J Community Health (2015) 40:124–130 DOI 10.1007/s10900-014-9908-9
ORIGINAL PAPER
Breast Cancer Prevention Knowledge, Beliefs, and Information Sources Between Non-Hispanic and Hispanic College Women for Risk Reduction Focus Cynthia Kratzke • Anup Amatya • Hugo Vilchis
Published online: 3 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Although growing research focuses on breast cancer screenings, little is known about breast cancer prevention with risk reduction awareness for ethnic differences among college-age women. This study examined breast cancer prevention knowledge, beliefs, and information sources between non-Hispanic and Hispanic college women. Using a cross-sectional study, women at a university in the Southwest completed a 51-item survey about breast cancer risk factors, beliefs, and media and interpersonal information sources. The study was guided by McGuire’s Input Output Persuasion Model. Of the 546 participants, non-Hispanic college women (n = 277) and Hispanic college women (n = 269) reported similar basic knowledge levels of modifiable breast cancer risk factors for alcohol consumption (52 %), obesity (72 %), childbearing after age 35 (63 %), and menopausal hormone therapy (68 %) using bivariate analyses. Most common information sources were Internet (75 %), magazines (69 %), provider (76 %) and friends (61 %). Least common sources were radio (44 %), newspapers (34 %), and mothers (36 %). Non-Hispanic college women with breast cancer family history were more likely to receive information from providers, friends, and mothers. C. Kratzke (&) A. Amatya Department of Public Health Sciences, MSC 3HLS, College of Health and Social Services, New Mexico State University, P.O. Box 30001, Las Cruces, NM 88003, USA e-mail: [email protected] H. Vilchis Border Epidemiology and Environmental Health Center, New Mexico State University, P.O. Box 30001, Las Cruces, NM 88003, USA H. Vilchis Polio Eradication Initiative, World Health Organization, Geneva, Switzerland
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Hispanic college women with a breast cancer family history were more likely to receive information from their mothers. Breast cancer prevention education for college women is needed to include risk reduction for modifiable health behavior changes as a new focus. Health professionals may target college women with more information sources including the Internet or apps. Keywords Breast cancer Prevention Healthcare education Health disparities
Introduction Breast cancer prevention education may help reduce the breast cancer burden [1–4]. Despite increased screening mammography, health disparities remain with breast cancer as the leading cause of cancer death among Hispanic women [1]. Primary prevention strategies including breast cancer risk factor awareness are needed for women to make better health-related decisions [3–5]. A growing body of research suggests nonadherence to modifiable risk factors such as healthy lifestyle habits and limited alcohol consumption is a public health concern that poses increased breast cancer risks for women [5–10]. For example, post-menopausal women who adhered to the American Cancer Society Nutrition and Physical Activity Cancer Prevention Guidelines for diet, physical activity, alcohol consumption, and weight lowered their breast cancer risk by 22 % compared to non-adherent post-menopausal women during a 12 year period [10]. For college women, breast cancer risk reduction awareness is critical since the college environment may be a decision starting point for dietary changes and alcohol consumption [11]. This population may learn and value healthy lifestyles and behaviors that may be links between
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lifestyle choices and cancer risk reduction over the years [11–13]. However, less attention has been directed toward breast cancer prevention among young women [5]. Few previous studies among primarily Caucasian college women suggest only basic breast health and breast selfexamination (BSE) knowledge [13] and breast cancer risk reduction knowledge [12]. A better understanding of breast cancer prevention knowledge is needed among college women for racial/ethnic differences since breast cancer health disparities exist [1]. Furthermore, little is known about underlying breast cancer beliefs among college women for breast cancer risk factors as misconceptions such as antiperspirant use or the breast size causing breast cancer [14, 15]. Breast cancer prevention interventions may reach audiences such as college women through targeted information sources [16]. Mass media channels as source selections for college women may include the Internet, magazines, and television [17–19]. Interpersonal source selections may include cancer prevention communication from mothers [20– 22], providers [23], and friends [24]. With increasing mobile technology use and Internet access, college women have readily available online breast cancer prevention information. Although previous studies focused on Internet use for cancer survivorship information sources [25–27], it is unclear as to Internet use among college women as a breast cancer prevention information source. Thus, understanding cancer information sources among college women provides a foundation how to reach and advance ways to educate women. The purpose of this study was to examine breast cancer prevention knowledge, beliefs, and information sources between non-Hispanic and Hispanic college women. Ethnic differences among college women for breast cancer risk reduction knowledge and information sources have not been examined extensively to our knowledge for college women. This study will be an important contribution to the health education literature so providers and health educators may address the needed breast cancer prevention education targeting college-age women. Recent studies only focused on young adolescent women and breast cancer prevention education [5, 28, 29]. McGuire’s Input–Output Persuasion Model guided this study [30]. The inputs are interpersonal information sources such as providers or friends who send the message. The inputs are media sources or channels as the way the message is sent such as the Internet, radio, magazines, or television. The outputs are the ways of acting on the message or awareness of the message.
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Southwest. New Mexico has one of the highest state breast cancer mortality rates for Hispanic women compared to the national breast cancer mortality rates for Hispanic women (19.3 deaths vs. 14.8 deaths per 100,000, respectively) [1]. Inclusion criteria required that participants were college women ages 18 and older. After receiving university institutional review board approval for the study protocol, we administered a paper and pencil survey to college women recruited during community health classes in fall 2011 and spring 2012. Response rate was nearly 90 % of the college women in classrooms when compared to class registrants. Exclusion of some students included younger age or survey noncompletion. We also recruited other college women ages 18 and older using e-news bulletin and faculty class announcements to participate in the online survey. A pilot was conducted with no changes prior to implementation. Informed consent was received from college women. Survey A 51-item survey was developed with sections for demographics, breast cancer prevention knowledge and beliefs, technology, and information sources. Some items were adapted from the National Health Information Trends Survey, a national survey conducted by the National Cancer Institute [31]. Items for BSE knowledge, technology, or types of breast cancer prevention information received from and given to mothers are described elsewhere [14, 18]. Demographic Characteristics Participants reported their age, university level, and race/ ethnicity. Demographics were dichotomized as age (18–22 and 23 and older), university levels (undergraduate and graduate), and race/ethnicity (non-Hispanic and Hispanic). Breast cancer family history (first- and second-degree) and perform BSE were measured as yes/no item. Family history was determined by having college women identify the family member. The first-degree and second-degree relatives were included in family history for this study. BSE self-efficacy was measured using an item with a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree and dichotomized to high or low levels of BSE selfefficacy. Breast Cancer Prevention Knowledge and Beliefs
Methods Using a cross-sectional study, a convenience sample of college women was recruited at one university in the
The nine items assessed the modifiable breast cancer risk factors such as increased weight, hormone replacement therapy, or alcohol consumption, non-modifiable factors
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such as breast cancer family history or increased age, and beliefs such as breast size contributing to breast cancer.
J Community Health (2015) 40:124–130 Table 1 Demographic characteristics Characteristics
Information Sources The breast cancer prevention media information sources or channels were assessed using five yes/no items. The items included receiving breast cancer prevention information within the last year from the Internet, radio, television, newspaper, and magazines. The interpersonal information sources assessed breast cancer prevention communication from providers, friends, or mothers. The mother-daughter communication item was assessed using one yes/no item, ‘‘Did you receive advice from your mother about things to do to lower your breast cancer risk?’’ Two items for communication from friends and provider were assessed using a 5-point Likert scale. The scale rankings ranged from 1 = strongly disagree to 5 = strongly agree and responses were dichotomized as disagree/agree. Data Analysis
Total N = 546 N (%)
Non-Hispanic n = 277 N (%)
Hispanic n = 269 N (%)
Age (mean = 23.3 years, SD = 7.75) 18–22
.285
385 (72)
118 (60)
197 (74)
23? University level
152 (28)
82 (30)
70 (26)
Undergraduate
477 (89)
230 (86)
247 (92)
56 (11)
36 (14)
20 (8)
Graduate
p value
.023*
Family history breast cancer
.014*
No
356 (65)
167 (60)
189 (70)
Yes
190 (35)
110 (40)
80 (30)
Low
276 (51)
130 (47)
147 (53)
High
270 (49)
147 (53)
123 (46)
No
244 (45)
124 (46)
120 (45)
Yes
295 (55)
146 (54)
149 (55)
BSE self-efficacy
.086
Perform BSE
.759
BSE Breast self-exam * p \ .05
Data analysis included descriptive statistics and bivariate analyses. Chi square tests examined the relationship between race/ethnicity and breast cancer risk reduction knowledge, media and interpersonal information sources, and demographics. SPSS Statistics, Version 20, was used to analyze data. The alpha level of .05 was used to determine statistical significance.
Results Table 1 shows a total of 546 college women were nearly evenly divided between non-Hispanic (51 %) and Hispanic college women (49 %) with a mean age of 23.3 (SD = 7.75). Non-Hispanics college women were significantly more likely to be undergraduate (92 %) compared to Hispanic college women (86 %) (p = .023). Non-Hispanic college women (40 %) were significantly more likely to have a breast cancer family history compared to Hispanic college women (30 %) (p = .014). Overall, 55 % performed BSE and 49 % had high level of BSE self-efficacy. Breast Cancer Prevention Knowledge and Beliefs Breast cancer prevention knowledge and belief levels were similar for non-Hispanic and Hispanic college women except for one item (Table 2). Unmodifiable breast cancer risk factor knowledge was higher compared to modifiable breast cancer risk factor knowledge. For unmodifiable breast cancer risk factors, the correct knowledge levels were breast cancer family history (95 %), age (90 %), late
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menopause (38 %), and early menstrual cycle (45 %). For modifiable risk factors, the knowledge levels were obesity (72 %), menopausal hormone therapy (68 %), alcohol consumption (52 %), and childbearing after 35 (63 %). For the belief score, non-Hispanic college women (92 %) were more likely to identify correctly the belief that the breast size is not related to breast cancer compared to Hispanic college women (87 %) (p = .047). Information Sources Figure 1 shows breast cancer prevention media and interpersonal information sources. For non-Hispanic college women, most common media channels or sources were the Internet (75 %), magazines (69 %), and television (56 %). The interpersonal sources were providers (72 %), friends (57 %), and mother (35 %). For Hispanic college women, most common media channels or sources were the Internet (74 %), magazines (69 %), and television (61 %). The interpersonal sources were providers (79 %), friends (65 %), and mother (36 %). Table 3 shows breast cancer prevention information sources within the non-Hispanic and Hispanic college women groups. Among non-Hispanic college women, a greater percentage of older college women reported using the radio (52 vs. 38 %, p = .038) and health communication from providers (87 vs. 69 %, p = .002) compared to younger college women. In contrast, a greater percentage of younger college women were more likely to report
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Table 2 Breast cancer risk factor knowledge and beliefs Items
Total Correct items
Hispanic Correct items
N (%)
NonHispanic Correct items n (%)
1. A woman’s chance of getting breast cancer does not increase as she gets older
485 (89.5)
241 (88.3)
244 (90.7)
.357
2. Women with large breasts are more likely to get breast cancer than women with small breasts
483 (89.3)
250 (91.9)
233 (86.6)
.047*
3. Taking hormone therapy medications to help treat signs of menopause increases your risk to develop breast cancer
370 (68.4)
192 (70.3)
178 (66.4)
.328
4. If no one in a woman’s family had breast cancer, the woman is not at risk for getting breast cancer
513 (95.0)
257 (94.8)
256 (95.2)
.859
5. Having your first menstrual period before age 12 increases your risk to develop breast cancer
245 (45.1)
123 (44.9)
122 (45.4)
.914
6. Drinking two or more alcoholic beverages daily increases your risk to develop breast cancer
281 (52.1)
136 (50.2)
145 (54.1)
.362
7. Being overweight 389 (72.0) in menopause does not increase your risk to develop breast cancer
187 (69.0)
202 (75.1)
.115
8. Having your first child after age 35 may increase your risk to develop breast cancer
339 (62.7)
180 (65.9)
159 (59.3)
.112
9. Beginning menopause after 55 increases your risk to develop breast cancer
206 (38.1)
106 (38.8)
100 (37.3)
.717
p value
n (%)
Fig. 1 Ethnic differences for information sources
* p \ .05, Chi square tests
communication from mothers compared to the older college women (40 vs. 27 %, p = .040). A greater percentage of college women with a breast cancer family history reported using the Internet (81 vs. 70 %, p = .048) and communication from providers (80 vs. 67 %, p = .019), friends (68 vs. 52 %, p = .009), and mothers (49 vs. 26 %, p \ .001) compared to college women without a breast cancer family history. No differences were identified between non-Hispanic women of two university levels for all the media sources and interpersonal sources. Among Hispanic college women, a greater percentage of older college women reported communication from providers compared to younger college women (90 vs. 75 %, p = .007). A greater percentage of college women with a breast cancer family history reported motherdaughter communication compared to college women without a breast cancer family history (50 vs. 30 %, p = .002). No differences were identified between Hispanic women of two university levels for all the media sources and interpersonal sources.
Discussion This study examined breast cancer risk factor knowledge, beliefs, and information sources among non-Hispanic and Hispanic college women. As one of the first studies to examine ethnic differences among college women, our findings provide insight for clinicians and health educators to address the unmet breast cancer prevention education needs of college women. Although an important sector of the adult population, college women have not been the target population for breast cancer prevention strategies compared to women ages 40 and older who receive mammograms. Findings show limited breast cancer risk reduction knowledge levels among college women about
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Table 3 Ethnic differences for breast cancer prevention information sources Media sources TV n (%)
Interpersonal sources Radio n (%)
Internet n (%)
Newspaper n (%)
Magazine n (%)
Provider n (%)
Friends n (%)
Mother n (%)
Non-Hispanic Age 18–22 23?
102 (54) 47 (57)
71 (38) 42 (52)*
140 (75) 60 (74)
62 (33) 26 (32)
135 (72) 50 (62)
129 (69) 71 (87)*
113 (60) 45 (55)
75 (40) 22 (27)*
126 (55)
91 (40)
167 (73)
78 (34)
161 (70)
166 (72)
137 (60)
86 (37)
21 (58)
19 (53)
29 (81)
9 (25)
21 (60)
31 (86)
18 (50)
9 (25)
No
87 (53)
72 (44)
116 (70)
112 (67)
Yes
67 (61)
44 (40)
117 (59)
83 (42)
45 (64)
3 (47)
150 (61)
University level Undergraduate Graduate BC family history 55 (33)
111 (67)
35 (32)
78 (72)
143 (73)
61 (31)
135 (69)
53 (77)
30 (43)
46 (68)
108 (44)
181 (73)
86 (35)
169 (69)
12 (60)
8 (40)
15 (79)
5 (20)
113 (60)
87 (46)
137 (73)
51 (64)
31 (39)
11 (76)
89 (81)*
88 (80)*
83 (52)
43 (26)
75 (68)*
54 (49)**
Hispanic Age 18–22 23?
147 (75)
125 (64)
75 (38)
48 (69)
21 (30)
193 (78)
158 (64)
90 (36)
12 (60)
18 (90)
15 (75)
6 (30)
69 (37)
129 (69)
146 (77)
120 (64)
57 (30)
24 (30)
54 (68)
66 (83)
54 (68)
40 (50)*
63 (90)*
University level Undergraduate Graduate BC family history No Yes BC Breast cancer * p \ .05; ** p \ .001; Chi square tests
modifiable risk factors especially for alcohol consumption. Findings also show higher breast cancer risk factor knowledge levels for non-modifiable risk factors such as family history which is consistent in previous studies [12]. It is important to note that research shows changing health behaviors to adhere to cancer prevention guidelines at an early age may help in breast cancer risk reduction for women at a later age [2, 4]. Similarly, identifying and addressing any misconceptions such breast size may also prove beneficial in improving beliefs about breast cancer. Consistent with other studies, the finding suggests the most common media information sources among college students were the Internet and magazines [17]. This finding is encouraging in that it supports needed breast cancer prevention education be sent and received by different sources for a targeted audience as guided by McGuire’s Input–Output Persuasion Model [30]. One possible explanation is that the all college women rely more on the Internet for information sources since they use technology daily on campus. In addition, there is increased use of smartphones with Internet access capabilities as health information sources. Further evaluation of information
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sources with smartphone technology and apps or Internet access among young women is warranted. Magazines may be more popular for college women compared to newspapers for breast cancer prevention information as in previous studies [17]. It was interesting that magazines and newspapers were used slightly more by all undergraduate college women than graduate college women but results were not significant. The information-seeking behaviors did not differ significantly between non-Hispanic and Hispanic college women for age or university level except for one source. Older non-Hispanic college women compared to younger non-Hispanic college women were more likely to report the radio as an information source. One unexpected finding was that only 36 % of the college women reported breast cancer prevention motherdaughter communication. Younger non-Hispanic college women were more likely to receive mother-daughter communication compared to older non-Hispanic college women. In contrast, there was no difference between younger and older Hispanic college women and motherdaughter communication. A possible explanation may be a willingness among Hispanic mothers to have
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conversations with their daughters about breast cancer. This finding underscores the importance for future research to develop and test mother-daughter communication messages including racial/ethnic differences or daughter-initiated messages to mothers [4, 28, 29, 32]. Translating empirical findings into public messages for mothers to share with daughters will serve to promote healthy lifestyles for cancer prevention. Another possible explanation is that younger non-Hispanic college women may have younger mothers than older non-Hispanic college women. Health communication about certain topics may indicate generational or cultural differences of acceptance [22–24]. In addition, future research may explore mother’s communication as information source after a breast cancer diagnosis since it may be assumed that breast cancer information is always shared with daughters [20]. The finding shows significant ethnic differences within groups for college women with a breast cancer family history and providers or friends as interpersonal sources. Although breast cancer family history was significantly related to providers and friends among non-Hispanic college women, it was not related to providers and friends among Hispanic college women. The results suggest further research to explore cultural differences for the prominent role that friends or providers play in breast cancer prevention and social support [23, 24]. One possible explanation is that Hispanic college women may discuss breast cancer with their friends which may strengthen the ability for Hispanic college women to communicate with their providers about breast cancer. Another possible explanation is that providers may not promote breast cancer prevention education consistently for non-Hispanic college women without a breast cancer family history. The needed patient education for college women from providers may enhance the ability of all college women to create healthy lifestyle habits and behaviors that influence breast cancer risk reduction.
Limitations Some limitations of this study should be considered. A cross-sectional design was used in the study and any causal relationships cannot be determined from the results. The data were measured with a self-report survey. It is possible that biased responses among college women for this health topic may cause errors. Mothers who are breast cancer survivors were included in the sample. Some mothers may not share information about the breast cancer diagnosis and treatment with their daughters. An open-ended item in the future may be added to identify attitudes of daughters of breast cancer survivors and information from mothers.
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Finally, generalizability is limited to similar populations of college women since a convenience sample was used in this study.
Conclusion The findings provide preliminary evidence in support of needed breast cancer prevention education to influence college women to make informed decisions about healthy lifestyles and modifiable risk factors for breast cancer risk reduction. The findings provide a foundation for future education using different information sources to target the college audience. The approach may include using more technology. Health providers and mothers may consider developing their important role to educate college-age women about breast cancer prevention and risk reduction modifiable factors. Future research can extend this study and identify specific messages preferred by college women for breast cancer prevention. By understanding these associations and starting with young women especially minority populations, it may be possible to reduce the breast cancer burden. Acknowledgments This work was supported by the New Mexico State University Faculty Rising Star Grant.
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ORIGINAL PAPER
Breast Cancer Prevention Knowledge, Beliefs, and Information Sources Between Non-Hispanic and Hispanic College Women for Risk Reduction Focus Cynthia Kratzke • Anup Amatya • Hugo Vilchis
Published online: 3 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Although growing research focuses on breast cancer screenings, little is known about breast cancer prevention with risk reduction awareness for ethnic differences among college-age women. This study examined breast cancer prevention knowledge, beliefs, and information sources between non-Hispanic and Hispanic college women. Using a cross-sectional study, women at a university in the Southwest completed a 51-item survey about breast cancer risk factors, beliefs, and media and interpersonal information sources. The study was guided by McGuire’s Input Output Persuasion Model. Of the 546 participants, non-Hispanic college women (n = 277) and Hispanic college women (n = 269) reported similar basic knowledge levels of modifiable breast cancer risk factors for alcohol consumption (52 %), obesity (72 %), childbearing after age 35 (63 %), and menopausal hormone therapy (68 %) using bivariate analyses. Most common information sources were Internet (75 %), magazines (69 %), provider (76 %) and friends (61 %). Least common sources were radio (44 %), newspapers (34 %), and mothers (36 %). Non-Hispanic college women with breast cancer family history were more likely to receive information from providers, friends, and mothers. C. Kratzke (&) A. Amatya Department of Public Health Sciences, MSC 3HLS, College of Health and Social Services, New Mexico State University, P.O. Box 30001, Las Cruces, NM 88003, USA e-mail: [email protected] H. Vilchis Border Epidemiology and Environmental Health Center, New Mexico State University, P.O. Box 30001, Las Cruces, NM 88003, USA H. Vilchis Polio Eradication Initiative, World Health Organization, Geneva, Switzerland
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Hispanic college women with a breast cancer family history were more likely to receive information from their mothers. Breast cancer prevention education for college women is needed to include risk reduction for modifiable health behavior changes as a new focus. Health professionals may target college women with more information sources including the Internet or apps. Keywords Breast cancer Prevention Healthcare education Health disparities
Introduction Breast cancer prevention education may help reduce the breast cancer burden [1–4]. Despite increased screening mammography, health disparities remain with breast cancer as the leading cause of cancer death among Hispanic women [1]. Primary prevention strategies including breast cancer risk factor awareness are needed for women to make better health-related decisions [3–5]. A growing body of research suggests nonadherence to modifiable risk factors such as healthy lifestyle habits and limited alcohol consumption is a public health concern that poses increased breast cancer risks for women [5–10]. For example, post-menopausal women who adhered to the American Cancer Society Nutrition and Physical Activity Cancer Prevention Guidelines for diet, physical activity, alcohol consumption, and weight lowered their breast cancer risk by 22 % compared to non-adherent post-menopausal women during a 12 year period [10]. For college women, breast cancer risk reduction awareness is critical since the college environment may be a decision starting point for dietary changes and alcohol consumption [11]. This population may learn and value healthy lifestyles and behaviors that may be links between
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lifestyle choices and cancer risk reduction over the years [11–13]. However, less attention has been directed toward breast cancer prevention among young women [5]. Few previous studies among primarily Caucasian college women suggest only basic breast health and breast selfexamination (BSE) knowledge [13] and breast cancer risk reduction knowledge [12]. A better understanding of breast cancer prevention knowledge is needed among college women for racial/ethnic differences since breast cancer health disparities exist [1]. Furthermore, little is known about underlying breast cancer beliefs among college women for breast cancer risk factors as misconceptions such as antiperspirant use or the breast size causing breast cancer [14, 15]. Breast cancer prevention interventions may reach audiences such as college women through targeted information sources [16]. Mass media channels as source selections for college women may include the Internet, magazines, and television [17–19]. Interpersonal source selections may include cancer prevention communication from mothers [20– 22], providers [23], and friends [24]. With increasing mobile technology use and Internet access, college women have readily available online breast cancer prevention information. Although previous studies focused on Internet use for cancer survivorship information sources [25–27], it is unclear as to Internet use among college women as a breast cancer prevention information source. Thus, understanding cancer information sources among college women provides a foundation how to reach and advance ways to educate women. The purpose of this study was to examine breast cancer prevention knowledge, beliefs, and information sources between non-Hispanic and Hispanic college women. Ethnic differences among college women for breast cancer risk reduction knowledge and information sources have not been examined extensively to our knowledge for college women. This study will be an important contribution to the health education literature so providers and health educators may address the needed breast cancer prevention education targeting college-age women. Recent studies only focused on young adolescent women and breast cancer prevention education [5, 28, 29]. McGuire’s Input–Output Persuasion Model guided this study [30]. The inputs are interpersonal information sources such as providers or friends who send the message. The inputs are media sources or channels as the way the message is sent such as the Internet, radio, magazines, or television. The outputs are the ways of acting on the message or awareness of the message.
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Southwest. New Mexico has one of the highest state breast cancer mortality rates for Hispanic women compared to the national breast cancer mortality rates for Hispanic women (19.3 deaths vs. 14.8 deaths per 100,000, respectively) [1]. Inclusion criteria required that participants were college women ages 18 and older. After receiving university institutional review board approval for the study protocol, we administered a paper and pencil survey to college women recruited during community health classes in fall 2011 and spring 2012. Response rate was nearly 90 % of the college women in classrooms when compared to class registrants. Exclusion of some students included younger age or survey noncompletion. We also recruited other college women ages 18 and older using e-news bulletin and faculty class announcements to participate in the online survey. A pilot was conducted with no changes prior to implementation. Informed consent was received from college women. Survey A 51-item survey was developed with sections for demographics, breast cancer prevention knowledge and beliefs, technology, and information sources. Some items were adapted from the National Health Information Trends Survey, a national survey conducted by the National Cancer Institute [31]. Items for BSE knowledge, technology, or types of breast cancer prevention information received from and given to mothers are described elsewhere [14, 18]. Demographic Characteristics Participants reported their age, university level, and race/ ethnicity. Demographics were dichotomized as age (18–22 and 23 and older), university levels (undergraduate and graduate), and race/ethnicity (non-Hispanic and Hispanic). Breast cancer family history (first- and second-degree) and perform BSE were measured as yes/no item. Family history was determined by having college women identify the family member. The first-degree and second-degree relatives were included in family history for this study. BSE self-efficacy was measured using an item with a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree and dichotomized to high or low levels of BSE selfefficacy. Breast Cancer Prevention Knowledge and Beliefs
Methods Using a cross-sectional study, a convenience sample of college women was recruited at one university in the
The nine items assessed the modifiable breast cancer risk factors such as increased weight, hormone replacement therapy, or alcohol consumption, non-modifiable factors
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such as breast cancer family history or increased age, and beliefs such as breast size contributing to breast cancer.
J Community Health (2015) 40:124–130 Table 1 Demographic characteristics Characteristics
Information Sources The breast cancer prevention media information sources or channels were assessed using five yes/no items. The items included receiving breast cancer prevention information within the last year from the Internet, radio, television, newspaper, and magazines. The interpersonal information sources assessed breast cancer prevention communication from providers, friends, or mothers. The mother-daughter communication item was assessed using one yes/no item, ‘‘Did you receive advice from your mother about things to do to lower your breast cancer risk?’’ Two items for communication from friends and provider were assessed using a 5-point Likert scale. The scale rankings ranged from 1 = strongly disagree to 5 = strongly agree and responses were dichotomized as disagree/agree. Data Analysis
Total N = 546 N (%)
Non-Hispanic n = 277 N (%)
Hispanic n = 269 N (%)
Age (mean = 23.3 years, SD = 7.75) 18–22
.285
385 (72)
118 (60)
197 (74)
23? University level
152 (28)
82 (30)
70 (26)
Undergraduate
477 (89)
230 (86)
247 (92)
56 (11)
36 (14)
20 (8)
Graduate
p value
.023*
Family history breast cancer
.014*
No
356 (65)
167 (60)
189 (70)
Yes
190 (35)
110 (40)
80 (30)
Low
276 (51)
130 (47)
147 (53)
High
270 (49)
147 (53)
123 (46)
No
244 (45)
124 (46)
120 (45)
Yes
295 (55)
146 (54)
149 (55)
BSE self-efficacy
.086
Perform BSE
.759
BSE Breast self-exam * p \ .05
Data analysis included descriptive statistics and bivariate analyses. Chi square tests examined the relationship between race/ethnicity and breast cancer risk reduction knowledge, media and interpersonal information sources, and demographics. SPSS Statistics, Version 20, was used to analyze data. The alpha level of .05 was used to determine statistical significance.
Results Table 1 shows a total of 546 college women were nearly evenly divided between non-Hispanic (51 %) and Hispanic college women (49 %) with a mean age of 23.3 (SD = 7.75). Non-Hispanics college women were significantly more likely to be undergraduate (92 %) compared to Hispanic college women (86 %) (p = .023). Non-Hispanic college women (40 %) were significantly more likely to have a breast cancer family history compared to Hispanic college women (30 %) (p = .014). Overall, 55 % performed BSE and 49 % had high level of BSE self-efficacy. Breast Cancer Prevention Knowledge and Beliefs Breast cancer prevention knowledge and belief levels were similar for non-Hispanic and Hispanic college women except for one item (Table 2). Unmodifiable breast cancer risk factor knowledge was higher compared to modifiable breast cancer risk factor knowledge. For unmodifiable breast cancer risk factors, the correct knowledge levels were breast cancer family history (95 %), age (90 %), late
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menopause (38 %), and early menstrual cycle (45 %). For modifiable risk factors, the knowledge levels were obesity (72 %), menopausal hormone therapy (68 %), alcohol consumption (52 %), and childbearing after 35 (63 %). For the belief score, non-Hispanic college women (92 %) were more likely to identify correctly the belief that the breast size is not related to breast cancer compared to Hispanic college women (87 %) (p = .047). Information Sources Figure 1 shows breast cancer prevention media and interpersonal information sources. For non-Hispanic college women, most common media channels or sources were the Internet (75 %), magazines (69 %), and television (56 %). The interpersonal sources were providers (72 %), friends (57 %), and mother (35 %). For Hispanic college women, most common media channels or sources were the Internet (74 %), magazines (69 %), and television (61 %). The interpersonal sources were providers (79 %), friends (65 %), and mother (36 %). Table 3 shows breast cancer prevention information sources within the non-Hispanic and Hispanic college women groups. Among non-Hispanic college women, a greater percentage of older college women reported using the radio (52 vs. 38 %, p = .038) and health communication from providers (87 vs. 69 %, p = .002) compared to younger college women. In contrast, a greater percentage of younger college women were more likely to report
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Table 2 Breast cancer risk factor knowledge and beliefs Items
Total Correct items
Hispanic Correct items
N (%)
NonHispanic Correct items n (%)
1. A woman’s chance of getting breast cancer does not increase as she gets older
485 (89.5)
241 (88.3)
244 (90.7)
.357
2. Women with large breasts are more likely to get breast cancer than women with small breasts
483 (89.3)
250 (91.9)
233 (86.6)
.047*
3. Taking hormone therapy medications to help treat signs of menopause increases your risk to develop breast cancer
370 (68.4)
192 (70.3)
178 (66.4)
.328
4. If no one in a woman’s family had breast cancer, the woman is not at risk for getting breast cancer
513 (95.0)
257 (94.8)
256 (95.2)
.859
5. Having your first menstrual period before age 12 increases your risk to develop breast cancer
245 (45.1)
123 (44.9)
122 (45.4)
.914
6. Drinking two or more alcoholic beverages daily increases your risk to develop breast cancer
281 (52.1)
136 (50.2)
145 (54.1)
.362
7. Being overweight 389 (72.0) in menopause does not increase your risk to develop breast cancer
187 (69.0)
202 (75.1)
.115
8. Having your first child after age 35 may increase your risk to develop breast cancer
339 (62.7)
180 (65.9)
159 (59.3)
.112
9. Beginning menopause after 55 increases your risk to develop breast cancer
206 (38.1)
106 (38.8)
100 (37.3)
.717
p value
n (%)
Fig. 1 Ethnic differences for information sources
* p \ .05, Chi square tests
communication from mothers compared to the older college women (40 vs. 27 %, p = .040). A greater percentage of college women with a breast cancer family history reported using the Internet (81 vs. 70 %, p = .048) and communication from providers (80 vs. 67 %, p = .019), friends (68 vs. 52 %, p = .009), and mothers (49 vs. 26 %, p \ .001) compared to college women without a breast cancer family history. No differences were identified between non-Hispanic women of two university levels for all the media sources and interpersonal sources. Among Hispanic college women, a greater percentage of older college women reported communication from providers compared to younger college women (90 vs. 75 %, p = .007). A greater percentage of college women with a breast cancer family history reported motherdaughter communication compared to college women without a breast cancer family history (50 vs. 30 %, p = .002). No differences were identified between Hispanic women of two university levels for all the media sources and interpersonal sources.
Discussion This study examined breast cancer risk factor knowledge, beliefs, and information sources among non-Hispanic and Hispanic college women. As one of the first studies to examine ethnic differences among college women, our findings provide insight for clinicians and health educators to address the unmet breast cancer prevention education needs of college women. Although an important sector of the adult population, college women have not been the target population for breast cancer prevention strategies compared to women ages 40 and older who receive mammograms. Findings show limited breast cancer risk reduction knowledge levels among college women about
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Table 3 Ethnic differences for breast cancer prevention information sources Media sources TV n (%)
Interpersonal sources Radio n (%)
Internet n (%)
Newspaper n (%)
Magazine n (%)
Provider n (%)
Friends n (%)
Mother n (%)
Non-Hispanic Age 18–22 23?
102 (54) 47 (57)
71 (38) 42 (52)*
140 (75) 60 (74)
62 (33) 26 (32)
135 (72) 50 (62)
129 (69) 71 (87)*
113 (60) 45 (55)
75 (40) 22 (27)*
126 (55)
91 (40)
167 (73)
78 (34)
161 (70)
166 (72)
137 (60)
86 (37)
21 (58)
19 (53)
29 (81)
9 (25)
21 (60)
31 (86)
18 (50)
9 (25)
No
87 (53)
72 (44)
116 (70)
112 (67)
Yes
67 (61)
44 (40)
117 (59)
83 (42)
45 (64)
3 (47)
150 (61)
University level Undergraduate Graduate BC family history 55 (33)
111 (67)
35 (32)
78 (72)
143 (73)
61 (31)
135 (69)
53 (77)
30 (43)
46 (68)
108 (44)
181 (73)
86 (35)
169 (69)
12 (60)
8 (40)
15 (79)
5 (20)
113 (60)
87 (46)
137 (73)
51 (64)
31 (39)
11 (76)
89 (81)*
88 (80)*
83 (52)
43 (26)
75 (68)*
54 (49)**
Hispanic Age 18–22 23?
147 (75)
125 (64)
75 (38)
48 (69)
21 (30)
193 (78)
158 (64)
90 (36)
12 (60)
18 (90)
15 (75)
6 (30)
69 (37)
129 (69)
146 (77)
120 (64)
57 (30)
24 (30)
54 (68)
66 (83)
54 (68)
40 (50)*
63 (90)*
University level Undergraduate Graduate BC family history No Yes BC Breast cancer * p \ .05; ** p \ .001; Chi square tests
modifiable risk factors especially for alcohol consumption. Findings also show higher breast cancer risk factor knowledge levels for non-modifiable risk factors such as family history which is consistent in previous studies [12]. It is important to note that research shows changing health behaviors to adhere to cancer prevention guidelines at an early age may help in breast cancer risk reduction for women at a later age [2, 4]. Similarly, identifying and addressing any misconceptions such breast size may also prove beneficial in improving beliefs about breast cancer. Consistent with other studies, the finding suggests the most common media information sources among college students were the Internet and magazines [17]. This finding is encouraging in that it supports needed breast cancer prevention education be sent and received by different sources for a targeted audience as guided by McGuire’s Input–Output Persuasion Model [30]. One possible explanation is that the all college women rely more on the Internet for information sources since they use technology daily on campus. In addition, there is increased use of smartphones with Internet access capabilities as health information sources. Further evaluation of information
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sources with smartphone technology and apps or Internet access among young women is warranted. Magazines may be more popular for college women compared to newspapers for breast cancer prevention information as in previous studies [17]. It was interesting that magazines and newspapers were used slightly more by all undergraduate college women than graduate college women but results were not significant. The information-seeking behaviors did not differ significantly between non-Hispanic and Hispanic college women for age or university level except for one source. Older non-Hispanic college women compared to younger non-Hispanic college women were more likely to report the radio as an information source. One unexpected finding was that only 36 % of the college women reported breast cancer prevention motherdaughter communication. Younger non-Hispanic college women were more likely to receive mother-daughter communication compared to older non-Hispanic college women. In contrast, there was no difference between younger and older Hispanic college women and motherdaughter communication. A possible explanation may be a willingness among Hispanic mothers to have
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conversations with their daughters about breast cancer. This finding underscores the importance for future research to develop and test mother-daughter communication messages including racial/ethnic differences or daughter-initiated messages to mothers [4, 28, 29, 32]. Translating empirical findings into public messages for mothers to share with daughters will serve to promote healthy lifestyles for cancer prevention. Another possible explanation is that younger non-Hispanic college women may have younger mothers than older non-Hispanic college women. Health communication about certain topics may indicate generational or cultural differences of acceptance [22–24]. In addition, future research may explore mother’s communication as information source after a breast cancer diagnosis since it may be assumed that breast cancer information is always shared with daughters [20]. The finding shows significant ethnic differences within groups for college women with a breast cancer family history and providers or friends as interpersonal sources. Although breast cancer family history was significantly related to providers and friends among non-Hispanic college women, it was not related to providers and friends among Hispanic college women. The results suggest further research to explore cultural differences for the prominent role that friends or providers play in breast cancer prevention and social support [23, 24]. One possible explanation is that Hispanic college women may discuss breast cancer with their friends which may strengthen the ability for Hispanic college women to communicate with their providers about breast cancer. Another possible explanation is that providers may not promote breast cancer prevention education consistently for non-Hispanic college women without a breast cancer family history. The needed patient education for college women from providers may enhance the ability of all college women to create healthy lifestyle habits and behaviors that influence breast cancer risk reduction.
Limitations Some limitations of this study should be considered. A cross-sectional design was used in the study and any causal relationships cannot be determined from the results. The data were measured with a self-report survey. It is possible that biased responses among college women for this health topic may cause errors. Mothers who are breast cancer survivors were included in the sample. Some mothers may not share information about the breast cancer diagnosis and treatment with their daughters. An open-ended item in the future may be added to identify attitudes of daughters of breast cancer survivors and information from mothers.
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Finally, generalizability is limited to similar populations of college women since a convenience sample was used in this study.
Conclusion The findings provide preliminary evidence in support of needed breast cancer prevention education to influence college women to make informed decisions about healthy lifestyles and modifiable risk factors for breast cancer risk reduction. The findings provide a foundation for future education using different information sources to target the college audience. The approach may include using more technology. Health providers and mothers may consider developing their important role to educate college-age women about breast cancer prevention and risk reduction modifiable factors. Future research can extend this study and identify specific messages preferred by college women for breast cancer prevention. By understanding these associations and starting with young women especially minority populations, it may be possible to reduce the breast cancer burden. Acknowledgments This work was supported by the New Mexico State University Faculty Rising Star Grant.
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