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Knowledge of Breast Self-Examination and Other Determinants’ Relationship on the Self-Rated Health of Elderly Women Kevin D. Evans and R. C. Bates Journal of Diagnostic Medical Sonography 2005; 21; 402 DOI: 10.1177/8756479305281179 The online version of this article can be found at: http://jdm.sagepub.com/cgi/content/abstract/21/5/402

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JDMS 21:402–412 September/October 2005

ARTICLE 10.1177/8756479305281179 JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY September/October 2005

VOL. 21, NO. 5

KNOWLEDGE OF BREAST SELF-EXAMINATION IN ELDERLY WOMEN / Evans, Bates JDMS 21:402–412

September/October 2005

JDMS 21:402–412

September/October 2005

Knowledge of Breast SelfExamination and Other Determinants’ Relationship on the Self-Rated Health of Elderly Women KEVIN D. EVANS, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS* R. C. BATES, EdD†

This study examines whether the knowledge of breast self-examination (BSE) could be a significant contributor to elderly women’s self-rated health. Additional variables were considered as potential influences on their self-rated health. This research used a quasi-experimental design and random selection to assign assisted living facilities to treatment and control groups. Participants in this study were women, age 75 years and older. All participants were gauged for breast cancer risk as a pretest measurement. Only the experimental group of older women received BSE instruction and then provided their self-rated health eight weeks later. BSE knowledge contributed statistically to the experimental elderly women’s self-rated mental health scores. Instrumental activities of daily living were statistically significant for both groups at explaining variance in their physical health scores. This research study, although limited, points to the value of providing BSE to elderly women and its influence on their mental health. Key words: breast self-examination, elderly women’s health, self-rated health, assisted living, instrumental activities of daily living

From *The School of Allied Medical Professions and †College of Education, The Ohio State University, Columbus, OH. Correspondence: Kevin D. Evans, The Ohio State University, The School of Allied Medical Professions, 453 West 10th Avenue, 340 A. Atwell Hall, Columbus, OH 43210. E-mail: [email protected]. Funding for this research was made possible by the Eunice Cowen Memorial Scholarship and The Ohio State University. The authors also wish to thank Larry Sachs, PhD, for his input and guidance with the statistics and research methods. DOI: 10.1177/8756479305281179

Exploring the possibility of extending elderly women’s lives by preventing advanced breast cancer acknowledges that additional factors can also affect their health. Preventative health initiatives need to address the increasing numbers of women who have an increased risk of breast cancer but could live successfully after their 80th birthday with associated health conditions.1 The major issue with promoting breast selfexamination (BSE) for elderly women is the need to promote continued research on the delivery of technique and its relation to breast cancer prevention.2 The evidence that has been provided indicates that BSE is a simple, low-cost, noninvasive procedure that is acceptable to elderly women. It


KNOWLEDGE OF BREAST SELF-EXAMINATION IN ELDERLY WOMEN / Evans, Bates

also facilitates increased use of mammography and clinical breast examinations, which could detect breast cancer.3,4 Unfortunately, knowledge of BSE has not been researched as contributing to a health behavior among elderly women that might stimulate a more active interest in the quality of their health.1 THEORETICAL BACKGROUND

The health-related quality-of-life (HRQL) model was proposed as a means to successfully characterize what patients have experienced as the result of their medical care. It also incorporates elements of physiological and biological measures of health.5 HRQL proposes that health is influenced on multiple levels. In their original work, Wilson and Cleary5 conceptualized a person’s health as being influenced by levels of physical functioning, social functioning, role functioning, mental health, and general health perceptions. There are some striking similarities between Wilson and Cleary’s work and the research on the behavior of older adults conducted by Lawton. 6 The press-competence theory was introduced as a way to describe an older person’s behavior as a function of the competence of that individual, as well as the social and economic support provided by the environment.6 Lawton’s theory on an aging individual’s behavior describes an adaptive response that is caused by a situation created by individual competence and environmental press. Health behavior can also be thought of as an adaptive behavior. Health behavior has been defined as those personal attributes and cognitive elements and behaviors that relate to health maintenance.7 Using the knowledge of a health behavior as the desired adaptive response to a set of influences could help in describing the resulting health of the individual. The theoretical framework of this study merged commonalities of the HRQL model with descriptive overlap of the press-competence theory. Common headings of individual competence and environmental press were used to propose variables that might interact with a health behavior, such as BSE, and ultimately influence self-rated health. The HRQL model identifies symptom status as an element of influence, but in this context, it

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was described as breast cancer risk. The integration of these theories is diagrammed in Figure 1. These variables formed the framework of the literature review for this project. The independent variables reviewed were individual competence, environmental press, and BSE, and the dependent variable was self-rated health. The intent of this research was to capture the right combination of factors in conjunction with breast self-examination to discover a possible relationship with self-rated health. INDIVIDUAL COMPETENCE’S INFLUENCE ON SELF-RATED HEALTH

The term individual competence refers to an individual’s cognitive and physical capacity to meet his or her own needs.8 The importance that individuals place on these factors could have an effect on the way that they report their health. The interplay between the physiologic and psychological factors that influence an individual’s behavior was described by Lawton6 as individual competence. An alternate method of describing the psychological influence on aging of the elderly woman has been captured by the continuity theory. According to this theory, individuals tend to maintain a consistent pattern of behavior as they age, substituting similar roles for lost ones and maintaining typical ways of adapting to the environment.9 Elderly women’s cognitive well-being is actually believed to be enhanced due to the changes in their social roles. For some elderly women, aging can actually bring about a gain in control. As old age approaches, the role of being responsible for the care of others changes to an increased level of selfcontrol.10 Building on the idea that elderly women gain cognitive control of their lives with aging, research studies have explored a health locus of control. A longitudinal study of this type was conducted with a group of 365 older adults over a six-year period. The elderly women in this study were noted to have a higher sense of control over their lives, were more prone to self-care behaviors, and were involved in more health-promoting activities.11 This study is pivotal in pointing to the importance of cognitive control and its connection with healthy behaviors.


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JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY September/October 2005 VOL. 21, NO. 5

FIG. 1. A theoretical framework composed of elements of health-related quality of life (HRLQ), environmental press-competence, and risk assessment. BSE, breast self-examination.

This brief discussion points to how elderly women’s individual competence is composed of multiple areas of functioning. To be able to capture the essence of some of these factors, the Instrumental Activities of Daily Living (IADL) scale has been used to measure individual care as well as mobility and mental functioning. 12 ENVIRONMENTAL PRESS INFLUENCE ON SELF-RATED HEALTH

Environmental press is a construct that has been defined as the aspect of settings in which people continually interact and subsequently activate their needs. These environments can be challenging, neutral, or supportive.8 A study of environmental press in assisted living facilities used a variety of variables that were likely to affect a population of elderly adults in assisted living facilities. The facilities in this research were selected at random and ranked by size. Among

those facilities, elderly adults were also selected at random to participate in a survey about the kind of stress that they encountered in their living situation.13 The variety of scales that were used to assess different variables in this well-designed study demonstrated that a cohesive and supportive assisted living environment was statistically linked to a higher quality of life among the residents. Continued research is needed to look into the effects that environmental press may have on elderly women and to look for similar relationships. One environmental instrument that has been used in these kinds of studies is the Sheltered Care Environment Scale (SCES).14 The SCES is important because it helps in assessing a facility’s environment by recording residents’ perceptions of forces that are affecting their behavior. The SCES has been used to assess assisted living facilities and provide a benchmark for comparing facilities’ independence and comfort.



Elderly women who chose assisted living facilities is an area that has been underresearched to determine if their health could be influenced by the environment. This variable could be included to examine connections with BSE and between selfrated health. SELF-RATED HEALTH

The outcome for a preventative health strategy is to positively influence a person’s health. Health has been traditionally assessed by objective means, but subjective ways of measuring health have begun to gain prominence. One way of measuring a person’s health is to ask that person to record his or her perception of health. In elderly women, selfrated health has been reported to be a better predictor of mortality and depression than objective health.10 The measure of elderly women’s subjective health has been studied in recent research efforts. In a large research study of older participants in the Netherlands, an attempt was made to find a direct relationship between several health measures (physiological and psychological) as an explanation of the level of self-rated health provided by participants.15 The study involved asking 8723 older participants, who were not institutionalized, about a single rating of their overall health. The sampling method was strictly followed and ensured a representative sample of all the age categories and sex. The results indicated that multiple measures of health were more accurate in assessing an older person than using a single measure of perceived health.15 This study is significant due to its large scale and statistical power. The conclusions of the study point to the fact that self-rated health is a multifactor process and could be better understood by including multiple measures of health as part of the assessment. The SF-12 is a scale that has been used to record self-rated health, and it reproduces the SF-36 scales in shorter length. According to Ware et al.,16 the differences between the two versions are less notable in large group studies. In addition, the most useful research studies have employed Ware et al.’s instrument as a generic core. The SF-12 data allow for results to be compared across similar studies

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and populations. They also accelerate the accumulation of interpretation guidelines essential to determining the clinical, economic, and social relevance of differences in health and outcomes.17 BREAST SELF-EXAMINATION IN RELATION TO SELF-RATED HEALTH STATUS

The technique of BSE is important because it is believed to help reduce the risk of mortality from breast cancer in elderly women. Because the statistics are unfavorable when studying the trend for breast cancer, this technique for elderly women is one of several ways to safeguard against advanced breast cancer. Breast cancer is responsible for a large and rising proportion of deaths among elderly women.18,19 The American Cancer Society and other breast cancer awareness groups have advocated for BSE as a suggested mechanism that women could use to detect early changes in breast tissue. A landmark research study was conducted by Grady20 on the level of BSE participation among older groups of women. In her study, she used 528 women and subdivided them into age groups. She next provided BSE instruction and reminder cards so that she could follow them over a period of two years to assess their ability in adopting this technique. She found that the study’s elderly women were the best in adopting BSE and practicing the technique correctly. The statistical analysis demonstrated that confidence in BSE was the best predictor of long-term use among elderly women. A smaller study was conducted to evaluate the effect of BSE instructions on the health behaviors of elderly women in a specific retirement facility. The results from a test group of elderly women indicated that they were fairly accurate in remembering the technique of BSE as it was presented. This effort to provide BSE to elderly women in a retirement facility included 62 subjects as part of an educational intervention.21 The results demonstrated increased knowledge and acceptance of the technique as a result of the program. This study was mainly descriptive; therefore, a need continues for a more structured study to be conducted to obtain results that could be applied to a larger population.


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A compatible study was designed to address the relationship between BSE and the early diagnosis of breast cancer among elderly women. The study recorded the ability and knowledge to perform BSE by 124 elderly women.22 In this study, 82% of respondents preformed BSE themselves. Fifty percent of the respondents reported previous instruction in the method of BSE. In the same group of elderly women, only 10% of respondents reported that they would obtain a mammogram if their physician recommended it. Also in this study, 16 rated their health excellent (12.9%), 33 respondents rated their health very good (26.6%), and 45 answered that their health was good (36.3%). The remaining 30 (24.2%) rated their health as fair or poor. This study was unique as it attempted to establish a relationship between BSE and self-rated health. It appears that each of the variables has been studied but not in a way that brings all the variables together to understand their interplay. Research that centers on the practice of BSE and other variables affecting elderly women’s self-rated health has yet to be conducted. Previous studies provide a background for staging a more comprehensive study dealing with the following research questions:

•

Does knowledge about a preventative health behavior such as BSE contribute to the selfrated health among elderly women?

Additional questions that this research addressed are as follows:

• • • •

Is the risk of breast cancer a determinant of their self-rated health? To what degree does individual competence influence the level of self-rated health for elderly women? To what degree does environmental press influence the level of self-rated health for elderly women? Which of the independent variables contributes most significantly to self-rated health?

Materials and Methods SAMPLE AND SETTING

For this research, a comparative control group research design was used to structure a study of elderly women with breast cancer risk. A purposive group of assisted living facilities was selected so that two groups were formed based on similar socioeconomic standards and racial composition. Two purposive groups of facilities were formed by random selection at the facility level to either a treatment or comparison group. This allowed for a stronger research design and the hope of forming groups that were more comparable. The activities directors were contacted at the facilities and asked to recruit participants for the instruction in BSE. The individual elderly women participants represented a convenient sample. The Human Subjects Committee at The Ohio State University approved the recruitment, informed consent, and data collection procedures. SUBJECTS

Participants, age 75 years or older, were recruited from the selected assisted living facilities as either control or experimental subjects based on the assignment of their facility. Potential participants were first notified by the activities directors about the study and the possibility of a workshop presentation at their facility. Both control and experimental participants were handled similarly with an invitation to join the study. The purpose of the study and the requirements of the participants were explained. All the assisted living facilities used a similar recruitment flyer. If a participant agreed to participate in the study, she was asked to sign a consent form for participation as well as a HIPPA form. Subjects were reminded that their participation was completely voluntary and in no way would compromise their health or living conditions. DATA COLLECTION

A quantitative survey instrument was compiled from three separate surveys that measured vari-



ables in this study. Checking the SF-12 instrument for its original reliability shows that it has a reliability of .89 for the physical health scores and .76 reliability for the mental health scores.23 The reliability of the SCES subscales of comfort and independence is reported through split-sample reliability scores of .90 and .80, respectively.14 The reliability of the IADL subscales has been computed based on elderly women living in an assisted living facility, and for that group, the reliability was .93.24 After obtaining informed consent, the Gail Model Risk Assessment tool was provided to all participants to calculate a breast cancer risk score.25 This score served as a measure of their five-year and lifetime risk for breast cancer prior to the intervention for the experimental group participants. It was also provided to the control group participants. The study continued for the experimental group with a video and workshop presentation on the BSE technique. A video and handheld practice models were also provided in order for the information to be rehearsed. The instruction was modeled to replicate interventions provided for elderly women in previous research studies.21,26,27 The control participants only received the combined survey instrument. The experimental subjects received the combined survey eight weeks after the workshop. The data from the survey were collected after a period of eight weeks to give each participant enough time to adopt the BSE health behavior. The active independent variable was knowledge of BSE, and the added rival independent variables were breast cancer risk, individual competence, and environmental press. The dependent variable was an elderly woman’s self-rated health status.

Results The total number of completed surveys was 92 from potentially 100 participants involved in the project. Of the 92 participants, the mean age for participation was 82 years (SD = 5.6). The minimum age of the participants was 75 years of age, and the maximum was 95 years of age. The two groups of participants appeared to be comparable on ages. The analysis was completed using the entire data set (N = 92).

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Scores for the variable BSE knowledge were compiled by using correct answers to questions that related to the content provided on BSE technique. The overall score was the number of correct responses. The mean score for BSE knowledge by the control participants in the study was 2.5 questions correct out of 6 possible questions (SD = 1.2). The mean score for BSE knowledge by the experimental participants in the study was 3.5 questions correct (SD = 1.1). Risk assessment was calculated, with the answers provided by the participants for a five-year and lifetime risk of breast cancer. The mean scores for five-year risk and lifetime risk were very comparable, with both groups demonstrating elevated risk due to their advancing age. The individual competence (IADL) was calculated by assigning a score of 1 for the choice of “no assistance” and 0 for all other choices provided within the instrument. The control group of respondents had a mean individual competence (IADL) score of 3.2 (SD = 1.3) out of possible score of 4. The experimental participants recorded a difference in individual competence by providing a mean score of 2.2 (SD = 1.5) out of 4. The two SCES subscales used to measure environmental press were comfort and independence. The control group of respondents had a mean comfort score of 3.2 (SD = 0.5). In addition, the control group also had a mean independence score of 2.7 (SD = 0.9). The experimental group of respondents had a mean comfort score of 3.2 (SD = 0.8). The experimental group also had a mean independence score of 2.8 (SD = 1.0). Last, the respondents were scored on the selfrated health questions (SF-12) to yield a physical health score and a mental health score. The elderly women in the control group had a physical health score mean of 46.4 (SD = 11.8) and a mental health score mean of 51.8 (SD = 9.7). The participants in the experimental group had a physical health score mean of 38.8 (SD = 10.6) and a mental health score mean of 50.1 (SD = 9.2). A one-tailed t test was conducted to compare the control group with the experimental group, with the expectation that the experimental group would have more knowledge of BSE. The t test demonstrated a t statistic of 3.93 with 90 degrees of free-


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TABLE 1. Two Group Comparisons of Variables Using the t Test Variable BSE Risk assessment (Gail model) Individual competence Environmental press (SCES) Self-rated health status (SF-12)

Measure

t

df

BSE knowledge Five-year risk Lifetime risk IADL score Comfort score Independence score Physical health score Mental health score

3.93a –0.30 –0.96 –3.56 0.05 –0.24 –3.25 –0.85

Significance (Two-Tailed) < .01a .76 .34 < .01 .96 .81 < .01 .40

90 90 90 90 63.86b 90 90 90

N = 92. BSE, breast self-examination; IADL, Instrumental Activities of Daily Living scale; SCES, Sheltered Care Environment Scale. a. One-tailed t test. b. Levene’s test for equality of variances was significant at .02; therefore, equal variances could not be assumed.

TABLE 2. Correlations Between the Variables in the Control Group Physical Health Score Mental health score BSE knowledge score Comfort score Independence score IADL score Five-year risk Lifetime risk

.14 –.35* .12 –.29* .42** .13 .20

Mental Health BSE Knowledge Score Score .12 .22 .00 .25 .11 .14

–.08 .20 –.10 .12 .02

Comfort Score

Independence Score

.25 .21 .15 .22

.02 .24 .20

IADL Score

.12 .17

Five-Year Risk

.94**

N = 92. BSE, breast self-examination; IADL, Instrumental Activities of Daily Living scale. *P < .05. **P < .01.

dom and a P value of < .01. This indicates that a significant difference existed between the experimental group and the control group about the level of knowledge for BSE. Two-tailed t tests were conducted for all the other variables to detect any differences between the experimental and control groups for the other variables that were included in the research. The results of the t test are reflected in Table 1. The variables of risk assessment, environmental press, and self-rated mental health demonstrated no significant differences, but the variables of individual competence and self-rated physical health did demonstrate differences between group measurements. A separate correlation was conducted for the variable scores provided by the control group. A Pearson product correlation coefficient was used to look for the relationship between the various measures provided by the control group. Lifetime and

five-year risk for breast cancer was positively correlated, which helped to reaffirm the work of Gail et al.25 The IADL score and physical health score demonstrated a significant direct correlation with each other. The BSE knowledge and physical health scores indicated an inverse relationship, and the independence score was inversely related to the physical health score of the control subjects. Refer to Table 2 for the values that were calculated. Correlations were also preformed between the variable measures provided by the experimental group. In this set of Pearson product correlations for the experimental group, five-year risk of breast cancer was shown to correlate with independence, and lifetime risk correlated with independence among the experimental group. Lifetime risk and five-year risk for breast cancer were again positively correlated. Positive correlations existed between IADL and physical health scores as well as BSE knowledge and mental health scores. Like-



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TABLE 3. Correlations Between the Variable Components for the Experimental Group Physical Health Score Mental health score BSE knowledge score Comfort score Independence score IADL score Five-year risk Lifetime risk

.19 .16 .02 –.00 .47** –.30 –.29

Mental Health BSE Knowledge Score Score .35* –.08 .37* .15 .03 .03

–.04 .17 –.14 –.18 –.13

Comfort Score

Independence Score

.10 .03 .06 .14

–.06 .36* .39*

IADL Score

–.10 –.043

Five-Year Risk

.96**

N = 92. BSE, breast self-examination; IADL, Instrumental Activities of Daily Living scale. *P < .05. **P < .01.

TABLE 4. Model Variance to Predict Self-Rated Physical Health in the Control Group Step 1 2

Variable Entered

R2 Change

P Value of R2 Change

IADL score BSE score

.17 .27

< .01 .02

BSE, breast self-examination; IADL, Instrumental Activities of Daily Living scale. Predict Physical Health = 3.620 × IADL × –2.961 × BSE score + 42.220. Total variance explained = 44%. F = 8.645.

TABLE 5. Model Variance to Predict Self-Rated Physical Health in the Experimental Group Step 1

Variable Entered

R2 Change


IADL score

.22

< .01

IADL, Instrumental Activities of Daily Living scale. Predict Physical Health = 3.326 × IADL + 31.339. Total variance explained = 22.4%. F = 11.538.

wise, independence with the mental health score was also positively correlated. Refer to Table 3 for all the correlation coefficients calculated for the experimental group. A stepwise regression analysis with a linear combination of the six independent variables was regressed on the dependent variable of self-rated health (two dependent scores) for both the control and experimental groups. Although three of the four models are statistically significant (P < .01), the variance explained is never above 44% among any of the models and therefore does not allow for adequate prediction of the dependent variable from the independent variables, regardless of group. Ta-

TABLE 6. Summary of Regression Analysis to Predict Self-Rated Mental Health in the Experimental Group Step 1 2

Variable Entered Independence score BSE score

R2 Change


.14 .09

.02 .04

BSE, breast self-examination. Predict Mental Health = 3.020 × Independence score × 2.597 × BSE score + 32.861. Total variance explained = 22.4%. F = 5.641.

bles 4, 5, 6 are provided to display the results of the stepwise regression. The first model generated explained the largest amount of variance for the control group’s physical health data, using the IADL scores (17.2%) and the BSE score (26.9%). Together, these variables, regressed on the control group’s physical health score, only explained 44% of the total variance. The second model of variance, which used the control group’s mental health score, indicated that no variable studied could explain the variance in this portion of self-rated health status. The third model of variance, which used the experimental group’s physical health score, indicated that IADL was responsible for explaining only 22.4% of the variance in this portion of self-rated health status. The final model of variance that used the experimental group’s mental health score indicated that independence was responsible for explaining the largest amount of variance (13.6%). The remainder of the variance was explained by the BSE score (8.8%) of the experimental group, which was regressed on its mental health score.


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Together, these two variable scores only explain 22.4% of total variance in this portion of self-rated health status. In addition, the statistical hypotheses that were proposed are answered in the following manner: 1. 2. 3. 4. 5.

A positive relationship between an elderly woman’s knowledge of BSE and her self-rated health status is accepted. A positive relationship between risk for breast cancer and an elderly woman’s self-rated health status is rejected. A positive relationship between individual competence and an elderly woman’s self-rated health status is accepted. A positive relationship between environmental press and an elderly woman’s self-rated health status is rejected. A significant portion of the variance in an elderly woman’s self-rated health status, which is explained by a stepwise combination of the tested independent variables, is accepted.

Discussion This research endeavor began with the desire to promote BSE against the backdrop of advanced breast cancer in elderly women. BSE was hypothesized to have a dual role in reducing breast cancer and being influential in the self-rated health of elderly women. BSE as a health behavior was investigated in conjunction with some concomitant factors such as breast cancer risk, individual competence, and environmental press to determine their influence on self-rated health. Reviewing the quantitative data from the elderly women in this study, BSE appeared to be a worthy endeavor and may have some influence on selfrated health. This is based on the indication that the experimental participants demonstrated a statistically significant difference in knowledge compared to those women in the control group, who did not receive any instruction on BSE. These results are mirrored in a recent study that was similarly constructed. The study used video kits about BSE to instruct an experimental group and a control group of 328 women age 60 years and older.28 This study demonstrated a similar increase in knowledge of BSE among the experimental participants who had received the video kits of instruction.

Among the elderly women in the control group of the current study, breast cancer risk on average was high, but that did not deter them from having an increased ability to perform activities of daily living. The measure of activities of daily living was also directly related to self-rated health. The control group indicated an inverse relation between less knowledge of BSE and their physical health score. The control group’s risk of breast cancer, by virtue of age, is a dangerous combination with this group’s decreased knowledge of BSE, especially if good health and productivity is to be maintained. Interestingly, a recent study looked at the death rates among women who did and did not participate in BSE. No differences existed in mortality between those who did and those who did not practice BSE.29 What was noted in the Hackshaw study29 was that more women who practiced BSE sought medical advice and breast biopsies more frequently than those who did not practice BSE. Perhaps BSE knowledge is not as specific to practice as it is to overall health behavior change. Two variables that were included in the original research model, which were hypothesized to have influence on self-rated health, were breast cancer risk and the environmental press subscale of comfort. These two measures proved to have no significant influence on self-rated health. Individual competence was linked to self-rated health status through the work of Wilson and Cleary,5 which was an important part of the theoretical model that did prove to be significant. The control group had a higher score on the IADL assessment than the experimental group. Although IADL scores pointed to a difference between groups, the groups’ individual measurements demonstrated a relationship with the dependent variable. IADL scores for both groups indicated a direct correlation with physical health scores. The IADL score also contributed to variance in the physical health scores in both groups. Independence, as one of the subscales of environmental press, did prove to be important to participants. Independence indicated a direct relationship with the mental health scores of the experimental group, but it had the reverse relationship on the control group’s physical health scores. Independence was also instrumental in explaining a



small portion of the variance in the mental health scores for the experimental participants. The physical health and mental health scores were used as measures of self-rated health. The control group had a higher physical health score than the experimental group, but the measures of mental health were very similar. Some comparisons can be made between these study participants’ self-rated health scores and those participants who have been previously evaluated by the SF-12. Ware et al.’s norms for the general U.S. population of females (N = 1332) indicated a physical health score mean of 49.1 (SD = 9.9) and a mental health score mean of 49.4 (SD = 9.8).23 In this comparison, the current study participants, by contrast, have lower physical health scores (control = 46.4; experimental = 38.8). However, the current study participants have higher mean mental health scores than the U.S. population of females (control = 51.8; experimental = 50.1). Additional comparisons can be made between these study participants and Ware et al.’s norms for the U.S. population of people age 75 and older (N = 217).23 The national norm of people 75+ years of age had a mean physical health score of 38.7 (SD = 11.0) and a mean mental health score of 50.1 (SD = 11.0). In this comparison, the control participants indicated a higher mean physical health score than the national norm of persons 75+ years, but the experimental participants indicated a similar mean physical health score as the national norm. All the older women in this study also had a similar mean mental health score compared to the national norm of persons 75+ years. Interesting as these comparisons might be, it is important to consider that the national norms were collected from men and women in this age group, and the norms were based only on a sample of 217 respondents. CLINICAL APPLICABILITY

This study indicated that the elderly women who experienced BSE training were able to answer, on average, 3.5 out of 5 questions correctly after 8 weeks of instruction. Although this study points to reasons that BSE might be more beneficial than for those who do not practice BSE, additional research is needed. In this study, BSE information did correlate with the experimental participants’ mental

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health scores. Knowledge of BSE also explained a portion of the variance in mental health scores as a measure of self-rated health. Although other factors obviously contribute to an elderly woman’s self-rated health, BSE appeared to be important for this group of elderly women and should continue to be incorporated as a health education strategy. The positive relationship that BSE might have with self-rated health makes it worth incorporating into patient education programs and preventative health initiatives. This study also indicated a stronger relationship between independent activities of daily living and the participants’ physical health scores. The positive contribution that the IADL score has on physical health scores, as well as its role in explaining a portion of the variance in physical health scores, makes it worthy of consideration. Initiatives should be included that promote elderly women to remain active and perform more of their daily activities. This information could be significant for breast imaging professionals who provide patient education for older female patients. It may also be important to advocate that older women need to do more of their daily activities, such as shopping, transportation, and preparing their medications, to maintain good physical health. Additional benefits of activity for these women might also enhance the way they feel about their overall health. Last, the independence scores were positively related to the mental health scores of the experimental participants, and although there was a low correlation, this might be an important issue to advocate. Continued independence may have an influence on elderly women’s self-rated health. Independence also explained a small portion of the variance in the mental health scores of the experimental participants. Continued investigation into the linkage of independence among elderly women and their health could be helpful as the demographics of the U.S. population shifts in favor of more elderly individuals.

References Constanza M: Breast cancer screening in older women: overview. J Gerontol 1992;47:1–3. 2. Masood S, Edwards P, Arnold M: Breast health: challenges and promises. J Fla Med Assoc 1996;83:459–465. 1.


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