ORIGINAL RESEARCH

Health Beliefs of African American

Women on Breast Self-Exam
Marlaine Registe, FNP-c, and Susan Padham Porterfield, FNP-c

ABSTRACT
Purpose: Investigate the relationship between African American womens health
beliefs in regard to breast cancer screening behaviors.
Data sources: A sample of 131 African American women, age 20-65, from a family
practice clinic and 3 rural churches in Southeast.
Conclusions: One-hundred and nine of the participants reported practicing breast
self-exam (BSE) within the past 12 months. However, 21 women had never practiced
BSE. Fear of not doing it correctly was a main barrier.
Implication for practice: Steps should be taken to increase confidence and resolve
barriers of African American women through the development of culturally sensitive
educational training on BSE and cancer prevention.

Keywords: African American, barriers, breast cancer, BSE

2012 American College of Nurse Practitioners

T he American Cancer Society estimates that

232,620 women are diagnosed with breast
cancer each year and 39,970 women will die.1
Breast cancer is second only to lung cancer as a cause of
cancer deaths in American women, accounting for 1 of
more widely adopted by Caucasian women and under-
used by AA women.3,6

every 3 cancers diagnosed in the United States. However,
research studies have shown the challenge to be greater
for African American (AA) women. Although AA women
have a lower incidence of breast cancer118 of every
100,000 compared to 133 of every 100,000 Caucasian
womenthey are more likely to die at a higher rate:
34.0 per 100,000 compared to 25.0 per 100,000
Caucasian women.1,2,3
Poverty, inferior health care, barriers to health care
access, health beliefs, personal behaviors, and later stage
of disease at diagnosis are some of the reasons attrib-
uted to this disparity.4,5 Multiple studies, however,
attribute the racial difference in survival rates (31 of
every 100,000 AA women compared to 27 of every
100,000 Caucasian women) to early detection practices
such as breast self-examination (BSE), clinical breast
examination (CBE), and mammography, which are
LITERATURE REVIEW
The literature indicates an association between breast can-
cer screening measures (ie, CBE, mammography, and BSE)
and more favorable clinical and pathological stages of dis-
ease. The most important predictor of survival is stage at
diagnosis.7 According to the American Cancer Society and
the US Preventive Services Task Force, screening is the key
to finding breast cancer in its early, treatable stages.1 The
role of the nurse practitioner (NP) is to identify sociocul-
tural factors that may influence screening and incorporate
them into health messages for AA women. Being proactive
in preventive measures may help lessen the existing dispar-
ity and improve survivalibility.8
BREAST CANCER KNOWLEDGE AND BELIEFS
AA women are diverse, with mixed ancestry from Africa,
Europe, the Americas, Asia, and the Caribbean. While a
cultural bond of a set of shared beliefs, values, and expe-
riences still exists, AA women are as socially, economi-

446 The Journal for Nurse Practitioners - JNP Volume 8, Issue 6, June 2012
cally, culturally, and ethnically diverse as other ethnic
groups.9 Evidence shows that a womans decision to par-
ticipate in cancer prevention, such as routine BSE and
mammogram, is influenced by cultural, ethnic, and eco-
nomic differences. Phillips and colleagues10 found AA
womens perception regarding cancer to reflect that dif-
ference. The AA women interviewed believed that only a
chosen few survive cancer, cancer can be caused by being
hit in the breast, cancer is a condition of the mind, and
breast cancer is a disease of Caucasian women. Bannings8
literature review indicated that factors linked to AA
women and breast health are religious and educational
awareness of breast cancer screening. Late detection may
result from social barriers such as poverty, social injustice,
and cultural issues.8
Barroso11 used the Health Belief Model and the
Health Locus of Control Construct to compare the dif-
ference in health beliefs in regard to breast cancer in 197
Caucasian and 152 AA women. Participants between the
ages of 19-93 were recruited from various settings in
central Florida. The researchers found significant differ-
ences between the 2 groups in regard to health beliefs
and other cancer items. The AA women were signifi-
cantly more likely to believe that health results from
luck/chance or depend on powerful others for their
health. Perceived susceptibility to cancer, doubts about
the value of early diagnosis, and beliefs about the seri-
ousness of breast cancer were all associated with this
powerful other.
Barrosos11 results showed evidence of knowledge
deficit regarding breast cancer among AA women and a
belief that their health in general and breast cancer in
particular has an element of chance or luck and that ill-
nesses such as breast cancer are in the hand of a higher
power or God who decides who gets breast cancer and
who gets cured. Another significant finding was that AA
women with a greater belief in powerful others also
believed that early diagnosis gives them a longer time to
worry and be sick.
The researchers11 said these beliefs might be the result
of cultural influences, such as family storytelling about
others with cancer. The researchers summarized that cul-
tural influences may play a more significant role than edu-
cation and that, by addressing the differences in health
beliefs in regard to breast cancer screening and early detec-
tion, health professionals may be able to reach this vulner-
able population.
www.npjournal.org
In looking at the relationships between health beliefs
and the practice of BSE, Graham12 used Champions13
revised Health Belief Model Scale. Of the 179 AA women
age 20-49 in the study, the results indicated a relationship
between health beliefs and BSE performance among AA
women. The health belief frame of reference was much
stronger in determining BSE performance for a given
individual than background characteristics.12 Frequency of
BSE was related to increased perceived seriousness of
breast cancer, benefits of BSE, and health motivation.
Frequency of BSE was inversely related to perceived barri-
ers. Graham found that age was directly related to BSE
performance within the context of perceived seriousness.
AA women over 40 perceived a greater threat and were
more motivated than younger women regarding breast
cancer prevention and early screening measures such as
BSE and mammograms.
McDonald and colleagues14 investigated breast can-
cer perceptions, knowledge, and screening behavior of
120 low-income, AA women residing in public hous-
ing. The randomly selected AA women were inter-
viewed to determine their perceptions of susceptibility
to breast cancer, disease severity, barriers to breast can-
cer screening, and benefits of mammography. Know-
ledge about breast cancer causes, risk factors, symptoms,
and screening were also assessed. The result showed that
80.7% of women 40 and older had a previous mammo-
gram, 92% reported having had a CBE, and 75.8% per-
formed BSE. Knowledge of breast cancer was poor;
most of the women did not perceive themselves or a
particular racial or economic group to be more suscep-
tible to breast cancer. They also did not perceive breast
cancer to be fatal and denied commonly cited barriers
to breast cancer screening.
The review of literature indicates a gap in knowl-
edge for AA women regarding BSE and cancer preven-
tion. It is imperative that health care providers
understand the perceived differences to better serve
women of different ethnicity.
METHODS
This is a descriptive, correlative study designed to exam-
ine the relationship between health beliefs, knowledge,
attitude, and the performance of BSE among AA women.
From November 2007 to February 2008, 131 AA women
between the ages of 20-65 with no history of breast can-
cer were recruited to participate in the study. They were
The Journal for Nurse Practitioners - JNP 447
recruited from 5 counties in the southeast United States
through community settings such as churches and doc-
tors offices and through friends and relatives of women
who self-identified during recruitment as AA, black, or
Caribbean. Criteria for exclusion were AA women with
any personal history of breast disease and those who do
not speak, understand, and write English.
SAMPLING PROCEDURE
Permission was received from the Institutional Review
Board, priests, pastors, and directors of each facility used
in this study. Subjects were recruited through advertise-
ments, flyers, church newsletter announcements, partici-
pants referrals, and womens social club announcements,
as well as through friends and relatives of women who
self-identified as AA.
At the start of each session participants received a
complete package containing the following: a consent
form and cover letter describing the purpose of the study,
what will be asked of participants, risks and benefits, confi-
dentiality, right to withdraw, and who to contact with
questions about the study. The purpose of the study was
verbally explained to all participants after they received the
package. They were also informed that participation was
voluntary and confidentiality ensured.
At the beginning of each session, the participants were
encouraged to ask as many questions as possible for clarifi-
cation purposes. At the churches, a time was set for group
meetings. At the beginning of each group meeting, the
study purpose and participation method were extensively
explained and questions satisfactorily answered. The partic-
ipants were provided an adequate amount of time (20-30
minutes) to complete the survey; the questionnaires were
then collected and placed in the researchers locked brief-
case. A 15-minute presentation on breast health and time
for questions and answers followed the data collection. For
participants in doctors offices, the packets were given to
women as they waited to be seen by health care providers,
and the primary investigator explained the purpose of the
research and answered any questions.
RESEARCH INSTRUMENTS
The 2 instruments used in this research study were the
demographic questionnaire and Champions13 Breast
Cancer Screening Instrument Scale. The demographic
questionnaire contains questions related to personal his-
tory: race (ethnicity), age, marital status, education,
448 The Journal for Nurse Practitioners - JNP
employment, health insurance, socioeconomic status, BSE
practice and recommendation of BSE by health profes-
sional, health screening history, and religion.
Champions13 Breast Cancer Screening Beliefs
Instrument consists of 41 items representing 6 scales:
susceptibility (5 items), seriousness (7 items), benefits of
BSE (6 items), barriers to BSE (6 items), confidence (11
items), and health motivation (6 items). Each concept
was measured in a distinct subscale that examines partic-
ipants perception of susceptibility to breast cancer, belief
in the seriousness of the threat of breast cancer to them-
selves, benefits of BSE, barriers to BSE, and their confi-
dence in performing BSE, as well as health motivation.
Each item is rated on a 5-point Likert-type scale, with
answers raging from strongly agree (5 point) to strongly
disagree (1 point). Champions13 revised instrument has
been reported as having a high internal consistency, with
Cronbachs alpha coefficients from .80-.88 and
test/retest correlations ranging from .45-.67.
RESULTS
Health Belief and BSE
Data analysis showed a significant positive correlation
between susceptibility and BSE practices (r = .218, P = .014),
negative but insignificant correlation between the concept
of benefits and BSE practice (r = -.145, P =.104), and a
negative and significant correlation between the concept of
health motivation and BSE frequency (r = -.209, P = .017).
No significant correlation existed between perceived seri-
ousness, barriers, and confidence.
Most participants agreed on the beneficial aspect of
BSE, but their confidence in their ability to do it prop-
erly was low. Seventy-nine (60.3%) agreed that BSE
could help detect breast lumps, and 88 (67.2%) agreed
with the statement, If I develop breast cancer, I will be
able to find a lump with BSE. Eighty-four (64.1%) par-
ticipants disagreed with the statement, It is extremely
likely I will get cancer in the future, 34 (26.0%) were
neutral, and only 13 women agreed. Ninety-five (72.5%)
disagreed with the statement, My chance of getting
breast cancer is great, 22 (16.8%) were neutral, and 14
(10.7%) agreed. Ninety-five (72.5%) of the participants
did not see themselves as more likely than the average
woman to get breast cancer.
Frequency of BSE decreases as susceptibility to
breast cancer decreases also, which accounts for the
fluctuations with BSE practices. A total of 30 (23.6%)
Volume 8, Issue 6, June 2012
participants practiced BSE monthly, 24 (18.9%) prac- Table 1. Demographic Information (N = 131)
ticed 8-12 times a year, 31 (24.4%) practiced 3-7 times, Age
and 42 (33.1%) practiced 2 or fewer times. An increase
20-29 56 (36.2%)
in perceived susceptibility has been linked to an
30-39 23 (18.1%)
increase in breast cancer screening.13 The expectation
40-49 28 (22%)
that a high BSE frequency would strongly correlate
with low barriers, high susceptibility, seriousness, bene- 50-59 13 (9.9%)
fits, and confidence, clearly was not the findings. 60-65 11 (8.4%)
Susceptibility (r = -.145, P = .104), benefits (r = -.145,
P = .104), barriers, confidence, and seriousness were Marital Status
not significantly correlated to BSE frequency. Single 56 (43.1%)
There was a negative correlation between the concept of
Married 40 (30 > 8%)
health motivation and BSE frequency (r = -209, P = .017).
Divorced 13 (9.9%)
The participants may lack activators (recommendation from
health care providers, culturally appropriate learning tools, Widowed 6 (4.6%)

health-minded friends and relatives) that are necessary to

change their perception of susceptibility to breast cancer and Education
its seriousness, increase benefits of BSE, decrease barriers to Masters or higher 18 (13.%)
BSE, and increase motivation to practice BSE on a regular Bachelor 27 (20.6%)
basis. Champion13 explained that many AAs report adequate
Associate 57 (43.5%)
frequencies for BSE, but they may not be proficient at it or
High school 19 (14.5%)
lack confidence in their ability. According to the results, the
participants who practiced BSE on a regular basis were more < High school 10 (7.6%)

likely to have better knowledge of breast cancer, more confi-

dence in their ability to perform BSE, lower perceived barri-
ers to BSE, and a higher value of their health.
Social Characteristics and BSE Performance
The secondary goal of the study was to examine the rela-
tionships among age, marital status, education, income
level, health insurance coverage, BSE recommendation by
health care providers, self- and family history of breast dis-
ease, and their effects on BSE performance by AA women.
Table 1 summarizes the demographic information. The
number of women who reported compliance to BSE is
surprisingly high. Most participants (109, 83.8%) reported
practicing BSE within the past 12 months. Most partici-
pants had health insurance coverage for yearly physicals
and mammograms, 48.9 % had health insurance, 99.2%
had no personal history of breast cancer, and 61.8% had
no family history of breast cancer. Based on the results of
the analyzed data, Pearsons correlation revealed that there
was negative but insignificant correlation between health
insurance, income, and BSE frequency at the 0.05 level of
confidence for health insurance (r = .013, P = .887) and
for income (r = .038, P = .673). As income increases, the
BSE frequency of the participants decreases.
Income ($)
10,000-29,999 52 (40.3%)
30,000-49,999 29 (21.7%)
50,000-60,000 17 (13.2%)
Unemployed 33 (24.8%)
Demographics and BSE
Data analysis showed no significant correlations among
age, marital status, education, and family history of breast
cancer. The findings were in accord with similar studies
on AA women.12,13 In contrast to Grahams study, this
studys findings revealed decreased BSE frequency associ-
ated with young adults (19 and younger), older adults (60
and older), and marital status (widowed). Younger women
(age 20-29) had the highest frequency score in a year
(36.2%), followed by the 40-49 range. The results
demonstrated that as age increases, frequency decreases.
In contrast, Graham12 reported that AA women over
40 perceived breast cancer to be a greater threat and,
therefore, were more motivated than younger women
regarding breast cancer prevention and early screening
measures such as BSE and mammograms. Data analysis

www.npjournal.org The Journal for Nurse Practitioners - JNP 449

indicated that decreased BSE frequency was associated not
only with the 60 and older women but also the 20 and
younger group as well. The younger women may under-
standably not view cancer as a threat, thus perceiving com-
pliance with BSE practice as a waste of time. A possible
explanation could be that the older AA women may lack
the motivation to practice breast screening or health pro-
moting activities because they may perceive a lack of con-
trol over the outcome of a potential disease, like breast
cancer, and also may have no understanding of the benefits
of BSE or the confidence to do it correctly.
Additionally, the older women may be focused on
chronic diseases that take priority over seemingly simple
tasks such as BSE. Champion13 examined factors that pre-
dicted mammography and BSE in a group of low-income
AA women and found that low frequency of BSE was
associated with marriage and widowhood.
In summary, the results of this study suggested that
breast cancer screening practices among AA women are
complex and difficult to generalize. Health care providers
should continue their efforts to increase the knowledge
base of this population by making cultural appropriate
learning tools available. They should also implement meas-
ures to improve the cultural competence of health profes-
sionals delivering care to this group.
DISCUSSION
Persuading asymptomatic people at risk to undergo rou-
tine cancer screening and prevention activities has been
found to be difficult. NPs and other health care profes-
sionals must be cognizant of the considerable hold that
cultural beliefs have on patients health perceptions,
health-seeking activities, and practices. This list, of course,
includes adherence to prescribed regimens. Providers are
in the best position to increase the knowledge base, dis-
pel cancer myths, break down barriers, and be a true
patient advocate, no matter the level of difficulty.8 The
first step should be an aim at increasing the knowledge
base and confidence of AA women through the develop-
ment of culturally sensitive group training that will
empower AA women and make them aware of their can-
cer risks and cancer screening measures.5,8
The second step should address specific cultural bar-
riers, such as cancer fatalism, fear, and perceived risk, the
greatest obstacles to overcome and the key to improving
AA womens participation in breast cancer prevention
and health maintenance. This may lead to an increase in
450 The Journal for Nurse Practitioners - JNP
BSE performance, mammography, and annual CBE, thus
a decrease in breast cancer mortality rates in AA women
and other minorities.
Lastly, NPs can start reaching out to community leaders
through advocacy groups and churches in AA communities.
Glanz et al4 found that core cultural values emphasizing
family, interdependence, religion, and a holistic view of
health to be important factors that influence screening
behaviors. Interventions aimed at teaching women about
BSE, thus truly decreasing the mortality rate of breast cancer
both for Caucasian and AA women, is a major objective
that all health care professionals should undertake.
RECOMMENDATIONS FOR FUTURE NURSING
RESEARCH
Multitudes of research studies address the high mortality rate
of AA women in regard to breast cancer and the lack of
participation in prevention and health maintenance activi-
ties. The results, however, are still inconclusive and some are
quite confusing. More effective studies are still needed. This
study suggests only possible explanations for their reticence
in obtaining routine screenings, thus leading to low survival
rates for AA women. The results of the current study should
not be accepted as definite but should be considered only as
a starting point in addressing the problem. More research
should be done to determine the roles of fatalism, lack of
access to proper care and treatment, and lack of culturally
competent providers in AA womens presentation with
more advanced stages of breast cancer at diagnosis.
Future research should also examine larger sample size
of multiethnic populations; the results of such studies could
lead to increased development of language-appropriate edu-
cational materials for non-English speakers and materials
appropriate to the clients educational level. Susceptibility to
cancer and effectiveness of early screenings and cancer treat-
ments are believed by some AA women to be associated
with chance or luck or powerful others, so future research
should focus on the relationship between AA women beliefs
about breast cancer and their health locust of control.
CONCLUSION
The health beliefs and health practices of AA women in
regard to breast cancer screening have been shown to be
extremely complex. Numerous studies have attempted to
address this issue but to no avail; their conflicting results
have only added to the confusion. The findings of this
study alone will not provide the sought-after answers but
Volume 8, Issue 6, June 2012

they may provide insight into AA womens health prac-
tices, beliefs, perceived barriers such as fear, perceived
risk, and fatalistic attitudesa better understanding of
which is the key to improving their participation in
breast cancer screening and health maintenance activities.
An increased awareness and understanding of facilitators
and barriers to breast cancer screening can assist health
care providers in not only addressing these issues but also
in the development of culturally sensitive and appropriate
educational interventions tailored for AA women. This
combination may lead to an increase in the performance
of BSE, thus a decrease in breast cancer mortality rates in
AA women and other minorities.
References
1. American Cancer Society. Cancer Facts & Figures 2011. Atlanta: American
Cancer Society; 2011.
2. National Cancer Institute. Breast Cancer Facts and Figures 2007. Bethesda:
National Cancer Institute; 2007.
3. American Cancer Society. Cancer Facts and Figures for African Americans.
Atlanta: American Cancer Society; 2011.
4. Glanz K, Croyle RT, Chollette VY, Pinn VW. Cancer-related health disparities
in women. Am J Public Health. 2003;9:292-298.
5. Phillips JM, Cohen MZ, Tarizan AJ. African American womens experiences
with breast cancer screening. J Nurs Scholarsh. 2001;33:135-140.
6. World Health Organization. Cancer Facts & Figures 2008. Geneva,
Switzerland: World Health Organization; 2007.
7. Yu XQ. Socioeconomic disparities in breast cancer survival: relation to stage
in diagnosis, treatment and race. BMC Cancer. 2009;9:364.
8. Banning M. Black women and breast health: a review of literature. Eur J
Oncol Nurs. 2011;15:16-22.
9. Williams MP, Brown L, Hill CE, Schwartz D. Promoting early breast cancer
screening: strategies with rural African American women. Am J Health Stud.
2001. http://findarticles.com/p/articles/mi_m0CTG/is_2_17/ai_85590923/.
Accessed April 6, 2012.
10. Phillips J, Cohen MZ, Moses G. Breast cancer screening and African
American women: fear, fatalism, and silence. Oncol Nurs Forum.
1999;26(6):198-205.
11. Barrosa J, McMillan S, Casey L, et al. Comparison between African-
American and white women in their beliefs about breast cancer and their
health locus of control. Cancer Nurs. 2000;23:268-276.
12. Graham ME, Liggons Y, Hypolite M. Health beliefs and self breast
examination in black women. J Cult Divers. 2002;9(2):49-54.
13. Champion VL, Scott CR. Reliability and validity of breast cancer screening
belief scales in African American women. Nurs Res. 1997;40:331-337.
14. McDonald P, Thorne D, Pearson J. Perceptions and knowledge of breast
cancer among African-American women residing in public housing. Ethnic
Disparity. 1999;9(1):81-89.
Marlaine Registe, MSN, FNP-c, is a nurse practitioner at CVS
Minute Clinic in Tallahassee, FL. Susan Padham Porterfield,
FNP-c, is an assistant professor in the FSU School of Nursing
in Tallahassee, FL, and can be reached at sporterfield@
nursing.fsu.edu. In compliance with national ethical guidelines,
the authors report no relationships with business or industry that
would pose a conflict of interest.
1555-4155/12/$ see front matter
2012 American College of Nurse Practitioners
http://dx.doi.org/10.1016/j.nurpra.2011.09.025

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