© 1999 by Oxford University Press
Journal of the National Cancer Institute Monographs, No. 25, 101-119,
1999
© 1999 Oxford University Press
Risk Perception and Risk Communication for Cancer Screening Behaviors: a Review
Correspondence to: Sally W. Vernon, Ph.D., School of Public Health, The University of Texas Health Science Center at Houston, P.O. Box 20186, Houston, TX 77225 (e-mail: svernon{at}utsph.sph.uth.tmc.edu).
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ABSTRACT |
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 Top Abstract IntroductionIs Perceived Risk for...What Factors Are Associated...Is the Relationship, if...Have Interventions to Change...Future Research NeedsNotesReferences |
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This review summarizes and synthesizes research findings on risk perception and risk communication related to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. The following questions are addressed: 1) Is perceived risk associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk? 3) Is the relationship between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in modifying risk perceptions? 5) Are these changes related to subsequent cancer screening behaviors? Methodologic issues are discussed, and future research needs are identified. There was consistent evidence that perceived risk was associated with mammography screening, but there were insufficient data on these associations for cervical or colorectal cancer screening behaviors. There was some evidence that perceived risk mediated the association between other variables and screening behaviors; however, because of the small number of studies, the findings are best viewed as hypothesis generating. Studies of interventions to modify risk perceptions provided some support for the view that they are modifiable, but there was conflicting evidence that these changes were related to subsequent cancer screening. Methodologic studies of how best to measure perceived risk are needed. Because most data on the correlates of perceived risk were cross-sectional, it is difficult to determine whether perceived risk is a cause or an effect in relation to cancer screening. Longitudinal studies that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception are needed to clarify this relationship.
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INTRODUCTION |
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TopAbstractIntroductionIs Perceived Risk for...What Factors Are Associated...Is the Relationship, if...Have Interventions to Change...Future Research NeedsNotesReferences |
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The purpose of this review is to summarize and synthesize research findings on risk perception and risk communication as they relate to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. In the case of screening tests or procedures with established efficacy and effectiveness, the goal of risk communication is to encourage or persuade persons to be tested. For screening procedures in which the risks and benefits are uncertain, e.g., mammography screening for women in their forties or prostate-specific antigen testing, the goal is informed decision making. Risk communication about screening behaviors will take different forms, depending on the strength of the scientific evidence establishing the risks and benefits associated with the tests or procedures in question.
Over the past decade, there have been many efforts by public health professionals to persuade
age-appropriate women to have mammograms and Pap tests. Many federally funded research
projects have developed, implemented, and evaluated theory-based educational interventions to
promote the initiation and maintenance of those behaviors (1-9). Table 1
shows data from the Behavioral Risk Factor Surveillance System
(BRFSS) on the prevalence of cervical, breast, and colorectal cancer screening behaviors for 1995
(10). The prevalence of "ever" and "recent"
Pap testing and mammography screening is relatively high, indicating that efforts to promote
screening for breast and cervical cancers have been reasonably successful overall. Because
guidelines for colorectal cancer screening have only recently been recommended (11), the dissemination of this information in the population has yet to occur.
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Recent reviews have summarized the literature on interventions to promote breast (12-15), cervical (14,16), and colorectal (17) cancer screenings. Therefore, the literature on educational interventions to promote cancer screening behaviors is not a focus of this review. Rather, the focus is on risk perception because, as noted by several authors (18,19), perceived risk is a central construct in a number of theories of health behavior [e.g., the Health Belief Model (20), the Precaution Adoption Model (21,22), the Transactional Model of Stress and Coping (23,24), the Self-regulation Model of Health Behavior (25,26), and the Protection Motivation Theory (27)]. Risk perception derives from threat appraisal, which is considered to be a major motivating factor in preventive and protective health behaviors. Threat appraisal is based on beliefs about disease risk and severity (28). As defined by Weinstein and Klein (29), perceived risk is one's belief about the likelihood of personal harm. Because risk perception may be an important motivator of a number of health-related behaviors, it is important to understand both the determinants of risk perception and the patterns of association between perceived risk and specific health-related behaviors to develop effective risk communication messages to encourage the adoption of behaviors that will improve health status.
Perceived risk has been used to explain cancer screening behaviors as well as in interventions to promote cancer screenings. However, the literature on perceived risk as it relates to cancer screening behaviors has not been examined systematically across cancer sites. The following terms have been used synonymously in the literature on cancer screening behaviors and are used synonymously here: perceived risk, risk perception, perceived susceptibility, perceived vulnerability, and subjective risk. Data on other social (e.g., socioeconomic status), cognitive (e.g., perceived barriers), and affective (e.g., worry) constructs are discussed as they relate to the relationship between perceived risk and cancer screening, i.e., as mediating or confounding variables. Specifically, the following questions are addressed: 1) Is perceived risk for various cancers associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk for cancer? 3) Is the relationship, if any, between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in changing or modifying cancer risk perceptions? and 5) Are these changes, if any, related to subsequent cancer screening behaviors? In addition, methodologic issues related to studying perceived risk in the context of cancer screening are discussed, and future research needs are identified.
Three computerized databases were searched from their inception through December 1998: MEDLINE® (from 1966), CANCERLIT® (from 1983), and PsychINFO® (from 1967). Medical subject headings were used to scan titles, abstracts, and subject headings in all databases with the use of the key words "cancer screening and risk perception," "perceived risk," "perceived susceptibility," "perceived vulnerability," or "subjective risk." The author reviewed all abstracts identified in the search and obtained articles that appeared relevant for more detailed evaluation. Meeting and dissertation abstracts and articles published in a language other than English were excluded. Reference lists of articles selected for inclusion in the review were examined, as were recent tables of contents of journals in which relevant articles were published.
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IS PERCEIVED RISK FOR VARIOUS CANCERS ASSOCIATED WITH RELEVANT CANCER SCREENING BEHAVIORS? |
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McCaul et al. (30) performed a meta-analysis of the relationship between perceived breast cancer risk and mammography screening and found that perceived risk was positively associated with mammography screening in 18 of 19 studies. Most of these studies were of women at average risk for breast cancer. The average effect size was r = 0.16, adjusted for sample size and was smaller for prospective (r = 0.10) compared with cross-sectional studies (r = 0.19). There was no support for the hypothesis that there was a curvilinear relationship between perceived risk and screening, i.e., that high and low perceived risk are negatively associated with screening (30). Worry also was positively associated with mammography screening (average weighted effect size was r = 0.14), although there were only six studies and the effect sizes ranged from r = -0.22 to 0.45 (30). There were few studies of the association between perceived risk and mammography screening among women at increased risk of breast cancer. Generally, the study populations were self-selected [e.g., (31-33)], and the results were inconsistent.
In a review of the literature on colorectal cancer screening adherence, Vernon (17) found that two (34,35) of eight studies reported a positive association between perceived risk and completion of fecal occult blood test (FOBT), while six studies (36-41) reported no association. Three studies (35,42,43) examined this association for sigmoidoscopy, and all found a positive association.
Three studies (44-46) performed multivariate analysis of a number of cognitive and attitudinal variables, including perceived risk, and cervical cancer screening. After controlling for other variables, one study (46) found a positive association with cervical screening, and two studies (44,45) found no association.
At this point, there are not enough data to draw firm conclusions about the pattern or magnitude of the associations between perceived risk and cervical cancer screening or any type of colorectal cancer screening. Although the magnitude of the overall effect size was small, studies have found a consistent and positive association between perceived risk and mammography screening in women at average risk of breast cancer (30).
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WHAT FACTORS ARE ASSOCIATED WITH PERCEIVED RISK FOR CANCER? |
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Twelve studies examined correlates of perceived risk for breast cancer (18,47-54), colorectal cancer (19,55), or "any" type of cancer (56). There were no studies of correlates of perceived risk of cervical cancer. Five studies (19,47,49,52,53) were of persons at increased risk on the basis of a family history of cancer. Ten (19,47-52,54-56) used a cross-sectional design; two (18,53) conducted both baseline and follow-up surveys.
Measures of perceived risk showed some similarity across studies (Table 2). Six studies (18,19,47,49,50,55) asked respondents to
compare their risk with a reference group, e.g., other women their age. Other measures included
asking persons to rate their perceived lifetime chance of developing a specific cancer or asking
respondents to rate their risk over a defined time period. Most response formats were Likert-style
with 4- to 6-point rating scales.
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In studies that examined the association between perceived risk and objective measures of risk (e.g., number of relatives with cancer), one (47) found no association; four (18,49-51) found a positive association with some, but not all, indicators of objective risk; and two (49,56) found inconsistent patterns across subgroups. Three studies (52-54) of women at increased risk of breast cancer compared a respondent's subjective risk with an objective risk estimate. Among women at increased risk for breast cancer, two studies (52,54) found that over 60% overestimated their breast cancer risk compared with Gail model scores (57), whereas another study (53) found that only 8% overestimated their breast cancer risk with the use of a method developed by Carter et al. (58) to assign objective medical risk. These marked differences may be because of differences in how subjective risk and objective risk were measured, or they may be because of differences in how women were recruited.
Two studies (47,49) of first-degree relatives of breast cancer patients
found that African-American women were less likely than white women to be aware that they
might be at increased risk of breast cancer because of a family history (Table 2
). In an analysis stratified by race, Hughes et al. (49) found
different correlates for perceived risk in the two groups. In studies that included cigarette
smoking, all (47,51,56) but one (55) found a
positive association with perceived risk.
Very few studies have examined psychologic or psychosocial measures in relation to
perceived risk (Table 2). Three studies (48,50,53)
found that subjective risk was positively associated with later stages of change based on the
transtheoretical model (59-61). Bowen et al. (54)
examined the associations between a number of psychologic variables and accuracy of risk
perception. Compared with women who underestimated their breast cancer risk, women who
overestimated or extremely overestimated their risk had higher scores on measures of depression,
anxiety, and coping abilities (54).
Four studies (18,19,50,55) asked respondents to state why they rated their risk as they did, and responses were categorized as risk-increasing or risk-decreasing with the use of a classification scheme developed by Weinstein (22). Lipkus et al. (50) and Aiken et al. (18) examined attributions of perceived risk for breast cancer. Both studies found that heredity was the most frequently cited cause, followed by physiology and personal actions. In both studies, hereditary and physiology were frequently mentioned as risk-increasing factors (by women who perceived their risk as above average) and as risk-decreasing factors (by women who perceived their risk as below average). Environment, psychology, and chance were not frequently mentioned in either study. In Aiken et al. (18), personal actions were cited as a risk-decreasing factor by women who perceived their risk as lower than average but were rarely mentioned as risk-increasing factors in either study.
Blalock et al. (19) and Lipkus et al. (55) examined attributions for perceived risk of colorectal cancer. Siblings of colorectal cancer patients (high-risk group) and siblings of general surgical patients (low-risk group) were more likely to view their personal actions as decreasing rather than increasing their risk, indicating that an optimistic bias was not operating differentially between the two groups (19). Physiology was mentioned with equal frequency by both groups as a risk-increasing and risk-decreasing factor. High-risk siblings were more likely to mention heredity as a risk-increasing than as a risk-decreasing factor, whereas low-risk siblings mentioned it with about equal (and low) frequency as risk increasing or risk decreasing. In multivariate analysis of heredity as a risk-increasing factor in the high-risk group, race was the only statistically significant predictor; 29% of white high-risk siblings cited heredity as a risk-increasing factor compared with 6% of African-American high-risk siblings.
In contrast to other studies of attributions (18,19,50), Lipkus et al. (55) found that, in a group of older, predominantly African-American clinic
users, most persons attributed their risk to psychologic causes; however, consistent with the other
studies, very few respondents cited environmental factors. In multivariate analysis, attributions of
risk were associated with perceived risk. Compared with persons who did not know why they
evaluated their risk as they did, persons who cited psychologic causes, heredity, or personal
actions were more likely to rate their risk as below average (Table 2).
Measures of perceived risk showed some similarity across studies. However, differences in the composition study populations, in the variables measured, and in the analytic approaches taken made it difficult to compare findings. In most studies, perceived risk was modestly associated with objective measures of risk; however, in three studies of women at increased risk of breast cancer, women were found to greatly overestimate (52,54) or underestimate (53) their objective risk. Very few studies examined psychologic or psychosocial correlates, but consistent patterns were found in the three studies that examined the association between stages of change based on the trans-theoretical model and perceived risk (48,50,53). Other correlates were not examined in enough studies to provide a basis for generalization.
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IS THE RELATIONSHIP, IF ANY, BETWEEN PERCEIVED RISK AND CANCER SCREENING BEHAVIORS MODIFIED BY OTHER FACTORS? |
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Four reports (28,46,62,63) evaluated the direct and mediating effects of perceived risk on screening compliance or on outcomes related to compliance, e.g., intention (Table 3
). Two reports
by Aiken et al. (62,63) used the same study population to
examine the relationship of four Health Belief Model constructs with
past mammography screening (63) and with prospective
compliance (62). In cross-sectional analysis, they found an
interaction between perceived susceptibility and perceived barriers
with compliance (63). In longitudinal analysis, Aiken et al.
(62) tested hypotheses about the direct and mediating effects
of Health Belief Model constructs on steps to compliance, a variable
composed of actions related to scheduling and completing a mammogram,
including obtaining one. They hypothesized that high scores on
perceived susceptibility and severity would lead to perceived benefits
and that greater benefits and fewer perceived barriers would lead to
compliance with mammography screening. Intention to obtain a mammogram
was hypothesized to link health beliefs and compliance. These
hypotheses were confirmed (Table 3).
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In a cross-sectional study designed to examine the relationship between social structure and social cognition, Orbell et al. (46) examined the effects of perceived susceptibility and a number of other social, cognitive, and attitudinal variables on cervical cancer screening (Table 3
). In path analysis, perceived susceptibility was directly
and indirectly associated with screening status (Table 3). In another report
that used data from a subset of the same population, i.e., women who were up to date on cervical
cancer screening, Orbell (28) examined the role of personal moral
obligation ("I think I should have a screening test") and other independent
variables, including perceived susceptibility, on the likelihood that women expected to have a
screening test in the future. Among women who were up to date on screening, perceived
susceptibility was not directly or indirectly associated with future expectations about having a Pap
test (Table 3). These studies provide some evidence for the indirect or mediating role of perceived risk in cancer screening behaviors; however, because there are so few studies and because of limitations in the study designs [all but one (62) were cross-sectional], the findings are probably best viewed as hypothesis generating.
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HAVE INTERVENTIONS TO CHANGE PERCEIVED RISK BEEN EFFECTIVE IN CHANGING OR MODIFYING CANCER RISK PERCEPTIONS? ARE THESE CHANGES, IF ANY, RELATED TO SUBSEQUENT CANCER SCREENING BEHAVIORS? |
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There have been few educational interventions explicitly designed to change cancer risk perceptions; however, several interventions used persuasive messages to increase mammography screening and also examined the effect of those messages on risk perceptions or other cognitive factors believed to influence cancer screening decisions. The study populations included community-based participants (62,64), volunteers from work sites (65), patients in general practice settings (66,67), and women at increased cancer risk (68-71). Three studies of women at increased risk were based on the same study population (69-71). All but one study (67) targeted breast cancer screening behaviors (62,64-66,68-71). Some studies used a theoretic model of behavior change to communicate risk information (62,65), whereas others (67-71) provided feedback about actual or objective risk on the basis of statistical models of risk, such as the Gail model (57). Theories and models of behavior change that were used as a basis for intervention development included the Health Belief Model (62,66) and prospect theory (65).
Aiken et al. (62) developed an intervention to increase mammography
screening on the basis of four constructs from the Health Belief Model (Table 4). Pretest and posttest scores on perceived susceptibility showed that scores on the
posttest measure increased in both intervention groups compared with the pretest measure of
susceptibility in the control group. Similarly, both intervention conditions showed a significant
increase from pretest to posttest scores on perceived susceptibility before and after controlling for
demographic factors. Compliance with mammography at 3 and 6 months was similar in the two
intervention groups and was modestly higher than that in the control group after controlling for
covariates (Table 4). Siero et al. (66) also used
the Health Belief Model to evaluate the effect of four messages that manipulated perceived
susceptibility and perceived severity on knowledge, attitudes, intention, and behavior related to
breast self-examination. One month after the intervention, there were no differences among
groups on perceived susceptibility or on other Health Belief Model constructs (Table 4). Banks et al. (65) developed intervention
messages on the basis of prospect theory to increase mammography screening (Table 4). Two groups of women employed by a large northeastern utility
company were randomly assigned to view videos at the work site that emphasized either the gains
or the benefits associated with getting a mammogram or the losses or the risks associated with not
getting a mammogram. At 12-month follow-up, a higher percentage of women who viewed the
video emphasizing loss-framed messages had obtained a mammogram compared with women who
viewed the video emphasizing gain-framed messages, and the intervention effect remained when
other variables were controlled (Table 4). Scores on perceived risk of
breast cancer, however, did not differ in the two groups immediately after the intervention.
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Lerman and colleagues (69-71) compared the effects of an educational intervention on breast cancer risk comprehension and related outcomes including mammography completion. The intervention group received an individualized probability estimate of the risk of developing breast cancer on the basis of the Gail model (57), whereas the control group received general information about guidelines for preventive health behaviors, including breast cancer screening (Table 4
). There was no
statistically significant difference in risk comprehension between the groups at 3-month follow-up,
and approximately two thirds of women in both groups continued to overestimate their lifetime
risk following risk counseling (69). The effectiveness of this intervention
in reducing breast cancer-specific distress as measured by Impact of Event Scale intrusion scores (72) and general psychologic distress (73) also was
evaluated (70). For breast cancer-specific distress, there was a statistically
significant interaction between treatment group and education (Table 4).
Furthermore, perceived risk (measured by perceived lifetime risk and by improved accuracy of
subjective risk estimates) was not found to mediate the effect of the intervention on Impact of
Event Scale scores among less educated participants. In a report (71) on
the effect of the intervention on mammography compliance, there also was an interaction between
treatment group and education. Among women with less education, the intervention led to
decreased mammography use; the intervention had no effect on mammography use among more
educated women (Table 4).
Bowen et al. (64) evaluated the effects of an educational intervention
designed to make women's risk perceptions more congruent with medical risk as assessed
by the Gail model (57) and to increase breast cancer screening intentions.
The intervention decreased perceived risk (as intended) but had no effect on screening intentions
(Table 4).
Alexander et al. (68) conducted a pretest and posttest evaluation of an
educational intervention that provided feedback about a woman's individual risk of
developing breast cancer. The U-Titer questionnaire (74) measured
subjective risk, and Gail model scores (57) assessed objective risk (Table
4). The median absolute difference between the Gail model risk score and
perceived risk was 39% before the education session and 1% after (Table 4).
Kreuter and Strecher (67) conducted a randomized controlled trial in
family practice patients to evaluate the effectiveness of providing feedback about risk of cancer
(any type), heart disease, stroke, and motor vehicle crash (Table 4).
Feedback was based on a comparison of an individual's objective risk on the Carter
Center's Health Risk Appraisal (75) with perceived risk for each
cause of death so that persons could be classified as overestimating (pessimistic bias) or
underestimating (optimistic bias) their risk on the basis of an objective criterion. In comparison
with actual risk, perceived risk of cancer was characterized by pessimistic bias. The intervention
reduced pessimistic bias for perceived cancer risk but did not reduce optimistic bias (Table 4).
Collectively, these findings provide some support for the effectiveness of persuasive educational messages to change risk perceptions. Six (62,64,66-69) of seven studies were successful in changing risk perceptions in the hypothesized direction. Two studies (62,65) found some support for the effect of the intervention on cancer screening behaviors (at least in the short term). However, three studies (64,66,71) found no effect of the intervention on breast cancer screening intentions or on self-reported behavior.
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FUTURE RESEARCH NEEDS |
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At present, we do not know what are the "best" measures of perceived risk. Therefore, we do not have good estimates of the prevalence of perceived risk for different types of cancer or for groups at different levels of risk, e.g., population risk, family history, or genetic risk. We also do not have good estimates of the extent to which persons overestimate or underestimate their risk and whether these patterns vary by cancer site, by different measures of objective risk status, or by the context in which risk information is conveyed, e.g., clinical or research settings and media coverage. As Slovic (76,77) pointed out, perceptions of risk are determined not only by unidimensional statistics of risk but also by qualitative characteristics of a particular risk. For instance, risk for preventable cancers may be perceived differently from those that are not. Although a number of recent studies (29,78-83) examined whether the method of presenting risk estimates affected responses to questions about risk perception, only two (82,83) examined risk estimates for cancer. One other study (84) examined the effects of numeracy on women's understanding of the benefits of mammography screening with the use of four quantitative formats and found that accuracy was strongly related to numeracy regardless of the format used to present information. Methodologic studies that included a variety of measures of perceived risk and that examined their relationship to measures of objective risk would contribute to our understanding of how best to measure this construct as well as to our knowledge about the prevalence of perceived risk and the extent to which it is underestimated or overestimated. These studies will be more informative if they are conducted in defined populations at different levels of cancer risk.
From the studies reviewed here, it is difficult to determine whether risk perception is a cause or an effect in relation to cancer screening. Aiken et al. (18) compared cross-sectional and longitudinal patterns of association between perceived risk and self-reported mammography compliance. In longitudinal analysis, perceived susceptibility at baseline was not associated with mammography compliance at follow-up (r = -0.05), but mammography compliance at baseline predicted perceived susceptibility at follow-up (r = 0.16; P<0.05) controlling for perceived susceptibility at baseline. Studies are needed that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception to clarify this relationship.
Only six studies (62,64,65,69-71) assessed the immediate effects of interventions on cognitive or psychologic processes as well as on subsequent screening behavior. At present, there are not enough studies of any one cancer site to draw conclusions about the direct and mediating effects of those processes in relation to screening compliance or to make comparisons across cancer sites. The effects of these processes could differ for persons at different levels of cancer risk or for cancers that may be preventable through early detection of premalignant lesions, such as cervical and colorectal cancers, and for those, such as breast cancer, where early detection confers a survival benefit but does not prevent the disease.
A potentially important factor that was not examined in relation to risk perception or cancer screening in any of the studies reviewed here is perceived behavioral control. In one of the early studies of predictors of compliance with fecal occult blood testing, DeVellis et al. (85) found that perceived behavioral control predicted completion of the test in siblings of colorectal cancer patients but not in siblings of non-colorectal cancer patients. Related concepts that were examined in only a few studies reviewed here were coping style and coping skills. Several investigators (23,25) have emphasized that, when raising awareness of a health threat, it is important to provide specific actions to reduce the threat. In a recently published study of first-degree relatives of breast cancer patients that applied this line of thought, Schwartz et al. (86) evaluated the effectiveness of an intervention based on problem-solving training (87) to reduce breast cancer-specific and general psychologic distress compared with a control group who received general health education. There was no overall effect of the intervention on cancer-specific distress as measured by Impact of Event Scale intrusion and avoidance subscale scores (72) or on the measure of general distress (73), although in a post hoc analysis, Impact of Event Scale scores decreased in women who reported that they regularly practiced problem-solving training compared with women in the control group and with women who did not regularly practice the intervention skills (86).
Fischhoff et al. (88) pointed out that, although there is evidence that risk estimates are subject to bias, there is less evidence showing that these biases result in inappropriate risk decisions or supporting the idea that people are waiting for accurate risk estimates so that they can make decisions. In relation to cancer screening decisions, we know very little about the behavioral consequences of overestimating or underestimating one's risk. Overestimation may result in hypervigilance, leading women to engage in excessive screening behaviors (32), or it may have the opposite effect (31,89). At present, we really do not know what the goal of interventions designed to influence risk perception should be. That is, we do not know if increasing the accuracy of risk perception will lead to the behavioral outcomes we want to promote. Intervention development would benefit from longitudinal descriptive data on changes in risk perception over time in relation to measures of psychologic status, cognitive factors, and screening participation. If risk perception is related to worry, anxiety, or psychologic distress, interventions may be needed to address those affective conditions as well.
There are virtually no data on what people want to know about the risks they face. This information will become increasingly important as technology increases our ability to identify healthy persons who will inevitably, e.g., Huntington's disease, or with a high degree of certainty, e.g., BRCA1/BRCA2 carriers, develop a disease. Identifying someone as at risk in the interest of prevention or early detection can have profound negative implications on a person's quality of life (90,91).
A number of disciplines have made important contributions to our understanding of risk perception, including geography, sociology, political science, anthropology, and psychology (76). To fully understand risk perception and to develop effective risk communications, we need to take into consideration the perspectives represented by those disciplines, including the role of individual differences in personality, emotion, cognitions, culture, and social processes (88). The primary focus in the studies reviewed here was on individual differences in perceived risk and on factors that modify its effects. However, attitudes and beliefs do not develop in a vacuum. From one perspective, an individual's choice is largely determined by social structural conditions. Habits, norms, and beliefs vary between different social groups and are patterned by the social structure, particularly the social class structure, producing similar views of the world (92). These patterns of socialization are reflected in beliefs and attitudes toward health and illness and health care. From a social epidemiologic perspective, there is a causal link between behavioral differences, socioeconomic circumstances, and health status (92,93). The reason socioeconomic status (SES) has been so consistently linked with disease is because it embodies resources like knowledge, prestige, money, and power that can be used to avoid risks for disease and death, for instance by adopting health innovations such as cancer screening (93). Link et al. (93) used data from the BRFSS to show how the SES distribution of mammography screening and Pap testing can have the unanticipated consequence of becoming a mechanism that links SES to cervical cancer and breast cancer mortality.
Although the social and cultural context in which risk communication messages are delivered influences not only how messages are understood but also whether or not they are acted on, other factors need to be considered as well. Rundall and Wheeler (94) showed that the effects of income on preventive services were mediated not only by perceived susceptibility but also by difficulties in access to services. Data from the BRFSS showed that the absence of insurance coverage was a significant barrier to mammography screening in the United States (95). For 1996-1997, self-reported mammography use for women 40 years old or older was 71% and 46% in women with and without insurance coverage, respectively. In a similar vein, data from the five National Cancer Institute (NCI) Breast Cancer Screening Consortium studies (96) showed that the prevalence of recent clinical breast examination and of receiving a physician's recommendation for a mammogram was higher in the two study sites where women were recruited from health maintenance organizations compared with other settings; these women also were more likely to be in the action stage of adoption as classified by the transtheoretical model (97).
As indicated by the data in Table 1, the success of efforts to promote
cervical cancer screening raises a question about when risk communication is no longer a primary
consideration in promoting the adoption of health-related behaviors. Seat belt use legislation made
it unnecessary to continue the largely unsuccessful attempts at persuading the public to use seat
belts by informing them of the risk of having a fatal accident. The high prevalence of cervical and
breast cancer screenings may be, in part, a result of successful efforts to embed the tests in the
medical care system and to provide insurance coverage for the tests. The data on mammography
use by insurance status (95,96) support the view that the success of risk
communication to promote cancer screening may depend on access to medical care and other
factors such as cultural beliefs and values (98,99). The task at hand is to
identify those factors for subgroups, like Hispanics, in which attempts to promote screening have
been less successful (16).
This review has focused on studies of correlates of perceived risk, on the direct and mediating effects of perceived risk in relation to cancer screening behaviors in individuals, and on risk communications targeted at individuals. It has not addressed the issue of risk communication through the mass media. As Slovic (76) pointed out a number of years ago, most lay persons acquire their information about hazards from the news media. This observation is no less true for information about disease risks and about the benefits of health-promoting behaviors. An excellent example of the media's depiction of breast cancer risk is provided by Lupton (100), who evaluated the messages in the Australian press about the disease from 1987 to 1990. These descriptions undoubtedly influenced many women's risk perceptions about breast cancer (not necessarily in a positive way) both by the overt content and by the more subtle messages that were conveyed. We can infer from secular trends showing an increase in mammography screening over the past decade that public health professionals and advocacy groups have succeeded in raising awareness about breast cancer and screening, despite the largely null findings from carefully designed, community-based randomized controlled trials to promote screening (1,3,5-8).
We need simultaneously to refine risk communication messages targeted at defined subgroups in the population and to improve our ability to effectively use mass communication channels to reach a broader audience. The former approach is likely to be more effective in promoting cancer screening for cancers such as cervical and breast cancers in which the prevalence of screening is high, whereas the latter approach is likely to be more effective, at least initially, in promoting cancers such as colorectal cancer in which the prevalence of screening is low.
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NOTES |
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I thank Colette Miesse for her contributions to many aspects of the work on this paper, including bibliographic searches and assistance with compiling data from the literature, and Brenda Brown for her assistance in preparing the final version of the manuscript.
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