Comparison of Three Methods to Increase Knowledge About Breast Cancer and Breast Cancer Screening in Screening Mammography Patients

Comparison of Three Methods to Increase Knowledge About Breast Cancer and Breast Cancer Screening in Screening Mammography Patients1 Dag Pavic, MD, Michael J. Schell, PhD, Ria D. Dancel, Sanjeda Sultana, MS, Li Lin, MS Samir V. Sejpal, MD, MPh, Etta D. Pisano, MD, FACR

Rationale and Objectives. The specific aim of the study was to determine which of several cost-effective interventions is best able to improve the breast cancer knowledge of women who present for screening mammography. Materials and Methods. A total of 198 English-speaking women, with no personal or family history of breast cancer, were recruited and randomized to four groups when they presented to the clinic for a screening mammogram. All women filled in a demographic data form and answered a questionnaire containing nine questions about breast cancer, risk, and screening to assess their knowledge and perception. Three educational interventions were tested in this study. The first consisted of a brochure, which provided answers to the questionnaire items and addressed the issues in more depth. The second intervention was an educational conversation with a specially trained mammography technologist. She reviewed the subject’s answers to the questionnaire items correcting and/or clarifying them. The third intervention consisted of the brochure together with the conversation with a trained technologist. There was also a control group that just filled in the study questionnaire but did not receive an educational intervention. The same questionnaire was administered by telephone 4 to 6 weeks after the screening experience to all study subjects. Changes in their knowledge and perceptions of breast cancer were measured and compared. Results. A statistically significant increase in knowledge was found in all of the three investigated groups compared to the control group. There were no statistically significant differences in the amount of increase between women who underwent different interventions. Conclusions. All three interventions resulted in increased knowledge about breast cancer and screening. No differences in the amount of knowledge increase were found between three interventions tested. The educational brochure seems to represent the most convenient and least costly method to increase knowledge about breast cancer and screening among women who present for screening mammography. Key Words. Breast cancer; screening; public awareness and education. ©

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From the Department of Radiology, University of North Carolina at Chapel Hill, CB# 7510, Chapel Hill, NC 27599-7510 (D.P.); Biostatistics Division, Department of Interdisciplinary Oncology, Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL (M.J.S.); School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (R.D.D.); Biomedical Sciences, Barry University, Miami Shores, FL (S.S.); Biostatistics and Data Management, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC (L.L.); Department of Radiation Oncology, Northwestern Universtiy, Chicago, IL (S.V.S.); and UNC Biomedical Research Imaging Center, Departments of Radiology and Biomedical Engineering, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (E.D.P.). Received May 24, 2006; accepted Jan 9, 2006. The results were presented at the 53rd Annual Meeting of Association of University Radiologists in Montreal, Canada, May 4 –7, 2005. This study was funded with an educational grant from The Society of Breast Imaging. Address correspondence to: D.P. e-mail: [email protected]

© AUR, 2007 doi:10.1016/j.acra.2007.01.011

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Breast cancer is the most common nonskin malignancy among women in the United States and second only to lung cancer as a cause of cancer-related death. In 2005, an estimated 211,240 new cases of invasive and 58,490 cases of in situ breast cancer were diagnosed in American women, while an estimated 40,410 women died of the disease (1). Screening mammography has been shown to significantly reduce breast cancer mortality in multiple trials (2). Despite government and public agency recommendations that women participate in screening mammography on a regular basis, as of 2002 about 38.5% of American women aged 40 years or older have not received a mammogram in the past year (3) and, as of 2000, about 45% have not received mammography and clinical breast examination (4). In order to increase breast screening practices among women, a multitude of facilitators and barriers to mammography have been identified and addressed (5–10). Studies have shown that physician recommendation is the strongest stimulus to increased mammography use (9,11– 13). Patient health beliefs, perceived risk, awareness of the need for mammography, and patient knowledge of risk factors are also important elements in increasing mammography utilization (9,12,14 –21). It has been shown that women’s beliefs and attitudes have a stronger influence on their screening practices than their educational level or knowledge about the breast cancer Tailored interventions that would target separate populations of women with different ethnic, cultural, and/or religious backgrounds are needed in order to efficiently change their attitudes and health beliefs (18 –20,22–26). Women have misperceptions and false beliefs regarding breast cancer. There is also a lack of knowledge on issues relating to breast cancer including information on individual risk of breast cancer, the variable aggressiveness and stages of different types of breast cancer, the understanding of the presence of false-positive tests, the effect of risk factors, the utility of mammography in detecting breast cancer, the role of compression in mammography, and what a diagnosis of breast cancer might mean to the patient (6,11,19 –21,27–29). Even women with high education demonstrate lack of knowledge related to breast cancer and screening (21). Different interventions aimed to influence women’s decisions regarding screening mammography have been described in literature. Grindel et al. (30) tested the effects of a 60-minute health education session that cen-

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tered on watching a video depicting the story of a fictional woman who underwent mammography. They tested changes in knowledge immediately after the intervention and 1 year later. They found an increase in knowledge on the first postintervention test, followed by a significant drop 1 year later. Champion et al. (24) compared three interventions to increase screening mammography in lowincome African American women. They found that an interactive intervention, i.e., computer-assisted instruction program, was more effective than an educational video or pamphlet. Sung et al. (31) investigated effects of an inhome educational intervention conducted by lay health workers targeted to low-income, inner-city black women. They found improved adherence to clinical breast examination and screening mammogram recommendations. These authors stated that “ high attrition rate weakened our ability to make conclusive statements about the exact impact of the intervention.” The above-mentioned strategies are time consuming and require considerable financial resources. We chose to compare low-cost interventions, without targeting a specific patient population. Mammography technologists potentially have considerable influence in affecting the quality of a patient’s experience with screening mammography and her likelihood of adhering to a screening protocol in the future (32–35). A well-trained technologist with friendly and compassionate attitude can positively influence future regular mammography utilization, and vice versa (34,35). This project explored an expansion of the role of mammography technologists to one that entails more than just breast positioning. They could educate women about screening guidelines and risk factors, answer questions regarding the procedure, and attend to the emotional needs of the women presenting for screening through reassurance (33,34,36). Providing an informational brochure with breast cancer screening information while the woman is in the waiting room is another low-cost strategy. Such a brochure can be used in variety of settings that are not necessarily limited to health care practices. These strategies were chosen for study not because they are the best possible interventions but because they could be implemented at many centers at little or no cost to the centers providing screening services. This is extremely important given the significant number of women who self-refer for screening, and these women do not necessarily undergo breast physical examination or have a conversation with other health care providers about their

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breast health (37–39). In addition, mammography is often performed as a “loss leader” in many centers, with little or no resources available for important educational efforts. The purpose of these educational efforts is to help women learn about the actual risks and benefits of screening that may affect their decisions to obtain a screening mammogram in the future. The specific aim of the study is to determine which low-cost intervention—an educational brochure, conversation/clarification by a mammography technologist, or a combination of both—is best able to improve the breast cancer knowledge of women who present for screening mammography.

MATERIALS AND METHODS Participants were women of all ethnicities who presented to our clinic for a screening mammogram between April and July 2004 and who were willing to participate in the study. Women were considered ineligible for the study if they did not have a telephone number or telephone contact, did not speak English, were illiterate, were unable to give informed consent, were experiencing a problem in their breast such as a lump, discharge, or a palpable mass (since these problems would exclude them from screening mammography protocol), or have had a prior breast cancer. They were recruited and randomized to four groups: three intervention groups and one control group. Fifty women were to be recruited in each group. The following demographic data were obtained for all women: patient age, ethnicity, education, family history of breast cancer, and prior breast cancer screening practices. Then all women answered a questionnaire (Fig. 1) containing nine questions about breast cancer, breast cancer risk, and screening to assess their knowledge and perceptions. The first seven of those questions were scored, while two questions regarding compression during mammography were not scored. A scoring key was used in evaluating results. A correct answer was given a full point in all scored questions. In some of the multiple choice questions, a half point was given for the answers neighboring the correct ones, namely: for answers b and d in question 1, for d in question 2, and for b in question 3. Subjects could achieve scores in the range of 0 –7 points.

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Three educational interventions were tested in this study. ●

The first intervention was the provision of an educational brochure. Once the patients had filled out the questionnaire and it had been collected, women in the first intervention group received a brochure while they were sitting in the waiting room. They were asked to read it carefully, because it contained the correct answers to the questions they just answered and addressed the issues in more depth.

The brochure consisted of a letter-size paper, formatted and folded in a way that there were three columns of text on one letter-sized page. The questionnaire with its answers was not included in the brochure. Educational text was printed in landscape orientation, using Times New Roman font size 14 to make it more legible, divided into eight paragraphs. Each paragraph had a bolded title, that is: 1 in 8, Early detection save lives, Family history is a risk factor, Age is a risk factor, Mammography is the most effective, 90 out of 100, Compression is necessary, Follow-up abnormal mammogram. Information needed for correct answers to the questionnaire was given in the text. Key pieces of information within the text were printed in bold letters to accentuate them. In this manner, they were easier to recognize by a reader, and memorization was facilitated. On the other side of the brochure there was main title: Facts about Breast Cancer and Screening Mammography. Web pages of the American Cancer Society, the National Cancer Institute, Cancer Net, and The Susan Komen Breast Cancer Foundation were also listed. These were included for those participants who wanted to learn more about breast cancer and screening. ●

The second intervention was a conversation/clarification of answers in the questionnaire by a specially trained mammography technologist. Women in this group did not receive a brochure. Once they had filled out the questionnaire, in the process of receiving their mammograms, the mammography technologist assigned to perform their mammograms clarified the answers while performing mammography in the examination room. The technologist was instructed regarding the appropriate amount of detail to give. For each question, she read the correct answer and additional explanation to the patient. There was only one technologist involved in the study, who performed mammograms on all study participants.

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Figure 1. Health Knowledge and Perception Questionnaire (correct answers are underlined).

●

The third intervention was combination of both interventions—the brochure and the conversation/clarification by the mammography technologist. After filling out the questionnaire, women in the third intervention group received dual intervention: an educational brochure while they were sitting in the waiting room and clarifications of their questions by a technologist in the examination room.

The women in the control group did not receive any educational intervention after filling out the questionnaire but simply underwent mammograms in the usual fashion. Be-

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fore performing the mammogram, a technologist collected the brochure from the patient, if one was given, regardless of group assignment. That assured that all the patients had equal conditions between their screening mammography and their telephone interview. The same questionnaire was administered in a telephone interview to all study subjects 4 – 6 weeks after the screening mammography. The difference in these two scores estimates the change in knowledge of the subject due to the intervention. Randomization was based on particular day of the week patients presented for screening. Women seen on

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Table 1 Participants’ distribution

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Table 2 Participants’ characteristics

Group

No. of Subjects

A: Control B: First intervention C: Second intervention D: Third intervention

50 50 50 48

Intervention

Characteristics

None Brochure Conversation/clarification Dual (brochure ⫹ conversation/clarification)

Age (y) Mean (SD) Race White Black Other Education Low Middle High Family history Yes No Recommendation Yes No Previous mammogram Yes No

Mondays were in the control group. Women seen on Tuesdays were in the first intervention group that received only a brochure. Those seen on Wednesdays received clarification of their answers by a technologist, only. Women seen on Thursdays received both interventions. We chose this approach in order to avoid possible seasonal bias. True randomization, with women choosing closed envelopes is not appropriate in these settings, because “contamination” of subjects might take place in noncontrolled conditions in a waiting room (i.e., a woman assigned as a control group member peeks over the shoulder of an intervention group member, reading the brochure). Furthermore, patients having different treatment (i.e., while being together in a waiting room, one woman receives a brochure and the other one does not) in breast cancer screening settings might be disturbing for the patients. We hypothesized the following changes in scores for the four groups: 0 in the nonintervention group (⌬A), 0.5 in each of the single-intervention group (⌬B, ⌬C), and 1 in the dual-intervention group (⌬D), with common standard deviation of 1.5. Simple loop order restricted analysis has been used for testing homogeneity of score changes with a simple loop ordering alternative (40,41). The null hypothesis was ⌬A ⫽ ⌬B ⫽ ⌬C ⫽ ⌬D versus the alternative that ⌬A ⱕ (⌬B,⌬C) ⱕ ⌬D with at least one inequality strict. Meanwhile, we have compared demographic characteristics, baseline score across groups, score changes of nonintervention group to single-intervention groups, and single-intervention groups to dual-intervention group. Based on the nature of the measurement, the statistical method used was ANOVA for age; Fisher’s exact test for race, family history, recommendation, and previous mammogram; exact Mantel-Haenszel ␹2 for education level; the Kruskal-Wallis test for comparing baseline score; and one-sided t-test with common variance pooled from all four groups for score change in two-group comparisons.

Group A

Group B

Group C

Group D

P-value

58.6 (9.3)

56.1 (10.7)

56.6 (10.7)

54.2 (11.0)

.22

44 5 1

40 9 1

40 8 2

38 8 2

.88

0 21 29

3 15 32

0 13 37

2 18 28

.26

25 25

22 28

19 31

16 32

.36

47 3

47 3

42 8

44 4

.30

49 1

47 3

45 5

45 3

.44

Education: low, less than high school; middle, high school graduate and some college/vocational training; high, college graduate and postgraduate; family history: family history of beast cancer (mother, sister, aunt, daughter); recommendation: told by physician or nurse to undergo routine screening mammogram.

To compare preintervention and postintervention scores to each question across groups, Cochran-Mantel-Haenszel statistics was used. For multiple comparisons, Bonferroni correction was used to adjust the P-values. Overall, for this study, a P-value is considered to be significant if it is less than 0.05/4 or .0125. All statistical analyses were performed with SAS statistical software (Version 9.1; SAS Institute Inc., Cary, NC). This study was approved by the university investigational review board.

RESULTS A total of 202 English-speaking women were included in the study. Four women were lost to follow-up; 198 patients were thus included in the study population. These were distributed among the study groups as shown in Table 1. The groups did not differ in demographic characteristics, as seen in Table 2.

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Table 3 Questionnaire scores and score improvements

total1 (SD) total2 (SD) Change (SD)

Group A (control)

Group B (brochure)

Group C (clarification)

Group D (dual intervention)

4.29 (1.26) 4.52 (1.19) ⫹0.23 (1.09)

4.44 (1.28) 5.28 (1.54) ⫹0.84 (1.25)

4.46 (1.16) 5.27 (1.40) ⫹0.81 (1.17)

4.08 (1.25) 4.88 (1.43) ⫹0.79 (1.20)

tions (2,5, and 6) seemed similar across either groups or preintervention and postintervention.

Table 4 Comparison of four interventions Comparison

P-value

B to A (brochure to no intervention) C to A (conversation to no intervention) D to B (dual intervention to brochure) D to C (dual intervention to conversation)

0.0052 0.0074 0.58 0.53

There were two total scores for the questionnaire, one (total1) was from the day when the screening mammogram was done. The second one (total2) was from the telephone interview, 4 – 6 weeks after screening mammography. The two scores and the difference between them, named “Change,” are shown in Table 3. There was no significant difference in the baseline scores (total1) among the four groups (P ⫽ .55). A simple loop order restricted analysis test rejected the null hypothesis of ⌬A ⫽ ⌬B ⫽ ⌬C ⫽ ⌬D at .05 significance level (P ⫽ .025) in favor of the alternative ⌬A ⱕ (⌬B, ⌬C) ⱕ ⌬D. We compared the dual-intervention group to each of the single-intervention groups and each single-intervention group to the control group. Table 4 contains the P-values for these four comparisons. At a .0125 (0.05/4, by Bonferroni correction) significance level, we can conclude that there is no significant difference between the dualintervention group (D) and either single-intervention group (B and C), but we did identify significant differences between each of the single-intervention groups and the nonintervention group (A). We compared preintervention and postintervention scores to each question across groups. There was no significant score difference for any question preintervention; however, questions 3 and 4 had significant mean scores difference across the four groups postintervention. Questions 1 and 7 also had increases in the correct rate, but there was no significant difference in postintervention score across the four groups. The scores for other ques-

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DISCUSSION We chose to compare effects of inexpensive educational interventions aimed to increase knowledge about breast cancer and screening: providing an educational brochure, having an educational conversation with a mammography technologist while performing the examination, and a combination of both. Our brochure contained information regarding breast cancer, risk, and screening. We wanted it to be short and concise in order to keep the reader’s attention and to make it inexpensive to print. The choice of questions in our questionnaire was based on the published literature. There are several published instruments for assessing breast cancer knowledge for use in women in the general population (17,42– 44). In several studies, breast cancer knowledge was examined in specific populations of women using specific instruments or as the part of more complex questionnaires, whether in women of particular geographic and/or ethnic origin (18 – 21,29) or in high-risk groups (45,46). We chose questions that were oriented toward a general screening population and that covered knowledge about breast cancer, breast cancer screening, and breast cancer risk. We wanted to keep the questionnaire short and easy to implement over the telephone and, at the same time, to remain sensitive enough to measure possible changes in knowledge before and after intervention. Perhaps more questions might have increased the sensitivity of our study, allowing smaller differences in knowledge between the intervention groups to become apparent. However, our results clearly showed that the questionnaire was sensitive enough. The information and questions about breast compression were included to make patients aware about the need and reasons for breast compression. We did not feel that the answers to these questions should be included in the study, because they are not directly related to knowledge

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about breast cancer. Therefore, in planning the study, prior to conducting it, we decided not to take these into account. They were included in the brochure as a bonus piece of information for the participants, in hope that better understanding of imaging principles might increase patients’ willingness to endure discomfort associated with compression during mammography. Only one technologist was involved in the study. Because a technologist’s personality, attitude, and performance have a high influence on screening mammography patients (32–35), we chose to have the same technologists for all the participants in order to provide more consistent study conditions. We hypothesized that there would be a bigger increase in knowledge in both single-intervention groups compared to the control group and that the dual-intervention group would show an even bigger change compared to the control and single-intervention groups. Our results showed that all three interventions resulted in increased knowledge, but no significant differences between the interventions were observed; i.e., the observed increase was not related to the extent of the educational effort. Both the educational brochure and the clarification/conversation with a mammography technologist covered the same issues. Women in group D, the dual-intervention group, received both interventions. The time elapsed between these two interventions might have been too short for them to really serve as separate educational efforts; that might explain why the dual intervention had the same benefit as the conversation or brochure alone. Limitations of our study include its short duration, not allowing for additional time after the examination for more focused conversation between the technologist and the patient, and limiting the positive effect of the brochure by not allowing the patient to take it home with her. Our study endpoint was a telephone interview conducted 4 – 6 weeks after the initial encounter. If we were able to repeat the telephone interview in 6 months or 1 year, we would be able to better evaluate long-term knowledge retention, which potentially has the effect on women’s screening practices. In a study conducted by Grindel et al. (30), an increase in knowledge measured 1 year after the 60-minute health education session was still present, but it was significantly lower compared to one demonstrated immediately after the intervention. In designing the study, we did not allow for additional time after the mammograms had been performed for more focused conversation between the technologist and the patient. At the end of the telephone interviews, partici-

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pants were asked to comment on their overall experience. One of the repeated comments was that having a conversation at the same time a mammogram was being performed was somewhat confusing to patients. The effect of conversation might have been improved if there was a dedicated time for it. In practice, the brochure would have been given to patient after the encounter. In planning the study, however, we felt that if we let the brochure be taken home it would introduce an uncontrollable effect on the experiment. Some of participants in groups B and D (those given brochure and having dual interventions) who had taken the brochure home might have looked it over between initial and telephone interview, reinforcing their knowledge and the effect of the brochure as an educational intervention. On the other hand, some of them might not have read it again. Therefore, we chose to eliminate that uncertainty from experiment by collecting the brochure from the participant. If it was given to patients, it could be read at will and its positive effect increased. Champion et al. (24) showed that the effect of a pamphlet they used in their study was greater than the effect of an educational video, and one of the reasons might have been the availability of the pamphlet after the initial encounter.

CONCLUSION We conclude that all three low-cost interventions resulted in increased knowledge about breast cancer and screening. No difference in the amount of knowledge increase was found between the three interventions. An educational brochure seems to represent the most convenient method to increase knowledge about breast cancer and screening among women who present for screening mammography. REFERENCES 1. Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, Feuer EJ, Thun MJ. Cancer statistics, 2005. CA Cancer J Clin 2005; 55: 10 –30. Available at: http://caonline.amcancersoc.org/cgi/content/full/ 55/1/10. Accessed Feb 02, 2006. Erratum in CA Cancer J Clin 2005; 55:259. 2. Tabar L, Smith RA, Vitak B, Yen MF, Chen TH, Warwick J, Myles JP, Duffy SW. Mammographic screening: a key factor in the control of breast cancer. Cancer J 2003; 9:15–27. 3. Breast Cancer Facts & Figures 2005–2006. Atlanta, Georgia: American Cancer Society. Available at: http://www.cancer.org/downloads/STT/ CAFF2005BrF.pdf. Accessed Feb 02, 2006. 4. American Cancer Society. Cancer Prevention & Early Detection. Facts & Figures 2004. Available at: http://www.cancer.org. Accessed Nov 11, 2005.

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5. Richards CL, Viadro CI, Earp JA. Bringing down the barriers to mammography: a review of current research and interventions. Breast Dis 1998; 10:33– 44. 6. Sanchez Ayendez M, Suarez-Perez E, Vazquez MO, Velez-Almodovar H, Nazario CM. Knowledge and beliefs of breast cancer among elderly women in Puerto Rico. P R Health Sci J 2001; 20:351–359. 7. Lauver DR, Settersten L, Kane JH, Henriques JB. Tailored messages, external barriers, and women’s utilization of professional breast cancer screening over time. Cancer 2003; 97:2724 –2735. 8. Partin MR, Slater JS. Promoting repeat mammography use: insights from a systematic needs assessment. Health Educ Behav 2003; 30:97– 112. 9. Rakowski W, Ehrich B, Goldstein MG, et al. Increasing mammography among women aged 40-74 by use of a stage-matched, tailored intervention. Prev Med 1998; 27:748 –756. 10. Champion VL. Strategies to increase mammography utilization. Med Care 1994; 32:118 –129. 11. Facione NC. Perceived risk of breast cancer: influence of heuristic thinking. Cancer Pract 2002; 10:256 –262. 12. Phillips KA, Kerlikowske K, Baker LC, Chang SW, Brown ML. Factors associated with women’s adherence to mammography screening guidelines. Health Serv Res 1998; 33:29 –53. 13. Rimer BK, Trock B, Engstrom PF, Lerman C, King E. Why do some women get regular mammograms? Am J Prev Med 1991; 7:69 –74. 14. Costanza ME, Stoddard A, Gaw VP, Zapka JG. The risk factors of age and family history and their relationship to screening mammography utilization. J Am Geriatr Soc 1992; 40:774 –778. 15. Rutledge DN, Barsevick A, Knobf MT, Bookbinder M. Breast cancer detection: knowledge, attitudes, and behaviors of women from Pennsylvania. Oncol Nurs Forum 2001; 28:1032–1040. 16. Rimer BK, Resch N, King E, Ross E, et al. Multistrategy health education program to increase mammography use among women ages 65 and older. Public Health Rep 1992; 107:369 –380. 17. Stillman MJ. Women’s health beliefs about breast cancer and breast self-examination. Nurs Res 1977; 26:121–127. 18. Han Y, Williams RD, Harrison RA. Breast cancer screening knowledge, attitudes, and practices among Korean American women. Oncol Nurs Forum 2000; 27:1585–1591. 19. Wu TY, Yu MY. Reliability and validity of the mammography screening beliefs questionnaire among Chinese American women. Cancer Nurs 2003; 26:131–142. 20. Bener A, Honein G, Carter AO, Da’ar Z, Miller C, Dunn EV. The determinants of breast cancer screening behavior: A focus group study of women in the United Arab Emirates. Oncol Nurs Forum 2002; 29:E91– E98. 21. Leslie NS, Deiriggi P, Gross S, DuRant E, Smith C, Veshnesky JG. Knowledge, attitudes, and practices surrounding breast cancer screening in educated Appalachian women. Oncol Nurs Forum 2003; 30:659 – 667. 22. Paskett ED, Tatum C, Rushing J, Michielutte R, Bell R, Foley KL, Bittoni M, Dickinson S. Racial differences in knowledge, attitudes, and cancer screening practices among a triracial rural population. Cancer 2004; 101:2650 –2659. 23. Gilliland FD, Rosenberg RD, Hunt WC, Stauber P, Key CR. Patterns of mammography use among Hispanic, American Indian, and non-Hispanic white women in New Mexico, 1994 –1997. Am J Epidemiol 2000; 152:432– 437. 24. Champion VL, Springston JK, Zollinger TW, Saywell RM Jr, Monahan PO, Zhao Q, Russell KM. Comparison of three interventions to increase mammography screening in low income African American women. Cancer Detect Prev 2006; 30:535–544. 25. Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in health promotion programs:

560

Academic Radiology, Vol 14, No 5, May 2007

26.

27.

28. 29.

30.

31.

32.

33. 34.

35.

36. 37. 38.

39.

40. 41.

42.

43. 44. 45.

46.

Targeted and tailored approaches, Health Educ Behav 2003; 30:133–146. Skinner CS, Strecher VJ, Hospers H. Physicians’ recommendations for mammography: Do tailored messages make a difference? Am J Public Health 1994; 84:43– 49. Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989 –1997) and Papanicolaou tests (1991–1997): Behavioral Risk Factor Surveillance System. MMWR CDC Surveill Summ 1999; 48:1–22. Mah Z, Bryant H. Age as a factor in breast cancer knowledge, attitudes and screening behaviour. CMAJ 1992; 146:2167–2174. Rutledge DN, Barsevick A, Knobf MT, Bookbinder M. Breast cancer detection: Knowledge, attitudes, and behaviors of women from Pennsylvania. Oncol Nurs Forum 2001; 28:1032–1040. Grindel CG, Brown L, Caplan L, Blumenthal D. The effect of breast cancer screening messages on knowledge, attitudes, perceived risk, and mammography screening of African American women in the rural South. Oncol Nurs Forum 2004; 31:801– 808. Sung JF, Blumenthal DS, Coates RJ, Williams JE, Alema-Mensah E, Liff JM. Effect of a cancer screening intervention conducted by lay health workers among inner-city women. Am J Prev Med 1997;13: 51–57. Weinberg AD, Cooper HP, Lane M, Kripalani S. Screening behaviors and long-term compliance with mammography guidelines in a breast cancer screening program. Am J Prev Med 1997; 13:29 –35. Kamm BL. Communicating with mammography patients. Radiol Technol 2000; 71:247–264. Carney PA, Harwood BG, Weiss JE, Eliassen MS, Goodrich ME. Factors associated with interval adherence to mammography screening in a population-based sample of New Hampshire women. Cancer 2002; 95:219 –227. Engelman KK, Cizik AM, Ellerbeck EF. Women’s satisfaction with their mammography experience: Results of a qualitative study. Women Health 2005; 42:17–35. Dowd SB, Ott K. The radiologic technologist’s role in patient education. Radiol Technol 1998; 69:443– 460. Suter LG, Elmore JG. Self-referral for screening mammography. J Gen Intern Med 1998; 10:710 –713. Monsees B, Destouet JM, Evens RG. The self-referred mammography patient: A new responsibility for radiologists. Radiology 1988; 166: 69 –70. Reynolds HE, Jackson VP. Self-referred mammography patients: Analysis of patients’ characteristics. AJR Am J Roentgenol 1991; 157:481– 484. Robertson T, Wright FT, Dykstra RL. Order-Restricted Statistical Inference. New York: Wiley, 1988. Singh B, Schell MJ, Wright FT. Approximations to the powers of the likelihood ratio tests: The loop ordering and slippage alternatives. Commun Stat Simulat 1995; 24:91–109. Vaeth PA. Women’s knowledge about breast cancer. Dimensions of knowledge and scale development. Am J Clin Oncol 1993; 16:446 – 454. McCance KL, Mooney KH, Smith KR, Field R. Validity and reliability of a breast cancer knowledge test. Am J Prev Med 1990; 6:93–98. Stager JL. The comprehensive Breast Cancer Knowledge Test: Validity and reliability. J Adv Nurs 1993; 18:1133–1140. Hailey BJ, Carter CL, Burnett DR. Breast cancer attitudes, knowledge, and screening behavior in women with and without a family history of breast cancer. Health Care Women Int 2000; 21:701–715. Ondrusek N, Warner E, Goel V. Development of a knowledge scale about breast cancer and heredity (BCHK). Breast Cancer Res Treat 1999; 53:69 –75.