Florida State University Libraries

Transcription

1 Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2008 The Relationship Between Health Beliefs and the Performance of Breast Self- Examination Among African American Women Marlaine F. Registe Follow this and additional works at the FSU Digital Library. For more information, please contact

2 FLORIDA STATE UNIVERSITY COLLEGE OF NURSING THE RELATIONSHIP BETWEEN HEALTH BELIEFS AND THE PERFORMANCE OF BREAST SELF-EXAMINATION AMONG AFRICAN AMERICAN WOMEN By MARLAINE F. REGISTE A Thesis submitted to the College of Nursing in partial fulfillment of the requirements for the degree of Masters of Science in Nursing Degree Awarded: Spring Semester, 2008

3 The members of the Committee approve the thesis of Marlaine F. Registe defended on March 20, Susan Porterfield Professor Co-Director Thesis Laurie Grubbs Professor Directing Thesis Roxanne Hauber Committee Member Approved: Dianne Speake, Associate Dean, College of Nursing Lisa A. Plowfield, Dean, College of Nursing The office of Graduate Studies has verified and approved the above named committee members. ii

4 DEDICATION This thesis is dedicated to my husband, Jacques Registe, for his continued support, encouragement, positive attitude, statistical and computer expertise, while writing the thesis and throughout. I would like to thank him most of all for keeping the family unit whole; cooking dinner, logging the kids to and from school and other activities, without any complaints, while I traveled down my educational road. He is the wind beneath my wings, without him I wouldn t have soared so high. To my children, Geoffrey, Aimee, Nathaniel, and Alix for understanding why Mom had to miss a few field trips, school plays and Boys Scout meetings. Thank you for keeping the noise down while I wrote. To my father, Marcel Joseph Florestal, my unsung hero, who instilled in me and all of his children, the love of books and learning. I would like to thank him most of all, for his dedication to his children and grandchildren and for pushing us so hard to be the best that we can be. Thank you Dad. iii

5 ACKNOWLEDGMENTS I would like to thank the following people for their unwavering support and assistance with the research project and for turning my time at Florida State University into such a positive experience. Dr. Susan Porterfield, Co-committee Chair, for her expert advice, patience, and prompt return of all works. I would like to thank Dr. Porterfield for all the time spent away from Camp Porterfield helping me turn an idea into this thesis. Working together with her and watching this project grow has been a wonderful experience. Dr. Laurie Grubbs, Committee Chair, for her guidance and assistance for the past two semesters with this research project. But most of all, I would like to thank Dr. Grubbs for the many clinical hours spent together at Patient First, teaching and guiding me in the process of becoming a competent and compassionate Nurse Practitioner. Dr. Roxanne Hauber, Committee Member, first of all for saying yes to coming on board in the middle of this research project. I would also like to thank Dr. Hauber for her insightful comments that pointed the direction to go with the data. Betty Brown for her statistical expertise, without her invaluable help the data wouldn t have made much sense to me or others. The word thank you is so inadequate in expressing my gratitude. Melanie Spells, my mentor and best friend, for her support, guidance and encouragement throughout this journey. I am thankful for the weekly phone calls, to see how you re doing, and the much anticipated and appreciated CAPN monthly meetings. Most of all, I am grateful for her invaluable guidance and priceless gift of so many, many clinical hours at Wilson Family Practice. Thank you for leading by example, I am happy and proud to call her friend. iv

6 TABLE OF CONTENTS DEDICATION...iii ACKNOWLEDGMENTS...iv LIST OF TABLES...vii LIST OF FIGURES...viii ABSTRACT...ix CHAPTER INTRODUCTION...1 STATEMENT OF THE PROBLEM...1 STATEMENT OF PURPOSE...3 RESEARCH QUESTIONS...3 THEORETICAL MODEL...3 OPERATIONAL DEFINITION...4 ASSUMPTIONS/LIMITATIONS...4 SUMMARY...4 CHAPTER REVIEW OF THE LITERATURE...6 BREAST CANCER AND SELF BREAST EXAMINATION...7 BREAST CANCER KNOWLEDGE AND BELIEFS...9 BARRIERS REGARDING BREAST CANCER...12 THE HEALTH BELIEF MODEL...14 THE HEALTH BELIEF MODEL SCALE...15 SUMMARY...16 CHAPTER METHODOLOGY...17 RESEARCH DESIGN...17 RESEARCH QUESTIONS...17 VARIABLES...17 SETTINGS...17 SAMPLE...18 SAMPLING PROCEDURE...18 PROTECTION OF HUMAN SUBJECTS...19 RESEARCH INSTRUMENTS...19 DATA ANALYSIS...20 SUMMARY...20 CHAPTER DATA ANALYSIS...21 DESCRIPTION OF SAMPLE...21 BREAST SELF EXAMINATION...21 HBMS SCALE AND BSE FREQUENCY...22 HEALTH BELIEFS, ATTITUDES AND KNOWLEDGE REGARDING BSE AND BREAST CANCER...23 SUSCEPTIBILITY...24 SERIOUSNESS...25 BENEFITS...25 BARRIERS...26 CONFIDENCE...26 HEALTH MOTIVATION...26 DEMOGRAPHICS...27 Demographic Data...27 v

7 Demographic Data and Frequency of BSE...29 HBMS VALIDITY AND RELIABILITY...31 Summary...31 CHAPTER HEALTH BELIEFS, ATTITUDES AND KNOWLEDGE REGARDING BREAST CANCER AND BSE...34 SOCIO-DEMOGRAPHIC CHARACTERISTICS AND BSE PERFORMANCE OF AFRICAN AMERICAN WOMEN...36 LIMITATIONS...37 IMPLICATIONS FOR NURSING PRACTICE AND EDUCATION...38 RECOMMENDATIONS FOR FUTURE NURSING RESEARCH...38 SUMMARY...39 APPENDIX A...40 HEALTH BELIEF MODEL SCALE...40 APPENDIX B...44 DEMOGRAPHIC DATA...44 APPENDIX C...46 PERMISSION LETTERS...46 APPENDIX D...55 IRB APPROVAL LETTER...55 APPENDIX E...58 CONSENT FORM...58 REFERENCES...62 BIOGRAPHICAL SKETCH...65 vi

8 LIST OF TABLES Table 1. BSE frequency for the past 12 months Table 2. Pearson s Correlations of HBMS Concepts and BSE Frequency Table 3. Demographic Data Table 4. Pearson s correlation of demographic data and BSE frequency Table 5. Recommendation of BSE by Health Professional Table 6. Internal Consistency and Reliability of the HBMS (N=131) vii

9 LIST OF FIGURES FIGURE 1. Health Belief Model viii

10 ABSTRACT Breast cancer is the second leading cause of cancer deaths of North American women. In the last thirty years, great strides have been made in the diagnosis and treatment of breast cancer, which have led to a reduction in breast cancer deaths. Research studies have shown, however, that the drop in the mortality rate observed in Caucasian women has not been replicated in African American women. African American women are more likely to die at a higher rate than Caucasian women. The racial difference in survival rates have been attributed to early detection practices such as those recommended by the American Cancer Society (ACS) and the National Cancer Institute (NCI); annual mammography, CBE, and monthly BSE, to be readily adopted by Caucasian women but underutilized by African American women. According to some well documented researches, a very small percentage (30%) of African American women, especially those at increased risks for hereditary diseases, adhere to the ACS recommendation guidelines. The purpose of this study was to investigate the relationship between African American women s health beliefs in regard to breast cancer and screening behaviors, knowledge and attitudes that may serve as incentives or barriers to their adherence to routine BSE practices. For the purpose of this research study, reference to African American women encompassed all women whose ancestors were brought from the continent of Africa to the Americas, Europe, and the Caribbean, involuntarily. The Health Belief Model (HBM), one of the most widely recognized conceptual frameworks of health behavior, served as the theoretical framework. The Breast Cancer Screening Beliefs Instrument Scale (HBMS) was the instrument used in this study. This instrument explores ethnic differences in attitudes toward health practices, health beliefs, risk estimates, and knowledge about breast cancer and breast cancer screenings. A convenience sample of 131 African American women, between the ages of 20-65, was recruited from different sites in north and south Florida. Forty six (36.2%) women were between the ages of 20-29, 23 (18.1%) women were between years old, and 28 (22.0%) women were Fifty six (43.1%) women were single women, 40 (30.8%) were married, 13 (9.9%) were divorced, and 6 (4.6%) were widowed. Twenty seven (20.6%) earned a Bachelor degree, 18 (13.7%) earned a Master s or higher degree, 57 (43.5%) an Associate s, 19 (14.5%) a high school diploma, 10 (7.6) had not graduated high school. Most participants were employed; 40.3% were in the 10,000-30,000 range, 21.7% made 30,000-50,000, and 13.2% were in the ix

11 50,000-60,000 annual income range. Most had insurance coverage for yearly physical and mammogram, 48.9 % had health insurance, 99.2% had no personal history of breast cancer, 61.8% had no family history of breast cancer. The number of women who reported compliance to BSE was surprisingly high. The majority of the participants 109 (83.8%) reported practicing BSE within the past 12 months. However, 21 (16.2%) women had never practiced BSE. The majority of the women, 105 (80.2%) reported that their primary health care providers recommended BSE and screening mammograms. The analyzed data, using the HBMS scale, revealed that increased perceived susceptibility to breast cancer, perceived benefits of BSE, and confidence were related to increased frequency of BSE. The study participants had poor knowledge of breast cancer and breast cancer treatments, did not feel susceptible to breast cancer, but were aware of the benefits of BSE. Data analysis showed significant correlation between susceptibility, benefits, health motivation and BSE frequency. No significant correlation existed between perceived seriousness, barriers, confidence and BSE frequency. There were also no significant correlations between socio-demographic characteristics: age, marital status, education, family history of breast cancer, and health insurance coverage. The analyzed data showed a negative correlation between income and BSE frequency, as income increases, BSE frequency decreases. Negative correlations were found between religion, health insurance coverage, personal history of breast disease and BSE performance. Recommendation by health care provider was positively related to increase BSE performance. Decrease BSE frequency was associated with young adults, nineteen or younger, 60 or older, and widowed women. In summary, the analyzed data showed that women who adhere to the American Cancer Society recommendations and practice BSE had better knowledge of breast cancer, were well aware of its benefits, had lower perceived barriers to BSE, and were confident in their ability to perform BSE properly. The results not only emphasized the complexity and strength of cultural beliefs in regard to African American women s health care practices, but have also highlighted the significant role that health care providers play in the lives of these women. x

12 CHAPTER 1 INTRODUCTION The National Cancer Institute (NCI) estimates that 178,480 women will be diagnosed with breast cancer and of these 40,460 women will die in 2007 (NCI, 2007). Breast cancer is second only to lung cancer as a cause of cancer deaths in American women, accounting for one of every three cancers diagnosed in the United States. However, research studies have shown the challenge to be greater for African American women. Although African American women have a lower incidence of breast cancer, 118 out of every 100,000 compare to 133 out of every 100,000 Caucasian women, African American women are more likely to die at a higher rate, 34.0 per 100,000 compare to 25.0 per 100,000 Caucasian women. (NCI, 2007; ACS, 2008; Hall et al., 2005). Poverty, inferior health care, barriers to health care access, health beliefs, personal behaviors, and later stage of disease at diagnosis, are some of the reasons attributed to this disparity (Hall et al., 2005; Ganz et al., 2003; Bibb, 2001). Multiple studies, however, attribute the racial difference in survival rates (31 out of every 100,000 African American women compared to 27 out of every 100,000 Caucasian women), to early detection practices such as breast self examination (BSE), clinical breast examination (CBE), and mammography which are adopted by Caucasian women and underutilized by African American women, (ACS, 2006; ACS, 2008; World Health Organization [WHO], 2007). The review of literature indicates an association between breast cancer screening measures, for example, CBE, mammography and the performance of BSE, and more favorable clinical and pathological stages of disease. The most important predictor of survival is stage at diagnosis. According to the American Cancer Society and the US preventive task force, screening is the key to finding breast cancer in its early, treatable stages (ACS, 2008). Consequently identifying socio-cultural factors that may influence screening and incorporating them into health messages for African American women may help lessen the existing disparity. Statement of the Problem From 1975 to 1991 cancer trends have shown a gradual increase in breast cancer death rates for both African American and Caucasian women. A period of more rapid increase was noted, from 1982 to By the early 1990 s, however, the overall incidence rates appeared to 1

13 have somewhat stabilized (ACS 1998; ACS, 2008). The only deviation happened in 1997, the number of women diagnosed with breast cancer for that year increased to nearly 213,000 (18%) instead of decreasing; but the number of women dying of breast cancer decreased to 41,000 (7%). Overall from 1990 to 2001, breast cancer mortality rates declined by 2.3% per year, with the greatest decreases among women under 50 years of age, there was a 6.3 percent decline between 1991 and 1995, with a larger decline in women under 65 (9.3 %) compared with women 65 and older (2.8 %) (ACS, 2008). However there was a significant difference between longterm breast cancer mortality rates for Caucasian and African American women. During the early 1980 s death cancer deaths for Caucasian and African American women were approximately equal, but from 1989 to 1992, the death rates decreased by 5% for Caucasian women but increased by 2% for African American. And in , African American women had a 36% higher death rate than Caucasian women. This resulted in a five year survival rate of 77% for African American women, but for Caucasian women the 5-year survival rate was 90% (ACS, 2008; Surveillance, Epidemiology, and End Results [SEER], 2003). The American Cancer Society attributed the lower five year survival rate to later stage at detection, poorer stage-specific survival, and to lack of access to appropriate and timely treatment (ACS, 2007; ACS, 2008). According to the ACS only 52% of all breast cancers diagnosed among African American women are diagnosed at a local stage, compared to 62% among Caucasian women (ACS, 2007). The American Cancer Society and the NCI support the correlation between regular screenings, which may include breast self examination (BSE), examination by health providers (CBE), and mammograms, and a more favorable clinical and pathological outcome. Breast self exam is an easy, safe, and effective measure that all women can perform for themselves; approximately 70% of all breast masses are self-detected. Research has shown that African Americans are less likely to perform BSE on a regular basis (AHRQ, 2005; Barton, 2006; Yarbrough, 2001). It should be noted however, that the American Cancer Society no longer recommends BSE as a mean of detecting cancer. According to the ACS, its usage alone has not been shown to decrease mortality rates (ACS, 2008). The American Cancer Society recommends BSE as an important viable substitute for women with inadequate access to health care such as those living in rural areas, where access to CBE and mammograms is difficult; the objective is that in a rural setting, women practicing BSE may detect breast cancer early enough for lifesaving treatment to be started at a stage where it could make a difference. 2

14 Statement of Purpose Breast cancer is one of few cancers that can be detected early through early screening strategies such as breast self examination. Despite the documented higher mortality rate for African American women compared to Caucasian women, few African American women, only about 30%, at increased risks for hereditary diseases adhere to the ACS recommendation guidelines (Kinney et al., 2002). The purpose of this study was to examine the relationship between health beliefs, knowledge, attitudes, and health behavior among African American women that may serve as barriers to the performance of breast self-examination. An increased awareness and understanding of these perceived barriers can assist health care providers in addressing issues such as knowledge deficits, belief differences and or misconceptions, which may in turn lead to an increase in BSE frequency. The influence of age, economic status, health insurance, education, self and family history of breast cancer on the performance of BSE will also be explored. Religion, which has been shown to be a significant factor in African American women s lives, will also be explored. Religion plays a central role in African American women s effort to cope with problems, including illnesses (Williams, 2001). Research Questions 1. What is the relationship between health beliefs, knowledge, attitudes and the frequency of breast self examination in African American women? 2. What is the relationship between education level, age, self history of breast disease, family history of breast cancer, socioeconomic status, health insurance, religion, and the frequency of breast self examination in African American women? 3. What is the relationship between a health care provider recommending BSE and frequency of BSE Performance? Theoretical Model Becker s revised Health Belief Model (HBM), one of the most widely recognized conceptual frameworks of health behavior, will serve as the theoretical framework for this research. The model is used to explain self care activities with a focus on behavior related to the prevention of disease, and health motivation concept (Becker, 1974; Rosenstock, 1974). The HBM rest on the basis that an individual s action to prevent a health problem, and adherence to health behaviors is related to the individual s perceived susceptibility, severity, benefits, barriers, as well as personal and social influences and attitudes (Champion, 1997). In other words, 3

15 individuals will take action if they: perceive the problem to be severe; 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. The HBM concepts, perceived seriousness, perceived benefits, perceived barriers, and health motivation are considered predictors of heath behavior of BSE (Graham, 2002; Champion, 1997; Stout, 1997). The main objective of using the Health Belief Model (HBM) in this study is to identify ethnic differences in attitudes toward health practices, health beliefs, risk estimates, knowledge and beliefs about breast cancer. Operational Definition 1. African American women refer to women whose ancestries are rooted in the continent of Africa. This includes also any woman who self-identify as African American. 2. Frequency of breast self-examination refers to number of inspections by a woman of her breast to detect breast cancer within a 12 month period of time. The demographic data relating to BSE frequency includes age of women, martial status, education, yearly income, self breast cancer history, religion, family history of breast cancer, and health insurance. 3. Health beliefs are measured by Champion s Breast Cancer Screening Beliefs Instrument which examines participants perception of susceptibility to breast cancer, belief in the seriousness of the threat of breast cancer to themselves, benefits of BSE, barriers to BSE, and their confidence in performing BSE as well as health motivation. 4. Religion encompasses religious thoughts, experiences, faith, and religious influences as proclaimed by each individual. 5. Insurance coverage is any coverage of routine screenings such as yearly physical exams and mammograms. Assumptions/Limitations During the course of this study, the researcher makes the assumptions that the women answered truthfully and that they considered health a priority. The limitation of this study was that the findings of this study can be applied only to African American women. Summary Despite the documented higher morbidity and mortality of breast cancer among African American women, and the benefits of early screening methods, it has been shown that African American women are less likely to perform BSE than Caucasian women. Researchers 4

16 hypothesized screening adaptation to be related to perceptions of risk, benefit, barriers, as well as personal and social influences and attitudes. The purpose of the study was to examine the relationships between health beliefs, knowledge, and attitudes among African American women that may serve as barriers to the performance of breast self-examination (BSE). An increased awareness and understanding of these perceived barriers can assist health care providers in addressing these concerns, which may lead to an increase in the performance of BSE. 5

17 CHAPTER 2 REVIEW OF THE LITERATURE The first goal of the study was to compare the BSE practice among African American women, those who practiced routine BSE and those women who did not. The second goal of the study was to examine the relationship between the health beliefs, knowledge, attitudes among the two groups of African American women and to see how they differ. The review of literature focused on breast cancer screening beliefs, and the four constructs of the Health Belief Model which are perceived susceptibility, perceived risk (seriousness), perceived benefits (risk reduction expectancies), perceived barriers to BSE, and self-efficacy. Breast self examination (BSE) is also discussed. The American Cancer Society reports that from 2001 to 2004, breast cancer diagnosis rates dropped an average of 3.7% each year and that breast cancer death rates also dropped about 2% each year. This decline is believed to be due in part to breast cancer screenings, such as yearly mammogram, and clinical breast examination (CBE), and monthly breast self examination (BSE), which facilitate early detection. The American Cancer Society also reports that African American women, unlike Caucasian women and women of other races, are not experiencing this positive outcome (ACS, 2008; NCI, 2007; ACS, 2006). African American women, even though they are at greatest risk of premature death due to late diagnosis, are less likely than Caucasian women to participate in early screenings and therefore are more likely to be diagnosed with advanced stage breast cancer and higher grade tumors (ACS, 2008; Barton, 2006; Yarbrough, Braden, 2001). Delayed diagnosis leads to advanced stage and high grade tumors which in regard to African American women, means a higher breast cancer mortality rate. Research found that most women, particularly women of color, women with less education, and older women are very resistant to health education interventions (Yarbrough, Braden, 2001; Balsheim, 1991). Efforts to reduce breast cancer mortality rate of African American women, must therefore center on the identification and management of factors such as socio-cultural differences, knowledge deficit regarding breast cancer and preventive measures, health beliefs, and attitudes that can serve as barriers. 6

18 Breast Cancer and Self Breast Examination Breast self examination is an easy, safe, and effective measure that all women can perform for themselves. The objective of BSE is to get women not only to become proficient at performing BSE but also to become familiar with the usual appearance and feel of their breast. It should also be noted that approximately 70% of all breast masses are self-detected (ACS, 2007). The Agency for Healthcare Research and Quality (AHRQ) reports that breast cancer screening, which includes, yearly mammogram, and clinical breast examination (CBE) and monthly breast self examination (BSE), have been found to be underutilized by African American women as well as other minorities and those with lower incomes (AHRQ, 2005; Barton, 2006; Yarbrough, Braden 2001). Kinney et al have found that only 30% of African American at increase risk for hereditary disease were adherent to cancer screening guidelines whereas most Caucasian women at increase risk were adherent to the guidelines (Isaacs et al., 2002 and Kinney et al., 2002). Garbers and Chiasson (2006) conducted a telephone-based survey to examine breast cancer screening and health behaviors among 300 African American and Caribbean women age 40-79, in New York City. The findings reveal one significant difference between the groups of women concerning breast cancer screening behavior, U.S.-born women were more likely ever to have performed breast self examination (BSE). No differences were found in sources of information on breast health. The researchers also found that while US born women had significantly different socio-demographic profiles (in terms of insurance status, marital status, educational attainment), they were no more likely to have had a mammogram than their foreign born counterpart. Adjusting for insurance status and source of care, there was no difference in the reported rates of CBE and mammography and sources of information on breast health or breast cancer screening. The strongest predictor of mammography was found to be physician recommendation; women with a provider recommendation were 8 times more likely ever to have had a mammogram. Only 52% of foreign born women, compared to 77% of US born women, ever had a provider recommend a mammogram. Physicians and health providers recommendation is therefore essential in the struggle to increase breast cancer screening among African American women. Champion (1997) examined predisposing factors associated with breast self exam (BSE) and mammography use in African American women. The sample consisted of 328 African American women living in a large Midwestern metropolitan area, who were at <=150% of poverty level, and between the ages of years old. Data were collected 7

19 over a period of 18 months. The Behavioral Model for Health Services Utilization (BMHSU) was the framework utilized in the study. The BMHSU investigated the predisposing variables (attitudes, knowledge, and demographic, enabling variables (health insurance, source of health care and mammography cost) which are important predictors of utilization, and need variables (physician recommendation) since mammography requires a physician s order. The results indicated that BSE frequency was significantly related to barriers, confidence, having thought about BSE, and having a regular doctor. BSE proficiency was related to susceptibility, benefits, barriers, confidence, knowledge, education and having thought about BSE. Age, BSE recommendation by health providers, having a regular physician and past symptoms were not significantly related to proficiency. Women who were married or widowed were significantly less likely to do BSE. Women who were more confident in their ability to do BSE, more knowledgeable were more likely to complete BSE with greater frequency. Those who perceived more barriers were more likely to complete BSE with less frequency. And those who had a regular physician were more likely to complete BSE more frequently. Husaini et al. (2005) investigated the effectiveness of a church based educational program aimed at increasing rates of adherence to regular breast cancer screening among urban and rural dwelling African American women age 40 and over. The second goal of the study was to discover barriers and facilitators to breast cancer screening among the two groups. The data were drawn from an intervention study in urban Nashville and a pilot extension of the study in five rural counties of West Tennessee. The rural and urban participants were similar with respect to some demographic characteristics, including age, marital status and church attendance. However the urban sample had significantly higher levels of education and income and had health insurance. The results showed differences between the two groups of women. The urban women reported discomfort with getting a mammogram as their number one reason for not getting one. The rural women were more likely not to get a mammogram because they did not perceive a need, because they thought mammography was embarrassing and because of their religious beliefs. Not thinking about mammogram and lack of physician recommendation were similar reasons for both the rural and urban group. The results also showed the church-based educational program to be equally effective in both areas; there was a 17.6% increase in mammography attainment from baseline in rural Tennessee and 22.3% increase in urban Nashville. The findings also showed that an 8

20 inexpensive church-based program could be a useful tool to reach the goal of decreasing the mortality rates of African American women with breast cancer. Breast Cancer Knowledge and Beliefs African American women are diverse, with mixed ancestry from Africa, Europe, the Americas, Asia, and the Caribbean. While there still exist a cultural bond, a set of shared beliefs, values, and experiences, African American women are as socially, economically, cultural and ethnically diverse as other ethnic groups (Williams, 2001). Evidence show that individuals decision to participate in cancer prevention behavior, such as routine BSE and mammogram, is influenced by cultural, ethnic, and economic differences. Phillips et al (1999) found African American women s perception regarding cancer to reflect that difference. The African American women interviewed believed that only a chosen few survive cancer and that cancer can be cause by being hit in the breast, cancer is a condition of the mind and that breast cancer is a disease of Caucasian women. Barroso et al (2000) used the HBM and the Health Locus of Control Construct to compare the difference in health beliefs in regard to breast cancer in 197 Caucasian and 152 African American women. Participants, between the ages of 19-93, were recruited from various setting in central Florida. The researchers found significant differences between the two groups in regard to health beliefs and other cancer items. The African American women were significantly more likely to believe that health results from luck/chance or to depend on powerful others for their health. Perceived susceptibility to cancer, doubts about the value of early diagnosis, and beliefs about the seriousness of breast cancer were all associated with this powerful other. Barroso s results showed evidence of knowledge deficit regarding breast cancer among African American women, and a belief that their health in general and breast cancer in particular has an element of chance or luck and illnesses such as breast cancer is in the hand of a higher power or God who decides who gets breast cancer and who gets cured of it. Another significant finding was that African American women with a greater belief in powerful others also believed that early diagnosis gives them a longer time to worry and be sick. The researchers stated that these beliefs may be the result of cultural influences, for example stories that are handed down through family storytelling about others with cancer. There was however, no relationship between health beliefs and years of education for African American women, less educated Caucasian women were more likely to believe that a cancer diagnosis equals death. The researchers summarized that cultural influences may play a more significant role than 9

21 education and by addressing the differences in health beliefs in regard to breast cancer screening and early detection, health professionals may be able to reach this vulnerable population. Graham (2001) examined the relationships between health beliefs and the practice of BSE in a sample of 179 African American women between the ages of Health beliefs were examined utilizing Champion s revised Health Belief Model Scale (1993). Results indicated that there was a relationship between health beliefs and BSE performance among African American women. The health belief frame of reference was much stronger in determining BSE performance for a given individual than background characteristics (Graham, 2001). 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. Age, she found, was directly related to BSE performance within the context of perceived seriousness. African American women over the age 40 perceived a greater threat and were more motivated than younger women regarding breast cancer prevention and early screening measures such as BSE and mammograms. Consedine et al. (2004) examined breast cancer knowledge deficits and beliefs in subpopulations of African American and Caribbean women. One thousand three hundred and sixty four African American, US-born white, English-speaking Caribbean, Haitian, Dominican, and eastern European women were recruited through stratified-cluster sampling. The results indicated that there were between-group differences in cancer knowledge and belief as well as within group variation, for example between US-born African American, Caribbean women and Haitian women in terms of particular knowledge and belief. Haitian women were most likely to believe that breast cancer is the result of bruises or a sore, with Eastern European and Dominican women next; US-born white women were least likely to hold this belief. Haitian women were also the most likely to hold the belief that chemicals in food cause cancer, followed by Eastern European and Dominican women, followed by English Caribbean and US-born Caucasian women. Haitians believed more strongly that God determined the course of cancer, followed by Dominicans and women from the English speaking Caribbean. Haitians and Dominicans were more likely to regard conventional cancer treatment as being just as harmful as the disease. African American and English Caribbean women had the highest scores on the belief that surgery causes cancer to spread, with US-born Caucasian women and Eastern European women having the lowest scores. Education seemed to have an effect among African American, Eastern 10

22 European and US-born Caucasian women, the less educated women endorsed the belief that conventional cancer treatment was just as harmful as the disease itself. Haitians and Eastern European women were more likely to believe that surgery can be helpful if the cancer is caught in time. Finally, Haitian women were more likely to believe that cancer is always fatal, followed by English-speaking Caribbean women and Dominican women, who endorsed this statement more strongly than did African American women, US-born white and Eastern European women (Consedine, et al., 2004). Rhoads et al. (2000) investigated breast cancer beliefs and behaviors in an ethnically mixed population. The study compared an ethnically mixed population of lower socioeconomic status women regarding their breast cancer beliefs, surgical decision-making, source of information, reactions to the diagnosis, and use of support groups. A 20 item oral survey was administered to a convenience sample of 30 women recruited at the San Francisco General Hospital breast clinic during The sample size consisted of 10 African Americans, 7 Caucasians, 6 Filipinos, 4 Chinese, and 3 Latinas. Education averaged 12 years. The findings revealed that breast cancer beliefs varied by ethnicity, age, and education. The Caucasian women in the study were more likely to believe that treatment for breast cancer is worse than the disease. Caucasian Women under 50 years old were more likely to believe that breast cancer can be prevented by breast-feeding. African American and Filipino women expressed less concern with the loss of a breast than Caucasian women. African American women were more concerned about having the disease/coping, concern about the treatments and pain/suffering (Rhoads, Luce & Knudson, 2000). McDonald et al (1999) investigated breast cancer perceptions, knowledge and screening behavior of low-income, African American women residing in public housing. One hundred twenty (120) randomly selected African American women were interviewed to determine their perceived susceptibility to breast cancer, perceived severity of the disease, perceived barriers to breast cancer screening, and perceived benefits of mammography. Knowledge about breast cancer causes, risk factors, symptoms, and screening were also assessed. The result showed that 80.7% of women aged 40 and older had a previous mammogram, 92% reported having had a CBE, 75.8% performed BSE. Knowledge of breast cancer was poor, most of the women did not perceive themselves or a particular racial or economic group to be more susceptible to breast 11

23 cancer. They also did not perceive breast cancer to be fatal and denied commonly cited barriers to breast cancer screening. Barriers Regarding Breast Cancer Bailey et al. (2000) identified a number of cultural beliefs held by some African American women regarding breast cancer for instance breast cancer as punishment from God. Silence is sometimes use as a way of dealing with illnesses, some believe that what is not address will not happen or will eventually disappear, others view breast cancer as a white women s disease, therefore not something that they should concern themselves about. Yewoubdar (1999) investigated the difference in beliefs and perceived risks of breast cancer and related cultural factors among African immigrants in California. The main objective of the study was to identify culturally specific factors that influence understanding of breast cancer symptom presentation, perceived risks, barriers to early detection and knowledge and acceptance of breast cancer screening guidelines among African immigrant women in California. The study design involved focus group interviews with 20 key informants and an in-depth interview with 100 African immigrant women. African immigrants perceived the occurrence of disease such as breast cancer in ways that are fundamentally different from the mainstream middle class American society and health care professionals. Traditional Africans believe that people have the power to influence their health and that of others. Good health is seen as the result of a harmonious relationship with nature. Illness is characterized as being natural or unnatural. Natural illness stems from natural causes (cold, air, rain, heat and impurities in the air and food). Unnatural illness on the other hand, originates from evil spirits and demons (Guidry, et al., 2000). Yewoubdar s findings revealed that cultural beliefs and knowledge deficit served as barriers for the African women, due to the fact that media information focuses mainly on breast cancer among American women, most of the women think that breast cancer is an American disease and do not see themselves at risk (Yewoubdar, 1999). Knowledge and attitude of Nigerian women toward breast cancer and early detection methods were investigated by Okabia et al. (2006). One thousand community-dwelling women from a semi-urban neighborhood in Nigeria were recruited for the study in January and February 2000 using interviewer-administered questionnaires designed to elicit socio-demographic information and knowledge, attitude and practices of these women towards breast cancer. Data analysis was carried out using Statistical Analysis Software (SAS) version 8.2. The study results 12

24 showed that participants had poor knowledge of breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had had clinical breast examination (CBE) in the past year. Women with a higher level of education (X 2 = 80.66, p < ) and those employed in professional jobs (X 2 = 47.11, p < ) were significantly more knowledgeable about breast cancer. Participants with a higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] ). The results of the study suggest that community-dwelling women in Nigeria have poor knowledge of breast cancer and practice of BSE and CBE. In addition, education appears to be the major determinant of level of knowledge and health behavior among the study participants. Breast cancer barriers for African American women in regard to interdependence of culture and psychosocial issues were investigated by Guidry, et al (2002). The study evaluated the cultural context of the behaviors and beliefs of African American women to determine the success or failure of breast cancer prevention and control interventions. He found that cultural and psychological reaction, such as fear, distrust, fatalism, and other historic rooted factors, are major determinants to participation in these interventions by African American women (Guidry, et al., 2002). Jernigan et al. (2001) investigated factors that influence cancer screening among older African American men and women. The goal of the study was to identify and explore psychosocial factors that influence the decision of older African Americans to engage in cancer screening. A series of focus groups, 26 males and 19 females participated, were held, the focus of which were psychosocial factors that facilitate or impede screenings. Facilitators included getting older, knowing someone who had cancer, or was a survivors and those who died as motivators. Barriers mentioned were, distrust of medical system, perceiving cancer as a death sentence. Men were more likely to identify cultural barriers such as not wanting to see a physician if they were symptom free. Women were more likely to identify structural barriers for example, the inconvenient location of health care facilities. Both male and female participants however indicated three major factors that appear to influence the receipt of cancer screening: the presence of symptoms, social support and religious beliefs. 13

25 Lukwago et al. (2003) focused on identifying socio-cultural factors that influence timely screening and ways to incorporate them into health messages for African American women. One thousand two hundred and forty one African American women aged 18 to 65 were recruited from 10 public health centers in the city of St. Louis, Mo. Socio-cultural constructs were measured with scales developed by the project team and found to perform well in psychometric testing in a pilot sample of 72 African American women from low income urban housing communities. The researchers found that receiving a recommendation from a health care provider was an important predictor of mammography use, and unlike many studies of breast cancer screening in underserved women, they did not find an association between education, income, and mammography use. Less knowledge about mammography, breast cancer, and its treatment were associated with women who were younger, less educated, unemployed, present time orientation, and those who had no family history of breast cancer (Lukwago, et al. 2003). The Health Belief Model The Health Belief Model is an effective tool that has been applied to a wide range of health behavior and subject populations. The HBM is based on the assumption that screening behaviors result from personal decisions that are founded on perceived susceptibility, perceived seriousness, benefits and barriers to action and confidence (Hall et al., 2005). According to Becker the Health Belief Model helps to explain and predict health behaviors by examining the relationships between beliefs, knowledge and decision to take action, as well as predicting health behaviors (Becker, 1974). Health motivation or cues to action has since then been added by Becker to the four original concepts, which are: perceived susceptibility, perceived severity/seriousness, perceived benefits, and perceived barriers. Becker postulates that health seeking behavior is influenced by a person s perception of a threat posed by a health problem and the value associated with actions aimed at reducing the threat (Graham, 2001). See Figure 1. for a summary of the concepts of the HBM. In other words, a person will take a health-related action, for example, BSE, if that person 1) feels breast cancer (a negative health condition) can be avoided, 2) has a positive expectation that taking a recommended action (performance of BSE) will avoid a negative health condition, for example, performing BSE will be effective at preventing breast cancer, and 3) believes that she can successfully take a recommended health action, for example, she can perform BSE with confidence (Graham, 2001; CancerNet, 2001). 14

26 Demographic Variables (age, sex, race, ethnicity, etc.) Socio-psychological variables (personality, social class, peer and reference group pressure etc.) Structural variables (knowledge about breast cancer, prior contact with breast cancer etc.) Perceived benefits of Preventive action (BSE) Perceived barriers to Preventive action (BSE) Perceived susceptibility to breast cancer Perceived seriousness (severity of breast cancer) Perceived threat of breast cancer Likelihood of taking recommended preventive health action (BSE) Cues to Action FIGURE 1. Health Belief Model (NINH, 2008) The Health Belief Model Scale The Health Belief Model Scale was developed in 1984, and revised in later works, by Dr. Victoria L. Champion (Champion, 1997; Facione, 2000). In 1993, to test the validity and reliability of the HBM, Champion revised the HBM and incorporated the concept of selfefficacy, which is one s confidence in the ability to successfully perform an action. She became the first to use the HBMS, Health Belief Model Instrument Scale, in relation to BSE performance/adherence. Self-efficacy in this study refers to African American women s confidence in their ability to perform BSE. Susceptibility in the study refers to African American women s perceived vulnerability to breast cancer or the risk of getting breast cancer. Severity refers to African American women s opinion of the seriousness of breast cancer and the cost associated with breast cancer. Benefits refer to the usefulness, perceived positive outcome, of 15

27 the advised action (performance of BSE) to reduce risk or seriousness. Barriers refer to real and psychological cost associated with BSE. The relationship between this model and the stated problem will result in more women performing BSE. Summary The incidence of breast cancer is lower among African American women but African American women tend to have a more advanced stage of the disease at diagnosis and poorer survival rates, stage-for-stage, than Caucasian women. In the year 2000 that rate was 30% more than that of Caucasian women (ACS, 2005). Research has shown a decrease in mortality, hence improved survival rate, with effective screening strategies such as BSE, CBE, and mammogram (NCI, 2007; ACS, 2006; Ries et al., 1996). African American women, however, are less likely than Caucasian women to perform BSE despite the documented higher morbidity and mortality of breast cancer among that population group. Efforts to reduce breast cancer mortality in African American women must, therefore center on early detection of the disease. The literature review supports the identified variables; susceptibility, benefits, confidence, knowledge, personal and social influences and attitudes, to be the significant factors associated with breast screening behaviors in regard to performance of BSE. The literature also reveals psychological barriers such as fear and perceived risk, to be the greatest obstacles to overcome and the key to improving African American women s participation in breast cancer prevention and health maintaining activities. Addressing these issues should take precedence in promoting breast cancer prevention teachings and techniques to African American women and other minorities. 16

28 CHAPTER 3 METHODOLOGY This chapter examines the methodology used to collect and analyze the data in order to establish relationship(s) between health beliefs, knowledge, and attitudes, among African American women in regard to the performance of BSE. Discussions will outline the study design, setting, sampling plan and procedure, research instrument, protection of human subjects and data analysis. Research Design This is a descriptive correlative study, designed to examine the relationship between health beliefs, knowledge, attitude and the performance of breast self examination (BSE) among African American women. The survey questionnaire, Champion s Breast Cancer Screening Beliefs Instrument Scale, found in Appendix A and demographic questions in Appendix B, addresses the research questions of the study: Research Questions 1. What is the relationship between health beliefs, knowledge, attitudes and the frequency of breast self examination in African American women? 2. What is the relationship between education level, age, self history of breast disease, family history of breast cancer, socioeconomic status, health insurance, spirituality and the frequency of breast self examination in African American women? 3. What is the relationship between a health care provider recommending BSE and frequency of BSE performance? Variables The independent variables in this study were health beliefs, knowledge, attitude and socio-demographics: age, educational level, family history, socioeconomic status, insurance coverage, and religion. The dependent variable was performance of breast self examination (BSE), as measured by question 9 and 10 of the demographic data. Settings The primary sites for recruitment were a moderate size family practice clinic, two rural churches in north Florida and one church in south Florida. These sites were chosen because they 17

29 serve a considerably diverse population of African American women, including a significant number of women age eighteen and older. Permission was granted from priests, pastors and directors of the facilities, for the use of each site. See Appendix C for all permission letters, including permission to use Champion s Breast Cancer Screening Beliefs Instrument (HBMS). Additional participants were identified through network sampling; friends and relatives of women who self identify during recruitment as African American, Black, or Caribbean. Sample From November, 2007 to February, 2008, 131 adult African American women between the ages of 20-65, with no history of breast cancer, who could read and understand English, were recruited to participate in the study. A convenience sample of 150 were targeted, 131 was the actual number of respondents who agreed to participate. They were recruited from five counties in Florida, (Broward, Leon, Gadsden, Madison, and Wakulla), through community settings such as churches, doctors offices, and through friends and relatives of women who self identify during recruitment as African American, Black or Caribbean. Criterions for exclusion in the study were African American women with any personal history of breast disease, and those who do not speak, understand and write English. Sampling Procedure Permission was first obtained from the Institutional Review Board at Florida States University. See Appendix D for the IRB approval. Permission was also granted from priests, pastors and directors of each facility, for the use of each site. Subjects were recruited through use of advertisement, flyers, church newsletter announcements, participants referral and women s social club announcements, as well as through friends and relatives of women who self identify as African American. At the start of each session participants received a complete package containing the following: 1) a consent form, cover letter describing the purpose of the study, what will be asked of participants, risks and benefits, confidentiality, right to withdraw and who to contact with question about the study. See Appendix E for the informed consent. The purpose of the study was verbally explained to all participants after they received the package. They were also informed that participation is voluntary, and confidentiality insured. At the beginning of each session, the participants were encouraged to ask as many questions as possible, for clarification purposes. The packet was given only to women who met each criterion, as they waited to be seen 18

30 by health care providers at the doctors offices. At the churches, a time was set for group meetings. At the beginning of each group meetings, the purpose of the study and method of participation were extensively explained and questions satisfactorily answered. The participants were provided adequate amount of time (20-30 minutes) to complete the survey; the questionnaires were then collected and placed in the researcher s locked briefcase. Collection of data was followed by refreshments and a fifteen minute power point presentation on breast health; which covered proper performance of BSE and signs and symptoms to report to health care providers as well as adequate time for follow-up questions. Protection of Human Subjects The rights of human subjects were protected, as follow, in accordance with the Florida State University Institutional Review Board (IRB): 1. Participants were informed that participation was completely voluntary and that they can stop anytime if they felt anxious or uncomfortable completing the survey. Participants were also guaranteed complete confidentiality and anonymity. 2. The informed consent form, delineating the purpose of the study, method of participation, allotted time, risks and benefits, right to withdraw and contact persons were given and explained in plain language to all participants. 3. The participants were informed that completing and returning the survey will be interpreted as consent and that names, signatures, address and phone numbers were not necessary. 4. Participants were instructed to place finished survey themselves in the designated receptacles. The collected data were kept confidential, according to the guidelines of Florida State University and the participating facilities. The researcher did not record participant s names and other identifying data. Participants were each assigned an identification number. No contact will be maintained with participants post study. The completed data is kept in a locked box in the researcher s home. Data was viewed only by researcher and statistical consultant. Data will be destroyed (shredded) after three years, in accordance to Florida State University. Research Instruments The two instruments used in this research study were the demographic questionnaire and Champion s Breast Cancer Screening Instrument Scale (HBMS). The demographic questionnaire 19

31 contains 16 questions related to participants personal history: race (ethnicity), age, marital status, education, employment, health insurance, socioeconomic status, BSE practice and recommendation of BSE by health professional, health screening history, and religion. Champion s Breast Cancer Screening Beliefs Instrument consists of 41-items, representing the six scales; susceptibility (5 items); seriousness (7 items); benefits-bse (6 items); barriers-bse (6 items); confidence (11 items); health motivation (7 items). Each concept was measured in a distinct sub-scale that examines participants perception of susceptibility to breast cancer, belief in the seriousness of the threat of breast cancer to themselves, benefits of BSE, barriers to BSE, and their confidence in performing BSE as well as health motivation. Each item is rated on a 5-point Likert-type scale; with answers raging from strongly agree (5 point) to strongly disagree (1 point). Champion revised HBMS instrument has been reported as having a high internal consistency with Cronbach s alpha coefficients from and test-retest correlations ranging from Data Analysis Statistical analysis of the collected data was done using the Statistical Package for Social Sciences (SPSS) Windows 16.0 version. Characteristics of African American women who perform breast self examination (BSE) were compared with those who did not perform BSE. Descriptive statistics; frequency counts, chi-squares, correlations, were done. Summary This descriptive correlative study was designed to examine the relationships between health beliefs, knowledge, and attitudes of African American women between the ages of 18-65, that may serve as barriers to the performance of breast self-examination (BSE). A convenience sample of 131 African American women were obtained through several sites such as churches, family practice clinics; additionally participants were also identified through network sampling; friends and relatives of women who self identify during recruitment as African American, Black or Caribbean. A demographic questionnaire and Champion s Health Belief Model Instrument Scale was used to measure the health belief of the women concerning the performance of breast self-examination. Descriptive statistics; frequency counts, chi-squares, and correlations were done to answer the research questions. 20

32 CHAPTER 4 DATA ANALYSIS This chapter includes description of the study sample and detailed results of the statistical analysis of the collected data. The primary goal of the study was to examine the relationship between health beliefs, knowledge, attitudes and the BSE performance among African American women. The secondary goal of the study was to examine the relationship between sociodemographic characteristics of African American women and their BSE performances. Description of Sample A convenience sample of 131 African American women was recruited through several sites in north and south Florida. Of the 200 questionnaires distributed, 131 were completed and returned to the researcher. A total of 69 women declined. Some U.S. borne participants categorized themselves as Haitians, Africans or West Indians, while others who were born elsewhere, but came to the U.S. young, categorized themselves as African Americans. For the purpose of this research study, African American women encompassed all women whose ancestries are rooted in the continent of Africa. Breast Self Examination Breast self examination, is an easy, safe, and effective measure that all women can perform for themselves. Breast self examination has been found to be underutilized by African American women and other minorities. The primary goal of the study was to examine the relationships between health beliefs, knowledge, attitudes and BSE performance among African American women. The BSE frequency of the selected women could not be calculated by chisquare test because 13 cells (54.2%) had expected counts less than five, n<5. Therefore BSE performance was cross-tabulated by age group. See Table 1 for a summary of BSE frequency for past 12 months. Based on the results of the data only 2 (1.6%) of the women under 20 reported performing BSE monthly. One (.8%) performed BSE 8-12 times per year, 3 (2.4%) performed BSE 3-7 times and 2 (1.6%) performed BSE 2 times or fewer. A total of 8 (6.3%) of women under 20 performed BSE sometimes within the past 12 months. Women 50 and over did slightly better. In the age range, 12 (9.4%) performed BSE sometimes within the past 12 months. 21

33 And the 60 and above range, 10 (7.9%) performed BSE sometimes within the past 12 months. Forty six (36.2%) of women between the ages of performed BSE, 21 (16.5%) reported performing BSE 2 times or fewer. Twenty three (18.1%) of women years old and 28 (22.0%) of women reported practicing BSE within the past 12 months. A total of 30 (23.6%) of participants practiced BSE monthly, 24 (18.9%) practiced 8-12 times, 31 (24.4%) practiced 3-7 times, and 42 (33.1%) practiced 2-or fewer times. Table 1. BSE frequency for the past 12 months Age Group BSE frequency (number and percentage) Total Monthly 8-12 times 3-7 times 2< times Under 20 2 (25%) 1(12.5%) 37.5%) 2(25%) (13%) 9(19.6%) 10(21.7%) 21(45.7%) (21.7%) 5(21.7%) 8(34.8%) 5(21.7%) (28.6%) 5(17.9%) 8(28.6%) 7(25%) (50%) 2(16.7%) 0(0%) 4(33.3%) > 3(30%) 2(20%) 2(20%) 3(30%) 10 Total 30(23.6%) 24(18.9%) 31(24.4%) 42(33.1%) 127 HBMS Scale and BSE frequency Researchers hypothesized that African American women s decision to participate in disease preventive behavior, such as routine BSE, and mammograms, is influenced by differences in cultural beliefs, which in turn affect health beliefs and attitudes. Becker, in 1994, has shown that interventions based on the HBM variables of perceived susceptibility, benefits, and barriers to increase breast cancer screening significantly. It was applied to the performance 22

34 of BSE and replicated variables of susceptibility, seriousness, benefits, barriers, health motivation, control, and knowledge of breast cancer and BSE were measured (Champion, 1987). Health Beliefs, Attitudes and Knowledge Regarding BSE and Breast Cancer The HBMS was instrumental in establishing relationships between the variables health beliefs, knowledge, attitudes among the African American participants in regard to breast cancer and the effects of these variables on their BSE performances. Questions 1-41 of the HBMS and question 1 of the demographic data were able to assess the health beliefs, knowledge and attitude regarding breast self examination, breast cancer, breast cancer treatments of the participants. In regard to their religious data, question number 20, the analyzed data showed that the majority of the participants, 66 (52.4) believed that God would help the doctors to cure their breast cancer and 26 (20.6%) agreed that the church praying for them would cure the cancer; 19 (15.1%) believed more in God to cure their cancer than medical treatment; and another 4 (3.2%) believed that only a religious miracle could cure their cancer. Each concept of the HBMS (susceptibility, seriousness, benefits, barriers, confidence, and health motivation), was measured in a distinct sub-scale that examine participants health beliefs and perception of susceptibility to breast cancer, belief in the seriousness of the threat of breast cancer to themselves, benefits of BSE, and barriers to BSE, their confidence in performing BSE and health motivation. Mean scores were obtained for each of the six sub-scale of the HBMS. The items in each sub-scale were added up to provide a total score for each of the subscales; obtaining the mean score of items in each sub-scale makes the data easier to interpret. Correlation between the concepts of the HBMS and BSE frequency was done to evaluate relationships between the concepts of the HBM (susceptibility, seriousness, benefits, barriers, confidence, and health motivation), and the frequency of BSE. Relationships between variables were determined using Pearson s correlation coefficients. The 0.05 level of significance was used throughout the study. See Table 2 for a summary of the correlations of HBMS concepts and BSE frequency. 23

35 Table 2. Pearson s Correlations of HBMS Concepts and BSE Frequency Susceptibility Seriousness Benefits Barrier Confidence BSE frequency Susceptibility Correlation 1 ** ** ** (*) Sig.(2 tail) N Seriousness Pearson correlation ** ** Sig.(2 tail) N Benefits Pearson correlation ** ** ** Sig.(2 tail) N Barriers Pearson correlation ** ** 1 ** ** Sig.(2 tail) N Confidence Pearson correlation ** ** 1 ** Sig.(2 tail) N Health Motivation Pearson correlation ** ** ** (*) Sig (2 tail) 0.17 N 130 BSE frequency In past 12 months Pearson correlation 0.218(*) ** ** ** 1 Sig.(2 tail) N ** correlation not significant at the 0.05 level * correlation is significant at the 0.05 level (2-tailed) Susceptibility The susceptibility sub-scale of the HBMS consists of five items, this sub-scale measures participants own opinions of their chances of getting cancer. Based upon the result of the data, Pearson s correlation showed a positive correlation between susceptibility and frequency of BSE (r=.218, p=.014). Eighty-four (64.1%) of the participants disagreed with the statement It is 24

36 extremely likely I will get cancer in the future, 34 (26.0%) were neutral; while only 13 women agreed with the statement. Ninety-five (72.5%) disagreed with the statement My chance of getting breast cancer is great, and 22 (16.8%) were neutral, and 14 (10.7%) agreed with the statement. Ninety-five (72.5%), didn t see themselves as more likely than the average woman to get breast cancer. For some of the women, perceived susceptibility was correlated to high BSE frequency. Seriousness The seven items on the seriousness sub-scale measure participants own opinions of the severity of breast cancer and the consequences. In other words, the participants perceived breast cancer to be a threat and that there s a possibility that they personally are at risk. Based upon the result of the data, Pearson s correlation showed no significant correlation between the concept of seriousness and BSE frequency at the 0.05 level of significance. The participants did perceived breast cancer to be serious. Sixty nine point two percent of respondents agreed with the statement, Thought of breast cancer scares me. And 50% agreed, My whole life would change if I get breast cancer. Benefits The six items on the benefit sub-scale measure participants own opinions of how favorable the outcomes of performing BSE to be. It is a participant s opinion that certain actions, if taken, can prevent a problem from occurring. For example, early detection through BSE will guarantee that a woman won t get breast cancer or will catch it early enough for a cure to be possible. Pearson correlation showed that there was negative but insignificant correlation between the concept of benefits and BSE frequency (r=-.145, p=.104). Seventy-one percent agreed with the statement completing BSE monthly for a year will decrease my chance of dying from breast cancer and 110 (85.3%) agreed with the statement completing BSE each month will allow me to find lump early. One hundred ten of the study s participants believed BSE to be beneficial. The majority of the participants 110 (85.3) agreed with the statement completing BSE each month will allow me to find lump early ; 93 (71.0%) agreed with the statement completing BSE monthly will decrease my chance of dying of breast cancer; and 80 (61.1%) agreed with the statement doing BSE monthly will decrease my chance of requiring radical surgery. Low perceived benefits of BSE are correlated to decrease BSE performance. 25

37 Barriers The six items of the barrier sub-scale measures participants opinions of physical or psychological blocks to the performance of BSE. Perceived barriers are negative outcomes related to the performance of BSE. Pearson s correlation revealed that there was no significant relationship, at the 0.05 level of significance, between the concept of barrier and BSE frequency. The majority of the participants reported low barriers to BSE performance. One hundred thirteen (86.3) disagreed with the statement BSE will be embarrassing to me ; 104 (79.4%) disagreed with the statement BSE during the next year will make me worry about BSE; and 100 (77%) disagreed with the statement I feel funny doing BSE. Confidence Confidence refers to a participant s own ability to perform BSE correctly and identify abnormality. Based on the results of the analyzed data, Pearson s correlation revealed that there was no significant correlation between the concept of confidence and BSE frequency at the 0.05 level of confidence. A quarter of the participants reported feeling neutral regarding their ability to find breast lumps of difference sizes. Twenty-eight (21.5%) chose neutral in regard to this statement, I am able to find quarter size breast lump ; and 27 (20.8%) were neutral in regard to the statement I am able to find dime size breast lump ; 23 were neutral in regard to the statement if I develop breast cancer, I will be able to find lump with BSE, 22 chose neutral in regard to their ability to find lump if BSE is practiced alone. Even though the participants were aware of the benefits of BSE, they weren t confident in their ability to do it properly. Health Motivation Health motivations are possible activators that turn individual s perception of their health into actions that they can take to stay healthy. Activators may increase the person s perception of susceptibility to a disease, its seriousness, increase benefits, decrease disadvantages and barriers, increase motivation to change. The majority of the African American women expressed a value for health. Respondents expressed a need to have information that will keep them healthy, exercise regularly and obtain yearly physicals even when they are symptoms free. However based upon the results of the data Pearson s correlation revealed a negative and significant but weak correlation between the concept of health motivation and BSE frequency (r=-.196, p=.027). Increase BSE frequency was noted in women highly motivated to take care of their health. 26

38 In summary Pearson s correlation revealed significant but weak positive correlation between susceptibility and BSE practices, r=.218, p=.014; negative but insignificant correlation between the concept of benefits and BSE practice (r=-.145, p=.104); and a negative and significant correlation between the concept of health motivation and BSE frequency (r=-.196, p=.027). The results indicated that African American women who perceived breast cancer to be a threat that they personally are at risk for, are motivated to practice BSE regularly and have confidence in their ability to perform BSE correctly. Demographics The demographic data, summarized in Table 3, provided information regarding: age, ethnicity or ethnic background, marital status, income, education, additional questions covered BSE practice, recommendation of BSE by health professionals and religion. Health insurance coverage, religion, and personal and family history of breast cancer are on Table 4, which looks at the correlation of this demographic data and BSE frequency. Demographic Data Age Group. Graham et. al.,(2002) reported that older African American women, over the age 40, perceived breast cancer to be a greater threat and were more motivated than younger women regarding breast cancer prevention and early screening measures such as BSE and mammograms (Graham, 2002). Age varied from less than 20 to over 60 years of age among the participants. There were 47 (35.9%) participants between years of age, 23 (17.6%) were ages The data showed decreased low BSE frequency among the 60 and older age group and the 19 and younger women. But based on the results of the analyzed data, Pearson s correlation revealed that there was no significant correlation between age and BSE frequency at the 0.05 level of confidence (r=.051, p=.564). Marital status. Marital status did not seem to have significant effect over BSE practice. The majority of the women were single, 65 (49.6%), 47 (35.9%) were married, 13 (9.9%) divorced, and 6 (4.6%) widowed. Based on the results of the analyzed data, Pearson s correlation revealed that there was no significant correlation between marital status and BSE frequency at the 0.05 level of confidence (r=.126, p=.153). Low BSE frequency was noted with widowed women, 4 out of 6 did not perform BSE. Income. 52 (40.3%) annual income fell between 10,000 and 30,000, 28 (21.7%) earned between 31,000 and 50,000, 17 (13.2%) earned between 51,000 and 60,000, 8 (6.2%) earned 27

39 60,000+ or more and 24 (18.6) had no income. Most of the participants with no income were college students. Based on the results of the analyzed data, Pearson s correlation revealed that there was negative but insignificant correlation Table 3. Demographic Data Age Group Frequency Percent < > Total Race/ethnic of origin African American Haitian Jamaican West Indian Total Martial Status Single Divorced Married Widowed Total Income 10,000-30, ,000-50, ,000-60, ,000-> Education Bachelor Graduate level Associate High School No high school Total

40 Education. 27 (20.6%) earned a Bachelor degree, 18 (13.7%) earned a Master s or higher degree, 57 (43.5%) earned an Associate s, 19 (14.5%) a high school diploma, 10 (7.6) had not graduated high school. Based on the results of the analyzed data, Pearson s correlation revealed that there was no significant correlation between education and BSE frequency at the 0.05 level of confidence (r=.129, p=.144)between income and BSE frequency at the 0.05 level of confidence (r=.038, p=.673). As income increases, the BSE frequency of the participants decreases. Demographic Data and Frequency of BSE Religion. Religion has been shown to be a significant factor in the lives of African Americans, especially African American women. One hundred and eighteen (92.9%) were affiliated with some type of religion, 9 (6.2%) did not consider themselves religious. Based on the results of the analyzed data, Pearson s correlation revealed that there was negative but insignificant correlation between religion and BSE frequency at the 0.05 level of confidence (r=-.061, p=.498). Health Insurance. Most participants had health insurance coverage for yearly physical and mammogram, 48.9 % had health insurance. Based on the results of the analyzed data, Pearson s correlation revealed that there was negative but insignificant correlation between health insurance and BSE frequency at the 0.05 level of confidence (r=.-013, p=.887). Personal/family History of Breast Cancer. Research has shown that a very small percentage (30%) of African American women, especially those at increased risks for hereditary diseases adhere to the ACS recommendation guidelines. The data was analyzed for the influence of self-history of fibrocystic breast disease and family history of breast cancer on BSE frequency and the results were then compared with those of African American women without any limitations. One hundred and thirteen (86.9%) of the participants had no personal history of breast cancer, 17 (13.1%) participants had a personal history of fibrocystic breast disease, 15 (11.5%) practiced BSE and 2 (1.5%) did not. Pearson s correlation revealed a negative correlation between personal history of breast disease and BSE performance, r=-.201, p=.022. Family history of breast cancer has been revealed by Pearson s correlation to have no significant correlation with BSE frequency (r=.019, p=.832). The results indicated that women with personal history of breast disease were more likely to have a higher BSE frequency compare to 29

41 those with no personal history of breast diseases. Table 4 summarizes the correlations between the demographic characteristics of the participants and BSE frequency. BSE by Health Professionals. Assessment of recommendation of primary healthcare providers on the participants BSE frequency revealed surprising results. One hundred and four (83.7%), of the women performed BSE. 94 (72.9%) received recommendation from health care providers and did it, 10 did not practice BSE, but of 14 women whose care provider never recommended BSE, only 3 practice BSE, 11(8.5) did not. Pearson chi-square tests revealed the result to be significant, X 2 =17.48, P<.001. Table 4. Pearson s correlation of demographic data and BSE frequency (*) indicates a weak correlation; N= 130 unless indicated History of BSE Performance Age group Pearson Correlation.051 Sig. (2-tailed).564 Marital Status Pearson Correlation.126 Sig. (2-tailed).153 Education Pearson Correlation.129 Sig. (2-tailed).144 Yearly Income Pearson Correlation Sig. (2-tailed).673 N 128 Breast Cancer History Pearson Correlation (*) Sig. (2-tailed).022 Religion Pearson Correlation Sig. (2-tailed).498 N 126 Family History of breast CA Pearson Correlation.019 Sig. (2-tailed).832 Health Insurance Pearson Correlation Sig. (2-tailed)

42 Recommendation by primary health care provider was a most significant difference found between the two groups. Pearson chi-square tests revealed the result to be significant, X 2 =17.48, P<.001 This findings has great implication for practice, according to the data, recommendations by health care providers could have resulted in more women practicing BSE, detecting breast tumors at an early stage is paramount to survival (ACS, 2008). For a summary of recommendation of BSE by health professionals and history of participants BSE frequency see Table 5. Table 5. Recommendation of BSE by Health Professional History of BSE Performance Yes (%) No (%) Total Recommendation of BSE Yes (%) 94 (72.9%) 10(80.6%) 104 By health professional No (%) 14 (8.5%) 11 (19.4%) 25 HBMS Validity and Reliability Champion established content validity for the revised HBMS in She revised the HBMS scales measuring perceived susceptibility, benefits and barriers and reported a high internal consistency with Cronbach s alpha coefficients ranging from and test-retest correlations ranging from Table 6 summarizes the reliability analysis done for this study showing an internal consistency, using Cronbach s alpha, ranging from.795 to.922. Summary Data analysis showed significant positive correlation between susceptibility and BSE practices (r=.218, p=.014); negative but insignificant correlation between the concept of benefits and BSE practice (r=-.145, p=.104); and a negative and significant correlation between the 31

43 concept of health motivation and BSE frequency (r=-209, p=.017). No significant correlation existed between perceived seriousness, barriers, and confidence. There were no significant correlations between socio-demographic characteristics: age, marital status, education, family history of breast cancer, health insurance coverage. Based on the results of the analyzed data, Pearson s correlation revealed that there was negative but insignificant correlation between Table 6. Internal Consistency and Reliability of the HBMS (N=131) Mean Std. Deviation Cronbach s Alpha Susceptibility Seriousness Benefits Barriers Confidence Health Motivation income and BSE frequency at the 0.05 level of confidence (r=.038, p=.673). As income increases, the BSE frequency of the participants decreases. A negative but insignificant correlation was found between religion and BSE frequency at the 0.05 level of confidence (r=.061, p=.498); and a negative correlation between personal history of breast disease and BSE performance, r=-.201, p=.022. Family history of breast cancer had no significant correlation with BSE frequency (r=.019, p=.832). Recommendation by health care provider was positively related to increase frequency of BSE. There was a negative correlation between personal history of breast disease and frequency of BSE performance. The results showed that women, who perceived the most benefits to BSE practice, were adherent to the ACS guidelines. They also had better knowledge of breast cancer, 32

44 more confidence in their ability to perform BSE, lower perceived barriers to BSE, and valued their health more. The results of the data indicated is that health beliefs play a more important role than demographics characteristics in determining BSE performances of African American women. 33

45 CHAPTER 5 DISCUSSION This chapter contains the following sections: a discussion of the study s findings, an application of the findings to this study s conceptual framework, a discussion of this study s assumptions and limitations, the implications for advance nursing practice and education, and recommendations for future research. Health Beliefs, Attitudes and Knowledge Regarding Breast Cancer and BSE The primary goal of the study was to examine the relationships between the health beliefs, knowledge, attitudes and the performance of BSE among African American women. Cultural beliefs have been found to have a considerable hold on patients health beliefs, healthseeking activities, and adherence to prescribed regimens such as BSE. Guidry, et al (2002) found that cultural and psychological reactions, such as fear, distrust, fatalism, and other historic rooted factors, to be major determinants to participation in health screening by African American women. Seeing cancer as a disease with no cure or as a disease that surgery and treatment can cure, can be a deterrent to compliance with BSE. The majority of the participants, 66 (52.4) reported that God would help the doctors to cure their breast cancer and 26 (20.6%) agreed that the church praying for them would cure the cancer; 19 (15.1%) believed more in God to cure their cancer than medical treatment; and another 4 (3.2%) believed that only a religious miracle could cure their cancer. This finding showed that study participants had knowledge deficit regarding breast cancer and breast cancer treatment. This finding is in accordance to similar findings by Barroso et al (2000). Their results showed evidence of knowledge deficit regarding breast cancer among African American women, and a belief that breast cancer has an element of chance or luck, God or a higher power decides who gets breast cancer and who gets cured of it. Their most significant finding was that African American women with a greater belief in powerful others also believed that early diagnosis gives them a longer time to worry about something that they were not in control of. Data analysis showed a significant positive correlation between susceptibility and BSE practices, r=.218, p=.014; negative but insignificant correlation between the concept of benefits and BSE practice (r=-.145, p=.104); and a negative and significant correlation between the 34

46 concept of health motivation and BSE frequency (r=-209, p=.017). No significant correlation existed between perceived seriousness, barriers, and confidence. The majority of the participants agreed on the beneficial aspect of BSE, but their confidence in their ability to do it properly was low. Seventy-nine (60.3) agreed that BSE could help detect breast lumps, 88 (67.2%) agreed with the statement if I develop breast cancer, I will be able to find a lump with BSE. Eighty-four (64.1%) of the participants disagree with the statement it is extremely likely I will get cancer in the future, 34 (26.0%) were neutral, while only 13 women agreed with the statement. Ninety-five (72.5%) disagreed with the statement My chance of getting breast cancer is great, 22 (16.8%) were neutral, 14 (10.7%) agreed. Ninety-five (72.5%) of the participants did not see themselves as more likely than the average woman to get breast cancer. Frequency of BSE decreases as susceptibility to breast cancer decreases also, which accounts for the fluctuations with BSE practices. A total of 30 (23.6%) of participants practiced BSE monthly, 24 (18.9%) practiced 8-12 times, 31 (24.4%) practiced 3-7 times, and 42 (33.1%) practiced 2-or fewer times. An increase in perceived susceptibility has been linked to an increase in breast cancer screening (Champion, 1998). The expectation was for a high BSE frequency to be strongly correlated with low barriers, high susceptibility, seriousness, benefits, and confidence, which clearly was not the findings; susceptibility (r=-.145, p=.104), benefits (r=-.145, p=.104); barriers, confidence, and seriousness were not significantly correlated to BSE frequency. There was a negative and significant correlation between the concept of health motivation and BSE frequency (r=-.196, p=.027). The participants may lack activators (recommendation from health care providers, culturally appropriate learning tools, health minded friends and relatives) that are necessary to change their perception of susceptibility to breast cancer and its seriousness, increase benefits of BSE, decrease barriers to BSE, and motivation to practice BSE on a regular basis. Champion explained that many African American report adequate frequencies for BSE but they may not be proficient at it or lack the confidence in their ability to do it properly. According to the results of the data, the participants who practiced BSE on a regular basis were more likely to have better knowledge of breast cancer, more confidence in their ability to perform BSE, lower perceived barriers to BSE, and place a higher value on their health. 35

47 Socio-demographic characteristics and BSE Performance of African American Women The secondary goal of the study was to examine the relationship between age, marital status, education, income level, health insurance coverage, recommendation of BSE by health care providers, self and family history of breast disease and their effects on the BSE performance of African American women. Recruited for the study were 131 adult African American women between the ages of Fifty six (36.2) of women were between the ages of 20-29, 23 (18.1%) of the women were between years old, and 28 (22.0%) of the women 40-49, 13 (9.9%) were ages 50-59, and 11 (8.4%) were ages The number of women who reported compliance to BSE is surprisingly high. The majority of the participants 109 (83.8%) reported practicing BSE within the past 12 months. Fifty-six (43.1%) women were single women, 40 (30.8%) were married, 13 (9.9%) were divorced, and 6 (4.6%) were widowed. Twenty-seven (20.6%) earned a Bachelor degree, 18 (13.7%) earned a Master s or higher degree, 57 (43.5%) earned an Associate s degree, 19 (14.5%) a high school diploma, 10 (7.6) had not graduated high school. Most participants were employed, 40.3% earned between 10,000 and 30,000 annually, 21.7% earned 30,000-50,000, and 13.2% were in the 50,000-60,000 annual income range. Most participants had health insurance coverage for yearly physical and mammogram, 48.9 % had health insurance, 99.2% had no personal history of breast cancer, and (61.8%) had no family history of breast cancer. Based on the results of the analyzed data, Pearson s correlation revealed that there was negative but insignificant correlation between health insurance, income and BSE frequency at the 0.05 level of confidence, for health insurance (r=.013, p=.887) and for income(r=.038, p=.673). As income increases, the BSE frequency of the participants decreases. Data analysis showed that there were no significant correlations between age, marital status, education, family history of breast cancer. The findings were in accord with similar studies on African American women, (Graham, 2002; Champion & Scott, 1997). In contrast to Graham s study, this study s findings revealed decrease in BSE frequency associated with young adults, nineteen and younger, older adults, sixty and older, and marital status (widowed). Younger women ages (36.2%) has the highest frequency score in a year, followed by the range. The results demonstrated that as age increases, frequency decreases. In contrast Graham reported that African American women over the age 40 perceived breast cancer to be a greater threat and were therefore more motivated than younger women regarding breast cancer prevention and early screening measures such as BSE and mammograms (Graham, 2002). Data 36

48 analysis indicated that decrease BSE frequency was associated not only with the 60 and older women but also the 20 and younger group as well. The younger women may understandably not view cancer as threat, thus compliance with BSE practice, as a waste of time. A possible explanation could be that the older African American women, 60 and older, may lack the motivation to practice breast screening or health promoting activities, because they may perceive a lack of control over the outcome of a potential disease, like breast cancer, and may also have no understanding of the benefits, BSE practice or the confidence to do BSE correctly. Champion (1997), examined factors that predicted mammography and breast self examination in a group of low income African American women, her findings revealed low frequency was associated with marriage and widowhood. In summary, the results of this study suggested that breast cancer screening practices among African American women is complex and difficult to generalize. Health officials should however continue in their efforts to increase the knowledge base of this population group by making available cultural appropriate learning tools, they should also implement measures to improve the cultural competence of health professionals delivering care to that population group. Limitations Several factors limited subjects participation in the study and only two factors limited the general ability of the study: 1. The length of the questionnaire, a total of 57 questions, was too limiting. Some of the participants stated that the length of the study and the amount of time it takes to answer the questions as being impractical. 2. Some participants stated that the type of questions asked were too personal. The personal aspect of the questions (income, education level, county of residence, religious affiliation, and some cancer related questions) were deterrent to participation and therefore limiting to the study. 3. A few of the older women stated that the frightful nature of the questions as the reason for non-participation. The avoidance of talking or thinking about cancer is common among older African American women. 4. Some of the participants could have provided answers that they felt were, the right answers versus what they actually believed and practiced. 37

49 5. Participants were selected from a specific geographical area of the United States, North and South Florida, the results therefore is limited only to the region and generalization to other parts of the country may not be possible. Implications for Nursing Practice and Education Persuading asymptomatic people at risk to undergo routine cancer screening and prevention activities has been found to be difficult. Nurse practitioners and other health care professionals must be cognizant of the considerable hold that cultural beliefs have on patients health beliefs, health-seeking activities, and health care practices, this of course include adherence to prescribed regimens. Providers are in the best position to increase the knowledge base, to dispel cancer myths, break down barriers and be a true patient advocate, no matter the level of difficulty. The first step should be aim at increasing the knowledge base and confidence of African American women through the development of culturally sensitive group educational training that will empower African American women as well as make them aware of their cancer risks, and cancer screening measures. The second step should address culturally specific barriers, e.g., cancer fatalism, fear and perceived risk, the greatest obstacles to overcome and the key to improving African American women s participation in breast cancer prevention and health maintaining activities. This may lead to an increase in the performance of BSE, and increase use of mammography and annual CBE, thus a decrease in breast cancer mortality rates in African American women and other minorities. Lastly, practitioners can start reaching out to community leaders through advocacy groups and churches in the African American communities. Glanz et al., (2003) found that core cultural values emphasizing family, interdependence, religion, and a holistic view of health to be important factors that influence screening behaviors. Interventions aim at teaching women about BSE, thus truly decreasing the mortality rate of breast cancer both for Caucasian and African American women, is a major role that all healthcare professionals should undertake. Recommendations For Future Nursing Research There are multitudes of research studies addressing the high mortality rate of African American women in regard to breast cancer and the lack of participation in breast cancer prevention and health maintaining activities, the results however are still inconclusive and some are quite confusing. More effective studies are still needed. This study suggests only possible explanations for their reticence in obtaining routine screenings, thus leading to low survival rates 38

50 for African American women. The results of the current study should not be accepted as definite, but should be considered only as starting point in addressing the problem. More research should be done to determine the roles of fatalism, lack of access to proper care and treatment, and lack of culturally competent providers, in African American women s presentation with more advanced stages of breast cancer at diagnosis. Future research should also examine larger sample size of multiethnic populations, the results of such studies could lead to increase development of more language appropriate educational materials for non-english speakers and materials appropriate to the clients educational level. Susceptibility to cancer and effectiveness of early screenings and cancer treatments are believed by some African American women to be associated with chance or luck or powerful others, future research should focus on the relationship between African American women beliefs about breast cancer and their health locust of control. Summary The health beliefs and health practices of African American women in regard to breast cancer screening have been shown to be extremely complex. Numerous studies have attempted to address this complex issue, but to no avail, their conflicting results have only added to the confusion. The findings of this study, alone, will not provide the sought after answers, but it may provide insight into African American women s health practices, beliefs, perceived barriers such as fear, perceived risk, and fatalistic attitudes, a better understanding of which is the key to improving their participation in breast cancer screening and health maintaining activities. An increased awareness and understanding of facilitators and barriers to breast cancer screening can assist health care providers in not only addressing these issues, but also in the development of culturally sensitive and appropriate educational interventions tailored for African American women, this may lead to an increase in the performance of BSE, thus a decrease in breast cancer mortality rates in African American women and other minorities. 39

51 APPENDIX A HEALTH BELIEF MODEL SCALE 40

52 Health Belief Model Scale Questionnaire Completion and return of this questionnaire will be interpreted as consent to a subject in this study. Please circle the correct choice, using the following codes for your answer: 1. SD = Strongly Disagree (You strongly disagree with the statement) 2. D = Disagree (You disagree with the statement) 3. N = Neutral (You have no feelings about this statement) 4. A = Agree (You agree with the statement) 5. SA = Strongly Agree (You strongly agree with the statement) SUSCEPTIBILITY 1. It is extremely likely that I will get breast cancer in the future. SD D N A SA 2. I feel that I will get breast cancer in the future. SD D N A SA 3. There is a good possibility that I will get breast cancer SD D N A SA in the next ten years. 4. My chances of getting breast cancer are great. SD D N A SA 5. I am more likely than the average woman to get breast cancer SD D N A SA SERIOUSNESS 6. The thought of breast cancer scares me. SD D N A SA 7. When I think of breast cancer, my heart beats faster. SD D N A SA 8. I am afraid to think about breast cancer. SD D N A SA 9. Problems I would experience with breast cancer would last a long time. SD D N A SA 10. Breast cancer would threaten a relationship with my husband or partner. SD D N A SA 11. If I had breast cancer, my whole life would change. SD D N A SA 12. If I developed breast cancer, I would not live longer than five years. SD D N A SA 41

53 BENEFITS OF BSE 13. When I do breast self-examination I feel good about myself. SD D N A SA 14. When I complete monthly breast self-examination I don t worry as much SD D N A SA about breast cancer. 15. Completing breast self-examination each month will allow me to SD D N A SA find lumps early. 16. If I complete breast self-examination monthly during the next year I will SD D N A SA decrease my chance of dying from breast cancer. 17. If I complete breast self-examination monthly I will decrease my chance of SD D N A SA requiring radical and disfiguring surgery if breast cancer occurs. 18. If I complete monthly breast self-examination it will help me find a lump SD D N A SA which might be cancer before it is detected by a doctor or a nurse. BARRIERS TO BSE 19. I feel funny doing breast self-examination. SD D N A SA 20. Doing breast self-examination during the next year will make me worry SD D N A SA about breast cancer. 21. Breast self-examination will be embarrassing to me. SD D N A SA 22. Doing breast self-examination will take too much time. SD D N A SA 23. Doing breast self-examination will be unpleasant. SD D N A SA 24. I don t have enough privacy to do breast self-examination. SD D N A SA CONFIDENCE 25. I know how to perform breast self examination. SD D N A SA 26. I am confident I can perform breast self-examination correctly. SD D N A SA 27. If I were to develop breast cancer, I would be able to find a lump by SD D N A SA performing breast self examination. 28. I am able to find a breast lump, if I practice breast self-examination alone. SD D N A SA 29. I am able to find a breast lump which is the size of a quarter. SD D N A SA 42

54 30. I am able to find a breast lump which is the size of a dime. SD D N A SA 31. I am able to find a breast lump which is the size of a pea. SD D N A SA 32. I am sure of the steps to follow for doing breast self-examination. SD D N A SA 33. I am able to identify normal and abnormal breast tissue when I do SD D N A SA breast self-examination. 34. When looking in the mirror, I can recognize abnormal changes in my breast. SD D N A SA 35. I can use the correct part of my fingers when I examine my breast. SD D N A SA HEALTH MOTIVATION 36. I want to discover health problems early. SD D N A SA 37. Maintaining good health is extremely important to me. SD D N A SA 38. I search for new information to improve health. SD D N A SA 39. I feel it is important to carry out activities which will improve my health. SD D N A SA 40. I exercise at least three times a week. SD D N A SA 41. I have regular health check-ups even when I am not sick. SD D N A SA 43

55 APPENDIX B DEMOGRAPHIC DATA 44

56 45

57 APPENDIX C PERMISSION LETTERS 46

58 50

59 51

60 52

61 53

62 54

63 APPENDIX D IRB APPROVAL LETTER 55

64 56