Using the Health Belief Model to Examine Differences in Mammography Compliance Among Black and White Women

1
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, ANP4
• 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.

2
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.
3
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)

4
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.

5
Methods

• Secondary data analysis
• Cross sectional study
• Subjects (n1045)
• 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

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Instrumentation

• Champion Breast Health Survey (4 Subscales on
  Likert Scale)
• Perceived susceptibility3 items
• beliefs of personal threat or harm related to
  breast cancer
• Perceived benefits7 items
• positive outcomes of obtaining a mammogram
• Perceived barriers16 items
• emotions, physical or structural concerns related
  to mammography behaviors
• Self-Efficacy10 items
• belief that one can successfully execute the
  behavior of obtaining a mammogram

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Instrumentation (cont.)

• Breast Cancer Fear Scale (Likert scale)
• Fear10 items
• perceived threat of breast cancer accompanied by
  intrusive thoughts, physiological arousal, and
  mood disturbances
• Powe Fatalism Inventory (Yes/No responses)
• Fatalism15 items
• belief that death is inevitable when cancer is
  present
• Demographic information
• Race, education, income
• Mammography use

8
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.

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Results Demographics
10
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 12th grade. Over half the
  sample (51) had an income that was 15,000 or
  below and 71 of the women were currently not
  employed.

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Initial Hypothesized Model
SES  
Education (1) Income (1)
SUSCEPT  
Susceptibility Scale Items (3)
BENEFITS  
Benefits Scale Items (7)  
COMPLY  
Mamcomp (1)  
BARRIERS  
Barriers Scale Items (16)

SELFEFF  
Self-Efficacy Scale Items (10)
FEAR  
Fear Scale Items (10)
FATALISM  
Fatalism Scale Items (15)
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Results Model Belief Variables
Variables Blacks ß (SE) Whites ß (SE)
Overall Model R2.09 R2.13
Income 0.15 (0.04) 0.03 (0.04)
Education 0.03 (0.05) 0.01 (0.04)
Perceived Susceptibility -0.02 (0.05) 0.08 (0.05)
Perceived Benefits 0.21 (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)
Fatalism 0.07 (0.05) -0.08 (0.05)
Fear -0.11 (0.05) -0.04 (0.05)
p lt .05
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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.

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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.

15
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 15,000.00. 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).

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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.

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References

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