Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

The Shortcomings of the Health Belief Model in Recognizing Perceived Barriers to Colon Cancer Screening Among African Americans – Sarah Hunt

The lifetime risk of developing colorectal cancer is 2.5-5% in the general population (9). Although highly preventable, colon cancer is the second leading cause of cancer death in the county (1,9). When comparing colon cancer incidence by race and ethnicity, it has been shown that African Americans have the highest incidence of colon cancer and lowest survival rates among all racial groups in the United States (5). But, why is there such discrepancy? Understanding the differences in the incidence and mortality rate between African Americans and Whites with colon cancer remains a perplexing problem. One might think that the severity of developing colon cancer would cause a person to pursue colon cancer screening (colonoscopy) regardless of race or ethnicity. Is it the result of lower socioeconomic status, lack of knowledge, access to healthcare or health insurance coverage? There is clearly not any one factor that explains the observed differences. Issues surrounding screening for colon cancer remain important in understanding the advanced stage of presentation for African Americans. In particular, a better understanding is needed of who is being screened and who is not and why (13). Despite recent colon cancer screening awareness initiatives, screening rates of African Americans continue to be sub-optimal. The problem lies in the fact that recent initiatives have not catered to the culture and history of African American populations. Future colon cancer screening initiatives need to provide specifically contextualized messages that will resonate with this population.

Importance of colon cancer screening

Unlike the majority of cancers, prevention and early detection of colon cancer is possible. For individuals with no additional risk factors, having colonoscopies beginning at age 50 have been found to be effective in identifying pre-cancerous colonic polyps and thus detecting a cancer at an early stage or preventing it entirely. When detected in early stages, colon cancer is highly treatable with 5-year survival rates as high as 90% (3). Of note, colon cancer incidence rates declined by 2.2% between 1998 and 2002. This decline has been attributed to increases in colon cancer screening (11). Despite availability, benefits and effectiveness of colon cancer screening, African Americans continue to be diagnosed with colon cancer at a later stage and are thus more likely to die from colon cancer than white Americans. (11).

Colon cancer screening and prevention programs in the U.S.

Currently, many cancer prevention awareness initiatives are based on the Health Belief Model (HBM). The HBM is a framework for understanding relationships among a person’s perception of a threat posed by a health problem and the likelihood of taking preventive health action aimed at reducing the threat (5). The HBM posits that a person will rationally weigh the risks and benefits of taking a preventive action and take that action when the benefits out-weigh the risks.

While this model is effective in identifying the way in which a person may perceive a disease and balance the risks and benefits of pursuing a preventive health action, it is too simplistic and fails to recognize many influential factors that play into a person’s decision-making analysis. The model suggests that undertaking a health action is dependent on an individual’s perceptions of the following: level of personal susceptibility to a particular illness, degree of severity of the consequences of the condition, the health action’s potential benefits in preventing susceptibility, and the physical, psychological, financial, and other barriers related to the advocated behavior (5). Contextualized factors that many times are extremely influential in a person’s decision are often not taken into consideration within the HBM.

One example of a colon cancer screening and prevention initiative that is based on the HBM is the Center for Disease Control’s Screen for Life campaign. The central messages of this initiative are (1):
  • Colorectal cancer is the second leading cancer killer in the U.S.
  • Screening saves lives.
  • Colorectal cancer often can be prevented. Regular screening tests can find precancerous polyps so they can be removed before they turn into cancer.
  • Screening can find colorectal cancer early, when treatment can be very effective.
  • Polyps and colorectal cancer may not cause symptoms, especially at first.
  • Both men and women are at risk.
  • Many insurance plans, including Medicare, help pay for colorectal cancer screening.
While these messages are valuable, they only identify a few of the perceived barriers and risks associated with lower participation in colon cancer screening (5). The above messages are superficial and exemplify the failure of the Health Belief Model to identify contextual factors – such as cost, fear or embarrassment of having a colonoscopy, competing demands, talking with one’s doctor about pursing this test, preparation, whether or not one is at risk etc. - that influence a person’s decision to pursue a preventive health action. These phrases are blanket messages attempting to speak to a diverse American population but, in reality do not make a strong impact. Specifically in the African American population, there are significant influential factors the Screen for Life campaign does not address.

Fear & Fatalistic Cancer Beliefs

Cancer fatalism is a psychological construct characterized by perceptions of “hopelessness, worthlessness, meaninglessness, powerlessness, and social despair” that has been found to be associated with cancer screening among African Americans (11). As previously mentioned, research has shown that African Americans tend to be diagnosed with colon cancer at a later stage, partly due to lack of adherence to screening recommendations. As a result, many individuals have seen relatives die from cancer (5). Consequently, a common belief among African Americans is that a cancer diagnosis is a death sentence. African Americans have shown to take a passive approach to early cancer detection and screening because of fear that if one seeks care, something wrong might be found (6). One study reported that although participants believed in the benefit of early diagnosis, they still remained reluctant to get tested for cancer if they felt well, even when they understood that cancer can be symptom free (12). Individuals may not seek out preventative health care as they would rather not know.

Many African Americans have generally spoke of the idea that once a person gets cancer, there is not much that can be done about it (6). Similarly, focus groups talking with African Americans about perceptions of colon cancer have noted that a common belief about cancer within African American communities is that cancer spreads during surgery – “when air touches the cancer” (6). African Americans may not even seek out care as a result of this incorrect knowledge. Fear and the concept that “ignorance is bliss” were also correlated with minimal use of services and follow-up with physicians (6). These fatalistic perceptions prevent individuals from pursuing early detection tests and cause them take a passive approach to early cancer detection and screening.

Lack of Communication

Lack of communication about colon cancer within African American communities stems from the fear associated with cancer. It has been reported that members of older generations do not talk about cancer and that there is a culture of silence and avoidance of the topic (6). This lack of communication prohibits knowledge and information about the benefits of colon cancer screening from spreading throughout a community. For reasons of fear and silence of the topic, an individual may also feel less inclined to initiate a conversation with his/her physician about colon cancer screening. Conversely, it is also important for physicians to communicate information and appropriate screening recommendations with patients.

Mistrust in the U.S. Health Care System

A legacy of racial discrimination in medical research and the health care system has been linked
to a low level of trust in medical care among African Americans (7). Marked by the Tuskegee Syphilis Study in 1932, where African Americans were wrongfully abused for medical research for decades, a general mistrust in the United States health care system continues to permeate. There is a collective memory among African Americans about their exploitation by the medical establishment. The Tuskegee Syphilis Study has emerged as the most prominent example of medical racism because it confirms, if not authenticates, long held and deeply entrenched beliefs within the Black community (8). Fear of exploitation, genocide, conspiracy and abuse continue to persist in African American Communities. As recent as 1990, links have been made between the Tuskegee Syphilis Study, AIDS and genocide:

“In September 1990, the article “AIDS: Is It Genocide?” appeared in Essence, a black woman’s magazine. The author noted: “As an increasing number of African Americans continue to sicken and die and as no cure for AIDS has been found some of us are beginning to think the unthinkable: Could AIDS be a virus that was manufactured to erase large numbers of us?” (8)
The mistrust that African Americans have in our health care system, in many ways, affects colon cancer screening. Research has shown that avoidance of the health care system is significantly associated with screening compliance and stage of adoption (11). Focus group participants in a recent research study looking at African American’s perceived barriers to colon cancer screening described how the current health care system does not meet patient care needs. They described the system as a direct cause of poor utilization of cancer screening by African Americans (6). They continue to feel that the health care system has alternative motives and is not advocating for their well-being. Consequently, many African Americans are not seeking out care. Differences in trust may reflect divergent cultural experiences of blacks and whites as well as differences in expectations for care. Improved understanding of these factors is needed if efforts to enhance patient access to and satisfaction with care are to be effective (7). Efforts are also necessary on the physicians’ part to be culturally competent when speaking to patients about colon cancer screening.


Increased education and awareness of colon cancer screening within African American communities must target the ideas of fear, fatalism and mistrust in the health care system to rectify this situation. Educational programs should be tailored to correct these misconceptions. In particular, research has shown that the constructs of fatalism are important to address within African American populations (11). Fear associated with colon cancer screening may be diminished by explaining the importance of early detection and its role in increasing the likelihood of positive health outcomes should something wrong be found (5). Health care professionals, with their ability to play such a great role in advocating for cancer screening, should be educated in how to talk with individuals of varying race and ethnic backgrounds about cancer screening with cultural competency.


1. Center for Disease Control and Prevention. Screen for Life Campaign. Atlanta, GA: Center for Disease Control and Prevention.
2. Center for Disease Control and Prevention. Colon Cancer Statistics. Atlants, GA: Center for Disease Control and Prevention
3. James A, Campbel M, Hudson M. Perceived Barriers and Benefits to Colon Cancer Screening among African Americans in North Carolina: How Does Perception Relate to Screening Behavior? Cancer Epidemiology, Biomarkers and Prevention 2007; 11: 529-534.
4. Center for Disease Control and Prevention. Comparing Colorectal Cancer by Race and Ethnicity. Atlanta, GA: Center for Disease Control and Prevention.
5. Green P, Kelly B. Colorectal Cancer Knowledge, Perceptions, and Behaviors in African Americans. Cancer Nursing 2004; 27: 206-215.
6. Greiner K, Born W, Nollen N, Ahluwalia J. Knowledge and Perceptions of Colorectal Cancer Screening Among Urban African Americans. Journal of General Internal Medicine 2005; 20: 971-983.
7. Boulware L, Cooper L, Ratner L, LaVeist T, Powe N. Race and Trust in the Health Care System. Public Health Reports 2003; 118: 358-365.
8. Gamble V. Under the Shadow of Tuskegee: African Americans and Health Care. American Journal of Public Health 1997; 87: 1773-1778.
9. Wackerbarth S, Peters J, Haist J. Do We Really Need All That Equipment? Factors Influencing Colorectal Cancer Screening Decisions. Qualitative Health Research 2005; 15: 539-554.
10. Oliffe J. Perceived Barriers and Benefits Were Factors in Decision Making About Colorectal Screening. Evidence Based Nursing 2006; 9: 31.
11. Lawsin C, DuHamel K, Weiss A, Rakowski W, Jandorf L. Colorectal Cancer Screening among Low-Income African Americans in East Harlem: A Theoretical Approach to Understanding Barriers and Promoters to Screening. Journal of Urban Health 2006; 84: 32-44.
12. Shokar N, Vernon S, Weller S. Cancer and Colorectal Cancer: Knowledge, Beliefs, and Screening Preferences of a Diverse Patient Population. Clinical Research and Methods 2005; 37: 341-347.
13. Polite B, Dignam J, Olopade O. Colorectal Cancer and Race: Understanding the differences in Outcomes Between African Americans and Whites. Medical Clinics of North America 2005; 89: 771-793.

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