Measures of intention, self-efficacy, perceived benefits, and subjective norms were significantly associated with mammography in this multiethnic cohort, overall and to some extent within racial/ethnic groups, and, with the exception of intention, racial/ethnic differences in association were not statistically significant. Therefore, the results here generally support the cross-cultural applicability of four of the five behavioral constructs to cancer screening, although they can raise questions about the validity and utility of standard questions. There is one important aspect of the data to recognize before discussing specific analyses. That is, because of the strong skew toward agreement with most of the behavioral constructs, there was a relatively small percentage (and therefore absolute number) of women who responded “no” or “don’t know.” This characteristic of the data almost certainly contributed to the very wide 95% CIs found within racial/ethnic groups for some constructs and thereby also reduced the likelihood of detecting racial/ethnic interactions with the behavioral constructs.
The longitudinal association between intention and recent mammography 2 years later was significant only among Whites, and the interaction term with race/ethnicity was statistically significant. Given the adjusted ORs in , it is clear that the interaction denotes the strong association for intention for Whites as the basis for the interaction result. Other studies have also found intention to be prospectively associated with mammography among middle-class U.S. White women (Han et al., 2007
). Possible reasons for the lack of association in the other racial/ethnic groups in our study include lack of temporal stability of intentions and complexity translating intentions into actions (Ajzen, 2001
) and the fact that our one-item measure was likely inadequate to measure the full spectrum of intention. The inductive study by Pasick, Barker, et al. (2009)
found likely variations in the meaning of stated intention, examples of social environmental (social context) influences that directly affected behavior in the absence of intention (i.e., women obtained a mammogram without having formed the intention to do so), and situations where favorable intention conflicted with other influences and screening was not obtained. In addition, except among Whites, a rather large proportion of women reported a recent mammogram at the time of the final survey among those who did not intend to get one at baseline. In addition to the reasons outlined by Pasick et al., this may be because of participation in the study, which was specifically designed to address barriers to screening among African American, Latina, Chinese, and Filipina women.
There was a significant longitudinal association between baseline self-efficacy and recent mammography 2 years later only for White women. The test for racial/ethnic interaction was not significant, but the adjusted OR “point estimates” were clearly not the same across the racial/ethnic groups. As noted above, percentages of “% yes” were high, so that the 95% CIs were wide and overlapped for the racial/ethnic groups, and it was not surprising that a test for interactions did not yield significance. Here too our one-item measure may not have had sufficient specificity to determine which of these women actually felt able or unable to obtain mammograms. As noted by Ajzen (2001)
, the perceived difficulty of a behavior, which we did not assess, is more important than perceived behavioral control. This latter point appears compatible with Burke et al. (2009)
, whose inductive analysis suggested that self-efficacy was experienced and perceived differently depending on the social context, particularly with regard to poverty and migration. According to those authors, although self-efficacy theory acknowledges complex contextual influences, operationalization of this construct in mammography studies and interventions fails to adequately account for them, resulting in simplified understandings of how women make decisions about their health behavior and how to motivate them to change their health behaviors.
We did not find a positive longitudinal relationship between perceived susceptibility to breast cancer and mammography, overall or in any racial/ethnic group. Although meta-analyses have found on average a positive association between perceived risk and mammography (e.g., Katapodi et al., 2004
), null associations have also been observed among Whites (Bowen, Alfano, McGregor, & Andersen, 2004
), Chinese Americans (Wu & Yu, 2003
), African Americans (Russell, Perkins, Zollinger, & Champion, 2006
), and Latinas (Palmer, Fernandez, Tortolero-Luna, Gonzales, & Mullen, 2005
). It is possible that our one-item measure of comparative susceptibility was inadequate to identify women who considered themselves at high risk for breast cancer. However, our measure was significantly associated with reporting a family history of breast cancer (data not shown), and there was considerable variation in response to the item. Each measure of perceived benefits predicted recent mammography among women overall, except for the benefit of lower mortality, which was significant only for Filipinas. In general, women responding yes to the benefit questions had a higher likelihood of a recent mammogram 2 years later. A smaller but still substantial percentage of women who responded no also had recent mammograms in that interval. Racial/ethnic interactions were not statistically significant. In a multiethnic cohort of older women (Glenn, Bastani, & Reuben, 2006
), there was no association between getting a mammogram and either belief in the efficacy of early detection or the likelihood of surviving breast cancer after 5 years.
The inductive findings of Joseph, Burke, Tuason, Barker, and Pasick (2009)
raise doubts about two assumptions inherent to the constructs of perceived susceptibility and perceived benefits: first, that people trust that the health care system will serve them effectively and, second, that people believe in and trust scientific principles and technical biomedical knowledge exclusively, over and above other healing beliefs and practices. In contrast to these assumptions, these authors conclude that beliefs about susceptibility to illness and benefits of preventive care are less significant or even antithetical in the face of worldviews that meld conscious and unconscious domains of social context into meanings of health and illness. Our cross-sectional analysis of subjective norms found screening to be associated with both normative beliefs and motivation to comply. Women who reported that their best friend or important people believed in annual mammography were more likely to have had a recent mammogram than those without such influences. Screening was also associated with trying to act on the beliefs of one’s sister or doctor, but the beliefs of one’s mother and husband were apparently not influential. A study including a multiethnic sample of inner-city women (Montaño, Thompson, Taylor, & Mahloch, 1997
) found that past mammography was associated with subjective norms regarding one’s doctor, but not one’s family, friends, people in the news, or others in medicine. In our study, associations with screening did not differ significantly by race/ethnicity for subjective norms. In the 3Cs qualitative interviews, Pasick, Barker, et al. (2009)
found support for the underlying assumption of subjective norms of the importance of significant others. However, their data suggested that many aspects of the operationalization of subjective norms are inconsistent with relational culture, “the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else” (p. 95S). In particular, the emphasis on definable, expressible beliefs both on the part of a respondent and among her referents is likely to be more implicit rather than overtly discussed; and although pressure to comply is also plausible, it is more likely that a process of consultation leads to a joint conclusion. A novel ethnographic analysis that was part of the 3Cs study, conducted by Washington, Burke, Joseph, Guerra, and Pasick (2009)
, identified a potentially important but missing referent from the subjective norms construct as used in the United States, adult daughters, whose influence on their mothers emerged as important for mammography decision making, consistent with results from an adaptation of Montaño and Taplin’s (1991)
items recently used in Spain (Andreu Vaillo, Galdón Garrido, Durá Ferrandis, Carretero Gómez, & Tuells Hernández, 2004
Our models explained only a modest proportion of variation in mammography screening behavior, comparable to the adjusted R2
of .27 obtained in a model of mammography compliance as a function of HBM constructs (Aiken, West, Woodward, & Reno, 1994
) and the R2
of .26 in a model of mammography participation as a function of TRA measures (Montaño & Taplin, 1991
). However, as noted by Sheeran (2002)
, it is important to consider that correlations with a binary outcome may be low even for large differences in proportions.
The strengths of our study include the measurement of several behavioral constructs used by prominent theoretical models, inclusion of multiple racial/ethnic groups and languages, a large population-based sample, and a longitudinal design. The limitations of our study include low response rates among Chinese and Filipina women, lack of variation in socioeconomic status within racial/ethnic groups, timing of interviews that precluded determining if a woman had a mammogram within 12 months after baseline, possible intervention effects on the relationship between constructs and final screening status, single-item measures for three of the constructs, overlap of subjective norms referent categories, and the use of self-reported screening data. In spite of these limitations, we found significant positive associations between measures of four of our constructs and screening, overall and within racial/ethnic groups. It is possible, however, that there were racial/ethnic differences in associations that we were unable to detect because of lack of power. In particular, the measures of self-efficacy, intention, and perceived benefits all showed a lack of variation in response that produced small race/ethnic-specific cell sizes in some analyses. Therefore, it was possible to obtain a significant association in only one racial/ethnic group without finding significant racial/ethnic differences in association, as occurred with the perceived benefit of lower mortality.
Unfortunately, with these data it is virtually impossible to differentiate between the properties of the item and the properties of the construct itself. For instance, the lack of association between perceived susceptibility and mammography may be because of poor measurement or lack of relevance of this construct in relation to screening in this population. In addition, it is important to note that although measures of association can provide support for or against a hypothesized relationship, they cannot provide a complete explanation of the underlying mechanism. A more in-depth study is required to fully understand these constructs and determine whether better cross-cultural measures can be developed. Such a study would build on the inductive work described elsewhere in this volume and extend to the development of multi-item measures. The new measures would be evaluated through a variety of methods (Harkness, Van de Vijver, & Mohler, 2003
), including cognitive interviewing, test–retest reliability assessment, and analytic techniques such as confirmatory factor analysis as well as further qualitative evaluation.
It could be argued that the development of widely applicable cross-cultural measures of these constructs is not only timely but also overdue. In recent years, measures of HBM constructs in relation to mammography have been used worldwide, chiefly through translations and adaptations of the Champion (1999)
Health Belief Model Scale. Although these studies provide convincing evidence for the widespread applicability of these constructs, their findings are by no means uniform. Positive associations between perceived benefits and mammography were found among women in Spain (Andreu Vaillo et al., 2004
), Turkey (Secginli & Nahcivan, 2006
), Korea (Hur, Kim, & Park, 2005
), and Israel (Soskolne, Marie, & Manor, 2007
). However, other studies found no association with mammography among women in Spain (Lostao, Joiner, Pettit, Chorot, & Sandín, 2001
), Turkey (Avci & Kurt, 2008
), Korea (Ham, 2006
), and Israel (Azaiza & Cohen, 2006
). Similar inconsistencies have been found with respect to the associations between mammography and both self-efficacy and, as noted above, perceived risk. Such promising, yet variable, findings call for a deeper understanding of the cultural and social contexts of health beliefs and behaviors as well as the development of measures that incorporate this understanding.