Motivation and emotion/Book/2020/Cancer screening motivation

Cancer screening motivation:
What are the motivational facilitators and barriers to participation in cancer screening programs?

Multimedia presentation (3 min)

Overview

Ever since the discovery of cancer in 1775, society’s knowledge and treatments have advanced significantly. However, the threat of cancer is still extremely relevant as, in 2018, cancer was the second leading cause of death across the globe. One of the best ways to prevent mortality in cancer is early detection, which can be achieved through education and cancer screening. Unfortunately, while education in most cultures is quite high, cancer screening rates are still very low. There are multiple motivational reasons that could explain why individuals may choose to either participate or avoid cancer screening examinations. The top three investigated in this book chapter are emotional factors, perceptions and beliefs and finally demographics. By investigating these factor researchers are hoping to identify ways in which to turn any motivational barriers into facilitators of cancer screening.

Cancer

Figure 1: Artistic representation of a cancer cell

Before going into motivational influencers of cancer screening decisions it is important to have a basic understanding of cancer. Cancer is a complex and diverse disease that comes in many different forms. It occurs when cells within the human body do not undergo apoptosis (programmed cell death) and continue to grow. These cells then create a mass which is commonly referred to as a tumour. Unfortunately cancer is not a new disease, there has been mentions of cancer from as early as 3000 BC. In 2018, the International Agency of Research on Cancer reported over 233, 773 individuals within Australia and New Zealand, 3, 679, 584 individuals in America, and 4, 229, 662 in Europe living with cancer.Regrettably, at this current time there is no hard and fast cure for cancer. However, this does not mean it is not treatable. There are many forms of treatments available that have varying rates of success depending on the development and location of the cancer. The three most common include Chemotherapy (the removal of cancer cells using anti-cancer drugs), Radiation therapy (the use of x-rays to damage or destroy cancer cells) and Surgery. Other less common treatments include; Complementary therapy, Hormone therapy, Immunotherapy and Palliative care. To this day as our knowledge and understanding of cancer grows so do our treatment methods. If these treatments pass through all the legal and ethical boards then they to what is known as clinical trials. These trials allow researchers to test the effectiveness of the treatment.Due to the lack of cure, one of the most crucial techniques to decreasing mortality rates of cancer, is early detection! The later the cancer is detected the harder it is to treat as the mass typically is bigger and spread out across the body.  Two of the major components of early detection are education and cancer screening. Though educational events and programs provided by general public health organizations, such as the World Health Organisation (WHO), people are provided with the necessary knowledge that they would need to identify cancer symptoms early. This allows them to be proactive and seek out assistance if they believe that they are experiencing any potential symptoms. Education also brings awareness to proactive health actions that are available to the general public. Which lead to the second key component of early detection, cancer screening. Cancer screening is a specific but simple test that allows for the early detection of any cancerous cells or potential future risks. Regrettably, as cancer is such a multifarious disease, at this current time there is no universal test. However, there are screening options for various specific types of cancer including but not limited to: breast cancer, bowel cancer, and colorectal cancer. Despite the increase in screening options available to the general public, the percentage of those undergoing a screening test remains low.

Case Study Sally is a 30-year-old Caucasian female, who has just been diagnosed with cancer. Unfortunately, the mass is large and primarily located in her breast. Specialists have advised that she seeks immediate treatment. To remove the cancerous cells, she will have to undergo intensive chemotherapy, with the potential need for surgery. Outside of being diagnosed with cancer, Sally lives a very healthy lifestyle that includes frequent exercise, a balanced diet and the avoidance of cancer risk behaviours such as smoking and prolonged time in the sun. Sally works 8 hour days 5 days a week in a sedentary office job. She also volunteers for the RSPCA at her local shelter between 8 and 12 on Saturday and coordinates a million paws walk in May each year. Once a year, her workplace offers free cancer screening for all employees. Every year, Sally chooses not to partake in these test as she believes that she is far too busy to participate . Furthermore, when Sally was in her early teens, she was in a server car accident which resulted in extensive scarring along her ribs. Sally has stated that she tends to avoid situations in which her scars may be view by others. No one in Sally’s immediate family or peer group has cancer. She has had little interest in furthering her knowledge, instead she prefers to read about animals.

Pondering What do you think were some of the barriers that prevented Sally from accessing the free cancer screening provided by her workplace?

Motivational influences

Despite the increase in screening options available to the general public, the percentage of those undergoing a screening test remains low. In 2020 Ampofo and colleagues, conducted a study to try and identify the barriers that prevent women in the Ashanti Region of Ghana from participating in cervical cancer screening. Their results showed that only 3% of those who participated in the study had partook in a cervical cancer screening test. While this shows an increase in tests taken by women in Ghana since 2014 (Nancy Innocentia Ebu, 2014), this is still very low. Furthermore, in 2006 researchers in Hong Kong conducted a telephone survey to identify factors linked with an increase of colorectal cancer (CRC) screening. Of the 1,004 participants, aged between 30 and 65 years, only 10% reported going for a CRC screening test (Joseph J. Y. Sung, 2008). These statistics suggest that while there has been some success with cancer screening there is still room for improvement.When investigating how to improve participation in cancer screening test, the first and probably most important question to ask is what prevents people from engaging in cancer screening? It is also important to consider what would enable individuals to access cancer screening services. Current research has identified a multitude of reasons why people might chose not to undergo a cancer screening test. These factors tend to fall into one of three categories; emotional factors, perceptions and beliefs and last but not least demographics. All three factors individually have been found to influence the likelihood of an individual seeking out preventive health behaviours. However, like most things in life, it is not as cut and dry as it may appear, as these factors often tend to interact and influence each other.

Emotional Factors

When making important decisions, it is ideal to think through the situation rationally and with little emotional input. Regrettably, emotions are not easy to disregard and often have an influence over an individual’s choices. According to Loewenstein and Lerner, emotions can be divided into two categories when making a decision; Anticipated emotions and Immediate emotions. Anticipated emotions are defined as the expectation of a future emotion and is often viewed in terms of gains and losses (Lowenstein, 2003). Whereas immediate emotions (Han, 2009) (otherwise known as true emotions) are the emotions experienced at the time of decision making.In relation to cancer screening, the top two emotions that typically act as barriers are fear (anticipated emotion) and embarrassment (immediate emotion). When thinking about personal risk of cancer, fear is often generated as a response to the potential threat to one’s life. This often leads to an avoidance of preventive behaviours such as cancer screening, as people are trying to prevent a potential emotional upset caused by a confirmed diagnosis (Philippa J. Murphy, 2018). In 2010, Jones and colleagues found that of the 660 participants 74% reported fear as the biggest barrier to bowel cancer screening. Additionally, one study conducted by Reynolds and colleagues (2018) found those who delayed cancer screening tests for bowel cancer typically had a higher level of knowledge and fear for a negative outcome (e.g. a diagnosis). They also identified that this avoidance was lower in those who had discussed their risks with their doctor. From their results, Reynolds and colleagues suggested that an important aspect of facilitating cancer screening is to understand how emotions, particularly fear, embarrassment and disgust, impact screening decisions. To do this further research is required.Cancer screening involves discussions about intimate and embarrassing topics. This embarrassment can lead to the avoidance of cancer screening. In 2018, researchers, Naomi N Modeste, Malcolm Cort and Janice E McLean, conducted a study to examine the potential factors associated with early detection of prostate cancer in men living in Guyana. Among other findings they identified embarrassment as a potential influencer for participation or recommendation for cancer screening. Another thing to consider when looking at participant embarrassment, is the type of cancer screening. In 2010, it was identified that, in Australia, bowel cancer screening rates are lower than that of breast and prostate cancer (Yip, 2010). Furthermore, multiple studies have been conducted, that explore the impact embarrassment has on colorectal cancer screening rates. During a colorectal cancer examination, embarrassment can be triggered by undesired intimacy during examinations and faecal/rectal embarrassment (Nathan S. Consedine I. L., 2010). Having said this, in a separate study, Consedine and colleagues (2011) individuals are less likely to experience embarrassment and intimacy concerns when their physician is of the same gender. As emotions, such as embarrassment, are internal phenomena it is difficult to pinpoint key influencers that will decrease their impact on cancer screening rates. However, with further research, the scope for what caused embarrassment during cancer screening examinations can be reduced and hopefully methods to facilitate participation in cancer screening, despite any emotional turmoil, will be developed.

Perceptions and Beliefs

When examining how perceptions and beliefs can affect an individual’s motivation to engage in health related behaviours, it is almost impossible not to discuss the Health Belief Model (HBM). The HBM was first proposed in the 1950’s and is still prevalent today. It proposes that individuals engage, and change health behaviours based on their perception of the following factors: susceptibility to the threat, the seriousness of the threat, the benefits and barriers of the protective behaviour, cues to action on the protective behaviour and their self-efficacy. A large portion of current research into barriers and facilitators of cancer screening often use the HBM as the theoretical basis for their research. One such study conducted in the United States found that, of the 202 Korean American immigrant women that participated, those who perceived their risk for developing breast cancer as high where more likely to undergo breast cancer screening than the individuals with a low risk perception (Hee Yun Lee, 2015) . This is reflected in Roth and colleagues’ study in 2018. Roth and colleagues found that in a community setting, an individual’s motivation to undergo lung cancer screening is determined by their perceptions of the benefit of early detection and risk to their safety, as well as any personal relationships. Furthermore, in 2002, LaToya T. Austin and Farah Ahmad conducted a literature review that explored current research on breast and cervical cancer screening in Hispanic women and the HBM. From their research they found that of the five factors in the HBM, perceived susceptibility was the biggest barrier for cancer screening among older Hispanic women and as respect of authority is a highly held value within the Hispanic culture, if properly implemented, the construct cues to action could be a major facilitator for cancer screening (LaToya T. Austin, 2002). Unfortunately, according to LaToya T. Austin and Farah Ahmad there is very limited research into the constructs, perceived seriousness and self-efficacy. They propose that this may be because self-efficacy was, at the time, relatively new as it was only added in to the HBM in 1988 and that majority of women perceive breast and cervical cancer as a serious disease.

Sally and the HBM When examining Sally’s case using the HBM, three out of the five constructs stand out. These are perception of susceptibility, perception of seriousness and barriers and benefits. As Sally lives a very healthy lifestyle with limited exposure to cancer (e.g. she is the first in her family and social group to be diagnosed with cancer) there is limited reason for her to believe that she is anything but healthy. Furthermore, as she tends to focus more on animals, her understanding of the seriousness of cancer may be limited thus causing her to underestimate her vulnerability to cancer. Finally, when combined with the factor that Sally is quite busy, Sally’s lack of exposure could also mean that the benefits of cancer screening are outweighed by the disadvantages (e.g. loss of time). However, while in Sally’s case these constructs act as barriers for cancer screening, this is not always the case. For those who have lost someone to cancer or who engages in cancer risk behaviours, such as smoking, may have a deeper understanding of the risks and seriousness of cancer. As a result, those individuals are more likely to engage in cancer screening if the opportunity arrives (Joshua A. Roth, 2018) (Hee Yun Lee, 2015). Additionally, if those of authority, such as doctors, encourage individuals to consider undergoing a cancer screening test then they are more likely to seek it out (LaToya T. Austin, 2002).

Demographic Factors

Culture

Unfortunately, cancer screening availability is not universal and as such participation rates of cancer screening varies across cultures. One of the main components that explains the differences in cancer screening across cultures is education rates. At this current time, policies for early detection vary country to country (World Health Organisation, 2020) and as such the amount of education available also varies. One systematic literature search in 2009 found that one of the major barriers to cancer screening among the African American and Hispanic cultures was the lack of education provided (Idris Guessous, 2009). However, within the Hispanic culture this barrier can be counterbalanced by cues to action, including discussions with familiar doctors (LaToya T. Austin, 2002). Furthermore, as mentioned above different cultures put emphases on different types of cancer and as such their cancer screening rates often reflect this. One such example is Australia, as bowel cancer screening rates are lower than that of breast and prostate cancer (Yip, 2010) which suggests that in Australia there is more emphasis on breast and prostate cancer.

Gender

Figure 2: Symbolic representation of gender

As identified in emotional factors, an individual's gender can also have an impact on their willingness to participate in cancer screening. In 2005, J. Wardle, A. Miles, and W. Atkin conducted a study examining the impact that gender difference has on participation in colorectal cancer screening. The results from this study suggested that men were more likely to undergo colorectal cancer examinations than women(J Wardle, 2005). Wardle and colleagues, proposed that this may be due to socioeconomic and attitudinal differences between the genders. Furthermore, Ritvo and colleagues found that women tended to display higher stress levels while males typically demonstrated procrastination behaviors. This is further supported by a study conducted by Wong and colleagues in 2013, as the results it was indicated that Asian women held higher concerns for a positive diagnosis. Both studies suggested that this worry can be lowered if personalized approaches for women are implemented. Additionally, Ritvo and colleagues suggested that further research is needed to identify methods in which to limit procrastination behaviours exhibited male populace.

Conclusion

Despite cancer being the second highest cause of death in 2018, there is still no cure. At this current time the best method to reduce mortality rate is early detection. This can be achieved through cancer screening tests. Unfortunately, cancer screening rates are still quite low. Current research has suggested various explanations as to why this may be. When exploring cancer screening rates in terms of motivation, people tend to be influenced by one of three categories: perceptions and beliefs, emotional factors and demographics. These three categories have been found to act as barriers to cancer screening however, research has found that these factors could also act as facilitators if the correct processes are put into place. Currently there is no universal approach to creating processes to encourage cancer screening processes. Yet, scientist still strive to raise cancer screening rate and hopefully with further research discover a cure.

Pondering From the readings what would you do think could be done to encouraged individuals like Sally to participating in the cancer screening? Are there any barriers preventing you from participating in a cancer screening test? If so, what are they? What would enable you to participate in cancer screening?

See also

• Breast cancer and anxiety (Book chapter, 2015)
• Cancer (Wikipedia)
• Chemotherapy and its effects on motivation: (Book chapter, 2016)
• Emotions in decision making (Wikipedia)
• Protection motivation and health (Book chapter, 2013)

References

Ama G. Ampofo, A. D.-N. (2020). A cross-sectional study of barriers to cervical cancer screening uptake in Ghana: An application of the health belief model. PLOS ONE, 1-16.

Han, S. a. (2009). Decision making. Oxford companion to emotion and the affective sciences, 111-113.

Hee Yun Lee, M. J. (2015). Breast Cancer Screening Behaviors Among Korean American Immigrant Women: Findings From the Health Belief Model. Journal of Transcultural Nursing, 450–457.

Idris Guessous, C. D. (2009). Colorectal cancer screening barriers and facilitators in older persons. Preventive Medicine, 3-10.

J Wardle, A. M. (2005). Gender differences in utilization of colorectal cancer screening. Journal of Medical Screening, 20–27.

Joseph J. Y. Sung, S. Y. (2008). Obstacles to Colorectal Cancer Screening in Chinese: A Study Based on the Health Belief Model. American Journal of Gastroenterology, 974–981.

Joshua A. Roth, L. C.-H. (2018). A qualitative study exploring patient motivations for screening for lung cancer. PLOS ONE.

LaToya T. Austin, F. A.-J. (2002). Breast and Cervical Cancer Screening in Hispanic Women: A Literature Review using the Health Belief Model. Women's Health Issues, 122-128.

Lisa M. Reynolds, I. P. (2018). Emotional predictors of bowel screening the avoidance-promoting role of fear embarrassment, and disgust. BMC Cancer, 518.

Lowenstein, G. a. (2003). The role of affect in decision making. New York: Oxford University Press.

Nancy Innocentia Ebu, S. C. (2014). Knowledge, practice, and barriers toward cervical cancer screening in Elmina, Southern Ghana. International Journal of Women’s Health, 31-39.

Naomi N Modeste, M. C. (2018). The protection motivation theory and its impact on prostate cancer screening in Guyana. Interational Public Health Journal, 181-187.

Nathan S. Consedine, I. L. (2010). The many faeces of colorectal cancer screening embarrassment: Preliminary psychometric development and links to screening outcome. The British Psychological Society, 559–579.

Nathan S. Consedine, M. K. (2011). Gender and Ethnic Differences in Colorectal Cancer Screening Embarrassment and Physician Gender Preferences . Oncology Nursing Forum , 409-417.

Paul Ritvo, R. E. (2013). Gender differences in attitudes impeding colorectal cancer screening. BMC Public Health.

External Links

• David Asch: Why it's so hard to make healthy decisions? (TED ideas worth spreading)
• How we're fighting cancer? (TED ideas worth spreading Playlist)
• Cancer council
• American Cancer Society: Cancer Basics and History
• International Agency for Research on Cancer
• The World Health Organisation (WHO) : Cancer