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Health beliefs, salience of breast cancer family history, and involvement with breast cancer issues: adherence to annual mammography screening recommendations
Cancer Detection and Prevention 27 (2003) 353–359
Health beliefs, salience of breast cancer family history, and involvement with breast cancer issues: adherence to annual mammography screening recommendations Lila J. Finney Rutten, Ph.D., MPH a,∗ , Ronald J. Iannotti, Ph.D. b a
Cancer Prevention Fellowship Program, Division of Cancer Prevention and the Division of Cancer Control and Population Sciences, National Cancer Institute, Department of Health and Human Services, 6130 Executive Blvd. Rm. 4051A MSC 7365, Bethesda, MD 20892-7326, USA b Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, Department of Health and Human Services, Bethesda, MD 20892-7326, USA Accepted 30 June 2003
Abstract Involvement in breast cancer (BC) issues, and the degree to which family history of BC influences perceived risk (salience of family history), have been proposed as additions to the Health Belief Model as applied to mammography adherence. Barriers and benefits of mammography, perceived susceptibility, severity, cues to action, salience of family history, and issue involvement with respect to BC were examined in adherent (n = 97) and non-adherent (n = 213) women. Adherent women with positive family histories reported greater benefits of mammography, greater response to cues to action, and higher salience of family history than women with negative family histories. Non-adherent women with positive family histories reported fewer benefits of mammography and greater issue involvement, and perceived BC as less severe than those with negative family histories. Benefits (OR = 1.51), susceptibility (OR = 1.41), issue involvement (OR = 1.59), severity (OR = 0.66), and cues to action (OR = 0.75) were significantly associated with adherence. Results have implications for evidence-based interventions. Published by Elsevier Ltd. on behalf of International Society for Preventive Oncology. Keywords: Patient adherence; Screening adherence; Reminder systems; Health belief model
1. Introduction The early detection of breast cancer (BC) through mammography screening is optimally effective when mammography is performed every 1–2 years. Current recommendations for mammography screening are every 1–2 years among women aged 40 and more [1–3]. Estimating the percentage of women who receive “regular” mammography screening in accordance with guidelines is complicated by both the nature of the sample and by how “regular” screening is defined [4]. Estimates from the 2000 National Health Interview Survey indicate that 70% of women aged 40 and more report having had a mammogram in the last 2 years [5]. Our investigation addresses the importance of regular screening through an examination of factors that affect adherence to annual mammography screening reminders among previously screened women. We compared factors associated with screening among adherent women (those ∗ Corresponding author. Tel.: +1-301-435-2842; fax: +1-301-480-2198. E-mail address: [email protected] (L.J. Finney Rutten).
who received a mammogram within 2 months of receiving a reminder letter) to factors associated with screening among non-adherent women (those who did not receive a mammogram within 2 months of receiving a reminder letter). Additionally, we examined the affect of family history of BC on relations between health beliefs and adherence. Prior investigations have not identified a clear association between positive family history of breast cancer and actual, self-reported, or intended screening adherence [6–15]. Although differences in the beliefs and behaviors of women with positive and negative family histories have been explored, this research focused on risk perceptions or concerns about mammography screening, and did not examine other potentially relevant health beliefs [10]. The inconsistent pattern of association between screening adherence and family history identified in past research, coupled with the scarcity of research focusing on differences in health beliefs among women with positive and negative BC histories, signal the need to explore women’s health beliefs regarding mammography and BC as a function of BC family history. Our investigation addresses this gap in previous research
0361-090X/$30.00 Published by Elsevier Ltd. on behalf of International Society for Preventive Oncology. doi:10.1016/S0361-090X(03)00133-8
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by examining differences in women’s health beliefs as a function of family history of BC. The Health Belief Model (HBM), first developed to guide research on utilization of medical screening programs [16], has been useful in conceptualizing a range of health behaviors [17–20]. Dimensions of the HBM include: benefits of recommended health actions, barriers to recommended health actions, susceptibility to developing disease, severity of disease, and cues to action that prompt recommended health actions. The application of the HBM to screening behaviors such as mammography, breast self-examination, and clinical breast examination in previous research attest to its appropriateness in assessing mammography screening [21–25]. In a previous study, we expanded the HBM to include issue involvement (degree of involvement in BC issues) and salience of BC family history (extent to which concerns about BC are related to family history). Our decision to include issue involvement and salience of family history in the model was based on previous research which demonstrates that prior experience with an illness and the degree to which individuals are involved with a particular health issue may affect adherence with health recommendations [26,27]. In our previous work [28], we developed and evaluated a questionnaire to assess this expanded HBM. Although the instrument had good reliability and validity, the sample in which it was evaluated included only adherent women; therefore, the relationship to mammography adherence could not be examined. In the current investigation, we use this expanded HBM to replicate and extend our earlier work. Specifically, we assessed the association of the components of the expanded HBM with adherence to annual mammography screening reminders, and explored differences in health beliefs as a function of adherence and BC family history. 2. Method 2.1. Sample Participants were recruited from a pool of women due for annual mammography from December 1999 through September 2000. Women selected for inclusion met the following criteria: (1) age at least 40 years, (2) recommended frequency of mammography no more than annual, (3) no previous BC diagnosis, (4) at least one prior mammogram at the facility, (5) records containing BC family history, and (6) non-Medicaid or non-Medicare status. We distributed the questionnaire in a small, not-for-profit hospital that provides care for primarily rural areas in Butler and Preble counties in Ohio, and in Franklin, Union, and Fayette counties in Indiana. Each month, we identified women in the patient database who were due for annual screening. Reminder letters were sent out to women 1 week prior to the month during which the recommended screening was due. We inserted packets containing the health
belief questionnaire into the mammography files of identified women. Upon arrival in the screening center for their appointments, women whose files contained a questionnaire were asked if they would be interested in completing the questionnaire. Women who agreed to participate received a packet containing a consent form and the questionnaire. We mailed the questionnaire to women who did not attend appointments within the 2 months following mailing of the reminder letters. Consent from women who were mailed the questionnaire was implied by return of completed questionnaires. The research protocol was approved by the Institutional Committee on the Use of Human Subjects in Research at Miami University in Oxford, Ohio, and by the participating hospital’s review board. 2.2. Measures The questionnaire, which we developed and tested in a previous investigation [28], was used to assess the following health beliefs: perceptions of the barriers and benefits of mammography, susceptibility to developing BC, severity of BC, cues to action that prompt screening participation, salience of family history of BC, and involvement in BC issues. A total of 45 items, assessed on 7-point Likert scales were included in the questionnaire to assess health beliefs. Each point on the Likert scale was associated with a response ranging from “completely disagree” to “completely agree” or “extremely unlikely” to “extremely likely.” Higher ranking on the Likert scale indicates greater agreement with the health beliefs that were assessed (e.g. a higher barrier score indicates greater perception of barriers). Individual questionnaire items were combined into scales for each health belief component by averaging responses. Details on individual items and scale development are published elsewhere [28]. We made minor changes to the original questionnaire: (1) we combined two apparently redundant cues to action items regarding the influence of television and newspapers on mammography decisions into one item assessing media influence; (2) content analysis suggested that the issue involvement item assessing the frequency of worrying about developing BC was conceptually distinct from the other issue involvement items; so we dropped this item; (3) we dropped the question about family income because participants in our previous study were resistant to this item; (4) we reworded the cues to action items in the mailed questionnaires to be appropriate to the non-adherent status of these respondents; for example, the item “Encouragement from family influenced my decision to obtain a mammogram” was reworded as “Encouragement from family influences whether I obtain a mammogram.” All questionnaire items and instructions were assessed to be at or below the ninth-grade reading level using Microsoft Word’s (version 1997) readability statistics algorithm. Family history of BC was determined by self-report in response to the question “Has any one in your family had breast cancer?” Respondents who selected a “yes” response
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were classified as having a positive family history of BC. For a subset of women (n = 87), we validated self-reported family history with patient records, which defined family history as having at least one blood relative diagnosed with BC. The resulting correlation was quite high (r = 0.85). The two additions to the HBM were salience of family history and issue involvement. Salience of family history items assessed the extent to which a woman’s concerns about BC were related to her family history. The issue involvement scale assessed involvement in information gathering and BC awareness activities. Sociodemographic characteristics were also assessed. The questionnaire took approximately 10 min to complete. 2.3. Analyses conducted We calculated Spearman’s correlations to examine the association of mammography adherence with sociodemographic variables, HBM components, salience of family history, and BC issue involvement. For both adherent and non-adherent women, we conducted a series of t-tests to examine differences in health beliefs between women with positive and negative BC family histories. We conducted a logistic regression to assess the extent to which sociodemographic factors, HBM components, issue involvement, and salience of family BC history predicted adherence with mammography screening reminders. 3. Results
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mailing of the reminder letters. Examination of adherence among women due for mammography during the first month that the questionnaire was administered revealed an adherence rate of 29% at 1 month and 45% at 1.5 months; however, the adherence rate increased to only 47% at 2 months. On the basis of the small increase in adherence from the 1.5to 2-month endpoints, a 2-month cutoff was designated for documenting adherence to reminder letters. 3.3. Predictor variables 3.3.1. Sociodemographic variables The sample included primarily middle-aged, Caucasian married women with employment outside of the home and high levels of education. The small number of minority women included in the sample precludes generalization of the results to minority populations. Sample distributions were similar for adherent and non-adherent women (Table 1). 3.3.2. Health belief variables, salience of family history, and issue involvement In our prior use of this questionnaire, individual questionnaire items assessing the HBM components were averaged to create scales for each health belief component [28]. We used the same scales in this investigation. The internal reliability of these scales was assessed with Cronbach’s alpha, which measures how well sets of items or variables cohere as a single, unidimensional measure. With the exception of
3.1. Response rate
Table 1 Sociodemographic characteristics of the sample
Among the 929 women who were due for annual mammography screening, 888 were given the opportunity to complete the health belief questionnaire. A total of 41 women were not asked to participate for the following reasons: missing patient files (n = 6); failure to mail out the questionnaire (n = 12); conflict of interest with the hospital (n = 2); and returned delivery from the United States Postal Service (n = 21). Among the 888 women asked to complete the questionnaire, 315 consented to participate, resulting in an overall response rate of 35%. Among compliant women (n = 391), 97 (25%) consented to complete the questionnaire. Among the non-compliant women (n = 538), 213 (40%) women consented to complete the questionnaire. Among those women who completed the questionnaire, 42% (n = 126) reported a positive family history of BC and 55.3% (n = 166) reported a negative family history. Seven participants indicated that they did not know their family history and were therefore excluded from analyses involving family history.
Sociodemographic factors
Adherent
Non-adherent
n (%)
n (%)
Age 40–49 50–59 60–69
31 (35.6) 43 (49.4) 13 (14.9)
83 (39.0) 89 (41.8) 41 (19.2)
Race Caucasian Minority
80 (94.1) 5 (5.9)
198 (93.0) 15 (7.0)
Education Less than high school High school graduate Some college/technical school College graduate Graduate school/advanced degree
6 25 17 22 17
Marital status Married Not married
73 (83.9) 14 (16.1)
174 (81.7) 39 (18.3)
3.2. Outcome variable
Employment Full-time Part-time Not employed
53 (60.9) 17 (19.5) 17 (19.5)
121 (57.1) 34 (16.0) 57 (26.9)
Adherence was based on chart documentation and defined as having a mammogram within the 2 months following
Note: Due to missing data, all n’s do not sum to total sample size (n = 300).
(6.9) (28.7) (19.5) (25.3) (19.5)
17 73 51 36 36
(8.0) (34.3) (23.9) (16.9) (16.9)
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Table 2 Reliability of health belief scales Health belief
No. of items
Cronbach’s alpha
Barriers Benefits Susceptibility Severity Cues to action Salience of family history Issue involvement
14 7 3 2 13 2 3
0.77 0.88 0.77 0.42 0.87 0.76 0.76
Table 4 Mean Likert-scale rating (S.D.) of health beliefs for adherent and non-adherent women with positive and negative family histories of breast cancer
Barrier Benefit Susceptibility
Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent
the severity scale, the reliability of these scales was confirmed in the present investigation (Table 2). Low reliability in measures of severity has been evidenced in previous applications of the HBM to mammography screening and likely reflects high consistency in perceptions of BC severity [20,25,29,30].
Severity
3.3.3. Association of screening adherence with sociodemographic factors None of the sociodemographic variables were significant predictors of adherence. Although previous investigations have found an association between sociodemographic factors and screening adherence, the sample in our investigation was homogenous, limiting the ability to detect significant associations [31–36].
Note: History (Hx ).
3.4. Association of screening adherence with HBM components, salience of family history, and issue involvement Several of the scaled components of the HBM were significantly associated with adherence (Table 3). Greater perceptions of barriers and severity, and greater endorsement of cues to action were negatively associated with adherence. Greater belief in the benefits of mammography and greater issue involvement were positively associated with adherence. 3.4.1. Differences among women with positive and negative family histories of breast cancer Significant differences in the mean of the 7-point Likert-scale rating of the HBM components were identified Table 3 Correlation of screening adherence with HBM components, salience of family history and issue involvement Health belief
r
P-value
Barriers Benefits Susceptibility Severity Cues to action Salience of family history Issue involvement
−0.22 0.21 0.09 −0.13 −0.19 −0.05 0.25
0.000 0.000 0.13 0.02 0.001 0.38 0.000
Cue to act Salience family Hx Issue involvement
Positive Hx
Negative Hx
Mean (SD)
Mean (SD)
2.4 2.5 6.4 6.0 4.2 4.0 4.7 4.9 4.1 4.2 5.0 4.6 4.4 3.9
2.3 2.8 6.2 6.0 3.1 3.1 4.9 5.2 3.4 4.2 2.1 3.1 4.2 3.5
(0.63) (0.83) (0.47) (0.74) (1.1) (1.2) (1.0) (1.1) (1.1) (1.2) (1.8) (1.8) (1.1) (1.2)
(0.64) (0.83) (0.90) (0.83) (1.2) (0.95) (1.0) (0.90) (0.93) (1.2) (0.94) (1.5) (1.1) (1.3)
P-value
0.51 0.03 0.09 0.78 0.000 0.000 0.49 0.05 0.003 0.96 0.000 0.000 0.39 0.01
between women with positive and negative family histories of BC (Table 4). For all women with a positive family history, whether adherent or non-adherent, perceived susceptibility and salience of family history were higher compared with women with a negative family history. Women with a positive family history who were adherent perceived greater benefits of mammography (marginal) and reported greater response to cues to action than women with a negative family history who were adherent. Women with a positive family history who were non-adherent perceived fewer barriers to mammography, perceived BC as less severe, and showed greater issue involvement than those with a negative family history who were non-adherent. 3.4.2. Health belief predictors of mammography Sociodemographic variables assessed included age, race/ethnicity, education, marital status, and employment. None of the sociodemographic factors were significantly associated with adherence in the logistic regression analysis. The regression model predicting mammography adherence from barriers, benefits, susceptibility, severity, cues to action, issue involvement, and salience of family history was statistically reliable (χ2 (7, N = 297) = 50.73, P < 0.001). Adherence was associated with greater perceptions of the Table 5 Predictors of mammography adherence Health belief
Odds ratio
95% CI
Barrier Benefit Susceptibility Severity Cue to act Salience of family history Issue involvement
0.79 1.51 1.41 0.66 0.75 0.83 1.59
(0.52, (1.02, (1.05, (0.49, (0.57, (0.68, (1.24,
Note: χ2 (7, N = 297) = 50.73.
1.18) 2.24) 1.89) 0.90) 0.97) 1.01) 2.03)
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benefits of mammography, higher perceived susceptibility to developing BC, greater issue involvement, lower perceived severity and lower response to cues to action (Table 5). Neither barriers nor salience of family history were significantly associated with adherence. 4. Discussion 4.1. Limitations Although the response rate among non-compliant women (40%) is consistent with response rates for mailed surveys, the response rate among compliant women who were asked to complete the questionnaire during their appointment is low (25%). The participating clinic makes a concerted effort to deliver care efficiently, and the low response rate reflects the limited time that women had to complete the questionnaire during their appointments. Participating staff members were trained in a specific protocol for soliciting participation, and periodic checks were made by the director of screening and the first author to ensure protocol adherence. Despite these measures, time limitations were apparently prohibitive. The low response rates obtained may limit the generalizability of the reported findings. Compounding this drawback is the unavailability of data pertaining to the characteristics of women who chose not to respond to the questionnaire versus those who completed the questionnaire. 4.2. Implications for intervention Consistent with previous research, greater barrier perception was associated with lower adherence [37–39]. Key barriers to adherence included concerns about the discomfort of mammography, being too busy to schedule a mammogram, and not thinking about having a mammogram. Efforts to address these barriers must focus on decreasing the discomfort of screening, providing convenient screening hours and locations, and implementing effective reminder systems. Attempts to decrease the discomfort of mammography may involve patient education efforts to inform women of the best times during her menstrual cycle to schedule a mammogram to avoid unnecessary discomfort. Additionally, refinement of current breast screening technology, and development and evaluation of alternative imaging technology, may provide more comfortable alternatives to mammography. Efforts should be made to improve the convenience of mammography screening. Mobile mammography vans, work site screening, and convenient screening hours, such as nights or weekends, may allow women facing multiple time demands to more easily obtain regular screening mammograms [40]. Finally, the use of patient reminder systems such as letters and phone calls appears to be an effective route for prompting women to schedule their annual screening mammogram.
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As expected, greater agreement with the benefits of mammography was significantly associated with adherence [37,41]. The benefits associated with adherence included having a mammogram as a usual part of one’s health exams, and believing that mammography increases peace of mind, sense of control, and lifespan. Inclusion of mammography as part of regular health exams may improve screening adherence. In fact, capitalizing on contact with the medical system by offering multiple services during each patient visit may improve adherence with a range of early detection behaviors. The negative association found between severity and adherence is inconsistent with the HBM. The average severity score was quite high (M = 4.99 on a 7-point scale); thus, the negative association between severity and adherence may be explained by previous research which suggests that low or moderate judgments of severity may be associated with higher adherence, while higher judgments of severity may be associated with lower adherence [17]. This finding implies that communication regarding the severity of BC should be tempered with the benefits of early detection and opportunities for engaging in early detection. Greater endorsement of cues to action was associated with lower adherence. This finding is inconsistent with previous investigations which have identified a positive association between response to cues to action and adherence with health recommendations [30,38,39]. This unexpected finding likely reflects the different wording of the cue to action items on the questionnaires completed by compliant and non-compliant women. Non-compliant women were possibly trying to imagine if the given cue would prompt them to engage in mammography, while compliant women likely assessed which cues to action items actually prompted them to attend their appointment. Further inspection of the data supports this explanation; modal responses to the cue to action items suggested that non-adherent women were endorsing more cues to action items overall than adherent women. Generally, both adherent and non-adherent women cited physician recommendation and reminder letters from a screening center as key cues to action. In this atmosphere of controversy surrounding screening recommendations, patients may rely more heavily upon the clinical judgment of their personal physicians in referral for mammography screening. Although physician recommendation has been demonstrated to be an important predictor of mammography screening, research has shown that many physicians do not adhere to recommendations in referral of patients for mammography screening [42–44]. Thus, continued effort to encourage physicians to recommend screening procedures is critical for increasing mammography screening. Consistent with predictions derived from previous investigations [26,27], adherence was significantly associated with greater issue involvement. Reading articles about BC and involvement in awareness or fund-raising activities for BC were associated with adherence. Opportunities for accessing information about BC have increased dramatically with the availability of such information on the World Wide Web
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(WWW). In addition to WWW applications, efforts to increase screening and preventive behavior may also involve the implementation of interactive health communication applications at screening centers and hospitals [45]. Differences in health beliefs between women with positive and those with negative BC family histories were identified, replicating and expanding previous findings [28]. Among both adherent and non-adherent women, those with positive BC family histories judged themselves to be significantly more susceptible to developing BC than women with negative family histories, suggesting that women with negative family histories perceive themselves to be at less risk for developing BC. This finding, in light of the fact that only 10% of breast cancers are thought to be hereditary [1], affirms the importance of stressing screening adherence among women with negative family histories of BC. For both adherent and non-adherent women, those with a positive family history of BC reported significantly higher salience of family history and issue involvement than women with a negative family history. Having a positive family history of BC appears to have bolstered involvement in BC issues. Screening adherence may be improved through interventions aimed at maintaining high levels of issue involvement among women with a positive history of BC and at increasing levels of issue involvement among women with a negative BC family history by providing access to quality health information. Non-adherent women with a positive family history reported lower perceptions of severity than women with a negative family history, while perceptions of severity were similar for adherent women regardless of family history. Although this finding appears counterintuitive, it is possible that women with a positive family history are motivated by the threat of the loss of a loved one and the threat of developing BC, to reduce their perceptions of severity. This explanation fits with Taylor’s [46] theorizing on cognitive adjustment to threatening events; the real threat of loss and disease among women with a positive family history may motivate restoration of control through reduction in perceptions of BC severity [46]. It is also possible that women with a positive family history may have had prior experiences with family members who had BC that did not result in death or disfigurement, thereby reducing perceptions of severity. Administration of the health belief questionnaire to both compliant and non-compliant women who have had a previous mammogram serves at least two purposes: (1) it acknowledges the importance of understanding factors associated with return for mammography; and (2) it allows insight into the differences in women’s health beliefs as a function of their adherence with annual mammography screening recommendations. Based on theoretical insight from the decision-making literature, our expansion of this model to include salience of family history and issue involvement provides a more comprehensive picture of the health beliefs associated with women’s use of mammography. Examination of the differences in women’s health
beliefs as a function of their family history of BC addresses the lack of specific attention in previous research to the impact of family history of BC on health beliefs, and refines our understanding of how such factors relate to adherence. Our investigation’s attention to such differences highlights important avenues for evidence-based interventions.
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Health beliefs, salience of breast cancer family history, and involvement with breast cancer issues: adherence to annual mammography screening recommendations Lila J. Finney Rutten, Ph.D., MPH a,∗ , Ronald J. Iannotti, Ph.D. b a
Cancer Prevention Fellowship Program, Division of Cancer Prevention and the Division of Cancer Control and Population Sciences, National Cancer Institute, Department of Health and Human Services, 6130 Executive Blvd. Rm. 4051A MSC 7365, Bethesda, MD 20892-7326, USA b Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, Department of Health and Human Services, Bethesda, MD 20892-7326, USA Accepted 30 June 2003
Abstract Involvement in breast cancer (BC) issues, and the degree to which family history of BC influences perceived risk (salience of family history), have been proposed as additions to the Health Belief Model as applied to mammography adherence. Barriers and benefits of mammography, perceived susceptibility, severity, cues to action, salience of family history, and issue involvement with respect to BC were examined in adherent (n = 97) and non-adherent (n = 213) women. Adherent women with positive family histories reported greater benefits of mammography, greater response to cues to action, and higher salience of family history than women with negative family histories. Non-adherent women with positive family histories reported fewer benefits of mammography and greater issue involvement, and perceived BC as less severe than those with negative family histories. Benefits (OR = 1.51), susceptibility (OR = 1.41), issue involvement (OR = 1.59), severity (OR = 0.66), and cues to action (OR = 0.75) were significantly associated with adherence. Results have implications for evidence-based interventions. Published by Elsevier Ltd. on behalf of International Society for Preventive Oncology. Keywords: Patient adherence; Screening adherence; Reminder systems; Health belief model
1. Introduction The early detection of breast cancer (BC) through mammography screening is optimally effective when mammography is performed every 1–2 years. Current recommendations for mammography screening are every 1–2 years among women aged 40 and more [1–3]. Estimating the percentage of women who receive “regular” mammography screening in accordance with guidelines is complicated by both the nature of the sample and by how “regular” screening is defined [4]. Estimates from the 2000 National Health Interview Survey indicate that 70% of women aged 40 and more report having had a mammogram in the last 2 years [5]. Our investigation addresses the importance of regular screening through an examination of factors that affect adherence to annual mammography screening reminders among previously screened women. We compared factors associated with screening among adherent women (those ∗ Corresponding author. Tel.: +1-301-435-2842; fax: +1-301-480-2198. E-mail address: [email protected] (L.J. Finney Rutten).
who received a mammogram within 2 months of receiving a reminder letter) to factors associated with screening among non-adherent women (those who did not receive a mammogram within 2 months of receiving a reminder letter). Additionally, we examined the affect of family history of BC on relations between health beliefs and adherence. Prior investigations have not identified a clear association between positive family history of breast cancer and actual, self-reported, or intended screening adherence [6–15]. Although differences in the beliefs and behaviors of women with positive and negative family histories have been explored, this research focused on risk perceptions or concerns about mammography screening, and did not examine other potentially relevant health beliefs [10]. The inconsistent pattern of association between screening adherence and family history identified in past research, coupled with the scarcity of research focusing on differences in health beliefs among women with positive and negative BC histories, signal the need to explore women’s health beliefs regarding mammography and BC as a function of BC family history. Our investigation addresses this gap in previous research
0361-090X/$30.00 Published by Elsevier Ltd. on behalf of International Society for Preventive Oncology. doi:10.1016/S0361-090X(03)00133-8
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by examining differences in women’s health beliefs as a function of family history of BC. The Health Belief Model (HBM), first developed to guide research on utilization of medical screening programs [16], has been useful in conceptualizing a range of health behaviors [17–20]. Dimensions of the HBM include: benefits of recommended health actions, barriers to recommended health actions, susceptibility to developing disease, severity of disease, and cues to action that prompt recommended health actions. The application of the HBM to screening behaviors such as mammography, breast self-examination, and clinical breast examination in previous research attest to its appropriateness in assessing mammography screening [21–25]. In a previous study, we expanded the HBM to include issue involvement (degree of involvement in BC issues) and salience of BC family history (extent to which concerns about BC are related to family history). Our decision to include issue involvement and salience of family history in the model was based on previous research which demonstrates that prior experience with an illness and the degree to which individuals are involved with a particular health issue may affect adherence with health recommendations [26,27]. In our previous work [28], we developed and evaluated a questionnaire to assess this expanded HBM. Although the instrument had good reliability and validity, the sample in which it was evaluated included only adherent women; therefore, the relationship to mammography adherence could not be examined. In the current investigation, we use this expanded HBM to replicate and extend our earlier work. Specifically, we assessed the association of the components of the expanded HBM with adherence to annual mammography screening reminders, and explored differences in health beliefs as a function of adherence and BC family history. 2. Method 2.1. Sample Participants were recruited from a pool of women due for annual mammography from December 1999 through September 2000. Women selected for inclusion met the following criteria: (1) age at least 40 years, (2) recommended frequency of mammography no more than annual, (3) no previous BC diagnosis, (4) at least one prior mammogram at the facility, (5) records containing BC family history, and (6) non-Medicaid or non-Medicare status. We distributed the questionnaire in a small, not-for-profit hospital that provides care for primarily rural areas in Butler and Preble counties in Ohio, and in Franklin, Union, and Fayette counties in Indiana. Each month, we identified women in the patient database who were due for annual screening. Reminder letters were sent out to women 1 week prior to the month during which the recommended screening was due. We inserted packets containing the health
belief questionnaire into the mammography files of identified women. Upon arrival in the screening center for their appointments, women whose files contained a questionnaire were asked if they would be interested in completing the questionnaire. Women who agreed to participate received a packet containing a consent form and the questionnaire. We mailed the questionnaire to women who did not attend appointments within the 2 months following mailing of the reminder letters. Consent from women who were mailed the questionnaire was implied by return of completed questionnaires. The research protocol was approved by the Institutional Committee on the Use of Human Subjects in Research at Miami University in Oxford, Ohio, and by the participating hospital’s review board. 2.2. Measures The questionnaire, which we developed and tested in a previous investigation [28], was used to assess the following health beliefs: perceptions of the barriers and benefits of mammography, susceptibility to developing BC, severity of BC, cues to action that prompt screening participation, salience of family history of BC, and involvement in BC issues. A total of 45 items, assessed on 7-point Likert scales were included in the questionnaire to assess health beliefs. Each point on the Likert scale was associated with a response ranging from “completely disagree” to “completely agree” or “extremely unlikely” to “extremely likely.” Higher ranking on the Likert scale indicates greater agreement with the health beliefs that were assessed (e.g. a higher barrier score indicates greater perception of barriers). Individual questionnaire items were combined into scales for each health belief component by averaging responses. Details on individual items and scale development are published elsewhere [28]. We made minor changes to the original questionnaire: (1) we combined two apparently redundant cues to action items regarding the influence of television and newspapers on mammography decisions into one item assessing media influence; (2) content analysis suggested that the issue involvement item assessing the frequency of worrying about developing BC was conceptually distinct from the other issue involvement items; so we dropped this item; (3) we dropped the question about family income because participants in our previous study were resistant to this item; (4) we reworded the cues to action items in the mailed questionnaires to be appropriate to the non-adherent status of these respondents; for example, the item “Encouragement from family influenced my decision to obtain a mammogram” was reworded as “Encouragement from family influences whether I obtain a mammogram.” All questionnaire items and instructions were assessed to be at or below the ninth-grade reading level using Microsoft Word’s (version 1997) readability statistics algorithm. Family history of BC was determined by self-report in response to the question “Has any one in your family had breast cancer?” Respondents who selected a “yes” response
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were classified as having a positive family history of BC. For a subset of women (n = 87), we validated self-reported family history with patient records, which defined family history as having at least one blood relative diagnosed with BC. The resulting correlation was quite high (r = 0.85). The two additions to the HBM were salience of family history and issue involvement. Salience of family history items assessed the extent to which a woman’s concerns about BC were related to her family history. The issue involvement scale assessed involvement in information gathering and BC awareness activities. Sociodemographic characteristics were also assessed. The questionnaire took approximately 10 min to complete. 2.3. Analyses conducted We calculated Spearman’s correlations to examine the association of mammography adherence with sociodemographic variables, HBM components, salience of family history, and BC issue involvement. For both adherent and non-adherent women, we conducted a series of t-tests to examine differences in health beliefs between women with positive and negative BC family histories. We conducted a logistic regression to assess the extent to which sociodemographic factors, HBM components, issue involvement, and salience of family BC history predicted adherence with mammography screening reminders. 3. Results
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mailing of the reminder letters. Examination of adherence among women due for mammography during the first month that the questionnaire was administered revealed an adherence rate of 29% at 1 month and 45% at 1.5 months; however, the adherence rate increased to only 47% at 2 months. On the basis of the small increase in adherence from the 1.5to 2-month endpoints, a 2-month cutoff was designated for documenting adherence to reminder letters. 3.3. Predictor variables 3.3.1. Sociodemographic variables The sample included primarily middle-aged, Caucasian married women with employment outside of the home and high levels of education. The small number of minority women included in the sample precludes generalization of the results to minority populations. Sample distributions were similar for adherent and non-adherent women (Table 1). 3.3.2. Health belief variables, salience of family history, and issue involvement In our prior use of this questionnaire, individual questionnaire items assessing the HBM components were averaged to create scales for each health belief component [28]. We used the same scales in this investigation. The internal reliability of these scales was assessed with Cronbach’s alpha, which measures how well sets of items or variables cohere as a single, unidimensional measure. With the exception of
3.1. Response rate
Table 1 Sociodemographic characteristics of the sample
Among the 929 women who were due for annual mammography screening, 888 were given the opportunity to complete the health belief questionnaire. A total of 41 women were not asked to participate for the following reasons: missing patient files (n = 6); failure to mail out the questionnaire (n = 12); conflict of interest with the hospital (n = 2); and returned delivery from the United States Postal Service (n = 21). Among the 888 women asked to complete the questionnaire, 315 consented to participate, resulting in an overall response rate of 35%. Among compliant women (n = 391), 97 (25%) consented to complete the questionnaire. Among the non-compliant women (n = 538), 213 (40%) women consented to complete the questionnaire. Among those women who completed the questionnaire, 42% (n = 126) reported a positive family history of BC and 55.3% (n = 166) reported a negative family history. Seven participants indicated that they did not know their family history and were therefore excluded from analyses involving family history.
Sociodemographic factors
Adherent
Non-adherent
n (%)
n (%)
Age 40–49 50–59 60–69
31 (35.6) 43 (49.4) 13 (14.9)
83 (39.0) 89 (41.8) 41 (19.2)
Race Caucasian Minority
80 (94.1) 5 (5.9)
198 (93.0) 15 (7.0)
Education Less than high school High school graduate Some college/technical school College graduate Graduate school/advanced degree
6 25 17 22 17
Marital status Married Not married
73 (83.9) 14 (16.1)
174 (81.7) 39 (18.3)
3.2. Outcome variable
Employment Full-time Part-time Not employed
53 (60.9) 17 (19.5) 17 (19.5)
121 (57.1) 34 (16.0) 57 (26.9)
Adherence was based on chart documentation and defined as having a mammogram within the 2 months following
Note: Due to missing data, all n’s do not sum to total sample size (n = 300).
(6.9) (28.7) (19.5) (25.3) (19.5)
17 73 51 36 36
(8.0) (34.3) (23.9) (16.9) (16.9)
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Table 2 Reliability of health belief scales Health belief
No. of items
Cronbach’s alpha
Barriers Benefits Susceptibility Severity Cues to action Salience of family history Issue involvement
14 7 3 2 13 2 3
0.77 0.88 0.77 0.42 0.87 0.76 0.76
Table 4 Mean Likert-scale rating (S.D.) of health beliefs for adherent and non-adherent women with positive and negative family histories of breast cancer
Barrier Benefit Susceptibility
Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent Adherent Non-adherent
the severity scale, the reliability of these scales was confirmed in the present investigation (Table 2). Low reliability in measures of severity has been evidenced in previous applications of the HBM to mammography screening and likely reflects high consistency in perceptions of BC severity [20,25,29,30].
Severity
3.3.3. Association of screening adherence with sociodemographic factors None of the sociodemographic variables were significant predictors of adherence. Although previous investigations have found an association between sociodemographic factors and screening adherence, the sample in our investigation was homogenous, limiting the ability to detect significant associations [31–36].
Note: History (Hx ).
3.4. Association of screening adherence with HBM components, salience of family history, and issue involvement Several of the scaled components of the HBM were significantly associated with adherence (Table 3). Greater perceptions of barriers and severity, and greater endorsement of cues to action were negatively associated with adherence. Greater belief in the benefits of mammography and greater issue involvement were positively associated with adherence. 3.4.1. Differences among women with positive and negative family histories of breast cancer Significant differences in the mean of the 7-point Likert-scale rating of the HBM components were identified Table 3 Correlation of screening adherence with HBM components, salience of family history and issue involvement Health belief
r
P-value
Barriers Benefits Susceptibility Severity Cues to action Salience of family history Issue involvement
−0.22 0.21 0.09 −0.13 −0.19 −0.05 0.25
0.000 0.000 0.13 0.02 0.001 0.38 0.000
Cue to act Salience family Hx Issue involvement
Positive Hx
Negative Hx
Mean (SD)
Mean (SD)
2.4 2.5 6.4 6.0 4.2 4.0 4.7 4.9 4.1 4.2 5.0 4.6 4.4 3.9
2.3 2.8 6.2 6.0 3.1 3.1 4.9 5.2 3.4 4.2 2.1 3.1 4.2 3.5
(0.63) (0.83) (0.47) (0.74) (1.1) (1.2) (1.0) (1.1) (1.1) (1.2) (1.8) (1.8) (1.1) (1.2)
(0.64) (0.83) (0.90) (0.83) (1.2) (0.95) (1.0) (0.90) (0.93) (1.2) (0.94) (1.5) (1.1) (1.3)
P-value
0.51 0.03 0.09 0.78 0.000 0.000 0.49 0.05 0.003 0.96 0.000 0.000 0.39 0.01
between women with positive and negative family histories of BC (Table 4). For all women with a positive family history, whether adherent or non-adherent, perceived susceptibility and salience of family history were higher compared with women with a negative family history. Women with a positive family history who were adherent perceived greater benefits of mammography (marginal) and reported greater response to cues to action than women with a negative family history who were adherent. Women with a positive family history who were non-adherent perceived fewer barriers to mammography, perceived BC as less severe, and showed greater issue involvement than those with a negative family history who were non-adherent. 3.4.2. Health belief predictors of mammography Sociodemographic variables assessed included age, race/ethnicity, education, marital status, and employment. None of the sociodemographic factors were significantly associated with adherence in the logistic regression analysis. The regression model predicting mammography adherence from barriers, benefits, susceptibility, severity, cues to action, issue involvement, and salience of family history was statistically reliable (χ2 (7, N = 297) = 50.73, P < 0.001). Adherence was associated with greater perceptions of the Table 5 Predictors of mammography adherence Health belief
Odds ratio
95% CI
Barrier Benefit Susceptibility Severity Cue to act Salience of family history Issue involvement
0.79 1.51 1.41 0.66 0.75 0.83 1.59
(0.52, (1.02, (1.05, (0.49, (0.57, (0.68, (1.24,
Note: χ2 (7, N = 297) = 50.73.
1.18) 2.24) 1.89) 0.90) 0.97) 1.01) 2.03)
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benefits of mammography, higher perceived susceptibility to developing BC, greater issue involvement, lower perceived severity and lower response to cues to action (Table 5). Neither barriers nor salience of family history were significantly associated with adherence. 4. Discussion 4.1. Limitations Although the response rate among non-compliant women (40%) is consistent with response rates for mailed surveys, the response rate among compliant women who were asked to complete the questionnaire during their appointment is low (25%). The participating clinic makes a concerted effort to deliver care efficiently, and the low response rate reflects the limited time that women had to complete the questionnaire during their appointments. Participating staff members were trained in a specific protocol for soliciting participation, and periodic checks were made by the director of screening and the first author to ensure protocol adherence. Despite these measures, time limitations were apparently prohibitive. The low response rates obtained may limit the generalizability of the reported findings. Compounding this drawback is the unavailability of data pertaining to the characteristics of women who chose not to respond to the questionnaire versus those who completed the questionnaire. 4.2. Implications for intervention Consistent with previous research, greater barrier perception was associated with lower adherence [37–39]. Key barriers to adherence included concerns about the discomfort of mammography, being too busy to schedule a mammogram, and not thinking about having a mammogram. Efforts to address these barriers must focus on decreasing the discomfort of screening, providing convenient screening hours and locations, and implementing effective reminder systems. Attempts to decrease the discomfort of mammography may involve patient education efforts to inform women of the best times during her menstrual cycle to schedule a mammogram to avoid unnecessary discomfort. Additionally, refinement of current breast screening technology, and development and evaluation of alternative imaging technology, may provide more comfortable alternatives to mammography. Efforts should be made to improve the convenience of mammography screening. Mobile mammography vans, work site screening, and convenient screening hours, such as nights or weekends, may allow women facing multiple time demands to more easily obtain regular screening mammograms [40]. Finally, the use of patient reminder systems such as letters and phone calls appears to be an effective route for prompting women to schedule their annual screening mammogram.
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As expected, greater agreement with the benefits of mammography was significantly associated with adherence [37,41]. The benefits associated with adherence included having a mammogram as a usual part of one’s health exams, and believing that mammography increases peace of mind, sense of control, and lifespan. Inclusion of mammography as part of regular health exams may improve screening adherence. In fact, capitalizing on contact with the medical system by offering multiple services during each patient visit may improve adherence with a range of early detection behaviors. The negative association found between severity and adherence is inconsistent with the HBM. The average severity score was quite high (M = 4.99 on a 7-point scale); thus, the negative association between severity and adherence may be explained by previous research which suggests that low or moderate judgments of severity may be associated with higher adherence, while higher judgments of severity may be associated with lower adherence [17]. This finding implies that communication regarding the severity of BC should be tempered with the benefits of early detection and opportunities for engaging in early detection. Greater endorsement of cues to action was associated with lower adherence. This finding is inconsistent with previous investigations which have identified a positive association between response to cues to action and adherence with health recommendations [30,38,39]. This unexpected finding likely reflects the different wording of the cue to action items on the questionnaires completed by compliant and non-compliant women. Non-compliant women were possibly trying to imagine if the given cue would prompt them to engage in mammography, while compliant women likely assessed which cues to action items actually prompted them to attend their appointment. Further inspection of the data supports this explanation; modal responses to the cue to action items suggested that non-adherent women were endorsing more cues to action items overall than adherent women. Generally, both adherent and non-adherent women cited physician recommendation and reminder letters from a screening center as key cues to action. In this atmosphere of controversy surrounding screening recommendations, patients may rely more heavily upon the clinical judgment of their personal physicians in referral for mammography screening. Although physician recommendation has been demonstrated to be an important predictor of mammography screening, research has shown that many physicians do not adhere to recommendations in referral of patients for mammography screening [42–44]. Thus, continued effort to encourage physicians to recommend screening procedures is critical for increasing mammography screening. Consistent with predictions derived from previous investigations [26,27], adherence was significantly associated with greater issue involvement. Reading articles about BC and involvement in awareness or fund-raising activities for BC were associated with adherence. Opportunities for accessing information about BC have increased dramatically with the availability of such information on the World Wide Web
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(WWW). In addition to WWW applications, efforts to increase screening and preventive behavior may also involve the implementation of interactive health communication applications at screening centers and hospitals [45]. Differences in health beliefs between women with positive and those with negative BC family histories were identified, replicating and expanding previous findings [28]. Among both adherent and non-adherent women, those with positive BC family histories judged themselves to be significantly more susceptible to developing BC than women with negative family histories, suggesting that women with negative family histories perceive themselves to be at less risk for developing BC. This finding, in light of the fact that only 10% of breast cancers are thought to be hereditary [1], affirms the importance of stressing screening adherence among women with negative family histories of BC. For both adherent and non-adherent women, those with a positive family history of BC reported significantly higher salience of family history and issue involvement than women with a negative family history. Having a positive family history of BC appears to have bolstered involvement in BC issues. Screening adherence may be improved through interventions aimed at maintaining high levels of issue involvement among women with a positive history of BC and at increasing levels of issue involvement among women with a negative BC family history by providing access to quality health information. Non-adherent women with a positive family history reported lower perceptions of severity than women with a negative family history, while perceptions of severity were similar for adherent women regardless of family history. Although this finding appears counterintuitive, it is possible that women with a positive family history are motivated by the threat of the loss of a loved one and the threat of developing BC, to reduce their perceptions of severity. This explanation fits with Taylor’s [46] theorizing on cognitive adjustment to threatening events; the real threat of loss and disease among women with a positive family history may motivate restoration of control through reduction in perceptions of BC severity [46]. It is also possible that women with a positive family history may have had prior experiences with family members who had BC that did not result in death or disfigurement, thereby reducing perceptions of severity. Administration of the health belief questionnaire to both compliant and non-compliant women who have had a previous mammogram serves at least two purposes: (1) it acknowledges the importance of understanding factors associated with return for mammography; and (2) it allows insight into the differences in women’s health beliefs as a function of their adherence with annual mammography screening recommendations. Based on theoretical insight from the decision-making literature, our expansion of this model to include salience of family history and issue involvement provides a more comprehensive picture of the health beliefs associated with women’s use of mammography. Examination of the differences in women’s health
beliefs as a function of their family history of BC addresses the lack of specific attention in previous research to the impact of family history of BC on health beliefs, and refines our understanding of how such factors relate to adherence. Our investigation’s attention to such differences highlights important avenues for evidence-based interventions.
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