PREVENTIVE MEDICINE 9, 388-397 (1980)

Factors Related to the Use of Cancer Early Detection Techniques1,2

JANE MCCUSKER**~ AND GARY R. MORROW?

Departments of *Preventive Medicine and Community Health and TPsychiatty, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue,

Box 644, Rochester, New York, 14642

This study investigated the relationship of certain variables to the use of early detection of cancer techniques in a socioeconomically homogeneous, largely white, employed middle class population with access to a personal physician. Five hundred and forty-three teachers and administrators in two suburban Rochester school districts were surveyed to collect information on sociodemographic variables, health care variables (health status, source of health care, use of early detection techniques, “preventive orientation” of physician, satis- faction with care), and other attitudes and beliefs including some based on the Health Belief Model. Almost all of the population had personal physicians: 56% reported checkups at least annually and 40% of the women practiced BSE at least monthly. Both frequency of checkups and BSE practice were related to the “preventive orientation” of the physician, to satisfaction with care, and to the belief in the benefit-cost ratio of checkups. In addition, increased frequency of checkups was related to sex (female), higher income, and perceived accessibility of care; increased frequency of BSE was related to greater health concern and to the belief that women can detect breast lumps better than physicians. The results suggest that, in individuals with personal physicians, an important determinant of the use of early detection techniques for cancer may be the quality of the physician-patient relationship, including demonstration of the physician’s concern with the importance of early detection.

INTRODUCTION Preventive health behavior has been defined as “any activity undertaken by a

person who believes himself to be healthy for the purpose of preventing disease or detecting disease in an asymptomatic state” (8). A variety of health behaviors may appropriately be named preventive, from primary preventive behaviors (such as not smoking and taking regular exercise) to secondary preventive ones which promote the early detection of disease (such as the use of screening tests and other procedures).

Previous research has indicated that while most of these behaviors are corre- lated at least weakly with one another, many people are not consistent in their behavior (11, 22). Early detection behaviors, for example, correlate only weakly with smoking behavior and the two behaviors have distinct but overlapping sets of determinants. This study focuses on some early detection behaviors for cancer, including the use of tests usually performed in a physician’s office (Pap test, breast exam, I-Iemoccult test, and sigmoidoscopy) as well as breast self-examination

’ Presented at the Third Annual Meeting of the American Society of Preventive Oncology, March 8, 1979, New York City.

z Supported in part by Cancer Core Support Grant 5-P30-CA 11198-10 awarded by the National Cancer Institute and the United Cancer Council, Inc., Genesee-Finger Lakes Region.

3 To whom requests for reprints should be addressed.

388 0091-7435/80/030388-10$02.00/O Copyright @ 1980 by Academic Press. Inc. All tights of reproduction in any form reserved.

FACTORS IN CANCER EARLY DETECTION 389

(BSE) which, although performed at home, must be learned from a health professional if it is to be performed correctly.

We examined the determinants of some cancer early detection behaviors as part of a research project to evaluate a labor union-sponsored cancer education pro- gram (17). Subjects in this project were school teachers and administrators, characterized by a high educational achievement, and good access to health ser- vices. As both the latter variables are important documented determinants of health services utilization (4,6, 10, 19), it seemed useful to assess the role of other sociodemographic, health care, and attitudinal variables in a population in which some important sources of variation had been controlled.

METHODS The study population consisted of school teachers and administrators from two

adjacent suburban school districts in Rochester, New York. These school districts had been selected to participate as experimental and control groups in the evalua- tion of an educational program on cancer prevention and early detection.

The data for this study were collected in questionnaires completed by both experimental and control group subjects. The questionnaires included sociodemographic and health care related items and a series of attitude items derived from the Health Belief Model (15), the Health Locus of Control Scale (20), and items adapted from other instruments which measured perceived health status, health concern, satisfaction with care, and other attitudes.

Subjects in the experimental district (n = 241) completed the questionnaires before receiving the educational program, while subjects in the control district (n = 302) completed the questionnaires only and did not subsequently receive the educational program. The two groups of subjects were very similar with respect to most of the sociodemographic variables measured in this study and showed no signiticant4 differences in either of the preventive behaviors measured. Because the data were collected before any intervention and because the two groups of sub- jects were so similar, the analysis was carried out on the combined results from the two groups.

Table 1 lists selected characteristics of the study population. Respondents were predominantly white, female, and married with a median age in the 30’s and a median family income of approximately $24,000. Almost all had access to a per- sonal physician: 12% in a Health Maintenance Organization (HMO) in one of the two then in Rochester, and 86% from a private doctor. Also listed are the two cancer prevention behaviors which were the dependent variables in this analysis?

(a) frequency of “checkups”: (visits to a physician without specific symptoms or complaints): 56% of the study population reported that they obtained checkups annually or more frequently;

(b) frequency of breast self-examination (BSE): 40% of the women in the study population reported that they practiced BSE monthly or more frequently.

4 The 5% level of statistical significance is used throughout this paper. 5 There was a statistically significant relationship between frequency of checkups and frequency of

BSE: 45% of the women with annual checkups also practiced BSE monthly or more frequently, compared with only 30% of the women with less frequent checkups.

390 MC CUSKER AND MORROW

TABLE 1 SELECTED CHARACTERISTICS OF THE STUDY POPULATION OF 543 PRIMARY AND

SECONDARY SCHOOL TEACHERS AND ADMINISTRATORS

n % -

Study group

Occupation

Sex

Age

Marital status

Religion

Ethnic group

Family income

Source of medical care

Chronic health problems

Frequency of checkups

Frequency of BSE (women only)

Experimental 241 Control 302 Teacher 517 Administrator 26 Male 151 Female 392 20-29 101 30-39 221 40-49 148 50+ 57 Unknown 16 Currently married 400 Wid., div., sep. 51 Never married 92 Catholic 202 Protestant 243 Jewish 34 Other/none 60 Unknown 4 White 533 Black 5 Other 4 Unknown 1 $16,000 & under 87 $16,001-$24,000 180 Over $24,0@0 266 Unknown 10 HMO 64 Private doctor 467 Other 10 Unknown 2 None 447 One or more 88 Unknown 8 Annually + 302 Every 2-3 years 168 Every 4-5 years 34 Less frequently 24 Never 14 Unknown 1 Monthly or more frequently 154 Less frequently 196 Never 37 Unknown 10

44 56 95

5 28 72 19 42 28 11 - 74

9 17 37 45

6 11 - 98

1 1

- 16 34 50 - 12 86

2 - 84 16 - 56 31

6 4 3

- 40 51 10 -

RESULTS Factors Related to Frequency of Checkups

The relationships of selected demographic and health care variables to fre- quency of checkups are shown in Table 2. Only sex, family income, and having

FACTORS IN CANCER EARLY DETECTION 391

TABLE 2 FREQUENCY OF CHECKUPS BY SELECTED DEMOGRAPHIC AND HEALTH CARE VARIABLES (n = 543)

Total receiving annual checkups

Total n % P*

Sex Male Female

Family income $24,000 or less Over $24,000

Age Under 40 40 and over

Religion Catholic Protestant Other

Marital status Never married Married Widowed, separated or

divorced Chronic health problems

None One or more

Source of medical care HMO Other

BSE instructionC Yes No

151 41 31 391 255 65 <O.Ol

co.01

ns.

266 134 50 266 164 62

321 172 54 205 123 60

201 110 55 243 140 58

94 50 53 n.s.

92 45 49 399 223 56

51 34 67 n.s.

446 237 53 88 57 65 n.s.

ns.

-co.05

64 35 55 418 217 56

321 217 68 68 36 53

a Missing values range from 1 to 17. * From x2 test; ns. indicates P > 0.05 (nonsignificant). c n = 392 females (3 missing values).

received BSE instruction show significant associations with frequency of check- ups, with women, high-income individuals, and women who have received BSE instruction having more frequent checkups.

Table 3 shows the relationship of selected attitude items in the questionnaire to frequency of checkups.6 The results indicate that people with more frequent check- ups express greater satisfaction with their health care (both quality of care and personal concern of physician), a greater concern with prevention by the provider (encouraging checkups), greater perceived convenience of care, and a greater perceived benefit-cost ratio of regular checkups. Health concern was not found related to frequency of checkups.

’ Only those attitude items are included here which were associated either with frequency of check- ups or frequency of BSE. Attitude items omitted because they were not associated with either behavior include: measures of threat (perceived susceptibility to and severity of cancer), other benefits of and barriers to early detection, Health Locus of Control scale items, and perceived health status.

392 MC CUSKER AND MORROW

TABLE 3 FREQUENCY OF CHECKUPS AND MEANS OF SELECTED ATTITUDE ITEMS (n = 543)

Frequency of checkups (mean)

Attitude item”

The health care I have received in the last few years has been excellent

My doctor is very concerned about me as a person

In the past, doctors and nurses have always encouraged me to get regular checkups

I sometimes do not see the doctor when I should because it’s inconvenient for me

Regular checkups cost more money than they are worth

I often think about my health Doctors are better at finding lumps in the

breast than the woman herself

Annual (n = 302)

2.0

3.3

2.7

4.6

5.9 3.5

3.5

Less than annual

(n = 240)

2.5

3.7

3.7

4.0

5.3 3.5

3.4

Pb

CO.01

CO.01

CO.01

CO.01

CO.01 ns.

ns.

n Measured on Likert scale from 1 (strongly agree) to 7 (strongly disagree). Missing values range from 4- 10.

’ From t test of difference between means; n.s. indicates P > 0.05.

A stepwise multiple regression’ assessed the joint relationship between sex, family income, and the five attitude items which had a significant association with frequency of checkups (Table 4).8 Together, these seven variables accounted for 23% of the variance in frequency of checkups, with concern with prevention by provider, sex, and perceived benefit-cost ratio of regular checkups making the most significant contributions.

Factors Related to Frequency of BSE Table 5 presents the results of analyses similar to those in Table 2 with BSE

frequency as the dependent variable. None of the demographic or health care variables show any relationship to frequency of BSE, except whether the woman had ever received BSE instruction.

Table 6 indicates that many of the attitude items related to frequency of check- ups were also found to be related to frequency of BSE (satisfaction with health care, concern with prevention by the provider, and greater perceived bene- fit-cost ratio of regular checkups). Perceived convenience of care was not found related to frequency of BSE. In addition, women practicing BSE monthly indi- cated a greater health concern and greater faith in the ability of women to detect lumps in their own breasts.

A stepwise multiple regression was carried out with BSE frequency as the dependent variable and BSE instruction and the six attitude items with significant associations with BSE frequency as independent variables (Table 7). Together,

’ Kim has defended the use of multiple regression analysis for ordinal data (9). w BSE instruction was omitted from the independent variables as it was only available for women.

FACTORS IN CANCER EARLY DETECTION 393

TABLE 4 RESULTS OF STEPWISE MULTIPLE REGRESSION ON FREQUENCY OF CHECKUPS (n = 523)”

Variable Order” Beta F P

Sex (male = 1, female = 2) 2 0.25 40.69 ‘Co.01 Income (~$24,000 = 1, >$24,000 = 2) 3 0.05 1.58 n.s. The health care I have received in the

last few years has been excellent 4 -0.04 1.13 n.s. My doctor is very concerned about

me as a person 5 -0.03 0.35 n.s. In the past doctors and nurses have

always encouraged me to get regular checkups 6 -0.27 40.82 CO.01

I sometimes do not see the doctor when I should because it’s inconvenient for me 7 0.10 5.99 CO.05

Regular checkups cost more than they are worth 1 0.16 16.08 10.01

R* = 0.23, F(7,515) = 21.63, P < 0.01

n Annual checkups = 2, less than annual = 1. b Order in which variables were entered into multiple regression.

these seven variables accounted for 13% of the variance in BSE frequency, with ability to detect breast lumps, BSE instruction, and health concern making the most substantial contributions.

Attitudes and HMO Membership HMO members in our sample did not differ in their perceptions of convenience

of care, benefit-cost ratio of early detection, or health concern from nonmem- bers. However, non-HMO members appeared significantly more satisfied with their health care (quality of care and personal concern of physician) and more likely to agree that physicians and nurses had encouraged them to get checkups.s

DISCUSSION The use of preventive services has been shown to be related to a number of

variables including access to health services, sociodemographic variables, and personal health beliefs and attitudes. In general, attitudes seem to play a smaller role in health behavior than access and sociodemographics (10). However, as access to health services is improved through greater coverage of the population by health insurance and by prepaid and other medical plans, attitudes may play a more important role in health services use. Efforts to change health behaviors may correspondingly need to focus more on ways of changing some of these attitudes.

The principal findings of this study in a population with access to a personal physician are the associations of frequency of both checkups and BSE with the apparent concern of the physician with prevention, belief in benefit-cost of early detection, and satisfaction with care (quality of care and personal concern of the

y Mean responses for HMO members and nonmembers respectively were (a) quality of care: 1.7 and 1.2; (b) personal concern of physician: 3.0 and 2.4; (c) checkups encouraged: 3.7 and 3.0.

394 MC CUSKER AND MORROW

TABLE 5 FREQUENCY OF BSE BY SELECTED DEMOGRAPHIC AND HEALTH CARE VARIABLES

(n = 392 FEMALES)”

Total reporting monthly BSE

Total n % Pb

Family income $24,000 or less Over $24,000

be Under 40 40 and over

Religion Catholic Protestant Other

Marital status Never married Married Widowed, separated

or divorced Chronic health problems

None One or more

172 60 35 206 91 44 n.s.

225 84 37 150 65 43 n.s.

141 50 36 182 83 46 61 20 33 n.s.

69 27 39 276 114 41

42 13 31 ns.

321 128 40 59 23 39 n.s.

Source of medical care HMO Other

BSE instruction Yes No

38 20 53 349 134 38 n.s.

320 143 45 67 11 16 co.01

a Missing values range from 5 to 17. b From x2 test; n.s. indicates P > 0.05.

physician). In addition, sex, family income, and convenience of care are related to frequency of checkups, and health concern is related to BSE frequency. HMO membership in this study was unrelated to either preventive behavior.

As these results are derived from a cross-sectional study, the question of cau- sality for any of these variables is problematic. Satisfaction with care (or any of the other attitude items termed “independent” in this study) have been shown to be an outcome as well as a determinant of use of preventive services (14). Other work has attempted to untangle these relationships without clear resolution (3). It is plausible to consider satisfaction with care and physician concern with preven- tion as determinants rather than outcomes of frequency of BSE practice. It is possible, however, that the associations may be indirect. For example, both the attitudes and the preventive behaviors might be related to a compliant type of personality.

Other research has suggested that patient satisfaction with care may be an important predictor of use. Patient perceptions of physician conduct (perceived quality of care and personal qualities of the physician) seem, in turn, to be the best

FACTORS IN CANCER EARLY DETECTION 395

TABLE 6 FREQUENCY OF BSE AND MEANS OF SELECTED ATTITUDE ITEMS (n = 392 FEMALES)

BSE frequency (mean)

Attitude item” Monthly

(n = 154)

Less than monthly

(n = 233) P*

The health care I have received in the last few years has been excellent 2.0 2.3 co.05

My doctor is very concerned about me as a person 3.2 3.1 co.05

In the past doctors and nurses have always encouraged me to get regular checkups 2.1 3.2 CO.01

I sometimes do not see the doctor when I should because it’s inconvenient for me 4.6 4.3 ns.

Regular checkups cost more money than they are worth 6.0 5.4 CO.01

I often think about my health 3.4 3.9 CO.01 Doctors are better at finding lumps in the

breast than the woman herself 3.8 3.1 CO.01

a Measured on Likert scale from 1 (strongly agree) to 7 (strongly disagree). Missing values range from 3 to 5.

* From t test of difference between means: ns. indicates P > 0.05.

predictors of satisfaction (21). Communication and physician awareness of patient concerns are other important aspects of the physician-patient interaction (7).

The associations of sex and family income with frequency of checkups have been observed previously. Nathanson (12) has proposed that the socialization and adult role patterns that are defined as appropriate for women in our society tend to

TABLE 7 RESULTS OF STEPWISE MULTIPLE REGRESSION ON FREQUENCY OF BSE

(II = 379 FEMALES)”

Variable OrdeP Beta F P

BSE instruction (no = 0, yes = 1) 2 0.17 12.32 CO.01 The health care I have received in

the last few years has been excellent 7 -0.05 0.91 n.s. My doctor is very concerned about

me as a person 6 -0.02 0.20 n.s. In the past, doctors and nurses have

always encouraged me to get regular checkups 5 -0.08 2.35 n.s.

Regular checkups cost more money than they are worth 4 0.09 3.41 n.s.

I often think about my health 1 -0.14 8.16 CO.01 Doctors are better at finding lumps in

the breast than the woman herself 3 0.20 16.20 CO.01 R2 = 0.13, F(7,371) = 7.85, P < 0.01

a Monthly BSE = 2, less than monthly = 1. * Order in which variables were entered into multiple regression.

396 MC CUSKER AND MORROW

lead to greater avoidance of risks and to taking preventive action particularly when this involves medical interventions. Family income can be viewed as a facilitator of use rather than as a more general indicator of socioeconomic status, high income providing easier accessibility to preventive services. Bite et al. (2) indicated that there has been a substantial reduction in the relationship between family income and physician use, which is now particularly sensitive to “out-of- pocket” costs of care. Lack of an association between family income and BSE practice is consistent with this theory, as, apart from the costs of training women to do BSE, there are no financial barriers to BSE practice.

The lack of an association of HMO membership with either frequency of check- ups or BSE frequency was surprising as HMOs stress prevention as part of their comprehensive care package and checkups are offered free of charge to members. Previous studies of persons enrolling in Rochester HMOs suggest that many do so at least in part because of the preventive services offered (13). However, one study comparing HMO members with nonmembers shows no differences in adults’ use of preventive services (16).

An explanation for this lack of association may be the fact that HMO members in this study tended to be less satisfied with their health care than nonmembers and felt that they had not been encouraged by their physician to practice preven- tive behaviors. However, HMO members were not asked how long they had been enrolled in an HMO, and their attitudes and preventive practices may to some extent have reflected preexisting patterns. It is relevant to note previous work suggesting that people joining HMOs seem to be characterized by lower satisfac- tion with their previous health care than nonjoiners (1,5, 18). One follow-up study of HMO members 1 year after joining a closed-panel plan showed higher satisfac- tion soon after joining but a subsequent decline, suggesting that initial expecta- tions may not have been met (1).

The results of this study suggest that in a population with a personal physician, the physician’s expressed concern with prevention and the patient’s satisfaction with care may be significant determinants of cancer prevention behaviors. Struc- tural changes in health delivery systems which facilitate the delivery of preventive services, such as HMOs, may not result in increased preventive behavior unless there are also some changes in the physician-patient interaction.

ACKNOWLEDGMENTS We are grateful for the contributions of Mark Prange and Jean Streppa to the questionnaire design

and data collection, of Cynthia Licata in data collection, and of Dee Strickland, Bill Martens, and Richard Williams for computer programming. Andrew Sorensen read and made comments on a draft.

REFERENCES 1. Ashcraft, M., Penchansky, R., Berki, S. E., Fortus, R. S., and Gray, J. Expectations and experi-

ence of HMO enrollees after one year: an analysis of satisfaction, utilization and costs. Med. Care 16, 14-32 (1978).

2. Bite, T. W., Eichhom, R. L., and Fox, P. D. Socioeconomic status and use of physician services: a reconsideration. Med. Care 10, 261-271 (1972).

3. Cafferata, G. L., and Roghmann, K. J. “Patient Satisfaction and the Use of Health Services: Explorations in Causality.” Unpublished manuscript, University of Rochester, 1978.

4. Coburn, D., and Pope, C. R. Socioeconomic status and preventive health behavior. /. Health Sm. Behav. 15, 67-78 (1974).

FACTORS IN CANCER EARLY DETECTION 397

5. Donabedian, A. An evaluation of prepaid group practice. fnquiry 6, 3-27 (1969). 6. Fink, R., Shapiro, S., and Lewison, J. The reluctant participant in a breast cancer screening

program. Pub. Health Rep. 83, 479-W (1968). 7. Hulka, B. S., Kupper, L. L., Cassel, J. C., and Babineau, R. A. Practice characteristics and

quality of primary medical care: the doctor-patient relationship. Med. Care 13, 808-820 (1975).

8. Kasl, S. V., and Cobb, S. Health behavior, illness behavior and sick role behavior. Arch. Envi- ron. He&h 12, 246-266 (1966).

9. Kim, J. 0. Multivariate analysis of ordinal variables. Amer. J. Sot. 81, 261-298 (1975). 10. Kravits, J. The relationship of attitudes to discretionary physician and dentist use by race and

income, in “Equity in Health Services: Empirical Analyses in Social Policy” (R. Anderson, J. Kravits, and 0. W. Anderson, Eds.). Ballinger, Cambridge, Mass., 1975.

11. Langlie, J. K. Social networks, health beliefs and preventive health behavior. J. Health Sot. Behav. 18, 244-260 (1977).

12. Nathanson, C. A. Sex roles as variables in preventive health behavior. J. Commun. Health 3, 142-155 (1977).

13. Roghmann, K. J., Gavett, J. W., Sorensen, A. A., Wells, S., and Wersinger, R. Who chooses prepaid medical care: survey results from two marketings of three new prepayment plans. Pub. Health Rep. 90, 516-527 (1975).

14. Roghmann, K. J., Hengst, A., and Zastowny, T. R. Satisfaction with medical care: its measure- ment and relation to utilization. Med. Cure 17, 461-479 (1979).

15. Rosenstock, 1. M. The Health Belief Model and preventive health behavior, in “The Health Belief Model and Personal Health Behavior” (M. Becker, Ed.). Slack, Thorofare, New Jersey, 1974.

16. Slesinger, D. P., Tessler, R. C., and Mechanic, D. The effects of social characteristics on the utilization of preventive medical services in contrasting health care programs. Med. Care 14, 392-404 (1976).

17. Streppa, J. “Controlled Evaluation of a Union-Sponsored Cancer Education Program.” Paper presented to the Occupational Health Section, 106th Annual Convention of the American Public Health Association, Los Angeles, October 17, 1978.

18. Tessler, R., and Mechanic D. Consumer satisfaction with prepaid group practice: a comparative study. J. Health Sot. Behall. 16, 95-113 (1975).

19. U.S. National Health Survey. “Use of Selected Medical Procedures Associated with Preventive Care.” U.S. Dept. of Health, Education and Welfare, Pub. No. (HRA) 77-1538, 1973.

20. Wallston, B. S., Wallston, K. A., Kaplan, G. D., and Maides, S. A. Development and validation of the Health Locus of Control (HLC) scale. J. Cons&. C/in. Psycho/. 44, 580-585 (1976).

21. Ware, J. E., and Doyle, B. J. “Physician Conduct and Other Factors That Affect Consumer Satisfaction with Medical Care.” Rand Paper Series, P-5670, Rand Corporation, Santa Monica, Calif., 1977.

22. Williams, A. F., and Wechsler, H. Interrelationship of preventive actions in health and other areas. Health Sen,. Rep. 87, 969-976 (1972).