Differences in health and cultural beliefs by stage of mammography screening adoption in African American women

Abstract

Behavioral studies show that women's stage of readiness to adopt mammography screening affects their screening rates and that beliefs about breast cancer and screening affect stages of screening. The purposes of this study were to determine, first, the relationship between particular health and cultural beliefs and stage of mammography screening adoption in urban African American women, and second, whether demographic and experiential characteristics differed by stage. Data were analyzed from 344 low-income African American women nonadherent to mammography screening who participated in a 21-month trial to increase screening. At baseline, these women were randomized into 1 of 3 groups: tailored interactive computer instruction, targeted video, or usual care. Participants were categorized by stage of mammography screening adoption at 6 months as precontemplators (not planning to have a mammogram), contemplators (planning to have a mammogram), or actors (had received a mammogram). Although demographic and experiential variables did not differentiate stages of screening adoption at 6 months postintervention, some health and cultural beliefs were significantly different among groups. Actors were more preventive-health–oriented than precontemplators and had fewer barriers to screening than did contemplators. Precontemplators had more barriers, less self-efficacy, and greater discomfort with the mammography screening environment than did contemplators or actors. These results will be useful, not to change cultural beliefs, but to guide the design of health education messages appropriate to an individual's culture and health belief system. Cancer 2007. © 2006 American Cancer Society.

African American women continue to experience disparity in breast cancer survival. 1–5 Although the incidence of breast cancer is lower in this population than in Caucasians, African Americans are more likely be diagnosed with late-stage presentation of breast cancer, 6 and they have higher death rates than any other racial or ethnic group. 7 Poverty contributes to these problems, since breast cancer mortality rates are relatively higher for poorer communities, 8–11 and minorities are more likely to be poor and to lack health insurance than non-Hispanic whites. 4, 12

Although poorer survival may be partially explained by biological differences, decreased access to health care, and inequalities in treatment, 2, 13–15 personal beliefs about cancer and screening also may interfere with early detection of breast cancer. Behavioral studies show that women's stage of readiness for mammography screening affects their participation in screening. 16 These stages are based on the transtheoretical model (TTM) 17 and are conceptualized as follows 1: precontemplation (no previous mammogram and no plan to have one in the coming year) 2; relapse precontemplation (had 1 or more mammograms in the past and is off schedule, with no plan to have one within the coming year) 3; contemplation (no previous mammogram but plans to get one within the coming year) 4; relapse contemplation (had 1 or more mammograms in the past and is off schedule, with a plan to have one within the coming year); and 5 action (had 1 mammogram on schedule and is planning another one according to screening guidelines). 18–20

Specific health beliefs have been associated with various TTM stages. 21–28 In their study of low-income African American women, Champion and Springston 29 found that women's perceptions of breast cancer susceptibility and benefits of and barriers to screening were stage-specific. Women who were precontemplators perceived significantly fewer risks for developing breast cancer and fewer benefits of mammography screening than did women who were in contemplation, action, or relapse. Barriers were higher for precontemplators and contemplators and lowest for women in the action stage. Similar findings resulted from a study of predominately African American women by Skinner et al. 30 Precontemplators had the lowest perceived benefits and highest barriers scores. Breast cancer knowledge was also lowest in the precontemplation stage. Contemplators were most worried about finding a lump. Women in the action stage had the fewest perceived barriers.

In addition to perceived risk, benefits, and barriers, cultural beliefs among African American women have been related to screening. 31, 32 Identified beliefs include perceptions about cancer and screening, including fear of cancer discovery, doctors, or treatment 33–40; a fatalistic view about the inevitability of death once diagnosed 35, 41–49; and present time orientation in general and specific to preventive health practices as well as crisis orientation toward medical care. 43, 44, 50, 51 Investigators have identified common folk beliefs about causes of cancer in African Americans, such as that surgery spreads cancer and that cancer is caused by a bruise or sore. 45, 52–54 There is also a confidence in folk remedies and nontraditional cancer treatments, 55 and social networks, collectivism, and racial pride have been found to influence breast cancer health-seeking behavior. 36, 47, 50, 56

Religious beliefs have also been associated with health behavior in African American women, with some studies demonstrating that religiosity can be a positive influence on specific health perceptions and behaviors among older African American women. 57, 58 Other work has suggested that religious thought, experience, and faith may sustain an individual, giving meaning and hope in seemingly overwhelming circumstances. 59–62 Examples of these religious influences include aspects of religious coping and reframing of health problems, a belief that God is the controlling force in health, and the need for faith in the healing power of God.

Women vary in relation to stages of mammography behavior, and little is known about the relationships of health and cultural beliefs to stage of mammography screening readiness in African American women. Understanding these relationships will increase our ability to develop staged-based mammography screening messages that are specifically tailored to both health and cultural beliefs. The purpose of this study was to determine the relationship between specific health and cultural beliefs and stage of mammography screening adoption in low-income African American women. The research questions were as follows:

• 1
  Do health and cultural beliefs relevant to mammography differ among African American women by stage of mammography screening adoption (precontemplators, contemplators, and actors)?
• 2
  Are particular demographic and experiential variables related to stage of mammography adoption in an African American population?

MATERIALS AND METHODS

Theoretical Framework

For this study, we used a combination of theories and models to guide our investigation. As opposed to rigidly applying a single theory, Witte argues for integrating aspects of successful and well-tested theories to develop persuasive campaigns for altering behavior. 63 Our intervention framework used the extended parallel process model (EPPM), 64, 65 the health belief model (HBM), 66 the Giger and Davidhizer transcultural assessment model (GDTAM), 67 and the Transtheoretical Model (TTM) 17 to identify constructs relevant to low-income African American women (Fig. 1).

Figure 1. Theoretical framework.

The EPPM was developed by Witte to address characteristics of the person and situation that are linked to health screening behavior (perceived threat and efficacy) and incorporates an anxiety/fear response resulting from cancer fatalism relevant to low-income African American women. The HBM identifies threat as a combination of perceived susceptibility and perceived severity. In the case of breast cancer, perceived seriousness is usually dropped because breast cancer is universally perceived as serious. Additionally, the HBM proposes that perceived benefits and barriers to an action influence behavior. The concepts of threat and response efficacy within the EPPM are analogous to the susceptibility and benefits concepts in the HBM. Self-efficacy (one's belief in one's ability to carry out an action) was incorporated in the HBM in 1988 and has been shown to relate to mammography screening behavior. Barriers are not specifically addressed in the EPPM, but past research has demonstrated their relevance to mammography screening. Cancer fatalism, as identified by Powe, 68 was included as a component separate from benefits.

To assess the relationships between cultural beliefs and health behavior, we used specific constructs from the GDTAM. These constructs were space and time orientation as well as social organization. For this study, space was conceptualized as personal space or the woman's sensory perceptions about the proximity and movement of objects within the physical space relative to her body during the mammography screening procedure. Time was conceptualized in terms of preventive health orientation or beliefs about the value of present- and future-time-oriented health practices. The social organization construct included the effect of religious beliefs learned through interaction with religious groups. Religious beliefs have been found to be an important dimension of African American breast cancer screening behavior and beliefs about cancer treatment. 47, 50, 54, 56, 58, 69–71

Stage constructs from the TTM were used for measuring the study outcome variable. As described, this model posits that health behavior change includes a series of stages defined by whether individuals have engaged in the behavior in the past and their intention to do so in the future.

Sample

Data came from a sample of African American women who were enrolled in a 21-month randomized controlled trial of mammography screening interventions tailored on health beliefs (Champion and coworkers, unpublished data). For this article, we will report beliefs and stage data at 6 months postintervention. Inclusion criteria included not having had a mammogram within the last 18 months, being 41–75 years old, and living at 175% of poverty level or lower. Women were excluded if they reported a history of breast cancer. Participants were accrued from community-based organizations and events, including multiservice centers, community health centers, public housing, churches, and 2 annual statewide African American health fairs and expositions. A total of 344 women, ranging from 41–75 years, agreed to participate out of 492 eligible women who were asked to participate, yielding a response rate of 69.9%.

Instruments

We used established instruments to measure health beliefs and cultural beliefs. 72–76 Additional measures included demographic and experiential characteristics and mammography stage of readiness. Descriptives of the health belief and cultural belief scales are listed in Table 1. All scales were revised and tested for reliability and validity in this study. All scales demonstrated construct validity through factor analysis and prediction of theoretical relationships, and all scales had satisfactory internal consistency reliability (Table 1).

Table 1. Scale Statistics

Scale	No. of items	Mean of item means	Mean of item SDs	Alpha
SD indicates standard deviation.
Susceptibility	4	3.08	1.80	.80
Benefits	4	6.09	1.44	.61
Barriers	19	2.33	1.93	.86
Self-efficacy	10	6.08	1.62	.80
Fear	8	3.31	1.44	.94
Fatalism	15	2.66	1.42	.84
Preventive health orientation
Active	8	4.21	0.81	.81
Passive	4	3.06	1.24	.63
Mammography environment	16	2.31	1.08	.91
Religious beliefs	19	4.33	0.86	.94

Health Beliefs

Perceived susceptibility

The perceived susceptibility scale included 4 items, with the first 3 respectively measuring the perceived likelihood of getting breast cancer in 5 years, 10 years, and during a lifetime. The fourth item reflected the perceived risk of getting breast cancer when compared to other women.

Perceived benefits

The 4-item perceived benefits scale measured the perceived effectiveness of the action or behavior to decrease the threat—in this case, death from breast cancer.

Perceived barriers

This 19-item scale measured barriers such as forgetting to get a mammogram, considering the treatment worse than the cure, fear of a mammogram causing breast cancer, feeling too old to get a mammogram, and perceiving no need because the physician already examines my breasts.

Self efficacy

The 10-item self efficacy scale had a one-dimensional factor structure with all items loading at 0.60 or above. This scale also discriminated between adherent and nonadherent women (P < .003).

Fear

The fear scale included 8 items that measured emotional reaction to thinking about breast cancer. The items were found to be valid and reliable in another study that included Caucasian and African American women. 76 Construct validity of this scale has been documented using factor analysis and testing of theoretical relationships.

Fatalism

This scale measured the participant's belief in the inevitability of dying if one has cancer, including when specific behaviors are engaged to treat it. This 15-item scale used a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree.

Cultural Beliefs

Preventive health orientation

The preventive health orientation scale consists of 2 subscales that use a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree. The first subscale, Active Preventive Health Orientation, consists of 8 items and measures beliefs about the importance of actively engaging in early detection of health problems and doing things to stay healthy. In this study, the factor analysis loadings for construct validity ranged from 0.49 to 0.80. The second subscale, Passive Preventive Health Orientation, a 4-item scale, measures the belief that one should seek health care only when ill and the belief that looking for health problems can cause them. This subscale had factor analysis loadings from 0.56 to 0.76. Both subscales predicted mammography screening adherence.

Mammography environment

This scale measures the discomfort individuals have or think they would experience in their immediate environment during a mammography screening procedure. The 16-item scale consists of items that measure the women's discomfort with the physical environment, including the effects of temperature, touch, and sound of the X-ray machine, as well as temperature, lighting, and appearance of the X-ray room. Items also address the interpersonal environment, including concerns related to privacy, interactions with staff, and cultural diversity within the setting. This instrument uses a 5-point Likert-type response scale ranging from 1 as strongly disagree to 5 as strongly agree. For construct validity, factor analysis revealed a 1-factor solution with item loadings from 0.49 to 0.79, and regression analysis showed its ability to significantly predict mammography screening adherence.

Religious beliefs

Health-related religious beliefs, such as, “I believe that God wants me to be concerned about my health,” “I believe that God expects me to take care of my body,” and “I believe that God will be with me if something happens to my health,” were measured by a 19-item scale. The belief items of the instrument employ a 5-point Likert scale with responses ranging from 1 as strongly disagree to 5 as strongly agree. The scale's construct validity was established by factor value loadings of 0.49–0.84 and also was substantiated by testing of theoretical relationships. 75

Demographic and Experiential Variables

Demographic variables measured included age, education level, marital status, and insurance coverage. Experiential variables included religious behaviors, past experience/history with the health provider, and family history of breast cancer.

Religious behaviors were measured by a 4-item scale respectively addressing the frequency of prayer; attendance of religious services; reading religious books, magazines, and pamphlets; and attendance at religious activities other than religious services using 1 as never or rarely; 2 as about once a month; 3 as 2–3 times each month; 4 as weekly; 5 as 2 or more times each week.

Past history with health provider was assessed by asking participants where they received their regular medical care. Family history of breast cancer was assessed by asking if any of the following relatives had breast cancer: female siblings and children, mother, and females on both maternal and paternal sides of the family.

Outcome Variable

Stage of mammography adoption

Mammography stages of readiness were conceptualized as precontemplation, contemplation, or action. At baseline, all women were nonadherent and thus in either the precontemplation or contemplation stage or were relapsers of the former or latter. Three items were used to create algorithms that identified study women as being in the precontemplation, contemplation, or action stage of readiness to obtain a mammogram. Those items respectively obtained the participants' past mammography history, their intent to be screened in the next 6 months, and the date of their most recent mammogram. Construct validation for precontemplation, contemplation, and action stages was established by Rakowski and colleagues via principal components analysis. 19

Procedure

Data for this analysis were obtained from 6-month postintervention measurements in a large intervention trial. All women were surveyed at baseline and at 1, 6, and 18 months postintervention. The data for this article came from the 6-month postintervention measures. The study was approved by the university institutional review board, and all procedures were followed.

In the trial, women, all of whom were currently nonadherent to screening, were randomly allocated to 1 of 3 groups: 1) pamphlet only, 2) culturally appropriate video, and 3) interactive computer-assisted instruction program. Women in the pamphlet group received a standard mammography pamphlet by mail encouraging adherence to breast cancer screening and a list of mammography facilities in their locale. Participants assigned to the video group viewed a videotape targeted to low-income African American women that encouraged mammography adherence. The women in the interactive computer group completed an interactive touch-screen computer program tailored to their individual beliefs and mammography stage. Referral information about how to obtain free or reduced-cost screening mammograms and follow-up care in the county was also made available upon request to every participant, regardless of her group assignment. The interventions have been further described elsewhere (Champion VL, Springston J, Zollinger TW, et al., unpublished data) All women were surveyed at baseline and at 1, 6, and 18 months postintervention.

Analysis

SPSS was used to complete data analysis. Stage of readiness was conceptualized as 3 categories, including 1 precontemplation and relapse precontemplation, 2 contemplation and relapse contemplation, and 3 action. We used χ² and one-way ANOVA with Tukey post hoc tests for assessing group differences.

RESULTS

Participant Characteristics

Demographic characteristics and experiential variables by stage are displayed in Table 2. There were 44 (15%) participants in the precontemplation stage, 158 (53%) in contemplation, and 97 (28.2%) participants who had moved to action by 6 months after intervention.

Table 2. Demographic and Experiential Variables by Stage of Mammography Screening Adoption

Characteristics	Precontemplation, n = 44	Contemplation, n = 158	Action, n = 97)
SD indicates standard deviation.
Mean age, y [SD]	49.7 [9.3]	50.9 [9.2]	51.7 [8.5]
Mean grade level	12.4	12.2	12.7
% Living with spouse or partner
Yes	38.6	31.0	27.8
No	61.4	69.0	72.2
% Has insurance
Yes	79.5	74.7	81.4
No	20.5	25.3	18.6
% Religious behaviors, [SD]	13.7 [4.2])	14.1 [3.7]	15.1 [3.7]
% Routine medical care
Family doctor	22.7	35.7	44.3
Emergency room	11.4	13.4	7.2
Other	65.9	51.0	48.5
% Family breast cancer history
Yes	0.0	2.5	1.0
No	100.0	97.5	99.0

The 3 groups defined by stage of screening adoption did not differ significantly by any of the demographic variables. Similarly, there were no significant differences in experiential variables by group. Although the overall F value (3.334, P = .04) was significant for religious practices, suggesting significant differences between contemplators and actors, post hoc tests, which control for multiple comparisons, did not reveal significance. The majority of participants received their routine health care from sources other than a regular family physician or emergency department. Although more actors received routine care from a family physician than from contemplators and precontemplators, this difference did not reach the level of significance.

Stage and Beliefs

Results related to our primary aim, to identify relationships between beliefs and stage, are displayed in Table 3. Health beliefs that significantly differed by stage were barriers to and self-efficacy for mammography screening. All 3 groups—precontemplators, contemplators, and actors—were significantly different from each other, with barriers progressively decreasing across stage. For self-efficacy beliefs, women in the precontemplation stage had less perceived self-efficacy than did women in the contemplation or action stages. Perceived benefits and susceptibility were not significantly different across stages.

Table 3. Belief Scale Differences by Stage of Mammography Screening Adoption

Scale	^1Precontemplation mean, n = 44	^2Contemplation mean, n = 158	^3Action mean, n = 97	F-value df = 2	Significant group differences
Group 1 indicates precontemplation; Group 2, contemplation; Group 3, action. Within-groups degrees of freedom were 296 for all variables except 295 for perceptions of mammography screening environment and 297 for passive preventive health orientation. *** P < .001. ** P < .01.
Susceptibility	11.0	12.0	10.9	1.63	NS
Benefits	22.8	24.5	24.0	2.67	NS
Barriers	48.0	39.0	32.9	11.69***	1 vs 2
					1 vs 3
					2 vs 3
Self-efficacy	54.4	60.2	61.8	6.34**	1 vs 2
					1 vs 3
Fear	23.7	23.6	24.9	.61	NS
Fatalism	39.4	40.3	36.9	2.93	NS
Preventive health
Active	32.4	33.5	34.7	4.75**	1 vs 3
Passive	12.8	12.0	11.0	4.77**	1 vs. 3
Mammography environment	42.1	37.3	34.1	7.69**	1 vs 2
					1 vs 3
Religious beliefs	79.1	82.6	83.0	1.93	NS

There were no significant differences in fear by stage. Fatalism displayed only marginal significance on the overall ANOVA F test (P = .055). However, because pairwise comparisons between stages were preplanned comparisons (even though we performed ANOVA to be conservative), it should be noted that the t test showed that those in precontemplation and contemplation had significantly higher fatalism scores than did those in action.

Cultural variables that differed by stage were feelings about the mammography screening environment and active and passive preventive health orientation. Women in the precontemplation stage had significantly more discomfort with the mammography screening environment than did women in the contemplation and action stages. Furthermore, women who got screened (action stage) were more active preventive-health–oriented and less passive preventive-health–oriented than were women who were not thinking about getting screened (precontemplation stage). Health-related religious beliefs did not differentiate stage of screening adoption.

DISCUSSION

Study results show that particular health and cultural beliefs to mammography screening differ across stages of mammography screening adoption for this sample of African American women with low incomes. Perceived barriers were significantly higher in precontemplators than in contemplators and actors, and contemplators had significantly more perceived barriers than did actors. Additionally, fatalism marginally separated precontemplators and contemplators from those in action. These findings are similar to those of Champion and Springston 29 and Skinner et al. 30 However, contrary to their study findings, risks and benefits were not significantly different across stages in our study. In both studies, perceived benefits were significantly different by stage, and Champion also found perceived susceptibility to be different by stage.

Self-efficacy was significantly different across stages. Women in the precontemplation stage had less confidence in their ability to get screened than did women in the contemplation and action stages. Other studies show that self-efficacy was a predictor on mammography screening intention. 77, 78

In our study, feelings about the mammography screening environment and preventive-health orientation were significantly different by stage. Women in precontemplation had more perceived discomfort with the mammography screening environment than did women in the other groups. Other studies show that concerns about lack of privacy during the mammogram procedure is 1 aspect of the screening environment that is related to decreased intention and receipt of mammography in African American women. 79, 80 Qualitative data from Thomas's 46 study of professional African American women showed that repeat mammography screening intention and adherence were affected by the mammography screening environment. Discomfort resulting from coldness of the room and equipment, and perceived impersonal attitudes of the healthcare providers and technicians emerged as consistent findings from the women.

Women in the precontemplation stage were less active and more passive in their preventive-health orientation than were women in the action stage. In their study of 8965 multiracial women, Pearlman et al. 81 showed that preventive health behaviors were predictive of stage of mammography screening adoption. Both precontemplators and contemplators were less likely to exercise than were actors, and contemplators were 1.4 times more likely to smoke than were actors.

In this study, stage of mammography adherence did not differ by health-related religious beliefs. This finding is inconsistent with previous studies that showed an association between religious beliefs and screening adherence. 50, 58, 69–71 One possible explanation is that the women in our study had fairly strong religious beliefs, with little variance in beliefs across stage of screening.

Study Limitations

The findings from this study are limited in generalization to all low-income African American women. Within-group differences in beliefs may exist, since African American women are a heterogeneous population. 82 Additionally, women could vary in their beliefs by region of country, and by urban, suburban, and rural locations. This study was limited to urban African American women living in the Midwest. Third, belief by age differences has been shown for African American women, 83, 84 and age was not controlled in this study. Finally, since other ethnic and racial groups were not included in our study, we do not know if study findings would differ across cultural groups.

Implications

The results are not intended to be used to change individuals' cultural beliefs. Rather, these results will help us to structure message delivery within a context that is appropriate to an individual's culture and health belief system. For example, during the mammography screening procedure, visual images should include environmental conditions that may cause discomfort, such as showing the appearance of the entire X-ray room and all the tasks of the staff or providing coping strategies that help women deal with privacy, tactile, and temperature issues that involve staff touching the women's breasts, and how the X-ray machine looks and feels. Another example includes having a breast cancer survivor actor acknowledge that, even though some women do not engage in preventive health practices for many different reasons, including cultural beliefs about their importance and efficacy; she can then explain how a mammogram saved her life because the lump was found early, which increased her chances of surviving or living. Although more research is needed, preliminary results suggest that addressing beliefs of African American women and mammography may lead to interventions to increase our rate of early detection.