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Bastien, Natalie E.
Perceived barriers to breast cancer screening
h [electronic resource] :
b a comparison of African American and Caucasian women /
by Natalie E. Bastien.
[Tampa, Fla.] :
University of South Florida,
Thesis (M.S.)--University of South Florida, 2005.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
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ABSTRACT: Although the incidence of breast cancer is high among Caucasian women, African American women continue to experience higher breast cancer mortality and lower survival rate in comparison to Caucasian women of the same age. Research regarding breast cancer screening among ethnic minority women from lower socioeconomic groups is extensive, but there is a lack of research that investigates barriers to breast cancer screening among African American women of higher socioeconomic status. The purpose of this study was to compare health beliefs of African American and Caucasian women regarding perceived barriers to breast cancer screening. The sample for this study consisted of 80 women, 40 African American and 40 Caucasian women, who were between the ages 40 to 80 years. The study was conducted at two local community churches located in Tampa, Florida. The barriers subscale from the Health Belief scale was used for data collection.Descriptive statistics were used to analyze demographic data, and independent t-test were used to compare the two groups in their perceived barriers. Results revealed that both groups perceived barriers to breast cancer, there were more similarities than differences. However, African American women were significantly more likely to indicate that having a mammogram would make them worry about breast cancer (p= 0.39). Although previous research has shown differences African American and Caucasian women, this study did not support those results. The two groups of women were similar in age, education, and marital status and all were active in their churches. Perhaps these similarities led to the lack of differences in perceived barriers scores between the two groups. This finding lends support to the idea that socioeconomic status more than race leads to disparities in breast screening.
Adviser: Susan C. McMillan. Ph.D.
Co-adviser: Cecila A. Lengacher. Ph.D., RN
t USF Electronic Theses and Dissertations.
Perceived Barriers to Breast Cancer Screening: A Comparison of African American and Caucasian Women by Natalie E. Bastien A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science Department of Health Science College of Nursing University of South Florida Major Professor: Susan C. McMillan, Ph.D., ARNP Cecile A. Lengacher, Ph.D., RN Mary S. Webb, Ph.D., RN Date of Approval: November 10, 2005 Keywords: mammography, self-examination, mortality, pain, incidence Copyright 2005, Natalie E. Bastien
Dedication I would like to give praise and thanks to God for always guiding me through life delicate and most difficult path. Thanks to my husband Sem Bastien for his commitment to always helping me achieve my goals. I also would like to thank my two sons Demarious and Colby, my mother and father Cassie and Wilfred Yarde for their dedicat ed support and encouragement. I want you all to know that I m very grateful of your devotions towards my academic achievement. Sem, thanks again for your understanding. Colby and Dee, I appreciate your patience. Mom and Dad, the words of encouragement will never be forgotten.
Acknowledgement I would like to begin by expressing my deepest appreciation to Dr. Susan McMillan for her support and guidance throughout my academic achievement as a graduate student. I also would like to extend my appreciation to Dr. Cecile Le ngacher and Dr. Mary Webb for their advising and willingness to be part of my thesis committee. Allow me to say that without the support and encouragement of all of you, the road to my academic success would have been a lot more difficult. Also, I would like to thank Melissa Legga tt for her dedicated time and patience with me, Thanks to Tricia Holtje for all of your assistance, you are also greatly appreciated. Last but not least, I would like to acknowledge and thank Alet ha Neal, and Remona Thomas for their support and encouragement. Thanks to everyone that took part in this journey with me. This rewarding experience will always be remembered.
i Table of Contents List of Tables iii List of Figures iv Abstract v Chapter One: Introduction 1 Problem Statement 3 Research Questions 3 Definition of Terms 4 Barriers 4 Significance to Nursing 4 Chapter Two: Review of Literature 7 Conceptual Model 7 Health Belief Model 8 Review of Empirical Research 10 Perceived Barriers 18 Summary 22 Chapter Three: Methods Sample and Setting 24 Instruments 25 Health Belief Model: Barrier Questionnaire 25 Validity and Reliability 25 Demographic Data Form 26 Procedures 26 Approval 26 Data Collection 26 Data Analysis 27 Research Question 1 27 Research Question 2 27 Chapter Four: Results, Discussion and Conclusions 28 Sample 28 Ranking Barriers 30 Discussion 33 Sample 35 Screening Behaviors 36 Ranking Behaviors 37 Barrier Items 38
ii Conclusion 39 Recommendation for Future Research 40 References 41 Appendices 44 Appendix A: Health Be lief Model Questionnaire 45 Appendix B: Permission for use of Health Belief Model 47 Appendix C: Demographic Data Collection Form 48 Appendix D: Approval Letters from Churches 50 Appendix E: IRB Approval Form 52 Appendix F: Informed Consent Letter 54 Appendix G: Certificate of Approval 55
iii List of Tables Table 1 Means and Standard Deviati ons and Range of Ages of Women 29 Table 2 Frequencies and Percentages of Women by Marital Status 29 Table 3 Frequencies and Percentages of Both Groups by Educational Level 29 Table 4 Independent t-test Compar ison of BSE Barriers among Both Groups 30 Table 5 Independent t-test Comparison of Barriers to Mammography among Groups 30 Table 6 Independent t-test Comparison of BSE Barrier Item Scores for Both Groups 31 Table 7 Independent t-test Comparison of Mammogram Items Scores for Both Groups 32 Table 8 Frequency and Percentages of Bo th Groups by Participation in Screening 33
iv List of Figure Figure 1. Health Belief Model 8
v Perceived Barriers to Breast Cancer Screening: A Comparison of African Amer ican and Caucasian Women Natalie E. Bastien ABSTRACT Although the incidence of breast cancer is high among Caucasian women, African American women continue to experience higher breast cancer mortality and lower survival rates in comparison to Caucasian women of the same age and cancer stage (Thomas, 2004). Research regarding breast cancer sc reening among ethnic minority women from lower socioeconomic groups is extensive, but there is a lack of research that investigates barriers to breast cancer scr eening among African American women of higher socioeconomic status. The purpose of this study was to compare health beliefs of African American and Ca ucasian women regarding perceived barriers to breast cancer screening. The sample for this study consisted of 80 women, 40 African American and 40 Caucasian women, who were between the ag es of 40 to 80 years. The study was conducted at two local community churches lo cated in Tampa, Florida. The barriers subscale from the Health Belief scale wa s used for data collection. Descriptive statistics were used to analyze demographic data, and independent ttests were used to compare the two groups in their perceived ba rriers. Results revealed that both groups perceived barriers to breast cancer screeni ng, there were more similarities than
vi differences. However, African American women were significantly more likely to indicate that having a mamm ogram would make them worry about breast cancer (p = 0.39). Although previous research has shown differences between African American and Caucasian women, this study did not s upport those results. The two groups of women were similar in age education and marital status and all were active in their churches. Perhaps these similarities led to th e lack of differences in perceived barriers scores between the two groups. This fi nding lends support to the idea that socioeconomic status more than race leads to disparities in br east cancer screening.
1 Chapter One Introduction Breast cancer is the most common cancer in African American and Caucasian women, and is the leadin g cause of death among American women age 40-44 (National Cancer Institute, 2005). Breast cancer mortality is second to lung cancer as the leading cause of all cancer deat hs in women (Yarbrough, Frogge, Goodman & Wald, 2000). In 2004, approximately 216,000 cas es of breast cancer were reported, and 40,000 deaths were related to breast cancer in the U.S. (Kasper, Braus, & Fauci, 2003). It is estimated that there will be 211,240 new invasive cases of breast cancer in 2005 the U. S., and 40,410 of those cases will result in death (Centers for Disease Control, 2005). The National Institutes of Health Consensus Development Conference statement emphasized that by the year 2009, more than 1.8 million women will be newly diagnosed with invasive breast cance r, and of that number 30% will die of breast cancer (Yarbro et al., 2000). Accordi ng to the National Breast Coalition, breast cancer mortality remains consistently higher among African American women than Caucasian women. Statistics related to breast cancer incidence, mort ality, and survival reveal a disparity between African Ameri can women and Caucasian women (Yarbro et al., 2000).
2 According to the American Cancer Society (ACS, 2005), the incidence of breast cancer is higher in Caucasian wome n, but African American women experience higher mortality and lower survival than Caucasian women. Statis tics reported by the American Cancer Society in the year of 2004 show the survival rate of breast cancer in African American women is 63% compared to 78% in Caucasian women. It is estimated for the year of 2005 the number of expected breast cancer cases among African American women will be 19,240, a nd 5,640 of those cases are expected to result in deaths. This data suggests that African American women are likely to have advanced disease when diagnosed, and ar e less likely to use secondary prevention procedures such as breast self examin ations (BSE) and mammography. According to the American Cancer Society (ACS, 2005), the key to surviving brea st cancer is early detection and treatment. Currently, mamm ography is the best method of detecting breast cancer that cannot be felt during clinical breast examination (ACS, 2005). Although increases in mammography scr eening among African American women have occurred, screening behaviors still va ry greatly among African American women (CDC, 2005). Disparity in the use of cancer screening and in s eeking care may be related to differences in the per ception of cancer risks (Thomas, 2004).
3 Statement of the Problem Although the incidence of breast cancer is higher among Caucasian women, African American women continue to experience higher breast cancer mortality and lower survival rates in comparison to Cau casian women of the same age and cancer stage (Thomas, 2004). Research regarding breast cancer sc reening among ethnic minority women from lower socioeconomic groups is extensive, but there is a lack of research that investigates barriers to breast cancer scr eening among African American women of higher socioeconomic status (Thomas, 2004). The problem to be studied is to examine the health beliefs of African American women regarding cancer screen ing related to perceived ba rriers, as compared with Caucasian women. The purpose of this study is to compare perceived barriers to breast cancer screening between African Am erican women and Caucasian women. Research Questions This study was designed to an swer the following questions: 1. Is there a significant difference between African American and Caucasian women in their perception of barriers to breast cancer screening? 2. What are the highest ranked barriers to breast cancer screening for Africa n American and Caucasian women?
4 Definition of Terms For the purposes of this study, the following term is defined: Barriers: Perceived emotions, physical or st ructural concerns related to mammography or BSE behavior that interferes with scre ening (Champion, 1999). Significance to Nursing According to the (CDC, 2005) many d eaths from breast cancer could be avoided by increasing cancer-screening rates among women at risk. African American women are more likely to die from cancer than Caucasian women. African American women have a higher mortality rate and a lower survival rate than Caucasian women. It is important as advanced practice nurses that we become aware of contributing factors that place African American women in a hi gher risk category of dying from breast cancer. As a clinician, an important goal would be to reach out to the African American community and educate them about breast cancer screening. Through education this can increase their awareness related to preven tion, intervention, and screening for detecting early stage breast can cer. Also, this process will give them the understanding of the extreme importance of br east cancer screening. If we could meet these goals through this process it is possi ble that outcomes related to breast cancer will and could improve among African Ameri can women, and breast cancer statistics rates will improve, such as a decrease in the mortality rate among and an increase in survival rates among African Ameri can women with breast cancer.
5 In the United States (U.S) breast cancer is a significant health issue among women. One goal of Healthy People 2010 is to increase the percentage of women aged 40 years and older who have a mammogram every two years to 70% Achieving this goal will require intervention strategies th at meet the needs of diverse population including African American women (Legler, 2004). This study may shed light on differences in perceived barriers to breast cancer screening in African American and Caucasia n women. Nurses are in the best position to address the needs of women at risk for breast cancer. During the screening process we have the capability of finding out pert inent information regarding the women we are treating. This could be done by assessing the, psychological, social and economic concerns during screening for breast cancer. We need to be aware of the specific needs of the African American women especially the psychosocial predic tors that contribute to them participating in breast cancer scr eening programs. Educa tion and being patient advocates are our responsibility as clinicians. We need to educate our clients, but we also need to be educated, and we need to be culturally competent. By being culturally competent this mean we are more sensitive towards the culture of the client. This allows us to understand why they may res pond to preventive health in a certain manner, and enlighten us about their understa nding of disease pro cess and treatment. We need to be aware of psychosocial and physical barriers that contribute to the problem of breast cancer among African Am erican women, which place them at a
6 greater risk of increased mortality, and decreased survival. Careful assessment can serve as a great tool in assessing ethnic and high-risk populations. Our enhanced knowledge can benefit the women to whom we deliver care.
7 Chapter Two Review of Literature This chapter reviews the empirical literatu re relevant to breas t cancer screening among African American and Caucasian women. First, the conceptual framework is presented. Then empirical research relevant to perceived barriers to breast cancer screening among African American women and Caucasian women is reviewed. This is followed by a summary of the literature. Conceptual Framework The Health Belief Model (HBM) is a m odel that serves as the conceptual framework for identifying and explaining factor s associated with the practice of disease detection screening and health promoting be haviors. According to (Rice, 2000) the HBM derived from Lewin, Dembo, Festinger, and Sears in 1944 Level of Aspiration Theory, which attempts to explain and pred ict health behaviors by focusing on attitudes and beliefs of individuals. The HBM was first proposed in the 1950s by social scientists for the United States Public Health Service to explain a persons lack of engagement in preventive health behaviors (Rice, 2000).
Health Belief Model 8 Figure 1. Health Belief Model (HBM)
9 According to Rice (2000), the HBM hypot hesized that hea lth related action depends on the following factors: 1) sufficien t motivation (or health concern) exists to make health issues salient or relevant; 2) there is a belief that one is susceptible (vulnerability) to a serious health problem or to squeal of that illness or condition (perceived threat). Perceived threat is identified by two key variables, perceived susceptibility and perceived severity. Th ere is a belief that following health recommendations is beneficial (perceived benefit) in reducin g the threat at a subjectively acceptable cost. Cost refers to perceived barriers that must be overcome to follow health recommendation. The HBM exp licates that for behavior change to occur, an individual must perc eive a disease as serious, must perceive themselves as at increased risk for developing the disease (s usceptibility), the perceived benefits of action must outweigh the perceived barriers to taking the action, cues to take action, and their confidence in their ability to perf orm the action must be high (self-efficacy) (Champion, 1987). According to Champion ( 1987), a number of studies have applied the Health Belief Model (HBM) to predicti on of breast self-examination (BSE). These studies have shown perceived ba rriers to be the strongest pr edictor of BSE. The Health Belief Model (HBM) established a framework for understanding h ealth behaviors and is often applied to breast cancer screen ing (Champion 1993, Foxall, Barron & Hauck, 1999). There is further discussion on the HBM and cancer barriers throughout this review.
10 Review of Empirical Research Perceived Barriers There are significant barriers associated w ith the lack of participation in breast cancer screening programs among African American women. Due to perceived barriers related to cancer screening, African American women may experience higher breast cancer mortality and lower survival rates compared with Caucasian women of comparable age and cancer. The following studi es address the barriers to breast cancer screening perceived by Af rican American women. Lukwago, and colleagues (2003) conduc ted a study examining associations between five factors: collectivism, spirituality, racial pride, pr esent and future time orientation and breast cancer related knowledge. They al so examined barriers to mammography and mammography use, stag e and change among urban African American women. The sample in this study consisted of African American women aged 18 to 65 (N=1241), recruited from 10 pub lic health centers in the city of St. Louis Missouri. Informed consent was obtained. Women aged 40 years and older were included in the analyses. Measures included socio-cultural constr ucts, breast cancer related knowledge, barriers to mammogr aphy, mammography use, and stage of change. Socio-cultural constructs were meas ured with scales deve loped by the project team (Lukwago et al., 2003).
11 Lukwago et al. (2003) also examined breast cancer-related knowledge, barriers to mammography, and mammography use and st age of change. Results showed that women who had a present time orientation were less educated, had lower incomes, were unemployed; report no history of breast cancer or breast cancer treatment. According to the authors, these women also had more barriers to mammography. Mammography use and stage of change presen t-orientation was ne gatively associated, and mammogram age and mammogram knowle dge were positively associated. Age, employment, physician or nurse reco mmendation to get a mammogram, and mammogram knowledge were positively associated with mammography stage of change .Lukwago et al. (2003) concluded that present-time orientation was negatively associated with breast cancer relate d knowledge and mammography, and positively associated with perceived barriers to ma mmography. They also c oncluded that having a present-time orientation is probably more likely associated to income than race. Receiving a recommendation from health a care provider was shown to be an important predictor of mammography in this study. It is suggested that practitioners working to promote mammography might cons ider integrating time-orientation and racial pride into their approaches for Afri can American women. This type of approach may enhance intervention strategies that are focused on promoting breast cancer screening among African American women and help eliminate breast cancer disparities.
12 Frequently cited breast cancer screeni ng for African American women included fear of finding a cancerous lump, cost, lack of provider recommendation, lack of knowledge about the need and recommenda tion for breast cancer screening. Also, limited perception of risk of developing breas t cancer, distrust in the health delivery system, and presence of multiple illnesses taking priority over breast cancer screening were indicated as fears to breast cancer screenin g (Phillips, Cohen, & Tarzian, 2001). Phillips et al. (2001) con ducted a qualitative study to describe the experience and meaning of breast cancer screening fo r ten African American women. The sample consisted of 23 low and middle-income Af rican American women. Eight low-income and 15 middle-income African American women without a known history of breast cancer were recruited from me tropolitan areas of the northeastern United States. Age ranged from 45 to 81 years, with a mean ag e of 52. Women over age 40 were recruited because of the recommendation to have a baseline mammogram by age 40. Women were included from both low and middle-in come categories because research with African American women showed that income level influenced life experience among African Americans. This study was based on hermeneutic phenomenological methods. Primary investigators collect ed data using open-ended uns tructured interviews that began by asking women to describe their e xperiences with breast cancer screening. Breast cancer screening refers to br east self-exam (BSE), mammography, and professional breast exam combined. Each part icipant was encouraged to describe her
13 experience completely. Interviews included asking women to describe the last time they did breast self-examination, and to describe their last professional breast examination. The interviewer asked probing que stions to allow the women to clarify and elaborate one or more of the screening methods, and they were asked to talk about that. Demographic data were also obtained from each woman. Participants were interviewed for 60 to 90 minutes (Phillips et al., 2001). Findings of the study showed that the themes in the study were similar between low and middle-income participants. However differences showed low-income women expressed problems with lack of access to healthcare while more middle-inco me women discussed use of alternative and holistic therapies. Overal l screening rates were less than optimal in both groups. Only ten participants (nine middle-income, one low-income) reported consistently practicing monthly BSE and having ma mmography, and professional breast examinations. Participants identified the overall them e minding the body, self, and spirit as major components in shaping breas t cancer beliefs, and pr actices. Spirituality and religious beliefs influenced their approach to BCS. Findings also indicated that social influences, social support, and pr ovider recommendation and support facilitated BCS (Phillips et al., 2001). According to Phillips et al. (2001) when barriers to accessibility, and acceptability of health care were reduce d, African American women were found more likely to engage in BCS. Participants indicated that race and et hnicity influenced
14 health-care experiences, and most of the pa rticipants mentioned character traits of their providers, such as caring and respect ful attributes as influencing the bond and degree. These findings showed that the history of distrust between African Americans and health care providers in the United States could be transcended through meaningful relationships. A ccording to the authors, building on naturally existing sources of support and improving patient-pro vider relationship has the potential for increasing BCS and earlier detection of cancer among African American women. Lauver, Settersten, Kane and Henrique s, (2001) believed that psychosocial variables such as beliefs, f eelings, and norms influenced health behaviors, and external conditions such as environmental variables also contributed to health behavior. To support this theory, Lauver et al. (2001) proposed that a message tailored on psychosocial variables, such as beliefs, fee lings and external barri ers regarding breast cancer screening would be more efficacious in promoting womens utilization of screening than a standard message that provided only prof essional, normative recommendation about screening. Lauver et al. (2001) conducted a rand omized controlled trial with three messages conditions. The purpose of the trial was to test the effects of alternative messages on mammography and clinical breast examination (CBE) utilization over time and to examine the combined effects of such messages and external barriers. Three messages were compared: no message (control group), recomm endations about
15 screening, or recommendations plus tailored discussion (on beliefs, feeling, costs, and access). The sample size consisted of 101 women from a diverse population, which included African American and Caucasian wo men (age range 51 to 80 years old) who had not had mammograms in the prior 13 mont hs. Advanced practice nurses delivered the messages over the telephone. Outcome measures were womens mammography and CBE utilization three to six months post intervention (short-term follow-up) and 13-16 months after short-term follow-up (l ong-term follow-up). The results concluded that overall, messages that we re tailored on theoretically derived concepts of beliefs, affect, and external barriers promoted breast screening among women with high external barriers to screening but had differential effect among women with low barriers. Both messages promoted mammogra phy and CBE utilization at shortterm follow-up. Utilization increased over time in all groups. Mammography utilization was greater for the tailored-message group compared with the r ecommendations only group at long-term follow-up. Among participants with high external barriers, participants in the message conditions, esp ecially the tailo red message had the highest screening rates. Among participants with low barriers, sc reening rates were similar across conditions. The most common extern al barriers to mammography were the high costs of screening, transportation, and parking. The investigators concluded that external barriers influenced health related behaviors, such as breast cancer screening.
16 Graham (2002) conducted a descriptive correlational design to examine the relationship between health beliefs and practice of breas t self-examination (BSE). Champions revised Health Belief Model Scale was used for data collection. One hundred and seventy-nine black women were recruited from a major teaching hospital, churches, and health fairs in New York C ity. Inclusion criteria included women age 20 to 49 that were able to read, write, and speak English. Participation meant responding to Champions Health Belief Survey, and a short questionnaire soliciting demographic information. Graham (2002) hypothesized that subjects who perceived greater barriers would report a lower frequency of BSE performance. Mean scores were obtained for barriers. Three of six items on the subscale emerged as making significant unique contributions to BSE, and the mean response to two ite ms supported the researcher hypotheses. The two items were: 1) Doing breast self-exami nation during the next year will make me worry about breast cancer, and 2) Doing br east self-examination will take too much time. A relationship was found between health beliefs and BSE among black women. Further, the study found that health belie f is much stronger in determining BSE performance for a given individual than background characteristics; this finding corroborates previous studies. The study re vealed that although women perform BSE, many of them fail to follow the American Cancer Society guidelines for breast cancer screening, and others fail to pe rform breast exams (Graham, 2002).
17 Rahman (2003) conducted a study to assess perceptions and acculturation issues in breast cancer scr eening among uninsured and underinsured women in Lucas County, Ohio. The sample consisted of women from different community-based organizations where they voluntarily particip ated in breast cancer education programs. Participants ranged in age from 15 to 82 years (mean age 41.95 years, SD=15.83), and 64% were African American. Participants were interviewed by nurse practitioners. Barrier questions were analyzed based on 276 responses and the logistic regression was conducted on 165 observations due to missing values in the covariates. The perceptions were based on the construc ts of Health Belief Model, such as perceived susceptibility to breast cancer, pe rceived cancer, perceived severity of the disease, perceived benefits of mammogr aphy, and perceived barriers of having a mammogram. Barrier questions consisted of having 14 previously identified barriers of having mammogram extracted from prev iously published research. The results related to perceived barriers to breast cancer screening showed that 87.5% of the participant agreed with the statement that they were afraid of having a mammogram because something wrong may be found. Other barriers included financial ability to pay for the mammogram, fear of treatment or surgery, and experiencing pain during the mammogram (Rahman, 2003). Paskett and colleagues (2004) conducted a study to increase mammography use among low-income minority, and rural wome n over 40 years of age. The sample
18 consisted of 295 African American women, 371 Native American women, 226 Caucasian women, and five women who were classified as being multiracial. Data from 892 women were analyzed for this study. Women in each racial group were compared with regard to demographics, cance r screening habits, breast carcinoma risk factors, and mammography adherence, as well as with regard to barriers, beliefs and knowledge regarding cancer sc reening. Survey comparisons were made among racial groups with respect to knowledge, attitudes, and beha viors regarding breast and cervical carcinoma screening. The results s howed that overall, Native American and African American women had lower levels of knowledge, more inaccurate beliefs, and more barriers to breast cancer screening compared with Caucasian women. The investigators concluded th at although all low-income rural women experienced significant barriers to cancer screening tests, these barr iers were more common for minority women when compared to wh ite women (Paskett et al., 2004). Ahmed, Fort, Elzey, and Bailey (2004) conducted a study through in-depth focus group discussion to gather information about facilitating fact ors and barriers to mammography screening from experiences of regularly compliant, underserved women. The sample consisted of 25 African American women, aged 40 and older with personal incomes of $15,000 or less, who adhered to r outine mammography screening guidelines (1-2 years from ages 40 thru 49 and annually beginning at age 59). The discussions centered on the influences they c onsidered as either empowering factors or
19 barriers to breast cancer scr eening. The results indicated that healthcare system barriers were one of the many barriers associated with barriers to mammography screening; this included physician characterist ics, the health care facility, the staff and management. Some described mammography as painful and several said that the discomfort of the procedures was discour aging. Another inhibitor described by the participants was that as they aged, the number and types of screening tests became overwhelming and depressing, and an increase in stress occurred while waiting for the results, they also found that while find ing nothing during a mammogram was a relief as well as satisfying and reassuring, a null finding sometimes produced an overconfidence (Ahmed et al., 2004). Ogedegbe and colleagues (2005) conducte d a qualitative stud y to elicit and explore the perceptions of barri ers to and facilitators of co lorectal, cervical, and breast cancer screening among minority women. The sample included 187 women, 44% were African American, and 51% were Latinos with an age range of 50 to 69. To be eligible for the study, the part icipants had to be able to speak, read, and write in English, Spanish, or Creole, and have visited one of the community health centers. Participants were asked open-ended ques tions designed to explore barriers and facilitators of cancer screeni ng behaviors. Each participan t interview was divided into sections focusing on particular screeni ng tests such as mammography, home fecal occult blood test (hFBOT), or sigmoidoscopy. Qualitative analysis of participants
20 response revealed three major categories of cancer screening behavior: 1) patient attitude and beliefs; 2) soci al network experience; and 3) accessibility of services. Results showed that attitudes and beliefs identified as barriers to cancer screening included a lack of knowledge about cancer sc reening or the diseas e cancer (patients never thought about screening, or heard of screening test) and a fear of cancer, and pain. Many of the participants indicated th at part of their f ear included the pain associated with the procedure, and th is prevented them from having the exam or procedure. Also, the lack of symp toms, such as pain, was identified as a barrier to mammography screening, and knowledge of someone who was harmed by cancer screening procedures, and discourag ement from family and friends were identified as cancer screening barriers. Exte rnal barriers included cost, transportation, and location. The most commonly cited barrie rs to breast cancer screening behaviors were the perception of the participant not needing the test due to good health, an absence of symptoms, and lack of knowledge. Other important barriers elicited from participant were the fear of pain, and the fear of having the test. Fear was the most commonly cited reason for not planning to have a mammogram in the future (Ogedegbe et al., 2005). Han, Wells, and Primas (2003) conducted a study to identify differences in the prevalence of ever having had a mammogr am, and having had a recent mammogram between older black women. They also compared factors associated with
21 mammography use in older black and white women. The sample consisted of 449 black women, and 3,328 white women. Data analys es of this study were obtained from the 1998 National Health Interview Survey ( NHIS). Chi-square tests were used to examine differences in the prevalence of mammography use and other investigated factors between older black and older white women. Second, multivariate logistic regression models were applied to evaluate th e effect of the investigated variables and their possible interactions on mammography use. The result of the two chi-square tests s howed that older white women were more likely to have ever had a mammogram than older black women. There was no difference in mammography use between olde r blacks and whites. The differences in the examined factors between older whites and older blacks included variables such as; age, education, marital status, income, and Medicare supplements. Older blacks were more likely to report poorer health, func tional disability, and a history of lifetime alcohol abstinence than whites. These inves tigators concluded that the differences in barriers to mammography use between older black and older white women included lack of health care for black women without a usual source of care. Older age and higher education level were risk factors fo r both older black and white women and the lack of recent mammography. Education eff ect was significantly stronger in older black women than in older white women. This study showed that having less than 12 years of education was a risk factor for mammography screening a nd was a barrier to
22 screening among older black and white women. It also suggested that having income was a risk factor for non-use of mammogr ams in older white women but not older black women. Not having an usual source of care was a barrier for both black and white women, but was a greater barrier for older black women. They also concluded that barriers to mammography use in olde r black and white women are complex, and future research is needed to confirm th e differences and investigate whether other factors are related to mammography use in older black and white women (Han et al., 2003). Summary According to statistics, breast cancer in cidence is higher in Caucasian women and breast cancer mortality is higher in African American women. Based on these facts, its apparent that there is a need for ongoing rese arch related to breast cancer screening and perceived barriers among African American wo men. Current literature indicates that there are many barriers that contribute to the lack of breast cancer screening among African American women. Barriers such as co st of health screen ing, lack of access to care, fear associated with cancer, and pain associated with cancer contributes to the mortality issues African American women are faced with in our society today. In order for African American women to have decrease d mortality and increased survival, there is a need for more research, education a nd intervention programs. Through research, education, and intervention programs, breast cancer screening among African American
23 women could improve. Through this process African American women could benefit from decreased barriers and improved outcomes.
24 Chapter Three Methods The purpose of this study was to compare perceived barriers related to breast cancer screening among African American and Caucasian women. This chapter discusses the sample, the setting, the instrument, the procedures and the data analysis. Sample and Setting Participants were 40 years of age or ol der to meet American Cancer Society guidelines for breast cancer sc reening (ACS, 2005). Forty Af rican American women and 40 Caucasian women were recruited to participate. Subjects were recruited from two local Baptist churches located in Tampa, Florid a. All subjects were able to read, write, speak, and understand English. Only African American and Caucasian women were included in this study. Women with a history of breast cancer, and Hispanic women of any color were excluded. Religion and marital status were not exclusion criteria. Sample size was based on a power analysis with alpha level set at .05 and power at .80. It was determined that a total of 80 women (40 in each group) would provide sufficient power to determine significant differences.
25 Instruments Health Belief Model: Barriers Questionnaire The Health Belief Model Questionnaire was the instrument used in this study (Appendix A). Consent to use the instrument was given by the author (Appendix B). The Health Belief Model sub-scales measure six co ncepts a) benefits, (b) health motivation, (c) self-efficacy, (d) susceptibility, (f) barrier s, and (e) seriousness. For the purpose of this study, perceived barriers are the only construct being measured (Champion, 1998). The barriers scale has two subscales, barriers to mammography (five items), and barriers to BSE (six items). The format of the subs cales is a 5-point Likert-type scale from strongly disagrees to strongl y agree. High scores on the sub-scales mean greater perceived barriers (Champion, 1998). Validity and Reliability. According to Champion (1999) the relati onship between barriers and compliance with mammography recommendations has b een critical in in fluencing women on screening behaviors. The construct barrier has been shown in past work to be related to mammography behavior. To support this th eory, content validity was evaluated. Construct validity was examined by using factor analysis. Overall, items reflected strong internal consistency reliability and test-ret est reliability. A Cronbach-alpha of .88 for the barrier scale was reported (C hampion et al., 1999).
26 Demographic Data Form A demographic tool was developed for this study (Appendix C). Data from the demographic includes age, marital status education level, occupation, primary care physician, ethnicity, religion preference, and church affiliation. Procedures Approvals Approval to conduct the study was obtained from the organizational leaders at the local churches where data was collected (A ppendix D). Then approval was received from the University of South Florida Health Scie nces Center Instituti onal Review Board for protection of human Subjects (Appendix E). Before the women completed the instrument, the study was explained with information about the study benefits, risks of participation, and confidentiality. Then in formed consent was obtained (Appendix F). A copy of the consent was given to each subject to keep for her records. The identity of the subjects was kept anonymous; no personal identif iers were on the data forms. Appendix (G) for Human Subjects Data Collection The investigator approached subjects by visiting each church on one occasion. Each subject was given a packet that include d an informed consent letter, demographic data form, and a HBM questionnaire. Upon co mpletion of the forms, the investigator collected them from each subject. Raw data wa s locked in a cabinet in a locked room.
27 Data Analysis Descriptive statistics were used to an alyze demographic data, including means, standard deviations, frequenc ies, and percentages. Data was entered and analyzed using the Statistical Package, for the So cial Sciences (SPSS) computer software version 12. Independent t-test comparisons were used for research question one. Research Question1: Is there a signifi cant difference between, African American and Caucasian women in their pe rception about breast cancer screening? Research Question 2: What are the highest ranked barriers to breast cancer screening for African American and Caucasian women? The mean score for each item on Barrier s subscale was analyzed and presented from greatest to least for each of the two groups. The two subscales were analyzed by examining frequencies and percentages for each group. Finally, an independent t-test was calculated for each item.
28 Chapter Four Results, Discussion, and Conclusions This chapter presents findings of the st udy. Included in this chapter are the study results with a discussion of the results, conclusions, and recommendation for future research. Results Sample The study group (n=80) consisted of 40 African American women and 40 Caucasian women. Ages ranged from 40 to 80 years for the African American women with a mean of 54.8 years, and for the Cau casian women, age ranged from 41 to 71 years with a mean of 54.7 (Table 1). Marital status included single, marri ed, divorced, widowed and separated; in both groups the majority of the subjects were married (Table 2). Education level of the sample ranged from j unior high through gra duate degrees. Subjects were very similar in their levels of e ducation, with Caucasian women having more graduate degrees (Table 3).
29 Table 1. Means, Standard Deviatio ns and Range of Ages of Women Group n mean SD range African American 40 54.8 10.4 40-80 Caucasian 40 54.7 9.3 41-71 Table 2. Frequencies and Percenta ges of Women by Marital Status Marital Status African American Caucasian Frequencies Percentages Frequencies Percentages Single 5 12.5 2 5 Married 25 63 29 72.5 Divorced 4 10 9 22.5 Widowed 4 10 0 0 Separated 2 5 0 0 Total 40 100 40 100 Table 3. Frequencies and Percentages of Af rican American Women by Education Level Education Level African American Caucasian Frequencies Percentages Frequencies Percentages Junior High 5 12.5 1 2.5 High School 16 40 15 37.5 College Degree 16 40 17 47.5 Graduate Degree 3 8 7 17.5 Total 40 100 40 100 To answer the first research question, analysis involved an independent t-test comparison of barriers to breast self-examina tion scores between African American and Caucasian women. There were no signifi cant differences found between two groups (Table 4).
30 Table 4. Independent t -test Comparison of Mean Subscale Barriers to Breast Self Examination Scores between African American and Caucasian Women Group n mean t p African American 40 11.2 0.610 0.54 Caucasian 40 10.5 Ranking Barriers To answer Research Question two, item means for the barrie rs to breast selfexamination (BSE) scores were calculated and placed in rank order (Table 6). There were similarities; no items showed significant differences. The grea test barrier noted was that African American women felt that doing breas t self examination during the next year would make them worry about breast cancer. The second subscale score was for barriers to mammography. The highest ranked barrier in both groups was would be painful. The lowest ranked barrier for both groups wa s would be embarrassing. A significant difference was found on one item, having a mammogram would make me worry about having breast cancer (p=.039) (Table 7). Table 5. Independent t -test Comparison of Mean Subscale Scores of Barriers to Mammography Scores between African American and Caucasian Women Group n mean t p African American 40 11.1 0.67 0.51 Caucasian 40 10.4
31 Table 6. Independent t-test comparison of Br east Self Examination (BSE) barrier item scores between African Ameri can and Caucasian Women African American Caucasian Exam BSE m m t p Doing BSE during the 2.22 1.88 -1.35 .182 next year will make me worry about breast cancer I feel funny doing 2.15 1.98 -.642 .523 BSE Doing BSE will be 1.80 1.75 -.218 .828 Embarrassing Doing BSE will be 1.80 1.80 .000 1.00 unpleasant Doing BSE will take too 1.70 1.57 .727 .470 much time I dont have enough privacy 1.60 1.43 -1.20 .235 to do BSE
32 Table 7. Independent t-test comparison of Mammography barrier item scores between African American and Caucasian Women African American Caucasian Exam Mammography m m t p Having a mammogram or x-ray would: Would be painful 2.92 2.65 -.906 .368 Make me worry about 2.42 1.80 -2.10 .039 breast cancer Would cost too much 2.10 2.08 -.097 .923 Would be embarrassing 1.97 2.10 .457 .649 Would take too much 1.63 1.77 .852 .397 time African American and Caucasian wo men were questioned about yearly mammography screening, and monthly breast self-examination. Eighty-five percent of the African American and 90% of the Caucasia n women reported that they had ever had a mammogram in the past year. Fifty-five per cent of the African American reported having yearly exams and 65% of the Caucasian wo men reported having yearly exams. African American women reported performing breast se lf-examinations more frequently than Caucasian women. (Table 8).
33 Table 8. Frequencies and Percents of Ameri can and Caucasian Women by Participation in Breast Self Examination and Mammography Exam African American Caucasian Mammogram/BSE Frequencies Percentages Frequencies Percentages Have you ever had a 34 85 36 90 mammogram Have you had a mammogram 22 55 26 65 the past 12 months Do you have a mammogram 7 17.5 6 15 scheduled Do you perform BSE monthly 24 60 19 47.5 Discussion If detected early, a diagnosis of breast can cer can be treated effectively with the end result of a positive outcome. By fo llowing the guidelines recommended by the ACS (2005), performing monthly breast exam, a nd getting yearly mammograms, undesirable outcomes related to breast cancer can be prevented. Although African American women have a lower incidence of breast cancer occurrence than Caucasian women, statistical da ta continues to show that more African American women die from breast cancer, because by the time they are diagnosed they have advanced infiltrating disease (ACS, 2004). The need for breast cancer screening and early detection remains a crucial issue for African American women. This study compared perceived barriers to breast cancer screening among African American and Caucasian women. There were remarkable similarities between the two
34 groups demographically. There was not much di fference in their edu cational levels, and participants were active in a local church. These two groups al so were similar in that the majority of the women in each group was ma rried and employed. Results of this study revealed that African American women re ported performing breast self-examination (BSE) somewhat more frequently than Caucasian women, and had mammograms less frequently than Caucasian women. This re sult was unlike previous studies that found significant differences among African Ameri can and Caucasian women. Lukwago et al. (2003) reported that African American wome n had a lack of know ledge about the need and recommendation for breast cancer screen ing. This study indicates that African American women have knowledge about breast cancer screening a nd are aware of the guidelines for screening. It is apparent that race did not a ffect results of this study as indicated in earlier studies. Phillips et al. (2001) indicated in their study that race and ethnicity influenced heal th care experiences. Although more than half of the wome n reported doing breast self-examination (BSE) and having had a mammogram, some di d not. Between 35 and 45% had not had a mammogram in the past year and 40 to 57% had not done m onthly breast selfexamination (BSE). It is evident that thes e women who attended church have awareness about breast cancer screeni ng. This may be the result of the church being actively involved in community outreach programs for breast cancer screening, or members that are involved in health care ministries with in the church. Also me mbers may have had
35 health care backgrounds. Somehow these wome n in the sample have been educated regarding breast cancer screening. This st udy indicates that the church may be a good place to reach out to women regarding breast ca ncer screening and that this could be the avenue to developing further outreach progr ams, intervention programs, and educating women. Also, clinicians could be utilized in this setting a nd can learn about the important impact that the churchs community plays in reaching out to comm unity, and being used as a resource for providing information to women about breast cancer screening. The church can have a positive impact on breast cancer screening programs. It is important that advanced nurses develop breast ca ncer screening programs and intervention programs that will target populations that are vulnerable. Nurses are challenged by the barriers that prevent the underserved from par ticipating in these programs. Clinicians and nurse educators need to come together to develop outreach programs that would provide education at a level of understa nding for targeted populations. Sample Findings from this study poi nt out that African Amer ican and Caucasian women in the sample were comparable in age, with very similar mean ages (54.8 and 54.7). The two groups educational levels were similar, but the Caucasian group had a higher level of graduate degrees, with 7.5% of Afri can American women having had graduate degrees, and 17.5% of Caucasian women havi ng graduate degrees. The study sample was limited to women from one geographic area. The study was also limited to African
36 American and Caucasian women only, no other ethnic groups were invi ted to participate in the study. Also, women with a history of breast cancer were not al lowed to participate in the study. Further, women were sampled fr om two Baptist churches in one middle and upper middle class community located near a large academic setting. Thus, results may not be generalizeable to all women. Screening Behaviors Surprisingly, findings from the study i ndicated that African American women performed breast self examination on a mont hly basis more frequently than Caucasian women, with 60% of African American wo men performing breast self examination monthly compared to 47.5% Caucasian women doing so. This result is supports previous research conducted by Graham (2002) who f ound that subjects who perceived greater barriers would report lower frequency of BSE performance. However, this present study showed that slightly more Caucasian women report having had mammograms compared to Afri can American women with 55% African American women and 65% Caucasian wome n having had mammogram. These findings support earlier studies conducte d by Phillip et al (2001) and Lauver et al (2001). Although no significant differences were found between African American and Caucasian women in their perceived barrier s to either mammography or breast selfexamination (BSE) some small differences em erged. African American perceived slightly more barriers than Caucasian women to br east self-examination (BSE) (mean=11.2) and
37 mammography (mean=10.5). The difference in pe rception regarding ba rriers to breast self examination (BSE) included worrying a bout breast cancer, taki ng too much time to perform the exam, and not having enough privacy. When ranking the health belief model variable of barriers to breast selfexamination BSE, and mammography total sc ores showed some differences between African American and Caucasian women. The findings from this study revealed that African American women were more likely to perceive more barriers to BSE and mammography than Caucasian women. Ranking of Perceived Barriers Barriers to breast self-examination (B SE) and mammography were ranked from greatest to least for both Af rican American and Caucasian women. African American women ranked barriers higher in comparison to Caucasian women. The highest ranked barrier to breast self examination (BSE) for the African American women were that they felt funny performing breast self examination (BSE), and that performing breast selfexamination (BSE) would make them worry a bout breast cancer. The l east barrier was I dont have enough privacy to do breast self -examination (BSE). The highest ranked barrier to mammography for African American women was that they felt that having a mammogram would be painful, having the mammogram would make them worry about breast cancer, and the exam would cost t oo much. The Caucasian women highest ranked barrier for breast self-examination (BSE), I feel funny doing breast self-examination
38 and doing breast self-examination (BSE) woul d make me worry about breast cancer. The least ranked barrier for the Caucasian group was I dont have enough privacy to do breast self-examination. Caucasian wome n greatest ranked barriers to mammography included, mammography would be painful and mammography would take too much time. The least barrier to mammography fo r the Caucasian women was mammography would be embarrassing. To further explore per ceived barriers to brea st cancer screening an analysis using an independe nt t-test comparison of means subscale scores of barriers to breast self-examination (B SE) and mammography scores between African American and Caucasian women were done. A signi ficant difference was found on one item, having a mammogram would make me worry about having breast cancer (p = 0.39). Barrier Items Pain was a significant barrier for African American women in comparison to Caucasian women in this study. African Amer ican women reported that they felt that having a mammogram or x-ray would be painfu l more frequently than Caucasian women. This finding is also supported by previ ous studies conducted by Rahman (2003) who found that women reported that experiencing pain during the mammogram as a barrier to having a mammogram. Another significant barr ier for African American women in this study was that they perceived that mammography would make them worry about cancer and they also perceived that performing breast self-examination BSE would make them worry about breast cancer. It was noted througho ut the study that these barrier items were
39 found to be the greatest barrier for African American women in comparison with Caucasian women. Caucasian women had fewer barriers than the African American women. The Caucasian group barriers consiste d of cost and embarrassment of having a mammogram. The fact that this group reported cost as a barrier is not an unusual finding. This finding supports findings from previous studies. Lauver et al (2001) found that one of the most common external barrier to mammography included high cost to screening, which influenced breast cancer screening this study sample included a diverse population of African American and Caucasian women. Conclusion This study found more similarities than differences between African American and Caucasian women in their perceived barr iers to breast cancer screening. Never the less it is important for African American women to be aware of the resources for detecting breast cancer, and it is important for them to continue to participate in breast cancer screening to prevent increased mort ality. Advanced practice nurses have a responsibility to be directly involved with the commun ity, educating our women and providing them with resources that will allow them to receive the necessary screening for breast cancer. The perceived ba rriers that were identified in this study need to be addressed. Women reported that they felt th at having a mammogram would be painful, and doing breast self examination (BSE) was time consuming, and some reported a lack of privacy. These barriers are al l issue that need to be examined for future prevention and
40 future research. It is important that th e awareness of the ACS guidelines for breast screening be voiced to all women, especia lly those that curren tly do not comply. Recommendation for Future Research It is important that there continues to be ongoing research re garding breast cancer screening, this study should be conducted using a sample consisting of a diverse population that includes other et hnic groups. This will provide a better, possibly a greater significant among different groups Exploring the research ca n enhance clinical practice among advanced nurses. This will allow a range of cultural experien ce for clinician, and help us identify each woman individuals need according to her cu lture, ethnicity, and beliefs. This study should be conducted in a diffe rent geographic region; this would help determine if the differences among African American women and Caucasian women related to perceives barriers to breast cancer screening are significant and if they are related to their ge ographic region.
41 References Ahmed, N. U., Fort, J. G., Elzey, J. D. & Ba iley, S. (2004). Empoweri ng factors in repeat mammography: Insights from th e stories of undeserved women. Journal of Ambulatory Care Manage, 27(4), 348-355. American Cancer Society (2005). Can cer Facts and Figures: Available at http://www.census.gov/ Retrieved April 8, 2005. American Psychological Association. (2001) Publication Manual of the American Psychological Association (5th ed). Washington, D.C : American Psychological Association. Centers for Disease Control. (2005). The National Breast a nd Cervical Cancer Early Detection Program. Available at http://www.cdc.gov/cnce r/nbccedp/index.htm Retrieved April 30, 2005. Champion, V. L. (1987). The relationship of br east self-examination to the Health Belief Model variables. Research in Nursing Health, 10, 375-382. Champion, V.L. (1993). Instrument refinement for breast cancer sc reening behaviors. Nursing Research, 42(3), 132-143. Champion, V.L. (1999). Revised susceptibil ity, benefits, and barriers scale for mammography screening. Research in Nursing, 22, 341-348.
42 Foxall, M. J., Barron, C. & Houfek, J. (1998). Ethnic differences in breast selfexamination practice and health beliefs. Journal of Advanced Nursing, 27(2), 419428. Graham, M. E. (2002). Health beliefs and self breast examination in black women. Journal of Cultural Diversity, 9, i2, 49-54. Han, B., Wells, B L. & Primus, M. (2003). Comparison of mammography use by older black and white women. Journal of the American Geriatric Society, 51, 203-212. Kasper, D. L., Braunwald, E., Fauci, A. S., Hauser, S. L., Longo, D. L. & Jameson, J. L. (2005). Breast Cancer. Harrison Principles of Internal Medicine. (16 th ed). 516523). McGraw-Hill INC. New York, Medical Publishing Division. Lauver, D., Settersen, L., Kane, J. H. & Henrique, J. B. (2003). Tailored messages, external barriers, and womens utilization of professional breast cancer screening overtime. American Cancer Society, 2724-2735. Legler, C. (2004). Breaking down barriers: Increasing screening mammography in African American women. Journal of the American Academy of Physician Assistants, 17, 1-9. Lukwago, S. N., Kreuter, M. W., Holt, C. L., Steger-May, K., Bucholz, D. C. & Skinner, C. S. (2003). Sociocultural correlates of breast cancer knowledge and screening in urban African American women. American Journal of Public Health, 93(80), 1271-1274. Menon, U., Champion, V. L., Larkin, G. N., Zollinger, T. W., Gerde, P. M., & Vernon, S. W., (2003). Beliefs associated with fecal occult blood test and colonoscopy use at worksite colon cancer screening program. American college of Occupational and Environmental Medicine, 45(8), 891-899.
43 National Cancer Institute (2005). Breas t cancer screening. Available at http://www.cancer.gov/cancert opics/pdq/screenin g/breast/healthprof essional/page 2 Retrieved April 18, 2005. Ogedegbe, G., Cassells, A. N., Robinson, C. M., Duhamel, K., Tobin, J. N., Sox, C. H. & Dietrich, A. J. (2005). Perceptions of ba rriers and facilitato rs of cancer early detection among low-income minority women in community health centers. Journal of the National Me dical Association, 97(2), 162-170. Paskett, E. D., Tatum, C., Rushing, J., Michie lutte, R., Bell, R., Foley, K. L., Bittoni, M. & Dickinson, S. (2004). Cancer. American Cancer Society 2650-2659. Phillips, J. M., Cohen, M. Z. & Tarzian, A. J. (2001). African American womens experiences with breast cancer screening. Journal of Nursing Scholarship, 33(2), 135-140. Rahman, S. M. (2003). Assessment of perceptio ns related to breast cancer prevention and behavioral practices in me dically underserved women. Journal of Multicultural Nursing Health, 9(3), 30-39. Rice, V. H. (2000). Handbook of Stress, copi ng, and health: Implications for nursing research and practice. (p p.337-339). London: Sage Publications, Inc. International Educational and Professional Publisher. Rosenstock, I.M., Strecher, V.J., & Becker, H.M. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15, 175-183. Thomas, E. (2004). African American womens breast memories, cancer beliefs, and screening behaviors. Cancer Nursing, 27(4), 295-302. Yarbro, C. H., Frogge, M. H., Goodman, M. & Groenwald, S. L. (2000). Breast cancer. Cancer Nursing Principles and Practice (5 th ed., pp. 995-1047). Mississauga, Ontario: Jones & Bartlett Publishers, Inc.
45 Appendix :A Health Belief Questionnaire Breast Self-Examination 1. I feel funny doing breast self-examination Strongly disagree Disagree Ne utral Agree Strongly Agree 2. Doing breast self-examination during the next year will make me worry about breast cancer. Strongly disagree Disagree Ne utral Agree Strongly agree 3. Breast self-examination will be embarrassing to me. Strongly disagree Disagree Ne utral Agree Strongly agree 4. Doing breast self-examination will take too much time. Strongly disagree Disagree Ne utral Agree Strongly agree 5. Doing breast self-examination will be unpleasant. Strongly disagree Disagree Ne utral Agree Strongly agree 6. I dont have enough privacy to do breast self-examination. Strongly disagree Disagree Ne utral Agree Strongly agree
46 Appendix: A Health Belief Questionnaire Mammography 1. Having a routine mammogram or x-ray of the breast would make me worry about breast cancer. Strongly disagree Disagree Neutral Agree Strongly agree 2. Having a mammogram or x-ray of the breast would be embarrassing. Strongly disagree Disagree Ne utral Agree Strongly agree 3. Having a mammogram or x-ray of the breast would take too much time. Strongly disagree Disagree Ne utral Agree Strongly agree 4. Having a mammogram or x-ray of the breast would be painful. Strongly disagree Disagree Ne utral Agree Strongly agree 5. Having a mammogram or x-ray of th e breast would cost too much. Strongly disagree Disagree Ne utral Agree Strongly agree
Appendix B 47
48 Appendix C: Demographic Questionnaire DEMOGRAPHIC QUESTIONNAIRE 1. What is your age? ____ 2. What is your ethnicity? a. Caucasian _____ b. African American_____ c. Hispanic_____ d. Non-Hispanic_________ e. American Indian______ f. Asian________ g. Pacific Islander______ h. Other_________ 3. Marital Status a. Single______ b. Married______ c. Divorced_______ d. Widowed________ e. Separated _______
49 Appendix C: (Continued) 4. What is your occupation? _____________________ 5. Please indicate with a check mark th e highest-grade level you completed. Elementary_____ Junior Hi gh______ High School_______ College Degree__________Graduate Degr ee________Doctoral Degree__________ 6. What is your religious? ____________________ 7. Church affiliation? Yes____ or No________ 8. Please answer yes or no to the follo wing questions regarding breast cancer screening and breast cancer. i. Do you have a history of breast cancer? Yes______ No_______ ii. Have you ever had a mammogram? Yes____ No_________ iii. Have you had a mammogram in the past 12 months? Yes______ No________ iv. Do you have a mammogram scheduled? Yes_____ No _______ v. Do you perform breast self-exam monthly? Yes __ No__ vi. Do you have a primary care physician? Yes____ No_______
Appendix : D 50
Appendix D 51
Appendix E 52
Appendix E (Continued) 53
54 University of South Florida College of Health Sciences Nursing INFORMED CONSENT Appendix F Dear Participant: I am a graduate student wanting to find out about perceived barriers to breast cancer screening among African American a nd Caucasian women over the age of 40. I am conducting a study that will identify some of these barriers, a nd would like your help in gathering this information. The next few pa ragraphs will define the main ideas of my study. The title of my study is Perceived Barriers to Breast Cancer Screening: A Comparison of African American and Caucasia n Women. The purpose of this study is to examine and compare perceived barriers related to breast can cer screening among African American women and Caucasian women. A brief questionnaire that asks questi ons regarding breast cancer screening is attached. It should take no more than 10 minutes to complete. Do not write your name on this questionnaire. Your identity will not be recorded; the study is completely anonymous. Your participation is completely voluntary. The study will cost nothing, and you will not be paid for your participation. There is no right or wrong answers on the questionnaires; please try to be accurate a nd honest when completing this questionnaire. At the completion of this study, I hope to have a better understanding of perceived barriers to breast cancer scr eening among African American and Caucasian women over the age of 40. Thank you for your participation. If you complete and turn in the questionnair e, I will take that as evidence of your consent to participate in the study. If you choose not to participate, just return the forms blank. Natalie Bastien, RN, BSN College of Health Sciences Nursing University of South Florida
Apendix G 55