Methods

We conducted a cross-sectional study with a non-probabilistic sample in a public health care facility in Northeast Mexico. The data collection took place from 2017 to 2018. The study was approved by the Hospital’s Research Bioethics Committee [HMBSSSNL-2016/748].

Results

Discussion

In this research, the objectives were to describe the distribution of women in different stages of change of mammography screening, identify associations between sociodemographic variables and the stages of change, and determine the relationship between sociodemographic variables and HBM variables. Therefore, identifying cognitive factors, such as beliefs, associated with the mammography screening may enhance its practice.

Most women aged 40 years and older were in the maintenance stage (32%) and relapse stage (28%). These results are similar to another study conducted in Mexico in which most of the participants were in the same stages (^{Salinas-Martínez et al., 2018}). Moreover, it has been shown that the percentage of Asian women living in the United States who were in the maintenance stage (48%) was higher than that of women in the other stages (^{Wu et al., 2009}).

On the other hand, these results differ from those obtained in other countries like Iran, where most women (75%) were in the stages of precontemplation and contemplation (^{Taymoori & Berry, 2009}). Similarly, most African American women were in the contemplation stage (^{Russell et al., 2007}). Iranian women still present barriers regarding mammography as it causes pain, takes a long time and is embarrassing. Similar to what was observed in African American women who, in addition to having lower incomes, which makes access to mammography difficult, also perceived more barriers.

However, these results suggest an increase in the use of the screening method in the population, in contrast of the reported in previous studies in Mexico (^{Jacobo-Galindo et al., 2014}; ^{López-Carrillo et al., 2014}; ^{Tenahua-Quitl et al., 2015}).

In the study, most women aged 40 to 49 years were in the contemplation stage and most women aged 50 to 59 and >60 years were in the maintenance stage. This result is similar to a study from Iran, where middle-aged women were more likely to be in the maintenance stage (^{Taymoori & Berry, 2009}). In Mexico, mammography is recommended starting at age 40, so women in this age range begin with the intention of having it done.

In the 50-year-old population groups, the percentages in maintenance and relapse are very similar, so it would be important to inquire about possible factors related to not performing a mammography regularly. Such as considering themselves without risk factors or having had several mammograms without findings.

In our sample, we found significant differences between the HBM variables scores and the stages of change. The scores for susceptibility were lower in the precontemplation stage than in more advanced stages. This result differs with another study, whereby there were no significant differences in this domain between the stages of change (^{Salinas-Martínez et al., 2018}). A study suggests that women who have low perceived susceptibility did not perceive the need to perform the health behavior (^{Taymoori & Berry, 2009}). In this case, it is expected that women in precontemplation do not perceive themselves in risk and would not practice the mammography screening.

As reported in other studies, perceived severity did not vary significantly between the stages of change (Moodi et al., 2012; ^{Salinas-Martínez et al., 2018}; ^{Shirzadi et al., 2017}). A study found that this variable had little variability because cancer was perceived as a serious disease by most women, even if they practice or not the behavior (^{Medina-Shepherd & Kleier, 2010}).

Our results corroborate the finding. Women in the precontemplation stage perceive fewer benefits in the use of mammography than women in more advanced stages. However, there were no significant differences in this variable between other stages (Taymoori et al., 2014; ^{Wu et al., 2009}). It is expected that women in precontemplation stage perceive less benefits and would not have a mammography.

The barriers mean score was lower in precontemplation than in the rest of the stages. This finding is similar to some studies, whereby women in the precontemplation stage perceived fewer barriers than women in more advanced stages (^{Russell et al., 2007}; ^{Salinas-Martínez et al., 2018}; ^{Shirzadi et al., 2017}). This result suggests that women in the contemplation stage are aware of certain limitations in performing a mammography. We consider it is important to continue exploring the relation between contemplation stage and specific perceived barriers as it may predispose women into not carrying out the mammography and avoid going to the action stage. A study in Mexico shows that perceived benefits predict the practice of mammography (^{Juárez-García et al. 2021}). Both data should be considered in the design of intervention for breast screening promotion.

The scores for perceived self-efficacy were different between the precontemplation stage and the other stages of change, specifically between the stages of contemplation and maintenance, and between the stages of maintenance and relapse. This finding corroborates other studies findings (Moodi et al., 2012; ^{Salinas-Martínez et al., 2018}) and evidences how self-efficacy varies among women who adhere to mammography screening and those who do not. This suggests that women in maintenance stage consider themselves capable of undergoing the mammography continuously. It could also be suggested that self-efficacy is an important factor to change from the contemplation stage to action and maintenance stages. The questions related to self-efficacy to get a mammogram show whether the person feels confident to go through the steps to get a mammogram. Therefore, it is important to consider, when promoting mammography, to inform about the procedure to perform it, i.e., where to go, who to contact, so that women feel confident that they will be able to get the mammogram.

We found significant differences in health motivation scores between the stages of contemplation and maintenance. Resembling another study that found that women in the maintenance stage had a higher health motivation than women in other stages (Moodi et al., 2012). This shows that people who are interested in their general health care may be more interested in performing a specific health care behavior such as mammography and continue to practice it. This also suggests that interventions to promote breast cancer screening methods may also include general health care information that can also contribute to the promotion of protective factors against breast cancer.

Also, we found that breast cancer screening behaviors such as breast self-examination (BSE) and clinical breast examination (CBE) were more common in women in the maintenance stage. This is relevant as in Mexico these screening methods are still recommended; the AEM from the age of 20 and the ECM from the age of 25. These findings suggest that women perform the 3 recommended screening methods to stay in good health. In addition, as mammography is recommended biannually, these other methods can help women to be attentive to changes in their breasts in case a symptom occurs and requires some examination before the established time.

This study has limitations. First, the collected data was self-reported by the participants and the performance of mammograms in their health card was not investigated. Second, the participants were from a regional hospital in Northeast Mexico, hence the results could not be generalized to other populations.

The relevance of the study is the finding of the different stages of mammography adoption and the beliefs related to them. The results can be useful for the development of educative interventions for breast cancer screening. Our results indicate that the number of women who undergo mammography has increased. Nonetheless, a considerable percentage (26.9%) of women remained in the stages of precontemplation and contemplation, i.e., did not undergo mammography. As well, women in maintenance stage report higher self-efficacy and health motivation. According to the health promotion perspective, an educational program that informs about breast cancer, its risk factors and screening methods can be useful for the population (^{Martínez-Montañez et al., 2009}).Therefore, implementing an educational intervention must consider the information needs of women on those stages, empower them to feel confident in performing a mammography, and interested in staying in good health.

Some interventions using both models (HBM and TTM) have shown that participants move to more advanced stages of change and undergo the mammography examination regularly. A study found that women that were in contemplation stage moved to action, and maintenance stage after TTM intervention (^{Lee-Lin et al., 2016}). Other study applied HBM intervention for cancer screening behaviors and reported an increase of perceived benefits and self-efficacy after the intervention (^{Ghaffari et al., 2019}).