The National Breast and Cervical Cancer Early Detection Program and its Failure to Reach Minorities – Julie Nguyen

Created in the early 1950s, the Health Belief Model (HBM) grew as a theory without consideration of practical problem solving (1). Rosenstock, one of HBM’s founders, further explains how this psychological model attempts to explain and predict health behaviors. The HBM relies on several factors that include the individual’s susceptibility to the disease, that the occurrence of the disease would have at least moderate severity on some component of life, and that the taking of a particular action would be beneficial. Rosenstock also notes the disconnect between practical problem solving and the evolution of the HBM. Although this theory’s wide use indicates its favored status for practical application, I argue that the practical applications of the HBM have many limitations, particularly with minority populations. Particularly true for The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the limitations of the HBM fails to increase cancer screenings in the United States (US) as intended.

The HBM applied: the failures of NBCCEDP and its outreach to minorities
The NBCCEDP, for example, still directs most of its energy and resources to provide cancer screenings using the HBM. The results of the NBCCEDP indicate the HBM to be useful for United States citizens overall but ineffective in changing behaviors for specific minority populations. After a decade-long program of screenings, the progress report states, “Minority populations . . . however, still have high incidence and mortality rates” (2). Instead of reformulating current approaches for minority populations, the NBCCEDP continues to rely heavily on the HBM to address minority populations within the US (3). The NBCCEDP merely categorizes minority populations in the US, like Hawaiian Americans, Vietnamese Americans, Chinese Americans, and applies the HBM to each specific population. In the Chinese American section of the Web site, lies a list of knowledge, attitudes and beliefs. The program similarly outlines the same list of knowledge, attitudes and beliefs for Vietnamese Americans. The outline reflects the NBCCEDP’s commitment to the HBM and the program’s failure to reach minority populations as summarized in its failure to use broader social science definitions in the conditions of the minority population and in the conditions of the societies where those minority populations exist.

The NBCCEDP similarly relies on the HBM’s limited assumption that intentions lead to behavior. The HBM’s assumption of intentions leading to behavior is arguably the weakest link in the theory (4). Assuming intention leads to behavior is fundamentally flawed, as we know that not everyone who intends to do something will do so effectively. For example, not everyone who intends to smoke successfully quits due to the addicting effects of nicotine, a concept not accounted for in the HBM (4). Applying this concept to the NBCCEDP and the HBM, the patient’s intention to prevent cervical or breast cancer will eventually lead to regular screenings for cancer. This concept of intention leading to behavior is invalidated by an unsuccessful outreach effort in Alameda and Santa Clara Counties, California (3). The failure of the outreach effort shows that a patient’s intentions do not lead to behavior. This campaign proves that the recognition of the Pap test for patients of the Alameda/Santa Clara Counties increased “but did not increase screening behavior” (3). Instead of using an effective social science theory, the NBCCEDP bases its intervention on the HBM, which lacks the reality component that many other social science theories offer.

Perceived costs vs. perceived barriers: A main driving force for the NBCCCEDP
It is an unrealistic to rely on the HBM’s narrow definition of perceived costs and barriers to address minority behavior. The HBM states that people will act when they outweigh the costs to the benefits of the disease (4). The HBM assumes rational thinking on behalf of the patient’s health-seeking behaviors. The NBCCEDP, additionally, assumes that minorities can accurately weigh the perceived benefits versus perceived costs of receiving a mammogram or Pap test. By showing that the perceived severity of cervical cancer may lead to increased screening, the NBCCEDP relies heavily on the HBM’s assumption that outweighing the benefits with the costs will increase screening (3). In a study describing cultural influences and access to care, the authors find that the most important reason for declining a screening test is that patients “didn’t have problems/symptoms” (5). This study invalidates HBM’s claim that patients accurately weigh the benefits and the costs. If the patient accurately weighs the costs and benefits of a mammogram or pap test, surely the patient will have the intention to screen for cancer and, therefore, act on that intention by being screened. Since the study indicates that minorities only screen if they have a problem or symptom, a conclusion can be derived that costs and benefits are not as important in decision-making for patients as the HBM purports.

The HBM’s perceived barriers, central to the model and application to the NBCCEDP, often limits the NBCCEDP’s ability to reach minorities. The HBM’s perceived barriers component derives from a social science theory many theorists call “contextualizing risk factors (7).” The theory calls for an “interpretive framework to understand why people came to be exposed to the risk” and “to determine the social conditions under which individual risk factors are related to disease (5).” A perceived barrier, according to these theorists, needs to be understood within a context, or experience, of the individual. The reasons behind the individual’s exposure to various risks and susceptibility to disease need further explanation in every solution. The NBCCEDP’s failure to look at the various individual risks in context of social conditions flawed its reach to minorities. For example, many groups exhibited low levels of literacy among differing minority populations while a few others did not (3). If women perceive themselves to be illiterate, or having low levels of literacy, this characteristic may greatly affect health-seeking behaviors. If women see a lack of education as a barrier, these women may not seek out medical care. If the NBCCEDP does not address this greater social issue, screening rates of low-literacy, minority women will remain stagnantly low. By attacking a general social problem, the NBCCEDP can greatly increase cancer screening through various, indirect methods like increasing literacy.

Self-Efficacy unrealized: NBCCEDP’s neglected component
The HBM’s failure to include a self-efficacy component also neglects the NBCCEDP’s initiative to reach minority populations in the US. Self-efficacy is summarized as an individuals’ “beliefs about their capabilities to produce designated levels of performance” (7). Applied to health, it is the individuals’ ability to sustain desired levels of performance. If further applied to cancer screenings, self-efficacy explains the reasoning behind regular cancer screenings. The NBCCEDP does not account for the lack of self-efficacy in minority populations. One study states that among Chinese Americans, “86% of respondents reported that they had once had a mammogram, [but] only 48.5% had a mammogram within the last year” (4). With an overwhelmingly low statistic for mammography retesting, self-efficacy is not realized under the NBCCEDP’s plans to reach minorities. As reported by the study, only half of the Chinese Americans received a mammogram in the last year. Chinese Americans, in this context, see themselves underpowered to sustain regular mammography screenings. As seen for minority Chinese Americans, the NBCCEDP fails to account for the self-efficacy component into its campaign to increase cancer screenings.

The NBCCEDP’s campaign to increase cancer screenings can not effectively reach minority populations as intended. As an important public health goal, health campaigns, such as the NBCCEDP, needs to use available research effectively and efficiently. The practical applications of various social science theories, including the HBM, are of the utmost importance in implementing the campaign and additionally in sustaining an effective campaign. While the HBM is important in realizing individual risk factors for the low levels of cancer screenings, the first 12 years of the NBCCEDP’s campaign show that it is inapplicable for minority populations in the US. Minority populations, particularly, do not accurately weigh perceived costs and perceived barriers to increase cancer screenings. Intentions and behavior are not directly correlated in the NBCCEDP’s goal to increase cancer screenings for minority populations. Self-efficacy, when used as a success indicator, is arguably one of the most important concepts surrounding public health campaigns for minority populations such as the NBCCEDP. Programs like the NBCCEDP need to broaden campaign perspectives to include various social science theories in respect to the minority population and in respect to the social conditions where the minority population exists. Only after the profession acknowledges and applies various, broad social science concepts can programs like the NBCCEDP effectively address sustainable, long-term, healthy behaviors for minority populations.

REFERENCES
1. Rosenstock, I.M. Historical Origins of the Health Belief Model.” Health Education Monographs 1974; 2:328-335.
2. Centers for Disease Control and Prevention. Summarizing the First 12 Years of Partnerships and Progress Against Breast and Cervical Cancer. http://www.cdc.gov/cancer/nbccedp/bccpdfs/national_report.pdf. Date Accessed: Nov 30 2007.
3. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program: Vietnamese American Women. Center for Disease Control. http://www.cdc.gov/cancer/nbccedp/publications/cc-strategies/vietnamese.htm. Date Accessed Dec 3 2oo7.
4. Siegel, M. Why Social and Behavioral Sciences in Public Health? A consideration of Three Failed Public Health Interventions Lecture. Date of Lecture: Sep 13 2007.
5. Phipps, E., Cohen, M.H., Sorn, R., Braitman, L.E. “A pilot study of cancer knowledge and screening behaviors of Vietnamese and Cambodian women.” Health Care for Women International. 1974; 20:195-207.
6. Bandura, A. Self-efficacy defined. Encyclopedia of human behavior. 1995; 4:71-81.
7. Yu, M., Wu, T., Mood, D. “Cultural affiliation and mammography screening of Chinese women in an urban county of Michigan.” Journal of Transcultural Nursing. 2005; 16:107-116.