Breast cancer is the most common cancer, and the second leading cause of cancer death among U.S. women [1]. After a period of declining (1999–2004), the incidence rate of breast cancer has slightly increased (0.4%) in recent years (2004–2014); however, the mortality rate of breast cancer has declined significantly (39%) over the past decades [1]. In 2019, an estimated 268,600 new cases of invasive breast cancer and 62,930 new cases of non-invasive breast cancer are expected to be diagnosed in women in the U.S.; also an estimated 41,760 women are expected to die from breast cancer [2].
Previous evidence suggest that the decrease of incidence and mortality rate were partially due to the extensive use of preventive mammograms, which offer opportunities for early detection and treatment of breast cancer [3, 4]. The latest American Cancer Society breast cancer screening guidelines recommend that “all women should begin having yearly mammograms by age 45, and can change to having mammograms every other year beginning at age 55” [5]. However, getting recommended mammograms is one of the unmet health care among female caregivers [6]. Approximately,23.5% of female caregivers never received a mammogram particularly, female caregivers have significantly lower odds of the receiving mammography [7, 8]. Notably, little knowledge is available on the associations among hours of caregiving, cancer beliefs, and female caregiver’s mammogram screening behavior.
Andersen’s Behavioral Model of Health Services Use is a leading model for analyzing the use of cancer prevention services. The conceptual model categorizes factors into three dynamics: predisposing factors, enabling factors, and need factors [9]. Predisposing factors are characteristics including demographics (e.g., age and gender), social structure (e.g., education, occupation, and ethnicity), and health beliefs (e.g., attitudes, values, and knowledge about health and health services) [9]. Significant age-related trends in mammogram use were observed [3, 10, 11, 12]. Previous studies generally reported that, after the age of 45 and particularly 65 to 75, older women are less likely than younger women to have mammograms [10, 13]. In addition, Burg and her colleagues suggested that receipt of mammogram improved with higher levels of education [13, 14]. However, other studies reveal no significant association between education and mammogram uptake [15]. Cancer beliefs play a critical role of using mammograms. A lack of knowledge regarding breast cancer and cancer screenings is a primary barrier for using mammograms, as suggested by previous studies [16, 17, 18, 19, 20]. Women’s perceived risk of breast cancer is positively associated with mammograms use [21].
Enabling factors include personal, family, and community resources that are necessary when using health care services, such as income, insurance coverage, medical care providers, and types of health service organizations in the community [9]. The financial matter is an aspect impacting mammography recipient. Women without insurance coverage, and women with low-income have an increased risk for late-stage breast cancer diagnosis due to lower mammography screening rates [22]. A recent study found that doctor recommendation and perceived barriers are predictors for both low- and high-income women’s usage of mammography [23].
Regarding caregiving factors, caregiver burden is an identified barrier for mammography screening [24]. Generally, caregivers who have caregiver procrastination and high burden have less frequent breast examinations [24]; however, another study found no significant association (Kim et al., 2004). Caregivers of people with chronic conditions (e.g., dementia) perceive a significantly greater caregiving burden, more mental health concerns (e.g., depression, anxiety, or hostility), and less preventive health care use than caregivers of other diseases [25]. However, caregivers of cancer patients have an increased likelihood of receiving cancer preventive screenings, including mammogram [26, 27]. Increase of likelihood may be due to the high supply of cancer information from medical professionals, leading to increased awareness of preventive screenings [27].
Need factors refer to the measured individual perceived need for using health care services including having chronic diseases or having poor health status [9]. People who have family cancer history and cancer survivals have increased odds in receiving mammograms [21, 28, 29]. Furthermore, the utilization rate of mammography is higher among women with family or personal breast cancer history than the general population of women [30, 31, 32, 33]. However, one study proposed that about a quarter of breast cancer survivors still underused annual surveillance mammography [28]. Additionally, women with comorbid health conditions have a greater likelihood of using mammograms due to increase in contact with health care provider [34]. In addition, depression is a risk factor for mammography underuse [35]. Women who are depressed are less likely to receive screening, and female caregivers are at risk of underuse due to the heavy caregiver burden [35, 36, 37].
By using the Behavioral Model of Health Services Use, our study compared mammogram screening behaviors between caregivers and non-caregivers to examine (1) the levels of mammogram receipt, (2) the role of caregiving factors, and (3) the role of cancer beliefs on mammogram screening of caregivers and non-caregivers. The hypotheses were:
1 The likelihood of using mammogram would be associated with predisposing factors (age, education, beliefs about cancer).
2 The likelihood of using mammogram would be associated with enabling factors (income, confident about getting health information, number of people under caregiver’s caregiving, caregiving hours per week, care receiver’s cancer, care receiver’s chronic illness).
3 The likelihood of using mammogram would be associated with need factors (general health, depression, ever had cancer, family ever had cancer).