Differences in Perceptions of Risk, Benefits, and Barriers by Stage of Mammography Adoption ABSTRACT

JOURNAL OF WOMEN S HEALTH Volume 12, Number 3, 2003 Mary Ann Liebert, Inc. Differences in Perceptions of Risk, Benefits, and Barriers by Stage of Mammography Adoption VICTORIA L. CHAMPION, R.N., D.N.S., 1 and CELETTE SUGG SKINNER, Ph.D. 2 ABSTRACT Purpose: The purpose of this report was to identify the relationship of mammography adoption with perceived susceptibility to breast cancer and perceived benefits and barriers to mammography. Methods: Stage of mammography adoption was based on the Transtheoretical Model. Previously validated scales for susceptibility, benefits, and barriers were administered. The sample included 694 women who were recruited from a large Health Maintenance Organization and general medicine clinic. The mean age was 61.2 years; 30% were African American and 67% were Caucasian. Results: Women who were currently compliant (action) had lower perceived barriers than other groups. Precontemplators and Relapse Precontemplators had lower perceived benefits scores than those who were currently compliant or those who were thinking of having a mammogram. Women who had never received a mammogram were more likely to feel they were too old for the procedure. Stage matched interventions are discussed. Conclusions: Beliefs differ among women in various stages of mammography adoption. These differences may inform interventions to increase mammography use. INTRODUCTION THE PURPOSE OF THIS REPORT is to identify among women 50 years or older differences in beliefs by stage of mammography adoption. Breast cancer remains the second leading cause of cancer mortality in females in the United States. 1 An estimated 39,600 women died of this disease in 2002. 1 Periodic mammography screening at ageappropriate intervals can reduce breast cancer mortality by 25% 35%. 2 6 One study found that almost 70% of women have had at least one mammogram, but only 36% of those aged $50 had been screened in the last year. 7 Mammography promotion interventions now need to extend beyond women who have never had a mammogram to those who do not continue screening as recommended. Before interventions can be developed to facilitate continued periodic screening, we should identify variables related to various stages of the mammography decision process. One useful framework for studying mammography behavior is the Transtheoretical Model (TTM). 8 The TTM conceptualizes behavior change as a process occurring in stages ranging from not thinking about changing the behavior (precontemplation), thinking about it but not yet taking action 1 Indiana University School of Nursing, Indianapolis, Indiana. 2 Duke University Medical Center, Durham, North Carolina. This work was funded by the National Cancer Institute and the National Institute of Nursing Research, R01 CA 58606. 277

278 (contemplation), action (making the behavior change), to maintenance of the behavior over time. Those who do not maintain the behavior change over time are relapsers. They may or may not be contemplating taking action again. The TTM has been found useful for application in a number of behaviors, including mammography. 8 10 Another useful framework for studying mammography behavior is the Health Belief Model (HBM). 11 The HBM s constructs of perceived susceptibility, benefits, and barriers have been found to predict use of mammography. 12 The American Cancer Society (ACS) recommends yearly mammography for women aged $50. Thus, there are women who have had previous mammograms but are not interval adherent because it has been more than a year since they were screened. Understanding health beliefs that differentiate women who are vs. those who are not considering having a first mammogram or repeat screening is important for developing interventions to encourage interval adherence. We report differences in perceived susceptibility, benefits pros and barriers cons, and selected demographic factors among five groups of women: (1) precontemplators, (2) contemplators, (3) actors, (4) relapse precontemplators (overdue for and not thinking about repeat screening), and (5) relapse contemplators (overdue for and thinking about having repeat mammograms). Background Integrated into the TTM s stages of behavior adoption is the decisional balance construct, which refers to an individual rationally reviewing both positive and negative aspects of a behavior and identifying expected gains and losses (for self and significant others) that would result from a behavior change. 13 These positives and negatives are referred to as pros and cons. 14 Prochaska 15 has reported significant differences in the balance of pros and cons related to stage for 12 behaviors: smoking, cocaine use, weight control, dietary fat intake, delinquency, safe sex, condom use, sunscreen use, radon gas exposure, exercise, mammography, and particular physician practices. Perceived pros increased as individuals moved from precontemplation to contemplation. For 10 of the 12 behaviors, cons decreased as individuals moved from contemplation to action. However, relapse as a separate stage was not addressed in this report. 15 In several studies assessing mammography stage of change, decisional balance has been significantly related to stage of mammography adoption. 16 18 Pro and con scores in general reflected a more positive balance for women in action or maintenance than for precontemplators or contemplators. Clark et al., 19 who compared a tailored stage-matched intervention to usual care and standard materials, found those receiving stage matched material were significantly more likely to obtain screening than were the usual care group (44.2% vs. 35.8% in the usual care group). The HBM constructs of perceived benefits and barriers are similar to the pros and cons in the TTM. 20 Previous studies also have linked perceived benefits and barriers to mammography adoption. 21,22 For instance, Skinner et al. 23 found differences in benefits and barriers by mammography stage, consistent with the previous works of Rakowski et al. 18 Brenes and Skinner 24 explored differences in HBM constructs by stage of mammography adoption, finding significant differences for all constructs except seriousness (which was not used). Because breast cancer is perceived universally as serious, we did not use the seriousness construct. Because we lack information about how women in precontemplation, contemplation, or action differ, this report addresses the following questions: 1. Do the respective magnitudes of perceived risk (susceptibility), perceived benefits (pros), perceived barriers (cons), and selected demographic/experimental variables differ by stage of mammography adoption (precontemplation, contemplation, action, relapse precontemplation, and relapse contemplation)? 2. Are there specific benefits or barriers or both that differ by stage of mammography adoption (precontemplation, contemplation, action, relapse precontemplation, and relapse contemplation)? Sample CHAMPION AND SKINNER MATERIALS AND METHODS For this report, we analyzed data from a sample of 694 women who completed both time 1 and time 2 data collection in a large National Cancer Institute (NCI)-funded project to increase breast cancer screening in women aged $50. Partici-

DIFFERENCES IN STAGE PERCEPTIONS FOR MAMMOGRAPHY 279 pants completed mailed surveys and returned them in postage-paid envelopes. Women were recruited from two sources: (1) a large health maintenance organization (HMO) serving a metropolitan area and (2) a university-related general medicine clinic serving primarily low-income African American women. The HMO generated a list of eligible women who were sent letters introducing the study. Letters were followed by telephone calls from trained research assistants, who further explained the study and asked if the women would be willing to participate. Eligibility criteria included not having a mammogram in the last 15 months, being $50 years old, and not having had breast cancer. Women were also asked if their healthcare providers had ever told them they did not need a mammogram. This was done to determine if a woman was considered to have a limited life span that might preclude mammography. If a woman indicated she would be willing to participate, an informed consent statement and preintervention questionnaire (time 1) were mailed. The second site, a general medicine clinic for indigent women, required a different strategy. Eligible women, identified from a computer list, were approached by research assistants while awaiting clinic appointments. If a woman agreed to participate, she signed an informed consent and completed the preintervention interview (time 1) in the clinic. Following baseline (time 1), women were randomly assigned to (1) usual care, (2) telephone counseling, (3) in-person counseling, (4) physician reminder, (5) telephone counseling and physician reminder, or (6) in-person counseling and physician reminder. Interventions delivered to groups 2 through 6 were designed to encourage mammography use. Approximately 2 months later, all women were mailed a second questionnaire. Data for this report reflect information gathered at time 2. During the interval between time 1 and time 2, some women received mammograms (action stage). Instruments Perceived risk (susceptibility). All scales were first assessed for reliability. Scale reliabilities with means and standard deviations (SD) are listed in Table 1. Scale values also were submitted to principal components factor analysis with Varimax rotation to determine construct validity. All analyses were conducted using SPSS PC (Chicago, IL). Perceived susceptibility was measured by a 3- item scale previously tested for validity and reliability. 11 Items measured perceived general likelihood of getting breast cancer, chances of getting breast cancer in the next few years, and chances of getting breast cancer sometime during my life. Likert responses ranging from Strongly agree to Strongly disagree (5-point scale) anchored items. The range of possible scores was 3 15. The scale had a reliability of 0.88 in this sample and demonstrated construct validity through factor analysis and correlation techniques. Perceived benefits and barriers. Pros and cons related to mammography were measured by scales developed previously based on the HBM constructs of benefits and barriers. Both scales used a 5-point Likert format from Strongly Agree to Strongly Disagree. The 5 benefit items assessed decreased worry, help in finding breast lumps early, decreased need for extensive treatment, perceived best way to find small lumps, and decreased chances of dying from breast cancer. Reliability for this scale was 0.75. The 11-item barriers-to-mammography scale assessed fear, lack of understanding, embarrassment, time, pain, and other factors identified in the research literature. 25 The scale s reliability in this sample was 0.86, and scores ranged from 11 to 55. Both benefits and barriers scales were tested for construct validity using factor analysis and correlation techniques. Mammography stage. Women were asked if they had ever had a mammogram and if they were TABLE 1. SCALE STATISTICS M Range SD Alpha n of Items Susceptibility 7.27 3 15 2.50 0.88 3 Benefits 19.88 5 25 3.24 0.75 5 Barriers 22.54 11 55 3.92 0.86 11 Knowledge 9.66 0 18 3.51 0.75 18

280 CHAMPION AND SKINNER considering having a mammogram, with options of Yes, in the next 30 days, Yes, in the next 6 months, Yes, within the next year, and No. Women were then asked when they had received their most recent mammogram and how many mammograms they had received in the last 5 years (for women $50, ACS recommends a mammogram every 12 months). Using an algorithm, each woman s answers were classified for one of five stages (Table 2). Knowledge about breast cancer and breast cancer screening was measured via an 18-item scale using questions with a yes/no/don t know format. Responses were coded as correct or incorrect (i.e., wrong answer or don t know). Internal consistency reliability was 0.75. Statistical analyses Analyses appropriate to level of measurement and research questions were run using SPSS. Chisquare analysis assessed the relationship between mammography stage and race. Race was dichotomized into Caucasian and African American. We used one-way analysis of variance (ANOVA) to assess mammography stage by age and education. Further analyses attempted to identify differences in perceived susceptibility, benefits, and barriers by age, race, and education. Differences by race were tested by one-way ANOVA, with susceptibility, benefits, and barriers being the respective dependent variables and race the independent variable. We calculated correlation coefficients to identify relationships of the interval-level data of benefits, barriers, and susceptibility to age and education. Research questions for summated scales were tested using one-way ANOVA with post hoc (Tukey) tests TABLE 2. for assessing group differences. We used an alpha of 0.05 for post hoc tests. Because individual benefits and barriers items were considered ordinal, they were first transformed to rank. We employed ANOVA for an overall F test to assess significant differences among groups after transformation. The overall F test took into consideration the multiple comparisons. Post hoc Tukey analysis was used to assess group differences. RESULTS Respective response rates were 44% from the HMO and 37% from the general medicine clinic. The response reflects commitment to a 2-year intervention project, not a focus of this report. The sample represented a wide age distribution, ages 50 92. Mean age was 61.2 with an SD of 9.7; 7% were over age 75. We measured education as number of school years completed (mean 12.5, SD 2.6). A total of 67% of the women were Caucasian, 30% were African American, and 3% were other. The demographic variables of education and age were assessed for significant relationships to mammography stage and to perceptions of susceptibility, benefits, and barriers. There were no significant differences in mammography stage by race, age, or education. Neither did perceived benefits or barriers vary significantly by race, age, or education. Research question 1 Research question 1 asked if magnitudes of perceived risk (susceptibility), perceived benefits (pros), or perceived barriers (cons) differ by stage MAMMOGRAPHY STAGE Mammography stage Definition % Frequency Precontemplation Never had a mammogram and not 7.5 52 thinking about having one in the next 6 months Contemplation Never had a mammogram but thinking 3.3 23 about having one in the next 6 months Action Had a mammogram since the 26 181 intervention Relapse Previous mammogram but not in the 17 118 precontemplation previous 15 months and not thinking about having one in the next 6 months Relapse Previous mammogram but not in the last 46 320 contemplation 15 months, and thinking about having one in the next 6 months

DIFFERENCES IN STAGE PERCEPTIONS FOR MAMMOGRAPHY 281 of mammography adoption (precontemplation, contemplation, action, relapse precontemplation, or relapse contemplation). Significant differences by stage emerged for all summated scales (Table 3). Barriers demonstrated the greatest difference, with benefits being second and susceptibility third. Actors and contemplators had higher susceptibility scores than either precontemplators or relapse precontemplators, but only relapse precontemplators were significantly different from relapse contemplators. For the summated barriers scale, more differences emerged. Actors had lower means than all other groups. Precontemplators and contemplators were not different from each other, but both groups had significantly higher perceived barriers than those who had previously had a mammogram (relapse precontemplators, relapse contemplators, or actors). Among relapsers, those contemplating rescreening had significantly lower perceived barriers than those in the precontemplation stage for rescreening as for actors. For benefits, both precontemplators and relapse precontemplators were significantly lower than relapse contemplators or actors. Precontemplators TABLE 3. ANOVA for susceptibility also had lower benefit scores than contemplators for those who had not had a mammogram. Research question 2 The second research question was whether specific benefits and barriers items differed among women who were in different stages of mammography adoption. All of the 11 items on the barrier scale demonstrated significant differences by group. Significant pairs are shown in Table 4, along with means and F ratios. A lower mean indicates fewer barriers. Precontemplators and contemplators usually had highest mean scores for the individual barriers items. Those in the action stage had the lowest. Among those who had received a previous mammogram but were overdue for rescreening, both relapse precontemplators and relapse contemplators were less likely to perceive barriers than those who had never had a mammogram. For relapse precontemplators, barrier perceptions were stronger than for relapse contemplators on three barriers: age, radiation, and memory. Actors were signif- BETWEEN-GROUP COMPARISONS FOR SUSCEPTIBILITY, BARRIERS, AND BENEFITS Means SD F ratio F probability 1 Precontemplation 7.43 2.53 3.0 0.018 2 Contemplation 8.27 2.37 3 Relapse precontemplation 7.60 2.56 4 Relapse contemplation 8.41 2.55 5 Action 8.32 2.74 df 5 (4,666) 1 and 3 different from 4 and 5 ANOVA for barriers 1 Precontemplation 26.18 6.57 26.81 0.0001 2 Contemplation 26.57 4.84 3 Relapse precontemplation 22.65 6.35 4 Relapse contemplation 20.12 6.55 5 Action 17.93 5.22 df 5 (4,666) 1, 2 different from 3, 4, and 5 3 different from 4 and 5 4 different from 5 ANOVA for benefits 1 Precontemplation 17.98 4.28 9.34 0.0001 2 Contemplation 20.26 2.30 3 Relapse precontemplation 19.02 3.55 4 Relapse contemplation 20.23 2.96 5 Action 20.56 3.11 df 5 (4,666), p # 0.05 1 and 3 different from 4 and 5 1 different from 2

282 CHAMPION AND SKINNER TABLE 4. BETWEEN-GROUP COMPARISONS FOR BARRIERS Significant pair Barrier Pre (1) Cont (2) R Pre (3) R Cont (4) Action (5) F ratio 1, 2, and 4, 5 Afraid something 433.3 511.1 384.9 341.5 303.7 11.36* 3 and 2, 5 wrong 5 and all Other problems 481.5 466.8 417.7 332.0 257.9 22.79* 4 and all 1, 3, 4, 5 Too old 481.5 456.6 394.7 332.6 296.9 16.30* 2 and 4, 5 3 and 4, 5 1, 2, and 3, 4, 5 Don t understand 459.3 487.1 373.8 341.0 307.8 11.75* 3 and 5 procedure 1, 2 and 3, 4, 5 Don t know how 480.5 461.6 352.7 345.5 309.8 12.15* 1 and 3, 4, 5 Embarrassment 466.6 476.8 367.1 339.4 307.5 11.21* 2 and 4, 3 3 and 5 1 and 4, 5 Time 454.4 516.4 375.6 342.7 299.4 13.90* 2 and 3, 4, 5 3 and 5 1, 2 and 4, 5 Pain 437.2 465.7 387.8 341.3 308.0 8.31* 3 and 5 4 and 5 Rude personnel 457.6 481.1 392.8 343.6 289.4 13.98* 1, 2 and 4, 5 1, 2, 3 and 4, 5 Radiation 483.7 443.5 399.7 321.2 314.1 14.17* 1, 2, 3, 4, and 5 Memory 392.1 453.6 375.6 366.7 279.2 10.19* *p 5 0.001. icantly different from at least one of the other groups on each item. Women who had not had a mammogram were more afraid to have mammograms because something might be wrong than those who had been screened at least once in the past. For actors, having other problems was less significant than for all other groups. Precontemplators had the highest score for other barriers. Feeling that they were too old (although there were not significant differences in age by stage) seemed to be a special problem for precontemplators, contemplators, and relapse precontemplators. Precontemplators and contemplators were more likely than other groups to not understand the mammography procedure and not know how to go about getting a mammogram. Precontemplators and relapse precontemplators were more likely than contemplators to cite embarrassment as a barrier to screening. Precontemplators and contemplators were significantly more likely than contemplators and actors to think that mammography personnel might be rude. Relapse precontemplators, contemplators, and precontemplators were significantly more concerned about radiation exposure than actors or relapse contemplators. Remembering to get a mammogram seemed to be a problem for all groups except those in action. Specific benefit items also illustrated some differences among those overdue for rescreening. Precontemplators were different on all benefit items except for treatment not being as bad. Precontemplators and relapse precontemplators perceived less benefit for mammography finding a small lump than those in action (Table 5). For the item mammograms would cause less worry, precontemplators had the lowest mean benefit and were significantly different from contemplators or actors.

DIFFERENCES IN STAGE PERCEPTIONS FOR MAMMOGRAPHY 283 TABLE 5. BETWEEN-GROUP COMPARISONS FOR BENEFITS Significant pair Benefit Pre (1) Cont (2) R Pre (3) R Cont (4) Action (5) F ratio 1 and 4, 5 No worry 273.7 366.2 323.8 358.2 372.5 3.74* 1, 3 and 4, 5 Find lump 265.0 361.0 305.6 363.4 379.4 6.50* N S Treatment not 292.0 340.8 322.1 357.8 370.9 2.63* bad 1 and 4, 5 Best way to 282.7 316.1 306.4 359.4 383.2 5.12* 3 and 5 find small lump 1, 3 and 4, 5 Decrease 282.4 327.5 297.9 364.9 371.5 5.00* chances of dying *p # 0.01. DISCUSSION Study results support the relationships between pros and cons hypothesized by the TTM in the mammography context. 16,24,26 Previous reports have found differences in decisional balance by stage of mammography adoption. For instance, Brenes and Skinner 24 found that regularly screened women have a more favorable decisional balance, and Champion 27 found that women in action/maintenance had higher perceived benefit scores and lower barriers scores than those who were not adherent. However, most studies have not looked at the specific benefits and barriers related to stage of mammography adoption. Our findings identify specific issues that particularly need to be addressed for women at different stages of considering mammography, depending on their screening histories. Important issues surfaced among women who had never had a mammogram, that is, precontemplators and contemplators. Compared with contemplators, precontemplators were more likely to believe they were too old to need a mammogram, not understand the procedure, not know how to go about getting a mammogram, have other problems that seemed more important, or cited the embarrassment or radiation exposure they perceived as being part of the mammography process. Many educational issues need to be addressed with this group of women. It is especially important for precontemplators to understand the relationship between age and breast cancer incidence. Simple graphs can be very helpful for this purpose. Precontemplators also may be experiencing other problems, such as arthritis or heart disease, that are more obvious or cause more symptoms. Understanding that breast cancer, unlike other problems, may be a silent disease until it is too late is important. Explanations of the mammography procedure with illustrations may help women vicariously experience mammography so that fear of the unknown does not interfere with scheduling. An interactive computer program or videotape could illustrate a woman of like culture or race being greeted in a mammography suite, putting on a gown, and having a mammogram. Precontemplators were particularly concerned about the time required for mammography and the possibility of encountering rude personnel. It might be useful for women who have never had a mammogram to be paired with a friend or buddy as she goes through the procedure. At a minimum, healthcare personnel need to be aware of the worries of women who have never had a mammogram. Although all stages were different from those of actors, contemplators had the highest mean on the item about the possibility of finding that something is wrong. Skinner et al. 28 reported similar findings. This barrier may be especially relevant for contemplators because they are now at the point of actually considering the procedure without having previously experienced the relief of a negative finding. Contemplators, like precontemplators, were concerned about other problems, did not understand the procedure, and did not know how to schedule a mammogram. Contemplators also had the most concerns about the time a mammogram requires as well as possible

284 pain and rude personnel. These findings are similar to those reported by Skinner et al., 23 who found differences in perceived mammography barriers by stage. As women who have not had mammograms start to consider the possibility, barriers may become more salient. Contemplators need focused attention by healthcare providers to discuss ways to minimize or remove any barriers to action. In particular, we need to do a better job of altering the perceived benefit/barrier ratio for this group of women who are close to action. Interventions could capitalize on our finding that women in contemplation had the highest mean perception that mammography would find lumps early and decrease worry. If indeed the positive benefit perception is there, decreasing barriers may be all that is needed to move such women from contemplation to action. Women who had received a previous mammogram but were overdue (i.e., those in relapse stages) differed in several respects from those in other stages. First, their barrier perceptions were lower than those of women who had never had a mammogram. Women in relapse precontemplation were significantly more concerned about radiation. Comparing the low radiation dose of mammograms to the dose in dental x-rays or other minor procedures may help decrease this barrier. We found actors different from women in all other stages for remembering to schedule a mammogram, consistent with the findings of Skinner et al. 23 that precontemplators, contemplators, and relapsers were different from actors in relation to many barriers. As previous research has shown, once women have had a mammogram, it is important to have in place a reminder system to maintain a regular schedule. 29 Relapse precontemplators perceived less benefit from mammography in relation to finding a lump early or decreasing the chances of dying. It could be that for these women, the benefit perception was linked only to the past screens and there was little understanding of the importance of continuing regular mammograms to detect breast cancer early. Relapse precontemplators, along with precontemplators who have never been screened, need to have benefits emphasized. Perhaps for relapse contemplators, a scheduled appointment each year would increase adherence. For relapse precontemplators, the issues may be more complex. Results suggest some differences between those who had never had a mammogram and CHAMPION AND SKINNER those who had one but had relapsed. For instance, those who had never had a mammogram but were thinking about having one (contemplators) were more likely than relapse contemplators to think they were too old to need mammograms. They were also more likely to say they did not understand the procedure, did not know how to get a mammogram, were embarrassed, did not have time, and were concerned about pain, radiation, and rude personnel. It seems logical that there are differences in women who had not had a mammogram vs. those who had. For women who are considering a mammogram, barriers become more relevant. These results seem to indicate that when women have experienced a prior mammogram, many barriers become less relevant. This illustrates a need to address barriers systematically especially when a woman has not had experience with mammography. Finally, two correlations linking susceptibility and particular demographic variables are worth noting. Perceived susceptibility decreased with increased age and education. The inverse relationship to age has been noted previously. 30 Older women may need to be reminded that they are at especially high risk for developing breast cancer. Perhaps those with less education have an unrealistically high perception of their susceptibility, which could lead to high fear levels and less screening, or perhaps better educated women believe they know and act on the breast cancer risk factors, such as low-fat diets and exercise, thus decreasing their risks. It is interesting that stage did not vary with age or race. Other studies have found that both older women and African American women are screened less frequently. 31,32 Although many intervention studies have addressed mammography adherence, most have not targeted approaches to mammography stage. The results of our study indicate real mean differences in perceptions of susceptibility, benefits, and barriers by stage of mammography adoption. In particular, specific benefit and barrier items reveal differences that may have intervention implications. Precontemplators and relapse precontemplators are more likely to need messages that emphasize the benefits of initial and continued screening. Contemplators need healthcare personnel to be especially sensitive to perceived barriers to action. In particular, contemplators women who have never had a mammogram

DIFFERENCES IN STAGE PERCEPTIONS FOR MAMMOGRAPHY 285 may need to be walked through the procedure. Relapsers need to have reminder systems in place so that forgetting is not a problem. By assessing individual beliefs and stage of adoption, tailoring can become even more individually specific. As with all descriptive work, caution is warranted. The convenience sample in these HMO and clinic populations may not represent the general population of women over 50. The response rate was low (37% and 44%), indicating a somewhat self-selecting sample and results that may not be generalizable to a larger population. Third, the cell sizes for precontemplators and contemplators were generally smaller than for women in relapse. This is indicative of the increased onetime mammography rates that have occurred in the last decade. Further follow-up will be necessary to better understand any intervention effects. 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