# Presentation: 668647

## Risk and Worry as Predictors of Cancer Screening Behavior:  Results Using HINTS Data

- Richard P. Moser, Ph.D.1, Kevin McCaul, Ph.D.2,
- Ellen Peters, Ph.D.3, Wendy Nelson, Ph.D.1,
- Stephen Marcus, Ph.D.1
- 1NCI 2North Dakota State University
- 3Decision Research/University of Oregon

- HINTS Data Users Conference
- January 21, 2005

## The Role of Susceptibility

- Key concept in Health Belief Model
- A *cognition*; can be assessed in several ways (Weinstein et al.) e.g.:
- Risk: Comprehension of the **likelihood **(probability/chance) of developing a disease
- As *affect*
- Importance in decision making (Loewenstein et al., 2001)
- Worry:
- Signifies importance
- Serves as salient reminder through rumination
- Motivates planning
- Both related to cancer screening (e.g., McCaul et al., 1996)

**Notes:**
Susceptibility is one of several important components of the HBM including Perceived Severity, Perceived Benefits, and Perceived Barriers.  Together these interact to explain health-related behavior

Empirical tests of this model suggest that Susceptibility is especially important in explaining health preventive behavior (as opposed to sick-role behavior)

HBM postulates that people will take action to prevent (screen for) heath conditions if they regard themselves as susceptible (at risk), if they believe it would have potentially serious consequences, if they believe that a course of action would be beneficial in reducing risk, if they believe that the anticipated barriers to taking action are outweighed by the benefits, and they are capable of take action.

Other terms synonymous with susceptibility:
Vulnerability
Risk

What is “risk”?
1) “risk” =potential negative consequences; e.g. “What illnesses can be caused by smoking cigarettes (drinking alcohol/engaging in unprotected sex)?”
2) Beliefs about the nature of these consequences—e.g., ““How long does a person typically live after being diagnosed with lung cancer?”
3) Likelihood (or probability/personal risk/susceptibility/chance) of developing a disease

In HINTS, Risk is assessed by asking:
“How likely do you think it is that you will develop _____ cancer in the future?  Would you say your chance of getting _____ cancer is...”
 Very low
 Somewhat low
 Moderate
 Somewhat high
 Very high

Some authors, however, have suggested that vulnerability can also be conceptualized as a “feeling” or set of feelings (Slovic, Finucane, Peters, & MacGregor, 2004). 

-Affect used as a heuristic (problem-solving technique) for decision making: 

-Worry about cancer adds to one’s list of reasons for trying to do something about cancer (if I’m this worried; it must be important).  
-It creates rumination, which has a good byproduct— keeping an issue “in mind” and serving as a reminder about possible actions.  
-And worry is bothersome, so it probably motivates plans to do something about the future, thereby reducing worry.

-”How often do you worry about getting ____ cancer?”
Rarely or never;
Sometimes
Often
All the time

-McCaul et al (1996)-Meta analysis; Studies that measured perceived risk (18 out of 19) showed that there was a linear relationship between feeling vulnerable to breast cancer and having obtained a screening.

-McCaul et al. (1996)-meta analysis-studies that measured worry (n = 6) showed that greater worry was related to higher screening levels.

What is unique about this study is that few, if any, studies have examined the independent effects of both perceived risk and worry in the same model and the interaction

## Health Behavior Outcomes:  Cancer Screening

- Reduces disease-related morbidity and mortality
- Increases cancer survival rates for certain types of cancer
- ACS/USPSTF Current screening guidelines
- Coded for analyses:
- Regular/Not Regular
- Mammography (Breast)
- FOBT (Colorectal)
- Lifetime (Yes/No)
- Sigmoidoscopy
- Colonoscopy
- PSA

**Notes:**
Mammography: Clinical trials evidence of reductions in breast cancer mortality by approximately 20-39% among women aged 50 to 74 and by approximately 17% among women aged 40-49.

Colorectal: Case control evidence for reductions in colon cancer mortality by 59% for sigmoidoscopy and evidence for reduced risk from one case control of colonoscopy. 

Evidence more mixed on PSA Screening

U.S. Preventative Services Task Force Current Recommendations:
 Breast- women 40+ every 1-2 years
 Colorectal-50+ should be screened (no frequency guidelines); ACS (2001) recommended annual FOBT; sigmoid every 5 years, colonoscopy every 10 years
 Prostate-USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE); recent change—earlier guideline (ACS, 2001)that may apply better to this group suggested men 50+ should be offered this annually

Regular Mammography= “When did you have your most recent mammogram to check for breast cancer?” and “How long before (your most recent mammogram) was the last one?”  Women 40+ who said that their two most recent mammograms were within two years of each other were coded as being “Regular” screeners; everyone else was coded as “Not Regular”. The exception to this was women between 40 and 42 years old; as long as their most recent mammogram was no more than two years ago, they were coded as Regular screeners. 

Regular FOBT= Respondents who answered that their most recent stool blood test was no more than one year ago and that the one before the most recent was no more than two years previous, were coded as being “Regular” screeners; everyone else was considered as “Not Regular”.  The exception to this was respondents between 50 and 52 years old; as long as their most recent stool blood test was no more than two years ago, they were coded as “Regular” screeners. 

Lifetime= Y/N Have you ever had a _____

## Analysis Plan

- Hierarchical Logistic Regression
- Predictors of interest-three blocks:
- 1) Sociodemographic variables
- Gender (where appropriate)
- Education
- Race/Ethnicity
- Age
- 2) Access to Care
- Health care coverage
- Regular provider
- 3) Risk, Worry and interaction
- Other
- Log likelihood analyses for nested models
- Correlate risk/worry

**Notes:**
Sought to answer the following research questions:
Are risk perceptions associated with cancer screening behaviors?
Is worry about cancer associated with cancer screening behaviors?
Do risk and worry operate “in parallel” or does worry moderate risk perceptions in predicting screening?

Education-4 categories
Race/ethnicity-2 categories
Age-continuous

Health care coverage (Yes/No)
Regular provider (Yes/No)

Risk/Worry—entered as continuous-preliminary analyses indicated that both risk and worry were linearly related to the respective outcomes 

Log likelihood analyses were conducted on each successive block added to the model, after the initial one, to test for significant changes in the model as groups of variables were added. 

## Results: Correlations Between Cancer Risk and Worry*

- Breast Cancer: *r *=.42
- Colorectal Cancer: *r *=.37
- Prostate Cancer: *r *=.34
- *all significant at *p* < .05

## Distribution of Risk/Worry Responses

**Notes:**
Breast
Colon

Y axis represents % of subjects who responded in each category

## Distribution of Risk/Worry Responses (cont.)

**Notes:**
Prostate

## Outcome: Regular/Not Regular Mammography Screening (n=2150)

**Risk****	****	****	****1.18****	****	****1.04 to 1.33**
**Worry****	****	****	****1.30****	****	****1.03 to 1.63**
- Risk x Worry		0.97		0.82 to 1.16
- Regular Provider
-    Yes			2.81		1.95 to 4.06
-    No			1.00		       ---
- Health Care Coverage
-    Yes			2.59		1.72 to 3.88
-    No			1.00		       ---
- Age			1.01		1.00 to 1.02
- Education
-    College Grad		2.17		1.41 to 3.33
-    Some College		2.12		1.37 to 3.30
-    High School Grad		1.71		1.07 to 2.73
-    Less than High School	1.00		       ---
- Race/Ethnicity
-    Other			1.05		0.77 to 1.43
-    White			1.00		       ---

- (*p *< .01)

-  (*p *< .01)

**Notes:**
Red= statistically significant

Blocks in reverse order—i.e., first block was sociodemographics which included age, educ, race/ethnicity

Women 40+

## Outcome: Ever/Never Sigmoidoscopy Screening (n=2078)

**Risk****	****	****	****1.16****	****	****0.99 to 1.35 (p<.06)**
**Worry****	****	****	****1.32****	****	****1.03 to 1.69**
- Risk x Worry		0.94		0.80 to 1.11
- Regular Provider
-    Yes			1.86		1.35 to 2.55
-    No			1.00		       ---
- Health Care Coverage
-    Yes			1.31	**	**0.60 to 2.83
-    No			1.00		       ---
- Age			1.03		1.02 to 1.05
- Education
-    College Grad		2.90		1.87 to 4.51
-    Some College		2.55		1.70 to 3.82
-    High School Grad		1.21		0.79 to 1.85
-    Less than High School	1.00		       ---
- Race/Ethnicity
-    Other			0.91		0.62 to 1.35
-    White			1.00		       ---
- Gender
-    Male			1.38		1.05 to 1.82
-    Female			1.00		       ---

*(p *< .01)

*(p* < .01)

**Notes:**
Men and women 50+

## Outcome: Ever/Never Colonoscopy Screening (n=2079)

**Risk****	****	****	****1.23****	****	****1.09 to 1.38**
**Worry****	****	****	****1.43****	****	****1.09 to 1.88**
- Risk x Worry		0.94		0.80 to 1.11
- Regular Provider
-    Yes			1.89		1.28 to 2.78
-    No			1.00		       ---
- Health Care Coverage
-    Yes			2.15		1.34 to 4.08
-    No			1.00		       ---
- Age			1.03		1.02 to 1.05
- Education
-    College Grad		1.05		0.65 to 1.70
-    Some College		1.06		0.69 to 1.64
-    High School Grad		0.93		0.64 to 1.35
-    Less than High School	1.00		       ---
- Race/Ethnicity
-    Other			0.90		0.62 to 1.29
-    White			1.00		       ---
- Gender
-    Male			1.25		0.97 to 1.61
-    Female			1.00		       ---

- (*p* < .01)

- (*p* < .01)

## Outcome: Regular/Not Regular FOBT Screening (n=1878)

- Risk			0.88		0.73 to 1.05
- Worry			1.00		0.70 to 1.42
- Risk x Worry		1.12		0.90 to 1.41
- Regular Provider
-    Yes			1.72		1.05 to 2.82
-    No			1.00		       ---
- Health Care Coverage
-    Yes			1.83	**	**0.71 to 4.74
-    No			1.00		       ---
- Age			1.01		1.00 to 1.03
- Education
-    College Grad		1.26		0.77 to 2.05
-    Some College		1.27		0.73 to 2.18
-    High School Grad		1.14		0.75 to 1.73
-    Less than High School	1.00		       ---
- Race/Ethnicity
-    Other			1.28		0.87 to 1.87
-    White			1.00		       ---
- Gender
-    Male			1.13		0.84 to 1.51
-    Female			1.00		       ---

- (Not significant)

- (*p* < .01)

## Outcome: Ever/Never PSA Screening (n=617)

- Risk			1.07		0.86 to 1.34
- Worry			1.33		0.81 to 2.17
- Risk x Worry		0.88		0.56 to 1.40
- Regular Provider
-    Yes			3.64		2.02 to 6.57
-    No			1.00		       ---
- Health Care Coverage
-    Yes			3.15		1.07 to 9.31
-    No			1.00		       ---
- Age			1.06		1.02 to 1.11
- Education
-    College Grad		0.81		0.30 to 2.21
-    Some College		0.91		0.33 to 2.54
-    High School Grad		2.06		0.74 to 5.74
-    Less than High School	1.00		       ---
- Race/Ethnicity
-    Other			0.73		0.36 to 1.49
-    White			1.00		       ---

- (Not significant)

- (*p* < .01)

**Notes:**
Men 50+

## Summary

- Both risk and worry are important predictors of some types of cancer screening
- Seem to operate independently; no interaction
- No curvilinear relationship with worry
- Do not predict FOBT/PSA screening; why not?

**Notes:**
Risk and worry are correlated but no sign. interaction

For worry, we also tested for a curvilinear relationship, given that some researchers and theorists have suggested that excessive worry can lead to avoidance of cancer screening.  We failed to observe any such relationships; instead, worry consistently showed a positive linear relationship with screening 

Why no sign. predictors for PSA and FOBT?
PSA-May be more routine part of exams for men; part of a normal check-up; some men not aware of it being done
FOBT-Since this is the least evasive procedure, may not be related to motivational aspects of risk and worry; may be seen as important but routine

Clinical implications:
Target high-risk individuals; intervene at either a cognitive or affective level to increase perceived risk or worry to get them to screen

Next steps
Test path analysis model

## Acknowledgements

- Kevin Dodd, Ph.D.
- Lila Finney Rutten, Ph.D., M.P.H.
- Helen Meissner, Ph.D.

**Notes:**
All NCI folks