Do health beliefs predict health behaviour? A follow-up analysis of breast self-examination

In a previous paper, we suggested that women who attended classes on breast self-examination showed significant improvements in behaviour, and that part of the reason was a change in their beliefs. Further analysis of our data confirms the original conclusion, and indicates that the perceived value of doing the behaviour is a more important predictor than perceived vulnerability to cancer.     

Do health beliefs predict health behaviour? An analysis of breast self-examination

The purpose of this paper is to explore the relationships between health beliefs and health behaviour. The study we report was conducted as part of a national campaign to evaluate the benefits of breast self-examination in the early detection of breast cancer, and the purpose of our analysis was to test the Health Belief Model of Becker and his colleagues. Three groups of women were investigated--278 who accepted an invitation to attend self-examination classes and were taught the techniques in detail, 262 who declined the invitation and 594 controls to whom no classes were offered--and beliefs and self-reported behaviour were measured shortly before the classes took place and again a year later. The campaign, it emerged, produced marked changes in both beliefs and behaviour, but the relationships between beliefs and behaviour were much weaker than the model had led us to expect and accounted for no more than a quarter of the variance. Alternative models are considered, notably Fishbein and Ajzen's Theory of Reasoned Action, and the paper concludes with some suggestions for improving health campaigns.     

The role of behavioral, normative and control beliefs in breast self-examination

CONTEXT: A limited number of studies have been conducted examining the role of beliefs in the prediction of breast self-examination (BSE) behavior in Australian women, particularly women under 50 years of age for which it is the primary method of early detection of breast cancer. OBJECTIVE: The present research investigated the differences in behavioral, normative and control beliefs between BSE performers and non-performers, within a theory of planned behavior framework, to assist in the development of specific education programs aimed at increasing BSE amongst this demographic group. METHOD: Two hundred and fifty-three women enrolled in an undergraduate psychology course completed a questionnaire assessing beliefs regarding BSE. One month later, these women reported their BSE behavior during the previous month. Multivariate analyses were performed to identify belief-based differences between BSE performers and non-performers. RESULTS: Underlying behavioral and control, but not normative, beliefs about BSE distinguished between BSE performers and non-performers. Performers were more likely than non-performers to believe that engaging in BSE would be associated with identifying a lump or breast change sooner and detecting a breast cancer earlier in its course. Non-performers were more likely to perceive factors such as forgetting to perform the behavior, lack of time, lack of knowledge about how to perform the behavior, laziness, and a lack of confidence in their ability to identify lumps and breast changes as factors preventing their control over the performance of BSE. CONCLUSIONS: The belief-based differences between BSE performers and non-performers found in this study can be used to inform health promotion strategies aimed at increasing BSE behavior in women less than 50 years of age.     

Is breast self-examination predicted by knowledge, attitudes, beliefs, or sociodemographic characteristics?

The relationship of women's sociodemographic characteristics, knowledge, attitudes, and beliefs to breast self-examination (BSE) practice is not clear. We therefore studied these variables among older women at risk for developing breast cancer to determine which might be associated with the sensitivity, specificity, and frequency of BSE practice. We interviewed 300 women 40 to 68 years of age and measured BSE sensitivity and specificity using manufactured silicone breast models containing lumps. Of 54 variables and 10 scales examined univariately, six were associated with BSE sensitivity, one was negatively associated with specificity, and 10 were associated with frequency. No variable was associated with more than one component of BSE practice, and BSE frequency was not associated with BSE sensitivity or specificity. Using multivariate analysis, BSE sensitivity was best explained by type of employment, health interest, and perceived vulnerability to breast cancer, which accounted for approximately 16% of the variance. BSE frequency was best explained by intention to perform BSE, knowing how to perform BSE, using the correct method of BSE, self-confidence in the ability to perform BSE monthly, and self-confidence in the ability to find small lumps. These variables accounted for 27% of the variance. Sociodemographic characteristics, knowledge, attitudes, and beliefs poorly predicted how accurately women practiced BSE but somewhat better predicted how often women practiced BSE.     

Psychosocial determinants of breast self-examination

To explore the psychosocial determinants of breast self-examination (BSE) among women, we studied a stratified random sample of 264 women students, faculty, and staff in a university community. The dependent variable of the study was self-reported frequency of BSE, and predictors included measures of general health predispositions, variables of the Health Belief Model, the impact of a woman's social network, a set of secondary non-health-related barriers and benefits, and the woman's evaluation of her personal health care system. Analysis of the data showed strong relationships between most of the predictor variables and BSE. Regression analysis showed that variables measuring a woman's recent experience in the health care system were stronger predictors of BSE practice than intrapersonal "health belief" variables. However, the independent variables included in the regression accounted for almost 35 percent of the total variance in BSE practice.     

A profile of Australian women practicing breast self-examination.

Breast self-examination (BSE) and medical breast examination practices were studied in a group of 1,103 women without diagnosed breast cancer, randomly sampled to conform in age and social status with breast cancer cases from the population of Brisbane, Australia between 1981 and 1985. Relationships between these practices and sociodemographic factors, breast cancer risk indicators, health related behaviors and source of knowledge about BSE were analyzed. Overall, 63% of women reported performing BSE. BSE was practiced frequently (monthly or more). BSE frequency was only weakly associated with breast cancer risk indicators. It was more strongly linked with age, the 20-44 year group being more likely to examine their breasts occasionally and the women 65 years and over being less likely to examine their breasts. Married women were the most likely to practice BSE frequently and widowed or single women most likely never to practice. Women who underwent cervical smear testing were more likely to perform BSE than those who did not have smear tests. Women who learned BSE from their doctors as opposed to other sources practiced BSE more frequently and were more likely to practice BSE exactly as taught.     

Impact of benign breast biopsy upon breast self-examination

Current American Cancer Society guidelines recommend monthly performance of breast self-examination (BSE) for women over 20 years of age. While the experience of a benign breast biopsy can result in elevated levels of distress, the impact of benign biopsy upon breast cancer (BC) screening behavior is not well known. The present study examined frequency of BSE practice in 102 women after benign breast biopsy (biopsy group). Telephone interviews were completed a mean of 21 days (initial interview) and 8 months after biopsy (follow-up interview). A healthy comparison (HC) group of women (n = 76) without a history of breast biopsy completed an initial interview only. Information regarding distress, dispositional characteristics, BC screening-related attitudes and behaviors, and subjective and objective risk for BC was collected. Results indicated that the biopsy and HC groups did not differ in typical (i.e., prebiopsy) practice of BSE. However, practice of BSE changed after biopsy with a general trend toward a decrease in BSE frequency. Only 8% of women in the biopsy group reported appropriate (once per month) practice of BSE at the 8-month Follow-up while 28% reported appropriate practice at the initial interview. Decreases in BSE performance after biopsy were characteristic of younger women, women who lacked confidence in the ability to perform BSE correctly, and women whose biopsy was preceded by discovery of a breast lump or abnormality during BSE. Results suggest the potential value of a psychoeducational intervention after biopsy to enhance appropriate performance of BSE.     

A breast self-examination program for high school students.

Breast self-examination (BSE) is an important adjunct to the detection of breast cancer at an early stage. High school students were instructed in the importance and methods of BSE. By use of questionnaires, the program was evaluated for interest, acceptability, and compliance. It was found that high school students were not adverse to learning about BSE, found the program acceptable, and maintained some compliance at one year.     

A community-wide program in breast self-examination training and maintenance

This study reports on the effects of innovative community-wide breast self-examination education approaches in increasing breast self-examination frequency and quality, and ability to detect breast lumps during a 1-year training program and a second-year maintenance program. Four Vermont communities were randomly assigned to receive breast self-examination training plus maintenance, training alone, control (with full measurement), and low-measurement control. Random digit dialing telephone surveys were conducted at baseline and at 1- and 2-year follow-up with a panel of 637 women representing all adult women in the first three communities. The low-measurement control community received only baseline and second-year follow-up surveys with a panel of 238 women. Home interviews to determine breast self-examination palpation skills and lump detection on silicone breast models were conducted in first- and second-year follow-up surveys. Results of the first-year follow-up survey indicated significant increases in breast self-examination frequency, quality, and number of lumps detected for women in communities receiving the training program compared with controls; in the second year, women in the community also receiving breast self-examination maintenance showed greater improvement in reported breast self-examination quality and detected more breast lumps than did women in other communities.     

The role of clinical breast examination and breast self-examination

The efficacy of screening by clinical breast examination (CBE) and/or breast self-examination (BSE) is reviewed using indirect evidence from randomized breast screening trials and that from observational studies. In countries where breast cancer is diagnosed at an advanced stage, screening by CBE with the teaching of BSE as an integral component will probably be effective in reducing breast cancer mortality. However, in technically advanced countries where adequate treatment is given, no screening modality is likely to be sufficiently beneficial to outweigh the harms of screening, especially false positives and over-diagnosis.     

An effective manual on breast self-examination

The effectiveness of a manual on breast self-examination was assessed in 190 female 11th- and 12th-grade students at a rural school in India's Haryana State. The students (average age, 16.6 years) completed a questionnaire on breast self-examination and related issues before they received copies of the manual and again 3 weeks after manual distribution. The pretested manual was culturally acceptable to both parents and teachers. At baseline, approximately 80% of the students had heard of breast cancer and over half believed it to be curable. Their principal sources of knowledge about breast cancer were television (38%), doctors (10%), friends and relatives (9%), and magazines (8%). On the baseline assessment, 8% of students achieved high scores, 83% obtained medium scores, and 9% had low scores. At retest 3 weeks after manual distribution, 79% achieved high scores and the remaining 21% had medium scores. Although knowledge of breast self-examination improved significantly, awareness of the structure of the breast and the increased risk of breast cancer in unmarried, childless women did not improve. A manual such as this can be used to educate young women about breast cancer prevention wherever there is a shortage of personnel trained to provide health education.     

Effects of public education about breast cancer and breast self-examination

In a field experiment severity of and susceptibility to breast cancer were varied in four different persuasive messages about breast cancer and breast self-examination (BSE). The purpose of this study was to find out whether such health messages in a real-life setting had an effect on knowledge about symptoms, attitudes and behavior relating to BSE. The second goal of this study was to investigate whether fear, aroused by these persuasive communications, had a significant role in influencing the recommended behavior (BSE). In spite of a successful manipulation of seriousness and susceptibility no differences for the dependent variables could be established between the experimental groups after one month. However, differences were found by comparing the experimental groups with the no health message group. After reading the pamphlet (no matter which of the four) women showed greater intention to perform BSE regularly. This could be attributed to a higher estimation of the chance of recovery through early detection of lumps (efficacy) after reading the pamphlet. The health messages also appeared to have a positive influence on compliance with recommended behavior: women examined their breasts more in the prescribed way. An inhibiting effect of fear on behavior (which is sometimes theoretically suggested) was not found. The effects of the pamphlet that were established are formed in a more informational, cognitive way.     

Knowledge and practice of breast self-examination by nurses

A qualitative study, with eleven nurses studying obstetric nursing in Teresina-PI, the objectives of which were to describe their knowledge and practice of measures to control breast cancer and to discuss the practice of self-examination by nurses. A focus group was used as technique. The results show death or mutilations, followed by a bad prognosis, such as significances associated with breast cancer. They mentioned control measures such as healthy habits and examinations, especially self-examination, mammography, ultrasonography, clinical, static and dynamic examination, and biopsy in the confirmation of malignancy. Among the guidelines provided to customers, self-examination, healthy food habits, physical activity and no addictions were the most important ones. It can be concluded that these professionals did not perform self-examination very often, but the majority had healthy food habits.     

Determinants of breast self-examination after a benign biopsy

Although breast self-examination (BSE) continues to be recommended as an adjunct to clinical screening techniques for the early detection of breast cancer, little is known about events that might negatively influence long-term adherence. The primary aim of this investigation was to determine if regularity of BSE would decline after a benign breast biopsy. Analyses are based on 655 women: 83 women who self-discovered the breast problem by BSE, 179 women in whom the problem was discovered by the health care system, and a control group of 393 women who had no history of breast problems. Frequency of BSE was assessed over two six-month periods and collapsed into three categories--nonpractitioner, irregular practitioner, and regular practitioner. Results indicated that the percentage of women in the self-discovered group who reported decreased regularity of BSE was over three times higher than that found in the control group. The largest percentage increase in BSE frequency was evidenced by the health care-discovered group. Logistic regressions revealed that the biopsy experience was a more powerful indicator of subsequent BSE practice than either sociodemographic characteristics or whether one engaged in other preventive health behaviors. The data provide substantial evidence that a benign biopsy can affect BSE practice, with the direction and magnitude of the change influenced by mode of discovery of the breast problem, perceived degree of confidence in ability to perform BSE, and level of practice before the biopsy. Postbiopsy educational strategies incorporating these findings and targeted at specific subgroups are outlined.     

Effectiveness of methods used to teach breast self-examination

The efficacy of breast self-examination (BSE) is limited by the extent to which women can be taught to perform a frequent and proficient examination. We randomized 783 women from a health maintenance organization into group instruction, individual instruction, individual instruction with a reminder system, or minimal intervention designed to simulate an office encounter where BSE was encouraged but not taught. The percentage of lumps 1 cm and smaller detected in silicone breast models, the number of false-positive detections, the search technique, and the self-reported BSE frequency were measured before and four months after intervention. Multiple tests for comparisons of interventions showed that the interventions containing BSE instruction were comparable in increasing true- and false-positive detection of lumps and in improving search technique, but the minimal intervention resulted in lower scores for all three outcomes (P less than .0001). Women in all four intervention groups increased their BSE frequency over the four-month follow-up period, but the greatest improvement in frequency was reported among women receiving reminders.     

Predictors of breast self-examination among family practice patients

The predictors of breast self-examination (BSE) and knowledge of BSE technique were examined among patients of a family practice group. There was found to be little relationship between the frequency with which women practiced BSE and their knowledge of effective BSE technique. The most important predictors of frequency of BSE were patients' perception of the social support for BSE and the extent to which they found BSE to be distasteful. Perceived health benefits of BSE were of less importance in predicting behavior. Knowledge of BSE technique was unrelated to any of these predictors. Women's self-reported confidence in their knowledge of BSE technique was only weakly related to their assessed knowledge. Further analysis showed that formal instruction in BSE was associated with a higher frequency of self-examination and greater knowledge of technique. The implication of the findings for family practice are discussed.     

Compliance with breast self-examination instruction in healthy adolescents

Compliance with breast self-examination was prospectively assessed in three groups of healthy outpatient adolescents 6 weeks, 3 months, and 6 months after instruction. Although 87%, 59%, and 71% of the three respective groups reported sporadic practice of breast self-examination, only 39%, 9%, and 18%, respectively, performed the procedure timed correctly with the menstrual cycle. Those adolescents tested at 6 weeks demonstrated a high degree of proficiency in replicating the procedure on a silicone model. There was no significant difference between demographic variables or personal health beliefs regarding breast cancer and breast self-examination compliance. Our findings suggest that adolescents can effectively perform breast self-examination, but their practice is erratic. Thus, we recommend that when instruction in breast self-examination is given, the examination schedule should be reinformed at a follow-up visit.