Participation in a Breast Cancer Screening Program: Influence of Past Behavior and Determinants on Future Screening Participation 1 Lilian Lechner, M.P.H.,* ,2 Hein de Vries, Ph.D.,* and Nicole Offermans, M.P.H.* *Department of Health Education & Promotion, University of Maastricht, 6200 MD Maastricht, The Netherlands Background. This study analyzed the relationship between past screening behavior, determinants, inten- tion, and future screening participation in the Dutch national breast cancer screening program. Methods. Participation at the first and second screening rounds was monitored. Furthermore, be- tween the first and the second screening rounds, women received a questionnaire (response 58%, n = 395). The questionnaire was based on the ASE model, including attitude (consequences, anticipated regret, and moral obligation), social influence (support and modeling), and self-efficacy. Other distal variables as- sessed were previous screening behavior, evaluation of screening characteristics, and demographics. Results. Participants at the second screening dif- fered from nonparticipants on all ASE determinants. Stepwise multiple regression analyses showed that for previous participants and nonparticipants different ASE determinants and distal variables explained the variance in intention to participate in the next screen- ing (30 to 45%). Logistic regression analyses showed that past behavior and intention (which mediated the effects of the ASE variables) were significant predic- tors of participation in the second screening. Conclusions. Differences between previous partici- pants and nonparticipants in determinants of inten- tion and future screening behavior can be used to im- prove participation and adherence to breast cancer screening. © 1997 Academic Press Key Words: breast cancer screening; attitude; antic- ipated regret; self-efficacy; past behavior. INTRODUCTION Breast cancer is the most prevalent type of cancer among women in the Netherlands [1] and most other Western countries [2,3]. Since there is still limited in- sight into the behaviors related to developing breast cancer [4,5], primary prevention of breast cancer proves to be very difficult. However, early detection does provide an important tool for implementing sec- ondary prevention. By performing regular breast can- cer screening on women from the high-risk age groups, possible cancer can be detected at an early stage so that the health loss for these women can be minimized [6,7]. In the Netherlands, a national breast screening pro- gram was started in 1989 [8] and eventually was implemented in all parts of the country. In this na- tional screening program, all women in the age group 50 to 70 years receive an invitation to attend a breast cancer screening in a specially designed screening unit every 2 years. However, research shows that despite high attendance rates in the first screening round, at- tendance in the following years declines with every new screening round [9–13]. Therefore, it seems highly relevant to gain insight into the reasons why women attend the screening and why this attendance declines with time. Theoretical Framework and Research Questions Social psychological model suggests that behavior is determined by the intention to perform this behavior. This intention, in general, is determined by three im- portant factors: attitude, social influence, and self- efficacy. These factors can be integrated in models such as the Model of Planned Behavior [14] or the ASE model (attitude–social influence–efficacy) [ 15,16], which was used in the present study (see Fig. 1). According to the ASE model, the first possible deter- minant of behavioral intention is the attitude, which consists of the advantages and disadvantages of a par- ticular behavior. These expected outcomes [17] can take place directly following the behavior or after a longer period. With respect to breast cancer screening, this time period between behavior and possible out- come seems particularly important: although long- term outcomes of screening might be very positive (par- ticipating in the screening could lengthen a healthy life), the short-term benefits of screening may not be so 1 This study was financially supported by a grant from the Dutch Cancer Society. 2 To whom correspondence and reprint requests should be ad- dressed at the Department of Health Education & Promotion, Uni- versity of Maastricht, P.O. Box 616, 6200 MD Maastricht, The Neth- erlands. Fax: 31(0)43-3671032. E-mail: lechner@gvo.unimaas.nl. PREVENTIVE MEDICINE 26, 473–482 (1997) ARTICLE NO. PM970161 473 0091-7435/97 $25.00 Copyright © 1997 by Academic Press All rights of reproduction in any form reserved.