From Qualitative Data to Instrument Development: The Women's Breast Conflict Scale

According to the World Health Organization (WHO), each year there is a 1-2% increase in the incidence of breast cancer worldwide (WHO, 2005). Given that a large percentage of cases occur in women with no identified risk factors or no early symptoms of the disease, the primary way to control breast cancer mortality is with early screening, diagnosis, and treatment. However, researchers report mammography screening rates have been declining over the past five years (Breen et al., 2007; Chagpar, Polk, & McMasters, 2008). Among women with access to health care, Ryerson, Miller, Eheman, Leadbetter, and White (2008) found a statistically significant decline in mammography screening among women age 40 to 59 years of age, particularly among non-Hispanic White women. Recent studies suggest that many women are initiating mammography later than recommended, not having mammography screening at recommended intervals, or not receiving appropriate and timely follow-up of positive screening results (Cokkinides, Bandi, Siegel, Ward, & Thun, 2007; Hahn et al., 2007; Taplin et al., 2004). Some women who complete a baseline mammogram at age 40 may not return every two years or every year for follow up mammograms as recommended, which could result in a more advanced tumor size or cancer stage at diagnosis if this disease occurs later in life. At a time when mammography screening rates appear to be declining, the population growth is predicted to increase (National Center for Health Statistics, National Health Interview Survey, 2007). This population increase will create a significant challenge to achieving the objective of increasing mammography screening rates. The U.S. Census Bureau (2002) predicts that the African American population will double in growth and the Hispanic population will triple in growth between the years 2020 and 2050. The length of time between an abnormal mammogram screening and related diagnostic tests is more than twice as long for African American and Hispanic/Latina women as it is for White women (Agency for Healthcare Research and Quality, 2000). In addition to identifying women least likely to participate in mammography screening per recommended guidelines, the new instrument proposed in this article has potential to serve as a means to identify women least likely to follow recommended diagnostic and treatment recommendations. Barriers to Mammography Screening Key contributors, particularly among diverse racial/ethnic groups, to low mammography screening rates include demographic factors, socioeconomic status, access, differences in beliefs and knowledge about cancer, and knowledge about cancer treatment (American Cancer Society, 2008). Other reasons women report for not following mammography screening guidelines include cost, no healthcare insurance, not able to take time off from work, belief that mammograms are not necessary or the mammogram test itself causes breast cancer, child care issues, or as one women stated: "My first mammogram was so painful, I will never have another one" (Thomas & Usher, 2009). Other women stated they simply forget to schedule an appointment or forget to keep their appointment. I propose other barriers to mammography screening (Thomas, 2004, 2006; Thomas & Usher). Findings from my qualitative research strongly suggest that women's life experiences, particularly experiences that occurred during adolescence, can have a lasting impact on women's mammography screening beliefs and subsequent behaviors. Five years of qualitative data collection resulted in the recognition of self/body image, teasing, societal/media influence, and family norms and values as barriers to mammography screening and contributors to what I have identified as a new concept: breast conflict. Summary of Qualitative Studies Leading to Development of the Instrument Study 1 My first study was a qualitative descriptive study, using narrative methods to generate data. …