In this study, we described the development and psychometric properties of a new instrument, called the mammography screening barriers scale or PBMS-23 for Iranian women. To our knowledge, PBMS-23 is the first scale designed to specifically measure barriers of mammography screening in Iranian women.
Generally, the findings showed satisfactory psychometric properties for the PBMS-23. Finally, the scale contained 23 items and 8 dimensions (Table 5) was finalized. The results showed that the content validity was reasonable. A content validity assessment is required, since inferences are made based on the final scale items. The item content must be deemed valid to instill confidence in all consequent inferences [19].
In addition, the results of construct validity showed a good structure for our PBMS-23. Construct validity is most directly related to the question of what the instrument is in fact measuring—what construct, trait, or concept underlies an individual’s performance or score on a measure. This refers to the degree to which inferences can be legitimately made from the observed scores to the theoretical constructs about which these observations are supposed to contain information [19].
Items included in the “believe in fate and destiny dimension” reflect this belief that all events that comprise the life of an individual are predetermined. These beliefs including that women are unable to do anything to prevent breast cancer, belief in fatalism and the inability to change fate might be barriers for screening health behavior [20].
These barriers do not exist in Rakowski scale that was developed based on decisional balance construct of the Trans-theoretical Model [21] and also in the Champion’s scale [22] and in the “Hyman-Baker mammography questionnaire” [23], which they had been developed based on the HBM, but in the scale that was developed for Chinese women [15] has been mentioned. Moreover in relation to our scale, the cancer fatalism scale developed by Powe , the degree of negativity and hopelessness of individuals associated with the cancer diagnosis was measured [24].
As most of Iranians are Muslim, this type of beliefs as a barrier may be as a result of Islamic teaching and ideology that heavily emphasizes “the will of God,” which means that birth, life, and death of all creatures are in God’s hands. Negative influences of spirituality and religiosity may lead to sense of fatalism or belief that the outcome of their health is controlled by fate or by God There are numerous quotations that can be provided from the main Islamic texts such as Quran, which states in the surah al-Imran that “no one will die except by God's permission” In other hand, the Islam holds individuals completely responsible for their personal wellness, health, and physical wellbeing. The dichotomy of these two apparently different points of views might provoke different beliefs.
Therefore, these types of beliefs can act as both barrier and motivated factors for mammography screening. When it comes to health care seeking behaviors, this means patients should effectively look for medical care and only then pray that God makes these medications and treatments effective. Yet, at the same time, it is reported that people have been actively engaged with their medical treatment and they showed that they are far from being passive or believe in fate [25].
“Distrust of mammography screening dimension” includes items reflect distrust in medical system, lack of expert/skill of health care providers/technicians doing mammography screening, distrust to mammography machines and misconceptions due to late detection of breast cancer and its adverse outcomes such as ineffectiveness of treatment and death. Distrust of the medical system as barrier of mammography screening was also reported previously [11].
Death due to late detection of cancer may make this belief that cancer will inevitably lead to death thus resulting in distrust of mammogram. In addition, distrust in medical diagnostics can create insecure feelings among women. Therefore, informing and educating women would be useful to create trust among women to engage voluntarily in mammography.
Breast conflict dimension represent a woman’s unpleasant feelings and dissatisfaction toward her breasts, which may adversely affect her decision to undertake the procedures for an early detection of breast cancer. Mammography is negatively related to breast conflict [26]. Self-esteem and self-efficacy development interventions and consultations might be effective to eliminate the breast conflict related beliefs.
One of the domains of PBMS-23 was “defense avoidance,” which reflect women’s high fear about breast cancer and high level of fear becomes the cause of avoiding to think about cancer which consequently might lead to not engaging in mammography screening. Additionally, fear dimension includes items reflecting women’s fear and negative expectations about the screening such as pain, being informed about breast cancer, and X-ray.
According to PBMS-23, in other scales, fear of being diagnosed with breast cancer, the imagining and thinking about getting cancer and its consequences, harmfulness of mammography, and mammogram procedure are mentioned as a reasons for not getting mammograms [15, 21-23]. Based on a Breast Cancer Fear Scale [27] thinking about breast cancer creates feelings such as fear, nervousness, upset, depressed, anxiety, uneasiness, tachycardia that might be considered as barriers for women’s participation in mammography screening programs.
Additionally, items of “lack of knowledge” dimension reflect low awareness about health services, screening and early detection of breast cancer as well as breast cancer. Evidences were found that breast cancer awareness interventions increase the likelihood of breast cancer screening attendance [28].
Based on health belief model, if individuals regard themselves as susceptible to a condition, would have potentially believed that anticipated benefits of taking an action for reducing either their susceptibility to or severity outweighs the barriers to action, they are likely to engage in healthy behavior [29].
In addition based on extended parallel process model and theories of stress and coping, people exposed to threading conditions doing appraisal that way if they feel capable of taking action and control threading conditions, they will control the risk accordingly. However, when they doubt their ability to minimize the threat, they focus instead on controlling their fear. They will also go into a state of denial, or defensive avoidance. In sum, perceived threat motivates action. Perceived efficacy (i.e. recommended response efficacy and self-efficacy) determines whether individuals control the danger and make behavioral changes or control their fear through psychological defense mechanisms [30, 31]. Therefore, fear may motivate the individual who believes the threat of breast cancer can be reduced by taking action (i.e. engaging in screening). However, if fear is too high, the behavioral response to control the fear will result in avoidance rather than participation in screening. If fear is too low, etc., the motivation for change will not be present. As a result, health promotion and public health practitioners should design comprehensive messages and interventions about mammography and benefits of early detection of breast cancer, so that it can influence the fear and informed decision about the adoption of mammography.
Contrasting/competing priorities dimension points out to the perceived issues that are more important than mammography. Women may have another health problems, or may have personal concerns, or their health has less priority in comparison to other interests or obligations that they may have such as job, family, and childcare [11].
Inconveniences/difficulties of mammography screening dimension items reflect issues such as lack of access to screening services, time consuming screening process, modesty and privacy concerning one’s breasts and uncomfortable feeling to discuss about breast issues, lack of family support, and perceived lack of good communication skills of health care providers.
In Iranian culture, family is valued and is considered a very important institution and family cohesion is also very important. In addition, emotional relationship between family members is strong and they are interdependent. Additionally, lack of spouse/family support, both personally and financially, played a role in mammography adherence. Furthermore, issues such as upsetting the family, especially their children, and worrying about family/children’s fate causes women to avoid pursuing their health problems or disclosing the existence of a problem. What was mentioned above , it could be explained by theory of planned behavior that whether important referent individuals approve or disapprove of performing the behavior, weighted by his or her motivation to comply with those referents. In addition, we should account for factors that are outside of control of women that may effect their screening behaviors [29]. In the cultural belief scale for mammography screening which developed by Russell, et al, they explained five subscales that is consistent with our scale [32].
Support from family members, peers, healthcare workers, decision-makers and insurance systems can facilitate mammography adoption, in other word, instrumental, informational and emotional support to perform preventive behaviors is essential.
Measurement is a fundamental activity of science, since it enables researchers to acquire knowledge about people, objects, events, and processes. Measurement scales are useful tools to attribute scores in some numerical dimension to phenomena that cannot be measured directly [19]. As such, we believe that this newly developed instrument may be especially helpful for healthcare teams to recognize and to plan preventive health strategies that are functional and targeted to specific conditions. The inclusion of eight domains in this scale further allows health experts to understand how domains in need can be improved. The scales also are useful in that they may be quickly administered and they allow for immediate assessments and interventions based upon the results.