Improving Participation in Breast Screening Programmes: A mixed methods study to increase breast screening uptake in Malta

Background: Breast cancer is the most common cancer among Maltese women. No studies have explored factors related to mammography underutilisation in Malta. This thesis aimed to explore barriers and facilitators to mammography screening among Maltese women to inform future screening interventions. Methods: Seven studies were conducted through mixed methods research. First, a survey instrument to assess associations between health beliefs, illness perceptions and mammography was piloted-tested among Maltese women (Study 1). Four quantitative studies explored associations and predictors to mammography use: study 2 investigated factors associated with a first screening invitation; study 3 investigated reattendance; studies 4 and 5 examined lifetime mammography practices and timely adherence respectively. A systematic review of interventions, which employed the Health Belief Model and/or Common-Sense Model to improve mammography uptake, was conducted (Study 6). Experts helped to construct a logic model of the problem and change objectives, while members of the public interpreted the quantitative findings through the World Café method. Study 7 consisted of face-to-face interviews with non-attendees. Intervention Mapping was used to synthesise the findings and propose recommendations to increase uptake. Findings: The survey instrument was valid and reliable for use with Maltese women (Study 1). Health beliefs were strong predictors of mammography underutilisation and illness perceptions improved non-attendance predictions (Studies 2-5). First attendance is associated with reattendance (Study 3). Illness perceptions however are rarely included in mammography interventions (Study 6). Experts supported multiple interventions, including physician recommendations, education and counselling, while members of the public identified the involvement of partners and daughters in health decision-making. Qualitative findings found that health-related knowledge was low, and that socio-cultural factors impeded attendance, particularly support networks, household dynamics, traumatic histories and mental health approaches (Study 7). Conclusion: Multiple, theoretical strategies are considered more effective. Interventions, implemented within the community setting, should target women’s barriers, particularly fear, when first invited. Family members and practitioners can help to address screening barriers