INTRODUCTION:

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. HBM is by far the most commonly used theory in health education and health promotion (Glanz, Rimer, and Lewis, 2002). It was developed in the 1950s as a way to explain why medical screening programs offered by the U.S. Public Health Service, particularly for tuberculosis, were not successful (Hochbaum, 1958). HBM bases its concept of the fact that, health behavior is determined by personal beliefs or perceptions about a disease and the strategies available to decrease its occurrence (Hochbaum, 1958).

The Health Belief Model finds its application in numerous areas wherein the individuals need to be communicated about the ill effects diseases and preventive measures which can be taken up to avert the crisis.The HBM has had the greatest influence in research related to prediction associated with breast cancer screening behaviors; several studies have used the HBM to understand breast cancer screening behaviors. The HBM model subscales measure six concepts, including perceived susceptibility, perceived seriousness, barriers, benefits, health motivation, and confidence (Champion 1999).

The Health Belief Model (HBM) has been used as a theoretical framework to study Breast Self-Examination and other breast cancer detection behaviors. The model stipulates that health-related behavior is influenced by a person’s perception of the threat posed by a health problem and by the value associated with his or her action to reduce that threat (Champion et al, 1997). The research paper outlines the concept of HBM with detailed representation of the subscale measures which make up the model. Furthermore the paper attempts to review the literature related to applicability of Health Belief Model for breast cancer screening and awareness.

LITERATURE REVIEW:

Health Belief Model – The Concept:

The model lists the following factors that are presumed to influence behavior change in response to a potential health threat:

The individual’s perceived susceptibility to the threat;

The individual’s perceived severity of the threat;

The individual’s perceptions that the recommended behavior will avert the threat (and any other additional benefits);

The individual’s perceptions of the costs of, and perceived barriers to, adopting the recommended behavior; and

The presence of cues to action (internal such as symptoms; external such as mass media advertising or interpersonal communications) that prompt the individual to act.

Figure 1: The Health Belief Model.

Perceived susceptibility:

As the first component of the HBM, perceived susceptibility is defined as a subjective perception of the risk of an illness. One’s belief regarding the chances of being diagnosed with a medical condition can be applied by defining populations at risk and risk levels (Janz et al., 2002). Individual risk may be based on personal characteristics or behavior. Comparisons of perceived susceptibility with action risk can also be conducted (Janz et al., 2002). Related to breast cancer screening behaviors, perceived susceptibility may include the risk of a breast cancer diagnosis in the long term or immediate future.

Perceived severity:

Perceived severity, formerly called perceived “seriousness” is the second construct of the HBM. Perceived severity speaks to an individual’s belief about the severity or seriousness of a disease and the sequence of events after diagnosis and personal feelings related to the consequences of a specific medical condition (Janz et al., 2002). Possible medical consequences may include death, disability, and pain; possible social consequences consist of effects on work, family life, and social relations (Janz et al., 2002).The combination of perceived susceptibility and perceived severity has been labeled perceived threat.

Perceived benefits:

The construct of perceived benefits is a person’s opinion of the value or usefulness of a new behavior in decreasing the risk of developing a disease. Also termed as perceived benefits of taking health action, the attitudes of health behavior changes are reliant on one’s view of the health benefits for performing a health action (Janz et al., 2002). Perceived benefits play a significant role in the adoption of secondary preventive behaviors, such as screenings. It is widely known and accepted that the earlier breast cancer is found, the greater the chances of survival. It is also known that breast self-examination (BSE), when done regularly, can be an effective means of early detection. But not all women do BSE regularly. They have to believe there is a benefit in adopting this behavior, which is exactly what was found to be true among black women: those who believed breast self-examinations were beneficial did them more frequently (Graham, 2002).

Perceived barriers:

Perceived barriers refer to the potential negative aspects of or obstructions to taking a recommended health action. This is the belief about physical and psychological costs of taking health action (Janz et al., 2002). An internal cost benefit analysis occurs, weighing the health action’s expected effectiveness against perceptions that it may become an obstacle. Potential barriers may include financial expense, danger, pain, difficulty, upset, inconvenience, and time-consumption (Janz et al., 2002). Perceived barriers to performing breast cancer screening behaviors were emotional, social, and physical. Even when women know that breast cancer is a serious disease, and one for which women are at risk and one for which the perception of threat is high, the barriers to performing BSE exert a greater influence over the behavior than does the threat of cancer itself (Champion, 1993; Champion andMenon, 1997; Umehand Rogan-Gibson, 2001). Some of these barriers include difficulty with starting a new behavior or developing a new habit, fear of not being able to perform BSE correctly, having to give up things in order to do BSE, and embarrassment (Umeh& Rogan-Gibson, 2001).

Self-efficacy:

Self-efficacy was added to the original four beliefs of the HBM in 1988 (Rosenstock, Strecher, and Becker, 1988). Self-efficacy is the belief in one’s own ability to do something (Bandura, 1977). If a person believes a new behavior is useful (perceived benefit), but does not think he or she is capable of doing it (perceived barrier), chances are that it will not be tried. According to Umehand Rogan-Gibson (2001), a significant factor in not performing BSE is fear of being unable to perform BSE correctly. In other words, unless a woman believes she is capable of performing BSE (that is, has BSE self-efficacy), this barrier will not be overcome and BSE will not be done.

Cues to action:

Cues to action, formerly known as motivation, are events, people, or things that move people to change their behavior. Examples of cues include media reports about preventing breast cancer, illness of a family member, and perceived benefits (Graham, 2002).

Breast Cancer Screening:

United Kingdom:

Norman and Brain (2005) sought to apply an extended health belief model (HBM) to the prediction of breast self-examination (BSE) among a sample of women with a family history of breast cancer in United Kingdom (UK). The HBM model was able to explain 33% of the variance in intention to perform BSE, with perceived susceptibility, perceived benefits, perceived emotional barriers, perceived skill barriers and self-efficacy emerging as significant independent predictors.

The results found that perceived benefits and perceived barriers were predictive of intention to perform Breast Self-Examination (BSE). Considering the prediction of BSE at 9-month follow-up, the study by Norman and Brain (2005) found that intention; perceived benefits, perceived skill barriers and self-efficacy were significant independent predictors of BSE performance. The present results are therefore broadly consistent with previous applications of the HBM in relation to BSE that have found significant effects for perceived benefits (e.g, Calnanand Rutter, 1986; Champion, 1990) and perceived barriers (e.g., Calnanand Rutter, 1986; Champion, 1987, 1988). In contrast, non-significant effects are typically reported for perceived severity (e.g., Rutledge and Davis, 1988), while the evidence for perceived susceptibility is mixed with some studies reporting significant effects (e.g., Calnanand Rutter, 1986; Champion, 1987, 1988, 1990) and others reporting no significant effects (e.g., Champion, 1985; Murray and McMillan, 1993).

Norman and Brain (2005) also cited that, though the utility of adding a measure of self-efficacy to the HBM, the present results support Rosenstock, Strecher and Becker’s (1988) assertion that the HBM should be expanded to focus on individuals’ confidence in their ability to perform a recommended behavior. Self-efficacy was found to be predictive of both behavioral intention and BSE at follow-up which is consistent with previous studies that have reported significant effects for self-efficacy in relation to BSE (e.g., Champion, 1990; Champion and Scott, 1997; Murray and McMillan, 1993). It is noteworthy that of the HBM variables, self-efficacy was the strongest predictor of both behavioral intention and BSE.

The present study also addressed the suggestion that behavioral intention should be considered as a mediating variable between the HBM and behavior (Norman, 1995). Behavioral intention was found to be predictive of BSE at time 2. However, when the HBM variables were added to the regression equation they were found to improve the prediction ofBSE, although behavioral intention remained as a significant independent predictor along with perceived benefits, perceived skill barriers and self-efficacy. Thus, despite being predictive of BSE, behavioral intention was unable to fully mediate the influence of the HBM variables.

The study also addressed the role of past behavior in the HBM. Past behavior was found to be the strongest predictor of both behavioral intention and BSE. Moreover, the addition of past behavior after the HBM variables led to significant increases in the amounts of variance explained in BSE intentions and BSE behavior. Similar findings have been reported in previous applications of the HBM (e.g., Calnanand Rutter, 1986; Champion, 1990).

The results indicate that the HBM was not a sufficient model of either behavioral intention or behavior. However, it should be noted that some of the HBM variables remained significant in the regression analyses after the addition of past behavior suggesting the HBM is able to partially mediate the influence of past behavior.

Thai Migrants in Australia:

Jirojwong and MacLennan (2002) conducted a research in Brisbane city of Australia on women who had migrated from Thailand areboth ethnic and non-ethnic Thais. Non -ethnic Thais includedrefugees from Vietnam, Burma and Cambodia who had been located temporarily in camps in Thailand.

However, a study conducted by Jirojwong and Manderson(2001) indicated that using the same recruitment method with the ethnic Thais, then the researcher would have gained a relatively high proportion of women with university education. Despite a high percentage of women (62%) reporting that they had conducted BSE at least once in the last 2 years, a substantially lower percentage (25%) examined their own breasts monthly. BSE among Thai migrant women inBrisbane was lower than BSE among many migrant groups in USA including Hispanic women (62%) and Hmong women (51%) (Tanjasiri et al.2001). The percentage was also lower than for Thai women in Thailand (34%).

As in studies of Black American, Australian, Hispanic American and Jordanian women (Savage and Clarke 1996, Champion and Scott 1997, Petro-NustusandMikhail 2002), the results indicate that the revised HBM is a useful framework to identify factors that influence BSE. Questions used in this study were based on interviews with Thai women in Australia and were intended to gain information relevant to cancer and cancer screening, and which might be relevant to Thai women in Thailand and Thai migrant women in other countries. Standardized questionnaires, such as the general questions on self-efficacy (Jerusalem, M., andSchwarzer, R. 1992), would be less useful to explain the use of screening among migrant women. Thai women in this study had limited comprehension of how to respond to commonly used scales, including the Likert scale.

Perceived susceptibility to breast cancer, cues or triggers for screening, self-efficacy and the overall HBM are important factors influencing BSE among Thai migrant women. Culture may determine the risk of having breast cancer as the majority of Hispanic American women perceived themselves as being less susceptible to breast cancer.

The relationship between belief of susceptibility to breast cancer and BSE was also found among Australian-born women in Australia (Savage and Clarke 1996). Health care personnel can provide information about risk factors forbreast cancer but sensitivity to women’s beliefs relating to therisk factors is an important component of health education. Women’s knowledge about breast cancer and their family history of breast cancer may also encourage them to conduct BSE regularly (Savage and Clarke 1996).

United States of America (U.S.A.):

The inability to detect the disease at an early period is the leading death cause of breast cancer. 38% of the breast cancer cases in Europe and 30% of the breast cancer cases in the USA are locally progressed cancers at the time of Diagnosis (Boyle and Lewin, 2008). Therefore, breast cancer should be detected with an early diagnosis and treatment should be initiated as early as possible using BSE and mammography which are perhaps the most effective methods. Yet, it is reported in the studies on the issue that women’s breast cancer screening rate is low (Petro-Nustusand Mikhail, 2002; Jarvandi et al., 2002; Ko et al., 2003; Durvasula et al., 2006; OluwatosinandOladepo, 2006). Besides, women’s health beliefs on screening methods generally affect utilization-rate of BSE, mammography and other methods.

They reported that, BSE is a very effective method for an early diagnosis and prevention of breast cancer. According to WHO, 90% of the women in whom breast cancer is diagnosed go to the clinics after they have detected mass/masses in their breasts using BSE (Boyle and Lewin, 2008). Therefore, it is very significant that women should know their own breasts and should develop awareness towards the changes in their breasts. But according to our study findings, none of the participants performed BSE regularly and only 10% of the women occasionally performed BSE. Main reason for which the participants did not perform BSE was “laziness and negligence”. It was also found out in the study that one of the five female academicians did not have knowledge about BSE and one of six female academicians regarded that it was unnecessary to perform BSE routinely. Most of the women regarded mammography as a painful procedure and experienced embarrassment and fear for mammography. Moreover, nearly one of the two women did not find routine mammography checks necessary.

Breast cancer screening with mammography is a very effective way to reduce mortality caused by breast cancer. In fact, it is expected to achieve 20% decrease in mortality thanks to mammography among the women aged ≥ 50 years. It is still a debated issue whether or not mammography is necessary for women aged < 50 years. However, more than 40% of the deaths caused by breast cancer diagnosed among those aged < 80 occur among the women aged between 35 and 49. Therefore, it is highly important to create awareness in terms of the early diagnosis of breast cancer among women aged < 50 years (Boyle and Lewin, 2008). Another considerable finding of the study was that female academicians avoided from BSE (40.0%) and mammography (85.8%) because they feared to find lumps; which pointed out that education is not enough to develop positive health behaviors about early diagnosis methods of breast cancer although our participants may have higher educational status.

The study did not reveal any correlation between mean scores of HBMS subscales and age, educational status, academic title, marital status and having child/children. When the literature was analyzed, it was understood that there were different study results. Likewise, the study of Altunkan et al., 2008 suggested that age, educational status and having a child/children did not affect women’s susceptibility towards breast cancer. On the other hand, unlike our study, the same study reported that women who were aged below 39, had primary school degree or below and did not have children had higher “barriers to BSE”. Besides, the same study demonstrated that “benefit of BSE” of women increased as age decreased and educational level increased (Altunkan et al., 2008). But the studies of Petro- Nustus and Mikhail presented a positive correlation between rate of BSE and advanced age and increased educational level, too.4 Similarly, the studies of Jarvandi et al. argued that those who were married and older performed BSE more often.

It was found out in the study that the female academicians who had family cancer history, acquired knowledge about breast cancer and whose academic specialty was on health presented higher mean scores in “susceptibility” and “seriousness” and “BSE self-efficacy” of HBMS but their mean scores of “barriers to BSE” and “barriers to mammography” were lower as compared with other women.

Select Parts of the World:

In the studies on relevant issue made in Turkey with women with different characteristics, it was emphasized that rate of BSE was low (Merey, 2002). In agreement with our finding, the study of Altunkan et al., 2008, reported that none of the women aged 20-60 performed BSE regularly and only 13.8 % of the women performed BSE occasionally (Altunkan et al., 2008). The study of Merey demonstrated that nearly all of the women did not perform BSE regularly (Merey, 2002). The studies made on this issue showed that main reasons for women’s negative thoughts and attitudes about breast cancer early diagnosis methods were the fear to find lump and the opinion that breast cancer was an incurable disease although it was early diagnosed (Kilic, et al., 2009).

This study corroborates work by other researchers (Erblich et al. 2000, Petro- Nustusand Mikhail 2002) on Jordanian women, Chinese Americans and American women which identified lack of confidence in BSE techniques and forgetting to do BSE as major barriers. Knowing the steps required, understanding the required frequency of BSE and being aware of the normal anatomy of their own breasts are issues which can be addressed by health personnel in assisting women to do BSE regularly.

DISCUSSIONS:

Information about correct BSE techniques, provided by health professionals through the media and other health education opportunities, increases BSE. Among Thai women, information relating to screening tests, including their importance in early detection of breast lumps and reducing the severity of cancers, may be distributed through informal organizations such as Thai restaurants. Non-print materials, such as videos, may be useful in delivering information; particularly for those who cannot read English well.Breast cancer screening with mammography is a very effective way to reduce mortality caused by breast cancer.

The research relating to health belief model and breast self-examination has been carried out in different geographies around the world. The research in UK focused on the HBM model was able to explain 33% of the variance in intention to perform BSE, with perceived susceptibility, perceived benefits, perceived emotional barriers, perceived skill barriers and self-efficacy emerging as significant independent predictors. As in studies of Black American, Australian, Hispanic American and Jordanian women (Savage and Clarke 1996, Champion and Scott 1997, Petro-Nustusand Mikhail 2002), the results indicate that the revised HBM is a useful framework to identify factors that influence BSE. Several barriers to the engagement of women in breast cancer screening have been discovered. More studies are needed in each country to determine barriers specific to each population. Sociocultural, religious, demographic, environmental, and psychological factors have all been shown to influence participation in breast cancer screening by women. As each population or cultural group has specific factors, it is important to investigate the barriers and facilitators affecting breast cancer screening participation in different segments of the population (Azaiza and Cohen, 2008; Baron-Epel, 2010). It is necessary to understand these barriers and facilitators to develop culturally appropriate and effective interventions (Donnelly et al., 2011).

Much of the literature reviewed found that professional recommendation motivated women to practice breast screening. This is a key finding in terms of improving interventions. Sending reminders in the form of a letter or SMS message was also found to be effective in increasing attendance at breast clinics (Soskolneet al., 2007; Baron- Epel, 2009). Health care providers need to be encouraged to take a proactive role in offering screenings (Bener et al., 2001; Montazeri et al., 2008) and to play a major part in promoting breast cancer screening. Social support and the realization that other women are participating in breast screening activities are important enablers in collectivist societies. Recommendation by a friend or family member is an effective facilitator. Soskolne et al. (2007) suggests that women who are already engaged in breast cancer screening activities could act as advocates in creating health behavior changes in their communities.

Using breast cancer survivors to educate women could promote breast cancer screening and inspire the view of cancer as a chronic disease rather than as a fatal disease. Hope of survival from a possible cancer diagnosis would encourage women to participate in breast screening activities (Baron-Epel and Klin, 2009).

CONCLUSION:

The literature review yielded results which can be used for further research which can be formulated for Asian countries to study the behavior of women towards breast self-examination using the health belief model.Lack of knowledge and confidence in the BSE technique was found to be a major barrier for many women. Thus providing more education about breast cancer and the benefits of screening for this disease is an essential first step. Educational programs that aim to change behavior by meeting women’s existing beliefs rather than changing these beliefs might be an effective approach to increase screening practices. Breast cancer awareness campaigns are effective educational tools; they have been shown to increase motivation in individual women and to improve the attitudes and awareness of physicians.

This literature review highlights the need for promotion of breast cancer screening and more research about the topic. Although recent years show a slight increase in research in this area, research is still very scarce and much work remains to be done if breast cancer screening is to achieve earlier detection and the consequent decreased mortality. Considerably more research is needed to identify and mitigate the barriers associated with different populations in countries before culturally appropriate, socially acceptable, effective intervention strategies can be developed.

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Received on 13.10.2017 Modified on 23.11.2017

Asian Journal of Management. 2018; 9(1):493-499.

DOI: 10.5958/2321-5763.2018.00077.X