The main contribution of our study is the demonstration that the decisional balance was associated with mammography screening behavior among women of different cultures and languages in accordance with the TTM. Among Latino, Chinese, Filipino, African American, and White women, the odds of mammography maintenance increased with higher levels of decisional balance. This result provides support for the cross-cultural application of the decisional balance measure to mammography screening—an important finding because the development of the TTM mammography measures occurred predominately among White women (
Chamot et al., 2001;
Lauver, Henriques, Settersten, & Bumann, 2003;
Rakowski et al., 1992).
This study also examined stages of mammography adoption, positive and negative attitudes toward screening (pros, cons, and decisional balance), and key sociodemographic characteristics. We found that when controlling for sociodemographic characteristics and access to medical care, women from all ethnic groups who were in maintenance viewed mammography more favorably than women who were in precontemplation. Access to medical care and socioeconomic factors were also correlated with women’s stage of readiness for mammography adoption as reported by other studies (
Levy-Storms, Bastani, & Reuben, 2004;
Otero-Sabogal et al., 2003). Women who were younger, did not have insurance or a regular doctor, had lived in the United States for less than 10 years, and perceived more barriers relative to benefits of mammography were more likely to be in precontemplation. As expected, recent immigrants were more likely to be new to mammography (action) or unfamiliar with mammography (precontemplation). Those women with private insurance were less likely to be in contemplation or precontemplation but were as likely to be in relapse as women with no insurance. Our logistic regression results indicate that the association between insurance status and relapse can be explained largely by other factors. In particular, compared to women with a regular doctor, those without one were more likely to be in relapse and less likely to have private insurance. This suggests that the intention to maintain screening is fostered not by having insurance per se but by having an ongoing relationship with a health care provider.
Other important variables, such as knowledge, attitudinal, behavioral, and contextual factors, may influence a woman’s decision to get annual mammograms. As reported by our Pathfinders colleagues (
Somkin et al., 2003), women who reported that there were too many forms to fill out and those who felt embarrassed at the last mammogram were less likely (ORs = 0.51 and 0.59, respectively) to receive mammograms regularly. Thus, although cost and lack of insurance are repeatedly cited as primary deterrents to regular use of breast cancer screening, simply having insurance is not enough to eliminate barriers to the regular use of mammography screening. In addition to cost and lack of insurance, individual, attitudinal, clinician, and health care system factors may further explain regular participation in mammography screening among low-income women (
Otero-Sabogal et al., 2004). Continuity of medical care was strongly associated with stages of mammography.
Chinese women were least likely to have lived in the United States 10 years or more, but even so, they were disproportionately likely to be in precontemplation and relapse. Latinas were least likely to have a regular doctor, and they also reported agreement with more barriers to mammography than women from the other ethnic groups. This finding indicates that the factors included in our model did not explain the overrepresentation of Chinese women in the precontemplation and relapse stages. In our sample, Chinese women were much less likely than women in other ethnic groups to report an intention to get a mammogram in the next year regardless of their screening history. Perhaps this is due in part to differences in the degree of commitment implied by a “yes” answer to, “Do you plan to have a mammogram in the next 12 months?” Low perceived need, lack of physician recommendation, and attitudes related to modesty and sexuality may also account for Chinese women’s reluctance to be screened (
Tang, Solomon, & McCracken, 2000). We also found ethnic differences in women’s agreement with the decisional balance statements assessing pros and cons. White and African American women who participated in regular mammography screening were significantly more likely to perceive greater benefits and fewer barriers to screening than women who did not get screened regularly (
Champion & Menon, 1997;
Holm, Frank, & Curtin, 1999).
Overall, Latinas agreed with a greater number of cons and had a lower decisional balance in maintenance than women in other ethnic groups when controlling for insurance and other demographic factors. This result is consistent with previous findings indicating that Latino ethnicity was a strong predictor of mammography underuse (
Calle, Flanders, Thun, & Martin, 1993). It is important to further explore whether Latinas’ lower decisional balance compared with the other ethnic groups can be explained by a tendency to agree with statements measuring perceived cons rather than truly negative attitudes toward mammography. As reported in other studies, a high proportion of African American women reported a dislike of mammography (
Andrews, 2001;
Champion & Menon, 1997;
Keemers-Gels et al., 2000). Fear of radiation, limited knowledge, (
Miller&Champion, 1997), and past experiences (
Champion & Menon, 1997) may explain this result. Chinese women reported a high number of pros as well as cons. Low education, low perceived need, lack of physician recommendation, and attitudes related to modesty and sexuality may account for Chinese women’s reluctance to be screened (
Tang et al., 2000). Filipino women agreed with a high number of pros and a low number of cons. Given that they also reported having insurance, being bilingual, and having a regular physician, the proportion of Filipino women in mammography maintenance was lower than expected. Modesty, traditional health beliefs, and gender roles may explain these results (
McBride et al., 1998).
Members of the Pathfinders research team have investigated this issue (
McPhee et al., 2002). Following our baseline telephone survey regarding receipt of mammogram, computerized and written medical records were examined in a subsample of 846 women to validate dates and locations of tests. Overall, the validation rate for mammogram self-report was 75.4%. Validation rates differed significantly by ethnicity for mammograms with African American, Chinese, and Filipino ethnicity associated with lower odds of validation compared to White ethnicity. These findings suggest that studies such as ours and other estimates of mammography screening may need to be adjusted downward. Additional validations should be conducted to confirm this result and ascertain the degree of correction needed.
There is still potential to improve our Decisional Balance Scale by identifying additional pros and cons to cover the full range of attitudes toward mammography across ethnically diverse groups. Understanding sociodemographic, cultural, attitudinal, behavioral, and contextual factors associated with breast cancer screening among women of different ethnic/racial backgrounds and developing adequate measures for those factors requires group-specific ethnographic studies using qualitative methods (focus groups, observations, and unstructured interviews).
This study had limitations. First, our results are based on a cross-sectional baseline survey of a longitudinal study and thus do not allow causal attributions to be made. Subsequent analyses from this study may illuminate the causal relationship between the decisional balance and screening stage. Also, although self-report is the usual method for eliciting screening behavior among women, because the cost of obtaining medical record data is substantial, self-reported rates for mammography among racial and ethnic groups may overestimate its use, and this issue has been investigated by members of the Pathfinders research team (
McPhee et al., 2002). Finally, our sample was selected from one urban county with a large multiethnic population, and we only selected women who could be contacted a second time. Thus, results may not be applicable to women who live in communities with different access to mammography screening services or even the broader population of women in Alameda County.
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