Breast cancer is the most commonly diagnosed tumorous cancer and the second leading cause of cancer-related deaths worldwide [1]. Besides that, the treatment costs for breast cancer are high and impose a huge economic burden on countries because of high rates of incidence and prevalence [2]. Although breast cancer incidence and prevalence are increasing, breast cancer mortality in high-income countries is decreasing because of early detection through mammogram screening and therapeutic advances at the community level [3]. Because the stage of cancer is considered to be the most important factor for the prognosis of most types of cancers and breast cancer is the leading reason for reduction of cancer-related mortality, early detection greatly contributes to decreasing the burden of cancer [4]. Women’s awareness plays an important role in the effective diagnosis of breast cancer at an early stage [5]. As a result, early diagnosis can help to improve survival, select less-invasive treatments, and achieve a higher quality of life, thus reducing the disease burden and treatment costs. Increasing incidence of breast cancer in low- and middle-income countries has led to numerous challenges for the healthcare providers, health authorities, and civil societies of these countries, resulting in placing the need for greater emphasis on the early detection of breast cancer [6].

Previous studies have identified various barriers to breast cancer screening behaviors. These barriers include difficulties in accessing screening services; the cultural context of the community; personal concerns regarding screening procedure; concerns regarding the sensitivity and efficacy of mammogram screening; pain [7,8]; psychosocial issues, such as fear of being diagnosed with breast cancer [7]; cost [9]; low perceived susceptibility [10]; and fear of malignant breast tumor detection [11]. Several studies on the early detection of breast cancer in Asian women have focused on sociodemographic characteristics, whereas cultural factors are not very well understood and may also have important relationships with breast cancer screening behaviors [12].

Certain types of barriers may be more or less important for specific cultural or ethnic subpopulations. In this regard, modesty has been reported as a specific barrier to adherence to mammography screening among Asian American women. Fear, embarrassment, and cost are the most common barriers to adherence among African American women [13]. Besides that, among Arab women who are living in the United States, in addition to the abovementioned barriers, lack of adopting health screening practices, stigmatization of cancer, fear, and ignorance about breast cancer screening were also found to be the barriers to mammography. Furthermore, certain culture-specific barriers have also been reported, including embarrassment, family relationships, fatalism, and consultation with unprofessional and elderly women [14].

Thus, further efforts should be made to motivate women to undergo screening and diagnostic mammogram procedures [3]. Given these data, effective factors on early detection of breast cancer should be explored; therefore, this study aimed to explore culture-specific barriers to mammography among Iranian women.

The present study was the qualitative part of a large research project om exploratory sequential mixed method design performed with the aim of explaining the barriers to mammography among Iranian women to develop a scale of mammography barriers. To achieve this purpose, a qualitative study design using conventional content analysis was adopted. Twenty-four women were selected from among those who had participated in the first phase of our study. The participants consisted of 17 women without history of mammography, six with history of mammography or family history of breast cancer, and one mammography technician (Table 1). Ethical approval for the study protocol was provided by the Ethics Committee of Tabriz University of Medical Sciences (ethics code: IR.TBZMED.REC. A/149-451). All the participants voluntarily signed the informed consent form to participate in the study before the interviews.

In total, five categories and 12 subcategories were extracted. The categories consisted of unawareness of mammography, fear control, prioritizing the need for mammography, inadequate competency of mammography centers, and a sense of losing family support (Table 2).

This qualitative study aimed to explore how Iranian women explain the barriers that they perceive as preventing them from undergoing mammography with special emphasis on cultural aspects. Ample evidence has indicated that individually perceived barriers are important predictors of healthy behaviors and behavioral change [13].

According to our findings, one of the perceived barriers to mammography was ‘unawareness of mammography.’ This factor highlights the influence of insufficient knowledge and lack of information on women’s decisions regarding mammography. Other researchers have also reported lack of knowledge and misunderstandings regarding mammography, screening, and breast cancer as barriers to mammography screening [7,15,16]. In addition, evidence indicates that Iranian women are less aware of the screening programs in the healthcare system of their country and the vast majority of patients are diagnosed only in advanced stages [7,17]. This must cause policy makers to pay more attention on establishing suitable diagnostic and treatment facilities and improving breast cancer control policies [8,18].

Besides that, similar to our results, lack of symptoms and lack of a family history of breast cancer that therefore decrease the risk of developing breast cancer have been found to cause the women to think that they do not need to undergo mammography [7,19]. Moreover, most women believe that only if healthcare providers or physicians recommend getting a mammogram, they would comply willingly. This indicates that insufficient education and inadequate access to healthcare services represent an important perceived barrier to health-promoting behaviors [20]. It seems that access to regular screening mammography is highly dependent on recommendation and referral by a primary care provider [21,22], and physicians’ recommendation for screening and counseling with female healthcare providers in healthcare centers may be influential in increasing mammography rates [23].

Healthcare providers in primary healthcare centers can also, through media, play an important role in promoting awareness of mammography and correcting false beliefs.

One of the identified themes in our study was fear control. Being afraid of various aspects of breast cancer can affect women’s perceptions regarding the ways of responding to mammography results and relevant recommendations. Based on our results, imagining and thinking about negative consequences of breast cancer tend to affect women’s decisions pertaining to undergoing mammography. Our participants’ viewpoints regarding the role of fear were consistent with the results of a study conducted in the United States on a group of Jordanian and Palestinian immigrant women. Those women reported having certain fears such as fear of chemotherapy and body changes that take place after examinations and treatment, fear of pain, and fear of death. Thus, they preferred not to know rather than to know, because they believed that diagnosis of breast cancer was equal to end and death [14]. In addition, harmfulness of mammography was considered as another barrier on getting mammograms as the women expressed their concerns about potential side effects of the mammogram procedure itself; for example, X-ray exposure [7,19] and squeezing/smashing of the breast during mammography may lead to breast cancer [19].

Several behavioral change theories can explain the role of fear in the formation of behavior. Based on the Health Belief Model and Witte’s Extended Parallel Process Model to assess the occurrence of permanent behavioral changes, one must feel threatened by his/her current behavioral patterns (perceived susceptibility and severity), i.e., women should first believe that they may develop a disease or condition and then perceive it as sufficiently life-threatening to take action for it [13,24]. In addition, based on the third construct of the transactional model of stress and coping process known as secondary appraisal, a person determines how much control he/she has over the stressors; then, based on this appraisal, he/she is engaged in either problem- or emotion-focused coping. Therefore, if individuals are not engaged in the problem-focused coping, they are likely to avoid stressful situations or deny the existence of a stressful situation and, instead, look on the brighter side of life [25].

Body image, obvious changes in the body shape after mastectomy, and unpleasant feelings about the size and shape of one’s breasts, new roles as an ‘unattractive’ women, or interference in sexual relationships can have negative impacts on woman’s decision to undergo mammography screening [26].

As a result, public health professionals and healthcare providers should provide coherent information about the benefits of mammography and the importance of early diagnosis of breast cancer. These may help women overcome their fear of mammography and to make informed decisions regarding getting them done.

Assuming various routine responsibilities and facing certain challenges may be considered important barriers to mammography adoption. This barrier is called conflicting priorities [23], competing priorities or lack of giving priority to one’s own health [14,27]. Women in one study reported that everything else comes first, and we forget about ourselves and taking care of ourselves. Generally, familial needs comprise the top priority in the lives of Iranian women [9]. In addition, consistent with our findings, high cost of living and medical services [7,27], not having insurance [7,27], inaccessibility [14,27], transportation difficulties [14,27], inconvenient facility location [7], and distance [23] are some factors that interfere with undergoing mammography. Generally, the cost of healthcare services is a commonly reported barrier to health-related behaviors, particularly screening. These costs influence people’s prioritization of the needs, especially in low-income countries.

Distrust in the medical diagnosis and the physicians because of potential lack of expertise and skills, as well as diagnostic errors, comprised one of the most common complaints of the study participants. Consistent with our findings, inability to get a doctor’s appointment [19], long period of waiting for confirmation of appointment, waiting a long time at the mammography centers, and waiting a long time to receive the test result were reported as the perceived barriers to mammography screening in other studies [7,19].

In some studies, the participants expressed doubts about the tests’ accuracy and technicians’ skills and therefore distrust in the healthcare system [24]. In addition, lack of the technicians and other healthcare providers’ respect on the needs and concerns of women, lack of good communication skills, and lack of respect on the privacy of the referred women prevented them from undergoing mammography.

Addressing the patients’ barriers and clearly and thoroughly explaining screening procedures have been significantly correlated with screening adherence [28]. Furthermore, lack of equipment, qualified professionals, and equipped facilities can adversely affect screening behaviors [14].

Lack of familial and social support might be influential in adhering to breast cancer screening [23]. Breast cancer has certain social implications such as divorce and, in some cases, feeling the loss of femininity. In some cultural subpopulations, husbands of women with cancer are advised by their families to abandon their wives and marry another woman to achieve sexually satisfying relationships, which is consistent with the observations in this study. Consistent with our results, men, in some cultures, have been reported to disapprove of undergoing breast cancer screening services and forbid women to refer to healthcare centers [14]. Believing in fatalism was drawn as another barrier to mammography. This is supported by a systematic review in which 64% of the studies showed a statistically significant association between fatalism and utilization of cancer screening services and the belief that all events that comprise the life of an individual are determined by God. Believing in fatalism can therefore serve as one of the barriers to undergoing mammography [20]. Some women in our study believed that having breast cancer was due to divine providence [14,19], and if God has willed them to undergo mammography for breast cancer, they will ultimately do it; however, it was found that believing in God and prayer played an important role in preventing cancer [14]. It has been reported that women with breast cancer prefer no one to know about their disease and generally consider it a sign of shame, signifying that a woman with breast cancer is damaged and worthless [14], which is consistent with our findings. As mentioned in the introduction, certain types of barriers might be more or less important for specific cultural or ethnic subpopulations, such as modesty among Asian–American women and embarrassment, cost of services among African American women [13], and stigmatization among Arab women who are living in the United States [14]. Therefore, before the development and implementation of interventions to encourage women to adhere to mammography, relevant barriers throughout the mammography process that are important and dominant factors with respect to women’s decision in the target population in refusing or accepting mammography screening should be identified [29].