ing guidelines and to express ambivalence than those who have kept current with their screening mammographies (Halabi et al., 2000). A survey of American women revealed that 95 percent were aware of the debate over screening mammography guidelines. Half reported being upset by the public disagreement among experts, and only 24 percent said the discussion had improved their understanding (Woloshin et al., 2000). Another survey of women conducted in western Washington state suggests that conflicting recommendations do not necessarily depress use of mammography. More important than controversy surrounding guidelines was physician recommendation and women’s self-reported likeliness to follow physician advice (Taplin et al, 1997b).

Values about the importance of breast cancer screening vary by race and ethnicity, but it is difficult to disentangle the extent to which these relate to socioeconomic variables. This interrelationship illustrates the overlaps between knowledge, attitudes, ability, and reinforcement as determinants of cancer screening. For example, researchers have used “willingness to pay” for mammography as an indicator of the relative importance that women assign to screening. One study of low-income, ethnically diverse women found that this willingness, which varied by ethnic group, was statistically associated with elements that this report classifies under knowledge (perceived risk of cancer or the knowledge that one needs a mammogram even after a clinical breast examination) and elements related to ability (household income) (Wagner et al., 2000).

Attitudes that are unmistakably cultural and ethnic also influence interest in breast cancer screening. Acculturation and the proportion of a woman’s life spent in the United States are important factors among some immigrant and ethnic populations, such as Korean women (Juon et al., 2000). A study of urban Chinese-American women age 60 and older revealed that acculturation and issues surrounding modesty affected ever having had a screening mammography or a clinical breast examination, and the lack of a physician recommendation affected having it in the past year. Cambodian women, even those with Asian-American physicians, are less likely to be screened if the physician is a man (Tu et al., 2000). Within Hispanic populations, attitudes differ among ethnoregional subgroups (Ramirez et al., 2000b).

Ability Access to health care and insurance coverage are closely correlated with whether women obtain screening mammography. As noted earlier with regard to HEDIS indicators, health maintenance organizations report that large proportions of their female enrollees have received regular screening mammographies. By 1992, 75 percent of women who had been members of the Kaiser Permanente, Northwest Region, health maintenance organization for at least 2 years had undergone a screening mammography (Glass et al., 1996).

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