing use of mammography. Also Urban et al. (1994) defined time cost
as the total time involved for a woman to obtain a mammogram, including
travel, waiting time, and the time required to received services. Glanz et al.
(1992) added cost considerations for employed women such as acquiring
mammography during work hours with or without pay, whether they had to
make up the time, or whether they had to take a sick day. Eley (1989)
indicates cost as monetary, cost in work time lost, cost due to additional
testing for false positive results, and cost of morbidity and mortality that the
screening procedure may increase as in possible radiation exposure.
Humphrey and Ballard (1989) identify, in addition to monetary cost, other
personal costs such as anxiety over false positive results. Although there can
be different facets of cost to a woman, monetary cost was the only
consideration in this study.

Lack of physician referral was defined for this study as a woman’s
perception of her physician’s absence of recommendation for obtaining a
mammogram. Lack of physician referral has been documented in many
studies (Bastini et al., 1991; Rirner et al., 1991; Stein et al., 1992; Urban et
al., 1994) as extremely important in encouraging women to obtain
mammography. If a woman’s physician does not recommend a mammogram
the woman may feel she does not need one. Authors have spoken of lack of

physician referral as lack of advisement (Glanz et al., 1992), a physician not

discussing mammography and early detection with the patient (Stein et al.,
1992), and lack of physician recommendation (Miller & Champion, 1993). In
some studies a physician recommendation is considered a cue to action for
the woman, however in all the studies, the lack of a specific recommendation
is considered a very strong hindrance and obstruction to mammography. For
this study lack of physician referral was defined as the absence of
mammography recommendation from the woman’ 5 physician.

Discomfort was defined in this study as a woman’s perception of
embarrassment and physical and emotional discomfort during the
mammographic procedure. Stomper et al. (1988) dedicated an entire research
project to discovering if mammography was painful. The study explored the
actual physical discomfort involved with the mammographic procedure. The
Mammography Attitudes and Usage Study (MMWR, 1990) included an
agree-disagree statement “I had a bad experience with my first one”
(mammogram). The text does not expand on what the bad experience might
have been, the answer is simply the opinion of the respondent. Stein et al.
(1992) and Rimer et al. (1989) include embarrassment and fear of pain in
their studies. Nettles-Carlson (1989) in discussing the need for breast
compression during mammography, indicates mammography is uncomfortable
for most women and painful for some others.

The breast is a very private and personal part of a woman. Having a
stranger visualize and handle one’s breasts could be a very embarrassing and
uncomfortable experience. Fear of embarrassment, emotional unpleasantness,
and physical pain can be a hindrance to a woman considering a mammogram

and for this study constitutes the definition of discomfort.

Fear of finding cancer in this study was defined as a woman’s feelings
of anxiety in regards to finding breast cancer if she takes the risk of obtaining
a screening mammogram. Horton et al. (1992) use the word “fear” when
asking about a woman’s concern of finding cancer, Champion (1992) uses the
word “worry”, and Gram and Slenker (1992) speak of breast cancer anxiety.
An older study by Maclean, Sinfield, Klein, and Hamden, (1984) has a
category of fears, worry, and anxiety. The respondents indicated they would
worry about what might happen to them if cancer was found, they did not
comprehend the concept of screening and as long as they were well they were
not going to look for trouble, and a screening mammogram was not merely
pointless but positively foolhardy. Anxiety about finding cancer can be a
hindrance to women contemplating mammography especially if the woman’s
personality leans toward worrying about the unknown. Fear of finding cancer
and anxiety concerning breast cancer was considered the definition of fear of
finding cancer.

Inaccessibility was defined for this study as a woman’s perception of
inconvenience and lack of availability in regard to mammography acquisition
in her geographic area. Most researchers (Culver & Alexander, 1989; Glanz
et al., 1992; Urban et al., 1994;) include access barriers such as
inconvenience due to available hours and locations of mammography units
especially in relation to work hours. Rimer et al. (1989) speak of access
related factors being inconvenience, too much trouble, lack of time or taking
too much time. Dodd (1993) feels availability of mammography must be
considered in the broad sense. As recently as 1982 at least 70% of practicing

radiologists had little or no formal training in the technical and interpretive

aspects of mammography. Availability is more than access to an x-ray
machine and a radiologist but should include accredited radiologists, certified
technicians, and modern certified equipment.

Access to mammography can be especially troublesome for employed
women whose work schedules conflict with the schedules of mammography
units. The geographic area a woman lives in can also be a hindrance when
seeking mammography, as some women may need to drive long distances to
acquire mammography. For this study inconvenience and lack of availability
in acquiring mammography was considered the definition for inaccessibility.

Lack of knowledge about mammography screening recommendations in
this study was defined as a deficit in a woman’s knowledge about screening
recommendations for mammography. Champion (1991) and Miller and
Champion (1993) present a conceptual definition of knowledge as cognitive
information about breast cancer. Schifeling and Hamblin (1991) found
women did not obtain mammography because they did not know they needed
one. Nettles-Carlson (1989) indicates some women do not know
mammography can identify breast cancer before it is palpable. Rimer et a1.
(1989) describes a major barrier in the belief of many women that they do not
need mammography if they do not have symptoms. This problem could be
categorized as a belief or as misinformation. The Mammography Attitudes
and Usage Study GVIMWR, 1990) indicates it is difficult to distinguish if
nonattendance is a lack of knowledge or an attitude or belief. Women who
have never had a mammogram respond that they do not believe they are at

risk as no one in their family has had breast cancer. Lack of knowledge of

10

screening guidelines can be an obstruction to the acquisition of
mammography and constitutes the definition of this barrier.
Development of Theoretical Model

This study used the Health Belief Model as a theoretical framework to
describe the relationship between the concepts. The Health Belief Model
seeks to understand a widespread failure of people to take advantage of
preventive and screening techniques for the early detection of asymptomatic

disease (Janz & Becker, 1984)

The Health Belief Model (HBM) has four main variables, perceived
susceptibility, perceived severity, perceived benefits, and perceived barriers.
Perceived susceptibility is an individual’s feeling of vulnerability to a
condition, a sense of measuring the risks and the likelihood of actually
becoming a victim of the disease in question. Perceived severity is an
individual’s perception of the seriousness of contracting an illness plus the
dimensions of medical and social consequences. The combination of
perceived susceptibility and perceived severity equals the perceived threat of
the disease. Perceived benefits are beliefs held by the individual regarding
the effectiveness of an action to reduce the threat of disease. A person must
feel the benefit is greater than the cost (barriers) to follow through with the
behavior. Perceived barriers are seen as the possible hindrances and
obstructions relative to following through with the suggested preventive
health behavior.

Rosenstock (197 4) maintains the level of perceived susceptibility and
perceived severity provides the force to act, and the perceived benefits minus

the barriers decides the course of action whether to go ahead with preventive

11

health care or not. However, as this model was used in many studies it was
felt there was another factor involved. It has been labeled a cue to action or a
trigger mechanism that prompts the individual to make a decision to carry out
the preventive health behavior. Some cues to action could be mass media
campaigns, advice fi'om others, reminder postcard from physician, illness of
family member or friend, or newspaper or magazine article. Other
considerations affecting the likelihood of carrying out preventive health
behavior are demographic, economic, and psychosocial factors.

Rosenstock, Strecher, and Becker, (1988) studied the Health Belief
Model along with Bandura’s (1986) social cognitive theory and have found
the two theories have much in common. After much study and discussion
Rosenstock et al. (1988) suggested another component should be added to the
Health Belief Model called self efficacy. Self efficacy is a person’s belief in
her ability to successfully perform a behavior that will positively influence the
outcome. Self efficacy is different from outcome expectation where a person
believes a specific behavior will lead to a certain outcome. Self efficacy is
the individual’s belief that she can actually carry out the specific behavior.

Figure 1 illustrates the Health Belief Model as it relates to breast
cancer. This investigator was only concerned with the barriers to
mammography but the following discussion will go through the entire model.
The arrows indicate how factors in one box can affect the concepts in another
box.

A woman’s decision to obtain a mammogram is very much influenced
by her perceived threat of breast cancer. A woman has a sense of her own

susceptibility to breast cancer. Her perceptions are affected by her family

12

history of breast cancer and whether she may already have symptoms of
possible breast disease. A woman is also influenced by her feelings of the
severity of breast cancer if she were to contract the disease.
The demographic factors that may affect the woman’s perceptions of the
threat of breast cancer are race, age, income, and educational level. It has
been shown repeatedly in studies that higher socioeconomic levels, higher
educational level, caucasian race, and younger females are more likely to
entertain screening health behaviors, specifically screening mammography
(Horton et al., 1992; Miller & Champion, 1993;1VIMWR, 1990). For this
study the factors chosen for sample selection were employed females and
ages 42-65. This was a secondary analysis of a previous study which
included only employed females, and the ages 42-65 were selected to identify
those women who might not be in compliance with ACS screening guidelines.

The psychosocial factors are marital status and employment status.
Some psychosocial factors have been documented in the literature as being
positive in encouraging mammography. Women who were married or had a
significant relationship were observed to be more likely to have adhered to
mammography guidelines (Bastini et al., 1991; Glanz et al., 1992). When
considering employed women, social support from co-workers and employers
has also been a positive factor for obtaining mammography (Culver &
Alexander, 1989; Glanz et al., 1992).

A cue to action usually precipitates the actual decision-making process

of whether or not a woman will obtain a mammogram. The cues could be

 

 

Demographic Variables

Age42-65, Income, Race,
Education, Female

13

 

V

 

 

 

l

 

 

Perceived Susceptibility to
Breast Cancer

Perceived Seriousness of
Breast Cancer

 

 

 

v

 

 

Perceived benefits of
Mammography and
Self Efficacy
Minus
PERCEIVED BARRIERS
TO MAMMOGRAPHY
COST, LACK OF
PHYSICIAN REFERRAL,
DISCOMFORT, FEAR,
OF FINDING CANCER,
INACCESSIBILITY,
and LACK OF
KNOWLEDGE OF
SCREENING GUIDELINES

 

 

Perceived Threat of
Breast Cancer

 

 

 

 

Cues to Action
ACS brochures

Mammography information ,

Mammography
recommendations

 

 

l

 

 

Likelihood of

'—' obtaining a

SUB SEQUENT
MAMMOGRAM

 

 

 

Figure 1 Health Belief Model and Regular Mammography Acquisition

Adapted from J anz & Becker. Health Education Quarterly, 1 1, 1984.

14

external such as a mass media campaign, a reminder note from a health care
provider, or the cues could be internal such as a questionable symptom.

The decision to obtain a mammogram is made from the measure of
benefits minus the barriers. A woman’s decision to acquire or not acquire a
mammogram depends on the weights of those barriers and benefits. If the
perceived benefits (assuming there are perceived benefits) outweigh the
barriers the woman will seek mammography. If the barriers outweigh the
benefits and self efficacy the result will be a decision to not obtain a
mammogram at this time.

This investigator focused on the barriers of cost, lack of physician
referral, discomfort, fear of finding cancer, inaccessibility, and lack of
knowledge. The investigator sought to find if these barriers are identified by
women who have not gotten their mammograms at the recommended interval.
Review and Sypthesis of Literature Within the Context of This Study

Cost has been documented in numerous studies as a barrier to
mammography. Researchers (Bastini et al., 1991; Harnwi, 1990; Horton et
al., 1992) document cost as a significant barrier to obtaining mammography.
Approximately 28%-46% of women indicated cost would prevent them from
acquiring mammography. There is disagreement from other researchers
(MDPH, 1990b; Urban et al., 1994) who have not found cost to be a
significant barrier. These latter researchers reported cost or lack of insurance
was not a significant barrier to mammography.

Urban et al. (1994) conducted a telephone survey of 1520 women age
50-75 in four Washington state communities. The researchers looked at out-

of-pocket cost for mammography, cost in time, inconvenience, and household

15

income. They created a variable indicating whether a woman’s health
insurance covered 50% or more of the price of the mammogram. This
variable and the interactions between it and those variables measuring time
cost, inconvenience, and income were added to test the hypothesis that the
importance of economic variables may be greater among women with poor
insurance coverage. These interactions were not statistically significant,
suggesting that the effects of time cost, inconvenience and income on
mammography use do not vary with insurance coverage. The researchers
submit the analysis provides no evidence that economic variables are more
important for low income or uninsured women. They do concede the effects
of economic variables on use of mammography were found to be important.
It is difficult to understand the researchers analytical process when their data
indicate 25% of women age 50-64 with no insurance had never had a
mammogram and only 39% were within guidelines. Also over one-half of the
women who didn’t know if their insurance would cover mammography had
never had a mammogram. Yet the researchers find that improved insurance
coverage would not affect mammography acquisition

Cost has been considered a major barrier to mammography. However
in this study the women were employed and insured. Few studies have
investigated this type of sample to see if cost is still identified as a banier.
Also is cost an issue for women who are not adhering to screening guidelines
even if they are insured? Some people are very concerned about accruing
unneeded costs to their insurance company.

There seems to be total agreement in the literature regarding the need

for physician recommendation. Lack of physician referral is probably the

16

greatest barrier to mammogram acquisition (Bastini et al., 1991; Dodd, 1993;
Stein et al., 1992; Urban et al., 1994). These researchers report mammogram
acquisition and intention of women are directly related to exposure to
physicians and physician referral. Researchers (Glanz et al., 1992) indicate
employed women whose doctors had advised them to have a mammogram
had higher screening rates than women reporting no such recommendation.
Adherence to screening guidelines seems to depend on the advisement of a
physician also (Glanz et al., 1992; Horton et al., 1992). Many women are
reluctant to suggest a mammogram if their physician does not mention it
(MMWR, 1990).

Lack of physician referral seems to be the greatest barrier to
mammography. Nearly every researcher emphasized the importance of
physician referral. Women who are white, well educated, and middle class
are known to be more likely to seek screening procedures. This means they
are more likely to have been in contact with health care providers. The
women in this study fit this prototype and have already had one mammogram.
The employed women in this study still need to be evaluated to see if they
identify lack of physician referral as a barrier to mammography adherence.

Nettles-Carlson (1998) and Stein et al. (1992) cite discomfort, pain, and
embarrassment as a deterrent to mammography and give recommendations to
remedy the situation. Gram and Slenker (1992) reported 11% of over 3000
women in a Norwegian study found the screening examination somewhat
painful. Horton et al. (1992) in a mammography attitudes and usage study of
980 Pennsylvania women contacted by random digit dialing, found 20% of

women who have never had a mammogram were concerned about

l7

embarrassment. No statistics for embarrassment were given for women who
had a mammogram but were not in compliance with screening guidelines
although they addressed other barriers with adherence. Perhaps there were
no significant statistics or perhaps the researchers thought once a woman had
obtained an initial mammogram she had overcome any embarrassment that
would deter subsequent mammograms. The researchers did not address pain
or discomfort in their study.

Stamper et al. (1988) found 49% of 1847 women surveyed immediately
after the mammography test experienced no discomfort, 39% experienced
mild discomfort, and the rest, 12%, experienced moderate to severe
discomfort. No women recorded that their discomfort was severe enough to
make them reconsider ever getting another mammogram.

Rimer et al. (1989) reported pain and embarrassment were
nonsigrrificant variables which did not permit discrimination between
compliers and noncompliers of mammography acquisition. No studies
concerning employed women were found to include discomfort in their list of
barriers and virtually no studies commented on compliance to screening
guidelines and discomfort.

There is disagreement in the literature as to whether discomfort and
embarrassment are a barrier to mammography. This current study of women
who have already had one mammogram may shed light on whether
discomfort is a barrier only to first time mammography acquisition or if it is
still a deterrent for women who have already experienced a mammogram.

Fear of finding cancer continues to be a barrier for some women

(Champion, 1992; Horton et al., 1992). Champion (1992) is the only study

18

that addressed compliance to guidelines in relation to fear of finding cancer.
She surveyed 322 women age 35 and older in a midwestem metropolitan
area. The researcher grouped cost, pain, time, embarrassment, and worry into
a barrier category. The barrier group was significant when addressing intent
to complete an initial mammography. However the barrier group was not
significantly related to compliance with mammography guidelines.

Horton et al. (1992) reported in a study of 980 women age 40 and older
that 11%-18% of women fear the procedure or fear that a mammogram will
find cancer. Gram and Slenker (1992) report one out of three women had
anxiety about breast cancer, however receiving normal results on a screening
mammogram decreased the prevalence of anxiety. In an older study of
women who declined breast screening (Maclean et al., 1984) researchers
reported almost 40% of 125 women voiced deep fears and concerns about
possible breast cancer. Twenty percent of the women were explicit about
feeling that one ought not to tempt fate and one should leave well enough
alone. In contrast Bastini et al. (1991) reported 68% of their sample indicated
that chances were very low that fear of finding cancer would prevent them
from getting a mammogram. However, the researchers did report fear of
finding cancer was associated with screening behavior and could function as a
barrier against being screened for those few women who indicated a problem.
No studies were found specifically addressing employed women and fear of
finding cancer. Probably many of the preceding studies included employed
women but employment was not a factor that was studied.

Anxiety and fear of finding cancer have been identified in several
studies (Horton et al., 1992; Maclean et al., 1984; Gram & Slenker, 1992).

19

The only study that addressed compliance to guidelines and fear of finding
cancer is Champion (1992) who found worry was not related to
mammography compliance. This result is different from other studies. It
needs to be addressed again with another sample such as the subjects in this
current study.

Inaccessibility seems to be more of a problem for working and rural
women but also continues to be a problem for women whose employment
status is not known as documented by Gram and Slenker (1992) and Culver
and Alexander (1989). Horton et al. (1992) reported 23% of 980 women
indicated it was hard to find time to get a mammogram. Rimer et al. (1989)
in a study of why 484 women resisted screening mammography, report access
as a significant barrier to mammography and a predictor of compliance. A
statistically significant number of respondents who had not acquired
mammography indicated that mammography was too much trouble and
inconvenient, and that they didn’t have enough time to acquire
mammography.

Glanz et al. (1992) interviewed 798 employed women from
Pennsylvania and New Jersey age 40 and older. Eighty-four percent reported
having had a mammogram and 72% were within screening guidelines.
Access factors were significant among women who had ever had a
mammogram but not among adhering women. Researchers found women
more likely to get a mammogram if they could obtain one during work hours
either at the worksite or by going to a mammography center. In a subgroup
of 17 9 women, 54% stated they obtained a mammogram during work hours,

two-thirds of them with pay. Some of these women also had access to a

20

mobile screening unit at their worksite and 58% reported driving no more
than five miles to get a mammogram. For the women in this subsarnple it
would appear that access is not a great barrier however, 28% reported it was
difficult to schedule a mammogram around their work schedule. No
comments were found about adherence to screening guidelines and access.
Access to screening mammography can be a problem for working
women. Especially if mammography units are only available week days and
at times that coincide with women’s work hours. There is disagreement in
the literature as to whether access is a barrier. Few studies have looked
solely at employed women and no studies were found that addressed
adherence to screening guidelines and inaccessibility to mammography.
Numerous studies agree that lack of knowledge of screening guidelines
is a barrier to mammography (Bastini et al., 1991; Glanz et al., 1992; Horton
et al., 1992). The researchers report women are more likely to have
mammography if they are aware of the screening guidelines. Miller and
Champion (1993) disagree in their report stating that knowledge was not
associated with utilization of mammography. The researchers had a
convenience sample of 161 women age 50 and older from four churches in a
large rnidwestem metropolitan area. Eighty-one percent had had a
mammogram, 39% had had a mammogram in the preceding year, and 24%
were compliant for three years. A seven item knowledge inventory was used
to assess breast cancer risk factors and mammography recommendations.
Internal consistency reliability for the sample data was only 0.37 . The
researchers submit this indicates that knowledge in relation to the various

items in the inventory varied considerably for individuals. Perhaps the low

21

alpha value of the knowledge inventory suggests a scale with poor reliability
and thus knowledge was not associated with utilization of mammography.
Bastini et al. (1991) and Champion (1991) found that women who knew the
screening mammography guidelines for their age were more likely to have
been screened according to the guidelines.

There is disagreement in the literature as to whether lack of knowledge
of screening guidelines is a barrier to mammography. One study (Glanz et
al., 1992) found lack of knowledge to be a barrier to employed women and is
the only study that addressed working women. Another employed sample
needs to be evaluated to see if they identify lack of knowledge of screening
guidelines as a barrier to mammography. Women who have had a
mammogram need to be investigated also to see if lack of knowledge can still
be a barrier to adherence to screening guidelines.

The barriers chosen for this study have been cited often in the literature
especially for first time mammography. What is not clear is whether
adherence to screening guidelines is affected by the same barriers. There are
few studies available concerning compliance to screening mammography and
also few studies involving employed women.

This study has value in indicating what barriers are identified so some
of those issues can be addressed. Also this study has value if certain barriers
are not identified so there can be some insight on which areas to focus
attention. The ultimate goal was to encourage regular mammography and
break down existing barriers. If we can identify the barriers we have a place
to start. Since breast cancer affects a large number of women, it definitely

merits more study to identify ways to decrease its morbidity and mortality.

22

Methodological and Conceptual Problems in the Literature
There are some methodological problems in the literature, one of which

is self reporting 03asfini et al., 1991; Horton et al., 1992; Stein et al., 1992).
Self reported data can lead to questions about validity and accuracy of its
content, especially if the subject matter is very personal or a respondent’s
views are contrary to popular public opinion at the time. Researchers have to
trust the respondent to report true feelings, and not the “acceptable” response.

Another problem is the retrospective nature of many studies.
Retrospective studies rely on questionnaires either written or verbal which
require a woman to remember when she had a mammogram (Bastini et al.,
1991; Champion, 1991; Horton et al., 1992; Rimer et al., 1989; Stein et al.,
1992; Urban et al., 1994). This memory or recall problem can greatly affect
the data. Also depending on the mood of the respondent or current life
events, her response regarding attitude variables could change from day to
day.

Self selection or convenience sampling is another problem related to
many studies (Bastini et al., 1991; Glanz et al., 1992; Horton et al., 1992;
Stein et al., 1992). Most of these studies used a random digit dialed
telephone interview and the subjects could decline if they did not want to
participate. Field studies about attitudes and behavior are not strictly
controlled studies. All the information comes from the respondent and if a
woman doesn’t want to participate she doesn’t have to. The available
subjects may be atypical of the population in regards to the variables being
measured. Women who are not interested in mammography, or are very

afraid of mammograms may decline to participate, leaving a piece of the total

23

population out of the picture. Conversely women who are very interested in
preventive health and mammography are probably more likely to volunteer to
be a part of a study. One has to wonder about the women who choose not to
participate in studies. What are their feelings about mammography and what
would they indicate about possible barriers?

Sample bias is another methodological problem that occurs when one is
not able to get a true sampling of subjects representing the total population.
The goal is to get a sample that represents the total population in regards to
race, education, socioeconomic status, age, etc. Bastini et al. (1991) reports
an under representation of Hispanics in Los Angeles County, California in
their study of screening mammography and barriers to use. Champion (1991)
required subjects to have an eighth grade reading capacity in her study.
Although researchers make choices on how best to conduct studies, this
particular study excluded illiterate and less educated women entirely. Also if
the studies that used telephone interviews were conducted during day time
hours, many working women could have been excluded.

Bastini et al. (1991) also wams about predicting mammographic
behavior from knowledge and attitudinal variables. The researchers used a
23 item questionnaire to measure demographic characteristics and
mammography knowledge, attitudes, intentions, and behaviors. They also
used the HBM for a theoretical model which postulates an individual’s
perceptions of severity, susceptibility, efficacy, and barriers will predict
whether a health behavior will occur. The researchers submit it is not entirely
clear whether attitudes influence obtaining a mammogram or whether

receiving a mammogram influences one’s attitudes. This is an example of ex

24

post facto research. There is a problem of inferring causal relationships after
the fact, because there was no manipulative control of the independent
variables.

None of these methodological problems can be completely deleted,
however the researcher needs to be aware of them. It is not possible to study
the entire population but researchers need to look at their methods to make
sure they do not exclude important sectors of the population. Also
researchers should be very careful abut making cause and effect claims
conceming the research and simply report the facts.

The literature relevant to barriers to screening mammography has been
reviewed to gain understanding as to why women are not getting
mammograms on a regular basis. The selected barriers, cost, lack of
physician referral, discomfort, fear of finding cancer, inaccessibility, and lack
of knowledge, for this study were well documented for first time
mammography. What is not clear is whether adherence to screening
guidelines is affected by the same barriers.

There are few studies (Glanz et al., 1992) that address barriers to
adherence to screening mammography guidelines among employed women.
Very little has been written about working women and any special needs they
may have concerning regular mammography. Employed women represent a
large segment of the female population of the US. One of nine women will
experience breast cancer in her lifetime. The morbidity and mortality of
breast cancer can have a significant impact upon the worksite through lost
work hours, training replacement employees, and disability and medical

insurance premiums.

25

There are also too few studies concerning adherence to screening
guidelines. Researchers have done well identifying barriers to initial
mammography. It is time to move on and study compliance issues in regards
to regular screening mammography. More groups of women need to be
investigated to get a more complete picture of the problems plaguing women
that lead to noncompliance with screening guidelines.

Methods
Rosea rch desigp

The research design was a descriptive secondary analysis of data from
Michigan State University research named Assessment of Baniers and
Facilitators to Screening for Breast Cancer--A Worksite Approach (Given et
al., 1991).The research question was: Do employed women ages 42-65 who
have h_ad one mgrpmpgram but failed to acquire subsequent mammograms
according to ACS guidelines identify cost. lack of physician referral.
discomfort. fear of findingcancer, inaccessibility, or lack of knowledgeirs
men to mammogram
Mel:

Sociodemographically the subjects from the original study were
employed females ages 35-65. They were predominately middle class,
educated, caucasian women. There were a few African-American and
Hispanic subjects included. The overall income levels ranged from $15,000
to greater than $50,000, and education levels ranged from less than high
school diploma through graduate school.

There were 17 9 respondents of the 1666 voluntary subjects returning

questionnaires from six different worksites who met the criteria for this study.

26

The criteria for sample selection were: (a) employed women working in the
Greater Lansing area, (b) ages 42-65, (c) gave a response of “yes” to having
had a mammogram, and ((1) recorded a date of her most recent mammogram
beyond the time limits recommended for her age by the ACS guidelines.
Data Collection

Since this is a secondary study, data collection was retrieved from a
computer disc that had responses from the questionnaire in a coded numerical
form. The data was originally collected from an 18 page questionnaire that
was distributed to women of six different worksites in 1990 in the Greater
Lansing area, either by mailing labels acquired from the company or directly
at an informational meeting. The respondents mailed the questionnaire back
to Michigan State University in a stamped self-addressed return envelope.
Operational Definition of Variables and Scoring

The independent variables: cost, lack of physician referral, discomfort,
fear of finding cancer, inconvenience, inaccessibility, and lack of knowledge
concerning screening mammography recommendations, were operationalized
by each subject’s personal response to the questionnaire, Health Practices: A
Worksite Survey (Given et al., 1991). The operational definition of each
variable is as follows.

Cost was defined by one item, response 33 card 3, asking if obtaining a
mammogram is a cost hardship. The Likert type question has four possible
answers ranging from 1 (stroneg disaggee) to 4 (strongly agzee). A high
score represents the perception of monetary hardship and a barrier to

mammography.

27

Lack of physician referral was defined by a combination of two items.
One of the two items which is in a Likert four point format was recoded to a
dichotomous format, the other item is a dichotomous variable using a “yes”
and “no” format. Response 52 card 3 is a response to a negative statement
“my doctor has never suggested that I have a mammo gram”. The question
explores a woman’ s perception of her doctor’ s recommendation for obtaining
a mammogram. The question is in Likert format with four possible answers
which are scored ranging from 1 (stongly disagree) to 4 (stroneg aggee) and
was recoded into a dichotomous variable. An answer of “agree” or “strongly
agree” was scored a “no” inferring a barrier, an answer of “disagree” or
‘strongly disagree” was scored as yes indicating a lack of perceived barrier.
Response 58 card 5 answers to the question of “has your doctor advised you
to obtain a screening mammography?”. This dichotomous question has two
possible responses and was scored as “no’ and “yes”. The two dichotomous
questions were grouped together and the subjects’ responses to both
questions have to constitute a barrier for lack of physician referral to be
considered a barrier.

Discomfort was defined by four items which in combination formed a
discomfort scale. The items included response 31 card 3 to the statement “a
mammogram is an embarrassing procedure”, response 32 card 3 dealing with
a mammogram being an unpleasant procedure in the participant’s perception,
response 34 card 3 addressing whether the participant feels a mammogram is
painful or physically uncomfortable, and response 41 card 3 addressing
whether a mammogram makes the participant feel uncomfortable. The above

four Likert type questions have four possible responses ranging from 1

(strongly disagree) to 4 (strongly agree). A high discomfort total scale score
indicated a perception of embarrassment and physical and emotional
discomfort and also a barrier to mammography. The possible range of the
total scale score was 4 to 16.

Fear of finding cancer was defined by a combination of two items
forming an anxiety scale. Response 35 card 3 addressed the statement “a
mammogram would make me feel anxious”, and response 44 card 3 states
“I’m afraid something abnormal would be found”. The above two questions
in four point Likert format have four possible responses ranging fi'om 1
(strongly disagree) to 4 (strongly agree). A high anxiety total scale score
represented a perception of fear and anxiety and a barrier to mammography.
The possible range was 2 to 8 for total scale score.

Inaccessibility was defined by three items which in combination will
form an access scale. Responses 36 and 40 card 3 deal with a mammogram
being inconvenient to arrange and not worth the effort. Response 38 card 3
addresses whether a mammogram is available in the participant’s area. The
four point Likert type questions have four possible responses from 1 (sggrgly
gsggrep) to 4 (strong1y agree). A high access total scale score indicated a
perception of inconvenience and lack of availability and also a barrier to
mammography. The possible range of the total scale score was 3 to 12.

Lack of knowledge about mammography screening recommendations
was defined by two items which in combination formed a knowledge scale.
Responses 42 and 48 card 3 addressed whether the participant knows when
she should obtain a mammogram. These two questions in four point Likert

format have four possible responses 1 (strongly disagree) to 4 (strongly

29

am). A high knowledge total scale score indicated a lack of knowledge
concerning mammography screening guidelines and also a barrier to
mammography. A possible range for the total scale score was 2 to 8.
Instrumentation

The instrument was the 18 questionnaire from Wave I (See Appendix
A) of the Michigan State study “Assessment of Barriers and Facilitators to
Screening for Breast Cancer:--a Worksite Approach” (Given et al., 1991).
The original wave I instrument was checked for reliability by Cronbach’s
alpha and yielded coefficients of 0.78 to 0.91 for the summated barrier scales.
Fourteen questions were extracted from the original questionnaire for this
current study. The questions included one on cost, two on lack of physician
referral, four on discomfort, two on fear of finding cancer, three on
inaccessibility, and two on lack of knowledge about screening mammography
recommendation. The discomfort, anxiety, access, and lack of knowledge
scales were tested for reliability by Cronbach’s coefficient alpha before going
on with the data analysis and yielded coefficients of 0.56 to 0.79. Cronbach’s
coefficient alpha correlates each individual item with each other item and the
total score. It can also help the researcher identify individual problem
questions that do not relate well to other questions in the scale.
Data Analysis

Data analysis was done with the SPSS/PC+ computer program.
Demographic characteristics of age, marital status, race, educational level,
and household income were described with descriptive statistics using

frequencies, percents, means, and standard deviations as appropriate.

30

The first barrier, cost, was reported in a frequency distribution, mean,
and standard deviation. The frequency and percent indicated how many
women identify cost as a barrier and how many do not. The mean and
standard deviation describe the average woman’s perception and the index of
variability. If the total mean score was greater than the midpoint of the range,
cost was considered a banier.

The lack of physician referral barrier was reported in a frequency
distribution and percent. The frequency and percent indicate how many
women identified lack of physician referral as a barrier and how many did
not. This barrier was measured by nominal data which can be analyzed
appropriately by frequency and percent. Also since the data were
proportional and categorical, chi-square statistics were used to test the
statistical significance of the proportion of women who answered yes as
opposed to the proportion of women who answered no. Chi-square was
considered significant if greater then 3.84 with 1 degree of freedom. A
barrier was found if the highest frequency was a “no” response.

The last four barriers had similar analysis since they each have
subscales. Discomfort had a four item discomfort scale. Fear of finding
cancer had a two item anxiety scale. The banier, inaccessibility, had a three
item access scale, and the barrier of lack of knowledge of screening
guidelines was analyzed by a two item knowledge scale. The total scale
scores were then described by mean and standard deviation. Ifthe total scale
mean was greater than the midpoint of the total scale the results were
considered a barrier. The standard deviation of the scale was used to discuss

the variability within the sample group.

31

Each single item of all the scales was also described by a frequency
distribution and percent, allowmg identification of how many women
perceived a barrier and how many did not. These statistical techniques are
appropriate for use with ordinal data.

Limitations and Assumptions

There is a limitation when using secondary data of trying to create new
scales from items not grouped together in the original project
conceptualization. Another limitation is that the data was self reported and
no attempt was made to validate the information through other sources. A
third limitation is the subjects were self selected so the results may not
represent the larger population.

Assumptions concerning the data are that the respondents answered the
questions honestly, and since secondary data is being used an assumption is
made that the data was entered in the computer accurately.

Protection of Human Subjects

The University Committee on Research Involving Human Subjects
(UCRIHS) at Michigan State University was contacted for approval
concerning protection of the rights and welfare of the respondents. Approval
for this project was issued March 24, 1995 (See Appendix B) before data
analysis began. A copy of the approval from UCRIHS for the original Wave
I study is also included in Appendix B. The identity of study respondents and

their responses remained anonymous as there were no names in the data.

32

Findings and Interpretation

This study investigated employed women ages 42-65 who have had one
mammogram but have not obtained a subsequent mammogram within the
recommendations of the ACS. The subjects’ responses to questions
pertaining to selected barriers, cost, lack of physician referral, discomfort,
fear of finding cancer, inaccessibility, and lack of knowledge of screening
guidelines were evaluated to see if this group of women identified these
barriers. Secondary data was used from a MSU study, Assessment of
Barriers and Facilitators to Screening for Breast Cancer-~A Worksite
Approach (Given et al., 1991).

Sociodemographic Characteristics

The sample consisted of 17 9 respondents who met the criteria of age 42-65,
employed, had a mammogram, and were currently noncompliant with ACS
guidelines for a subsequent mammogram. The subjects had a mean age of 52
years (§2=5.75) and ranged fiorn 42 to 65 years of age. The majority of
subjects were married (p=125, 69.8%), white (p=165, 92.2%), educated past
high school diploma (p=107, 59.8%), and reported an annual household
income greater than $35,000 (r_1=119, 69.3%). See Table 1 for more detailed

characteristics of the sample.

33

Table l

Sociodemographic characteristics of noncompliant women (n=179)

 

 

Lariable Frequency Percentagp
Age
42-49 67 37.0
50-59 92 52.0
60-65 20 11.0
Marital status
single/never married 7 3 .9
widowed 3 1.7
married/living as married 125 69.8
divorced 43 24.0
other 1 0.6
Race
white 165 92.2
black 11 6.1
hispanic 1 0.6
arnerican indian/alaskan 1 0.6
chinese 1 0.6
Education
less than 8th grade 1 0.6
8'h-11th grade 7 3.9
high school/ged 64 35.8
post high school/tech 15 8.4
1-3 years college 47 26.3
college graduate 19 10.6
graduate school 26 14.5

Table l (cont’d)

 

 

firiable Frequency Percerggg
Income

less than $15,999 2 1.2
$15,000-20,999 8 4.7
$21,000-25,999 13 7 .6
$26,000-30,999 l4 8. 1
$31 ,000-35,999 16 9.3
$36,000-40,999 24 14.0
$41 ,000-45,999 23 13 .4
$46,000-50,000 16 9.3
greater than $50,000 56 32.6
missing 7

W

The research question was Do employed women ages 42-65 who ha_v_e_
had one mammogzam but failed to acquire subsequent mammogzams
according to ACS guidelines identify cost. lack of physician referrfial,
discomfort. fear of finding cancer. inaficcessibility. or lack of lgrowlem
barriers to mammogzaphy.

Valid percents were used in this study to describe the subjects who
responded to the question. Subjects who did not respond to the specific
question were excluded from the percentage figures.

The first barrier examined was cost and 89.4% subjects (p=151) disagreed or
strongly disagreed that mammogram cost was a hardship for them. The low
mean M4 .7) indicated the average response disagreed that cost was a
hardship and the narrow standard deviation (S_D=0.78) indicated there is very
little variability among the sample for this barrier. Only eighteen

35

Table 2

quency and pgrcent of cost hardship barrier related to
mammography (n=179)

 

 

Frequency Percent
Strongly agree 8 4.7
Agree 10 5.9
Disagree 75 44.4
Strongly disagree 76 45.0
Missing 10

 

women or 10.6% indicated that cost was a barrier (See Table 2). Analysis of
the data reveals cost was not a barrier for this sample.

All of the subjects in the sample were employed and were insured. Ten
per cent of the women agreed that cost was still a problem. When asked
about their insurance coverage 59.5% (p=103) thought their insurance
covered mammography, 18.5% (p=32) reported it was not covered, and
22.0% (p=3 8) did not know if their insurance covered mammography. This
would indicate that even though some women didn’t know if their insurance
covered mammography and others knew mammography was not covered,
cost still was not perceived to be a problem. Only 10 (5.9%) women had an

income level less than $20,000. Family size was not included in the survey.

36

Ten subjects (5.6%) did not answer this question but even if they agreed with
the question it would not have changed the outcome significantly.

Another consideration about cost and this particular sample is the
majority of these women were considerably above the poverty level. The
annual household income for 78.6% (p=l 19) of the subjects was greater than
$35,000, indicating most respondents could likely pay for a mammogram
easier than a poor or uninsured woman. The literature continues to support
cost as a barrier for lower income, uninsured women (Horton et al., 1994).
However, there were few low income women and no uninsured women in this
sample. Thus, cost was not a barrier for this sample.

The barrier, lack of physician referral, was explored with a combination
of two questions. One question was in Likert form and recoded to a yes and
no answer and then the two nominal questions were grouped together for
statistical analysis utilizing chi square. One hundred forty-six women
(98.6%) answered yes to both questions indicating their physician had
advised mammography, and they disagreed with the statement “my doctor has
never suggested mammography”. Two respondents (1.4%) answered “no”,
indicating their physician had not advised mammography and agreed “my
doctor has never suggested mammography. Seven subjects, excluded from the
analysis, gave conflicting answers to the two questions possibly due to the
negative statement There were 24 (13.4%) missing observations perhaps the
negative statement was confusing but no matter what their answers the
outcome of this barrier would not be significantly changed. Of the 148
females whose answers to both questions are consistent there was a

significant difference in proportion of their responses. The chi-square value

37

was 148, d_f =1, and a significance of 0.00. The chi-square value also
indicates the subjects did not randomly fall into a group as a result of chance,
but the preponderance of women agree that lack of physician referral was not
a barrier for this sample. There is currently disagreement as to
mammography guidelines among various cancer specialty groups. Some feel
mammography screening of women in their 40’s is not cost effective and has
not decreased mortality rates for women this age. Consequently there can be
confusion for physicians and clients as to what guidelines to follow. It is not
known how this controversy may have impacted this study but it may have
been a limitation.

The literature disagrees with this finding and suggests lack of physician
referral is the greatest barrier to acquisition of mammography (Bastini et al.,
1991; Dodd, 1993; Urban et al., 1994). The two questions used in this
survey are better suited for investigating women who have never had a
mammogram. It is possible the subject’s physician may have suggested a
mammogram at least once, but not on a regular basis. A different question
indicating the physician suggested mammography on a regular basis may have
yielded an answer consistent with the literature. So it is difficult to determine
if these women are different from those in the literature or if the questions did
not adequately evaluate physician recommendation for adherence to screening
guidelines.

The literature (Horton et al., 1991) also suggests that well educated,
higher income, and younger women are more likely to obtain mammography
and preventive health care. Many of the subjects in the sample fit this

description and may have disagreed with other studies about lack of referral

38

due to their higher socioeconomic status and possibly more frequent contact
with health care services. For this sample, lack of physician referral was not
a barrier.

The third barrier investigated was that of discomfort with four questions
(see Table 3). The question indicating a mammogram makes me feel
uncomfortable revealed 64 women (37.5%) agreed or strongly agreed and
107 women (62.5%) disagreed or strongly disagreed. The question
concerning mammography being an unpleasant procedure was agreed or
strongly agreed with by 83 (48.8%) of the subjects, and 87 (51.2%) disagreed
or strongly disagreed with the statement. Concerning the statement a
mammogram is an embarrassing procedure, 41 women (23.9%) agreed or
strongly agreed and 130 women (76.0%) who disagreed or strongly disagreed
with the statement. The subjects responded to the question about
mammography being painful with 60 (35.5%) indicating agreement and 109
(64.5%) indicating disagreement. Overall the women did not report
discomfort as a barrier. There were 8-10 (4.5%-5.6%) missing observations
per question. It is unknown why the subjects did not answer the questions. It
is possible the nine women who did not answer the question about
unpleasantrress could completely change the outcome and lead to a barrier
outcome if they all agreed with the statement. However it is not likely they
would have all agreed.

The four preceding questions were grouped together in a discomfort
scale which appropriately addressed discomfort and comprises a valid scale.
Cronbach’s alpha reliability test was used to evaluate internal consistency.

The alpha coefficient was 0.79 indicating a reliable scale. A scale is

39

Table 3

Frguency and Erecnt of discomfort items related to mammography
(n=l79)

 

Uncomfortable Unpleasant Embarrassing Painful

 

n % n % n % n %
Strongly agree 9 5.3 17 10.0 4 2.3 17 10.1
Agree 55 32.2 66 38.8 37 21.6 43 25.4
Disagree 63 36.8 60 35.3 79 46.2 84 49.7

Stronglydisagree 44 25.7 27 15.9 51 29.8 25 14.8

Missing 8 9 8 10

considered to be reliable if the coefficient is 0.70 or greater. The possible
range of the total scale score was 4 to 16, a total scale mean greater than 10
indicated a barrier. The total scale mean was 8.87 (S_D 2.66) indicating the
average respondent disagreed that discomfort was a barrier. However, the
standard deviation indicates there was a fair amount of variability among the
subjects extending into the category of agree. An evaluation of the individual
questions revealed 83 subjects (48.8%) responded mammography was an
unpleasant procedure and 37.5% (p=64) agreed mammography made them
feel uncomfortable. Similarly 35.5% (p=60) agreed mammography was
painful. It must be remembered these respondents have already had one

mammogram, these are not preconceived ideas before an initial mammogram.

40

The responses given are from a personal experience with mammography and
should be taken seriously as the respondents’ perception of the procedure.

There is disagreement in the literature as to discomfort being a barrier.
Some researchers have found no evidence of discomfort being a barrier
(Rimer et al., 1989) other investigators (Gram & Slenker, 1992; Horton et al.,
1992) still identify discomfort as a barrier. The results of this study could
indicate discomfort can be a barrier for 35%-48% of women who have
already experienced a mammogram, but most women do not identify
discomfort as a barrier.

Another barrier, fear of finding cancer, was explored with a two item
scale (See Table 4). The questions dealt with a mammogram making me
anxious, and being afraid something abnormal would be found. The
questions address the barrier appropriately and form a valid scale. One
hundred twenty-six subjects (75.9%) disagreed or strongly disagreed with the
anxiety statement, 40 women (24.1%) agreed or strongly agreed with the
statement. The “fear of finding something abnormal” statement yielded 139
(81.2%) disagree or stingily disagree responses and 32 (18.7%) agree or
strongly agree responses. There were 8-13 missing observations perhaps they
didn’t feel the question applied to them, it is not likely their answers would
have changed the outcome of the barrier.

The anxiety scale was formed by grouping the two previous questions
together and Cronbach’s alpha was used to test reliability. The alpha
coefficient (0.56) was lower on this scale, and the reliability of this scale
should be interpreted with caution. The low reliability could be due to the

content of the questions or because it is only a two item scale, for longer

41

scales are more reliable than short scales. The possible range of the total
scale score was 2 to 8, a total scale mean greater than 5 indicated a barrier.
The total scale mean 3.86 indicated most subjects disagreed with the anxiety
scale as being a barrier to mammography. There is moderate variability
(S_D=1.30) among respondents but still the majority fall within the category of
disagree. So for this sample, anxiety and fear of finding cancer was not a

barrier.

Table 4

Frguency and percent of anxiety items related to mammography
(n=l79

 

Makes me anxious Afraid abnormal findings

 

 

n % n %
Strongly agree 3 1.8 6 3.5
Agree 37 22.3 26 15.2
Disagree 83 50.0 76 44.4
Strongly disagree 43 25.9 63 36.8
Missing 13 8

 

Researchers Horton et al., (1992) and Gram and Slenker, (1992) cite

fear of finding cancer as a barrier to mammography. However the barrier

42

seems to be more related to the first mammogram and Champion (1992)
reports anxiety is not significantly related to compliance with ACS guidelines.
The respondents in this sample have all had a mammogram and the majority
disagree that anxiety and fear of finding cancer are a barrier to regular
mammography.

The barrier of inaccessibility (Table 5) included three questions. The
first statement explored if a mammogram was inconvenient to arrange. One
hundred thirty-nine women (81.7%) disagreed or strongly disagreed and 31
women (18.2%) agreed or strongly agreed. A second statement addressed if
a mammogram was not available in her area. One hundred sixty-two subjects
disagreed or strongly disagreed (95.9%), and only seven subjects (4.2%)
agreed or strongly agreed with this statement. A third statement stated a
mammogram is not worth the effort. One hundred sixty-three subjects
(95.3%) responded with disagreement or strong disagreement, and only eight
or 4.6% of women agreed or strongly agreed. The questions address the
barrier appropriately and form a valid scale. There were 8-10 missing
observations, maybe a few women skipped the page all of these questions
were on in the survey as it seems to be nearly the same number for each
question. It is not likely the missing respondents would have significantly
changed the outcome of this barrier.

These three questions were grouped together to form an inaccessibility
scale and Cronbach’s alpha was used to test for reliability. The alpha
coefficient was .68, total scale mean 4.69, and standard deviation 1.65. scale
was considered reliable as it was a short scale. The possible total scale range

was 3 to 12 and a total scale mean greater than 7.5 indicated a barrier.

43

Table 5

Freguency and percent of inaccessibility items related to mammography
(n=l79)

 

 

 

Inconvenient Not available Not worth effort
n % n % n %
Strongly agree 6 3.5 4 2.4 4 2.3
Agree 25 14.7 3 1.8 4 2.3
Disagree 81 47.6 49 29.0 53 31.0
Strongly disagree 58 34.1 113 66.9 110 64.3
Missing 9 10 8

 

The total scale mean M=4.69) indicated most of the respondents felt that
mammography is definitely available and worth the effort. The standard
deviation (S_D—11.65) indicated there was moderate variability among the
respondents. For the women in this sample accessibility was not a barrier.
The literature (Gram & Slenker, 1992; Horton etal., 1992) indicates
accessibility continues to be a problem for employed women and rural
women. The women in the sample were employed but probably not rural as
they worked in the Greater Lansing area. The fact of being employed could
contribute to the 18% response of mammography being inconvenient to
arrange due to work schedules and mammography unit availability during

nonwork hours.

The last barrier, lack of knowledge, included two questions (See Table
6). The first question stated “I don’t know when I need a mammogram”.
One hundred forty-six (86.9%) women disagreed or strongly disagreed and
22 (13.1%) agreed or strongly agreed with the statement. The second
statement said “I forget when I’m supposed to have a mammogram”. This
statement was disagreed or strongly disagreed with by 131 (77.5%) of the
subjects, 38 (22.5%) of the women agreed or strongly agreed. There were 11
and 10 missing observations for these questions and even if those subjects
agreed with the questions, the outcome of the barrier would not be
significantly changed.

The preceding two questions were grouped together to form a scale and
tested for reliability with Cronbach’s alpha. The alpha coefficient was .63
and the scale should be interpreted with some caution. The low alpha level
could be due to question content or the fact of only having two items. The
possible total scale range was 2 to 8 and a total scale mean of greater than 5
indicated a barrier. The standard deviation (S_D=1.29) indicated there was
not alot of variability among the responses. The total scale mean (M=3.69)
indicated for this sample that respondents do know when a mammogram is
recommended and that lack of knowledge of screening guidelines is not a
barrier. However, these questions do not actually evaluate if the subject truly
knows screening guidelines and is not a valid scale for assessing knowledge
of screening guidelines.

The questions in this study only ask for her perception of her knowledge

of screening guidelines. There is no way to know from these questions if the

45

Table 6

quency and percent of lack of knowledge of ACS gg'delines (n=179)

 

 

 

Don’mow when needed I forget when to have
n % n %
Strongly agree 4 2.4 3 1.8
Agree 18 10.7 35 20.7
Disagree 83 49.4 73 43.2
Stongly disagree 63 37.5 58 34.3
Missing 11 10

 

respondent actually knows the ACS guidelines for mammography. Some
researchers indicate that lack of knowledge of screening guidelines is a barrier
to mammography (Horton et al., 1992; Bastini et al., 1991; Glanz et al., 1992).
Some disagree (Miller & Champion, 1993). For this sample, lack of knowledge
of screening guidelines was not found to be a barrier.

In summation none of the barriers investigated, cost, lack of physician
referral, discomfort, fear of finding cancer, inaccessibility, and lack of
knowledge of screening guidelines were found to be barriers. None of the
individual questions or scales yielded statistical evidence of a barrier.
However, approximately 24% (p=40) of the subjects have some fears about
finding cancer if they obtain a mammogram, approximately 18%(p=31) find

obtaining a mammogram inconvenient, and 22 % (p=3 8) forget when they are

46

supposed to have a mammogram. Forty-eight percent (p=83) agree
mammography is unpleasant, 37.5% (p=64) indicated mammography made
her feel uncomfortable, and 35.5% (p=60) agree mammography is painful.
These women should not be overlooked. The barriers selected for this study
are regularly cited in the literature for first time mammography, however
barriers for compliance to ACS guidelines has only been explored recently.
For this sample set there are probably other barriers to regular mammography
that need to be discovered.

The Health Belief Model is a good guide for this type of study as it
addresses acquisition of preventive and screening services. However, this

investigator did not attempt to prove the effectiveness of the model.

Discussion

Limitations

One of the main limitations of this study was sample bias in that it does
not represent all American women or even the general woman population of
the Greater Lansing area. The majority of women in this study were
educated, white, well above poverty level, and employed. The sample of this
study was different from many other studies because the higher
sociodemographic characteristics indicated the women were educated, white,
middle class, and employed. The literature finds this type of woman is more
likely to seek screening, however the women in this study still did not meet
screening guidelines. This could be why they rejected all of the selected
barriers. Consequently results of this study cannot be generalized to women

who are less well educated, poor, or of minority race.

47

Another limitation was the subjects in the sample were all self selected
by voluntarily returning the questionnaire. Those women not interested in
preventive health or breast issues would be less likely to take the time to
complete along questionnaire. Conversely women very interested in breast
and health issues may have been more likely to return the questionnaire. Due
to the fact that the subjects in the study had at least one mammogram, one
could imply they were interested in health maintenance and promotion and
would be more likely to participate in a survey. This type of woman is less
likely to perceive barriers to mammography as in contrast to a woman who is
very closed to screening and feels it is unnecessary or is simply a plot by
health care providers to make more money. Again a self selected subject may
indicate less barriers to mammography than a woman afraid of or not
interested in women’s health issues resulting in a limitation for this study.

The study also relied on self reporting and retrospection requiring the
subjects to recall information such as the date of her last mammogram. The
subject had to write down a month and year of her last mammogram in the
survey. Time seems to go by faster than people are aware. If the subjects
incorrectly reported the date, this process could lead to obvious inaccuracies,
and no attempt was made to validate the date of last mammogram with the
subject’s physician or if the attitudes and beliefs reported were valid.

Use of secondary data was another limitation to this study. There are
problems with sureness of fit when taking questions fi'om another study and
incorporating them into a new study. There is a problem with reliability when
selecting specific questions and trying to form new scales. This was

encountered when the anxiety scale had a reliability of 0.56. Also are the old

48

questions asking the same thing that the new study is investigating? Some of
the questions when evaluated a second time did not represent the barrier well.
For example the physician referral questions did not evaluate if a physician
was recommending mammography on a regular basis according to ACS
guidelines. The questions only evaluated if the physician had ever
recommended a mammogram. Consequently different questions may have
changed the outcome of the physician referral banier. Also the knowledge of
screening guidelines questions did not evaluate the subjects’ knowledge of
screening guidelines but only her perception of her knowledge. Questions
evaluating the subjects’ knowledge of screening guidelines may have changed
the result of that barrier.

No statistical analysis was attempted in this study to correlate barriers
or to show cause and effect. Although some women identified a barrier, one
cannot conclude that barrier is the reason they did not acquire another
mammogram on a timely basis. It must also be remembered this study is
about women who have already had one mammogram. These results cannot
be applied to women who have never had a mammogram.

Another limitation of this study was the limited literature available
concerning mammography and adherence to screening guidelines. Most of
the research studies addressed first time mammography. With so few
documented barriers specific to regular mammography it was difficult to forge
ahead with this study. The same concepts from the Health Belief Model
should apply, as a first or subsequent mammogram is a screening or
preventive behavior. To make the model work, more emphasis may need to

be placed on creating benefits if few actual barriers are found. The same

49

barriers should be explored to see if they are identified by women obtaining
subsequent mammograms. However a prior experience with mammography
may nullify some known barriers to first time mammography. Research must
continue to identify barriers to repeat mammography. Suggestions for further
research will follow later in this discussion.
Implications for Advanced Nursing Practice

Breast cancer is the second major cause of cancer death today for
women in the U. S. Early detection and treatment is the most effective avenue
to saving lives and decreasing morbidity. The best tool available for early
detection of breast cancer is mammography. The number of women utilizing
a single mammogram is increasing but many women are not obtaining
mammography on a regular basis. To be consistently effective in the early
detection of breast cancer a mammogram needs to be done at regular
intervals. The following discussion will relate how the advanced practice
nurse has a critical role in helping women meet this objective. None of the
barriers, cost, lack of physician referral, discomfort, fear of finding cancer,
inaccessibility, and lack of knowledge of screening guidelines, investigated in
this study were identified. The subjects were primarily white, educated, and
middle class. They had had one mammogram but had not obtained one
recently within the ACS guidelines.

Cost was not identified in this study and is not a barrier for this sample.
In primary care the advanced practice nurse should be aware if the client has
insurance coverage. If the client is insured the CNS should look for other
barriers to mammography as cost is probably not one of them. However the

CNS should be aware of cost as a possible barrier in primary care as not all

50

clients will be as well off as the sample. The CNS should be aware of local
programs available to assist low income women with mammography
screening, or refer to the local health department which currently has an
excellent program for women age 40 and older who have low income or no
insurance.

Lack of physician referral was not identified as a barrier in this
particular study. In advanced practice the CNS should continue to
recommend mammography on a regular basis as many mammography units
require referral from a health care provider. The CNS should follow up on
the clients to make sure a mammography was obtained. The CNS should be
aware of other barriers to regular mammography. Some women simply refuse
mammography even though recommended by her health care provider. The
CNS can act as assessor to discover the barrier, and as educator to inform the
client about breast cancer. Emphasis should be placed on early detection and
improved prognosis if found early, versus if discovered after metastasis.
Finally the CNS can act as counselor and change agent by listening to and
addressing the client’s fears, by discussing possible consequences if she
doesn’t get a mammogram, and by being very firm that the CNS’
recommendation is use of regular mammography.

The CNS can use the HBM as a guide in assessing a client. Is the client
aware of breast cancer? Does she feel it is serious? Is she susceptible? Is
breast cancer a threat? Does she know about mammography? Can she
express any benefits or barriers to mammography? This is an excellent time

for informing clients of the increased cure rate when breast cancer is found

51

and treated early. The client should then be asked when a mammogram can
be scheduled for her.

The CNS in a collaborative role can encourage fellow primary care
providers to utilize screening mammography. The advanced practice nurse
can plan an inservice or continuing education session for providers and nurses
on breast cancer, early detection, and treatment. A discussion of successes
with regular screening can inspire other providers to be more vigilant in
recommending regular mammography. A discussion of current guideline
recommendations can help keep co-providers abreast of any new changes in
the recommendations. Also a discussion of situations that could lead to
possible legal litigation, such as not following up if a client fails to get her
mammogram, may be helpful to inspire other providers to take breast health
seriously. The advanced practice nurse can also instigate peer review
meetings on a regular basis and be especially vigilant to look for
documentation of regular screening mammograms.

As noted earlier the questions used in this study for the physician
referral barrier were not well suited to evaluate adherence to regular
screening mammography. The questions did not ask if the physician had
recommended mammography within the last year or two according to age
appropriate guidelines. It is possible this study disagreed with the literature
for this reason. In any event the CNS must incorporate regular
mammography into the health maintenance portion of practice and refer
clients for mammography on a regular basis. In many areas a referral is still

needed for a woman to obtain a mammogram.

52

The CNS in a community role can speak to women’s groups about
health care and screening guidelines. The CNS can be an advocate to
empower women to play a more active role in their health maintenance and
screening strategies. Women should be empowered to ask their health care
providers for a mammogram if it has not been recommended. Women should
know screening guidelines and the recommendations for their age group.

Overall this study did not indicate discomfort as a barrier to
mammography. So the CNS needs to be looking for other deterrents to
mammography. However nearly one-half of participants (48%) indicated
mammography was unpleasant. The CNS needs to be aware many women do
not enjoy undergoing a mammogram. The participants in this study had
already experienced one mammogram. So their responses were related to
actual experience not a preconceived idea. The CNS in counseling clients
could draw a comparison with other procedures, such as tetanus shots or
dental work, that may be unpleasant but people still comply or make their
children comply.

The client needs to understand why compression is important for a clear
mammogram reading and that every effort will be made to accomplish the
procedure as quickly and gently as possible. Every attempt should be made
to make the client comfortable during the mammogram procedure. A female
technician, privacy, and comfortable surroundings in the exam room are
suggestions to decrease unpleasantness. The CNS can also in a collaborative
role communicate with the technician complaints of pain etc. that clients
report. The CNS can offer suggestions to the technician to improve the
client’s perception of the procedure. An attempt should be made to schedule

53

mammography as soon after monthly menses as breast are less sensitive
during that time period.

Anxiety and fear of finding cancer were not identified in this study as
barriers to mammography. The advanced practice nurse will need to listen
carefully, ask open ended questions, and assess for other reasons why the
client did not obtain a mammogram. However in this study 24% (p=40)
admitted to some anxiety about obtaining a mammogram. In primary care _
practice the advanced practice nurse will also have clients who are afraid to
look for trouble. The CNS should inform clients as to the value of looking for
and finding problems early when they are more curable and less disfiguring.
Explore the client’s beliefs as to whether breast cancer is curable if found
early or is it always a death sentence. The CNS should also strive to
communicate as quickly as possible negative test results to alleviate some of
the worry and anxiety associated with waiting and not knowing results.

The participants in this study did not identify inaccessibility as a barrier
either. The respondents were probably not rural which the literature indicates
as a main access banier. However the participants were employed which the
literature has indicated as a problem for access to mammography. If the CNS
knows the client has no problem getting off work to get a mammogram or can
get a mammogram outside of work hours, the CNS should look for other
barriers. However 18% (p=31) of the women in the study did find
mammography inconvenient to arrange. The CNS in primary care should be
aware of this potential barrier among clients. The CNS should be aware of
available marmnography centers in the area and the hours they are open. The

schedules of employed women often conflict with regular business hours.

54

The CNS could also act as change agent to instigate extended hours for the
mammography center if it proves to be a barrier in the area. The CNS could
investigate the number of potential people affected by limited mammography
hours. To show need perhaps a poll of employed women who would like
extended hours could be done. The CNS must also project how extended
hours could be beneficial to the mammography unit as well as the client.

Lack of knowledge of mammography screening guidelines was not
found to be a barrier among the participants of this study. In primary care if a
noncompliant client knows the recommended interval suggested for
mammography for her age group, other barriers need to be investigated. As
noted earlier the questions used in this study did not actually measure a
respondent’s knowledge of screening guidelines. The questions merely asked
if they knew when they needed a mammogram and if they forgot when they
are supposed to get a mammogram. These questions evaluate the perception
of the respondent’s knowledge. Some women think they only need
mammography when they have symptoms.

In this study 22% (p=3 8) of respondents agree they forget when they
are supposed to get a mammogram. For those women the CNS should
remind the client and offer to set up her appointment. A yearly reminder
letter can be sent to clients stating it is time to get your mammogram. Videos
can be running in the waiting room of primary care offices that emphasize the
need for mammography. The media is helpful in informing women of when a
mammogram is needed, but the media should speak more directly to the fact
of women needing regular annual mammograms if over the age of 50. The

advanced practice nurse should inform clients of the ACS recommendations

55

for screening guidelines. Posters in the primary care setting can be very
effective. The client should understand a mammogram has limitations and
should be combined with a yearly clinical breast exam and monthly breast self
exam if breast cancer morbidity and mortality rates are to be reduced. The
advanced practice nurse can be actively involved with the local ACS and
organize a mammogram drive, or write articles in the local papers
encouraging mammography, or publish testimonials fiom local women who
are “living” proof that mammography is life saving.

This study dealt specifically with employed women. Nearly one-half of
the work force is made up of women, and women are remaining in the work
place more years than ever before (Glanz et al., 1992). As more women over
the age of 40 continue to be employed, breast cancer can affect a large
number of employees and employers. The worksite can be an excellent place
to contact large groups of women. There is also the aspect of social support
among co-workers to encourage preventive screening behaviors. The
researchers report spouses or significant others are important in encouraging
women to obtain mammography (Bastini et al., 1991; Glanz et al., 1992).
Thirty percent of the women in this study indicated they were single. The
advanced practice nurse should be concerned about social support for this
group of women. Social support could be found among co-workers, other
family members or the therapeutic use of self on the part of the advanced
practice nurse. The advanced practice nurse needs to be creative in finding
ways to encourage social support.

Worksite wellness programs can save lives, decrease morbidity,

increase productivity, and decrease the cost of long term care if breast cancer

56

is detected in its early stages. The CNS working in industrial settings, etc.,
can be a very positive influence on women and health care maintenance.
There is also a need to stress health screening services as being important
along with sick benefits when deciding on insurance coverage if the employee
has a choice. The advanced practice nurse can initiate conversations among
women about mammography and encourage women individually to obtain a
regular screening mammogram. Posters about the work place concerning
breast cancer and screening mammography can also have an impact on
women and their mates. The CNS can also initiate a policy for time off work
to get a mammogram, or arrange for a mobile mammography van to come to
the worksite.

The CNS can stress to employers their responsibility to contribute to the
well being of their employees’ health. The are also benefits to employers
such as decreased costs for lost work hours, decreased cost for training and
finding replacement employees, less paper work, and not having to pay
continued benefits to an ill employee who is not productive for the company.

There were no significant barriers to repeat mammography as evidenced
in this study, but perhaps there were no perceived benefits to women either?
According to the Health Belief Model the benefits must outweigh the barriers
for a woman to seek mammography. To make this model work there have to
be benefits. For working women, the advanced practice nurse could work
with employers to create benefits. The advanced practice nurse could seek or
create benefits that will encourage women to obtain repeat mammography.
Perhaps a paid day off with overtime wages when getting screening

procedures such as a pap smear, mammogram, and dental check up would be

57

a strong enough benefit to encourage women to get a mammogram. Maybe a
cash rebate from an employer if a woman gets a mammogram, or a voucher at
a nice restaurant for two. The advanced practice nurse needs to be creative to
find other benefits, perhaps other forms of community support could be found
to promote benefits. The advanced practice nurse should try to identify with
the client what other benefits would be valued. The Health Belief Model as
related to mammography acquisition may need to be modified to indicate an
increase in benefits may be needed to encourage the action of obtaining a
mammogram.

The CNS in primary care should be a vigilant crusader for regular
mammography by making mammography an integral part of health
maintenance and promotion. The CNS should be politically active to help
improve access to health maintenance for all women. The CNS should have
an understanding of the players in the delivery of health maintenance and
screening behaviors. There are providers, payers of services, and policy
makers. All three groups need to be persuaded of the value of regular
mammography. By joining nursing organizations the advanced practice nurse
can band together with other nurse providers to introduce new bills or lobby
in the legislature for better health care for women. Nursing organizations can
have a stronger voice than individuals when trying to impact the health care
and political systems.

Should health care screening be legislated? We require children to be
immunized to attend public school, perhaps requirements to join an HMO,
Medicare, other insurances, or to obtain life insurance could include

mandatory screening techniques including mammography. This approach

58

could result in decreased payments for expensive treatments and long term
care, and save lives.

In summary the CNS can be a very effective agent in the fight against
breast cancer in primary care and in the community, in health care systems,
and in political systems. The CNS has many roles as educator, advocate,
clinician, assessor, counselor, change agent, collaborator, role model, and
researcher. The CNS needs to be a vigilant advocate of regular
mammography and continue to diligently assess for other barriers that deter
mammogram acquisition and compliance.

Recommendations for further research

The goal of this research was to add to the existing knowledge of
barriers to regular mammography. The barriers explored were cost, physician
referral, discomfort, fear of finding cancer, inaccessibility, and lack of
knowledge of screening guidelines. The study results indicated none of the
listed barriers were identified by the sample. Consequently there must be
other reasons why this sample did not acquire mammography on a timely
basis. If compliance to mammography is to increase, further research related
to barriers to timely mammography is needed.

The numbers are increasing for women who are obtaining first time
mammography. But researchers need to ask more questions about why
women are not obtaining mammography on a regular basis. Findings from
this study would indicate there could be barriers other than those utilized in
this investigation.

This study could be repeated investigating other groups of women with

similar sociodemographic characteristics to see if they concur with the

59

findings of this study. Further questions concerning physician referral should
evaluate if the physician is recommending mammography according to ACS
guidelines or in a haphazard fashion. Further questions concerning
knowledge of screening guidelines should actually test the subject’s
knowledge not just ask if she knows when to get a mammogram. If the
subject agrees a mammogram is unpleasant, uncomfortable, or inconvenient, a
second question could be added asking if the problem is severe enough to
influence her to put ofl‘ getting a mammogram.

Statistical analysis of this study only evaluated if the subject was
currently delinquent in acquiring mammography. Further research could
evaluate if a subject is slightly delinquent (up to one year), or decidedly
delinquent (two or more years). The barriers could then be assessed again to
see if they are different for the two delinquent groups. Questions addressing
procrastination could be added.

Research will need to include open ended questions asking why women
have not been compliant with mammography. Focus groups could be used to
encourage women to talk about why they have not gotten a mammogram
within recommended guidelines. This may yield some ideas about other
barriers. Individual interviews with noncompliance women similar to the
sample group may yield new barriers. The researcher should use questions
that cover existing barriers and also an open ended question of why didn’t
you get your mammogram on time. The researcher may need to use probing
questions concerning the subject’s answer to why. The researcher should not
alienate the subject but project a genuine attitude of wanting to find out the

barriers to regular mammography. Other questions could be, are you

60

procrastinating? Do you feel there are no benefits to getting a mammogram
according to guidelines? Is a yearly mammogram too frequent? Is a yearly
mammogram a waste of resources? Do your fiiends get regular
mammograms? Do you feel confident you are free of breast cancer if you
have one negative mammogram? Do you feel at risk for breast cancer? Are
you afraid of radiation exposure?

If new baniers are identified another study using a similar sample could
be conducted. Care should be taken to be sure questions address compliance
issues not just an initial mammogram. This approach may identify new
barriers that need to be addressed. As women have become more compliant
with obtaining at least a first mammogram, more attention needs to be
focused on finding barriers to regular mammography. While a single
mammogram can be an effective tool in screening for breast cancer, regular
mammography is more effective in picking up subtle changes in breast tissue
and detecting breast cancer in its first stages.

A longitudinal study could be done with a similar sample, repeating the
questions of this study along with others exploring more barriers and possible
benefits to mammography. Another section could address intentions on
obtaining a mammogram. A follow up contact six months later could be used
to see if the respondents had obtained a mammogram, and if the questionnaire
had served as a cue to action. Yearly questionnaires could be sent for up to
five years exploring intentions and new barriers and benefits as they arise. It
would be interesting to find out how long it takes until mammography

becomes a very integral part of a woman’s screening and prevention routine.

61

The workplace is an excellent opportunity to contact a large group of
women, with over 67% women now in the work force (US. Department of
Labor, 1991). Further research is needed to explore how best to impact this
large group of women with the positive and practical aspects of screening
techniques and health care. How does one empower women to become more
involved in demanding screening health care? How does one educate women
it is better to look early for problems rather than to wait until a problem is
evident? Other groups such as the nonemployed, minorities, and poor also
need to be surveyed for barriers to regular mammography. Women can be
contacted through local church groups, civic minded groups, craft guilds,
professional groups or simply survey women in the grocery store or ask if
they would be willing to participate in a study.

Summag

The goal of this study was to add one more piece to the scientific
knowledge concerning mammogram acquisition and compliance to guidelines.
The study was a descriptive secondary analysis of data exploring barriers to
regular mammography among employed women using the Health Belief
Model framework. Respondents in the study rejected all of the selected
barriers. However, findings of the study indicate discomfort is a barrier to
some women and also, to a lesser degree, inconvenience, fear of finding
something abnormal, and lack of knowledge about screening guidelines. The
CNS should also be open to the possibility of other barriers related to
mammography compliance. The CNS’ overall goal in this area is to decrease
the morbidity and mortality of breast cancer among women. The best way to

accomplish this goal is to increase women’s use of regular mammography.

APPENDICES

APPENDIX A

(32

APPENDIX A

HEALTH case’mcrrces: A, vomrrr sunvrr

This questionnaire is being distributed to women 35 years of age and older at their
worksite. The purpose of the questionnaire is to learn more about breast cancer
screen ng.

Please take 20-30 minutes to answer these questions. When you are finished, return
the questionnaire in stamped addressed envelope.

In up-coming weeks all women in the worksite will receive information about
bre:;t cancer screening. A follow-up questionnaire will be mailed in 6
men s.

This project is funded by the Michigan Department of Public Health and is being
carried out by Investigators at Michigan State University, College of Nursing and
College of Human Medicine.

Your participation is voluntary, and your answers to all questions will remain
strictly confidential.

hank you for your time in completing these questions.

Please return this questionnaire anthin two weeks.

To: Barbara Given, Ph.D., R.N., F.A.A.N.
A-230 Life Sciences Bldg.
.College of Nursing
' Hichi an State University
East ansing. it! 48824

63

uses
Page 1
ID ' _ _ 1-4
CARD 5-6
. HAVE 1 7
PERSONAL HISTORY STUDY 5 8
DATE _ /_ _ /_ _ 9-14
AGENCY 15
The first set of questions ask you about your personal health and family history.
Please write in the date of your birth. (WRITE 1H)
.—-—J —J _ o ’ -----
No. Date Yr. - 16 11 13 19 20 21

In the past five years, how many times have you had:

a. Complete physical exam __ Hrite in! 22
b. Dental check-up __Hrite in!

c. Pap smear :Hrite in!

Have you ever used birth control pills? (CHECK ONE)

_YES (1) __‘NO (2) (If N0, go to question 0 4) _Don't Know (3) (GO TO 13) 53
l” If YES, for approximately how many years have you taken (or did you take:|

 

birth control pills?

 

 

 

 

 

 

___(Hrite in total number of years) I? 57
Have you ever been pregnant? (CHECK ONE)
_ YES (1) _ NO (2) (1f NO, go to question 5) 53
If YES, Flow many pregnancies have you 5.3? WRITE IN) __ 55 35
How many full term deliveries (9 months) have you had? (NRITE 1N) _ 3T .3?
what was your e at the time of the delivery of our first bab ?
HRITE 1N voun i2: __ . y y fl 5?
Have you ever taken hormones such as: (Check one for each)
a Estrogen __ YES 1 _ NO 2 __ DON’T KNOH 3 _ 35
b Premarin __ YES 1 __ NO 2 __ DON’T KNOH 3 __ 36
c Provera __ YES __ NO 2 __ DON’T KNOH 3 _ 37
d DES -- ___YES NO _DON'TKNOH 3 _38
e Other
(PLEASE SPECIFY) .... _.
39 40
At what age did you begin menses (menstrual periods)? 71’ 75

__(Hrite in age)

64

UUCS - 10 _ ..
Page 2 ' CARD

" Have you reached menopause? (CHECK ONE)
__ YES (1) _ NO (2) _ DON'T KNOii (3)

If YES at what age did you begin menopause?
(Hrite'in age) __ , IT IS

 

 

8. Have you ever had a hysterectomy (uterus removed)? (CHECK ONE)

_ No (1)

_ Uterus only (2)

_ Uterus and ovaries removed. (3)

_ Don’t know (4)

_ Other (Please specify: (5) l

31

313i

9. How often do you usually eat well-balanced meals? (CHECK ONE)

_ Less than once a month (I)

_ At least once a month, bu not every week (2)
_ At least once a week. but not every day (3)
_ Almost every day (4)

10. How often do you usually exercise? (CHECK ONE)
_ Less than once a month' (I)

._ At least once a month. bu not,every week (2)
_ At least once a week. but not every day (3)
_ Almost every day (4)

11. Do you currently smoke? (CHECK ONE)
_YES (1) ___NO (2) (Co to question 12)

If YES. for how many years? __ (Years) 4 51' If
And how many packs per day? __ 53

 

 

12. Do you currently drink-alcoholic beverages daily? (CHECK ONE)

51
__YES (1) _NO (2)

13. Have you ever had a breast may (a surgical procedure on your breast)? (CHECK ONE)
_ YES (1) __ NO (2) (If NO. go to question 14) SS
‘ If YES. what wereThe results? (CW‘

__.Positive for cancer (I

__ Negative for cancer 2 .

_ Positive for other breast disease (3;
_ Negative for other breast disease 4
_ Don’t knowL results (5)

 

5'6

 

 

 

65

uses 10 ....
Page 3 CM - -
14. Have you my; been diagnosed with breast cancer? (CHECK ONE) ' 57

_ YES (1) __ NO (2) (if NO. go to question 15)

 

 

If YES, what year were you diagnosed? (Hrite in year) .3 g_
If you were diagnosed with breast cancer, what treatment did you

receive? (CHECK ALL THAT APPLY) -

_ Mastectomy (Surgical removal of the breast) __ SO
_ Lumpectomy or wide excision (Removal of lung only from breast) _ 61
_ Radiation (X-Ray treatment to breast) _ 62
_ Chemotherapy (Cancer drugs) __ 63
_ Hormones _ 64
__ Other (Please specify 1 _ SS

 

 

 

 

The next questions focus on family history of breast cancer.

15. Has your mother ever had breast cancer? (CHECK ALL THAT APPLY)

_ Yes (1) (Age of diagnosis) __
Mother’s age at time of Death (Hrite in age)

0 (2)
n’t know (3)

 

 

 

 

 

 

 

 

16. Have any of your sisters had breast cancer? (CHECK ONE) I6
_ Yes (1) _ No (2) _ Have no sisters (3) _ Don’t Know(4)
If YES. Hrite in Number of Sisters diagnosed with cancer: I7
Sisters’age at time
of cancer dia nosis:'
_ Hrite in age) _(Year of diagnosis) __ __ _ _
18 19 20 21
_ (Hrite in age) _(Year of diagnosis) __ _ _
22 23 24 i?
_ (Hrite in age) _(Year of diagnosis) _ __ __ __
(it it. ‘ ) (Y f di i ’ 26 27 28 29
_ renae_;earo anoss ____,
g g 30 31 32 33
Has either of your grandmothers had breast cancer? (CHECK ONE) 51’
_ Yes 1 _ Grandmother’s a e at time of diagnosis
i)’ 9 55 3'6

__ No (
__ Don’t Know (3)

665

ve‘cs ‘ ’ ID __
Page 4 CARD

Have any of your aunts had breast cancer? (CHECK ONE)
_ m (1) _ No (2) _ No Aunts (3) ' _ Don’t Know 14)

, umber of aunts diagnosed with breasticancer: ’
.___ (Hrite in f of aunts with cancer) 33 39

Have any of your daughters had breast cancer? (CHECK ONE)

 

 

 

 

4'6
_.Yes (1) __ No (an _No Daughters (3)
___Don't ow (4) :Oaughters are too young (5)
. umber of Dazghters diagnosed with breast‘éancer: 3
__ (Hrite in n I If
' , 1
MAMMOGRAH EXAM S

 

 

 

  

 

A mammogram is an K-ray that is taken of the breasts to find an abnorma y

be further examined for cancer. The mammogram machine presses against the breast
while a front and side view X-ray of each breast is taken: The next set of questions
focus on the mammogram.

Have you ever had a mammogram? (CHECK ONE)

 

 

 

' 1'5
___ YES (1) (go to question 2) ' ___ NO (2)
, why have you never had a mammogram? (Plbase Hrite inz) I7 I5
(Co to Question 3)
If YES to question 1, about how often do you have a-mammogram? (CHECK ONE) I9

_More often than every year (1)
:Each year (2)

:Every two years (3)

_Every three ears (4)

_Less often t an every three years (5)

2a. Hhen did you have your last mammogram? (HRITE 1N) ______/____
Month Year 2O 21' H 23'

2b. Which of the following best describes what prompted you to have your most recent
mammogram? (CHECK ALL THAT APPLY)

_To follow up a breast problem] something unusual (1) .__ 24
_1t was part of my routine check- -up 2) __ 25
:A health care professional recommen ed it (3) ' __ 26
___ _A friend or relative was recently diagnosed with a breast problem (4) __ 27
___ A relative or friend recommended that 1 have a mammogram.(5) 28

 

___ Other (6) Please Specify:

HOCS
Page 5

677

IO _M_
CARDI_,_

3. How much do you agree or disagree with each of the following statements about

mammograms? (CIRCLE ONE RESPONSE EOR EACH)

STRONGLY
DISAGREE

- orsacarr

AGREE

STRONGLY
AGREE

 

p.
q.

1‘.

ram:
is an embarrassing procedure
is an unpleasant procedure

is a cost hardship

is sinful or physically

wou d make me feel anxious

is inconvenient to arrange
causes me concern about

is not available in my area
doesn’t seem necessary

is not worth the effort

it makes me feel uncomfortable
I don’t know when I need a

I have too many other worries
to have a mammogram

I’m afraid something abnormal
would be found

I want t9 improve my chances
of early detection of an
abnorma "k '

1 want to eep control of my
health

I’m Just too busy to have a
mammogram

I forget when I am supposed
to have,the mammogram

I don’t really know how to
ask to have a mammogram,

I am confident the mammography
will be done correctly

I want to be the first to
know if something is wrong

"h doctor has never suggested
t at I have a mammogram

My health care Professional
has digsgungggg me from having
a mammogram

OTHER REASONS FOR NOT HAVING
A MAMMOGRAN (Hrite in)

u u ”uhuuuufluuwflu

HH---

NNNNNNNN

N N NNNNNNNNNNNNN

U U “U““UUUHUUHQDU

UUUUUUUU

. - OO&O&OOO‘-..‘

b“.‘fi.¢b

 

 

In the next year. how likely are you to have a mumogram? (CHECK ONE)

Definitel (1)

Very like y (2)
Somewhat likely (3;
Not Very Likely 4
Not at all likely (S)

2.

68

uses ID _ _
Page 6 - CARD

goEyhat extent is getting a mammogram on a regular basis a priority for you? (CHECK
N

 

 

 

57

__ Not at all (1)

_ To a small extent (2)

___,To some extent (3)

___ To a great extent (4) .10 , 1 4

Farm SELF EXAMINATION] cam gs, s-e

HAVE 1 - 7
STUDY 1 8
DATE __l_ _l_ _ 9-14
AGENCY_ _ _ 15

 

 

Breast self examination (BSE) is when you have been trained by a health care
professional to carry out a specific procedure once a month to check yggn_gun breasts
for lumps or unusual changes. The fo lowing questions relate to breast self
examination. (Answer these questions related to you following a specific procedure
monthly and have been taught specifically to do so.) The procedure includes
inspection. palpation. frequency and positioning.

Oid ANYONE ever teach you to do Breast Self Examination (BSE) monthly following a

,specific procedure? (CHECK ONE)

 

 

 

 

 

 

 

 

 

TE
___ YES (1) ___ NO (2) (Co'to Question 2)
If YES, who ..mgnt you roomy)
_Physician (1) ° ' , , - __,17
__Nurse (2) _ 13
:Other Health Professional (3) __ 19
:Self Instructional Booklet (4) _ 20
:Other (5) (Please specify: 1 __ 21
__lirite n the year first taught__ __ __
22 23
Have you ever done a Breast Self Examination (BSE) following a specific procedure?
(CHECK ONE) .
2T
_ Yes 1)
___ No ( ) (If No. go to question 7)
___ No, but 1 do check my breasts sometimes (3) (go to question 4)
Are you_CURRENTLY practicing Breast Self Examinations according to a procedure? 25
_ Yes (1) .
___ No have never racticed Breast Self Examination (2)
___ No not current y, but have practiced self exam in past (3)
If‘NOT currently conducting BSE’but did in the past, why did you stop
practicing BSE? (Please Hrite in: 23 27

 

 

Have YOU ever discovered anything unusual in your breast? (CHECK ONE)

_NO. never found anything abnormal (1) (Go to question 45)
_YES. found abnormal mass or lump (2 )

 

€59

vecs ID __
Page 7 CARD

If YES to uestion 44, did you ever see a health care professional about an
aEnormal finding Ehat you found while performing a breast self exam? (CHECK
ONE) - ..
__ YES (I) _ NO (2) 29

 

About how often do you examine your own breasts according to specific guidelines?
(CHECK ONE) SD

___ Never (1)

_Once a month (2) 3T
_Nore than once a month (3)

_Yearly (4)

_Other (specify) (5)

Mhen was the you examined your own breasts using a specific
procedure? (CHECK ONE) ' .

Over a year ago (I) - -
Over 6 months ago ut within3 the past year (2)
Between 3 and 6 months ago

Between 1 and 3 monthsa

_Hithin the last month (5?04

' NOTE: Even inyou havi’EIIIRIdone a Breast Self Examination (BSE). please
answer the following questions. .

lllll

 

 

 

 

 

dNEih. next year, how likely are you to do HONIHLI breast self examinations? (CHECK

33'

Definitely (1)

Very likely (2)
Somewhat likely (3
Not very likely (4
_Not at all likely (5)

Indicate by CIRCLINC (ONE RESPONSE) how much you agree with each of the
following statements about Breast Self Examinations? TO TO TO A
A

NOT SMALL SOME GREAT
AT ALL EXTENT EXTENT EXTENT

 

Breast Siif Examination:

a. is an embarrassing procedure

b. is an unpleasant procedure

c. is painful or physically uncomfortable ‘
makes me feel anxious ‘

doesn’t seem necessary

is not worth the effort

makes me {:31 uncomfortable

I don't know when 1 need to do exams'

I wouldn't know what is normal

I have too many other worries'

I’m afraid of finding something abnormal'

1 want to improve my chances of early

detection of an abnormality

I want to keep control of my health

f????9?99

pun—nununnuu
~ -------
u uuuwuuuwuuuu
& ..¥&&8%.....

llllllllllll

B
C
.-e

7()

Page 8 CARD"

TO A T0 TO A
NOT SHALL SONE GREAT
AT ALL EXTENT EXTENT EXTENT

 

DFEast Self Examinition:
n. I’m Just too busy

1 47
o. I forget when I am supposed to do the l
1

Z 48
49
so

STE!!!

self-exam
p I don' t really know how to do the breast
self-exam
q. No one has ever taught me the correct procedure 1
r Other (please write in:

N N ”N
u a» we»
a. a. as.

 

 

 

PHYSICAL (CLINICAL) BREAST EXAN

 

 

 

A Physical (Clinical) Breast Examination is when the breast is felt for lumps or
abnormalities by a doctor or other health professional. The following questions deal
with examinations done be Health Care Professionals. '

Hm you ever had a WWW
Musical? (cuecx our) '

_vrs (1) _No (2) [co to Question 2] - S?

If YES, about how ofien do you have physical (clinical) breast examinations
by a health care professional? (CHECK ONE)

 

. 55
Each year (1)
Every two years (2) 55
Less often than every two years (3
Don't Know if I ever had a physica (Clinical) breast exam (4)

 

5:E}ES. why did you have your most recent physical (clinical) breast exam? (CHECK

53
_To follow up a breast problem/ something unusual (1)

:It was part of my routine check-up (2)

:A health care professional recommended it 3)

:A friend or relative was recently diagnos with a breast problem (4)
:Other (5) (Please Specify: 57 53

In the NEXT YEAR, how likely are you to have a Physical (Clinical) Breast Examination?
(CHECK ONE)

_Definitel (1)
:Very like y (2)
:Somewhat likely (3)
:Not Very likely
:Not at all likely (5)

 

 

 

 

'71

vet: to - -
Page 9 M .. ..
Hho USUALLY conducts your physical (clinical) breast exams? (CHECK ONE) ED

Never had a physical (clinical) examination (1)

Family practice. physician, or internist (2)

Obstetrician, gynecologist or other specialist (3)

Surgeon (4)

Nurse practitioner or clinical nurse specialist (5)

Technician at mammography center (6) __,__
___ Other (7) (Please Specify l 1 2

3b. Hhat is the sex of the person who USUALLY conducts your Physical Breast exams?
(CHECK ONE) ‘5

___ Male (1) ___ Female (2)
who would you prefer complete your clinical breast examination? (CHECK ONE) 61

___ Family physician or internist (1)

___ Gynecologist or other specialist (2)

___ Specialist in breast care (3)

__ Surgeon (4)

___ Nurse practitioner or Clinical Nurse Specialist (5) __
___ Other (6) (Hrite in 65 66

Do you have a preference as to the sex of the health care professional who performs your
clinical (physical) breast exams? (CHECK ONE) . 3’.

 

,__, Prefer female (I)
___ Prefer male (2):
___ No preference (3)

How mgch do you agree or disagree with the following statements about clinical breast
exams

A Physical (Clinical) STRONGLY STRONGLY
' OISAGREE OISAGREE AGREE AGREE

a. is an embarrassing procedure 1 2 3 4 __,6B
b. is an unpleasant procedure 1 2 3 4 __ 69
c. is a hardship due to cost 1 2 3 4 __ 70
d. is painful or physically 1 2 3 4 ___71
uncomfortable
e. would make me feel anxious 1 2 3 4 __ 72
f. is convenient to arrange I 2 3 4 __ 73
9. doesn’t seem necessary 1 2 3 4 ,__ 74
h. is not worth the effort 1 2 3 4 __ 75
1. makes me feel uncomfortable I 2 3 4 __ 76
J.- Clinical exam is important to early I 2 3 4 __ 77
detection of an abnormality
k. I don’t know when 1 need exams 1 2 3 4 __ 76
l. 1 have too many other worries 1 2 3 4 __ 79
m. I’m afraid something would be 1 2 3 4 BO
found by clinical exam
n. I want to improve my chances of 1 2 3 4 .__ 61

early detection so have an exam

'72

 

 

 

 

HBCS
Page 10
ID _ _ _ 1-4
CARD 5-6
HAVE 1 7
5m MY 1 8
DATE _/_ J_ _ 9-14
AGENCY_ _ _ 15
A Physical (Clinical) STRONGLY STRONGLY
° OISAGREE OISAGREE AGREE AGREE
o. I want to keep control of my health 1 2 3 4 __ 16
p. I’m Just too usy to have an exam 1 2 3 4 __ 17
q. I forget when 1 am supposed to have 1 2 3 4 __ 1B
exams
r. I don’t really know how to.ask for 1 2 3 4 __ 19
an exam
1 am confident thg_gxgm_1111_hg 1 2 3 4 __ 20
W111
t. My doctor has never suggested 1 2 3 4 __ 21
having exam
u. Other Comments: (please write in) __ __
22 23

 

 

If you have breast cancer, how confident are you that an abnormality could be detected
by a clinical breast examination conducted by a health care professional? (CHECK ONE)

Extremely Confident (I) . IT
Very Confident (2) ,

Somewhat Confident 3

Not Very Confident

Not al All Confident (5)

The following set of questions focus on eariy :etection of breast cancer. Early

detection means finding an abnormality in the early stages. For breast cancer this
means when the lump is small and has not spread to other areas of the body.

If found early enough, breast cancer can be cured. (CHECK ONE)

___ Strongly Agree (1)
_Agree (2)
_Disagree (3)
_Strongly Disa ree (4)
_Don’ rm «(5?

Unless she has symptoms, a woman doesn’t need a mammogram. (CHECK ONE)

___ Strongly Agree (1)
_Agree (2)
_Disagree (3)
:Strongly Disa ree (4)
_Don' t know (5

'73

vats In
Page 11 CM : :

Nammograms can detect early abnormalities likely to be breast cancer. (CHECK ONE)

_Strongly Agree (1)
:Agree (2)

O sagree (3)
:Stronglyw Oisa ree (4)
_Don' tn (5?

One; a person develops cancer. it is usually too late to do anything about it. (CHECK
ONE
23

___ Strongly Agree (1)
_A 02H

___ O sagree (3)
_Strongly Disa ree (4)
_Oon’ t knw «(5

Early detection would improve one's chances for cure of breast cancer? (CHECK ONE)
_Strongly Agree (1)
ree

:0 sagree 3)
:Stronglyw isa ree (4)
_Oon’ tn (5?

If you had a lump. in our breast.'how confident do you feel that 19“ would be able to
detect it? (CHECK ONE. 55

_Not at all confident (1)
:Somewhat confident (2)
:Ouite confident (3)
_Extremely confiden (4)

. ‘How confident are you that a aggressignal physical (clinical) breast examination could

detect a lump in a woman’s breast? (CHECK ONE)

_Not at all confident (1)
:Somewhat confident (2)
:Ouite confident (3)
:Extremely confident (4)

Now confident are you that a launggnm|_ggn1d_ detect an abnormality likely to‘be breast
cancer? (CHEW ONE) 52

___,Not at all confident (1)
___ Somewhat confident (2)
___ Quite confident.(3)

.___ Extremely confident (4)

31'

Early detection of breast cancer by a nammggrgn;would improve a woman’s chances of
recovery? (CHECK ONE) 35
___ Strongly Agree (1)

_ 49"" (2)

__ Disagree (3)

_ Strongly Disa ree (4)

___ Don’t know (5

in.

l.

2.

74

ms 10 _ _
Page 12 ' CM

If the W showed no signs of breast cancer. how confident would you be that it is
correct? (CHECK ONE) . fl

___ Not at all confident (l)
‘___ Souewhat confident (2)
__ Quite confident (3)

___ Extrewely confident (i)

The next series of questions ask you about’tha influence that others light have on your
decisions or actions to seek or not to participate in breast cancer screening.

 

 

 

How n;ny close friends of yours have been diagnosed with breast cancer in the past 5
years -

iirite in the number

2 ' ' , 353

 

 

To the best of your knowledge, how did your friend(s) find out about the
cancer?‘ (Chick bale} '

_ Don’t know (1)

_ Accidentally found the lump (2)

___ Noticed something wrong by self breast examination (3)
___ Health care professional found it (i)

 

 

 

 

 

 

 

 

 

 

 

 

 

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2:3,?"Exfiiifi'itiifil'2:1330m3°8§ Wcifl‘fioiiliifififii"fi‘flmilanfiflé"§§:}
(CHECK on: FOR EACH)

Breast Professional
oxscussm: YES no $315175?- vss no
W 53 5'5 W
Jim: 71' TE 3'5
mm 74' 3? 73
ML '47 35 1?
ML '56 31' ii
332?}, 35 a 3:

 

 

 

 

 

 

HBCS
Page 13

.l. Have any of the following persons
b) ghtain clinical breast exam

WLQBEACH TYPE OF E

'75

IO _‘_
C30d5._l_

to: ai pgnfgrl Breast Self Exaninations:

 

ADVISED:
DoctorLi

Breast .

YES I no

Professional
unsun-
YES NO

YES

 

..liunss

 

.Ellllr

 

Fri nd

 

Maker

 

 

 

 

Other:
|Specify

 

 

 

 

 

 

4. Have any of the following persons discoura
Exaninations (BSE); b) obtainin

screening? (CHECK ONE FOR EACH

a Clinica

CARD
HAVE 1

smov 5
one _/_ _/_ _, 9-1
Acme? -

.

3111M
ination; or c) ghtain a Mammography screening? (CHECK ONE

3| 3| 3| 3| 3|
3| 3| 3| 8| 3|
3| 3| 2| 8| 3|

“I
"1'
3|
N

l
5.

e-e
0.0““. U

god you fron:. a) perforuing Breast Self
Breast Exam; and c) obtaining a Mammography

 

DISCOURASED:
DDSIIF

Breast

YES

NO

mummmm

Professional

Buss
YES

YES

 

flgrse

 

mm!

 

Erisnd

 

m?

 

Literature/
Mil

 

 

 

 

Other:
5mm

 

 

 

 

 

 

3| 3| 3| 5| 3|
8| 8| 8| 3| 2|
8| 3| '32I 8| 8|

“I
H
3|
3|

2|
“I
0|
”I
CB

HBCS
Page 14

Hith regard to breast cancer screenin
and advice of each of the following,
breast examinations. and Mammography)? (CHECK ONE FOR EACH)

'76

IO
CAID""

practices, how important to you is the opinion
i.e., Breast Self Examinations (BSE). clinical

 

VERY

SONEUHAT

mum—MAMA!"

 

 

 

 

 

NOT AI ALL
IMPORTANT

 

 

 

 

3| 8| 8| 8|

 

 

 

)

N e-fi

 

persons (e.g..
Nancy Reagan,

 

 

 

 

3|

 

 

Ann Jillian.

How frequently are the following discussed among female employees with whom you work?
SEVERAL TIMES ONCE A S - 10 TIMES

(CHECK ONE FOR EACH)

  

SELDOH

8| 3| 8| 3|

How frequently do you INITIATE discussion of the following with others at work? (CHECK
SEVERAL TIMES ONCE A S - 10 TIMES

ONE FOR EACH)

  

SELDON

Nil 2| 8| 3|

7"7

HBCS IO ....
Page 15 CM - ..

CONCERNS I
The following questions explore concerns women have about getting breast cancer. He
want you to answer these questions in the way that you generally think about these

issues.. Let us know your usual feelings.

As compared with other women of your age, what do you think is the chances that you will
develop breast cancer in the next five years? (CHECK ONE) :5

 

 

Much less than other women (1)
Somewhat less than other women :2)
About the same as other women ( )
Somewhat higher than other women (4)
' Much higher than other women (5)

Hhat is the chance that someone like yourself will develop breast cancer sometime during
your lifetime? (CHECK ONE) 5‘

Much less than other women (1)
Somewhat less than other women (2)
About the same as other women ( )
Somewhat higher than other women (4)
Much higher than other women (5)

do you think are the chances that any woman in the USA will have breast cancer some

Hhat

day? (CHECK ONE) _ 3!
About 1 in S (l)
About 1 in 10 2
About 1 in 25 3

AboutlinSO 4
Less than 1 in 50 (S)

serious do you think the risk of breast cancer is for women in the 0.5.?

§|||||

Extremely Serious (1)
Very Serious (2)
Somewhat Serious 3}
Not Very Serious 4
_ Not at All Serious (S)

If you were to develop breast cancer, how probable do you think it is that it would have
spread before it was discovered? (CHECK ONE) 37

_ Not at all probable (l)
_ Somewhat probable (2)
_ Very probable (3

__ Extremely probab e (4)
__ Can’t Predict (S)

 

"Who do you think .is more likely to get breast cancer? (CHECK ONE) 53

_ Homen under age SO 51)
__ Homen over age 50 ( )

Age make no difference (3)
Don’t know (4)

 

78

vaés ID __
PagelS CARD__

Could a woman have breast cancer without having any symptoms or feeling ill? (CHECK ONE)
Yes 1) _ 53
No 5;)

Don t know (3)

If a woman didn't have any symptoms but was 50 years of age or .older, how often should
she get a manogram? (CHECK ONE) 5'6

Every year (1)

Every two years 32)

_ Only when she ha a problem/symtom (3)
Don’t know (4)

If you do 11g}. notice anything unusual in your breasts. how sure can you be that you
don’t have reast cancer? (CHECK ONE) 3T

Not at all sure (1)
_ Somewhat sure (2)
Quite sure (3)
_ Extremely sure (4)

. Please indicate below how important you believe each of these are in mung breast
cancer. Circle one number for each using the responses listed below:

 

 

 

 

 

 

 

NOT
IHPORTAN’T SMEHHAT VERY EXTREMEL
AT ALL IMPORTANT IMPORTANT IMPORT
a. Viruses l 2 3 4 _ 62
b. Stress l 2 3 4 _ 63
c. Diet 1 2 3 4 _ 64'
d. Run down physically l 2 3 4 _ 65
e. Environmental chemicals 1 2 3 4 _ 66
f. family history of breast l 2 3 4 _ 67
cancer
3. Smoking 1 2 3 4 _ 68
. InJury to the breast 1 2 3 4 _ 69
;- :r...*n~w..,.,...g.. . i : a : - ;°
. r o o _ 1
babies fu term
k. Breast- eedin l 2 3 4 _ 12
l. Exposure to t e sun 1 2 -3 4 __ 73
m. Natural hormone levels 1 2 3 4 _ 74
n. Oral contraceptives l 2 3 4 __ 7S

 

 

 

 

 

 

79

Page 17

IO____ 14

, CARD oz
rumour HAVE 1 7
STUDY .4. e
‘ DATE _, J: J. _, 9-14
AGENCY_ IS

 

 

This final series of questions asks for background information about you. includin {our
loyment and occupation. He remind you that all the information you provi'd e wil
he d in the strictest confidence and will not be linked to you as an individual.

Hhat is your current employment status? (CHECK ONE)

 

 

 

 

__-iiork full-time I T3

:Hork part- -time 2

:Volunteer (non-sa aried) (3)

:Retired

:On leave or disability 5 __ _

_Other (please specify) 6 17 18
How long have you been employed with your present company or organization? TE '2'0’
Please HRIILIN number of years employed:
Please m the title of (your position: fi .27
Do you have health insurance? (Check- one) 5

_ YES (1)

TE: THIS INFOMATIM IS BEING GATHERED IN ORDER TO PROVIDE DETAILED INFORHATI
SARDING BREAST CANCER SCREENING COVERAGE.

If YES, please W the name of your health insurance comany and group or contract
code I (you wil ike y find these numbers on your health insurance card):

no (2)

 

 

 

 

 

 

Name of Insurance Comany 54' 5S
GrouplCode Rafi-235357535357
Is this insurance coverage provided by: (CHECK ALL THAT APPLY)
Your employer _ 35
Your spouse _ 36
_Other family member’ s employer _ 37
_Self pay _ 38
_ Medicaid __ 39
_ Medicare _ 4O
__ Not insured _ 41
Other (please specify: . | ..

 

10.

II

80

vets IO __
Page 10 ‘ CARD "

-p

Does your health insurance pay for scanning physical breast exams by health care
professionals? (CHECK ONE)

YES (I) __ N0 (2) Don’t Know (3)
Vhat does your health insurance pay for screening ma-ograms? (CHECK ALL THAT 'APPLY)

 

 

 

' Routine Mauaography. when no known problem exists (I) 45
__ Onl for Referra Nanographies. to Rule out suspected abnormality (2) 4S
_ Fol ow-up for Knpwn Abnormalities (3) 47
Don’t Know (4) 4B

Hhat is you race or ethnic background? (CHECK ONE)
_ iihite 31 I?

 

Black 2

Hispan c (3)

_ American ndian/Alaskan native (4)

_ Chinese (5) '

__ Japanese (6)

_ Fi° ipino Hawaiian, Korean, Vietnamese (7)

_ Other (P ease specify: i (B)

 

.' iihat is your marital status? Are you: (CHECK ME)

_ Single . never married (I) 50
__ Hidowed (2)

__ Married or living as married (3)

__ Separated (4)
_ Divorced £5) '
__ OTHER (SP C FY: i (6)

iihat is the highest grade (or level) of education that you completed? (CHECK ONE)

Less than Bth grade (I) 51
Bth grade to 1 th grade (2)

._____ High school graduate/BED (3)

Post high school. trade or technical school (4)

One to three years of college (5)

College graduate (6)

Graduate and/or professional school (1)

Hhich category best describes your total combined mm income hm (from all
adult sources living in your household)? (CHECK ONE -- OPTIONAL)

_ Less than ”5.000 (I) . 52
__ SZI.000-S25.000
_ 531,000-335,000

S36,000-S40.000
__ “LOGO-$45,000
__ 846,000-350,000

More than $50,000 (9)

Thank you again for your time and interest in completing these questions.

 

 

CNOM-“N

81.

vac: IO __
Page I! CARE

Now that you have completed this questionnaire. please place it in the convenient. self-
addressed stamped envelope and drop it in the mail. He appreciate you responding to

“his so promptly.

He will want to include you in the second questionnaire. which will follow in
approximately 6 months.

If you have any additional comments about experiences with breast cancer, screening, or
the factors which you feel influence women’s breast cancer screening practices. please
feel free to note these below.

Thank.youl

Please return within two weeks

/rs
5/11/90

APPENDIX B

82

APPENDIX B

MICHIGAN STATE
u N I v E R SIT Y

Haroh 28, 1995

To: Rome Rome
2593 N. Abbe

Cosine. a: 48619

RE: IRBI:

5-151

TITLE! DO ENPLOYED "CHEN A088 40-65 WHO HAVE HAD ORE
flhflHOORAN BUT FAILED TO AC UIRE SUBS! DENT
HAHHOGRAHS ACCORDING TO AC GUIDELINE IDENTIFY
SELECTED BARRIERS?

REVISION REQUESTED! "IA

CATEGORY! 1"

APPROVAL DATE! 03 24,98

The Univermity Committee on Reeeerch Involving Human 8ub2ectm'(0¢fl1fi8)
review of thim project im complete. I an pleamed to adv me that the
rightm and welfare of the human mubjecte appear to be adequately
protected and methodm to obtain informed c1

oneent are appropriate.
herefore, the UCRIHS approved thim project including any revimion
limted above.

IEREHALI

 

UCRIHS approval im valid for one calendar year, beginning with
the approval date mhown above. Invemtigatorm planning to
continue a project be ond one year muet uae the green renewal
form (enclosed with tie original approval letter or when a

pro ect ie renewed) to meek u ate certification. Therm im a
max mum of four much expedite renewalm meible. Invemtigatorm
wiehing to continue a roject beyond the time need to mubmit it
again or complete rev ew.

RBVIBIONII UCRIHS mumt review an! changem in procedurem involving human
mubjectm. rior to in tiation of t e change. If thim im done at
the time o renewal, please use the green renewal form. To
revime an np roved protocol at ann 0 her time during the year

mend your wr tten requeet to the CRIHS Cha’r, requeeting revised

:pproval and referencing the project'm the

P

and title. Include
n {our requeet a deecr tion of the change and an: revimed
inm rumentm, conment formm or mdvertimementm that r

e applicable.
rmoenrwe/

CHANGED!

 

should either of the followin arise during the oourme of the
work, inveeti etorm muet noti I
a

UCRIHS romptlys ll) problemm
unexpected e de effectm comp ntm, e c. nvo v ng uman
i i l
GTSEG= mubjectm or 25 chengem in the reeearch environment or new
RESEARCH information n iceting greater riek to the human mub ectm than
ex m e u en e pro oco wam prev oua y rev e an approve .
AND i t d h th t l i l i wed d
GRADUATE ,,
we can be of an future hel leame do not hemitate to contact um
STUDIES at (811)383-2100 oz' I'M (517)335-I111.
iiaiveniig Cemmiiiee em . ~
Research involving 3‘“°.r.

   
       

flunmtflwnh
(oceans) .
m”‘““”" a id 3. w i ht ‘ .
mammalian. uci'una chair-9 '
mm W .I .- ‘ . ' .
«mow Dim”- . ,_ . _
sun-35521” cos Barbara A. Given

FAX: mun-mi

83

MICHIGAN STA ' UNIVERSITY

 

uumnsm cowumu o'er RESEARCH momma um umuvo . macaw . eases-mt
Hum SUBJECT! (poems:

no em mm.

in?) ass-ma

August 7. l990 IRB# 89-367

Barbara Given. R.N., PhD.
Family Care Study
8100 Clinical Center

Dear Dr. Given:

RE: “ASSESSMENT OF BARRIERS AND FACILITATORS TO SCREENING FOR BREAST
CANCERuA WORKSITE APPROACH IRB# 89—367'

UCRIHS' review of the above referenced prolect has now been completed. i am pleased
to advise that the rights and welfare of the human sublects appear to be adequately

protected and the Committee. therefore. approved this project at its meeting on August
6, l990.

You are reminded that UCRIHS approval is valid for one calendar year. If you plan to

continue this project beyond one year. please make provisions for obtaining appropriate
UCRIHS approval one month prlor to August 6. l99l.

Any changes in procedures involving human subjects must be reviewed by the UCRIHS
prior to initiation of the change. UCRIHS must also be notified promptly oi any problems

(unexpected side effects. complaints, etc.) involving human sublects during the course of
the work.

Thank you for bringing this project to our attention. If we can be oi any future help.
please do not hesitate to let us know.

  
 

. Hudzlk. PhD.
hair, UCRIHS

JKH/sar

HS U in mm A/flneae'ee Anion/Equal Opportunity Inna-time

LIST OF REFERENCES

84

LIST OF REFERENCES

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and practices in early cancer detection. CA-A Cancer Journal for Clinicians
fl_0_, 77-101.

 

American Cancer Society. (1995) Cancer Facts and Figures-1995. New
York: American Cancer Society.

Bandura, A. (1986). Social Foundations of Thought and Action: A
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Bassett, L. W., Manjikian, V., & Gold, R. H. (1990). Mammography
and breast cancer screening. Surgical Clinics of North America, 70, 7 7 5-7 99.

Bastini, R., Marcus, A. C., & Hollatz-Brown, A. (1991). Screening

mammography rates and barriers to use: A Los Angeles County survey.
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Champion, V. L. (1991).The relationship of selected variables to breast

cancer detection behaviors in women 35 and older. Oncology Nursing Forum,
_lfi, 733-739.

Champion, V.L. (1992). Compliance with guidelines for mammography
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Culver, J ., & Alexander, E. J. (1989). Implementing the American
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Dodd, G. D. (1993). screening for breast cancer. Cancer. 7;. 1038-
1042.

 

Eley, J. W. (1989). Analyzing costs and benefits of mammography
screening in the workplace. American Association of Occupational Nurses
Journal 37 171-177.

 

85

Given, B., Given, C.W., & Dirnitrov, N. (1991). Assessment of barriers
and facilitators to screenmgfor breast cancer--a worksite approach. Lansing,
MI: Michigan State University.

Glanz, K., Resch, N., Blake, A., Gorchov, P. M., & Rimer, B. K.
(1992). Factors associated with adherence to breast cancer screening among
working women. Journal of Medicine 34 1071-1078.

 

Gram, I. T., & Slenker, S. E. (1992). Cancer anxiety and attitudes
toward mammography among screening attenders, nonattenders, and women
never invited. American J ourpal of Public Health. 8;, 249-251.

Harnwi, D. A. (1990). Screening mammography: Increasing the efl'ort
toward breast cancer detection. N_urse Practitioner. 15. 27-32.

Henson, D. E., & Ries, L. A. (1990). Progress in early breast cancer
detection. Cancer 65 2155-2158.

 

Horton, J. A., Romans, M. C., & Cruess, D. F. (1992). Mammography
attitudes and usage study, 1992. Women’s Health Issues. 2. 180-188.

Humphrey, L. L., & Ballard, K. J. (1989). Early detection of breast
cancer in women. Primgry Care. 16. 115-132.

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A
decade later. Health Education Quarterly. 11. 1-47 .

Maclean, U., Sinfield, D., Klein, 8., & Hamden, B. (1984). Women who

decline breast screening. J ourngl of Epidemiology and Community Health,
3_8, 278-283.

Michigan Department of Public Health. (1990a). Breast cancer screening

and detection in Michigan: Recommendations to reduce mortalig. Lansing,
MI: Michigan Department of Public Health.

Michigan Department of Public Health. (1990b) Factors related to

screening mammography in women fifty years of age and older: Survey
findings in Genesee and Ingham countiesLLansing, MI: Michigan
Department of Public Health.

Miller, A. M., & Champion, V. L. (1993). Mammography in women >
50 years of age. Cancer Nursing. 16. 260-269.

Morbidity and Mortality Weekly Report. (1990) Use of Mammography-
United States, 1990, MMWR. 32 621-630.

Nettles-Carlson, B. (1989). Early detection of breast cancer. Journal of
Obstetrics. Gynecologic. and Neonatal Nursing, 18, 37 3-381.

Rimer, B. K., Keintz, M. K., Kessler, H. B., Engstrom, P. F., & Rosan,

J. R. (1989). Why women resist screening mammography: Patient-related
barriers. Radiology. 172, 243-246.

Rosenstock, I. M. (1974). Historical origins of the Health Belief Model.
Health Education Quarterly. 2. 328-335.

Rosenstock, I. M., Strecher, V. J ., & Becker, M. H. (1988). Social

learning theory and the Health Belief Model. Health Education QuarterlyJ 5.
17 5-1 83 .

Schifeling, D. J ., & Hamblin, J. E. (1991). Early diagnosis of breast
cancer. Postgraduate Medicine, 89, 55-62.

Stein, J. A., Fox, S. A., Murata, P. J ., & Morisky, D. E. (1992).
Mammography usage and the Health Belief Model. Health Education
Quarterly. 19. 447-462.,

Stomper, P.C., Kopans, D. B., Sadowsky, M. L., Sonnenfeld, M. R.,
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Medicine. 148. 521-524.

87

US. Department of Labor, Bureau of Labor Statistics.
(1991).Employment and Earnings, 38, (8), 1-9.

Urban, M., Anderson, G. L., & Peacock, S. (1994). Mammography
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