Using the Health Belief Model to Examine Differences in Mammography Compliance Among Black and White Women Susan S. Thomas, Ph.D. 1 Victoria L. Champion, DNS, RN, FAAN 2 Theodore K. Miller, Ph.D. 3 Usha Menon, Ph.D., RN, ANP 4 1. Cancer Prevention Fellow, National Cancer Institute, Bethesda, MD. 2. Associate Dean for Research. Indiana University School of Nursing, Indianapolis, IN. 3. Professor, Indiana University School of Public and Environmental Affairs. 4. Assistant Professor, University of Utah College of Nursing, Salt Lake City, Utah.

Abstract One of the most effective tools in early detection of breast cancer is regular screening mammography. Current studies indicate, however, mammography utilization rates in the general population, and more so in the Black community, continue to fall below objectives set forth by leading health agencies. As a result, there have been efforts to identify health beliefs that may impact screening mammography that are unique to Black and White women. This cross sectional study used the Health Belief Model as the theoretical basis of a secondary data analysis to establish differences in health beliefs among Black and White women related to mammography. Data were obtained from members of IU Medical Group or outpatients of the General Medicine Clinic of Barnes-Jewish Hospital. Data analysis was conducted using structural equation modeling. Results indicate that for White women, the Health Belief Model hypothesized in this study explained 13% of the variance associated with mammography compliance and 9% for Black women. Additionally, there were differences between specific variables that appeared to have the most explanatory power for the two groups. These findings indicate that the Health Belief Model, while a good starting point, does not completely explain differences that exist between health beliefs and their impact on mammography use for Black and White women.

Introduction One in nine women will develop breast cancer by the time she is 85 years old (ACS, 1999). Black women are less likely to develop breast cancer, but more likely to die as a result, partly due to later stage of breast cancer diagnosis (McDonald, 1999). Rates of mammography use in certain states such as Indiana and Missouri are below both Healthy People 2010 & ACS 2008 Objectives (ACS, 2001). Health beliefs are significant predictors of mammography compliance (Stein, Fox, & Murata, 1991)

Aim of the Study The primary aim of this study was to use the Health Belief Model (HBM) as the theoretical basis to examine health beliefs related to screening mammography among Black and White women.

Methods Secondary data analysis Cross sectional study Subjects (n=1045) Sites: General Medicine Clinic of Barnes-Jewish Hospital (St. Louis, MO) 2 HMOs in Indianapolis, IN – Methodist Medical Group & IU Medical Group Inclusion criteria: Women age 51 or older No mammogram in previous 15 months No personal history of breast cancer Self-identified as Black or White Having completed both Time 1 and Time 2 interviews

Instrumentation Champion Breast Health Survey (4 Subscales on Likert Scale) Perceived susceptibility—3 items beliefs of personal threat or harm related to breast cancer Perceived benefits—7 items positive outcomes of obtaining a mammogram Perceived barriers—16 items emotions, physical or structural concerns related to mammography behaviors Self-Efficacy—10 items belief that one can successfully execute the behavior of obtaining a mammogram

Instrumentation (cont.) Breast Cancer Fear Scale (Likert scale) Fear—10 items perceived threat of breast cancer accompanied by intrusive thoughts, physiological arousal, and mood disturbances Powe Fatalism Inventory (Yes/No responses) Fatalism—15 items belief that death is inevitable when cancer is present Demographic information Race, education, income Mammography use

Data Analysis Exploratory data analysis SPSS 10.0 Descriptive statistics Structural Equation Modeling LISREL 8.3 Overall model based on health beliefs and demographic information developed. Model tested for both Black and White women to examine differences between two groups.

Results: Demographics

The study consisted of 1045 women form St.Louis, MO and Indianapolis, IN who were part of a larger study to increase mammography compliance. Blacks made up 53% of the sample and Whites comprised the remaining 47%. The average age of the women was 65 with a mean education of 12 years, and 66% of the sample finishing 12 th grade. Over half the sample (51%) had an income that was $15,000 or below and 71% of the women were currently not employed.

Initial Hypothesized Model SES FATALISM SUSCEPT BENEFITS BARRIERS SELFEFF FEAR Education (1) Income (1) Susceptibility Scale Items (3) Benefits Scale Items (7) Barriers Scale Items (16) Self-Efficacy Scale Items (10) Fear Scale Items (10) Fatalism Scale Items (15) COMPLY Mamcomp (1)

Results: Model & Belief Variables VariablesBlacks β (SE) Whites β (SE) Overall ModelR 2 =.09R 2 =.13 Income0.15 (0.04)*0.03 (0.04) Education0.03 (0.05)0.01 (0.04) Perceived Susceptibility-0.02 (0.05)0.08 (0.05) Perceived Benefits0.21 (0.08)*-0.28 (0.09)* Perceived Barriers-0.19 (0.08)*-0.32 (0.06)* Self efficacy-0.14 (0.06)0.19 (0.09)* Fatalism0.07 (0.05)-0.08 (0.05) Fear-0.11 (0.05)*-0.04 (0.05) * p <.05

Results: Model For White women, the Health Belief Model hypothesized in this study explained about 13% of the variance associated with mammography compliance. For Black women, the Health Belief Model hypothesized in this study explained approximately 9% of the variance associated with mammography compliance.

Results: Belief Variables For White women, the health beliefs that were significantly related to mammography compliance included: perceived benefits, perceived barriers, and self-efficacy. As expected, perceived barriers were inversely related to and self-efficacy was directly related to mammography compliance. For White women, however, perceived benefits were inversely related to mammography compliance. In general, previous research indicates that the opposite is true, usually the more perceived benefits of mammography that a woman has, the more likely she is to be mammography compliant.

Results: Belief Variables For Black women, the variables significantly related to mammography compliance were income, perceived benefits, perceived barriers, and fear. There was a direct relationship between income and mammography compliance. Sixty eight percent of the Black women in this study had incomes below $15,000.00, compared to 70% of the White women who had incomes above $15, Perceived benefits have generally been found to be positively associated with mammography compliance in previous studies (Aiken et al., 1994; Holm et al., 1999). Conversely, there was a negative relationship between perceived barriers and mammography compliance, similar to results found by others (Philips and Wilbur, 1995).

Conclusions There appear to be differences in mammography use among Black and White women that can be partially attributed to health beliefs. The HBM, while a good starting point, does not appear to completely explain differences that exist in health beliefs or mammography behavior of Black and White women. Future Directions: Expand existing models of health behavior such as the HBM or explore new models that incorporate the current racial and socioeconomic variability in the United States.

References Aiken, L.S., West, S.G., Woodward, C.K., & Reno, R.R. (1994). Health beliefs and compliance with mammography-screening recommendations in asymptomatic women. Health Psychology, 13, American Cancer Society. (1999). Cancer facts and figures (ACS Publication No ). Atlanta, GA: American Cancer Society. American Cancer Society (b). (2001b). Cancer prevention and early detection facts and figures (ACS Publication No ). Atlanta, GA: American Cancer Society. Holm, C.J., Frank, D.I., & Curtin, J. (1999). Health beliefs, health locus of control, and women’s mammography. Cancer Nursing, 22, McDonald, C.J. (1999). Cancer statistics, 1999: Challenges in minority populations. CA, 49, 6-7. Phillips, J.M., & Wilbur, J. (1995). Adherence to breast cancer screening guidelines among African- American women of differing employment status. Cancer Nursing 18, Stein, JA, Fox, S.A., & Murata, P.J. (1991). The influence of ethnicity, socioeconomic status, and psychological barriers on use of mammography. Journal of Health and Social Behavior, 32,