more likely to have screening mammograms if they perceived that family and friends were also having them and were supportive (Maxwell, Bastani, and Warda, 1997). Another study suggested that African-American women with large social networks were more likely to have mammograms than those without large networks (Kang, Bloom, and Romano, 1994). The way in which larger networks may operate to increase mammography use is not well understood.

Environmental Influences

A range of environmental influences may either pose barriers to or facilitate women’s use of mammography screening. Lack of access is the most important environmental influence for women with a lower socioeconomic status, especially those who live in rural areas (Breen et al., 2001). These findings are confirmed across all ethnic groups (Mickey et al., 1995; Pinhey, Iverson, and Workman, 1994; Serxner and Chung, 1992; Morgan, Park, and Cortes, 1995). One study (Kreher et al., 1995) reported that urban and rural women did not differ in their expressed intent to have mammograms in the next 2 years, but nearly twice as many urban women as rural women reported having had mammograms. Similar concerns have been observed for other groups as well; Kelly and colleagues (1996) reported that barriers for Cambodian women who should be getting mammograms included lack of transportation and fear of a large, technical medical center.

Indeed, access also may involve issues of comfort with health care systems. Women who do not speak English may have difficulty navigating the health care system, as shown by Morgan, Park, and Cortes (1995) in a study conducted on disadvantaged Hispanic women living in Bronx, New York. Foreign-born Hispanic women who are recent immigrants to the United States (and who have low levels of acculturation) are less likely to use mammography than Hispanics who have lived here for some time (O’Malley et al., 1999). Access factors may account for these differences, however. Indeed, access to screening appears to be a stronger pre-



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