Analysis Of Breast Cancer Screening Procedures Using Health Belief Model
Breast cancer and associated risk factors:
Breast cancer is the most commonly occurring cancer in women and the second most common cancer overall. More than 2 million cases were diagnosed in 2018 worldwide. (“Breast cancer statistics,” 2018) Genetic factors constitute about 80% of the major risk factor leading to cancer. Specifically, BRCA 1 and BRCA 2 gene mutations are responsible for malignancy (Feng et al., 2018) Breast cancer occurs very rarely in men due to incomplete development of breast without mammary glands and extremely low levels of estrogen, the hormone responsible for stimulation of breast cells. (“Breast Cancer Risk Factors,” n.d.) Other risk factors are aging, having dense breasts, radioactive therapy, use of drugs containing Diethylstilbestrol (DES), previous history of breast cancer, positive family history, long reproductive period. These set of risk factors cannot be changed. Those that can be changed are physical inactivity, improper intake of hormones, improper reproductive history like avoiding breastfeeding, consumption of alcohol and obesity control. (“CDC - What Are the Risk Factors for Breast Cancer?” 2018).
The signs of breast cancer are new lump on breast or arm pits, discharge from nipples except for milk, pain, reddish or flaky skin on nipples or breast, pulling in of nipples, Thickening or swelling in any part of the breast and change in size and shape of the breasts. However, sometimes the signs may occur due to any other disease. (“CDC - What Are the Symptoms of Breast Cancer?” 2018) Procedures treating breast cancer results in severe psychological suffering, anxiety, financial hardships depression and disfigurement. Sometimes life threatening too (Guilford, McKinley, & Turner, 2017). Hence, it is better to diagnose the disease in first place through readily available screening procedures to save lives rather than going through all the pain and suffering after having the disease.
According to ACS guidelines, women from the age 40- 45 years should undergo mammography annually till 50 years and the following years biennially. In 2018,266120 cases of invasive cancer are diagnosed and 40920 deaths are reported in USA. Age- adjusted mortality decreased from 1989-2015 with 322600 deaths averted through screening procedures. The favorable statistics are not evenly distributed. Through 2010-2015 death rates are 42% more in African Americans than whites. (Smith et al., 2018). But the new incidence rates are low in African Americans than Whites (“Comparing Breast Cancer Screening Rates Among Different Groups | Susan G. Komen®,” n.d.)
There are several barriers associated with withdrawal of participation from the screening, the first one being health insurance, 68% of those with insurance has undergone screening procedures compared to 31% with no health insurance. There are other barriers as well like lack of closest screening centers, lack of availability of health care provider, difficulty to get sick leaves, lack of child care, lack of awareness, lack of income and fear of bad news, cultural and language differences (“Comparing Breast Cancer Screening Rates Among Different Groups | Susan G. Komen®,” n.d.)
According to the fact sheet 2015 by ACS there are differences in prevalence of mammography in women from 40years older in a way that NHW stands 50%, NHB 55% , Asian Americans stands 47%, Alaskan native 46% and Hispanic women 46%.(Street, n.d.)A study conducted among the Asian Americans to assess the influence of ethnicity on perceptions of susceptibly and seriousness related to breast cancer came out with the results that the Filipino and Chinese women had significantly higher levels of perceived susceptibility and seriousness than Asian Indian women. Also, the common barriers across the three groups are: being examined by male practitioner, having the breast touched by a stranger and being exposed to unnecessary radiation. African American women face knowledge-based barriers and pain. (Wu, West, Chen, & Hergert, 2006) Poor knowledge on risks related to breast cancer and screening procedures, cultural and language barriers are responsible for the lower screening participation among the Hispanic women. (Ramirez et al., 2000)
Health belief model:
The health belief model was developed in 1950s, the period in which main attention of US public health service is entirely on disease prevention and very little on treatment of disease. The originators of this model were Godfrey Hochbaum, Stephen Kegels, Irwin Rosenstock. This model deals with the relationship between health behavior, practices and utilization of health care services, influenced by theory of Kurt Lewin which states that the world of the perceiver determines what an individual will do or will not do. According to this theory a person’s motivation to perform a health behavior depends on three main factors: individual perceptions like susceptibility, severity and importance of health to the individual, modifying behaviors like demographic variables, cues to action, perceived threat and the probability of likelihood of action. When the individual perceives threat and simultaneously cued to action and if the perceived benefits outweigh the perceived barriers then the individual engages in the preventive health behavior. Hochbaum, G., Rosenstock, I., & Kegels, S. (1952). Health belief model. United States Public Health Service.
The main constructs are perceived severity, perceived susceptibility, perceived benefits, perceived barriers, modifying factors, cues to action and self-efficacy. The significant constructs in health belief model is perceived barriers followed by perceived susceptibility, perceived severity being the least significant Perceived susceptibility refers to one’s perception of risk of a health condition and perceived severity refers to seriousness of contracting an illness, both of which are together called as perceived threat. Perceived benefits are responsible for outcome of action since it makes the individual feel that a certain behavior is efficacious even though susceptibility and severity are initial driving factors. Perceptions such as the negative outcomes of the behavior, time factor, cost, feasibility are compared with the efficacy of the action fall under the perceived barriers which when outweighed leads to the action of the recommended behavior. Other modifying factors like socioeconomic factors, ethnicity etc. indirectly effects all other constructs. Cues to action helps to result in a positive outcome in case of diseases with higher perceived threat. Self-efficacy concept was introduced by Bandura in 1977 which refers to the conviction of an individual to perform a behavior for an expected outcome. (Janz & Becker, 1984)
Application of HBM:
The purpose of application of health belief model to breast screening procedures would be to plan an intervention to make more individuals take part in the screening procedures. For the model to yield effective results all the constructs must be included in questionnaire as follows:
- Perceived susceptibility: Belief that chances of getting breast cancer are high?
- Perceived severity: Is my life endangered if I have a breast cancer?
- Perceived benefits: Getting a mammogram saves my life, mammogram is beneficial as it diagnoses disease before it gets even worse.
- Perceived barriers: getting a mammogram is too costly
- Modifying variables: are there any other socioeconomic factors that hinders the likelihood of action?
- Cues to action: looking at the flyers make me think about mammogram
- Self-efficacy: How sure are you that you know how to make an appointment to get a mammogram?
From the literature review it is evident that there are financial and accessibility barriers that prevent people from participating in the screening programs. These barriers may be due to lack of knowledge about the free health care services, ignorant about the available health care clinic. These can be intervened by scheduling programs during holidays at accessible locations and providing facilities for the child care and implementing more economical, cost-effective programs
Another significant factor to be considered from literature is differences in perception towards the disease among different groups. Low perception to seriousness and susceptibility, poor knowledge related to breast cancer can be increased through awareness programs that provide the information, detailed course of the disease and health consequences followed by the occurrence of disease.
The cultural and language barriers are reviewed, and it is to be noted that these barriers influence the behavior of people to participate in screening programs. Language and cultural barriers could be eliminated by designing the screening programs in a multi-lingual and multi-cultural approach with female practitioners to make the patients comfortable as some women feel embarrassed to get checkup done by male practitioner and benefits of the screening programs being clearly explained. Further, cues to action could be used to make people with high perception of threat to take one more step to change their behavior.
Guilford, K., McKinley, E., & Turner, L. (2017). Breast cancer knowledge, beliefs, and screening behaviours of college women: Application of the Health Belief Model. American Journal of Health Education, 48(4), 256–263. https://doi.org/10.1080/19325037.2017.1316694 Smith, R. A., Andrews, K. S., Brooks, D., Fedewa, S. A., Manassaram?Baptiste, D., Saslow, D., … Wender, R. C. (2018). Cancer screening in the United States, 2018: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians, 68(4), 297–316. https://doi.org/10.3322/caac.21446 Street, W. (n.d.). Breast Cancer Facts & Figures 2017-2018, 44. Breast Cancer Risk Factors: Being a Woman. (n.d.). Retrieved November 18, 2018, from https://www.breastcancer.org/risk/factors/woman Feng, Y., Spezia, M., Huang, S., Yuan, C., Zeng, Z., Zhang, L., … Ren, G. (2018). Breast cancer development and progression: Risk factors, cancer stem cells, signaling pathways, genomics, and molecular pathogenesis. Genes & Diseases, 5(2), 77–106. https://doi.org/10.1016/j.gendis.2018.05.001 Guilford, K., McKinley, E., & Turner, L. (2017). Breast Cancer Knowledge, Beliefs, and Screening Behaviours of College Women: Application of the Health Belief Model. American Journal of Health Education, 48(4), 256–263. https://doi.org/10.1080/19325037.2017.1316694 Breast cancer statistics. (2018, August 22). Retrieved November 18, 2018, from https://www.wcrf.org/dietandcancer/cancer-trends/breast-cancer-statistics CDC - What Are the Risk Factors for Breast Cancer? (2018, September 11). Retrieved from https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm Wu, T.-Y., West, B., Chen, Y.-W., & Hergert, C. (2006). Health beliefs and practices related to breast cancer screening in Filipino, Chinese and Asian-Indian women. Cancer Detection and Prevention, 30(1), 58–66. https://doi.org/10.1016/j.cdp.2005.06.013 Ramirez, A. G., Talavera, G. A., Villarreal, R., Suarez, L., McAlister, A., Trapido, E., … Marti, J. (2000). Breast cancer screening in regional Hispanic populations. Health Education Research, 15(5), 559–568. https://doi.org/10.1093/her/15.5.559 Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: a decade later. Health Education Quarterly, 11(1), 1–47. https://doi.org/10.1177/109019818401100101