Exploring environmental barriers to participation in mammography screening in an HMO

Despite an upward trend in mammography screening rates, rates among some demographic subgroups and rates of annual mammography remain low. Behavioral-based interventions which move beyond invitational strategies to help women overcome their personal barriers may be necessary to increase participation. We developed a heuristic model based on the Health Belief Model and Social Learning Theory with the central hypothesis that the relative importance of environmental barriers in predicting screening behavior is a function of the woman's perceived risk, preventive orientation, and/or concerns about mammography. We completed telephone interviews with 313 women who did not obtain a mammogram and 350 women who had a mammogram within 365 days of an invitation from a Health Maintenance Organization-based breast cancer screening program. Results of multivariate analyses indicated that perceived risk did not mitigate the influence of logistic inconveniences associated with obtaining a mammogram. Preventive orientation as measured by smoking status interacted with belief that symptoms are a necessary prerequisite to a mammogram as a powerful predictor of participation; the greatest negative impact of concerns on participation was found among smokers. A similar relationship between concerns and participation, although only marginally significant, was observed among those who perceived it to be difficult to get to the screening center. Implications of the results for development of behavioral interventions and additional research are discussed.