Black, Hispanic, and Asian respondents to HINTS perceived themselves at lower risk for getting cancer (lower PCR) than White respondents. These differences remained after controlling for age, education, marital status, gender and the mode in which the survey was administered (mail vs. RDD). Blacks perceived their cancer risk to be lower than Whites, in part, because they were less likely to have or know that they have a family history of cancer, and because they were less likely to believe that everything causes cancer than Whites. Similar patterns were found for Hispanics and Asians, except that being less likely to have smoked also accounted for lower PCR among Hispanics and Asians with respect to Whites. Although adding these mediators to the adjusted model of PCR significantly reduced the association between race and PCR, even after accounting for these effects, being Black, Hispanic, or Asian remained significantly associated with lower PCR. Additional research is needed to identify other factors that contribute to racial/ethnic differences in PCR.
The relation between race and reported family history of cancer is consistent with past research (20
), including a previous study in which we found that racial/ethnic minorities, and especially immigrants within these groups, were less likely to report a family history of cancer than Whites and non-immigrants (22
). Given disparities in cancer incidence and prevalence, Blacks should have a greater likelihood of reporting that they have or had a family member who was diagnosed with cancer than Whites. Although other Asians and Hispanics have lower cancer incidence, in our previous work we suggested that the differences in family history of cancer reporting were in excess of what would be expected due to racial/ethnic differences in cancer incidence (22
), and that these differences are likely due, in part, to minorities and immigrants being relatively less likely to know their family history of cancer. We predicted that less knowledge of family history of cancer among immigrants and racial/ethnic minorities could result in health care providers and non-Whites themselves underestimating their cancer risk. Results from the present study support this hypothesis. Lower reporting of family history of cancer among non-Whites, compared to Whites, did predict relatively lower PCR in non-Whites.
Hispanics and Asians were less likely than Whites to have smoked during their lifetimes, which, in turn, was associated with lower PCR compared to Whites. It is realistic for people who have never smoked to appraise their cancer risk as lower than those who have; however, future research should investigate whether people distinguish between smoking as a risk factor for cancers that are strongly associated with smoking (e.g., lung cancer, bladder cancer) and others that are less strongly associated with smoking (e.g., breast cancer, prostate cancer). It is possible that generalized beliefs that, as a nonsmoker, one is at relatively lower risk for all cancers could impede appropriate screening and other prevention behaviors. Physical inactivity and low fruit and vegetable consumption are associated with increased risk for several kinds of cancer (30
). According to the 2005 Behavioral Risk Factor Surveillance System survey, there are racial/ethnic differences in physical activity and fruit and vegetable consumption (31
). However, self-reported physical activity is higher among Whites than among Blacks, Hispanics or Asian/Pacific Islanders, a pattern that would not account for lower perceptions of risk among non-Whites compared to Whites. Asians/Pacific Islanders consume more fruits and vegetables than Whites (no differences across the other three races). Fruit and vegetable consumption was not assessed in the full HINTS 2007 sample; therefore, we were not able to explore whether fruit and vegetable consumption accounted for lower PCR among Asians compared to Whites.
We tested a second model of racial/ethnic differences in PCR: whether factors that typically predict PCR only do so for Whites, contributing to the lower PCR among non-Whites with respect to Whites. For example, if non-White groups have had less access to personally relevant cancer risk information, do not believe that cancer risk information is personally applicable, or do not trust cancer risk information (32
), their PCR may not be calibrated to known risk factors (e.g., family history of cancer, smoking). This explanation received some support. Among Hispanics, PCR varied less strongly as a function of family history of cancer than among Whites and Blacks. Hispanics may be less aware of family history risk due to language and other barriers that can make the dissemination of health information difficult. The finding is important for qualifying previous reports that people with a family history of cancer perceive themselves at higher risk for cancer (3
): this may not be true among Hispanics. In combination, lower reporting (and knowledge) of family history of cancer and lack of influence of family history on PCR among Hispanics, suggest that tailored public health and health care provider-delivered messages about the importance of family history for cancer risk and encouraging family communication about cancer may be a means of increasing awareness of cancer risk among non-Whites.
Race Differences in Perceived Cancer Risk Across the Lifespan
The findings are consistent with and expand on previous research that demonstrated that older age is associated with lower PCR (9
) by showing that the effect varies as a function of race. Perceived cancer risk was lower in older Whites than younger Whites, but similar downward slopes were not found among non-Whites. This, in effect, narrowed the gap between PCR in older Whites and Non-Whites. Racial/Ethnic differences in age-related trajectories would explain why one might not find racial/ethnic differences in PCR in samples populated primarily by older adults; this would not be due to high PCR among older non-Whites, but rather to low PCR among older Whites. The age-related differences in PCR among Whites could be a cohort effect if large-scale cancer prevention awareness efforts initiated in the early 1980s (34
) only reached certain sectors of the public. Efforts to communicate about cancer and cancer risk and prevention may have been more successful at reaching Whites coming into adulthood during this period, but less successful at reaching non-Whites and Whites who were older at the time.
Do Individual-Level Cancer Risk Perceptions Reflect Community-Level Cancer Salience?
The existence of racial/ethnic differences in PCR suggests that community-level dynamics influence PCR. Individual-level perceptions of cancer risk may vary as a function of the salience of the disease in one’s larger racial/ethnic community and, or peer groups. In the United States, social networks tend to be racially homogenous (35
)and race/ethnicity is a central component of identity and social categorization (36
); therefore, people may be most likely to base their cancer risk perceptions on the experiences and beliefs of same-race/ethnic peers and models, and images of members of their race/ethnic group. Cancer risk salience may reflect cancer incidence and mortality in one’s racial/ethnic group, prevalence of cancer in one’s social network, and the degree to which cancer is discussed openly within one’s network and larger community. Cultural variability in openness about cancer (37
) may also contribute to the relative salience of cancer risk in a given community. Risk perceptions, and even whether risk perception is a meaningful construct for a given group, are shaped by culturally-informed systems of beliefs about health and illness (41
). These systems of beliefs may be inconsistent with those promoted by the mainstream U.S. medical establishment, which could reduce the relevance and effectiveness of traditional risk and prevention communication in some communities (41
Strengths, Limitations and Future Directions
There has been limited research on variability in cancer risk perceptions across racial/ethnic groups even though cancer screening is known to be lower in non-White groups, and low PCR can be a barrier to screening and other cancer prevention behaviors. In the present study we examined whether, in a nationally representative sample, non-Whites had lower PCR than Whites and tested several possible explanations for these differences. Results indicated that racial/ethnic differences in awareness of family history, experience with risk behaviors (i.e., smoking) and salience of cancer risk information could cause racial/ethnic differences in cancer risk perceptions; however, these results should be considered suggestive because we used correlational, cross-sectional data to test these pathways. Laboratory-based experimental and, or community-based quasi-experimental research is needed to confirm the causal pathways proposed on the basis of our findings. Fortunately, logical plausibility also lends support to the proposed pathways. It is reasonable that people who have never smoked might perceive their cancer risk to be lower; the reverse, that low PCR causes lower likelihood of being a smoker, is far less plausible. Similarly, although lower PCR could, to an extent, contribute to people being less attentive to information about, and less able to report their family history of cancer, this is probably less likely than knowing (or not knowing) that one has a family history of cancer affecting perceptions of risk. Finally, we proposed that racial/ethnic differences in the belief that everything causes cancer predict PCR. Although beliefs about the causes of cancer would seem to be antecedent to beliefs about risk perception, it is possible that the two constructs could be reciprocally related if global perceptions of risk shape how people process health information about cancer risk-factors.
The study has a number of other limitations. Although the White, Black, and Hispanic sub-samples were relatively large, the Asian sample was relatively small (N = 181), resulting in relatively less stable estimates for comparisons between Asians and Whites. Also, approximately 8%of the eligible cases were dropped from the analysis due to missing values on one or more of the key variables of interest. There were significant differences between participants who were dropped versus those retained with respect to demographic and other characteristics. We do not believe, however, that dropping these cases substantially affected the results of the study. If anything, they may have weakened the findings. Participants who were dropped were, on average, more likely to be non-White and perceive their risk to be lower than those who were retained.
Despite the constraints of using a dataset not originally designed for the purpose of the present work, it was possible to identify several determinants of lower PCR among non-Whites compared to Whites, perhaps most importantly, lower likelihood of reporting family history of cancer among non-Whites relative to Whites. However, many additional hypotheses merit examination. Qualitative research has generated several possible explanations for why cancer risk perceptions are lower in Black communities, including mistrust of a predominantly White medical establishment, lack of personally relevant cancer information, and lack of perceived personal control over health outcomes (32
). This qualitative work ought to be extended to other non-White populations, and survey work is needed to test whether these explanations are born out in larger representative samples. Finally, we studied perceptions of global cancer risk. Perhaps most the pressing need is for research that examines racial/ethnic differences in PCR for specific cancers, including more fine-grained analyses of different aspects of risk (e.g., comparative versus absolute risk; risk of developing cancer versus risk of dying of cancer; or affective versus cognitive components of risk perception), and whether these risk perceptions are associated with cancer screening rates and prevention behavior.