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Factors influencing performance discrepancies in breast self-examination practices of adult female graduate… Armstrong, Ingrid Erna 1984

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C.» Factors Influencing Performance Discrepancies in Breast Self-examination Practices of Adult Female Graduate Students by Ingrid Erna Armstrong R.N., Vancouver General Hospital, Vancouver, 1969 B.S.N., University of B r i t i s h Columbia, 1979 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Administrative, Adult and Higher Education) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1984 © Ingrid Erna Armstrong, 1984 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f Administrative, Adult and Higher Education The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date May, 1984 DE-6 (3/81) i F a c t o r s I n f l u e n c i n g Performance D i s c r e p a n c i e s i n Breast S e l f - e x a m i n a t i o n P r a c t i c e s of A d u l t Female Graduate Students ABSTRACT A performance d i s c r e p a n c y e x i s t s when t h e r e i s a d i f f e r e n c e between a c t u a l and d e s i r e d performance. In the h e a l t h care f i e l d , the term compliance i s used to d e s c r i b e such d i s c r e p a n c i e s . The usual response i n such i n s t a n c e s i s the development of an e d u c a t i o n a l program. Such approaches are concerned with remedies not problem s o l v i n g . T h i s r e s e a r c h p r o j e c t was an attempt at problem s o l v i n g i n the s p e c i f i c area of b r e a s t s e l f - e x a m i n a t i o n . A broad r e s e a r c h q u e s t i o n was used: What f a c t o r s are r e l a t e d to end behaviour i n brea s t s e l f -examination p r a c t i c e s ? Based on a l i t e r a t u r e review, a paradigm was developed which attempted to e x p l a i n p a r t i c i p a t i o n i n the p r e v e n t i v e h e a l t h measure of br e a s t s e l f - e x a m i n a t i o n . I t was f e l t t h a t t h i s a c t i v i t y i n v o l v e d a complex emotional response to the t h r e a t of cancer and that any attempt to e x p l a i n behaviour would r e q u i r e the examination of a wide range of v a r i a b l e s . A data c o l l e c t i o n instrument was c r e a t e d u s i n g _ a combination of p r e v i o u s l y and newly developed q u e s t i o n s . The female s t u d e n t s e n r o l l e d i n the U n i v e r s i t y of B r i t i s h Columbia, Ad u l t E d u c a t i o n D i v i s i o n c l a s s e s were chosen as the re s e a r c h group because of t h e i r g e o g r a p h i c a l p r o x i m i t y , t h e i r uniform e d u c a t i o n a l l e v e l and t h e i r o c c u p a t i o n a l backgrounds. T h i s group of women p r o v i d e d an o p p o r t u n i t y t o compare women with i i e x p e r i e n c e i n the h e a l t h care f i e l d to women with a non-health background. Small sample s i z e and homogeniety of s u b j e c t s on the v a r i a b l e s t e s t e d p r e c l u d e d e x t e n s i v e s t a t i s t i c a l a n a l y s i s of r e s u l t s . Some i n t e r e s t i n g p o i n t s do appear i n the data, however., and s e v e r a l independent v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d t o b r e a s t s e l f - e x a m i n a t i o n p r a c t i c e s . I m p l i c a t i o n s f o r f u t u r e r e s e a r c h and f o r t e a c h i n g b r e a s t s e l f - e x a m i n a t i o n are g i v e n . i i i TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES . . . v LIST OF FIGURES v i ACKNOWLEDGEMENT v i i CHAPTER I: INTRODUCTION 1 The S i g n i f i c a n c e Of Performance D i s c r e p a n c i e s In BSE .... 3 Purpose Of The Study 6 CHAPTER I I : REVIEW OF THE LITERATURE 8 P a r t i c i p a t i o n Research 10 B a r r i e r s To Learning 27 Health Education And Compliance 41 Education And Compliance 54 Locus Of C o n t r o l 60 Summary 79 CHAPTER I I I : THEORETICAL FRAMEWORK FOR THE STUDY 86 Theory U n d e r l y i n g The BSE Paradigm 86 Breast S e l f - E x a m i n a t i o n P a r t i c i p a t i o n Paridigm 92 The Research Question 96 CHAPTER IV: METHODOLOGY 97 P i l o t Study 104 S e l e c t i o n Of The Research Group 107 Data C o l l e c t i o n 107 S t r a t e g i e s For Data A n a l y s i s .....112 CHAPTER V: FINDINGS 115 Respondent C h a r a c t e r i s t i c s 115 i v Expectancy 116 Valence 131 B a r r i e r s To BSE 138 P a r t i c i p a t i o n In BSE 142 L i m i t a t i o n s Of The Data 146 D i s c u s s i o n Of R e s u l t s 146 D i s c u s s i o n Of R e s u l t s For B a r r i e r V a r i a b l e s 151 D i s c u s s i o n Of P a r t i c i p a t i o n In BSE 152 CHAPTER VI:ANALYSIS OF BSE 155 S t a t i s t i c a l A n a l y s i s 156 D i s c u s s i o n Of R e s u l t s 161 CHAPTER V I I : SUMMARY AND IMPLICATIONS 166 L i m i t a t i o n s Of The Study 167 Research F i n d i n g s 171 I m p l i c a t i o n s For Research 176 I m p l i c a t i o n s For Teaching BSE 179 REFERENCES 185 APPENDIX A: LETTER OF INITIAL CONTACT 195 APPENDIX B: QUESTIONNAIRE 197 V LIST OF TABLES TABLE 1: EXCLUDED BSE KNOWLEDGE COMPONENTS 117 TABLE 2: EXPERIENCE WITH BREAST DISEASE 127 TABLE 3: PERCEIVED RELATIONSHIP BETWEEN BREAST LUMPS AND CANCER 128 TABLE 4: CONFIDENCE IN PERSONAL ABILITY TO DETECT BREAST DISEASE 129 TABLE 5: PRIORITY RATINGS FOR THE VALUE OF HEALTH 132 TABLE 6: DEGREE OF AGREEMENT WITH SATISFACTION WITH BSE HABITS STATEMENT 133 TABLE 7: PERCEIVED SUSCEPTIBILITY TO BREAST DISEASE 134 TABLE 8: PERCEIVED EFFECT OF BARRIERS ON BSE FREQUENCY OF PRACTICE 139 TABLE 9: FREQUENCY OF BSE PRACTICE 143 TABLE 10: BSE PRACTICE RATING 143 TABLE 11: COMPLETENESS DISCREPANCIES IN BSE PRACTICE 145 TABLE 12: VARIABLES WITH A SIGNIFICANT (p<.05) PEARSON PRODUCT MOMENT CORRRELATION WITH BSE PRACTICE OR BSE PRACTICE RATE 1 60 v i LIST OF FIGURES FIGURE 1: PARADIGM OF RECRUITMENT IN ADULT EDUCATION 17 FIGURE 2: CHAIN OF RESPONSE (COR) MODEL FOR UNDERSTANDING PARTICIPATION IN ADULT LEARNING ACTIVITIES 24 FIGURE 3: ORIGINAL FORMULATION OF THE HEALTH BELIEF MODEL . 49 FIGURE 4:BREAST SELF-EXAMINATION PARADIGM 93 FIGURE 5: BSE INFORMATION SOURCES 120 FIGURE 6: BSE INFORMATION PRESENTATION METHODS 122 ACKNOWLEDGEMENT S p e c i a l thanks to K j e l l Rubenson and Tom Sork for t h e i r p a t i e n c e , encouragement and sound advice MarDell P a r r i s h for h i s i n v a l u a b l e h e l p with the computer Family and f r i e n d s f o r t h e i r support and t h e i r forebearance with an u n s o c i a l and seemingly p e r p e t u a l house guest Donald James Armstrong for h i s t o l e r a n c e and h i s encouragement. His support made i t a l l p o s s i b l e . 1 CHAPTER I INTRODUCTION There are many s i t u a t i o n s where what people are doing i s not what someone wants them to do. Mager and Pipe (1970) have termed t h i s a performance d i s c r e p a n c y and d e f i n e d i t as a d i f f e r e n c e between a c t u a l and d e s i r e d performance (p. 7). The concern of t h i s study i s a performance di s c r e p a n c y i n v o l v i n g p r e v e n t i v e h e a l t h behaviour. H e a l t h educators are f r e q u e n t l y faced with women who do not perform breast s e l f examination (BSE). While p r e - a d u l t s are sometimes the focus of concern the most frequent t a r g e t p o p u l a t i o n i s women ac r o s s the a d u l t l i f e s p a n . The usual means of attempting to e l i m i n a t e such performance d i s c r e p a n c i e s i s an e d u c a t i o n a l program. Mager and Pipe c a u t i o n a g a i n s t using any such s i n g l e s o l u t i o n . They suggest that t e a c h i n g or t r a i n i n g approaches can be p i t s i n t o which a great d e a l of energy and money may be poured u n p r o d u c t i v e l y . Such approaches are concerned with remedies not prob l e m - s o l v i n g . They provide i n f o r m a t i o n or s k i l l development when lack of inf o r m a t i o n or s k i l l may not be the problem. Mager and Pipe have coined the phrase "oughta wanna" to h e l p in determining whether a performance descrepancy i s due to a l a c k of s k i l l or knowledge. They contend that when you hear t h i s term or some v a r i a t i o n of i t , i t i s almost c e r t a i n 2 t h a t a s k i l l d e f i c i e n c y d o e s n o t e x i s t . Some e x a m p l e s f a c e d by h e a l t h e d u c a t o r s a r e : I f p e o p l e know t h e y s h o u l d n o t s m o k e - - t h e y o u g h t a wanna s t o p . I f p e o p l e know s a f e t y p r e c a u t i o n s a r e f o r t h e i r own g o o d - - t h e y o u g h t a wanna f o l l o w them. I f p e o p l e know o v e r - e a t i n g c a u s e s o b e s i t y - - t h e y o u g h t a wanna c u t down on t h e i r c a l o r i c i n t a k e . I f women know a b o u t t h e b e n e f i t s o f B S E - - t h e y o u g h t a wanna p r a c t i c e i t r e g u l a r l y . Mager a n d P i p e c o n t e n d t h a t "you o u g h t a wanna do i t f o r y o u r own g o o d " i s one o f t h e w e a k e s t m o t i v a t o r s f o r i n f l u e n c i n g a c h a n g e i n b e h a v i o u r when p e o p l e a l r e a d y know how t o do s o m e t h i n g . I n f o r m a t i o n a n d e x h o r t a t i o n w i l l n o t n e c e s s a r i l y c h a n g e an " o u g h t a wanna" s i t u a t i o n . E v e n when a g e n u i n e s k i l l d e f i c i e n c y e x i s t s , t r a i n i n g i s o n l y one o f t h e r e m e d i e s (Mager & P i p e , p. 21). Mager a n d P i p e s u g g e s t t h a t t h e f i r s t s t e p t o w a r d e l i m i n a t i n g a p e r f o r m a n c e d i s c r e p a n c y i s u n d e r s t a n d i n g i t . I f k n o w l e d g e o r s k i l l i s m i s s i n g e i t h e r t h e r e q u i r e m e n t s c a n be c h a n g e d o r t e a c h i n g c a n be u s e d t o p r o v i d e t h e m i s s i n g c o m p o n e n t s . I f k n o w l e d g e o r s k i l l i s p r e s e n t t h e n t h e c o n d i t i o n s u n d e r w h i c h t h e p e r f o r m a n c e i s e x p e c t e d s h o u l d be c h a n g e d . I n e i t h e r c a s e , t o f o l l o w t h e i r r e m e d i e s a t h o r o u g h k n o w l e d g e o f t h e e x p e c t e d p e r f o r m a n c e a n d t h e c o n d i t i o n s i n w h i c h i t o c c u r s i s n e e d e d . I t i s t o t h i s end t h a t t h i s s t u d y a i m s . I d e n t i f i c a t i o n p e r se o f a d i s c r e p a n c y i n a c t u a l v e r s u s d e s i r e d b e h a v i o u r i s n o t s u f f i c i e n t r e a s o n f o r f u r t h e r s t u d y o r a c t i o n . The d i s c r e p a n c y must be i m p o r t a n t enough t o j u s t i f y s u c h a r e s p o n s e . Does l a c k o f c o m p l i a n c e w i t h BSE 3 recommendations warrant further consideration? The Significance of Performance Discrepancies in BSE Certainly health research has produced some sobering s t a t i s t i c s about breast cancer. It i s the most common type of cancer in women, approximately one in fourteen w i l l experience i t , mortality rate has not decreased for several decades and survival i s more l i k e l y i f the lump is detected when i t is small (which does not necessarily mean "early") (Alcoe & McDermot, 1979). There is no known method to prevent breast cancer (Bullough, 1980). Currently the ten-year survival rate for a l l women who have had diagnosed breast cancer i s one t h i r d , with a smaller lump (less than 2 cm.) and no nodal involvement improving those figures to 80 to 90 percent (Alcoe & McDermot). Given our present knowledge of the disease the f e l t need, as expressed in the l i t e r a t u r e , seems to be the inst i g a t i o n of early diagnosis (Alcoe & McDermot, 1979; Bullough, 1980; Edwards, 1980; Flynn, 1980; H a l l , Adams, Stein, Stephenson, Goldstein & Pennypacker, 1980; Stillman, 1977; Turnbull, 1978). Is BSE the vehicle for providing such early diagnosis? Physician examination has long been an accepted approach to early diagnosis. Bullough (1980) reports, however, that breast examinations done by physicians are not done as frequently as they should be. She c i t e s a 1973 Gallop p o l l in which 24 percent of the sample of 1300 women had not had a breast examination by a physician in the last f i v e years. Frequent physician involvement in thi s area cannot be assumed. Despite 4 t h i s p a t t e r n of examination by p h y s i c i a n s , they are s t i l l one of the main sources of BSE inf o r m a t i o n (Bullough, 1980; H a l l , G o l s t e i n & S t e i n , 1977; T u r n b u l l , 1978). However, there does not appear to be any research which has determined what p h y s i c i a n s teach or when, how or how f r e q u e n t l y they do i t . I t seems wise t o know "what i s " before proceeding to "what should be. " Another d i a g n o s t i c approach i s the use of the v a r i o u s s c r e e n i n g techniques which have been employed to detect breast a b n o r m a l i t i e s . S a f e t y , e f f e c t i v e n e s s and c o s t - b e n e f i t a n a l y s i s are some of the i s s u e s i n v o l v e d i n a s s e s s i n g t h i s approach. Many of the sc r e e n i n g programs have i n c l u d e d p h y s i c a l examination, mammogram or xeromammogram and/or a thermogram. Often BSE tea c h i n g i s a l s o i n c l u d e d . The s a f e t y i s s u e f o r mammograms or xeromammograms i s s t i l l c o n t e s t e d . While t h e i r use to i n v e s t i g a t e q u e s t i o n a b l e t i s s u e change i s g e n e r a l l y accepted, c o n t r o v e r s y remains over t h e i r use f o r mass s c r e e n i n g . There i s some q u e s t i o n about whether these x-ray procedures may, over time, i n c r e a s e r i s k of breast cancer (Alcoe & McDermot, 1979). They may a l s o d e t e c t changes which are too small or b o r d e r l i n e and u n r e l i a b l e d i a g n o s i s may cause unnecessary surgery (Alcoe & McDermot, 1979; Bullough, 1980; S t i l l m a n , 1977). The co s t of screening the e n t i r e female p o p u l a t i o n i s a l s o p r o h i b i t i v e as both s o p h i s t i c a t e d equipment and h i g h l y t r a i n e d personnel are r e q u i r e d ( Alcoe & McDermot, 1979; G a s t r i n , 1980). Costs may vary, however, depending on the use of p a r a - p r o f e s s i o n a l h e l p and type of technique ( K i r c h & K l e i n , 5 1978). Regardless of the type of screening, there has s t i l l been a f a i r l y large number of false positives, false negatives and i n t e r v a l cases (Alcoe & McDermot, 1979; Kirch & Klein, 1978). Interval cases are those which are detected between scheduled examinations. How does BSE compare as a r e l i a b l e , c o s t - e f f e c t i v e health practice? Kirch and Klein (1978) suggest the use of BSE along with other screening approaches may decrease the number of interval cases. Its importance would increase as the inter-examination in t e r v a l between other approaches increases. Hall et a l . (1977) report that 94 percent of cancerous lesions are po t e n t i a l l y palpable. As size increases the de t e c t a b i l i t y increases. Since the smaller the size the greater the survival rate, the user of BSE needs to have s u f f i c i e n t s k i l l to detect these smaller lumps. They report that some studies have shown that BSE can result in detection of tumors in the size range that maximizes survival and minimizes a x i l l a r y node involvement. Hall et a l . (1980) report more recent evidence that those who practice BSE had more favourably c l i n i c a l l y staged disease, fewer involved lymph nodes and smaller tumors, than those who did not. They contend that not only is BSE the most cost-e f f e c t i v e screening procedure available but since the majority of breast lumps are detected by women themselves, i t has a central role to play in early detection and prolonged s u r v i v a l . Gastrin (1980) reports on a massive study in Finland where BSE was taught to 56,000 women aged 20 to 80 and which resulted 6 in g r e a t l y reduced m o r t a l i t y i n new breast cancer cases. He contends that s i n c e breast s c r e e n i n g cannot be arranged f r e q u e n t l y enough f o r a l l women, teaching BSE i s an e f f e c t i v e economic s o l u t i o n which can be used to reach l a r g e numbers of women. Despi t e the seemingly obvious b e n e f i t s of BSE, a performance dis c r e p a n c y s t i l l e x i s t s . S t i l l m a n (1977) r e p o r t s that four out of f i v e women know of BSE but only 23 percent p r a c t i c e i t monthly. T h i s assessment of widespread knowledge but low compliance i s r e i t e r a t e d i n much of the l i t e r a t u r e (Alcoe & McDermot, 1979; Edwards, 1980; Fl y n n , 1981; H a l l et a l . , 1977; Howe, 1981; T u r n b u l l , 1978). Although a high percentage of lumps are found by women themselves the d i s c o v e r y i s u s u a l l y as a r e s u l t of a c c i d e n t rather than planned examination. M o t i v a t i o n to employ t h i s h e a l t h p r a c t i c e i s not we l l understood and remains a major c h a l l e n g e . Purpose of the Study Performance d i s c r e p a n c i e s occur in BSE p r a c t i c e s d e s p i t e i t s b e n e f i t s . P r o v i d i n g BSE in f o r m a t i o n u s i n g t r a d i t i o n a l t e a c h i n g approaches may not be the only or the best s o l u t i o n . Mager and Pipe suggest prob l e m - s o l v i n g before rushing in with remedies. The aim of t h i s study i s to examine and determine the v a r i a b l e s which i n f l u e n c e p a r t i c i p a t i o n i n t h i s p r e v e n t i v e h e a l t h p r a c t i c e . I t i s hoped that a b e t t e r understanding of these v a r i a b l e s w i l l suggest methods, techniques and d e v i c e s which may improve BSE tea c h i n g e f f e c t i v e n e s s and -which c o u l d 7 then be t e s t e d i n a c t u a l BSE teaching programs. In the chapters which f o l l o w BSE and the f a c t o r s which may i n f l u e n c e i t w i l l be explo r e d . Chapter II provides a review of the l i t e r a t u r e which seems r e l a t e d to the resea r c h t o p i c . Research on p a r t i c i p a t i o n i n e d u c a t i o n a l a c t i v i t i e s , b a r r i e r s to l e a r n i n g , h e a l t h education and compliance, BSE education and compliance and l o c u s of c o n t r o l w i l l be examined. Chapter III d e s c r i b e s the BSE P a r t i c i p a t i o n Paradigm developed f o r t h i s p r o j e c t and the theory u n d e r l y i n g i t s development. A s i n g l e , broad r e s e a r c h q u e s t i o n w i l l be presented. Chapter IV pr o v i d e s a s p e c i f i c d e s c r i p t i o n of methodology i n c l u d i n g instrument development, data c o l l e c t i o n and s t r a t e g i e s f o r data a n a l y s i s . A d e s c r i p t i o n and d i s c u s s i o n of f i n d i n g s using the BSE paradigm w i l l be given i n Chapter V. Chapter VI examines BSE using the BSE paradigm and the r e l a t i o n s h i p s between v a r i a b l e s which i t suggests. L i m i t a t i o n s of the r e s e a r c h are o u t l i n e d i n the f i n a l c h a p t er. A summary of the resea r c h and suggested i m p l i c a t i o n s for f u t u r e r e s e a r c h and f o r teaching BSE are a l s o given i n t h i s c o n c l u d i n g chapter. 8 CHAPTER II REVIEW OF THE LITERATURE Teaching BSE i n v o l v e s educating women ac r o s s the a d u l t l i f e s p a n . Since a d u l t s i n general are a heterogenous group the h e a l t h educator i s faced with a complex e d u c a t i o n a l s i t u a t i o n . In a d d i t i o n , the process of any education can be d e f i n e d as a d e l i b e r a t e and systematic attempt to change behaviour through l e a r n i n g (Cropley, 1977, p, 37) and l e a r n i n g i s not a simple p r o c e s s . In i t s broadest sense l e a r n i n g i s a dynamic "process of a d a p t a t i o n to the environment" (Cropley, p, 39). I t i s a c r e a t i v e process of s e l e c t i o n and r e o r g a n i z a t i o n that i n v o l v e s reinforcement, presence or absence of a p p r o p r i a t e p a t t e r n s of m o t i v a t i o n , a t t i t u d e s to the persons and m a t e r i a l s i n v o l v e d and a host of other a f f e c t i v e and c o g n i t i v e v a r i a b l e s (Cropley, p. 38). Learning i n c l u d e s a c q u i s i t i o n of s c h o l a r l y , p r o f e s s i o n a l or v o c a t i o n a l knowledge but i t a l s o i n v o l v e s " m o t i v a t i o n a l , c o g n i t i v e , a f f e c t i v e , e t h i c a l , a e s t h e t i c and pers o n a l growth" (Cropley, p. 39). As an acknowledgement of the complexity of the e d u c a t i o n a l process i n g e n e r a l , and the t a r g e t group f o r BSE s p e c i f i c a l l y , t h i s l i t e r a t u r e review w i l l attempt to examine the issue of l e a r n i n g from a broad p e r s p e c t i v e before f o c u s i n g on the s p e c i f i c i s s u e of l e a r n i n g about BSE. : I t i s hoped that a b e t t e r understanding of the v a r i a b l e s which may be i n f l u e n c i n g BSE 9 behaviour p a t t e r n s w i l l r e s u l t . The u l t i m a t e aim i s to improve BSE e d u c a t i o n a l programs. With t h i s i n mind and i n search of v a r i a b l e s which may i n f l u e n c e p a r t i c u l a r l y the d e c i s i o n to p a r t i c i p a t e i n the p r e v e n t i v e h e a l t h behaviour of BSE, the broad category of p a r t i c i p a t i o n research w i l l be reviewed. B a r r i e r s to a c t u a l l e a r n i n g i s another category of r e s e a r c h which may r e v e a l v a r i a b l e s which i n f l u e n c e the s p e c i f i c s i t u a t i o n of l e a r n i n g in a h e a l t h - r e l a t e d e d u c a t i o n a l program. T h i s i s the second broad category which w i l l be reviewed from the p e r s p e c t i v e of a d u l t l e a r n i n g i n g e n e r a l . A s p e c i f i c i ssue r e l a t e d to h e a l t h education i s compliance. T h i s i s the term used by the h e a l t h community to r e f e r to the degree of d e s i r e d behaviour change r e l a t e d to h e a l t h advice r e c e i v e d . T h i s t o p i c w i l l be reviewed f i r s t from the p e r s p e c t i v e of h e a l t h behaviour g e n e r a l l y and then as i t i n v o l v e s BSE behaviour s p e c i f i c a l l y . P e r c e p t i o n s or e x p e c t a t i o n s are a r e c c u r r i n g v a r i a b l e i n the r e s e a r c h areas mentioned. T h i s v a r i a b l e i s examined by the l o c u s of c o n t r o l l i t e r a t u r e . The l i t e r a t u r e review w i l l conclude with an examination of t h i s s p e c i f i c area of r e s e a r c h . A summary of the research f i n d i n g s f o l l o w s . 10 Pa r t i c i p a t i o n Research Rubenson's Expectancy-Valence Paradigm In an e f f o r t to synthesize the knowledge available about adult education and adult motivation for learning Rubenson (1977) has developed the Expectancy-Valence Paradigm. It i s his contention that the researcher must consider both the micro and the macro levels of structural conditions in which an individual is found, that individual's psychological conceptual apparatus and the link between these two elements. While his aim i s - to examine adult education p a r t i c i p a t i o n and recruitment of adults into adult education programs, his analysis and conceptual framework can be used to look at the issue of adult learning in general as well as the s p e c i f i c recruitment dilemma. Pa r t i c i p a t i o n in a learning a c t i v i t y is one aspect of the learning process. If the research concern is a performance discrepancy and education i s seen as one remedy for changing the undesired behaviour then a knowledge of issues which i n h i b i t i n i t i a l p a r t i c i p a t i o n in a learning a c t i v i t y i s needed. Underlying theory. As a basis for his model building, Rubenson examined various theories of motivation. He distinguished three schools. The s c i e n t i f i c - p h y s i c a l school uses drive theories rooted in biology and physics. Behaviour is explained in terms of drives and i n s t i n c t s . The humanist school sees man as innately able to reach s e l f - r e a l i z a t i o n but he is hindered in this endeavour by the blocking factors in his 11 environment. The c o g n i t i v e school e x p l a i n s behaviour i n terms of a c q u i r e d experiences and the p s y c h o l o g i c a l environment. Emotions, needs and motives play a major r o l e . Rubenson opts f o r the c o g n i t i v e approach and chooses the expectancy-valence concept as an u n d e r l y i n g theory i n h i s model. Valence r e f e r s to the a f f e c t i v e a t t i t u d e one has about the r e s u l t that a c e r t a i n course of a c t i o n may have. I t i s connected to the p e r c e p t i o n of what an a c t i v i t y can l e a d to i n the f u t u r e . D e s i r e f o r or a v e r s i o n to the a c t i v i t y i s based on the a n t i c i p a t e d s a t i s f a c t i o n or d i s s a t i s f a c t i o n r e l a t e d to the outcome. Expectancy i s the b e l i e f about the l i k e l i h o o d of a p a r t i c u l a r outcome f o l l o w i n g a p a r t i c u l a r a c t . The s t r e n g t h of an expectancy i s a f u n c t i o n of the s u b j e c t i v e c e r t a i n t y about the r e l a t i o n s h i p of an act and an outcome. A woman's b e l i e f about her a b i l i t y to d e t e c t a breast lump c o u l d be expected to a f f e c t her expectancy of success with BSE. Her b e l i e f about the outcome of f i n d i n g a breast lump ( i e . , e a r l y d e t e c t i o n i s r e l a t e d to i n c r e a s e d chances of a c u r e ) , c o u l d be expected to i n f l u e n c e her a f f e c t i v e a t t i t u d e about c a r r y i n g out BSE. I f f i n d i n g a breast lump i s r e l a t e d to negative f e e l i n g s about surgery or the p o s s i b i l i t y of the f e a r e d d i a g n o s i s of cancer, one would a n t i c i p a t e that the valence r e l a t e d to BSE would be a f f e c t e d a c c o r d i n g l y . Not only would one expect BSE behaviour p a t t e r n s to be a f f e c t e d , one would expect avoidance of or p a r t i c i p a t i o n in BSE t e a c h i n g programs to be c o r r e l a t e d to i n d i v i d u a l valence.and expectency r e l a t e d to BSE as a p r e v e n t i v e h e a l t h measure. 12 Rubenson relates his concept to adult education recruitment by suggesting that there w i l l be a high probability of enrollment i f a person sees such p a r t i c i p a t i o n as a means of sa t i s f y i n g his needs (valence) and believes that his a b i l i t y w i l l make thi s p a r t i c i p a t i o n lead to desirable outcomes (expectancy) (1977, p. 9). He contends that a person's values and expectations are closely related to the way he regards himself and to the attitudes in the groups around him. Self-evaluation and factors influencing i t begin to play an important role. Rubenson examines the expectancy-valence theory in li g h t of adult education p a r t i c i p a t i o n research. Since no studies exist which d i r e c t l y relate valence and expectancy factors to adult education p a r t i c i p a t i o n , he supports his framework with research on motives for study, on recruitment obstacles and on part ic ipants. One powerful motive for p a r t i c i p a t i o n seems to be the desire to make p r a c t i c a l use of the knowledge acquired. Non-vocational motives are more common among intermediate and higher s o c i a l status people than among those with limited opportunities in t h i s area. Requirement to study because of their situation was the most common reason for people to take courses for par t i c u l a r q u a l i f i c a t i o n s . As people pass through the l i f e cycles, needs and so c i a l roles change. A person's expected tasks d i f f e r depending on his b i o l o g i c a l development, his personal ambitions and the so c i a l pressures and expectations he is under. Rubenson suggests that findings show a connection 1 3 between the s i t u a t i o n people are i n and t h e i r p a r t i c i p a t i o n i n education (Rubenson, 1977, pp. 10-12). Is there any connection between the s i t u a t i o n a woman i s i n and her p a r t i c i p a t i o n i n education about BSE? Is p a r t i c i p a t i o n i n BSE l e a r n i n g o p p o r t u n i t i e s r e l a t e d to s o c i a l s t a t u s , age, recent p e r s o n a l , f a m i l y or f r i e n d s ' experience with cancer and r e l a t e d p e r s o n a l l a c k of knowledge or s k i l l , s o c i a l pressure to c a r r y out BSE r e g u l a r l y or p e r s o n a l ambitions r e l a t e d to h e a l t h s t a t u s ? The r e s e a r c h on motives f o r study suggests there might be some connection between these f a c t o r s . Recruitment impediments have not had as much a t t e n t i o n i n r e s e a r c h as have motives. E x t e r n a l environmental o b s t a c l e s have been emphasized. P s y c h o l o g i c a l impediments or those " r e l a t e d to the s e l f - c o n f i d e n c e of the i n d i v i d u a l , h i s l e v e l of a s p i r a t i o n , and h i s a t t i t u d e to a d u l t education" (Rubenson, 1977, p. 12), have o f t e n been n e g l e c t e d . Among the p o i n t s r e v e a l e d by Rubenson's (1977) resea r c h review a r e : those i n t e r e s t e d i n p a r t i c i p a t i n g were l e s s l i k e l y to p l e a d p s y c h o l o g i c a l impediments than those who were not i n t e r e s t e d , both groups p l e a d e x t e r n a l o b s t a c l e s to the same extent; l a c k of i n f o r m a t i o n was more l i k e l y to be named by n o n - p a r t i c i p a n t s ; fear of s t u d i e s was more common in o l d e r r a t h e r than younger persons; c o s t was a b a r r i e r to women more than men; one of the most powerful p s y c h o l o g i c a l impediments i s the i n d i v i d u a l ' s b e l i e f that p a r t i c i p a t i o n would not improve h i s l i v i n g s i t u a t i o n ; a negative experience of school i s a frequent cause of f e e l i n g education was not p e r s o n a l l y a t t r a c t i v e ; p o s s i b i l i t i e s of studying d u r i n g 1 4 working hours i s a powerful recruitment f a c t o r ; f i n a n c i a l i n c e n t i v e s d i d not have a m a t e r i a l e f f e c t except f o r recruitment among housewives. Rubenson's c o n c l u s i o n i s to suggest that both e x t e r n a l environmental and i n t e r n a l p s y c h o l o g i c a l o b s t a c l e s must be examined to understand the problems of re c r u i t m e n t . The t h i r d area Rubenson reviewed was p a r t i c i p a t i o n s t u d i e s . In comparing p a r t i c i p a n t s and n o n - p a r t i c i p a n t s , some of the re s e a r c h f i n d i n g s a r e : formal education and a d u l t education are connected; white c o l l a r workers tend to p a r t i c i p a t e more i n ad u l t education than manual workers; those with s t i m u l a t i n g and a c t i v e l e i s u r e time tend to have a higher i n c i d e n c e of a d u l t education p a r t i c i p a t i o n ; upper s o c i a l c l a s s e s f o l l o w forms of education which provide p a y - o f f s in terms of income, s t a t u s , occupation or p o l i t i c a l e f f i c a c y . Rubenson concludes that p a r t i c i p a t i o n i s dependent on whether an i n d i v i d u a l sees any value i n educ a t i o n . He f e e l s that incongruency between p e r s o n a l p r e s s u r e s and e d u c a t i o n a l o p p o r t u n i t i e s may be part of the reason under-educated people have f a i r l y low p a r t i c i p a t i o n r a t e s . In a d d i t i o n , people may not be able to r e l a t e t h e i r needs to the o p p o r t u n i t i e s a v a i l a b l e (Rubenson, 1977, p. 16). Given the r e l a t i o n s h i p between expectancy concerning the value of s t u d i e s and a c t u a l p a r t i c i p a t i o n , Rubenson sees s e l f -e v a l u a t i o n as a major c o n t r i b u t i n g f a c t o r . S e l f - e v a l u a t i o n i s taken to mean "the gen e r a l or g l o b a l value which the i n d i v i d u a l a s c r i b e s to hi m s e l f as an o b j e c t " (Rubenson, 1977, p. 18). I t i s based on both an a f f e c t i v e r e a c t i o n and a c o g n i t i v e e v a l u a t i o n . Rubenson s t a t e s that 1 5 "people are motivated to seek to achieve s t a t e s compatible with the views they have a c q u i r e d concerning themselves, others and the world around them" (1977, p. 17). His review of the l i t e r a t u r e found support f o r a d i r e c t r e l a t i o n s h i p between s e l f -p e r c e p t i o n , a d u l t education p a r t i c i p a t i o n and achievement. People with a p o s i t i v e s e l f - e v a l u a t i o n g e n e r a l l y succeed b e t t e r in achievement-oriented s i t u a t i o n s than those with a negative s e l f - e v a l u a t i o n . While developmemt of s e l f - e v a l u a t i o n has not been c l e a r l y e x p l a i n e d i n the l i t e r a t u r e i t seems to be r e l a t e d to s o c i a l i n t e r a c t i o n . V a l u a t i o n s and a t t i t u d e s e l i c i t e d from o t h e r s , e s p e c i a l l y those of importance to us, i n f l u e n c e the way we see o u r s e l v e s . In connection with t h i s theory Rubenson examined the c h i l d h o o d environment, the school environment and the work environment. He found evidence to show that the degree of h i e r a r c h i c a l s t r u c t u r e i n each of these s i t u a t i o n s i s r e l a t e d to s e l f - e v a l u a t i o n . In other words, s e l f - e v a l u a t i o n seems to be connected to a c h i l d h o o d , school and work environment which permits and encourages i n d i v i d u a l i n i t i a t i v e s (Rubenson, 1977, p. 23). Since s e l f - e v a l u a t i o n i s r e l a t i v e l y s t a b l e over time and c r i t e r i a by which one a p p r a i s e s o n e s e l f change over the l i f e c y c l e , Rubenson concludes that when outward environmental changes occur, the i n d i v i d u a l has to "change h i s behaviour to prevent t h i s l e a d i n g to dissonance" (1977, p. 23). S o c i a l i z a t i o n does not stop with maturity and Rubenson examines the i n f l u e n c e s of groups on the i n d i v i d u a l . The values of member and r e f e r e n c e groups i n f l u e n c e an i n d i v i d u a l ' s v a l u e s . Member groups are groups i n which a person i s an acknowledged 1 6 member and referenc e groups are ones whose norms are u t i l i z e d to s a t i s f y i n d i v i d u a l needs but i n which membership i s not o v e r t . Member groups serve as re f e r e n c e groups i n one way or another but not a l l ref e r e n c e groups are member groups. Based on Houle's f i n d i n g that education programs based on i n d i v i d u a l s ' i n t e r e s t s r e c r u i t e d a smaller number of people than those based on group values, i t seems that course s e l e c t i o n i s determined more by group values than i n d i v i d u a l i n t e r e s t s (Rubenson, 1977, p. 24). Rubenson sees these f i n d i n g s as a u s e f u l t o o l f o r understanding d i f f e r e n c e s between under-educated and w e l l -educated people and d i f f e r e n c e s w i t h i n under-educated groups. Given t h e i r access to r e f e r e n c e groups with a p o s i t i v e a t t i t u d e to education, white c o l l a r workers are i n an e d u c a t i o n a l l y favourable environment. Rubenson concludes that " i t i s not enough to t r y to inform and i n f l u e n c e i n d i v i d u a l persons, one a l s o has to work through the groups to which the i n d i v i d u a l belongs and i d e n t i f i e s himself with" (1977, p. 25). While f r i e n d s and fami l y are an important r e f e r e n c e group i t i s d i f f i c u l t to reach them and work o r g a n i z a t i o n s are a v a i l a b l e t a r g e t s f o r e d u c a t i o n a l e n t e r p r i s e s . Rubenson sees the in c r e a s e d j u s t i f i c a t i o n f o r t a l k i n g about studying with c o l l e a g u e s and the inc r e a s e d exposure to the b e n e f i t s of education may ease the d e c i s i o n to p a r t i c i p a t e (1977, p. 26). D e s c r i p t i o n of the paradigm. Based on h i s l i t e r a t u r e review and using Lewin's f i e l d theory, Rubenson developed h i s paradigm (Figure 1). His premise i s that behaviour i s a f u n c t i o n of both the environment and the i n d i v i d u a l . Past FIgure 1. Paradigm of Recruitment In Adult Education S o c i a l i z a t i o n through family, school and work Congent ta i PropertIes Act Ive Preparedness Structura1 factors In the environment (the degree of h i e r a r c h i c structure, < values of member, and reference groups, study poss1bl11tles) Expectation' the expectation that education w i l l have c e r t a i n d e s i r a b l e consequences x the expectation of being able to p a r t i c i p a t e In and complete the education Perception and •+ i n t e r p r e t a t i o n of the environment Force (the strength whereof w i l l determine behaviour) Valence of education Current needs of the Individual The Individual's experience of needs 1 Source: Rubenson, 1977, p. 30. 18 experience i s important i n terms of the t r a c e s i t has l e f t i n the person's p s y c h o l o g i c a l f i e l d . A study of the i n t e r a c t i o n between s t r u c t u r a l f a c t o r s and the i n d i v i d u a l ' s conceptual apparatus leads to i n t e r p r e t a t i o n of behaviour. A c t i v e preparedness which a r i s e s out of s o c i a l i z a t i o n w i t h i n the f a m i l y , the school and o c c u p a t i o n a l l i f e i n f l u e n c e s expectancy and p e r c e p t i o n s and i n t e r p r e t a t i o n of the environment. The l a t t e r , a r i s i n g out of s t r u c t u r a l f a c t o r s i n the environment, three of which are the degree of h i e r a r c h i c s t r u c t u r e , values of member and r e f e r e n c e groups and study p o s s i b i l i t i e s , a l s o i n f l u e n c e s expectancy d i r e c t l y and i s i n f l u e n c e d as w e l l by the i n d i v i d u a l ' s experience of needs. These needs r e f l e c t h i s m a t e r i a l s i t u a t i o n and the developmental tasks with which he i s c o n f r o n t e d . In a d d i t i o n to i n f l u e n c i n g environmental p e r c e p t i o n and i n t e r p r e t a t i o n , needs give r i s e to the valence of education which, i n t u r n , i s a l s o i n f l u e n c e d by expectancy. The two r e s u l t s , expectancy and valence, combine to form a fo r c e which determines behaviour. Use of the paradigm. Using t h i s paradigm, Rubenson analysed a major study of young, undereducated men i n Sweden (Rubenson, 1975). He found that as Tough (1969) suggests, a d u l t education p a r t i c i p a t i o n i s more complex than i s g e n e r a l l y assumed. As i n the Johnstone and R i v e r a study (1965) he found there were g e n e r a l l y two kinds of o b s t a c l e s : environmental and p s y c h o l o g i c a l . Environmental o b s t a c l e s i n c l u d e d f a c t o r s beyond the i n d i v i d u a l ' s c o n t r o l and while no s i n g l e o b s t a c l e was c l e a r l y dominant, examples c i t e d were working hours, care of 19 c h i l d r e n and a v a i l a b i l i t y of courses. P s y c h o l o g i c a l o b s t a c l e s r e f e r r e d to i n t e r n a l f a c t o r s such as s e l f - c o n f i d e n c e , l e v e l of ambition and a t t i t u d e toward a d u l t e d u c a t i o n . Too l i t t l e i n f o r m a t i o n about a v a i l a b l e o p p o r t u n i t i e s was a strong d e f e r e n t with those who wanted to p a r t i c i p a t e but d i d not. Rubenson drew s e v e r a l c o n c l u s i o n s . He f e l t that a d i s t i n c t i o n had to be drawn between those who are i n t e r e s t e d i n a d u l t education and do not p a r t i c i p a t e and those who are not i n t e r e s t e d at a l l . D i f f e r e n t recruitment measures are needed f o r each category. The former group need more in f o r m a t i o n about a v a i l a b l e experiences and scheduled courses d u r i n g work hours. Success with the l a t t e r group, Rubenson f e l t , can only occur i f t h e i r a t t i t u d e s are changed. The e n t i r e complex of problems and needs experienced by p a r t i c i p a n t s must be taken i n t o account. In terms of BSE one would want to examine i n f o r m a t i o n seeking p a t t e r n s i n l i g h t of both e x t e r n a l and i n t e r n a l o b s t a c l e s . Knowledge of sources of BSE i n f o r m a t i o n , b e l i e f s about i t s v a l u e , p o s i t i v e or negative i n f l u e n c e s of p r e v i o u s l e a r n i n g experiences and a v a i l a b i l i t y of BSE i n f o r m a t i o n sources may be r e l a t e d to u l t i m a t e BSE l e a r n i n g p a t t e r n s . S e l f -e v a l u a t i o n seems to be an important i n f l u e n c e on e d u c a t i o n a l a c t i v i t i e s and i t seems to be i n f l u e n c e d by the h i e r a r c h i a l s t r u c t u r e e s p e c i a l l y i n a person's work l i f e . Are work s i t u a t i o n and BSE e d u c a t i o n a l or p r a c t i c e p a t t e r n s connected? Reference groups may a l s o exert an i n f l u e n c e and t h e i r a t t i t u d e s may play a p a r t i n i n d i v i d u a l B S E - r e l a t e d behaviour. Are there 20 any d i f f e r e n c e s between those i n t e r e s t e d i n i n c r e a s i n g t h e i r knowledge of BSE and those who are not? A l l these f a c t o r s may suggest i m p l i c a t i o n s r e l a t e d to pl a n n i n g and r e c r u i t i n g f o r a BSE t e a c h i n g program. O b s t a c l e s to P a r t i c i p a t i o n Carp, Peterson and Roelf (1974) conducted r e s e a r c h f o r the Commission on N o n - T r a d i t i o n a l Study. In t h e i r study they asked would-be l e a r n e r s to i n d i c a t e , from a l i s t of 24 items, the thi n g s they f e l t were important i n keeping them from l e a r n i n g what they wanted to l e a r n . They found the most widely reported p o t e n t i a l o b s t a c l e was f i n a n c i a l c o s t . F i f t y - t h r e e percent c i t e d t h i s item, 46 percent c i t e d not enough time, 35 percent d i d not want to go to school f u l l - t i m e , 32 percent c i t e d home r e s p o n s i b i l i t i e s , 28 percent chose job r e s p o n s i b i l i t i e s as a b a r r i e r and 21 percent p i c k e d the amount of time r e q u i r e d to complete the program. Each of these c a t e g o r i e s were i n d i c a t e d by at at l e a s t o n e - f i f t h of the group. Job r e s p o n s i b i l i t i e s were mentioned by twice as many men as women. Women were ten times as concerned about lac k of c h i l d care and f e l t g e n e r a l l y more c o n s t r a i n e d by c o s t . Age caused a v a r i a n c e i n b a r r i e r c h o i c e as w e l l . Those under 35 saw cost as more of a d e f e r e n t . Younger people d i d not want to go to school f u l l time and were t i r e d of school and classrooms. Not enough time, home r e s p o n s i b i l i t i e s and care of c h i l d r e n were concerns of middle-age groups and f e e l i n g s of being too o l d and not having enough energy i n c r e a s e d with age and was seen e s p e c i a l l y among women. Whites mentioned not enough time and home r e s p o n s i b i l i t i e s twice 21 as much as b l a c k s and bl a c k s mentioned low grades i n the past, not meeting entrance requirements, c o s t , c h i l d care and lack of t r a n s p o r t a t i o n and study f a c i l i t i e s twice as o f t e n as whites. Researchers concluded that time and cost seemed to be the g r e a t e s t b a r r i e r s f o r t h e i r s u b j e c t s (Carp, Peterson & R o e l f s , 1974). Although c o s t i s not u s u a l l y an is s u e i n h e a l t h - r e l a t e d e d u c a t i o n a l programs, time may be an important i n f l u e n c e . In a d d i t i o n , p l a n n i n g h e a l t h education in t r a d i t i o n a l " s c h o o l i n g " arrangements and atmosphere may i n f l u e n c e a t t i t u d e s i n terms of per s o n a l a b i l i t y or d e s i r a b i l i t y of p a r t i c i p a t i n g . C e r t a i n e t h n i c groups may be p a r t i c u l a r l y s e n s i t i v e to t h i s i s s u e . Cross (1981) grouped l e a r n i n g o b s t a c l e s c i t e d i n survey f i n d i n g s under three headings: s i t u a t i o n a l , i n s t i t u t i o n a l and d i s p o s i t i o n a l b a r r i e r s . S i t u a t i o n a l b a r r i e r s a r i s e from one's s i t u a t i o n in l i f e at any given time. I n s t i t u t i o n a l b a r r i e r s are those p r a c t i c e s and procedures that exclude or discourage a d u l t p a r t i c i p a t i o n i n e d u c a t i o n a l a c t i v i t i e s . D i s p o s i t i o n a l b a r r i e r s are r e l a t e d to one's a t t i t u d e s and s e l f - p e r c e p t i o n s about one s e l f as a l e a r n e r . Under s i t u a t i o n a l b a r r i e r s Cross found that c o s t and lack of time l e a d a l l other b a r r i e r s . Cost i s d i f f i c u l t to assess as a b a r r i e r . People mention i t but Cross f e e l s that many probably do not have an idea of the cost of v a r i o u s o p t i o n s . In a d d i t i o n , w i l l i n g n e s s to pay has not been found to be the same t h i n g as a b i l i t y to pay. F a c t o r s such as the purpose of the course ( l e s s i s spent on pl e a s u r e versus j o b - o r i e n t e d c o u r s e s ) , sex (men are u s u a l l y more w i l l i n g to pay than women) and age 22 (o l d e r people are more w i l l i n g to pay) are mentioned (Cross, 1981, p. 101). Cross a l s o p o i n t s out that using cost as an excuse i s a more s o c i a l l y a c c e p t a b l e reason f o r not t a k i n g a course. In one study people who were l e s s d e f e n s i v e mentioned c o s t as a b a r r i e r l e s s o f t e n and Cross concludes that the context i n which a q u e s t i o n i s asked about b a r r i e r s to l e a r n i n g p l a y s an important part i n the answers g i v e n . I n s t i t u t i o n a l b a r r i e r s ranked second i n importance to s i t u a t i o n a l b a r r i e r s . They e x i s t e d p r i m a r i l y i n programs dev i s e d f o r f u l l - t i m e l e a r n e r s but a f f e c t e d between 10 and 25 percent of p o t e n t i a l l e a r n e r s i n most surveys. Cross p o i n t s out that many i n s t i t u t i o n s have attempted to e l i m i n a t e many of these b a r r i e r s by sc h e d u l i n g c l a s s e s at more a c c e s s i b l e p l a c e s and times and by c r e a t i n g more f l e x i b l e admissions procedures but many people s t i l l thought these b a r r i e r s e x i s t e d . She concludes that " i f an i n d i v i d u a l t h i n k s that courses would not be of i n t e r e s t or that they are scheduled only d u r i n g the i n d i v i d u a l ' s working day, then the p e r c e p t i o n i t s e l f a c t s as a b a r r i e r whether i t a c t u a l l y e x i s t s or not" (p. 104). She groups i n s t i t u t i o n a l b a r r i e r s i n t o f i v e a reas: s c h e d u l i n g ; l o c a t i o n and t r a n s p o r t a t i o n ; lack of courses that are i n t e r e s t i n g , p r a c t i c a l or r e l e v a n t ; procedures; and time requirements. The ones most f r e q u e n t l y mentioned are inconvenient l o c a t i o n s and schedules and lack of i n t e r e s t i n g or r e l e v a n t courses. The is s u e of the relevance or p e r c e i v e d value of BSE courses a r i s e s . I t appears that t h i s may be a v i t a l l i n k between BSE behaviour, i n f o r m a t i o n and i n f o r m a t i o n source. 23 Cross mentions s o c i a l d e s i r a b i l i t y as an issue i n measuring d i s p o s i t i o n a l b a r r i e r s . Excuses that are most s o c i a l l y a c c e p t a b l e are more l i k e l y to be g i v e n . U n i n t e r e s t e d respondents are f r e q u e n t l y dropped from s t u d i e s and thus an important d i s c l o s u r e source fo r d i s p o s i t i o n a l b a r r i e r s i s l o s t . Under t h i s heading Cross groups such things as being too o l d , l a c k of c o n f i d e n c e i n one's own a b i l i t y and lack of energy or stamina. In c o n c l u s i o n , Cross suggests that methodology changes r e s u l t s of r e s e a r c h on b a r r i e r s to l e a r n i n g . Surveys give broad r e s u l t s but tend to minimize d i s p o s i t i o n a l f a c t o r s . The experimental approach s t u d i e s what people do as opposed to what they say they might do. Using t h e o r i e s to h e l p examine b a r r i e r s and e x p l a i n v a r i o u s aspects of a d u l t l e a r n i n g c o u l d provide a powerful t o o l but t h i s approach has been u n d e r - u t i l i z e d i n Cross's e s t i m a t i o n . Cross's Chain of Response Model A f t e r examining t h e o r i e s put forward by o t h e r s , Cross puts forward her Chain of Responses (COR) Model (Figure 2). The model assumes that " p a r t i c i p a t i o n in a l e a r n i n g a c t i v i t y , whether i n organized c l a s s e s or s e l f - d i r e c t e d , i s not a s i n g l e act but the r e s u l t of a chain of responses, each based on an e v a l u a t i o n of the p o s i t i o n of the i n d i v i d u a l in h i s or her environment" (p. 125). Behaviour i s seen as a c o n s t a n t l y f l o w i n g stream i n f l u e n c e d by f o r c e s which s t a r t with the i n d i v i d u a l and move to i n c r e a s i n g l y e x t e r n a l c o n d i t i o n s but which a l s o flow i n the opposite d i r e c t i o n s i n c e s e l f - p e r c e p t i o n s 24 Figure 2 Chain of Response (COR) Model for Understanding P a r t i c i p a t i o n in Adult Learning A c t i v i t i e s L i f e t r a n s i t i o n s Information S e l f - e v a l u a t i o n Importance of goals x f and expectat ions Opportuni t ies ^ that p a r t i c i p a t i o n . ^ a n d b a r r i e r s ^ P a r t i c i p a t i o n <$ . w i l l meet goals «i At t i tudes about education Source: Cross, 1 9 8 1 , p. 1 2 4 . and a t t i tudes are changed by p a r t i c i p a t i o n in learn ing a c t i v i t i e s and in te rac t ion with external c o n d i t i o n s . S e l f - e v a l u a t i o n i s the s ta r t of the chain of responses which make up the COR model. Cross uses m o t i v a t i o n - f o r -achievement research to point out the inf luences of s e l f -eva luat ion . If persons lack conf idence in the i r own a b i l i t i e s , sometimes c a l l e d " f a i l u r e threatened" or "de f i c iency o r i e n t e d " , they avoid s i tua t ions which threaten the i r s e l f - e s t e e m . S e l f -evaluat ion inf luences and is in f luenced by a t t i t u d e s toward educat ion. These a t t i t u d e s a r i s e out of personal experiences and a t t i tudes of the past and the experiences and a t t i tudes of f r iends and s i g n i f i c a n t o thers . Thus unhappy chi ldhood school experiences or reference group d isapprova l can lead to avoidance of adult educat ion. Cross suggests a " r e l a t i v e l y stable and c h a r a c t e r i s t i c stance toward lea rn ing" (1981, p. 126) e x i s t s 25 which can be e i t h e r p o s i t i v e or n e g a t i v e . T h i s c h a r a c t e r i s t i c stance responds to the importance of goals and the e x p e c t a t i o n that p a r t i c i p a t i o n w i l l meet g o a l s . If a g o a l i s important and i s seen as a c h i e v a b l e through educ a t i o n , m o t i v a t i o n i s strong and i f not, m o t i v a t i o n decreases. Self-esteem i s r e l a t e d to e x p e c t a t i o n s of success and i n the COR model there i s movement in both d i r e c t i o n s between the i n i t i a l s e l f - e v a l u a t i o n and e d u c a t i o n a l a t t i t u d e s , and expectancy. L i f e t r a n s i t i o n s , change p e r i o d s which r e q u i r e making adjustments, i n f l u e n c e a t t i t u d e s towards goals and e x p e c t a t i o n s about p a r t i c i p a t i o n as w e l l . Gradual t r a n s i t i o n s i n l i f e and dramatic changes can both t r i g g e r a d e s i r e f o r l e a r n i n g . Cross mentions Havighurst's "teachable moment" concept which i m p l i e s that there are times of s p e c i a l s e n s i t i v i t y f o r l e a r n i n g c e r t a i n t h i n g s . An example i s the i n t e r e s t new parents show in p a r e n t i n g c l a s s e s . Are there such teachable moments r e l a t e d to BSE? There may be p a r t i c u l a r events which would t r i g g e r an i n c r e a s e d i n t e r e s t or m o t i v a t i o n to p a r t i c i p a t e i n a BSE education program and to develop new p r e v e n t i v e h e a l t h p r a c t i c e s . It i s at t h i s p o i n t that b a r r i e r s and s p e c i a l o p p o r t u n i t i e s fo r l e a r n i n g appear i n Cross's c h a i n of responses. Once the i n d i v i d u a l i s motivated they w i l l be encouraged to seek out the s p e c i a l o p p o r t u n i t i e s and overcome modest b a r r i e r s . Those who are weakly motivated may be encouraged by awareness of o p p o r t u n i t i e s but modest b a r r i e r s may f o r e s t a l l p a r t i c i p a t i o n . A v a i l a b i l i t y of accurate i n f o r m a t i o n i s c r i t i c a l . Without i t b a r r i e r s may seem unsurmountable. 26 From t h i s p o i n t i n the COR model the i n d i v i d u a l steps on to p a r t i c i p a t i o n . The c y c l e i s complete when p a r t i c i p a t i o n i n f l u e n c e s s e l f - e v a l u a t i o n and a t t i t u d e s about education, and m o t i v a t i o n i s i n f l u e n c e d by the end r e s u l t . Cross suggests that c u r r e n t l y most e f f o r t s to a t t r a c t a d u l t s to l e a r n i n g occurs at the o p p o r t u n i t i e s and b a r r i e r s stage. Reducing b a r r i e r s or enhancing o p p o r t u n i t i e s may not reach the person who has weak mo t i v a t i o n before t h i s p o i n t i n the model. Cross suggests that while the i n f l u e n c e may flow backward in the model, most people w i l l need to be motivated to some extent before removal of e x t e r n a l b a r r i e r s w i l l make a d i f f e r e n c e . More a t t e n t i o n than has been p r e v i o u s l y given to such i n t e r n a l v a r i a b l e s as s e l f -e v a l u a t i o n and e d u c a t i o n a l a t t i t u d e s i s needed. Thus, as with Rubenson's model, there i s emphasis oh l o o k i n g beyond the obvious e x t e r n a l b a r r i e r s . The a d u l t educator may w e l l wonder why removal of these obvious b a r r i e r s has not r e s u l t e d i n a f l o o d of l e a r n e r s eager to sample t h e i r o f f e r i n g s . Cross suggests that i n the chain of responses which r e s u l t s i n p a r t i c i p a t i o n and l e a r n i n g , m o t i v a t i o n i s the key and s e l f - e v a l u a t i o n i s the s t a r t i n g p o i n t . With a p o s i t i v e s e l f -concept and high e x p e c t a t i o n s of success b a r r i e r s seem surmountable. T h i s group of students needs i n f o r m a t i o n about resources and s i t u a t i o n a l and i n s t i t u t i o n a l arrangements that f a c i l i t a t e p a r t i c i p a t i o n . As was mentioned e a r l i e r , a l e a r n i n g environment which f o s t e r s continued p o s i t i v e s e l f - e s t e e m w i l l h e l p keep m o t i v a t i o n high and the i n f l u e n c e of b a r r i e r s to a minimum. 27 A f t e r d e c i d i n g to p a r t i c i p a t e in an a c t u a l l e a r n i n g s i t u a t i o n other b a r r i e r s e x i s t which i n f l u e n c e the outcome of such p a r i c i p a t i o n . Involvement in a l e a r n i n g a c t i v i t y does not guarantee d e s i r e d behaviour change. V a r i a b l e s which i n f l u e n c e behaviour duri n g and a f t e r e d u c a t i o n a l experiences are another f a c t o r i n understanding the l i n k between BSE behaviour and i t s i n f l u e n c i n g v a r i a b l e s . B a r r i e r s to L earning The ISSTAL Model Smith (1980) has developed a model to examine i n d i v i d u a l d i s c r e t i o n a r y behaviour. He d e f i n e s d i s c r e t i o n a r y time as "the time a v a i l a b l e f o r a c t i v i t i e s not e s s e n t i a l to making a l i v i n g or s u s t a i n i n g l i f e . i n a s o c i e t y " (Smith et a l . , 1980, p. 1). S p e c i f i c a l l y , he i s aiming at s o c i a l behaviour or that human behaviour which i s " s i g n i f i c a n t l y shaped by c u l t u r e , custom, and norms and by the presence ( a c t u a l or imagined) of o t h e r s " (p. 1). He f e e l s that s i n c e d i s c r e t i o n a r y time a c t i v i t y i s the most v a r i a b l e and l e a s t p r e d i c t a b l e behaviour, a model which helps e x p l a i n i t w i l l f a c i l i t a t e e x p l a n a t i o n of behaviour other than such l e i s u r e time a c t i v i t y . The f a c t o r s which i n f l u e n c e these d e c i s i o n s can h e l p us understand the i n f l u e n c e s and b a r r i e r s a c t i v e i n a l e a r n i n g s i t u a t i o n . One of Smith's foremost concerns was that the great fund of knowledge in the s o c i a l and b e h a v i o u r a l s c i e n c e f i e l d was not i n t e g r a t e d . He f e l t that compartmentalized d i s c i p l i n a r y 28 s t r u c t u r e s and s p e c i a l i z a t i o n has l e d to s p e c i a l i s t s i n one s u b f i e l d being unaware of p a r a l l e l or r e l e v a n t advances i n r e l a t e d s u b f i e l d s or d i s c i p l i n e s . He suggests that i n order to develop a broader theory of s o c i a l behaviour "an i n t e r d i s c i p l i n a r y s y n t h e s i s of our pooled knowledge about both formal and i n f o r m a l s o c i a l p a r t i c i p a t i o n " (p. 3) i s e s s e n t i a l . Smith has developed a s i x - c l a s s scheme which he f e e l s i n c l u d e s the broad range of independent v a r i a b l e s which must be taken i n t o account. He c a l l s i t the I n t e r d i s c i p l i n a r y S e q u e n t i a l S p e c i f i c i t y Time A l l o c a t i o n L i f e s p a n (ISSTAL) Model. S e q u e n t i a l S p e c i f i c i t y r e f e r s to a p r o g r e s s i o n from the most general to the most s p e c i f i c v a r i a b l e s i n terms of breadth of relevance to the end behaviour. T h i s i n c l u d e s long-range time-based sequenced e f f e c t s as w e l l as the short-range space and time e f f e c t s . The proper order of the s i x c l a s s e s i n h i s scheme i s : e x t e r n a l c o n t e x t u a l f a c t o r s ; s o c i a l background and s o c i a l r o l e v a r i a b l e s ; p e r s o n a l t r a i t s and i n t e l l e c t u a l c a p a c i t i e s ; a t t i t u n d i n a l d i s p o s i t i o n s ( v a l u e s , a t t i t u d e s , e x p e c t a t i o n s and i n t e n t i o n s ) ; r e t a i n e d i n f o r m a t i o n (images, b e l i e f s , knowledge and p l a n s ) ; and s i t u a t i o n a l v a r i a b l e s (immediate awareness and d e f i n i t i o n of the s i t u a t i o n ) . These c a t e g o r i e s are a r e s u l t of examination of the r e s e a r c h a c r o s s the s o c i a l s c i e n c e d i s c i p l i n e s . They are Smith's attempt to s y n t h e s i z e the f i n d i n g s thus f a r and to provide a conceptual framework f o r e x p l a i n i n g d i s c r e t i o n a r y time a c t i v i t i e s . A b r i e f examination of each of the c l a s s e s that make up the model w i l l h e l p to see what has been i n c l u d e d . 29 E x t e r n a l c o n t e x t u a l f a c t o r s . The f i r s t c l a s s of f a c t o r s are the e x t e r n a l c o n t e x t u a l f a c t o r s . They i n c l u d e "the whole range of determinants of a given person" (p. 35). Four types of f a c t o r s are g i v e n . B i o p h y s i c a l environmental f a c t o r s r e f e r to a l l nonhuman aspects of the surrounding world which impinge upon the i n d i v i d u a l ' s l i f e . I t i n c l u d e s such t h i n g s as c l i m a t e , topography, p o l l u t i o n , animals and human-made o b j e c t s . B i o l o g i c a l and p h y s i c a l c h a r a c t e r i s t i c s of human p o p u l a t i o n s comprise the second sub-set of f a c t o r s . A s i n g l e p o p u l a t i o n i s d e f i n e d as " a l l those l i v i n g i n a given n a t i o n , s o c i e t y , c u l t u r e or t e r r i t o r y " (p. 38). Average s t a t u r e , general l e v e l of p h y s i c a l h e a l t h , modal s k i n pigmentation and physiognomy, s p a t i a l d i s t r i b u t i o n and p o p u l a t i o n d e n s i t y are i n c l u d e d . C u l t u r a l f a c t o r s , the t h i r d sub-set, i n c l u d e s " a l l the s o c i a l l y c r e a t e d and t r a n s m i t t e d general values, ideas, b e l i e f s , and symbolizing systems that d i f f e r e n t i a t e s o c i e t i e s , e t h n i c groups, l i n g u i s t i c groups, or even d i f f e r e n t age-cohorts" (p, 38). These are the b a s i c p a t t e r n s of values and ideas which are r e l a t i v e l y s t a b l e a c r o s s time and w i t h i n i n d i v i d u a l s which are i n g r a i n e d d u r i n g c h i l d h o o d s o c i a l i z a t i o n . S o c i a l - s t r u c t u r a l f a c t o r s , on the other hand, vary from r o l e to r o l e or group to group w i t h i n the s o c i e t y or s u b c u l t u r e . They are the normative e x p e c t a t i o n s f o r behaviour i n s p e c i a l i z e d r o l e s , s p e c i f i c s o c i a l or i n s t i t u t i o n a l contexts and p a r t i c u l a r groups or o r g a n i z a t i o n s . They can be lear n e d at any stage i n l i f e . They d i f f e r from c u l t u r a l f a c t o r s mainly i n that they do not c h a r a c t e r i z e a l l or even n e a r l y a l l members of a s o c i e t y or 30 group. They r e f e r to the d e t a i l of s o c i a l l i f e while c u l t u r e r e f e r s to the broad s o c i a l p a t t e r n s . Smith suggests that r e s e a r c h , i n order to examine the e f f e c t of these f a c t o r s , must sample not j u s t i n d i v i d u a l s but s i t e s and s i t u a t i o n s that d i f f e r i n terms of the c o n t e x t u a l f a c t o r of i n t e r e s t . P e rsonal i n d i v i d u a l c h a r a t e r i s t i c s and c o n t e x t u a l e f f e c t s must be separated to c o n t r o l f o r the e f f e c t of one versus the other. Changes in the i n d i v i d u a l ' s s o c i a l and h i s t o r i c a l context must a l s o be measured. Contextual v a r i a b l e s can a l s o o v e r l a p with the next main category of f a c t o r s , s o c i a l background and s o c i a l r o l e s . D i f f e r e n t p h y s i c a l or s o c i a l i n f l u e n c e s may occur with d i f f e r e n t s o c i a l r o l e e x p e c t a t i o n s and attempts should be made to d i s t i n g u i s h the i n f l u e n c e exerted by each s e p a r a t e l y . S o c i a l background and s o c i a l r o l e v a r i a b l e s . S o c i a l background and s o c i a l r o l e f a c t o r s c h a r a c t e r i z e i n d i v i d u a l s i n terms of "past, present, and p o t e n t i a l s o c i a l p o s i t i o n s , r o l e s and r e l a t i o n s h i p s , p e r s o n a l e x p e r i e n t i a l and a c t i v i t y h i s t o r y , and p h y s i c a l s t a t e s past and pre s e n t " (p. 40). The f a m i l i a r demographic data f i t i n here. One sub-type i n t h i s c l a s s of f a c t o r s i s p h y s i c a l and p h y s i o l o g i c a l c h a r a c t e r i s t i c s . When s o c i e t y a s s i g n s a s o c i a l meaning to such t h i n g s as h e i g h t , weight, sex, age, e t c . , they become s o c i a l f a c t o r s . A s c r i b e d s o c i a l p o s i t i o n s and r o l e s , another sub-type of f a c t o r s , are those r o l e s which s o c i e t y a s c r i b e s a c c o r d i n g to v a r i o u s c o n d i t i o n s . P h y s i c a l c h a r a c t e r i s t i c s such as age or p h y s i c a l handicaps may r e s u l t i n r o l e e x p e c t a t i o n s which may or may not be a p p r o p r i a t e to the a c t u a l i n d i v i d u a l . Someone may not f i t 31 i n t o a stereotype of " e l d e r l y " or "handicapped" j u s t because they have c e r t a i n p h y s i c a l t r a i t s . Smith uses gender as another example where i n c o r r e c t g e n e r a l i z a t i o n s have been made. He contends i t i s a continuous v a r i a b l e r e f e r r i n g to a broad range of sex-typed s o c i a l behaviour, normative e x p e c t a t i o n s , s e l f -imagery and b e l i e f s . V o luntary or achieved s o c i a l p o s i t i o n s and r o l e s , a t h i r d sub-type, r e f e r s to those p o s i t i o n s and r o l e s which may be entered and can be l e f t v o l u n t a r i l y . Once again, Smith c a u t i o n s about t r e a t i n g these s o c i a l r o l e s as nominal v a r i a b l e s . Such s c a l e s as p o l i t i c a l membership ranks r e f e r to a continuum of a t t i t u d e s , p e r c e p t i o n s e t c e t e r a . The r e l i a b i l i t y and v a l i d i t y of the r e s u l t s of s t u d i e s which attempt to use such nominal l a b e l s to c o r r e l a t e data i s q u e s t i o n a b l e and d i s c r e p a n c i e s among s t u d i e s become d i f f i c u l t to r e s o l v e . Smith's l i t e r a t u r e review suggests that the "degree of r o l e consensus i s a major determinant of the s t r e n g t h of r e l a t i o n s h i p s found between s o c i a l r o l e measures and behavior" (p. 43). Experience and a c t i v i t y h i s t o r y , the f o u r t h sub-type of f a c t o r s i n t h i s category, r e f e r s to an i n d i v i d u a l ' s p e r s o n a l h i s t o r y . They are a c o m p i l a t i o n of what has happened i n t h e i r l i f e t i m e thus f a r . Timing and frequency are the d i f f i c u l t data to c o l l e c t s i n c e memories are o f t e n f a u l t y and l o g i t u d i n a l s t u d i e s are r a r e . The l a s t sub-set of f a c t o r s under s o c i a l background and s o c i a l r o l e s i n c l u d e s r e s o u r c e s , possessions and access to r e s o u r c e s . While Smith f e e l s that resources are a strong 32 determinant of d i s c r e t i o n a r y behaviour, he contends that the v a r i a b l e s u s u a l l y measured are only crude i n d i c a t o r s . A f t e r a given income, funds may not be s t r o n g l y r e l a t e d to p a r t i c u l a r behaviour. D i r e c t measures of s o c i a l c l a s s r o l e or l i f e - s t y l e r o l e e x p e c t a t i o n s would provide more accuracy and explanatory power a c c o r d i n g to Smith. D i r e c t measurement of the context combined with s e l f - r e p o r t might be e s s e n t i a l as what people's p e r s p e c t i v e of what i s a v a i l a b l e may vary and the i n t e r a c t i o n of g e o g r a p h i c a l s i t u a t i o n and s o c i a l f a c t o r s may present q u i t e d i f f e r e n t resources i n d i f f e r e n t p h y s i c a l s e t t i n g s . Personal t r a i t s and i n t e l l e c t u a l c a p a c i t i e s . F o l l o w i n g s o c i a l background and s o c i a l r o l e s i s the more p e r s o n a l i z e d category of p e r s o n a l i t y t r a i t s and i n t e l l e c t u a l c a p a c i t i e s . There i s tremendous v a r i a t i o n i n i n d i v i d u a l p a t t e r n s under t h i s heading. Smith d e f i n e s p e r s o n a l i t y t r a i t s as " r e l a t i v e l y enduring (over time and s i t u a t i o n s ) d i s p o s i t i o n s of i n d i v i d u a l s to t h i n k , f e e l , want, and act i n c e r t a i n ways and not in o t h e r s , depending on the circumstances" (p. 47). People react not only to e x t e r n a l i n f l u e n c e s but to i n t e r n a l i n f l u e n c e s of changing c o g n i t i o n s , p h y s i c a l s t a t e s , emotions and i n t e n t i o n s as w e l l . Smith uses c o n a t i o n to d e s c r i b e w i l l , wanting or i n t e n t i o n . He contends that any p e r s o n a l i t y t r a i t i n v o l v e s overt as w e l l as c o v e r t behaviour which occurs s i m u l t a n e o u s l y . The c a p a c i t y to respond cannot be observed u n t i l there i s a w i l l i n g n e s s to respond. L i m i t a t i o n s on the c u r r e n t i n d i v i d u a l c a p a c i t i e s i n c l u d e c o n t e x t u a l f a c t o r s , temporary i n d i v i d u a l p h y s i c a l c h a r a c t e r i s t i c s and the i n d i v i d u a l ' s i n t e l l e c t per se (p. 48). 33 I n t e l l e c t u a l c a p a c i t y i s p r o p e r l y measured, Smith contends, i n the absence of e x t e r n a l c o n t e x t u a l or temporary i n t e r n a l p h y s i o l o g i c a l l i m i t a t i o n s . T h i s seems very d i f f i c u l t to achieve and may e x p l a i n why only a small number of i n t e l l e c t u a l c a p a c i t y v a r i a b l e s are u s u a l l y i n c l u d e d i n resea r c h on s o c i a l behaviour. A t t i t u d i n a l d i s p o s i t i o n s . A t t i t u d i n a l d i s p o s i t i o n s make up the next category i n the ISSTAL model. They are i n t e r n a l m o t i v a t o r s which are le a r n e d and i n v o l v e c o g n i t i v e i n t e g r a t i o n and which i m p l i c i t l y i n v o l v e c o v e r t behaviour (p. 52). They are s i m i l a r to p e r s o n a l i t y t r a i t s but are l e s s enduring or more s i t u a t i o n a l l y l i n k e d . Smith l i s t s four d i s p o s i t i o n s and suggests that they f a l l along a continuum of t r a n s s i t u a t i o n a l a p p l i c a b i l i t y . Values are more l i k e l y to apply a c r o s s many s i t u a t i o n s , a t t i t u d e s across fewer, e x p e c t a t i o n s a c r o s s s t i l l fewer and i n t e n t i o n s are most l i k e l y to be s i t u a t i o n bound. Each of these l a b e l s i n v o l v e thoughts, f e e l i n g s , d e s i r e s and overt a c t i v i t y . Smith c a u t i o n s that i f one focuses on s p e c i f i c i n t e n t i o n s without a t t e n t i o n to values "one l i m i t s one's understanding of the f a c t o r s that 'cause' that behaviour" (p. 57). His o r d e r i n g of these c o n s t r u c t s represent i n c r e a s i n g p r e d i c t i v e relevance and explanatory power f o r a given behaviour in a given s i t u a t i o n . He sees them not only as components of p e r s o n a l i t y but a l s o as components of m o t i v a t i o n . Current m o t i v a t i o n c o u l d be thought of as "the net or combined r e s u l t a n t of a l l such m o t i v a t i o n a l d i s p o s i t i o n s r e l e v a n t to that s i t u a t i o n " (p. 58). Combined with c u r r e n t c a p a c i t i e s , c u r r e n t m o t i v a t i o n i s one of the most important elements i n the 34 s e q u e n t i a l s p e c i f i c i t y part of the ISSTAL model. They combine to l a r g e l y determine the a c t i v i t i e s of any i n d i v i d u a l . S o c i a l behaviour u l t i m a t e l y tends to operate through these two elements. Retained i n f o r m a t i o n . One step c l o s e r to the end d i s c r e t i o n a r y behaviour i s the category of r e t a i n e d i n f o r m a t i o n . Images, b e l i e f s , knowledge and plans combine to make up t h i s c l a s s of f a c t o r s . Information can be p e r c e i v e d from the immediate surroundings or from memory as a r e s u l t of l e a r n i n g . Retained i n f o r m a t i o n , as Smith d e f i n e s i t , r e f e r s to an i n d i v i d u a l ' s " c o n t i n u i n g , enduring, and u s u a l l y growing stock of in f o r m a t i o n i n the b r a i n " (p. 59). Such i n f o r m a t i o n may be nonsymbolic, a c t u a l images, or symbolic, coded m a t e r i a l such as b e l i e f s and knowledge. B e l i e f s imply a r e l a t i o n s h i p between v a r i o u s items of i n f o r m a t i o n . Smith uses knowledge to r e f e r to b e l i e f s people have that they f e e l have a high p r o b a b i l i t y of being t r u e . T h i s i s a pe r s o n a l b e l i e f and may not correspond t o r e a l i t y . Plans, another s p e c i a l kind of b e l i e f , are those b i t s of i n f o r m a t i o n used or intended f o r use as guides f o r overt a c t i o n . Smith sees r e t a i n e d i n f o r m a t i o n p l a y i n g a major r o l e i n i n d i v i d u a l d e f i n i t i o n of the s i t u a t i o n , c u r r e n t c a p a c i t i e s , and current, m o t i v a t i o n . C o g n i t i v e p r o c e s s i n g of past experiences, in the form of r e t a i n e d i n f o r m a t i o n , and c u r r e n t s t i m u l i produce the p o s s i b l e i n d i v i d u a l c h o i c e s . Smith c a u t i o n s , however, that a v a i l a b i l i t y of info r m a t i o n and expectancies based on them may not n e c e s s a r i l y mean any p a r t i c u l a r ones w i l l be used to c r e a t e m o t i v a t i o n i n any given s i t u a t i o n . D i f f e r e n t items may be used 35 at d i f f e r e n t times i n d i f f e r e n t s i t u a t i o n s f o r d i f f e r e n t purposes. Smith p o i n t s out that t h i s i s a very complex area and much more r e s e a r c h i s needed to understand an i n d i v i d u a l ' s use of h i s memory bank. S i t u a t i o n a l v a r i a b l e s . The s i x t h set of determinants of s o c i a l behaviour are the s i t u a t i o n a l v a r i a b l e s . They i n c l u d e d e f i n i t i o n of the s i t u a t i o n or "the end r e s u l t of the c o g n i t i v e process by which an i n d i v i d u a l takes i n s e n s a t i o n s and p e r c e p t i o n s or remembers s t o r e d i n f o r m a t i o n , puts i t a l l together, and makes w h o l i s t i c sense of what i s c u r r e n t l y happening" (p. 62). Inputs from the environment and s t i m u l i from the mind are experienced by the i n d i v i d u a l . Smith terms t h i s immediate awareness. Since an i n t e r n a l environment i s part of any s i t u a t i o n . Researchers must attempt to measure these v a r i a b l e s as w e l l . Smith suggests that s e l f - r e p o r t i s needed to know what the conscious experience of an i n d i v i d u a l i s . He emphasizes that behaviour i n v o l v e s "unique i n d i v i d u a l consciousness of f e e l i n g , wanting, knowing, a c t i n g , c o n t r o l l i n g and changing one's own behavior" (p. 63). He goes on to say that "at every p o i n t i n an i n d i v i d u a l ' s l i f e span, there e x i s t s both a c u r r e n t d e f i n i t i o n of the present s i t u a t i o n and an ongoing c o g n i t i v e syntheses through which the present s i t u a t i o n i s being c o n t i n u a l l y r e d e f i n e d " (p. 63). T h i s process of f i l t e r i n g the immediate present as i t i s p e r c e i v e d through past experiences, i s the most proximal determinant of i n d i v i d u a l d i s c r e t i o n a r y behaviour i n the ISSTAL model. S y n t h e s i s of emotions, b e l i e f s and other i n f o r m a t i o n or s t i m u l i , past or 36 present, d e f i n e s the present s i t u a t i o n and r e s u l t s in c u r r e n t m o t i v a t i o n which determines behaviour " w i t h i n the l i m i t s set by c u r r e n t c a p a c i t i e s , c u r r e n t context and c u r r e n t r e s o u r c e s " (p. 64). The educator examining Smith's work can r e a d i l y see that i n order to a c c u r a t e l y understand the b a r r i e r s which e x i s t f o r i n d i v i d u a l s at any given time a broad range of v a r i a b l e s must be addressed. Broad ranges of v a r i a b l e s have been noted i n the past but the depth of the examination needs to be i n c r e a s e d . Broad c a t e g o r i e s have been taken to be i n d i c a t i v e of c e r t a i n f a c t o r s when they are, i n f a c t , a conglomerate of more f i n i t e c h a r a c t e r i s t i c s . Increased understanding w i l l not occur u n t i l more p r e c i s i o n i s made in a d u l t education research data g a t h e r i n g and a n a l y s i s . True r e l a t i o n s h i p s w i l l continue to be overlooked and remedial a c t i o n s w i l l remain broad i n s t e a d of s p e c i f i c i n t h e i r t a r g e t s . Increased e f f i c i e n c y and more e f f e c t i v e approaches w i l l only be the outcome of more ac c u r a t e and d e t a i l e d r e s e a r c h . Smith's a n a l y s i s and r e s u l t i n g model provide g u i d e l i n e s i n beginning such r e s e a r c h . I n d i v i d u a l s need to be examined not only as a c o l l e c t i o n of experiences which s t i l l i n f l u e n c e t h e i r a t t i t u d e s and values but a l s o as s o c i a l animals which continue to be susceptable to ever-present s o c i a l i z a t i o n i n f l u e n c e s . While some broad f a c t o r s i n f l u e n c e a wide range of people, each i n d i v i d u a l has a p e r s o n a l mesh of experiences, a t t i t u d e s , v a l u e s , e t c . through which such broad v a r i a b l e s are f i l t e r e d and i n t e r p r e t e d . I t i s t h i s uniquely i n d i v i d u a l p e r c e p t i o n which u l t i m a t e l y decides what i s 37 d e s i r a b l e , what the b a r r i e r s are to a c h i e v i n g i t and whether the d e s i r e i s great enough to i n i t i a l l y and c o n t i n u a l l y overcome these b a r r i e r s . P e r s o n a l i t y F a c t o r s Hand and Puder (1967) examined p e r s o n a l i t y f a c t o r s which may i n t e r f e r e with the l e a r n i n g of a d u l t b a s i c education s t u d e n t s . They contend that students b r i n g much more than t h e i r p h y s i c a l presence to the l e a r n i n g experience. T h e i r premise i s that p e r s o n a l c h a r a c t e r i s t i c s and emotional f a c t o r s appear to i n h i b i t l e a r n i n g as w e l l as p a r t i c i p a t i o n i n e d u c a t i o n a l a c t i v i t i e s . They see students as having " h i e r a r c h i e s of emotion and experience which can i n h i b i t or m a t e r i a l l y a f f e c t i n many ways the s o c i a l i n t e r a c t i o n and c l i m a t e f o r l e a r n i n g w i t h i n the classroom m i l i e u " (p. 1 ) . From t h e i r review of the l i t e r a t u r e they see s e l f - c o n c e p t as being the hidden key to l e a r n i n g behaviour and i n t e r n a l i z a t i o n of what a person t h i n k s of him, the b a s i s of developing s e l f - c o n c e p t . Learning i s i n t e r n a l i z e d more r a p i d l y i f i t i s p e r c e i v e d p o s i t i v e l y i n r e l a t i o n to the l e a r n e r ' s view of S e l f and l e a r n i n g r e l a t e d to negative aspects of S e l f i s avoided, r e j e c t e d and only r a r e l y i n t e r n a l i z e d . (Could the r e j e c t i o n of BSE be because of a p e r c e p t i o n that f i n d i n g a breast lump i s r e l a t e d to the body's " f a i l u r e " to stay h e a lthy?) Hand and Puder suggest that past negative experiences with l e a r n i n g can le a d to a " c l o s e d s e l f " which i s f e a r f u l of anything new and a v i c i o u s c y c l e of avoidance of l e a r n i n g o c c u r s . C a l l i n g a t t e n t i o n to the e m o t i o n a l l y loaded s i t u a t i o n 38 i n the classroom, teaching through the use of methods by which the student cannot l e a r n and p o i n t i n g out only student f a i l u r e and not student success are c i t e d as sources of a c l o s e d mind (p. 4). People's d i s p o s i t i o n to a c l o s e d system Of t h i n k i n g i s " i n p r o p o r t i o n to the degree to which they are made to f e e l alone, i s o l a t e d and h e l p l e s s i n the world i n which they l i v e , and thus anxious of what the f u t u r e holds in .store" (Hand & Puder, 1967, p. 6). Other r e s e a r c h shows more dogmatism i n lower socio-economic s t a t u s persons than i n h i g h - s t a t u s persons (Hand & Puder, p. 10). Dogmatism i n t e r f e r e s with l e a r n i n g through i t s production of the f e e l i n g of being manipulated or v i c t i m i z e d by fo r c e s beyond one's c o n t r o l . People f e e l that t h e i r own e f f o r t s have l i t t l e to do with what happens to them. Hand and Puder suggest that dogmatism may be an i n h i b i t i n g f a c t o r to l e a r n i n g of the c u l t u r a l l y disadvantaged and the i l l i t e r a t e (p. 13). Any p s y c h o l o g i c a l d i s t u r b a n c e that decreases awareness or prevents acceptance of new knowledge decreases e f f i c i e n c y of performance and Hand and Puder see a n x i e t y and r e l a t e d emotions and a c l o s e d b e l i e f system as two c o n d i t i o n s that f a l l i n t o t h i s s i t u a t i o n . The degree to which a student i s ab l e to c o n t r o l h i s a n x i e t y i s " d i r e c t l y r e l a t e d to h i s l e v e l of achievement, and the student's a b i l i t y to conform to and accept a u t h o r i t y demands w i l l determine the amount of academic sucess" (p. 16). When i n d i v i d u a l s are a f r a i d they tend to judge a stimulus person such as a teacher as f e a r f u l . In a d d i t i o n , i n s t r u c t i o n s from such a u t h o r i t y f i g u r e s which are designed to i n h i b i t t h e i r f e e l i n g s 39 tend to enhance t h i s e f f e c t (p. 17). It seems c l e a r that the l e a r n i n g atmosphere i s of paramount importance. If s e l f - c o n c e p t i s the key to l e a r n i n g and a t t i t u d e s of others i s the source of i t s development then the educator must c u l t i v a t e a p o s i t i v e , encouraging a t t i t u d e with s t u d e n t s . The i d e a l l e a r n i n g s i t u a t i o n s seem to be ones which a v o i d e m o t i o n a l l y - l o a d e d , a n x i e t y - p r o d u c i n g c o n f r o n t a t i o n , which at l e a s t i n i t i a l l y use methods with which the l e a r n e r can i d e n t i f y , which c r e a t e and emphasize success rather than f a i l u r e , which encourage and support c r i t i c a l t h i n k i n g and which put at l e a s t some measure of c o n t r o l in the hands of the students. Gearing l e a r n i n g a c t i v i t i e s to the p o s i t i v e aspects of the l e a r n e r i s more l i k e l y to produce l e a r n i n g than a focus on the negative a s p e c t s . T h i s r e q u i r e s , of course, some understanding of the student's p e r c e p t i o n of what aspects of himself are p o s i t i v e and which ne g a t i v e . The aim must be to f o s t e r a p o s i t i v e s e l f - c o n c e p t and minimize a n x i e t y surrounding the l e a r n i n g e xperience. P h y s i o l o g i c a l and P s y c h o l o g i c a l Changes of Adulthood A d u l t s must contend with many p h y s i o l o g i c a l and p s y c h o l o g i c a l changes that c h a r a c t e r i s t i c a l l y take p l a c e i n adulthood and N o r r i s (1977) examined t h e i r e f f e c t on l e a r n i n g . He observed that the many p h y s i o l o g i c a l changes occurred g r a d u a l l y and at d i f f e r e n t r a t e s among i n d i v i d u a l s . Since the changes occurred over time and were g e n e r a l l y gradual, most a d u l t s were unaware of them u n t i l a traumatic experience accentuated them. At t h i s - p o i n t the a d u l t may underestimate h i s 40 power to l e a r n or to perform t a s k s . N o r r i s suggests that changes in i n t e r e s t s and m o t i v a t i o n may occur. N o r r i s found that although p s y c h o l o g i c a l a b i l i t y peaked i n the e a r l y twenties, a d u l t s can l e a r n almost anything they want. The more experience they have with l e a r n i n g , the e a s i e r the l e a r n i n g task becomes. In a d d i t i o n , the g r e a t e r the i n d i v i d u a l ' s i n t e l l i g e n c e and the greater the amount of education he has the slower h i s d e c l i n e i n l e a r n i n g a b i l i t y w i l l be. N o r r i s contends that a d u l t m o t i v a t i o n to l e a r n i s seen best w i t h i n a framework of needs, g o a l s , h a b i t s , values and s e l f -concept. W i l l i n g n e s s to l e a r n was r e l a t e d to p e r c e p t i o n of the value of l e a r n i n g , to the acceptance of what and how to l e a r n , to the need f o r s e l f - e s t e e m or s o c i a l a f f i l i a t i o n and to e x p e c t a t i o n s from l i f e . In reviewing the b a r r i e r s - t o - l e a r n i n g l i t e r a t u r e some common threads have emerged: Learners are h i g h l y complex. The d e c i s i o n s they make, the a t t i t u d e s and values they have, t h e i r sources of m o t i v a t i o n and in p a r t i c u l a r the b a r r i e r s they p e r c e i v e are h i g h l y i n d i v i d u a l i z e d . They are a r e s u l t of a l i f e - l o n g s o c i a l i z a t i o n p r o c e s s . Educators who wish to understand and reduce or d e a l with the l e a r n i n g b a r r i e r s a d u l t s must overcome before s u c c e s s f u l l e a r n i n g occurs must approach t h e i r task from a broad r e s e a r c h base. A l l aspects of s o c i a l s c i e n c e r e s e a r c h can help in understanding, a n t i c i p a t i n g and reducing the o b s t a c l e s ' t o a d u l t l e a r n i n g . 41-H e a l t h Education and Compliance Health educators have attempted to apply s i m i l a r r e s e a r c h to the problem they l a b e l "compliance." They have encountered many d i f f i c u l t i e s . An i n i t i a l problem i s d e f i n i n g or even using the term compliance. The Meaning of Compliance One encounters many suggestions i n the l i t e r a t u r e f o r the meaning of compliance. T a g l i a c o z z o and Ima (1970) r e f e r to "motivation to u t i l i z e medical f a c i l i t i e s - and to adhere to medical a d v i c e " (p. 772). Linde and Janz (1979) i n t h e i r study of the e f f e c t of a te a c h i n g program on c a r d i a c p a t i e n t s d e f i n e d compliance as "follow-through on recommendations and therapy p r e s c r i b e d by the a p p r o p r i a t e h e a l t h car p r o v i d e r " (p. 282). Windsor, Green and Roseman (1980) r e f e r to "adherence to the recommended regimen" (p. 6). Sackett and Haynes (1976) speak of s e l e c t i n g "compliance" to symbolize "the extent to which the p a t i e n t ' s behavior ( i n terms of t a k i n g medication, f o l l o w i n g d i e t s or exe c u t i n g other l i f e - s t y l e changes) c o i n c i d e s with the c l i n i c a l p r e s c r i p t i o n " (p. 1). A l l these d e f i n i t i o n s seem s i m i l a r to Mager and Pipe's term: performance d i s c r e p a n c y . There i s a d i f f e r e n c e between a c t u a l and d e s i r e d performance. Compliance r e f e r s to the occurrence of t h i s problem i n a s p e c i f i c a l l y h e a l t h o r i e n t e d s i t u a t i o n . Sackett and Haynes (1976) p o i n t e d out the hazards i n v o l v e d in using the term "compliance." They were concerned about the p o s s i b l e negative connotations which surrounded the word. The 42 World Book D i c t i o n a r y (1973) g i v e s as a synonym "submission" and i n c l u d e s i n i t s d e f i n i t i o n "doing as another wishes" and " y i e l d i n g to a request or command" (p. 437). Sackett and Haynes p o i n t out that the idea of a d i c t a t o r i a l c l i n i c a l p r e s c r i p t i o n which i s s u e s an e d i c t to be obeyed would be d i s t a s t e f u l to some as would the c onnotations of " s i n and serfdom" (p. 1) which accompany the f a i l u r e to y i e l d i n such a s i t u a t i o n . However, a c o l l e c t i o n of academics and p r o f e s s i o n a l s i n a workshop/symposium on compliance i n 1974 f e l t that other terms would have s i m i l a r d i f f i c u l t i e s and that compliance d i d f i t the p a t i e n t ' s " y i e l d " to h e a l t h i n s t r u c t i o n s and a d v i c e . Whether the regimen was decided upon by an a u t h o r i t a r i a n c l i n i c i a n or developed by a consensual process between a h e a l t h p r o f e s s i o n a l and a c i t i z e n d i d not change t h i s subsequent a c t i o n on the c l i e n t ' s p a r t . Haynes (1979) recommended t h a t , s i n c e the term i s now thoroughly rooted and any unhealthy c o n n o t a t i o n s serve as a reminder of e t h i c a l and s o c i a l i s s u e s i n compliance re s e a r c h , i t remain i n use and be intended as nonjudgemental. What d i f f e r e n c e does i t make how the term i s defined? The d i f f i c u l t i e s a r i s e when an attempt i s made to compare compliance r e s e a r c h . Marston (1970) i n her review of l i t e r a t u r e on compliance with medical regimens, p o i n t e d out that comparing compliance r a t e s from d i f f e r e n t s t u d i e s i s u s u a l l y m i s l e a d i n g . She a t t r i b u t e s t h i s , i n p a r t , to wide v a r i a t i o n s i n the o p e r a t i o n a l d e f i n i t i o n s of compliance. T h i s sentiment i s v o i c e d r e p e a t e d l y as workers i n the f i e l d attempt to e x p l a i n the wide range of r e s u l t s o f t e n seem in compliance l i t e r a t u r e (Becker & 43 Maiman, 1975; Haynes et a l . , 1979; Linde & Janz, 1979; Marston, 1970; Windsor, Green & Roseman, 1980). The problem, as Sackett and Snow (1979) point out, i s that when a variety of d e f i n i t i o n s have been employed in d i f f e r e n t ways the confidence with which one can use the resulting conclusions i s limited. Defining Non-compliance In addition to the problem of defining compliance, there i s a similar problem with defining noncompliance. Gordis (1979) addresses the issue of defining the population in compliance research and the subsequent ef f e c t s on the r e s u l t s . Of the population at risk for any given health problem, some seek health assessment and some do not. Of those who seek health assessment, some require a treatment regimen and some do not. Of those who have been advised of a need for treatment, some come for help and some do not. Of those who come for help, some follow the therapeutic instructions and some do not. If the research concentrates only on the last group of people what happens to the meaning of the results in the overall picture when those who did not show up at a l l or those who f a i l e d to return after i n i t i a l p a r t i c i p a t i o n are not considered? Gordis suggests that inclusion in the research of the e x p l i c i t d e f i n i t i o n employed for noncompliance i s e s s e n t i a l . Sackett and Snow (1979) point out another issue of population bias in the research. They discuss the need for studies of inception cohorts. The problem i s that cost and d i f f i c u l t y in following a l l members of an i n i t i a l group beginning a therapeutic regimen often prohibit such a sampling 44 approach. I n v e s t i g a t o r s more o f t e n study a l l the p a t i e n t s c u r r e n t l y i n v o l v e d i n a h e a l t h program. Those who may be l o s t in such an approach are: p a t i e n t s who d i s l i k e d the regimen and sought h e l p elsewhere; p a t i e n t s who d i s l i k e d the regimen and were switched to an a l t e r n a t i v e ; p a t i e n t s who refused to comply and were so d i s r u p t i v e that they were asked to go elsewhere; p a t i e n t s who stopped complying and succumbed to the i l l n e s s . A c r o s s - s e c t i o n a l survey which f a i l s to look at the e n t i r e i n i t i a l p o p u l a t i o n would " c l e a r l y produce a s p u r i o u s l y high estimate of compliance that obscured the e f f e c t of time" (p. 12). Measurement of Compliance In a d d i t i o n to the sampling design and the d e f i n i t i o n d i f f i c u l t i e s , the measurement of compliance presents a major c h a l l e n g e to the r e s e a r c h e r . Becker and Maiman (1975), i n d i s c u s s i n g the m u l t i p l i c i t y of f i n d i n g s , suggest that the cause has been the past p r e d i l e c t i o n f o r examining e a s i l y i d e n t i f i a b l e and q u a n t i f i a b l e dimensions of the p a t i e n t , the regimen and the i l l n e s s . Such c h a r a c t e r i s t i c s as demographic and s o c i a l data, the type, complexity, d i s c o m f o r t , and d u r a t i o n of the therapy and the " m e d i c a l l y " d e f i n e d s e r i o u s n e s s , d u r a t i o n and d i s a b i l i t y of the i l l n e s s have been c o l l e c t e d and q u a n t i f i e d f o r i m p l i c a t i o n s . Becker and Maiman q u e s t i o n the u s e f u l n e s s of such data. Can much be done about many of these i s s u e s ? What about those who, d e s p i t e many adverse c h a r a c t e r i s t i c s , continue to f o l l o w the recommended therapy? What about the a t t i t u d e s and s u b j e c t i v e p e r c e p t i o n s that give meaning to the a s s o c i a t i o n s between these c h a r a c t e r i s t i c s and compliant behaviour? Such 45 data, they a s s e r t , may sometimes p r e d i c t compliance but i t does not e x p l a i n the phenomenon i t s e l f . They go on to say that " p a t i e n t noncompliance has become the best documented, but l e a s t understood, h e a l t h - r e l a t e d behavior" (p. 11). Gordis (1979) c a t e g o r i z e s methods of measuring compliance as d i r e c t or i n d i r e c t . The d i r e c t methods are a r e f l e c t i o n of many medication compliance s t u d i e s . They i n v o l v e blood and u r i n e medication l e v e l s . The important i s s u e here i s the "pharmacokinetic v a r i a t i o n s " (p. 27). T h i s r e f e r s to the d i f f e r e n c e s among i n d i v i d u a l s i n a b s o r p t i o n , d i s t r i b u t i o n , metabolism and e x c r e t i o n of drugs. These may a r i s e from d i f f e r e n c e s i n the amount of drug absorbed a c c o r d i n g to the form ( t a b l e t , c a p s u l e , syrup, etc.) i n which the drug i s administered or from d i f f e r e n c e s i n how i n d i v i d u a l s metabolize the same drug. The i n d i r e c t ways of measuring compliance which Gordis l i s t e d are p i l l counts, p a t i e n t s e l f - r e p o r t s , p h y s i c i a n assessments of compliance and t h e r a p e u t i c or p r e v e n t i v e outcome. P i l l counts are the comparison between the medication remaining and the amount that should remain given the q u a n t i t y i n i t i a l l y dispensed and the time e l a p s e d . The v a l i d i t y of the r e s u l t s i s hampered by s e v e r a l i s s u e s . P a t i e n t s may not r e t u r n medication f o r measurement of amount remaining (Webb, 1980). F a i l u r e to r e t u r n medication does not n e c e s s a r i l y mean that the p a t i e n t has taken the drug (Marston, 1970). Medication measurement does not i n d i c a t e whether i t was taken in the d e s i r e d p a t t e r n or manner ( F e i n s t e i n , 1979). What about the v a l i d i t y of p a t i e n t s e l f - r e p o r t ? Even 46 Hippocrates noted that "patients often l i e when they state that they have taken certain medicines" (Gordis, 1979, p. 35). Recent investigation has supported this observation. When other measurements (eg. p i l l counts, urine tests, etc.) are compared to patient-report, wide descrepancies occur with self-report generally r e f l e c t i n g an overestimation of compliant behaviour (Gordis, 1979; Marston, 1970; Windsor et a l . , 1980). One interesting aspect of thi s i s that those who admit to low compliance have been found to show the greatest response to compliance-improving strategies (Sackett, 1979). This i s an encouraging finding for health educators i f they are dealing with patients f a l l i n g into t h i s category. How do physicians compare when they attempt to assess patient compliance? Unfortunately, their estimates are poor indicators. It has been found that physicians consistently overestimated patient compliance (Gordis, 1979; Marston, 1970; Windsor et a l . , 1980). Generally their predictions are "of very limited value" for research or day-to-day p r a c t i c a l application (Gordis, 1979, p. 40). Using the outcome of the treatment or preventive regimen seems, on the surface, to be a reasonable approach to measurement of compliance. Even here there are issues which the researcher and the reader of research needs to take into account before accepting r e s u l t s . Sometimes the link between regimen and goal i s cl e a r . When both are synonymous, as in having a tooth f i l l e d or a mole excised, the goal is obviously an indicator of compliance with the regimen prescribed. In other 47 cases the l i n k i s not so c l e a r . The goal may be reached because of other f a c t o r s . Sackett (1979) g i v e s the example of the f a t man who does not f o l l o w h i s d i e t but looses weight because of i n c r e a s e d e x e r c i s e or development of a d i s e a s e process. In s t i l l other cases, those who have complied with suggestions have f a i l e d to meet the goal because they needed more or a l t e r n a t e treatment and those who have f a i l e d to comply adequately have met the goal anyway (Sackett, 1979). Sackett concludes that the regimen needs to be vigorous enough to do the job among compliant p a t i e n t s . Gordis (1979) p o i n t s out that when a p r e s c r i b e d drug dosage s u b s t a n t i a l l y exceeds minimum e f f e c t i v e dosage, low compliance may not reduce e f f e c t i v e n e s s of therapy at a l l . The l e v e l of therapy needed to reach the outcome must be determined to make use of outcome data as a measure of compliance. Because of the changing l e v e l of treatment needed for e f f e c t i v e n e s s , i n v e s t i g a t o r s f r e q u e n t l y o p e r a t i o n a l l y d e f i n e compliance as a c e r t a i n degree of p r e s c r i b e d behaviour. D e v i a t i o n s are t o l e r a t e d to t h i s a r b i t r a r y c u t - o f f p o i n t . The r e s u l t i n g compliance data would d i f f e r s u b s t a n t i a l l y from a study which t o l e r a t e d no d e v i a t i o n from the regimen set out (Marston, 1970). The reader who attempted to compare only r e s e a r c h c o n c l u s i o n s would be hardpressed to make sense of such c o n f l i c t i n g evidence. Parson's Sick Role Theory In the quest to understand and improve compliance in the h e a l t h care f i e l d many f a c t o r s have been s t u d i e d f o r p o s s i b l e a s s o c i a t i o n with compliant behaviour. One theory which has 48 f r e q u e n t l y been used to e x p l a i n the h e a l t h a c t i o n of the a d u l t i s Parson's s i c k r o l e theory. The b a s i c premise i s that a person's a c t i o n frame of r e f e r e n c e i s r e l a t e d to the e x p e c t a t i o n s of v a r i o u s o b j e c t s i n the s i t u a t i o n . These o b j e c t s i n c l u d e s o c i a l (human), p h y s i c a l (means and c o n d i t i o n s of h i s a c t i o n s ) , and symbolic ( c u l t u r a l ) elements (Vincent, 1971, pp. 509-510). For compliance to occur there must be a "complementarity of e x p e c t a t i o n s " (Vincent, 1971, p. 510). Assumption of the s i c k r o l e may be more l e g i t i m a t e f o r c h r o n i c i l l n e s s than acute i l l n e s s (Marston, 1970, p. 312). The theory suggests that r e g a r d l e s s of the s i t u a t i o n , there i s an e x p e c t a t i o n that p a t i e n t s w i l l f o l l o w p h y s i c i a n recommendations. Hea l t h behaviour f r e q u e n t l y f a i l s to meet t h i s c r i t e r i a (Marston, 1970, p. 312). The H e a l t h B e l i e f Model A person's b e l i e f s about h e a l t h were i n c o r p o r a t e d i n t o a h e a l t h b e l i e f model by s e v e r a l p s y c h o l o g i s t s working at the U n i t e d S t a t e d P u b l i c H e a l t h S e r v i c e in the 1950's (see F i g u r e 3). The o r i g i n a l aim was to e x p l a i n the chances of an i n d i v i d u a l undertaking a recommended p r e v e n t i v e h e a l t h a c t i o n . In the model, h e a l t h a c t i o n i s dependent on the person's p e r c e p t i o n s of s u s c e p t i b i l i t y , of s e v e r i t y of the consequences, of p o t e n t i a l b e n e f i t s of the h e a l t h a c t i o n and of the b a r r i e r s ( p h y s i c a l , p s y c h o l o g i c a l , f i n a n c i a l , e tc.) r e l a t e d to the behaviour. A cue to a c t i o n i s needed to t r i g g e r the a p p r o p r i a t e behaviour. While t h i s model has been u s e f u l i n approaching the i s s u e of compliance, i n v e s t i g a t i o n s have suggested that there F i g u r e 3 . I N D I V I D U A L P E R C E P T I O N S O r i g i n a l F o r m u l a t i o n o f t h e H e a l t h B e l i e f M o d e l M O D I F Y I N G F A C T O R S L I K E L I H O O D OF A C T I O N D e m o g r a p h i c v a r i a b l e s ( a g e , s e x , r a c e . e t h n l c l t y , e t c . ) S o c l o p s y c h o l o g l e a l v a r i a b l e s ( p e r s o n a l i t y . s o c i a l c l a s s , p e e r a n d r e f e r e n c e g r o u p p r e s s u r e , e t c . ) r I P e r c e i v e d s u s c e p t i b i l i t y t o d i s e a s e " x " P e r c e i v e d s e r i o u s n e s s ( s e v e r i t y ) d i s e a s e " x " P e r c e i v e d t h r e a t o f d i s e a s e " x " P e r c e i v e d b e n e f i t s o f p r e v e n t i v e a c t i o n m i n u s P e r c e i v e d b a r r i e r s t o p r e v e n t i v e a c t i o n L i k e l i h o o d o f t a k i n g r e c o m m e n d e d p r e v e n t i v e h e a l t h a c t i o n C u e s t o A c t i o n M a s s m e d i a c a m p a i g n s A d v i c e f r o m o t h e r s R e m i n d e r p o s t c a r d f r o m p h y s i c i a n o r d e n t i s t I l l n e s s o f f a m i l y m e m b e r o r f r i e n d N e w s p a p e r o r m a g a z i n e a r t i c l e S o u r c e : B e c k e r , M . H . , M a i m a n , L . A . , K l r s c h t , J . P . , H a e f n e r , D . P . , D r a c h m a n , R. H . , & T a y l o r , D . W. P a t i e n t P e r c e p t i o n s a n d C o m p l i a n c e : R e c e n t S t u d i e s o f t h e H e a l t h B e l i e f M o d e l . I n R. B . H a y n e s , D . W. T a y l o r , & D . L . S a c k e t t ( E d s . ) , C o m p l i a n c e I n H e a l t h C a r e . B a l t i m o r e : J o h n s H o p k i n s U n i v e r s i t y P r e s s , 1 9 7 9 , p . . 7 9 . -50 may be a b i d i r e c t i o n a l r e l a t i o n s h i p between h e a l t h b e l i e f s and compliance. Health b e l i e f s change to correspond to a c t u a l compliance and v i c e versa (Becker et a l . , 1979, p. 81). The Knowledge Component As a teacher, the temptation i s to make sure the p a t i e n t has a l l the in f o r m a t i o n and then, s u r e l y , he w i l l comply with "what's best f o r him." A look at re s e a r c h of the knowledge component should q u i c k l y convince h e a l t h educators that the s i t u a t i o n i s f a r more complex. Haynes et a l . (1979), i n t h e i r survey of compliance l i t e r a t u r e , l i s t under knowledge of disease or therapy 18 a r t i c l e s f i n d i n g a p o s i t i v e a s s o c i a t i o n with compliance and 22 a r t i c l e s f i n d i n g no a s s o c i a t i o n with compliance. Under education they l i s t 24 a r t i c l e s i n d i c a t i n g p o s i t i v e a s s o c i a t i o n , 49 a r t i c l e s with no a s s o c i a t i o n and 3 f i n d i n g negative a s s o c i a t i o n with compliance. Marston (1970), in her review of the l i t e r a t u r e , concluded that knowledge alone has not provided s u f f i c i e n t m o t i v a t i o n f o r p a t i e n t s to f o l l o w t h e i r regimens ( p. 321). Linde and Janz . (1979) contend, however, that such s t u d i e s do not negate the worth of h e a l t h education or the e t h i c a l o b l i g a t i o n to inform the p a t i e n t . They p o i n t out that s i n c e p a t i e n t s cannot be expected to comply with regimens that they do not understand, s i n c e medical knowledge advances c o n t i n u a l l y , and s i n c e understanding depends on knowledge that i s made a v a i l a b l e , treatment becomes more and more an e d u c a t i o n a l problem (p. 282). Lane and Evans (1979) report knowledge as an i n t e r v e n i n g v a r i a b l e . I t c r e a t e s p o t e n t i a l f o r compliance but i s not i n i t s e l f a s i g n i f i c a n t 51 outcome (p. 33) . The involvement of other motivations in combination with knowledge was examined by Tagliacozzo and Ima (1970). They found that where substantial experience with i l l n e s s and s o c i a l f a c i l i t a t i o n of medical care existed, patients with low knowledge were as l i k e l y to attend outpatient c l i n i c s as were patients with high knowledge. On the other hand, knowledge played a s i g n i f i c a n t role in behaviour of patients with limited experience with i l l n e s s and who saw i l l n e s s as i n t e r f e r i n g with their d a i l y a f f a i r s (p. 773). The researchers saw t h i s as a suggestion that knowledge can add motivation not supplied by other motivations. They reinforce the idea that "teaching e f f o r t s must not only address themselves to communicating medically approved ways of conceptualizing i l l n e s s but, simultaneously, must influence other d e f i n i t i o n s and conditions which motivate patients to give medical care more central importance" (p. 773). Ethics and Compliance An i n i t i a l word about ethics seems in order before the educator zealously sets about producing compliance. Seltzer et a l . (1980) point out that achievement of a treatment goal i s dependent on three things: accurate diagnosis; appropriate therapy; and adequate compliance (p. 638). If the diagnosis is wrong the whole exercise is f u t i l e ; i f the therapy does more harm than good then compliance increases r i s k ; i f the patient is not informed and w i l l i n g to p a r t i c i p a t e his legal rights are jeopardized. 52 Given that these c r i t e r i a are met, the educator i s faced with the task of planning and executing health education that w i l l take into account the complexities of the health consumer. Improving Compliance Haynes (1976) outlined three categories of strategies for improving compliance. Educational strategies focus on transmission of information with development of knowledge and attitudes being the objectives. Behaviour-oriented methods focus on behaviours involved in compliance. They try to reduce barriers, to cue or stimulate compliance and to reward or reinforce compliance. The t h i r d strategy combines these two approaches. His review of the l i t e r a t u r e indicated that behavioural and combined strategies were more e f f e c t i v e . He cautioned, however, that frequently when the strategy was stopped, compliance dropped to o r i g i n a l l e v e l s . Morris and Halperin (1979) concluded that, especially with longer term therapy, interventions which provide s o c i a l support and e f f i c i e n t feedback, and which are t a i l o r e d to the patient's needs seem necessary in addition to information communication (p. 5). Green (1979) agrees that a combination of learning opportunities i s required in health education. The three types of determinants which educational strategies should influence are predisposing factors, the enabling factors and the reinforcing factors. He refers, as an example, to an experiment where attitudes toward the therapy represented the predisposing 53 factors, support of r e l a t i v e s and friends represented reinforcing factors and a c c e s s i b i l i t y of services represented the enabling factors. Health behaviour, he asserts, i s multicausal and more than one method is required to achieve l a s t i n g change (p. 160). He goes on to say that the methods employed in health education must be selected and combined "on the basis of c l e a r l y delineated objectives derived from a diagnosis of the p a r t i c u l a r behaviour in question" (p. 161). While health education i s frequently part of other programs, he sees i t as being very diverse. He linked some s p e c i f i c methods and techniques to s p e c i f i c s i t u a t i o n s . Cues at appropriate i n t e r v a l s , for example, help when frequency of health action i s the issue. Methods which reinforce s o c i a l supports are useful i f persistence is required. Mass media campaigns are useful techniques when re c r u i t i n g individuals to engage in more prompt health actions. Sp e c i f i c situations need s p e c i f i c and multi-dimentional approaches. The health educator must assess each issue and approach i t in a unique way. This multi-method approach is supported by several researchers (Lane & Evan, 1979; Marston, 1970; Windsor et a l . , 1980) . Another reccurring theme in the l i t e r a t u r e i s the value of involving the patient in his care. Clark (1980) asserts that "the patient who participated in ide n t i f y i n g and p r i o r i t i z i n g problems, defining objectives and evaluation methods and establishing time frames i s more l i k e l y to comply" (p. 58). This sentiment is supported by many writers (Bowers, 1980; 54 Fiore, 1979; Geyman, 1980; Given et a l . , 1979; Hogue, 1979; Vincent, 1971; Windsor et a l . , 1980; Wise, 1979). Just one example of how the patient can be involved i s the use of a written contract. Commitment to a self-designed program with rewards and punishments can provide incentive to work toward a s e l f - e s t a b l i s h e d goal (Dunbar et a l . , 1979; Windsor et a l . , 1980; Wise, 1979). BSE Education and Compliance BSE as a useful preventive health behaviour has already been discussed but i t seems pertinent at this time to examine i t in terms of a s p e c i f i c area involving concerns about compliance. There are many factors which may influence the degree of compliance with BSE practices. Factors Influencing BSE Practice Turnbull (1978) examined some of the s o c i a l and a t t i t u d i n a l factors involved. She points out that women's attitudes toward the breast and cancer are frequently emotional. A quick perusal of lay magazines and advertisements w i l l give ample evidence of the role breasts play in our culture. The bosom " i s a major sex symbol" (Turnbull, p. 98). C o n f l i c t between emotions and sound preventive health measures may r e s u l t . In reviewing the l i t e r a t u r e she found that monthly breast examinations cause many women to worry, that physicians play the single most important role in motivating BSE though th e i r role potential i s limited, and that higher education levels are associated with increased 55 p r a c t i c e of p r e v e n t i v e h e a l t h measures. Her resea r c h found that f a c t o r s which i n f l u e n c e d both h e a l t h and non-health o r i e n t e d women were, i n descending order, the media (TV, r a d i o , newspapers, books), c o n v e r s a t i o n s with f a m i l y then those with f r i e n d s , c o n v e r s a t i o n s with d o c t o r s and f i n a l l y with nurses. The r o l e of nurses i n i n f l u e n c i n g behaviour seems q u e s t i o n a b l e but i t i s unclear whether T u r n b u l l ' s f i g u r e s suggest a decreased " a b i l i t y " to i n f l u e n c e or a p r e s e n t l y - d e c r e a s e d a c t i v i t y by nurses i n teaching women i n t h i s f i e l d and, t h e r e f o r e , decreased " o p p o r t u n i t y " to i n f l u e n c e BSE frequency. While n u r s i n g i s f r e q u e n t l y i d e n t i f i e d as an a p p r o p r i a t e change agent (Bullough, 1980; Edwards, 1980; Fl y n n , 1981; S t i l l m a n , 1977; T u r n b u l l , 1978; W i l l i a m s , 1979), there are some i s s u e s which need to be con s i d e r e d . T u r n b u l l found that nurses' understanding about h e a l t h d i d not d i r e c t them to higher p r e v e n t i v e h e a l t h p r a c t i c e s . She reminds us that r e c o g n i t i o n must be given to the need f o r i n s t r u c t i n g h e a l t h p r o f e s s i o n a l s as w e l l . Flynn (1981) suggests that nurses are not prepared to teach BSE j u s t because they are nurses or females. These c a u t i o n a r y comments do not preclude the use of nurses as change agents. They serve as a reminder that teacher t r a i n i n g may be needed even i f the educator i s a p r a c t i c i n g h e a l t h p r o f e s s i o n a l . Knowledge and s k i l l cannot be taken f o r granted. Even p h y s i c i a n s need to compare approaches and techniques to achieve c o n s i s t e n c y . Alcoe and McDermot (1979) r e p o r t that t e a c h i n g c l i n i c s are we l l u t i l i z e d but qu e s t i o n whether attendance may r e f l e c t only a d e s i r e to be checked by a p r o f e s s i o n a l person rather than a 56 d e s i r e to l e a r n BSE. Flynn (1981) suggests that BSE does not devalue or take the pl a c e of p r o f e s s i o n a l examination. Rather, BSE i s an a f f i r m a t i o n of the a t t i t u d e that people are capable and must assume r e s p o n s i b i l i t y f o r t h e i r own h e a l t h . She suggests that BSE i s a r o u t i n e h e a l t h p r a c t i c e l i k e brushing t e e t h or e a t i n g . In her tea c h i n g p r o j e c t , Williams (1979) s t r e s s e s the f a c t that most bre a s t problems are not cancer and f e e l s that t h i s i s e s s e n t i a l i n f o r m a t i o n to share in an attempt to l e s s e n f e a r . Fear was l i s t e d f r e q u e n t l y i n her i n i t i a l survey as a reason f o r not c o n t i n u i n g to p r a c t i c e BSE. Fear can be a p o s i t i v e or a negative m o t i v a t o r . Some rese a r c h e r s have found that women who p e r c e i v e themselves as being more s u s c e p t i b l e to breast d i s e a s e do tend to p r a c t i c e BSE to some degree ( S t i l l m a n , 1977) but the percentage which f o l l o w the i d e a l of monthly BSE i s s t i l l low. Se v e r a l p o s s i b l e m o t i v a t o r s have been mentioned. Fear, r e l i g i o n , age and b e l i e f s about p e r c e i v e d b e n e f i t or s u s c e p t i b i l i t y have a l l been l i n k e d to rate of p r a c t i c e . Some other i n f l u e n t i a l f a c t o r s c i t e d i n the l i t e r a t u r e are f o r g e t t i n g , lack of understanding, degree of confidence i n t h e i r a b i l i t y to detect a lump and lack of b a s i c knowledge on how to c a r r y out BSE. Techniques f o r Improving BSE Compliance Edwards (1980) has suggested s e v e r a l approaches which might i n c r e a s e m o t i v a t i o n to p r a c t i c e BSE. She suggests cues such as a calendar f o r s e l f - m o n i t o r i n g and peer support such as t a l k i n g with f r i e n d s or f a m i l y might h e l p decrease f o r g e t f u l n e s s . 57 M o d e l l i n g the behaviour or p r o v i d i n g guided p r a c t i c e has helped i n c r e a s e i n f o r m a t i o n r e t e n t i o n . Her r e s e a r c h has r e v e a l e d that modeling alone i s an e f f e c t i v e method f o r changing BSE behaviour. She suggests that modelling be i n c o r p o r a t e d i n i n s t r u c t i o n of BSE. She a l s o encourages the i n c l u s i o n of s i g n i f i c a n t o t hers i n the t e a c h i n g p r o c e s s . H a l l et a l . (1980) suggest the use of a s i l a s t i c breast model with graduated lumps and guided p r a c t i c e with feedback. T h e i r work has shown that such t r a i n i n g can improve the percentage of c o r r e c t d e t e c t i o n s as w e l l as i n c r e a s e a woman's confidence in her examination s k i l l . Since confidence i n her a b i l i t y to perform BSE tends to i n c r e a s e a woman's ra t e of p r a c t i c e t h i s can make a s i g n i f i c a n t c o n t r i b u t i o n to t e a c h i n g e f f e c t i v e n e s s . I t i s a l s o suggested that s i n c e t h i s t r a i n i n g i s p r e d i c t i v e of more accurate BSE the use of models may be used to develop a c r i t e r i o n l e v e l of performance to be reached before t r a i n i n g t e r m i n a t e s . T h i s c o u l d be of great value i n the e v a l u a t i o n p r o c e s s . The use of s p e c i f i c outcome c r i t e r i a may be h e l p f u l i n e v a l u a t i n g teaching e f f e c t i v e n e s s . H a l l et a l , (1977) suggest that breast examination s k i l l s can be broken down i n t o three components. Motor s k i l l s i n c l u d e the p r e c i s e manual a c t i v i t y such as the systematic search over the breast area with an optimal amount of p r e s s u r e . Sensory or p s y c h o p h y s i c a l aspects or the r e l a t i o n s h i p between changes in p h y s i c a l s t i m u l i and responding changes in behaviour are a l s o i n v o l v e d . They mention two types of t h r e s h o l d s : the minimum stimulus that w i l l evoke a s e n s a t i o n and the minimum amount of 58 stimulus change which evokes a se n s a t i o n of d i f f e r e n c e . The f i n a l component i s the s i g n a l d e t e c t i o n or the human v i g i l a n c e l e v e l . T h i s r e f e r s to the d e t e c t i o n performance of the observer. How o f t e n do they c o r r e c t l y d e t e c t a change and how of t e n do they give f a l s e alarms? P r o f i c i e n c y i n s i g n a l d e t e c t i o n i s f a c i l i t a t e d by feedback and p r a c t i c e . In a l l i n s t a n c e s H a l l et a l . suggest that use of a s i l a s t i c breast model can be used to improve performance. One d i f f i c u l t y i s that when t r a i n i n g ends, feedback decreases i n the home s e t t i n g . They suggest that a t r a i n i n g model a v a i l a b l e i n p h y s i c i a n o f f i c e s or i n c l i n i c s c o u l d be used to i d e n t i f y s p e c i f i c b e h a v i o u r a l o b j e c t i v e s f o r e v a l u a t i o n . The c h o i c e of a s p e c i f i c technique or combination of techniques c a l l s f o r t h o u g h t f u l and c r e a t i v e d e c i s i o n s . The Mama Program i n F i n l a n d ( G a s t r i n , 1980) i s a good example of a h i g h l y e f f e c t i v e program which combines many i s s u e s , f a c t o r s . a n d approaches. They use person-to-person i n s t r u c t i o n , follow-up i n q u i r y , t e l e v i s i o n education and p r o v i s i o n of medical s p e c i a l i s t s f o r c o n s u l t a t i o n . A f t e r two years, 70 percent of the women were p e r s i s t i n g with r e g u l a r BSE. Teaching Approaches Howe (1981) r e f e r r e d to in n o v a t i o n adoption t h e o r i e s to develop her approach to teaching BSE. C r i t e r i a which i n f l u e n c e the p e r c e p t i o n of an in n o v a t i o n i n c l u d e s i m p l i c i t y or ease of understanding and use; r e l a t i v e advantage or the advantage over o l d approaches or ideas; c o m p a t i b i l i t y or the f i t with the r e c e i v e r ' s present v a l u e s , b e l i e f s and needs; t r i a l a b i l i t y or 59 the degree to which the inn o v a t i o n can be t r i e d and r e j e c t e d ; and o b s e r v a b i l i t y or the extent to which r e s u l t s can be seen. Howe i n c o r p o r a t e d these ideas i n the development of a simple (the BSE procedure c o n s i s t e d of only four sentences) pamphlet and found that i n comparison to a much longer more e l a b o r a t e pamphlet i t proved more s u c c e s s f u l . Since the media has become a major modality f o r tea c h i n g (Bullough, 1980) these c r i t e r i a may be u s e f u l guides. S t i l l m a n (1977) s t u d i e d h e a l t h b e l i e f s about bre a s t cancer and BSE. She found that a high b e l i e f in p e r c e i v e d b e n e f i t s of BSE and p e r c e i v e d s u s c e p t i b i l i t y d i d not n e c e s s a r i l y i n c r e a s e p r a c t i c e of t h i s p r e v e n t i v e h e a l t h measure. She hypothesizes that medical h i s t o r y , r e l i g i o u s background and a t t i t u d e toward body, h e a l t h and l o n g e v i t y may a l s o be important f a c t o r s i n f l u e n c i n g end behaviour. Her comment on r e l i g i o n as an i n f l u e n c i n g f a c t o r a r i s e s from her f i n d i n g s that Jewish women d i d not tend to l a b e l themselves as being at higher r i s k although they were. In a d d i t i o n , C a t h o l i c s in her study, while they scored lowest on both b e l i e f s ( p e r c e i v e d b e n e f i t s and p e r c e i v e d s u s c e p t i b i l i t y ) , tended to have a higher average r a t e of p r a c t i c e . She found that a l a r g e percentage of C a t h o l i c women f e l t BSE was embarrassing. Those who were embarrassed seemed to be s t r o n g l y a f f e c t e d by i t and in that subgroup there was a higher percentage of n o n - p r a c t i c e r s . I t seems that high r i s k t a r g e t p o p u l a t i o n s may not be aware of t h e i r i n c r e a s e d s u s c e p t i b i l i t y and r i s k cannot be assumed to act as a p o s i t i v e m o t i v a t o r . R e l i g i o n may a f f e c t r e a c t i o n s to content and c e r t a i n 60 h e a l t h p r a c t i c e s themselves. A l t e r n a t i v e s may have to be determined and c e r t a i n l y p r e s e n t a t i o n and o r g a n i z a t i o n f o r teaching may have to be a d j u s t e d a c c o r d i n g l y . D i s c u s s i o n groups and group p r a c t i c e may not be the d e s i r e d approach with those who f i n d the t o p i c embarrassing. One-to-one p r e s e n t a t i o n may be p r e f e r a b l e . Health b e l i e f s and p e r c e i v e d s u s c e p t i b i l i t y to h e a l t h d i s o r d e r s may not i n f l u e n c e behaviour e x a c t l y as a n t i c i p a t e d but they are v a r i a b l e s which act as motivators i n h e a l t h behaviour and must be d e a l t with i n some s u i t a b l e manner i f h e a l t h t e a c h ing i s to be e f f e c t i v e . S e v e r a l r e s e a r c h e r s have r e f e r r e d to the l e a r n e r ' s p e r c e p t i o n s or e x p e c t a t i o n s (Cross, 1980; Howe, 1981; N o r r i s , 1977; Rubenson, 1977; Smith, 1980; S t i l l m a n , 1977). There i s a s p e c i f i c body of research which s t u d i e s g e n e r a l e x p e c t a t i o n s and which may h e l p to i n c r e a s e our knowledge of the v a r i a b l e s i n f l u e n c i n g behaviour i n a performance d i s c r e p a n c y s i t u a t i o n . That res e a r c h i n v o l v e s the locus of c o n t r o l concept. Locus of C o n t r o l An understanding of the i n f l u e n c e f e e l i n g s of c o n t r o l or powerlessness exert c o u l d help i n c r e a s e the a b i l i t y to p r e d i c t and change behaviour. Proponents of the l o c u s of c o n t r o l concept s t r i v e to e x p l a i n behaviour by examining p e r c e p t i o n s or e x p e c t a t i o n s that i n d i v i d u a l s have in given s i t u a t i o n s . 61 P e r c e p t i o n s of C o n t r o l L e f c o u r t (1973) contends that the p e r c e p t i o n of being f r e e or c o n t r o l l e d i n our a c t i o n s i s not a given but a r e s u l t of a c o n s t r u c t i v e p r o c e s s . He speaks of freedom and c o n t r o l as i l l u s i o n s - - ideas man inv e n t s to "make sense of h i s experience" ( L e f c o u r t , 1973, p. 417). A major f a c e t of knowing something, L e f c o u r t s t a t e s , i s p r e d i c t a b i l i t y . In h i s experiments he noted that noise caused a s t a t e of a r o u s a l when i t was u n a n t i c i p a t e d or i t s s i g n i f i c a n c e was not understood. I f , on the other hand, the o r i g i n , meaning and r e s u l t s of a noise were understood then the noise was " p r e d i c t a b l e " and i t s impact was minimized. The o r d i n a r y sounds of a furnace are used by L e f c o u r t to i l l u s t r a t e h i s i d e a s . I f we know the noise we hear i s a furnace and we know what must be done to i t and when, t h i s element of p r e d i c t a b i l i t y about the meaning of the noise allows us some sense of conf i d e n c e that we can act to c r e a t e d e s i r a b l e e f f e c t s . Along the same v e i n , i f we can p r e d i c t something i s coming we can prepare o u r s e l v e s f o r i t and thereby minimize i t s impact. L e f c o u r t contends that i t i s through the " p e r c e p t i o n of t h i s a b i l i t y 'to do something' that we a r r i v e at the concept of p e r c e i v e d c o n t r o l " (1973, p. 419). The Locus of C o n t r o l Concept The e f f e c t s of t h i s p e r c e p t i o n of c o n t r o l are addressed by the l o c u s of c o n t r o l concept. R o t t e r ' s i n i t i a l comprehensive review of the subject w i l l be used to o u t l i n e the ba s i c ideas put forward by t h i s theory. 62 Rotter (1966) relates the role of perception of control to acqu i s i t i o n and performance of s k i l l s and knowledge. The role of reinforcement, reward or g r a t i f i c a t i o n i s influenced, he says, by the individual's view of the event. The underlying idea in the locus of control concept i s the generalized expectancies for internal versus external control of reinforcement. The perception of the causal relationship between reinforcements and behaviour i s not necessarily a l l or nothing. It can vary in degree. The hypothesis i s not a bimodal d i s t r i b u t i o n of i n t e r n a l i t y versus e x t e r a l i t y but rather a d i s t r i b u t i o n approximating a normal curve with varying degrees of each (Rotter, 1966, p. 57). One of the causes of action or reaction in any situation i s thi s perception of the relationship between rewards and their determinants. Rotter describes the concept of external versus internal control: When a reinforcement is perceived by the subject as following some action of his own but not being e n t i r e l y contingent upon his action, then in our culture, i t is t y p i c a l l y perceived as the result of luck, chance, fate, as under the control of powerful others, or as unpredictable because of the great complexity of the forces surrounding him. when the event i s interpreted in t h i s way by an i n d i v i d u a l , we have labeled this a bel i e f in external cont r o l . If the person perceives that the event is contingent upon his own behaviour or his own r e l a t i v e l y permanent c h a r a c t e r i s t i c s , we have termed this a bel i e f in 63 i n t e r n a l c o n t r o l . I t i s hypothesized that t h i s v a r i a b l e i s of major s i g n i f i c a n c e i n understanding the nature of l e a r n i n g processes in d i f f e r e n t kinds of l e a r n i n g s i t u a t i o n s and a l s o that c o n s i s t e n t i n d i v i d u a l d i f f e r e n c e s e x i s t among i n d i v i d u a l s i n the degree to which they are l i k e l y to a t t r i b u t e p e r s o n a l c o n t r o l to reward i n the same s i t u a t i o n . (p.1) Fo l l o w i n g s o c i a l l e a r n i n g theory, "a reinforcement a c t s to strengthen an 'expectancy' that a p a r t i c u l a r behaviour or event w i l l be followed by that reinforcement in the f u t u r e " ( R o t t e r , 1966, p. 2). In t h i s behaviour-reinforcement sequence, e x p e c t a t i o n w i l l be a f f e c t e d by the degree to which the person sees the reinforcement as contingent upon h i s own behaviour. The expectancy w i l l be strengthened or reduced by the occurrence of reinforcement or by i t s absence to the degree that a r e l a t i o n s h i p i s b e l i e v e d to e x i s t . The l e s s one b e l i e v e s a reinforcement i s contingent on one's own behaviour the l e s s i t s occurrence w i l l i n c r e a s e one's expectancy of i t . Thus p e r s o n a l experiences w i l l r e s u l t i n an i n d i v i d u a l expectancy set rega r d i n g the r e l a t i o n s h i p between reinforcements and a c t i o n s . In a d d i t i o n , e x p e c t a t i o n s w i l l g e n e r a l i z e from s p e c i f i c s i t u a t i o n s to s i t u a t i o n s p e r c e i v e d as s i m i l a r . Rotter contends that "a g e n e r a l i z e d a t t i t u d e , b e l i e f , or expectancy r e g a r d i n g the nature of the c a u s a l r e l a t i o n s h i p between one's own behaviour and i t s consequences might a f f e c t a v a r i e t y of be h a v i o u r a l c h o i c e s i n a broad band of l i f e s i t u a t i o n s " (1966, p. 2). 64 S i t u a t i o n - s p e c i f i c E x p e c t a t i o n s One c a u t i o n must be made before i m p l i c a t i o n s f o r a p p l i c a t i o n of t h i s theory are examined. I n d i v i d u a l behaviour in any given s p e c i f i c s i t u a t i o n i s not t h e o r i z e d as s o l e l y c o n t i n g e n t on these g e n e r a l i z e d e x p e c t a n c i e s . S p e c i f i c e x p e ctancies and the value of p o t e n t i a l reinforcements combine with g e n e r a l i z e d expectancies to determine f i n a l s e l e c t i o n of behaviour i n s p e c i f i c c o n d i t i o n s . The more s p e c i f i c e x pectancies e x i s t i n the s i t u a t i o n , the more the r o l e played by g e n e r a l i z e d expectancies i s decreased. In other words, "the more c l e a r l y and u n i f o r m l y a s i t u a t i o n i s l a b e l l e d as s k i l l or luck determined, in a given c u l t u r e , the l e s s e r the r o l e such a g e n e r a l i z e d expectancy would p l a y i n determining i n d i v i d u a l d i f f e r e n c e s i n behaviour" ( R o t t e r , 1966, p. 2 ) . Understanding the r o l e of g e n e r a l i z e d expectancies and the premises under which the i n t e r n a l - e x t e r n a l locus of c o n t r o l measure was developed seems v i t a l to a p p l i c a t i o n of r e s e a r c h i n t h i s a r ea. In h i s review of the misconceptions r e l a t e d to the locus of c o n t r o l c o n s t r u c t Rotter ( 1 9 7 5 ) reminds' us that there are four c l a s s e s of v a r i a b l e s i n s o c i a l l e a r n i n g theory. They are behaviours, e x p e c t a n c i e s , reinforcements and p s y c h o l o g i c a l s i t u a t i o n s . The g e n e r a l formula f o r behaviour on which Rotter has based h i s work i s that "the p o t e n t i a l f o r a behaviour to occur i n any s p e c i f i c p s y c h o l o g i c a l s i t u a t i o n i s a f u n c t i o n of the expectancy that the behaviour w i l l l e a d to a p a r t i c u l a r reinforcement i n that s i t u a t i o n and the value of that reinforcement" ( 1 9 7 5 , p . 5 7 ) . 65 Using LOC to P r e d i c t Behaviour If we are i n t e r e s t e d i n the p r e d i c t i o n and change of behaviour i n a d u l t s then c o n t r o l e x p ectancies may provide us with u s e f u l i n f o r m a t i o n . A d u l t s i n our western c u l t u r e are expected to accept r e s p o n s i b i l i t y f o r t h e i r own behaviour and many t h e o r i s t s i n the area of c o u n s e l l i n g emphasize development of an acceptance of p e r s o n a l r e s p o n s i b i l i t y f o r behaviour as a s i g n i f i c a n t o b j e c t i v e i n any h e l p i n g r e l a t i o n s h i p (Mink, 1975). S u r e l y one's p e r c e p t i o n of p e r s o n a l c o n t r o l w i l l i n f l u e n c e acceptance of r e s p o n s i b i l i t y f o r behaviour i n a p a r t i c u l a r s i t u a t i o n . I f the person b e l i e v e s "I am in c o n t r o l " then t h e i r c h o i c e of behaviour will.demand r e s p o n s i b l e thought. I f , on the other hand, one b e l i e v e s "someone or something e l s e c o n t r o l s what happens here" then one might be l e a d to conclude that " I t does not matter what I do, what happens, happens." If L e f c o u r t ' s r e s u l t s are t r u e and p r e d i c t a b i l i t y c r e a t e s a sense of c o n f i d e n c e that we can act e f f e c t i v e l y , then p r o v i d i n g p r e d i c t a b i l i t y i n e d u c a t i o n a l s i t u a t i o n s c o u l d i n c r e a s e student c o n f i d e n c e . T h e i r c h o i c e of behaviour might be more t h o u g h t f u l i f they c o u l d i n f l u e n c e the outcome. One element a f f e c t i n g the a c q u i s i t i o n of s k i l l s and knowledge might be i n d i v i d u a l viewpoints of reward. An educator's view of a p a r t i c u l a r event as "rewarding" might not be shared by a l l the students i n v o l v e d . V a r i a t i o n in student attempts to achieve that "reward" c o u l d be expected. Part of the i n f o r m a t i o n the educator might seek i n any given e d u c a t i o n a l s i t u a t i o n i s an understanding of t h e s e — i n d i v i d u a l student 66 p e r c e p t i o n s and t h e i r sources. C u l t u r a l d e f i n i t i o n s and i n f l u e n c e s , i n d i v i d u a l p r e v i o u s experiences which are s i m i l a r to the present s i t u a t i o n , g e n e r a l i z e d as w e l l as s i t u a t i o n - s p e c i f i c a t t i t u d e s , values and expectancies and i n d i v i d u a l p e r c e p t i o n s of the s p e c i f i c s i t u a t i o n are a l l kinds of i n f o r m a t i o n that would i n c r e a s e the educator's understanding of a p a r t i c u l a r e d u c a t i o n a l s i t u a t i o n and a p a r t i c u l a r group of students. A d u l t s accumulate many unique exp e r i e n c e s . These experiences h e l p them to develop unique e x p e c t a t i o n s and p e r c e p t i o n s about s p e c i f i c s i t u a t i o n s . If i t i s true that we have g e n e r a l i z e d and s i t u a t i o n - s p e c i f i c e x p e c t a t i o n s which guide our behaviour, then s u r e l y our p r o p e n s i t y to i n c r e a s e our s k i l l , knowledge or s e n s i t i v e n e s s in any given s i t u a t i o n i s , i n p a r t , a r e s u l t of the e x p e c t a t i o n s that we have about i t . If one's aim i s to a s s i s t an i n d i v i d u a l to accomplish that task, then knowledge about the r o l e which that i n d i v i d u a l ' s e x p e c t a t i o n s can play c o u l d h e l p one to manipulate the components of l e a r n i n g such that the outcome i s enhanced. LOC and BSE Education In the case of teaching BSE procedures, knowledge of student p e r c e p t i o n s of personal c o n t r o l and r e l a t e d f e e l i n g s of r e s p o n s i b i l i t y f o r f o l l o w i n g p r e v e n t i v e h e a l t h p r a c t i c e s r e l a t e d to BSE might have i m p l i c a t i o n s f o r p l a n n i n g and p r e s e n t a t i o n of content as w e l l as follow-up s e s s i o n s . Is a f e e l i n g of lack of c o n t r o l over what a f f e c t s p e r s o n a l h e a l t h s t a t u s r e l a t e d to p r e v e n t i v e h e a l t h p r a c t i c e s ? Are there any p a r t i c u l a r kinds of i n f o r m a t i o n or s k i l l s r e l a t e d to f e e l i n g s of c o n t r o l and 67 subsequent p r e v e n t i v e h e a l t h behaviour? What kinds of r e s u l t s are p e r c e i v e d as "rewards?" Could f i n d i n g a lump be p e r c e i v e d as a reward ( i e . , r e l a t e d to e a r l y treatment of cancer) by some and punishment ( i e . , r e l a t e d to m u t i l a t i n g surgery) by others? Does t h i s d i f f e r e n t p e r s p e c t i v e i n f l u e n c e BSE p a t t e r n s or i n t e r e s t i n developing BSE s k i l l s ? Is the manipulation of the components of l e a r n i n g r e l a t e d to subsequent p e r c e p t i o n s of c o n t r o l and BSE behaviour p a t t e r n s ? I f locus of c o n t r o l and BSE behaviour p a t t e r n s are c o r r e l a t e d i t seems u s e f u l to have such knowledge to enhance the a b i l i t y to a n t i c i p a t e p o s s i b l e student needs and r e a c t i o n s and plan f o r them. V i c t o r Joe (1971) examined some of the p o s s i b l e antecedents of p e r c e p t i o n of c o n t r o l i n h i s review of the i n t e r n a l - e x t e r n a l c o n t r o l c o n s t r u c t and the I-E s c a l e which has been used to measure i t . He found that past reinforcement experiences i n f l u e n c e the tendency toward an i n t e r n a l or e x t e r n a l p e r c e p t i o n . S e v e r a l s t u d i e s r e p o r t e d a warm, pe r m i s s i v e , f l e x i b l e , approving parent, c o n s i s t e n t in d i s c i p l i n e and encouraging of independence behaviours, i s more l i k e l y to f o s t e r a b e l i e f i n i n t e r n a l c o n t r o l . While more resea r c h i s needed in t h i s area as Joe suggests, perhaps some i m p l i c a t i o n s f o r a d u l t educators can be i n f e r r e d . A d u l t s w i l l b r i n g to the l e a r n i n g s i t u a t i o n c e r t a i n kinds of behaviour on the p a r t of the p e r c e i v e d a u t h o r i t y f i g u r e s . A teacher i s f r e q u e n t l y seen as the power holder i n the teacher-student r e l a t i o n s h i p . C e r t a i n kinds of behaviour on the part of the p e r c e i v e d a u t h o r i t y may t r i g g e r c e r t a i n g e n e r a l i z e d or s p e c i f i c p e r c e p t i o n s . These 68 p e r c e p t i o n s may then i n f l u e n c e student behaviour and r e a c t i o n s . In a d d i t i o n , c e r t a i n teacher behaviour may p a r t i c u l a r l y f o s t e r the development of e i t h e r i n t e r n a l or e x t e r n a l p e r c e p t i o n s . Examining the r e l a t i o n s h i p between the methodology used to teach BSE i n f o r m a t i o n and subsequent BSE behaviour p a t t e r n s and s p e c i f i c f e e l i n g s of c o n t r o l r e l a t e d to breast d i s e a s e might give some c l u e to p l a n n i n g more e f f e c t i v e BSE t e a c h i ng programs. If c e r t a i n teacher a t t i t u d e s or t e a c h i n g methods are r e l a t e d to p a r t i c u l a r outcomes and one outcome i s more d e s i r a b l e than than another the i m p l i c a t i o n s are obvious. Is one l o c u s of c o n t r o l p e r c e p t i o n g e n e r a l l y b e t t e r than the c o n t r o l other? The D e s i r a b i l i t y of an I n t e r n a l Versus an E x t e r n a l LOC Joe's review of the r e s e a r c h found that i n comparison with i n t e r n a l s , e x t e r n a l s were r e l a t i v e l y anxious, a g g r e s s i v e and dogmatic. They were l e s s t r u s t f u l and more s u s p i c i o u s of o t h e r s . They had lower needs f o r s o c i a l a p p r o v a l . They had experienced more f e e l i n g s of powerlessness and more f r u s t r a t i o n v i a e x t e r n a l f o r c e s and were thus more prone to manifest a g g r e s s i o n and h o s t i l i t y on the pen-and-paper I-E measure. They were more concerned with fear of f a i l u r e than i n achievement per se. There i s some qu e s t i o n of how l o c u s of c o n t r o l and academic achievement i n t e r a c t and while i n t e r n a l s tend to show g r e a t e r i n t e r e s t and e f f o r t , t h e i r achievements are not always higher (Joe, 1971, p. 628). Even given t h a t , i t seems that e x t e r n a l i t y would be a b a r r i e r to l e a r n i n g . Anxiety, a g g r e s s i o n and s u s p i c i o n i n t e r f e r e with l e a r n i n g as does lack of i n s i g h t and i n a b i l i t y to deal with f r u s t r a t i o n c o n s t r u c t i v e l y . Can we 69 r i g h t l y assume that i n t e r n a l i t y i s always more d e s i r a b l e ? Rotter (1975) c a u t i o n s a g a i n s t t h i s "good-guy bad-guy" dichotomy (p. 60). He mentions s e v e r a l s t u d i e s which have suggested that i n t e r n a l s may repress f a i l u r e s or unpleasant experiences and may report l e s s a n x i e t y and b e t t e r adjustment. T h i s may be r e l a t e d to the f a c t that e x t e r n a l s see the cause of such events as not a r i s i n g from t h e i r own behaviour and, t h e r e f o r e , f a i l u r e s are more a c c e p t a b l e . Rotter q u e s t i o n s whether t a k i n g r e s p o n s i b i l i t y f o r one's a c t i o n s may i n c r e a s e f e e l i n g s of g u i l t and may, t h e r e f o r e , not i n d i c a t e b e t t e r adjustment. In a d d i t i o n , he p o i n t s out that there i s a l i m i t on p e r s o n a l c o n t r o l . F e e l i n g s of c o n t r o l which are unwarranted by r e a l i t y may l e a d to trauma. Rotter reminds us of the hypothesis that locus of c o n t r o l has a c u r v i l i n e a r r e l a t i o n s h i p to adjustment (1971. p. 61). E i t h e r extreme would be u n d e s i r a b l e and some middle stance might be the most b e n e f i c i a l . In r e l a t i o n to breast cancer, a b e l i e f that there i s no element of p e r s o n a l c o n t r o l may l e a d to avoidance of BSE. On the other hand, a b e l i e f that there i s t o t a l p e r s o n a l c o n t r o l may l e a d to a tendency to ignore e a r l y s i g n s and symptoms s i n c e i t i s b e l i e v e d that harmful e f f e c t s can be w i l l e d away. S i t u a t i o n - s p e c i f i c Measurement T o o l s P r e d i c t i n g behaviour from a g e n e r a l i z e d expectancy may seem reasonable but i t becomes l e s s reasonable "the more s t r u c t u r e d , the more f a m i l i a r , and the more unambiguous a p a r t i c u l a r s i t u a t i o n i s " ( R o t t e r , 1975, p. 60). In these i n s t a n c e s , s i t u a t i o n - s p e c i f i c e x p e c t a t i o n s and the value p l a c e d upon 70 reinforcements come i n t o p l a y . In a d d i t i o n , other competing reinforcements begin to i n f l u e n c e behaviour. There has been some s u c c e s s f u l p r e d i c t i o n of academic achievement using l o c u s of c o n t r o l i n younger c h i l d r e n but by c o l l e g e entrance t h i s i s no longer apparent. Rotter suggests that the student's f a m i l i a r i t y with the academic s i t u a t i o n i n f l u e n c e s h i s a b i l i t y to a chieve w i t h i n i t . He knows what he has to do to succeed. Research i n t h i s area has concentrated on motor s k i l l s which are f a r l e s s ambiguous than many other academic s i t u a t i o n s and perhaps the i n f l u e n c e of the g e n e r a l i z e d expectancy of i n t e r n a l or e x t e r n a l c o n t r o l i n these more novel and ambiguous s i t u a t i o n s has j u s t not been measured as y e t . Rotter (1975) reminds us that our measurement t o o l s f o r i n t e r n a l - e x t e r n a l locus of c o n t r o l are l i m i t e d . He suggests the need fo r more p r e c i s e measurement instruments or instruments which are broken down to address the m u l t i d e m e n s i o n a l i t y of l o c u s of c o n t r o l . Perhaps a s i t u a t i o n - s p e c i f i c l o c u s of c o n t r o l instrument would be a b e t t e r measurement and concomitant use of a s c a l e to measure such r e l a t e d f a c t o r s as v a l u e s and t r u s t would c l a r i f y f i n d i n g s . W a l l s t o n , W a l l s t o n , Kaplan and Maides (1976) have developed a l o c u s of c o n t r o l measurement t o o l s p e c i f i c to h e a l t h behaviour, the Health Locus of C o n t r o l (HLC) S c a l e . They based t h e i r work on the assumption that such a s c a l e would provide more s e n s i t i v e p r e d i c t i o n s . T h e i r research examined expectancy and reinforcement value s i n c e Rotter (1954) purposed that behaviour i s a j o i n t f u n c t i o n of these two concepts. They suggested that j u s t as development of a s p e c i f i c HLC instrument 71 may provide more s e n s i t i v e r e s u l t s , a b e l i e f s c a l e r e l e v a n t to s p e c i f i c c o n d i t i o n s or behaviours may provide b e t t e r p r e d i c t i o n of behaviour i n a p a r t i c u l a r s i t u a t i o n . In t h e i r review of locus of c o n t r o l l i t e r a t u r e r e l a t e d to h e a l t h Wallston and Wallston (1978) found support f o r using t h i s concept to analyse h e a l t h r e l a t e d behaviour. Even with the more s p e c i f i c HLC s c a l e , however, they c a u t i o n a g a i n s t using only one measurement t o o l to p r e d i c t h e a l t h behaviour. They suggest that numerous f a c t o r s are i n v o l v e d and l i s t value of h e a l t h , m o t i v a t i o n , s o c i a l supports, p r e v i o u s behaviour and p e r c e i v e d c o s t s and b e n e f i t s of s p e c i a l a c t i o n s as some p o s s i b l e v a r i a b l e s (p. 113). In the case of p r e v e n t i v e h e a l t h care, W a l l s t o n and Maides (1976) suggest that h e a l t h - r e l a t e d i n f o r m a t i o n - s e e k i n g behaviour may be as much r e l a t e d to value of h e a l t h as a b e l i e f in p r e v e n t i v e h e a l t h c a r e . S h i f t i n g C o n t r o l O r i e n t a t i o n s Toward I n t e r n a l i t y While there are d i f f i c u l t i e s with measurement t o o l s and while p e r c e p t i o n s of i n t e r n a l c o n t r o l must be based on r e a l i t y , support remains f o r the d e s i r a b i l i t y of i n t e r n a l i t y . As has been mentioned, a d u l t s i n our western c u l t u r e are expected to accept r e s p o n s i b i l i t y f o r t h e i r own behaviour and many c o u n s e l l o r s emphasize development of pe r s o n a l r e s p o n s i b i l i t y i n a h e l p i n g r e l a t i o n s h i p . In the h e a l t h care f i e l d there i s a d e f i n i t e s h i f t towards i n c r e a s e d h e a l t h consumer r e s p o n s i b i l i t y for p e r s o n a l h e a l t h h a b i t s . If i n t e r n a l i t y i n c r e a s e s acceptance of p e r s o n a l r e s p o n s i b i l i t y f o r h e a l t h and p r e v e n t i v e h e a l t h measures than some degree of i n t e r n a l i t y may be d e s i r a b l e . 72 Dowell (1977) uses s i m i l a r reasoning to support a c o n t e n t i o n that " c o n t r o l expectancy becomes a c r u c i a l v a r i a b l e i n i n s t r u c t i o n a l e f f i c a c y " (p. 4). He examines a d u l t education i n the community c o l l e g e s e t t i n g and suggests that p a r t i c u l a r s t r a t e g i e s can be used to e f f e c t a s h i f t from e x t e r n a l i t y to i n t e r n a l i t y . He f e e l s that the a b i l i t y to master one's own environment and succeed i n academic s e t t i n g s i s more c l o s e l y r e l a t e d to a person's e x p e c t a t i o n r e g a r d i n g t h e i r a b i l i t y to succeed than i t i s to m o t i v a t i o n . " M o t i v a t i o n becomes a f u n c t i o n of one's b e l i e f i n one's a b i l i t y to succeed" (Dowell, 1977. p. 3). F o l l o w i n g Dowell's reasoning one might assume that a d u l t s may have many sources of m o t i v a t i o n but one of the most important c o r r e l a t e s to l e a r n i n g success i s one's p e r s o n a l p e r c e p t i o n of one's a b i l i t y to succeed. Previous experiences i n the academic f i e l d may f o s t e r the development of p e r c e p t i o n s that one i s not i n c o n t r o l of the outcome of any academic endeavour. T h i s c o u l d c e r t a i n l y act as a b a r r i e r to any c u r r e n t l e a r n i n g . In a d d i t i o n , l e a r n i n g as as a d u l t i s f r e q u e n t l y a new experience f o r many a d u l t students. Since the s i t u a t i o n i s novel one c o u l d a n t i c i p a t e that g e n e r a l i z e d p e r c e p t i o n s might p l a y a l a r g e r p a r t with students i n t h i s i n s t a n c e . S i m i l a r l y , i n the context of p r e v e n t i v e h e a l t h behaviour, p e r c e p t i o n s about the a b i l i t y to succeed may a f f e c t e d u c a t i o n a l outcomes. In the s p e c i f i c case of BSE a student may f e e l that the procedure i s too d i f f i c u l t or that they c o u l d not detec t b r e a s t changes e a r l y enough to make any d i f f e r e n c e . They may av o i d l e a r n i n g experiences a l l together or p a r t i c i p a t e i n 73 l e a r n i n g about BSE i n a h a l f hearted way with poor r e s u l t s . In a d d i t i o n , p r e v i o u s negative experiences of t h e i r own or t h e i r f a m i l y or t h e i r f r i e n d s i n the area of BSE or other p r e v e n t i v e h e a l t h measures may act as a b a r r i e r to any c u r r e n t l e a r n i n g . P r e v i o u s s u c c e s s f u l experiences and a r e s u l t i n g f e e l i n g of p e r s o n a l c o n t r o l , on the other hand, may act as a m o t i v a t i o n to l e a r n and to subsequently c a r r y out p r e v e n t i v e h e a l t h measures such as BSE. Tseng (1970) found that with v o c a t i o n a l r e h a b i l i t a t i o n c l i e n t s , p e r c e p t i o n s of p e r s o n a l c o n t r o l or i n t e r n a l i t y d i d make a s i g n i f i c a n t d i f f e r e n c e in job p r o f i c i e n c y , e m p l o y a b i l i t y and t r a i n i n g s a t i s f a c t i o n . I n t e r n a l s had i n c r e a s e d a b i l i t y to work with o t h e r s ; they were more c o o p e r a t i v e and s e l f - r e l i a n t ; they had i n c r e a s e d work t o l e r a n c e and work knowledge; they had i n c r e a s e d t r a i n i n g s a t i s f a c t i o n and i n c r e a s e d need f o r achievement. I t would seem that these a d u l t s d i d f u n c t i o n i n a more p r o d u c t i v e way when t h e i r p e r c e p t i o n s of c o n t r o l were i n t e r n a l r a t h e r than e x t e r n a l . Roueche and Mink (1975), a l s o working with a d u l t s i n a community c o l l e g e s e t t i n g , found that the "overwhelming m a j o r i t y of students r e p o r t e d a p o s i t i v e a s s o c i a t i o n between i n t e r n a l i t y and achievement behaviour" (p. 7). . They suggest that s h i f t i n g student c o n t r o l o r i e n t a t i o n toward i n t e r n a l i t y can improve the l e a r n i n g p r o c e s s . E c k s t e i n and E c k s t e i n (1979) agree that an e x t e r n a l locus of c o n t r o l c o u l d a d v e r s e l y a f f e c t a person's a t t i t u d e s and i n t e r p e r s o n a l r e l a t i o n s h i p s . They found s h i f t i n g from 74 e x t e r n a l i t y to i n t e r n a l i t y using an experimental seminar format l e d to i n c r e a s e d congruence between r e a l and i d e a l s e l f -concepts. It seems that a d u l t s behave more p r o d u c t i v e l y when they possess an i n t e r n a l locus of c o n t r o l . T e n t a t i v e l y , a more i n t e r n a l r a t h e r than e x t e r n a l l o c u s of c o n t r o l seems d e s i r a b l e . C o n c l u s i o n s about the d e s i r a b i l i t y of i n t e r n a l i t y c o u l d be v a l i d a t e d by observing b e h a v i o u r a l change and changes in l e v e l of achievement a f t e r a s h i f t to i n t e r n a l i t y has been accomplished. Another v a r i a b l e which i n f l u e n c e s r e s e a r c h f i n d i n g s i s the phenomenon of the "defensive e x t e r n a l . " I t was f e l t that e x t e r n a l i t y would l o g i c a l l y c r e a t e p a s s i v i t y . Research soon found, however, that some e x t e r n a l s behaved very c o m p e t i t i v e l y and achieved scores as high as i n t e r n a l s ( R o t t e r , 1975, p. 64). T h i s apparent c o n t r a d i c t i o n has been e x p l a i n e d by the d i f f e r e n t i a t i o n of d e f e n s i v e and p a s s i v e e x t e r n a l s . Since p a s s i v i t y i s not valued i n our s o c i e t y some e x t e r n a l s l e a r n to be c o m p e t i t i v e , s t r i v i n g and ambitious in c e r t a i n s i t u a t i o n s . T h i s may e x p l a i n some of the r e s e a r c h f i n d i n g s which have found p r e d i c t a b i l i t y with c h i l d r e n but not with c o l l e g e students. School age c h i l d r e n tend to represent a broader range of a b i l i t i e s then c o l l e g e students do. C o l l e g e students represent a s e l e c t e d p o p u l a t i o n , those who have proven academic achievement l e v e l s , and may c o n t a i n more d e f e n s i v e e x t e r n a l s . While r e l a t i v e l y few s t u d i e s have been done with o l d e r a d u l t s , i t seems reasonable to assume that the p o p u l a t i o n i n v o l v e d i n 75 a d u l t education a c t i v i t i e s r e p r e s e n t s a broader spectrum of people than the c o l l e g e p o p u l a t i o n used in r e s e a r c h to determine p r e d i c t a b i l i t y of academic performance using the I-E s c a l e . Use of l o c u s of c o n t r o l f o r p r e d i c t i o n of performance may be u s e f u l with t h i s broader a d u l t p o p u l a t i o n . K i v e t t et a l . (1977) found that when job s i t u a t i o n s p r o v i d e d c o n t r o l over o b j e c t s such as people or l a r g e machinery there was i n c r e a s e d p e r c e p t i o n of c o n t r o l over the environment. Thus l a b o r e r s or s e r v i c e workers tended to have more p e r c e p t i o n of c o n t r o l than c l e r i c a l workers. The r e s e a r c h e r s p o s t u l a t e d that f e e l i n g s of powerlessness from the work s i t u a t i o n may be g e n e r a l i z e d to other aspects of the environment. T h i s may apply to the p r e v e n t i v e h e a l t h area as w e l l . The Age F a c t o r Age i s a f a c t o r which has not been s u f f i c i e n t l y separated from the f a c t o r s i n f l u e n c i n g I-E p e r c e p t i o n development. U n f o r t u n a t e l y , most of the r e s e a r c h to date has been done with the c o l l e g e p o p u l a t i o n . K i v e t t et a l . suggest that s i n c e new experiences can modify e x p e c t a t i o n s and behaviour, " m o d i f i c a t i o n in the meaningful environment ( p h y s i c a l , p s y c h o l o g i c a l and s o c i a l ) can r e s u l t i n m o d i f i c a t i o n i n p e r c e i v e d c o n t r o l which may be e i t h e r d i r e c t l y or i n d i r e c t l y r e l a t e d to age" (p. 208). I t may be that environmental and c i r c u m s t a n t i a l changes are more apt to c r e a t e p e r c e p t i o n of c o n t r o l changes than age per se. B i e l b y and S i e g l e r (1977) examined the developmental nature of i n t e r n a l - e x t e r n a l l o c u s of c o n t r o l i n middle and o l d age. They t e s t e d a d u l t s from 46 to 49 years o l d over a p e r i o d of 76 e i g h t y e a r s . They found that l o c u s of c o n t r o l was c l o s e r to a f f e c t balance than to v e r b a l i n t e l l i g e n c e . Since the l a t t e r has been found to be s t a b l e a c r o s s the l i f e span and the former more i n f l u e n c e d by change i n circumstances, t h i s seems to i n d i c a t e t hat the g e n e r a l i z e d p e r c e p t i o n s do change over the a d u l t years as circumstances change. Should we be l o o k i n g more c l o s e l y at s i t u a t i o n s and p r e v i o u s experiences and p e r c e p t i o n s than the s p e c i f i c age of students? Lao (1976) d i r e c t l y addressed t h i s i s s u e of i n t e r n a l -e x t e r n a l c o n t r o l and age. She compared c o l l e g e students with t h e i r parents and found the middle-aged parents s i g n i f i c a n t l y more i n t e r n a l then t h e i r sons. Lao suggests that i n c r e a s e d mastery and competence i n the middle a d u l t years may account f o r inc r e a s e d p e r c e p t i o n s of i n t e r n a l i t y . Since l e v e l of h e a l t h i s f r e q u e n t l y p e r c e i v e d to be r e l a t e d to age i t may be that age i s r e l a t e d to f e e l i n g s of p e r s o n a l c o n t r o l over one's h e a l t h s t a t u s . Increased age may r e s u l t i n f e e l i n g s of i n c r e a s e d s u s c e p t i b i l i t y to h e a l t h hazards and act as a motivator f o r i n c r e a s e d p r e v e n t i v e h e a l t h behaviour f o r those who f e e l that they are i n c o n t r o l . I t may, on the other hand, be seen as an antecedent to decreased c o n t r o l over p e r s o n a l h e a l t h s t a t u s and act as a d e f e r e n t to p r e v e n t i v e h e a l t h behaviour. I m p l i c a t i o n s f o r Adult Educators Many r e s e a r c h e r s contend that i n t e r n a l i t y i s more d e s i r a b l e than e x t e r n a l i t y . While r e s e a r c h f i n d i n g s are c o n f l i c t i n g on some p o i n t s such as the source of c o n t r o l p r e c e p t i o n s and the 77 role generalized versus s i t u a t i o n - s p e c i f i c perceptions play, generally i n t e r n a l i t y does seem to be more functional. With the caution that i t must be based on r e a l i t y , i n t e r n a l i t y would seem to be more favourable to productive involvement in a given situation than externality. The defensive external i s productive in s p e c i f i c situations but in more general terms i n t e r n a l i t y seems more productive in a broad spectrum of human a c t i v i t i e s . Two implications for the adult educator come to mind. When students display i n t e r n a l i t y this perception should be fostered and reinforced. When students display externality some e f f o r t to help them move in the di r e c t i o n of increased perceptions of personal control seems worthwhile. Several researchers have made attempts in t h i s area and have examined the effects of both educator behaviour and i n s t r u c t i o n a l methodology. Kinder and Kilman (1976) found that leader structure influenced outcomes in group situations. With college participants ranging in age from 18 to 52 years, they found that an i n i t i a l period of high leader structure with a movement toward less leader structure produced more positive r e s u l t s . They suggest that t h i s sequence i s optimum for both internal and external persons (1976, p. 861). The age range used in this experiment is p a r t i c u l a r l y encouraging to adult education situations. While their study was very small--only 23 subjects--Kilman and S o t i l e (1976) showed some interesting effects of leader structure that could be followed up. They found that internals 78 f u n c t i o n e d b e t t e r i n an u n s t r u c t u r e d leader r o l e s i t u a t i o n and e x t e r n a l s d i d b e t t e r i n a s t r u c t u r e d s i t u a t i o n . No s i n g l e i n s t r u c t i o n a l process i s optimal f o r a l l students and a l l e d u c a t i o n a l goals and i t has been suggested that methods should be matched to i n d i v i d u a l d i f f e r e n c e s . D a n i e l s and Stevens (1976) found that i n t e r n a l s were more motivated with a c o n t r a c t format s i n c e marks were w i t h i n the student's c o n t r o l . E x t e r n a l s were more motivated by the l e c t u r e method where the teacher was i n c o n t r o l . They found that there was a strong i n t e r a c t i o n between l o c u s of c o n t r o l and these two methods and that the c o n t r a c t approach was not the most d e s i r a b l e method f o r everyone. Newsom and Foxworth (1979) supported the use of c o n t r a c t l e a r n i n g . They worked with a d u l t s in ABE GED c l a s s e s . They found that teachers who were aware of the concepts of locu s of c o n t r o l d i d not have as much impact on developing i n t e r n a l i t y as d i d a c t u a l t e a c h i n g methods. While e x t e r n a l s were i n i t i a l l y r e s i s t a n t to the use of the c o n t r a c t method the f i n a l r e s u l t s of t h e i r study i n d i c a t e i t i s a u s e f u l method of producing s h i f t s towards i n t e r n a l i t y . T h i s makes sense s i n c e e x t e r n a l s would need time to get used to a method which f o r c e d them to take c o n t r o l of the l e a r n i n g s i t u a t i o n . A gradual s h i f t of more r e s p o n s i b i l i t y f o r the e x t e r n a l student seems more l i k e l y to produce p o s i t i v e change. Teachers have been s t u d i e d to look at the e f f e c t of locus of c o n t r o l on them as w e l l . Powel and Vega (1972) looked at kindergarden teachers and teacher a i d e s . They found that 79 i n t e r n a l i t y correlated with many variables which have been found to be related to teacher effectiveness. Internals had a less self-righteous or h y p o c r i t i c a l attitude toward others, a greater teaching p o t e n t i a l i t y , a more positive work attitude and a more democratic approach to teaching. Zahn (1980) related teacher burnout to the many externality-producing factors which adult educators have to face in their jobs. Lack of control over conditions of work i s one of the factors mentioned. It seems that the locus of control concept can be useful in helping understand the teacher as well as in planning the teaching experience. There seems to be support for l i n k i n g LOC and teaching methodology. If LOC, and s p e c i f i c a l l y HLC, is related to BSE behaviour and teaching method is related to either HLC or BSE behaviour or both, then BSE teaching effectiveness may be enhanced by applying knowledge of these relationships. HLC i s only one variable and not an infa l a b l e predictor of health behaviour but adding th i s information to the variety of other pertinent factors suggested by the research could provide a key component to BSE teaching programs. Summary The f e l t need in terms of breast cancer i s early diagnosis. BSE as a vehicle for early diagnosis compares favourably with other screening approaches (Alcoe & McDermot, 1979; Bullough, 1980; Hall et a l . , 1977, 1980; Gastrin, 1981; Stillman, 1977). Despite the apparent benefits of BSE, performance descrepancies 80 continue to e x i s t i n a high percentage of women (Alcoe & McDermot, 1979; Edwards, 1980; Fly n n , 1981; H a l l et a l . , 1977; Howe, 1981; T u r n b u l l , 1978). A b e t t e r understanding of the r e l a t i o n s h i p s between BSE and v a r i a b l e s which may i n f l u e n c e i t should provide some g u i d e l i n e s f o r pla n n i n g more e f f e c t i v e BSE teac h i n g programs. P a r t i c i p a t i o n r e s e a r c h suggests some of the v a r i a b l e s which i n f l u e n c e i n i t i a l i n t e r e s t and a c t u a l p a r t i c i p a t i o n in a l e a r n i n g a c t i v i t y . Rubenson (1977) puts f o r t h the expectancy-valence theory to e x p l a i n the p a r t i c i p a t i o n phenomenon. His work suggests that i f the h e a l t h educator i s i n t e r e s t e d i n understanding what i n f l u e n c e s women to engage i n l e a r n i n g about BSE an understanding about the expectancies and a f f e c t i v e a t t i t u d e s r e l a t e d to the t o p i c i s needed. Rubenson suggests that s e l f - e v a l u a t i o n , p e r s o n a l v a l u e s , member and ref e r e n c e group a t t i t u d e s socio-economic s t a t u s , s i t u a t i o n a l requirements f o r i n f o r m a t i o n , changing l i f e - c y c l e needs, e x t e r n a l environmental and i n t e r n a l p s y c h o l o g i c a l o b s t a c l e s and the degree of congruency between p e r s o n a l p r e s s u r e s and e d u c a t i o n a l o p p o r t u n i t i e s are some p o s s i b l e i n f l u e n c i n g f a c t o r s . Carp, Peterson and R o e l f s (1974) suggest that time may be a major o b s t a c l e to p a r t i c i p a t i o n i n e d u c a t i o n a l endeavours. The arrangements and atmosphere of the program may a l s o be f a c t o r s which i n f l u e n c e the appeal to p o t e n t i a l c l i e n t s . Cross's (1981) Chain of Responses Model emphasized the i n t e r a c t i o n of f o r c e s and behaviour i n a c o n s t a n t l y flowing stream between p e r s o n a l and e x t e r n a l f o r c e s . L i f e t r a n s i t i o n s 81 can p l a y an important r o l e and teachable moments may a r i s e where s p e c i a l s e n s i t i v i t y f o r l e a r n i n g c e r t a i n t h i n g s occurs. The degree of m o t i v a t i o n a f f e c t s the a b i l i t y to overcome b a r r i e r s which e x i s t . Accurate i n f o r m a t i o n p l a y s a key r o l e in d e a l i n g with o p p o r t u n i t i e s and b a r r i e r s . Cross emphasizes the need to dea l with m o t i v a t i o n as w e l l as reducing b a r r i e r s or enhancing o p p o r t u n i t i e s s i n c e the l a t t e r w i l l not h e l p the person who l a c k s the former. Once p a r t i c i p a t i o n occurs the outcome of a l e a r n i n g a c t i v i t y i s i n f l u e n c e d by many f a c t o r s . Smith (1980) examines what he terms d i s c r e t i o n a r y behaviours and pr o v i d e s a d e t a i l e d l i s t of v a r i a b l e s which he suggests i n f l u e n c e end behaviour i n a given s i t u a t i o n i n which an i n d i v i d u a l chooses to i n t e r a c t . H is theory suggests a s e q u e n t i a l p r o g r e s s i o n from general to s p e c i f i c v a r i a b l e s which are i n f l u e n c e d by a time f a c t o r and whose impact on end behaviour i n c r e a s e s as they approach the immediate time and space of the s i t u a t i o n . At any given p o i n t an i n d i v i d u a l f i l t e r s h i s c u r r e n t d e f i n i t i o n of the present s i t u a t i o n through a c o g n i t i v e s y n t h e s i s of h i s past e x p e r i e n c e s . T h i s s y n t h e s i s of past and present r e s u l t s i n c u r r e n t m o t i v a t i o n and determines behaviour. Smith s t r e s s e s the need f o r a broad but p r e c i s e examination of s p e c i f i c v a r i a b l e s and t h e i r r e l a t i o n s h i p s . Behaviour i s a r e s u l t of a uniquely i n d i v i d u a l p rocess. Hand and Puder (1967) looked at i n d i v i d u a l p e r s o n a l i t y f a c t o r s which a f f e c t l e a r n i n g . They s i n g l e out s e l f - c o n c e p t as a hidden key. The educator's a t t i t u d e and the l e a r n i n g 82 atmosphere can play an important role in influencing student response. Norris (1977) points out that many physiological changes occur over the adult lifespan which may cause changes in interests and motivation. Psychological a b i l i t y , however, remains. As educational experience increases ease of learning increases. Motivation to learn is best examined, Norris contends, through a framework of needs, goals, habits, values, self-concept and l i f e expectations. Learning in the health education f i e l d i s frequently measured in terms of compliance with recommendations and therapy prescribed by health care providers. It i s the performance discrepancy issue in the health context. Variations in the d e f i n i t i o n of the term compliance has inhibited comparison of compliance research and Gordis (1979) suggests that an e x p l i c i t d e f i n i t i o n for both compliance and noncompliance be employed. Accurate measurement of compliance i s d i f f i c u l t . Psychologists with the United States Public Health Service developed a health b e l i e f model. This model explains health behaviour in terms of a person's perceptions of s u s c e p t i b i l i t y , severity of consequences, potential benefits and b a r r i e r s . Cues often trigger behaviour. Examination of the knowledge component of compliance has indicated that acquisition of information does not guarantee desired behaviour, Lane and Evans (1979) describe knowledge as an intervening variable that creates potential for compliance. Seltzer et a l . (1980) caution that an e t h i c a l issue arises 83 when attempting to produce compliance s i n c e an accurate d i a g n o s i s and an a p p r o p r i a t e therapy i s a l s o r e q u i r e d before goals can be achieved. In an absence of the l a t t e r two items i n c r e a s e d compliance may i n c r e a s e p a t i e n t r i s k . An examination of the s t r a t e g i e s used to improve compliance i n d i c a t e s that p a r t i c u l a r approaches tend to be more u s e f u l than o t h e r s . Haynes (1976) suggests that b e h a v i o u r a l and combined e d u c a t i o n a l and b e h a v i o u r a l approaches seem most e f f e c t i v e . M o r r i s and H a l p e r i n (1979) support i n t e r v e n t i o n s t a i l o r e d to p a t i e n t needs and which pr o v i d e s o c i a l support, e f f i c i e n t feedback and adequate i n f o r m a t i o n . Green (1979) suggests a combination of l e a r n i n g o p p o r t u n i t i e s which deal with p r e d i s p o s i n g f a c t o r s , e n a b l i n g f a c t o r s and r e i n f o r c i n g f a c t o r s . He suggests that s p e c i f i c methods and techniques should be l i n k e d to s p e c i f i c s i t u a t i o n s and that a m u l t i - d i m e n s i o n a l approach i s best. Increased involvement of the p a t i e n t i n h i s care i s supported by many w r i t e r s (Bowers, 1980; C l a r k , 1980; F i o r e , 1979; Geyman, 1980; Given et a l . , 1979; Hogue, 1979; V i n c e n t , 1971; Windsor et a l . , 1980; Wise, 1979). Study of compliance i n the area of BSE i n d i c a t e s some s p e c i f i c concerns. T u r n b u l l (1978) p o i n t s out c o n f l i c t between emotions and p r e v e n t i v e h e a l t h measures. She contends that women's a t t i t u d e s toward the b r e a s t and cancer are f r e q u e n t l y emotional and that h e a l t h p r o f e s s i o n a l s are not immune to these i n h i b i t i n g concerns. W i l l i a m s (1979) found that fear was f r e q u e n t l y an i n h i b i t i n g f a c t o r but S t i l l m a n (1977) found that women who p e r c e i v e themselves as being more s u s c e p t i b l e to 84 breast cancer do tend to p r a c t i c e BSE to some degree. Other m o t i v a t o r s l i n k e d to r a t e of p r a c t i c e are r e l i g i o n , age, f o r g e t t i n g , lack of understanding, degree of confidence i n a b i l i t y to d e t e c t a lump and degree of b a s i c knowledge on how to c a r r y out BSE. S e v e r a l approaches have been suggested f o r i n c r e a s i n g m o t i v a t i o n to p r a c t i c e BSE: use of cues and m o d e l l i n g behaviour or guided p r a c t i c e (Edwards, 1980); use of a s i l a s t i c breast model ( H a l l et a l . , 1980); a combination of person-to-person i n s t r u c t i o n , follow-up i n q u i r y , t e l e v i s i o n education and p r o v i s i o n of medical c o n s u l t a n t s ( G a s t r i n , 1981). S t i l l m a n (1977) suggests that a high b e l i e f i n p e r c e i v e d b e n e f i t s of BSE or p e r c e i v e d s u s c e p t i b i l i t y do not n e c e s s a r i l y l e a d to i n c r e a s e d BSE p r a c t i c e r a t e s . She suggests the use of a l t e r n a t i v e t e a c h i n g approaches depending on c l i e n t a t t i t u d e s and concerns. Plans to d e a l with h e a l t h b e l i e f s and p e r c e i v e d s u s c e p t i b i l i t y should be i n c l u d e d . In terms of end behaviour, two v a r i a b l e s have f r e q u e n t l y r e c c u r r e d i n the r e s e a r c h - - p e r s o n a l v a l u e s and p e r s o n a l e x p e c t a t i o n s . E x p e c t a t i o n s of c o n t r o l g e n e r a l l y or s p e c i f i c a l l y are examined by the l o c u s of c o n t r o l r e s e a r c h . The theory u n d e r l y i n g t h i s approach contends that f e e l i n g s of c o n t r o l or powerlessness p l a y a p a r t in e x p l a i n i n g i n d i v i d u a l behaviour i n a given s i t u a t i o n . While LOC measurement t o o l s are l i m i t e d in t h e i r accuracy f o r p r e d i c t i o n , t o o l s which are focused on more s i t u a t i o n - s p e c i f i c e x p e c t a t i o n s may i n c r e a s e success. The H e a l t h Locus of C o n t r o l measurement t o o l seems to be more 85 accurate f o r measuring e x p e c t a t i o n s i n h e a l t h - r e l a t e d s i t u a t i o n s (Wallston et a l . , 1976). W a l l s t o n et a l . support the use of more than one measurement t o o l f o r p r e d i c t i o n of h e a l t h behaviour and suggest that i n f o r m a t i o n - s e e k i n g behaviour may be as r e l a t e d to value of h e a l t h as a b e l i e f i n p r e v e n t i v e h e a l t h c a r e . The q u e s t i o n of d e s i r a b i l i t y of i n t e r n a l i t y versus e x t e r n a l i t y i n terms of LOC has been examined and g e n e r a l l y some degree of i n t e r n a l i t y seems most b e n e f i c i a l (Dowel, 1977; E c k s t e i n & E c k s t e i n , 1979; Roueche & Mink, 1975; Tseng, 1970). S t u d i e s have a l s o shown that a s h i f t from e x t e r n a l i t y to more i n t e r n a l LOC i s p o s s i b l e through e d u c a t i o n a l approachs that take i n t o account student c o n t r o l p e r c e p t i o n s ( D a n i e l s & Stevens, 1976; Kinder & Kilman, 1976; Newsom & Foxworth, 1979). Since LOC may be a manipulable v a r i a b l e i t seems worthwhile to i n v e s t i g a t e i t s e f f e c t on s p e c i f i c behaviour. In the case of BSE a l i n k between BSE p r a c t i c e s and HLC would suggest that p a r t i c u l a r e d u c a t i o n a l approaches may be more b e n e f i c i a l than o t h e r s . In the f o l l o w i n g chapter a paradigm which attempts to e x p l a i n p a r t i c i p a t i o n i n BSE i s o u t l i n e d . T h i s pardigm i s based on the l i t e r a t u r e review and i s used as the t h e o r e t i c a l framework for the study. 86 CHAPTER I I I THEORETICAL FRAMEWORK FOR THE STUDY The aim of t h i s study was to examine performance d i s c r e p a n c i e s i n BSE p r a c t i c e s and r e l a t e them to teaching needs. Research from a v a r i e t y of sources was used to develop a conceptual framework f o r the f o r c e s which determine BSE p r a c t i c e s . Research q u e s t i o n s arose from t h i s conceptual framework. T h i s chapter i n c l u d e s a d e s c r i p t i o n of the t h e o r e t i c a l framework developed f o r t h i s study and the broad r e s e a r c h q u e s t i o n which was subsequently i n v e s t i g a t e d . Theory U n d e r l y i n g the BSE Paradigm In an attempt to examine performance d i s c r e p a n c i e s i n BSE p r a c t i c e s , a Breast S e l f - E x a m i n a t i o n Paradigm was developed. A v a r i e t y of sources from the l i t e r a t u r e were used as u n d e r l y i n g theory f o r t h i s paradigm. P a r t i c i p a t i o n i n c a r r y i n g out the p r e v e n t i v e h e a l t h measure of BSE was a major concern. P a r t i c i p a t i o n r e s e a r c h was used i n an e f f o r t to understand p a r t i c i p a t i o n in BSE p r a c t i c e s , to analyse p r e v i o u s p a r t i c i p a t i o n i n BSE teaching s e s s i o n s and to a n t i c i p a t e the is s u e s i n v o l v e d i n p a r t i c i p a t i o n i n fut u r e BSE teaching programs. Rubenson*s (1977) Expectancy-Valence Paradigm was a major u n d e r l y i n g theory base in the t h e o r e t i c a l 87 framework of t h i s study. Rubenson contends that the micro and macro l e v e l s of s t r u c t u r a l c o n d i t i o n s in which an i n d i v i d u a l i s found, the i n d i v i d u a l ' s p s y c h o l o g i c a l conceptual apparatus and the l i n k between these two elements must be c o n s i d e r e d when attempting to understand end behaviour. Emotions, needs, motives and v a l u e s play a major r o l e . Expectancy i s a f u n c t i o n of the s u b j e c t i v e c e r t a i n t y about the r e l a t i o n s h i p between an act and an outcome (Rubenson, 1977). In a n a l y s i n g p a r t i c i p a t i o n i n the p r e v e n t i v e h e a l t h p r a c t i c e of BSE, i t was a n t i c i p a t e d t h at e x p e c t a t i o n s about the consequences of c a r r y i n g out BSE and e x p e c t a t i o n s about p e r s o n a l a b i l i t y to c a r r y out such an a c t i v i t y would combine to c r e a t e an o v e r a l l expectancy i n r e l a t i o n to BSE. E x p e c t a t i o n s would be i n f l u e n c e d by a number of f o r c e s . Reference and member group a t t i t u d e s and values i n f l u e n c e i n d i v i d u a l a t t i t u d e s and v a l u e s . Personal e x p e c t a t i o n s i n r e l a t i o n to l e a r n i n g about a p a r t i c u l a r a c t i v i t y would i n f l u e n c e e x p e c t a t i o n s of success i n c a r r y i n g i t out. Previous l e a r n i n g experiences i n r e l a t i o n to BSE may p l a y a major r o l e . Motives f o r l e a r n i n g about BSE may change. Age, s o c i a l p r essure or i n c r e a s e d f e e l i n g s of s u s c e p t i b i l i t y may combine to produce a d e s i r e to i n c r e a s e p e r s o n a l knowledge and s k i l l i n r e l a t i o n to BSE. An examination of changes i n BSE h a b i t s c o u l d i n c r e a s e our understanding of the f o r c e s that p l a y a part i n i n f l u e n c i n g behaviour i n t h i s a r ea. An understanding of the events and f o r c e s which have produced changes i n behaviour i n the past may provide i n f o r m a t i o n about v a r i a b l e s which c o u l d be manipulated to produce changes with others i n the 88 f u t u r e . There may be a connection between i n f l u e n c e s encountered s p e c i f i c a l l y i n the work s i t u a t i o n and p r a c t i c e . The s u b j e c t s were d i v i d e d between h e a l t h and non-health o r i e n t e d groups i n terms of o c c u p a t i o n a l experience to examine t h i s i s s u e . I t was a n t i c i p a t e d that workers in a h e a l t h - o r i e n t e d s i t u a t i o n would be exposed to r e f e r e n c e and member groups who value h e a l t h h i g h l y . P a r t i c i p a t i n g i n h e a l t h teaching may r e q u i r e a gr e a t e r knowledge base and may act as a motivator to in c r e a s e p e r s o n a l knowledge and s k i l l s . I f t h i s i s t r u e , does i t n e c e s s a r i l y f o l l o w that fewer performance d i s c r e p a n c i e s occur with those working in h e a l t h - r e l a t e d jobs? Looking at a v a r i e t y of f a c t o r s which may be o p e r a t i n g c o u l d h e l p to us to understand any d i f f e r e n c e s which may or may not occur between these sub-groups. A person's c u r r e n t needs and that i n d i v i d u a l ' s experience of p e r s o n a l needs i n f l u e n c e not only t h e i r p e r c e p t i o n and i n t e r p r e t a t i o n of t h e i r environment and u l t i m a t e l y r e l a t e d expectancy, but a l s o the valence of a given a c t i v i t y . Valence r e f e r s to the a f f e c t i v e a t t i t u d e one has about the r e s u l t that a c e r t a i n course of a c t i o n may have (Rubenson, 1977). In r e l a t i o n to p a r t i c i p a t i o n i n BSE, i t i s connected to the p e r c e p t i o n of what BSE can l e a d to i n the f u t u r e . B e l i e f s about the r e s u l t s of f i n d i n g b r e a s t changes c o u l d a f f e c t the emotional a t t i t u d e s about the value of BSE. If the i n d i v i d u a l acknowledges the need to c o n t r o l her own h e a l t h s t a t u s and sees BSE as one means of s a t i s f y i n g t h at need, t h i s may i n f l u e n c e her a f f e c t i v e a t t i t u d e toward p a r t i c i p a t i n g i n BSE. Lack of knowledge about h e a l t h 89 needs or the role of BSE, or fear of breast disease may create a negative attitude toward BSE and thereby influence p a r t i c i p a t i o n in t h i s preventive health practice. Many of the ideas put forward by Cross (1981) when she presented her Chain of Responses (COR) model overlap Rubenson's theory of p a r t i c i p a t i o n . She discusses the st r u c t u r a l , s o c i a l and c u l t u r a l factors which influence learning. She approaches them, however, from the viewpoint of barriers to learning. These barriers not only influence an individual's perception and interpretation of the environment and thereby the l e v e l of personal motivation but they also exist as obstacles which must be overcome before p a r t i c i p a t i o n in an a c t i v i t y occurs. Many of her s i t u a t i o n a l , i n s t i t u t i o n a l and d i s p o s i t i o n a l b a r r i e r s correspond to the s t r u c t u r a l , s o c i a l and c u l t u r a l factors in the s o c i a l i z a t i o n experiences in Rubenson's model. This i s especially so in re l a t i o n to previous learning experiences and resulting attitudes toward learning and personal a b i l i t y . Cross stresses the value of goals and expectations about p a r t i c i p a t i o n . These ideas overlap the expectancy and valence factors in Rubenson's model. Cross suggests that l i f e t r a n s i t i o n s influence behaviour. L i f e t r a n s i t i o n s involve change periods. In thi s study such change periods were seen to influence the current needs of the individual with the possible result of creating a teachable moment where that individual's perception of needs changes. Her a f f e c t i v e attitude toward BSE or her perception and interpretation of the enviroment may change. 90 Cross suggests that before p a r t i c i p a t i o n i n an a c t i v i t y occurs that e x i s t i n g b a r r i e r s must be overcome. In t h i s study's framework b a r r i e r s occur between expectancy and valence and end behaviour. They u l t i m a t e l y a f f e c t p a r t i c i p a t i o n i n BSE a c t i v i t i e s . B a r r i e r s to p a r t i c i p a t i o n that have been suggested by v a r i o u s r e s e a r c h e r s a r e : time, c o n f l i c t i n g r e s p o n s i b i l i t i e s and energy l e v e l (Carp, Peterson & R o e l f , 1974); the degree of a c c u r a t e i n f o r m a t i o n (Cross, 1981); and l e v e l of s k i l l ( H a l l et a l . , 1977). Smith (1980) o u t l i n e d a comprehensive l i s t of f a c t o r s which he suggests u l t i m a t e l y i n f l u e n c e -end behaviour i n s i t u a t i o n s where the i n d i v i d u a l i s allowed a degree of p e r s o n a l d e s c r e t i o n . His ideas were used i n t h i s study's t h e o r e t i c a l framework in an attempt to c r e a t e a broad and comprehensive a n a l y s i s of an i n d i v i d u a l ' s u l t i m a t e d e c i s i o n to p a r t i c i p a t e i n BSE. Many of h i s suggestions o v e r l a p with ideas a l r e a d y mentioned by Rubenson and Cross. Smith's ideas were used to add s p e c i f i c i t y i n v a r i o u s c a t e g o r i e s in the t h e o r e t i c a l framework: s o c i a l i z a t i o n i n c l u d e s s o c i a l background and s o c i a l r o l e f a c t o r s ; c o n g e n i t a l p r o p e r t i e s i n c l u d e b i o l o g i c a l and p h y s i c a l c h a r a c t e r i s t i c s ; a c t i v e preparedness i n c l u d e s p e r s o n a l i t y t r a i t s and i n t e l l e c t u a l c a p a c i t i e s and i s i n f l u e n c e d by r e t a i n e d i n f o r m a t i o n ; environmental f a c t o r s i n c l u d e b i o p h y s i c a l and s o c i a l - s t r u c t u r a l f a c t o r s ; p e r c e p t i o n and i n t e r p r e t a t i o n of the environment i n v o l v e s immediate awareness and d e f i n i t i o n of the s i t u a t i o n . The c a u t i o u s and broad p e r s p e c t i v e presented by Smith should be h e l p f u l i n i n c r e a s i n g the accuracy with which data are a n a l y s e d . 91 The Health B e l i e f Model (Becker et a l . , 1979) suggests that before an i n d i v i d u a l undertakes a recommended p r e v e n t i v e h e a l t h a c t i o n , a cue to such a c t i o n i s needed to t r i g g e r a p p r o p r i a t e behaviour. Cues may i n v o l v e reminders and advice from a v a r i e t y of sources or they may i n v o l v e r e l a t e d p e r s o n a l i l l n e s s or i l l n e s s i n v o l v i n g s i g n i f i c a n t o t h e r s . T h i s concept was i n c l u d e d in the study's t h e o r e t i c a l framework as one of the f a c t o r s i n f l u e n c i n g the i n d i v i d u a l ' s p e r c e p t i o n of needs. Cues, in and of themselves, are not seen as a u t o m a t i c a l l y r e s u l t i n g i n a c t i o n . They are a f a c t o r which i n f l u e n c e s p e r c e p t i o n but i s i n turn s u s c e p t i b l e to p e r s o n a l expectancy and valence i n v o l v e d i n the s i t u a t i o n and, t h e r e f o r e , may or may not s t i m u l a t e end behaviour. Other ideas i n the H e a l t h B e l i e f Model which f i t i n t o the study's framework ar e : p e r c e i v e d s u s c e p t i b i l i t y under p e r c e p t i o n of needs; demographic and s o c i o - p s y c o l o g i c a l v a r i a b l e s under s o c i a l i z a t i o n , c o n g e n i t a l p r o p e r t i e s and environmental f a c t o r s ; and p e r c e i v e d b e n e f i t s and b a r r i e r s under expectancy and v a l e n c e . The knowledge component has been d e s c r i b e d as a very complex i s s u e i n compliance. Lane and Evans (1979) i d e n t i f y i t as an i n t e r v e n i n g v a r i a b l e . I t c r e a t e s p o t e n t i a l f o r compliance. In t h i s study's framework i t appears as part of a c t i v e preparedness in the form of r e t a i n e d i n f o r m a t i o n . P e r c e p t i o n and i n t e r p r e t a t i o n of the environment i s i n f l u e n c e d by the o p p o r t u n i t y to l e a r n , the source of the i n f o r m a t i o n , the methodology used to present i n f o r m a t i o n and the accuracy of i n f o r m a t i o n . An i n d i v i d u a l ' s p e r c e p t i o n of her needs i s 92 i n f l u e n c e d by her knowledge of h e a l t h needs and the r o l e of BSE. A r e a l or p e r c e i v e d lack of i n f o r m a t i o n may act as a b a r r i e r to eventual p a r t i c i p a t i o n in BSE. While knowledge may play a s i g n i f i c a n t r o l e i n end behaviour i t i s recognized that i t i s only one of many motivators of a c t i o n . The l a s t l a r g e body of r e s e a r c h which i n f l u e n c e d t h i s study's t h e o r e t i c a l framework i s the locus of c o n t r o l r e s e a r c h . T h i s l i t e r a t u r e suggests that f e e l i n g s of p e r s o n a l c o n t r o l or powerlessness c r e a t e s general e x p e c t a t i o n s i n a given s i t u a t i o n and a f f e c t s end behaviour a c c o r d i n g l y . In t h i s study l o c u s of c o n t r o l i n the s p e c i f i c area of h e a l t h was seen as a part of the s o c i a l i z a t i o n p rocess. I t i n f l u e n c e s a c t i v e preparedness through i t s e f f e c t on s e l f - e v a l u a t i o n . I t can i n f l u e n c e e x p e c t a t i o n s about BSE d i r e c t l y or through pe r s o n a l p e r c e p t i o n s and i n t e r p r e t a t i o n s of the environment. It was p e r c e i v e d as one of the manipulable v a r i a b l e s which i n f l u e n c e p a r t i c i p a t i o n i n BSE. Breast S e l f - E x a m i n a t i o n P a r t i c i p a t i o n Paridigm Based on the r e s e a r c h which has been d e s c r i b e d , a Breast S e l f - E x a m i n a t i o n P a r t i c i p a t i o n Paradigm was developed. T h i s paradigm was an attempt to organize theory i n t o a framework. T h i s framework was used to develop a data c o l l e c t i o n t o o l and as a b a s i s f o r data a n a l y s i s . While a v a r i e t y of t h e o r e t i c a l ideas was used in i t s development, the major u n d e r l y i n g theory was Rubenson's (1977) Expectancy-Valence Paradigm. The BSE p a r t i c i p a t i o n paradigm f a c t o r s and t h e i r a n t i c i p a t e d r e l a t i o n s h i p s are given i n the f o l l o w i n g diagram (Figure 4). FIGURE 4. BREAST SELF-EXAMINATIOH PARADIGM SOCIALIZATION THROUGH FAMILY,SCHOOL AND WORK -prev i o u s h e a l t h experiences - p r e v i o u s l e a r n i n g experiences - a t t i t u d e s toward h e a l t h - e x p e c t a t i o n s of c o n t r o l over own h e a l t h (HLC) CONGENITAL PROPERTIES - b i o l o g i c a l and p h y s i c a l c h a r a c t e r i s t i c s ACTIVE PREPAREDNESS - s e l f - e v a l u a t i o n - p e r s o n a l i t y t r a i t s and I n t e l l e c t u a l c a p a c i t i e s - r e t a i n e d Information EXPECTANCY - e x p e c t a t i o n s about the outcome of p r a c t i c i n g BSE - e x p e c t a t i o n s about the a b i l i t y to c a r r y out RSE STRUCTURAL,SOCIAL AND CULTURAL FACTORS IN THE ENVIRONMENT - h e a l t h values of member and ~ — " reference groups - o p p o r t u n i t y to l e a r n about BSE -source of BSE Information presentat ion I PERCEPTION ANT) INTERPRETATION OF THE ENVIRONMENT -Immediate awareness and d e f i n i t i o n of the s i t u a t i o n BARRIERS TO BSE -time - c o n f l i c t i n g r e s p o n s i b i l i t i e s _ -energy l e v e l - r e a l or p e r c e i v e d l a c k of a c c u r a t e PARTICIPATION IN BSE VALEUCE - a f f e c t i v e a t t i t u d e about the outcome of p a r t i c i p a t i n g i n BSE i n f o r m a t i o n or s k i l l CURRENT NEEDS OF THE INDIVIDUAL - l i f e t r a n s i t i o n s -personal h e a l t h s t a t u s THE INDIVIDUAL'S PERCEPTION OF MEETS -value of h e a l t h -value of PSE -knowledge of h e a l t h needs and the r o l e of BSE - a t t i t u d e toward the treatment of breast disease -cues to a c t i o n -teachable moment -perceived s u s c e p t i b i l i t y to breast d i s e a s e VO 94 P a r t i c i p a t i o n i n BSE as a p r e v e n t i v e h e a l t h p r a c t i c e i s the end behaviour of concern f o r t h i s study. V a r i o u s f o r c e s are seen as important v a r i a b l e s which determine i n d i v i d u a l a c t i o n s . S e l f - e v a l u a t i o n , p e r s o n a l i t y t r a i t s and i n t e l l e c t u a l c a p a c i t i e s and r e t a i n e d i n f o r m a t i o n combine to c r e a t e a s t a t e of a c t i v e preparedness i n an i n d i v i d u a l . T h i s s t a t e a r i s e s from s o c i a l i z a t i o n through f a m i l y , school and work. S o c i a l background and s o c i a l r o l e f a c t o r s are represented here. Previous h e a l t h experiences, a t t i t u d e s toward l e a r n i n g , and ex p e c t a t i o n s of c o n t r o l over one's own h e a l t h are some important f a c t o r s s p e c i f i c a l l y i n v o l v e d i n BSE. A c t i v e preparedness may i n f l u e n c e expectancy toward BSE d i r e c t l y or through i t s i n f l u e n c e on a person's p e r c e p t i o n and i n t e r p r e t a t i o n of the envi ronment. Per c e p t i o n and i n t e r p r e t a t i o n of the environment i s that i n d i v i d u a l ' s immediate awareness and d e f i n i t i o n of the s i t u a t i o n . I t i s i n f l u e n c e d not only by a person's a c t i v e preparedness but by s t r u c t u r a l , s o c i a l and c u l t u r a l f a c t o r s i n the environment and by that i n d i v i d u a l ' s p e r c e p t i o n of her needs. Environmental f a c t o r s which seem p a r t i c u l a r l y important i n examining BSE p r a c t i c e s i n c l u d e : h e a l t h v a l u e s of member and re f e r e n c e groups; o p p o r t u n i t y to l e a r n about BSE; the source of BSE i n f o r m a t i o n ; the methodology used to present BSE i n f o r m a t i o n . The i n d i v i d u a l ' s p e r c e p t i o n of needs i s i n f l u e n c e d by her cur r e n t needs which i n turn are i n f l u e n c e d by l i f e t r a n s i t i o n s and p e r s o n a l h e a l t h s t a t u s and by v a r i o u s f a c t o r s s p e c i f i c to 95 BSE. These f a c t o r s i n c l u d e : value of h e a l t h ; value of BSE; knowledge of h e a l t h needs and the r o l e of BSE; a t t i t u d e s toward the treatment of b r e a s t d i s e a s e ; cues to a c t i o n which may e x i s t ; the presence or absence of a "teachable moment"; and p e r c e i v e d s u s c e p t i b i l i t y to breast d i s e a s e . P e r c e p t i o n and i n t e r p r e t a t i o n of the environment i n t u r n , i n f l u e n c e s expectancy. Expectancy i n c l u d e s e x p e c t a t i o n s about the outcome of p r a c t i c i n g BSE and e x p e c t a t i o n s about p e r s o n a l a b i l i t y to c a r r y out BSE. Valence, the other major determinant of end behaviour, i n v o l v e s the a f f e c t i v e a t t i t u d e about the outcome of p a r t i c i p a t i n g i n BSE. I t i s i n f l u e n c e d by expectancy and the i n d i v i d u a l ' s p e r c e p t i o n of needs. Together with expectancy, valence helps determine the c h o i c e of p a r t i c i p a t i n g i n BSE or not. The degree of m o t i v a t i o n c r e a t e d by expectancy and valence may, however, encounter b a r r i e r s to a c t u a l p a r t i c i p a t i o n i n BSE p r a c t i c e . If such b a r r i e r s e x i s t , m o t i v a t i o n must be s u f f i c i e n t to overcome t h e i r i n f l u e n c e on the i n d i v i d u a l ' s c h o ice of behaviour. B a r r i e r s which are a n t i c i p a t e d include time r e s t r a i n t s , c o n f l i c t i n g r e s p o n s i b i l i t i e s , energy l e v e l , r e a l or p e r c e i v e d l a c k of a c c u r a t e i n f o r m a t i o n and r e a l or p e r c e i v e d lac k of s k i l l . Based on t h i s paradigm f o r BSE p a r t i c i p a t i o n , a broad r e s e a r c h q u e s t i o n was formulated. 96 The Research Question The two main concerns of t h i s study were performance d i s c r e p a n c i e s i n BSE p r a c t i c e and i m p l i c a t i o n s f o r teaching BSE. The end behaviour in q u e s t i o n , p a r t i c i p a t i o n i n the p r e v e n t i v e h e a l t h p r a c t i c e of BSE, was viewed as r e s u l t i n g from a complex i n t e r a c t i o n of v a r i a b l e s . The s p e c i f i c f a c t o r s which i n f l u e n c e BSE p r a c t i c e s are unknown. Using the BSE p a r t i c i p a t i o n paradigm as a t h e o r e t i c a l framework, a broad research q u e s t i o n was used for the study: What f a c t o r s are r e l a t e d to end behaviour i n BSE pra c t i c e s ? I t was a n t i c i p a t e d that only a small p o r t i o n of the suggested i n f l u e n c i n g f a c t o r s c o u l d be i s o l a t e d and measured. An attempt would t h e r e f o r e be made to analyse the i n t e r a c t i o n of a s e l e c t e d number of these v a r i a b l e s and t h e i r e f f e c t on BSE p r a c t i c e s . I m p l i c a t i o n s f o r t e a c h i n g BSE would be suggested based on these research f i n d i n g s . 97 CHAPTER IV METHODOLOGY Examination of performance d i s c r e p a n c i e s i n BSE p r a c t i c e s was based on the Breast S e l f - E x a m i n a t i o n Paradigm. A data c o l l e c t i o n instrument was developed then a p i l o t study was c a r r i e d out to improve and r e f i n e the q u e s t i o n n a i r e . A plan f o r data c o l l e c t i o n and data a n a l y s i s was formulated, a re s e a r c h group was s e l e c t e d and data c o l l e c t i o n was subsequently c a r r i e d out. T h i s chapter d e s c r i b e s the instrument development, the p i l o t study, the s e l e c t i o n of the re s e a r c h group, data c o l l e c t i o n and the plan f o r data a n a l y s i s . Instrument Development S e l e c t i o n of V a r i a b l e s Based on the review of the l i t e r a t u r e , the BSE p a r t i c i p a t i o n paradigm o u t l i n e d a wide v a r i e t y of v a r i a b l e s which may i n f l u e n c e BSE p r a c t i c e . Although the t o p i c was to be broadly examined, the data c o l l e c t i o n t o o l had to be of reasonable l e n g t h . A wide range of responses was a n t i c i p a t e d and yet data that were reasonably d e t a i l e d and s p e c i f i c were r e q u i r e d f o r u s e f u l a n a l y s i s . While the sample p o p u l a t i o n was very narrowly defined--female u n i v e r s i t y students t a k i n g courses 98 o f f e r e d by the U n i v e r s i t y of B r i t i s h Columbia Adult Education D i v i s i o n - - i t s experience with the research t o p i c was expected to i n c l u d e a wide range of p o s s i b i l i t i e s . Since the t o p i c of the s u r v e y - - p r a c t i c e of and a t t i t u d e s toward BSE-- has the p o t e n t i a l f o r being a very s e n s i t i v e s u b j e c t , s p e c i a l care i n approach and q u e s t i o n wording was necessary. These i s s u e s p l u s the r e s e a r c h e r ' s i n e x p e r i e n c e with q u e s t i o n n a i r e development and survey r e s e a r c h , n e c e s s i t a t e d a more focussed approach to the t o p i c than the broad, all-encompassing approach of the BSE P a r t i c i p a t i o n Paradigm. A l l aspects of each v a r i a b l e c o u l d not be examined i f the study was to be of a reasonable and workable length.. The four major c a t e g o r i e s f o r data c o l l e c t i o n were: p a r t i c i p a t i o n i n BSE; expectancy i n r e l a t i o n to BSE; valence i n r e l a t i o n to BSE; and b a r r i e r s to BSE. BSE p r a c t i c e . P a r t i c i p a t i o n in BSE was l a b e l l e d BSE p r a c t i c e and measured i n terms of r a t e and completeness. The d e s c r i p t i o n of BSE i n the widely used Canadian Cancer S o c i e t y pamphlet "Breast S e l f - E x a m i n a t i o n : I t Could Save Your L i f e " was used as the d e s i r e d performance. There were four components to "complete" BSE: 1) The v i s u a l component- v i s u a l l y examining both b r e a s t s . 2) The systematic component- a systematic approach to examine a l l the t i s s u e i n v o l v e d . 3) The a x i l l a component- i n c l u d i n g an examination of both a x i l l a as part of the BSE procedure. 4) The time component- c a r r y i n g out BSE every month j u s t a f t e r menses. 99 D i s c r e p a n c i e s i n BSE p r a c t i c e were r a t e d a c c o r d i n g to the number of BSE components that were m i s s i n g . The time component of BSE i n c l u d e d not only the frequency with which BSE was c a r r i e d out but a l s o the time of the month in which i t was done. Subjects may c a r r y out BSE c o r r e c t l y but f a i l to do i t on a monthly b a s i s . For t h i s reason data on r a t e of BSE p r a c t i c e were c o l l e c t e d s e p a r a t e l y and i n a d d i t i o n to the general data on BSE p r a c t i c e . Expectancy. Expectancy i n c l u d e s e x p e c t a t i o n s about the outcome of p r a c t i c i n g BSE and e x p e c t a t i o n s about pe r s o n a l a b i l i t y to c a r r y out BSE. These e x p e c t a t i o n s a r i s e from: s o c i a l i z a t i o n through f a m i l y , school and work; c o n g e n i t a l p r o p e r t i e s ; a c t i v e preparedness; s t r u c t u r a l , s o c i a l and c u l t u r a l f a c t o r s i n the environment; and p e r c e p t i o n and i n t e r p r e t a t i o n of the environment. Data were c o l l e c t e d on the f o l l o w i n g i n f l u e n c e s and i n d i c a t o r s of expectancy: 1. Knowledge of BSE i n c l u d i n g the degree of confidence in t h e i r present BSE knowledge. 2. Experience with BSE i n c l u d i n g BSE i n f o r m a t i o n source, methods of p r e s e n t a t i o n used to p r o v i d e BSE i n f o r m a t i o n , BSE follow-up l e a r n i n g s e s s i o n s and commencement of BSE. 3. I n f l u e n c e of member and r e f e r e n c e groups through reminders from f a m i l y , f r i e n d s or p h y s i c i a n s to c a r r y out BSE. 4. Experience with breast d i s e a s e , i n c l u d i n g outcomes, i n v o l v i n g themselves, t h e i r f a m i l y , t h e i r f r i e n d s 1 00 or anyone they knew. 5. P e r c e p t i o n s of BSE i n c l u d i n g the r e l a t i o n s h i p between breast lumps and cancer and the e f f e c t BSE has on the outcome of breast d i s e a s e . 6. S e l f - e v a l u a t i o n i n c l u d i n g e x p e c t a t i o n s of p e r s o n a l c o n t r o l over h e a l t h (HLC) and p e r c e p t i o n of p e r s o n a l a b i l i t y to detect breast d i s e a s e . 7. Experience i n the h e a l t h care f i e l d . Valence. Valence r e f e r s to the a f f e c t i v e a t t i t u d e about the outcome of p a r t i c i p a t i n g i n BSE. I t i s r e l a t e d to e x p e c t a t i o n s about BSE s i n c e d i f f e r e n t emotional r e a c t i o n s are r e l a t e d to d i f f e r e n t e x p e c t a t i o n s . A strong emotional r e a c t i o n to cancer and' an e x p e c t a t i o n that most breast lumps are cancerous would l i k e l y produce a s t r o n g l y emotional a t t i t u d e about p r a c t i c i n g BSE. These emotional or a f f e c t i v e a t t i t u d e s are i n f l u e n c e d by a person's c u r r e n t s t a t u s and p e r c e p t i o n of her needs. Data were c o l l e c t e d on the f o l l o w i n g t o p i c s : 1. Value of h e a l t h 2. Value of BSE 3. P e r c e p t i o n of p e r s o n a l needs i n terms of BSE i n c l u d i n g s a t i s f a c t i o n with c u r r e n t BSE h a b i t s and p e r c e i v e d r e s p o n s i b i l i t y f o r p e r s o n a l h e a l t h . 4. Current l i f e i n f l u e n c e s i n c l u d i n g age, student s t a t u s and c u r r e n t o c c u p a t i o n . 5. P e r c e i v e d s u s c e p t i b i l i t y to b r e a s t d i s e a s e . 6. Cues to BSE p r a c t i c e . 7. I n f l u e n c e s on BSE h a b i t s . 101 8. A t t i t u d e toward the outcome of p a r t i c i p a t i n g in BSE i n c l u d i n g p e r c e p t i o n s of the r e l a t i o n s h i p between d i s f i g u r i n g surgery and breast d i s e a s e , the i n f l u e n c e BSE has on fear of breast d i s e a s e and the degree to. which BSE i s an uncomfortable e x p e r i e n c e . B a r r i e r s to BSE. Even given a l l the f o r c e s which may encourage BSE, f a c t o r s may e x i s t which i n t e r f e r e with i t s p r a c t i c e . These r e s t r i c t i n g f o r c e s must be overcome before p a r t i c i p a t i o n i n BSE o c c u r s . Some of the f o r c e s which may act as b a r r i e r s to a c t i o n are time r e s t r a i n t s , c o n f l i c t i n g r e s p o n s i b l i t i e s , low energy l e v e l , fear and r e a l or p e r c e i v e d lac k of accurate i n f o r m a t i o n or s k i l l . Data were c o l l e c t e d on the p e r c e i v e d i n f l u e n c e o f : 1. Simply f o r g e t t i n g . 2. Lack of time. 3. Lack of energy. 4. Not knowing how to examine your b r e a s t s . 5. Fear of what you w i l l f i n d . Respondents were asked to i n d i c a t e the degree to which the above f a c t o r s i n f l u e n c e d how o f t e n they examined t h e i r b r e a s t s . Q u e s t i o n n a i r e Development Des p i t e i t s drawbacks, i t was decided that a q u e s t i o n n a i r e was the only reasonable method of data c o l l e c t i o n given the scope of the t o p i c s to be covered and the l i m i t e d time and resources a v a i l a b l e . A combination of p r e v i o u s l y and newly developed q u e s t i o n s was used. 1 02 The p r e v i o u s l y developed t o o l s i n c l u d e d the Health Locus of C o n t r o l Scale as i t was developed by Wallston, W a l l s t o n , Kaplan and Maides and re p o r t e d i n the Handbook of S c a l e s and In d i c e s of  Heal t h Behaviour (1976). I t was f e l t that no changes should be made to e i t h e r the i n s t r u c t i o n s or the wording of t h i s s c a l e . The purpose of the study was not to c r e a t e a new locus of c o n t r o l s c a l e but to use an e x i s t i n g s c a l e to determine i f locu s of c o n t r o l might be a f a c t o r worth pursuing i n the examination of BSE p r a c t i c e s . Part of the Value Scale developed by Rokeach (1973) was used to c o l l e c t i n f o r m a t i o n about the value given to h e a l t h . In p a r t , t h i s s c a l e requests respondents to rank eighteen t e r m i n a l v a l u e s . "Health, optimal p h y s i c a l and mental f u n c t i o n i n g " was added to t h i s l i s t f o r the purpose of t h i s study. Rokeach requests respondents to rank order a l l of the values g i v e n . Since t h i s study was concerned about h e a l t h i n r e l a t i o n to other values and s i n c e the ranking of other values was not to be examined, study p a r t i c i p a n t s were not asked to rank a l l of the v a l u e s . I t would be too time consuming and would provide a great deal of data that would not be needed. Questions designed to c o l l e c t data on breast s e l f -examination had to be developed s p e c i f i c a l l y f o r t h i s study. S e v e r a l suggestions from the l i t e r a t u r e concerning development of q u e s t i o n n a i r e s were used as g u i d e l i n e s . In the o v e r a l l sequencing of quest i o n s an e f f o r t was made to c r e a t e the best p s y c h o l o g i c a l r a t h e r than l o g i c a l sequence as i s recommended by S e l l t i z , Wrightsman and Cook (1980). Berdie 1 03 and Anderson (1974) suggest that one should begin with a few i n t e r e s t i n g and non-threatening q u e s t i o n s and a v o i d ending with important items. If the most important items are at the end of a long q u e s t i o n n a i r e when a t t e n t i o n and i n t e r e s t may be f l a g g i n g , the response to these more important q u e s t i o n s may s u f f e r i n t h e i r accuracy. Oppenheim (1966) suggests that the q u e s t i o n n a i r e should s t a r t with f a c t u a l r a t h e r than a t t i t u d i n a l q u e s t i o n s . He d e s c r i b e s a funnel approach. One begins with very broad q u e s t i o n s and becomes more s p e c i f i c as the q u e s t i o n n a i r e proceeds. These were the general ideas behind the sequencing of the q u e s t i o n s on the data c o l l e c t i o n t o o l . The q u e s t i o n n a i r e progressed from opening e x e r c i s e s which exp l o r e d general values and b e l i e f s through general experiences and knowledge about the s p e c i f i c t o p i c at hand, to s p e c i f i c knowledge and behaviour and i t s i n f l u e n c e s and f i n a l l y , to p e r s o n a l a t t i t u d e s and views. A f t e r a l l the i n f o r m a t i o n about the r e s e a r c h t o p i c had been gathered, the demographic data were c o l l e c t e d . The q u e s t i o n n a i r e ended with simple q u e s t i o n s which were easy f o r respondents to answer. In a d d i t i o n to c r e a t i n g a t h e o r e t i c a l l y sound q u e s t i o n n a i r e , the U n i v e r s i t y of B r i t i s h Columbia requirements concerning e t h i c a l i s s u e s i n r e s e a r c h had to be met. The q u e s t i o n n a i r e i n c l u d e d an explanatory l e t t e r which e x p l a i n e d the b e n e f i t s to be d e r i v e d , a d e s c r i p t i o n of the procedures to be c a r r i e d out, a reminder that withdrawal or r e f u s a l to answer q u e s t i o n s would not b r i n g a p r e j u d i c i a l response, the time requirements f o r study p a r t i c i p a t i o n and i n f o r m a t i o n concerning 1 04 anonymity and consent. With these ideas and requirements i n mind, the q u e s t i o n n a i r e was developed and then r e v i s e d and r e f i n e d using four d i f f e r e n t p i l o t study groups. P i l o t Study In a l l , t h i r t y - o n e women p a r t i c i p a t e d i n the p i l o t study. Of t h i s group, f i v e women were nu r s i n g i n s t r u c t o r s c u r r e n t l y t eaching in a u n i v e r s i t y nursing school program. Two of these i n s t r u c t o r s were a c t i v e l y i n v o l v e d i n de v e l o p i n g and teaching n u r s i n g course content on BSE. Of the t o t a l p i l o t p r o j e c t s u b j e c t s , 18 had a n u r s i n g background and 13 had a tea c h i n g or other non-health background. The forms which were developed in the p i l o t study i n c l u d e d a l e t t e r of i n i t i a l c o n t a c t which was to be sent to a l l p o t e n t i a l r e s e a r c h s u b j e c t s p r i o r to a c t u a l data c o l l e c t i o n as we l l as the a c t u a l q u e s t i o n n a i r e . The q u e s t i o n n a i r e i n c l u d e d an explanatory l e t t e r , a value s s e c t i o n , a h e a l t h b e l i e f s s e c t i o n and a s e c t i o n on BSE i t s e l f . The l e t t e r of i n i t i a l c o n t a c t was to be sent to each p o t e n t i a l respondent i n an attempt to arouse i n t e r e s t and c r e a t e a d e s i r e to be a part of such a study. Berdie and Anderson (1974) suggest that u n i v e r s i t y undergraduates respond more favourably to a p e r s o n a l i z e d approach (p. 53) and a s p e c i a l e f f o r t was made to c r e a t e a p e r s o n a l i z e d tone. A f t e r p i l o t i n g some of the t e c h n i c a l jargon such as "performance d i s c r e p a n c i e s " and "survey approach" were omitted and some rewording took p l a c e 1 05 to i n c r e a s e c l a r i t y i n both the l e t t e r of i n i t i a l contact and the explanatory l e t t e r . In the values s e c t i o n of the q u e s t i o n n a i r e respondents were i n i t i a l l y asked to p i c k out ten v a l u e s and then c i r c l e the f i v e which were most important. P i l o t t e s t i n g i n d i c a t e d that respondents g e n e r a l l y l i k e d t h i s s e c t i o n and few changes were made. The second set of i n s t r u c t i o n s at the bottom of the page was p l a c e d i n a box to separate and b r i n g a t t e n t i o n to them and spacing was rearranged so that there was more room between o p t i o n s . I n i t i a l responses i n d i c a t e d that the data d i d not give a very d i s c r i m i n a t i n g range of responses and respondents were subsequently asked to chose only f i v e values and to rank the top t h r e e . T h i s seemed to give a b e t t e r spread of responses. The h e a l t h b e l i e f s s e c t i o n of the q u e s t i o n n a i r e c o n s i s t e d of the H e a l t h Locus of C o n t r o l S c a l e . The p r e s e n t a t i o n of the s c a l e underwent s e v e r a l changes to improve spacing and f a c i l i t a t e completion and p r o c e s s i n g of t h i s s e c t i o n . Four respondents i n the p i l o t study c r i t i c i z e d q u e s t i o n number f i v e . They f e l t i t was u n c l e a r . I t was f e l t that the q u e s t i o n c o u l d be i n t e r p r e t e d i n more than one way but i t was not changed f o r t h i s study because v a l i d i t y and r e l i a b i l i t y r e s u l t s f o r t h i s s c a l e would then be i n v a l i d . The breast s e l f - e x a m i n a t i o n p o r t i o n of the q u e s t i o n n a i r e underwent major changes d u r i n g p i l o t i n g . Much of the p i l o t t e s t i n g e f f o r t went i n t o the development of ever more c l e a r and s u c c i n c t q u e s t i o n s and the arrangement of the most b e n e f i c i e n t sequencing. In terms of format, the aim i s to produce an 1 06 a t t r a c t i v e and i n t e r e s t i n g q u e s t i o n n a i r e which can be e f f i c i e n t l y completed in the minimum amount of time. Oppenheim (1966) reminds us that while open-ended q u e s t i o n s are easy to ask, they are d i f f i c u l t to answer and even harder to a n a l y s e . He suggests a minimum of open-ended q u e s t i o n s and the use of d i f f e r e n t type forms, headings, boxes and i n s e r t s to f u r t h e r decrease the e f f o r t that must be made by respondents. S e v e r a l t o p i c s were i n i t i a l l y examined using open-ended q u e s t i o n s and then i n f o r m a t i o n a r i s i n g from the l i t e r a t u r e and these p e r s o n a l responses were combined to c r e a t e m u l t i p l e c h o i c e q u e s t i o n s or c l o s e d q u e s t i o n s which r e q u i r e d only a yes/no response. L i b e r a l use was made of the "other" o p t i o n and room f o r e x p l a n a t i o n of answers was given i n order to allow f o r a wider range of responses while making response q u i c k e r and e a s i e r f o r what appeared to be the bulk of the respondents. Important p a r t s of i n s t r u c t i o n s were u n d e r l i n e d and boxed where emphasis was needed. S p e c i f i c examples were given f o r some opt i o n s in order to c l a r i f y q u e s t i o n s . Some qu e s t i o n s such as the one concerning p e r s o n a l experience with breast d i s e a s e , were l e f t i n a f a i r l y open format s i n c e anything more would have c r e a t e d a very complicated and long s e r i e s of quest i o n s which would not have been r e l e v a n t f o r a l a r g e number of respondents. Some items were e l i m i n a t e d a f t e r they f a i l e d to provide d i s c r i m i n a t i n g data and most were r e v i s e d and reworded s e v e r a l times. The f i n a l form of the q u e s t i o n n a i r e can be found in Appendix B. 107 S e l e c t i o n of the Research Group L i m i t a t i o n s of time and resources r e q u i r e d ' t h e s e l e c t i o n of a r e s e a r c h group which c o u l d be reached w i t h i n a reasonable l e n g t h of time. Since p e r s o n a l contact between the resear c h e r and the re s e a r c h s u b j e c t s would probably encourage p a r t i c i p a t i o n when the re s e a r c h t o p i c was so s e n s i t i v e , a group which was i n c l o s e g e o g r a p h i c a l p r o x i m i t y was a l s o d e s i r a b l e . The s i z e of the study would have to be l i m i t e d and i t was f e l t that a group which would have some r e c o g n i z a b l e unique c h a r a c t e r i s t i c s would a s s i s t i n data a n a l y s i s . E d u c a t i o n a l l e v e l i s an important aspect of the l e a r n i n g environment and i t was decided that e d u c a t i o n a l l e v e l would be h e l d constant. The s e l e c t i o n of the female students e n r o l l e d i n the UBC Adult Education D i v i s i o n c l a s s e s met the above c r i t e r i a . In a d d i t i o n , they provided an o p p o r t u n i t y to compare the e f f e c t of experience i n the h e a l t h care f i e l d on the dependent v a r i a b l e . Students i n these c l a s s e s g e n e r a l l y f a l l i n t o two l a r g e groups, nurses and other h e a l t h care workers, and educators i n v o l v e d i n e i t h e r v a r i o u s l e v e l s of the p r o v i n c i a l school system or i n ad u l t e d u c a t i o n . Data C o l l e c t i o n There were three b a s i c aspects to the data c o l l e c t i o n p r ocess. The f i r s t i n v o l v e d the i n i t i a l c o n t a c t which a l e r t e d p o t e n t i a l p a r t i c i p a n t s t o the resea r c h p r o j e c t . The next step was a c t u a l c o n t a c t and d i s t r i b u t i o n of the data c o l l e c t i o n t o o l . 108 An ongoing and c o n c l u d i n g aspect of the process i n v o l v e d those a c t i o n s taken to encourage p a r t i c i p a t i o n . I n i t i a l c o n t a c t i n v o l v e d the r e c e i p t of the l e t t e r s p e c i f i c a l l y designed f o r that purpose (see Appendix A). The l e t t e r was to be sent through the r e g u l a r m a i l s e r v i c e to a l l women e n r o l l e d i n c l a s s e s given by U.B.C.'s Adult Education D i v i s i o n . T h i s proved to be a d i f f i c u l t task s i n c e there was not a c u r r e n t l i s t of m a i l i n g addresses f o r t h i s group of students. A c c o r d i n g to c l a s s l i s t s , there were 156 female students r e g i s t e r e d i n Adult Education c l a s s e s . Addresses were found f o r 132 students. Approximately two weeks p r i o r to the planned data c o l l e c t i o n schedule, l e t t e r s of i n i t i a l c o ntact were sent to a l l those students f o r whom addresses had been found. Nine l e t t e r s were returned because of wrong addresses. Given the q u e s t i o n a b l e accuracy of the m a i l i n g l i s t , one can only assume that approximately 79 percent of the p o t e n t i a l r e s e a r c h s u b j e c t s r e c e i v e d t h i s i n i t i a l c o ntact l e t t e r . A schedule f o r meeting with the p o t e n t i a l r e s e a r c h s u b j e c t s was developed with the he l p of the p r o f e s s o r s t e a c h i n g the cu r r e n t Adult Education c l a s s e s ( i e . , second term c l a s s e s of the U.B.C. 1982-83 Winter S e s s i o n ) . T h i s schedule ran from Wednesday to Wednesday and i n c l u d e d day and evening c l a s s e s . The time span i n v o l v e d was important to the l a s t aspect of data c o l l e c t i o n — e n c o u r a g i n g p a r t i c i p a t i o n — a n d w i l l be d i s c u s s e d l a t e r . The r e s e a r c h e r met with the students a f t e r the c l a s s e s had commenced but e i t h e r before the day's work had begun or j u s t 109 before a break. She was i n t r o d u c e d by the p r o f e s s o r and before handing out the q u e s t i o n n a i r e she d i s c u s s e d v a r i o u s aspects of the p r o j e c t . Many of the p o i n t s that were covered were in the l e t t e r of i n i t i a l c o n t a c t and again i n the i n t r o d u c t o r y l e t t e r of the q u e s t i o n n a i r e . I t was f e l t , however, that some students would not have r e c e i v e d the i n i t i a l c o ntact l e t t e r and many may not read the cover l e t t e r . A r e p e t i t i o n of these aspects of the study would remind students of t h e i r r i g h t s and might a l s o serve as an i n c e n t i v e to p a r t i c i p a t e . Students were a l s o given some p r o c e s s i n g i n f o r m a t i o n about the q u e s t i o n n a i r e i t s e l f . Most people in the p i l o t study took from 15 to 30 minutes to f i l l out the q u e s t i o n n a i r e so students were t o l d that they c o u l d a n t i c i p a t e a s i m i l a r time commitment i f they chose to p a r t i c i p a t e . They were t o l d where c o p i e s c o u l d be obtained i f o r i g i n a l q u e s t i o n n a i r e s were l o s t and the d e a d l i n e f o r r e t u r n i n g the forms was given. The method of r e t u r n i n g completed forms was e x p l a i n e d . The forms were to be returned through the campus mail or dropped i n t o a marked box i n the A d u l t Education b u i l d i n g . Before d i s t r i b u t i n g the forms the r e s e a r c h e r asked i f students had any questions and answered any that arose. Some students were e n r o l l e d i n more than one a d u l t education c l a s s and they were, t h e r e f o r e , s u b j e c t e d to s e v e r a l appeals f o r p a r t i c i p a t i o n . They were only given one copy of the q u e s t i o n n a i r e . Students were given a q u e s t i o n n a i r e f o r p e r u s a l and t o l d that they c o u l d then decide whether they wanted to p a r t i c i p a t e . Only one student r e f u s e d to accept the form. Only those students who attended c l a s s e s d u r i n g the week of 110 q u e s t i o n n a i r e d i s t r i b u t i o n were su b j e c t e d to t h i s p e r s o n a l appeal by the r e s e a r c h e r . In t o t a l , 119 q u e s t i o n n a i r e s were d i s t r i b u t e d . The r e s e a r c h e r , a f e l l o w student, made a p e r s o n a l appeal as she handed out the data c o l l e c t i o n t o o l s . I t was hoped that t h i s o p p o r t u n i t y to meet and qu e s t i o n the resear c h e r would i n c r e a s e i n t e r e s t i n the p r o j e c t . I t was an attempt to make p a r t i c i p a t i o n not j u s t a matter of f i l l i n g out yet another form, but an o p p o r t u n i t y to j o i n a f e l l o w student i n a s i n c e r e attempt to examine a worthwhile t o p i c of concern. I t a l s o gave the researcher a chance to a l l a y concerns and answer q u e s t i o n s that might e x i s t but that she has not a n t i c i p a t e d and had, t h e r e f o r e , not addressed i n her w r i t t e n m a t e r i a l . The endorsement of f a c u l t y members was a l s o seen as a v a l u a b l e a s s e t i n t h i s attempt to encourage p a r t i c i p a t i o n . The researc h e r was p e r s o n a l l y i n t r o d u c e d to students by t h e i r p r o f e s s o r s . A l l f a c u l t y members were sent a request by the researc h e r to remind students i n subsequent c l a s s e s to r e t u r n t h e i r completed forms. Such a reminder would support p a r t i c i p a t i o n as w e l l as serve as an encouragement to r e t u r n completed forms. A v i s u a l reminder was provided by b r i g h t l y c o l o u r e d p o s t e r s which were p l a c e d at s t r a t e g i c spots around the Adult Education b u i l d i n g . These p o s t e r s announced the p r o j e c t i n l a r g e red and black l e t t e r s . They c r e a t e d d i s c u s s i o n and seemed to in c r e a s e awareness of the p r o j e c t e s p e c i a l l y i n the i n i t i a l stages of data c o l l e c t i o n . 111 The aim was to hand out data c o l l e c t i o n t o o l s , r a i s e awareness of the r e s e a r c h p r o j e c t and gather completed q u e s t i o n n a i r e s w i t h i n a f a i r l y short time span while awareness was s t i l l h igh and i n c l i n a t i o n to p a r t i c i p a t e s t i l l f r e s h . Due to u n a n t i c i p a t e d time requirements f o r p r e p a r i n g the q u e s t i o n n a i r e , data c o l l e c t i o n o c c u r r e d l a t e i n the academic year. Students are o f t e n overwhelmed with end of term assignments and upcoming exams. The r e s e a r c h e r , a f t e r being reminded by one group of students of the d i f f i c u l t i e s that they faced, t h e r e a f t e r brought t h i s t o p i c up as she presented the p r o j e c t to each c l a s s . T h i s acknowledged her concern about t h e i r o b l i g a t i o n s and a l s o p r o v i d e d an o p p o r t u n i t y f o r students to vent t h e i r f e e l i n g s on t h i s matter. Subsequent groups d i d t a l k about t h e i r workload but d i d not v o i c e strong f e e l i n g s about the t i m i n g of the p r o j e c t . Q u e s t i o n n a i r e s were c o l l e c t e d from i n d i v i d u a l students and from the well-marked box s t r a t e g i c a l l y p l a c e d i n the foyer of the Adult Education b u i l d i n g . While the m a j o r i t y of q u e s t i o n n a i r e s were returned w i t h i n the f i r s t two weeks, students were given a month i n which to complete and r e t u r n the data c o l l e c t i o n t o o l . An examination of the response r a t e produced the f o l l o w i n g i n f o r m a t i o n . A l l research s u b j e c t s were female students e n r o l l e d i n second term c l a s s e s given by U.B.C.'s Adult Education D i v i s i o n i n the 1982-83 Winter S e s s i o n . According to c l a s s l i s t s , 156 female students were r e g i s t e r e d i n these c l a s s e s . During the wee-k of data c o l l e c t i o n 120 p o t e n t i a l 1 12 r e s e a r c h s u b j e c t s attended c l a s s . One student r e f u s e d to accept a q u e s t i o n n a i r e which l e f t a t o t a l of 119 q u e s t i o n n a i r e s d i s t r i b u t e d . Of t h i s group, 66 r e t u r n e d completed q u e s t i o n n a i r e s . T h i s represented a r e t u r n r a t e of 55 p e r c e n t . In g e n e r a l a l l respondents completed a l l the q u e s t i o n s . There were a few exceptions and these w i l l be d i s c u s s e d as those t o p i c s concerned are d i s c u s s e d . I t would be d e s i r a b l e to compare the respondents to the non-respondents to determine whether the r e s e a r c h s u b j e c t s were r e p r e s e n t a t i v e of the r e s e a r c h group. U n f o r t u n a t e l y , data were not a v a i l a b l e on the non-respondents. The r e s e a r c h group was unique and no p r e v i o u s group c h a r a c t e r i s t i c s had been c o l l e c t e d . Anonimity was an important aspect of the c u r r e n t r e s e a r c h s i n c e respondents would be s h a r i n g very p e r s o n a l experiences, f e e l i n g s and a t t i t u d e s . Non-respondents c o u l d not, t h e r e f o r e , be i d e n t i f i e d f o r examination and comparison. S t r a t e g i e s f o r Data A n a l y s i s Data a n a l y s i s i s l i m i t e d by the form of measurement in which data have been c o l l e c t e d . The m a j o r i t y of data c o l l e c t e d i n t h i s r e s e a r c h p r o j e c t f a l l i n t o the category of nominal or o r d i n a l measurement. A n a l y s i s i s a l s o l i m i t e d by r e s e a r c h e r c o n t r o l over the v a r i a b l e s measured. In t h i s ex post f a c t o r e s e a r c h , e d u c a t i o n a l l e v e l was the only v a r i a b l e which was c o n t r o l l e d . A t h i r d l i m i t a t i o n of data a n a l y s i s i s the make-up of the r e s e a r c h sample. The sample in t h i s r e s e a r c h c o n s i s t e d of v o l u n t e e r s from a h i g h l y educated s e l e c t group of u n i v e r s i t y 113. students. L i m i t a t i o n s of the study are d i s c u s s e d at more length i n the l a s t chapter of t h i s r e p o r t . I t was decided that the f i r s t s tep of data a n a l y s i s would be an examination of each of the v a r i a b l e s i n terms of frequency d i s t r i b u t i o n s . T h i s would summarize the v a r i a b l e s and h e l p to i n d i c a t e where l o g i c a l groupings of scores were i n d i c a t e d . The purpose of t h i s i n v e s t i g a t i o n was not j u s t to c o l l e c t d e s c r i p t i v e data but to explore p o s s i b l e r e l a t i o n s h i p s between v a r i a b l e s . A f t e r data had been grouped and t a l l i e d , r e l a t i o n s h i p s between v a r i a b l e s would be examined. Since much of the data were c o l l e c t e d as nominal or o r d i n a l measurements, se t s of data had to be compared as f r e q u e n c i e s i n in two or more c a t e g o r i e s . The s t a t i s t i c a l t e s t u s u a l l y used for examining such data i s the Chi-square s t a t i s t i c . While t h i s s t a t i s t i c has three p o s s i b l e a p p l i c a t i o n s , the a p p l i c a t i o n of i n t e r e s t f o r t h i s p r o j e c t was t e s t i n g independence or determining whether v a r i a b l e s are s t a t i s t i c a l l y independent. P o s s i b l e r e l a t i o n s h i p s between the dependent v a r i a b l e , BSE p r a c t i c e , and a v a r i e t y of independent v a r i a b l e s were the main concern. In a d d i t i o n , r e l a t i o n s h i p s which may e x i s t between some of the independent v a r i a b l e s might be h e l p f u l i n understanding BSE d i s c r e p a n c i e s and these were examined as w e l l . Data would a l s o be examined as p a i r e d s e t s of s c o r e s . Examination of t h i s type of data c a l l s f o r c o r r e l a t i o n and r e g r e s s i o n a n a l y s i s . The Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t would u s u a l l y be used to measure the s t r e n g t h of a s s o c i a t i o n between i n t e r v a l v a r i a b l e s . In the s t r i c t sense 1 14 this s t a t i s t i c a l method cannot be used in th i s study since none of the data were in true interval form. However, i t is frequently used with ordinal variables for three reasons. It i s a more powerful s t a t i s t i c a l method, i t provides more ea s i l y interpreted results and i t i s necessary for most of the multivariate s t a t i s t i c s . Its use i s generally preferred when possible (Borg & G a l l , 1983, p. 586). The Spearman Rank corr e l a t i o n test was used to measure the strength of association between pairs of ranked data. A l l testing was done using the .05 significance l e v e l . Data were coded and prepared for the computer by the researcher. V e r i f i c a t i o n of the coding was accomplished by randomly selecting subject scores and comparing the coding data with the o r i g i n a l data. Data were entered into the computer by the researcher and v e r i f i e d by the researcher and an assistant comparing computer data with o r i g i n a l coded data. Data analysis was carried out using the UBC S t a t i s t i c a l Package for the Social Sciences, Version 9.00 (Lai, 1983). Research results w i l l be presented and discussed in the following two chapters. A descriptive presentation of the variables w i l l be presented in Chapter V. The relationships between independent variables w i l l be explored in this chapter as well. An analysis of BSE using the BSE Paradigm and crosstabulation and correlation results w i l l then be given in Chapter VI. 1 1 5 CHAPTER V FINDINGS The purpose of t h i s chapter i s to give a d e s c r i p t i v e p r e s e n t a t i o n of the v a r i a b l e s chosen f o r study and to d i s c u s s those f i n d i n g s . The r e l a t i o n s h i p s between independent v a r i a b l e s are a l s o examined. The four components of the BSE Paradigm which were s t u d i e d a r e : p a r t i c i p a t i o n i n BSE; expectancy; valence; and b a r r i e r s to BSE. P a r t i c i p a t i o n i n BSE was the end behaviour or dependent v a r i a b l e and w i l l be d i s c u s s e d l a s t . Expectancy, valence and b a r r i e r s to BSE were the suggested independent v a r i a b l e s . These v a r i a b l e s are represented by a v a r i e t y of i n f l u e n c i n g f a c t o r s or i n d i c a t o r s on which data were c o l l e c t e d and analysed. Before these v a r i a b l e s are d i s c u s s e d a b r i e f d e s c r i p t i o n of the respondent c h a r a c t e r i s t i c s w i l l be g i v e n . Respondent C h a r a c t e r i s t i c s There were 66 respondents. None of the r e s e a r c h s u b j e c t s were under twenty or over s i x t y . Age was c o l l e c t e d i n c a t e g o r i e s which covered a ten year span. The modal category contained 46 percent of the s u b j e c t s and covered the ages from t h i r t y to t h i r t y - n i n e years of age. The next l a r g e s t group, or 27 percent, were twenty to twenty-nine years o l d . Twenty-one percent were f o r t y to f o r t y - n i n e and only four s u b j e c t s , 6 1 16 percent, f e l l i n t o the f i f t y to f i f t y - n i n e year o l d category. The bulk of the sample, 73 percent, were between the ages of twenty to t h i r t y - n i n e . Forty-one percent of r e s e a r c h s u b j e c t s attended school f u l l - t i m e . T h i r t y percent were part-time students. Current student s t a t u s c o u l d not be c a l c u l a t e d f o r 29 percent of the s u b j e c t s . A f i n a l demographic c h a r a c t e r i s t i c of i n t e r e s t was o c c u p a t i o n . Of those who returned completed q u e s t i o n n a i r e s , 59 percent were c u r r e n t l y employed or had past experience i n the h e a l t h care f i e l d . The remaining 41 percent had non-health o c c u p a t i o n a l e x p e r i e n c e s . Expectancy Data were gathered on seven aspects of expectancy. The r e s e a r c h r e s u l t s w i l l be given f o r each of these aspects and the c r o s s t a b u l a t i o n between them and other independent v a r i a b l e s w i l l be d i s c u s s e d . BSE Knowledge Complete knowledge was deemed to be knowing the four components d e s c r i b e d i n the Canadian Cancer S o c i e t y pamphlet on BSE. One i n d i v i d u a l f a i l e d to f i l l out t h i s p o r t i o n of the q u e s t i o n n a i r e . Although they were aware of c e r t a i n components of BSE some s u b j e c t s f a i l e d to c a r r y them out. Fourteen people i n d i c a t e d t h at they d i d not c a r r y out i n t h e i r p r a c t i c e a t l e a s t one 1 17 component of BSE that they knew they should do. Two of these s u b j e c t s f a i l e d to c a r r y out any BSE although they knew two components of i t . The v i s u a l component was known but not c a r r i e d out by four women, the systematic component was known but not c a r r i e d out by nine women and the time component was known but not c a r r i e d out by three women. Although the a x i l l a component was not known by the highest number of s u b j e c t s (47 p e r c e n t ) , when i t was known i t was re p o r t e d as being p r a c t i c e d . When a l l p o s s i b l e combinations of knowledge components were examined, 24 percent of the re s e a r c h s u b j e c t s i n d i c a t e d a complete knowledge of BSE. Th i s c o n t r a s t s s h a r p l y with the 5 percent of the res e a r c h s u b j e c t s who i n c l u d e d a l l four components of BSE i n t h e i r p r a c t i c e . Each of the knowledge components was examined i n d i v i d u a l l y to determine the frequency with which i t was missing as part of the d e s c r i b e d recommended BSE procedure. Table 1. Excluded BSE Knowledge Components (n=66) Excluded Components % M i s s i n g % Not M i s s i n g No v i s u a l 45 55 No systematic 18 82 No a x i l l a 48 52 No time 35 65 1 18 Note t h a t the systematic .component was excluded by 18 percent of the s u b j e c t s . T h i s i s markedly below the number of s u b j e c t s who excluded any of the other three components. Another aspect of knowledge on which data were c o l l e c t e d , was the i n d i v i d u a l ' s confidence with her present BSE knowledge. Su b j e c t s were asked to r a t e the degree to which they agreed or d i s a g r e e d with the f o l l o w i n g statement: I f e e l c o n f i d e n t with my present l e v e l of knowledge about c a r r y i n g out breast s e l f -examination. Data were a v a i l a b l e from a l l 66 r e s e a r c h s u b j e c t s . Frequency data r e v e a l e d that 80 percent of the respondents " s l i g h t l y , moderately or s t r o n g l y agreed" with the statement. These data were c r o s s t a b u l a t e d with BSE knowledge and BSE p r a c t i c e , the r e l a t i o n s h i p s were not s i g n i f i c a n t . C r o s s t a b u l a t i o n with other independent v a r i a b l e s . BSE knowledge was c r o s s t a b u l a t e d with the f o l l o w i n g v a r i a b l e s : c onfidence with BSE knowledge; a l l of the BSE i n f o r m a t i o n sources and BSE i n f o r m a t i o n p r e s e n t a t i o n methods; the t o t a l number of BSE i n f o r m a t i o n sources experienced; the t o t a l number of BSE i n f o r m a t i o n p r e s e n t a t i o n methods experienced; the age of BSE commencement; BSE follow-up s e s s i o n s ; confidence with BSE a b i l i t y ; and experience i n the h e a l t h care f i e l d . None of these v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d using the .05 s i g n i f i c a n c e l e v e l . Experience with BSE Data were c o l l e c t e d on s e v e r a l aspects of experience with BSE as a p r e v e n t i v e h e a l t h a c t i v i t y . The source of BSE i n f o r m a t i o n was examined as were the types of t e a c h i n g methods 1 19 experienced. Data were c o l l e c t e d concerning the occurrence of BSE follow-up l e a r n i n g s e s s i o n s and respondents were asked about the commencement of t h e i r p e r s o n a l BSE p r a c t i c e s . BSE i n f o r m a t i o n sources. Data were c o l l e c t e d on two aspects of i n f o r m a t i o n sources. F i r s t , s u b j e c t s were asked whether i n f o r m a t i o n was r e c e i v e d from a p a r t i c u l a r source and then they were asked to i n d i c a t e which source or sources were most u s e f u l . F i g u r e 5 shows the data on in f o r m a t i o n source r a t i n g s . The category "other" allowed respondents to l i s t sources which were not a l r e a d y i n d i c a t e d . Of the 25 people who i n d i c a t e d another source of i n f o r m a t i o n , 14 mentioned nurses t r a i n i n g ; 5 mentioned textbooks; 2 mentioned nurses i n s p e c i a l s i t u a t i o n s - - p u b l i c h e a l t h nurse, p r e n a t a l c l a s s i n s t r u c t o r . Each of the f o l l o w i n g was mentioned once: s e l f - h e l p group, TV show, a f i l m , a workshop on BSE and a video i n the d o c t o r ' s o f f i c e . These sources were u n d e r l i n e d as most u s e f u l eleven times. Nursing education was u n d e r l i n e d as most u s e f u l seven times, a f i l m , the s e l f - h e l p group and the workshop on BSE were a l s o u n d e r l i n e d as most u s e f u l . Note i n F i g u r e 5 t h a t the pamphlet as a source of in f o r m a t i o n was r a t e d h i g h e s t in each of the c a t e g o r i e s . I t was most f r e q u e n t l y experienced, i t was the one chosen most o f t e n as being "most u s e f u l " and i t had the hi g h e s t percentage when those e x p e r i e n c i n g a p a r t i c u l a r source chose i t as a "most u s e f u l " source ( i e . , ch o i c e of "most u s e f u l " as a percentage of those who had experienced that s o u r c e ) . The second h i g h e s t category i n which the r a t i n g "most u s e f u l " as a percentage of those who FIGURE 5. BSE INFORMATION SOURCES Percentage of n 100 9 5 _ 90 Pamphlet Doctor Magazine Nurse Other Friend T e l e v i s i o n Work Family Radio (57) (54) (51) (29) (26) (21) advertisement a s s o c i a t e member avertlsement (19) . (18) (12) (9) Information Source — — — =source experienced as a percentage of the t o t a l number of respondents (n=66) ="most u s e f u l " source as a percentage of the t o t a l number of respondents (n=66) — — — =chosen "most u s e f u l " by those who have experienced the source i e . "most u s e f u l " as a percentage of those who have experienced t h i s source (n given below each source) 121 had experienced the category as compared to a percentage of the whole sample, was "other." There was a dramatic increase i n t h i s c h o i c e as "most u s e f u l " when i t had been experienced. The g r e a t e s t number of "most u s e f u l " sources i n t h i s category was nurses t r a i n i n g and 79 percent of those who had experienced i t chose nurses t r a i n i n g as a "most u s e f u l " source. While the doctor as a source was second i n both the number e x p e r i e n c i n g i t and the "most u s e f u l " source, i t f e l l behind "other" in the "most u s e f u l when the source has been experienced" category. Many of these c a t e g o r i e s were not even experienced by a s i g n i f i c a n t p o r t i o n of the sample p o p u l a t i o n . Only pamphlets, d o c t o r s and magazines reached more than 50 percent of t h i s group of women. A l a r g e percentage of t h i s p o p u l a t i o n c o n s i s t e d of nurses and yet nurses p r o v i d e d i n f o r m a t i o n on BSE for only 44 percent of the whole group. BSE i n f o r m a t i o n p r e s e n t a t i o n methods. Data on methods of BSE i n f o r m a t i o n p r e s e n t a t i o n that had been experienced was c o l l e c t e d i n a manner s i m i l a r to data c o l l e c t i o n on BSE i n f o r m a t i o n sources. Respondents were asked to i n d i c a t e which p r e s e n t a t i o n methods that they had experienced and which had been most u s e f u l . F i g u r e 6 shows the data f o r the r a t i n g s of BSE p r e s e n t a t i o n methods. The category "other" drew s i x responses. F i l m s were mentioned by 5 of these respondents and t h i s method was chosen as "most u s e f u l " by 4 out of the 5. One person mentioned using "touchy f e e l e y s " , a t e a c h i n g device c o n s i s t i n g of sponges with nodules i n them which are used to p r a c t i c e p a l p a t i o n of lumps. FIGURE 6. BSE INFORMATION PRESENTATION METHODS Fereentage of n 1 0 0 _ _ W r i t t e n P i c t u r e s Spoken Demonstration Two-way Guided Demonstration Guided Demonstration Demonstration Other Guided Information or information on d i s c u s s i o n p r a c t i c e on other p r a c t i c e w i t h teacher mechanical (7) p r a c t i c e (61) sketches (57) s e l f (31) on 6elf (19) on other model model mechanical (57) (Al) (23) (11) (11) (9) model (5) P r e s e n t a t i o n Method ' " p r e s e n t a t i o n method experienced as a percentage of the t o t a l number of respondents (n-66) -"most u s e f u l " p r e s e n t a t i o n method as a percentage of the t o t a l number of respondents (n=66) — — -chosen "most u s e f u l by those who have experienced the method i e . "most u s e f u l " as a percentage of those who have experienced t h i s method (n given below each method) . 1 23 T h i s i n d i v i d u a l found t h i s method "most u s e f u l . " Only four methods were experienced by over 50 percent of the sample: w r i t t e n i n f o r m a t i o n ; p i c t u r e s or sketches; spoken i n f o r m a t i o n ; and demonstration on the respondent. The p r e s e n t a t i o n methods that were i n d i c a t e d as "most u s e f u l " by the g r e a t e s t number of respondents were p i c t u r e s or sketches and demonstration on the respondent. Each of these methods were i n d i c a t e d "most u s e f u l " by 45 percent of the sample. Guided p r a c t i c e with you examining y o u r s e l f was the next most chosen category with one t h i r d of the sample choosing i t as "most u s e f u l . " When one examines the "most u s e f u l " c h o i c e s of c a t e g o r i e s by those who had experienced them, 5 methods were chosen by more than 50 percent of the sample: guided p r a c t i c e on o n e s e l f ; demonstration on the respondent; other; guided p r a c t i c e on another person; and p i c t u r e s and sketches. Of these f i v e , two had very low f r e q u e n c i e s . "Other" methods were experienced by only seven people and guided p r a c t i c e on another person by only eleven people. Although of the people i n these c a t e g o r i e s 71 and 55 percent r e s p e c t i v e l y chose i t as "most u s e f u l " , the small numbers of respondents i n v o l v e d l e s s e n s the power of these f i n d i n g s . Two of the other three p r e s e n t a t i o n methods were experienced by over 50 percent of the sample and were subsequently chosen as "most u s e f u l " by over 50 percent of those who experienced them. Demonstration on the respondent was experienced by 62 percent of the sample and was chosen as "most 124 useful" by 73 percent of those who experienced i t . Pictures or sketches were experienced by 86 percent of the sample and was chosen "most useful" by 53 percent of those who experienced them. Guided practice on yourself was the most strongly endorsed of a l l the methods. Only 35 percent of the sample had experienced t h i s method of teaching but of those 23 women, 96 percent chose i t as a "most useful" method. Another respondent who had not experienced t h i s teaching method commented that she f e l t i t would have been most useful had i t occurred. Follow-up learning sessions. Experiences of learning BSE were also examined in terms of follow-up learning sessions. In the questionnaire respondents were asked i f they had experienced follow-up sessions and were then asked to describe them. Only 18 people indicated follow-up sessions. Nine of these sessions involved physicians and 5 of them indicated that their doctor at least asked them about their BSE habits at each v i s i t . Only two people said that their doctor asked them to demonstrate their BSE at each v i s i t . Commencement of BSE. It was thought that i n i t i a l experiences with BSE may have some bearing on present habits. Those people who practice BSE were asked i f they remembered when they started and what influenced them at that time. Data were col l e c t e d on 62 subjects. Three women did not practice BSE and therefore t h i s topic was not applicable and one person f a i l e d to answer the question. Of the 62 women on whom data are available, 83 percent remembered when they started BSE. The act of remembering the event was unrelated to present BSE knowledge 125 or p r a c t i c e . Age of commencement ranged from 14 to 40 years of age. The h i g h e s t percentage, 46 percent, s t a r t e d i n t h e i r t wenties. Another 27 percent s t a r t e d when they were 19 or younger. Only 3 women (5 percent) s t a r t e d i n t h e i r f o r t i e s . F o r t y - n i n e women d e s c r i b e d the i n f l u e n c e s surrounding t h e i r commencement of BSE. The i n f l u e n c e mentioned most o f t e n was nurses t r a i n i n g . T h i r t y - f i v e percent s t a r t e d d u r i n g nurses t r a i n i n g . Twenty-two percent s t a r t e d a f t e r t h e i r doctor suggested i t . Other i n f l u e n c e s mentioned were: fear of cancer f o l l o w i n g experiences of f a m i l y or f r i e n d s - 16 percent; development of breast c y s t s p e r s o n a l l y or i n f r i e n d s - 10 percent; reading about BSE i n magazines or hearing about i t through s i m i l a r p u b l i c i t y - 1 0 percent; r e l a t e d p e r s o n a l or f a m i l y d i s e a s e ( p o s i t i v e pap smears, c e r v i c a l p o l y p s ) - 4 percent; hearing i t at a women's h e a l t h c l i n i c - 2 percent. I n f l u e n c e of Member and Reference Groups An e f f o r t was made to c o l l e c t some data on the i n f l u e n c e of f a m i l y , f r i e n d s and p h y s i c i a n s on BSE behaviour. Respondents were asked how o f t e n they f e l t t h e i r f a m i l y , t h e i r f r i e n d s and t h e i r d o c t o r s reminded them to c a r r y out BSE. F a m i l i e s gave the l e a s t number of BSE reminders. They accounted f o r the l a r g e s t group of "never" g i v i n g reminders and only reminded " f r e q u e n t l y " f o r 2 women. F r i e n d s were a c l o s e second in l a c k of reminders and f a i l e d to give c o n s i s t e n t reminders to anyone. Although 11 percent of doctors f o r t h i s sample of women "always" gave t h e i r p a t i e n t s a BSE reminder, 29 percent "never" gave reminders. While 30 percent of p h y s i c i a n s 126 gave reminders f a i r l y c o n s i s t e n t l y , a much g r e a t e r number, 68 percent only " o c c a s i o n a l l y , h a r d l y ever or never" gave BSE remi nders. Experiences With Breast Disease In an attempt to organize the wide range of responses to t h i s q u e s t i o n the data were c a t e g o r i z e d as experience of breast d i s e a s e i n v o l v i n g : the respondent; a c l o s e f r i e n d ; the f a m i l y ; or anyone they knew. If breast d i s e a s e had been experienced i n any of these c a t e g o r i e s i t was then f u r t h e r c a t e g o r i z e d as i n v o l v i n g cancer, benign d i s e a s e or cancer and benign d i s e a s e . In a d d i t i o n , the outcome of the experiences with breast d i s e a s e were t a b u l a t e d . The outcome of those who had had p e r s o n a l experience with breast d i s e a s e was r a t e d as s u c c e s s f u l treatment, unknown outcome ( i n s u f f i c i e n t time lapse to assess) and c o n t i n u i n g treatment or symptoms. Some people could not be r a t e d due to a lack of i n f o r m a t i o n . In terms of breast d i s e a s e i n v o l v i n g others a v a r i e t y of outcomes was p o s s i b l e and c a t e g o r i e s had to be expanded to i n c l u d e death as an outcome. Again there were those f o r whom i n s u f f i c i e n t data e x i s t e d f o r r a t i n g . Table 2 p r o v i d e s frequency data f o r the type of experience with breast d i s e a s e . Although a l a r g e percentage of the respondents had experience with breast d i s e a s e the outcome of those experiences covered the whole range of p o s s i b i l i t i e s and no obvious trends were seen i n the data. The small numbers i n each p o s s i b l e category prevented s t a t i s t i c a l a n a l y s i s . 1 27 Table 2. Experience with Breast Disease (n=66) Source of Experience Type of Experience (percentages) None Cancer Benign Cancer and Benign No Data T o t a l P e rsonal 82 1 1 5 0 1 1 00 Family 68 18 9 3 1 1 00 Close f r i e n d 71 18 9 1 0 100 Anyone you know 56 30 6 4 3 100 P e r c e p t i o n of BSE Two q u e s t i o n s were r e l a t e d to p e r c e p t i o n of BSE. One d e a l t with the p e r c e i v e d i n f l u e n c e of BSE on the outcome of breast disease and the other with p e r c e p t i o n s about breast lumps and t h e i r r e l a t i o n s h i p to cancer. The second q u e s t i o n e x p l o r e d e x p e c t a t i o n s about what f i n d i n g b r e a s t lumps mean. In t h i s r e s e a r c h p r o j e c t women were asked to i n d i c a t e the frequency with which breast lumps are caused by cancer. Table 3 shows the frequency data. When asked about the i n f l u e n c e of BSE on the outcome of breast d i s e a s e most respondents f e l t that BSE does indeed improve the outcome. The m a j o r i t y of respondents were d e f i n i t e l y p o s i t i v e in t h e i r support of the b e n e f i t of BSE. Ei g h t y percent f e l t BSE "almost always or always" g r e a t l y improves the outcome of breast d i s e a s e . 1 28 Table 3. Perceived Relationship Between Breast Lumps and Cancer (n=66) Cancer as a cause of breast lumps % Never 3 Hardly ever 6 Occasionally 64 Frequently 26 Almost always 1 Always 0 Total 1 00 Perceptions of Personal Control In any issue dealing with health, a general expectation about personal control over your health e x i s t s . This general expectation about health was measured using the Health Locus of Control Scale. Health Locus of Control. HLC data were missing for three individuals. None these women answered question number f i v e . This was the question which caused d i f f i c u l t i e s for some of the p i l o t test subjects. They objected to the wording of the question. The computed HLC scores ranged from 14 to 52. The median score, the one used to determine i n t e r n a l i t y or externality, was 31. This resulted in 30 individuals with an internal HLC and 28 individuals with an external HLC. 1 29 I t was f e l t that the HLC score would r e l a t e to the general f e e l i n g of r e s p o n s i b i l i t y f o r your own h e a l t h . T h i s was not t r u e , however, s i n c e 49 percent of those with an i n t e r n a l HLC and 51 percent of those with an e x t e r n a l HLC agreed to some extent that they were p e r s o n a l l y r e s p o n s i b l e f o r m a i n t a i n i n g t h e i r own h e a l t h . Confidence i n BSE a b i l i t y . A more s p e c i f i c measurement of e x p e c t a t i o n s concerning BSE was attempted with the q u e s t i o n about confidence in your a b i l i t y to d e t e c t breast d i s e a s e . Table 4 shows the frequency data f o r t h i s q u e s t i o n . Table 4. Confidence in Personal A b i l i t y To Detect Breast Disease (n=66) Degree of agreement with statement of confidence i n a b i l i t y % S t r o n g l y d i s a g r e e 9 Moderately d i s a g r e e 1 1 S l i g h t l y d i s a g r e e 4 S l i g h t l y agree 1 5 Moderately agree 47 S t r o n g l y agree 1 4 T o t a l 100 1 30 Experience i n the Health Care F i e l d The l a s t aspect of expectancy that was examined was experience i n the h e a l t h care f i e l d . The re s e a r c h group c o n t a i n e d 27 women with p r e v i o u s experience i n the h e a l t h care f i e l d : 33 nurses; 1 p h y s i o - t h e r a p i s t ; and 5 other women who had some s o r t of h e a l t h care e x p e r i e n c e . That meant that 41 percent had a non-health background and 59 percent had a h e a l t h background. T h i s c a t e g o r i z a t i o n i n t o h e a l t h and non-health was used to c r o s s t a b u l a t e t h i s data with other v a r i a b l e s . Women with a h e a l t h background were not any more l i k e l y to f e e l that BSE w i l l improve the outcome of breast d i s e a s e . A l l of those with a h e a l t h background f e l t that BSE would improve the outcome of breast d i s e a s e e i t h e r " f r e q u e n t l y , almost always or always" but t h i s was a l s o true f o r 85 percent of the non-health group. Although a g r e a t e r number of those with a h e a l t h versus a non-h e a l t h background chose h e a l t h as the number one p r i o r i t y i n t h e i r r a t i n g of the value of h e a l t h (32 percent of h e a l t h versus 18 percent of non-health respondents), 21 percent of those with a h e a l t h background d i d not chose h e a l t h at a l l . The l a r g e s t s i n g l e group of those with a h e a l t h background chose h e a l t h as a number one p r i o r i t y and the l a r g e s t s i n g l e group of those with a non-health background d i d not ra t e h e a l t h i n t h e i r top f i v e v a l u e s . However, when the the groups which chose h e a l t h as the number one or number two p r i o r i t y were combined, 50 percent of the h e a l t h group and 47 percent of the non-health group f e l l i n t o t h i s combined category. H e a l t h was a high p r i o r i t y f o r a l a r g e percentage of a l l the women i n t h i s r e s e a r c h group. When 131 experience i n the h e a l t h care f i e l d was c r o s s t a b u l a t e d with the e f f e c t of BSE on fear of breast d i s e a s e 89 percent of the non-h e a l t h group and 87 percent of the h e a l t h group f e l t BSE i n c r e a s e d t h e i r f ear only " o c c a s i o n a l l y , h a r d l y ever or never." T h i s r e l a t i o n s h i p was not s t a t i s t i c a l l y s i g n i f i c a n t . Valence Data were c o l l e c t e d on e i g h t aspects of v a l e n c e . Data f o r each of these aspects w i l l be given and when c r o s s t a b u l a t i o n between them and other independent v a r i a b l e s was c a r r i e d out, those r e s u l t s w i l l a l s o be g i v e n . Value of Health Respondents were asked to chose t h e i r top f i v e p r i o r i t i e s out of a l i s t of 19 v a l u e s . H e a l t h , optimal p h y s i c a l and mental f u n c t i o n i n g , was one of the c h o i c e s . Table 5 shows the frequency with which h e a l t h was chosen as a p r i o r i t y . There were no s i g n i f i c a n t s t a t i s t i c a l r e l a t i o n s h i p s between p r i o r i t y r a t i n g s of h e a l t h and experience i n the h e a l t h care f i e l d or value of BSE. Value of BSE The wording of the q u e s t i o n s concerning the value of BSE was changed s e v e r a l times d u r i n g p i l o t t e s t i n g . The f i n a l v e r s i o n asked respondents to i n d i c a t e the degree of t h e i r agreement or disagreement with the f o l l o w i n g statement about BSE: The most v a l u a b l e p r e v e n t i v e h e a l t h p r a c t i c e f o r women i s br e a s t s e l f - e x a m i n a t i o n . The m a j o r i t y of the sample supported 1 32 Table 5. P r i o r i t y Ratings For the Value of Hea l t h (n=65) Hea l t h P r i o r i t y Rating % #1 P r i o r i t y 26 #2 P r i o r i t y 23 #3 P r i o r i t y 1 4 In top f i v e 1 1 Not chosen 26 T o t a l 100 the value of BSE and 73 percent agreed to some extent that BSE was the most v a l u a b l e h e a l t h p r a c t i c e f o r women. BSE and Pe r c e p t i o n of Personal Needs One aspect of p e r c e p t i o n of pers o n a l h e a l t h needs i s the general f e e l i n g of r e s p o n s i b i l i t y for one's own h e a l t h . Respondents were asked to agree or di s a g r e e with the f o l l o w i n g statement: I am p e r s o n a l l y r e s p o n s i b l e f o r m a i n t a i n i n g my own h e a l t h . Responses were h e a v i l y weighted on the p o s i t i v e end of the s c a l e and 89 percent of the respondents moderately or s t r o n g l y agreed. Only one respondent s t r o n g l y d i s a g r e e d . She s t i l l c a r r i e d out BSE monthly and had only a completeness dis c r e p a n c y i n her BSE p r a c t i c e . Two of the three women who had no BSE p r a c t i c e d i s c r e p a n c i e s were r a t e d as having an i n t e r n a l HLC and they a l l s t r o n g l y supported the statement about pe r s o n a l r e s p o n s i b i l i t y . I t was thought that f e l t needs i n terms of BSE would be 133 measured to some extent by a s k i n g about the degree of p e r s o n a l s a t i s f a c t i o n with c u r r e n t BSE h a b i t s . The frequency data are given i n Table 6. Table 6. L e v e l of Agreement With S a t i s f a c t i o n With BSE H a b i t s Statement (n=66) L e v e l of Agreement % S t r o n g l y d i s a g r e e 1 5 Moderately d i s a g r e e 21 S l i g h t l y d i s a g r e e 1 1 S l i g h t l y agree 1 1 Moderately agree 24 S t r o n g l y agree 1 8 T o t a l 100 Current L i f e I n f l u e n c e s General aspects of l i f e on which data were c o l l e c t e d f o r t h i s sample i n c l u d e d age, c u r r e n t student s t a t u s and c u r r e n t o c c u p a t i o n . These r e s e a r c h p o p u l a t i o n c h a r a c t e r i s t i c s are given with the sample d e s c r i p t i o n at the beginning of t h i s c h a pter. P e r c e i v e d S u s c e p t i b i l i t y to Breast Disease Reasearch s u b j e c t s were asked about t h e i r p e r c e i v e d s u s c e p t i b i l i t y to breast d i s e a s e i n two ways. They were asked to r a t e t h e i r s u s c e p t i b i l i t y to b r e a s t d i s e a s e using a s c a l e that ranged from very high to very low. They were a l s o asked to 1 34 r a t e the degree of i n f l u e n c e f e e l i n g s of pe r s o n a l s u s c e p t i b i l i t y had over t h e i r BSE p r a c t i c e . The sample spread over the e n t i r e range of breast d i s e a s e s u s c e p t i b i l i t y p e r c e p t i o n r a t i n g s . Twenty-one percent f e l t they had a "very low" r a t i n g and 5 percent f e l t t h e i r s u s c e p t i b i l i t y was "very h i g h . " The d i s p e r s i o n f o r breast d i s e a s e s u s c e p t i b i l i t y p e r c e p t i o n s f o l l o w s . Table 7. Per c e i v e d S u s c e p t i b i l i t y To Breast Disease (n=65) S u s c e p t i b i l i t y Ra t i n g % Low or very low 45 Average 35 High or very high 20 T o t a l 1 00 One woman r a t e d h e r s e l f high i n s u s c e p t i b i l i t y but d i d not p r a c t i c e BSE and s a i d she would not do anything i f she d i s c o v e r e d something on examination. Her mother had d i e d of bone metasteses a f t e r b r e a s t cancer treatment. When p e r c e i v e d s u s c e p t i b i l i t y to breast d i s e a s e was c r o s s t a b u l a t e d with age and the i n f l u e n c e of f e e l i n g s of pe r s o n a l s u s c e p t i b i l i t y , r e s u l t s were not s i g n i f i c a n t . 1 35 Cues to BSE P r a c t i c e Another i n f l u e n c e on an i n d i v i d u a l ' s p e r c e p t i o n of needs i s the presence of cues which a c t as reminders to a c t i o n . There was some misunderstanding about the q u e s t i o n which gathered t h i s data. I t suggested that sometimes p a r t i c u l a r t h i n g s helped to remind women to c a r r y out BSE and asked respondents i f t h i s was true f o r them. If i t was, they were asked to complete the statement: I remember to examine my br e a s t s when . Some women d e s c r i b e d what c o u l d be termed cues i n t h e i r answers to other q u e s t i o n s r a t h e r than i n response to t h i s one. T h i r t y - n i n e women i n d i c a t e d cues d i d remind them to examine t h e i r b r e a s t s . Some of the reminders mentioned were: -menstral c y c l e (31 percent) - a r t i c l e s , d i s p l a y s or TV shows mentioning BSE (23 percent) - h e a r i n g of breast lumps or cancer i n ot h e r s (13 percent) -sore under arms or b r e a s t s (10 percent) - r e l a x i n g i n the tub or shower (8 percent) - s t a r t i n g a new packet of b i r t h c o n t r o l p i l l s (8 percent) -a v i s i t to the doctor (5 percent) - s e e i n g myself nude (3 percent) - p e r s o n a l breast d i s e a s e (3 percent) I n f l u e n c e s on I n i t i a t i n g or Changing BSE Habi t s C l o s e l y r e l a t e d to cues f o r BSE i s the more general t o p i c of i n f l u e n c e s on BSE ha b i t change. T h i s meant to cover those t h i n g s which may have been an i n f l u e n c e to i n i t i a t e BSE or to change BSE h a b i t s r a t h e r than those which a ct as ongoing 1 36 reminders. A v a r i e t y of responses were given as i n f l u e n c e s f o r i n i t i a t i n g BSE (55 responses): -nurses t r a i n i n g (33 percent) -doctor's a d v i c e (22 percent) -development of f i b r o c y s t i c b reast d i s e a s e (9 percent) -a magazine a r t i c l e (9 percent) - f a m i l y experience with b r e a s t d i s e a s e (7 percent) - f r i e n d s experience with breast d i s e a s e (5 percent) -recommendation by a nurse (4 percent) -concern i n v o l v i n g o r a l c o n t r a c e p t i v e s (2 percent) - p o s i t i v e pap smear (2 percent) - f e a r of breast cancer (2 percent) -reminders from husband to p r a c t i c e BSE (2 percent) - b i r t h of f i r s t c h i l d (2 percent) -BSE t r a i n i n g i n a p o s t - n a t a l c l a s s (2 percent) The f o l l o w i n g responses were given as reasons f o r changing BSE h a b i t s (13 r e s p o n s e s ) : - i n i t i a l i n c r e a s e i n BSE a f t e r breast s u r g e r y / f i r s t l e a r n i n g the procedure/ f i r s t f i n d i n g a lump/ h e a r i n g other people t a l k about i t , but l e s s c o n s i s t e n c y as time passed (77 percent) - i n c r e a s e d c o n s i s t e n c y a f t e r worrying with s e v e r a l f r i e n d s who had breast b i o p s i e s (8 percent), -temporary decrease in BSE h a b i t s a f t e r f i n d i n g a breast lump and being so f r e q u e n t l y examined as a r e s u l t (8 percent) 1 37 - i n c r e a s e d c o n s i s t e n c y a f t e r h earing about an aunt's bre a s t cancer (8 percent) The i n f l u e n c e s most f r e q u e n t l y mentioned as a stimulus f o r more frequent examination was f i n d i n g a new lump. U n f o r t u n a t e l y the l a r g e s t group of women re p o r t e d only an i n i t i a l i n c r e a s e i n h a b i t s a f t e r a p a r t i c u l a r i n c i d e n t and a f t e r time passed and i n i t i a l concern d i e d down, h a b i t s decreased. A t t i t u d e s Toward the Outcome of Breast Disease A t t i t u d e s toward BSE can be i n f l u e n c e d by the a f f e c t i v e r e a c t i o n to breast d i s e a s e . P e r c e p t i o n s about breast surgery and the r e l a t i o n s h i p between BSE and fear of breast d i s e a s e are two aspects of t h i s a f f e c t i v e a t t i t u d e . Research s u b j e c t s were asked to i n d i c a t e the frequency with which they f e l t BSE in c r e a s e d t h e i r f e ar of breast d i s e a s e and the frequency with which they f e l t breast changes found d u r i n g BSE l e a d to d i s f i g u r i n g surgery. A key word i s " d i s f i g u r i n g . " I t was meant to tap the strong f e e l i n g s a s s o c i a t e d with r a d i c a l mastectomies. Of course, the m a j o r i t y of breast changes found d u r i n g BSE do not r e q u i r e such d r a s t i c treatment. The purpose of the q u e s t i o n was to determine the degree to which such an outcome or the fe a r of i t i n f l u e n c e d behaviour. The g r e a t e s t percentage of the sample, 68 percent, f e l t that d i s f i g u r i n g surgery was only " o c c a s i o n a l l y " the outcome of change found d u r i n g BSE. The next l a r g e s t group, 17 percent, f e l t i t "hardly ever" o c c u r r e d . Only one person f e l t that " d i s f i g u r i n g " surgery was an outcome "almost always" and two women f e l t that i t "never" r e s u l t e d . 1 38 Another q u e s t i o n concerned with f e e l i n g s of fear i n r e l a t i o n to breast d i s e a s e was the one which asked how f r e q u e n t l y breast s e l f - e x a m i n a t i o n i n c r e a s e d t h e i r fear of breast d i s e a s e . The m a j o r i t y of the women in the sample, 88 percent, f e l t BSE i n c r e a s e d t h e i r f e ar of breast d i s e a s e only " o c c a s i o n a l l y , h a r d l y ever or never." A l a r g e group, 47 p e r c e n t , f e l t that t h i s "never" occ u r r e d . The degree to which BSE i n c r e a s e d fear of breast d i s e a s e was not r e l a t e d to BSE p r a c t i c e or experience in the h e a l t h care f i e l d . A f i n a l measure of a t t i t u d e toward BSE i n v o l v e d the degree to which respondents found BSE to be an uncomfortable exp e r i e n c e . The m a j o r i t y , 62 percent, f e l t that c a r r y i n g out BSE was not an uncomfortable experience. While t h i s l e f t 38 percent of the group who f e l t some degree of d i s c o m f o r t was a s s o c i a t e d with BSE, the low number in each r a t i n g made comparison with other v a r i a b l e s d i f f i c u l t . No s i g n i f i c a n t r e l a t i o n s h i p was found with experience i n the h e a l t h care f i e l d , the degree to which BSE i n c r e a s e d f e a r of breast d i s e a s e , age, c o n f i d e n c e with present BSE knowledge, p e r c e i v e d s u s c e p t i b i l i t y to b reast d i s e a s e , p e r c e i v e d degree that breast lumps are caused by cancer, experience with breast d i s e a s e , or outcome of breast d i s e a s e e x p e r i e n c e s . B a r r i e r s to BSE Data were c o l l e c t e d on f i v e areas which may be a c t i n g as b a r r i e r s to BSE p r a c t i c e . Table 8 p r o v i d e s frequency data f o r these v a r i a b l e s . 1 39 Table 8. P e r c e i v e d E f f e c t of B a r r i e r s on BSE Frequency of P r a c t i c e Barr i e r Frequency of i n f l u e n c e (percentage) 1 . 2. 3. 4. 5. 6. T o t a l Simply f o r g e t t i n g (66) 1 4 8 1 7 1 2 21 29 1 00 Lack of time (65) 46 25 19 3 6 1 100 Lack of energy (64) 45 28 1 1 9 5 2 100 Not knowing how to examine your b r e a s t s (65) 68 14 9 1 1 6 1 00 Fear of what you w i l l f i n d (66) 58 1 7 1 4 3 3 6 100 Frequency Ra t i n g s : 1= never i n f l u e n c e s 2= h a r d l y ever i n f l u e n c e s 3= o c c a s i o n a l l y i n f l u e n c e s 4= f r e q u e n t l y i n f l u e n c e s 5= almost always i n f l u e n c e s 6= always i n f l u e n c e s Note: The number of s u b j e c t s f o r each b a r r i e r category i s given i n parentheses. Simply F o r g e t t i n g Simply f o r g e t t i n g was p e r c e i v e d to be a f a c t o r by most of the respondents. I t was i n d i c a t e d as an i n f l u e n c e at l e a s t " o c c a s i o n a l l y " and f r e q u e n t l y more o f t e n by 79 percent of the sample. When comparing f o r g e t t i n g as an i n f l u e n c e on p r a c t i c e with presence of cues to p r a c t i c e , there was no r e l a t i o n s h i p . Of 140 those who mentioned cues, 46 percent " o c c a s i o n a l l y , h a r d l y ever or never" simply f o r g o t and 54 percent " f r e q u e n t l y , almost always or always" simply f o r g o t . F u l l - t i m e students were no more l i k e l y to simply f o r g e t BSE than part-time students. Nor were those of a non-health background any more l i k e l y to simply f o r g e t than those with a h e a l t h background. Lack of Time E i g h t y - n i n e percent of the respondents f e l t that time was not a b i g i n f l u e n c e on t h e i r BSE p r a c t i c e . I t was thought that i n c r e a s i n g job or school r e s p o n s i b i l i t i e s might i n c r e a s e the i n f l u e n c e of t h i s f a c t o r but t h i s was not i n d i c a t e d by the data. F u l l - t i m e students d i d not f i n d lack of time any bigger an i n f l u e n c e than those who were p a r t - t i m e . The " o c c a s i o n a l to never" c a t e g o r i e s were chosen by 93 percent of f u l l - t i m e students and 90 percent of pa r t - t i m e students. Lack of energy Lack of energy was not seen as a frequent i n f l u e n c e on BSE p r a c t i c e r a t e . The m a j o r i t y , 73 percent, f e l t i t "hardly ever or never" i n f l u e n c e d them. Lack of energy was not r e l a t e d to BSE p r a c t i c e , present student s t a t u s or c u r r e n t o c c u p a t i o n . Not Knowing How to Examine Your Breasts Not knowing how to c a r r y out BSE was a l s o not p e r c e i v e d as an i n f l u e n c e on t h e i r BSE h a b i t s by the m a j o r i t y of the sample. It was seen as "never" i n f l u e n c i n g 68 percent and another 23 percent f e l t i t "hardly ever" or only " o c c a s i o n a l l y " i n f l u e n c e d 141 them. T h i s makes a t o t a l of 91 percent who r e j e c t e d t h i s as an important f a c t o r i n t h e i r BSE h a b i t s . Fear of What You W i l l F i n d Only 12 percent of the sample f e l t t h i s f a c t o r i n f l u e n c e d them more than " o c c a s i o n a l l y . " No r e l a t i o n s h i p was apparent with the degree to which BSE was uncomfortable or with past experience i n the h e a l t h care f i e l d . Other i n f l u e n c e s Respondents were asked about i n f l u e n c e s on t h e i r BSE p r a c t i c e other than those which had been mentioned. Some d e s c r i b e d cues to a c t i o n which have a l r e a d y been d i s c u s s e d . The f o l l o w i n g are the other i n f l u e n c e s s u b j e c t s d e s c r i b e d : - f e e l i n g " I t can't happen to me" (3 women) - r e a l i z i n g I would not take any a c t i o n even i f I d i d f i n d something (1 woman) -l a c k of concern about bre a s t d i s e a s e because I never get s i c k (1 woman) -not having e s t a b l i s h e d the h a b i t (1 woman) -not being convinced that d i s c o v e r i n g a lump e a r l y w i l l have more p o s i t i v e consequences then d i s c o v e r i n g i t l a t e (1 woman) -not knowing what an abnormality would f e e l l i k e (1 woman) -negative a t t i t u d e towards my female body a f t e r 3 or 4 days of menstral cramps makes me fo r g e t (1 woman) - f e e l i n g s i l l y (1 woman) 1 42 - f e a r i n g I would not de t e c t changes soon enough (1 woman) -being aware that e a r l y d e t e c t i o n i s important (1 woman) - i n c r e a s i n g r a t e of cancer i n Canadian women (1 woman) Only the l a s t three i n f l u e n c e s mentioned i n c r e a s e d p r a c t i c e . The others a l l decreased p r a c t i c e . P a r t i c i p a t i o n i n BSE Data on BSE p r a c t i c e s were c o l l e c t e d by two q u e s t i o n s . The f i r s t , a c l o s e d q u e s t i o n with o p t i o n s from which a choice was to be made, requested i n f o r m a t i o n about r a t e of p r a c t i c e . Data on how BSE examinations were c a r r i e d out were c o l l e c t e d with a combination of open-ended q u e s t i o n s . F i r s t respondents d e s c r i b e d what they f e l t the recommended method of BSE was and then they i n d i c a t e d whether t h i s i s what they do. Using the data from the knowledge ques t i o n (BSE qu e s t i o n #5), the response from the pers o n a l BSE p r a c t i c e q u e s t i o n (BSE qu e s t i o n #7) and the response from the ra t e of p r a c t i c e q u e s t i o n (BSE qu e s t i o n #6), each subject was given a BSE p r a c t i c e r a t i n g . In t o t a l , a BSE p r a c t i c e r a t i n g was a v a i l a b l e f o r 92 percent of the resea r c h s u b j e c t s . Tables 9 and 10 provide the data that were c o l l e c t e d f o r BSE p r a c t i c e . Table 9 i n d i c a t e s that the mode was once or more every three months. T h i s o p t i o n r e c e i v e d 17 percent more responses 1 43 Table 9. Frequency of BSE Practice (Percentages) (n=65) Frequency of Practice Frequency Cumulat ive Frequency BSE monthly 25 25 BSE once or more every three months 20 66 BSE once per year 20 86 BSE less than once per year 9 95 No BSE 5 1 00 Table 10 BSE Practice Rating (percentages) (n=61) BSE Practice Rating Frequency No discrepancies 5 Rate discrepancy only 1 5 Completeness discrepancy only 20 Rate and completeness discrepancy 61 than the closest category—monthly BSE—and considerably more than the other three categories. When the various categories of practice were combined, 95 percent of the research group indicated that they practiced BSE oh either a regular or irregular basis. Only 3 respondents indicated that they never ca r r i e d out BSE. 1 44 Of those who p r a c t i c e d BSE, only three were rated as having no d i s c r e p a n c i e s a c c o r d i n g to t h e i r r e p o r t e d behaviour. By f a r the l a r g e s t group, 61 percent, i n d i c a t e d that they had both r a t e and completeness d i s c r e p a n c i e s i n t h e i r BSE p r a c t i c e s . Of those who had only one kind of d i s c r e p a n c y , 57 percent had a completeness d i s c r e p a n c y and 43 percent had a rate d i s c r e p a n c y . Only 15 respondents i n d i c a t e d that they m o d i f i e d t h e i r BSE from what they had d e s c r i b e d as the recommended method. Three s u b j e c t s noted that while they r e a l i z e d that they "should" do a v i s u a l i n s p e c t i o n , they d i d not. Two s a i d they d i d not always c a r r y out BSE j u s t a f t e r menstration but one of these women s t i l l d i d BSE more than once a month. Two admitted that they d i d a quick, s h o r t - h a n d . v e r s i o n . Three s a i d they d i d t h e i r BSE in the shower or bathtub. Two admitted they were not very s y s t e m a t i c . One subject had one sore breast and checked i t but only gave her other breast a c u r s o r y check. One person s t a t e d that though she c a r r i e d out a complete BSE c o n s i s t e n t l y , she d i d not n e c e s s a r i l y c a r r y out a l l the steps at one time. She d i d them at her convenience. One woman admitted that she d i d BSE q u i c k l y hoping not to f i n d a n y t h i n g . Since she had f i b r o c y s t i c b reast d i s e a s e , however, she always found something. She f e l t t h i s made i t a very negative experience and while she was aware of the r i s k she was running in not doing a thorough BSE she concluded that "I hate the whole b u s i n e s s ! " D e t a i l s of d i s c r e p a n c i e s i n BSE p r a c t i c e are found i n Table 11. There does not seem to be any s i g n i f i c a n t d i f f e r e n c e in the 145 T a b l e 1 1 . C o m p l e t e n e s s D i s c r e p a n c i e s i n E S E P r a c t i c e T y p e o f D i s c r e p a n c y * * O n l y C o m p l e t e n e s s D i s c r e p a n c i e s C o m p l e t e n e s s a n d R a t e D i s c r e p a n c i e s F r e q u e n c y n = 1 2 F r e q u e n c y n-=37 T l ine 4 (33) 19 5 1 S y s t e m a t 1 c 3 (25) 14 38 V i s u a l 7 (58) 23 62 A x i l l a 7 (58) 2 1 57 # o f M i s s l n q C o m p o n e n t s O n l y C o m p l e t e n e s s D 1 s c r e p a n c i e s C o m p l e t e n e s s a n d R a t e D i s c r e p a n c i e s F r e q u e n c y X* n= 12 F r e q u e n c y % n=37 f o u r 0 ( 0 ) 5 13 t h r e e 1 (8) 6 16 t w o 4 (33) 13 35 o n e 6 (50) 13 35 m i s s i n g d a t a 1 (8) 0 O T o t a l 1 0 0 100 • B r a c k e t s h a v e b e e n u s e d b e c a u s e o f t h e l o w n u m b e r o f s u b j e c t s a n d i t s r e s u l t i n g e f f e c t o n p e r c e n t a g e s . * * N o t e t h a t t h e c o l u m n s d o n o t t o t a l t o 1 0 0 p e r c e n t . T h i s I s b e c a u s e m a n y s u b j e c t s h a d m o r e t h a n o n e t y p e o f d i s c r e p a n c y a n d t h e r e f o r e a p p e a r i n m o r e t h a n o n e c a t e g o r y . types of d i s c r e p a n c i e s ind i ca ted by those who had only a completeness d iscrepancy as compared to those who had both a rate and completeness d isc repancy . V i s u a l and a x i l l a d i sc repanc ies were highest for both groups. Note, however, that of those who d i d not have a rate discrepancy ( i e . , completeness d i sc repanc ies o n l y ) , none were missing a l l four completeness components. Of those who had both a rate and completeness d iscrepancy , 13 percent f a i l e d to mention any of the four 146 completeness components. Those who were carrying out BSE on a monthly basis reported doing at least one component of BSE c o r r e c t l y . In addition, of t h i s group, 50 percent were missing only one BSE component. Another t h i r d were missing only two components. While only one of the 8 women with only a completeness discrepancy was missing three components, 30 percent of those with both a rate and completeness discrepancy were missing either three or four components of BSE. Limitations of the Data Data analysis was severely hampered by the small sample size and the lack of s u f f i c i e n t numbers in the various categories into which data were divided. Data tended to group around the mean and did not allow for examination of the t o t a l range of responses that such data might cover. As a result more advanced multivariate s t a t i s t i c a l analysis could not be done. The discussion that follows should be examined with these li m i t a t i o n s in mind. Discussion of Results Results w i l l be discussed in the groupings indicated by the BSE Paradigm. The independent variables--expectancy variables, valence variables and barrier v a r i a b l e s - - w i l l be discussed f i r s t and then results for the dependent variable—BSE p r a c t i c e — w i l l be examined. 1 47 D i s c u s s i o n of R e s u l t s f o r Expectancy V a r i a b l e s When the frequency with which each of the BSE knowledge components was mis s i n g i s examined, the systemic component i s excluded by a markedly lower number of s u b j e c t s than any of the three other components. I t may be that a systemic approach makes good common sense and i s , t h e r e f o r e , e a s i l y remembered, While l o o k i n g c l o s e l y at your b r e a s t s makes sense as w e l l , l o o k i n g f o r s p e c i f i c d e t a i l s l i k e n i p p l e d i s c h a r g e , puckering of the s k i n or changes i n s i z e or shape r e q u i r e s more than common sense. I t r e q u i r e s some f u r t h e r knowledge about what one should look f o r . Data on the source of BSE in f o r m a t i o n suggest that in terms of p e r c e i v e d u s e f u l n e s s , pamphlets, d o c t o r s , magazines, nurses t r a i n i n g and nurses seem to merit most a t t e n t i o n . Nurses teaching other nurses were h i g h l y r a t e d . I t i s assumed that in most nurses t r a i n i n g courses nurses were the i n s t r u c t o r s . Nurses only p r o v i d e d i n f o r m a t i o n to l e s s than h a l f the s u b j e c t s , however, even though a l a r g e percentage of s u b j e c t s were nurses. Data on BSE p r e s e n t a t i o n methods suggest that an educator p l a n n i n g a BSE t e a c h i n g s e s s i o n would f i n d the f o l l o w i n g methods most l i k e l y to appeal to the g r e a t e s t number of respondents: p i c t u r e s or sketches, f i l m s , demonstration on the l e a r n e r , guided p r a c t i c e with the l e a r n e r examining h e r s e l f and guided p r a c t i c e on another person. A l a r g e percentage of t h i s sample o b v i o u s l y f e l t that p i c t u r e s or sketches were of more use than w r i t t e n or spoken i n f o r m a t i o n and demonstration on themselves was found more u s e f u l by an even higher percentage. These 1 48 p r e f e r e n c e s may be true only f o r women with a high l e v e l of education, however, s i n c e the sample from which the data were c o l l e c t e d was made up of u n i v e r s i t y students. In r e t r o s p e c t , data on BSE follow-up l e a r n i n g s e s s i o n s provide only part of the i n f o r m a t i o n needed. In t h e i r d e s c r i p t i o n s of follow-up s e s s i o n s most respondents f a i l e d to provide many of the d e t a i l s one would want. Some of the data one would l i k e i s : the number of f o l l o w - u p s e s s i o n s ; the frequency with which follow-up s e s s i o n s occur; and the time lapse s i n c e the l a s t follow-up s e s s i o n . A number of respondents i n d i c a t e d that they had had follow-up s e s s i o n s but they f a i l e d to d e s c r i b e them. Part of the problem seems to have been the manner i n which the q u e s t i o n was asked. The data concerning the i n f l u e n c i n g f a c t o r s on BSE commencement support the c o n t e n t i o n that p h y s i c i a n s are an important source of BSE i n f o r m a t i o n . In a d d i t i o n , nurses t r a i n i n g may c r e a t e a teachable moment such as Cross (1980) d e s c r i b e d . Personal a n x i e t y about breast d i s e a s e f o l l o w i n g experiences with b r e a s t or r e l a t e d d i s e a s e i n oneself or one's loved ones a l s o appears to i n f l u e n c e behaviour to some e x t e n t . The occurrence of such experiences may a l s o act to i n c r e a s e s u s c e p t i b i l i t y to t e a c h i n g . The lack of s i g n i f i c a n t r e l a t i o n s h i p s between commencement data and p e r s o n a l knowledge and p r a c t i c e may suggest a f a i l u r e on the p a r t of the education process r a t h e r than a l a c k of r e l a t i o n s h i p between the i n f l u e n c e of these s i t u a t i o n s and end behaviour. People are i n f l u e n c e d by them but the degree to which t h e i r behaviour changes because of 1 49 them may be r e l a t e d to the e x i s t e n c e and s t r e n g t h of other f a c t o r s . The time span between these i n f l u e n c i n g experiences and the present may a l s o be a f a c t o r . In general these s u b j e c t s r e c e i v e d l i t t l e i n the way of r e g u l a r encouragement to c a r r y out BSE from t h e i r f a m i l y , f r i e n d s or p h y s i c i a n s . F a m i l i e s may not always be on hand to give reminders. S o c i e t a l taboos on d i s c u s s i n g such a personal t o p i c may i n f l u e n c e both f a m i l y and f r i e n d s and discourage them from g i v i n g BSE reminders. P h y s i c i a n s , on the other hand, have l i t t l e excuse fo r f a i l i n g to at l e a s t ask about p r e v e n t i v e h e a l t h h a b i t s such as BSE. 'The present data do not e x p l a i n the reason f o r the r e s u l t s . Because of i t s complexity and p o t e n t i a l f o r emotional upheaval, i t i s obvious that the data on p e r s o n a l experiences with breast d i s e a s e were f a r too complex for a s i n g l e q u e s t i o n . Given the shortcomings of the present data i t i s not s u r p r i s i n g that no s i g n i f i c a n t s t a t i s t i c a l c o r r e l a t i o n s were found with t h i s v a r i a b l e . T h i s area, which may provide important c l u e s to end behaviour,.was p o o r l y examined. A problem with data c o l l e c t i o n may e x p l a i n the lack of a r e l a t i o n s h i p between HLC and the g e n e r a l f e e l i n g of r e s p o n s i b i l i t y f o r your own h e a l t h . I t may be that the general h e a l t h r e s p o n s i b i l i t y statement was too s u p e r f i c i a l and that i t i s d i f f i c u l t to deny such r e s p o n s i b i l i t y at a conscious l e v e l . The HLC S c a l e may be t a p i n g a deeper consciousness where people deal more with c o n t r o l then p e r c e i v e d r e s p o n s i b i l i t y . On the s u r f a c e you can agree that you should not abuse your body but on 1 50 a deeper l e v e l you may f e e l that you can only do so much. Part of the s o c i a l i z a t i o n process occurs i n the work s e t t i n g . Previous and ongoing experiences with h e a l t h , our own and o t h e r s , h e l p to form our a t t i t u d e s toward h e a l t h , our h e a l t h knowledge base and our p e r c e p t i o n and i n t e r p r e t a t i o n of s i t u a t i o n s i n v o l v i n g h e a l t h i s s u e s . In t h i s group of h i g h l y educated u n i v e r s i t y women, h e a l t h was f r e q u e n t l y a high p r i o r i t y i n t h e i r l i v e s r e g a r d l e s s of t h e i r past experiences i n the h e a l t h f i e l d . D i s c u s s i o n of R e s u l t s f o r Valence V a r i a b l e s Values and a t t i t u d e s are d i f f i c u l t to measure with a simple q u e s t i o n and answer format. The statement about BSE which was used compares i t to other p r e v e n t i v e h e a l t h p r a c t i c e s and thus may be i n f l u e n c e d by strong f e e l i n g s about some other p r e v e n t i v e h e a l t h p r a c t i c e . In r e t r o s p e c t t h i s q u e s t i o n i s only a p a r t i a l examination of the value p l a c e d on BSE. A strong statement was d e s i r a b l e to separate the degrees of value placed on BSE. A simple statement about i t s b e n e f i t s would most l i k e l y r e c e i v e support from everyone and such data would.be of no v a l u e . A format such as that used f o r general value of h e a l t h when i t i s obvious that the q u e s t i o n n a i r e i s d e a l i n g with BSE would a l s o l i k e l y produce a high r a t i n g of BSE as respondents would be tempted to give the researcher what she i s p e r c e i v e d to want. A s t r o n g l y worded statement was expected to produce personal r a t i n g f o r BSE. T h i s d i d produce a wider range of responses i n the p i l o t study but the d i f f i c u l t y of measuring values i n terms of BSE was c e r t a i n l y not e n t i r e l y overcome. 151 The f a c t that more women with a h e a l t h background d i s a g r e e d to some extent with the statement that BSE i s the most v a l u a b l e p r e v e n t i v e h e a l t h p r a c t i c e f o r women may i n d i c a t e that a g r e a t e r knowledge of other p r e v e n t i v e h e a l t h measures i n f l u e n c e d t h e i r responses. I t does not n e c e s s a r i l y mean that they thought BSE had no va l u e . D i s c u s s i o n of R e s u l t s f o r B a r r i e r V a r i a b l e s Simply f o r g e t t i n g was the most f r e q u e n t l y i n d i c a t e d b a r r i e r v a r i a b l e . I t may be the r e s u l t of s e v e r a l f a c t o r s . I t might be due to as simple a t h i n g as c o n f l i c t i n g r e s p o n s i b i l i t i e s or i t may be due to such complex f a c t o r s as a conscious or unconscious d e s i r e not to c a r r y out BSE. The cause f o r simply f o r g e t t i n g was not explor e d . I t was a n t i c i p a t e d that most respondents would not have been able to e x p l a i n "why" they f o r g o t . I t i s reasonable to suspect that t h i s reason f o r not doing BSE r e g u l a r l y i s an easy way of e x p l a i n i n g one's behaviour. I t i s more s o c i a l l y a c c e p t a b l e to say "I f o r g o t " than to admit to f e a r , d i s c o m f o r t , embarrassment, apathy, or other more p e r s o n a l f a c t o r s . On the other hand, i t i s easy to simply f o r g e t an a c t i o n which should be done only once a month and p r e f e r a b l y a f t e r menses. I t i s much e a s i e r to remember t h i n g s that have to be done more f r e q u e n t l y or that have b u i l t - i n reminders to jog the memory. We remember to brush our t e e t h every day because i t i s a r e g u l a r d a i l y h a b i t and your mouth f e e l s so much cl e a n e r and f r e s h e r a f t e r w a r d s . Many of the cues mentioned by resear c h s u b j e c t s d i d not occur on a r e g u l a r b a s i s . Such t h i n g s as magazine a r t i c l e s on BSE, a t r i p to the doctor or breast d i s e a s e 1 52 i n your f a m i l y or f r i e n d s do not occur on a monthly b a s i s . Simply f o r g e t t i n g o b v i o u s l y i s p e r c e i v e d to be a frequent cause of BSE r a t e d i s c r e p a n c i e s . The cause or causes f o r t h i s are not c l e a r nor i s the remedy. Unless other m o t i v a t o r s are strong enough to overcome i t , simply f o r g e t t i n g may be a formidable b a r r i e r . There are no s p e c i f i c reminders and examining one's b r e a s t s does not make them f e e l b e t t e r . It may even i n c r e a s e a n x i e t y . The "other" i n f l u e n c e s d e s c r i b e d by the r e s e a r c h s u b j e c t s were mentioned by too few s u b j e c t s to warrant f u r t h e r s t a t i s t i c a l a n a l y s i s . However, knowing a l e a r n e r has some of these f e e l i n g s might h e l p the educator. Another aspect of t h i s data that should be remembered i s that i t was pr o v i d e d on a v o l u n t e e r b a s i s . Subjects p r o v i d e d that data which they wished to share. In a d d i t i o n , they c o u l d only p r o v i d e i n f o r m a t i o n that they had. They c o u l d not pro v i d e e x p l a n a t i o n s that they d i d not know nor i n s i g h t which they d i d not possess. Many of the i n f l u e n c e s e x p l o r e d may e x i s t to a gr e a t e r or l e s s e r degree than i s i n d i c a t e d by the data. D i s c u s s i o n of P a r t i c i p a t i o n i n BSE The r a t i n g of d i s c r e p a n c i e s was p a r t l y based on what respondents d e s c r i b e d as the recommended method of BSE. T h i s i n f o r m a t i o n was combined with t h e i r i n d i c a t i o n that they c a r r i e d i t out or mo d i f i e d i t . Data c o l l e c t i o n on BSE knowledge and BSE p r a c t i c e was, t h e r e f o r e , very c l o s e l y l i n k e d i n t h i s q u e s t i o n n a i r e . As a r e s u l t i t i s very d i f f i c u l t to e n t i r e l y 1 53 separate the two v a r i a b l e s . The qu e s t i o n s were ad j u s t e d d u r i n g the p i l o t study to make i t e a s i e r f o r respondents to respond with the l e a s t amount of e f f o r t and s u b t l e and perhaps important data seem to have been l o s t in the proc e s s . It i s obvious that s e v e r a l s u b j e c t s knew some aspects of the recommended BSE r o u t i n e even though they d i d not i n c l u d e i t in t h e i r BSE d e s c r i p t i o n . Some s u b j e c t s i n d i c a t e d that t h e i r menstral p e r i o d was a reminder to c a r r y out BSE (BSE qu e s t i o n #9). Obviously they knew that t h i s was the recommended time f o r BSE yet they f a i l e d to i n c l u d e the timing aspect in t h e i r d e s c r i p t i o n of the recommended BSE procedure. When such c l u e s to f u r t h e r knowledge appeared, the knowledge r a t i n g f o r these s u b j e c t s was changed. T h i s serves to i l l u s t r a t e that perhaps others knew of some aspects of BSE but f a i l e d to i n c l u d e them in t h e i r BSE d e s c r i p t i o n s . They may have taken them f o r granted, f e l t that they were too obvious to be d e t a i l e d or they may simply have t e m p o r a r i l y f o r g o t t e n them. Although f a u l t s i n the q u e s t i o n n a i r e d e f i n i t e l y hampered data a n a l y s i s the r a t e s of p r a c t i c e f o r these r e s e a r c h s u b j e c t s d i d correspond to some degree with p r e v i o u s l y r e p o r t e d r e s e a r c h . S t i l l m a n (1977) r e p o r t e d that only 23 percent of women p r a c t i c e BSE monthly. T h i s ra t e i s very c l o s e t o the 24 percent of those i n t h i s study who i n d i c a t e d monthly BSE. A very high percentage, 95 percent, p r a c t i c e d some form of BSE. I t i s d i f f i c u l t to compare t h i s f i g u r e with p r e v i o u s compliance re s e a r c h s i n c e the d e f i n i t i o n of compliance v a r i e s g r e a t l y . Although there may be r a t e or completeness d i s c r e p a n c i e s , does a 154 s i m i l a r l y high percentage of the g e n e r a l p u b l i c c a r r y out BSE i n some form? The l i t e r a t u r e u n i f o r m l y r e p o r t s low compliance. Perhaps the problem i s not that women f a i l to c a r r y out BSE but that the m a j o r i t y do not do i t c o r r e c t l y . The research group was not r e p r e s e n t a t i v e of the g e n e r a l .population i n at l e a s t one a s p e c t . E d u c a t i o n a l l e v e l was the only v a r i a b l e which was h e l d constant f o r t h i s p r o j e c t . A l l respondents were u n i v e r s i t y s t u d e n t s . D i f f e r e n t e d u c a t i o n a l l e v e l s may produce d i f f e r e n t r e s u l t s . In t h i s r e s e a r c h group those who c a r r i e d out BSE monthly ( i e . , no r a t e d i s c r e p a n c y ) , were g e n e r a l l y missing fewer completeness components than those who had both rate and completeness d i s c r e p a n c i e s . The data suggest that i f an i n d i v i d u a l does not c a r r y out BSE on a monthly b a s i s , she i s more l i k e l y to have more d i s c r e p a n c i e s i n her p r a c t i c e than someone who does. Is t h i s r e l a t e d to m o t i v a t i o n ? If you are motivated enough to c a r r y out BSE monthly are you more l i k e l y to be motivated to c a r r y i t out c o r r e c t l y than someone who i s not motivated to do a monthly BSE? Is t h i s r e l a t e d to the value a t t a c h e d to BSE? In the chapter which f o l l o w s an attempt i s made to e x p l a i n BSE using the r e l a t i o n s h i p s suggested by the BSE Paradigm. 155 CHAPTER VI ANALYSIS OF BSE The BSE P a r t i c i p a t i o n Paradigm was based on the l i t e r a t u r e review and was intended to e x p l a i n the i n f l u e n c e s on p a r t i c i p a t i o n i n the p r e v e n t i v e h e a l t h behaviour of BSE. BSE was c r o s s t a b u l a t e d with a l l of the independent v a r i a b l e s . Those v a r i a b l e s which were q u a s i - i n t e r v a l were t r e a t e d as i n t e r v a l data and a Pearson's Product Moment C o r r e l a t i o n C o e f f i c i e n t was c a l c u l a t e d . As has been mentioned, i t i s the s t a t i s t i c a l t e s t of c h o i c e where p o s s i b l e . I t i s the most s t a b l e b i v a r i a t e c o r r e l a t i o n technique with the s m a l l e s t standard e r r o r (Borg & G a l l , 1983, p. 587). For those v a r i a b l e s which were c l e a r l y nominal, a c h i - s q u a r e t e s t for independence was done. At t h i s time a word should be s a i d about the e f f e c t of sample s i z e on attempts to study r e l a t i o n s h i p s between v a r i a b l e s . One assumption of the Chi-square s t a t i s t i c to t e s t independence i s that the sample should be l a r g e enough so that every expected frequency i s at l e a s t ten when there i s one degree of freedom and at l e a s t f i v e when there i s more than one degree of freedom ( K i r k , 1978, p. 341). The lack of s u f f i c i e n t s u b j e c t s i n each category was a problem with every v a r i a b l e s t u d i e d . T h i s throws i n t o q u e s t i o n the r e l i a b i l i t y of the s t a t i s t i c s computed. The small sample s i z e makes f u r t h e r s t a t i s t i c a l study i m p o s s i b l e . In an attempt to i n c r e a s e the frequency f o r each category a s m a l l e r number of c a t g o r i e s f o r 1 56 each variable was frequently created. Pearson Product Moment Correlations C o e f f i c i e n t s are affected by many factors. The magnitude of relationships are underestimated when the relationship between variables i s nonlinear, when the range of either variable is truncated or when d i s t r i b u t i o n s are skewed and the magnitude of relationships are overestimated when the sample contains subgroups with means that d i f f e r for both variables or the sample is comprised of extreme groups (Kirk, 1978, p. 115). The results of the s t a t i s t i c a l analysis w i l l be presented and then discussed. S t a t i s t i c a l Analysis Nominal Data Chi-square s t a t i s t i c s were carr i e d out between BSE and the the following variables (the resulting chi-square and the degrees of freedom are given in parentheses): Expectancy Variables health locus of control (1.38, df=3) BSE information sources doctor (5.64, df=6) nurse (2.98, df=6) pamphlet (1.35, df=6) magazine (4.86, df=6) t e l e v i s i o n advertisement (4.34, df=6) radio advertisement (4.38, df=6) family member (2.28, df=6) 157 f r i e n d (13.24, df=6) work a s s o c i a t e (5.62, df=6) t o t a l number of i n f o r m a t i o n sources (9.65, df=9) BSE i n f o r m a t i o n p r e s e n t a t i o n sources spoken i n f o r m a t i o n (5.91, df=6) w r i t t e n i n f o r m a t i o n (15.23, df=6) p i c t u r e s or sketches (2.58, df=6) two-way d i s c u s s i o n with the respondent (10.50, df=6) demonstration on the respondent (7.21, df=6) demonstration with a mechanical model (2.66, df=6) demonstration with another person (5.62, df=6) demonstration with the teacher as model (9.80, df=6) guided p r a c t i c e with a mechanical model (3.62, df=6) guided p r a c t i c e with another person (10.30, df=6) guided p r a c t i c e with the respondent (15.02, df=6) t o t a l number of sources experienced (4.49, df=8) follow-up l e a r n i n g s e s s i o n s (1.56, df=3) commencement of BSE (1.04, df=3) pe r s o n a l experience with breast d i s e a s e (14.77, df=6) f a m i l y experience with breast d i s e a s e (4.34, df=6) c l o s e f r i e n d with experience with breast d i s e a s e (4.49, df=6) anyone known with experience with breast d i s e a s e (5.96, df=6) p e r s o n a l outcome of br e a s t d i s e a s e (4.65, df=9) outcome of breast d i s e a s e in others (17.39, df=l8) experience i n the h e a l t h care f i e l d (7.27, df=3) 1 58 Valence V a r i a b l e s cues to BSE (3.30, df=3) i n f l u e n c e s on changes of BSE h a b i t s (3.59, df = 3) c u r r e n t occupation (9.43, df=6) student s t a t u s i n school (0.90, df=3) age at l a s t b i r t h d a y (4.76, df=3) When the assumptions of the chi - s q u a r e s t a t i s t i c were a p p l i e d , none of the r e s u l t s were s t a t i s t i c a l l y s i g n i f i c a n t . Many of the c a t e g o r i e s formed by c r o s s t a b u l a t i o n had f r e q u e n c i e s of l e s s than f i v e . I n t e r v a l Data Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t s were c a l c u l a t e d between the BSE p r a c t i c e r a t i n g s ( c a l c u l a t e d a c c o r d i n g to the number of d i s c r e p a n c i e s in p r a c t i c e ) and frequency of BSE p r a c t i c e (BSE p r a c t i c e rate) and the f o l l o w i n g v a r i a b l e s ( an a s t e r i s k i n d i c a t e s a s i g n i f i c a n t Pearson's r ) : Expectancy V a r i a b l e s *BSE knowledge (r=0.264, n=60) C o n f i d e n c e with BSE knowledge (r=-0.236, n=61) C o n f i d e n c e with BSE a b i l i t y (r=-0.282, n=6l) *BSE improves outcome of breast d i s e a s e (r=-0.3l3, n=6l) *BSE reminders from your doctor (r=-0.209, n=60) BSE reminders from your f a m i l y (r=-0.057, n=6l) BSE reminders from your f r i e n d s (r=-0.164, n=6l) r e l a t i o n s h i p betweem breast lumps and cancer (r=0.143, n=61) 159 Valence V a r i a b l e s *value of h e a l t h (r=0.135, n = 60) *p e r c e i v e d s u s c e p t i b i l i t y to breast d i s e a s e (r=-0.286, n=60) * s a t i s f a c t i o n with BSE h a b i t s (r = -0.434, n = 61 ) *BSE as an uncomfortable experience (r=0.240, n=6l) *value of BSE (r=-0.285, n=61) BSE e f f e c t on fear of breast d i s e a s e (r=-0.l06, n=6l) pe r s o n a l r e s p o n s i b i l i t y f o r p e r s o n a l h e a l t h (r=-0.154, n=6l) BSE leads to d i s f i g u r i n g surgery (r=-0.043, n=60) B a r r i e r V a r i a b l e s * l a c k of BSE a b i l i t y (r 0.146, n=60) *simply f o r g e t t i n g (r=0.475, n=61) lack of time (r=0.008, n=60) lack of energy (r=0.l84, n=59) fear of what you w i l l f i n d (r=0.114, n=6l) f e e l i n g p e r s o n a l l y s u s c e p t i b l e (r=-0.097, n=61) Table 12 pr o v i d e s the s i g n i f i c a n t Pearson Product Moment c o r r e l a t i ons. The f o l l o w i n g r e l a t i o n s h i p s are found between v a r i a b l e s . The number of mis s i n g knowledge components, the p e r c e p t i o n that BSE i n c r e a s e s fear of breast d i s e a s e and the p e r c e p t i o n that simply f o r g e t t i n g i n f l u e n c e s BSE are p o s i t i v e l y r e l a t e d to the BSE p r a c t i c e r a t i n g . The p e r c e p t i o n of s u s c e p t i b i l i t y to breast d i s e a s e , the degree of confidence with present BSE knowledge, the degree of confidence with present BSE a b i l i t y , the degree of 1 60 Table 12. Variables with a Si g n i f i c a n t (p<.05) Pearson Product Moment Correlation with BSE Practice or BSE Practice Rate Var iables BSE Practice BSE Practice Rate r r BSE knowledge 0.264 0.231 Perceived s u s c e p t i b i l i t y to breast disease -0.286 Confidence with BSE knowledge -0.236 -0.407 .000 Confidence with BSE a b i l i t y -0.282 -0.281 Sa t i s f a c t i o n with BSE habits -0.434 -0.500 ) Value of BSE -0.285 -0.352 BSE influence on the outcome of breast disease -0.313 -0.460 BSE as an uncomfortable experience 0.240 0.223 Simply forgetting as an influence on BSE practice 0.475 0.543 Lack of BSE a b i l i t y as an influence on BSE practice 0.328 BSE reminders by doctors -0.274 Value of health 0.268 s a t i s f a c t i o n with present BSE habits, the value given to BSE as a preventive health practice and the bel i e f that BSE improves the outcome of breast disease were negatively related to BSE practice rating. When only the rate of BSE was used for co r r e l a t i o n , the same relationships are apparent (rate of practice was related to the variables in the same way as the BSE 161 p r a c t i c e r a t i n g ) , except that p e r c e i v e d s u s c e p t i b i l i t y to b r e a s t d i s e a s e was not r e l a t e d to BSE r a t e alone. In a d d i t i o n , three other v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d to the rate of BSE p r a c t i c e but not to the o v e r a l l l e v e l of d i s c r e p a n c i e s i n BSE p r a c t i c e . The p e r c e p t i o n that l a c k of BSE a b i l i t y i n f l u e n c e s BSE p r a c t i c e and the value given to h e a l t h were p o s i t i v e l y r e l a t e d to the r a t e of BSE p r a c t i c e and the frequency of BSE reminders given by doctors was n e g a t i v e l y r e l a t e d to the r a t e of p r a c t i c e . D i s c u s s i o n of R e s u l t s As has been d i s c u s s e d , r e s u l t s must be viewed in l i g h t of the l i m i t a t i o n s of the data. Chi-square s t a t i s t i c a l a n a l y s i s d i d not produce s i g n i f i c a n t r e s u l t s . Although t h i s p r e c l u d e s the development of s p e c i f i c and d e f i n i t e c o n c l u s i o n s , i n d i v i d u a l responses do r a i s e q u e s t i o n s about the r e l a t i o n s h i p s between v a r i a b l e s and f u r t h e r i n v e s t i g a t i o n with a more d e t a i l e d focus and a l a r g e r and more v a r i e d r e s e a r c h group might serve to c l a r i f y the i n f l u e n c e s on BSE p r a c t i c e and the v a l i d i t y of the BSE P a r t i c i p a t i o n Paradigm. The s t a t i s t i c a l a n a l y s i s using Pearson Product Moment C o r r e l a t i o n C o e f f i c i e n t s p r o v i d e s some s i g n i f i c a n t r e s u l t s . When there was a low number of m i s s i n g BSE knowledge components, there was more l i k e l y to be a high BSE r a t i n g (a low number of BSE d i s c r e p a n c i e s ) . A high p e r c e p t i o n that BSE i n c r e a s e s fear of breast d i s e a s e was a l s o more l i k e l y to occur when BSE 1 62 d i s c r e p a n c i e s were low. When simply f o r g e t t i n g was seen as an in f r e q u e n t i n f l u e n c e of BSE p r a c t i c e , d i s c r e p a n c i e s were a l s o more l i k e l y to be low. When con f i d e n c e with personal BSE knowledge or BSE a b i l i t y was low, BSE d i s c r e p a n c i e s were l i k e l y to be high. A high number of BSE p r a c t i c e d i s c r e p a n c i e s were a l s o more l i k e l y to correspond to a high p e r c e p t i o n of s u s c e p t i b i l i t y to breast d i s e a s e and gr e a t e r disagreement that the subject was s a t i s f i e d with her present BSE h a b i t s , that BSE was the most v a l u a b l e p r e v e n t i v e h e a l t h p r a c t i c e f o r women or that BSE improved the outcome of breast d i s e a s e . A high p e r c e p t i o n that lack of BSE a b i l i t y i n f l u e n c e s BSE p r a c t i c e and BSE reminders given very i n f r e q u e n t l y by doc t o r s were more l i k e l y to occur with a low rate of BSE p r a c t i c e . How can these s i g n i f i c a n t r e s u l t s be i n t e r p r e t e d ? K i r k (1978) p o i n t s out that there i s no s i n g l e r a t i n g f o r the s i z e of r which i s a p p l i c a b l e to a l l s i t u a t i o n s (p. 108). An a p p r e c i a b l e p r o p o r t i o n of v a r i a n c e between v a r i a b l e s i s not ex p l a i n e d by t h e i r r e l a t i o n s h i p as measured by a Pearson r u n t i l the r i s over .7 (e x p l a n a t i o n of 50 percent of v a r i a n c e r e q u i r e s an r of .71). V a r i a b l e s r e l a t e d to BSE p r a c t i c e with a Pearson's r equal to or g r e a t e r than .30 (9 percent of v a r i a n c e e x p l a i n e d by the l i n e a r r e l a t i o n s h i p between the v a r i a b l e s ) , i n c l u d e s a t i s f a c t i o n with BSE h a b i t s , p e r c e p t i o n of the i n f l u e n c e of BSE on the outcome of breast d i s e a s e and the p e r c e p t i o n that simply f o r g e t t i n g i n f l u e n c e d frequency of BSE p r a c t i c e . In a d d i t i o n , c o n f i d e n c e with BSE knowledge, value of BSE and a p e r c e p t i o n 163 that l a c k of BSE a b i l i t y i n f l u e n c e s frequency of BSE p r a c t i c e were r e l a t e d to r a t e of BSE p r a c t i c e with a Pearson's r of over .30 as w e l l . Confidence with BSE knowledge was r e l a t e d to r a t e of p r a c t i c e and although a low number of mis s i n g knowledge components was l i k e l y to be present when there were a low number of d i s c r e p a n c i e s i n BSE p r a c t i c e , knowledge of BSE d i d not guarantee a p p r o p r i a t e a c t i o n . Many women d i d not use the knowledge that they had. In a d d i t i o n , some s u b j e c t s may not c a r r y out a l l of the components that they know about on a c o n s i s t e n t b a s i s . They may do some things a l l of the time and some only p a r t of the time. T h i s d e t a i l of data was not e l i c i t e d by the q u e s t i o n n a i r e used. In any event, i t i s obvious that at l e a s t some of the people, though they know what they should do, do not f o l l o w through i n t h e i r p r a c t i c e . The reasons fo r t h i s behaviour have not been s p e c i f i c a l l y i n v e s t i g a t e d i n t h i s r e s e a r c h . Data seem to i n d i c a t e that when more of the c r u c i a l a spects of knowledge are r e t a i n e d , more a p p r o p r i a t e a c t i o n i s more l i k e l y to f o l l o w . However, there i s no i n d i c a t i o n of which comes f i r s t . Does g r e a t e r knowledge motivate fewer d i s c r e p a n c i e s i n p r a c t i c e or does a d e s i r e to p r a c t i c e BSE c o r r e c t l y motivate the r e t e n t i o n of greater knowledge? Health educators who s t r i v e only to p r o v i d e knowledge i n the hope that the d e s i r e d l e v e l of compliance w i l l f o l l o w w i l l undoubtedly be d i s a p p o i n t e d . The degree of s a t i s f a c t i o n with BSE h a b i t s may not i n f a c t 1 64 be a measure of f e l t need. I t may i n d i c a t e t h a t , because of t h e i r knowledge of BSE, these women were aware of the d i s c r e p a n c i e s between what h e a l t h a u t h o r i t i e s suggested that they do and what they were a c t u a l l y doing. A high d i s c r e p a n c y in BSE may then produce a low r a t e of s a t i s f a c t i o n r a t h e r than the degree of d i s s a t i s f a c t i o n a f f e c t i n g a c t u a l BSE p r a c t i c e . Cancer i s s t i l l a very s e r i o u s and t h r e a t e n i n g d i s e a s e . Presumably e x p e c t a t i o n s about BSE and i t s i n f l u e n c e on the outcome of breast disease and p e r c e p t i o n s of personal s u s c e p t i b i l i t y would d i f f e r i f e x p e c t a t i o n s about breast d i s e a s e d i f f e r e d . In r e a l i t y many breast problems are due to f i b r o c y s t i c d i s e a s e , not cancer. Fear of cancer may r e s u l t i n r e l u c t a n c e to monitor b r e a s t s r e g u l a r l y . On the other hand, fear of cancer might act as a stimulus to be very m e t i c u l u s i n BSE. Although p e r c e p t i o n s about BSE and BSE p r a c t i c e were r e l a t e d i n t h i s data, the f i n e r p o i n t s of the s i t u a t i o n have not been c l a r i f i e d . Simply f o r g e t t i n g as an easy e x p l a n a t i o n f o r behaviour has alr e a d y been d i s c u s s e d . The r e l a t i o n s h i p between p e r c e p t i o n s of the i n f l u e n c e of simply f o r g e t t i n g on the r a t e of p r a c t i c e and a c t u a l p r a c t i c e may be more of an i n d i c a t i o n of p e r s o n a l p e r c e p t i o n s and s e l f - r a t i o n a l i z a t i o n f a t h e r than poor memory. However, memory h e l p e r s may h e l p improve r a t e of p r a c t i c e and t h i s c o u l d be examined e x p e r i m e n t a l l y . Personal values are r e l a t e d to behaviour but they may' not cause behaviour. I t may be that a general value of h e a l t h i s too n o n - s p e c i f i c to e x p l a i n a s i n g l e s p e c i f i c h e a l t h behaviour 1 65 such as BSE. Rokeach (1973) suggests t h a t , through experience in a p a r t i c u l a r context, we i n t e g r a t e absolute values we have been taught i n t o a h i e r a r c h i c a l l y organized system where each value i s ordered in p r i o r i t y or importance r e l a t i v e to other v a l u e s . In a given s i t u a t i o n , the b e h a v i o u r a l outcome w i l l be a r e s u l t of the r e l a t i v e importance of a l l the competing values that have been a c t i v a t e d (p. 6). Obviously the p r a c t i c e of BSE must have some value i n order to encourage v o l u n t a r y p r a c t i c e of i t but even i f i t i s valued, other f o r c e s may combine to i n f l u e n c e the r a t e at which i t i s c a r r i e d out. Although the BSE P a r t i c i p a t i o n Paradigm has not been s o l i d l y supported i n i t s e n t i r e t y , some v a r i a b l e s d i d produce s i g n i f i c a n t r e s u l t s and t h e i r i n c l u s i o n i n the paradigm was supported. The l i m i t e d sample does not, however, j u s t i f y the e x c l u s i o n of a l l the v a r i a b l e s which produced n o n - s i g n i f i c a n t r e s u l t s . The f o l l o w i n g chapter summarizes t h i s research p r o j e c t and o u t l i n e s i m p l i c a t i o n s f o r f u r t h e r BSE research and f o r pl a n n i n g BSE t e a c h i n g . 166 CHAPTER VII SUMMARY AND IMPLICATIONS Breast cancer i s the most common type of cancer i n women. One i n fourteen women w i l l experience i t and t h e i r chances of s u r v i v a l have not decreased f o r s e v e r a l decades. The c u r r e n t ten-year s u r v i v a l r a t e i s 33 percent. If the lump i s l e s s than 2 cm. and there i s no nodal involvement, s u r v i v a l r a t e s i n c r e a s e to 80 percent. Most cancerous l e s i o n s are p a l p a b l e i n a s i z e range that maximizes s u r v i v a l . Breast s e l f - e x a m i n a t i o n has been found to be a r e l i a b l e , safe and c o s t - e f f e c t i v e approach which can r e s u l t i n reduced m o r t a l i t y from cancer. Many s t u d i e s show that there i s widespread knowledge of BSE but that many women do not p r a c t i c e i t c o r r e c t l y . Although a high percentage of lumps are found by women themselves, such d i s c o v e r i e s are u s u a l l y a c c i d e n t a l . A frequent attempted remedy f o r such performance d i s c r e p a n c i e s ( d i f f e r e n c e s between a c t u a l and d e s i r e d performance) i s a te a c h i n g program. Before such a remedy can be e f f e c t i v e , however, one must understand the u n d e r l y i n g i s s u e s . Knowledge or s k i l l may not be the only or the major components of the problem. The purpose of t h i s r e s e a r c h p r o j e c t was to examine BSE as a p r e v e n t i v e h e a l t h a c t i v i t y and to determine the fo r c e s which are r e l a t e d to i t s p r a c t i c e . 167 L i m i t a t i o n s of the Study T h i s p r o j e c t was an example of ex post f a c t o r e s e a r c h . T h i s type of r e s e a r c h i s l i m i t e d i n that the dependent v a r i a b l e has a l r e a d y occurred and independent v a r i a b l e s are s t u d i e d i n r e t r o s p e c t . There i s no c o n t r o l over independent v a r i a b l e s or the e f f e c t of time. Correlations.between v a r i a b l e s i n d i c a t e the presence of a r e l a t i o n s h i p but they do not e x p l a i n the reason fo r the r e l a t i o n s h i p . There are a wide range of p o s s i b l e causes when v a r i a b l e s are not c o n t r o l l e d . Subjects cannot be randomly assigned to groups but rather they a s s i g n themselves through s e l f - r e p o r t . K e r l i n g e r (1967) p o i n t s out that t h i s s e l f -s e l e c t i o n may be done on the b a s i s of c h a r a c t e r i s t i c s other than those in which the i n v e s t i g a t o r may be i n t e r e s t e d (p. 362). As a r e s u l t extraneous v a r i a b l e s which may be r e l a t e d to the v a r i a b l e s of the r e s e a r c h problem but which are not taken i n t o account by the i n v e s t i g a t o r may i n f l u e n c e r e s e a r c h f i n d i n g s . The small sample s i z e d i d not p rovide a very l a r g e spread in responses and a n a l y s i s of s p e c i f i c aspects of the data was l i m i t e d . Data were grouped in an attempt to i n c r e a s e the frequency f o r each category and improve r e l i a b i l i t y of the c h i -square t e s t . U n f o r t u n a t e l y , grouping data has i t s own disadvantages. Data are i n v a r i a b l y l o s t . In a d d i t i o n , non-unique frequency d i s t r i b u t i o n s are formed and the grouping scheme which i s chosen a f f e c t s the values of the d e s c r i p t i v e s t a t i s t i c s ( K i r k , 1978, p. 27). Data c o l l e c t i o n r e l i e d on s u b j e c t s e l f - r e p o r t . S e l l t i z , Wrightsman and Cook (1980) p o i n t out s e v e r a l l i m i t a t i o n s to 168 s e l f - r e p o r t . Only that m a t e r i a l that the sub j e c t i s w i l l i n g and able to r e p o r t can be c o l l e c t e d . Subjects may be unaware of unconcious d r i v e s and s e l f - d i a g n o s i s i s l i m i t e d by i n d i v i d u a l a b i l i t y and self-awareness. Confidence i n v e r b a l r e p o r t s decreases when sub j e c t matter might be embarrassing, when the t r u t h might be unfavourable or when s u b j e c t s might attempt to amuse, a s t o n i s h or c r e a t e a c e r t a i n s o c i a l e f f e c t (p. 147). These l i m i t a t i o n s of s e l f - r e p o r t may have had a s e r i o u s e f f e c t on data c o l l e c t e d f o r t h i s p r o j e c t . Health i s s u e s can produce very strong r e a c t i o n s . The idea of t a k i n g r e s p o n s i b i l i t y f o r ma i n t a i n i n g one's own h e a l t h has gained i n c r e a s i n g support i n Canadian c u l t u r e and a c t i o n s and b e l i e f s c o n t r a r y to t h i s idea might be admitted only r e l u c t a n t l y . Issues i n v o l v i n g women's br e a s t s might produce embarrassment and other strong emotional responses. Cancer i s s t i l l a very f r i g h t e n i n g d i s e a s e and i s capable of arousing strong emotions. Research s u b j e c t s were no doubt a f f e c t e d to some extent by some or a l l of these i s s u e s and the data that they p r o v i d e d would, t h e r e f o r e , a l s o be a f f e c t e d in v a r i o u s , u n p r e d i c t a b l e ways. Subject s were not o b l i g a t e d to provide data. T h e i r p a r t i c i p a t i o n was v o l u n t a r y . Samples which r e l y on v o l u n t e e r c o - o p e r a t i o n may no longer be r e p r e s e n t a t i v e of the research group. Research on the subject of v o l u n t e e r s versus non-v o l u n t e e r s has shown that they do d i f f e r (Borg & G a l l , 1979). G e n e r a l i z a b i l i t y of r e s e a r c h r e s u l t s i s l i m i t e d s i n c e data are not a v a i l a b l e on those who d i d not p a r t i c i p a t e . Comparing re s e a r c h s u b j e c t s with those who d i d not vol u n t e e r helps to 169 determine d i f f e r e n c e s which might a f f e c t r e s u l t s . The only data a v a i l a b l e f o r the e n t i r e r e s e a r c h group i s that a l l s u b j e c t s were at the u n i v e r s i t y l e v e l of e d u c a t i o n . Other sample p o p u l a t i o n c h a r a c t e r i s t i c s are u n a v a i l a b l e ' f o r comparison. Since e d u c a t i o n a l l e v e l was the v a r i a b l e used to c r e a t e the r e s e a r c h group, the e f f e c t of education on the dependent v a r i a b l e cannot be determined. Fur t h e r r e s e a r c h using samples of v a r y i n g e d u c a t i o n a l l e v e l s are needed to assess the e f f e c t of t h i s v a r i a b l e . Research s u b j e c t s were a l l c u r r e n t l y a t t e n d i n g u n i v e r s i t y . At the time of the data c o l l e c t i o n , the u n i v e r s i t y year was coming to a c l o s e and there were many end of term demands on students. Some p o t e n t i a l p a r t i c i p a n t s admitted that they would not be p a r t i c i p a t i n g because of the time pre s s u r e s that they were under. Rate of response was undoubtedly a f f e c t e d . Those who responded would be under s i m i l a r p r e s s u r e s and t h e i r responses may have been a f f e c t e d by those other demands on t h e i r time and energy. Most of the s t a t i s t i c a l r e s u l t s of t h i s r e s e a r c h were n o n s i g n i f i c a n t . T h i s does not n e c e s s a r i l y mean that a l l v a r i a b l e s t e s t e d were not r e l a t e d to BSE p r a c t i c e . Negative f i n d i n g s in r e s e a r c h can r e s u l t from any of a number of r e s e a r c h f a u l t s . K e r l i n g e r (1967) suggests that negative or i n c o n c l u s i v e r e s u l t s may be due to i n c o r r e c t theory and hypotheses, i n a p p r o p r i a t e or i n c o r r e c t methodology, f a u l t y a n a l y s i s or poor measurement (p. 620). C o l l e c t i n g v a l i d and r e l i a b l e data using a q u e s t i o n n a i r e 1 70 r e q u i r e s the development of a w e l l c o n s t r u c t e d data c o l l e c t i o n t o o l . Using a q u e s t i o n n a i r e as the data c o l l e c t i o n t o o l has both advantages and disadvantages. A q u e s t i o n n a i r e p r o v i d e s anonymity and an o p p o r t u n i t y to answer q u e s t i o n s f r e e l y without being c o n f r o n t e d . S e n s i t i v e or embarrassing q u e s t i o n s might r e c e i v e more spontaneous and accurate answers when only an anonymous w r i t t e n response i s requested. A l a r g e number of respondents can be canvassed i n a r e l a t i v e l y short time p e r i o d and with a minimum of resea r c h p e r s o n n e l . However, the q u e s t i o n n a i r e format, with i t s aim f o r s i m p l i c i t y and resonable l e n g t h , makes i t d i f f i c u l t to account f o r every p o s s i b l e answer. In a d d i t i o n , there are times when the researcher wants to f o r c e the respondent to make a choice and an o p p o r t u n i t y f o r an open-ended response in every q u e s t i o n i s not always d e s i r a b l e . The wording of each q u e s t i o n i s of utmost importance and though p i l o t t e s t i n g can a s s i s t i n improving q u e s t i o n c l a r i t y , e r r o r s and omissions are d i f f i c u l t to e l i m i n a t e e n t i r e l y . T o p i c s cannot be explored on an i n d i v i d u a l b a s i s when more data are needed f o r c l a r i f i c a t i o n . Although the anonymity of a q u e s t i o n n a i r e may encourage some respondents to provide more in f o r m a t i o n on t o p i c s which are p a r t i c u l a r l y embarrassing or emotional, the q u e s t i o n n a i r e format i s s e r i o u s l y l a c k i n g when c o l l e c t i n g data on many of the more complex i s s u e s of BSE. On a number of occasions the data p r o v i d e d were i n s u f f i c i e n t to rate s u b j e c t s and data were l o s t . Although c o n s i d e r a b l e e f f o r t was made in the development of the q u e s t i o n n a i r e , t h i s was the f i r s t time i t was used and v a l i d i t y and r e l i a b i l i t y i s q u e s t i o n a b l e . 1 7 1 S e l l t i z , Wrightsman and Cook (1980) suggest that i n t e r n a l and e x t e r n a l v a l i d i t y of r e s e a r c h i s more r e a d i l y assessed when there i s a l a r g e r r e s e a r c h program r a t h e r than the r e s u l t s of only a s i n g l e instance of survey r e s e a r c h (p. 81). Research F i n d i n g s Given i t s l i m i t a t i o n s , the r e s e a r c h f i n d i n g s n e i t h e r c o n f i r m nor negate the i n i t i a l t h e o r e t i c a l framework f o r the study. Some of the f i n d i n g s may. be of use i n p l a n n i n g f u t u r e r e s e a r c h or o r g a n i z i n g BSE t e a c h i n g s e s s i o n s . F i n d i n g s on BSE p r a c t i c e s were c o n s i s t e n t with previous r e s e a r c h which i n d i c a t e d a high percentage of BSE p r a c t i c e d i s c r e p a n c i e s . For t h i s sample, when BSE was c a r r i e d out monthly there were l i k e l y to be fewer completeness d i s c r e p a n c i e s . T h i s may mean that the g r e a t e r the m o t i v a t i o n to c a r r y out BSE the g r e a t e r the l i k e l i h o o d of a more complete breast examination. T h i s tends to support the t h e o r e t i c a l framework which suggests a v a r i e t y of f a c t o r s combine and i n t e r a c t to i n f l u e n c e end behaviour. S p e c i f i c sources or combinations of sources that i n f l u e n c e p a r t i c i p a t i o n i n BSE have not been e s t a b l i s h e d with t h i s r e s e a r c h . While a l l of the r e s e a r c h s u b j e c t s knew of BSE and 24 percent i n d i c a t e d a complete knowledge, only 3 i n d i v i d u a l s p r a c t i c e d BSE c o r r e c t l y . T h i s i s i n keeping with much of the compliance r e s e a r c h which i n d i c a t e s that knowledge does not n e c e s s a r i l y r e s u l t i n a p p r o p r i a t e a c t i o n . The v a r i o u s components of BSE were remembered in v a r y i n g degrees. The 1 72 systematic component was remembered most f r e q u e n t l y . The a x i l l a component was l e a s t f r e q u e n t l y remembered. The v i s u a l i n s p e c t i o n and the c o r r e c t time were f o r g o t t e n almost as f r e q u e n t l y as p a l p a t i o n of the a x i l l a . The l a t t e r three components r e q u i r e some understanding of breast d i s e a s e while the systematic component i s easy to guess using only common sense. A s i m p l i f i e d reminder which helps women to remember a l l four components might improve knowledge l e v e l s . Although complete knowledge does not ensure c o r r e c t end behaviour, knowledge i s a p r e r e q u i s i t e f o r c o r r e c t and complete p r a c t i c e . While knowledge and BSE p r a c t i c e were s t a t i s t i c a l l y r e l a t e d , the flaws of data c o l l e c t i o n makes the meaning of t h i s r e l a t i o n s h i p q u e s t i o n a b l e . Data were not c o l l e c t e d independently f o r each of these v a r i a b l e s . A c l o s e r look at the complex r e l a t i o n s h i p between them might provide a b e t t e r understanding of t h e i r i n t e r a c t i o n . The pamphlet was reported most f r e q u e n t l y as a source and most f r e q u e n t l y chosen as "most u s e f u l . " I t seems to be an important and u s e f u l t o o l . Nurses, once they c o n t a c t e d the l e a r n e r , were p e r c e i v e d to be e f f e c t i v e t e a c h e r s . T h i s i s e s p e c i a l l y t rue when they are t e a c h i n g other nurses. The methods of BSE i n f o r m a t i o n p r e s e n t a t i o n which were most f r e q u e n t l y p e r c e i v e d as "most u s e f u l " were p i c t u r e s and sketches, demonstration on the respondent, and guided p r a c t i c e with you examining y o u r s e l f . When they had been experienced, f i l m s and guided p r a c t i c e on another person" were a l s o f r e q u e n t l y chosen as "most u s e f u l . " Guided p r a c t i c e on y o u r s e l f was the 1 73 most s t r o n g l y endorsed of a l l the p r e s e n t a t i o n methods when i t had been experienced. BSE p r a c t i c e seemed r e l a t e d to f i l m s and guided p r a c t i c e on y o u r s e l f but the small numbers i n the sample make t h i s r e l a t i o n s h i p tenuous. When follow-up l e a r n i n g s e s s i o n s went beyond j u s t a qu e s t i o n about h a b i t s and i n c l u d e d r e t u r n demonstration on a r e g u l a r b a s i s , a higher degree of compliance was shown. Since t h i s only a p p l i e d to two i n d i v i d u a l s , however, t h i s r e l a t i o n s h i p r e q u i r e s f u r t h e r i n v e s t i g a t i o n . The gr e a t e r m a j o r i t y of the sample d i d not r e c e i v e any r e g u l a r reminders to c a r r y out BSE from t h e i r f a m i l y , t h e i r f r i e n d s or t h e i r d o c t o r . Experiences with breast d i s e a s e can be very complex and were p o o r l y i n v e s t i g a t e d i n t h i s p r o j e c t . Because of i t s complexity, i t seems l i k e l y that t h i s p o s s i b l e i n f l u e n c e on BSE would be b e t t e r s t u d i e d i n a re s e a r c h p r o j e c t concerned s o l e l y with t h i s v a r i a b l e . Having experience i n the h e a l t h care f i e l d does not r e s u l t in g r e a t e r compliance with BSE. Women with a h e a l t h background w i l l q u i t e l i k e l y have BSE d i s c r e p a n c i e s even i f they have a high l e v e l of BSE knowledge. One cannot assume knowledge or compliance when a h e a l t h background i s p r e s e n t . Although the BSE value concept was p o o r l y measured, data suggest that there may be a r e l a t i o n s h i p between the value p l a c e d on BSE and BSE p r a c t i c e . BSE p r a c t i c e and the degree of pers o n a l s a t i s f a c t i o n with c u r r e n t BSE h a b i t s were r e l a t e d i n t h i s sample. I t appeared that the gr e a t e r the amount of BSE dis c r e p a n c y the grea t e r the 174 d i s s a t i s f a c t i o n with BSE h a b i t s . These women seemed to be aware of the s t a t u s of t h e i r BSE p r a c t i c e but d i s s a t i s f a c t i o n d i d not produce behaviour change. L e v e l s of d i s s a t i s f a c t i o n were not measured but i n most cases i t d i d not appear to be strong enough to a f f e c t behaviour. None of the c u r r e n t l i f e i n f l u e n c e s measured--age, c u r r e n t o c c u p a t i o n , c u r r e n t student status--were r e l a t e d to BSE p r a c t i c e f o r t h i s sample. The i n f l u e n c e of p e r c e i v e d s u s c e p t i b i l i t y to b r e a s t d i s e a s e was u n c l e a r . There may be a p o i n t beyond which p e r c e i v e d s u s c e p t i b i l i t y begins to act as a negative i n f l u e n c e . A c e r t a i n amount of a n x i e t y about p e r s o n a l s u s c e p t i b i l i t y may act as a b a r r i e r to BSE. Although there was some misunderstanding about what was meant by cues to BSE, a v a r i e t y of i n f l u e n c e s were mentioned. A high percentage of those with one or l e s s d i s c r e p a n c y in t h e i r BSE p r a c t i c e d i d mention the i n f l u e n c e , of cues. The most f r e q u e n t l y mentioned sources of cues are the menstral c y c l e , media coverage and hearing about breast d i s e a s e i n o t h e r s . While the presence of cues was not s t a t i s t i c a l l y r e l a t e d to p r a c t i c e , the methodology of data c o l l e c t i o n was f a u l t y and more p r e c i s e data might provide d i f f e r e n t r e s u l t s . In a d d i t i o n , many of the cues mentioned were not r e g u l a r monthly cues and the use of a r e g u l a r cue to a c t i o n might prove b e n e f i c i a l . There d i d seem to be p a r t i c u l a r experiences which s t i m u l a t e d the p r a c t i c e of BSE. The f o r c e s most f r e q u e n t l y mentioned as having i n s t i g a t e d change were d o c t o r s ' advice, nurses t r a i n i n g , magazine a r t i c l e s and f a m i l y or p e r s o n a l breast 175 d i s e a s e . Doctors have the p o t e n t i a l to be powerful f o r c e s f o r change and, although many do not r e g u l a r l y i n v o l v e themselves with t h e i r p a t i e n t s ' BSE h a b i t s , there are i n d i c a t i o n s that such involvement c o u l d produce a s i g n i f i c a n t change in BSE p r a c t i c e . P a r t i c u l a r experiences do seem to c r e a t e a "teachable moment." A t t i t u d e s toward BSE and a n x i e t y surrounding BSE were p o o r l y measured. The wording and format of the q u e s t i o n s appeared to measure only s u p e r f i c i a l responses. Many women are anxious about cancer and, i n p a r t i c u l a r , breast cancer. The way such a n x i e t y a f f e c t s behaviour i s not c l e a r . There i s some i n d i c a t i o n that low l e v e l s of a n x i e t y i n the presence of other m o t i v a t i n g f a c t o r s may s t i m u l a t e BSE. High l e v e l s of a n x i e t y , on the other hand, can act as a b a r r i e r to BSE p r a c t i c e . Some women with a high s u s c e p t i b i l i t y and t r a g i c p e r s o n a l or f a m i l y experiences are adamant about not p r a c t i c i n g BSE. The l e v e l of a n x i e t y may be a key to e x p l a i n i n g end behaviour. What degree of a n x i e t y a c t s as a p o s i t i v e f o r c e and when does i t begin to act as a b a r r i e r ? Could the development of s t r o n g l y p o s i t i v e m o t i v a t o r s overcome high a n x i e t y ? Could h i g h - r i s k women with a high a n x i e t y l e v e l b e n e f i t from more intense p e r s o n a l t e a c h i n g programs which aim to decrease a n x i e t y and i n c r e a s e m o t i v a t i o n through the development of more p o s i t i v e a t t i t u d e s and expectat ions? Examination of the b a r r i e r s to BSE as p e r c e i v e d by the respondents was l i m i t e d by the i n s i g h t of the i n d i v i d u a l s and by t h e i r w i l l i n g n e s s to share negative aspects of themselves. The only suggested b a r r i e r which d i d s o l i c i t e s i g n i f i c a n t response 176 was "simply f o r g e t t i n g . " T h i s excuse f o r e x p l a i n i n g a l a c k of compliance i s an easy one. It i s , in g e n e r a l , a s o c i a l l y a c c e p t a b l e excuse. I t i s a s u p e r f i c i a l answer and one which does not r e f l e c t p a r t i c u l a r l y p o o r l y on s e l f - i m a g e . Only a few respondents provided more pers o n a l reasons f o r e i t h e r doing or not doing BSE. S e v e r a l of them i n d i c a t e d a p e r s o n a l d e n i a l of the i n c i d e n c e of breast d i s e a s e by saying i t was not going to happen to them. Such powerful emotional r e a c t i o n s are not e a s i l y d e a l t with. Simple p r e s e n t a t i o n of BSE i n f o r m a t i o n and i n c i d e n c e of breast cancer w i l l not overcome such s t r o n g l y h e l d b e l i e f s . Even when many p o s i t i v e motivators e x i s t something o f t e n i n t e r f e r e s with a p p r o p r i a t e a c t i o n . I m p l i c a t i o n s f o r Research Many of the n o n - s i g n i f i c a n t r e s u l t s may have been due to a flawed r e s e a r c h design or data c o l l e c t i o n instrument. Some of the r e s u l t s suggest that f u r t h e r r e s e a r c h i s needed to c l a r i f y r e l a t i o n s h i p s between v a r i a b l e s . The sample s i z e was small and the r e s e a r c h group was homogeneous on many f a c t o r s . A l a r g e r r e s e a r c h group with d i f f e r e n t l e v e l s of education and a v a r i e t y of o c c u p a t i o n a l backgrounds might p r o v i d e more d i s c r i m i n a t i n g data and allow f o r a more s p e c i f i c a n a l y s i s of a g r e a t e r v a r i e t y of data categor i e s . A study designed s p e c i f i c a l l y to c o l l e c t i n t e r v a l data might p r o v i d e stronger support f o r the r e l a t i o n s h i p s suggested i n t h i s data. 1 77 The use of i n t e r v i e w s where more probing q u e s t i o n s can be asked as necessary or where s u b j e c t s can demonstrate t h e i r p e r s o n a l h a b i t s might i n c r e a s e accuracy and depth of data c o l l e c t i o n . Questions c o u l d be e x p l a i n e d and more data requested as necessary. I t may be b e n e f i c i a l to make a d e f i n i t e s e p a r a t i o n between c o l l e c t i n g data on knowledge as opposed to p r a c t i c e . Would i t produce more independent data i f s u b j e c t s are asked to d e s c r i b e what they do when they c a r r y out BSE and then l a t e r i n the q u e s t i o n n a i r e asked about BSE knowledge? The f i r s t q u e s t i o n c o u l d be open-ended with respondents d e s c r i b i n g t h e i r behaviour in t h e i r own words. The second c o u l d be a l i s t of behaviours from which s u b j e c t s chose those t h i n g s which "should" be part of BSE. Another format would be to provide d e s c r i p t i o n s of s e v e r a l i n d i v i d u a l s c a r r y i n g out BSE and then have respondents p i c k out the one which i s most c o r r e c t . Nurses in t h i s study d i d not have any g r e a t e r knowledge or compliance than those with a non-health background. It would be i n t e r e s t i n g to know i f t h i s t r e n d was true f o r other h e a l t h p r o f e s s i o n a l s e s p e c i a l l y female d o c t o r s and those who c u r r e n t l y teach BSE. The same q u e s t i o n a p p l i e s to the a t t i t u d e s of male p h y s i c i a n s . Since doctors can be a p o s i t i v e i n f l u e n c e on BSE h a b i t s , t h e i r p ersonal a t t i t u d e s and p r a c t i c e s would a f f e c t t h e i r i n t e r a c t i o n s with others on t h i s t o p i c . Is there uniform support f o r BSE i n the medical p r o f e s s i o n ? Since h e a l t h p r o f e s s i o n a l s are to a great extent the major source of BSE i n f o r m a t i o n and encouragement, f u r t h e r r e s e a r c h i n the area of 1 78 h e a l t h p r o f e s s i o n a l s and t h e i r a t t i t u d e s toward BSE might r e v e a l a major flaw i n the BSE teaching h i e r a r c h y . Experimental r e s e a r c h which examined the e f f e c t of frequent use of cues to a c t i o n s might c l a r i f y the p o t e n t i a l f o r s t i m u l a t i n g r e g u l a r BSE using cues. The e f f e c t of a v a r i e t y of memory h e l p e r s should be s t u d i e d i n an e f f o r t to decrease the i n f l u e n c e of "simply f o r g e t t i n g . " Personal experiences with breast d i s e a s e cover a wide range of p o s s i b i l i t i e s . More comprehensive data might r e s u l t from i n t e r v i e w s . Separation of the t o p i c i n t o malignant and benign d i s e a s e might c l a r i f y r e s u l t s when the q u e s t i o n n a i r e format i s used. Separate r e s e a r c h which focusses on t h i s s u b j e c t may be needed. The e f f e c t of l o c u s of c o n t r o l may r e q u i r e the development of a s p e c i f i c BSE s c a l e . The r e l a t i o n s h i p between locus of c o n t r o l and BSE p r a c t i c e s might a l s o be c l a r i f i e d i f s u b j e c t s with d i f f e r e n t education l e v e l s and BSE knowledge l e v e l s were compared. In a d d i t i o n , more s p e c i f i c and p r e c i s e c o l l e c t i o n of data on the f o l l o w i n g t o p i c s i s needed before t h e i r i n f l u e n c e on BSE can be understood: follow-up t e a c h i n g s e s s i o n s ; the time span between p e r c e i v e d i n f l u e n c i n g f a c t o r s on BSE p r a c t i c e and present BSE h a b i t s ; s t r o n g l y emotional responses to breast cancer; l e v e l of a n x i e t y surrounding breast cancer and BSE; the degree of p e r c e i v e d s u s c e p t i b i l i t y to breast cancer; and a t t i t u d e s and values surrounding BSE. 1 79 I m p l i c a t i o n s f o r Teaching BSE Breast s e l f - e x a m i n a t i o n i s a p o t e n t i a l l y emotional a c t i v i t y . The complex i n t e r a c t i o n of i n f l u e n c e s on p a r t i c i p a t i o n in BSE remains p o o r l y understood. I t i s c l e a r , however, that a simple p r e s e n t a t i o n of the f a c t s along with a demonstration of what should be done i s not enough to produce a p p r o p r i a t e a c t i o n . Many women know about BSE and even c a r r y i t out to some extent. The g o a l , however, i s c o r r e c t and re g u l a r BSE. Although the reason f o r noncompliance i s not c l e a r , some s p e c i f i c t e a c h i n g approachs may improve the s i t u a t i o n . Although t h i s r e s e a r c h p r o j e c t does not provide answers, one can p r o j e c t beyond the c o n f i n e s and l i m i t a t i o n s of the data to suggest t e a c h i n g approaches which c o u l d then be ev a l u a t e d to determine i f they have m e r i t . The f o l l o w i n g suggestions are such p r o j e c t i o n s and r e q u i r e v e r i f i c a t i o n in p r a c t i c e . Since many women al r e a d y know about BSE but f a i l to c a r r y i t out c o r r e c t l y , t e a c h i n g programs should not focus s o l e l y on p r o v i d i n g i n i t i a l i n f o r m a t i o n . An attempt should be made to reach those women who a l r e a d y know about BSE. Teaching programs, while p r o v i d i n g i n f o r m a t i o n and p r a c t i c a l s k i l l s , must address a t t i t u d e s , e x p e c t a t i o n s , f e a r s and other b a r r i e r s r e l a t e d to breast d i s e a s e and breast s e l f -examination. P r o v i d i n g m o t i v a t i o n for c a r r y i n g out BSE should be as important a part of the te a c h i n g program as i s p r o v i d i n g i n f o r m a t i o n . Assumptions should not be made about the m o t i v a t i o n a l power of f e a r or knowledge. Women with a high r i s k of breast cancer and those who have strong emotional r e a c t i o n s 180 to BSE and breast cancer may b e n e f i t from more i n d i v i d u a l a t t e n t i o n . P a r t i c u l a r experiences may in c r e a s e i n t e r e s t and m o t i v a t i o n to l e a r n about and p r a c t i c e BSE. Educators should be aware of and make s p e c i a l e f f o r t s to reach these women. Women i n v o l v e d in nurses t r a i n i n g may be p a r t i c u l a r l y open to improving t h e i r own h e a l t h h a b i t s . Since t h i s would not only b e n e f i t them but has the p o t e n t i a l f o r c r e a t i n g f u t u r e change agents i n the h e a l t h care system, i t seems worthwhile to make a concentrated e f f o r t d u r i n g nurses t r a i n i n g to s t i m u l a t e b e l i e f i n and a c t i v e p a r t i c i p a t i o n i n BSE p r a c t i c e . Another group of women who appear to be open to l e a r n i n g and p r a c t i c i n g BSE are those who have r e c e n t l y developed breast d i s e a s e or who have had fa m i l y or f r i e n d s with breast d i s e a s e . T h i s c o u l d be a s p e c i a l t a r g e t group f o r BSE teaching programs. Using the media, e s p e c i a l l y magazines, c o u l d be an e f f e c t i v e way to inform those who are unaware of BSE and to s t i m u l a t e BSE i n those who are informed. Having such a stimulus on a r e g u l a r b a s i s may act as a cue to p r a c t i c e BSE r e g u l a r l y . More re s e a r c h i s needed to v e r i f y t h i s d e s i r e d e f f e c t . S p e c i f i c approaches which have been given support by past l e a r n e r s should be kept i n mind when s e l e c t i n g t e a c h i n g methods and t o o l s . Demonstrations on the l e a r n e r and guided p r a c t i c e with the l e a r n e r examining h e r s e l f have r e c e i v e d p a r t i c u l a r l y p o s i t i v e responses. The p r o v i s i o n of p r i v a c y f o r these a c t i v i t i e s would be e s s e n t i a l i n order to a l l a y embarrassment. Pamphlets c o u l d be used as a method of reaching a wide range of 181 l e a r n e r s , as a way of r e i n f o r c i n g past l e a r n i n g and as a take-home reminder and r e f e r e n c e f o l l o w i n g formal t e a c h i n g . P r e s e n t i n g BSE i n simple, easy to l e a r n steps c o u l d improve knowledge l e v e l s and decrease " f o r g e t t i n g " as an excuse for poor p r a c t i c e . Using a reminder c r u t c h such as the LAST system which w i l l be d e s c r i b e d , might h e l p i n d i v i d u a l s remember the four components of BSE. Howe (1981) b e l i e v e d that a s i m p l i f i e d approach to teaching BSE i s b e n e f i c i a l . She developed a four step plan f o r BSE. Perhaps a s i m i l a r approach would be b e n e f i c i a l to a i d i n g women to remember the components of BSE. Many people use catchy verses or words to h e l p remember th i n g s ( i e . , 30 days has September, A p r i l , June and November e t c . ) . A c a t c h phrase f o r BSE might be LAST. The teacher would set the stage by reminding the l e a r n e r that t h e i r body must LAST a l i f e t i m e and that they can help by paying a t t e n t i o n to the s i g n a l s that t h e i r body give s them. One way to h e l p make your body LAST i s r e g u l a r BSE. The LAST approach to BSE would be as f o l l o w s : L- stands f o r l o o k i n g , a v i s u a l i n s p e c t i o n A- stands f o r a x i l l a or armpit, remember to examine under your arms S- stands f o r s y s t e m a t i c , not j u s t a random but a systematic examination which w i l l not miss any p a r t of the breast or lymph system T- stands f o r t i m i n g , a r e g u l a r examination on a monthly b a s i s with a recommendation that the b r e a s t s are e a s i e s t to examine j u s t a f t e r menses when any engorgement i s decreased 182 T h i s i s j u s t an example of a memory helper which might a s s i s t l e a r n e r s to remember a l l of the components of BSE. One must keep i n mind, of course, that complete knowledge does not n e c e s s a r i l y t r a n s l a t e i n t o completely c o r r e c t ' p r a c t i c e . However, one does have to have the knowledge before one can c a r r y out a l l the steps of the procedure. Simply f o r g e t t i n g i s seen as a b a r r i e r f o r many women. Educators should encourage the use of cues to a c t as reminders. Use of the menstral c y c l e as a r e g u l a r cue f o r BSE and marks on the calendar are pe r s o n a l cues that can be used. F r i e n d s , f a m i l i e s and p h y s i c i a n s have not been widely used as sources f o r encouragement or reminders. Educators should not assume p h y s i c i a n s are a c t i v e l y i n v o l v e d . S p e c i a l e f f o r t s to i n c r e a s e involvement of t h i s p o t e n t i a l l y powerful source of BSE inf o r m a t i o n and encouragement seems i n order. Family members should be i n c l u d e d i n t e a c h i n g e f f o r t s and encouraged to get in v o l v e d and provide support. H o l d i n g c l a s s e s f o r groups of f r i e n d s or i n work s e t t i n g s where a s s o c i a t e s c o u l d a t t e n d together would make BSE a t o p i c f o r d i s c u s s i o n and women c o u l d be encouraged to remind and support one another. Awareness of the s t a t u s of pers o n a l BSE h a b i t s may be a good s t a r t i n g p l a c e f o r the educator wishing to improve those h a b i t s . An e x p l o r a t i o n of pe r s o n a l a t t i t u d e s and values might heighten awareness of the f a c t o r s behind p e r s o n a l h a b i t s . Increased p e r s o n a l awareness might l e d to a more honest a p p r a i s a l of the is s u e s surounding BSE and both teacher and student c o u l d then c o n f r o n t those f a c t o r s which seemed to 183 prevent appropriate BSE practice. Such personal discussions would, of course, require the development of trust between teacher and learner and such an approach would require one-to-one or small group interaction. This would be inappropriate for general BSE teaching but i t might be useful for high risk women who have BSE practice discrepancies. Nurse educators, i f they wish to play an important role in teaching BSE, must contact a greater population. They can take heart in the fact that when they have been a source of information they have been rated highly. Educators should examine their own attitudes and behaviour in terms of BSE.. It i s d i f f i c u l t to cover-up personal biases. In order to help others to examine themselves and make changes in their behaviour, the teacher must f i r s t go through the process of self-examination. Egan (1975) suggests that a s k i l l e d helper must model the behaviour that he hopes to help others achieve and that he must f i r s t explore and understand his own behaviour before he can as s i s t others in their s e l f -examination (pp. 22-24). Our understanding of BSE and the factors which influence p a r t i c i p a t i o n in thi s preventive health measure is poorly understood. Educators should be a c t i v e l y involved in increasing our knowledge. They should not only be educators but active researchers. The outcome of their teaching e f f o r t s should be monitored and experimental approaches to teaching BSE closely controlled and recorded. The e f f e c t i v e teacher must also be a s c i e n t i f i c observer and respond to the results of each teaching 1 84 e f f o r t . BSE can be an e f f e c t i v e t o o l i n combating breast cancer. There i s some evidence that a g r e a t e r number of women are beginning to a p p r e c i a t e t h i s f a c t . Mahoney (1983) r e p o r t s that between 1981 and 1982 there was a s i g n i f i c a n t i n c r e a s e i n the number of women r e p o r t i n g to h i s c l i n i c who were performing s a t i s f a c t o r y b reast examinations. Between 1978 and 1982 there was a l s o a s i g n i f i c a n t i n c r e a s e i n the p r o p o r t i o n of breast cancers d e t e c t e d as a r e s u l t of BSE and a decrease i n those found a c c i d e n t a l l y or through a r o u t i n e p h y s i c i a n ' s examination. While t h i s i s encouraging, many women are s t i l l not c a r r y i n g out t h i s simple but e f f e c t i v e procedure. E f f o r t s must be made to understand the i n f l u e n c e s on BSE behaviour and to use t h i s knowledge to help women improve t h e i r chances of combating one of the major causes of m o r t a l i t y f o r women--breast cancer. 185 REFERENCES Alco e , S. Y., & McDermot, R. S. R. 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(ERIC Document Reproduction S e r v i c e No. ED 114137) Rubenson, K. R e k r y t e r i n g t i l l V u x e n u t b i l k n i n g . Varberg: Acta U n i v e r s i t a t i s Gothoburgensis, 1975. Rubenson, K. P a r t i c i p a t i o n i n Recurrent E d u c a t i o n : A resea r c h Review. Discussion-paper presented to CERI Conference on Developments in Recurrent Education, 1977. Sackett, D. L. A compliance practicum f o r the busy p r a c t i t i o n e r . In R. B. Haynes, D. W. T a y l o r & D. L. Sackett (Eds.), Compliance i n Health Care. B a l t i m o r e : 1 92 Johns Hopkins U n i v e r s i t y Press, 1979. Sackett, D. L., & Haynes, R. B. Compliance With Therapeutic Regimens. B a l t i m o r e : Johns Hopkins U n i v e r s i t y Press, 1976. Sackett, D. L., & Snow, J . C. The magnitude of compliance and noncompliance. In R. B. Haynes, D. W. T a y l o r & D. L. Sackett (Eds.), Compliance in H e a l t h Care. B a l t i m o r e : Johns Hopkins U n i v e r s i t y Press, 1979. S e l l t i z , C , Wrightsman, L. S., & Cooke, S. W. Research Methods in S o c i a l R e l a t i o n s . 4th E d i t i o n , L. H. Kidder, Ed. New York: H o l t , Rinehart and Winston, 1976. S e l t z e r , A., R o n c a r i , I., & G a r f i n k e l , P. E f f e c t of p a t i e n t education on medication compliance. Canadian J o u r n a l of P s y c h i a t r y , 1980, 25 (8), 638-45. Smith, D. H. Determinants of i n d i v i d u a l s ' d i s c r e t i o n a r y use of time. In D. H. Smith & J . Macaulay (Eds.), Part i c i p a t ion in S o c i a l and P o l i t i c a l A c t i v i t i e s . San F r a n c i s c o ; Jossey-Bass, 1980. S t i l l m a n , M. J . Women's h e a l t h b e l i e f s about breast cancer and breast s e l f - e x a m i n a t i o n . Nursing Research, 1977, 26. (2), 121-127. T a g l i a c o z z o , D. M., & Ima, K. Knowledge of i l l n e s s as a p r e d i c a t o r of p a t i e n t behavior. J o u r n a l of Chronic  Disease, 1970, 22, 765-775. Tseng, M. S. Locus of c o n t r o l as a determinant of job p r o f i c i e n c y , employabi1ity, and t r a i n i n g s a t i s f a c t i o n of v o c a t i o n a l r e h a b i l i t a t i o n c l i e n t s . J o u r n a l of Counseling  Psychology, 1970, 487-491. 193 T u r n b u l l , E. M. E f f e c t of b a s i c p r e v e n t i v e h e a l t h p r a c t i c e s and mass media on the p r a c t i c e of breast s e l f - e x a m i n a t i o n . Nursing Research, 1978, 27 (2), 98-102. V i n c e n t , P. F a c t o r s i n f l u e n c i n g p a t i e n t noncompliance: a t h e o r e t i c a l approach. Nursing Research, 1971, 20 (6), 509-516. Wa l l s t o n , K. A., & Maides, S. H e a l t h - r e l a t e d i n f o r m a t i o n seeking as a f u n c t i o n of h e a l t h - r e l a t e d l o c u s of c o n t r o l and h e a l t h v a l u e . J o u r n a l of Research i n P e r s o n a l i t y , 1976, W_ 215-222. Wall s t o n , B. S., & Wal l s t o n , K. A. Locus of c o n t r o l and h e a l t h : a review of the l i t e r a t u r e . H e a l t h Education Monographs, Spr i n g , 1978, 107-117. Wallston.B. S., W a l l s t o n , K. A., Kaplan, G. D., & Maides, S. A. Development and v a l i d a t i o n of the Health Locus of C o n t r o l (HLC) S c a l e . J o u r n a l of C o n s u l t i n g and C l i n i c a l Psychology, 1976, 44, 580-585. Webb, P. A. E f f e c t i v e n e s s of p a t i e n t education and p s y c h o s o c i a l c o u n s e l i n g i n promoting compliance and c o n t r o l among hyper t e n s i v e p a t i e n t s . J o u r n a l of Family P r a c t i c e , 1980, 10 (6), 1047-55. W i l l i a m s , K. Breast s e l f - e x a m i n a t i o n : the per s o n a l touch. Nursing Times, 1979, October 11, 311-319. Windsor, R. A., Green, L. W., & Roseman, J . M. He a l t h promotion and maintenance f o r p a t i e n t s with c h r o n i c o b s t r u c t i v e pulmonary d i s e a s e : a review. J o u r n a l of Chronic Disease, 1980, 33 (1), 5-12. 194 Wise, P. S. B a r r i e r s (or enhancers) to a d u l t p a t i e n t e d u c a t i o n . J o u r n a l of Continuing Education f o r Nurses, 1979, j_0 (6) , 1 1-16. Zahn, J . Burnout in a d u l t educators. L i f e l o n g L e a r ning; The  Adult Years, 1980, 4 (4), 4-6. Appendix A: L e t t e r of I n i t i a l Contact 196 THE UNTVERSITY OF BRITISH COLUMBIA ADULT EDUCATION DIVISION DEPARTMENT OF ADMINISTRATIVE, ADULT AND HIGHER EDUCATION 5769 TORONTO ROAD Dear You are a female student i n an Adult Education class. This makes you of v i t a l interest to a study I am currently carrying out as part of my Masters Thesis-under the supervision of Dr. K j e l l Rubenson and Dr. Thomas Sork. Your cooperation i n j o i n i n g the project w i l l provide useful information to help me i n my study of breast self-examination practices. This i s a topic of interest to me not only i n terms of completing a degree requirement but also i n terms of improving my effectiveness as a nurse-educator teaching about preventive health measures. My aim i s to use individual opinions and experiences to help Improve program planning. Your personal experiences and attitudes would be invaluable i n such a search. Don't f e e l that you have to be an expert on the topic of the study, breast self-examination, to participate. The concern of the study i s personal experiences, attitudes and values and you are the expert on these issues as they concern you. You can expect to see me speaking about my project after one of your regular Adult Education classes sometime i n the near future. I w i l l be handing out my data c o l l e c t i o n forms at that time. I hope to use the results to suggest better ways of setting up health.teaching programs concerned with breast self-examination. I f you are interested i n a summary of the results they w i l l be available on request.- -You are not required to j o i n i n t h i s project and your par t i c i p a t i o n w i l l be on a s t r i c t l y volunteer basis. When you f i l l out the data c o l l e c t i o n form, however, you w i l l be providing valuable help i n my research efforts and, i n . addition, you w i l l be taking an opportunity to explore your own feelings and attitudes toward t h i s important area of preventive health. The issue involves not only women of a l l ages, i t involves a l l women. I hope that you w i l l participate and share your unique experiences. Sincerely yours, Ingrid Armstrong, R.N., B.S.N. Appendix B: Quest i o n n a i re PERFORMANCE DISCREPANCIES IN BREAST SELF-EXAMINATION PRACTICES OF FEMALE UNIVERSITY STUDENTS FEMALE UNIVERSITY STUDENT QUESTIONNAIRE ADULT EDUCATION MASTERS THESIS Prepared By INGRID ARMSTRONG Thesis A d v i s o r s : Dr. K j e l l Rubenson Dr. Thomas Sork 199 THE UNIVERSITY OF BRITISH COLUMBIA ADULT EDUCATION DIVISION DEPARTMENT OF ADMINISTRATIVE, ADULT AND HIGHER EDUCATION 5760 TORONTO ROAD Hi! This form i s a data c o l l e c t i o n tool designed to explore your stance on health and, i n p a r t i c u l a r , your stance on breast self-examination. The aim of this study i s to suggest more e f f e c t i v e planning strategies for breast self-examination teaching programs. Do not f e e l that you must be an "expert" to answer the questions. It i s your unique experiences and thoughts on the subject in which we are most interested. You w i l l notice that your name i s not requested anywhere on the form. Your answers w i l l be anonymous and reported only as part of a sample. The numbers on each page do not i d e n t i f y you in any way but are only there to help keep together forms when pages become separated. Any information that you provide i s s t r i c t l y voluntary but an e f f o r t has been made to ask for only the information that i s relevant to the topic and whose l i n k with our concerns i s supported by the l i t e r a t u r e . D e t a i l s asked about your job experiences are aimed at a s s i s t i n g in separating people into health and non-health oriented job c l a s s i f i c a t i o n s . No separate consent form i s included so that anonymity can be protected. A completed questionnaire w i l l be assumed to indicate consent to p a r t i c i p a t e i n t h i s project as a volunteer. This form usually takes less than h a l f an hour to complete v If you misplace i t you can get another copy from the adult education secretary. When you have completed your form please return i t i n the envelope provided to the adult education b u i l d i n g on Toronto Road. Please complete and return the form AS SOON AS POSSIBLE. If you want a copy of the results you may contact Ingrid Armstrong through the Adult Education D i v i s i o n . Thank you for your help i n t h i s project. 200 J. VALUES Listed below i n alphabetical order are 19 values. Your task i s to pick out the f i v e (5) values which are most important to YOU as guiding p r i n c i p l e s i n YOUR l i f e . Feel free to make any marks or checks that you wish on the paper as you study the l i s t and begin to choose only f i v e of the items. Underline your f i n a l choices.. Do not be concerned by the order i n which the items which you underline appear. They are l i s t e d a l p h a b e t i c a l l y and are not intended to give any greater importance to any p a r t i c u l a r value. A COMFORTABLE LIFE (a prosperous l i f e ) INNER HARMONY (freedom from inner c o n f l i c t ) AN EXCITING LIFE (a stimulating, active l i f e ) MATURE LOVE (sexual and s p i r i t u a l intimacy) A SENSE OF ACCOMPLISHMENT (la s t i n g contibution) NATIONAL SECURITY' (protection from attack) A WORLD AT PEACE (free of war and c o n f l i c t ) PLEASURE (an enjoyable, l e i s u r e l y l i f e ) A WORLD.OF BEAUTY (beauty of nature and the arts) SALVATION (saved, eternal l i f e ) EQUALITY (brotherhood, equal opportunity for a l l ) . SELF-RESPECT • (self-esteem) FAMILY SECURITY (taking care of loved ones) SOCIAL RECOGNITION (respect, admiration) FREEDOM (independence, free choice) TRUE FRIENDSHIP (close companionship) HAPPINESS (contentedness) WISDOM (a mature understanding of l i f e ) HEALTH (optimal physical and mental functioning) WAIT! Have you underlined only f i v e (5) items? Go over t h i s personal l i s t of f i v e and. put a number one (1) beside the value which i s the MOST important to you. Put a number two (2) beside the value which i s SECOND MOST important to you. Put a number three (3) beside the value which i s THIRD MOST important to you. PLEASE TURN OVER 201 2 . HEALTH BELIEFS The following items try to determine the way i n which d i f f e r e n t people view c e r t a i n important health-related issues. Each item i s a b e l i e f statement with which you may agree or disagree. Below each statement i s a scale which ranges from strongly disagree (1) to strongly agree (6). For each item you are to c i r c l e the number that_ represents the extent to which you disagree or agree with the statement. The more strongly you agree with a statement, the higher w i l l be the number you c i r c l e . The more strongly you disagree with a statement, the lower w i l l be the number you c i r c l e . Please c i r c l e only one number. This i s a measure of your personal b e l i e f s ; obviously there are no right or wrong answers. Please answer these items c a r e f u l l y but do not spend too much time on any one item. Be sure to answer every item. Also, try to respond to each item independently when making your choice; do not be influenced by your previous choices. It i s important that you respond according to your actual b e l i e f s and not according to how you f e e l you should believe. 202 HEALTH BELIEFS QUESTIONNAIRE Strongly Disagree Moderately Disagree S l i g h t l y Disagree S l i g h t l y Agree Moderately Agree I Strongly Agree 0© QS © (b 1. IF I TAKE CARE OF MYSELF, I CAN AVOID ILLNESS 2. WHENEVER I GET SICK IT IS BECAUSE OF SOMETHING I'VE DONE OR NOT DONE , 3. . GODD.-.HEALTH: IS. LARGELY ..A MATTER OF FORTUNE, 4. NO MATTER WHAT I DO, IF I AM GOING TO GET SICK I WILL GET SICK 5. MOST PEOPLE DO NOT REALIZE THE EXTENT TO WHICH THEIR ILLNESSES ARE CONTROLLED BY ACCIDENTAL HAPPENINGS 6. I CAN ONLY DO WHAT MY DOCTOR TELLS ME TO DO 7. THERE ARE SO MANY STRANGE DISEASES AROUND THAT YOU CAN NEVER KNOW HOW OR WHEN YOU MIGHT PICK ONE UP 8. WHEN I" FEEL ILL, I KNOW IT IS BECAUSE I HAVE NOT BEEN GETTING THE PROPER EXERCISE OR EATING RIGHT 9. PEOPLE WHO NEVER GET SICK ARE JUST PLAIN LUCKY 10. PEOPLE'S ILL HEALTH RESULTS FROM THEIR OWN CARELESSNESS 11. I AM DIRECTLY RESPONSIBLE FOR MY OWN HEALTH 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 2 3 4 5 6 5 6 5 6 PLEASE TURN OVER 203 BREAST SELF-EXAMINATION Breast self-examination is an activity recommended for women by health professionals whereby they examine their own breasts to detect changes in breast tissue. The questions which follow are concerned with your personal experiences, attitudes and understanding. Please read each question carefully and choose the answer(s) which BEST APPLY TO YOU. 1. Have you ever heard of the need to regularly examine your own breasts to detect changes in breast tissue? No Yes If you answered No, you have never heard of this preventive health measure, only three more questions on this questionnaire w i l l apply to you. Please go on to questions #17, #18 and #19. If you have heard of this preventive health practice, please go on to question #2. 2. People often hear about breast self-examination from a variety of sources. Please check ( ) a l l of the sources that have given you information about breast self-examination'. Underline the one(s) that you feel were most useful. a doctor a nurse a pamphlet a magazine article a TV advertisement a radio advertisement a family member a friend a work associate other (please l i s t any other information sources that you have encountered.) WAIT! In question #2, have you underlined the sources that you feel were most useful? 204 5. 3. Information can be presented in a number of ways. Which of. the following have you experienced when learning about breast self-examination? Please check ( ) a l l of the different approaches that you can remember experiencing. Underline the one(s) that you feel were most useful. spoken information written information pictures or sketches two-way discussion with you demonstration with a mechanical model demonstration with another person demonstration with the teacher using themselves as a model demonstration on you guided practice with you examining a mechanical model guided practice with you examining another person guided practice with you examining yourself other (Please l i s t any other presentation methods that you have encountered) WAIT! In question #3, have you underlined the approaches that you feel were most useful? 4. Did any of the breast self-examination information sources with which you have had contact provide a follow-up learning session (ie. was there an opportunity at a later date for discussion, questions, supervised practice, return demonstration, etc.)? No Yes Please describe your follow-up experience or the circumstances or issues which may have interfered with your participation in such an activity. PLEASE TURN OVER 205 6. The recommended method of breast self-examination includes a variety of activities. Please l i s t a l l of the things a person should do to carry out a complete breast self-examination. Do not be concerned about your level of expertise in answering this question. Answer i t at WHATEVER level of understanding that you have. Try to give a l l of the details that you can remember were recommended to you including when the examination should be done. Which of the following categories most accurately describes YOUR breast self-examination habits? No breast self-examination Breast self-examination less than once a year (ie. once a year or less) Breast self-examination at least once a year (ie. 1 to 3 times a year) Breast self-examination at least once every three months (ie. A to 11 times per year) Monthly breast self-examination (ie. 12 or more times per year and at least once every month) 206 7. IF YOU DO NOT CARRY OUT BREAST SELF-EXAMINATION SKIP ITEMS ill TO #9. 7. For a variety of reasons, women frequently do not carry out breast self-examination exactly as i t has been recommended to them. When you examine your breasts do you follow the procedure exactly as you have described i t in question //5? No Yes If you modify your examination in any way please describe what you do. 8. Do you remember when and under what circumstances you f i r s t started examining your breasts? No Yes. If you answered Yes: a) At what age did you start examining your breasts? b) What influenced you to start examining your breasts? 9. Sometimes particular things help remind women to carry out their breast self-examination. Is this true for you? No Yes, I remember to examine my breasts when 10. Sometimes breast self-examination habits change. Have your habits ever varied or changed? No Yes Being as specific as you can and including any influences that you feel are or were involved, explain how your habits are or were different. PLEASE TURN OVER 207 11. Many factors can influence how often women examine t h e i r breasts. C i r c l e the number which r e f l e c t s the degree of influence each of these factors have on how often you examine your breasts. Never influences me Hardly ever influences me Occasionally influences me Frequently influences me Almost always influences me Alwayslirifluences me a. LACK OF TIME b. LACK OF ENERGY c. FEAR OF WHAT I'LL FIND. d. NOT KNOWING EXACTLY HOW TO EXAMINE MY BREASTS e. FEELING PERSONALLY SUSCEPTIBLE TO BREAST DISEASE 0® (3)0 f. SIMPLY FORGETTING. 2 2 2 3 3 3 4 4 4 3 3 5 5 5 5 5 6 • 6 6 6 6 12. Can you think of any other factors besides the ones mentioned i n question eleven (above) that influence how often you examine your breasts? No Yes, they are: 13. Have any of the following people experienced breast disease? you personally a member of your b i o l o g i c a l family a close f r i e n d of yours anyone you know none of the above Please explain the experience(s) b r i e f l y . When did i t happen? What was the outcome? If the person involved was a member of your b i o l o g i c a l family or just someone you know please include your s p e c i f i c r e l a t i o n s h i p . 208 14. How would you rate your s u s c e p t i b i l i t y to breast disease? very low low ayerage high very high 15. Beside each of the statements that follow i s a scale which ranges from strongly disagree (1) to strongly agree (6). For each item c i r c l e the number that represents the extent to which you agree or disagree with the statement. The more strongly you disagree the lower w i l l be the number that you c i r c l e . Please c i r c l e ONLY ONE NUMBER. Strongly Disagree Moderately Disagree S l i g h t l y Disagree S l i g h t l y Agree Moderately Agree J Strongly Agree 0 @ d ) 0 ©( i ) a. I FEEL CONFIDENT WITH MY PRESENT LEVEL OF KNOWLEDGE ABOUT CARRYING OUT BREAST SELF-EXAMINATION b. I FEEL CONFIDENT THAT I COULD DETECT CHANGES IN MY BREAST TISSUE c. I FEEL SATISFIED WITH MY PRESENT BREAST SELF-EXAMINATION HABITS d. I FIND BREAST SELF-EXAMINATION TO BE AN UNCOMFORTABLE EXPERIENCE e. THE MOST VALUABLE PREVENTIVE HEALTH PRACTICE FOR WOMEN IS BREAST SELF-EXAMINATION f. I AM PERSONALLY RESPONSIBLE FOR MAINTAINING MY OWN HEALTH 3 4 5 6 3 4 5 6 3 4 5 6 PLEASE TURN OVER 209 10. 16. Beside each of the following statements is a scale which ranges from never (1) to always (6). For each Item circle the number which reflects how often you feel the situation described in the statement occurs. Never Hardly Ever BREAST SELF-EXAMINATION BREAST SELF-EXAMINATION BREAST SELF-EXAMINATION d. I USE THE PADS OF MY FINGERS WHEN EXAMINING MY BREASTS e. BREAST CHANGES FOUND DURING BREAST SELF-EXAMINATION LEAD1 TO DISFIGURING SURGURY f. BREAST SELF-EXAMINATION INCREASES. MY FEAR OF BREAST DISEASE g. . BECAUSE IT RESULTS IN EARLIER DETECTION OF BREAST CHANGES, REGULAR BREAST SELF-EXAMINATION GREATLY IMPROVES THE OUTCOME OF BREAST DISEASE... h. BREAST LUMPS ARE CAUSED BY CANCER Oc :asionally Frequently Almost Always j Always Q 0 ( 9 0 0 ( i ) CARRY OUT CARRY OUT CARRY OUT 3 4 3 4 3 4 3 4 3 4 3 4 2 3 4 5 6 2 3 4 5 6 210 11. Now that the topic of breast self-examination has been explored could you provide some personal-data to help i n the s t a t i s t i c a l analysis of thi s study. 17. What i s (are) your current occupation(s)? eg. teacher, nurse, homemaker, f u l l or part time student. 18. Do you now or have you ever worked i n the health care f i e l d ? No Yes. What i s (was) the name of your job? eg. nurse, physio-therapist, etc. 19. How old were you at your l a s t birthday? 19 or younger 20-29 30-39 40-49 50-59 60 or older THANK YOU! Your help i n f i l l i n g out this form i s invaluable. Please return your completed form c/o Ingrid Armstrong to the Adult Education b u i l d i n g at 5760 Toronto Road i n the envelope provided AS^SODN AS POSSIBLE. A l l forms should be.returned by MARCH 18, 1983. 

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