Distrust, predisposition to use health services and breast cancer screening: results from a multicultural community-based survey.

PURPOSE: To examine whether and how distrust of the health system and predisposition to use healthcare services influence frequency of mammograms and Clinical Breast Exams (CBEs). METHODS: A community-based survey recruited 184 women (age 47+/-12); 49% were college-educated, 77% had health insurance, and 57% were non-white. Distrust was measured with a four-item scale (Cronbach alpha=0.71); predisposition to use health services with an 11-item scale (Cronbach alpha=0.84). Ordinal regression analysis was used to test two models examining "time since last mammogram" and "time since last CBE." The later model had a better goodness-of-fit, as indicated by a non-significant, Pearson coefficient. FINDINGS: Distrust to the health system was significantly correlated with age (r=-0.19*), income (r=-0.16*), and predisposition to use health services (r=-0.26**). Distrust predicted time since last CBE (B: 0.37, SE: 0.19*), which in turn was significantly correlated with time since last mammogram (r=0.44**). Predisposition to use health services predicted time since last CBE (B: -0.78, SE: 0.19**) and time since last mammogram (B: -0.47, SE: 0.22**). Insurance predicted time since last CBE (B: -0.94, SE: 0.44*), while age (B: -0.21, SE: 0.03**) and income (B: -0.19, SE: 0.09*) predicted time since last mammogram. CONCLUSION: Distrust of the healthcare system and predisposition to use health services influence breast cancer screening directly. Distrust interferes with behavioral patterns that favor recurrent breast cancer screening. PRACTICE IMPLICATIONS: Trustworthiness in the healthcare system and positive attitudes for the use of, health services enhance routine breast cancer screening. *p<0.05, **p<0.001.

Why some women have an optimistic or a pessimistic bias about their breast cancer risk: experiences, heuristics, and knowledge of risk factors.

Perceived risk to a health problem is formed by inferential rules called heuristics and by comparative judgments that assess how one's risk compares to the risk of others. The purpose of this cross-sectional, community-based survey was to examine how experiences with breast cancer, knowledge of risk factors, and specific heuristics inform risk judgments for oneself, for friends/peers, and comparative judgments for breast cancer (risk friends/peers - risk self). We recruited an English-speaking, multicultural (57% nonwhite) sample of 184 middle-aged (47 + or - 12 years old), well-educated women. Fifty percent of participants perceived that their breast cancer risk was the same as the risk of their friends/peers; 10% were pessimistic (risk friends/peers - risk self < 0), whereas 40% were optimistic (risk friends/peers - risk self > 0). Family history of breast cancer and worry informed risk judgments for oneself. The availability and cultural heuristics specific for black women informed risk judgments for friends/peers. Knowledge of risk factors and interactions of knowledge with the availability, representativeness, and simulation heuristics informed comparative judgments (risk friends/peers - risk self). We discuss cognitive mechanisms with which experiences, knowledge, and heuristics influence comparative breast cancer risk judgments. Risk communication interventions should assess knowledge deficits, contextual variables, and specific heuristics that activate differential information processing mechanisms.

Underestimation of breast cancer risk: influence on screening behavior.

PURPOSE/OBJECTIVES: To describe perceived breast cancer risk, identify the percentage of women with inaccurate risk perceptions, and examine the influence of perceived and objective risk on screening behavior. DESIGN: Descriptive, correlational, cross-sectional. SETTING: Community settings in a metropolitan area on the western coast of the United States. SAMPLE: Multicultural sample of 184 English-speaking women (57% non-Caucasian, X age = 47 +/- 12 years) who have never been diagnosed with cancer. METHODS: Two perceived risk scales (verbal and comparative) and the Gail model were used to assess perceived and objective breast cancer risk, respectively. MAIN RESEARCH VARIABLES: Perceived breast cancer risk, objective breast cancer risk, screening behavior. FINDINGS: Participants reported that they "probably will not" get breast cancer and that their risk was "somewhat lower" than average. Family history of breast cancer was a significant predictor of perceived risk. Demographic characteristics and objective risk factors were not associated with perceived risk. Most women at high risk for breast cancer (89%) underestimated their actual risk; fewer women with low to average risk for breast cancer (9%) overestimated their risk. Age, Gail scores, and health insurance status promoted breast cancer screening; underestimation of risk had the opposite effect. CONCLUSIONS: Inaccurate perceptions of risk do not promote optimal breast cancer screening. The finding has implications for most women at high risk for developing breast cancer who underestimate their risk. IMPLICATIONS FOR NURSING: Oncology nurses can use risk assessment tools to provide individualized counseling regarding breast cancer risk factors and screening. Women at high risk who underestimate their risk could benefit from additional screening and from advances in cancer chemoprevention.

Perceived prejudice in healthcare and women's health protective behavior.

BACKGROUND: The literature documents significant claims of experienced prejudice in healthcare delivery in relationship to ethnicity, race, female gender, and homosexual orientation. Studies link perceived prejudice with negative healthcare outcomes, particularly in hypertension, heart disease, depression, and human immunodeficiency virus or acquired immune deficiency syndrome. OBJECTIVES: To examine the impact of perceived prejudice in healthcare delivery on women's early cancer detection behavior and women's decisions to seek care for illness symptoms. METHODS: Community women stratified by age, income, education, and race or ethnicity were surveyed regarding healthcare visits and cancer detection behavior. Perceived and experienced prejudice in healthcare delivery was measured by the Perceived Prejudice in Health Care Scale and follow-up interview. RESULTS: Experienced prejudice in healthcare delivery was linked significantly with failed adherence to cancer screening guidelines and fewer provider visits for serious illness. After controlling for demographics, experienced prejudice explained significant variance in perceived access to care. Although many who experienced prejudice in relationship to their race, income level, sexual orientation, or a combination of these returned for healthcare services, others were alienated sufficiently to decrease their health protective behavior. DISCUSSION: Subjective perceptions of prejudice are a significant influence in women's health protective behaviors. These findings demonstrate that policies requiring healthcare teams to be trained in professional ethics and cultural competence are vital to the goal of quality in care delivery and are needed to achieve optimal healthcare outcomes for women.

The cognitive structuring of patient delay in breast cancer.

The reasons women give for delaying diagnosis of breast cancer symptoms are numerous and striking. Yet none prove reliable as indicators of those who will delay, and most women overcome all barriers to seek immediate diagnosis. This study looks more deeply into the reasoning of symptomatic women sustaining confidence in a decision to delay diagnosis of self-discovered breast symptoms. Using argument and heuristic analysis, we examined the structure and soundness of the reasoning in interviews with 28 women from the San Francisco Bay area monitoring breast symptoms. Fifteen women were sustaining decisions to delay seeking diagnosis. Their arguments' structure and soundness, and their dependence on heuristic strategies, were compared with those of women who did not delay. Prompt diagnosis-seekers used vivid stories of other women with breast cancer to explain their diagnosis seeking, and the others used similar stories to justify on-going decisions to delay. Diagnosis-seekers offered more arguments for doing so than for delay. Delayers offered fewer arguments for seeking diagnosis and many more for delay. Delayers abandoned sound and usually compelling arguments to seek diagnosis, relying instead on false information, poorly reasoned arguments, and self-created dominance structures around decisions to delay. Decisions to delay were resilient, yet required maintenance to sustain. Intervention studies aimed at decreasing patient delay should address the thinking process by questioning reliance on mistaken claims of control over possibly advancing cancer, satisficing (corner-cutting to arrive at a minimally adequate solution to achieve a goal) when scheduling diagnostic visits, simulating a benign diagnosis rather than the prevention of late-staged cancer, prioritizing fear control over protection of life. Interventions might also include challenging mistaken analogies and the too facile abandonment of sound arguments for seeking prompt diagnosis.

Perceived breast cancer risk: heuristic reasoning and search for a dominance structure.

Studies suggest that people construct their risk perceptions by using inferential rules called heuristics. The purpose of this study was to identify heuristics that influence perceived breast cancer risk. We examined 11 interviews from women of diverse ethnic/cultural backgrounds who were recruited from community settings. Narratives in which women elaborated about their own breast cancer risk were analyzed with Argument and Heuristic Reasoning Analysis methodology, which is based on applied logic. The availability, simulation, representativeness, affect, and perceived control heuristics, and search for a dominance structure were commonly used for making risk assessments. Risk assessments were based on experiences with an abnormal breast symptom, experiences with affected family members and friends, beliefs about living a healthy lifestyle, and trust in health providers. Assessment of the potential threat of a breast symptom was facilitated by the search for a dominance structure. Experiences with family members and friends were incorporated into risk assessments through the availability, simulation, representativeness, and affect heuristics. Mistrust in health providers led to an inappropriate dependence on the perceived control heuristic. Identified heuristics appear to create predictable biases and suggest that perceived breast cancer risk is based on common cognitive patterns.

Predictors of perceived breast cancer risk and the relation between perceived risk and breast cancer screening: a meta-analytic review.

BACKGROUND: Perceived risk is a principal variable in theoretical models that attempt to predict the adoption of health-protective behaviors. METHODS: This meta-analysis synthesizes findings from 42 studies, identified in PubMed and PsycInfo from 1985 onward. Studies examined demographic and psychological variables as predictors of perceived breast cancer risk and the relationship between perceived risk and breast cancer screening. Statistical relationships, weighted for sample size, were transformed to effect sizes and 95% CIs. RESULTS: Women do not have accurate perceptions of their breast cancer risk (N = 5561, g = 1.10). Overall, they have an optimistic bias about their personal risk (g = 0.99). However, having a positive family history (N = 70660, g = 0.88), recruitment site, and measurement error confounded these results. Perceived risk is weakly influenced by age (N = 38000, g = 0.13) and education (N = 1979, g = 0.16), and is moderately affected by race/culture (N = 2192, g = 0.38) and worry (N = 6090, g = 0.49). There is an association between perceived risk and mammography screening (N = 52766, g = 0.19). It is not clear whether perceived risk influences adherence to breast self-examination. Women who perceived a higher breast cancer risk were more likely to pursue genetic testing or undergo prophylactic mastectomy. CONCLUSION: Perceived breast cancer risk depends on psychological and cognitive variables and influences adherence to mammography screening guidelines.

The J-Delay scale: a measure of the likelihood of patient delay in breast cancer.

Patient delay in seeking treatment for breast cancer is a major contributing factor to morbidity and mortality. No instruments have previously been developed to predict the likelihood of patient delay. This report describes the development and testing of the J-Delay scale, designed to estimate a woman's risk of making the judgment to delay versus to seek immediate evaluation of self-discovered breast symptoms that might signal breast cancer. The J-Delay scale items were developed in four qualitative studies (28 focus groups, combined N = 147 women). The J-Delay scale was tested in 2 large, community-based samples varying across age, income, and ethnicity (combined N = 1,290). Content validity was supported by narrative analysis. Criterion validity was supported by the correct prediction of patient delay in 69%-86% of surveyed and interviewed women with symptoms of 3 months' or more duration. Internal consistency reliability was .83 in English samples (n = 596 and 352) and .81 in a Spanish sample (n = 222). Test-retest reliability after 3-4 months (n = 251) was supported by consistent assignment in 88.8% of cases. The J-Delay is a valid and reliable tool to identify women at risk for patient delay. Women identified as likely to delay medical attention must be targeted for early detection interventions focused on patient delay.

Perceived risk of breast cancer: influence of heuristic thinking.

PURPOSE: The purpose of this study was to examine the influence of heuristic reasoning on women's perceived risk for developing breast cancer, and to test for an expected bias in the direction of optimism that is predicted by recent research on human cognition. DESCRIPTION OF STUDY: In total, 770 women recruited in community settings were surveyed regarding cancer screening behavior and their perceived risk of developing breast cancer. RESULTS: Most women perceived their risk of breast cancer to be lower than that of other women (3:1), confirming the expected bias toward optimism, and this finding was not attributable to the personality trait of optimism. Women following mammography guidelines showed greater optimism that their risk was low. Cancer knowledge and education diminished unwarranted optimism. Women with a history of benign breast disease, with a female relative with breast cancer, or both overestimated their risk. All findings suggest that heuristic thinking is being used to estimate personal cancer risk. CLINICAL IMPLICATIONS: Clinicians should expect women to be optimistic about their personal risk of developing breast cancer. As a result, women may put off breast cancer screening or delay the evaluation of breast symptoms that may signal breast cancer. Helping women to understand their relative risk is an essential part of a health promotion visit.

The influence of social support on breast cancer screening in a multicultural community sample.

PURPOSE/OBJECTIVES: To examine the relationship between women's reported social support and their adherence to recommended breast cancer screening guidelines. DESIGN: Descriptive, cross-sectional survey. SETTING: Community women's organizations throughout the San Francisco Bay Area. SAMPLE: 833 mostly low-income women with a mean age of 46.2 years from three racial or ethnic groups (i.e., Latina, Caucasian, and African American) who were not breast cancer survivors. METHODS: Social support was measured with a five-item, four-point, Likert scale developed for the study (Cronbach's alpha = 0.7248). Adherence to screening guidelines was measured by asking frequency of performing breast self-examination (BSE) and frequency of obtaining a clinical breast examination (CBE) and a mammogram. Research assistants and leaders of women's organizations conducted the survey in work and community settings. MAIN RESEARCH VARIABLES: Social support, performance of BSE, obtaining a CBE and a mammogram, income, education, spoken language, and level of acculturation. FINDINGS: Higher levels of social support were related to higher income and higher education. Lower levels of social support were associated with being Latina, completing the survey in Spanish, and being born abroad. Women who did not adhere to screening guidelines (for BSE or CBE) reported less social support. CONCLUSIONS: Social support is associated with adherence to breast cancer screening guidelines. IMPLICATIONS FOR NURSING: Nurses should assess women's levels of social support as a factor when evaluating adherence to breast cancer screening guidelines.

The self-reported likelihood of patient delay in breast cancer: new thoughts for early detection.

BACKGROUND: Delayed presentation of self-discovered breast symptoms influences stage of cancer at diagnosis and decreases breast cancer survival. METHODS: A total of 699 asymptomatic women (black, white, and Latino), recruited in community settings and stratified by age, income, and educational level, were surveyed for their likelihood to delay (J-Delay scale) in the event of a breast symptom discovery. Models of likelihood were tested with logistic regression analyses. RESULTS: A total of 166 women (23.7%) reported likelihood to delay. Lower income, lower educational level, self identification as Latino or black, experienced prejudice in care delivery, perceived lack of access to health care, fatalism about breast cancer, poor health care utilization habits, self-care behavior, spouse/partner and employer perceived constraints, problem-solving style, and a lack of knowledge of breast cancer's presenting symptoms were associated with likelihood to delay. A combined sample multiple logistic regression model correctly predicted 40.6% of women reporting a likelihood to delay, 94.9% of those not likely to delay, and 82.4% (551 of 669) of cases overall. CONCLUSIONS: Self-reported likelihood of patient delay is measurable in advance of symptom occurrence, and this measure is consistent with behavioral and knowledge variables previously linked with advanced breast cancer at diagnosis.