Mammography and Health Promotion

in Women Ages 50 to 75

By
Deborah M. Piotrowski, BSN

Submitted in Partial Fulfillment of the Requirements

for the Master of Science in Nursing Degree

Approved By:

JiKfith Schilling, Ph.D., CRNP
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Committee Chairperson
Edinboro University of Pennsylvania

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Alice Conway, Ph.D., RN $
Committee Member
Edinboro/University of Pennsylvania
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J: j^deisel, Ph D., RN
Fmpittee Member
finboro University of Pennsylvania

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Abstract
Mammography and Health Promotion in Women Ages 50 to 75

Literature indicates that mammography is the single most effective method of
screening for breast cancer. Several patient-related barriers to mammography for older women
have been described (Costanza, 1994).

A survey of mature women was conducted in Chautauqua County, New York to

determine if women who engaged in moderate physical activity, such as walking 15 to 30 minutes
five to seven days per week also obtained yearly mammograms. The tool utilized was a

researcher-developed survey that assessed the frequency of mammography screening as
recommended by the American Cancer Society, and regular participation in moderate physical
activity. The sample consisted of 66 mature women between the ages of 50 and 75. Most
participants had a regular place for health care and most frequently went to a physician’s office for
their health care. All the study participants were covered by some type of health insurance.

Patient-related barriers to mammography screening reported by Weinberg et al. (1997) were not

perceived as barriers by these research participants. The results of this study indicated that
women who engaged in moderate physical activity were less likely to obtain yearly mammograms.

The hypothesis that mature women who engage in the health promoting behavior of regular
moderate exercise are more likely to obtain routine mammograms was rejected.

Table of Contents

Content

Page

Abstract

ii

List of Tables

vi

Chapter I. Introduction

1

Background of the Problem

1

Statement of the Problem

3

Theoretical Framework

3

Research Question

5

Assumptions

5

Definition of Terms

5

Limitations

6

Summary

6

8

Chapter II. Review of Literature

8

Mammography
Barriers to Mammography

12

Associated Health Promoting Behavior

13

Summary

16

18

Chapter III. Research Methodology

18

Hypothesis
iii

Content

Page

Operational Definitions

18

Research Design

19

Sample

19

Data Collection

19

Instrumentation

20

Data Analysis

20

Informed Consent

21

Summary

21

Chapter IV. Research Results

23

Description of Sample

23

Knowledge of Mammography

23

Participation in Physical Activity

24

Perceived Barriers to Mammography

27

Health Care and Health Insurance

28

Relationship Between Moderate Physical Activity
and Routine Mammograms

29

Research Subjects’ Comments

30

Summary ...

31

32

Chapter V. Discussion

iv

Content

Page

Discussion of Research Findings

32

Knowledge of Mammography

32

Participation in Physical Activity

32

Perceived Barriers to Mammography

33

Health Care and Health Insurance

33

Relationship Between Moderate Physical Activity
And Routine Mammograms

34

Conclusions

34

Recommendations

35

Summary

36

References,

37

Appendixes

41

A. Survey

41

B. Cover Letter

45

C. Script

46

D. Research Subjects’ Comments

47

v

List of Tables
Table

Page

1. Analysis of Mammogram

25

2. Reason for Most Recent Mammogram

25

3. Mammograms Over Last 5 Years

26

4. Suggested Most Recent Mammogram

26

5. Frequency of Physical Activity

27

6. Perceived Barriers to Mammography

28

7. Regular Place for Health Care

29

8. Type of Health Care Provider

30

9. Chi Square Analysis of Independent and Dependent Variable

31

vi

1
Chapter I

Introduction
Breast cancer accounts for one out of every three cancer diagnoses in

women in the United States (Parker, Tong, Bolden, & Wingo, 1997). In 1998,
approximately 180,300 new cases of invasive breast cancer are expected to be

diagnosed, and 43,900 women are expected to die from the disease. Only lung
cancer causes more cancer deaths in women (Landis, Murray, Bolden, & Wingo,

1998).
Background of the Problem

Mammography is the single most effective method of screening for breast
cancer since it can detect disease several years before physical symptoms are

apparent to a woman or her health care provider (Landis et al., 1998). The goal of

screening with mammography is to reduce mortality from breast cancer
(Kerlikowske, Grady, & Rubin, 1995). Healthy People 2000 (U.S. Public Health
Service, 1991) objectives called for annual mammography for women over age 50
to increase to 30% between 1990 and 1994, to 45% by 1998, and to 80% by the

year 2000. The vision offered for the new century by Healthy People 2000
focused on the need to significantly reduce preventable death and disability, to

enhance the quality of life by promoting health, and to reduce the disparities in the
health status of populations within our society.

2

Clinical breast examination and mammography, when combined, are the
most accurate methods for breast cancer screening (Mayer-Oakes, Atchison, &

Matthias, 1996). Mammography has been found to be less utilized as a screening
tool, particularly by older women (Fox, Siu, & Stein, 1994). A 1992 study

demonstrated significant increases in mammography screening rates among
women ages 65 to 74 (Coleman & Feuer). Even with these increases however,
only 17% to 38% of women in this age group reported that they had ever had a
mammogram. Women older than 70 have had especially low participation rates in

breast cancer screening programs (Mayer-Oakes et al., 1996).
Several patient-related barriers to mammography for older women have

been described (Costanza, 1994). Some of these barriers included

sociodemographic factors such as increased age, low income, low educational
levels, and minority status. Other reported barriers included no regular source of
health care, a lack of knowledge concerning the benefits of mammography, and

pain associated with mammography (Costanza).
The use of other health promoting behaviors such as regularly seeing a

dentist, obtaining appropriate immunizations, as well as undergoing other cancer
screening such as Pap smears, have been associated with mammography use in
both younger and older women (Hobbs, Smith, & George, 1980). Moderate
physical activity decreased the risk of cardiovascular disease mortality, and was

3

associated with a decreased risk of colon cancer. The most popular leisure-time

physical activities among adults were walking and gardening (U.S. Health
Department of Health and Human Services, 1996).

Statement of the Problem

Research has demonstrated that preventive health behaviors can promote
health and decrease mortality (Murphy, 1996). Age was most strongly associated

with breast cancer in women. Data from the Surveillance, Epidemiology, and End

Results program of the National Cancer Institute showed that the age-adjusted
incidence rate for invasive breast cancer among women age 50 and over in 1994
was 352 per 100,000 compared to 31.1 per 100,000 in women under 50 years of
age (Ries, Kosary, Hankey, & Miller 1997). Older women increased their rate of

initial mammography screening to 35% in 1990 compared to 17.25% in 1987,

however their use of mammography remains below that of middle-aged women

(Breen & Kessler, 1994).

Theoretical Framework
The Dorothea Orem Self-Care Deficit Theory was the theoretical
framework for this research study (Orem, 1995). Orem s general theory of nursing

comprises three interrelated theories: theory of self-care, theory of self-care deficit,
and theory of nursing systems.
Orem (1995) defined self-care as the practice of activities that individuals

4

initiate and perform on their own behalf in maintaining life, health, and
well-being. Orem referred to self-care as deliberate action. These health

promotional behaviors are learned with a goal and purpose in mind. A woman

obtains routine mammograms knowing she can detect breast cancer at an earlier

stage. To perform a self-care action, one must first have knowledge of the action
and how it relates to continued life, health, or well-being.

Orem (1995) described self-care agency as the power of individuals to
engage in self-care. Self-care agency is an acquired ability that is effected by

conditions and factors in the environment. A woman who has few educational
opportunities may have less ability to seek information about health care than one

who has many educational opportunities.
Nursing agency is a complex property or attribute of persons educated and

trained as nurses for helping others meet therapeutic self-care demands (Orem,
1995). Orem (1995) described nursing agency as activated or unactivated.
Activated agency produces diagnoses, prescriptions, and regulation of self-care for
persons with self-care deficits associated with their health state. When nursing

agency is activated, a nursing system is produced. There are three types of nursing
systems: wholly compensatory, partly compensatory, and supportive-educative

(Orem, 1995). When a patient provides all self-care, and the nurse performs
supportive and educative action, the system is supportive-educative.

5
The role of the nurse practitioner can be viewed within the context of

Orem s theory. By identifying how women perceive health promotion,
educational-supportive roles can be directed. Educating and supporting women
about breast cancer and breast cancer screening are components of the supportive-

educative nursing system.

Research Question
The following research question was addressed in this study:

Is there a relationship between frequency of mammography screening and
the health promoting behavior of moderate physical activity, in women ages

50 to 75?

Assumptions
The assumptions for this study were that:

1. Study participants answered survey questions honestly.

2. Not all women routinely participated in mammography screening.
3. Participants could read and understand the study survey.

Limitations

This study had several limitations:
1. A nonrandom sample population from a senior citizen site and

women’s church group was used. This small convenience sample affected the

validity and generalizability of the study s findings.

6

2. The reliability of the researcher-written survey was not established.
3. The health promoting behaviors the researcher evaluated were limited to

mammography and physical activity.

Definition of Terms
The terms used in this study were defined as follows:
1. Health promoting behaviors are behaviors that a person might engage in

to promote personal health or well-being (Mayer-Oakes et al., 1996).

2. Mammography is a low-dose radiography of the breast tissue (McCool,
1994).

3. Moderate physical activity is 15 to 30 minutes of brisk walking or raking
leaves, swimming laps for 20 minutes, mowing the lawn for 30 minutes, or
running for 15 minutes 5 to 7 days per week (U.S.Department of Health and
Human Services, 1996).
4. Primary care is the provision of integrated, accessible health care

services by clinicians who are accountable for addressing a large majority of
personal health care needs, developing a sustained partnership with patients, and

practicing in the context of family and community (Murphy, 1996).
Summary
Breast cancer can be detected at an early stage with the use of

mammography. As women age, their incidence of breast cancer increases.

7
Regular mammography is important to decreasing mortality and morbidity. This
study compared the use of mammography and participation in moderate physical

activity, by a group of women ages 50 to 75. Study assumptions, definitions, and

limitations were identified.
The Orem Self-Care Deficit Theory (1995) can help guide nurse
practitioners through support and education of their patients for participation in

health promoting behaviors. Nurse practitioners can educate their patients about
the importance of breast cancer screening on a one-to-one basis in their offices,

and through public education. By increasing mammography use and health
promoting behaviors among women ages 50 to 75, nurse practitioners can help
decrease mortality and morbidity in this population.

8
Chapter II

Review of Literature
This review of literature identifies studies relating to mammography,
barriers to mammography, breast cancer incidence, and health promotion
behaviors. The health promotion behaviors studied are mammography and

physical activity.
Mammography

Breast cancer is the second most common cancer in women, excluding skin
cancer, and accounts for one out of every three cancer diagnoses among women in
the United States (Parker et al., 1997). US breast cancer incidence increased at an

annual rate of about 1% from the 1940s to 1980 (Feuer, Wun, & Boring, 1993). It
increased at a noticeably higher rate of 4% per year for the period from 1982 to

1987. This increase followed the publication of the American Cancer Society’s
breast cancer detection guidelines in 1980 and the initiation of a Breast Cancer

Awareness Campaign (Miller, Ries, & Hankey, 1992). Between 1980 and 1987, a
32% increase in breast cancer incidence was associated with identification of
early-stage disease due to increased numbers of women undergoing

mammography for the first time (White, Lee, & Kristal, 1990). The percentage of
women older than age 40 who had had at least one mammogram rose from 38/o in
1987 to 69% in 1990, and the percentage of women who had had a mammogram

9

in the previous year rose from 17% to 33% over the same period (Ries et al.,

1991). The breast cancer mortality rate was fairly constant, increasing about 1.5%
from 1973 to 1990 (Hoeksema & Law, 1996). Hoeksema and Law reported that

there was a reduction in breast cancer mortality of 5.3% for the years from 1991 to
1995.

A study done by Swanson et al. (1993) compared breast cancer among
black and white women from 1983 to 1989. They found that in 1983 white

women’s rate of ductal carcinoma-in-situ of the breast was 3 per 1,000 and in
1989 was 9.4 per 1,000 compared to black women who had a rate of 3.2 per 1,000
in 1983 and 8.1 per 1,000 in 1989. The rate of invasive breast cancers smaller

than 1.0 cm, and without axillary lymph node involvement at diagnosis, was 8.0
per 1,000 in 1983 and 24.0 per 1,000 in 1989 for all women ages 50 to 59.

Swanson et al. (1993) concluded in their analysis that the dramatic increases in

breast cancer diagnoses resulted primarily from an increasing prevalence of
screening for breast cancer.

Breen and Kessler (1994) examined mammography rates reported by

women in the National Health Interview Surveys of 1990 and 1987. They found
that education remained a strong positive predictor of breast cancer screening.

They compared educational attainment for women more than 40 years of age who

reported a screening mammogram in the last year. Of the women reporting a

10
screening mammogram during the pastyear, 71.8% of white women ages 50 to 75

had at least a high school education compared to 44.4% of black women. Among
all women ages 40 and over who reported a screening mammogram in the last
year, 23% had less than a high school education and 41% had more than a high

school education.

Between 1979 and 1981, 45,140 women in Edinburgh, Scotland aged 45 to
64 were entered into a randomized trial of breast cancer screening by
mammography and clinical examination (Roberts, Alexander, Anderson, Chetty, &
Donnan, 1990). All women aged 45 to 64 in 84 general practices in the city were

registered. One-half of the women were invited for screening (study population);

the other one-half formed the control population. The study’s main objective was
to assess the value of screening for breast cancer by mammography and clinical

examination in reducing mortality from breast cancer. The cancer detection rate
was highest at the initial patient visit with mammography detecting 96% of the

cases. In some cases, a palpable lump was found at assessment only after review
of mammographic findings. In this study, only 3% of cancers were discovered

solely because of clinical examination. At each subsequent patient examination
involving mammography, the cancer detection rate was around 3 per 1,000 wome

screened compared to 6.2 per 1,000 at the initial screening (Roberts et al., 1990).
In intervening years, when clinical examination alone was done, the can

11

detection rate fell to about 1 per 1,000. More cancers were detected by
mammography; of those that were, 25% required localization at biopsy because

they were nonpalpable. The cumulative incidence of breast cancer among
screened women remained higher at 31% compared to the control group at 25%
Total breast cancer mortality, however, was higher in the unscreened control

group. Overall there were 1,274 deaths (80.7 per 10,000) in the study population,
compared to 1,490 (100.8 per 10,000) in the control population.

The Breast Cancer Detection Demonstration Project (BCDDP) was
inspired by early reports of favorable results from the Health Insurance Program of

Greater New York study (Smart, Byrne, Smith, Garfmkel, & Letton, 1997). The

BCDDP was designed as a demonstration project to introduce breast cancer
screening into the United States for the purpose of reducing breast cancer

mortality. The BCDDP was not designed as a trial to evaluate the impact of

mammographic screening on survival or mortality, therefore there was no

comparison group. The BCDDP enrolled 283,222 volunteer women ages 35 to 74
at 29 centers across the United States. This project provided 5 years of screenino

with physical examination and two-view mammography for the 283,222 study
participants. Approximately 35,513 women were ages 35 to 39, 93,471 wo

were ages 40 to 49 years, S3,514 were ages 50 to 59, 39,471 were ages 60 to 69,
and 31,253 were ages 70 to 74. Smart et al. (1997) reported on the women

12

diagnosed with breast cancer in the BCDDP between 1973 and 1980. The study
was based on a 96% follow-up from 1993 to 1995 of 4,051 women who were
initially diagnosed with breast cancer. Of this cohort of 4,051 women, 66% were
still alive and 34% had died by 1995. Breast cancer deaths accounted for 54% of

all the deaths. The proportion of the cancers detected by mammography alone was

90.2/o , and 28.6/o of all the cancers were smaller than 1.0 cm. Survival patterns
were similar across age groups. Among women who died of breast cancer by
1995, the mean time from diagnosis to death was 6.7 years; the time ranged from

6.0 to 6.6 years in women aged 54 years and younger compared with 6.6 to 7.1
years in women older than 54 years.
Barriers to Mammography

The literature points out several patient-related barriers to mammography .
A study done by Fox et al. (1994) included a sample of 977 women older than 50
years. Two hundred fifty-three women were between the ages of 50 and 64 and
724 were older than 64 years. The majority of the women were high school

graduates. Almost one-third of the women older than 64 years had household
incomes under $15,000. The majority of the women were white in all age groups,

Four variables were identified in explaining mammography utilization patterns.
These were physician-patient communication patterns, race, age of the w

and health status of the women. Physician-patient communication was the most

13
common factor predictive of mammography use. Of women requesting a referral

for mammography, 18% were aged 50 to 64, 16% were age 65 to 69, and 11%
were age 70 to 74. Participants who reported that their physician suggested
mammography were 73% age 50 to 64, 71% age 65 to 69, and 69 % age 70 to 74.

There were also racial differences in the physicians’ discussions of screening for
breast cancer, particularly in the 50 to 64 year age group. Early detection was
discussed with 75% of whites versus 53% of nonwhites. Women in the 65 to 69

year old age group reported the highest frequency of mammography utilization at
57%, with utilization declining with age. Among women 70 to 74 years old, 15%

report having never been screened. Few screened women reported poor health. Of

women aged 65 to 74 years old who were in fair or better health, 76% reported
biennial screening. Other patient-related barriers to screening have been identified

as pain, procrastination, cost, lack of insurance, poor accessibility, embarrassment,
concerns about radiation, fear of being diagnosed with breast cancer, and lack of a

regular clinician (Weinberg, Cooper, & Lane 1997).
Associated Health Promoting Behaviors
Regular physical activity has long been regarded as an important

component of a healthy lifestyle (Pate, Pratt, & Blair, 1995). Physical activity

recommendations in Healthy People200Q are to increase to at least 30 % the
proportion of people aged 6 and older who engaged regularly in light to moderate

14

physical activity for at least 30 minutes per day. However, only about 22% of
adults are usually active at this recommended level, 54% are only occasionally
active at this level, and 24% or more are completely sedentary (U.S. Public Health

Service, 1991).
A research meta-analysis was released in 1996 by the U.S. Public Health

Service (U.S. Department of Health and Human Services, 1996). The major
purpose of the report was to summarize the existing literature concerning the role
of physical activity in preventing disease. This report concentrated on endurance­
type physical activity involving repeated use of large muscles, such as walking or

bicycling. The health benefits of this type of activity have been studied
extensively. This compilation of studies concluded that regular physical activity
reduced the risk for developing or dying from coronary heart disease, type 2

diabetes mellitus, hypertension, and colon cancer. Physical activity also reduced

symptoms of anxiety and depression; contributed to the development and
maintenance of healthier bones, muscles, and joints; and helped to control weight.
Physical activity may also help older adults maintain the ability to live
independently, and prevent falling and fractures.

Overall, this meta-analysis demonstrated that health benefits occurred at a
moderate level of activity. Second, although physical activity did not need to be

vigorous to provide health benefits, the degree

of health benefit was directly

15
related to the amount of regular physical activity. A moderate amount of physical
activity can be achieved in many ways and must be sustained throughout life in

order to produce benefits. Persons who are unable or unwilling to adhere to a
structured exercise program can incorporate physical activity appropriate to their

personal preferences and life circumstances into their daily lives. Examples of
moderate activity include raking leaves for 30 minutes, a 30 minute brisk walk,
swimming laps for 20 minutes, mowing the lawn for 30 minutes, or running for 15

minutes. Those who currently achieve moderate amounts of physical activity on a
regular basis can obtain further benefits by increasing the duration, intensity, or
frequency of activity (U.S. Department of Health and Human Services, 1996).
Sherman, D’Agostino, Cobb, & Kannel (1994) studied 285 men and

women aged 75 years or older who were free of cardiovascular disease. Subjects

were ranked by baseline physical activity levels and grouped into quartiles. After

adjustments were made for cardiac risk factors, chronic obstructive pulmonary

disease, and cancer, women in the most sedentary group had a relative risk of
death that was four times that of the second most active group. The mortality and

cardiovascular disease rates at 10 years for women in the third most active quartile

were 237 per 1,000 compared to 745 per 1,000 in the least active quartile. There
appeared to be an excess of sudden cardiac death in women in the most active
quartile with 13 deaths, compared to the second most active quartile with 5 deaths,

16

and the least active women with 5 deaths. The death rate in the second quartile
was one-third that of the least active group. However, on the average, women in
the most active quartile still lived longer than those in the least active quartile. The

researchers concluded that women aged 75 years or older who participated in
moderate physical activity live longer.

Thune, Brenn, Lund, & Gaard (1997) found that physical activity during

leisure time and at work was associated with a reduced risk of breast cancer. They
studied a population of 31, 209 women in three counties in Norway. Physical

activity during leisure hours was graded from 1 to 4. Grade 1 was assigned to
those who engaged in sedentary activities; grade 2 to those who spent at least 4

hours a week walking, bicycling, or engaging in other types of physical activity;
grade 3 to those who spent at least 4 hours a week exercising to keep fit and
participating in recreational athletics; and a grade 4 to those who engaged in
regular, vigorous training or participating in competitive sports several times a

week. Women who exercised at least 4 hours a week during leisure time had a

37% reduction in the risk of breast cancer. A reduction in the cumulative
exposure to estrogens may in part explain the preventive effect of leisure time

activity.
Summary
This literature review has focused on the mortality and morbidity of breast

17

cancer as well as the benefits of mammography. Patient-related behaviors that
prevent women from obtaining mammograms were discussed.

Healthy People 2000 goals were identified in relation to mammography and

physical activity (U.S. Public Health Service, 1991). The relationship between
routine mammography and regular physical activity, and mortality and morbidity,
was reviewed.

Nurse practitioners are in a key position to discuss with the older
population that moderate physical activity leads to health benefit and help their

clients become physically active (Burns, 1996). The nurse practitioner can review

daily activities and estimate how much total time is spent in at least moderate
physical activity.

18

Chapter HI
Research Methodology

This descriptive study was designed to gather baseline data to determine if
women ages 50 to 75 who participate in the health promotion activity of moderate

physical activity were more likely to obtain routine mammograms than other
women of this age group. The researcher did not manipulate the variables in any
way.

Hypothesis

Mature women who engage in health promoting behavior such as moderate
physical activity are more likely to obtain routine mammograms than other mature
women.

Operational Definitions

The following operational definitions were designed by the researcher and

determined the criteria for inclusion in this study:
1. Moderate physical activity is brisk walking, jogging, raking leaves, lawn
imming for 15 to 30 minutes, 5 to 7 days per week (U.S.
mowing, bicycling, swimmi:

Department of Health and Human Services, 1996).

2. Routine mammography is mammography performed annually for
women beginning age 50.
3. Mature women are women ages 50 to 75 years old.

19

Research Design
A non-experimental survey design was utilized for this descriptive research

study. Frequency data was collected and analyzed. This descriptive study was
devised to determine if mature women who engage in moderate physical activity

are more likely to obtain routine mammograms than other mature women.

Sample

A convenience sample of 66 women located in Chautauqua County, New
York was utilized for this descriptive study. The sample was obtained by mailing

surveys to women ages 50 to 75 who were members of a senior citizen group in

Jamestown, New York. A list of women ages 50 to 75 who were members of this
senior citizen group was obtained from the director of the group. The researcher

also surveyed a church group of mature women in Lakewood, NY. The researcher
distributed the surveys at a meeting of the church group in mid-February, 1998.

Data Collection

There were 100 surveys mailed out the second week of February, 1998 to

members of a senior citizen group in Chautauqua County, New York. A self
addressed stamped envelope was included and the surveys were mailed back to the
senior citizen office by the participants. The surveys were then given to the

researcher. Sixty surveys were returned, three of which were considered invalid
f°r analysis because one or more parts of the surveys were not comp

20

researcher attended a church group meeting and distributed the surveys to a group

of seventeen women. They were then completed and returned to a box supplied by
the researcher. Nine surveys were considered valid for analysis. The final study

sample consisted of 66 participants.
Instrumentation

The research survey (Appendix A) was made up of four parts. Part A

consisted of seven questions pertaining to past mammograms and physical activity.
It was used to identify when participants had obtained mammograms and how

often they engaged in physical activity. Part B consisted of eight Likert-type
questions about feelings. These identified whether or not barriers to

mammography identified in the literature applied to this study group. Part C was
five questions concerning the type of health care and health insurance the

participants had. Part D contained four demographics questions.
The survey was pilot tested by five mature women on a hospital auxiliary in

Chautauqua County. The survey took approximately 10 minutes to complete. The

pilot demonstrated the survey to be understandable and analyzable. Questions that
were not clear to the participants were modified.
PatgAialysis

The data analysis was as follows:
1. Total percentages from all the

respondents for (a) participation in

21

physical activity, and (b) participation in mammography were calculated.
2. Comparison was made between frequency of mammography screening

and the health promoting behavior of moderate physical activity in the survey
participants.
3. Data were reported as aggregate data.

4. Data analysis included descriptive statistics and Chi Square analysis.
5. In part B of the research survey, the answers to questions 2,4, and 6

were reversed when entered as data to correspond to whether mammography was

perceived as a barrier.
Informed Consent

Informed consent was assured with the use of a cover letter accompanying

each questionnaire (Appendix B). The cover letter introduced the researcher and
identified the purpose of this study. It informed participants that information
obtained by the survey was anonymous and confidential. Names were not required

on the survey. Participation was voluntary and consent was assumed with the
return of the completed survey. Data was reported as aggregate data. The study

results were made available to the participant groups.

Lumm,
This descriptive study sought to determine if mature women wh

in moderate physical activity are more likely to obtain mammograms than

gg

22
mature women. These female study participants ranged in age from 50 to 75 and
resided in Chautauqua County, New York.
Data was collected by a mailed survey, and by surveying women attending

a church group. Informed consent was inferred by the participants completing the

surveys and mailing them back or returning them to the researcher.
The data collected from this descriptive study identified the percentage of

mature women who engaged in moderate physical activity and those who also
participated in mammography. It also compared the number of mature women
who participated in moderate physical activity and obtained routine mammograms

with those mature women who did not.

23

Chapter IV

Research Results
This nonexperimental study was conducted in Chautauqua County with a
convenience sample of 66 mature women. A four-part survey was distributed to

women who were members of a senior citizen group, and a women’s church group in
Chautauqua County, NewYork. Data collection took place during 3 weeks in the

spring of 1998.
This chapter presents the results for this study. Sociodemographic

characteristics of the participants are presented followed by presentation of findings
and analysis of the independent and dependent variable.

Description of Sample
Four questions on the survey described the sample. All the research

participants were between the ages 50 to 75 and resided in Chautauqua County, NY.

There were 4 (6.06%) participants who had completed an eighth grade education
while 26 (39.39%) had finished high school. There were 18 who had some college
education (27.27%) and 18 (27.27%) who completed college. Almost all the women,

65 (98.48%) were white, and 1 (1.52%) was a native American.
Knowledge of Mammography

Mammograms and physical activity were assessed in Part A of the

questionnaire. The majority of the women, 65 (98.48%) had heard of a mammogram,

24

and 1 (1.52%) had never heard of a mammogram (Table 1). Sixty-four (96.97%) of
the women had had a mammogram while 2 (3.03%) had never had a mammogram.

The average number of months since the last mammogram was 18.8 months. For the
majority of participants, (55%) their most recent mammogram was done as part of a
regular check-up (Table 2). A physician most frequently suggested the most recent
mammogram (46 or 69.70%) while 16 (24.24%) participants had requested their most
recent mammogram (Table 3). Most participants had had a mammogram either 2
years ago or 1 year ago (Table 4).

Table 1
Analysis of Mammogram
n

Had heard of a mammogram

%

65

95.48%

1

1.52%

Had ever had a mammogram

64

96.97%

Had never had a mammogram

2

3.03%

Had never heard of a mammogram

n= 66 surveys returned
Participation in Physical Activity
Question number 7 of part A assessed how often the participants engaged in

moderate physical activity such as: brisk walking, jogging, raking leaves, lawn

25

Table 2

Reason for Most Recent Mammogram

Reason

n

%

Current Breast Problem

1

1.52%

Previous Breast Problem

6

9.09%

55

83.33%

2

3.03%

Part of a Regular Check Up

Don’t Remember
n=66 surveys were returned

Table 3

Who Suggested Most Recent Mammogram
n

%

Physician

46

69.70%

Patient requested

18

27.27%

n=66 surveys returned

mowing, bicycling, and swimming (Table 5). There were 24 (36.40/o) who
participated in physical activity either once a week or less than once a week. There

were 28 (42.42%) women who engaged in physical activity three to five times per

26

Table 4
Mammograms Over Last 5 Years

Year

n

%

This year

17

25.76%

One year ago

33

50.00%

Two years ago

37

56.06%

Three years ago

25

37.88%

Four years ago

25

37.88%

Five years ago

20

30.30%

3

4.55%

None in last five years

n= 66 surveys returned

week, while only 8 (12.12%) participated the recommended five to seven times per
week.
Perceived Barriers to Mammography
Part B of the survey contained eight questions concerning beliefs and feelings
about mammograms. The Likert scale was utilized with possible scores ranging from

one to five. A score of three was neutral. A score of four or five indicated that there
were no perceived barriers to obtaining mammograms, and a score of one or two

T1

Table 5

Frequency of Physical Activity

Frequency

n

Less than once a week

13

19.70%

Once a week

11

16.67%

3 to 5 times per week

28

42.42%

5 to 7 times per week

8

12.12%

Never

6

9.09%

%

n=66 surveys returned

indicated a perceived barrier to mammography. The average was calculated for each
question (Table 6). According to these data, mammograms were perceived as
expensive. For some women this may be a barrier to obtaining routine mammograms.
Answers to the remainder of the questions indicated there were no other perceived

barriers to mammography.
Health Care and Health Insurance

Part C of the survey questionnaire contained data about participants health

care and health insurance. In response to question 1 in this part, most participants (62
or 93.94%) had a regular place to go for health care, and 4 (6%) did not have a

28

Table 6

Perceived Barriers to Mammography

Barrier

Average Score

Finding breast cancer early is worth cost

4.62

Would expose me to a lot of radiation

3.86

Is inexpensive

2.97

Would be painful

3.61

Would not embarrass me

3.95

Would be inconvenient

4.09

Would relieve worries about breast cancer

4.03

There is a convenient place to get a mammogram

4.33

Note, (1) strongly disagree (2) disagree (3) neutral (4) agree (5) strongly agree
regular place. Their regular place for health care was most often a physician’s office

(Table 7). Almost one-half of patients, 32 (48.48%), had a family practice physician
as their regular health care provider (Table 8). There were 43 (65.15%) who had

Medicare for their insurance, 10 (15.15%) who had an HMO, and 13 (19.70%) who
had private insurance.

Relationship Between Moderate Physical Activity and Routine Mammogram

The research hypothesis stated that mature women who engage the health

29

Table 7

Regular Place for Health Care

Place
Doctor’s office

n

%

57

86.36%

Hospital emergency room

1

1.52%

Hospital outpatient clinic

5

7.58%

No regular place

3

4.5%

n= 66 surveys returned
promoting behavior of moderate physical activity are more likely to obtain routine

mammograms than are other mature women. There were a total of three (5%)

respondents who engaged in moderate physical activity and also obtained routine
mammograms. There were 5 (8%) women who engaged in moderate physical activity
but did not obtain routine mammograms. Chi square analysis conducted for

comparison of these two groups revealed a significant difference between the two
groups for this sample, X (4,n=66)= 18.16, p<6.63. The hypothesis was not

supported. It appeared evident that these women who engaged moderate physical
activity were less likely to obtain routine mammograms. The majority of the survey

participants, 45 (68%) did not obtain routine mammograms or engage in moderate
physical activity (Table 9).

30

Table 8

Type of Health Care Provider

Type of Provider

n

Chiropractor

0

0.00%

Family practice physician

32

48.48%

Internal medicine physician

21

31.82%

Nurse practitioner

2

3.03%

OB/gynecologist

4

6.06%

Osteopath

2

3.03%

Not sure

1

1.52%

%

n= 66 surveys returned

Additional Comments

The final survey question invited comments from the research participants.
There were nine respondents who had included comments. Of their comments, three
of them thought mammograms were expensive. Four of the participants felt

mammograms were important in helping to detect breast cancer. One participant felt
there was a lack of follow up by doctors for negative results and one stated that
mammograms can be painful. All participant comments are contained in Appendix D.

31

Table 9
Chi Square Analysis of Independent and Dependent Variable

Routine
mammogram
Moderate physical

3 (5%)

No routine
mammogram

5 (8%)

Total

8 (13%)

activity participation

No moderate

13 (20%)

45 (68%)

58 (88%)

physical activity

X (4,n=66)=18.16, g<6.63

Summary
This chapter presented the results from the survey of mammography and
health promotion. These results were interpreted through descriptive statistics and
the percentage of each response was provided. Analysis of responses and additional

comments was also provided. The hypothesis that mature women who engage in

health promoting behavior such as moderate physical activity are more likely to obtain
routine mammograms than other mature women was rejected.

32
Chapter V
Discussion
This chapter provides a discussion of results from the survey of 66 mature

women in Chautauqua County, New York. These results were utilized to determine
if mature women who were engaging in moderate physical activity were also

obtaining routine mammograms. Conclusions and recommendations are also
provided.

Discussion of Research Findings

This section provides a discussion of the findings from this research project.
These findings were compared with studies identified in the literature review.

Knowledge of Mammography. Routine mammograms are recommended
annually for women over age 50 by the American Cancer Society. Breen and Kessler

(1994) identified that women who were white and had a high school education were
more likely to report a screening mammogram in the last year. In this study, the
sample of women was 98.48% white. The researcher found that among the women
with a high school education, (26 or 39.39%) there were 15 (57.70%) who obtained a
mammogram this year or one year ago. Among the women who had some college or

were college graduates (36 or 54.54%), there were 25 (69.40%) who had obtained a

mammogram this year or one year ago. In this study, educational achievement was
not a major predictor of mammogram use.
Participation in Physical Activity. The meta-analysis released in 1996 by the

U.S. Department of Health and Human Services demonstrated that health benefits

33
occurred at a moderate level of physical activity (U.S. Department of Health and
Human Services, 1996). Almost one-half of the participants, (30 or 45.45%), engaged

in physical activity once a week, less than once a week, or never. There were 28
(42.42%) women who engaged in physical activity three to five times per week with

only 8 (12.12%) achieving the recommended five to seven times per week (Table 5).

The stringent criteria of moderate physical activity in this study may have led to the
small number of women participating at this level of physical activity.
Perceived Barriers to Mammography. Patient-related barriers to

mammography screening reported by Weinberg et al. (1997) included pain, cost, lack

of insurance, embarrassment, concerns about radiation, fear of being diagnosed with
breast cancer, and lack of a regular clinician. These survey respondents felt that
mammograms were not inexpensive, but that finding breast cancer early was worth
the cost. They responded that there was a convenient place to get a mammogram and

did not feel that mammograms exposed them to a lot of radiation. The participants
did not feel having a mammogram would embarrass them or that it was painful
(Table 6).

Health Care and Health Insurance. Most participants, 62 (93.94%), had a
regular place to go for health care. Most women, 57 (86.36%), went to a physician’s

office for their health care. Their health care provider most often, (32 or 48.48%),
was a family practice physician. All the participants were covered by some type of

health insurance. The majority (43 or 65.15%) were covered by Medicare insurance.
The remainder, 23 (34.85%) were covered either by private insurance or an HMO.

34

Relationship Between Moderate Physical Activity and Routine Mammograms.
Chi Square analysis was conducted in order to compare women who engaged in
moderate physical activity and obtained routine mammograms, with those women

who engaged in moderate physical activity and did not obtain routine mammograms.

Analysis revealed this information as statistically significant at X (4,n=66)=18.16,
p<6.63. The hypothesis is not supported. Data analysis showed that women who
engage in moderate physical activity are less likely to obtain routine mammograms.

It can be speculated that the stringent criteria for moderate physical activity is
difficult to achieve for most mature women. If the criteria for moderate physical
activity also included those women who engage in physical activity three to five times

per week the number of participants would have been larger.

Conclusions
The research hypothesis stated that mature women who engage in health
promoting behavior such as moderate physical activity are more likely to obtain

routine mammograms than other mature women. Data analysis revealed that women

who engaged in moderate physical activity are less likely to obtain routine
mammograms. The hypothesis for this study was not supported.
This researcher found that women who had at least a high school education
were more likely to obtain a screening mammogram this year or one year ago. Those

women who had some college or a college education were even more likely to obtain
a mammogram this year or one year ago.

There were only 8 (12.12%) research participants who participated in

35
moderate physical activity, the recommended five to seven times per week. The

researcher found that most of the women in the sample, 58 (87.90%), did not

participate in moderate physical activity.
Patient-related barriers to mammography screening reported by Weinberg et
al. (1997) did not appear to be perceived as barriers by the research participants,
except cost. Most participants felt a mammogram was worth the cost, and they were

not concerned about exposure to a lot of radiation. They also felt there was a
convenient place to obtain a mammogram and that it would not embarrass them or be
painful.

The majority, 62 (93.94%), of the participants had a regular place to go for
health care and 57 (86.36%) went to a physician’s office for health care. Weinberg et

al. (1997) reported that their participants reported that their physician most often

suggsted mammography. In this research study, only 46 (69.70%) of the participants’
physician suggested their most recent mammogram. All the study participants were

covered by some type of insurance with the majority of the women 43 (65.15%)
covered by Medicare.

Recommendations
This study found that mature women who engage in moderate physical

activity do not obtain routine mammograms. Further information is required to
determine what reasons there are for women not participating in mammography

screening. Some recommendations to gain that information are.
1. Repeat this study with a larger sample size.

36

2. Repeat this study with a more diverse research sample.

3. Study primary care providers regarding their perceptions of guidelines for routine

mammography.
If the first two recommended studies would confirm the lack of breast cancer
screening with mammography among mature women, then the third study could be

performed to determine if knowledge deficit by primary care providers is one of the

causes. If, in fact, knowledge deficit were a cause, education of primary care
providers, as well as public education and education in the primary care providers’
offices, would be indicated.

According to Dorothea Orem (1995), the primary care provider should assist

women by educating and supporting them about breast cancer and breast cancer
screening. The primary care provider, by identifying how women perceive health

promotion, can direct educational-supportive roles.

Summary
This chapter provided a summary of this research project. Data indicated that
women who engaged in moderate physical activity do not obtain routine

mammograms. Discussion of implications of these findings and recommendations for
further studies were provided.

37

References
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mammography. Evidence from the 1987 and 1990 national interview surveys.

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Coleman, E. A., & Feuer, E. J. (1992). Breast cancer screening among women
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961-966.

Costanza, M. E. (1994). The extent of breast cancer screening in older women.
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Feuer, E. J., Wun, L. M., & Boring, C. C. (1993). The lifetime risk of
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Fox, S. A., Siu, A. L., & Stein, J. A. (1994). The importance of physician
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Hobbs, P., Smith, A., & George, W. D. (1980). Acceptors and rejecters of an
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Hoeksema, M. J., & Law, C. (1996). Cancer mortality rates fall: A turning point
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Kerlikowske, K„ Grady, D„ & Rubin, S. (1995). Efficacy of screening

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Preventive Medicine, 12(1). 44-50.
Me Cool, W. (1994). Barriers to breast screening in older women. Journal of

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Murphy, P. (1996). Primary care for women, health assessment, health

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41

Appendix A
Mammography Survey
PLEASE DO NOT PUT YOUR NAME ON THIS

Part A: This part is about mammograms you have had in the past and about
physical activity. 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 taking a picture. Have you ever heard of a mammogram?
a. Yes
b. No
c. Not sure
2. Have you ever had a mammogram?
a. Yes
b. No

c. Not sure

3. About when was your most recent mammogram?
I ______
Month
Year

4. Was your most recent mammogram done because of a problem or as part of a
regular check-up?
a. Current breast problem
b. Previous breast problem
c. Part of a regular check-up
d. Don’t remember
e. Other (Specify)
5. Thinking about the last 5 years, when did you have a mammogram? (Circle all
that apply.)
a. this year
e. 4 years ago
f. 5 years ago
b. 1 year ago
g. None in last 5 years
c. 2 years ago
h. not sure
d. 3 years ago

6. Who first suggested you get your most recent mammogram?
a. Doctor or other health care provider
b. I asked for a mammogram
c. Don’t remember
d. Other (Specify)
_

42

7. How often do you engage in moderate physical activity (for example, brisk
walkingjogging, raking leaves, lawn mowing, bicycling, swimming) for 15 to 30
minutes:
a. Less than once a week
c. 3 to 5 times a week e. Never
b. Once a week
d. 5 to 7 times a week

Part B: Please complete, even if you have never had a mammogram. This part
is about beliefs and feelings you have about getting mammograms. There are no
right answers. Circle the one answer that best agrees with your views.
Strongly
disagree
(1)

Disagree
(2)

Neutral

Agree

(3)

(4)

Strongly
agree
(5)

1. Finding breast cancer early is worth the cost of a mammogram.
(1)
(2)
(3)
(4)
(5)
2. Having a mammogram would expose me to a lot of radiation.

(1)

(2)

(3)

(4)

(5)

3. Having a mammogram is inexpensive.
(1)
(2)
(3)

(4)

(5)

(4)

(5)

5. Having a mammogram would not embarrass me.
(1)
(2)
(3)
(4)

(5)

6. Having a mammogram would be inconvenient for me.
(1)
(2)
(3)
(4)

(5)

4. Having a mammogram would be painful.
(1)

(2)

(3)

7. Having a mammogram would relieve my worries about cancer.
(1)
(2)
(3)
(4)
((5)

8. There is a convenient place for me to get a mammogram.
(1)
(2)
(3)
(4)

(5)

43

Part C: This group of questions is about your health care and health insurance.
Please circle the answer that most closely describes your own situation.
1. Is there a regular place you usually go for health care?
a. Yes
b. No

2. If you have a regular place for health care, what kind of place is it?
a. Doctor’s office
b. Hospital emergency room
c. Hospital outpatient clinic
d. Some other place (Specify)
3. At the place you go for regular health care, do you have a person you regard as
your regular doctor or health care provider?
a. Yes
b. No
4. What kind of doctor or health care provider is that regular person?
a. Chiropractor
b. Family practice physician
c. Internal medicine physician
d. Nurse practitioner
e. OB/gynecologist
f. Osteopath
g. Other (Specify)
h. Not sure

5. What kind of health insurance do you have for yourself at the present time?
a. No health insurance
b. Medicare
c. HMO
d. Private insurance
e. Other (Specify)
f. Not sure
Part D: The last part of the survey asks about you and your family.
1. Age
b. Other
a. 50 to 75 years old
2. In what COUNTY do you live?

44
3. What is the highest level of school that you completed?
a. 0 to 8th grade
c. Some college
b. 9th to 12th grade
d. College graduate

4. Which of the following best describes your race?
a. White
c.c. African-American
African-American
e. Other
b. Asian
d.d. Hispanic/Latin
Hispanic/Latin
f Don’t wish to answer
5. Is there anything else you would like to add? Please feel free to comment.

Thank you for your help with this study

45

Appendix B
Cover Letter

Dear RSVP Member,
Hello, my name is Debbie Piotrowski. I am a registered nurse and a family
nurse practitioner student at Edinboro University of Pennsylvania.
I am sending this letter to all women members of RSVP who are between the
ages of 50 and 75. Ellen Coffaro was kind enough to develop a mailing list.
I am conducting a survey to identify if there is a relationship between
frequency of getting mammograms and physical activity in women ages 50 to 75.
Past studies have determined that mammography is the single, most effective method
of breast cancer screening.
Participation will be anonymous and all responses will be confidential.
Completion of the survey will mean that you have consented to be a part of this study.
The survey will take approximately 10 minutes to fill out. After completing the
survey, please put it in the enclosed stamped envelope and place it in the mail. When
your survey reaches the RSVP office, it will be taken out of the envelope and put
among all of the other surveys. This will maintain anonymity since no one will know
who did or did not return a survey.
The results of the study will be available in the RSVP office in May.

Thank you so much. I appreciate your help; this topic is so important to all women!

46
Appendix C

Script
Hello, my name is Debbie Piotrowski. I am a registered nurse and a family
nurse practitioner student at Edinboro University of Pennsylvania.
I am conducting a survey to identify if there is a relationship between
frequency of getting mammograms and physical activity in women ages 50 to 75.
Past studies have determined that mammography is the single, most effective method
of breast cancer screening.
Participants will be anonymous and all responses will be confidential.
Completion of the survey will mean that you have consented to participation in this
study. The completion of the survey will take approximately 10 minutes. After
completing the survey please place it in the envelope provided.
Results of the survey will be available in the church office in May.

Thank you so much. I appreciate your help; this topic is so important for all women!

47
Appendix D
Research Subjects’ Comments
1. The lack of follow up by doctors as a result of a negative result. Would like

mammography providers to list options for follow up. I have had to call my doctor to
get results.
2. Doctors charge too much! Too much coming back to build up the cost.

3. I am a breast cancer survivor. Mammograms are a life saver. Early detection is
very important for your survival. I encourage everyone, both male and female to get
a mammogram each year. I had breast cancer in 1971 and had a mastectomy.

4. Mammograms can be slightly painful especially when pressing down on breast.
5. What price is there for knowing you have a healthy body and you can sleep at

night and when questioned about mammogram you can say yes.
6. I think every woman should have one no matter what her age.

7. A more cost effective medical insurance is needed.
8. I feel strongly that it is important to have a mammogram every year.
9. I feel medicare should cover annual mammograms.