Table 4:

Barriers and facilitators of decision or referral for mammography

 Skills and beliefs about capabilities to explain why screening not recommended“I say look, it’s not recommended … [explains harms] … And it’s your choice, I’m happy to send you if you want. But the reality is… you’ve got a higher risk of having unnecessary procedures and it’s not recommended.” — Participant 018
 EnvironmentActions of radiology department (to accept all or decline all) reinforce behaviour. If the department acted in a guideline-concordant manner, this was a facilitator; if not, it was a barrier.
“Based on your experience and as if having like 10 denials from the hospital, you know, that you have to have a good and complete family history. You try to justify your decision, why I’m going to do a mammogram at age 45 in this patient, put the family history and the risk factors. And in this way most of the time they are very cooperative.” — Participant 013
 EmotionProviders described their past patient experience and belief that screening would have changed patient outcome.
“I think you screen. And I know it’s certainly not guideline-based, but I find it really hard to extrapolate guidelines to a person sitting in front of me. And you know, we all know women in their forties that have been diagnosed with breast cancer, they all have stories, and those stories are pretty impactful.” — Participant 003
“It’s very hard to tell someone they can’t have something and then take on the burden of, oh, I hope they don’t develop breast cancer at 45 and I’m the one that told them not to do it.” — Participant 002
 Social influenceProviders were influenced by radiology guidelines and patient concerns about cancer risk.
The Medical Post had a very good short blurb from [radiologist] … she basically said that the Canadian Task Force was flawed, that the people on the panel weren’t mammographers, their stats were flawed. And I believed her, she had good data and she does this every day.” — Participant 005
Knowledge and beliefs about consequencesProviders tended to overestimate benefits or underestimate harms of screening.