• mammography;
  • African Americans;
  • culture;
  • attitude to health


  1. Top of page
  2. Abstract

Behavioral studies show that women's stage of readiness to adopt mammography screening affects their screening rates and that beliefs about breast cancer and screening affect stages of screening. The purposes of this study were to determine, first, the relationship between particular health and cultural beliefs and stage of mammography screening adoption in urban African American women, and second, whether demographic and experiential characteristics differed by stage. Data were analyzed from 344 low-income African American women nonadherent to mammography screening who participated in a 21-month trial to increase screening. At baseline, these women were randomized into 1 of 3 groups: tailored interactive computer instruction, targeted video, or usual care. Participants were categorized by stage of mammography screening adoption at 6 months as precontemplators (not planning to have a mammogram), contemplators (planning to have a mammogram), or actors (had received a mammogram). Although demographic and experiential variables did not differentiate stages of screening adoption at 6 months postintervention, some health and cultural beliefs were significantly different among groups. Actors were more preventive-health–oriented than precontemplators and had fewer barriers to screening than did contemplators. Precontemplators had more barriers, less self-efficacy, and greater discomfort with the mammography screening environment than did contemplators or actors. These results will be useful, not to change cultural beliefs, but to guide the design of health education messages appropriate to an individual's culture and health belief system. Cancer 2007. © 2006 American Cancer Society.

African American women continue to experience disparity in breast cancer survival. 1–5 Although the incidence of breast cancer is lower in this population than in Caucasians, African Americans are more likely be diagnosed with late-stage presentation of breast cancer, 6 and they have higher death rates than any other racial or ethnic group. 7 Poverty contributes to these problems, since breast cancer mortality rates are relatively higher for poorer communities, 8–11 and minorities are more likely to be poor and to lack health insurance than non-Hispanic whites. 4, 12

Although poorer survival may be partially explained by biological differences, decreased access to health care, and inequalities in treatment, 2, 13–15 personal beliefs about cancer and screening also may interfere with early detection of breast cancer. Behavioral studies show that women's stage of readiness for mammography screening affects their participation in screening. 16 These stages are based on the transtheoretical model (TTM) 17 and are conceptualized as follows 1: precontemplation (no previous mammogram and no plan to have one in the coming year) 2; relapse precontemplation (had 1 or more mammograms in the past and is off schedule, with no plan to have one within the coming year) 3; contemplation (no previous mammogram but plans to get one within the coming year) 4; relapse contemplation (had 1 or more mammograms in the past and is off schedule, with a plan to have one within the coming year); and 5 action (had 1 mammogram on schedule and is planning another one according to screening guidelines). 18–20

Specific health beliefs have been associated with various TTM stages. 21–28 In their study of low-income African American women, Champion and Springston 29 found that women's perceptions of breast cancer susceptibility and benefits of and barriers to screening were stage-specific. Women who were precontemplators perceived significantly fewer risks for developing breast cancer and fewer benefits of mammography screening than did women who were in contemplation, action, or relapse. Barriers were higher for precontemplators and contemplators and lowest for women in the action stage. Similar findings resulted from a study of predominately African American women by Skinner et al. 30 Precontemplators had the lowest perceived benefits and highest barriers scores. Breast cancer knowledge was also lowest in the precontemplation stage. Contemplators were most worried about finding a lump. Women in the action stage had the fewest perceived barriers.

In addition to perceived risk, benefits, and barriers, cultural beliefs among African American women have been related to screening. 31, 32 Identified beliefs include perceptions about cancer and screening, including fear of cancer discovery, doctors, or treatment 33–40; a fatalistic view about the inevitability of death once diagnosed 35, 41–49; and present time orientation in general and specific to preventive health practices as well as crisis orientation toward medical care. 43, 44, 50, 51 Investigators have identified common folk beliefs about causes of cancer in African Americans, such as that surgery spreads cancer and that cancer is caused by a bruise or sore. 45, 52–54 There is also a confidence in folk remedies and nontraditional cancer treatments, 55 and social networks, collectivism, and racial pride have been found to influence breast cancer health-seeking behavior. 36, 47, 50, 56

Religious beliefs have also been associated with health behavior in African American women, with some studies demonstrating that religiosity can be a positive influence on specific health perceptions and behaviors among older African American women. 57, 58 Other work has suggested that religious thought, experience, and faith may sustain an individual, giving meaning and hope in seemingly overwhelming circumstances. 59–62 Examples of these religious influences include aspects of religious coping and reframing of health problems, a belief that God is the controlling force in health, and the need for faith in the healing power of God.

Women vary in relation to stages of mammography behavior, and little is known about the relationships of health and cultural beliefs to stage of mammography screening readiness in African American women. Understanding these relationships will increase our ability to develop staged-based mammography screening messages that are specifically tailored to both health and cultural beliefs. The purpose of this study was to determine the relationship between specific health and cultural beliefs and stage of mammography screening adoption in low-income African American women. The research questions were as follows:

  • 1
    Do health and cultural beliefs relevant to mammography differ among African American women by stage of mammography screening adoption (precontemplators, contemplators, and actors)?
  • 2
    Are particular demographic and experiential variables related to stage of mammography adoption in an African American population?


  1. Top of page
  2. Abstract

Theoretical Framework

For this study, we used a combination of theories and models to guide our investigation. As opposed to rigidly applying a single theory, Witte argues for integrating aspects of successful and well-tested theories to develop persuasive campaigns for altering behavior. 63 Our intervention framework used the extended parallel process model (EPPM), 64, 65 the health belief model (HBM), 66 the Giger and Davidhizer transcultural assessment model (GDTAM), 67 and the Transtheoretical Model (TTM) 17 to identify constructs relevant to low-income African American women (Fig. 1).

thumbnail image

Figure 1. Theoretical framework.

Download figure to PowerPoint

The EPPM was developed by Witte to address characteristics of the person and situation that are linked to health screening behavior (perceived threat and efficacy) and incorporates an anxiety/fear response resulting from cancer fatalism relevant to low-income African American women. The HBM identifies threat as a combination of perceived susceptibility and perceived severity. In the case of breast cancer, perceived seriousness is usually dropped because breast cancer is universally perceived as serious. Additionally, the HBM proposes that perceived benefits and barriers to an action influence behavior. The concepts of threat and response efficacy within the EPPM are analogous to the susceptibility and benefits concepts in the HBM. Self-efficacy (one's belief in one's ability to carry out an action) was incorporated in the HBM in 1988 and has been shown to relate to mammography screening behavior. Barriers are not specifically addressed in the EPPM, but past research has demonstrated their relevance to mammography screening. Cancer fatalism, as identified by Powe, 68 was included as a component separate from benefits.

To assess the relationships between cultural beliefs and health behavior, we used specific constructs from the GDTAM. These constructs were space and time orientation as well as social organization. For this study, space was conceptualized as personal space or the woman's sensory perceptions about the proximity and movement of objects within the physical space relative to her body during the mammography screening procedure. Time was conceptualized in terms of preventive health orientation or beliefs about the value of present- and future-time-oriented health practices. The social organization construct included the effect of religious beliefs learned through interaction with religious groups. Religious beliefs have been found to be an important dimension of African American breast cancer screening behavior and beliefs about cancer treatment. 47, 50, 54, 56, 58, 69–71

Stage constructs from the TTM were used for measuring the study outcome variable. As described, this model posits that health behavior change includes a series of stages defined by whether individuals have engaged in the behavior in the past and their intention to do so in the future.


Data came from a sample of African American women who were enrolled in a 21-month randomized controlled trial of mammography screening interventions tailored on health beliefs (Champion and coworkers, unpublished data). For this article, we will report beliefs and stage data at 6 months postintervention. Inclusion criteria included not having had a mammogram within the last 18 months, being 41–75 years old, and living at 175% of poverty level or lower. Women were excluded if they reported a history of breast cancer. Participants were accrued from community-based organizations and events, including multiservice centers, community health centers, public housing, churches, and 2 annual statewide African American health fairs and expositions. A total of 344 women, ranging from 41–75 years, agreed to participate out of 492 eligible women who were asked to participate, yielding a response rate of 69.9%.


We used established instruments to measure health beliefs and cultural beliefs. 72–76 Additional measures included demographic and experiential characteristics and mammography stage of readiness. Descriptives of the health belief and cultural belief scales are listed in Table 1. All scales were revised and tested for reliability and validity in this study. All scales demonstrated construct validity through factor analysis and prediction of theoretical relationships, and all scales had satisfactory internal consistency reliability (Table 1).

Table 1. Scale Statistics
ScaleNo. of itemsMean of item meansMean of item SDsAlpha
  1. SD indicates standard deviation.

Preventive health orientation
Mammography environment162.311.08.91
Religious beliefs194.330.86.94

Health Beliefs

Perceived susceptibility

The perceived susceptibility scale included 4 items, with the first 3 respectively measuring the perceived likelihood of getting breast cancer in 5 years, 10 years, and during a lifetime. The fourth item reflected the perceived risk of getting breast cancer when compared to other women.

Perceived benefits

The 4-item perceived benefits scale measured the perceived effectiveness of the action or behavior to decrease the threat—in this case, death from breast cancer.

Perceived barriers

This 19-item scale measured barriers such as forgetting to get a mammogram, considering the treatment worse than the cure, fear of a mammogram causing breast cancer, feeling too old to get a mammogram, and perceiving no need because the physician already examines my breasts.

Self efficacy

The 10-item self efficacy scale had a one-dimensional factor structure with all items loading at 0.60 or above. This scale also discriminated between adherent and nonadherent women (P < .003).


The fear scale included 8 items that measured emotional reaction to thinking about breast cancer. The items were found to be valid and reliable in another study that included Caucasian and African American women. 76 Construct validity of this scale has been documented using factor analysis and testing of theoretical relationships.


This scale measured the participant's belief in the inevitability of dying if one has cancer, including when specific behaviors are engaged to treat it. This 15-item scale used a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree.

Cultural Beliefs

Preventive health orientation

The preventive health orientation scale consists of 2 subscales that use a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree. The first subscale, Active Preventive Health Orientation, consists of 8 items and measures beliefs about the importance of actively engaging in early detection of health problems and doing things to stay healthy. In this study, the factor analysis loadings for construct validity ranged from 0.49 to 0.80. The second subscale, Passive Preventive Health Orientation, a 4-item scale, measures the belief that one should seek health care only when ill and the belief that looking for health problems can cause them. This subscale had factor analysis loadings from 0.56 to 0.76. Both subscales predicted mammography screening adherence.

Mammography environment

This scale measures the discomfort individuals have or think they would experience in their immediate environment during a mammography screening procedure. The 16-item scale consists of items that measure the women's discomfort with the physical environment, including the effects of temperature, touch, and sound of the X-ray machine, as well as temperature, lighting, and appearance of the X-ray room. Items also address the interpersonal environment, including concerns related to privacy, interactions with staff, and cultural diversity within the setting. This instrument uses a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree. For construct validity, factor analysis revealed a 1-factor solution with item loadings from 0.49 to 0.79, and regression analysis showed its ability to significantly predict mammography screening adherence.

Religious beliefs

Health-related religious beliefs, such as, “I believe that God wants me to be concerned about my health,” “I believe that God expects me to take care of my body,” and “I believe that God will be with me if something happens to my health,” were measured by a 19-item scale. The belief items of the instrument employ a 5-point Likert scale with responses ranging from 1 as strongly disagree to 5 as strongly agree. The scale's construct validity was established by factor value loadings of 0.49–0.84 and also was substantiated by testing of theoretical relationships. 75

Demographic and Experiential Variables

Demographic variables measured included age, education level, marital status, and insurance coverage. Experiential variables included religious behaviors, past experience/history with the health provider, and family history of breast cancer.

Religious behaviors were measured by a 4-item scale respectively addressing the frequency of prayer; attendance of religious services; reading religious books, magazines, and pamphlets; and attendance at religious activities other than religious services using 1 as never or rarely; 2 as about once a month; 3 as 2–3 times each month; 4 as weekly; 5 as 2 or more times each week.

Past history with health provider was assessed by asking participants where they received their regular medical care. Family history of breast cancer was assessed by asking if any of the following relatives had breast cancer: female siblings and children, mother, and females on both maternal and paternal sides of the family.

Outcome Variable

Stage of mammography adoption

Mammography stages of readiness were conceptualized as precontemplation, contemplation, or action. At baseline, all women were nonadherent and thus in either the precontemplation or contemplation stage or were relapsers of the former or latter. Three items were used to create algorithms that identified study women as being in the precontemplation, contemplation, or action stage of readiness to obtain a mammogram. Those items respectively obtained the participants' past mammography history, their intent to be screened in the next 6 months, and the date of their most recent mammogram. Construct validation for precontemplation, contemplation, and action stages was established by Rakowski and colleagues via principal components analysis. 19


Data for this analysis were obtained from 6-month postintervention measurements in a large intervention trial. All women were surveyed at baseline and at 1, 6, and 18 months postintervention. The data for this article came from the 6-month postintervention measures. The study was approved by the university institutional review board, and all procedures were followed.

In the trial, women, all of whom were currently nonadherent to screening, were randomly allocated to 1 of 3 groups: 1) pamphlet only, 2) culturally appropriate video, and 3) interactive computer-assisted instruction program. Women in the pamphlet group received a standard mammography pamphlet by mail encouraging adherence to breast cancer screening and a list of mammography facilities in their locale. Participants assigned to the video group viewed a videotape targeted to low-income African American women that encouraged mammography adherence. The women in the interactive computer group completed an interactive touch-screen computer program tailored to their individual beliefs and mammography stage. Referral information about how to obtain free or reduced-cost screening mammograms and follow-up care in the county was also made available upon request to every participant, regardless of her group assignment. The interventions have been further described elsewhere (Champion VL, Springston J, Zollinger TW, et al., unpublished data) All women were surveyed at baseline and at 1, 6, and 18 months postintervention.


SPSS was used to complete data analysis. Stage of readiness was conceptualized as 3 categories, including 1 precontemplation and relapse precontemplation, 2 contemplation and relapse contemplation, and 3 action. We used χ2 and one-way ANOVA with Tukey post hoc tests for assessing group differences.


  1. Top of page
  2. Abstract

Participant Characteristics

Demographic characteristics and experiential variables by stage are displayed in Table 2. There were 44 (15%) participants in the precontemplation stage, 158 (53%) in contemplation, and 97 (28.2%) participants who had moved to action by 6 months after intervention.

Table 2. Demographic and Experiential Variables by Stage of Mammography Screening Adoption
CharacteristicsPrecontemplation, n = 44Contemplation, n = 158Action, n = 97)
  1. SD indicates standard deviation.

Mean age, y [SD]49.7 [9.3]50.9 [9.2]51.7 [8.5]
Mean grade level12.412.212.7
% Living with spouse or partner
% Has insurance
% Religious behaviors, [SD]13.7 [4.2])14.1 [3.7]15.1 [3.7]
% Routine medical care
 Family doctor22.735.744.3
 Emergency room11.413.47.2
% Family breast cancer history

The 3 groups defined by stage of screening adoption did not differ significantly by any of the demographic variables. Similarly, there were no significant differences in experiential variables by group. Although the overall F value (3.334, P = .04) was significant for religious practices, suggesting significant differences between contemplators and actors, post hoc tests, which control for multiple comparisons, did not reveal significance. The majority of participants received their routine health care from sources other than a regular family physician or emergency department. Although more actors received routine care from a family physician than from contemplators and precontemplators, this difference did not reach the level of significance.

Stage and Beliefs

Results related to our primary aim, to identify relationships between beliefs and stage, are displayed in Table 3. Health beliefs that significantly differed by stage were barriers to and self-efficacy for mammography screening. All 3 groups—precontemplators, contemplators, and actors—were significantly different from each other, with barriers progressively decreasing across stage. For self-efficacy beliefs, women in the precontemplation stage had less perceived self-efficacy than did women in the contemplation or action stages. Perceived benefits and susceptibility were not significantly different across stages.

Table 3. Belief Scale Differences by Stage of Mammography Screening Adoption
Scale1Precontemplation mean, n = 442Contemplation mean, n = 1583Action mean, n = 97F-value df = 2Significant group differences
  • Group 1 indicates precontemplation; Group 2, contemplation; Group 3, action.

  • Within-groups degrees of freedom were 296 for all variables except 295 for perceptions of mammography screening environment and 297 for passive preventive health orientation.

  • ***

    P < .001.

  • **

    P < .01.

Barriers48.039.032.911.69***1 vs 2
     1 vs 3
     2 vs 3
Self-efficacy54.460.261.86.34**1 vs 2
     1 vs 3
Preventive health
 Active32.433.534.74.75**1 vs 3
 Passive12.812.011.04.77**1 vs. 3
Mammography environment42.137.334.17.69**1 vs 2
     1 vs 3
Religious beliefs79.182.683.01.93NS

There were no significant differences in fear by stage. Fatalism displayed only marginal significance on the overall ANOVA F test (P = .055). However, because pairwise comparisons between stages were preplanned comparisons (even though we performed ANOVA to be conservative), it should be noted that the t test showed that those in precontemplation and contemplation had significantly higher fatalism scores than did those in action.

Cultural variables that differed by stage were feelings about the mammography screening environment and active and passive preventive health orientation. Women in the precontemplation stage had significantly more discomfort with the mammography screening environment than did women in the contemplation and action stages. Furthermore, women who got screened (action stage) were more active preventive-health–oriented and less passive preventive-health–oriented than were women who were not thinking about getting screened (precontemplation stage). Health-related religious beliefs did not differentiate stage of screening adoption.


  1. Top of page
  2. Abstract

Study results show that particular health and cultural beliefs to mammography screening differ across stages of mammography screening adoption for this sample of African American women with low incomes. Perceived barriers were significantly higher in precontemplators than in contemplators and actors, and contemplators had significantly more perceived barriers than did actors. Additionally, fatalism marginally separated precontemplators and contemplators from those in action. These findings are similar to those of Champion and Springston 29 and Skinner et al. 30 However, contrary to their study findings, risks and benefits were not significantly different across stages in our study. In both studies, perceived benefits were significantly different by stage, and Champion also found perceived susceptibility to be different by stage.

Self-efficacy was significantly different across stages. Women in the precontemplation stage had less confidence in their ability to get screened than did women in the contemplation and action stages. Other studies show that self-efficacy was a predictor on mammography screening intention. 77, 78

In our study, feelings about the mammography screening environment and preventive-health orientation were significantly different by stage. Women in precontemplation had more perceived discomfort with the mammography screening environment than did women in the other groups. Other studies show that concerns about lack of privacy during the mammogram procedure is 1 aspect of the screening environment that is related to decreased intention and receipt of mammography in African American women. 79, 80 Qualitative data from Thomas's 46 study of professional African American women showed that repeat mammography screening intention and adherence were affected by the mammography screening environment. Discomfort resulting from coldness of the room and equipment, and perceived impersonal attitudes of the healthcare providers and technicians emerged as consistent findings from the women.

Women in the precontemplation stage were less active and more passive in their preventive-health orientation than were women in the action stage. In their study of 8965 multiracial women, Pearlman et al. 81 showed that preventive health behaviors were predictive of stage of mammography screening adoption. Both precontemplators and contemplators were less likely to exercise than were actors, and contemplators were 1.4 times more likely to smoke than were actors.

In this study, stage of mammography adherence did not differ by health-related religious beliefs. This finding is inconsistent with previous studies that showed an association between religious beliefs and screening adherence. 50, 58, 69–71 One possible explanation is that the women in our study had fairly strong religious beliefs, with little variance in beliefs across stage of screening.

Study Limitations

The findings from this study are limited in generalization to all low-income African American women. Within-group differences in beliefs may exist, since African American women are a heterogeneous population. 82 Additionally, women could vary in their beliefs by region of country, and by urban, suburban, and rural locations. This study was limited to urban African American women living in the Midwest. Third, belief by age differences has been shown for African American women, 83, 84 and age was not controlled in this study. Finally, since other ethnic and racial groups were not included in our study, we do not know if study findings would differ across cultural groups.


The results are not intended to be used to change individuals' cultural beliefs. Rather, these results will help us to structure message delivery within a context that is appropriate to an individual's culture and health belief system. For example, during the mammography screening procedure, visual images should include environmental conditions that may cause discomfort, such as showing the appearance of the entire X-ray room and all the tasks of the staff or providing coping strategies that help women deal with privacy, tactile, and temperature issues that involve staff touching the women's breasts, and how the X-ray machine looks and feels. Another example includes having a breast cancer survivor actor acknowledge that, even though some women do not engage in preventive health practices for many different reasons, including cultural beliefs about their importance and efficacy; she can then explain how a mammogram saved her life because the lump was found early, which increased her chances of surviving or living. Although more research is needed, preliminary results suggest that addressing beliefs of African American women and mammography may lead to interventions to increase our rate of early detection.


  1. Top of page
  2. Abstract
  • 1
    Ghafoor A, Jemal A, Ward E, Cokkinides V, Smith R, Thun M. Trends in breast cancer by race and ethnicity. CA Cancer J Clin. 2003; 53: 342355.
  • 2
    Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005; 55: 1030.
  • 3
    Jemal A, Clegg LX, Ward E, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer. 2004; 101: 327.
  • 4
    Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004; 54: 7893.
  • 5
    Glanz K, Croyle RT, Chollette VY, Pinn VW. Cancer-related health disparities in women. Am J Public Health. 2003; 93: 292298.
  • 6
    Clegg LX, Li FP, Hankey BF, Chu K, Edwards BK. Cancer survival among US whites and minorities: A SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med. 2002; 162: 19851993 (see comment).
  • 7
    RiesLAG, EisnerMP, KosaryCL, et al., eds. SEER Cancer Statistics Review, 1995–2001. Bethesda, MA: National Cancer Institute; 2004. Available at
  • 8
    Singh GK, Miller BA, Hankley BF, Edwards BK. Area Socioeconomic Variations in US Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975–1999 ( NCI Cancer Surveillance Monograph Series, No. 4). Bethesda, MD: National Cancer Institute; 2003. NIH Pub. No. 03-5417.
  • 9
    Freeman HP. Poverty, culture, and social injustice: Determinants of cancer disparities. CA Cancer J Clin. 2004; 54: 7277 (comment).
  • 10
    HaynesMA, SmedleyBD, eds. The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and Medically Underserved. Washington, DC: National Academy Press; 1999.
  • 11
    Brawley OW. Disaggregating the effects of race and poverty on breast cancer outcomes. J Natl Cancer Inst. 2002; 94: 471473 (comment).
  • 12
    US Census Bureau. US interim projections by age, sex, race, and Hispanic origin. US Census Bureau. Available at
  • 13
    Brawley OW, Freeman HP. Race and outcomes: Is this the end of the beginning for minority health research? J Natl Cancer Inst. 1999; 91: 19081909 (comment).
  • 14
    Polite BN, Olopade OI. Breast cancer and race: A rising tide does not lift all boats equally. Perspect Biol Med. 2005; 48( 1, Suppl): S166S175 (review).
  • 15
    Marchick J, Henson DE. Correlations between access to mammography and breast cancer stage at diagnosis. Cancer. 2005; 103: 15711580.
  • 16
    Spencer L, Pagell F, Adams T. Applying the transtheoretical model to cancer screening behavior. Am J Health Behav. 2005; 29: 3656.
  • 17
    Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997; 12: 3848.
  • 18
    Rakowski W, Clark MA, Pearlman DN, et al. Integrating pros and cons for mammography and Pap testing: Extending the construct of decisional balance to two behaviors. Prev Med. 1997; 26(5, Part 1): 664673.
  • 19
    Rakowski W, Fulton JP, Feldman JP. Women's decision making about mammography: A replication of the relationship between stages of adoption and decisional balance. Health Psychol. 1993; 12: 209214.
  • 20
    Rakowski W, Dube CE, Marcus BH, Prochaska JO, Velicer WF, Abrams DB. Assessing elements of women's decisions about mammography. Health Psychol. 1992; 11: 111118.
  • 21
    Champion V, Huster G. Effect of interventions on stage of mammography adoption. J Behav Med. 1995; 18: 169187.
  • 22
    Champion VL. Beliefs about breast cancer and mammography by behavioral stage. Oncol Nurs Forum. 1994; 21: 10091014.
  • 23
    Champion VL, Skinner CS, Foster JL. The effects of standard care counseling or telephone/in-person counseling on beliefs, knowledge, and behavior related to mammography screening. Oncol Nurs Forum. 2000; 27: 15651571.
  • 24
    Champion VL, Skinner CS, Menon U, Seshadri R, Anzalone DC, Rawl SM. Comparisons of tailored mammography interventions at two months postintervention. Ann Behav Med. 2002; 24: 211218.
  • 25
    Champion VL, Skinner CS. Differences in perceptions of risk, benefits, and barriers by stage of mammography adoption. J Womens Health. 2003; 12: 277286.
  • 26
    Champion V, Maraj M, Hui S, et al. Comparison of tailored interventions to increase mammography screening in nonadherent older women. Prev Med. 2003; 36: 150158.
  • 27
    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(5, Part 1): 748756.
  • 28
    Clark MA, Rakowski W, Ehrich B, et al. The effect of a stage-matched and tailored intervention on repeat mammography. Am J Prev Med. 2002; 22: 17.
  • 29
    Champion VL, Springston J. Mammography adherence and beliefs in a sample of low-income African American women. Int J Behav Med. 1999; 6: 228240.
  • 30
    Skinner CS, Arfken CL, Sykes RK. Knowledge, perceptions, and mammography stage of adoption among older urban women. Am J Prev Med. 1998; 14: 5463.
  • 31
    Hoffman-Goetz L, Mills SL. Cultural barriers to cancer screening among African American women: A critical review of the qualitative literature. Womens Health. 1997; 3: 183201.
  • 32
    Smith ED, Phillips JM, Price MM. Screening and early detection among racial and ethnic minority women. Semin Oncol Nurs. 2001; 17: 159170.
  • 33
    Danigelis NL, Roberson NL, Worden JK, et al. Breast screening by African-American women: Insights from a household survey and focus groups. Am J Prev Med. 1995; 11: 311317.
  • 34
    Friedman LC, Webb JA, Weinberg AD, Lane M, Cooper HP, Woodruff A. Breast cancer screening: Racial/ethnic differences in behaviors and beliefs. J Cancer Educ. 1995; 10: 213216.
  • 35
    Phillips JM, Cohen MZ, Moses G. Breast cancer screening and African American women: Fear, fatalism, and silence. Oncol Nurs Forum. 1999; 26: 561571.
  • 36
    Tessaro I, Eng E, Smith J. Breast cancer screening in older African American women: Qualitative research findings. Am J Health Promot. 1994; 8: 286292.
  • 37
    Russell KM, Swenson MM, Skelton AM, Shedd-Steele R. The meaning of health in mammography screening for African American women. Health Care Women Int. 2003; 24: 2739.
  • 38
    Mayne L, Earp J. Initial and repeat mammography screening: Different behaviors/different predictors. J Rural Health. 2003; 19: 6371.
  • 39
    Adams ML, Becker H, Stout PS, et al. The role of emotion in mammography screening of African American women. J Natl Black Nurses Assoc. 2004; 15: 1723.
  • 40
    Young RF, Severson RK. Breast cancer screening barriers and mammography completion in older minority women. Breast Cancer Res Treat. 2005; 89: 111118.
  • 41
    Phillips JM. Breast cancer and African American women: Moving beyond fear, fatalism, and silence. Oncol Nurs Forum. 1999; 26: 10011007.
  • 42
    Jennings K. Getting Black women to screen for cancer: Incorporating health beliefs into practice. J Am Acad Nurse Pract. 1996; 8: 5359.
  • 43
    Russell KM, Perkins SM, Zollinger TW, Champion VL. Socio-cultural context of mammography screening use. Oncol Nurs Forum. 2006; 33: 105112.
  • 44
    Shankar S, Selvin E, Alberg AJ. Perceptions of cancer in an African-American community: A focus group report. Ethn Dis. 2002; 12: 276283.
  • 45
    Magai C, Consedine N, Conway F, Neugut A, Culver C. Diversity matters: Unique populations of women and breast cancer screening. Cancer. 2004; 100: 23002307.
  • 46
    Thomas EC. African American women's breast memories, cancer beliefs, and screening behaviors. Cancer Nurs. 2004; 27: 295302.
  • 47
    Bailey EJ, Erwin DO, Belin P. Using cultural beliefs and patterns to improve mammography utilization among African American women: The Witness Project. J Natl Med Assoc. 2000; 92: 136142.
  • 48
    Mayo RM, Ureda JR, Parker VG. Importance of fatalism in understanding mammography screening in rural elderly women. J Women Aging. 2001; 13: 5772.
  • 49
    Consedine NS, Magai C, Neugut AI. The contribution of emotional characteristics to breast cancer screening among women from six ethnic groups. Prev Med. 2004; 38: 6477.
  • 50
    Lukwago SN, Kreuter MW, Holt CL, Steger-May K, Bucholtz DC, Skinner CS. Sociocultural correlates of breast cancer knowledge and screening in urban African American women. Am J Public Health. 2003; 93: 12711274.
  • 51
    Hughes C, Lerman C, Lustbader E. Ethnic differences in risk perception among women at increased risk for breast cancer. Breast Cancer Res Treat. 1996; 40: 2535.
  • 52
    Mathews HF, Lannin DR, Mitchell JP. Coming to terms with advanced breast cancer: Black women's narratives from eastern North Carolina. Soc Sci Med. 1994; 38: 789800.
  • 53
    Gregg J, Curry RH. Explanatory models for cancer among African-American women at two Atlanta neighborhood health centers: The implications for a cancer screening program. Soc Sci Med. 1994; 39: 519526.
  • 54
    Lannin DR, Mathews HF, Mitchell J, Swanson MS, Swanson FH, Edwards MS. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. JAMA. 1998; 279: 18011807.
  • 55
    Loehrer PJ Sr, Greger HA, Weinberger M, et al. Knowledge and beliefs about cancer in a socioeconomically disadvantaged population. Cancer. 1991; 68: 16651671.
  • 56
    Phillips JM, Cohen MZ, Tarzian AJ. African American women's experiences with breast cancer screening. J Nurs Scholarsh. 2001; 33: 135140.
  • 57
    Powe BD, Weinrich S. An intervention to decrease cancer fatalism among rural elders. Oncol Nurs Forum. 1999; 26: 583588.
  • 58
    Price JH, Desmond SM, Slenker S, Smith D, Stewart PW. Urban Black women's perceptions of breast cancer and mammography. J Community Health. 1992; 17: 191204.
  • 59
    Dombeck M, Karl J. Spiritual issues in mental health care. J Relig Health. 1987; 26: 183197.
  • 60
    Dwyer JW, Clarke LL, Miller MK. The effect of religious concentration and affiliation on county cancer mortality rates. J Health Soc Behav. 1990; 31: 185202.
  • 61
    Emblen JD. Religion and spirituality defined according to current use in nursing literature. J Prof Nurs. 1992; 8: 4147.
  • 62
    Scandrett A. Religion as a support component in the health behavior of Black Americans. J Relig Health. 1994; 33: 123129.
  • 63
    Witte K. Fishing for success: Using the persuasive health message framework to generate effective campaign messages. In: MaibachE, ParrottRL, eds. Designing Health Messages: Approaches from Communication Theory and Public Health Practice. Thousand Oaks, CA: Sage; 1995: 145166.
  • 64
    Witte K. Putting the fear back into fear appeals: The extended parallel process model. Commun Monogr. 1992; 59: 329349.
  • 65
    Witte K. Fear control and danger control: A test of the extended parallel process model (EPPM). Commun Monogr. 1994; 61: 113134.
  • 66
    Janz NK, Champion VL, Strecher VJ. The health belief model. In: GlanzK, RimerBK, LewisFM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3rd edn. San Francisco, CA: Jossey-Bass; 2002: 4566.
  • 67
    Giger JN, Davidhizer RE. Transcultural Nursing: Assessment and Intervention, 3rd edn. St. Louis, MO: Mosby; 1999.
  • 68
    Powe BD. Cancer fatalism among elderly Caucasians and African Americans. Oncol Nurs Forum. 1995; 22: 13551359.
  • 69
    Holt CL, Lukwago SN, Kreuter MW. Spirituality, breast cancer beliefs and mammography utilization among urban African American women. J Health Psychol. 2003; 8: 383396.
  • 70
    Kinney AY, Emery G, Dudley WN, Croyle RT. Screening behaviors among African American women at high risk for breast cancer: Do beliefs about God matter? Oncol Nurs Forum. 2002; 29: 835843.
  • 71
    Mitchell J, Lannin DR, Mathews HF, Swanson MS. Religious beliefs and breast cancer screening. J Women's Health. 2002; 11: 907915.
  • 72
    Champion VL, Scott CR. Reliability and validity of breast cancer screening belief scales in African American women. Nurs Res. 1997; 46: 331337.
  • 73
    Champion VL. Revised susceptibility, benefits, and barriers scale for mammography screening. Res Nurs Health. 1999; 22: 341348.
  • 74
    Russell KM, Champion VL, Perkins SM. Development of cultural belief scales for mammography screening. Oncol Nurs Forum. 2003; 30: 633640.
  • 75
    Wagle AM. The Effects of Health-Specific Religiousness on Mammography Adherence of Older African American Women in an Urban Setting. Unpublished doctoral dissertation. Indianapolis, IA: Indiana University; 2003.
  • 76
    Champion VL, Skinner CS, Menon U, et al. A breast cancer fear scale: Psychometric development. J Health Psychol. 2004; 9: 753762.
  • 77
    Allen JD, Sorensen G, Stoddard AM, Colditz G, Peterson K. Intention to have a mammogram in the future among women who have underused mammography in the past. Health Educ Behav. 1998; 25: 474488.
  • 78
    Savage SA, Clarke VA. Factors associated with screening mammography and breast self-examination intentions. Health Educ Res. 1996; 11: 409421.
  • 79
    Allen B,Jr, Bastani R, Bazargan S, Leonard E. Assessing screening mammography utilization in an urban area. J Natl Med Assoc. 2002; 94: 514.
  • 80
    Crump SR, Mayberry RM, Taylor BD, Barefield KP, Thomas PE. Factors related to noncompliance with screening mammogram appointments among low-income African American women. J Natl Med Assoc. 2000; 92: 237246.
  • 81
    Pearlman DN, Rakowski W, Ehrich B, Clark MA. Breast cancer screening practices among Black, Hispanic, and White women: Reassessing differences. Am J Prev Med. 1996; 12: 327337.
  • 82
    Spector RE. Cultural Diversity in Health and Illness, Vol. 4. Stamford, CT: Appleton and Lange; 1996.
  • 83
    Jones BA, Patterson EA, Calvocoressi L. Mammography screening in African American women: Evaluating the research. Cancer. 2003; 97( 1, Suppl): 258272.
  • 84
    Rawl SM, Champion VL, Menon U, Foster JL. The impact of age and race on mammography practices. Health Care Women Int. 2000; 21: 583597.