Perceived Susceptibilities, Benefits, and Barriers to Breast and Cervical Cancer

Screenings of Women in a Rural Alaska Community

by

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THESIS

Denise C. Ekstrom

Presented to the Faculty o f the

School o f Nursing

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College o f Health & Social Welfare

University o f Alaska Anchorage

In Partial Fulfillment o f the Requirements

For the Degree of

MASTER OF SCIENCE, NURSING SCIENCE

March 2004

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UMI Number: 1421620

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Perceived susceptibilities, benefits, and barriers to breast and cervical cancer

screenings of women in a rural Alaska community
by
Denise C. Ekstrom
THESIS

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APPROVED: Thesis Committee

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Jackie Pnaum

- lS ~ -o 4 Date

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Diarme Toebe, PhD

Chairperson

Bernice Cannon, MPH, MS

ACCEPTED:

f(L

Tina D. DeLapp, Ed.D

DirectoFr-School of Isfui^ihE

Date

Date
Deant'tfollege of Health and Social Welfare

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Abstract
The purpose o f this research study was to investigate how women perceived their
suseeptibilities, benefits, and barriers to breast and cervical cancer screenings in a rural
Alaska community. One hundred ninety three participants were used. The study design
was a quantitative, descriptive approach based on the Health B elief Model using a
modified version o f the Champion Health Belief Model (1999) scale. The breast and

cervical cancer screening methods examined were self-breast exams, mammograms, and
Pap testing. Women did not feel susceptible to breast and cervical cancer. They did

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pereeived benefits to self-breast exams. Women did not perceive any barriers to breast
and cervical cancer screenings. Age and education level were statistically significant

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when exploring perceived suseeptibility to breast cancer. Age and method o f payment for
mammograms and Pap testing were statistically significant when perceived barriers to

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breast eancer screenings were explored.

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Acknowledgements
I would like to aeknowledge the support and care from my husband, Carl and
three ehildren Cara, Patrick, and Catherine. I would also like to thank the community of
Whitestone Farms, and Dianne Toebe.
My family and I have grown up together during the thesis process, whieh has only
improved our relationships. We all have done things we thought we never could, from

laundry to research to editing to writing, and doing it over and over again. The proeess
was well worth the time and was truly a team effort. We are better people beeause o f the

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endeavor.

Whitestone Farms provided spiritual support through the loeal chureh and general

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day-to-day help with the little things that, if not taken care of, can be overwhelming.
There are too many to identify individually, so thank you all. I was truly surrounded with

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love and encouragement.

My Chairperson, Dianne Toebe was invaluable. She provided encouragement,

was always willing to work with me, and her tenacity to get the job done, and done well,
was inspirational.

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TABLE OF CONTENTS
PAGE
Abstract............................................................................................................................................ i
Acknowledgements....................................................................................................................... ii
Table o f Contents......................................................................................................................... iii
List of T ables................................................................................................................................. v

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Chapter 1. Introduction................................................................................................................. 1
Problem .....................................................................................................................................2
Purpose......................................................................................................................................4
Operational Definitions...........................................................................................................5
Significance to Nursing...........................................................................................................7
Theoretical Framework.......................................................................................................... 7
Summary.................................................................................................................................10

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Chapter 2. Review o f Literature................................................................................................. 11

National Guidelines for Breast and Cervical Cancer Screenings...................................11
W omens Rural Health C are................................................................................................ 12
Susceptibility.......................................................................................................................... 17
B enefits...................................................................................................................................19
Other Breast and Cervical Cancer Screening Barriers..................................................... 19
Health Care Providers Importance in C are........................................................................21
Summary................................................................................................................................ 23
Chapter 3. M ethods..................................................................................................................... 24
Study Design..........................................................................................................................24
Sample.....................................................................................................................................25
Data C ollection..................................................................................................................... 25
Human Subjects Protection..................................................................................................26
Instrum ent.............................................................................................................................. 26
Data A nalysis.........................................................................................................................28
Summary................................................................................................................................ 28
Chapter 4. R esults........................................................................................................................29
Research Question 1 .............................................................................................................29
Research Question 2 .............................................................................................................32
Research Question 3 .............................................................................................................33
Research Question 4 .............................................................................................................33

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Research Question 5 .............................................................................................................34

Reliability............................................................................................................................... 34
Additional findings...............................................................................................................35
Age and Perceived Suseeptibility to Breast Caneer......................................................... 35
Age and Perceived Benefits o f M am m ogram s................................................................. 35
Age and Perceived Barriers to M ammograms.................................................................. 36
Age and Perceived Barriers to Pap T esting...................................................................... 36
Education Level and Perceived Susceptibility to Breast C ancer................................... 37
Method o f Payment and Perceived Barriers to M ammograms.......................................38
Method o f Payment and Perceived Barriers to Pap testing........................................... 38
Summary................................................................................................................................ 39

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Chapter 5. D iscussion.................................................................................................................40
Perceptions............................................................................................................................. 40
Demographics....................................................................................................................... 43
Conceptual Framework........................................................................................................ 43
Implications for N ursing...................................................................................................... 45
Lim itations.............................................................................................................................46
Recommendations for Further Research............................................................................47
Summary................................................................................................................................ 48
References.....................................................................................................................................49

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A ppendixes...................................................................................................................................58
A Champion Health Belief Model (1999) Questionnaire................................................58
B Consent Form .................................................................................................................... 59
C Permission for Survey Tool U se .....................................................................................63

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List of Tables
Table 1 Age............................................................................................................ 30
Table 2 Level o f Education.................................................................................. 30
Table 3 Household Income.................................................................................. 31
Table 4 History o f Cancer.................................................................................... 31

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Table 5 Method o f Payment................................................................................. 32

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CHAPTER 1
INTRODUCTION
Access to health care for all is lacking in the United States (U.S. Department of
Health & Human Services [USDHHS], 2000). The United States has a goal for
improving womens health care regardless o f raee, age, gender, status, or geographic
location (National W omens Law Center, 2001). The National W omens Law Center
reported that overall, most states were failing to meet the nations goal for improving

womens health care. Discoveries regarding factors that prohibit, interfere with, or

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restrain women from receiving preventive health eare unfold as health care and its
delivery are researched (Hart, Salsherg, Phillips, & Lishner, 2002; Martin, 2000;

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Schootman & Fuortes, 1999). Perceptions regarding preventive health care may limit or
encourage preventive health care behavior.

Preventive health care attitudes may he influenced by an individuals definition of

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health (Pender, 1990). Perceived personal threats or risks of disease may influence ones
health care practices such as breast and cervical cancer screenings (Becker, 1974;
Rosenstock, Strecher, & Becker, 1988). Attitudes in regard to susceptibility to disease
may help predict whether screening behaviors will be practiced (Champion, 1988;
Rosenstock et al.).
Perceived benefits o f preventive health behaviors may lead to action (Champion,
1988; Rosenstock, 1974; Rosenstock et al., 1988; Rutledge, 1987). Rosenstock (1974)
commented that beliefs regarding the benefit o f preventive health behaviors might reduce
the susceptibility to certain diseases. The cost or barriers to the preventive health

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behaviors may determine whether the aetion is actually taken (Rosenstoek et al., 1988).
The higher the cost o f the health behaviors, the less likely the preventive health behaviors
will he practiced (Champion).
Attitudes in regard to barriers to receiving preventive health care such as breast
and cervical cancer screenings have been researched (Bastani et al., 2002; Champion,
1984; Gasalberti, 2002; Watkins, Gabali, Winkleby, Gaona, & Lebaron, 2002). Barriers

to receiving health eare were less education, low-income level, lack o f access, no health
insurance, and minority raee (Champion, 1995; Coughlin, Thompson, Hall, Logan, &

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Uhler, 2002; Schulz, Ludwick, Cukr, & Kelly, 2002). Plans for community health care
development can be established by evaluating and understanding barriers to receiving

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breast and cervical cancer screenings, (Hiatt et al., 2001).

Alaska faces its own set o f challenges concerning preventive health care for

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women (USDHHS, 2000). Issues such as accessibility due to weather conditions and
distance are some o f the challenges Alaskan women face (USDHHS). In Alaska nearly
one fourth o f the states population lives in towns and villages accessible only by boat or
aircraft where severe weather conditions often limit travel, causing delays in obtaining
care (Department o f Health and Social Services [DHSS], 2002).
Problem
W omens health care encompasses issues such as breast and cervical cancer
(USDHHS, 2000). Greenlee, Hill-Harmon, Murray, and Thun (2001) reported 192,200
new cases o f breast caneer and 12,900 new cases o f cervical cancer in the United States
for 2001. Breast cancer is the second leading cause o f eaneer death in American women

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3
(American Cancer Society [ACS], 2002; Lewis, Corcoran-Perry, Narayan, & Lally,
1999). The rate o f invasive cervical cancer has decreased significantly with the
widespread use o f the Papanicolaou (Pap) test (Bastani et a l, 2002; Janicek & Averette,
2001; Ruhin, 2001; Schulz et al., 2002). Early detection and treatment o f these diseases
decrease the mortality rate in women (Centers for Disease Control [CDC], 2001; Schulz
et al., 2002). Despite these statistics, medically underserved women often face harriers to

health care (Schulz et al.).

The nations overall provision o f womens health care is severely lacking

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(National W omens Law Center, 2001). The United States is working to improve the
quality and availability o f health care among women. A focus on underserved women has

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prompted the U.S. government to action. The Breast and Cervical Cancer Prevention and
Treatment Act o f 2000 (Public Law 106-354) was passed to provide screenings for these

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diseases. The National Breast and Cervical Cancer Early Detection Program (NBCCDP)
uses federal money to provide screenings for breast and cervical cancer for underserved
women (CDC, 2001). This act should promote the utilization o f these screenings across
the nation.

Access to health care in Alaska is o f particular interest since there are several
medically underserved regions in Alaska (USDHSS, 2002). Living in medically
underserved areas has been identified as one reason for lack o f health care seeking
behaviors in these populations (USDHSS). Lack o f access to breast and cervical cancer
screenings affects womens quality o f life if these cancers go undiagnosed until later
stages o f the diseases (Carr et al., 1996). Availability and distribution o f breast and

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4
cervical cancer screening services in Alaska should be researched to determine whether
the benefit o f these services is reaching all women in the state.
There are limited breast and cervical cancer screening services in Alaska (DHSS,
2002). No public womens health care services are listed in several rural Alaska
communities with some communities having a minimum of 100 miles to travel in order to
access health care (DHSS). Therefore, women are required to travel a long distance in

order to receive breast and cervical cancer screening services.

Purpose

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The purpose o f this study was to investigate how women perceive their
susceptibilities, benefits, and barriers to breast and cervical cancer screenings in a rural

1.

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Alaska community. The following questions were presented:

What are the demographics regarding age, race, level o f education, category

2.

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of income, and method o f payment for health screenings?

How do women in a rural Alaska community perceive their susceptibilities to

breast and cervical cancer?

3.

How do women in a rural Alaska community perceive benefits o f breast and

cervical cancer screenings?

4.

How do women in a rural Alaska community perceive barriers to breast and

cervical cancer screenings?

5.

What is the difference in perceived susceptibility to breast cancer between

women who have not reported breast cancer themselves or in an immediate
family member (sister and/or mother) and those who have reported breast

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cancer in themselves or in an immediate family member (sister and/or

mother)?
The researcher wanted to discover if women in a rural Alaska community felt
susceptible to breast and cervical cancer, believed that taking action by practicing
preventive health screenings related to breast and cervieal cancer could reduce the
likelihood o f the diseases, and if women felt that there were harriers to performing SBE,

receiving mammograms and Pap tests.

Operational Definitions

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Conceptually, the perceived susceptibility to breast and cervical cancer was

defined as the degree to which participants believed that they were at risk for breast and

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cervical cancer. Perceived benefits o f breast cancer screening were defined as the degree
to which participants believe that there were benefits o f performing a self-breast exam

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(SBE) and receiving a mammography. Perceived benefits o f cervical cancer screening

were defined as the degree to which participants believe that there was a benefit o f
receiving Pap testing. Perceived barriers to breast eancer screening were defined as the
degree to which participants believe that there were barriers to performing a SBE and
receiving a mammography. For example, woman may have felt too embarrassed or it
would take too much time to perform a SBE or receive a mammography. Perceived
harriers to cervical cancer were defined as the degree to which participants believe that
there were barriers to receiving a Pap test. For example, it would cost too much money to
receive a Pap test or having a Pap test would be too painful.

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The operational definitions were based on responses to items included in the
Champion Health Belief Model Questionnaire (1999), which is included as Appendix A.
Perceived benefits o f breast caneer screening included two variables: perceived benefits
o f self-breast exams (SBE), which was the sum o f responses to items 6-11 and perceived
benefits o f mammograms (the sum o f responses to items 18-23). Perceived barriers to
breast cancer screening also had two components: barriers to SBE (sum o f responses to

items 12-17) and barriers to mammograms (sum o f responses to items 24-28).

A similar approach was used to operationally define perceived susceptibility,

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benefits of, and barriers to screening for cervical cancer. Perceived susceptibility to
cervical cancer was operationally defined as the sum o f responses to items 29-33.

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Because the only screening method to detect cervical cancer was the Pap test, perceived
benefits o f and barriers to cervical cancer screening had only one component. Perceived

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benefits o f screening were operationally defined as the sum o f responses to items 34-39,
while perceived barriers was the sum o f responses to items 40-44.
The womens perceived susceptibilities, benefits, and barriers were measured
based on the rating scale of: 1 - strongly disagree, 2 - disagree, 3 - neutral, 4 - agree, 5 strongly agree. When measuring perceived susceptibilities, a score o f one would indicate
the woman did not feel susceptible to breast or cervical cancer. A score o f five would
indicate she felt strongly susceptible to breast or cervical cancer.
A rural community was defined as a community with a population o f less than
3,000. The questions were sent to a random sampling o f women listed on the
communitys voter registration list. Women were those age 19 and older.

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Significance to Nursing
The Advanced Practice Nurse (APN) has a significant role in serving rural areas
(Knudtson, 2000). Originally, the APN role was established to provide services in these
areas, thus expanding the availability o f health care (History, n.d.). The APN provides a
significant avenue for promoting health and wellness (Whitehead, 2001). Instruction
regarding the importance o f screening and early detection o f breast and cervical cancer

can motivate women to seek these vital health prevention services. Along with the ability
to educate, the APN has the necessary skills to perform the screenings and serve as a

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gatekeeper to more advanced health care (Burgener & Moore, 2002).

Early detection is a proven key to increasing womens quality o f life (ACS, 2002;

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Rosenfeld, 1998). The APN focuses on health prevention using cost effective measures,
thus adding incentive in the development o f rural clinics (Burgener & Moore, 2002).

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Answering research questions about possible barriers to womens health care provides
insight to community needs the APN was trained to fulfill (Burgener & Moore).
Providing services such as these demonstrates commitment on the part o f the APN, who
fills in some o f the crucial gaps in rural health care (BCnudtson, 2000; Magilvy & Brown,
1997).
Theoretical Framework
The Health Belief Model (HBM) provided the theoretical framework for this
study. The HBM has been used as a predictor o f compliance with health behaviors
(Becker, 1974). Originally developed to measure perceived suseeptibilities, seriousness,
benefits, and barriers to health related behaviors, three o f the original four concepts o f the

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