www.whijournal.comWomen’s Health Issues 19 (2009) 425–433

ONE MORE HURDLE TO INCREASINGMAMMOGRAPHY SCREENING

Pubescent, Adolescent, and Prior MammographyScreening Experiences

Eileen Thomas, PhD, RNa,*, and LaToya Usher, MS, RNb

aUniversity of Colorado Denver, Aurora, ColoradobFederal Bureau of Prisons, Lexington, Kentucky

Received 11 November 2008; revised 8 July 2009; accepted 15 July 2009

Background. Approximately $8.1 billion dollars is spent each year in the United States alone on

Supported bystudy.

* CorrespondUCDenver, ColleMail Stop: C28Fax: 303 724-856

E-mail: Eileen

Copyright � 200Published by Els

the treatment of breast cancer. Survival rates are dependent on access to, and utilization of,early detection services. The primary reason for disparity in breast cancer mortality is the delay

in time to diagnosis, resulting in poor prognosis. Despite ongoing research to understand bar-riers to mammography screening, recent studies report a decrease in mammography screeningamong all racial groups.

Methods. A qualitative approach was used to elicit information from 36 White non- Hispanic,

African-American, Hispanic, and Native American women without a history of breast cancer.Women were invited to share written or audiotape-recorded narratives about experiencespertaining to their breasts and their mammography screening experiences.

Findings. Major categories identified were: teasing, family norms and values, media/societalinfluence, body image, and mammography screening experiences. The resulting effects of

these experiences left these women with feelings of shame and ‘‘conflict’’ regarding theirbreasts. The major theme identified was breast conflict. Findings suggest that breast conflictmay persist throughout the lifespan and can have a negative influence on a woman’s decision

to participate in mammography screening.

Conclusion. The authors hypothesize that experiences that occur during adolescence pertain-ing to young girls’ breasts can influence a women’s body image, which in turn can later inlife affect health-seeking behaviors related to mammography screening. These findings have

implications for public health practice in planning for breast cancer screening, education,and interventions for women from diverse racial/ethnics groups.

Introduction

Findings from previous research (Thomas, 2003,2004, 2006) and findings from this study, which in-

cluded White, Hispanic, African-American, and Na-tive American women, suggest that ‘‘breast conflict’’is a latent tension underlying experiences that occur

a funding from NIH/NINR: 1-R15 as part of a larger

ence to: Eileen Thomas, Assistant Professor,ge of Nursing, 13121 E 19th Avenue, Room 4311,8-18, Aurora, CO 80045; Phone: 303 724-8540;0..thomas@ucdenver.edu.

9 by the Jacobs Institute of Women’s Health.evier Inc.

during adolescence. Breast conflict is defined accord-ing to the authors as: The oblivious discord womenexperience regarding personal feelings about theirbreasts and how women define themselves in relationto their breasts based on messages received from peersand society; in other words, the conditions for conflictare present but women are neither aware of, nor dothey recognize, that they are defining themselves inrelation to their breasts. The authors posit that thisbreast conflict seems to persist throughout the lifespan. Breast conflict can have a negative influenceon a woman’s beliefs and attitudes regarding breastcancer and her decision to participate in mammogra-phy screening. If this conflict is not identified and

1049-3867/09 $-See front matter.doi:10.1016/j.whi.2009.07.002

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433426

addressed, breast conflict could continue throughouta woman’s life time, resulting in continuing underutili-zation in, or inconsistent use of, mammography screen-ing. The authors’ working assumptions is that breastconflict is likely a multidimensional construct withboth detrimental and potentially beneficial effects. Det-rimental effects from not seeking mammographyscreening result in increased breast cancer mortalityand morbidity, whereas the beneficial effects would re-sult in more positive breast cancer outcomes, the resultof early detection and treatment. The authors posit thatbreast conflict is a process that can increase (detrimen-tal effects) or decrease (beneficial effects) depending onunanticipated events that may occur across a woman’slifespan, for example, death of a family member frombreast cancer. The purpose of this paper is to reportthe findings from a qualitative study that lead theauthor to the identification of a new concept identifiedas breast conflict.

Background and Significance

Cancer, the second leading cause of death in the UnitedStates, is a significant burden in terms of morbidity andeconomic and emotional costs. Breast cancer is the mostcommon non-skin cancer and the second leading causeof cancer-related death (after lung cancer) in womenworldwide (World Health Organization, 2005).Approximately $8.1 billion are spent each year in theUnited States alone on the treatment of breast cancer(Brown, Riley, Schussler, & Etzioni, 2002). Survivalrates are dependent on access to, and utilization of,early detection services. Breast cancer death ratesremain high among ethnic minority women despitea lower incidence rate compared with White women(National Cancer Institute, 2007). The American CancerSociety (2003) reports that the primary reason is a delayin time to diagnosis, resulting in poor prognosis. En-couraging not only early but regular mammographyscreening has been a major challenge. Despite ongoingresearch to understand barriers to mammographyscreening, the rates of mammography use among eth-nic minority women have not increased substantially.In fact, recent studies report a decrease in mammogra-phy screening among all racial groups (Breen et al.2007). Preliminary data strongly suggest that women’searly experiences pertaining to their breasts and associ-ated gender issues have a significant influence onwomen’s mammography screening behaviors(Thomas, 2003, 2004, 2006). Understanding barriers tomammography screening among White, Hispanic,African-American, and Native American women isa critical step in the goal of increasing screening.

In the United States, the occurrence of breast canceris highest for White women, followed by AfricanAmericans, Asians, Hispanics/Latinas, and NativeAmericans. African-American women are more likely

to die from breast cancer within 5 years after diagnosisthan White women. Survival statistics for Hispanic/Latina women are also poor. Hispanic/Latina womenare 1.5 times more likely to die from this disease thanWhite women (Amend, Hicks, & Ambrosone, 2006;Dignam, 2000; Newman, 2005; Pisani, Parkin, Bray, &Ferlay, 1999). Although breast cancer is diagnosedabout 40% less often among Hispanic/Latina women,it is often diagnosed at a later stage than in non-His-panic women. Lower use of breast cancer screening,such as mammography, may contribute to the delayin diagnosis among this population. After accountingfor differences in age, compared with White women,Hispanic/Latina women are almost 3 times morelikely to have been diagnosed at a later stage of the dis-ease, and about 2 times more likely to have largertumors with characteristics that predict poorer clinicaloutcomes (Watlington, Byers, Mouchawar, Sauaia, &Ellis, 2007).

Native American women pose unique challenges interms of obtaining accurate statistics on prevalenceand receiving timely treatment. Mortality rates frombreast cancer among Native American women arelikely underestimated for several reasons. First, manyNative American women who have breast cancer donot get biopsies and only biopsy-confirmed breast can-cer is reported in cancer statistics. Second, many Na-tive American women who die off the reservation arelisted as ‘‘White’’ on their death certificates (Burhans-stipanov, 1996). Cancer rates that were previouslyreported to be lower in Native Americans have beenshown to be increasing over the past 20 years. Addi-tionally, there is no single national database that accu-rately presents comprehensive cancer data for NativeAmericans. Controlling for age, stage, and grade of dis-ease, and census-tract poverty level, Native Americanwomen are 4 times more likely than other racial ethnicgroups to receive their first breast cancer-directed sur-gery more than 6 months after diagnosis (Wilson et al.,2000).

There has not been a significant improvement inbreast cancer mortality rates among women from eth-nic minority groups. In 2000, there were over 30% morebreast cancer deaths among African-American womencompared with White women (Ries et al., 2003).Research findings suggest ‘‘first generation HispanicAmerican women with breast cancer have a relativedelay in the timeliness of their cancer diagnosis andshould be targeted in interventions designed to in-crease the use of breast cancer screening’’ (Herdeen &White, 2001, p. 123). Breast cancer is the leading causeof cancer death among this population. Overall, ethnicminority women consistently have disproportionatelypoorer breast cancer outcomes. Identifying breast can-cer in its early stages is the key to successful treatment.

Mammography screening has not increased signifi-cantly among ethnic minority groups; in fact,

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433 427

researchers report mammography rates have been de-clining over the past 5 years (Breen et al. 2007; Chagpar,Polk, & McMasters, 2008). Therefore, it is essential thatresearchers consider new and innovative approaches tobetter identify and understand barriers to mammogra-phy screening and early breast cancer diagnosis amongethnic minority groups. Although many women havehad at least one screening mammogram, many womenhave had no screening or have not been consistent withrecommended mammography screening guidelines.For women to benefit from mammography, regularscreening is needed. Despite campaigns for early breastcancer detection, many women still do not obtain mam-mography screening as recommended by the ACS.

Access to health care alone is not sufficient for mam-mography screening to take place. Native Americans,for example, are eligible for free comprehensive healthcare through the Indian Health Service, which includeroutine mammography screening for women 40 yearsof age and older, yet only half choose or are able touse these services. Some Native American womenfind that no Indian Health Service facilities are accessi-ble to them and Indian Health Service usually does notcover the cost of care provided outside its system(Cobb & Paisano, 1998). Among women with accessto health care, Ryerson, Miller, Eheman, Leadbetter,and White (2008) found a significant decline in mam-mography screening among women between theages of 40 and 59 who were insured, particularlyamong White non-Hispanic women. And the NationalCancer Institute reports that, in 2005, mammographyscreening rates fell for White non-Hispanic, Blacknon-Hispanic, and Hispanic women (National CancerInstitute, 2007). The literature on breast cancer screen-ing behaviors and barriers to screening among ethnicminority women is substantial. However, researchershave not explored barriers to mammography screen-ing in relation to women’s life experiences concerningtheir breasts, particularly experiences that occurredduring adolescence. This study sought to exploreamong a racially and ethnic diverse group of women,their life experiences in relation to their current mam-mography screening behaviors.

Framework

Critical social theory and feminist perspectives wereused as the critical lens, or framework, that guidedthis investigation. Breast cancer screening behaviorsof women and minority women, in particular, relatenot only to the larger picture of social, economic, andcultural oppression, but are related to gender issuesof being a woman or an ethnic minority woman inthe United States. The focus of this study was on exam-ining covert barriers to women’s mammographyscreening behaviors through a feminist perspectivewithin the framework of critical social theory.

Feminist perspectives and critical social theory takeinto consideration the social context represented inthe lived experience of the participants. One historicand contemporary perspective from critical socialtheory that influenced this inquiry is that language isparamount to how people comprehend meaning andcreate knowledge (Calhoun, 1995). Rather than sepa-rating women’s experiences from the contexts in whichthey occur, feminist scholarship recognizes women’sexperiences as connected to the larger political, social,and economic environment. The use of feministperspectives in this study helped the investigators tosee patterns and interrelationships, as well as implica-tions for questions that an inquiry from a nonfeministperspective may not have revealed.

Methods

This qualitative, descriptive study used narrativemethods to generate data. The purpose of narrativemethods in research is to gain an understanding ofhow people think or act in the context in whichthey live through their stories. Written informed con-sent was obtained before the start of data collection.Participants were asked to share written or audio-tape-recorded narratives about specific events thatoccurred throughout their lives related to theirbreasts, mammography screening experiences, andcurrent mammography screening behaviors. For thepurpose of this study, no distinction was made be-tween the terms stories and narratives; they wereused interchangeably. Narratives were selected forthis investigation because this type of data provideddepth to the personal experiences that were not likelyto be attained by interviews alone.

Participants and recruitmentWe recruited 36 White non-Hispanic, African-American,English-speaking Hispanic/Latina, and non-pueblodwelling Native American women, age 42 and older,without a personal history of breast cancer to par-ticipate in this study. Recruitment flyers were placedin local newspapers and community newsletters.Participants were recruited from response to theadvertisements as well as word-of-mouth referrals.Recruitment and data collection took place over an11-month period, between 2005 and 2006, in twocounties located in the central regions of a Southwest-ern state. Eight women, 50 to 66 years of age partici-pated in the Hispanic group, nine were AfricanAmerican participants, 42 to 60 years of age, eightwere non-pueblo dwelling Native American women,43 to 65 years of age, and 11 participants were Whitenon-Hispanic participants ages 56 to 69 years.

The study was reviewed and approved by a univer-sity institutional review board. All participants wereasked to choose a pseudonym for identification

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433428

purposes. Participants were offered the option of writ-ing or recording their stories on audiotape. A notebookor tape recorder was provided to the participant basedon their preference. The women were asked to share atleast three stories about experiences regarding times intheir lives when their breasts may have had special sig-nificance for them. In addition, the women were askedto share a story about a mammography screeningexperience. If the participant had never had a mammo-gram, the participant was directed to discuss the rea-son for not having a mammogram. All participantsreported having at least one mammogram, althoughmany reported they had not had a mammogramwithin the past two years.

At the end of a 4-week period, the stories were col-lected and reviewed. Follow-up audiotape-recordedinterviews were conducted for clarification and elabo-ration. Interview questions were developed from theindividual participants’ personal narrative. Duringthe follow-up interview, participants discussed theircurrent mammography screening behaviors. Narra-tives (audiotape-recorded or written) and interviewswere transcribed verbatim by a paid transcriptionist.A total of 36 interviews were conducted and redun-dancy of responses occurred; continued data collectionat the end of the study added little new information.The women shared stories about early experiencesduring puberty and stories about their mammographyscreening experiences. The 4-week period allowed thewomen time to reflect on times in their lives when theirbreasts were significant to them and the subsequentfollow-up interview provided clarity for theresearchers.

Data analysisInitial descriptive line-by-line coding, using the wordsor phrases of the participants, involved looking forrepetition within and across the transcripts. The listof codes was examined to identify common conceptsthat described participants’ descriptions and experi-ences concerning their breasts. Similar code termsand phrases were grouped together and then re-grouped to include all of the identified concepts intocategories of similar topics. Looking for relationships,the categories were resorted into groups of similarcontent and meaning. The categories were furtherreviewed, paying particular attention to similaritiesand differences in women’s breast-related experience,including their mammography screening experiences.Finally, a theme was identified by reviewing andorganizing the categories into a common topic. Twocolleagues, experienced in qualitative data analysis,coded the transcripts independently to verify theanalysis process and the resulting categories andtheme.

Multiple contacts with the participants (three in-person encounters and multiple methods of data col-

lection utilizing narratives and in person interviews)contributed to the reliability of the data. In addition,the involvement of peers during the analysis processaided in reducing bias that can occur when a single re-searcher analyzes text. The use of both narratives andfollow-up interviews created an additional strengthand enhanced the credibility of the data.

Findings

Participants were asked to share experiences abouttimes in their lives when their breasts may have hadspecial significance for them. In every case, among allracial and ethnic groups, the women shared informa-tion about experiences during puberty, particularlyexperiences of being teased by both their peers (malesand females) and adults within and outside their fam-ily structure. There were no differences in the women’searly life experiences regarding stories about theirbreasts based on their race/ethnicity. Women in eachracial/ethnic group shared stories about painful mam-mography experiences and stories about family normsor teasing that occurred during puberty regardingtheir breasts. Teasing centered on situations wherethe women perceived negativity regarding body imagedirectly related to women’s breasts.

CategoriesIn qualitative analysis, code words or phrases are iden-tified by reviewing the raw data (transcripts). A groupof code words or phrases that have common elementsthat relate to a particular set of patterns or recurrencesthroughout the transcripts are then organized intoclusters of similar topics. The major categories, identi-fied during the analysis process, that may influencemammography seeking behaviors were: adolescentteasing, breast and body image, family norms andvalues, media/societal influences, and mammographyscreening experiences (Table 1). Recognizing that hu-man realities are complex, a qualitative methodologyinvolves a focus on human experiences. Using a narra-tive approach, this study focused on discovering asso-ciations between women’s experiences regarding theirbreasts, including mammography screening experi-ences, and their current mammography screeningbehaviors. Gaining insight in the area of women’sexperiences across the lifespan may aid in developingnew strategies to assist women in their decision toparticipate in mammography screening.

Adolescent teasing/breast and body image. Shroff andThompson’s (2006) research supported the importanceof specific friend and peer influences as potential risksfactors for body image, eating disturbances and self-esteem among adolescent girls. The opinion of peersis highly valued by adolescent females, thus impacting

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433 429

satisfaction with body image. One White participantstated:

Tabl

Ado

Fam

Medinfl

Brea

Mamex

From that point on (8th grade) I was conflicted aboutmy breasts. There were girls who were jealous.they hadn’t developed yet. Mean girls said, ‘‘Jeez,what size ARE you?’’ We were [myself and twoother girls] subjected to as much off color humoras could happen in 1959. So there I was with boyswho might never look up at my face again and girlswho were as uncomfortable as I was.

A woman’s body image includes the symbolic mean-ing and importance of her breasts (Kraus, 1999; Spencer,

e 1. Participant Quotes and Corresponding Category by Race/Ethnic

Category Participa

lescent teasing I used to get teased by some boys and callefaded from my memories. I think it has aperception as a woman.

Because of all that early teasing by boys, girmy breasts as a nuisance.

Despite the nuns attempt to keep us focusethey all knew. ‘‘Look whose got tits!’’ orThat’s when I began carrying my books cthrough high school.

The boys were in the practice of snapping bembarrassing. I felt I didn’t fit in, but I didPoor J. who was called ‘‘Peneplain’’ (it wanearly featureless land).

ily norms and values When I was an adult, I found out my aunt hthe time . . . but as all conversations regamom cut to the chase and didn’t elabora

My upbringing was very reserved. We didand breasts. I didn’t know what to expec

When I started to develop, my mother told mwould really hurt and cause cancer.

My puberty celebration was at 13 years of acheering my way through womanhood wis a Blessing Way, all night chant for goo

ia and societaluence

I think for many years the media (televisionthe way I feel about my breasts. About 7implants. Why in God’s name would anobtaining the perfect body as seen on TV

We attach so much meaning to them [breastto have a status and maybe personality,

When my first love was breaking up with m‘‘didn’t have any tits!’’

It saddens me that this is a society so obsessts and body image I was kind of small, so it was a challenge to

other girls. Surprise, surprise, I wasn’t nI am just not happy about my body image;I tend to wear large clothes. I’m working on

attention to my breasts. I hated my bodyimplants put in but I could never afford

After writing these stories about breast issuea woman.

mography screeningperiences

I was embarrassed and felt ashamed when Ia mammogram since. Any diagnostic tessomething horrible, something no one w

I had the mammogram; it was one of the mthrough.

. . . getting a mammogram isn’t a very dignyour breasts is typically performed in m

I was afraid to have the mammogram beca

1996). Body image has been defined as how a personviews her physical appearance. Society’s standards foran ideal body image when incorporated into a person’sevaluation of their physical appearance can contributeto an altered body image (Roy & Andrews, 1991). Stud-ies that address body image are typically related to bodysize or eating disorders and perceptual studies of bodyimage most often examine a person’s accuracy in theirbody size estimates. However, perceptual dimensionsof body image can also be related to social appearancecomparison of peers or images seen in the media (Peli-can et al., 2005; Shroff & Thompson, 2006). Alterations

ity

nt Quotes Race/Ethnicity

d flat chest. This teasing never completelylways somehow had an impact on my

White

ls, my mother and aunts, to this day, I think of African American

d, the whispers among the boys . . . told me‘‘Wow, never knew she had such knockers.’’lutched to my chest and continued to do so all

Hispanic

ras. I didn’t have a bra to snap; it wasn’t get teased by my peers not like my friend.s an earth science reference . . . an area of flat,

Native American

ad a radical mastectomy, no one discussed atrding more intimate parts of our bodies, myte at all.

White

not talk about personal things like body partst during puberty.

African American

e to be careful not to get hit in the chest that it Hispanic

ge, with a lot of support from my family andas a great excitement. The puberty ceremony

d blessing.

Native American

, magazines, and movies) have also impactedyears ago . . . I considered having breast

yone want implants? It has to be the need for.

White

s]. I find myself thinking of how breasts seemseparate from the rest of the body.

African American

e, he told me in part it was due to the fact that I Hispanic

sed with material and physical attributes. Native Americankeep my breast stuffed and hidden from the

ormal. I was skinny and breasts rule.White

I wish I didn’t have breasts. African Americanbeing as nonsexual as possible and not bring. . . I know I would have been tempted to getit!

Hispanic

s, I realize how symbolic the breasts can be to Native American

exposed my breast. I have never returned fort is scary. You are going for this test to rule outants.

White

ost painful experiences that I have had to go African American

ified process. Having another person touchuch more intimate circumstances.

Hispanic

use of stories I had heard. Native American

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433430

in internal or external and environmental stimuli can al-ter one’s satisfaction with body image in the absence ofbreast cancer. Studies suggest that women who believetheir breasts are important to their feelings of femininityand attractiveness experience greater dissatisfactionwith their body image after breast cancer treatment(Kraus, 1999; Martin & Hanson, 2000). A Native Amer-ican woman explains:

If I ever lost my breast, I don’t think I would like it, itwould do something to my self confidence. it doesmake you feel like a woman, a whole woman whenyou have both breasts. Your breasts have an impacton perceptions of yourself as a woman. The thoughtthat it [breast] might be cut away, even partial, Ithink it’s a loss to a woman. a woman losesa part of their self identify during that time.

This dissatisfaction with body image can occur be-fore, or because of a threat of a breast cancer diagnosis.In addition, dissatisfaction with body image can be theresult of teasing. For example, a White participantstated:

I used to get teased by some boys and called birdlegs and flat chest. This teasing probably has nevercompletely faded from my memories, I think it hasalways somehow had an impact on my perceptionas a woman. I think somehow I have felt less at-tractive because of small breasts. As I grow older, Ihave given up on my breasts.

Teasing that occurs during adolescence regardinggirls’ breast size and shape could influence women’sperceptions about their breasts and body image andlater in life their mammogram beliefs and behaviors.Vander Wal and Thelen (2000) found that peer teasingis a significant predictor of body image dissatisfaction.Body image factors may influence many health promo-tion behaviors (Grogan, 2006), including participationin mammography screening.

Media/societal influence and family norms and values. Themedia plays a critical role in the way females perceivetheir bodies. The ideal of the perfect body is impactedby diverse advertisements, retail, and the entertain-ment industry. All of this influences the culture of theideal of beauty and attractiveness (Jung & Lennon,2003). As early as adolescence, females are bombardedwith the appearance of the body and become preoccu-pied with how they believe their body should lookcompared with what is seen in the media. Researchersfound a strong causal link for women and girls be-tween sociocultural norms for ideal appearance andappearance-contingent self-worth (Strahan, LaFrance,Wilson, Spencer, & Zanna, 2008). When confrontedwith sociocultural messages, women integrate theminto their self-worth and self-esteem. With repeatedexposure to societal messages, women continue tomeasure their self-worth based on appearance that

has been dictated by the societal norms. An African-American participant reported that, ‘‘Society wantsand expects women to be shaped a certain way, likethe movie stars and models you see in the movies.’’A major reason given for not participating in breastcancer screening includes the fear of a breast cancerdiagnosis. Thomas (2006) suggests that, in addition tosymbolic meaning and media or societal views, familynorms and values can also influence a woman’s deci-sion to participate in mammography screening. Healthbehaviors that begin during adolescence form thefoundation for health behaviors that are carried intoadulthood. Culture and family norms and values con-tribute to the experience of health and prospectivehealth behaviors. A Hispanic participant reflects backon an experience as a teen:

Some girls slouched and tried to hide the fact oftheir development but I never did. I think one ofthe reasons was that my father instilled the beliefin all his kids that we should be proud of who wewere and carry ourselves with our head held highand square shoulders.

A Native American participant shared ‘‘[my] grand-mother always told me, don’t show off your breasts,you know you’re not supposed to show that part ofyour body, so it was always wrapped up in layers.’’

Parents are important role models throughoutchildhood and adolescence (Harper, 1990). In addi-tion to serving as role models for health promotionbehaviors such as proper nutrition and exercise, par-ents can be instrumental in the development of life-long health-related behaviors by participating themselves in cancerscreening activities and talking with their adolescentdaughters about health promotion and disease pre-vention activities such as mammography screening.Mothers’ participation in breast self-examination andmammography screening can encourage similarbehaviors in their daughters. Open discussion furtherreinforces the importance of routine physical examina-tions and breast cancer screening thus setting the stagefor the development of life-long healthy habits.

Mammography screening experiences and currentbehaviors. Over half (58%) of the women stated theyhad no plans on returning after their first mammogramexperience. All but two women reported the benefits ofmammography and early screening even though themajority of participants reported a less than favorablefirst mammography screening experience. All of theparticipants shared a story about their first mammog-raphy screening experience and current mammogra-phy screening behaviors. Following are participantcomments regarding their first or an early mammog-raphy screening experience and current screeningbehaviors.

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433 431

One White woman reported: ‘‘I had a double set ofmammograms taken as the first set was ‘cloudy’ what-ever that means. No report came in the mail, threeyears later I went back for another mammogram.’’ AHispanic woman shared the following experience re-garding her first mammography screening experience:

I believe I was 52 years old. The room was cold; themachine even colder, while the technician’s attitudewas near arctic. I awkwardly stooped over as shesqueezed my breast in a vise like thingy. I thoughthow much is this really different from a porno flick?

Another White woman shared:

The woman who assisted me with my mammogramwas very kind and caring. but I was embarrassedand felt ashamed when I exposed my breast. I stillfeel ashamed. I have never returned for a breastexam or mammogram since.

Referring to a mammography experience, an African-American woman stated:

Having another person touch your breasts so metic-ulously is typically performed in much more inti-mate circumstances. To have my breasts, a symbolof womanhood, handled that way went againsthow I typically view myself and them. To havesomeone manipulating that portion of my bodywith such clinical detachment stood in stark con-trast with the messages we are bombarded withconstantly about breasts. I found myself thinkingof how breasts seem to have status and maybepersonality separate from the rest of the body.

In addition to a fear of the mammogram examina-tion, finding a lump and fear of a breast cancer diagno-sis was a concern for one African-American participant:

I was afraid to have the mammography because ofstories I had heard, but I was even more afraid ofwhat the cause of this lump in my breast was. Idid have the mammography and it turned out tobe one of the most painful experiences that I havehad to go through. I do understand the importanceof getting the mammography. I do understand thatprevention and early detection is the best way tosave lives. I may go back, it won’t be easy.

Because of a painful first mammogram experience,some women choose not to return for their secondmammogram as defined according breast cancerscreening guidelines. After having her first mammo-gram at the age of 40, this White participant did nothave another mammogram for over 10 years:

I had my first mammogram at the age of 40. As mostwomen will agree, it was not a pleasant experience.All the jokes you hear about laying down and havinga car run over you were real close to my first experi-ence. At age 53, I had another normal mammogram.

Findings from this study are congruent with find-ings from other qualitative studies (Cronan, 2008 Phil-

lips, Cohen, & Tarzian, 2001; Thomas, 2004;).Commonly cited barriers to mammography screeninginclude fear of finding a lump, lack of knowledgeabout the need for mammography screening, andfear of the pain associated with mammography.

Overall theme

Breast conflict. The women expressed various forms ofconflict regarding their breasts. For example, some ofthe women shared concerns about showing versusnot showing their breasts. For some women, estab-lished family values dictated women’s comfort levelregarding exposing their breasts either in social ormedical settings. Some of these women found it diffi-cult to separate exposing their breasts, regardless ofthe setting. Some women shared that breasts can bringboth positive and negative attention. One African-American woman shared, ‘‘I have mixed feelings aboutmy breasts, I love them and I hate them.’’ Another His-panic woman stated, ‘‘I was taught to cover my breasts,but as I got older I found out that men are fixated onbreasts so I started wearing skimpy clothes to get atten-tion.’’ However, another Hispanic participant shared,‘‘I had mixed feelings about my breasts because mybreasts brought both good attention and unwanted at-tention.’’ Another Native American woman shared,‘‘Breasts are good because they give life to your chil-dren when you breastfeed but breasts can also killyou if you get cancer.’’

Discussion

This study was designed to explore women’s life expe-riences concerning their breasts and their currentmammography screening behaviors. Regardless ofrace/ethnicity, all the women shared stories aboutteasing that occurred during adolescence and storiesabout their thoughts regarding the influence of the me-dia on their self image related to their breasts. Familynorms and values were discussed regarding the em-phasis on modesty concerning women’s breasts. Thefindings did not indicate any differences in thewomen’s early perceptions of their breasts in relationto their current mammography screening behaviors.The women in this study who reported having a mam-mogram within the past two years shared similarstories about early teasing and the impact of the mediaon their identity and expressed concerns regardingtheir identity if they were diagnosed with breast can-cer. These same women had a relative or close friendwith breast cancer who did not survive, which theystated influenced their decision to participate in mam-mography screening. However, these women alsoshared their reluctance to participate in mammogra-phy screening per ACS guidelines and admitted theywere not always consistent with screenings.

E. Thomas and L. Usher / Women’s Health Issues 19 (2009) 425–433432

Findings from this study demonstrate the need toconsider the impact of past experiences on women’scurrent health promotion behaviors related to mam-mography screening. Despite efforts to promote breastcancer screening, particularly among ethnic minoritypopulations, exploring women’s mammographyscreening behaviors in relation to experiences concern-ing specific life events has not been a focus of publichealth efforts to decrease the disparity breast canceroutcomes. As health care providers continue to carefor more people from diverse ethnic and racialbackgrounds, findings from this study providesa more in-depth understanding about the influence ofpast experiences on health promotion behaviors, andspecifically mammography screening behaviors. Inaddition, findings may lay a foundation for the devel-opment of a model that addresses ethnic minoritywomen’s health promotion behaviors related to mam-mography screening. Results from this study revealedbarriers to mammography screening that had notbeen considered in the past, experiences that occur dur-ing adolescence, such as teasing, media influence, andfamily norms and values.

Awoman’s body image includes the symbolic mean-ing and importance of her breasts (Kraus, 1999; Spen-cer, 1996). Thomas (2006) suggests that, in addition tosymbolic meaning and societal views, family normsand values and other experiences that occur during ad-olescence, can influence a woman’s decision to partic-ipate in mammography screening. Body image factorsmay influence many health promotion behaviors (Gro-gan, 2006), including participation in mammographyscreening. Findings from this study suggest percep-tions formed during puberty and adolescence canleave women with feelings of shame and conflict re-garding their breasts. During the developmental stageof adolescence, young people strive for independenceand begin to make decisions that impact them for therest of their lives.

Findings from this study suggest that perceptionsformed during puberty and adolescence can leavewomen with feelings of shame and conflict regardingtheir breasts. Health care providers should consider as-sessing appearance-related teasing in their patients’lives to identify women who may be at risk for bodyimage disturbance functioning that could result in un-derutilization of mammography screening and otherhealth promotion behaviors. Mammography techni-cians should be educated in the long-term implicationsof women’s perceptions of ‘‘bad’’ mammogram experi-ences. Negative body image resulting from a firstmammogram experience, media images, early teasing,or family norms and values can have profound effectson a woman’s self-perception. Feminine beauty repre-sented in women’s magazines or the movies reinforcestereotyped portrayals of femininity. Studies involvingwomen with and without breast cancer, and studies

involving post-mastectomy patients, suggest linkswith breast dissatisfaction and diminished self-esteemor doubts about one’s femininity (Grant, 1996). Awom-an’s definition of self is often based on a lifetime offeedback about having breasts and the possibility ofbreast cancer threatens this self-perception (Wilmoth,2001).

This study has several strengths that highlight theimportance of the findings. The present study is thefirst to explore women’s experiences in relation to theircurrent mammography screening behaviors. In addi-tion, the inclusion of women from four racial/ethnicgroups provided the opportunity to explore women’sexperiences and behaviors from a multiculturalperspective.

However, the women who participated in this studywere from a select geographical area and select groupof women who saw the recruitment flyer or advertise-ment for the study in the newspaper. It is likely thatwomen from other parts of the United States mightshare different experiences. Regardless of race/ethnic-ity, negative body image resulting from early life expe-riences, particularly those experiences that occurduring adolescence, can conceivably have an impacton health promotion behaviors such as mammographyscreening. Future research includes testing the authors’breast conflict concept with a larger sample of womenfrom diverse racial/ethnic groups.

AcknowledgmentsThe first author acknowledges the National Institutes of HealthNational Center on Minority Health and Health Disparities, thewomen who shared their experiences, and the editorial assistanceof Suzanne Lareau, RN, MS, FAAN.

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Author DescriptionsEileen Thomas, PhD, RN, is an assistant professor at

the University of Colorado Denver, College of Nursingin Aurora, Colorado, USA.

LaToya Usher, MS, RN is a health systems specialistfor the Federal Bureau of Prisons in Lexington, Ken-tucky.