Further evidence of the role of cultural beliefs in women’s decisions to have a mammogram has been observed across cultural groups, including a reluctance to use Western health care among Chinese-American women (Facione, Giancarlo, and Chan, 2000); cultural beliefs about fate among Filipino Americans (Maxwell, Bastani, and Warda, 1997) or karma among Cambodian-American women (Taylor et al., 1999b); concerns about modesty (Schulmeister and Lifsey, 1999; Dibble, Vanoni, and Miaskowski, 1997; Kelly et al., 1996); and beliefs that breast cancer is tied to guilt and punishment among Arabian women (Brushin, Gonzalez, and Payne, 1997).

Perceived Norms

The factors discussed in this section include perceived norms about mammography—influences from providers of health care services, family, and community groups. Norms include the overall perception about what most “important” others are saying and doing about the behavior. According to a number of reviews (Snell and Buck, 1996; Wagner, 1998; Rimer, 1994; Rimer et al., 2000a), the strongest predictor of mammography use is a recommendation or referral from a physician, arguably the most “important other” in relation to recommended medical practices such as mammography. This finding is consistent across all ethnic and age groups (Burack and Liang, 1989; McDonald et al., 1999; Maxwell, Bastani, and Warda, 1997; Risendal et al., 1999; O’Malley et al., 1999). Moreover, this finding has been robust over time. Valdez et al. (2001) reported the importance of a doctor recommendation for low-income Hispanic women. Some studies indicate that women in lower socioeconomic areas who receive their health care from emergency rooms and clinics are less likely to be advised to have mammography recommended by their health care providers (Snell and Buck, 1996). O’Malley et al. (2001) noted that only about half the women in their study of low-income women in North Carolina reported that their physicians had advised them to have mammograms. White women were more likely to report such

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