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Carney et al.1 noted that many eligible women have never had a screening mammogram. Potential explanations are offered. An additional consideration is that acceptance of screening is influenced strongly by social beliefs and perceptions.

The health belief model (HBM) suggests that behavior (participation in screening) is related to the degree of perceived health threat (breast cancer) and the belief that the health behavior (screening) will reduce the threat.2 Risk is not merely a scientific, objective assessment of a threat but is shaped by social and cultural factors. The HBM also suggests that women with high perceived barriers will be less likely to attend for screening. Barriers include demographic and logistic factors, anxiety and depression, beliefs, attitudes, and knowledge.3

Not everyone subscribes to the western biomedical perspective regarding illness. Individuals may have alternate belief systems, perhaps placing greater emphasis on religious faith.

Pfeffer has noted that many women are too frightened by cancer to consider mammography.4 Kee et al. observed that major reasons for nonattendance were related to feelings of indifference or ignorance of screening issues and to fear of pain or embarrassment.5 Pfeffer noted that many women minimize their risk of breast cancer by distinguishing themselves from women they consider “candidates” for breast cancer.4

Incomplete knowledge or misconceptions should be targeted through specific educational and awareness strategies. Various strategies need to be developed that are compatible with different views of health and illness. This will be a challenge. Vernon et al. noted that it is unknown whether the same educational messages and contact strategies are effective equally across age, racial, and socioeconomic groups.3

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Michael Jefford M.B.B.S., Ph.D.*, * Division of Hematology and Medical Oncology, Peter MacCallum Cancer Center, Victoria, Australia.