THESIS HURS 1998 G454a
c.2
Gienger, Diane J.

Adherence to mammography
guidelines in women
1998.
Adherence to Mammography Guidelines in Women
with and without a Family History of Breast Cancer

by
Diane J. Gienger, RN, BSN

Submitted in Partial Fulfillment of the Requirements
For the Master of Science in Nursing Degree

Approved by:

Alice Conway, R2^< PhD.
Committee Chairperson of
Edinboro University of Pennsylvania

Mai ,ou Keller, CRNP, Ph D.
Committee Member of
Edinboro University of Pennsylvania

JfpatX, Geisel, RN, Ph.D.
Z;^L-Committe Member of
Edinboro University of Pennsylvania

Date

Abstract
Adherence to Mammography Guidelines in
Women with and without a Family History of Breast Cancer

The purpose of this study was to determine if women with a family
history of breast cancer are adhering to the recommended guidelines for
mammography use more often than women without a family history of

breast cancer. Literature indicates these women are at high risk for

contracting breast cancer and compliance with mammography screening is

low (Center for Disease Control, 1997). An existing survey authored by

Dr. Anna Miller (Miller & Champion, 1996) that examined demographics,

compliance, attitudes, beliefs, influencing factors and knowledge of
mammography usage was utilized. The sample consisted of 90 women
from 2 sites in northwestern Pennsylvania. The results from this study

indicate that women with a family history do not adhere to guidelines
more than women without a family history. The compliance rate of having

at least one mammogram was 80% in the group with a family history and

78% in the group without a family history of breast cancer. This is higher
than what is reported in the literature. Having a health care provider

recommend a mammogram was the greatest measure of adherence.
The results were consistent with Dr. Miller’s study, and indicate that

primary care providers are in a valuable position to influence compliance.
ii

Acknowledgments

I would like to take this opportunity to thank Dr. Alice Conway
for her support and direction as chairperson of this project, and Dr. Geisel

and Dr. Keller for their assistance as members of my committee. My
sincere gratitude to Shari Powell, MBA for her time and expert advice on
my data analysis. I would like to thank the women of northwestern
Pennsylvania who participated in this project, and Ann Lee, CRNP for her

years of support and inspiration. Finally, a special thanks goes to my
husband Ed, and my children Eddie and Megan for their patience, support
and assistance throughout this project.

iii

Table of Contents
Content

Page

Abstract.

ii

Acknowledgments.

in

List of Tables.

vii

List of Figure.

viii

Chapter I - Introduction

1

Background of the Problem

1

Theoretical Framework

2

Statement of Purpose

5

Definition of Terms.

6

Assumptions.

6

Limitations

7

Summary.

7

Chapter II - Review of the Literature.

9

Incidence and Prevalence of Breast Cancer

9

Risk Factors.

10

Mammography.

11

Guidelines for Mamography Use.

12

Compliance

13

Summary.

15

iv

Chapter III - Methodology,

17

Hypothesis,

17

Research Design

17

Operation Definitions

17

Sample and Procedures

18

Informed Consent,

18

Instrumentation,

19

Pilot Study.

20

Analysis of Data.

20

Summary,

21

22

Chapter IV - Results,

Response Rate of the Eligible Population

22

Profile of Respondents

22

Comparison to the Benchmark Study.

23

Comparison of Respondents with a Family History.

28

Health Care Practices.

29

Attitudes Toward Breast Cancer,

29

Attitudes Toward Mammograms.

29

Adherence to Guidelines.

30

Demographics, Belief s and Attitudes.

31

v

Influencing Factors

32

Health Care Practices.

32

Summary.

33

Chapter V - Discussion and Recommendations

34

Discussion.

34

Recommendations.

36

Summary

37

References.

38

Appendixes

42

A. Consent from particpating sites.

42

B. Cover letter and survey.

44

C. Letter of Permission - Survey Usage.

58

vi

Influencing Factors.

32

Health Care Practices

32

Summary.

33

Chapter V - Discussion and Recommendations.

34

Discussion

34

Recommendations

36

Summary.

37

References

38

Appendixes

42

A. Consent from particpating sites

42

B. Cover letter and survey

44

C. Letter of Permission - Survey Usage.

58

vi

List of Tables

Table

Page

Tablet. Age Demographic.

23

Table 2. Income Demographic.

24

Table 3. Maritial, Race and Employment Demographic.

25

Table 4. Comparisons to Benchmark study-mammography usage.. 26
Table 5. Comparisons to Benchmark study-healthcare practices

27

Table 6. Beliefs about breast cancer.

28

Table 7. Attitudes towards breast cancer.

30

Table 8. Attitudes towards mammograms.

30

Table 9. Adherence to guidelines.

33

vii

List of Figure

Figure

Page

Figure 1. The Health Belief Model

viii

4

1

Chapter 1
Introduction
This chapter provides a brief overview of the prevalence of breast cancer today

and the benefits of mammography screening. Becker’s Health Belief Model is used as

the theoretical framework for this study (Becker, 1974). Assumptions, limitations and

definitions of terms are provided.
Background of the Problem
Breast cancer is the most common type of cancer in women and the second

leading cause of cancer death in American women (American Cancer Society [ACS],

1997). Almost every person seen in clinical practice today has been affected by this
disease, either the patient, a family member, a friend, or a neighbor. The average

lifetime risk for a woman in the United States of developing breast cancer is
approximately 1 in 9 (United States Public Health Service [USPHS], 1994).
Currently, breast cancer cannot be prevented; however, increased survival rates can be

obtained through early diagnosis (Miller & Champion, 1996). Mammography is the

most effective means of early detection for breast cancer, with sensitivity estimates of

70% to 90% and specificity estimates of 90% to 95% (USPHS, 1994). The American
Cancer Society estimates that in 1995 alone, some 33,800 women aged 40 to 49 years
were diagnosed with having breast cancer (Feig, 1996).

A woman is considered to be at high risk for developing breast cancer if she
has a sister, daughter, or mother with a history of breast cancer. A positive family

history of breast cancer raises the risk two to three times for developing the disease

2

(Constanza, Stoddard, Gaw, & Zapka, 1992). Annual mammography is recommended
for women with a family history of breast cancer (Bowman, Braly, Johnson, & Mikuta,

1996). However, despite the effectiveness of mammography in reducing mortality,
screening rates remain low, with only 21% adherence in the past three years (Miller &

Champion, 1996). Ironically, many of the women at the highest risk for cancer are
among those least likely to be screened (Bowman, et al., 1996).

Theoretical Framework
The theoretical framework utilized in this research is Becker’s Health Belief

Model as it applies to mammography usage. The Health Belief Model is a popular
conceptual framework in nursing, especially in studies focusing on patient compliance

and preventative health care practices (Polit & Hungler, 1995). The model postulates

that health-seeking behavior is influenced by a person’s perception of a threat posed by
a health problem, and the value associated with actions aimed at reducing the threat

(Becker, Haefner, & Kasl, 1977).
M.H. Becker (1974) based his psychosocial model on the work done by I.M.
Rosenstock in the 1950's, who looked at reasons why the public failed to take

advantage of Mobil chest X-ray’s being offered to screen for tuberculosis. The Health
Belief Model is widely used in explaining why people do or do not take health
promotion measures (Fulton, et al, 1991). In this study, the Health Belief Model is

used to identify factors which contribute to the adherence of mammography
guidelines.

There are five basic components described in Becker’s Health Belief Model

3
(See Figure 1). The first component, perceived susceptibility, refers to a person’s

perception that a health problem is personally relevant or that a diagnosis of illness is
accurate (Becker, et al., 1977). It is the individual’s own belief on how susceptible he

is to the particular illness. According to the Health Belief Model, health behaviors are

more likely if an individual feels susceptible to a condition. The second component,
perceived seriousness, looks at how serious the person thinks the illness will be for
them if they do have it, and the impact it may have on their life. The third component,

perceived threat of a disease, is the combination of what the person considers the

perceived susceptibility and perceived seriousness to be. These components equal the
perceived threat for the patient (Stein, Fox, Murata & Morisky, 1992).
The fourth part of the model is the modifying factors. These factors include
demographic variables such as age and gender. It addresses the question whether one

gender take advantage of health promotion more than the other. It considers

education levels in relation to rate of compliance. It examines if some races are more
likely to comply with health promotion than others. The social and psychological
factors examined include the expectations of society and socioeconomic class. The

structural variables examined are the patient s own knowledge of the disease,

including peer pressure.
Internal or external cues to action are other modifying variables (Becker,

1974). An internal cue is described as the feeling that a person may be getting the
illness in question. An external cue is described as a public figure coming forward to

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5

disclose and call attention to a particular illness. Another example would be a clinician
reminding a patient that a screening test is due.

The last component of the Health Belief Model is likelihood of action. This
component describes the likelihood of the person actually taking the preventative
action. Likelihood of action includes the perceived benefit of the preventative action,

or that the test will be accurate, minus the perceived barriers to action. The perceived
barriers include factors such as the high cost of a test, whether they have access to the

test, or any discomfort that may be involved in taking the test. Demographics also

affect and influence these perceptions and impact likelihood of taking action.
Nurse practitioners are in a position at this stage to educate women with a

family history of breast cancer thereby influencing perceptions. They can advise
patents if they are at an increased risk of developing the disease, and let them know of

the screening tools available today. It can be important for clinicians to be aware of
the factors that explain why people do or do not take advantage of these screening
services when they have been made available to them.
Statement of Purpose
The literature shows that cancer screening in women has remained substantially

lower than national health objectives for all types of malignancies (Bowman, et al.,

1996). The purpose of this research is to determine if women age 40 years and older,
with a family history of breast cancer, are adhering to recommended mammography

guidelines. A comparison between mammography adherence in women with and
without a family history will be examined. This will be determined through a self-

6

administered survey of women who are at least 40 years old who have a positive

family history of breast cancer. A convenience sample of patients in two sites, an
Internal Medicine practice and a rural health clinic, both located in northwestern

Pennsylvania will be used.
Definition of terms

The terms of this study are identified as:

1. Family history of breast cancer is breast cancer in a first-degree relative such
as a sister, daughter, or mother (United States Public Health Service Handbook,

1994).
2. Mammography is low dosage X-rays of the breast. (Stein, et al., 1992)

3. Mammography guidelines are defined as women 40 years of age and older

who have a family history of breast cancer or who are otherwise at increased risk

should have annual mammography.(United States Public Health Service Handbook,
1994).

4. Adherence is a clinician-patient partnership where both agree on a course of
treatment that the patient agrees to undertake (Platt, Tippy, & Turek, 1994)
Assumptions
The assumptions of this study are identified as follows:

1. The participants of the study can understand the questions and terms used in
the survey.
2. The participants of the survey will honestly answer the questions concerning

their medical background.

7
3. The survey correctly measures variables associated with obtaining a
mammogram.

Limitations
The limitations of this study are as follows:

1. This study used a convenience sample obtained from two sites in Northwest
Pennsylvania which may effect the generalizability of the study.
2. Information required self- recall of events (mammography) that may have

happened over a long period of time, and is dependent of the respondent’s memory.
3. Women with unknown family history cannot be classified.

Summary

Breast cancer affects one out of every nine women in the United States

(American Cancer Society, 1997). Mammography has been proven to increase
survival rates in women with breast cancer (Harris, Lippman, Veronesi, & Willet,
1992). Improved survival rates are related to the increased availability and usage of

mammography, yet usage is still substantially lower than the recommended health
guidelines (Cady, Evans, & Feig, 1997).
Women who have a family history of breast cancer are at a high risk for

developing breast cancer. The purpose of this study is to investigate the adherence to
mammography guidelines in women age 40 years and older, with a family history of

breast cancer. This information was determined through a self-administered survey

distributed in two medical practices in northwestern Pennsylvania. Assumptions,
limitations and terms utilized in this study have been provided.

8
The Health Belief Model, developed by Becker (1974), was used as the model

for this study. The Health Belief Model has often been used to organize theoretical

predictors of preventive health actions, including individual perceptions of disease,
individual perceptions of preventive actions, and modifying factors such as social,

demographic, and structural characteristics (Fulton, et al., 1991). Once these
predictors of health actions are identified, the nurse practitioner is in a better position

to help educate these patients towards better compliance.

9

Chapter II

Review of the Literature

This chapter provides a review of current literature on mammography and
breast cancer, including risk factors. The purpose of this chapter is to provide the

reader with the incidence and prevalence of breast cancer today, risk factors involved,
and mammography effectiveness, usage and guidelines. It also examines the literature
on compliance of women to recommended mammogram guidelines.

Incidence and Prevalence of Breast Cancer

Breast cancer is a major cause of concern for women in the United States

today (Harris, et al, 1992). The latest figures from the American Cancer Society
report that in 1997, breast cancer will be diagnosed in over 180,000 women and

almost 44,000 women will die from this disease. At the present time, breast cancer is

the second leading cause of cancer death among American women following lung
cancer, and the leading cause of death for those aged 40 to 55 years (Abraham &

Seremetis, 1997). The incidence of breast cancer in the United States has increased
over the last decade (Harris et al, 1992). In their study of recent trends in cancer

morbidity and mortality, Frey, McMillian & Cowan (1992) found that one of every
nine women in the United States will develop breast cancer. Game, Aspegren and

Balldin (1997), in looking at recent trends in breast cancer, found that mortality had
declined significantly for the first time recently. This data showed a 6.8% decrease in
deaths from 1989-1993, the lowest it has been since 1950. They believed use of

mammography to be a factor in the improved survival rate.

10

Risk Factors

There is no known cause or methods for preventing breast cancer from

occurring (Constanza, et al, 1992). Genetic and environmental factors are thought to
play a role (Harris, et al, 1992). There are however, established risk factors associated
with the disease. These include positive family history in a first degree relative, early

menarche and late menopause, late age at first child birth (> 30 years), nulliparity,

exposure to radiation and increasing age (Abraham & Seremetis, 1997). The most
recent risk factor identified is having the Breast Cancer [BRCA] 1 gene (Claus,
Schildkraut, and Thompson, 1996). This research includes the discovery of the genes

which are believed to control hereditary breast cancer. These genes are believed to
account for 90 % of early- onset hereditary breast cancer. Their research indicates that

a mutation of the BRCA 1 gene leads to a estimated 55% risk of developing breast
cancer by age 60 and a 27% risk by age 80.
Sattin, et al. (1985) studied family history and the risk of breast cancer. They

found that women who had an affected first-degree relative had a risk of 2.3 times
more than women without a family history of the disease. Prior to the discovery of the

BRCA genes, family history of breast cancer was identified as the highest of the
relative risk factors (Harris, et al, 1992). Sattin, et al. found that a woman with a

mother or a sister with breast cancer had an especially high incidence if that relative
developed breast cancer before menopause (2.8 fold increased risk). The study also

found that if both a mother and a sister had breast cancer, they had a greater risk than
a woman with only one affected first degree relative (14 fold vs. 2.3 fold risk).

11
Mammography
Although at this time there is no primary prevention for breast cancer, there are

several secondary screening tools available. These include self- breast examination,

clinical breast examination, and mammography (Bowman, et al. 1996). Mammography
has been defined as low dose x-rays of the breast to detect any abnormalities (Stein, et

al, 1992). Mammography has been the most successful screening tool (Harris, et al,
1992).
Mammography has reduced the risk of death from breast cancer in the United

States by 19-30% in women aged 50-74 years old (Center for Disease Control [CDC],
1997). A meta-analysis by Kerlikowske, Grady, Rubin, Sandrock, & Emster (1995)

concluded that screening mammography significantly reduces breast cancer mortality

in women 26% after nine years of follow up. This study looked at women age 50 to 74
years and determined that there is a benefit with mammography use regardless of

number of mammographic views taken, the screening interval or duration of follow­
up. Breast cancers detected early have a better prognosis than cancers detected in late

stages before the tumor metastasizes (Harris, et al, 1992).
There has been controversy in the effectiveness of mammography screening for
women who are 49 years old and younger. Taber, Fagerberg, and Duffy (1992)

reported in their study that there is no statistically significant reduction in mortality in
women age 40 to 49 years who have mammogram. This may be attributed to more

dense, fibroglandular breast tissue which makes interpretation difficult. A recent metaanalysis by Sickle and Kopans (1995) however, shows a 21% reduction in mortality

12

for women in this age group who had an annual mammogram.

In recent years, mammography has been improved and technology h;tas
developed that has increased visualization of the breast and reduced exposure to

radiation (Harris, et al, 1992). In mammography, both breast views are compared by

symmetry of architecture, positioning, and distribution of density .Two standard views
are obtained when a screening mammogram is ordered; the medialateral oblique view

which shows the breast compressed along a plane that extends through the nipple from

the upper outer quadrant to the lower inner quadrant, and the craniocaudal view,
which shows compression applied from the top to the bottom of the breast (Abraham
& Seremetis, 1997). The patient receives only minimal radiation from the procedure,

and no case of breast cancer has been shown to result from having a mammogram
(Cady et al, 1997).
Guidelines for Mammography Use

The benefits of breast cancer screening to reduce mortality in the population

can be achieved only if screening guidelines are followed and a large population of
women receive screening examinations regularly (CDC, 1997). There has been change

and debate in the recommended screening guidelines for women and mammography in

recent years. Most organizations, including the American Cancer Society and the
National Cancer Institute revised their guidelines in March of 1997. The current

recommendations are as follows: The National Cancer Institute is recommending
screening mammogram eveiy 1-2 years for women aged 40 years and older if they are
at average risk for breast cancer, and annually if they are at high risk. The American

13
Cancer Society (1997) now recommends annual mammography for all women aged 40
years and older. This was an increase in frequency from their earlier guidelines which

had recommended only every 1-2 years (Abraham & Seremetis, 1997). However, the
U.S. Preventive Task Force (1996) recommends screening mammogram every 1-2
years for women aged 50-69 years. It is recommended that a high-risk woman who is

younger also receive a screening mammogram. Results of a study done by
Kerlikowske, Grady, Barclay, Sickles & Ernster (1996) show that a higher proportion
of invasive cancers among women aged 40-49 years may be detected by annual

screening as opposed to screening every other year, providing support that women
beginning at age 40 benefit from this procedure. A study done by Feig (1995),

suggested that annual screening of women aged 40-49 years may result in the same

mortality reduction as women 50-75 years old at 2 to 3 year intervals. Harris et al.
(1992) state that the most frequently diagnosed cancer for this age group is ductal

carcinoma in situ, which may not progress to invasive cancer at all, and that false
positive results are more often seen in younger women.

Compliance

In order for mammography to be effective, compliance to the recommended
guidelines need to be followed. At the present time, adherence to all medical
treatments and recommendations has been poor, with only one third of women

following recommendations completely (Hatt, Tippy, & Turk, 1994). Results of the
National Cancer Institute Screening Consortium (1990) identified only 25-41% of all
women as having had a mammogram within the las. year. Th. Center for Disease

14
Control reported that from 1989 to 1995, the percentage of women over age 40 who

received a mammogram during the preceding 2 years, had increased in the 39 states
who participated in the study . This increase ranged from 9-45% mammography

utilization of women over the age of 40 years per state (CDC, 1997)
The Health Belief Model (Becker, 1974), the theoretical framework for this

study, looks at predictors of compliance. These predictors include the perceived

susceptibility of contracting the disease, the perceived personal harm related to

actually having the disease, the positive attributes related to the screening procedure
its self, social influences and socio-economic status, and cues to action (including
clinician recommendation and reminders). It also looks at knowledge about the
disease, perceived control over the disease, and confidence that the screening
procedure will be accurate. According to Champion (1991), who looked at these

factors in breast cancer detection, susceptibility, social influence and knowledge are

related to increased mammography use according to guidelines. Of the adherent
group, 64% were predicted by these factors. Knowledge of the disease rated the

highest predictor (discriminant coefficient of 0.75), followed by social influence
(discriminant coefficient of 0.48), and susceptibility to the disease (discriminant

coefficient of 0.36). Results of the National Breast Cancer Screening Consortium
(1990), found that the two most common reasons for non-compliance were lack of
physician recommendation (cues to action), 12-42% depending on the site, and lack of

knowledge that they needed a mammogram, 40-67% depending on the site. Kaplan,

Weinberg, Small & Herndon (1991), looked at the behaviors ofwomen a. high risk for

15
breast cancer. They found that their mammography compliance was not substantially
different from that of women without risk factors (37% vs

15-30%). According to

Fulton, et al. (1991) in a study of predictors of breast cancer screening, the perceived
benefits of mammography were more predictive of a women having a mammogram

(41%) than their perceived risk of contracting breast cancer (30%) or the perceived
severity of actually having the disease (36%).
Summary

This chapter has provided a review of the literature on breast cancer,

mammography and compliance. Breast cancer is increasing in the United States with
one out of every nine women affected by the disease. It is the second leading cause of

cancer death among women. There has been an increase in incidence and for the first

time, a decrease in mortality (ACS, 1997).
Established risk factors associated with breast cancer such as a family history of
breast cancer in a first-degree relative increasing a woman’s risk of contracting cancer

by 2-3 times were discussed. The recent discovery of the genetic marker BRCA 1, was
also discussed.

Mammography as the most effective screening tool for the disease was
discussed. The many changes in the guidelines for mammography use were identified,
and the controversy in the use of mammography in women under age 50 years was
identified. The technological advances that have increased the visualization of the

breast and reduced exposure to radiation were identified.
The historically poor compliance with mammography was discussed. The

16

several predictors of compliance according to the Health Belief Model (Becker, 1974),

the theoretical framework for this study were identified. The current finding that
having a high risk for breast cancer does not correlate with an increase in

mammography use was noted.

17
Chapter III

Research Methodology
This chapter describes the methodology utilized in this study, included in this
chapter are the hypothesis, research design, procedures, sample and Wormed consent.

Hypothesis
Women with a family history of breast cancer adhere to mammography

guidelines more frequently than women without a family history of breast cancer.

Research Design
This study utilized a non-experimental survey research design, and was a
comparative, descriptive study. The goal of the study was to gather information

regarding the behaviors and influencing factors of susceptibility, health motivation,
social influence, benefits and barriers in women aged 40 and over with a family history
of breast cancer, on seeking mammography and present the differences in those that
adhere to guidelines and those who do not.

Operational Definitions

1. Mammography is low dose X-rays of the breast for screening or diagnostic
purposes.
2. Family history of breast cancer is a diagnosed incidence of breast cancer in a

sister, mother, daughter, grandmother, aunt or cousin.
3. Susceptibility is an individual’s own belief on how likely she is to contract a

disease.

4. Health motivation is how likely an

individual is to seek health promotion and

18

disease prevention.

5. Social influence is the role of influence that society, famiiy .nd fads play in

determining if a health promotion measure is taken or not.
6. Benefits are the positive aspects of engaging in a health promotion behavior such

as detecting a disease early or ruling out a disease in an individual.

7. Barriers are the factors which prevent an individual from seeking health
promotion such as cost, convenience, fear and embarrassment.
Sample and Procedures
The convenience sample was women age 40 years or older. The women all

resided in the United States and read English.
This study utilized two groups for convenience sampling in order to obtain a
more representative socio-economic sample. Consent was obtained from participating

sites (Appendix A). The survey (Appendix B) was given to women who visited either
an Internal Medicine Practice or a rural health clinic in northwestern Pennsylvania.

The receptionist at the front desk offered the women a survey to fill out while they

waited to see the clinician. The survey included a cover letter with directions and
informed consent attached. There was a box in the inner office where the surveys were
placed after completion, where they were later picked up by the researcher. The time
frame of approximately two weeks was given for the completion and collection of
surveys. A combined total of 90 surveys was collected from these sites.

Informed Consent
An introduction accompanied the survey to allow the participants to know the

19

purpose. The completion and return of the survey was deemed

informed consent. All

data remained confidential and anonyi'mous. The participants were asked not to put
their name on the survey. The data was reported in the aggregate.
Instrumentation

A survey was utilized as the research tool. An existing survey created to study
mammography use in women was obtained from the author, Anna M. Miller, RN,
DNS, Professor of Nursing at Indiana University, Indianapolis. Permission was

granted to use the survey or any portion of it for this research (Appendix C).
Survey questions were taken from prior mammography research and included

the National Cancer Institute (NCI) “core” questions about breast cancer screening
(National Cancer Institute Breast Cancer Screening Consortium, 1990). Content
validity for Dr. Miller’s survey was reviewed by experts from five nationally known

breast cancer researchers. The reliability for the five attitudinal scales was 0.89 to
0.93 for susceptibility, 0.80 to 0.84 for health motivation, 0.77 to 0.94 for social

influence, 0.68 to 0.80 for benefits, and 0.84 for barriers. The construct validity had
been tested using factor analysis and multiple regression. (Miller & Champion, 1996).

The first page consists of information describing the purpose of the study and
instructions on completing the survey. Informed consent by filling out the survey was

explained. Part A consists of questions about mammograms that were done in the

past. Part B consists of questions about personal feelings regarding breast cancer.
The five-point Likert scale was used for these questions. Responses range form

“strongly agree” to “strongly disagree.

Part C also used the Likert Scale and was

20
about beliefs and feelings about getting mammograms. Part D consisted of questions
regarding personal knowledge about breast cancer and mammograms. Part E asked

questions about general health care. Part F consisted of questions about personal
health and their health history. Part G was about influencing factors from other

people. The final section consisted of demographic questions.
Minor modifications made to the survey include changing the age of women
sampled from 50 years old to 40 years old. This was done due to the recent changes

in mammogram recommendations lowering the age of beginning recommended
screening to 40 years. The women aged 50 years and older were compared with Dr.

Miller’s findings during data analysis to insure validity. Several issues dealing with

insurance and other preventative health services were also eliminated, since they were
not relevant with the hypothesis.
Pilot Study

The survey was piloted by eight members of a northwestern Pennsylvania

women’s social organization. None of these women were used in the actual study.

Feedback on clarity of content and length of time to complete was requested. No

changes were made in the content of the original survey. The survey took 10 minutes
to complete.
Analysis of Data

Analysis of the data was performed using Lotus 1-2-3 computer software
package. The z-test, the test for difference between proportions from two samples
was used (Hamburg, 1997). It was calculated thatJi< 012, and differences do exist at

21

the 95% confidence level, with 12% being a significant difference. Percentages were
calculated to describe and analyze the data from the study. The data was compared

against the original study to insure validity.
Summary

The goal of this study was to determine if women with a family history of

breast cancer are adhering to recommended mammography guidelines more than
women without a family history of breast cancer. Influencing factors of barriers,

beliefs, attitudes and knowledge were also evaluated. This was done through a self­

administered survey obtained from Anna M. Miller. RN, DNS. Surveys were placed in
two sites over a period of 2 weeks. The surveys were collected by the researcher and

data analysis was performed. Comments were invited but not received.

22

Chapter IV
Results

This study was undertaken to determine if women with a family history of

breast cancer adhere to recommended guidelines, and what were the influencing
factors. The results of the study are presented in this chapter and tables are used to

compare and contrast the groups.
Response Rate of the Eligible Population
The survey (Appendix B) was given to women visiting either an Internal
Medicine Practice or a rural health clinic in northwestern Pennsylvania. The total

respondents equaled 90. Respondents were screened by knowledgeable office

personnel for eligibility (age 40 years and older) at both sites by consulting the patient
chart if needed. The response rate for the internal medical practice was 66% (33) and
57% (57) for the clinic. The survey took approximately 10 minutes to complete.

This study data was compared to the Benchmark study from which the survey was
obtained (Miller & Champion, 1996) for validity purposes, using this study’s
respondents age 50 and older.

Profile of Respondents

There were no significant differences between the group with and the group
without a family history of breast cancer in demographics of age, marital stat

household income, ethnicity, education

level, occupation, type of neighborhood, or

number in household.
The median age of the respondents

was 51.0 years, with a range of

23
40-80 years (Table 1). Median income was $55-74,000 per year (Table 2). For
education, the median income was 13 years (Table 2). The majority of the

respondents were married (82%), white (96%), and considered themselves

homemakers (51%)(Table 3).
Table 1.

Age Demographic with and without family history
Age

Total

With History

Without History Age 50+ Benchmark

<45

27%

23%

29%

0%

0%

45-54

46%

50%

42%

51%

46%

55-64

16%

14%

18%

27%

65+

12%

14%

11%

22%

49%

<50

47%

41%

51%

50+

54%

60%

49%

100%

100%

Median 51.0 yr.

50 yr.

52.0 yr.

65.7 yrs.

Note. 45-64 yr. was combined in benchmark study (n-1083).
Comparison to the Benchmark study

To compare this investigator's data with the benchmark study, respondents age
50 years and older were used, since

this was the age used in their study. The

northwestern Pennsylvania [NWPA] respondents were less likely to be age 65 or older
(49% vs. 22%) respectively and

more likely to be married (55% vs 84%) and

homemakers (10% vs 53%), while benchmark respondents were more likely
retired. This study had a higher percentage of white population (98% vs 75%) and a

24

lower population of black respondents (2% vs 22%), than the Benchmark (Table 3).
Table 2.

Income Demographic
Income $

Total

<$20,000

1%

2%

0%

0%

20-40,000

28%

31%

24%

24%

40-54,000

18%

19%

18%

22%

55-74,000

17%

10%

22%

20%

74,000-up

28%

27%

29%

29%

Median

With History Without History 50+

$55-74,000 $40-54,000 $40-54,000

Benchmark

$40-54,000 $30-40,000

Note. Benchmark breakdown data unavailable.

Comparison with the benchmark study on key measures related to breast

cancer and mammography usage indicate the following similarities: frequency of
having a mammogram, the person recommending getting a mammogram (Table 4).

Frequency of having a regular health care provider, likelihood of having a
mammogram next year, incidence of having a
visits to the doctor are also similar (Table 5).

friend with breast cancer, and number of

25

Table 3.

Marital, Race and Employment Demographics
Total

With History Without History 50+

Benchmark

Status
2%

2%

2%

0%

7%

Married

82%

73%

91%

84%

55%

Other

15%

25%

7%

16%

36%

White

96%

95%

96%

98%

75%

Black

2%

2%

2%

2%

22%

Other

2%

2%

2%

0%

3%

Single

Race

Employment

Employed

40%

39%

40%

26%

31%

Retired

11%

14%

9%

20%

50%

Homemaker 46%

40%

51%

53%

10%

Note. Marital status ‘other’ refers to widowed, separated or divorced

26

Table 4.

Comparisons to Benchmark Study
NWPA Study

Ever had mammogram

90%

Benchmark Study

85%

Frequency of mammograms
This year

31%

35%

One year ago

55%

50%

2 years ago

39%

43%

3 years ago

33%

30%

4 years ago

27%

25%

5 years ago

22%

20%

0%

4%

None in last 5 year
Recommended by

Doctor

65%

Respondent request

24%

75%

17%

27
Table 5

Comparisons to Benchmark study on health care practices.

NWPA Study

Benchmark Study

Annual exam (last 5 years')
0

6%

5%

1

4%

6%

2

14%

8%

3-5

67%

56%

>5

8%

20%

Regular health care provider 96%

93%

Type of provider
Chiropractor

0%

0.5%

Family/G.P.

41%

30%

Internal Medicine

31%

30%

Nurse Practitioner

12%

0.5%

OB/GYN

10%

6%

Osteopath

4%

0.5%

Differences were found in the incidence of the number of relatives with breast

cancer which is lower in the NWPA study. The proportion seeing a family medicine
doctor or Nurse Practitioner as their primary care provider was higher in the Edinboro
study. Adherence to mammography guidelines

significantly higher at the one year

28
level (72% vs 49%) in the benchmark, but comparable at the three year level (24% vs
21%).
Comparison of Respondents with a family history vs. those without a family history
Beliefs and Knowledge about Breast cancer

In the group with a family history of breast cancer, 36% correctly answered

that 1 out of 9 women will get cancer in their lifetime, vs 18% in the non-family
history group (Table 6). The question of a mother or sister having cancer as being a

high risk was answered correctly in both groups with no significant difference (78%
with a family history vs 81% without). Knowledge regarding the new guidelines of
yearly mammogram starting at age 40 was significantly higher in the group with a

family history, with 64% vs 38% answering correctly. The guidelines for women over
50 years was answered correctly with no significant differences in the groups.
Table 6

Beliefs about breast cancer

Will get breast cancer in their lifetime

Family History

Without Family History

1 out of 5

27%

36%

1 out of 9

36%*

18%

1 out of 25

14%

16%

Not sure

23%

31%*

n=90, *p< 0.12

29
Health Care Practices

There were no differences between groups in having a regular health care
provider, or what type of provider it was. There were no differences in access to

health care or what type of insurance the respondent had. A significant difference was
found in a doctor recommending having a mammogram (75% with a family history vs.

62% without a family history). For having regular doctor checkups, the respondents
with a family history of breast cancer had a 43% rate of having a regular checkup

every year vs. 28% in the non family history group.

Attitudes toward Breast Cancer
Although there was no difference in behavior towards obtaining a
mammogram, there were some significant differences in attitudes toward breast
cancer. In the group with a family history, 14% felt they were extremely likely to get
breast cancer in the future, whereas 0% of the non-family history felt this way. The

feeling that breast cancer was a hopeless disease was answered by 5% for the group
with a family history and 7% for the group without (Table 7).

Attitudes towards Mammograms
In the group with a family history, 34/o vs 15% in the group without a family
history .greed that a mammogram would be painful Attitudes ofembanassment and
peace of mind were not significant (Table 8).

30

Table 7

Attitudes towards breast cancer
With Family History

Questions

Agree

Likely to get breast cancer

Disagree

14%*

Breast cancer hopeless

5%

Whatever will be will be

71%*

64%
84%

16%

Without Family History

Agree
0%

7%

58%

Disagree

75%
97%*
29%*

n=90, *p< 0.12

Table 8
Attitudes towards mammograms

With Family History
Agree

Disagree

Peace of mind

74%

18%*

Would be painful

34%*

Would be embarrassing

16%

Worry about finding cancer

36%

Questions

Without Family History

Agree
80%*

Disagree

4%

15%

68%

64%

9%

84%*

54%

32%

60%*

59%

n=90, *p<0.12

Adherence to Mammography Guidelines
In this study the total number of surveys counted was 90. The total population
of ever having a mammogram was 79%. Of this group, 63% had a mammogram this

31

or last year. Having a mammogram two years in a row accounted for 31% of the
group. This study defined this group as having had a mammogram this and last year,

or had a mammogram last year and two years ago, or age 40 years and had a
mammogram this or last year. Only 27% had a mammogram for 3 consecutive years.

This was defined as having had a mammogram this year, last year and two years ago,
or having a mammogram last year, two years ago and three years ago, or age 40 and
having one mammogram this or last year. Of note is that 8 people age 40 years never

had a mammogram.
In the group of respondents with a family history of breast cancer, 80% had at

least one mammogram. In the group that did not have a family history of breast

cancer, 78% had at least one mammogram, not a significant difference. There was no

significant differences in the two groups in regard to adherence to the recommended
guidelines. In the group with a family history of breast cancer, 61% vs. 64% without a
family history had a mammogram this year, 30% vs.33% had a mammogram this year

and last year, and 27% had mammograms for three consecutive years (Table 9). The

data did not support the hypothesis of this study that women with a family history of
breast cancer adhere to mammography guidelines more often that women without a

family history, thus the hypothesis was rejected.
Demographics, Beliefs and Attitudes
The adherent group had a

median income of $45-54,000 vs the non-adherent

group income of 140-54,000. The adherent group had 39% graduating from college

or graduate school, vs 1 8% in the non-adherent group. The adherent group had 46%

32

working outside the home vs 30% for the non-adherents.

In attitudes towards breast cancer, the adherent group agreed 88% that woman

with breast cancer can live a normal life VS. 57% in the non-adherent group. In

looking at beliefs, 81% of the adherent group vs 67% of the non-adherent group

correctly answered the question they were at high risk for developing breast cancer it
their mother or sister had it. The adherent group had 81% believing that a

mammogram was very efficient in detecting breast cancer vs 61% in the non-adherent
group. The adherent group had 88% answer that a person with breast cancer can lead
a normal life vs 57% in the non-adherent group, a significant difference. The adherent

group answered 2% that the were embarrassed having a mammogram, while the non­
adherent group answered 30% of the time that they were embarrassed, also a

significant difference.
Influencing Factors
The influencing factor of having a husband or partner approve of

mammography was significantly higher in the adherent group, with 88/o approving vs.
54% in the non-adherent group. Having children approve of mammography was also
significantly higher, with the adherent group approving 79/o vs 33/o in the non

adherent group. Close friends approving was higher in the adherent group, 91% vs the
non adherent group answering 69% they approved.

Health care practices
Having a health care provider recommend a mammogram was 79% in the

adherent group vs. 4S% in the non-adherent group. This study showed that 25% of

33

the adherent group had non-cancerous breast disease vs. 42% in the non-adherent

group. The adherent group was more likely to do breast self-examinations every
month than the non-adherent group (25% vs. 12%). The certainty of getting a

mammogram if it was recommended by a health care provider was significantly higher
in the adherent group, 95% , vs. the non-adherent group who answered 45%. The
percentage of women having yearly examinations for the last five years was 48% for
the adherent group, vs. 14% for the non-adherent group.

Table 9.
Adherence to guidelines
With Family History

Without Family History

Mammogram Frequency

One year

61%

64%

Two years

30%

33%

Three years

27%

27%

Note, n = 44 with Family History, n = 45 without Family History
Summary

This chapter presented the results from the survey to determine if women with

a history of breast are adhering to recommended guidelines, and the influencing
factors. These results were interpreted through descriptive analysis and compared to

the Benchmark study on key issues. The data does not support the hypothesis of the

study. Physician recommendation was the most influencing factor on whether women
had mammograms.

34
Chapter V

Discussion and Recommendations

This study was undertaken to evaluate if women with a family history of breast

cancer adhere to mammography guidelines more than

women without a family history

of breast cancer. A survey obtained from a similar study performed in 1996 was used
to investigate demographic questions, knowledge of breast cancer, influencing factors,
beliefs and attitudes, health care practices and family history of women in northwestern
Pennsylvania. The results of this study were compared against the study which
developed the survey for validity. There were no major differences between the

results of the two surveys.

Discussion
The hypothesis of this study; women with a family history of breast cancer

adhere is guidelines more than women without a family history of breast cancer, was
not supported by this research. For all respondents, the one time mammography rate
was 79%. This is slightly higher than the 72% reported in the literature (Constanza,

Stoddard, Gaw & Zapka, 1992). Adherence did drop slightly after one year, but did

not drop much for two to three years in a row, implying that once a woman starts
adhering, she continues to do so. Women with a family history of breast cancer and
with out a family history of breast cancer were very similar when compared at the one,

two, and three year rate for adherence to guidelines.
The greatest predictor of having a mammogram was having a physician

35

recommend it The National Breast Cancer Consortium

(1990) found that the two

most common reasons women gave for never having a mammogram were that they did
not know they needed it, and that their health care provider had not recommended it
The relationship between mammography use and physician recommendation

emphasizes the need for regular contact with a heath care provider.
Having annual examinations was higher in the adherent group (48%) vs the

non-adherent group (14%). Yearly contact with a primary health provider gives more
opportunities for mammography recommendation and education to take place

(Bowman, Braly, Johnson & Mikuta, 1996). Health care providers should be aware of
their influence on compliance and encouraged to use reminder or tracking systems.

Attitudes were also a predictor of adherence. The adherent group answered
88% that a woman with breast cancer can live a normal life, with only 57% answering

in the non-adherent group. This suggests that the non-adherent group may fear the

discovery of breast cancer if they have a mammogram, so they choose not to adhere to
the guidelines. Embarrassment of getting a mammogram was higher in the non-

adherent group (30%) than in the adherent group (2%), implying that this was a factor

in negatively influencing preventing women from obtaining a mammogram. The

literature reports that embarrassment is a barrier in mammography adherence, and can
be minimized by stating that the technicians are almost always women (Stein, et al,

1992).

Knowledge wad also a significant predictor of adherence, with 81% of the
adherent group vs 67% of the non-adherent group correctly answering questions

36
regarding they were at high risk if they h;
iave a first degree relative with breast cancer.

Consul, Stoddard, Gaw & Zapka (! 992) found that knowMgc of family

„

associated with increased utilization. The influencing facMr rf
mother, child or close fhend approve of mammography was higher in the adherent
group Education for the entire family and community regarding the benefits of

mammography screening may increase adherence.
Becker s Health Belief Model was used as the theoretical framework for this
study. Cues to action such as health care provider reminders, and perceived benefits

and barriers (such as convenience and embarrassment) were more predictive of
adhering to mammogram guidelines than knowledge. This confirms that all of the

components in the Health Belief Model are important in determining the likelihood of
a women adhering to the mammography guidelines, and it is important that each

component be addressed.
Education of mammography’s effectiveness of finding breast cancer early, and
of the treatments and survival rates of breast cancer patients should be discussed.
Factors which promote usage of mammogram such as making the screening more

convenient and helping women overcome their embarrassment may help these barriers.
Providing a more comfortable setting and prompting family members to encourage
women to have a mammogram may increase compliance.

Recommendations

Further research is needed to determine the most effective way to decrease the

barriers for adhering to mammography guidelines.

Based on the results of this study

the following recommendations were made:
1. The study should be replicated using a larger sample size and with a more

racial and geographical mix, since both this study and the benchmark study did not.
2. Mammography recommendation needs to be part of eveiy woman’s health

care and that current, accurate information be provided at these visits
3 Community outreach activities promoting breast cancer awareness aimed at

the entire family should be encouraged.
Summary

This study suggests that many factors contribute to compliance in obtaining a

mammogram and with following the recommended guidelines. Becker’s Health Belief
Model (1977) was used to show the modifying factors which determine the likelihood

of compliance with guidelines. Nurse practitioners are in a position to influence
compliance with current information on efficiency of mammography and reminders

during regular check-ups. Written materials should be developed and distributed to
women and family members to reenforce these issues. This study demonstrated that
women with a family history of breast cancer should be carefully identified and

screened since this high risk group does not comply with the current guidelines. If this
group of women are better educated they can make more positive choices regarding

potentially life saving procedures.

38
References

Abraham, C.L. & Seremetis, S. (1997). Bretuit health al midlife: Guidelines for
screening and patient evaluation. Geriatrics.(6) 58-65

American Cancer Society. Cancer facts and figures, 1997. Atlanta, Georgia:

American Cancer Society, 1997.
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Thorofare, NJ: Charles B. Slack, Inc.
Becker, M. H., Haefner, D. P., & Kasl, S.V. (1977). Selected psychosocial
models and correlates of individual health-related behaviors. Medical Care. 15,27-46

Bowman, M.A., Braly, P.S., Johnson, S., & Mikuta, J.J., MD. (1996). Who
are you screening for cancer- and when? Patient Care , August 15, 1996, 54-76.

Cady, B., Evans, W.P., & Feig, S.A. (1997). Breast Cancer Update- Progress

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Center for Disease Control. (1997). Self-Reported Use of Mammography.

MMWR^46, 937-940.
Claus, E.B., Schildkraut, J.M.. & Thompson, W.B (1996). The genetic

attributable risk of breast and ovarian cancer. Cancer, TL, 2318 2
Constanza, M.E., Stoddard, A, Gaw, V.P., & Zapka, 1 G (1992). The Risk
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Mammography Utilization, tamal
Feig, S. (1996). Strategies for Improving Sensitivity of Screening

Mammography for Women Aged 40 to 49 Years. JAMA 276: 73-74
Feig, S. (1995). Estimation of currently attainable benefit from

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screening of women aged 40-49 years. Cancer. 75. 2412-2419.
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Fulton, J.P., Buechner, J.S., Scott, H.D., DeBuono, B.A., Feldman, J.P.,

Smith, R. A., & Kovenock, D. (1991). A Study Guided by the Health Belief Model of
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declining mortality from breast carcinoma. Trends in Malmjo, Sweden 1961-1992.
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Harris, J.R., Lippman, M.E., Veronesi, U., & Willett, W. (1992). Breast

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Kaplan, K., Weinberg, G., Small. A., & Herndon, J. (1991). Breast C
Screening among Relatives of Women with Breast Cancer. Amencanjou_

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Public Health, 81,(9), 1174-1179.

Kerlikowske, K., Grady, D., Barclay,

Sickles. EA, &

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Effect of Age, Breast Density, and Fattdly History on the Sensitivity of Flrst Scrcen]ng
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Kerlikowske, K„ Grady, D„ Rubin, S.M. Sandrock, C„ & Ernster, V.L.
(1995). Efficacy of Screening Mammography- A Meta analysis. JAMA, 273, 149-154.
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41
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(4)

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42
Appendix A

April 21, 1998

TO WHOM IT MAY CONCERN:

Diane Gienger has my permission to distribute her survey to patients in my
office. I understand that this project is a requirement for her MSN degree at Edinboro
University of Pennsylvania. It is understood that the patient’s decision to participate is

completely voluntary.

Sincerely,

John C. Jageman, M.D.

JCJ/ms

43

Wattsburg Family Health Center
A Service of Union City Memorial Hospital
P.O. Box 61
14430 Main Street
Wattsburg, Pennsylvania 16442
814 / 739-2225

SAINT
VINCENT
March 4, 1998

To Whom It May Concern:

Diane Gienger has my permission to distribute her
survey at this clinic.

I understand that this project

is a requirement for her Master of Science in Nursing

Degree at Edinboro University of Pennsylvania.

It is

understood that participation is completely voluntary.
Sincerely,
A.cr'

Marjorie J. Severo, RN, MSN, CRNP

44

Appendix B

MAMMOGRAPHY USE BY WOMEN
40 YEARS AND OLDER:
INFLUENCING FACTORS
Directions
Hello! My name is Diane and I am a Registered Nurse working on my Master’s
Degree at Edinboro University. This is a survey about what women 40 years and
older think, believe, and know about mammography and breast cancer. This survey is
for research purposes only and will have no effect on your health care in this office.

If you are at least 40 years old and have never had a diagnosis of breast cancer, please
fill out the questions in this survey. It should take you about 10 minutes to complete.
Please answer the questions as honestly as possible. Please answer each question.
Your views are an important part of this study. If you are uncertain, choose “not
sure” or “other”. If you have any comments, please write them in the space provided
at the end of the survey.
By filling out the survey, you are giving consent to be in this study. Do not put your
name on the survey. Your answers will be anonymous and combined with other
women’s answers.

Thank you for your time. You may now begin.

Adapted with permission from Anna M. Miller, DNS, RN
School of Nursing
Indiana University
Indianapolis, Indiana

45

SURVEY
Part A: This part is about mammograms you have had in the past. Circle the ONE
answer that best fits your experience OR fill in the blanks.
1.

A mammogram is an x-ray of the breasts, done by a machine that presses against
the breast while the picture is taken. Have you ever heard of a mammogram?

1.
2.
3.

2.

Have you ever had a mammogram?

1.
2.
3.

3.

Yes
No
Not sure

Yes
No (Skip to Part B, Page 3)
Not sure

About when was your most recent mammogram?
/

Month
4.

Was your most recent mammogram done because of a problem or as part of a
regular checkup?

1.
2.
3.
4.
5.
5.

Year

Current breast problem
Previous breast problem
Part of a regular checkup
Don’t remember
Other (Specify)

Thinking about the last 5 years, when did you have a mammogram? (Circle all
that apply.)

0.
1.
2.
3.
4.
5.
6.
7.

Had one this year
Had one 1 year ago
Had one 2 years ago
Had one 3 years ago
Had one 4 years ago
Had one 5 years ago
Have not had a mammogram in last 5 years
Not sure

46

6.

Who suggested you get your most recent mammogram?

1.
2.
3.
4.

7.

Did you have a doctor’s order for your most recent mammogram?
1.
2.
3.

8.

Doctor or other health care provider suggested getting a
mammogram
I asked for a mammogram
Don’t remember
Other (Specify)
_

Yes
No; I went to a breast center where I did not need a doctor’s order.
Don’t remember

For your most recent mammogram, how much money did you or your family
have to pay? (Give your best estimate.)
$

Don’t remember

Part B: This part is about your feelings about breast cancer. There are no right
answers. Each woman’s experience is different. Circle the ONE answer that best
agrees with how you feel. If you are not sure about a question, circle Neutral.
1.

2.

3.

4.

It is extremely likely I
will get breast cancer in
the future.
Breast cancer can be
cured if caught early.

I feel I will get breast
cancer in the future.
Women with breast
cancer can still live a
normal life.

Strongly
Disagree
Strongly
Disagree
Strongly
Disagree

Strongly
Disagree

Disagree

Disagree

Disagree

Disagree

Neutral

Neutral

Neutral

Neutral

Agree

Strongly
Agree

Agree

Strongly
Agree

Agree

Strongly
Agree

Agree

Strongly
Agree

47

5.

6.

7.

8.

9.

10.

11.

12.

There is a strong
chance I will get breast
cancer in the next 10
years.

Strongly
Disagree

I want to control breast
cancer by finding lumps
early.

Strongly
Disagree

Disagree

Strongly
Disagree

Disagree

My chances of getting
breast cancer are high.

Whatever will be, will
be; if I am going to get
breast cancer, I will.
I am more likely than
the average woman to
get breast cancer.

Strongly
Disagree

Disagree

Disagree

Agree

Strongly
Agree

Neutral

Agree

Strongly
Agree

Neutral

Agree

Strongly
Agree

Agree

Strongly
Agree

Neutral

Neutral

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Breast cancer is a
hopeless disease.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I can control breast
cancer by finding lumps
early.

Strongly
Disagree

Agree

Strongly
Agree

My chances of
developing breast
cancer in the future are
high.

Strongly
Disagree

Agree

Strongly
Agree

Disagree

Disagree

Neutral

Neutral

PART C: This part is about beliefs and feelings vom have about getting mammograms. Again,
there are no right answers. Circle the ONE answer that best agrees with
views.
1.

Finding breast cancer
early is worth the cost
of a mammogram.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

48

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Getting a mammogram
would give me peace of
mind.
Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

People who are
important to me would
feel better if I got a
mammogram.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Having a mammogram
would expose me to a
lot of radiation.
Having a mammogram
would be painful.
Having a mammogram
would cost too much.

Having a mammogram
would be embarrassing.
Having a mammogram
would make me worry
about /iMzffng breast
cancer.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Having a mammogram
would take too much
time.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I have bad feelings
about having a
mammogram.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Having a mammogram
would be inconvenient
for me.

49
12.

There is a convenient
place for me to get a
mammogram.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Part D: This part is about information related to breast cancer and mammograms.
Circle the ONE answer that is most correct. Most people will not know all the
answers.
1.

On the average, how many women will get breast cancer sometime during their
lives?
1.
2.
3.

4.

2.

Who is more likely to get breast cancer?

1.
2.
3.

4.
3.

Women under 50 years of age
Women over 50 years of age
Age makes no difference
Not sure

Who is more likely to get breast cancer?
1.
2.
3.

4.
4.

1 woman out of 5
1 woman out of 9
1 woman out of 25
Not sure

Women whose mother and/or sister(s) have had breast cancer
Women whose mother and/or sister(s) have NOT had breast cancer
No difference
Not sure

At what age should most women get a first (baseline) mammogram, if they have
nonain or lumps, AND no family history of breast cancer?

1.
2.
3.

4.
5.
6.

Between ages 35 and 40
Between ages 40 and 45
Between ages 45 and 50
Age 50 years and over
Not at all
Not sure

50

5.

How often should most women between 40 and 49 get a mammogram, if they
lUmPS
f(lmilV
°fbreast cancer? Answer only
1.
2.
3.

4.
5.
6.
6.

How often should women 50 years of age or older get a mammogram? Answer
only if age 50 or older.
1.
2.
3.

4.
5.
6.

7.

Yearly
Every other year
Every 3-5 years
Once
Not at all
Not sure

Yearly
Every other year
Every 3-5 years
Once
Not at all
Not sure

How effective is a mammogram in finding breast cancer early?

1.
2.
3.

4.
5.

Very effective
Slightly effective
Not very effective
Not at all effective
Not sure

Part E: This group of questions is about your health care. Please circle the answer
that most closely describes your own situation.
1.

At the place you go for regular health care, do you have a person you regard as
your regular doctor or health care provider?

1.
2.

Yes
No

51

2.

What kind of doctor or health care provider is that regular person?
1.
2.
3.
4.
5.
6.

7.
3.

Has your regular doctor or health care provider ever suggested you have a
mammogram when you did NOT have pain or lumps?

1.
2.
3.

4.

3.

4.
5.

No health insurance
Blue Cross/Blue Shield (non-HMO)
Commercial (Prudential, Lincoln, etc., non-HMO)
HMO (Specify which one)
Other (Specify)
Not sure

Which of the following do you get?
1.
2.
3.
4.
5.

6.

Yes
No
Not sure

What kind of health insurance do you have/or yourself at the present time?
NOTE: If you are covered by both your own and your husband’s insurance, list
your husband’s insurance under “Other”.
0.
1.
2.

5.

Chiropractor
Family or General Practitioner
Internal Medicine/Intemist
Nurse Practitioner
OB/Gynecologist
Osteopath
Other (Specify)

Medicare
Medicaid
Both Medicare and Medicaid
Neither
Not sure

Has the cost of a mammogram ever kept you from getting
you had no breast pain or lumps?.
1.
2.
3.

Yes
No
Not sure

a mammogram yvhen

52

7.
answer this question as if it did not

1.
2.
3.

4.
5.
6.

’

Less than $25
$25 to $35
More than $35, less than $50
$50
More than $50
Other (Specify)
__

Part F: This part is about your own health and health history. Circle the ONE answer
that best describes your own experiences, OR fill in the blanks. There are no right
answers, as each woman’s experience is different.
1.

Have you ever been diagnosed with non-cancerous breast disease?

1.
2.
3.

2.

How many of your relatives have ever had breast cancer?

0.
1.
2.
3.

4.
5.
6.

3.

Yes
No
Don’t know

None
One
Two
Three
Four
Five
Other (Specify)
Not sure

7.
If you had a relative with breast cancer, was this/these relative® you- • fit*
all that apply.

1.
2.
3.

4.
5.
6.

Mother
Sister
Daughter
Grandmother
Aunt
Cousin

53
4.

How many of your close friends have ever had breast cancer?
0.
1.
2.
3.
4.
5.
6.

7.
5.

Self breast examination is when a woman checks her own breasts for lumps.
During the past year, did you examine your breasts for breast cancer?

1.
2.
6.

Yes

No

During the past year, how many times did you examine your breasts?
0.
1.
2.
3.
4.
5.

6.
7.
8.
9.

10.
11.

12.
13.

7.

None
One
Two
Three
Four
Five
Other (Specify)
Not sure

Did not examine
1 time during the past year
2 times during the past year
3 times during the past year
4 times during the past year
5 times during the past year
6 times during the past year
7 times during the past year
8 times during the past year
9 times during the past year
10 times during the past year
11 times during the past year
12 times during the past year
More than 12 times during the past year

Thinking about the last 5 years, how often did you go to the doctor for regular

checkups?
No visits or regular checkups
0.
1 time
1.
2 times
2.
3 times
3.
4.
5.
6.

7.

4 times
5 times

More than 5 times
Not sure

54

8.

In the next year, how likely are you to get a mammogram?
1.
2.
3.
4.

9.

Very likely
Somewhat likely
Not very likely
Not at all likely

If your regular doctor told you to get a mammogram, how certain are you that
you would get one?

1.
2.
3.

4.

Very certain
Somewhat certain
Not very certain
Not at all certain

Part G: This part is about the influence other people have on whether women get
mammograms.
NOTE: If you have no contact with any of the persons listed below, please do not
answer that question. For example, if you are unmarried or have no partner, you
would not circle anything for husband (partner).
The first questions are about how much certain people approve or disapprove ofyour
having a mammogram. Circle the ONE best answer for each person.

1.
2.

3.

4.

5.
6.

Husband
(Partner)

Strongly
Disapproves

Mother

Strongly
Disapproves

Children

Strongly
Disapproves

Doctor

Strongly
Disapproves

Nurse

Strongly
Disapproves

Close

Strongly
Disapproves

friends

Disapproves

Neutral

Approves

Strongly
Approves

Disapproves

Neutral

Approves

Strongly
Approves

Neutral

Approves

Strongly
Approves

Approves

Strongly
Approves

Neutral

Approves

Strongly
Approves

Neutral

Approves

Strongly
Approves

Disapproves
Disapproves
Disapproves
Disapproves

Neutral

55

The next questions are about how much influence (each of these persons has on your getting a
mammogram. Circle the ONE best answer for each person.
1.

Husband
(Partner)

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

2.

Mother

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

3.

Children

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

4.

Doctor

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

5.

Nurse

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

6.

Close friends

No
Influence

Some
Influence

Moderate
Influence

Strong
Influence

Part H: This part is about your beliefs about health care practices. Circle the ONE
answer that best agrees with your views.
1.

2.

3.

It is important to
discover health problems
early.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

Maintaining good health
is extremely important to
me.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

It is important to do
things that will improve
my health.

Strongly
Disagree

Agree

Strongly
Agree

Disagree

Neutral

56

Part I: The last part of the survey asks about you and your family. Please circle the
ONE best answer OR fill in the blank.
1.

How many people live in your household on a regular basis, including yourself/

1.
2.
3.

4.
5.
6.
2.

In what kind of neighborhood do you live?
1.

2.
3.

4.
5.
3.

One
Two
Three
Four
Five
Other (Specify)

Urban/City
Suburban
Country
Small Town
Other (Specify)

What is your work situation now?

1.
2.
3.

4.
5.
6.

Full time employed for pay
Part time employed for pay
Laid off
Full time homemaker
Retired
Other (Specify)

4.

What is your occupation?

5.

What is the highest level or grade in school that you completed?

Years
6.

Which of the following best describes your background?

1.
2.
3.

4.
5.

White
African-American
Hispanic/Latino
Asian
Other (Specify)

57

7.

What is your marital status?

1.
2.
3.
4.
5.
8.

In the past year, what was your total gross household income from all sources,
including pensions, social security, disability, interest, etc.
1.
2.
3.
4.
5.
6.
7.
8.
9.

9.

Married
Separated
Widowed
Divorced
Never Married

Less than $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $44,000
$45,000 - $54,000
$55,000 - $64,000
$65,000 - $74,000
Over $74,000
Not sure

What is your age?

THANK YOU
You are now finished. Thank you for filling out the survey.
Please use this space for comments you might have.

58
Appendix C

(nna M. Miller

r

6132 North Central Avenue
Indianapolis. Indiana 46220
(317) 255-4972

October 16, 1997
Diana J. Gienger
6412 Arborwood Lane
Erie, PA 16505

Dear Diana Gienger:

Enclosed find a copy of the survey tool used for my dissertation study, which formed the
basis for the Nursing Research article. Also enclosed are several xeroxed sheets that indicate
the coding for subscales of benefits, barriers, knowledge, etc. You have my permission to
use whatever portions are useful for your research, asking only that you acknowledge the
source.
I wish you well in looking at adherence to mammography guidelines in women who have a
family history of breast cancer, and both Dr. Champion and I would appreciate hearing the
results of your study. Please feel free to call me if you have questions after receiving these
materials.
My apologies for the delay -1 am working in Indianapolis and my Ball State University mail
is delayed in getting to me.

Sincerely,
Anna M. Miller, DNS, RN