J Canc Educ
DOI 10.1007/s13187-017-1236-1
Stages of Change for Mammography Among Mexican Women
and a Decisional Balance Comparison Across Countries
Ana María Salinas-Martínez 1,2 & David Emmanuel Castañeda-Vásquez 2 &
Norma Guadalupe García-Morales 2 & Norma Edith Oliva-Sosa 1 & Laura Hermila de-la-
Garza-Salinas 3 & Georgina Mayela Núñez-Rocha 2 & José Manuel Ramírez-Aranda 4
# American Association for Cancer Education 2017
Abstract An analysis of the adoption of secondary preven-
tive behaviors is significant in regions with disparities in
mammography use and breast cancer survival. Therefore, we
determined the cognitive factors and the degree to which they
differentiate stages of change in mammography among
Mexican women. We also compared the decisional balance
performance at Mexico, Switzerland, South Korea, and the
USA. A cross-sectional study was designed for women in
the stages of precontemplation (n = 240), contemplation
(n = 243), action (n = 205), maintenance (n = 311), and relapse
(n = 348). We only considered those ≥40 years with no cancer
history. We measured the pros, cons, and self-efficacy, among
other components. The decisional balance was estimated, and
the result was transformed into T-scores. Odds ratios (OR) and
95% confidence intervals (CI) were estimated with multino-
mial logistic regression using precontemplation as the refer-
ence group. The decisional balance distinguished stages par-
tially: in contemplation, the OR was 1.26 (95%CI 1.08, 1.47)
and in maintenance, 1.34 (95%CI 1.13, 1.59); in action and
relapse, the statistical significance was marginal (p < 0.10).
* Ana María Salinas-Martínez
amsalinasmartinez@gmail.com
1
Epidemiologic and Health Services Research Unit, Mexican Institute
of Social Security, Ave. Lincoln S/N esquina Ma. Jesús Candia. Col.
Valle Verde, 2° sector, Monterrey, N.L. CP 64360, Mexico
2
School of Public Health and Nutrition, Autonomous University of
Nuevo Leon, Monterrey, N.L., Mexico
3
Health Planning Division, Mexican Institute of Social Security,
Monterrey, N.L., Mexico
4
School of Medicine, Family Medicine Department, Autonomous
University of Nuevo Leon, Monterrey, N.L., Mexico
The decisional balance T-score performance registered varia-
tions among countries. Additionally, the effect of self-efficacy
progressively ascended from contemplation to action and
maintenance (OR = 1.29 [95%CI 1.05, 1.58], 1.53 [95%CI
1.20, 1.96], and 2.48 [95%CI 1.82, 3.39], respectively).
Furthermore, risk perception and severity did not have an
effect on stages of change among Mexican women.
Recognition of what provokes action in a population is a
key factor in the efficacy of screening programs. Variations
among countries highlight the necessity for importance of
investigating cognitive determinants for mammography in
specific areas.
Keywords Mammography . Stages of change .
Transtheoretical model . Breast cancer
Introduction
Breast cancer is undoubtedly a relevant public health problem.
It continues to be the most common type of cancer in women
in developing countries, and it is already the second leading
cause of death from cancer in developed countries [1]. The
regular use of mammography has contributed to improving
the survival rate of patients with breast cancer with an early
diagnosis [2, 3]. However, the degree of participation of wom-
en continues to be lesser than desirable in some regions, de-
spite efforts to transmit the benefits of breast cancer screening.
In the urban parts of Mexico, for example, the frequency of
mammography use in the last 2 years in women aged 50 years
old or more has been reported to be between 15.3 and 39.1%
depending on the absence or presence of health insurance
coverage, respectively [4]. Meanwhile, in the USA, it has been
documented to be 72.6% [5] and in Europe, 61.4%, based on a
3-year window [6].

An analysis of the adoption of secondary preventive behav-
ior is significant from the theoretical, clinical, and public health
point of view, especially in populations with a disparity be-
tween relatively low rates of mammography use and potentially
improvable survival rates. Mammography use is usually mea-
sured on a dichotomous scale taking into account the compli-
ance with a pre-established criterion (e.g., has had a mammo-
gram in the past 2 years: yes vs no). The Transtheoretical
Model (TTM) assumes that not everyone is in the same dispo-
sition to adopt a behavioral change and postulates the early
stages of behavior such as precontemplation (not ready to
adopt) and contemplation (ready to adopt), and advanced
stages such as action (beginning to adopt) and maintenance
(continuous adoption). In addition, it recognizes that progress
is not necessarily linear; that is, there can be relapses and re-
gression to earlier stages. In an effort to comprise a preventive
behavior, the TTM also includes self-efficacy and decisional
balance resulting from motivational and cognitive factors that
act as barriers (cons) and facilitators (pros). In general, the
model predicts an advance from one stage to another with an
increase in self-efficacy and favorable beliefs and a decline in
unfavorable beliefs [7, 8]. On the other hand, the Health Belief
Model (HBM) includes variables such as benefits and barriers,
comparable to the pros and cons of TTM, as well as perceived
threat and disease severity [9]. It has also been integrated with
TTM [10, 11]. Additionally, the Triandis Theory can increase
the understanding of the steps involved in mammography. This
model includes social norms with regard to referents such as
partners, relatives, friends, or health professionals, comparable
to the pros and cons of TTM [12].
The TTM originally demonstrated its construct valid-
ity for the stages of change for mammography among
white American women with completed high school or
with some education beyond high school [13], and its
application continued to be acceptable in the USA in
populations of different ethnic origins [14–18]. It has
also been used in South Korea [19, 20], Iran [21],
Canada [22], Switzerland [23], and Spain [24]. There
is a shortage of this type of research among Latin-
American women, and very little information on the
motivational and cognitive factors influencing mammog-
raphy use are available [25–28]. The beliefs which mo-
tivate the use of breast cancer screening may vary ac-
cording to the culture with respect to traditions and
socioeconomic status. Therefore, it is necessary to ana-
lyze whether the distinction between the stages of
change for mammography remains in specific communi-
ties. For this reason, we aimed to determine the cogni-
tive factors and the degree to which they differentiate
the stages of change in mammography among Mexican
women. We also compared the role of decisional bal-
ance in the populations of Mexico, Switzerland [23],
South Korea [20], and the USA [8].
J Canc Educ
Methods
A comparative cross-sectional study was designed and carried
out between January 2014 and March 2015 in the northeast of
Mexico. Five groups of women were identified according to
their stages of change for mammography: precontemplation
(never had a mammogram and has no intention of having one
in the next 12 months; n = 240), contemplation (never had a
mammogram but intending to have one in the next 12 months;
n = 243), action (had one mammogram in the last 2 years;
n = 205), maintenance (≥2 consecutive mammograms, the last
of which took place less than 2 years ago; n = 311), and
relapse (had a history of mammography use; however, the last
one done more than 2 years ago; n = 348). The study popula-
tion was selected consecutively, and the criteria for selection
were as follows: (a) minimum age of 40 years, (b) no current
or previous diagnosis of any type of cancer, and (c) currently
not pregnant. The participants were chosen from among the
companions of patients in primary care facilities of the public
healthcare sector. The study protocol was approved by the
local committees of ethics and health research. All of the par-
ticipants gave their informed consent, and they were not com-
pensated for their involvement in the study.
The cognitive factors included in the study were identified
as components of TTM, HBM, and Triandis’ Theory. Five
beliefs favorable to mammography (pros) were measured
and five beliefs against it (cons) (1 = totally disagree, 4 = totally
agree). However, the factor analysis showed three dimensions:
favorable beliefs (5 items, alpha = 0.54); unfavorable beliefs
(4 items, alpha = 0.62); and the third one, with the item
BWould you be afraid to learn that you had cancer,^ which
was analyzed separately. The decisional balance was estimat-
ed by subtracting the cons from the pros, and the result was
transformed into T-scores (mean = 50, standard devia-
tion = 10); the higher the score, the more favorable balance
toward the use of mammography. Self-efficacy was evaluated
according to the perceived capacity to undergo a mammogram
despite the discomfort, embarrassment, and the negative opin-
ion of others with respect to its utility, and not having symp-
toms (1 = not at all sure, 4 = very sure; alpha 0.86). The
perception of risk was measured as an absolute risk on two
scales, categorically (how much risk do you think you have of
having breast cancer someday; 1 = none, 4 = very high) and
not categorically (from 1 to 10, in which 1 is the lowest and 10
is the highest). Likewise, as the perception of comparative risk
(how much risk do you think you have of having breast cancer
someday compared to a woman of your age or a woman with
a family history of breast cancer; 1 = less or none, 3 = greater).
The perception of severity was measured in terms of health
recovery (In general, how curable do you think breast cancer
is; 1 = very curable, 4 = not curable). Social norm was eval-
uated according to the approval for mammogram use by the
family, spouse, neighbors, or a friend (1 = the decision does
J Canc Educ
not depend on the opinion of the person referred to, 3 = the
decision depends a lot on the opinion of the person referred to;
alpha 0.79). Participants’ history of Pap smears in the last
2 years, and family members’ history of mammography use
(mother, sister, or daughter) or breast cancer (grandmother,
mother, sister, or daughter) were asked, and participants’
sociodemographic profiles were identified (age, civil status,
educational level, occupation, place of residence, health insur-
ance status, and a history of diabetes or hypertension). The
information was collected through interviews, after which ac-
curate breast cancer information was given, and a mammo-
gram was recommended as needed.
The analysis consisted of descriptive statistics and a one-way
analysis of variance (ANOVA) for multiple comparisons of
quantitative variables; when the distribution of the variable was
not normal, the Kruskal-Wallis H test was applied. A chi-squared
test was used for multiple comparisons of variables on a categor-
ical scale. The magnitude of association or relative weight was
determined with odds ratio (OR) and confidence interval (CI) of
95%, through multinomial logistic regression, by using the stage
of precontemplation as the reference. In the multivariate model,
all the cognitive factors were considered independent variables
except risk perception, since it was not shown to be associated
with stage of use in the univariate analysis. The ORs of decision-
al balance were calculated for every 16 units of T-scores (equiv-
alent to 1 standard deviation) and those of self-efficacy and social
norm for every 10 units of T-scores (equivalent to 1 standard
deviation). Finally, we compared the pros, cons, and decisional
balance T-scores with the results published by Chamot et al. [23],
who randomly selected women from the general population of
Switzerland, by Kang et al. [20], who recruited women from
three urban areas of South Korea, and by Rakowski et al. [8],
whose report was based on a sample of women drawn from three
worksites in the USA. We searched MEDLINE, EBSCO,
ScienceDirect, and PsycINFO for more relevant articles, but we
only used previous citations, because they had available data on
the pros, cons, and decisional balance T-scores by stages of
change for mammography. A brief description of cited studies
is shown in Table 1.
Results
The mean age of the study population was 50.1 ± 7.7 years.
Participants in the maintenance and relapse stages were on an
average 4 years older than those in the early stages (p < 0.001).
Women in the maintenance stage had higher education
(p < 0.03), and women in the precontemplation stage had a lower
frequency of history of Pap smears and family history of mam-
mography use or breast cancer (p < 0.001) (Table 2). Of the total
participants, 18% had a previous diagnosis of diabetes, and
24.3% had a diagnosis of hypertension; no differences were reg-
istered by stages of change for mammography (p > 0.05).
Cognitive Factors and Stages of Change
for Mammography
The majority of the pros and cons were significantly associat-
ed with stages of change for mammography (Table 3). The
mean T-score of decisional balance was negative in the
precontemplation stage; that is, there were more cons than
pros (−7.0 [95%CI −9.6, −4.4]); comparable in the contem-
plation and relapse stages; that is, the pros and cons were very
similar (0.6 [95%CI −1.5, 2.7] and 0.01 [95%CI −1.7, 1.7],
respectively); and positive in the action and maintenance
stages; that is, there were more pros than cons (1.3 [95%CI
−0.9, 3.5] and 4.4 [95%CI 3.1, 5.7], respectively).
International comparisons are presented in Figs. 1 and 2.
The multivariate analysis showed that for every additional
standard deviation of the decisional balance, there were great-
er possibilities of being in contemplation with an OR = 1.36
(95%CI 1.18, 1.57); in action with an OR = 1.29 (95%CI 1.11,
1.50); in maintenance with an OR = 1.60 (95%CI 1.36, 1.88);
and in relapse with an OR = 1.29 (95%CI 1.13, 1.46).
However, the presence of self-efficacy in the same multiple
logistic model lowered the effect of decisional balance, espe-
cially on the action and relapse stages that registered p < 0.10
(Table 4). With respect to the social norm, contemplation was
differentiated by a greater dependence on the opinion of a
family member at the univariate level (p < 0.03), and action
by a greater dependence on the opinion of a neighbor or best
friend (p < 0.05) (Table 3). This component was associated
with all stages of change (Table 4). In terms of severity, 28.2%
believed that breast cancer was incurable, a belief that was
more frequent in maintenance (p < 0.02) (Table 3).
However, its effect dissipated in the multivariate analysis.
The mean of self-efficacy was 3.7 ± 0.5, and it clearly distin-
guished between stages of change. It ascended progressively
from precontemplation to maintenance and presented an even-
tual significant descent to relapse (p < 0.001) (Fig. 3). Its effect
was maintained even after adjustment for potential con-
founders (Table 4).
The mean of absolute risk was 4.4 ± 2.5; 8.8% perceived a
high or very high risk of having breast cancer someday, and
7.1% believed that their risk was higher than a person of the
same age. On the other hand, 12.1% believed that their risk
was higher than a person with a family history of breast can-
cer. Neither the perception of the absolute risk nor compara-
tive risk distinguished the stages of change.
Non-cognitive Factors and Stages of Change
for Mammography
Regardless of the age and educational level, the history of Pap
smears differentiated the early stage of contemplation from the
later stages of action and maintenance in an increasing and
significant way. The use of mammography by the mother,
 J Canc Educ

Table 1 Description of studies cited for pros, cons, and decisional balance comparisons

Study Study population profile Stages of change definition Pros and cons measurement

Chamot et al. [23] -Women ≥40 years with no history
of breast cancer (n = 909).
-Mean age 56.4 years
- 29.2% with ≤10 years of education
Kang et al. [20] -Women ≥30 years with no history
of breast cancer (n = 328)
-Mean age 37.7 ± 6.1 years
-66.8% had at least a college
education
-52.7% were employed
Rakowski et al. [8] -Women ≥40 years (n = 142)
-Mean age 52.6 ± 8.7 years
-85.2% were non-Hispanic Whites
-62.7% were high school graduates
-100% were employed
-Precontemplation, never -Self-administered questionnaires.
had a mammogram and has no intention to -Instrument containing 5 pros and
have one in the next 6 months 5 cons; responses on a 5-point
-Contemplation, no mammogram in the past Likert scale
2 years, but plans to have one in the next
6 months
-Action, had a mammogram in the past 2 years,
and intends to have one in the future
-Maintenance, had at least two mammograms in
the past 4 years, one of them in the last 2 years
and plans to have one in the future
-Relapse, had one or more mammograms, none
during the last 2 years and does not plan to get
one in the next 6 months
-Precontemplation, never had a mammogram and -Self-administered questionnaires
has no intention to have one that year -Instrument containing 6 pros and 7
-Contemplation, never had a mammogram but plans cons; responses on a 5-point
to have one within a year Likert scale
-Action, had a mammogram and plans to have one
within a year
-Maintenance, had received mammograms regularly
and plans to have one within a year
-Relapsed, had received mammograms previously
and has no plans to have one within a year
-Precontemplation, never had a mammogram and has -Self-administered questionnaires
no intention to have one in the coming year -Instrument containing 6 pros and 7
-Contemplation, never had a mammogram but plans cons; responses on a 5-point
to have one in the coming year; or, has ≥1 prior Likert scale
mammograms and has no intention to have one in
the coming year
-Action, had a mammogram and plans to have one in
the coming year
-Maintenance, had more than one mammogram and
plans to have one in the coming year

sister, or daughter was associated with all stages. A family
history of breast cancer distinguished all stages, except the
contemplation stage (Table 4).
Discussion
Mammography is a secondary preventive action that can pre-
vent the loss of years of life, aside from reducing substantial
suffering, provided that recommended guidelines are ob-
served. Thus, it is essential to recognize the cognitive factors
that favor women to achieve positive health behavior changes.
We identified the stage of precontemplation as having the
lowest pros and the highest cons; however, in the action, con-
templation, and relapse stages, the pros and cons were equiv-
alent in Mexican women. Champion and Skinner [10] also
found fewer pros in precontemplation and similar pros in ac-
tion, contemplation, and relapse. Nonetheless, in some other
studies, the pros have not been able to differentiate between
the stages of change [15, 16]. The decisional balance distin-
guished stages partially; for every unit of increase in the deci-
sional balance, the possibilities of being in contemplation
increased by 26% and of being in maintenance by 34%; and
the statistical significance was marginal in action and relapse.
Otero et al. [14] did not show a decisional balance effect on
action or relapse in the Latina population. International com-
parisons showed an interaction of pros and cons mostly in the
stage of contemplation; only in the USA, this interaction oc-
curred close to the stage of action. The greatest difference
between the countries was observed for the maintenance
stage; South Korea showed the highest favorable balance to-
ward the use of mammography and Mexico, the lowest [8, 20,
23]. The variations between the countries can be attributed to
sociocultural and health care access differences as well as to
the classification of stages; for example, in Switzerland, the
intention of undergoing mammography considered the fol-
lowing 6 months as the time window, whereas the rest of the
countries used the following 12 months.
Self-efficacy stood out due to its progressively ascending
effect; for every unit of increase in self-efficacy, the possibilities
of being in contemplation increased by 30%, in action by 50%,
and in maintenance, more than twice the possibility. Russell
et al. [15] did not identify a progressive result in an African-
American population. A Chilean study found that self-efficacy
J Canc Educ

Table 2 Sociodemographic description according to stages of change for mammography (n = 1347)

Precontemplation1 Contemplation2 Action3 Maintenance4 Relapse5 p

(n = 240) (n = 243) (n = 205) (n = 310) (n = 348) value

Age (years) (mean ± standard deviation) 48.0 ± 7.4 48.3 ± 6.9 48.9 52.0 ± 7.3a 52.0 <0.001
± 7.8 ± 7.8a
Marital status, with partner 70.4% 74.9% 71.2% 78.7% 73.0% 0.18
Schooling
Primary 23.8% 23.0% 23.4% 20.3% 24.4% <0.03
Secondary 31.4% 22.2% 24.9% 19.0% 24.7%
High school or more 44.8% 54.7% 51.7% 60.8% 50.9%
Occupation, economically active 41.2% 47.3% 47.1% 36.7% 37.1% 0.02
Place of residence, urban 91.6% 92.6% 93.6% 94.5% 93.0% 0.74
Health insurance coverage, yes 89.1% 86.0% 90.7% 87.1% 86.8% 0.52
Use of Papanicolaou within the last 2 years 43.3% 60.9% 82.4% 88.4% 53.7% <0.001
Family history of mammography use 50.0% 74.9% 79.0% 83.5% 73.3% <0.001
(mother, sister, or daughter)
Family history of breast cancer 3.8% 5.8% 12.2% 11.6% 10.1% <0.001
(grandmother, mother, sister, or
daughter)

a
Multiple post-hoc comparisons based on LSD test (least significant difference test) with a p value < 0.05: 4 and 5 vs 1, 2, and 3

had a mediating result, because participants who had been ad-
vised by family members to have a mammogram had four
times the possibility of undergoing the test in the next 6 months
when they felt capable of doing it [25]. In our study, the depen-
dence on the opinion of others was associated with all stages of
change for mammography, regardless of self-efficacy. A family
history of mammogram use tripled the possibility of being in
maintenance suggesting that interventions should consider the
opinion of family and friends, in addition to health profes-
sionals’ recommendations. A central concern of cancer educa-
tion is health behavior. Screening programs intend to motivate
individuals by means perceived by authorities to be in the

Table 3 Perception of favorable beliefs (pros), unfavorable beliefs (cons), social norms, and severity, according to stages of change for
mammography (n = 1347)

Precontemplation Contemplation Action Maintenance Relapse p

(n = 240) (n = 243) (n = 205) (n = 310) (n = 348) value

Perception of favorable beliefs (pros) (totally agree that mammography…)

Is useful even without symptoms 70.7% 88.1% 87.8% 94.5% 87.3% <0.001
Facilitates a cure for cancer through early detection 86.7% 90.9% 89.8% 94.2% 92.8% 0.05
Helps to confirm that all is well 87.1% 88.9% 95.1% 92.6% 92.0% 0.06
Is the best way to detect breast cancer in time 79.1% 90.1% 87.8% 89.1% 86.5% <0.01
Detects tumors that cannot be felt in a medical exam 62.1% 79.0% 81.0% 83.9% 76.7% <0.001
Perception of unfavorable beliefs (cons) (totally or somewhat agree that mammography…)
Is a waste of time 5.0% 4.1% 2.9% 0.6% 3.5% <0.02
Is only necessary when a family member has had breast 24.2% 16.5% 13.7% 6.4% 15.0% <0.001
cancer
Is only necessary when there are symptoms 30.5% 15.2% 12.7% 8.4% 18.1% <0.001
With age stops being useful 23.0% 16.5% 17.6% 14.1% 18.4% 0.11
You are afraid to learn that you have cancer 63.3% 61.7% 59.5% 57.6% 62.4% 0.63
Social norms (decision depends a lot on…)
The opinion of a family member 7.9% 11.9% 8.3% 9.3% 10.1% <0.03
The opinion of a neighbor or friend 2.9% 5.3% 5.9% 2.6% 4.3% <0.05
The opinion of your partner (no partner = no dependence) 5.0% 11.1% 7.3% 8.4% 9.8% 0.15
Perception of high severity (totally agree…)
In general, breast cancer is incurable 25.8% 27.6% 27.3% 32.2% 27.3% <0.02
 J Canc Educ

P=Precontemplation, C=Contemplation, A=Action, M= Maintenance y R=Relapse.

Fig. 1 Pros and cons in the populations of Mexico, Switzerland [23], South Korea [20], and the USA [8]

populations’ best interests. Conversely, tailored communica-
tion represents custom-made education rather than a one-fit-
for-all approach, and TTM and HBM components facilitate
tailoring health messages with promising results [29, 30].
Moreover, Noar et al. [31] evidenced a trend in favor of devel-
oping health behavior change based on the number of theoret-
ical behavioral factors used for tailoring messages (4–5 or
more). From this perspective, the present study indicated that
self-efficacy, social norms, and decisional balance are the key
cognitive factors for tailoring health messages.
We identified that more than one-fourth of the participants
viewed breast cancer as an incurable disease, a belief that was
initially more frequent in the stage of maintenance, but the effect
dissipated in the multivariate analysis. Another Mexican study
showed no association between the belief Bcancer is not invari-
ably fatal^ and mammogram use within last 2 years [28]. Neither

Fig. 2 Decisional balance in the

populations of Mexico,
Switzerland [23], South Korea
[20], and the USA [8]

P=Precontemplation, C=Contemplation, A=Action, M= Maintenance y R=Relapse.

J Canc Educ

Table 4 Multivariate analysis of multinomial regression using precontemplation as the reference stage (n = 1347)

Stages of change for mammography

Contemplation Action Maintenance Relapse

(n = 243) (n = 205) (n = 310) (n = 348)

Decisional balancea 1.26 (1.08, 1.47)*** 1.15 (0.97, 1.35)† 1.34 (1.13, 1.59)*** 1.14 (0.99, 1.31)†
b
Self-efficacy 1.29 (1.05, 1.58)* 1.53 (1.20, 1.96)** 2.48 (1.82, 3.39)*** 1.56 (1.29, 1.90)***
Social normb 1.65 (1.32, 2.08)*** 1.43 (1.11, 1.83)** 1.57 (1.23, 2.00)*** 1.47 (1.17, 1.84)***
Positive state of mindb 1.17 (0.97, 1.41) 1.11 (0.91, 1.35) 1.30 (1.07, 1.58)*** 1.03 (0.87, 1.22)
Agec 1.02 (0.99, 1.05) 1.05 (1.02, 1.08)*** 1.10 (1.07, 1.14)*** 1.09 (1.06, 1.11)***
High school or more 1.35 (0.90, 2.02) 1.17 (0.76, 1.81) 1.92 (1.26, 2.93)*** 1.53 (1.04, 2.24)*
Use of Papanicolaou within the last 2 years 1.64 (1.09, 2.46)* 4.80 (2.95, 7.79)*** 8.07 (4.84, 13.5)*** 1.22 (0.83, 1.78)
Family history of mammography use 2.18 (1.43, 3.32)*** 2.25 (1.42, 3.56)*** 2.99 (1.88, 4.76)*** 2.19 (1.49, 3.23)***
(mother, sister, or daughter)
Family history of breast cancer 1.83 (0.67, 4.95) 4.58 (1.79, 11.76)*** 3.97 (1.55, 10.2)*** 3.36 (1.36, 8.26)**
(grandmother, mother, sister, or daughter)

Other variables in the model: occupation and severity perception (p > 0.05)
†
p < 0.10, *p < 0.05, **p < 0.01, ***p < 0.001
a
For every 16 units of T-scores (equivalent to 1 standard deviation)
b
For every 10 units of T-scores (equivalent to 1 standard deviation)
c
Per year

the perception of absolute risk nor comparative risk distinguished threat severity prompt efforts to change the stressful situation
between the stages of change. Related literature shows inconsis- by active coping and problem-solving strategies, such as under-
tent results [10, 11, 15, 17, 21, 23]. The Transactional Model of going mammograms. However, denial and avoidance maladap-
Stress and Coping posits that perception of personal risk and tive responses can occur, negatively affecting health-promoting

Fig. 3 Self-Efficacy according to

stages of change for
mammography (mean and 95%
confidence interval)† (n = 1347)

† (1 to 4 scale, 4= Very sure). Multiple post-hoc comparisons based

on LSD test (Least Significant Difference test) with a p value <0.001:
a
P<C,<A,<M, R; bC >P,<A,<M,=R; cA >P,>C,<M,=R; d M
>P,>C,>A,>R; e R >P,=C,=A,<M. P = Precontemplation, C
=Contemplation, A =Action, M =Maintenance and R=Relapse.

practices [32]. Future studies are needed for explaining why
severity and susceptibility were not associated with the stages
of change for mammography among Mexican women.
Demographic and social variables may influence perceptions
and health-related behaviors. In our study, age increased the pos-
sibility of later stages of change, and higher the education, the
higher the possibility of maintenance and relapse. A family his-
tory of breast cancer was not particularly associated with the
stage of contemplation; this could be due to unfortunate experi-
ences with breast cancer and coping failure. Promotional cam-
paigns should make greater efforts to influence women with a
family history of breast cancer at an early stage, because they
constitute a high-risk population.
This study has limitations. We could not develop a
population-based study but included participants who were com-
panions of patients in primary care, and no differences were
detected by women visiting the doctor periodically due to diabe-
tes or hypertension across stages. We recognized the existence of
external factors related to mammography such as those
concerning access to health care (e.g., distribution of health ser-
vices facilities, means of transportation, travel time to and waiting
time for health care, and consumer’s satisfaction) [33, 34]. Two
previous Mexican studies showed that the perception of organi-
zational and structural factors played a significant role in the use
of breast cancer screening [27, 28]. We did not evaluate these and
other aspects of quality of care but considered the history of Pap
smear as an approximate measure of access. In fact, this variable
resulted in a strong association with the action and maintenance
stages of change for mammography suggesting women defeated
access barriers. Additionally, most of the population included in
the study had health insurance coverage and lived in an urban
area. Consequently, it is possible that the results observed will not
apply to women from regions with less access to healthcare
services or with no health insurance. Forthcoming research
should consider prospective studies to corroborate present
findings.
This is the first study in Mexico and Latin America which
identified cognitive components that contribute to intended
mammography uptake and provided useful information for dif-
ferentiating populations that are reluctant to begin undergoing
mammograms (precontemplation), reinitiating (relapse), or main-
taining the long-term use of mammography. The effect of deci-
sional balance and self-efficacy was evidenced, although the rel-
ative contribution of the latter was greater and progressively in-
creased across the stages of change. The performance of pros,
cons, and decisional balance registered variations with respect to
international populations. The findings also highlighted the effect
of social norms, a personal history of Pap smears, and a family
history of mammography use or breast cancer. Specifically, risk
perception and severity did not have an influence on the stages of
change for mammography among Mexican women. This em-
phasized the importance of examining cognitive determinants of
mammography in particular societies. Decision makers and
J Canc Educ
public health authorities should keep in mind the importance of
stages of change for mammography in the promotion of early
breast cancer detection.
Acknowledgments We gratefully acknowledge the unconditional col-
laboration of Dr. Rebeca Thelma Martínez and Dr. José Guadalupe
Sánchez, whose support was essential to the development of this study.
Compliance with Ethical Standards All procedures performed in the
study were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declara-
tion and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants includ-
ed in the study.
This article does not contain any studies with animals performed by
any of the authors.
Conflict of Interest The authors declare that they have no conflict of
interest.
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