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... torate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. 11. SPONSOR/MONITOR'S REPORT NUMBER(S) 12. DISTRIBUTION / AVAILABILITY STATEMENT Approved for Public Release; Distribution Unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT Abstract provided on next page. 15. SUBJECT TERMS Perceived risk, breast cancer screening, Gail model, optimistic bias, knowledge of risk factors, worry, habits of using health services, heuristic thinking, search for dominance structure 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT 18. NUMBER OF PAGES 19a. NAME OF RESPONSIBLE PERSON USAMRMC a. REPORT U b. ABSTRACT U c. THIS PAGE U UU 131 19b. TELEPHONE NUMBER (include area code) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std. Z39.18 Abstract: The study described perceived breast cancer risk, compared subjective and objective risk estimates, and examined the influence of heuristic reasoning in women's narratives. The survey used three probability scales (Verbal, Comparative, Numerical) and the Gail model to measure perceived and objective risk. Aim 3 was addressed with argument and heuristic reasoning analysis. We recruited a multicultural, educated sample of 184 English-speaking women from community settings. Fifty four provided an in-depth interview. Participants held an optimistic bias regarding their breast cancer risk (comparative optimism and better-than-average), and underestimated their objective risk calculated with the Gail model. Breast cancer worry was a significant predictor of breast cancer risk. Better-educated and higher-income women reported lower levels of worry, while Black women were more likely than Asian and White women to report higher levels of worry, but not higher levels of perceived risk. Most participants did not know that older age is a breast cancer risk factor, and older women did not perceive higher risk. These findings imply that women's knowledge of breast cancer risk factors was incomplete, despite their high educational level. Age and family history are independent predictors of sporadic and hereditary/familial breast cancer risk; yet, women could not distinguish between the two forms of the disease. Most participants (70%) were adherent to mammography and clinical breast exam (CBE) screening guidelines, which can be attributed to high access to screening services and efforts from health care providers. Age, having health insurance, and higher 5-year Gail scores were significant predictors of frequency of screening mammograms and CBEs. Distrust of the health system was the single most important predictor of predisposition to use health services, which in turn was another significant predictor of screening mammograms and CBEs. Interactions among distrust, age, education, and race highlight the importance of distinguishing among racial/cultural, socioeconomic, and cognitive contributors to distrust. Distrust takes the greatest toll among vulnerable groups of women in predisposition to use health services and decision-making regarding breast cancer risk management. Analysis of the 54 interviews revealed that experiences with affected family members and friends, and breast symptoms influence perceived risk though affective and cognitive mechanisms. Distrust of the health care system was also mentioned as a factor that influences utilization of breast cancer screening services. Heuristics (logical shortcuts) facilitated women's riskassessments. The narrative data provide evidence that supports theories of two systems of reasoning: deliberative and associative reasoning.