Defense Date


Document Type


Degree Name

Doctor of Philosophy


Social and Behavioral Health

First Advisor

Vanessa B. Sheppard, PhD


PURPOSE: Annual surveillance mammography is a critical part of routine cancer care for breast cancer (BC) survivors; reducing mortality by 39%. However, disparities exist with regard to adherence to surveillance mammograms among BC survivors; Black women are 44% less likely to adhere than their White counterparts. Despite the existence of this racial disparity for over a decade, little is known about factors that explain reasons for Black BC survivors’ non-adherence. This is because most studies have not evaluated the role of healthcare delivery or psychosocial factors. Guided by the Behavioral Model for Vulnerable Populations, the purpose of this mixed methods dissertation is to examine the influence of predisposing (race, residential area), enabling (health care access) and need factors (years from diagnosis) on adherence to surveillance mammography in Black and White BC survivors. Specific study aims are to: (a) Determine racial differences and influential factors in survivors breast cancer beliefs (b) Evaluate the contribution of health care access, socioeconomic status and perceived health on adherence to surveillance mammography (c) Explore surveillance mammography experiences of survivors engaged in social media.

METHODS: Three cross-sectional studies were conducted of which two analyzed data from datasets and one collected primary qualitative and quantitative data. All studies evaluated theory driven determinants to better understand adherence to nationally recommended surveillance mammography guidelines. Adjusted multivariable logistic regression models were used to assess the independent and joint associations between independent study variables (e.g., race) on study outcome (e.g., adherence). Eight virtual focus groups were conducted with BC survivors through social media platforms (e.g., Facebook, reedit) to further explore barriers and facilitators of survivor’s surveillance experiences. A thematic analysis approach using grounded theory techniques analyzed online focus group to identify thematic findings.

RESULTS: Overall, survivors reported high rates of adherence to surveillance mammography (72-70%). Influential factors on adherence involved an interaction with race, rather than just race alone: Black women living in non-metropolitan areas were more likely to be non-adherent compared to White women living in non-metropolitan residential areas. Similarly, Black women with lower levels of patient provider communication had lower adherence versus White women with lower communication levels. The presence of health care access, and health insurance were salient enabling factors on survivor’s adherence, across qualitative and secondary findings. Longer time from diagnosis and having underwent mastectomy surgery were the top need factors associated with non-adherence. Regarding breast cancer beliefs, satisfaction with financial aspects regarding health care and clinical factors such as BC stage were influential factors in survivors perceived severity and cancer recurrence beliefs.

CONCLUSION: This was the first mixed method study to describe psychosocial and healthcare delivery factors in adherence to surveillance mammography guidelines among Black and White BC survivors. Study findings extends scientific knowledge in BC survivors health beliefs and predictors (e.g., provider-communication) of surveillance mammography, with special attention on Black women’s surveillance experiences. This study provides new insight in cancer care delivery by: (1) advancing breast cancer survivorship research, (2) informing future research direction and (3) clinical implications to refine current surveillance guidelines and to improve barriers to surveillance, with special attention to racial/ethnic populations.


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