Psychological models have attempted to explain the perceptions and beliefs underlying the decision to attend screening. However research efforts to turn these models into predictors of attendance behaviour have met with varying levels of success [5], suggesting that the theory is relevant, but may not capture the full picture. Additional considerations linked to demographic background, individual differences in psychological attributes, as well as events which cue thoughts about mammography screening are also likely to inform the decision to attend.

With knowledge of working in a location and its particular mix of client groups, the practitioner is well placed to assess which factor(s) is (are) influential in this process. Whilst no single approach will suit all potential attendees, it is hoped that awareness of a range of factors, such as those discussed in this section, will encourage or confirm the practitioner’s efforts in understanding what lies behind an individual’s decision to attend for a mammogram.

The psychological contributors to a decision to attend for screening or not, may be broken down into specific components. The Health Beliefs Model [6] suggests that we assess the threat posed by a specific cause of illness taking into account our own susceptibility and perceptions of the severity of a potential health problem, calculations about which may be prompted by a cue, such as the arrival of an invitation for an appointment or seeing an awareness raising advertisement. From this starting point, the Model suggests we balance the benefits and barriers provided by the prospect of preventative action. For mammography this means that clients are unlikely to come forward when perceiving there is little chance of developing breast cancer, but are more likely to attend for screening if there is knowledge about highly increased mortality if the cancer remains undetected [7]. Considerable efforts have been made to raise public awareness of breast cancer in recent years, particularly in the UK, resulting in increased availability of information about both of these aspects of threat [3]. However the psychological impact of information concerning breast cancer and screening has also been more carefully considered.

Previous research has documented that women tend to overestimate their own breast cancer risk, causing them to suffer high levels of anxiety about developing the disease [8, 9]. Interestingly, Yavan et al. [10] found that in a sample of Turkish women at average risk they actually perceived themselves at 50 % or more risk of developing breast cancer, and this rate increased as they got older; other research such as Jones et al.’s [11] large-scale Australian studies suggest instead that younger women perceive the most elevated risk. Either way the consequence of this inaccurate perception of risk and associated levels of anxiety may adversely affect attendance for regular screening in these women. It is unclear what causes such inaccuracies, and it would seem reasonable to examine the effectiveness of the process of communication of risk itself. Historically, research has documented that international variations in risk communication have made no difference to inaccurate risk perception [12–15].

Recently, the UK’s Independent Breast Screening Review Panel [16] indicated a number of policy recommendations to the NHS Breast Screening Programme, one of which concerned the communication of risk and benefit of routine mammograms. It is important that ‘clear communication of the harms and benefits of screening to women is essential. It is at the core of how a modern health system should function’ [17]. However, it may be that as the risks or harms are more effectively communicated, women who already overestimate their risk may tend to utilise this information and conclude that screening is unsafe, and decline the invitation to attend for routine mammograms. A study in Germany looked at risk information for colorectal screening; they found that risk information was most effective when presented in a traditional format, offering simple advice and general guidelines. Conversely if risk information was presented as evidence-based information that considered specific criteria it was more likely to lead to some rationalisation of inaction, i.e. people tended to devalue this information, minimise their perceived risk, and use this as a reason for non-attendance [18].

The nature of mammography means that a decision about its personal relevance relies on a combination of physical and psychological considerations. As if to complicate matters, both of these sets of factors are subject to variations in the individual’s perceptions too.

However the anecdotal themes of embarrassment, discomfort and pain [19] indicate that for a proportion of women the process itself is physically challenging, in a manner which may well be separate from any consideration about perceptions of the potential benefit of having a mammogram. Naturally any professional carrying out the screening will do their best to mentally prepare the individual and qualm any concerns, so it is not surprising that attendees are generally positive about the staff working in this field – it has even been noted that satisfaction with the practitioner can actually help to reduce reports of pain and embarrassment [20].

Nevertheless anyone experiencing serious discomfort or pain is likely to remember that feeling and hold that association with the experience of having a mammogram. It has been suggested that enhancing the levels of control clients have over the mammography procedure could further assist in countering discomfort [21]. Meanwhile research is ongoing to determine the compression forces required on the breast to obtain a viable image (see section “Perceptions of risk and pain” and Chaps.​ 20, 21 and 22) and clearly advances in practice are required to minimise the expectation and/or perception of pain or discomfort from the process of deciding whether or not to attend or re-attend.

The Health Beliefs Model also highlights the cost-benefit analysis made by an individual which determines their next step after assessing their personal risk. For a positive decision to attend screening, it has been suggested that the benefits of the behaviour should outweigh the potential barriers to taking action. For example, this requires confidence in the ability of the mammogram to detect cancer, although painful, or otherwise off-putting, experience can over-ride this potential benefit [7].

The Theory of Planned Behaviour [22] goes further to consider judgements of what is the prevalent social expectation when deciding whether to attend or not – in other words do family members, friends and colleagues go for screening? However there are limitations in the ability of either approach to predict behaviour. For example studies conducted in different ethnic groups have pointed to the usefulness of the Health Beliefs Model; but additionally suggest the role of culturally distinct factors, in determining attendance for mammography [e.g. 23–25].

Previous research has documented that uptake in women in some groups may be negatively influenced by such factors as lack of knowledge, language barriers, reduced access to medical services and unhelpful attitudes of health professionals [26]. However the role of social support, including a close friendship, supportive relationships with family, or membership of a group (e.g. as a volunteer) can positively predict attendance for a mammogram, whereas isolation from peers – such as indicated by living alone or with children only – or through absence of social participation, significantly increases the likelihood of non-attendance [27].

Furthermore, it is important to consider that mammography is one of three ways in which women are encouraged to take preventative action with regard to breast cancer, along with self-examination and a clinical consultation with their doctor if a sign or symptom is noted. More recent comparisons of women’s perceptions in relation to all three techniques suggest fewer ethnic-group differences in perceived threat or barriers associated with each, but instead differences in the perceptions of the benefits of mammography, along with varying scores for self-efficacy and health motivation [28]. Individual differences due to enduring personal characteristics, such as self-efficacy, have also been proposed as key factors predicting compliance with health-related behaviours [29].

Taken together these findings suggest individual perceptions of factors beyond the individual’s control make the prospect of having a mammogram – and a preventative approach to ill health generally – harder to follow through. The Malmo Diet and Cancer Cohort Study in Sweden has identified perceptions of lower levels of control among non-attenders, who might answer positively to questions such as ‘things do not turn out the way I had wished’ [27]. However efforts to combat weak control beliefs through encouraging women across the English county of Kent to plan to attend have yielded positive results, by increasing attendance for mammography. Women who were required to plan their attendance had tended to report reduced confidence in their capacity to overcome difficulties in attending and the act of planning helped them to problem solve in a way that may well have influenced their motivation to take up the screening invitation [30]. Such a focus on implementation intentions, i.e. helping to link planning and then acting, holds particular promise for those who have intentions to attend but see difficulties in doing so [30].

Joffe [31] points out that ‘people are motivated to represent the risks which they face in a way which protects them, and the groups with which they identify, from threat’ (p. 10). Consistent with this, it is more likely that women consider mammograms in a manner which strengthens the ability to build psychological defences, i.e. safeguarding feelings at an individual and social level. This is clearly a phenomenon shared by anyone rationalising a particular course of action and can mean changing one’s beliefs (e.g. It is a good idea to attend for a mammogram) to justify one’s behaviour (e.g. I did not attend my mammogram appointment), so that one believes differently (e.g. My friends tend not to go for a mammogram and they’re fine, so I will be fine too). This example of cognitive dissonance illustrates how the logic of decision making about attending for a mammogram can be altered and yet the theoretical approaches considered so far assume such decisions are based on a controlled process free from the influence of negative emotions and from beliefs which disagree with the health promotion literature [32].

It has been recognised that recent experiences of stress outside of work increase the chances of not attending for a mammogram [27], however previous research has suggested that psychosocial factors such as fear and fatalism can negatively influence whether a woman accepts an invitation to attend for routine screening [33].