Effects of Health Belief and Cancer Fatalism on the Practice of Breast Cancer Screening Among Nigerian Women

In Nigeria, late presentation has been described as the hallmark of breast cancer and reasons given include poverty, under-education, lack of knowledge and poor access to care (Akhigbe & Omuemu, 2009; Okobia et al, 2006; Atoyebi et al, 1997). However, studies have shown that even when these factors are statistically controlled, African-Americans are still less likely to participate in cancer screening (Powe 1996). It was therefore concluded that other factors such as cultural values and beliefs may operate independent of variables such as poverty and education in affecting the decision to go for screening.


Introduction
Breast cancer has been reported as the highest cause of cancer deaths amongst women worldwide. The incidence and prevalence of cancer is rapidly increasing in the developed and developing countries. More than 10 million people are diagnosed with cancer every year. It is estimated that there will be 15 million new cases every year by 2020 (Horton, 2006) Rising incidence of breast cancer as well as earlier age of presentation has been reported in developing countries. Since no cure has been found for breast cancer, early diagnosis and early treatment have been found to yield a better survival rate.
T h e r e i s n o w s t r o n g e v i d e n c e t h a t a n i n d i v i d u a l ' s r i s k o f d e v e l o p i n g c a n c e r c a n b e substantially reduced by healthy behavior such as participating in cancer screening according to recommended guidelines. The American Cancer Society posits that if we can effectively promote healthy behaviors, much of the suffering and death from cancer can be prevented or reduced (American Cancer Society, 2002).
However, poor practice of breast cancer screening methods has been reported in many studies in Nigeria (Akhigbe & Omuemu, 2009;Okobia et al, 2006). Beyond poor knowledge, or ignorance, several other factors have been found to influence the practice of breast cancer screening in different countries, including Nigeria.
In Nigeria, late presentation has been described as the hallmark of breast cancer and reasons given include poverty, under-education, lack of knowledge and poor access to care (Akhigbe & Omuemu, 2009;Okobia et al, 2006;Atoyebi et al, 1997). However, studies have shown that even when these factors are statistically controlled, African-Americans are still less likely to participate in cancer screening (Powe 1996). It was therefore concluded that other factors such as cultural values and beliefs may operate independent of variables such as poverty and education in affecting the decision to go for screening.
Health beliefs differ from culture to culture. In Nigeria, beliefs are usually influenced by cultural and religious values, which in turn influence health behavior such as response to screening awareness campaigns.
The Health Belief Model (HBM) has been used as a theoretical framework to study Breast Self-Examination and other breast cancer detection behaviors. The model stipulates that www.intechopen.com health-related behavior is influenced by a person's perception of the threat posed by a health problem and by the value associated with his or her action to reduce that threat (Champion et al, 1997).
Cancer fatalism, the belief that death is inevitable when cancer is present has also been identified as a barrier to participation in cancer screening, detection and treatment. Cancer fatalism is believed to be the result of cultural, historical and socioeconomic factors that have influenced the lived experience of African-Americans (Powe, 1996).
Nigeria is the most populous black African nation and breast cancer screening practice has been extremely poor. As has been found in other parts of the world, people of African origin are less likely to participate in cancer screening programs. (Powe, 1996) Breast cancer tends to be discovered in the later stages, when treatment options are limited and mortality rates increase, which is similar to reports in Nigeria.
If we are to develop materials for educational intervention, they have to be culturally sensitive as the goal of such a drive will be to increase breast cancer knowledge, decrease cancer fatalism and improve participation in breast cancer screening among Nigerian women.
Health beliefs and fatalism have been studied in various populations as means of identifying other strategies to help promote positive health behaviors, such as cancer screening. There is limited information concerning such a study in Nigeria.

Health belief model
The Health Belief Model (HBM) is by far the most commonly used theory in health education and health promotion (Glanz, Rimer, & Lewis, 2002).
The HBM is a method used to evaluate and explain individual differences in preventative health behavior (Janz et al, 2002). The HBM has had the greatest influence in research related to prediction associated with breast cancer screening behaviors; several studies have used the HBM to understand breast cancer screening behaviors. The HBM model subscales measure six concepts, including perceived susceptibility, perceived seriousness, barriers, benefits, health motivation, and confidence (Champion 1999).

Perceived susceptibility
As the first component of the HBM, perceived susceptibility is defined as a subjective perception of the risk of an illness. One's belief regarding the chances of being diagnosed with a medical condition can be applied by defining populations at risk and risk levels (Janz et al., 2002). Individual risk may be based on personal characteristics or behavior. Comparisons of perceived susceptibility with action risk can also be conducted (Janz et al., 2002). Related to breast cancer screening behaviors, perceived susceptibility may include the risk of a breast cancer diagnosis in the long term or immediate future.

Perceived severity
Perceived severity, formerly called perceived "seriousness" is the second construct of the HBM. Perceived severity speaks to an individual's belief about the severity or seriousness of www.intechopen.com a disease and the sequence of events after diagnosis and personal feelings related to the consequences of a specific medical condition (Janz,Champion, & Stretcher, 2002). Possible medical consequences may include death, disability, and pain; possible social consequences consist of effects on work, family life, and social relations (Janz et al., 2002).The combination of perceived susceptibility and perceived severity has been labeled perceived threat.

Perceived benefits
The construct of perceived benefits is a person's opinion of the value or usefulness of a new behavior in decreasing the risk of developing a disease. Also termed as perceived benefits of taking health action, the attitudes of health behavior changes are reliant on one's view of the health benefits for performing a health action (Janz et al.,2002). Perceived benefits play a significant role in the adoption of secondary preventive behaviours, such as screenings. It is widely known and accepted that the earlier breast cancer is found, the greater the chances of survival. It is also known that breast self-examination (BSE), when done regularly, can be an effective means of early detection. But not all women do BSE regularly. They have to believe there is a benefit in adopting this behavior, which is exactly what was found to be true among black women: those who believed breast self-examinations were beneficial did them more frequently (Graham, 2002).

Perceived barriers
Perceived barriers refer to the potential negative aspects of or obstructions to taking a recommended health action. This is the belief about physical and psychological costs of taking health action (Janz et al., 2002). An internal cost benefit analysis occurs, weighing the health action's expected effectiveness against perceptions that it may become an obstacle. Potential barriers may include financial expense, danger, pain, difficulty, upset, inconvenience, and time-consumption (Janz et al., 2002). Perceived barriers to performing breast cancer screening behaviors were emotional, social, and physical.
Even when women know that breast cancer is a serious disease, and one for which women are at risk and one for which the perception of threat is high, the barriers to performing BSE exert a greater influence over the behavior than does the threat of cancer itself (Champion, 1993;Champion & Menon, 1997;Umeh & Rogan-Gibson, 2001). Some of these barriers include difficulty with starting a new behavior or developing a new habit, fear of not being able to perform BSE correctly, having to give up things in order to do BSE, and embarrassment (Umeh & Rogan-Gibson, 2001).

Self-efficacy
Self-efficacy was added to the original four beliefs of the HBM in 1988 (Rosenstock, Strecher, & Becker, 1988). Self-efficacy is the belief in one's own ability to do something (Bandura, 1977). If a person believes a new behavior is useful (perceived benefit), but does not think he or she is capable of doing it (perceived barrier), chances are that it will not be tried. According to Umeh & Rogan-Gibson (2001), a significant factor in not performing BSE is fear of being unable to perform BSE correctly. In other words, unless a woman believes she is capable of performing BSE (that is, has BSE self-efficacy), this barrier will not be overcome and BSE will not be done. www.intechopen.com

Cues to action
Cues to action, formerly known as motivation, are events, people, or things that move people to change their behavior. Examples of cues include media reports about preventing breast cancer, illness of a family member, and perceived benefits (Graham, 2002).

Cancer fatalism
Studies have revealed that fatalism may be a deterrent to participation in health promoting behaviours. Fatalism is the belief that all things in the world are under the control of some invisible force, and we are powerless to do anything about it. Fatalism is in general the view which holds that all events in the history of the world, and, in particular, the actions and incidents which make up the story of each individual life are determined by fate (Knight, 2003). Fatalism is the belief that situations, such as illnesses or catastrophic events, happen because of a higher power (such as God), or they are just meant to happen, and cannot be avoided (Talbert PY, 2008). Indeed, fatalism has a strong tie with religion.
Religious beliefs are particularly dominant among Nigerians, and together with a passionate confidence in God are such beliefs in fatalism, magic, witchcraft, and demons. Although Christianity and Islam have replaced traditional religions, the thoughts of the people about life, and their attitude to it, are still shaped by the old worldview. They exhibit this in their day-to-day interpersonal interactions (Jegede, 2002). These beliefs therefore remain, even in educated people long after their possible conversion to Christianity or Islam. As a result, fatalism remains a part of the average Nigerian's worldview. Worldview may be defined as the mental grid through which one sees the world (Sarma, 2007).
Cancer fatalism is a situational manifestation of fatalism in which individuals may feel powerless in the face of cancer and may view a diagnosis of cancer as a struggle against insurmountable odds (Powe & Johnson, 1995).
This study therefore seeks to understand the perception of Nigerian women about breast cancer screening using the health beliefs model with the subscales of perceived susceptibility, perceived severity, perceived benefits and barriers as well as self-efficacy and cues to action, including cancer fatalism.

Hypotheses
1. There is no significant relationship between the practice of breast self-examination and perceived barriers. 2. There is no significant relationship between participants' use of mammography and perceived barriers. 3. There is no significant association between breast cancer fatalism and breast selfexamination.

Methodology
This study employed a descriptive correlation design, with health beliefs and cancer fatalism operationalized by the participants' responses to Champion's Health Belief Model Scale and Powe's Cancer Fatalism Scale respectively.

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The study evaluated the effects of health belief and cancer fatalism on the practice of breast cancer screening among educated Nigerian women. The dependent variables were breast self-examination and mammography. The independent variables were the components of the health belief model, and cancer fatalism.

Data collection
Purposive sampling was employed in recruiting two hundred and twenty five participants from among female health professionals (consisting of medical doctors, nurses, pharmacists and radiographers) in the Teaching Hospital and female teachers in secondary schools in the Benin City metropolis, aged between 30 and 60. The choice of purposive sampling technique "ensures that only elements relevant to the research are included and guarantees that extra care is taken to select those elements that satisfy the requirements of the research" (Nworgu, 1991). Informed consent was obtained and participants were assured confidentiality of responses. Participation meant responding to a questionnaire soliciting demographic information as well as the Champion's Health Belief Model Scale and the Powe Cancer Fatalism Scale.

Instruments
Champion's Health Belief Model Scale: HBM scales for measuring beliefs related to breast cancer were assessed for content validity by a panel of three health educators who are familiar with the HBM and breast cancer screenings. It was agreed that the first item in the subscale of perceived susceptibility (It is extremely likely I will get breast cancer in the future) might meet with a strong denial by the average Nigerian woman. A pilot testing of the instrument subsequently revealed two items in the Health Belief Model scale that considerably lowered the internal consistency of the subscales. Together with an item in the Cues to action subscale (I have regular health check-ups even when I am not sick), these two items were excluded. All HBM scales were measured on a five-point Likert type scale with the following coding: strongly disagree (1); disagree (2); neutral (3); agree (4); and strongly agree (5).
Powe Cancer Fatalism Scale: Participants' level of breast cancer fatalism was assessed with the Powe Cancer Fatalism Scale (Powe, 1995). The Inventory is a 15-item questionnaire based on the philosophic origins and attributes of cancer fatalism (fear, predetermination, pessimism, inevitable death), with a Yes or No response. Each "Yes" response was scored as one point and a "No" response as zero, giving the possible range of scores from 0 to 15.
Higher scores on the Powe Scale reflect higher degrees of fatalism. A score of zero to five indicates a low degree of fatalism, scores from six to ten indicate a moderate degree of fatalism, and scores from eleven to fifteen reflect a high degree of fatalism. In a study aimed at differentiating higher versus lower levels of cancer fatalism among a sample of African American women, Powe (2001) selected a mean score of 8 as a cut-off point, coding scores of 0 to 8 as low cancer fatalism and scores 9 to 15 as high cancer fatalism. In this study, a cutoff point determined by median split was used to classify participants as "High" and "Low" Breast Cancer Fatalism individuals. Participants with scores equal to or greater than 13 were categorized as "High Fatalism" individuals and those whose scores on this scale were below 13 were classified as "Low Fatalism" individuals.
The Statistical Package for the Social Science (SPSS) computer software programme (version 16 for Windows) was used to conduct frequency analyses and correlations.

Results
Cronbach's alpha tests of reliabilities, conducted to assess the internal consistency of the six HBM subscales (i.e., susceptibility, severity, benefits, barriers, self-efficacy, and cues to action) and the fatalism scale are presented in Table 1. All alpha coefficients were in the .82 to .97 which suggests the instrument had acceptable to excellent internal consistency (DeVillis, 2003).

Demographic data
The survey population consisted of 225 women aged between 30 and 60 years who completed the survey instrument. Majority of the respondents (83.1%) were between 30 -49 years of age. Most (95.1%) were married.
Educationally, 55.1% had completed University education while 44.9% had post-secondary but not university education. Post-secondary education includes training schools for nursing, medical laboratory science, radiography as well as colleges of education. Until recently, most of these schools offered certificate or diploma courses. Their products work as nurses, laboratory scientists, radiographers and teachers in primary and junior secondary schools. Health professionals, including doctors, pharmacists, nurses, medical laboratory scientists and radiographers accounted for 24.9% of the study population, while the remaining 75.1% were secondary school teachers. Nigeria is a multi-ethnic nation and Benin City is the capital of Edo State where the Binis and Ishans constitute a sizable proportion of the population. The Binis/Ishans constitute 56.4% with the Igbos and Yorubas together with a string of closely related ethnic groups contributing almost equally to the study population. The southern part of Nigeria is predominantly Christian, hence 88.4% professed Christianity as their religion.
None of the respondents has ever been diagnosed with breast cancer but 7.1% reported that a family member or friend has experienced breast cancer. 35.6% of the respondents regularly do breast self-examination while 64.4% do not. Only a minute proportion of the study population (6.7%) has ever had a mammogram done, an overwhelming percentage has never had a mammogram done.

Health belief model characteristics
Participants were asked to indicate the degree to which they agreed or disagreed with statements related to perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy of breast cancer screening.

Perceived susceptibility
Majority of the respondents had high scores on the Perceived Susceptibility subscale. 79.5% either agreed or strongly agreed that their chances of getting breast cancer in the next few years are great. Similarly, majority either agreed or strongly agreed they feel they will get breast cancer sometime in their lifetime (77.3%), and concerned about the likelihood of developing breast cancer (53.3%). Table 3 shows a profile of perceived susceptibility.

Perceived severity
Although majority of participants agreed with the statements: Breast cancer would threaten a relationship with my boyfriend, husband or partner (39.6%); and If I developed breast cancer, I would not live longer than 5 years (69.3%), many neither agreed nor disagreed with most of the perceived severity subscale items.

Perceived benefits of breast self-examination
An overwhelming majority of the participants either disagreed or strongly disagreed with the statements: When I do breast self-examination, I am doing something to take care of myself (75.5%); Completing breast self-examination each month may help me to find breast lumps early (77.1%); Completing breast self-examination each month may decrease my chances of dying from breast cancer (68%); and If I find a lump early through breast self-examination, my treatment for breast cancer may not be as bad (69.3%). This reflects low perceived benefits to all the items in this subscale.

Perceived benefits of mammogram
Majority of the respondents do not agree that mammography has benefits as follows: When I get a recommended mammogram or x-ray of the breast, I feel good about myself (54.3%); When I get a mammogram or x-ray of the breast, I don't worry as much about breast cancer (52.9%); Having a mammogram or x-ray of the breast will help me find lumps early (60.9%); Having a mammogram or x-ray of the breast will decrease my chance of dying from breast cancer (51.5%); and Having a mammogram will help me find a lump before it can be felt by me or a health professional (58.2%). Very few participants agreed with the statements, while many others neither agreed nor disagreed, as seen in Table 4 3.

Perceived barriers to BSE
Participants were asked to indicate to what degree they agreed or disagreed with statements related to perceived barriers of breast cancer screening. On all the items in this subscale, participants were more in agreement with each statement. However, five items received remarkably higher agreement:

Perceived barriers to mammogram
Majority of respondents agree or strongly agree with most of the statements in this subscale but those who neither agree nor disagree were in the majority on the following: It is difficult to get transportation for a mammogram or X-ray of the breast (50.2%); Having a mammogram or Xray of the breast costs too much money (42.2%); I cannot remember to schedule an appointment for a mammogram or X-ray of the breast (57.3%).  Table 6. Frequency and Percentages of Participants Self efficacy and Cues to action Responses.

Fatalism scores
Majority of the participants were in agreement with all the items of the fatalism scale, with the following items having seventy-five percentile "Yes  Table 8. Summary of regression analysis on breast self-examination and perceived barriers.
From  Table 9. Summary of regression analysis on mammography practice and perceived barriers.
From Table 9 r = .415, f = 4.020, p > .001. This indicates a significant correlation. Therefore the hypothesis which stated that perceived barriers will have no effect on mammography practice is rejected.
Lastly, there is no significant association between breast cancer fatalism and the practice of breast self-examination. These results indicate that there is no statistically significant relationship between breast cancer fatalism and breast self-examination practice Χ 2 (1, n = 225) = 2.39, p = .122, phi = .113 There is no association between breast cancer fatalism and breast self-examination.

Discussion
Majority of women see themselves as susceptible to having breast cancer and yet an abysmally low proportion does nothing to prevent breast cancer by adopting the standard screening practices. Lack of knowledge about preventative measures has been a frequent finding from studies in this environment (Akhigbe & Omuemu, 2009).
The scores on the perceived benefits of breast self-examination subscale reflect low perceived benefits. A low knowledge of screening methods for breast cancer, even among final year medical students had been reported in this environment ). The finding of low perceived benefits in the present study is therefore not surprising.
Participants generally do not recognise the perceived benefits of screening mammography. This may explain why mammography use is very low in the study population (6.7% Nigeria. There is as yet no national health policy concerning breast cancer screening but several health and advocacy groups have been calling on the relevant health authorities to formulate and implement such a policy. However, appropriate health policy even with government funding will not necessarily increase mammography usage; awareness has to be created and populaton at risk have to know what benefits they stand to gain from having screening mammography done. The present study has revealed a high level of breast cancer fatalism among Nigerian women. It is therefore not surprising that the respondents who have shown high levels of perceived susceptibility still do not take preventative measures. It is like 'If it will happen, nothing can stop it from happening'. Powe (1996) observed that many factors affect a person's decision to participate in cancer screening; poor access to care, poverty, undereducation, and lack of knowledge regarding cancer have a negative relationship to participation in cancer screening. Studies have shown that being African American is positively correlated with these factors, and that even when these factors are statistically controlled, African Americans are still less likely to participate in cancer screening. Could the findings among African Americans be a 'cultural carry-over' from their roots?
The present study appears to be highly supportive of the preceding conclusion. The academic and professional background of the study participants is clearly remarkable and above average, all of them working as either health professionals or secondary school teachers. They however have high scores in perceived susceptibility subscale of the HBM and very low score in the perceived benefits subscale; besides the practice of BSE and mammography is pitiably low. This poses a problem for working out appropriate, culturally relevant educational protocol for increasing breast cancer screening practices among Nigerian women. Having adequate knowledge of breast cancer and breast cancer screening methods is clearly not enough. Cultural barriers such as breast cancer fatalism will need to be overcome using appropriate educational intervention.
Three hypotheses were tested. The rejection of the first hypothesis shows that perceived barriers have a direct negative effect on the practice of breast self-examination among the study population. Previous studies have noted poor knowledge of breast self-examination practice as a screening method among Nigerian women irrespective of their level of education or professional status (Odusanya & Tayo 2001;Akhigbe & Omuemu 2009). From the item responses on the perceived barrier subscale, such factors as large breast size and inadequate self-efficacy in performing a breast self-examination constitute major barriers. Focused educational intervention remains the obvious solution.
The rejection of the second hypothesis shows that perceived barriers have a direct negative effect on mammography practice among the study population. There is a technology requirement for mammography practice. This makes economic consideration a veritable factor to overcoming this barrier. Unfortunately, health professional do not seem to fare better in their knowledge and practice of mammography, as this study and previous studies have consistently shown. There is therefore an urgent need for a review of training curricula by health institutions to include cancer awareness and screening methods. This may positively impact on the health behavior of those who are expected to teach others. www.intechopen.com The third hypothesis was accepted, that is, there is no significant relationship between cancer fatalism and the practice of breast self-examination. Cancer fatalism is deeply rooted in ethno religious beliefs of the people. The individual, having resigned herself to fate or luck does nothing as prevention. Cancer fatalism, however, is a complex phenomenon with far-reaching implications (Powe & Finnie, 2003).

Conclusion
There is paucity of research publications on the effects of health belief model and cancer fatalism with regards to breast cancer among Nigerian women.
There is need to for us to understand the psychological and psychosocial barriers that deter Nigerian women from having adequate breast cancer awareness as well as routine screening. Such information will be useful in putting together culturally relevant awareness literature and media content that address these barriers.
From the health belief model, there are significant barriers that impact negatively on the practice of the two main screening methods, breast self-examination for which no tools or economic input is required, and screening mammography with the obvious advantages. Another significant finding is the high level of breast cancer fatalism among the study population. This represents a helpless resignation to accepting whatever the "death sentence" of breast cancer brings to the afflicted. Fatalism has remained a major cultural setback in this setting.
This study therefore represents preliminary findings that should form the basis for further research.