Attachment and barriers to cervical screening

Abstract

The present study explored the role of attachment insecurity in cervical screening behaviors and barriers in a sample of 257 female undergraduates. Information on attachment dimensions as well as attachment style was collected. Attachment anxiety and attachment avoidance were associated with decreased likelihood of having participated in cervical screening and positively associated with screening barriers. Screening barriers were elevated among individuals with insecure attachment styles (preoccupied, fearful, and dismissing), and dismissing participants were less likely to have engaged in screening compared to secure participants. Our findings demonstrate that attachment insecurity may be a risk factor for inadequate cervical screening and screening barriers.

Keywords

attachment cervical screening Pap test perceived barriers

Attachment theory, originally developed by Bowlby (1969), posits that individuals are greatly impacted by the child–caregiver relationship established in the first few years of life. The emotional bond formed between child and caregiver serves as an “internal working model”—a schema that the individual will use throughout life for expectations in intimate relationships (Bowlby, 1969). Individual differences in relationship expectations and behavior patterns depict one’s attachment style, a stable set of characteristics, which in turn are linked to a variety of social and psychological factors including affect regulation, social interactions, and coping mechanisms (Maunder and Hunter, 2008).

Bartholomew and Horowitz (1991) suggested that attachment can be characterized by combinations of two attachment dimensions—anxiety and avoidance. Attachment anxiety is characterized by a fear of rejection and need for dependence on one’s partner, while attachment avoidance is characterized by chronic self- reliance and discomfort with closeness to others (Brennan et al., 1998). Individuals range from high to low on attachment anxiety and attachment avoidance. According to Bartholomew and Horowitz’s (1991) model, securely attached individuals are low on both anxiety and avoidant dimensions, while elevations on either attachment dimension—anxiety or avoidance—would classify individuals as insecurely attached. Insecure attachment can be further broken down into attachment styles of anxious ambivalent or preoccupied (low avoidance and high anxiety), fearful (high avoidance and high anxiety), and dismissing (high avoidance and low anxiety; Bartholomew and Horowitz, 1991).

In recent years, attachment has been suggested as a potentially important factor in the maintenance of good health and in the development and presentation (i.e. symptom reporting) of acute and chronic illnesses (Feeney, 2000; Feeney and Ryan, 1994; Kafetsios and Sideridis, 2006; McWilliams and Bailey, 2010; Maunder and Hunter, 2001, 2008; Oliveira and Costa, 2009). Maunder and Hunter (2001) proposed that attachment insecurity is a risk factor for the development of health problems through three possible pathways. First, attachment insecurity may increase one’s susceptibility to stress and stress-related physiological changes. Indeed, research has indicated a relationship between attachment insecurity and hyperactivity of stress-related physiological systems (Diamond and Fagundes, 2010; Gunnar et al., 1996; Maunder and Hunter, 2008), increased cortisol production during acute stress (Luijk et al., 2010; Quirin et al., 2008), and an increased vagal tone (Gallo and Matthews, 2006; Maunder et al., 2006), which in turn are risk factors for the development of disease and chronic illness (McEwen and Seeman, 1999; Thayer and Sternberg, 2006).

The second path involves maladaptive use of “regulators of affect.” Because attachment insecurity leads to poor emotion regulation, insecurely attached individuals may be more likely to engage in maladaptive coping through problematic substance use, eating behaviors, and sexual behaviors (Maunder and Hunter, 2001). Supporting this pathway, research indicates a relationship between attachment insecurity and increased substance use (e.g. Brennan et al., 1998; Peterson et al., 2010), disinhibited eating behaviors (Wilkinson et al., 2010), and disordered eating behaviors (e.g. Tasca et al., 2009).

Finally, and of interest in the present study, attachment insecurity may contribute to the development of health problems through inadequate participation in protective health behaviors (Maunder and Hunter, 2001, 2008). Indeed, Huntsinger and Luecken (2004) found that compared to those who were securely attached, insecurely attached participants were less likely to engage in health behaviors (e.g. eating healthily, exercising regularly, and avoiding tobacco and alcohol). Similarly, Scharfe and Eldredge (2001) found a positive relationship between attachment security and protective health behaviors.

While the relationship between attachment insecurity and poor health may be, at least partially, explained by insufficient participation in health-protective behaviors (Maunder and Hunter, 2008), to our knowledge, no research has investigated its association with preventive screening behaviors. Attachment patterns have been associated with misuse, overuse, and underuse of the health-care system (e.g. especially fearful avoidant; Ciechanowski et al., 2002); however, much of the research on attachment and health-care seeking has focused on symptom reporting and related health-care use (Kidd and Sheffield, 2005; Kotler et al., 1994; Wearden et al., 2003, 2006). Therefore, the purpose of the present study was to investigate the association between attachment and an important form of preventive health-care use—cervical screening.

Worldwide, cervical cancer is the second most common cancer among women (Parkin et al., 2002), and screening for precancerous and cancerous cell changes of the cervix is currently the most effective prevention measure against the disease (Thun et al., 2010). Following the introduction of the Pap test, the current standard for cervical screening (Health Canada, 2002), rates of cervical cancer plummeted and remained relatively low in developed countries, where screening is widely available (Kowalski and Brown, 1994). Although this public health program has largely been a success, the greatest risk factor for mortality from cervical cancer is lack of screening (Health Canada, 2002). Despite the wide availability of the Pap test in most developed countries, women report a variety of barriers to participation in cervical screening. Barriers discourage or inhibit women from attending regular screening; they can include difficulty in finding a suitable health-care provider, anxiety, fear, and embarrassment (Black et al., 2011; Glasgow et al., 2000; Hennig and Knowles, 1990; Sutton and Rutherford, 2005). As such, in the present study, we explored the role of attachment in cervical screening behaviors and perceptions.

While the mechanisms underlying the relationship between attachment and health remain largely theoretical (Maunder and Hunter, 2001, 2008), research suggests that the secure attachment pattern is protective against the development of health problems (Huntsinger and Luecken, 2004; McWilliams and Bailey, 2010). The protective health behavior of interest in the present study, cervical screening, can be a stressful procedure because of both the discomfort of the exam and the potentially distressing test results (Miller and Roussi, 2010). Compared to insecurely attached individuals, those with a secure attachment style may be more likely to participate in screening and perceive fewer barriers to it because of adequate affect regulation (i.e. the ability to effectively cope with stressful aspects of cervical screening) and because of a greater likelihood of appropriately using health-care services (Maunder and Hunter, 2001, 2008). In order to fully explore the role of attachment in cervical screening, both categorical and dimensional measures were used (i.e. the Relationship Questionnaire (RQ) and Experience in Close Relationships (ECR) scale).

Additionally, neuroticism and sexual behavior were included as covariates in the present study to help clearly discern the influence of attachment on cervical screening. Neuroticism has been correlated with insecure attachment (Shaver and Brennan, 1992) and, therefore, was important to control for in examining the influence of attachment on cervical screening behaviors and barriers. Sexual intercourse experience was included as a covariate because of the previously determined relationship between sexual experience and past Pap test participation (Hill and Gick, 2011). Specifically, women with sexual intercourse experience participate in screening more than women who have not engaged in sexual intercourse. Therefore, the influence of this behavior was controlled in assessing the relationship between attachment and Pap test participation and barriers in the present study. We hypothesized that after controlling for the influence of neuroticism and sexual intercourse experience, attachment insecurity would be negatively predictive of cervical screening and positively predictive of screening barriers.

Method

Participants and procedure

Participants of this study were 257 female undergraduate students recruited from the online participant pool of a Canadian University in January and February 2009 to participate in a study on “personality, health beliefs, and health behaviors.” All participants received grade-raising credit (1%) in a psychology course for participation in this study. Following completion of informed consent forms, participants completed the questionnaires in university classrooms and were fully debriefed on the goals of this study following questionnaire completion; participants were also given contact information for resources about cervical screening during debriefing. This study was approved by the University Ethics Committee for Psychological Research.

Measures

Attachment

In the present study, information on attachment was collected using two questionnaires, one to collect information on the continuous dimensions—anxiety and avoidance—and another to collect information on the four attachment styles: secure, preoccupied, fearful, and dismissing.

Experience in Close Relationships

Brennan et al. (1998) developed the ECR scale from a factor analytic study investigating adult attachment behaviors. Consistent with Bartholomew and Horowitz’s (1991) orthogonal dimensions of attachment, the 36-item ECR was developed as a two-dimensional continuous measure, assessing both attachment anxiety (18 items) and attachment avoidance (18 items) using 7-point Likert scales. Both the attachment anxiety (α = .91) and the attachment avoidance (α = .87) dimensions had high internal consistency in the present study.

Relationship Questionnaire

Developed by Bartholomew and Horowitz (1991), the RQ consists of four paragraphs, each describing an attachment style—secure, preoccupied, fearful, and dismissing. Participants were asked to select the paragraph that best suited them. The RQ has been shown to have high stability across an 8-month period (Scharfe and Bartholomew, 1994). Although the RQ is used less in research, its brevity and convenience lend well to use in clinical settings (e.g. Ciechanowski and Katon, 2006).

Pap test barriers

An original questionnaire was used to assess Pap test barriers in the present study. The full version of the scale has been published in a separate article on the relationship between cervical screening barriers and the big five personality dimensions (see Hill and Gick, 2011). Participants were asked to rate the 11 items, each regarding a potential barrier to cervical screening (e.g. too time-consuming, embarrassing), on a 7-point Likert scale ranging from “strongly disagree” to “strongly agree.” A total Pap test barriers score was calculated by determining the mean Likert scale response. In the present study, the scale had excellent internal reliability (α = .89).

Lifestyle and Behaviors Questionnaire

The Lifestyle and Behaviors Questionnaire collected information on the participant’s sexual activity and Pap test history. Participants indicated whether they had engaged in sexual intercourse and whether they had received a Pap test (both yes/no response options).

Neuroticism subscale of the Big Five Inventory

In completing the Neuroticism subscale of the Big Five Inventory (BFI; John et al., 1991), participants rated each of the eight items (short phrases) on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” After appropriately coding the items, a total score was determined by calculating the mean response. In the present study, the Neuroticism subscale of the BFI had adequate internal reliability (α = .76).

Statistical approach

Hierarchical regressions were performed to assess the influence of attachment anxiety and attachment avoidance on outcome variables, after controlling for relevant behavioral and psychological variables. Past Pap test participation (dichotomous variable: “no” scored as 1 and “yes” scored as 2) and Pap test barriers were entered as dependent variables into logistic and linear models, respectively. Because cervical screening most often begins at the age of 18 years or when a woman becomes sexually active (Health Canada, 2002), experience with sexual intercourse was an important variable to include as a covariate in the study. Experience with sexual intercourse (dichotomous variable: “no” scored as 1 and “yes” scored as 2) was entered into Block 1 of the model, and neuroticism was entered into Block 2 of the regression models to control for the covariance between the personality trait and the attachment dimensions. Finally, in Block 3, attachment anxiety and attachment avoidance were entered into the model. Prior to conducting the analyses, data were screened; regression assumptions were met, and no multivariate or univariate outliers were identified.

Results

Descriptives and correlations

Participants in our sample ranged in age from 17 to 45 years (M = 20.31, standard deviation (SD) = 3.82). Regarding previous screening and sexual experience, 134 participants (51.7% of the sample) had received a Pap test prior to completing our study, and 181 (69.9% of sample) had engaged in sexual intercourse. Pearson bivariate correlations were conducted on continuous variables of the models: neuroticism, attachment anxiety, and attachment avoidance. Attachment anxiety and attachment avoidance were positively correlated (r = .317, p < .001), similar to the previous research (Maunder and Hunter, 2008). Neuroticism was also positively correlated with both attachment anxiety (r = .595, p < .001) and attachment avoidance (r = .218, p < .001).

Pap test behavior and attachment

Table 1 displays the results of the hierarchical logistic regression of the attachment dimensions on Pap test participation. The final model—including all four variables as predictors— indicated that even after controlling for sexual intercourse experience and neuroticism, attachment anxiety and attachment avoidance significantly predicted Pap test behavior. Increases in either attachment anxiety or attachment avoidance significantly decreased the odds of having received a Pap test.

Table 1.

Hierarchical logistic regression of attachment dimensions on Pap test participation.

Predictor variable	Wald	p	Odds ratio	95% CI	X ²	p	Nagelkerke R²
Block 1					101.84	<.001	.436
Intercourse experience	52.63	<.001	35.23	13.46–92.22
Block 2					102.13	<.001	.437
Intercourse experience	52.58	<.001	35.24	13.45–92.27
Neuroticism	.291	.590	.903	.62–1.31
Block 3 (final model)					113.88	<.001	.478
Intercourse experience	48.96	<.001	32.21	12.18–85.17
Neuroticism	1.98	.160	1.45	.87–2.41
Attachment anxiety	4.51	.034	.67	.46–.97
Attachment avoidance	4.50	.034	.65	.43–.97

CI: confidence interval.

Chi-square tests were performed using the categorical measure of attachment (RQ) to see whether the results with the continuous ECR measure could be replicated. Due to missing data on the RQ (three cases), a slightly smaller sample (n = 254) was used for analyses involving the RQ. In the present study, 106 (41.7%) participants were classified as securely attached, 73 (28.23%) as fearful, 37 (14.3%) as preoccupied, and 38 (14.7%) as dismissing. A cross-tabulation of the relationship between Pap test participation and attachment style is displayed in Table 2. For the chi-square analyses, a Bonferroni correction (.013) was applied due to comparisons being made between secure and each of the insecure attachment styles (three comparisons). Participants classified as securely attached were significantly more likely to have received a Pap test compared to participants with a dismissing attachment style, χ² (1) = 6.24, p = .012. There were no significant relationships found between Pap test participation and preoccupied attachment (vs secure), χ² (1) = 2.33, p = .127, or fearful attachment (vs secure), χ² (1) = 1.65, p = .199.

Table 2.

Cross-tabulation of Pap test participation and attachment style.

		Attachment style				Total
		Secure	Fearful	Preoccupied	Dismissing
Past Pap test participation	No	42 (40%)	36 (49.3%)	20 (54%)	24 (63.1%)	122 (48%)
	Yes	64 (60%)	37 (50.7%)	17 (46%)	14 (36.8%)	132 (52%)
	Total	106 (100%)	73 (100%)	37 (100%)	38 (100%)	254 (100%)

Pap test barriers and attachment

Table 3 displays the results of the hierarchical linear regression assessing the association between the attachment dimensions and barriers to the Pap test. Prior to entering the attachment dimensions into the model, both covariates—intercourse experience and neuroticism— significantly predicted Pap test barriers. In the final model, sexual intercourse experience, attachment anxiety, and attachment avoidance were the only significant predictors. Sexual intercourse experience was negatively predictive of Pap test barriers (β = −.42, p < .001), and attachment anxiety (β = .14, p = .017) and attachment avoidance (β = .14, p = .041) were positively predictive of Pap test barriers.

Table 3.

Hierarchical linear regression of attachment dimensions on Pap test barriers.

Predictor variable	β	p	R	R ²	Adjusted R²	F	df	p
Block 1			.461	.212	.209	68.64	1, 255	<.001
Intercourse experience	−.46	<.001
Block 2			.488	.238	.232	39.63	2, 254	<.001
Intercourse experience	−.46	<.001
Neuroticism	.16	.004
Block 3 (final model)			.522	.273	.261	23.64	4, 252	<.001
Intercourse experience	−.42	<.001
Neuroticism	.04	.582
Attachment anxiety	.14	.017
Attachment avoidance	.14	.041

df: degree of freedom.

We further explored the relationship between Pap test barriers and attachment using the RQ. A one-way analysis of variance (ANOVA) revealed significant differences in Pap test barriers across attachment styles, F(3, 250) = 4.93, p = .002. Dunnett’s post hoc test revealed significant mean differences in Pap test barriers between the secure attachment style and each of the insecure attachment styles: fearful (p = .006), preoccupied (p = .017), and dismissing (p = .037). Individuals with the secure attachment style (M = 3.10, SD = 1.37) had significantly lower Pap test barriers than those with a fearful attachment style (M = 3.72, SD = 1.25), a preoccupied attachment style (M = 3.80, SD = 1.41), and a dismissing attachment style (M = 3.72, SD = 1.25).

Discussion

Previous cervical screening research has emphasized the important role of psychological factors—such as personality, the quality of the health-care provider relationship, sexual trauma, and anxiety about the screening procedure—in understanding screening perceptions and the uptake of such preventive health behaviors (e.g. Black et al., 2011; Hill and Gick, 2011; Pedersen and Cohen, 2010; Von Wagner et al., 2011). Our findings highlight attachment as another important psychological variable to consider in understanding women’s cervical screening perceptions and behaviors. We found that attachment insecurity was associated with cervical screening barriers and less participation in screening. Our results, a novel finding in the field, suggest that inadequate screening may be yet another mechanism linking attachment insecurity and health risks.

As hypothesized, both attachment anxiety and attachment avoidance were associated with decreased odds of having received a Pap test. Both attachment dimensions have been linked to risky sexual behaviors such as increased sexual activity and a young age at first intercourse (Bogaert and Sadava, 2002; Gentzler and Kerns, 2004), which in turn may increase the risk of contracting the human papillomavirus (HPV)—the sexually transmitted virus that causes cervical cancer (Clifford et al., 2003). Therefore, because of its association with cervical cancer risk-related behaviors (i.e. lack of screening and sexual activity; Health Canada, 2002), attachment insecurity may in turn be a risk factor for the development of cervical cancer. The actual association between cervical cancer development and attachment was beyond the scope of the present study but would be an interesting and advantageous research avenue for future studies on this topic.

It is notable that in assessing Pap test participation in relation to the RQ attachment styles, there was only a significant difference between secure and dismissing attachment styles. The reason for the lack of difference between secure and the remaining insecure attachment styles (fearful, preoccupied) is unclear. At first glance, it would appear that attachment anxiety may be a factor. Both fearful and preoccupied attachment styles are characterized by high attachment anxiety (and high attachment avoidance and low attachment avoidance, respectively), whereas dismissing attachment is characterized by low attachment anxiety (and high attachment avoidance). Therefore, it could be that attachment anxiety is related to health risk cognitions or sexual behaviors, which in turn propel an individual to participate in screening. However, anxious attachment as measured by the ECR was negatively associated with Pap test participation, thus limiting an explanation based solely on attachment anxiety. Further research is needed to replicate these results and clarify their meaning.

Our findings revealed that Pap test barriers were associated with attachment insecurity, a result congruent across both the ECR and RQ attachment measures. Specifically, both attachment anxiety and attachment avoidance were positively predictive of Pap test barriers. The results of the RQ generally confirmed this finding; compared to secure attachment, Pap test barriers were greater among individuals with an insecure attachment style. Because of the ease of completion of the RQ (1 item) compared to the ECR (36 items), the RQ could possibly be used in clinical settings among health-care professionals wishing to address attachment concerns and encourage appropriate screening behaviors. Additionally, while attachment styles are fairly ingrained, it is possible that secure attachment systems could be activated through clinical treatment programs (Levy et al., 2011). Awareness of the health risks associated with insecure attachment may prompt physicians to refer patients to such programs in hopes of improving overall emotional and physical well-being. In turn, attachment security may allow the patient to cope appropriately with the perceived barriers associated with cervical screening.

Maunder and Hunter (2001, 2008) proposed that attachment insecurity is a risk factor for inadequate participation in health-protective behaviors, but the mechanisms underlying this relationship remain speculative. One possibility is that because attachment security is associated with trust in others and suitable help-seeking behaviors (Larose et al., 1999), individuals who are securely attached also seek health care when appropriate. Additionally, attachment security has been linked to the ability to employ effective coping mechanisms (Mikulincer and Florian, 1995, Schmidt et al., 2012), which in turn could also be applied to cervical screening. Compared to those who are insecurely attached, securely attached individuals are more likely to perceive threats as challenges (Mikulincer and Florian, 1998) and, in turn, effectively cope with such threats. It is possible that cervical screening may be perceived as a threat because of the stressful aspects of screening (e.g. the discomfort of the exam and waiting for test results), and therefore, attachment insecurity could be a hindrance in coping with these stressors. In order to clarify the association between attachment and cervical screening, future research should consider exploring potential moderators and mediators of the association, such as coping mechanisms and threat appraisals.

Limitations

The use of an undergraduate sample of women who are fairly homogeneous in age, socioeconomic status, and education is a limitation of the present study. However, the use of a relatively young sample of women meant that some of the participants had not yet engaged in sexual activity or started screening, which in turn allowed these variables to be tested in our statistical models. Although we found an association between having received a Pap test and attachment, future investigations in this field may wish to delve further into this topic by assessing other important variables such as frequency of Pap tests and screening behaviors following abnormal test results. Additionally, future research should also consider using women from the general population to test whether these associations persist in more diverse samples of women.

The statistical models used in the present study tested whether the attachment dimensions predicted cervical screening behaviors and perceptions. However, causality should not be assumed due to the quasi-experimental nature of the present study. That is, while we proposed that attachment insecurity may lead to poor screening attendance or elevated barriers, we cannot confidently conclude the direction of the associations. Furthermore, as previously mentioned, there could be a wide variety of mediators possibly explaining the relationship between attachment security and cervical screening, which in turn could be the subject of future investigations.

Conclusion

In the present study, we explored the association between attachment and cervical screening behaviors and perceptions. Our findings add to the growing literature highlighting potential health risks of attachment insecurity and, consequently, health-protective effects of attachment security (e.g. Huntsinger and Luecken, 2004; McWilliams and Bailey, 2010; Scharfe and Eldredge, 2001). Not only are our findings novel to the attachment-health literature, but they also provide some insight for health-care professionals on the psychological factors that may influence patients’ screening behaviors and perceptions. Future research should continue to build on this line of research to further elucidate the relationship between attachment and other types of preventive screening.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Bartholomew

Horowitz

(1991) Attachments styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology 61: 226–244.

Black

McCulloch

Martin

. (2011) Young women and cervical cancer screening: What barriers persist? Canadian Journal of Nursing Research 43: 8–21.

Bogaert

Sadava

(2002) Adult attachment and sexual behavior. Personal Relationships 9: 191–204.

Bowlby

(1969) Attachment and Loss, Vol. 1: Attachment. New York: Basic Books.

Brennan

Clark

Shaver

(1998) Self-report measurement of adult attachment: An integrative overview. In: Simpson

Rholes

(eds) Attachment Theory and Close Relationships. New York: Guilford Press, pp. 46–76.

Ciechanowski

Katon

(2006) The interpersonal experience of health care through the eyes of patients with diabetes. Social Science & Medicine 63: 3067–3079.

Ciechanowski

Walker

Katon

. (2002) Attachment theory: A model for health care utilization and somatisation. Psychosomatic Medicine 64: 660–667.

Clifford

Smith

Munoz

. (2003) Human papillomavirus types in invasive cervical cancer worldwide: A meta-analysis. British Journal of Cancer 88: 63–73.

Diamond

Fagundes

(2010) Psychobiological research on attachment. Journal of Social and Personal Relationships 27: 218–225.

10.

Feeney

(2000) Implications of attachment style for patterns of health and illness. Child Care Health and Development 26: 277–288.

11.

Feeney

Ryan

(1994) Attachment style and affect regulation: Relationships with health behavior and family experiences of illness in a student sample. Health Psychology 13: 334–345.

12.

Gallo

Matthews

(2006) Adolescents’ attachment orientation influences ambulatory blood pressure responses to everyday social interactions. Psychosomatic Medicine 68: 253–261.

13.

Gentzler

Kerns

(2004) Associations between insecure attachment and sexual experiences. Personal Relationships 11: 249–265.

14.

Glasgow

Whitlock

Valanis

. (2000) Barriers to mammography and pap smear screening among women who recently had neither, one or both types of screening. Annals of Behavioral Medicine 22: 223–228.

15.

Gunnar

Brodersen

Nachmias

. (1996) Stress reactivity and attachment security. Developmental Psychobiology 29: 191–204.

16.

Health Canada (2002) Cervical cancer screening in Canada: 1998 Surveillance Report. Available at: www.phac-aspc.gc.ca/publicat/ccsic-dccuac/pdf/cervical-e3.pdf (accessed 13 July 2009).

17.

Hennig

Knowles

(1990) Factors influencing women over 40 years to take precautions against cervical cancer. Journal of Applied Social Psychology 20: 1612–1621.

18.

Hill

Gick

(2011) The big five and cervical screening barriers: Evidence for the influence of conscientiousness, extraversion and openness. Personality and Individual Differences 50: 662–667.

19.

Huntsinger

Luecken

(2004) Attachment relationships and health behavior: The mediational role of self-esteem. Psychology & Health 19: 515–526.

20.

John

Donahue

Kentle

(1991) The Big Five Inventory—Versions 4a and 54. Berkeley, CA: Institute of Personality and Social Research, University of California.

21.

Kafetsios

Sideridis

(2006) Attachment, social support and well-being in young and older adults. Journal of Health Psychology 11: 863–875.

22.

Kidd

Sheffield

(2005) Attachment style and symptom reporting: Examining the mediating effects of anger and social support. British Journal of Health Psychology 10: 531–541.

23.

Kotler

Buzwell

Romeo

. (1994) Avoidant attachment as a risk factor for health. British Journal of Medical Psychology 67: 237–245.

24.

Kowalski

Brown

(1994) Psychosocial barriers to cervical cancer screening: Concerns with self-presentation and social evaluation. Journal of Applied Social Psychology 24: 941–958.

25.

Larose

Bernier

Soucy

. (1999) Attachment style dimensions, network orientation, and the process of seeking help from college teachers. Journal of Social and Personal Relationships 16: 225–247.

26.

Levy

Ellison

Scott

. (2011) Attachment style. Journal of Clinical Psychology 67: 193–203.

27.

Luijk

Saridjan

Tharner

. (2010) Attachment, depression, and cortisol: Deviant patterns in insecure-resistant and disorganized infants. Developmental Psychobiology 52: 441–452.

28.

McEwen

Seeman

(1999) Protective and damaging effects of mediators of stress: Elaborating and testing the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences 896: 30–47.

29.

McWilliams

Bailey

(2010) Associations between adult attachment ratings and health: Evidence from the National Comorbidity Survey Replication. Health Psychology 29: 446–453.

30.

Maunder

Hunter

(2001) Attachment and psychosomatic medicine: Developmental contributions to stress and disease. Psychosomatic Medicine 63: 556–567.

31.

Maunder

Hunter

(2008) Attachment relationships as determinants of physical health. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36: 11–32.

32.

Maunder

Lancee

Nolan

. (2006) The relationship of attachment insecurity to subjective stress and autonomic functions during standardized acute stress in healthy adults. Journal of Psychosomatic Research 60: 283–290.

33.

Mikulincer

Florian

(1995) Appraisal of and coping with a real-life stressful situation: The contribution of attachment styles. Personality and Social Psychology Bulletin 21: 406–414.

34.

Mikulincer

Florian

(1998) The relationship between adult attachment styles and emotional and cognitive reactions to stressful events. In: Simpson

Rholes

(eds) Attachment Theory and Close Relationships. New York: Guilford Press, pp. 143–165.

35.

Miller

Roussi

(2010) Cervical cancer screening. In: Holland

Breitbart

(eds) Psycho-Oncology. New York: Oxford University Press, pp. 84–89.

36.

Oliveira

Costa

(2009) Interrelationships of adult attachment orientations, health status and worrying among fibromyalgia patients. Journal of Health Psychology 14: 1184–1195.

37.

Parkin

Bray

Ferlay

. (2002) Global cancer statistics. CA-A Journal for Clinicians 55: 74–108.

38.

Pedersen

Cohen

(2010) Identifying and overcoming barriers to cervical screening in women with a history of sexual violence and posttraumatic stress disorder. Journal of Womens Health 19: 1239–1241.

39.

Peterson

Buser

Westburg

(2010) Effects of familial attachment, social support, involvement, and self-esteem on youth substance use and sexual risk taking. The Family Journal 18: 369–376.

40.

Quirin

Pruessner

Kuhl

(2008) HPA system regulation and adult attachment anxiety: Individual differences in reactive and awakening cortisol. Psychoneuroendocrinology 31: 581–590.

41.

Scharfe

Bartholomew

(1994) Reliability and stability of adult attachment patterns. Personal Relationships 1: 23–43.

42.

Scharfe

Eldredge

(2001) Associations between attachment representations and health behaviors in late adolescence. Journal of Health Psychology 6: 295–307.

43.

Schmidt

Blank

Bellizzi

. (2012) The relationship of coping strategies, social support, and attachment style with posttraumatic growth in cancer survivors. Journal of Health Psychology. Epub ahead of print 17 January 2012. DOI: 10.1177/1359105311429203.

44.

Shaver

Brennan

(1992) Attachment styles and the “big five” personality traits: Their connections with each other and with romantic relationship outcomes. Personality and Social Psychology Bulletin 18: 536–545.

45.

Sutton

Rutherford

(2005) Sociodemographic and attitudinal correlates of cervical screening uptake in a national sample of women in Britain. Social Science & Medicine 61: 2460–2465.

46.

Tasca

Szadkowski

Illing

. (2009) Adult attachment, depression and eating disorder symptoms: The mediating role of affect regulation strategies. Personality and Individual Differences 47: 662–667.

47.

Thayer

Sternberg

(2006) Beyond heart rate variability: Vagal regulation of allostatic systems. Annals of the New York Academy of Sciences 1088: 361–372.

48.

Thun

DeLancey

Center

. (2010) The global burden of cancer: Priorities for prevention. Carcinogenesis 31: 100–110.

49.

Von Wagner

Good

Whitaker

. (2011) Psychosocial determinants of socioeconomic inequalities in cancer screening participation: A conceptual framework. Epidemiologic Reviews 33: 135–147.

50.

Wearden

Cook

Vaughan-Jones

(2003) Adult attachment, alexithymia, symptom reporting, and health-related coping. Journal of Psychosomatic Research 55: 341–347.

51.

Wearden

Perryman

Ward

(2006) Adult attachment, reassurance seeking and hypochondriacal concerns in college students. Journal of Health Psychology 11: 877–886.

52.

Wilkinson

Rowe

Bishop

. (2010) Attachment anxiety, disinhibited eating, and body mass index in adulthood. International Journal of Obesity 34: 1442–1445.