Teoria Cognitivo Social y Cancer de Seno - Miller 1996

Psychological Bulletin
1996, Vol. 119, No. 1, 70-94
Copyright 1996 by the American Ps~hological Association, Inc.

0033-2909/96/$3.00
Applying Cognitive-Social Theory to Health-Protective Behavior:

Breast Self-Examination in Cancer Screening
Suzanne M. Miller
Yuichi Shoda
Fox Chase Cancer Center
Columbia University
Karen Hurley
Temple University
'This article applies recent developments in cognitive-social theory to health-protective behavior,
articulating a Cognitive-Social Health Information Processing (C-SHIP) model. This model of the
genesis and maintenance of health-protective behavior focuses on the individual's encodings and
construals, expectancies, affects, goals and values, self-regulatory competencies, and their interactions with each other and the health-relevant information in the course of cognitive-affective processing. In processing health information, individuals are assumed to differ in both the accessibility
of these mental representations and the organization of relationshipsamong them. In this article, the
model is applied to analyze and integrate the often-confusing findings on breast self-examination in
cancer screening. Implications are considered for assessments and interventions to enhance adherence to complex, long-term, health-protective regimens, tailored to the needs and characteristics of
the individual.
There has been an explosion of interest and research in health

psychology in the last decade, fueled by the excitement of successfully applying basic psychological concepts to understand
how people deal with health challenges (e.g., Baum & Singer,
1987; Gatchel, Baum, & Krantz, 1989; Lazarus, 1991; H. Leventhal, 1983; Rodin & Salovey, 1989; Weiss, 1992). This rapidly growing field encompasses disease prevention and early detection, as well as short- and long-term management of disease
course and consequences (Taylor, 1990, 1995). It is also concerned with individual differences in selecting and processing
information about health-related risks, needs, and stressors.
As the core topics and implicit goals within health psychology
have become clear, the processing of health-related information
has been given a major role. In studies of the variables that affect
health-information processing, investigators within the field
can select from a wide array of conceptual models and terms
to guide their work. Under close examination, however, most
available current models address only partial aspects or components in the processing of health-relevant information and individual differences in health-protective behavior. Ideally, one
needs to provide a complete account, from selection and encoding to the construction, enactment, and maintenance of healthprotective behavior patterns. Moreover, these models tend to
show considerable conceptual and measurement overlap, often
differing more in emphases and terminology than in essential
features, as Weinstein ( 1993 ) has observed.
It can be argued that the independent development of similar
models to analyze this key topic attests to the robustness of the
phenomena and to the utility of the constructs commonly employed in different efforts to account for them. However, it also
makes it difficult to relate findings from studies conceptualized
in different theoretical languages. It would be useful to place the
specific constructs and findings relevant to health-information
processing into a more general framework. Such a framework
should allow one to integrate and clarify the relationships
among the constructs used in different models within health
psychology and in closely related fields that deal with overlapping issues, including social, personality, clinical, developmental, and cognitive psychology.
For that purpose, the present article begins with an outline of
the cognitive-social learning theory of social information processing and individual differences (Mischel, 1973, 1990; Mischel & Shoda, 1995). Rather than limited to the ideas of any
single theorist or as a specific model of a particular type of behavior, it was proposed as a deliberately cumulative general
framework--or a metatheory--to invite the contributions and
Suzanne M. Miller, Division of Population Science, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Yuichi Shoda, Department of
Psychology, Columbia University; Karen Hurley, Department of Psychology, Temple University.
Preparation of this article was supported in part by Grants CA4659 l,
CA58999, and CA61280 from the National Cancer Institute, Grant
PBR-72 from the American Cancer Society, and Grants MH39349 and
MH45994 from the National Institute of Mental Health.
We are especially indebted to Walter Miscbel for his insightful and
constructive comments on many drafts of this article. We also thank
Paul Engstrom, Lizette Peterson, William H. Redd, Ann O'Leary, Howard Leventhal, Victoria Champion, Caryn Lerman, Barbara Rimer,
Mark Schwartz, Michele Rodoletz, Pagona Roussi, Megan Mills, Danika AItman, and Joanne Schwartz for their helpful feedback on earlier
drafts.
Correspondence concerning this article should be addressed to Suzanne M. Miller, Division of Population Science, Fox Chase Cancer
Center, 215 South Broad Street, 5th Floor, Philadelphia, Pennsylvania
19107. Electronic mail may be sent to sm miUer@fccc.edu.
70
COGNITIVE SOCIAL THEORY AND CANCER SCREENING

domain-specific applications of diverse theorists and researchers dealing with various substantive content areas. Strengthened
by a voluminous body of research and theorizing (e.g., Bandura, 1986; Cantor & Kihlstrom, |987) and building on earlier
cognitive and social learning contributions (e.g., Beck, 1976; G.
Kelly, 1955; Rotter, 1954), for more than 2 decades this cognitive-social approach I has been stimulating an increasingly
comprehensive conceptual analysis of cognitive, social, and
affective mediating processes that underlie individual differences in diverse domains of behavior in the areas of personality,
social, developmental, and clinical psychology (e.g., Bandura,
1977a, 1977b, 1986; Carver & Scheier, 1981; Cervone, 1989;
Dodge, 1986; Dweck, 1990; Foa & Kozak, 1986; Foa & Riggs,
1993; Foa, Zinbarg, & Rothbaum, 1992; Horowitz, 1991; Janis,
1967; Mischel, 1973; Sarason, 1979; Singer & Salovey, 1991 ).
Most recently, this general framework has been developed
into a comprehensive theory of personality as a cognitiveaffective mediating system (Mischel & Shoda, 1995). In this
article, we use this overarching cognitive-social perspective as a
framework to organize a review of the empirical literature on
breast cancer screeningmfocusing on breast self-examination
(BSE) practice and adherencemand illustrating its heuristic
value for the field of behavioral medicine and health psychology
more generally. We believe that such a unifying conceptual
framework needs to be articulated at this juncture to provide a
common language and broad perspective that can facilitate the
development of health psychology into a cumulative science, 2
linked to the concepts and findings of basic areas of psychology.
Breast Cancer Screening as a Prototype for

Health-Protective Behaviors
We focus on research on breast cancer screening for a number
of reasons. First, the prevalence of breast cancer makes understanding the determinants of screening behaviors an urgent
matter. Breast cancer is currently the most common cancer in
women and the second leading cause of all cancer-related deaths
in the United States (Boring, Squires, & Tong, 1992; Council
on Scientific Affairs, 1989). It is estimated that one out of every
nine women in this country will eventually develop the disease
(American Cancer Society, 1993 ), and an estimated 12 million
women possess two or more of the major risk factors for breast
cancer (Vogel, i 991 ). Although breast cancer cannot be prevented at present, the good news is that 93% of women will survive at least 5 years after treatment if the disease is detected
in its early stages (American Cancer Society, 1993). Thus, by
increasing compliance rates with the screening practices that
facilitate early detection, health psychologists can contribute
importantly to improving health outcomes for women.
BSE has been promoted for over 40 years as a low-cost cancer
screening technique (Eggertsen & Bergman, 1983). It involves a
monthly procedure in which a woman visually inspects and manually palpates her breasts and underarm area in a systematic fashion to detect lumps, thickening, changes in contour, swelling, dimpling of the skin, and discharge from or changes in the nipple
(American Cancer Society, 1987). Findings of several studies,
both retrospective and prospective, show that breast cancer patients who reported BSE practice before the discovery of their disease present with smaller tumors and are less likely to have axillary
71
lymph node involvement than are women who do not perform

BSE (e.g., Foster & Costanza, 1984; Foster et al., 1978; Greenwald
et al., 1978; Lockeret al., 1989; Semiglazov & Moiseenko, 1987).
Nonetheless, many questions remain about the sensitivity of BSE
relative to other screening behaviors (especially mammography)
and about the degree to which the practice of BSE contributes to
survival rates from the disease in women who are also obtaining
mammograms (Baines, 1989; Grady, 1992; O'Malley & Fletcbet;
1987; Senie, Lesser; Kinne, & Rosen, 1994). Hov~v~ the
effectivenessof BSE depends on whether it is practiced regularly and
competently (GIVIO, 1991; Huguley & Brown, 1981; Newcomb et
al., 1991). For example, only 25-35% of women perform BSE at
the recommended frequency (Celentano & Holtzman, 1983;
Champion, 1988; Murray & McMillan, 1993), and even fewer do
so proficiently (Celentano & Holtzman, 1983; GIVIO, 1991; Howe,
1981; Jacob, Penn, & Brown, 1989; Roberts, French, & Duffy,
1984; Sheley & Lessan, 1986). It is therefore important to specify
the conditions that facilitate the regular performance of proficient
BSE and to identify the women most likely to practice BSE competently and to profi[ from it.
A good deal of research already exists on the psychological
antecedents and correlates of adherence and failures to adhere
to a monthly regimen of BSE. The present article analyzes the
psychological processes underlying BSE decision and adherence, guided particularly by cognitive-affective system theory
(Mischel & Shoda, 1995), which provides a unifying framework at a broad theoretical level. This framework is based on
general psychological principles that apply to cognitive and
emotional processing and individual differences across diverse
content domains, potentially connecting research in health psychology to the larger discipline. However, the theory of the cognitive-affective system is structured at a metatheoretical level
and requires, indeed explicitly calls for, specific applications to
substantive content domains.
Drawing on this metatheory, we articulate a Cognitive-Social
Health Information Processing model (C-SHIP), which we apply to breast cancer screening and specifically to the performance of BSE. The goal is to examine the utility of the C-SHIP,
using the same constructs to describe individual differences in
health-protective behavior and to analyze the psychological processes that generate them. We do this by trying to clarify and
integrate the diverse and sometimes potentially conflicting
findings that emerge from research on the performance of BSE.
The final section addresses the implications of this framework
for the types of interventions required to promote the practice
of BSE, as well as for assessment and for research in other domains of health-protective behaviors.
Cognitive-Social A p p r o a c h to Health Information
Processing ( C - S H I P )
The C-SHIP includes two basic components: (a) a set of cognitive-affective units in the hypothesized information-processl Note that the terms social cognitive and cognitive social have become virtually interchangeablein the literature (Miscbel, 1993).
2The major models in this area have recently been compared systematically (Weinstein, 1993), therefore these differencesare not again reviewedhere.
72
MILLER, SHODA, AND HURLEY
ing system and (b) the structure and dynamic processes

through which these units interact to generate health-protective
behavior.
Choice of Mediating Units

With regard to the choice of mediating units, the C-SHIP incorporates the cumulative findings and concepts emerging from cognitive and social theories of social information professing over
many years (e.~, Bandura, 1986; Cantor & Kihlstrom, 1987;
Carver & Scheier, 1981; Dodge, 1986; Mischel, 1973, 1990).
These basic units, called cognitive-affective units (Mischel &
Shoda, 1995), include the mental representations of the person's
encoding constructs and strategies, beliefs, expectancies; affects,
goals, and values. These units have had a long history in psychology and play a role as variables or constructs in one or more existing theories in the health domain (Glanz, Lewis, & Rimer, 1990).
Cognitive-social theory is not unique in the mediating units it
identifies: These constructs are common products that have
emerged over many years in psychology, reflecting the shared heritage of the field as a cumulative science. Thus, how people process
information about their health risks, prospects, and self-protective
options greatly depends on their strategies for encoding or interpreting health information about their illness states and symptoms
(Gritz & Bastani, 1993; E. Leventhal, Suls, & Leventhal, 1993; H.
Leventhal, 1970; H. Leventhal, Diefenbach, & Leventhal, 1992).
Likewise, most models of health-protective behaviors include the
expectancy and value constructs (Fischoff, Goitein, & Shapira,
1982; Rotter, 1954). The health belief model (Becket; 1974; Janz
& Becker, 1984; Kirscht, 1988; H. Leventhal, Hochbaum, & Rosenstock, 1960) and protection motivation theory (Maddux &
Rogers, 1983; Prentice-Dunn & Rogers, 1986) emphasize the person's attention to the cost and health consequences for not performing recommended behaviors, as do subjective expected utility
theory (Edwards, 1954; Ronis, 1992; Sutton, 1982), the theory of
reasoned action (Ajzen & Fishbein, 1980; Fishbein & Ajzen,
1975 ), and the theory of planned behavior (Ajzen, 1985; Ajzen &
Madden, 1986), although each uses somewhat different terms.
As the above-cited models have recognized, health-protective
decisions reflect subjective expectancies and perceived psychological costs, rather than their objective assessment. Behavior is
influenced by the construals, expectancies, and values that are
salient for the person in a specific situation and by the affects or
emotions that are triggered when potentially harmful or beneficial consequences to the self are perceived (C. Smith & Lazarus, 1990). These cognitive-emotional reactions also hinge on
such features of the situation as how information about health
outcomes is framed psychologically (Rothman, Salovey, Antone, Keough, & Martin, 1993; Rothman, Salovey, Turvey, &
Fishkin, 1993; Wilson, Purdon, & Wallston, 1988) and on current mood state (Salovey & Birnbaum, 1989).
Furthermore, one type of expectancy, self-efficacy--assessed
by asking people to indicate their degree of confidence that they
can do a particular task (which is described in detail)--has long
been recognized as an especially important determinant of
effort and persistence (Bandura, 1977a, 1977b, 1978, 1981 ). A
person's belief that he or she can execute the behavior required
by a particular situation is especially germane for the maintenance of difficult health-relevant behaviors (Bandura, 1986;
O'Leary, 1985, 1992), and it has been shown that self-efficacy

expectations predict effective performance of difficult tasks,
particularly when the potential outcome is highly important to
the individual (Lau, Hartman, & Ware, 1986 ).
The types of units hypothesized in the C-SHIP are shown in
Table 1. Note again that such units as construals, beliefs, expectancies, and values are common denominators in most contemporary models about people's intuitive decision-making processes with regard to health information. In recent years, much
evidence also has shown that affect influences social information processing and that the processing of information important to the self necessarily activates affects (e.g., Bower, 1981;
Contrada, Leventhal, & O'Leary, 1990; Foa & Kozak, 1986; C.
Smith & Lazarus, 1990; Wright & Mischel, 1982; Zajonc,
1980). Thus, the distinguishing feature of this set of mediating
units or person variables (Mischel, 1973 ) is not its uniqueness
but its eclectic comprehensiveness in the effort to incorporate
cumulative findings from diverse directions over many years.
ProcessingStructure and Dynamics: Organization of the

Mediating Units
Most important is the second component oftbe C-SHIP. Like
the cognitive-affective system theory from which it is derived
(Miscbel & Shoda, 1995), the C-SHIP assumes that individuals
differ not only in the cognitive-affective mediating units accessible to them but also in the structure and dynamics that govern
the cognitive-affective information processing through which
these units interact in the genesis of health-protective behavior.
Thus, it addresses both (a) the variables (dimensions) on which
individuals importantly differ (e.g., their encodings, expectancies, values, affective states, and goals and values) in cognitiveaffective information processing and (b) the processing structure and dynamics within the system that account for and underlie these differences. In the theory, for a given individual or
type (e.g., a "monitor," cf. Miller, 1995), this organization is
both stable and distinctive in its structure and dynamics, which
guide and constrain the patterns and sequences of activation
among the mediating units that are generated when relevant information is processed over the course of time.
A number of features make this theoretical framework promising for applications to analyses of health-protective behavior.
As noted above, the approach is comprehensive and cumulative,
drawing on the established concepts and findings of the larger
field. Furthermore, it takes account of not only the role of cognition but also affect and does so at all phases of information
processing from encoding through behavior generation, execution, and long-term maintenance of difficult but desired behavior. It deals with cognitive-emotional processing, as the individual interprets, transforms, and acts on the information, over
long temporal spans of the sort often experienced when coping
with severe threats of health and illness. It explicitly addresses
the execution of complex, long-term behaviors that are difficult
to generate and maintain, for example, that require purposeful
delay of gratification and self-regulation, and that are essential
for many aspects of effective health-protective planning and behavior. It is therefore of direct relevance to such health-protective behaviors as self-screening procedures for early detection
73
Table 1
Types of Cognitive-Affective Mediating Units in Health Information Processing

and Execution of Health-Protective Behavior
Health-relevantencodings
Strategies and constructs for encoding of self and situations with regard to health and wellness, health
risks and vulnerabilities, and illness and disease. Includes attentional strategies for selecting and
processing potential health-threats and dangers (e.g., monitoring-blunting by scanning for and
amplifying, or avoiding and attenuating, information about possible health dangers and stressors).
Health beliefsand expectancies

Specific beliefs and expectations activated in health information processing. Includes expectancies about
both outcomes (e.g., subjective likelihood of one's developing breast cancer based on one's genetic
pedigree and lung cancer from smoking) and self-efficacyexpectancies (e.g., for adhering to regular BSE
in cancer screening and for giving up tobacco).
Affects (emotions)
Affective states activated in health information processing (e.g., anxiety, depression, hopefulness, negative
feelings about the self, irritability, and anger).
Health goals and values

Desired and valued health outcomes and states and their subjective importance (e.g., it is critical to have
healthy breasts) and goals for health-relevant life projects (e.g., dieting and exercising regularly).
Self-regulatory competenciesand skillsfor generatingand maintaining health-protectivebehavior

Knowledge and strategies for dealing with specific barriers to health-protective behaviors and for
construction and maintenance of health-protective behaviors (e.g., skills required for proficient breast
self-examination in cancer screening). Includes self-regulatory strategies and behavioral scripts (e.g., selfrewards and anxiety management) for executing, maintaining, and adhering to long-term, healthprotective behavior plans and life projects (e.g., strategies for goal-directed delay of gratification).
Note. From "A Cognitive-Affective System Theory of Personality: Reconceptualizing Situations, Dispositions, Dynamics, and Invariance in Personality Structures;' by W. Mischel and Y. Shoda, 1995, Psychological Review, 102, p. 253. Copyright 1995 by the American Psychological Association. Adapted with
permission of the authors.
of cance~ adherence to stringent diets, and smoking cessation
regimens.
Finally, the approach also focuses attention on the important psychological features of the situation as perceived and interpreted by
the individual and thus makes the psychological context a central
component in the cognitive-affective processing of information. As
has been demonstrated at least at a theoretical level (Mischel &
Shoda, 1995), it should allow better understanding and prediction
not only of overall individual differences in broad behavioral averages (e.g., the overall tendency to monitor for information about
health threats and dangers) but also of specific patterns of Person
Situation interaction (e.g., if A, then she monitors for health threats;
but if B, then she avoids them) as expressions of the same underlying system. The challenge is to examine the utility of this metatheoretical conception for health-protective behavior ~nerally, and
for BSE in Imrficular, which is our goal in the next section.
protective behavior requires, as a first step, identifying the contents

of the cognitive-affective units that are likely to be activated in the
relevant population, in this case when women deal with information
about breast cancer. For that purpose, below we turn to the literature
on BSE in cancer screening
The C-SHIP analysis of the distinctive component behaviors
involved in BSE distinguishes the intention to do BSE (i.e., the
decision "I will do BSE") from the execution of the behaviors
themselves (i.e., the performance of BSE). Conceptually and
methodologically, this distinction between the formation of intentions (choices and decisions) and their behavioral enactment
in vivo is important because they involve different, albeit
closely interacting processes and determinants (e.g., Mischel,
1974; Mischel, Cantor, & Feldman, in press). We therefore consider them separately, first discussing the formation of decisions
and intentions and, thereafter, their execution and maintenance
at the performance level.
Application o f the C - S H I P to BSE

The foregoing assumptions of the C-SHIP suggest that when individuals encounter Information about BSE and breast cancer; they
differ stably in the ease with which various construals, expectancies,
affects, goals, and self-regulatory strategies become activated. In adclifton, the theory predicts that stable differences also exist in the
strengths and patterns of the organization of interrelations through
which these mental representations are activated by particular types
of BSE-relevant information and through which they interact in
the genesis and maintenance of health-protective behavior. Thus,
an application of the C-SHIP to any particular domain of health-
Formation of Decisions and Intentions to Perform B S E

Cognitive-Affective Mediating Units Influencing the
Decision
In general theoretical terms, the types of cognitive-affective
mediating units relevant for processing information about
breast cancer and BSE are indicated in Table 1. In the BSE research literature, several of these types of units have been investigated as individual difference variables that may influence
health-protective intentions and decisions.
74
Encoding of health-relevant information: Perceived vulnerability Individual differences in encoding mediate the relationship
between the objective risk information that the individual receives
and her subjective, perceived vulnerability to breast cancer. Some
individuals are more likely to see health threats everywhere and to
scan for them, attending intently to bodily cues and symptoms,
whereas others tend not to attend to such information and actively
avoid it (Barsky & Klerman, 1983; Kellner, 1990; Miller; 1995, in
press; Pennebaker, 1982; Salovey & Birnbaum, 1989). The importance of individual differences in encoding when processing risk
information is consistent with the finding of low correlations between a woman's objective risk status and her perceived susceptibility to breast cancea; which has typically been only in the 0.2
range (Aiken, West, Woodward, & Reno, 1994; Calnan & Rutter,
1988; Rutledge, Hartmann, Kinman, & Winfield, 1988; Schwartz
et al., 1995). In a recent study, in which women with a familial
history of breast cancer were presented with detailed information
about their personal risk, a striking two thirds of the participants
continued to significantly overestimate their susceptibility to the
disease after the risk counseling session (Lerman, Lustbader, et al.,
1995). Other women at objectively high risk appear to dramatically underestimate their vulnerability (Kash, Holland, Halper, &
Miller, 1992; see also Blalock, DeVellis, Atifi, & Sandier, 1990).
Close examination of the literature on beliefs about one's personal risk of contracting breast cancer shows that researchers in
this domain have combined diverse items as measures of the construal of subjective vulnerability. Sample items range from "I am
less likely than the average woman to develop breast cancer"
(Ronis & Harel, 1989), to "I worry a lot about getting breast cancer" ( Champion, 1984 ), to "Whenever I hear of a friend or relative
. . getting breast cancer, it makes me realize that I could get it,
too" (Stillman, 1977). Perhaps, in part, because of this diversity,
results in the literature have been mixed, such that some studies
show a positive relationship between perceived susceptibility and
BSE frequency (Calnan, 1984; Champion, 1988, 1990; Ronis &
Hard, 1989; Wyper, 1990), whereas others fail to obtain this effect
(Bennett, Lawrence, Fleischmann, Gifford, & Slack, 1983; Champion, 1984, 1985, 1987; Murray & McMiUan, 1993; Rutledge,
1987). Among those that do show a positive association, the relationships are typically of a modest statistical magnitude, with correlations ranging from 0.14 to 0.25. These findings are consistent
with research in other health domains, which shows a small, nonzero mean effect size between perceived susceptibility and screening behaviors (e.g., testicular self-exam, fecal occult blood testing,
and asymptomatic venereal disease testing; Harrison, Mullen, &
Green, 1992). 3
Ej~cacy and confidence. Research indicates that women
differ in their self-confidence about their self-examination technique and their ability to use BSE to detect lesions. A number
of studies have shown that high self-efficacy beliefs (generally
assumed as confidence in one's ability to perform BSE) are associated with higher levels of BSE adherence (Bennett et al.,
1983; Fletcher, Morgan, O'Malley, Earp, & Degnan, 1989; Jacob et al., 1989; Murray & McMillan, 1993; Ronis & Kaiser,
1985; Rutledge & Davis, 1988; Shepperd, Solomon, Atkins,
Foster, & Frankowski, 1990; Stefanek & Wilcox, 1991; Strauss,
Solomon, Costanza, Worden, & Foster, 1987 vs. Kash et al.,
1992). However, these results are difficult to interpret because
BSE practice was assessed retrospectively. Only a handful of
studies have used a prospective design in which beliefs about

one's self-efficacy are used to predict the subsequent performance of BSE. These findings generally indicate a positive--but
moderate--relationship between baseline self-efficacy beliefs
and later BSE adherence (Champion, 1990; Clarke, Hill, Rassaby, White, & Hirst, 1991; Janz, Becker, Haefner, Rutt, &
Weissfeld, 1990). 4 In one study, for example, women who participated in a BSE training class were recontacted 1 year later
(Clarke et al., 1991 ). Level of confidence in performing BSE at
the initial interview correlated positively (r = .19) with frequency of BSE practice in the year following the training class.
From the C~SHIP perspective, whereas self-efficacy is a good
single indicator of performance, it also constitutes only one aspect of the relevant mediating units in the processing of healthprotective information, whose impact on behavior depends on
its relation to other units activated during processing within the
individual's system (e.g., other expectancies and beliefs as well
as affects, goals, and values). For example, the value an individual places on her health, her beliefs about the seriousness of a
health threat, as well as her beliefs in the effectiveness of specific
behaviors to reduce the consequences of the threat, all play an
important, interconnected role (see also Bond, Aiken, & Somerville, 1992).
Values and goals: Perceived costs and benefits. Although researchers usually assume that health is a universally valued goal,
in fact, this has not been shown to be the case (Lau et al., 1986;
Quadrel & Lau, 1989; Ware & Young, 1979). Moreover, goals
and values (e.g., one's feelings about one's sexuality, appearance, health, and mortality) appear to change over the life
course (Hooker, 1992; Thurnher, 1974). For example, not surprisingly, when asked to imagine that they need to undergo
breast cancer surgery, younger women are more concerned that
the surgery will make them feel less attractive and are more concerned about how others will feel about them (Bennett et al.,
1983). Furthermore, research in related domains has shown
that older persons value their health more highly and mention
health concerns as their most-hoped-for and most-dreaded
"possible selves" more frequently than do college-aged individuals (Hooker, 1992).
Past experience, of course, enters into these subjective costbenefit calculations. For example, a woman's level of anxiety
about finding a lump may be less if she has survived an episode
of breast cancer because this experience would enable her to
reconstrue the threat in less terrifying terms ("I had it, and I am
OK"; Berrenberg, 1989). Furthermore, rather than responding
to the anxiety about finding a lump by avoidance and denial,
3 Similar to the BSE literature, the research on fear-arousing communications in general is mixed, such that some studies find a 0-shaped
relationship between fear and adoption of, or adherence to, health-protective behaviors, whereas other studies find a positive, linear relationship (see Sutton, 1982, for a review).
4 One study reported no relationship between self-efficacybeliefs and
subsequent performance (Calnan & Moss, 1984). Howev~ BSE practice
was defined in terms not only of how frequently the behavior vos performed but also of how competently it was performed. This combined
assessment may have dampened the effectof self-efficacyon BSE because
women otten overestimatethe quality of their exams (Celentano & Holtzman, 1983;Jacob et al., 1989).

she may have learned through the first episode to actively engage
in appropriate health-protective behaviors ("If I do BSE, I can
make sure that any further problems are caught early and dealt
with"). Consistent with these hypotheses, women with a personal history of breast cancer have been found to be more likely
to perform BSE than those who have been treated for a benign
(nonmalignant) breast tumor (Strauss et al., 1987), although
the number who practice BSE regularly still falls short of optimum adherence (Taylor et al., 1984).
Summary. A woman's BSE intentions and decisions are influenced by her beliefs that a health threat (e.g., breast cancer)
is serious and personally relevant and that there are effective
measures available to minimize its consequences (Aiken, West,
Woodward, Reno, & Reynolds, 1994). As diverse models of
health-protective decisions have noted repeatedly, the decision
to perform BSE depends, in part, on the perceived trade-offbetween the benefits and value of detection and treatment as compared with their costs (e.g., Becker, 1985; Prochaska, 1994) and
compared with the benefits of continued inaction (e.g., avoiding
the anxiety provoked by performing BSE; Rogers, 1983).
In this subjective arithmetic, individual differences in beliefs
about the general utility of early detection and treatment also
importantly affect the decision to perform BSE. Those women
who doubt the utility of medical intervention ("Breast cancer is
not curable") are unlikely to undertake BSE (Lerman et al.,
1991; Sheley & Lessan, 1986). Likewise, Ronis and Harel
(1989) found that women who believed that delayed treatment
increased the severity of breast cancer outcomes rated BSE as
more beneficial in reducing the potential severity of the disease
and its treatment. Perceived benefits, in turn, were related to
increased frequency of BSE. Conversely, women who did not
believe in the value of early treatment perceived fewer benefits
to BSE and were less likely to examine their breasts.
Interactions Within the System: The Structure and

Dynamics of Health Information Processing
The modest but statistically significant additive linear effects
found in the literature reviewed above are consistent with the
C-SHIP assumption that when women encounter BSE-relevant
information, they differ stably in the ease with which various
construals, expectancies, values, and affects become activated.
For example, one woman may have chronically higher levels of
perceived vulnerability to breast cancer ("I may develop breast
cancer"), whereas another woman may typically feel less vulnerable. One woman may tend to easily activate positive outcome expectations, whereas another is readily pessimistic about
her prospects. One woman may be more likely to experience
anxious feelings, and the other to have positive feelings when
contemplating BSE.
Figure 1 illustrates examples of specific mental representations of the types of cognitive-affective units, shown in Table 1
and identified in the literature, that are potentially accessible
to an individual when encountering information about breast
cancer. Thus, it illustrates a cognitive-affective domain map
(Mischel & Shoda, 1995 ) of the types of mental representations
likely to become activated when women consider breast cancer
and make decisions about BSE. The arrows illustrate some potential patterns of relations among these units: Solid lines show
75
positive activation in which the activation of one unit activates

another; broken lines show negative activation in which the activation of one unit deactivates (inhibits ~another.
A given individual is characterized by a distinctive set of accessible cognitions and affects and a stable organization of the
associations among them. From the present perspective, this organization, this stable structure, constrains and guides the dynamics of cognitive-affective health information processing by
the individual. Thus, in addition to differences in the chronic
accessibility levels of particular types of cognitions and affects
(e.g., Higgins, in press), the theory predicts that stable differences will also exist between people in the strengths and patterns
of the organization of interrelations through which these mental
representations are activated by particular types of BSE-relevant information and through which they interact in the genesis
of health-protective behavior. This type of processing system
yields substantial Person X Situation, " / f . . . t h e n . . . " interaction effects (e.g., if A, she will X; but if B, she will Y),
and the theory predicts that these interactions will constrain the
level of predictability possible from additive, linear analyses of
single variables, yielding nonzero but low correlations (Mischel
& Shoda, 1995; Shoda, 1990). Such correlations, in fact, characterize the empirical literature reviewed above and found in
the field more generally (Taylor, 1995 ).
Illustrative Interactions Between Health Risk

Information and the Organization of Cognitive-Affective
Units: Prototypic Exemplars
The C-SHIP emphasizes that the impact of health-relevant
information depends on the interactions among cognitive representations and affects that become activated in the system.
To illustrate these interactions within the C-SHIP framework,
consider the effects of genetic risk information about breast cancer on the intention to perform BSE. We focus on two prototypic exemplars of processing types characterized by radically
different organization in the structure of their outcome and
efficacy expectations and affects with regard to breast cancer
and the value of early detection.
Prototypic negative expectancy organization. Figure 2 depicts a prototypic organization with negative outcome and
efficacy expectancies about breast cancer and the utility of BSE.
Of all the potential relations shown in the BSE domain map
(Figure 1 ), those that represent the more dominant pathways
of activation for this type of individual are shown with thick
arrows. As in the first figure (and throughout this article), solid
arrows indicate positive activation, and broken arrows indicate
negative activation (deactivation). It shows that if this type of
woman discovers that she is at high-genetic risk for developing
breast cancer, the outcome expectancy that "Cancer will grow
undetected, and I'll ultimately die from it" is strongly activated
(arrow 3), increasing anxiety and depression (arrow 7).
The effect of BSE training sessions is to activate the self-efficacy belief, "If I have breast cancer, I can find it with BSE"
(arrow 2), which, combined with the perception of personal
risk for breast cancer, leads to the expectation that "Sooner or
later, I'll detect a lump" (arrows 4 and 5 ). This, in turn, triggers
the expectancy that treatment will be painful but ineffective
(arrow 9), simply prolonging the pain which further activates
76

Information about BSE
and its effectiveness
Information about breast cancer

and personal risk level
\
Recommendation
to perform BSE
,51
.....
\1
"1 may develop breast

cancer"
1
"If I have breast cancer,

I can find it with BSE"
"\\~ 4
.\
\\\
\\\\
"Cancer may grow

undetected, and
rll ultimately die from it'
6
/
"Sooner or later,
Ill detect a lump'
lOj"
/8
11/
'rll get early, effective

treatment, and I'll be
~\ cured, extending healthy
\ productivelife"
,
7 '~,,
"1 will do BSE regularly"

(Intention to BSE)
"1'11be subjected to
painful but ineffective
treatment, only to
prolong the pain'
12
13~
.......... ~
14 ,
Anxiety, depression
Figure 1. Domain map of forming intentions to perform breast self-examination (BSE), illustrating cognitive-affective units potentially accessible to an individual and the structure (organization) of relations
among them. Solid lines illustrate positive (activating) relations from one unit to another; broken lines
illustrate negative (deactivating) relations.
feelings of anxiety and depression (arrow 13) and undermines

the intention to perform BSE (arrow 14). In summary, if a
woman with this type of cognitive-affective organization is exposed to genetic risk information, the result is increased anxiety
and depression and reduced tendency to perform BSE. However, if not exposed to the genetic risk information, the intention
to perform BSE, prompted by the reminder to perform BSE,
remains activated. Therefore, for this type of processing organization, a simple reminder to perform BSE may be most useful,
whereas making the personal genetic risk status salient would
be detrimental.
Prototypic positive expectancy organization. In contrast,
drawing on the same common domain map shown in Figure 1,
Figure 3 depicts a hypothetical organization of BSE-relevant cognitions and affects prototypic of a woman with positive outcome
and efficacy expectations about breast cancer and the value of
BSE. In this organization, information regarding high-genetic risk
for breast cancer does not strongly activate the expectancy that
cancer will grow undetected and become fatal. The more dominant pathway activates the expectation of being able to detect a
lump with BSE. In contrast to the organization shown in Figure 2,

this expectation then trig~m the outcome expectancy that early,
effective treatment will be obtained, enabling a healthy, productive
life, which keeps the level of anxiety or depression manageable. In
contrast, if this type of woman is not exposed to risk information,
the intention to perform BSE is not as strongly activated because
the personal consequences of develeping cancer and the ul~ty of
detecting it early through BSE are not activated. Thus, given this
type of organization, the intention to perform BSE is monger if
the woman is exposed to risk information but is weaker if she is
not exposed to risk information, yielding a pattern o f / f . . , then
relationships that is directly opposite to the one characteristic
for the organization shown in Figure 2.
As these illustrations indicate, the C-SHIP analysis includes, but
goes beyond, simple overall differences between types of individuals in their general levels of anxiety and tendency to perform BSE.
Thus, it also provides a route to predict for individuals with different types of processing organizations their specific patterns of
health-protective behavior in relation to different types of information. It makes it possible to specify more precisely the distine

Information about breast
cancer and personal dsk level

77
Recommendation
to perform BSE
1E
"1 m a y develop breaet
"If I have breast cancer,
cancer"
I can find It with BSE"
"1'11get early, effective

. . . .
n - alth
cureo, exzenaz g ne
y
-~-r o -o-u" 'cVo life'
L
,!2
~ "
- v . k.. o,,~...,...z , , .
'- .-~ - - ' ? ~ - .-':- "~
palflluI DUI[ inelllrecllve
, ~ t
o n ~ ta
"prolong
~ - " - - ' ~ the pain"
"~ -
13
."
i
14
Anxiety, depression
Figure2. Illustrative processing structures and dynamics in forming intentions and decisions to perform
breast self-examination (BSE). This figure illustrates a processing prototype of a woman who is characterized by negative expectancies. Thick solid lines indicate positive (activating) relations among units; thick
broken lines show negative (deactivating) relations. Thin lines illustrate potential pathways but are not
salient for the particular prototype.
five profiles of i f . . . then.., situation-behavior relationships

(e.g., if A, then she does BSE; but if B, she becomes anxious and
avoids it ) that characterize them stably ( Mischel & Shoda, 1995).
Specifically, as was seen in the examples above, information about
cancer risk status has the opposite effect depending on the organization of relations among BSE-relevant cognitions and affects: For
women with the organization shown in Figure 2, exposure to information about their risk for cancer is predicted to strengthen
their intention to perform BSE; whereas for those with the organization shown in Figure 3, the same personal risk information is
predicted to have the opposite effect.
Predicting the Two Opposing Effects of Risk Information

The foregoing analysis in terms of types of processing organizations is also consistent with, and helps to explain, the two opposing
effects of risk information observed in the BSE literature. On the
one hand, believing that one is susceptible to breast cancer has
been found to strengthen BSE adherence (Champion, 1988, 1990;
Ronis & Harel, 1989; Wyper, 1990). On the other hand, such a
belief has also been found to increase the negative affect and anxious arousal that become activated, which can become overwhelming and thereby leads either to avoidance of the behavior (Kash et
at., 1992; Lerman et al., 1991; Rippetoe & Rogers, 1987; Strauss
et at., 1987) or to maladaptive hypervigilence (i.e., weekly or even
daily BSE; Lerman, Kash, & Stefanek, 1994; Stefanek & Wilcox,
1991).
From the C-SHIP perspective, when individuals characterized by different types of organization are present in the same
study and not distinguished in the analysis, the overall results
are likely to be inconsistent and confusing. That is, depending
on the organization of the BSE-relevant cognitions and affects
typical within a particular sample of women assessed, the overall effects of information about health risks on the performance
of BSE could average out to be positive, negligible, or even negative. As reviewed above, and consistent with these theoretical
expectations, the empirical literature is mixed: Whereas some
studies show that perceived susceptibility to breast cancer leads
to increased frequency of BSE (Champion, 1988, 1990; Ronis
& Harel, 1989; Wyper, 1990), other studies find that it has no
78

Information about breast cancer
and personal risk level

Recommendation
to perform BSE
15
cancer"
"If I have breast rancor,

I can find It with BSE"
5
'Cancer may grow
i'~tnd~itme~atd~ndrom
e~ it"
"Sooner or later,
I'll detect a lump"
I will do BSE regularly"

(Intention to BSE)
~j..~""~
10/
' /
tt
"
//
" Ill
' get eady, effective
tz,l z a ~ w )
I'll b e subjected t o
treatment, onlyto
prolong the pain"
t~zd I'll ~
~_m~,l'--"'~,~n"~l'~'l~l~hu
\~~ n d ' " ~ , ' i ~ ; " . . . . . . . .
\r- . . . . . . . ~----
'\
la
'
"
1,
Anxiety, depression
Figure3. Illustrative processing structures and dynamics in forming intentions and decisions to perform
breast self-examination (BSE). This figure illustrates a woman characterized by positive expectancies.
Thick solid lines indicate positive (activating) relations among units; thick broken lines show negative
(deactivating) relations. Thin lines illustrate potential pathways but are not salient for the particular
prototype.
effect (Bennett et al., 1983; Champion, 1984, 1985, 1987; Rutledge, 1987). From the present perspective, these seeming contradictions in the research findings may, in fact, reflect the presence of the types of interactions that the C-SHIP predicts and
that would inevitably undermine the level and stability of the
overall correlation between perceived vulnerability and BSE
practice, unless the relevant processing characteristics of the
women were to be taken into account.
Understanding the Inverted U-Shaped Relation Between

Negative Arousal and BSE Performance
To illustrate the effects of different aspects of the possible organization shown in the domain map, we have used two radically different prototypes, depicted in Figures 2 and 3, as examples. In most people, however, the organization is not as extreme, and aspects of both types are present within the system.
In such a system, health risk information can readily activate
processes with opposing effects, in essence combining elements
of the organization shown in both Figures 2 and 3.
Such a system also speaks to the curvilinear effects of risk informarion found in the breast screening literature, such as the inverted U-shaped relationship between the level of negative arousal
and the intention to perform BSE (see also Janis, 1967; Janis &
Leventhal, 1967; Lerman & Schwartz, 1993). Exposure to risk
information in this processing system can increase both the intention to perform BSE and the level of anxiety about doing it. These
effects are demonstrated in a study by Rippetoe and Rogers
(1987). College-aged women were presented with either a highthreat informational brochure, which vividly portrayed the severity of breast cancer and the threat posed to one's health, or a lowthreat informational brochure, which downplayed the severity of
breast cancer and its prevalence among younger women. The
group that received the threatening message manifested higher levels of perceived severity of breast cancer; which, in turn, were positively associated with greater intentions to perform BSE. At the
same time, the threatening message was associated with increased
levels of anxiety, which were in turn associated with higher levels
of (maladaptive) avoidant ideation (e.g., "I try not to think about
the po~ibility of developing breast cancer"). Although avoid,ant

thinking significantly reduced anxiety, it also resulted in decreased
intention to perform BSE. As is widely known, moderate levels of
arousal tend to enhance performance, whereas high levels
dermine it (e.g., Hebb, 1972).
In the context of BSE, this analysis predicts that women with
moderate levels of worry will be more likely to perform regular
BSE than will those who have low or high levels (e.g., Lerman
et al., 1991; see also Fajardo, Saint-Germain, Meakem, Rose, &
Hillman, 1992; Kash et al., 1992). The prediction that excessive negative arousal can undermine--rather than enhance-BSE practice among women with more than average perceived
risk has received considerable empirical support. For example,
a study of first-degree female relatives of breast cancer patients
found that greater anxiety and greater perceived susceptibility
predicted poor adherence to the regular performance of BSE
(Kash et al., 1992). Moreover, in this study, women who performed BSE monthly tended to be those who perceived their
chances of getting breast cancer as moderate, whereas those who
perceived their chances as high never performed BSE.
Interactions With Individual Differences:

Monitoring-Blunting of Health Risk Information
The foregoing C-SHIP analysis focused on the interaction between a person's processing system and the risk information to
which she is exposed. Rather than being simply at the mercy of
the information the situation of the moment happens to supply,
individuals also differ in how actively they seek, amplify, and
process different types of health-relevant information, as discussed next (Miller, 1989, 1995, in press).
To illustrate, high monitors( "low blunters" ) generally see health
threats pervasively and scan for them, attending intently to bodily
cues, symptoms, and risk information (Miller, Combs, & Kruus,
1993; Miller, Roussi, Altman, Helm, & Steinberg, 1994; Miller,
Roussi, Caputo, & Kruus, 1995; Schwartz, Lerman, Miller, Daly,
& Masny, 1995). They tend to see themselves as fragile and vulnerable and are sensitive to cues about possible disease and illness,
particularly when dealing with potentially chronic, uncontrollable
stressors (Miller, Brody, & Summerton, 1988; Miller, Leinbach, &
Brody, 1989; Miller et al., 1994; Muris & van Zuuren, 1992; Steptoe & Vogele, 1992; van Zuuren & Wolfs, 1991 ). This cognitiveattentional focus on threat and danger activates anxiety and prolonged arousal states (Gard, Edwards, Harris, & McCormack,
1988; Lerman et al., 1990; Miller & Mangan, 1983; Phipps &
Zinn, 1986; van Zuuren, 1993; E Wardle et al., 1993; J. Wardle,
1995; J. Wardle, Pernet, Collins, & Bourne, 1994).
In the face of persistent, highly severe threats, which high monitors encode as particularly catastrophic (Lerman et al., 1995; Miller et al., 1994, 1995, in press; Muds, de Jong, van Zuuren, & ter
Horst, 1994; Schwartz et al., 1995; Sparks & Spirek, 1988; van
Zuuren & Muris, 1993), intrusive ideation and accompanying
anxiety may become unbearable and trigger avoidance efforts.
High monitors therefore may ultimately tend to resort to extreme
defensive strategies, such as denial and disengagement, in an increasingly d~perate effort to suppress and distance themselves
from awareness of their own intrusive ideation. Low monitors (or
high blunters), however, in the extremes tend to encode personal
risks by denying their existence and to avoid threatening cues from
the outset, refusing to attend to and assimilate information that is
79
discrepant with their core beliefthat they are "OK--no problem"

(Miller et al., 1993, 1994; Mill~ Rodoletz, Schroeder, Mangan, &
Sedlacek, in press). Consequently, anxiety is not aroused and, with
their sense of invulnerability, they may not form even the intention
to practice BSE (see also Salovey & Birnbaum, 1989; Weinstein,
1983, 1984, 1989). Effective coping with threat should be greater
when individuals develop discriminativeness and flexibility in their
attentional strategies, so they can assimilate new information ( e.g.,
allowing them to accept the need for BSE), without becoming obsessivelyattuned to the threat and excessively anxious.
From Intentions to Execution and Adherence: Beyond

Choice to Health-Protective Action
Although intentions and decisions are important steps in the
processing of health information, the C-SHIP suggests that they
are of limited value in predicting actual adherence to a regimen
of regular BSE because that requires not only good intentions
but also the activation and maintenance of effective self-regulatory strategies. Just as many people find that a New Year's resolution to exercise regularly falls by the wayside after a few short
weeks (Brownell, Marlatt, Lichtenstein, & Wilson, 1986 ), a significant number of women form the intention to do BSE and
even attempt it but do not perform the exam at the recommended frequency.
In fact, surveys show that although 70% to 75% of women
report performing BSE at least once a year, only 25% to 35%
actually adhere to a monthly regimen (Celentano & Holtzman,
1983; Champion, 1988; Murray & McMillan, 1993). In one
study, 61% of women attending a BSE class indicated that they
intended to perform BSE on a monthly basis in the following
year. However, when contacted I year later, only 22% of the sample had achieved that goal (Clarke et al., 1991; see also Salazar
et al., 1994). Thus, for most women, the problem is not just one
of needing to be convinced to try BSE but rather of maintaining
the behavior proficiently and consistently over time.
Domain Map for BSE." From Information Input to

Performance and Adherence
The challenge, then, is to narrow the large gap between the
intention to perform BSE consistently and its fulfillment. A
unique contribution of the proposed model is that it delineates
the self-regulatory process as it operates on the execution of
health-protective regimens, particularly those that are difficult
to execute and that must be maintained over time. It thus encompasses both the decision processes through which BSE intentions are formed and the self-regulatory processes through
which they are potentially translated into action, as depicted
schematically in Figure 4. These self-management processes al~
critical because long-term adherence requires special strategies
for both motivating and cuing BSE, while simultaneously dealing with anxiety, distraction, frustration, and other barriers in
the execution of the relevant procedures, as discussed next.
Figure 4 illustrates the interactions among the cognitive and
affective units in the self-regulatory process. Specifically, it adds
cognitions and affects relevant for BSE performance to those
already identified as influencing BSE decisions (Figure 1) and
shows the potential interactions among them that affect the for-
80
mation of the intention to perform BSE as well as the actual

performance. Thus, Figure 4 serves as a cognitive-affective domain map (Mischel & Shoda, 1995) of the mental representations potentially activated as the person continues to consider
BSE and tries to perform it.
Figure 4 shows that the accessible knowledge for performing
BSE becomes activated by the individual's long-term intention
and plans to perform BSE (arrow 17), as well as by specific
external inputs such as the reminder to do it (arrow 18), which,
when sufficiently activated, generates BSE performance. As the
figure indicates, intentions and reminders, of course, are not the
only salient units that affect the performance of BSE, as discussed next.
immediate likelihood of finding an abnormality (Mayer & Solomon, 1992). Performing BSE, then, can be a frightening behavior, in the sense that it is designed to detect~rather than to
prevent~breast cancer. Thus, performing BSE (or in some
cases, even the thought of performing it) leads many women to
worry even more about the possibility of breast cancer
(Rutledge & Davis, 1988) and about the stress of a "false
alarm" (Hill, Gardner, & Rassaby, 1985). The most desirable
outcome or reward of BSE may be to not find a lump, which
may reinforce avoidance behaviors rather than careful self inspection. Indeed, women who report that they are afraid of
finding a lump are less likely to perform BSE regularly (Hill et
al., 1985). Discovering a benign lump during the course of BSE
actually may extinguish the behavior because it can cue excessive vulnerability and threat (Janz et al., 1990).
Excessive negative arousal when a lump is found has also
been shown to lead some women to delay seeking professional
evaluation of the abnormality (see Facione, 1993, for a review).
In short, the very act of examining one's own breasts in a clini-
Activation of Cognitions and Affect During BSE

A major problem for people who attempt to practice screening behaviors like BSE is the peculiar nature of the "rewards"
they provide. When a woman performs BSE, it increases the

Informationabout BSE
cancer and personal risk level and its effectiveness
\~,
'\
i
i
Rocommendation
to perform BSE
cancer"
/""\
3/
\~
llS
'If I have breast

I can find it with BSE'
,
/
BSE training
and practice
,I
Reminders to
perform BSE
/1,
24
--
"Cool', 'objective" representations:task-relevant

serf-instructions;
thoughtS;contingent
self-rewards
\
\\
\"\'\,\
\\
'/
'\~I
Cancer may grow

undetected, and
//
rll ultimatelydie from i t ' J
,
"1 will do B S E regularly"

~
-~---
'Sooner or later,
I'll detect a lump"
( I n t e n t i o n to B S E ) _
/4
$
+ IL
17
10//
11 1
-.
"1'11be subjected to 4 ----~treatment, and I'll be

painful but ineffeictive
cured, extending healthy treatment, only to
productive life'
prolong the pain"
'
',
'.
7\ ,
12
J'
14 ,~' 16/
\\
20
'~,27
. . . . 29.
/,
-- .... -
28 ..... e-i\.
~
~
"Hot', 'arousing'
reprasantati
ons:negat~v
statements about
self; anxiety-arousing
ideation
///
J
- ~,~" Anxiety,depression
Forming intentions to perform BSE
Performing
~BSE
"1'11get early, effective
\\
~4
Behavioral scripts
and procedural
k n o w l e d g e for B S E
I I
Behavioral execution of intentions
Figure 4. Illustrative domain map: from input to intention to performance. BSE = breast self-examination. For simplicity, only illustrative feedback loops are shown (e.g., 23, 24, and 30), but conceptually such
loops are assumed throughout the system (e.g., from hot, arousing representations to the expectation "I
may develop breast cancer").
"~

cal manner primes a cognitive focus on what these behaviors
could lead one to find and on the disease itself. This focus on
disease, in turn, may activate the perception "I could die"
which feeds back to further threaten core constructs about the
survival of the self. Research suggests that the level of arousal
and anxiety activated by potentially threatening cues is greatly
affected by how the individual mentally represents the information, for example, whether she focuses on the cue aspects of information (e.g., "Now I need to look for changes in the nipple,"
Figure 4, arrow 21 ), or a hot aspect (e.g., " I f I find a lump, that
means hundreds of thousands of cancer cells are already there,"
Figure 4, arrow 22).
Transforming Aversive Situations: Hot Versus Cool

Representations
In one long-term program of research, major cognitive strategies for transforming an aversive self-control situation into one that
can be mastered have been analyzed in detail (e.g., Mischel, 1974;
Mischel et al., in press; Mischel, Ebbesen, & Zeiss, 1972; Mischel,
Shoda, & Rodrignez, 1989; Rodriguez, Mischel, & Shoda, 1989).
In these studies, young children are free to continue to wait for a
preferred outcome (e.g., two cookies) that is more valuable but
delayed or to settle for a less valued but immediately available gratification (e.g., one cookie). With increasing cognitive maturity,
individuals become more able to psychologically transform and
abstract the desired but delayed gratifications by focusing on their
cod, nonarousing or symbolic and informative features (rather
than on their consummatory, hot, and arousing qualities). These
transformations minimize the aversiveness and frustration of the
situation, making p ~ f u l
self-control possible and even easy
(Miscbel, 1974, 1981 ).
For example, when preschoolers think about food rewards for
which they are trying to wait in arousing or hot ways (e.g., by
focusing on their taste), it is almost impossible for them to delay
at all. However, if they attend to the nonconsummatory or cool
qualities of the rewards (e.g., by turning them into a picture
mentally and framing it), they can easily delay for the reward
(and even longer than if they simply distract themselves from
the aversiveness of the situation). Thus, to bridge the delay and
sustain the effort required to obtain the more desirable goal and
resist more immediate temptations, it is as if children must
mentally note what they are waiting or working for by reminding themselves of it periodically and symbolically through cool
mental representation (e.g., Mischel & Moore, 1980). However,
during the remaining time, they must focus on other, less frustrating internal and external stimuli.
Calibrating Affective Reactions

Adherence to BSE thus requires the woman to activate her cognitive-affective, self-regulatory processes and to finely calibrate
her affective responses. For example, if her thoughts about BSE
are too emotionally hot or threatening the task becomes highly
aversive and is avoided. Yet, it is the potential threat that motivates
the initial intention to perform BSE. The person thus needs to
balance occasional "back of the mind," cool representations of
why it is a good idea to maintain the behavior, while paying attention to the specific steps of the task itself(e.g., Mischel, 1974; Mis-
81
chel et al., 1989). Such representations maintain the decision to

perform regular BSE (arrow 25) and further activate the skills or
"procedural knowledge" for actually enacting BSE (arrow 26),
resulting in more careful, attentive examination. It r n ~ also activate positive outcome expectancies (e.g., "If I find a lump, it'll be
OK," because "I'1 get early, effective treatment, and r l be cured";
arrow 24), which reinforce the decision for a regular regimen of
BSE (arrow 10), while also reducing anxiety (arrow 12). This
analysis of the process is consistent with the literature on the utility
of sensory monitoring of somatic sensations (Cioffi, 1991; H. Leventhal & Everhart, 1979; H. I.eventhal & Mosbach, 1983), that
is, focusing on objective concrete quality of somatic sensations and
avoiding the emotional (hot) interpretation of them as distressing,
which seems analogous to a cool framing in the delay paradigm.
In contrast to a task-relevant cool focus, hot and negative self
statements made during the self-regulatory process can adversely
affect persistence in predictable ways. For example, as shown in
Figure 4, if in the course of BSE a woman focuses her feelings on
her fear of finding a malignant tumor and its consequences ('Tll
be subjected to painful but ineffective treatment, only to prolong
the pain") or on her difficulty in discriminating a change in her
breast (e.g., "I'm no good at this---I'll never get it right"), the
effect would be to increase her level of anxiety, and soon she extinguishes herself from even trying. Indeed, in one study, women with
lower self-efficacy beliefs about their ability to carry out BSE reported greater hopelessness and fear and an increased use of avoidant coping strategies, which led to decreased intentions to perform
BSE, when compared with women who have higher self-efficacy
beliefs (Rippetoe & Rogers, 1987). Instead, task-relevant thoughts
(e.g., "Good, now I have to check this area") may provide the
necessary guidance to sustain the required behavior (Dweck &
Leggett, 1988; Sarason, Sarason, Keefe, Hayes, & Shearin, 1986).
This analysis suggests that rewards for BSE may need to be incorporated into self statements and other purposeful strategies,as part
of the woman's effort to self-regulate and maintain confidence during adherence attempts.
These conclusions--drawn mostly from laboratory experiments--are consistent with clinical research on the types of spontaneous coping strategies, that appear to be adaptive for dealing
with a diagnosis of cancer, such as various forms of distancing
(Dunkel-schetter; Feinstein, Taylor, & Falke, 1992). Distancing
seems to involve mental representations and cognitive transformations similar to those discussed as cooling, abstracting, and reframing in the context of self-controlwhen dealing with the aversiveness of delay of gratification (Mischel et al., 1989 ).
Individuals may differ substantially in their tendency to focus on
the hot, arousing, threatening cues in a situation. For example,
when performing BSE, high monitors would tend to encode ambiguous information as threatening and to e ~ t e
its significance and their personal risk. As indicated previously, their attention to danger signs may ~ e r a t e a high degree of hot, intrusive,
and repetitive ideation about the stressor that cannot be readily
switched off(Miller et al., 1993, 1994, in press; Schwartz et al.,
1995). Thus, although these individuals may initiate a regimen
such as BSE (Steptoe & O'Sullivan, 1986), their persistent focus
on threat is likely to undermine their efforts to adhere. Indeed, a
major reason offered by women for not performing BSE is the
anxiety-generating nature of the behavior (E Kelly, 1979; Rutledge & Davis, 1988), and high monitors are even more sensitized
82
to such risk cues (e.g., Lerman, Daly, Masny, & Balshem, 1994;
Schwartz et al., 1995; van Zuuren, 1993; van Zuuren & Muris,
1993; van Zuuren & Wolfs, 1991; E Wardle et al., 1993).
In conclusion, from the present perspective, the ideal self-regulatory strategy requires a flexible balance of hot and cool ideation,
of both distancing and "tuning in" of blunting and monitoring
(e.g., Chiu, Hong, Mischel, & Shoda, 1995; Christensen, Smith,
Turn~ & Cundick, 1994; Millet; Combs, & Stoddard, 1989; Miller et al., 1993; Mischel et al., in press). To adhere, the woman
must focus on the threat sufficiently to motivate action but then
focus on the necessary step-by-stop health-protective behavior. She
must cool and abstract the situation to create the psychological
distance that allows her to tune out the aversiveness and anxiety,
while concentrating on the task contingencies and encouraging her
performance and progress at each point (e.g., Meichenbaum,
1992; Meiehenbaum & Deffenbachet; 1988; Mischel et al., 1989).
To effectively maintain such behavior once initiated requires the
woman to use a complex array of self-regulatory skills. She has to
monitor her proficiency against a cleat; accurate standard that she
believes she can reasonably meet and reinforce herselfcovertly and
overtly for adherence. At the same time, she must refrain both
from distractions and from attending to interfering anxiety-inducing ideation (e.g., Meichenbaum, 1977, 1992; Meichenbaum &
Deffenbacher, 1988; Sm;ason, 1984; Sarason et al., 1986).
Procedural Knowledge for Effective BSE.

Effective BSE requires proficient psychomotor performance
of complex self-examination procedures, drawing on skills that
need special training (Mayer & Solomon, 1992). The availability of these skills in a woman's repertoire for generating potential behaviors is a prerequisite for the performance of BSE.
Clearly such competency is a necessary, but by no means the
sufficient, condition for adherence (e.g., Champion, 1990,
1995; Mischel et al., in press; Richardson et al., 1987). Cognitive-social theory (Mischel, 1973, 1990; Mischel & Shoda,
1995) emphasizes the role of competencies, conceptualized as
the individual's ability to enact or generate a given behavior pattern at the performance level, which is procedural knowledge,
not merely to be able to describe or recognize it, which is declarative knowledge (see also Anderson, 1983 ). Unfortunately,
in the context of assessing knowledge of BSE, there has generally
been a failure to recognize the distinction between declarative
and procedural types of knowledge. For example, a woman may
possess even less procedural knowledge of BSE than is captured
by her answers on self-report tests that essentially assess her ability to accurately retrieve and verbally label and describe information about BSE.
Prototypic Processing Exemplars of BSE Avoidance and

Adherence
As emphasized above, and shown in the domain map (Figure
4), two different types of cognitions, hot and cool, may become
activated during the performance of BSE. We next consider the
effects of each type of representation and illustrate two prototypic organizations that differ in this regard.
Hot ideation includes arousing representations and negative
statements about self as well as anxiety-arousing ideation. In the
prototype of BSE avoidance shown in Figure 5, such cognitions

are activated during BSE (arrow 22), which in turn activate
negative outcome expectancies (arrow 29), such as "I'll be subjected to painful but ineffective treatment, only to prolong the
pain," and also activate negative affect (anxiety and depression )
as indicated by arrows 13 and 30. The negative affects, in turn,
tend to deactivate BSE intentions (arrow 14), as well as the
scripts for BSE enactment (arrow 16). In addition, these hot
representations during BSE may directly undermine BSE intentions (arrow 28) and deactivate the scripts for BSE enactment (arrow 27). Collectively, these influences form a negative
feedback loop that interferes with the continued performance
of BSE and may even revise the decision to attempt it in the
future. Given such an organization, neither recommendations
to perform BSE nor periodic reminders to do so are effective,
and their impact would be at most short lived.
In contrast, in the prototype of BSE adherence shown in Figure
6, performing BSE activates cool cognitions, which include objective representations and task-relevant thoughts and self instructions (arrow 21 ). These cognitions, in turn, strengthen the selfefficacy expectation that "If I have breast cancer, I can find it with
BSE" (arrow 23), as well as positive outcome expectancies such
as "I'll get early, effective treatment, and I'll be cured, extending
healthy productive life" (arrow 24). These cognitions, in turn, reinforce the intention to perform regular BSE (arrow 10), while
reducing the level of negative affects (arrow 12) and preventing the
affects from interfering with the intention and performance of
BSE. Task-relevant thoughts and self instructions also activate the
intentions and performance of BSE (arrows 25 and 26). In the
prototype of BSE adherence, this organization of activation pathways thus forms a positive feedback loop that enhances the current
performance of BSE as well as the future performance of regular
BSE. Given this organization, recommendations to perform BSE
and periodic reminders to perform BSE activate a self-regulatory
process that sustains the activation levels of the intentions for and
performance of BSE.
Feedback activationfrom performance. Unlike a sequential
stage theory analysis in which the individual progresses through
a fixed sequence (Prochaska & DiClemente, 1983; Prochaska
et al., 1994; Weinstein, 1988; Weinstein & Sandman, 1992),
the present model emphasizes the dynamic interactions during
processing that occur over time. It avoids the core assumptions
of stage theories, that is, it does not hypothesize the types of
invariant, unidirectional sequences in information processing
that have proved t be problematic and difficult to support for
diverse reasons articulated recently by Bandura (1995). Note
that, as depicted in Figure 4, cognitive-affective processing of
health risk information continues over time and includes feedback activations from performance. In the model, the self-regulatory process also interacts with the network of cognitions and
affects that generated the original decision to perform BSE and
lead the woman to maintain or revise it over time.
C-SHIP versus stage theories. Thus, in contrast to stage
theories, the interactions over time hypothesized in the C-SHIP
model include the reactivation of cognitions and affects that initially influenced intentions and decisions in ways which can
feedback and either undermine or strengthen them, as shown in
arrows 23, 24, 29, and 30 of Figure 4 (also see Champion &
Miller, 1992; Rippetoe & Rogers, 1987). As illustrated in the
83

cancer and personal risk level

Recommendation
to perform BSE
/
1
Reminders to
perform BSE
BSE training
and practice
\\
..........
15
23
"| may develop breast
cancer"
~
4
Cancer may grow

/~/ I
undetected, and
/ \ t ~
rll ultimately die from it" /
\ I /
1
\
\
\
\
\
~/
"111get early, effective

cured, extending healthy
productive life"
7 ~
"
"', 12
24
~
~
,
:.
,,/
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\
~ . ~
;
,"
,"
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n,~ " ' " , , ,
.
.
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-27
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: , ' . ....
.."
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to ~
painful but Ineffective ,"
treatment, only to
,
prolong the pain"
:
13~,
Be avioral sc 'p
,,nd . . . . ,~-ral
= ~^.~'~'M"~',~'==o= - "
- ,,.,,w,ou~o.v . . . .
%
#
".. %., : ."
-c,
repre' cer, - ~ v e sentations: task-relevant 4
/~._t~
thoughts; self-instructions;
//contingent self-rewards
rl "
regula y
(Intention to BSE)
17
10/ 11 I
"
lwdl
do BSE
//8
"Soonerorlater,
/
,
~_.~_~
"If I have breast cancer, ".P-----Ican find it with BSE"

/
_
~
%%"Hot', "arousing"
......... mpmen=uon,:,epUva
-- slatements about
~
J
4P
self; anxlety..arouMng
Ideation
~"
--_~D. Anxiety, depression
Forming intentions to perform BSE
I I
Behavioral execution of intentions - -
Figure 5. Illustrative activation networks during breast self-examination (BSE) that undermine effective
performance. During BSE, hot, arousing representations are activated and undermine BSE performance
by activating negative thoughts, anxiety, and depression. Thick solid lines indicate positive (activating)
relations among units; thick broken lines show negative (deactivating) relations. Thin lines illustrate potential pathways but are not salient for the particular prototype.
figure, rather than proceeding in a fixed linear progression,

events that occur at later phases in cognitive-affective processing (e.g., if intense anxiety is activated during BSE
performance), in turn, can feedback to influence construals of
one's health risk and one's efficacy beliefs with regard to healthprotective behaviors (Salovey & Bimbaum, 1989), and thus revise initial intentions and decisions formed in earlier phases in
a dynamic reciprocal interaction process.
Automaticity of health-relevant information processing and

behavior patterns. Like the cognitive-affective system theory
on which it is based (Mischel & Shoda, 1995), the C-SHIP assumes that individuals are characterized by a stable pattern of
dynamic interactions among the cognitive-affective units that
are processed in parallel and not necessarily under conscious
control. Once a woman has successfully incorporated a regimen
such as BSE into her life routine, the behavior pattern can become relatively habitual, provided that it is strongly linked to a
distinctive cue that occurs regularly at the appropriate time
( e.g., on the first day of each month, marked on one's calendar ).

Thus, certain health beliefs (e.g., personal vulnerability) may
play a more central role while the person is in the process of
making a decision about whether to adopt "the behavior
(Weinstein & Sandman, 1992). Thereafter, to the degree that
adherence to BSE becomes automatic and habitual, the processing dynamics that underlie it can be activated by appropriate
cues in a predictable pattern or program. It follows that the
effects of initial health beliefs on future BSE behavior have been
found to be mainly on the original decision to perform BSE
and do not necessarily continue to influence BSE performance
every month (Champion & Miller, 1992).
Implications and Conclusions
We now discuss the implications of the C-SHIP for assessments of individuals with regard to the practice of BSE and for
the design of interventions to enhance BSE adherence, and we
84
MILLER SHODA, AND HURLEY
Informationabout breast
Intormation
about BSE
cancer and personal risk level and its effliveness
Recommendation Remindersto
to perform BSE
performBSE
~18
2a
"I may develop breast
cancer"
\
"'. 4
"If I have breast cancar, ~,~

I can find It wlth BSE"
/
jr
6
\ I ~'-'---\ J. (
"I'll get early, elRecuve

hiullilltil~t llllti4I'II i
...... " ........
curel.,e=.~,d/ng healthy
prooucu7 life
7'\,,
"1 w i l l d o B S E regularly"
/ I n t e n t i o n to B S E I ,
~
.
.
" ,-,
"Soo~T~or later,
10/4
I'll detect a ump" j "
..v. . . . .
\
\
- - "Cool", "oblecUve" repreuntations: tuk-relevant

thoughts; self-instructions
contingent eelf-rewarde
24
'O.ancermay grow
undetected, and
/
I'll ultimatelydie from it' /
[
BSE training
and practice
'>%,12
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11 i
,'
,'
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;
:
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29
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14:
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,,
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o
p
: egatlve
- - - - statementsabout
~l-
....
:'
elll,i,t o
",.
"1'11 u '
d to
be S b i l e
treatmentt only to
prolongthe pain"
13\
",
,
~,
Beh. a v i o r a l . s c r ! p t s
and proceoural
k n o w l e d e for B S E
~.i
~ 0 /
serf"anxiety arousinn
.ideation
,.
-,~,
"
///
Anxiety, depr:sion
- -
Forming intentions to perform BSE - - t
Behavioral execution of intentions
Figure 6. Illustrative activation networks during breast self-examination (BSE) that enhance effective
performance. Performance of BSE activates cool, objective representations which, in turn, activate other
cognitions and affects that maintain and enhance performance. Thick solid lines indicate positive
(activating) relations among units; thick broken lines show negative (deactivating) relations. Thin lines
illustrate potential pathways but are not salient for the particular prototype.
explore the relevance of the model for health-protective behaviors more generally.
Implications for Assessment and Research

The C-SHIP has clear implications for assessment and research strategies in health psychology in general, and for BSE in
particular. It begins by calling for assessments of the theoretically relevant underlying cognitive-social person variables:
what the individual construes, expects, and values and the
affects that become activated, as well as her cognitive, social,
and solf-regulatory competencies in specific relationship to particular health threats and perceived risks (e.g., Nezu, 1986).
Construction of Domain Maps

Specifically, a first step is the construction of cognitive-affecrive domain maps like those illustrated in the previous section
for BSE (Figures 1 and 4). Such assessments focus on the specific cognitions and affects and their organization of relationships, activated by particular types of health-relevant information (e.g., personal breast cancer risks). This focus on context
and specific cognitions and affects that become activated in
characteristic patterns of organization contrasts with more traditional assessments. The latter describe "what the woman is
like in general" with regard to health risks in terms of such variables as generalized expectancies, or global traits, or they aggregate her overall health-relevant behaviors together to form a
broad index of her heath habits on the whole.
Instead, the C-SHIP analysis requires assessments that are
targeted as directly and precisely as possible to the underlying
cognitive-affective units and their organization in the processingOfparticular types of health information by individuals with
different types of processing structures (Lauver & Angerame,
1988). The emphasis on context and on the interaction of the

person's information processing characteristics with the psychological features of the health-relevant information processed
requires assessments of expectancies, beliefs, and affects that
are specific to the situation and behavior domain (e.g., "I am
confident that I can perform BSE"; Bandura, 1986), rather
than global characterizations (e.g., "I am a competent
person").
Focus on Dynamic Person Situation Interactions

Particularly important, the C-SHIP approach focuses on the
organization among the cognitive-affective units within the person that determines individual differences in response to health
information. It is therefore necessary to include assessments of
those interactive, dynamic aspects in the processing of information for the behaviors of interest. This requires considering, but
going beyond, additive, linear effects to take into account important Person x Situation interactions that are predicted from
the C-SHIP perspective. Currently, most studies typically enter
each of the variables selected into a regression equation and
identify the optiminum weights for making an additive prediction of behavior. For example, in such an approach, one includes exposure to information about health risks, self-efficacy
about BSE, expectancies about the outcome of cancer treatment, and anxiety level, in a multiple regression analysis to predict intention to perform BSE. This essentially additive approach obscures the potential dynamic relationships among
cognitions and affects during the processing of health information that determine relevant behavior. It thus ignores the interactions between the type of health information and the type
of processing system that are at the core of the C-SHIP and
whose importance was illustrated in this article. The C-SHIP
thus directly meets a conceptual need recognized in earlier perceptive reviews of the limitations of the existing models for predicting breast cancer screening adherence: namely, greater attention must be directed at such interactions, rather than just at
main effects (Curry & Emmons, 1994).
The assumption that individual differences exist not only in
the overall accessibility of each mediating unit but also in the
relations--in the processing dynamics--through which they
are interconnected and become activated in relation to psychological cues in the situation has clear implications. For example,
even if two women are similar in their overall level of anxiety,
for one woman thinking about doing BSE may increase anxiety;
in contrast for another, it may decrease it. Thus, although the
regression analysis--correlational approach yields useful information about the additive, linear influence of individual health
belief variables on BSE, it bypasses---and even obscures--the
kind of Person Situation interactions emphasized by the CSHIP model. It calls for research and analytic methodologies
sensiiive at least to the interaction among cognitive-affective
mediating units. It focuses on individual differences in the relationships among the units, in addition to their chronic accessibility in the processing of health-relevant information.
To clarify and harness such Person Situation interactions
requires a shift from global to specific, contextualized analyses
and assessments. Several recent studies have shown that the relevant individual differences can be identified with easy-to-administer self-report measures and that interventions tailored to
85
reflect these differences result in improved breast cancer screening outcomes (Champion & Scott, 1993; Jacob, Penn, Kulik, &
Spieth, 1992). For example, people characterized as high monitors (compared with low monitors) may differ in the types of
interventions that facilitate sustained adherence (Davis, Maguire, Haraphongse, & Schaumberger, 1994; Gattuso, Litt, & Fitzgerald, 1992; Jacob et al., 1992; Lerman et al., 1990; LudwickRosenthal & Neufeld, 1993; Miller & Mangan, 1983; Steptoe
& O'Sullivan, 1986; Watkins, Weaver, & Odegaard, 1986). As
noted previously, for high monitors, the challenge is to reduce
their tendency to overinterpret cues as threatening and to encode themselves as highly vulnerable, to decrease their negative
expectations, to enhance their self-confidence and knowledge
base, and to provide them with strategies for the modulation of
anxiety. In short, they need targeted interventions that help
them to circumvent their tendency to respond automatically by
becoming excessively anxious and ultimately denying their need
for undertaking cancer screening behaviors.
Examples from Monitoring-Blunting

In many medical contexts, as when undergoing an aversive but
time-limited procedure, high monitors have been found to fare
better when provided with accurate and detailed but highly reassuring sensory and procedural information about their situation
and its management. This helps to reduce uncertainty, undercut
catastrophic ideation, and enable step-by-step preparation (Davis
t al., 1994; Efran, Chorney, Ascho; & Lukens, 1989; Gattuso et
al., 1992; Jacob et al., 1992; Lerman et al., 1990; Ludwick-Rosenthal& Neufeld, 1993; Miller et al., 1993; Miller, Combs, et al.,
1989; H. Leventhal, 1989; Miller& Mangan, 1983; Sparks, 1989;
Watkins et al., 1986 ). In contrast, low monitors (or high blunters )
appear to fare better with more minimal action-oriented mt~'~at~s,
with sufficient opportunity to psychologically tune out from what
is facing them in these contexts (Avants, Margolin, & Salovey,
1990; Efran et al., 1989; Litt, Nye, & Shafet; 1992; Ludwick-Rosenthal & Neufeld, 1993; Miller & Mangan, 1983; Watkins et al.,
1986).
Whether monitors benefit from exposure to the information
they seek also depends on the type of information and the partitular medical situation. Thus, they appear to become more
distressed than low monitors, and to cope less well, when provided with medical information about severe, persistent, longterm threats that are difficult for them to control or escape. This
seems to be the case when they learn that they are at increasedgenetic risk for breast or ovarian cancer (Lerman, Daly, et al.,
1994, in press; Miller, Roussi, et al., 1994; Schwartz et al., 1995;
E Wardle et al., 1993; J. Wardle, 1995; J. Wardle et al., 1994).
In t h e e situations, the information needs to be presented to
high monitors in a manner that distances or cools it, so their
sense of vulnerability and distress does not panic them, and the
personal relevance of the disease is framed less negatively. With
breast cancer risk, for example, the high monitor needs to be
reassured, in a reasonable manner, about the low probability of
detecting a lump and the high potential for early cure ifa lump
is found. For example, she can be encouraged to reconstrue the
act of BSE from the catastrophic encodin~ "This is too anxiety
inducing because I am going to discover that I really have a large
and inoperable tumor that has already metastasized throughout
86
my body" to the less catastrophic encoding, " I f I perform BSE,

I can catch a small tumor before it grows or spreads to the rest
of my body."
The C-SHIP framework thus directs attention to finegrained, person-specific analyses. As another example, in the
case of high monitors, there may be distinctive subtypes that
have different correlates and hence require more tailored intervention efforts (Miller, 1995). One monitoring woman may encode herself as highly susceptible to breast cancer but also construe her situation as manageable because she sees herself as
in control of her health. Another monitoring woman may both
construe her health as fragile and her future as hopeless because
she believes that she can do little to impact on her health prospects. The latter--but not the formeruwoman has little motivation to perform BSE and hence benefit from exposure to reassuring information and manipulations that enable her to encode herself as more personally powerful and in control (Miller
& O'Leary, 1993). Thus, there are concurrent, interconnecting
processes among multiple relevant cognitive social variables
that influence the response to health information, as illustrated
in Figure 4, from selection and encoding, to formation of intentions, to execution and performance of health-protective
behavior.
Focus on Skills for Adherence

The C-SHIP also calls attention to the need to conduct assessments that tap the actual skills needed to carry out BSE. Although
having a woman demonstrate breast examination either on herself
or on a silicon model appears to be the most valid indicator of her
BSE proficiency, only a minority of studies obtain such measures
(Mayer & Solomon, 1992; Pinto & Fuqua, 1991 ). In most studies,
knowledge about the appropriate performance of BSE is assessed
by multiple-choice tests or olxn-ended descriptions. As discussed
above, these methods tap a different area of competence
(declarative knowledge) than a woman's actual ability to conduct
a BSE following exposure to instructional material (procedural
knowledge). It may be particularly important to accurately assess
the procedural knowledge of older women because a strictly verbal
assessment of their BSE skills would not uncover age-related
difficulties in visual acuity, tactile sensitivity, and mobility of the
upper extremities (Baulch, Larson, Dodd, & Deitrich, 1992; Rutledge, 1992). The discrepancy between one's ability to execute
the procedure and one's ability to verbalize the process may also
produce lower knowledge scores on oral or written assessments for
those who are unaccustomed to formal test taking, as is the case
with women of lower socioeconomic status (Mayer & Solomon,
1992).
In addition, beyond BSE skill itself, assessment needs to incorporate direct measures of the woman's self-regulatory competencies for initiating and maintaining BSE behavior. This includes
assessments of her repertoire of available strategies for self-cuing
BSE and for monitoring and reinforcing herself as she is practicing
it. Perhaps most key--and notably lacking in the BSE literature-is the inclusion of measures that reflect how the woman actually
modulates her anxiety and directs her attention during BSE performance (e.g., her use of negative vs. positive self statements;
Meichenbaum, 1977; Sarason et al., 1986).
Targeting the Specific Population

Assessments not only need to be domain specific and variable
specific but also have to be IX~ulation specific. One cannot generMize to different types of individuals and cultures who differ on
the person variables, reflecting their quite different experiences,
barriers, and social norms. ~
the people who are at highest
risk have the most limited knowledge about cancer risks, cancer
symptoms, and preventive regimens (Bostick, Sprafka, Vimig, &
Potter, 1993) and have the least access to such information. The
literature consistently shows that lack of knowledge of cancer and
cancer-control guidelines--including breast cancer and BSE--is
greatest among low-income (Shepperd et al., 1990), older
(Costanza, Stoddard, Gaw, & Zapka, 1992; Mah & Bryant, 1992;
Rimer, Jones, Wilson, Bennett, & Engstrom, 1983), and minority
populations (Price, Desmond, Slenker, Smith, & Stewart, 1992;
Richardson et al., 1987; Saint-C_rermain & Longman, 1993).
For example, in a study of women aged 60-74 years of age, one
quarter of the sample mistakenly believed that women under 65
are more at risk for breast cancer (King, R i m ~ Balshem, Ross, &
Seay, t 993). Another study found that older women ( ages 65-75)
were less knowledgeable about age as a risk factor than younger
women ( ages 50-64 ) and perceived themselves to be less susceptible to the disease (Costanza et al., 1992). Thus, a significant proportion of the population, particularly older women, appear to underestimate their susceptibility to breast cancer because they lack
accurate knowledge about their level of risk and, therefore, perceive BSE to be irrelevant. Howevez; misinformation about the
causes of breast cancer may lead some women to overestimate
their susceptibility to the disease. In one study, a fairly large subset
of the sample (20%) endorsed the erroneous belief that an injury
or blow to the breast can cause breast cancer (Richardson et al.,
1987; see also Saint-Germain & Longman, 1993).
Focus on Coping Over Time

The analyses must also take account of the changing nature
of the process of coping over time, in response to evolving circumstances and health challenges. Just as one cannot assume
generalizability across different tasks and populations, one cannot assume stability over different stages of disease risk. For example, consider a woman who is highly anxious about performing BSE and then is diagnosed with breast cancer. Rather than
responding by feeling progressively more personally fragile and
susceptible, she may eventually reframe and restructure her
core self-constructs to accommodate to the seriousness of her
condition to make it more personally acceptable and meaningful. Her expectancies, values, and goals would also likely shift to
accommodate to the new data. As the process continues and the
health facts change, relevant self-regulatory strategies are also
likely to be adapted (e.g., Carver et al., 1993; Gotay, 1984; Morris, Greer, & White, 1977; Redd et al., 1991 ). Understanding
and predicting with increasing precision the processes that underlie these changes is another major challenge for research in
this area.
Implications for Interventions

The hypothesized person variables and their mental representations-the cognitive-affective units (Table 1 )--are based

on all analysis of the psychological processes that underlie individual differences in the particular set of behaviors of interest
( e.g., adherence to proficient BSE). Therefore, they also are directly relevant to, and virtually dictate, the psychological interventions needed to influence those behaviors. Thus, the same
person variables invoked to describe and understand individual
differences in the practice of health-protective behaviors also
inform the health psychologist about the specific components
required in interventions designed to facilitate those behaviors
and to help reduce the individual's risk status.
87
one study (Meyerowitz & Chaiken, 1987 ), women who read an

informational pamphlet stressing the negative consequences of
not performing BSE (loss frame) were more likely to subsequently practice the behavior than were women who received
information stressing the positive consequences of BSE performance (gain frame). The only difference between the loss and
gain frame manipulations was in their impact on self-efficacy
expectations, with women in the first condition reporting
greater levels of self-confidence. Findings like these underscore
the importance of specifically enhancing self-efficacy expectations (Bandura, 1986).
Influencing Health-Protective Decisions and Intentions

The C-SHIP approach to intervention begins by considering
how to represent the target behaviors, such as BSE, so perceivers
encode the behaviors as self relevant and personally desirable
and construe them as positive rather than as aversive, frightening, or irrelevant to the self. In intervention efforts, to help perceivers reframe and reencode activities like cancer screening to
enhance their value, the task is similar to the one faced by health
educators trying to encourage people to incorporate condom
use into sexual foreplay rather than to view putting on a condom
as an interruption or as a reminder of the potential for disease
(see Fisher & Fisher, 1992, for a review ). Conceptually, this requires changing the meaning of the situation and of the task for
the perceiver.
In the context of BSE, the needed cognitive transformations
requirereframing the behavior to focus on how these behaviors
can "take the worry away," provide mental relief, and entitle
the woman to think about herself more positively (e.g., as self
assured, in charge, and fully alive to enjoy life)--while still
calmly be able to take the earliest possible action if a problem
arises to stop it before it stops her (Lehman & Salovey, 1990;
Meiehenbaum, 1977, 1992; Meichenbaum & Fong, 1992; Salovey & Singer, 1991; Sarason et al., 1986). The C-SHIP model
also emphasizes the need to tailor influence attempts to the encoding strategies of the particular individuals. To initiate
health-protective behaviors, the individual must expect such behaviors to lead to valued positive outcomes and perceive other
options and courses of action to have less desirable consequences. Inevitably, the anticipated long-term outcomes in
these choices generally are aversive in different degrees and involve different types of negative consequences at varying future
times. As discussed earlier, for example, a woman may construe
performing BSE as a route for finding a malignant lump sooner,
getting a mastectomy sooner, and dealing with death sooner,
perhaps after greater and longer exposure to pain and disfigurement, than if she lets "nature take its course?' Educational
campaigns that call attention to the need for such behaviors as
performing BSE may be helpful in creating positive beliefs
about its value and disinhibiting fears about routine BSE
(Champion & Scott, 1993; Glanz et al., 1990; Rippetoe & Rogers, 1987).
In many health domains, the effectiveness of a variety of interventions has been shown to be related to the extent to which
the intervention increases the individual's expectancy that he or
she can execute the desired behavior (Gattuso et al, 1992; Lorig
& Holman, 1993; O'Leary, Shoor, Lorig, & Holman, 1988; Rippetoe & Rogers, 1987; Wojcik, I988). As a typical example, in
Enhancing Cancer Screening Competencies: Proficiency

as Well as Persistence
With regard to BSE, the present approach emphasizes the need
to include educational interventions targeted to the acquisition
and retrieval of the specific psychomotor skills required for BSE
proficiency. Intervention attempts need to teach procedural competencies (i.e., how to enact complex psychomotor behavior such
as BSE) not just declarative knowledge (i.e., how to verbalize
about the process) because the types of learning experiences that
facilitate one type of knowledge may have tittle value for the other
(Anderson, 1983, 1993 ). The most efficient training regimens entail not simply the transmission of factual or declarative knowledge about BSE but involve teaching the relevant s~lls, preferably
targeted to the woman's own breasts and finl~'s. That is, they need
to convey detailed procedural knowledge and enactive compeence (Champion & Scott, 1993). Indeed, studies comparing supervised practice versus verbal-written instruction ~aerally find
the former to be superior in producing BSE proficiency (Assaf,
Cummings, Graham, Mettlin, & Marshall, 1985). ~ y
promising strategies combine modeling and rehearsal (with a
breast model) in both teaching and motivating women to practice
the behavior (Marty, McDermott, & Christiansen, 1983; P. Smith
& Halley, t988).
Promoting Self-Regulatory Sktiis jor Adherence

As emphasized above, adherence to BSE regimens is particularly difficult to maintain long term because of the peculiar payoffs that they yield: Finding a lump in the breast--or anticipating finding one--is a terrifying prospect for most women, rather
than a compelling, immediate reinforcer for sustaining BSE. It
would take considerable self persuasion and reasoning to offset
this fear and to comfort oneself effectively, with the value of
early detection as a possible.way to reduce the long-term health
risks from failing to perform BSE. Thus, to make adherence a
reality requires engaging the individual's enduring commitment to develop, self cue, and execute a complex set of selfregulatory skills (e.g., Nezu, 1986). These include self-monitoring, self-reinforcement, appropriate cognitive focus and self instructions, as well as mastery and rehearsal of BSE skills at the
level of proficient, procedural knowledge (psychomotor
enactment ), not merely abstract verbal knowledge. Attempts to
assess and predict individual differences in BSE adherence, as
well as interventions designed to increase its practice, obviously
should focus on as many of these components as possible, as
88
directly and specifically as can be accomplished (Champion,

1995).
Long-term adherence to breast cancer screening regimens
such as BSE requires a complex array of self-regulatory skills
(Turk, Salovey, & Litt, 1986 ), and the C-SHIP model suggests a
number of specific intervention strategies for buttressing them.
They include self cuing (e.g., by providing prompts in the form
of postcard and telephone reminders, BSE record forms, and
reminder stickers and calendars; Bennett et al., 1990; Grady,
1984; Grady, Goodenow, & Borkin, 1988; Hall, 1992), self reinforcement (e.g., by providing external rewards such as social
approval or self-administered rewards such as a favorite treat;
Grady et al., 1988), and the use of balanced mental representation (e.g., by training the woman to focus on BSE practice in
less arousing terms, to manage her emotional state, and to engage in appropriate problem solving and planfulness; Meichenbaum, 1992).
Conclusions
In conclusion, a model was articulated that focuses on the

individual's cognitive-affective mediating units and the organization of relationships through which they become activated in
response to health-relevant information. The model, based on a
comprehensive and cumulative metatheory and drawing on the
established concepts and findings of the psychological science
(Mischel & Shoda, 1995), was applied to analyze BSE in cancer
screening. Like the metatheory on which it is based, the C-SHIP
encompasses not only the role of cognition but also of affect and
does so at all phases of information processing, from encoding
through behavior generation, execution, and long-term maintenance (adherence). It deals with individual differences in the
accessibility of cognitive-affective mediating units and with the
organization of the relationships among them which guides and
constrains health-relevant information processing. In processing health information, individuals (and types) differ in their
available encoding strategies, beliefs--values (including subjective expectancies, values, and goals), the affective states triggered, their health-relevant construction competencies, knowledge, and self-regulatory strategies for enacting health-protective behaviors. We considered how these cognitive-affective
units become activated and interact during the processing of
health information and, in particular, during women's attempts
to deal with breast cancer threats and to adhere to BSE
regimens.
The analyses illustrated that cognitive-affective mediating
units do not function separately in isolation but in a pattern of
relationships guided by a stable organization that characterizes
the individual. The model explicitly incorporates the role of the
situation or context, focusing attention on the psychological features of the situation as perceived and interpreted by the individual. It addresses the dynamics of the interactions between
those construals and the other cognitions and affects that they
prime and activate within the processing system as the individual interprets, transforms, and acts on the information. The
model is designed to understand and predict not only individual
differences in average levels of various types of behavior but also
their meaningful patterns of stable variability across situations
(e.g., if A, she does X ; but if B, she does Y), as essential expres-
sions of the same underlying system (Mischel & Shoda, 1995 ).

Finally, it deals not only with health-protective choices and intentions but also addresses in detail the bebavior-generation and
execution process and the cognitive-affective dynamics required for maintenance of difficult future-oriented behaviors of
the sort needed for long-term health-protective efforts (e.g., proficient BSE adherence, fitness, and effective weight control). A
major challenge in future research on the processing of health
information is to identify the distinctive processing strategies
and dynamics that characterize different types of individuals
when encountering various types of health-relevant information so that intervention strategies can be tailored specifically to
their needs.
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Received August 5, 1993
Revision received February 16, 1995
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Psychological Bulletin

1996, Vol. 119, No. 1, 70-94

Copyright 1996 by the American Ps~hological Association, Inc.

Applying Cognitive-Social Theory to Health-Protective Behavior:

Fox Chase Cancer Center

There has been an explosion of interest and research in health

COGNITIVE SOCIAL THEORY AND CANCER SCREENING

Breast Cancer Screening as a Prototype for

lymph node involvement than are women who do not perform

MILLER, SHODA, AND HURLEY

ing system and (b) the structure and dynamic processes

Choice of Mediating Units

O'Leary, 1985, 1992), and it has been shown that self-efficacy

ProcessingStructure and Dynamics: Organization of the

COGNITIVE SOCIAL THEORY AND CANCER SCREENING

Types of Cognitive-Affective Mediating Units in Health Information Processing

Health beliefsand expectancies

Health goals and values

Self-regulatory competenciesand skillsfor generatingand maintaining health-protectivebehavior

protective behavior requires, as a first step, identifying the contents

Application o f the C - S H I P to BSE

Formation of Decisions and Intentions to Perform B S E

MILLER, SHODA, AND HURLEY

studies have used a prospective design in which beliefs about

COGNITIVE SOCIAL THEORY AND CANCER SCREENING

Interactions Within the System: The Structure and

positive activation in which the activation of one unit activates

Illustrative Interactions Between Health Risk

MILLER, SHODA, AND HURLEY

Information about breast cancer

"1 may develop breast

"If I have breast cancer,

"Cancer may grow

'rll get early, effective

"1 will do BSE regularly"

feelings of anxiety and depression (arrow 13) and undermines

lump with BSE. In contrast to the organization shown in Figure 2,

COGNITIVE SOCIAL THEORY AND CANCER SCREENING

Information about BSE

"If I have breast cancer,

I can find It with BSE"

"1'11get early, effective

five profiles of i f . . . then.., situation-behavior relationships

Predicting the Two Opposing Effects of Risk Information

MILLER, SHODA, AND HURLEY

Information about BSE

"If I have breast rancor,

'Cancer may grow

I will do BSE regularly"

Understanding the Inverted U-Shaped Relation Between

COGNITIVE SOCIAL THEORY AND CANCER SCREENING

Interactions With Individual Differences:

discrepant with their core beliefthat they are "OK--no problem"

From Intentions to Execution and Adherence: Beyond

Domain Map for BSE." From Information Input to

MILLER, SHODA, AND HURLEY

mation of the intention to perform BSE as well as the actual

Activation of Cognitions and Affect During BSE

Information about breast

'If I have breast

"1 may develop breast

"Cool', 'objective" representations:task-relevant

Cancer may grow

"1 will do B S E regularly"