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Mammography stages of change in middle-aged women with schizophrenia: An exploratory analysis
© Lindamer et al; licensee BioMed Central Ltd. 2006
Received: 20 June 2006
Accepted: 30 October 2006
Published: 30 October 2006
Health care providers and educators who seek to create health promotion programs and individualized comprehensive care plans for women with schizophrenia are hindered by the lack of data to guide their efforts.
This study tested the hypothesis that women with schizophrenia adhere to mammography screening guidelines at the same rate as other same-age women. The study also investigated the validity of the Health Belief (HB) and Stages of Change (SOC) models for breast cancer screening among women with schizophrenia.
Socio-demographic and clinical variables, as well as knowledge, attitudes, and barriers were assessed as a function of stage of change related to breast cancer screening in 46 women with schizophrenia.
Women with schizophrenia were statistically less likely to be adherent to the screening recommendations than those without schizophrenia. Some support was found for the validity of the HB and SOC models for breast cancer screening in women with schizophrenia. Women in the Precontemplation stage had significantly higher negative attitude scores compared to Contemplation and Action/Maintenance stages (59.7, 45.7, and 43.2, respectively), and there was a trend for more barriers in the Precontemplation group (4.6, 2.6, 2.7 respectively).
Given the small sample size, further research on the rates of breast cancer screening in women with schizophrenia is warranted. Nonetheless, these data suggest that providers who care for women with schizophrenia may need to make take additional measures to ensure that this population receives appropriate screening so as to not put them at greater risk for a late-stage diagnosis of breast cancer. Furthermore, these pilot data suggest that HB and SOC theory-based interventions may be valid for increasing mammography rates in women with schizophrenia.
In the last decade, the overall incidence of breast cancer has remained stable, while mortality has decreased . Some, but not all, studies showed that rates of late-stage diagnoses have decreased [2–5]. At least a portion of the success in reducing breast cancer-related morbidity and mortality can be attributed to the early detection afforded by regular use of screening mammography among women 40 and older. Although breast cancer screening has been steadily increasing since the late 1980's and overall rates are approaching the defined targets [i.e., Healthy People 2010 ], use of mammography in some groups of women is still low . Underserved women include those who are poor, less educated, non-Caucasian, living in rural areas , lacking health insurance or a usual source of care, physically challenged , coping with cognitive limitations , and diagnosed with severe and persistent psychiatric disorders, such as schizophrenia and related psychotic disorders [10, 11].
Researchers have developed specific interventions to increase breast cancer screening in many of these under-represented groups . However, there remains a relative lack of studies investigating the breast cancer screening rates of women with psychotic disorders. Little is known about the knowledge and benefits of, attitudes toward, and barriers to mammography in women with schizophrenia, and there is a similar paucity of interventions to promote screening in this group .
Moreover, older women with psychosis may be at increased risk for breast cancer because of factors related to their psychiatric disorder or its treatment. Some [14–16], but not all [17–21], studies have found an increased risk of breast cancer in women with schizophrenia, the reasons for which are not yet clear. This may, in part, be due to the fact that women with schizophrenia are more likely to have the general risk factors commonly associated with increased incidence of breast cancer, such as nulliparity, obesity, high fat diet, or physical inactivity [22, 23]. In addition, there may be factors specifically related to schizophrenia and its treatment that increase risk for breast cancer . Barriers to medical care, such as fear of condemnation, stigma, and limited finances, also restricted access to early detection and treatment among women with schizophrenia .
To understand the use of mammography, researchers have employed constructs from theories of health behavior change, such as the Health Belief (HB) model  and the Stages of Change (SOC) model . The Health Belief model  considers health behavior a result of the interplay among variables that include perceived susceptibility to illness, perceived severity of illness, perceived benefits of taking health action, perceived barriers to taking action, and repetitive cues to health action. According to this model, women are more likely to undergo mammography if they believe that they are susceptible to breast cancer, consider its consequences severe, are aware of the benefits of screening, perceive that the benefits outweigh the barriers, and receive repeated cues to be screened. Perceived susceptibility and perceived barriers are usually the most important predictors of preventive health behavior, including mammography use [29, 30], and most, but not all, studies testing the HB model in mammography have supported the model [30–42].
The Stages of Change Model has also been useful in understanding breast cancer screening. Specifically, the stages of adoption of the behavior and decisional balance have been used to predict rates of mammography in the general population [43–45]. The model proposes that people pass through a series of progressively more committed stages in the course of changing a health-related behavior: Precontemplation (not even thinking about the target behavior), Contemplation (currently not doing the behavior, but considering the adoption of the behavior), Action (beginning to adopt the behavior), and Maintenance (sustaining the behavior over time). An algorithm was developed for mammography stages of change that included these five stages, as well as two others, Relapse Precontemplation, and Relapse Contemplation that differ from the Precontemplation and Contemplation stages, in that women in these categories have had a mammogram in the past, are not currently on schedule, and may or may not be considering undergoing mammography in the next six months [46, 45]. In this algorithm, the criteria for scoring positively (having a mammogram) were age dependent: women age 40–49 were expected to be screened at least every two years and women aged 50 and older, yearly. Several investigators have applied the concept of stages of change to assessing the efficacy of interventions to improve mammography adherence [44, 47, 48].
Decisional Balance, another construct of the SOC model, has been applied to mammography. It is a summary index derived from perceived positive (pros) and perceived negative (cons) features of the target behavior . The model hypothesizes that people in the Action and Maintenance stages have a positive decisional balance (pros>cons) and that people in Pre-contemplation have a negative balance (cons>pros). Persons in Contemplation have a decisional balance that falls between Pre-contemplation and Action and are expected to be closer to neutral or zero point of equal pros and cons.
To date, there has been limited application of the SOC model to promoting recommended health behaviors in persons with schizophrenia. Some have examined stages of change to address alcohol use in schizophrenia with mixed results [50–52]. Others have reported validity of the model with respect to smoking cessation in schizophrenia . Some have criticized the application of SOC model in persons with schizophrenia because some of these individuals lack several of the essential characteristics posited by the theory that are necessary to change behavior–namely, motivation and self-control, cognitive and behavioral coping skills, and social support . The success of the SOC model, however, may be dependent on the behavior targeted for change and the characteristics of the sample. For example, eliminating addictive behaviors, such as substance use, may be very different from promoting preventive health behaviors, such as increasing the use of mammography. Furthermore, dually diagnosed persons (schizophrenia and substance use disorder) often have the more severe symptoms , poorer medication compliance , and increased use of institutional and emergency services [57, 58] than non-substance addicted persons, suggesting that these individuals are not representative of all persons with schizophrenia.
At least one study has examined constructs of the HB and SOC models jointly for mammography use in a predominantly Caucasian middle class population. Champion and colleagues  found that women in the Action and Maintenance stages perceived significantly higher susceptibility, more seriousness, fewer barriers, and more benefits than those in the Pre-contemplation or Contemplation stages. No studies were found that described the relationship among knowledge and benefits of attitudes toward, and barriers to, breast cancer screening and stage of change in middle-aged women with schizophrenia, a group that possesses many risk factors for breast cancer.
The purpose of this study was to test the following three hypotheses: 1) women with schizophrenia are less likely to adhere to recommended screening guidelines than other same-age women; 2) the Health Belief and Stages of Change models will be a viable models for predicting breast cancer screening among women with schizophrenia; and 3) women with schizophrenia who are classified as being in the Precontemplation or Contemplation stage will have lower scores on their test of knowledge and benefits, more barriers to cancer screening, and more negative attitudes toward cancer screening (more negative decisional balance scores) than women with schizophrenia in the Action or Maintenance stages, a pattern that is typical in the general population.
Women were eligible for the study if they had a DSM-IV  diagnosis of schizophrenia or schizoaffective disorder, were at least 40 years of age, were community-dwelling outpatients under the care of a psychiatrist, had no known diagnosis of dementia, had a history negative for breast cancer, were psychiatrically and medically stable, and were able to give informed consent.
All women gave written, informed consent, following a protocol approved by the researchers' Institutional Review Board. Trained research assistants met with each woman to conduct the interviews and to administer verbally the five survey instruments. All data were based on self-report unless the participant could not provide key information, such as date of last mammogram. In these cases, medical records were reviewed with the subject's consent.
Socio-demographic and Clinical Information
Socio-demographic information, medical history, and gynecology service use were gathered from face-to-face interviews. The Positive and Negative Syndrome Scale (PANSS)  was used to assess positive and negative symptoms of schizophrenia, as well as general psychopathology.
Stage of Change for Mammography
The stage of change definitions for mammography followed the age-based recommendations; at least every two years for ages 40–49 and yearly for age 50 and older [44, 46]. Precomtemplation stage consisted of women who never had a mammogram and were not considering receiving one; whereas Relapse Contemplation included women who had undergone mammography in the past but had not had one in the recommended time frame and were not considering having one. Women were classified as being in the Contemplation stage if they had never had a mammogram but were considering undergoing mammography, and similarly they were categorized as Relapse Contemplation if they had a mammogram in the past but not within the recommended time frame and were considering having one. Action stage was defined as being adherent with the screening recommendations, and Maintenance stage was defined as having had more than one mammogram according to the recommendations.
Knowledge toward and Benefits of Breast Cancer and Barriers to Screening
Knowledge and benefits about breast cancer and mammography were assessed using the questionnaire developed by Skinner and colleagues . It consisted of eight true/false items about breast cancer knowledge and five items about perceived benefits of mammography. A total score was computed by summing the number of correct responses to both the knowledge and benefit items for a maximum score of 13.
The measures developed by Rakowski and colleagues  were used to measure decisional balance for mammography. It is a summary index that quantifies the net results of balancing of pros and cons for adopting a new health behavior. The women rated their agreement according to a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree) with each of six "pro" statements and seven "con" statements for mammography. An index of decisional balance was calculated by transforming the "pro" index and "con" index for the mammography scales into percents, and subtracting the "con" percent from the "pro" percent. Positive decisional balance scores indicate a favorable assessment of pros versus cons (historically characteristic of a person already performing the behavior); negative values indicate a more unfavorable assessment (historically characteristic of persons not yet committed to the behavior). Decisional balance of about zero represents a mixed perspective of positive and negative opinions, which is typical among persons contemplating the behavior.
The Health Belief model purports that a person also considers the barriers in deciding whether or not to adopt a new health behavior. Some barriers are attitudinal, while others are instrumental (e.g., cost, transportation). The heterogeneity in the types of barriers necessitates that they be examined separately from knowledge (perceived susceptibility, severity and benefits) or attitudes (decisional balance). Participants also responded to a list of 15 items representing possible barriers to mammography that was used by Skinner and colleagues . The total score was the total number of items positively endorsed.
Descriptive characteristics of the sample by stage of change were analyzed using Chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables. Separate ANOVAs were conducted for each of the dependent variables (total score on the test of knowledge and benefits; total percent positive attitude, total percent negative, the decisional index, and number of barriers), and Spearman rho correlations were conducted to assess the relationship between the dependent variable and stage of change. Post-hoc analysis of individual items of the Decisional Balance and Barriers questionnaires for mammography were conducted using Chi-square tests. For this analysis, the 5-point Likkert scale of the Decisional Balance questionnaire was collapsed into two categories: agree and disagree. All tests were two-tailed with alpha set at 0.05. The slightly increased experiment-wide Type I error that might result by using an alpha of 0.05 for each dependent variable, rather than alpha of 0.01 (Bonferroni corrected), outweighed the possible Type II error, given the importance of understanding knowledge and benefits of attitudes toward, and barriers to, breast cancer screening and developing interventions to reduce risk for breast cancer for this group.
Subjects were a sample of convenience and consisted of 46 women between the ages of 44 and 72 years with a mean age of 52.9 (SD = 6.0 years). They were predominantly Caucasian (80%), and all were participating in on-going studies at a university-affiliated research center. The majority (65%) had never been married, and they averaged 12.3 (± 1.9) years of education. Most participants (73.3%) resided in an assisted care facility.
Means (SD) or percentages for socio-demographic, clinical, and service use by stage of adoption in older women with schizophrenia.
Precontemplation (n = 10)
Contemplation (n= 7)
Action/Maintenance (n = 29)
F or χ2 Value
Ethnicity (% Cauc.)
Marital Status (% ever married)
Living Situation (% Assisted Living)
Primary Care Provider (%yes)
Annual Physical Exam (%yes)
Annual Pelvic Exam (%yes)
Annual Pap (%yes)
Annual Mammogram (%yes) Age≥50 years
Annual Mammogram (%yes) Age<50 years
Using the algorithm developed by Skinner and colleagues , only 4.3% (n = 2) of women with schizophrenia were classified as being in the Precontemplation stage; while, 17.4% (n = 8) were rated as being in the Relapse Precontemplation stage. None of the women met the definition for the Contemplation stage, 15.2% (n = 7) were categorized as being in Relapse Contemplation, 13.1% (n = 6) met criteria for the Action and 50% (n = 23) were classified as being in the Maintenance stage. Given the small sample sizes, the Precontemplation stage was combined with the Relapse Precontemplation stage (n = 10) and the Action stage was combined with the Maintenance stage (n = 29). Relapse Contemplation remained a separate category (n = 7). Three groups were created: 1) women who were not considering having a mammogram in the future whether or not they had one in the past (Precomtemplation, 21.7%); 2) women who underwent mammography more than two years ago, who were considering having another (Contemplation, 15.2%); and 3) women who had a mammogram in at least the past two years and who regularly underwent age-appropriate screening (Action/Maintenance, 63%).
Means (SD) on measures of breast cancer screening knowledge, barriers, and decisional balance by stage of adoption.
Precontemplation (n = 10)
Contemplation (n= 7)
Action/Maintenance (n = 29)
Knowledge and Benefits (total score)
Barriers (total score)
Positive Decisional Balance (%)
Negative Decisional Balance (%)
Decisional Balance Index
To further examine the relationship between measures of decisional balance and stage of change, Spearman rho correlations were conducted. The Negative Decisional Balance score, and consequently the Decisional Balance Index, were found to be significantly inversely associated with stage of change (rho = -.394, p = .007 and rho = -.391, p = .007, respectively). In contrast, Positive Decisional Balance score, Knowledge score, and Barrier score were not associated with stage of change. Post-hoc analysis of the individual items on the Decisional Balance questionnaire revealed that 55.6% of women in the Precontemplation group believed that a mammogram was not needed if a clinical breast exam was preformed compared to 18.5% of the women in the Action/Maintenance group and none in the Contemplation group. (Chi-square = 7.292, d.f, = 2, p = .026.) Furthermore, all of the women in the Precontemplation group indicated that they would not have a mammogram if the doctor seemed to doubt that one was needed. In contrast, only 57.1% of the Contemplation group and 40.7% of the Action/Maintenance group endorsed this negative attitude (Chi-square = 7.892, d.f. = 2, p = .019.) No other significant differences were found among the groups. Lending further support for this observation, post-hoc analysis of the 13-item Barriers questionnaire also disclosed a significantly greater propensity for women in the Precontemplation group to not have a mammogram if a clinical breast exam was performed or if the doctor doubted the need for one.
We found that the proportion of women who received mammograms in the past year was lower than the rate reported for the general population in California (41.3% versus 60.5% for ages 40–64)  and more closely aligned with screening rates for minority populations living in the same community [63–65]. The low rate of screening may be considered even more disconcerting in view of the fact that nearly all of the women reported that they had insurance (88.8%), a primary care physician (91.1%), and annual physical examinations (73.3%). This low screening rate places them at a considerably greater risk of having a breast cancer discovered at a late stage, thereby supporting the first hypothesis.
As further support of the first hypothesis, only 41% endorsed having annual mammograms and only 63% of women reported undergoing mammography within the past two years (as defined by being in the Action or Maintenance stage), a rate lower than that seen in the general population and consistent with other research examining preventive care in women with severe mental illness [11, 66]. One study found that 62% of their sample of women with schizophrenia had mammograms in the last two years . Another study reported that women with schizophrenia and a low-income comparison group received similar preventive services, but the rates of mammography were not directly reported. It is not clear from this study, whether these women with schizophrenia received breast cancer screening at less than the recommended rates because of low income, lack of a physician referral, or due to their psychiatric illness. Further research is warranted to develop effective interventions.
Data from this study also supported the second hypothesis. We found some support for the validity of the Health Belief and Stages of Change models for predicting mammography adherence in women with schizophrenia. From Champion and colleagues'  study of women without schizophrenia, those in the Action and Maintenance stage perceived significantly higher susceptibility, more seriousness, fewer barriers, and more benefits than those in the Precomptemplation or Comtemplation stages. We did not find significant differences on measures of knowledge and benefits of breast cancer screening in our sample. However, women in the Precomtemplation stage did report more barriers, which differed from the other two stages of change categories, but at the trend level only. We did, however, find support for the shift of Decisional Balance over the stages of change, as predicted by the Stages of Change model. Interestingly, positive attitudes did not vary across stage of change. Negative attitudes, however, were lower in the women who were currently adhering to recommended mammography screening guidelines, suggesting that interventions with this group might be more effective if focused on ways of reducing negative attitudes.
The third hypothesis was also supported. A pattern was observed between knowledge and benefits of, attitudes toward, and barriers to breast cancer screening by stage of change in women with schizophrenia that has been reported in non-psychiatric groups. The more negative attitudes toward mammography were found in women with schizophrenia who were categorized as being in the Precontemplation stage, a finding that is consistent with the Stage of Change Model.
The findings from this study must be generalized with caution because the sample is small, the study participants were stable outpatients on antipsychotic medication, and only one large metropolitan region was studied. Moreover, a self-selection bias cannot be overlooked; by agreeing to participate in research, these women have set themselves apart from those women with schizophrenia who refused the invitation to participate. Finally, this was a cross-sectional study of stages of changes for mammography. According to the theory, a longitudinal study is needed to verify the shift in decisional balance over time.
This study found that rates of breast cancer screening in women with schizophrenia were below the recommended guidelines, which may put them at greater risk for a late-stage breast cancer diagnosis. Moreover, this exploratory study of the application of the HB and SOC models to mammography in older women with schizophrenia suggests that these models may be useful for understanding and promoting the use of breast cancer screening in this population. Unlike the findings for reducing substance use behaviors in persons with schizophrenia, these results suggest the HB and SOC models may have utility in promoting some positive health behaviors in women with schizophrenia.
This work was supported, in part, by the National Institute of Mental Health grant MH66248 Center grant and grant R34 MH071539, the VISN 22 Mental Illness Research, Education and Clinical Center (MIRECC), the National Institutes of Health's Division of National Center on Minority Health and Health Disparities EXPORT grant P60MD00220; and the National Cancer Institute's grants R25 CA65745, Cancer Center Core Gant #5 P30 CA023100-22, and Minority Institution/Cancer Center Partnership Program grants #U56 CA92079 and #U56 CA9208.
- National Cancer Institute: Cancer Progress Report 2001. 2001, [http://progressreport.cancer.gov]Google Scholar
- Schootman M, Jeffe D, Reschke A, Aft R: The full potential of breast cancer screening use to reduce mortality has not yet been realized in the United States. Breast Cancer Res Treat. 2004, 2815–03: 1-4.Google Scholar
- Kriclar A, Farac K, Smith D, Sweenly A, McCrodie M, Armstrong BK: Breast cancer in South Wales in 1972–1995: Tumor size and the impact of mammographic screening. Int J Cancer. 1999, 81: 877-880. 10.1002/(SICI)1097-0215(19990611)81:6<877::AID-IJC7>3.0.CO;2-F.View ArticleGoogle Scholar
- McCann J, Stockton D, Day N: Breast cancer in East Anglia: The impact of the breast screening programme on stage at diagnosis. J Med Screen. 1998, 5: 42-48.View ArticlePubMedGoogle Scholar
- Schouten LS, De Rijke JM, Schlangen JT, Verbeek AL: Evaluation of the effect of breast cancer screening by record linkage with the cancer registry. J Med Screen. 1998, 5: 37-41.View ArticlePubMedGoogle Scholar
- U.S. Department of Health and Human Services – Public Health Service: Healthy People 2000 – National Health Promotion and Disease Prevention Objectives. 1990, Washington, DC: U.S. Government Printing OfficeView ArticleGoogle Scholar
- Calle EE, Flanders WD, Thun MJ, Martin LM: Demographic predictors of mammography and pap smear screening in US women. Am J Public Health. 1993, 83: 53-60.View ArticlePubMedPubMed CentralGoogle Scholar
- Sadler GR, Huang J, Padden C, Elion L, Galey T, Gunsauls DC, Brauer B: Bringing health care information to the deaf community. J Cancer Educ. 2001, 16: 105-108.PubMedGoogle Scholar
- Legg JS, Clement DG, White KR: Are women with self-reported cognitive limitations at risk for underutilization of mammography?. J Health Care Poor Underserved. 2004, 15: 688-702.View ArticlePubMedGoogle Scholar
- Lindamer LA, Buse DC, Auslander A, Unutzer J, Bartels SJ, Jeste DV: A comparison of gynecological variables and services use in older women with and without schizophrenia. Psychiatr Serv. 2003, 54: 902-904. 10.1176/appi.ps.54.6.902.View ArticlePubMedGoogle Scholar
- Dickerson FB, Pater A, Origoni AE: Health behaviors and health status of older women with schizophrenia. Psychiatr Serv. 2002, 53: 882-884. 10.1176/appi.ps.53.7.882.View ArticlePubMedGoogle Scholar
- Rimer BK, Resch N, King E, Ross E, Lerman C, Boyce A, Kessler H, Engstrom PF: Multistrategy health education program to increase mammography use among women ages 65 or older. Public Health Rep. 1992, 107: 369-380.PubMedPubMed CentralGoogle Scholar
- Lantz PM, Stencil D, Lippert MT, Beversdorf S, Jaros L, Remington PL: Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Am J Public Health. 1995, 85: 834-836.View ArticlePubMedPubMed CentralGoogle Scholar
- Ettigi P, Lal S, Friesen H: Prolactin, phenothiazine, admission to mental hospital and carcinoma of the breast. Lancet. 1973, II: 266-267. 10.1016/S0140-6736(73)93175-9.View ArticleGoogle Scholar
- Masterson E, O'Shea B: Smoking and malignancy in schizophrenia. Br J Psychiatry. 1984, 145: 429-432.View ArticlePubMedGoogle Scholar
- Baldwin JA: Schizophrenia and physical disease. Psychol Med. 1979, 9: 611-618.View ArticlePubMedGoogle Scholar
- Brugmanns J, Verbruggen R, Dom J: Prolactin, phenothiazine, admission to mental hospital and carcinoma of the breast. Lancet. 1973, II: 502-503. 10.1016/S0140-6736(73)92102-8.View ArticleGoogle Scholar
- Halbreich U, Shen J, Panaro V: Are chronic psychiatric patients at increased risk for developing breast cancer. Am J Psychiatry. 1996, 153: 559-560.View ArticlePubMedGoogle Scholar
- Lichtermann D, Ekelund J, Pukkala E, Tanskanen A, Lonnqvist J: Incidence of cancer among persons with schizophrenia and their relatives. Arch Gen Psychiatry. 2001, 58: 573-578. 10.1001/archpsyc.58.6.573.View ArticlePubMedGoogle Scholar
- Oksbjerg DS, Munk LT, Mellemkjaer L, Johansen C, Mortensen PB: Schizophrenia and the risk for breast cancer. Schizophr Res. 2003, 62: 89-92. 10.1016/S0920-9964(02)00430-9.View ArticleGoogle Scholar
- Barak Y, Achiron A, Mandel M, Mirecki I, Aizenberg D: Reduced cancer incidence among patients with schizophrenia. Cancer. 2005, 104: 2817-2821. 10.1002/cncr.21574.View ArticlePubMedGoogle Scholar
- Brown S, Birtwistle J, Roe L, Thompson C: The unhealthy lifestyle of people with schizophrenia. Psychol Med. 1999, 29: 697-701. 10.1017/S0033291798008186.View ArticlePubMedGoogle Scholar
- American Cancer Society: Cancer Facts and Figures. 2001, Atlanta, GA: The SocietyGoogle Scholar
- Wang PS, Walker AM, Tsuang MT, Orav EJ, Glynn RJ, Levin R, Avorn J: Dopamine antagonists and the development of breast cancer. Arch Gen Psychiatry. 2002, 59: 1147-1154. 10.1001/archpsyc.59.12.1147.View ArticlePubMedGoogle Scholar
- Carney CP, Allen J, Doebbeling BN: Receipt of clinical preventive medical services among psychiatric patients. Psychiatr Serv. 2002, 53: 1028-1030. 10.1176/appi.ps.53.8.1028.View ArticlePubMedGoogle Scholar
- Rosenstock IM: Why people use health services. Memorial Fund Quarterly. 1966, 44: 94-121. 10.2307/3348967.View ArticleGoogle Scholar
- Prochaska JO, Velicer WF: The transtheoretical model of health behavior change. American Journal of Health Promotion. 1997, 12: 38-48.View ArticlePubMedGoogle Scholar
- Becker MH: The health belief model and personal health behavior. Health Education Monthly. 1974, 2: 324-508.Google Scholar
- Janz NK, Becker MH: The health belief model: A decade later. Health Educ Q. 1984, 11: 1-47.View ArticlePubMedGoogle Scholar
- Rutledge DN, Hartmann WH, Kinman PO, Winfeld AC: Exploration of factors affecting mammography behaviors. Prev Med. 1988, 17: 412-422. 10.1016/0091-7435(88)90040-0.View ArticlePubMedGoogle Scholar
- Aiken LS, West SG, Woodward CK, Reno RR: Health beliefs and compliance with mammography screenign reccomendations in asymptomatic females. Health Psychol. 1994, 13: 122-129. 10.1037/0278-6220.127.116.11.View ArticlePubMedGoogle Scholar
- Champion VL: Compliance with guidelines for mammography screening. Cancer Detect Prev. 1992, 16: 253-258.PubMedGoogle Scholar
- Burack RC, Liang J: The acceptance and completion of mammography by older Black women. Am J Public Health. 1989, 79: 721-726.View ArticlePubMedPubMed CentralGoogle Scholar
- Calnan M: The health belief model and participation in programs for the early detection of breast cancer: A comparative analysis. Social Science Medicine. 1984, 19: 823-830. 10.1016/0277-9536(84)90399-X.View ArticlePubMedGoogle Scholar
- Champion VL: The relationship of selected variables to breast cancer detection behaviors in women 35 and older. Oncol Nurs Forum. 1991, 18: 733-739.PubMedGoogle Scholar
- Champion VL: Beliefs about breast cancer and mammography by behavioral stage. Oncol Nurs Forum. 1994, 21: 1009-1014.PubMedGoogle Scholar
- Fajardo LL, Saint-Germain M, Meaken TJI, Rose C, Hillman BJ: Factors influencing women to undergo screening mammography. Radiology. 1992, 184: 59-63.View ArticlePubMedGoogle Scholar
- Fulton JP, Buechner JS, Scott HD: A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 or older. Public Health Rep. 1991, 106: 410-420.PubMedPubMed CentralGoogle Scholar
- Murray M, McMillan C: Health beliefs, locus of control, emotional control and women's cancer screening beliefs. Br J Clin Psychol. 1993, 32: 87-100.View ArticlePubMedGoogle Scholar
- Rimer BK, Trock B, Engstrom PF, Lerman C, King E: Why do some women get regular mammograms?. American Journal of Preventative Medicine. 1991, 7: 69-74.Google Scholar
- Stein JA, Fox SA, Murata PJ, Morisky DE: Mammography usage and the health belief model. Health Educ Q. 1992, 19: 447-462.View ArticlePubMedGoogle Scholar
- Rimer BK, Keintz MK, Kessler HB, Engstrom PF, Rosan JR: Why women resist screening mammography: Patient-related barriers. Radiology. 1989, 172: 243-246.View ArticlePubMedGoogle Scholar
- Rakowski W, Dube CE, Marcus BH, Prochaska JO, Velicer WF, Wayne F, Abrams DB: Assessing elements of women's decisions about mammography. Health Psychol. 1992, 11: 111-118. 10.1037/0278-618.104.22.168.View ArticlePubMedGoogle Scholar
- Rakowski W, Ehrich B, Goldstein MG, Rimer BK, Pearlman DN, Clark MA, Velicer WF, Woolverton HI: Increasing mammography among women aged 40–74 by use of a stage-matched, tailored intervention. Preventative Medicine. 1998, 27: 748-756. 10.1006/pmed.1998.0354.View ArticleGoogle Scholar
- Rakowski W, Fulton JP, Feldman JP: Women's decision about mammography: A replication of the relationship between stages of adoption and decisional balance. Health Psychol. 1993, 12: 209-214. 10.1037/0278-622.214.171.124.View ArticlePubMedGoogle Scholar
- Skinner CS, Arfken CL, Sykes RK: Knowledge, perceptions, and mammography stage of adoption among older urban women. Am J Prev Med. 1998, 14: 54-63. 10.1016/S0749-3797(97)00008-1.View ArticlePubMedGoogle Scholar
- Crane LA, Leakey TA, Rimer BK, Wolfe P, Woodworth MA, Warnecke RB: Effectiveness of a telephone outcall intervention to promote screening mammography among low-income women. Prev Med. 1998, 27: S39-S49. 10.1006/pmed.1998.0395.View ArticlePubMedGoogle Scholar
- Crane LA, Leakey TA, Ehrsam G, Rimer BK, Warnecke RB: Effectiveness and cost-effectiveness of multiple outcalls to promote mammography among low-income women. Cancer Epidemiol Biomarkers Prev. 2002, 9: 923-931.Google Scholar
- Rakowski W, Stoddard AM, Rimer BK, Fox SA, Andersen MR, Urban N, Lane DS, Costanza ME: Confirmatory analysis of opinions regarding the pros and cons of mammography. Health Psychol. 1997, 16: 433-441. 10.1037/0278-6126.96.36.1993.View ArticlePubMedGoogle Scholar
- Carey KB, Maisto SA, Carey MP, Purnine DM: Measuring readiness-to-change substance misuse among psychiatric outpatients: I. Reliability and validity of self-report measures. J Stud Alcohol. 2001, 62: 79-88.View ArticlePubMedPubMed CentralGoogle Scholar
- Addington J, el-Guebaly N, Duchak V, Hodgins D: Using measures of readiness to change in individuals with schizophrenia. Journal of Drug and Alcohol Abuse. 1991, 25: 151-161. 10.1081/ADA-100101851.View ArticleGoogle Scholar
- Velasquez MM, Carbonari JP, DiClemente CC: Psychiatric severity and behavior change in alcoholism: The relation of the trantheoretical model variables to psychiatric distress in dually diagnosed patients. Addict Behav. 1999, 24: 481-496. 10.1016/S0306-4603(98)00103-8.View ArticlePubMedGoogle Scholar
- Esterberg ML, Compton MT: Smoking behavior in persons with a schizophrenia-spectrum disorder: a qualitative investigation of the transtheoretical model. Soc Sci Med. 2005, 61: 293-303. 10.1016/j.socscimed.2004.11.057.View ArticlePubMedGoogle Scholar
- Bellack AS, DiClemente CC: Treating substance abuse among patients with schizophrenia. Psychiatr Serv. 1999, 50: 75-80.View ArticlePubMedGoogle Scholar
- Carey MP, Casey KB, Meisler AW: Psychiatric symptoms in mentally ill chemical abusers. Journal of Nervous & Mental Disease. 1991, 179: 136-138. 10.1097/00005053-199103000-00004.View ArticleGoogle Scholar
- Owen RR, Fischer EP, Booth BM, Cuffel BJ: Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatr Serv. 1996, 47: 853-858.View ArticlePubMedGoogle Scholar
- Bartels SJ, Teague GB, Drake RE, Clark RE, Bush PW, Noordsy DL: Substance abuse in schizophrenia: Service utilization and costs. Journal of Nervous & Mental Disease. 1993, 181: 227-232. 10.1097/00005053-199304000-00003.View ArticleGoogle Scholar
- Folsom DP, Hawthorne W, Lindamer L, Gilmer T, Bailey A, Golshan S, Garcia P, Unutzer J, Hough R, Jeste DV: Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005, 162: 370-376. 10.1176/appi.ajp.162.2.370.View ArticlePubMedGoogle Scholar
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 2000, Washington, DC: American Psychiatric Association, FourGoogle Scholar
- Kay S, Fiszbein A, Opler LA: The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull. 1987, 13: 261-276.View ArticlePubMedGoogle Scholar
- Skinner CS, Strecher VJ, Hospers H: Physicians' recommendations for mammography: Do tailored messages make a difference?. Amercian Journal of Public Health. 1994, 84: 43-49.View ArticleGoogle Scholar
- American Cancer Society: Breast Cancer Facts and Figures 2001–2002. No. 8610.01R. 2002Google Scholar
- Sadler GR, Gunsauls DC, Huang J, Padden C, Elion L, Galey T, Brauer B, Ko CM: Bringing breast cancer education to deaf women. J Cancer Educ. 2001, 16: 225-228.PubMedGoogle Scholar
- Sadler GR, Thomas AG, Dhanjal SK, Gebrekristos B, Wright FA: Breast cancer screening adherence in Africa-American Women: Black cosmetologists promoting health. Cancer Supplement. 1998, 83: 1836-1839.View ArticleGoogle Scholar
- Sadler GR, Thomas AG, Yen JY, Dhanjal SK, Ko CM, Tran CH, Wang K: Breast cancer education program based in Asian grocery stores. J Cancer Educ. 2000, 15: 173-177.PubMedGoogle Scholar
- Steiner JL, Hoff RA, Moffett C, Reynolds H, Mitchell M, Rosenheck R: Preventive health care for mentally ill women. Psychiatr Serv. 1998, 49: 696-698.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://0-www.biomedcentral.com.brum.beds.ac.uk/1471-244X/6/49/prepub
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