Health beliefs and self breast examination in black women
Mary Ella Graham
Abstract: The relationship between health beliefs and practice of breast self examination (BSE) in a sample of 179 black women, 20 to 49 years of age, was investigated., Health beliefs were operationalized by employing Champion’s revised Health Belief Model Scale (1993) to collect data. Data analyses included multiple regression analysis to examine BSE behavior in relation to selected demographic attributes and health beliefs. Results indicated that health beliefs were much stronger in determining BSE performance for a given individual than were demographic characteristics. The frequency of BSE was related to increased perceived seriousness of breast cancer, benefits of BSE, and health motivation. Frequency of BSE was inversely related to perceived barriers.
Key Words: Self Breast Examination, Black Women’s Health,
Breast cancer is one of the most common types of cancer affecting women today, accounting for one of every three cancer diagnoses in the United States (American Cancer Society [ACS], 1997-1998; Parker, Tong, Bolden, & Wingo, 1997). In 1998, over 180,000 new cases of invasive breast cancer among American women were predicted to be diagnosed-and approximately 44,00O women, or one fourth, were expected to die (Parker et al., 1997). Over the past 20 years, breast cancer incidence trends have shown a gradual increase between 1973 and 1982 and a period of more rapid increase between 1982 and 1987 (ACS, 1996). Since 1990, the overall incidence rates appear to have stabilized. Stabilization is believed to be related to the use of breast cancer screening methods (ACS, 1997-1998). Although population-based data show that white women are affected by breast cancer at a 20% higher rate than black women, the reverse is true for women younger than 40 with black women affected 10 to 40 percent more than whites (Lazzaro, Mitzell, Thompson, & Weber, 1998).
There has been an increase in the incidence rates of breast cancer for black and white women alike and a decline in the mortality rate for both races. This decline is more pronounced in whites (Ries, Kosary, Hankey, Miller et al., 1997; ACS 1997-1998; Miller, KoloneI, Bernstein, Young, Swanson, West, Key, Lift, Glover, Alexander et al., 1996). Between 1990-1994, the mortality rates in white women decreased 6.1%, compared to a decrease of 1% in black women. Black women have the highest mortality rates in the age groups 30-54 years and 55-69 years (CancerNet, 2001). The current five year survival rate is only 70% in black women compared to 86% in white women (ACS, 1997-1998). This may be directly related to early detection in white women and the exhibition to a more aggressive tumor in African-American women making treatment outcomes more problematic (Eley, Hill, Chen, Austin, Wesley, Muss, et al., 1994; CancerNet, 2001). Experts attribute the racial difference in survival rates (89.6% for stage I) to early detection practices adopted by white women as opposed to biological difference (ACS, 1997-1998).
The literature offers evidence that there is an association between regular BSE and more favorable clinical and pathological stages of disease. The 5-year survival rate for localized breast cancer has increased from 72% in the 1940s to 97% in the 1990s, if detected early by BSE or mammogram (ACS, 1997-1998). Approximately 70% of all breast masses are self-detected, yet many women fail to carry out this important monthly practice (Dondero & Lichtman, 1990).
Black women are less likely to perform BSE than white women. Nemcek (1989).
The purpose of this research was to examine the relationships between health beliefs of black women and BSE. The influences of selected demographic attributes on BSE were also explored: age, family history of breast cancer, religion, and highest education level attained.
Four hypotheses were formulated.
1 Perceived seriousness or threat of breast cancer: subjects who perceive a higher level of threat will report a higher frequency of BSE performance.
2 Perceived benefits of BSE: subjects who perceive greater benefit from BSE performance will report a higher frequency of BSE performance.
3 Perceived barriers or negative aspects of BSE: subjects who perceive greater barriers will report a lower frequency of BSE performance.
4 Perceived health motivation or belief that practice will improve health: subjects who report a higher frequency in engaging in health promoting activities will report a higher frequency of BSE.
Becker’s revised Health Belief Model, 1974 (HBM) provided the theoretical framework for this research. While the model is used to explain self-care activities, it has a focus on behavior related to the prevention of disease, Becker, (1974); Rosenstock, (1974). The original concepts of Becker’s HBM were perceived seriousness, perceived susceptibility, perceived benefits and perceived barriers. Becker modified this model adding the concept of health motivation. The foundation of the HBM is that individuals will take action to prevent, control, or treat a health problem if they: perceive the problem to be severe in nature; perceive the action they will take to have some benefit in producing favorable outcomes; and if they perceive few barriers to taking a particular action (Stout, 1997). The following concepts were considered predictors of the health behavior of BSE:
* Perceived seriousness–how threatening the condition/disease is viewed, that is, having at least moderate severity on her lifestyle, in order to practice BSE. According to the HBM a woman’s emotions and beliefs about breast cancer may interfere with her perception of the degree of seriousness, thereby affecting her performance or practice of BSE.
* Perceived benefits–the degree to which one believes taking a specific action to prevent a condition will be useful. The more beneficial one believes a behavior to be, the more it will be practiced. The norms and pressures within one’s social group may influence perceived health beliefs.
* Perceived barriers–aspects that inhibit the performance of BSE. The more barriers perceived with performing BSE the less frequently it will be performed. Barriers associated with BSE are inconvenience, pain, fear of finding a lump, and embarrassment.
* Health motivation–A cue, or cues, to action that promote the decision making to perform BSE. Media reports about preventing breast cancer, illness of a family member, and perceived benefits are examples of cues.
There are also modifying factors influencing BSE. These include age, gender, socioeconomic status, education, previous experience with the disease and known risk factors, such as heredity and race.
REVIEW OF THE LITERATURE
Studies exploring the relationship between health beliefs, health behavior, and the performance of BSE are reported by Barron, Houfek and Foxal (1997), Champion (1984, 1988), Nemcek (1990), Sensiba and Stewart (1995), and Wyper (1990). Self-concept, locus and of control and self concept were investigated in relation to BSE by Glenn and Moore, (1990), and Nemcek, (1990). Two studies were reviewed that examined racial differences in preventive health behavior including breast screening behaviors. Friedman, Webb, Weinberg, Lane, Cooper, & Woodruff, (1995); Gray, (1990) examined the influence of demographic variables and the frequency of BSE.
Health beliefs and BSE: Champion (1984) investigated the relationship between HBM variables and frequency BSE in 301 women. The variables of being younger, coming from. a higher socioeconomic status, and educated at a higher level did not influence the number of times women performed BSE. In a later study Champion (1988) conducted a correlation study to identify attitudinal variables related to older women’s (over 35 years of age) intentions and actual performance of BSE. A probability sample of 380 women was included. Champion reported that participants felt moderately susceptible to breast cancer but rated perceived seriousness, benefits, health motivation, and confidence as high. In addition, most participants reported relatively few perceived barriers. Only 27.9 of her sample reported performing BSE at least every month.
Wyper (1990) studied 202 women employing Champion’s Health Belief Model Scale (1984). The frequency of BSE reported were: at least once a month (45%), less often than once a month (41%), or never (14%).
Nemcek’s (1990) research was designed to determine the existence of a relationship among the frequency of BSE, health beliefs, health locus of control, and health value of 95 black women using the HBM. There were no significant associations between frequency of BSE, perceived barriers and locus of control.
Sensiba and Stewart (1995) examined perceived barriers to BSE. Based on a sample of 374 women, they concluded that while there was no relationship between age or educational level and frequency of BSE, perceptual differences in individual barrier items existed among different age and education groups. Middle age women expressed greater fear of finding a lump than women of younger or older age groups. Older women were least afraid and highly educated women showed less fear of finding a lump but were more apt to forget to do BSE.
Barron, Houfek, and Foxal (1997), investigated coping styles in 269 women’s practice of BSE.They reported that coping style (categorized by level of anxiety) predicted proficiency and frequency of BSE. Benefits, general motivation, health information, beliefs of barriers, confidence, seriousness and susceptibility were not predictors of BSE. A significant finding is that “perceived barriers’ was the most consistent health belief concept related to BSE.
Self-concept, locus of control and self concept: Glenn and Moore (1990), investigated the relationship between a woman’s practice of BSE, self-concept, locus of control, and knowledge of treatment options. In a convenience sample of 311 women (ages 20-75) subjects who practiced BSE more frequently had a higher self-concept and were more aware of breast cancer treatment options.
Racial differences in preventive health behaviors: Gray (1990) in a study of 347 women reported non-significant association between demographic variables and the frequency of BSE.
Friedman et al. (1995) examined racial and ethnic differences in breast cancer screening behaviors of 259 asymptomatic women, 50 years of age or older. Findings of this study conclude that Hispanics were more likely than African-Americans to report having a mammography in the preceding year. Whites and Hispanics were more likely than African Americans to having had a clinical breast examination. Friedman et al., also reported that African-Americans and Hispanics were more likely than Caucasians to practice monthly breast-self examination. This last finding is quite different than the result in Nemcek’s study. Friedman et al. further noted that African-American women were more likely to report cancer-related fears or worries as barriers to mammography. Caucasian were more likely to report being too busy or inconvenienced.
According to the literature factors that contribute to BSE are education, attitude, and beliefs.
Based on a limited number of studies, there are some relationships between the Health Belief Model (HBM) and frequency of BSE. These relationships are usually not very strong. Given the mortality rate of black women with breast cancer, health beliefs and the practice of BSE by black women warrant further study.
A descriptive correlation design was employed. Health beliefs were operationalized by participants’ responses to Champion’s revised Health Belief Survey (1993).
The Institutional Review Board of a major teaching hospital in New York City granted approval for this study. Informed consent was obtained and participants were assured confidentiality of responses. One-hundred seventy-nine participants were recruited from the hospital, churches and health fairs. Participation meant responding both to Champion’s Health Belief Survey and to a short questionnaire soliciting demographic information Data were collected, by the researchers, while subjects were waiting for a scheduled appointment with a physician and during the time they were in a community setting such as a senior citizen’s center.
Health beliefs were viewed as the extent to which personal behavior is affected by one’s perceived seriousness of disease, benefits from behaviors, barriers against performance of behaviors, and health motivation. Champion’s (1993) revised Health Belief Model Scale (HBMS) consists of 29 items to measure these four concepts. Each concept was measured in a distinct sub-scale. The four sub-scales consist of six to seven items each. Items for each sub-scale are arranged on a 5 point Likert-type scale with “5” indicating strongly agree and “1” indicating strongly disagree. Respondents are also requested to indicate the frequency in which they performed BSE.. Additional items were designed to identify the demographics of study participants.
Reliability and Validity
Champion (1993) reports a high internal consistency with Chronbach alpha coefficients for the revised scales ranging from .80 to .88 and test-retest correlations ranging from .45 to .67. In this current research the Chronbach alpha coefficients ranged from .62 to .86. Refer to Table 1
A convenience sample of 179 black women was recruited from a major teaching hospital in New York City, and from community settings as churches and health fairs. Criteria for sample selection included the ability to respond to the questionnaire by reading and writing English and being between 20 to 49 years old. Although Cohen’s power analysis called for a sample size of 88 subjects, a larger sample was recruited to ensure adequate representation of the population.
Demographic data collected information about: age, national background, highest education level attained, religion, and family history of breast cancer. Thirty-eight (21%) women were under 27 years of age; Fifty-seven (32 %) were between the ages of 27 and 34 years old; and eighty-four (47 %) were over the age of 34 years. Eighty-two women were African-Americans (46%), 14 were Jamaican (8%), 10 were Haitian (6%), and 9 were Guyanese (5%). The remaining 64 (36%) of respondents reported other countries as their place of origin. Slightly more than one-half (54.6%) of participants were not born in the U.S.
The majority (n=100, 53%) were educated at a technical institution or at the college level. Another 17% attended graduate school. Seventy-four percent of participants associated themselves with some religion; the rest indicated “none” or “no denomination.” Eight respondents reported a family history of breast cancer.
DATA ANALYSIS AND RESULTS
Mean scores were obtained for each item on the four scales. Refer to Table 2 for examples of scores on selected items, the composite mean, and the standard deviation for each of the four sub-scales. Multiple regression analysis were calculated by examining demographic attributes, health related beliefs and the behavioral outcome of BSE. The stepwise procedure was used entering each item for each sub-scale one at a time in the regression analysis.
Seriousness: There are 7 items on the seriousness sub-scale. It appeared that BSE is influenced by the extent to which the average respondent perceived the threat of risk and that older women take this matter more seriously. However, once age was statistically controlled the mean response to one item was consistent with the research hypothesis, whereas the mean response to two other items contradicted the hypothesis. The item consistent with the research hypothesis (r=.08) is “when I think about breast cancer my heart beats faster.” The responses to the other two items, “if I developed breast cancer, I would not liver than 5 years” and “if I had breast cancer my whole life would change” contradicted the hypothesis. Eighty percent of the sample agreed with the statement “The thought of breast cancer scares me.” More than 60% disagreed with the item “If I had breast cancer my whole life would change.” The response distribution centered around the midpoint or neutral category with respect to the remaining items.
Benefits: Based on the six items on the benefit subscale there was a statistically significant relationship (p<.02). This hypothesis was supported. None of the background variables contributed to the relationship between BSE performance and perceived benefits. Three items emerged as being significantly related to BSE. These were: when I do breast self-examination I feel good about myself", "when I complete monthly breast self-examination I don't worry as much about breast cancer , and "if I complete breast self-examination monthly I will decrease my chances of requiring radical or disfiguring surgery if breast cancer occurs. For four of the six items, there was a high degree of consensus. Over 90% of respondents agreed with the statement "completing BSE each month will allow me to find lumps early . Eighty-four percent agreed with the statement If I complete monthly BSE it will help me to find a lump which might be cancer before it is detected by a doctor or nurse."
Barriers: Three of six items on this sub-scale emerged as making significant unique contributions to BSE. The mean response to two items support the research hypotheses one does not. The two items supporting the research hypothesis were: “doing breast self-examination during the next year will make me worry about breast cancer”, and “doing, breast self-examination will take too much time The one item that does not support the hypothesis was” I don’t have enough privacy to do breast self-examination. There was high degree of consensus toward the “disagree” end of the response scale.
Health Motivation: Two background variables in combination with only one health motivation item emerged as significant predictors of BSE performance (age and place of origin, Guyanese) p>.05. Of the 7 items on the health motivation subscale there was a direct relationship between those who agreed with the statement “I have regular health check-ups when I am not sick” and BSE performance. The majority of respondents agreed with such principles as the importance of discovering, health problems early, maintaining good health getting updated information, and the importance of engaging in healthful activities. BSE Performance. The single outcome measure in this study is the extent to which respondent self-reported engaging in breast self-examination. The response scale offered 7 choices (1 for more than once per month to 7 for never) in relation to the question “How often do you examine your breast?” The resulting distribution had two peaks, one at each end of the scale. Forty-four percent indicated every month or frequently and 28% indicated less than every six months or never. Each of the three middle frequency categories were selected by 10% or fewer of the respondents. In order to make the response distribution of the dependent variable more normal in shape, the 7 categories were reduced to 5 with the three middle categories collapsed into one. The response poles were reversed, as well, instead of having “more than once per month” and “never” coded as 1 and 7 respectively as they were in the original scale, they were recoded as 6 and 1 respectively to reflect a higher number associated with higher BSE performance as shown in Table 3.
The regression analyses that there was a relationship between health beliefs and BSE among black women, and that the health belief frame of reference is much stronger in determining BSE performance for a given individual than background characteristics which corroborates the study of Sensiba and Stewart (1995).
With respect to the research hypotheses the study produced mixed results. When the composite score for each sub-scale was taken into account little of the variance was explained for predicting BSE. The use of multiple regression enabled explanation of a greater percentage of the variance being accounted for when individual scale items were used. The role of two demographic variables contributed to BSE. Age was directly related to BSE performance within the context of perceived seriousness. Age and having been born in Guyana within the context of health motivation were related to BSE. The fact that black women over the age of 40 may perceive a greater threat and be more motivated than women under age 30 makes sense. Respondents born in Guyana were more health motivated than others, but the variable revealed no relationship to BSE performance.
IMPLICATIONS FOR PRACTICE
The results from this and other studies indicate that although women perform BSE, many still fail to follow ACS guidelines, while others fail to perform this task altogether. Less than half (44.1%) of the 179 women in this study examined their breasts once a month or more. There is a great need for ongoing study of health beliefs in black women and its effect on BSE. Women from different ethnic or cultural backgrounds view health differently and this must be taken into consideration. The degree to which an individual not born in the U.S. adheres to health beliefs of the so called “American culture” may depend on the degree of acculturation. Those who have not adapted to this culture may not adhere to many of the health practices. Nurses must have an understanding of the diversity of black women prerequisite to promoting successful interactions and educational programs.
Table 1: Alpha Coefficients for Five Sub-scales
Sub-scale Alpha coefficient
Health Motivation .68
Table 2: Number of Items, Composite Means, Composite Standard
Deviations, and Examples of Items in of Individual Sub-scales
(Perceived Seriousness, Benefits, Barriers and Health Motivation. *
Sub-scale Examples of Items
Seriousness “The thought of breast cancer scares me.”
“I would not live longer than 5 years.”
Benefits “When I do BSE I feel good about myself.”
“Completing BSE will allow me to find lumps early.”
Barriers “I feel funny doing BSE.”
“I don’t have enough privacy to do BSE.”
Health “I want to discover health problems early.”
Motivation “I feel it is important to improve health.”
Sub-scale Number Composite Composite Standard
of items mean ** Deviation ***
Seriousness 7 3.22 .73
Benefits 6 3.77 .54
Barriers 6 1.76 .66
Health 7 4.00 .54
* Some statements listed are shortened from those in the actual survey;
** mean calculated for all items on a specific subscale;
*** SD calculated for all items on a specific subscale.
Table 3: Revised Breast Self Examination Scale
Response Number Percent
Categories (N = 179)
Never 21 11.7%
Every 6 Months * 29 16.2%
2 to 6 months 50 27.9%
Every month 50 27.9%
Once Per Month 29 16.2%
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Mary Ella Graham, PhD, is Dean of the School of Nursing, Tennessee State University in Nashville, TN.
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