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This is to certify that the

dissertation entitled

CORRELATES OF PERFORMANCE OF BREAST
SELF-EXAMINATION IN COLLEGE WOMEN

presented by

Patricia Ponto

has been accepted towards fulfillment
of the requirements for

_Ph'.o. _deg,eein Psycho1ogy_

/ Major professor
Ela1ne Donelson

Date¥ 4/25/85

MS U is an Affirmative Action/Equal Opportunity Institution

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I -‘li

CORRELATES OF PERFORMANCE‘OF BREAST SELF-EXAMINATION
IN COLLEGE WOMEN

by
Patricia Ponto

A DISSERTAITON

Sunnitted to
Michigan State University
in partial fullfillment of the requirements
for the degree of

DOCTOR.OF PHILOSOPHY

Department of Psychology

1985

ABSTRPCT
(IDRRELATES OF BREAST SELF-EXAMINATIQNI IN CIDLLESE W

By

Patricia Ponto

The purpose of this research was to explore the variables that
are related to the frequency of breast self-exanination (8813) by young
wanen. The sample consisted of 195 college women. The following four
factors were investigated, as measured by the instrunents indicated:

a lack of a general preventive health orientation (Lau's 1982 scale);
difficulties with the specific health behavior of BSE: (Stillman's 1977
scale); the lack of a general positive body image (Second and
Jourard's 1953 Body Cathexis Scale), and problems arising from the
focus on the particular body part of the breasts (scales devised by
the researcher). Pearson product-manent correlations and a multiple
regression analysis were employed in testing the hypotheses.

The major conclusion of this study is that frequency of BSE for
these college wanen can be predicted best by an equation utilizing the
following five variables: accurate knowledge and performance of the
basic steps involved in the procedure, anbarrassuent about the
procedure, a lack of perceived susceptibility to breast cancer,
acquaintance with a breast cancer victim, and the impact of sexual
experiences on views of breasts. Frequency of 388 was also positively

correlated at statistically significant levels with knowledge of the

increased risk for breast cancer if relatives have had the disease,
confidence in canpetence to perform BSE, and the importance of her
breasts to the subject.

Practical implications for BSE instruction of college wauen were

discussed. Practical and theoretical directions for future research

were proposed.

Everyone I know told me that writing a dissertation was nuch
easier than writing a master's thesis because one was an experienced
researcher and, presumably, aware of any conflicts with carpetence,
discipline, or whatever . . . Unfortunately, that was not the case for
me; but I learned a good deal once again. Many peOple helped with or
witnessed that learning in important ways. I want to thank sane of
them particularly:

Elaine Donelson, for her curiousity and encouragement, and for
the respect she has consistently shown for me and my work;

Robin Redner, for her patient and careful direction during the
scale construction and data analysis;

Sue DJPUiS and Robin Stein, for their canpetent and enthusiastic
research assistance:

Chuck Green and Jane Dickie, for providing day-to—day boosts
during the final blitz;

Dale Dillavou, for providing day-to-day boosts during the early
days and for introducing me to word processing;

Peggy Walsh, Wendy Fielder, Michelle Klee, and Rondy Scheidt for
offering support and encouragement at many points along the way and
for celebrating the milestones with me;

Gloria Krysiak, for being an old friend who understood well the

importance of finishing and urged me on:

ii

Marty Aldenbrand, for helping me to understand things for a long
time and to fashion tools to continue that process;

Vernon Ponto (Dad), for believing in me over the long haul;

Tan, Sue, and Katie Ponto, for providing a stable and caring
fanily anchor;

and Tan Breznau, for being a wonderful cheerleader and for
providing a rational voice again and again.

It's hard to believe that I'm finished.

iii

TABLE OF C(NTE‘NTS

mm . . . . . . . . . . . .
TABLE OF WI‘ENTS . . . . . . . . . . .
LIST OF TABLES . . . . . . . . . . . .
INTRDIIJCTIQJ . . . . . . . . . . . . .
REVIEW OF THE LITERATURE . . . . . . . . .
Breast Self-Examination . . . . . . . .
Preventive Health Orientation . . . . . .
Body Image . . . . . . . . . . . .
Perceptions of and Experiences with Breasts .
STATEMENT OF HYPOTHESES . . . . . . . . .
METHOD . . . . . . . . . . . . . . .
Subjects . . . . . . . . . . . . .
Materials . . . . . . . . . . . . .
Procedure . . . . . . . . . . . . .
Measurement of Variables . . . . . . . .
The Dependent Measure . . . . . . . .
Independent Variables . . . . . . . .
Tests of the Hypotheses . . . . . . . .
RESULTS . . . . . . . . . . . . . .
Description of the Subjects' Instruction in and
Hypothesis 1 . . . . . . . . . . . .
Hypothesis 2 . . . . . . . . . . . .

Hypothesis3............

iv

ii

iv

vii

15
18
21
32
3'7
37
39
42
43
43
45
49
50
50

59

Hypothesis4.............
Multiple Regression Analysis . . . . . . .
DISCUSSION . . . . . . . . . . . . . .
Introduction . . . . . . . . . . . . .
Overview of Subjects and their Practice of BSE .
Prediction of Frequency of Breast Self-Examination
The Effect of General Preventive Health Orientation
The Effect of Awareness of Breast Cancer and 883 .
Knowledge of Breast Cancer . . . . . . .
Perceived Susceptibility to Breast Cancer . .
KnowledgeofBSE. . . . . . . . . . .
Perceived Benefits of BSE . . . . . . . .
Confidence in Competence to Perform BSE . . .
Social Influence to Perform BSE . . . . . .

The Effect of Body Image and Self-Esteem . . .

The Effect of Perceptions of and Experiences with Breasts

Importance of Breasts . . . . . . . . .
Canfort with Breasts . . . . . . . . .
Attractiveness of and Satisfaction with Breasts
Develognental Experiences with Breasts . . .
Sexual Experiences with Breasts . . . . . .

Experiences Involving Breast Cancer . . . .

Carparison of the Results of this Study to the Literature

Practical Implications . . . . . . . . .
mtum ResearCh O O O O O O O O O O O O
smry O O 0 O O O O O O O O O O O

APPENDICES O O O O O O O O O O O O O O

59
64
70
7O
71
72
75
76
77
79
80
81
81
82
82
90
84
84
85

85

$8

87
9O
93
95

98

Appendix A - Survey of Wanen's Health Beliefs and
my AttitUdes O O O O O O I O 0

Appendix B - Lau's Scale for Preventive Health Orientation
Appendix C - Stillman's Knowledge of Breast Cancer Scale .
Appendix D — Stillman's Perceived Benefits of BSE and

Perceived Susceptibility to Breast

Cancer Scales . . . . . . . . . .
Appendix E -- Knowledge of Breast Self-Examinatim Scale .
Appendix F -— Secord and Jourard's Body Cathexis Scale .
Appendix G -- Rosenberg's Self-Esteem Scale . . . . .

Appendix H -- Correlation Matrix for Variables Entered in the
Multiple Regression Equation . . . .

LIST OF REFERM$ O 0 O O O O O O O O O O O O 0

vi

98
146

148

150
152
153

154

155

156

LIST OF TABLES

1. Basic Demographic Information on Subjects . . . . . . . . 38
2. Measurenent of Frequency of Breast Self-Examination . . . . 44
3. Instruction in Breast Self-Examination . . . . . . . . 51

4. Stimuli for Performance of Breast Self-Examination by
SporadicPerformers..............53

5. Reasons for mrformance and Nonperformance of Breast Self-
EXMimtim O O O O O O O O O O O 0 0 O O I 55

6. Itens Carprising Perceptions Scales . . . . . . . . . . 60
7. Itens Carprising Sexual Experiences Scales . . . . . . . 62
8. Scales involving Past and Anticipated Response to Breast Cancer 63
9. Basis for Decisions to Enter Independent Variables into

Multiple Regression Equation and Means, Standard

Deviations and Number of Subjects . . . . . . . . . . 66
10. Summary of Multiple Regression Steps . . . . . . . . . 69

11. Correlation Matrix for variables Entered in the Multiple
Regression Equation . . . . . . . . . . . . . . 155

vii

Breast cancer is the nunber one cancer killer of wunen,
accounting for slightly more than a quarter of the malignancies in
wanen (American Cancer Society, 1980). It is the leading cause of
death in wanen aged 40 to 44 (American Cancer Society, 1978) and ranks
second to heart disease as the cause of death in wanen of all ages
(National Cancer Institute, 1980). One wcman out of every eleven will
develop breast cancer at sane time during her life (American Cancer
Society, 1980).

There is no known definitive cure for breast cancerf The best
hope for decreasing mortality and improving Lrggw lies in early
detection of the disease. At present, there are three camIonly
available methods of detection. They are: 1) physical examination of Eat;
the breast by the mnan or her physician; 2) nianmography, a soft
tissue x-ray of the breast; and 3) thermography, an infra-red
tanperature picture of the breast. Though there is considerable
dispute about the relative efficacy of these methods, breast
self-examination (hereafter, BSE) is usually viewed as a simple,
econanical, safe, consuner-involved aid to early detection (Keller,
George, and Podell, 1980; Lowe, 1977; Miller, Norcross and Bass,
1980). As such, BSE has been strongly promoted, especially over the

last decade, by such major health organizations as the American Cancer

Society, the National Cancer Institute, and Planned Parenthood.

During that time period, significant strides have been made in
informing wanen of the importance of BSE and in increasing the number
of wanen who perform BSE on at least an occasional basis. There is
still, however, nuch work to be done, as indicated by a National
Cancer Institute survey oanpleted in 1979. The results of that poll
revealed that 96% of the wanen surveyed knew of BSE, 77% had practiced

A—N_-

Wt once and 40% practiced it monthly Those percentages were

WMWH....u v-r-

higher than the results fran a similar poll done in 1973 that
indicated 77% of the wanen surveyed knew of BSE, 55% had performed it
at least once, and 18% performed it on a regular monthly basis.

The improvement in the level of wanen's knowledge and performance

in the five years between polls is clear. The needs to increase the

“A“... ..._,._‘_
""‘"‘-—-rr-W..—»—..- “—mri

40% of regular monthly performance, to understand why 37% of the wanen

who have performed BSE do not continue to do so, and to discover why
56% of the wanen who are informed of BSE do not regularly practice it
are clear to the majority of those involved in this work (Hall,
Goldstein & Stein, 1977; love, 1977; Miller, Norcross & Bass, 1980:
National Cancer Institute, 1980; Nichols & Waters, 1983). Research is

needed in such areas as the reasons for performance and

R—fi--..._.4._

non-performance, the variables that differentiate mrformers fran
a“

non-performers, and the most effective educational techniques. It is
the purpose of the current study to address the first two of these

issues with respect to a pOpulation of college-aged wanen.

REVIEW OF THE LITERATURE

Breast Self-Examination

 

Muchoftheresearchthathasbeendone intheareaofBSEhas
been conducted in the last ten years and has centered on
identification of demographic variables and other correlates that
differentiate performers fran non-performers and on documentation of
the reasons for non-performance (Reddy, 1984: Zapka & Mamon, 1982).
Exanination of these investigations reveal several broad areas of
interest: thics, other health behaviors, awareness of breast

. _u-.n~o.—
,._.—...«.--.-~ “1..., —.-. .e. H vm .—....‘ ,- ‘uw gm .u’m- -m.

cancer, awareness of BSE, and stated reasons for non-performance.

The major demographic variables that have been investigated are
age, education, socioeconanic status, and marital status. Fran her
review of the literature, Reddy (1984) concludes that "Danographics .
. . appear to bear no consistent relationship to BSE” (p.- 3).

”MThe most frequent finding in the investigation of the
relationship between BSE and age shows younger wanen performing BSE

more often than those older. In a large scale study (N_=726), Marchant

_.____.,_ " n 'w «an «mi
I ah

and Neuroth (1978) foind wanen under 40 more likely to examine their 1 $991"
breasts than those over 40. In a second large scale study (N=1,216) ‘11") , 5“,)
done by Senie, Rose, lesser, and Kinne (1981), pre-menopausal wanen
were more likely to perform BSE than those older. Similar

associations have been found by Celentano and Holtzman (1983), Nichols

and Waters (1983), and Roberts, French, and Duffy (1984). Scilken

(1977) and Roach and O'Fallon (1983) found, in contrast, no link
between BSE performance and age of subjects. Edwards (1980), Miller,
Norcross, and Bass (1980), and Stillman (1977), found higher BSE
performance rates among their over 40 subjects. Finally, Howe (1981)
in another large scale study (_lg=708) found the highest percentage of
wanen who never perform BSE and the highest percentage of those who
perform it more frequently than once a month in her subjects over the
age of 40.

The variable of educational level has shown similar discrepant
findings. The majority of studies link frequency of BSE to higher
educational level: Howe (1981), [owe (1979), Miller et a1. (1980),
and Senie et al. ( 1981). Scilken (1977) did not find a relationship
with education, but states that such a difference may have been
obscured by her requiranent of a high shool diplana for participation
in the study. Roach and O'Fallon (1983) also report that educational
level and BSE were not significantly related in their investigation.
Finally, Edwards (1980) found the highest frequency of BSE among her
subjects with less than a high school education.

There was no significant relationship between socioeconanic
status and BSE frequency found in studies by Huguley and Brown (1981),
McCusker and Morrow (1980), and Reeder, Berkanovic, and Marcus (1980).
Celentano and Holtzman (1983) did find such a link with “more affluent
airmen" reporting more frequent BSE (p. 1321).

A statistically significant relationship between BSE performance
and marital status was found by McCusker and Morrow (1980), Senie et

a1. (1981), and Howe (1980). In the first two studies, those wanen

who were presently married reported more frequent BSE performance than

those who were not. The third study revealed a significant
association between marital status and limp—detecting ability, with
those presently married shoving greater lunp—detecting ability than
those not. Celentano and Holtzman (1983) did not find a difference in
BSE performance based on marital status.

In sunnary, this review of the literature suggests that the
denographic correlates of age and education show the most consistent
relationship to BSE.

A second broad area of correlates of BSE that has been
investigated relatively heavily is that of other health behaviors.
Senie et a1. (1981) found a link between frequency of medical
examinations and frequency of BSE. Howe (1981) found significant
positive relationships between frequency of BSE and both medical
preventive health behaviors (defined as preventive health behaviors
that require a visit to a physician) and autonanous preventive health
behaviors (defined as those health practices than can occur
independent of medical visits). Lowe (1979) studied the particulars
of medical consultation and found three categories of wanen who
perform BSE less often: twose who are less likely to visit a
gynecologist than another type of physician, tlgse whose doctors less
frequently examine their breasts for them, andgthose who feel less
canfortable discussing health concerns with their physicians.
McCusker and Morrow (1980) report a link between frequency of BSE and
subjects' satisfaction with health care and theexistence of a
preventive orientation in their health care providers. In contrast,

Celentano and Holtzman (1983) found no link between medical care

utilization (including visiting an obstetrician-gynecologist or having

a personal physician) and frequency of BSE.

Investigating other specific health behaviors, Haran, Hobbs, and
Pendleton (1981) found a link between BSE and the requests for chest
x-rays and cervical anears. They conclude: “It seems fairly clear,
therefore, that current awareness of BSE is linked with previous
health behavior where the initiative for seeking screening reSts with
the individual" (p.107). Roberts, et al. (1984) found knowledge of
BSE was related to the following previous health care behaviors:
wearing of seatbelts, regular dental check-ups, and seeking of
cervical smears.

A third group of correlates that has been investigated centers on
awareness of breast cancer: knowledge of the disease, perceived
vulnerability to it, and a personal or family history of it.

Knowledge of breast cancer, particularly the risk factors it

involves and its symptans, canprises the first of these factors.

Again, the findings are inconsistent. Knowledge of breast cancer was

MW‘
MW

 

 

found to be related to BSE performance by Spring and Kosch (1982) in

.W 9M“ “"“""" '

 

M.

their sample of benign breast disease patients. Roberts et a1. (1984)
investigated general knowledge of breast cancer and its relationship

1’ wa—

to "know-how” of BSE technique. They concluded: "There was a marked
andgign1f1cant asymmetry in the relationship between the two types of
score, indicating that good general knowledge (of breast cancer) was
not always matched by good know-how (of breast self-examination)" (p.
795). Focusing more specifically on breast cancer syuptans, Celentano
and Holtzman (1983) found that knowledge of warning signs was

unrelated to BSE canpetence in their study. In contrast, awareness of

risk factors was found to be related to BSE performance by Glenn

( 1981) and Stranborg (1981). Stranborg notes the particular
inportance of knowledge of genetic predisposition, stating that this
risk factor is one of the most important and most ccnuonly recognized.

Issues of susceptibility and vulnerability to breast cancer have
also been investigated. Spring and Kosch (1982) found perceived
vulnerability to be an influential factor in BSE performance,
particularly in their sample of benign breast disease patients.
Edwards (1980) explains her finding that older wanen are more frequent
practicers by pointing to the possibility that younger subjects might
not perceive the same degree of susceptibility. Celentano and
Holtzmann (1983), however, found BSE canpetence to be unrelated to
perceived susceptibility.

Another correlate that has been investigated is thewindiyidual's
personal history with breast problems/disease and familial history
with—breast cancer Roberts et a1. (1984) found that their subjects
with personal experience with breast problans knew moreabout breast
cancer and ahour’lBiSEiutechnique‘ thanflthose without E1155 experience.
Senie et al. (1981) also found a signficiant relationship between BSE
frequency and prior benign breast disease. Senie et al. and Huguley
and Brown (1981) found that a history of breast cancer in the family
related significantly to BSE practice and frequency. In contrast,
Roach and O'Fallon (1983) found no association between frequency of
BSE and prior contact with cancer. Finally, Worden et a1. (1983)
foind that wanen with a family history of breast cancer knew more
about breast cancer than other wanen, but performed BSE slightly less
frequently than the others.

In sutmary, the relationship between frequency of BSE and the

\
three variables involving awareness of breast cancer (knowledge,

1 3 “WM“
perceived vulnerab111ty, personal or family history) is inconsistent.

“M-..—

 

I,“ "W

Awarenesspfi BSE. is the fourth major area of investigation and

includes three variables: knowledgew of BSE, confidence in carpetence

._.. “An“.

 

"M“ ‘-" -— .‘.~. ~,

to perform BSE, and social influence to perform it. The Hknow-hav

 

 

 

score of the Roberts et a1. (1984) study cited earlier introduces the
inportant variable of knowledge of the breast self-examination
procedure. A further finding of the Roberts et a1. study was that
men who had tried BSE showed significantly higher ”know-how” scores
than those who had not. In contrast, Edwards (1980) did not find a
significant relationship between knowledge of BSE and frequency.
Spring and Kosch (1982) note very generally that ”knowledge of BSE:
influences behavior" and Kelly (1979) cites a lack of knowledge of the
procedure as a major reason given by her subjects for their
non-performance of BSE. Further consideration of knowledge of
technique and efforts to measure it appears in a later section
concerning frequency and proficiency.

Confidence in ability to perform BSE or to detect breast
abnormality has been relatively consistently associated with BSE
frequency. Fran her review of the literature, Reddy (1984) concludes
that personal confidence about performing the technique is an
inportant factor in determining both BSE frequency and proficiency.
Spring and Kosch (1982) agree, citing confidence as one of three major
factors (with perceived vulnerability and knowledge of the procedure)
influencing performance of BSE. Celentano and Holtznann (1983),
Edwards (1980), Keller et al. (1980), and Zapka and Mamon (1982) also

report statistically significant associations between BSE: frequency

and level of confidence. Zapka and Manon add a note of caution,
however. They found that few of their subjects who did BSE and
reported confidence in their technique actually performed the
procedure correctly and thoroughly. (Their evaluation of performance
focused on the number of positions and minutes involved in the
examination.) Howe (1980) reports the only negative association
between confidence and BSE performance. It is a difference that
underscores Zapka and Mamon's point. She found no statistically
significant association between wanen's confidence in noting breast
cancer symptans and their lunp detection ability.

The issue of social influence to perform BSE has been alluded to
frequently but rarely studied. Howe (1981) found that 10% of her
sample experienced no social influence to perform BSE, and 38% had
only one or two people who influenced their practice of BSE. She
wonders if "this lack of social influence and support may leave wanen
unsure about the acceptability or normativeness of doing BSE" (p.
254). Worden et a1. (1982) attribute the success of their educational
programs to the supportive wanen's club contexts in which they took
place. Their explanation is as follows: "Perhaps a wcman in the
audience felt some unusually strong peer influence as she gathered
with friends in a neighbor's bane, discussed her views on personal
health problems, and for weeks afterward was reminded of her
experience as she saw her friends in her daily routine" (p. 338).
They suggest that future skills training be conducted in a context in
which influential peers show high social approval, so that BSE canes
to be perceived as a social norm and to be motivated by that

perception.

10

In summary, confidence shows a relatively consistent, positive
relationship with reported BSE frequency. Social influence has not
been studied often, but there is sane indication that a lack of it is
associated. with non-performance of BSE. The relationship between
knowledge of BSE and frequency of performance is more inconsistent.

The final area of investigation to be reviewed has, as its focus,

 

 

 

sWor non-performance. A nunber of variables considered
above (lack of perceived vulnerability to breast cancer, lack of
knowledge of BSE technique, lack of confidence in carpetence to
perform BSE) are cited as reasons for non-performance. In addition,
the following three factors have been stated frequently and
investigated: inhibitions about BSE, forgetfulness, and a factor that
ccmbines fear, anxiety, and worry.

Sunmarizing the research on inhibitions about performing BSE,
Reddy (1984) notes that embarrassment about BSE has been
"inconsistently associated" with BSE performance. Zapka and Manon
found modesty to be an important personal barrier to BSE performance.
They found that their subjects who strongly disagreed with the
statements that examining their breasts was embarrassing, that they
were uncanfortable touching their breasts, and that they were
eubarrassed about a physician examining their breasts, were more
likely to perform BSE regularly than those who agreed with those
statenents. Worden and his colleagues (1982) described wcmen
admitting to inhibitions as a major sensitive subgroup. They found
that these wanen were as informed as others about breast cancer and
that they increased BSE frequency as a result of a persuasive appeals

educational program; but that their increase in frequency was not as

11

large as the non-inhibited group. Worden and his colleagues suggest
that an important research direction is an examination of the
“underlying factors that may aid in persuading such women to perform
BSE" (p. 338). Howe (1981) found nodesty (operaticnalized as
discanfort talking about breast concerns) to have a nearly linear
negative association with BSE frequency. Stillman (1977) and
Stranborg (1981) also found a negative relationship between BSE:
frequency and arbarrassment about the procedure. Miller, Norcross,
and Bass (1980) broaden this area sanewhat by concluding that not only
examination by self and others, but also uneasiness about the body in
general are important areas of investigation in understanding BSE. In
contrast to Reddy's conclusion, then, this review of the literature
suggests that embarrassment is consistently related to non-performance
of BSE.

Forgetfulness has also been cited frequently as a factor in
non-performance of BSE. Olenn (1981), for instance, found
forgetfulness and lack of confidence to be the two major reasons for
irregular BSE practice in her sample of wanen taught the procedure by
a nurse as part of a visit to a physician. Turnbull (1978) and
Keller, George, and Podell (1980) surveyed wanen of varied ages and
report that approximately two-thirds offered forgetfulness as a reason
for their non-performance of BSE. Similar results have been found
with college students (Medical World News, 1980). Carstenson and
O'Grady's (1980) investigation of high school students revealed that
forgetulness was the major reason for non-carpliance with BSE. These
researchers point to a contrast between their young subjects and older

wanen who ”voiced fears or embarrassment as reasons for

12

non-canpliance" (p. 1294). Keller and her colleagues are intrigued
by the role of forgetfulness in the non-performance of BSE and
hypothesize that it may be related to the next factor to be considered
in this reviewrof the literature, that of fear, anxiety, and worry.

About the final reason of fear, anxiety, and worry, Reddy (1984)
concludes that “Fears of discovering breast cancer and breast loss
have been found to impede BSE: in sane studies, but not in others"

(p. 4). Researchers reporting that BSE is impeded by this factor
include Keller, George, and Podell (1982), Wbrden et al. (1982), Kelly
(1978), Stillman (1977), and Thrnbull (1978). Keller and her
colleagues cite fear and anxiety as one of three major factors in
non-performance (along with ignorance about the importance of BSE and
lack of specific knowledge about BSE). Worden and his colleagues
describe anxieties related to breast cancer and breast cancer
treatment as a major "disincentive” to BSE (p. 338). Kelly, Stillman,
and TUrnbull each found that about one-fourth (26.8%, 22%, 23%,
respectively) of their subjects cited the frightening nature of the
examination or the worry that it caused as reasons for
nonsperfonmance.

In contrast, Haran, Hobbs, and Pendleton (1981), who expected to
find current anxiety concerning breast cancer would be inversely
related to awareness of BSE, actually found the opposite: a “slight
association” between being worried about breast cancer and higher
awareness of BSE (p. 107). Similarly, Siero, Kok, and Pruyn (1984)
found that intention to perform BSE increased as fear of breast cancer
increased. They did not observe such a direct relationship to

behavior, but conclude that ”there are no clear indications that fear

13

inhibits canpliance with the reommended behavior“ (p. 887). Again,
as Reddy indicates, the findings linking perfonmance of BSE
*with the variablelof fear, anxiety, and worry are inconsistent.

The areas of investigation into the non-performance of BSE
obviously cover a great deal of information. The information can be
organized into several major approaches to understanding the problem.
The first approach, which results fronnthe investigation of the
relationship between BSE and other health behaviors, is that a lack of
a preventive health orientation may be a major factor in the
non—performance of BSE. The second approach attanpts to draw together
the various findings about breast cancer and BSE and suggests that
non-performance may result not so much from a lack of a general health
orientation, but rather fron specific problens with breast cancer or
BSE. A third approach is derived frcm the stated reasons for
non-performance of inhibition, forgetfulness, and fear, anxiety, and
worry. These variables are particularly intriguing to the researcher
as they appear to be less clearcut or definite than the earlier
factors which focus on behaviors or awareness of factual information.
These final variables are also interesting in that at least two are
affect-laden (inhibition and fear, anxiety, and worry), while the
third may be if Keller and her associates are accurate in their
assessnent that the cannonly reported reason of forgetfulness is
related to fear, anxiety, and worry. The more vague and affective
tone of these factors suggests the interesting hypothesis that
underlying psychological processes may figure significantly in wanen's
failure to perform BSE.

That notion is supported and extended by the authors of the

14

National Cancer Institute publication, Breast Cancer Dig_e_st. In 1979,

 

they wrote:
Much more research needs to be conducted on the
psychological variables that influence wanen's avoidance

of BSE. Studies are needed to docunent what subconsciois

factors influence a wonan's emotional response to

information about breast cancer and to suggestions

concerning detection processes (p. 60).

The extension of the notion is, then, that the psychological factors
or processes may include unconscious elanents.

This approach also gains support fron studies conducted in the
related area of delay in seeking medical care for breast
abnormalities. Delay, especially that between the wonan's original
awareness of symptcms and her pursuit of medical advice, is regarded
by most investigators as a very significant problem area. Gold
(1964), Buls, Jones, Bennett and Chan (1976) and Margarey, Todd, and
Blizard (1977) all conclude that underlying psychological processes
are an important factor in delay. Margarey et a1. write:

“the practice of BSE and the delay of wanen with breast symptons are
determined by factors beyond COHSClClJS awareness and control”

(p. 231). They suggest that in future research about the practice of
BSE, ”attention must be directed towards non-rational unconscious
factors" (p. 234).

Clues about the underlying processes or unconscion factors
involved in wanen's avoidance of BSE might be discovered by exploring
women's perceptions of their breasts and experiences with them. Such
investigation is supported by the work that has been done on the
importance of satisfaction and experience with bodies to body image

and view of the self. That information will be presented in a

following section as support for the exploration of breast

15

perceptions and experiences and for two additional reasons. First, at
least one study (Scilken, 1977) has linked body image to’BSE;
investigation of body hmage in the current study could, then, serve as
a replication of that work. Secondly, investigation of general body
image may serve as an important canparison point for the more specific
focus, the breasts. The question underlying this comparison is: Is
overall body image the important underlying variable or is there
something about this specific body part (the breasts) that influences
wanen to avoid BSE?

In the current study, the problem of lack of performance of BSE
by this group of young wanen will be approached fran folr
perspectives: their general preventive health orientation, their
views toward BSE specifically, their feelings about their bodies in
general, and their descriptions of their perceptions and experiences
with their breasts in particular.

The difficulties with this health practice have already been
described. In addition, sane of the work done in the general
preventive health orientation area has been introduced. The remainder
of the literature review will focus first on the theoretical
underpinnings of the general preventive health orientation and its
specific application to BSE. .A consideration of the impact‘of body
image and an introduction to the important perceptions of and
experiences with breasts will follow.

Preventive Health Orientation

Full understanding of BSE must place it in its context as a

preventive health behavior. A theoretical framework for explaining

preventive health behavior has been developed by Hochbaum,

16

Leventhal, Kegeles and Rosenstock (cited in Maiman and Becker, 1974).
Since its developnent, the framework, called the Health Belief Model
(HEM), has served as the theoretical base for a number of studies
related not only to preventive health behaviors (Rosenstock, 1974),
but to illness (Kirscht, 1974), the sick role (Becker, 1974), and
chronic illness behavior (Kasl, 1974).

The»model proposes that for a person to take a preventive health
action, he/she must 1) be in a psychological state of readiness to
take action and 2) believe that the specific action would be
beneficial. The psychological state of readiness contains two
elements: the person must believe that he/she is personally
susceptible to the disease (perceived susceptibility) and that the
disease would have at least moderately serious consequences (perceived
severity). The benefits of the specific action could include either
reducing the susceptibility to the disease or reducing the seriousness
of the disease should it occur (perceived benefits). The model
further proposes that if a person believes himself/herself to be
susceptible to a disease that is also serious in consequences, a force
exists motivating him/her to action. Whether the action is taken
depends on the individual's subjective beliefs about its effectiveness
and benefits. Thus, negative aspects of the action (e.g., painlor
anbarrassnent) may prevent positive action from occurring, even when
readiness to act (the combination of perceived susceptibility and
severity) is high.

In addition to the awareness of perceived susceptibility,
severity, and benefits, the model proposes that a cue to action is

necessary to trigger the desired health behavior. The cue can be

17

internal (e.g., a sympton) or external (e.g., advertising). The
intensity of the cue necessary for action varies according to the
individual's level of readiness.

Stilhman (1977) and Hallal (1982) have applied the Health Belief
Model to breast self-emination. Fran her review of the literature,
Hallal concluded that the HEM factor of perceived severity need not be
studied because other research has demonstrated that cancer is always
perceived as maximally seriois (Haefner and Kirscht, 1970; Kegeles,
Kirscht, Haefner and Rosenstock, 1965). She and Stilhman both
investigated the relationship between BSE performance and perceived
susceptibility to breast cancer and perceived benefits of BSE.

Stillman studied 122 wanen aged 20-59. She designed an
instrunent based on the HBM that measures perceived susceptibility to
breast cancer and perceived benefits of BSE. She found that 87% of
the sample scored in the high range for perceived susceptibility to
breast cancer and 97% in the high range for perceived benefits of BSE.
Thus, there was little discrimination among subjects on these
variables. The analysis of the relationships between these high
beliefs and practice rates revealed, interestingly, that approximately
1/3 of the subjects had high beliefs and high practice rates, but
about 1/4 had high beliefs and never practiced BSE. One of the major
conclusions of Stillman's study, then, was that it is difficult to
”state unequivocally that beliefs cause behavior in this situation”
(1977, p. 126). Stillman notes further that 65% of her subjects who
showed high perceived susceptibility practiced BSE to sure extent

while 85% of those with high perceived benefits beliefs did so.

18

Hallal's sample consisted of 207 wanen aged 18 years or older.
She used Stillman's health beliefs instnment and found a significant
positive correlation between practicing BSE and obtaining higher
scores on both subscales. She reports a ”more impressive level of
significance“ (p. 141) for the ”Perceived Benefits“ scale than for the
”Perceived Susceptibility" scale. She concludes that sane wanen who
hold a high belief in susceptibility to breast cancer may be so
frightened by their belief that they are nonpracticers as a form of
denial.

Both Stillman and Hallal studied a wider age range of wanen than
will be included in the current investigation. It will be interesting
to oonpare the responses of these late adolescents/young women to
those they obtained. Of particular interest should be the perceived
susceptibility ratings. It seems unlikely that these young wanen will
perceive thanselves as particularly susceptible to breast cancer or
any other physical illness. Their lack of perceived susceptibility
(based largely on an accurate reading of epideuiology) may interfere
significantly with their developnent of a preventive health
orientation generally and, more specifically, with the practice of
BSE.
may:

The concept of body image is an important one in both
neurological and psychological/psychiatric theory. The original
source of information on body image was the neurological clinic.
Neurologists were interested in the distortions in body image of
persons with disease conditions and amputations. The interest of

psychology and psychiatry in body image initially centered on the

19

body image distortions of persons with psychiatric disorders like
schizOphrenia.

A review of the body image research by Schilder (1950) revealed
that body image is developed from sensory inpressions, nuscle tone,
perception of gravity, pain, action, and interest of others toward the
body, and any other clues the individual receives about his/her body.

Fisher and Cleveland (1968) did a second major review of the body
image literature. They defined body image as ”an image of his (sic)
own body which the individual has evolved through experience“ (p. x).
The image evolves, in their opinion, fron the many experiences of the
individual with his/her body and through the reactions of others to
the body. Fisher and Cleveland, then, anphasized the importance of
psychological factors in the formation of body image.

Another approach to the way persons perceive their bodies is that
taken by Secord and Jourard (1953). Believing that an ”individual's
attitudes towards his (sic) body are of crucial importance to any
conprehensive theory of personality” (p. 343) , these authors have
focused on body cathexis, the degree of expressed feeling of
satisfaction with the various part or processes of the body. They
hypothesized that feelings about the body are carmensurate with
feelings about the self. Negative feelings are, then, associated with
anxiety and feelings of insecurity involving the self.

Scilken (1977) enployed this hypothesis of Secord and Jourard in
her investigation of BSE. She extended the idea of a negative
relationship between body satisfaction and anxiety over the body to
suggest that the less anxious person, who has more positive feelings

aboit her body, "will not find self-examination excessively

20

threatening" (p. 20). Scilken found the link that she predicted
between BSE: and body cathexis; i.e., that wanen who self-examined
their breasts expressed more satisfaction with their bodies than those
who did not. This finding was, in fact, her single significant
. result. Scilken concludes and this researcher concurs that:
It seems reasonable that a person who expresses
satisfaction with her body would behave in a manner

congruent with maintaining the body in a healthy state.

Since she is generally satisfied with her body, the risk of

finding an irregularity would not be a cause for excessive

concern (1977, p. 21).

Reasoning in a fashion similar to Scilken and in the related area
of view of self, Hallal (1982) investigated the impact of self-concept
on BSE: practice. She hypothsized that "a person with a higher
self-concept level would be more concerned with health in a general
way” (p. 138) and, thus, likely to have a more positive attitude
toward good health practices (including early detection behaviors like
BSE). She also hypothsized that a "person with a higher self-concept
level might perceive the bodily touching necessary to perform BSE as a
nonembarrassing activity“ (p. 138). Her findings revealed a
significant positive correlation between frequency of BSE and overall
self-esteem. In addition, the measure of overall self-esteem was the
strongest predictor of BSE: practice, accounting for 12% of the
variance in her sample. The instrunent Hallal used (Tennessee
Self-Concept Scale) also allowed her to differentiate various aspects
of self-concept. In support of Scilken's work with body image,
Hallal, too, folnd a significant, positive correlation betwen physical

self-esteem and frequency of BSE.

21

Perceptions of and Ehrperiences with Breasts

 

 

There is very little research information directly concerning
wanen and their perceptions of and experiences with their breasts.
There apwam to be sane awareness among researchers of air culture's
preoccupation with breasts, especially with an idealized sexual view
of than. The implications of the preoccupation and the impact of the
idealized sexual view on women and their perceptions of their breasts
have been studied rarely, hoever. The major experiences of yoing
wanen with their breasts are breast developnent at puberty and,
possibly, sexual experience that involves breast manipulation. The
importance of early breast developnent has been a subject of sane
theoretical concern, but has not been researched anpirically to any
large extent. There is even less theoretical and empirical
information relating sexual experiences to views of breasts. A third
potentially important experience with breasts is knowing a breast
cancer victim and sharing that experience. Although the link between
BSE and familial history of breast cancer has been investigated, a
more detailed exploration of the impact of that experience has not
been done. Mastectany has been studied more extensively. Information
about its impact on the wanan herself may be useful in understanding
the inpact of the experience on those close to her.

The view of the breast that predaninates in this culture, if one
is to judge on the basis of magazines, billboards, and
television cannercials, is an idealized sexual view. Jesser (1971),
whose major interest is breast attention, underscores the media's use
and the culture's preoccuption with breasts: "It is undeniable that

breast display, concern, and attention are widely institutionalized

22

activities in our society and that the motifs suggesting this are
frequently found in the plethora of messages fran the mass media" (p.
13). Margaret Mead (1949) also cannented on this culture's anphasis
on breasts. Although observing a universal awareness of the
significance of breast developnent in faninine psychology, she found
that in the United States, the breast is so idealized that it has
beoane the primary source of identification with the fanale role.

Orr culture's preoccupation with the ideal sexual view of breasts
appears to be widely acknowledged, but not studied directly or
rigorously. A unique, non-scientific investigation of breasts is
found in one of the few books devoted exlusively to breasts, which is

entitled Breasts: Wanen Speak about their Breasts and their Lives

 

(Ayalah 8 Weinstock, 1979). This book began as a photographic essay
when the authors became aware of the extensive use of idealized
breasts in the media world of advertising in the United States. They
set out to produce a photographic catalog of real breasts of wanen of
all ages as "an antidote to the standard media images" (p. 10) and as
an effort to ”help nurture in wanen an acceptance of their on breasts
and an appreciation of the uniqueness and dignity of individual
bodies“ (p. 10). As they started their work, the authors found that
the wanen who were their subjects wanted to talk about themselves and
their experiences with their breasts during the photo sessions and
that one remark wolld lead to a flood of other associations, including
the apparent surfacing of many buried feelings and memories.

Listening to the wanen speak, the authors were struck by the link
between wanen's feelings about their breasts and about themselves.

They noted "nunerols and varied instances of causality which linked a

23

wanan's breasts to her personality or life-style" (p. 24). They were
also “amazed at how basic and profoundly fundamental the experience of
having breasts actually was in wanen's lives” (p. 24). Their original
plan for the book was modified to include the men's stories as the
authors “realized our book was not only about women's breasts, but
also aboit wanan's lives today, and the timeless experience of being a
wanan" (p. 24).

The inportance of breasts to wanen's views of themselves and
their lives is, then, arphasized by Ayalah and Weinstock. The notion
was also presented by weiss (1976). She quotes an unnamed
psychiatrist as stating "A wanan's attitude toward her breasts is a
localized focus of her feelings about herself as a whole. Her
feelings are related to her entire background, family attitudes, and
emotional developnent" (p. 15). Weiss herself calments further: "A
wanan's reaction to her breasts is a canplex auction. It affects her
total self-image, her sexual view of herself, and her reaction to
other wanen as well as men" (p. 9). Weiss, then, underscores Ayalah
and Weinstock's impression of the distinct importance of a wanan's
feelings about her breasts to her sense of herself. She suggests, in
addition, the complexity of those feelings and the interpersonal, as
well as the intrapsychic, dimension of the feelings.

The theoretical notion that links women's feelings abolt their
breasts to their concept of thanselves has received sane atpirical
support fran a study of college wanen by Lerner, Orlos, and Knapp
(1976). They foind that the ratings these wanen gave their breasts
served as a significant predictor of their self-concept. In their

multiple regression analysis, chest was the third body part to enter

24

the equation (after face and waist) predicting self-concept. It
accounted for an additional 2.08% of the variance (the entire
prediction equation, which involved five variables, accounted for
22.32% of the variance).

In addition to the relationship between perception of breasts and
self-concept, a second important aspect of breast perceptions involves
a consideration of the psychological impact of the culture's ideal
sexual view on women's views of themselves.

Again, this aspect of breasts has not been well studied. Fran
the stories the wanen tell in the Ayalah and Weinstock book, it seems
that many women, probably nest, spend a good bit of time at sane point
in their lives thinking about the discrepancy between this current
cultural ideal and their own very real breasts. In two anpirical
studies, one focusing on reasons for manmaplasty and the other on
recalled breast developnent experiences, the importance of the ideal
view is also considered.

Wanen seeking augmentation manmaplasty essentially choose surgery
in an effort to more closely approximate the sexual ideal. Beale,
Lisper, and Palm (1980) studied sixty-four wanen about to undergo
augnentation manmaplasty because of small or sagging breasts. They
found that these wanen lacked the ability to view their own bodies
realistically and connected the appearance of their breasts to feeling
unfeminine. The authors also found that the wanen seeking
augnentation surgery canpared themselves and their bodies to others
nuch nere than did the twenty-five wanen in their control group. The
wmen, then, appeared to be both preoccupied with the sexual ideal and

convinced of its relationship to their own experience of fanininity.

25

In studying college women who were recalling their adolescent
experience of breast developnent, Kelly and Menking ( 1979) foind that
nearly half of the wanen were dissatisifed with their breasts, nestly
because of size. They also found that nearly half of their subjects
had an ideal in advance of or during their own breast developnent and
that those without an early ideal view were nere likely to feel
satisfied with their breasts at present. Finally, they found that
observation of other real breasts - nest importantly, those of the
subjects' mothers - seared to lead to nere realistic expectations.
These data, then, also suggest the possible negative effects of an
ideal view and the importance of a more realistic appraisal.

Having looked at perceptions of breasts and, in particular, the
culture's idealized sexual view of them, the three experiences with
breasts will be considered next. As noted earlier, the impact of
breast development, the first of the three experiences, has received
sane theoretical consideration, but little empirical investigation.
Benedek (1979) emphasized the latter in her contents about the
dilenmas in research on female adolescent development: "More data
need to be collected about adolescent girls' attitudes toward breast
develognent, a long-neglected topic in psychological research about
female adolescents and adults" (p. 17). Given that neglect, what is
currently known/hypothesized about female adolescent breast
development?

First, the importance of breast development seems to rest mainly
on its nature as the first secondary sex characteristic that is
visible to both the girl and the rest of the world. Benedek notes:

"since fanale genitals cannot be observed, the body parts that are

26

visible to the self and others, the breasts, cane to occupy an
inordinate aneunt of psychic space” (p. 236). She further describes
the impact of breast developnent:
Breast developnent tends to be a sensitive and
aretionally laden aspect of body change for nest girls. It

is of note that with breast growth, a new body part is

added, going well beyond merely enlarging an existing

structure. No wonder the breasts are often dissociated fran

the rest of the body for quite sane time, experienced as

“not-me", as appendages that don't quite belong - yet. The

breasts represent sexuality, the nest overt signal to self

and others that the body is maturing. Thus they often

becane the focus for conflict related to sexual feelings.

Since they also represent nethering or the possibility of

nurture, they are a concrete symbol of the dual nature of a

wanan's sexuality (p. 244).

Benedek's second point, then, centers on the newness of this body
part, the difference that the change in structure brings, and the
difficulty in integrating the change. Faust (1979), too, describes
the importance of sane of these change aspects of adolescent breast
developnent: ”Fran the standpoint of the developing person, the
termination of childhood and the imninence of puberty are signalled by
obvious external changes, sane of which are qualitatively different
and discontinuous with one's earlier appearance, for instance, the
beginning of breast develognent . . ." (p. 428). Rosenbaum also
addresses the issue of the bodily transformation at puberty and
concludes that it brings about a change in the " 'cchesive sense' of
the body itself and requires several revisions of the body gestalt"
(1979, p. 235).

A third issue that Benedek addresses is that of the breasts as

representative of the “dual nature of a wanan's sexuality” (p. 244).

Rosenbaum picks up this thane and, in describing "The changing body

27

image of the adolescent girl,“ speaks to the ”need to integrate the
dual image: acceptance of the body as sexually active and potentially
child-bearing“ (1979, p. 236). Bardwick (1971) also addresses both
issues. She suggests, first, that the "extraordinary change in her
sexual body at adolescence“ is “perhaps the single nest significant
threat to a girl's mature sexuality“ (p. 48). Second, she states her
belief that adolescents are very anbivalent about the reproductive
functions of their bodies and that “The resolution of this crucial
ambivalence toward the sexual body is a task that extends beyond
adolescence . . . and affects . . . their general level of confidence
or self-esteem" (p. 52).

Following the initial breast developnent, the second major set of
experiences with their breasts that young wanen are likely to have in
this culture are sexual in nature. Interestingly, even less
information is available about the impact of these experiences on
young waren's views of their breasts than about developnental
experiences. That many of these yolng wanen college students have
had or would be currently involved in sexual experiences receives
support fran Kallen and Doughty (1982) who report that 55% of the
females in their college student sample reported having had sexual
intercoirse. Mahoney (1979) found that 90% of the female college
students in his survey reported that they had experienced manual
stimulation of breasts by a male and 82% reported oral stimulation of
breasts by a male.

Only one study known to this researcher cannents on the
relationship between sexual experience and views of the breasts

Specifically. One other study connects sexual experiences to views of

28

the body as a whole.

Kelly and Menking ( 1979) address the issue specifically by
focusing on the inpact of early petting experiences on yoing wanen's
views of their breasts. They hypothesize that:

Petting experiences might serve as highly individualistic

soirces of tactual feedback with regard to one's physical

self. Because petting or tolching experiences are nest

often viewed positively, feedback with regard to breasts

is probably positive. These individualistic touching

‘ experiences might well be the key to mitigating social

stereotypes with regard to breast ideals . . . (p. 23).

Kallen and Doughty (1982), in their study of self-perception,
weight, courtship behavior, and self-esteem, address the impact of
sexual experience on college students' views of themselves generally.
They found that female virgins showed lower self-esteem and saw
thanselves as less physically attractive than non-virgins. They
hypothesize that the higher self-esteem and perception of physical
attractiveness is a result of:

. . . those involved in a sexual relationship . . .
(receiving) . . . feedback about the physical self fran a
Specific other; the fact that the other finds pleasure in
the body provides sane feedback about one's own physical
attractiveness (p. 19).

These authors note further that, for their obese subjects,
”experiencing a relationship which includes coitus mitigates the
stigna" of their overweight condition (p. 17).

The third experience with breasts to be investigated is
mastectany and its inpact. The research that has been done on
mastectany is, to date, largely a collection of camenly held clinical
observations and opinions, rather than rigorous, empirical work

(Meyerowitz, 1980; Morris, 1979). This research shows that undergoing

mastectany is an intensely ambivalent experience for nest wanen.

29

Researchers note that, on the positive side, the operation can
literally save the wanan's life or, at least, deter death and is,
thus, sought as a valued antidote to breast cancer. On the other side
of the experience, however, the loss of the breast and what is
described as the “violation of the beloved body” (Bard and Sutherland,
1955, p. 670) are deeply traunatic events for nest wanen (Bard and
Sutherland, 1955: Ervin, 1973; Meyerowitz, 1970).

Eloquent descriptions of the trauma and the ambivalence
surroinding it cane fran the wanen who have written about their own
mastectaw experiences. Lords (1980), in her thought-filled

recounting of her response to the surgery, The Cancer Joirnals,

 

describes both its positive life-sustaining nature and its negative
body-violating one. About the former, she writes ”knowing that I
would have paid nere than even my beloved breast out of my body to
preserve that self that was not merely physically defined and count it
well spent" (p. 32). Later, she reflects the other side of the
response: ”I'd give anything not to have cancer and my beautiful
breast gone, fled with my love of it" (p. 76).

The loss of the breast in all of its enetional significance is
frequently addressed by those writing of breast cancer and mastectany.
Their descriptions of the loss generally center on its impact as a
'nutilating assault. to the femininity of the wanen who undergo it"
(Polivy, 1975, p. 282). Most authors do not attempt to specify the
loss beyond that general statement. No early articles did, hoever,
try to clarify the relationship between the loss of a breast and the
wanan's sense of her femininity. Renneker and Cutler (1952)

anphasized that the loss of the breast damages feminine pride in the

30

critical areas of sexuality and netherhood. Bard and Sutherland
(1955) argued for the inportance of understanding the individual
meaning of the breast to each wanan undergoing mastectany. In a
statement similar to Renneker and Cutler's, they observed that the
degree of ”resolution of fears pertaining to achievement of
heterosexuality and netherhood" is an inportant aspect of this
understanding (p. 671).

A grief process similar to that described by Kubler-Ross (1972)
has been observed by a nunber of those writing about the impact of
mastectany (Grandstaff, 1976; Thanas, 1978; Schain, 1976). The stages
are defined in nedical terms and assigned on the basis of their
position in time with respect to operative and other treatment
procedures. What they reveal, however, is a basic process of neurning
the lost breast. Their canton elanents include an initial period of
shock, which is often accanpanied by denial of the loss. That time is
followed by a gradually expanding and painful awareness of the full
meaning of the loss. It usually involves periods of intense anger,
guilt, anxiety, and depression. After the working through of these
emotional responses, these researchers suggest that nest waten cane to
sane adjustment to the loss.

Finally, the work that has been done on the use of denial by
wanen suffering fran breast cancer may be of value in understanding
the importance of breasts and mastectany. Denial seats to be involved
in the initial reaction of nearly every patient to her mastectany.
Fran her review of the literature, Polivy (1975) concludes that there
is ”evidence that mastectany is so overwhelming that the patient must

resort to denial in sane form" (p. 288). Most authors in the field

31

describe the period of denial as a brief one, largely because the
patient is forced to face the reality of hospital routines and pain,
and the need to change dressings. At tines, however, the denial does
persist. The nest startling evidence of its persistence was revealed
in a study by Bard and Waxenburg (1957). In interviews of nineteen
patients who had had mastectanies six to ten weeks earlier, they foind
that five refused to aanit ever having a serious operation and seven
more did not adnit to having been treated for a tuner or cancer.

To sunnarize the research on perceptions of and experiences with
breasts reveals that:

There is limited evidence suggesting the inportance of
perceptions by linking view of breasts to self-concept.

There is also sate evidence that preoccupation with the sexual
ideal interferes with breast satisfaction.

The developnent of breasts (as the first visible secondary sex
characteristic) appears to be a very significant experience in that it
signals the end of childhood, causes a major transformations of body
image, and introduces the adolescent girl to the maternal/sexual
nature of breasts.

Sexual experiences may be important in that they may provide
individualized, positive feedback aboit one's physical attractiveness
generally or about one's breasts nere specifically.

Finally, the mastectany literature provides testineny of the
inportance of these body parts, especially through its presentation of
the grieving process associated with the loss of the breast and the
denial that is seen so often as a response to the detection of a

breast abrermality.

STATEMENT OF HYPOTHESES

In attempting to account for the lack of performance of BSE, fair
7
of the factors suggested by the literature are the laleof a general

M-.wma—w
I-wl—a‘m

preventive health orientation difffl‘llties wih the specific health
practicefiofflBflSE, the lack of a general positive body image, and
problans ariging fran the focus on the particular body partof the
breasts. Previous research has concentrated on various aspects of the
first three factors. There has been little effort to draw all three
factors together in one study. The current investigation not only
provides that comprehensive approach, but also presents a new
dimension to the research, the impact of perceptions of and
experiences with breasts. This fourth factor is aimed at exploring
the effect of underlying psychological processes on BSE performance.
The hypotheses for this study center on the four factors.

The first factor, a general preventive health orientation, can be
operationalized as the number of preventive health behaviors in which
an individual engages. As indicated in the literature review, Hoe
(1981), Lowe (1979), McCusker and Morrow (1980), and Senie et a1.
(1981) all found positive relationships between BSE performance and
various aspects of physician-based health behaviors. In addition,
Haran et a1. (1981), Howe (1981), and Roberts (1984) found

relationships between BSE: and self-care (autonanous) health behaviors,

such as the wearing of seat belts. In the current study,

32

33

the general preventive health orientation of these young wanen will be
measured as their participation in a variety of autonoteus and
physician-based preventive health behaviors. The hypothesis is:

Hypothesis _1_: There will be a positive association between a general

 

preventive health orientation (as measured by participation in a
variety of health behaviors) and frequency of BSE performance.

The secowd major factor consists of difficulties with the
specific health behavior of BSE. As noted in the literature review,
various difficulties have been documented in previous research. Aneng
them are: a lack of knowledge about breast cancer (Olenn, 1981;
Spring & Kosch, 1982; Stronborg, 1981); a lack of perceived
susceptibility to breast cancer (Hallal, 1982; Spring & Kosch, 1982;
Stillman, 1977); a lack of perceived benefits of BSE (Hallal, 1982;
Stillman, 1977); a lack of knowledge about BSE (Kelly, 1979; Roberts
et al., 1984): a lack of confidence in canpetence to perform BSE:
(Celentano s. Boltzmann, 1983; Edwards, 1980; Keller et al., 1982;
Zapka & Manen, 1982); a lack of social influence to perform BSE (Howe,
1981).

The general hypothesis is that there will be a positive
association between the positive counterparts of these difficulties
and the frequency of BSE. Stated nere specifically:

Hypothesis _2_: There will be a positive association between frequency

 

of BSE performance and:
2a) krewledge about breast cancer;
2b) awareness of personal susceptibility to breast cancer;
2c) awareness of perceived benefits of BSE;

2d) knowledge about BSE;

34

2e) confidence in corpetence to perform BSE;

2f) social influence to perform BSE.

The third factor, body image, has been linked to BSE in two
previous studies. As reted in the review of the literature, Scilken
(1977) found a link between body cathexis (degree of expressed
satisfaction with one's body) and BSE performance. This finding,
which was her single significant result, indicated that wanen who
self-exanined their breasts expressed nere satisfaction with their
bodies than the wanen who did not. In a second study of BSE, Hallal
(1981) foind a significant positive correlation between physical
self-concept as measured by the Tennessee Self Concept Scale and the
practice of BSE. In addition, Hallal found a significant relationship
between overall self-esteem and frequency of BSE. Self-esteem, as a
variable related to body image, will also be investigated in this
study. The predictions of the third hypothesis, based on the results
of these two studies, are:

Hypothesis 3: There will be a positive association between frequency
of BSE performance and:

3a) body image;

3b) self-esteem

The impact of positive perceptions toward the breasts is deduced
fron the relationship noted earlier between positive body image and
performance of BSE. It seems likely that if positive feelings abolt
bodies in general are related to frequency of performance of BSE
(Scilken, 1977), such a relationship would also exist with regard to
positive feelings about breasts specifically. The particular areas of

interest, derived largely fran the literature on the impact of the

3S

ideal sexual view, include the subjects' ratings of the importance and
attractiveness of their breasts and their satisfaction with them. In
addition, confort with breasts will be investigated. As indicated in
the literature review (Howe, 1981; Stillman, 1977; Stronborg, 1981;
‘Worden et al., 1982: Zapka and Mamcn, 1982), modestyior inhibitions
about touching breasts have been found to interfere with BSE
performance.

The experiences involved in this fourth factor include adolescent
breast develcpnent, sexual exploration and activity, and acquaintance
with a breast cancer victhn.

The importance of the experience of breast developnent during
adolescence was well summarizd in the work of Benedek (1979) cited in
the literature review. Fran her work, it seems likely that enetional
responses to breasts during adolescence underly and influence later
feelings about breasts.

The impact of early sexual activity on feelings about breasts was
addressed specifically by Kelly and Menking (1979), who believe that
satisfying petting experiences positively influence young women's
perceptions of their breasts. In addition, Kallen and Doughty's work
(1982) presents the impact of sexual intercourse experiences on
self-esteem.and sense of physical attractiveness. Inferences from
these investigations led to the current hypothesis that the role of
breasts in sexual activities and the satisfaction derived from those
activities will influence perceptions of and feelings about breasts.

There are two parts to the final experience studied, mastectany.
The first involves being acquainted with a wanan who has had breast

cancer. As indicated earlier, the literature shows a connection

between a familial history of breast cancer and BSE: practice and
frequency (Huguley & Brown, 1981; Senie et a1, 1981). This
investigation expanded that variable to include knowing any wanan (in
the family or otherwise) who has had this disease. It also expanded
the issue by exploring the impact of knowing a breast cancer victim in
nere depth than previous researchers have.

The second related aspect of the issue involves one's anticipated
response to breast cancer and mastectany. As suggested earlier, the
anticipation of discovering a breast cancer sympton through BSE and,
then, needing to face the diagnostic and treatment processes appears
to be part of the reason ,for the response of fear, anxiety, and worry
to this health practice (Keller et al., 1980; Kelly, 1978; Stillman,
1977). It will be interesting, then, to exanine these young wonen's
practice of BSE: in light of their anticipated response to their own
potential breast cancer and its treatment.

To sunmarize this fourth factor:

Hypothesis 4: There will be a positive association between frequency

 

of BSE performance and:
4a) perceived importance of breasts;
4b) perceived attractiveness of breasts;
4c) satisfaction with breasts;
4d) canfort with breasts;
4e) adolescent developmental experiences;
4f) sexual experiences;
49) experience of knowing a breast cancer victim;

4h) anticipated response to breast cancer and mastectany.

Subjects

The survey was completed by 197 female students enrolled in
Introductory Psychology classes at Michigan State University during
Fall term of 1983. The subjects were recruited throigh the human
subjects pool which offers credit in Introductory Psychology for
research participation. The recruiting device was a sign-up sheet
annolncing a "Survey of Wanen's Health Behaviors and Body Attitudes."

Two of the 197 students who completed the survey had had
children. Because of the possible differences in their attitudes
toward their breasts and their bodies as a result of pregnancy, child—
birth, and mothering, the data fran these two subjects were eliminated
fran the study. The resulting N was, then, 195.

The 195 subjects ranged in age frcnll7 years to 24 years. The
modal age was 18 (_n=109) and the median age was 18.6. The vast
majority of these subjects are white (_Q=176). Their major religiois
preferences are Catholic (gé77) and Protestant (na69). The largest
nunbers of students cane fran a suburban setting (2:98) or a city of
fewer than 250,000 people (3349).

All but three of these subjects have never married (33191). Two
were married for the first time when they canpleted the survey, one
was divorced, and one was living with a lover. None of the wanen
included in the data analysis had had children. Further specifi-

cations of the demcgraphic characteristics are found in Table l.
' 37

 

 

38

Table 1

Basic Denegraphic Information on Subjects

 

292 my _____Per°ent
17 5 2.6
18 109 55.9
19 47 24.1
20 26 13.3
21 6 3.1
22 l .5
24 l .5
Sum 195' 10070
Race
White 176 90.3
Black 14 7.2
Oriental 3 l . 5
Hispanic 1 .5
Other __3; .5
Sum 195 100.0

Religious Preference

 

 

Protestant 69 35.4
Catholic 77 39.5
Jewish 10 8.2
Agnostic 6 3.1
Atheist 2 1.0
(Other 12_ 9.7
Sum 189* 96.9*

Type of Community Subject Comes From

 

Rural 26 13.3
Suburban 98 50.3
Small City
(less than 250,000 49 25. 1
people)
Large City
(More than 250,000 22. 11.3
people)
Sum 195 100.0

* Six subjects (3.1%) did not answer this question.

39

Materials

The survey is a forty-five page questionnaire (Appendix A)
that contains several previolsly developed measures and many
questions developed by the researcher from the theoretical and
alpirical literature on breasts and BSE.* The latter were
evaluated and revised through a pilot study.

The previously developedumeasures are:

» 1) a brief health behaviors questionnaire devised by

Lau (1982): 1

2) a questionnaire covering knowledge about breast cancer,
sense of perceived susceptibility to breast cancer, and awareness
of perceived benefits of BSE developed by Stilhman (1977);

3) the Body Cathexis Scale devised by Secord and Jourard
(1953);

4) the Self-Esteem Scale devised by Rosenberg (1965).

The health behaviors questionnaire (pp. 4-6 of survey and
Appendix B) was developed by Lau (1982) as part of a predictive
validity investigation of his Health Locus of Control measure.
Seven behaviors are measured: eating proper foods, wearing a seat
belt while riding in a car, brushing one's teeth after meals,
getting regular physical activity, controlling one's weight, and
visiting doctors and dentists for regular check-ups. Lau notes
that the first five behaviors were summed to form an overall
measure of self-care behaviors, while the last two were sumed to
measure regular visits to medical professionals. Tau does not
*Please note that the canplete survey is presented in Appendix A
and that, in addition, the scales that canprise it are presented

separately in the retaining Appendices or in tables in the
Results section.

 

40

report any reliability or validity investigations of the scale. In a
personal connunication, he indicated that correlations between various
health behaviors were typically low (.2, .3 or less).

The Stillman (1977) questionnaire consists of five sections. The
first deals with factual knowledge about breast cancer, covering sane
of the camen misperceptions often held by wanen with respect to
prevalence, age groups affected, possible causal factors (see p. 16 of
survey and Appendix C). Section II of Stillman's instrunent measures
subjects' perceived susceptibility to breast cancer and perceived
benefits of BSE. It consists of Likert-type scales in which the
subject responds to nine statements on an agree-disagree continuum,
and to one statement in terms of a carparison with other wanen (see p.
19-20 of survey and Appendix D). The odd-numbered items measure
perceived susceptibility, while the even-numbered items focus on
perceived benefits. Stilhman's scoring procedure is described in
Appendix D. The remaining three sections of Stillman's questionnaire
deal with the subjects' actual practice of BSE and demographic data.
They were not used in this survey, largely because they were not
published. Similar information is sought in the portion of the
questionnaire developed by the researcher.

Stillman investigated content validity of her instrunent by
having five graduate nursing students evaluate whether the items on
the attitude scales measured the variables under investigation
(perceived susceptibility and perceived benefits). They also reviewed
the instrument for clarity, readability, and understandability. The
instrunent was then pretested on 20 wanen considered representative of

the anticipated sample. The pretest revealed that the instrument

41

obtained the data sought and that the items on the attitude scale
discriminated ”to sane degree" aneng subjects (1977, p. 124).

The Secord and Jourard (1953) Body Cathexis Scale attempts to
measure satisfaction with various aSpects of the body. Forty-six
physical characteristics (parts and processes) are listed and subjects
rate their satisfaction with each on a five-point Likert scale.
Split-half reliabilities for the original sanple were .78 for males
and .83 for fanales. Convergent validity showed that physical
self-esteem and general esteem correlated .58 for‘males and .83 for
fanales. No test-retest data were reported.

The Self-Esteem Scale developed by Rosenberg (1965) measures the
self-acceptance aspect of self-esteem by having the subject rate ten
items that reflect liking and/or approving of the self on a four-point
scale (Robinson & Shaver, 1973). Investigation of reliability reveals
a Guttman scale reproducibility coefficient of .92 (Robinson & Shaver,
1973) and a test-retest correlation over two weeks of .85 (Silber &
Tippett, 1965). With respect to convergent validity, Silber and
Tippett found that the scale correlated fron .56 to .83 with several
similar measures and clinical assessment. Robinson and Shaver
conclude that ”This scale is a nedel short measure aimed at one aspect
of self-estean" (p. 82).

The remainder of the current survey was devised by the
researcher. The major elements are a personal data sheet (p. 3), a
block of questions concerning the subjects' experience with and
current practice of BSE (p. 21-26), and a rather lengthy section (p.
27-47) devoted to the subjects' perceptions of and experiences with

their breasts. Scales developed fran the final section will be

42

described later in this chapter and presented in tables in the Results
section. The itens corprising those scales were developed fron a
pilot study in which the perceptions of and experiences with breasts
were approached largely through open-ended itans. The responses to
those itans were carefully considered and, o1 the basis of the
information obtained, the open-ended questions were revised to a
forced choice format for the final questionnaire.

Much of the data gathered in the last section of the survey has
ret been analyzed in the current investigation because it did not
pertain directly to BSE. Those data have a nere general and
theoretical focus, aimed at fuller understanding of the role of
wonen's breasts in their lives.

Procedure

As indicated earlier, a sign-up sheet annoincing a “Survey of
Wanen's Health Behaviors and Body Attitudes” was posted in classroans
where Introductory Psychology was taught. It instructed the
participants to neet with research assistants (both of whan were
wanen) in a large classroan on campus. A research assistant first
explained the goal of the study, the investigation of young wanen's
health behaviors and body attitudes. Next, the participants were
handed copies of the survey and were asked to read the cover letter
(see Appendix A) and consent form and to rareve than fran the survey
packet. Then, they were instructed to canplete the survey and, when
finished, to return the completed form and report to a second roan.
This procedure for distribution and collection of surveys was approved
by the University Catmittee on Research Involving Human Subjects.

The second stage of the nesting included a short film on BSE

43

produced by the American Cancer Society, the distribution of ACS
pamphlets on BSE: and breast cancer, sane brief cannents about the
inportance and benefits of this health behavior by a second research
assistant, and an opportunity to examine a “Betsy" (simulated breast
nedel provided by ACS) for lures. Finally, the assistants validated

the research participation cards of the subjects.

 

Measurement of Variables

The Dependent Measure. The dependent variable on which the study

 

is based is frequency of performance of breast self-examination In
order to get as accurate a self-report measure as possible, the
subjects were asked to indicate the frequency of their breast
self-examination at three different points in the survey through three
different questions. The questions, the number of subjects who gave
each response and the corresponding percents are presented in Table 2.

The correlations aneng these three variables were as follows:

r

1&2=.83
rl&3=.60
r2&3=.66

mo techniques were devised to canbine the information fran these
variables. First, in order to make the differing response categories
as canparable as possible, each of the three variables was transformed
into E-scores and, then, the z-scores were sunned. The alpha for this
resulting scale is .87. Second, recognizing the approximate
equivalence of the six response categories of the first two questions
and the strong correlation between then (_r_'= .83), the responses to
those questions were averaged. The alpha for the second canposite

score is .91.

44

Table 2
Measurement of Frequency of Breast Self-Examination

(1) How frequently do you examine your breasts for lunps or
other abnormalities? (Check one.)

W _____Per Cent

Never 74 37.9
Once or twice a year 48 24.6
Three or fair times a year 11 5.6
Every couple of nenths 31 15.9
Once a nenth 20 10.3
More than once a nenth _11 5.6

Sun 195 99.9*

(2) How many times have you examined your breasts in the last
twelve nenths? (Check one.)

0 times 57 29.2
1-2 times 57 29.2
3-4 times 36 18.5
5-7 times 17 8.7
8—11 tines 11 5.6
12 or nere tines _l_‘_l_ 8.7
Sum 195 99.9*

(3) How many times in the last three nenths have you examined your
breasts? (Please be exact.)

Nunber of breast

 

 

self-examinations
0 106 54.4
1 38 19.5
2 20 10.3
3 12 6.2
4 6 3.1
5 2 1.0
6 . 6 3.1
7 1 .5
8 3 1.5
9 _1. _-_§
Sum 1 5 99.9*

* Divergence fron 100% is due to romding error.

Analyses of the data involved both of the canposite scores and
showed very similar patterns of results. Because of the need to
simplify the reporting of the large number of results and because of
the high correlation between the two catpcsite scores (f .96), the
researcher decided to focus on one of the scores. The second
carposite score, the average of the responses to the first two
questions, was chosen because it showed a slightly higher alpha than
the other scale (.91 canpared to .87) and because it is easier to
interpret and discuss. ‘

The dependent measure, reported frequency of BSE, is
qJerationalized as the average of the responses to these two
questions:

How frequently do you examine your breasts?

How many tines have ya: examined your breasts in the last

twelve months?

Independent Variables. General preventive health orientation was
measured as the score obtained on the Lau (1982) health behaviors
questionnaire. The internal consistency of the scale for these
subjects is low (alpha= .33). Various rational and empirical attempts
to inprove the scale's internal consistency were made, but did not
prove fruitful. Therefore, the original strategy, which was to
canbine all seven variables, was enployed in spite of its low internal
consistency.

Knowledge about breast cancer, awareness of personal
susceptibilin to breast cancer, and awareness of perceived benefits

of BSE were measured through the Stillman (1977) scales. For this

46

sanple of college-aged woren, the indexes of internal consistency of
all three of the scales were quite low (.18, .58, .43, respectively).
Attenpts were made to improve the alphas by devising new scales that
contained the nest highly intercorrelated items. Internal consistency
ratings for the new scales were still low; consequently, the items
fran each scale that discriminated best among subjects were selected
to represent these independent variables. The itans and their
correlations with BSE frequency will be reported in the Results
section.
Knowledge of breast self-examination was measured in two ways.
if; Subjects were first asked which steps involved in BSE they perform as
part of their usual breast self-examination. Secondgthey were asked
which steps ”should be done as part of a canprehensive breast
self-examination" (See page 25 of survey). The original scale
consisted of itars that are part of the usual recomended practice of
BSE (e.g.,”put arm of breast to be examined behind hea ") and foils
(e.g., "put arm of breast to be examined at side"). The initial plan
was to subtract the number of foils endorsed from the number of
correct steps endorsed. The purposes of this approach were two: to
get as accurate a measurement as possible of the quality of these
wanen's knowledge and performance of BSE and to correct for time
individuals who would sinply endorse every option. Internal
consistency investigations of the scale using this initial strategy
were disappointing because the alphas were very low. As a
consequence, the inter-correlations of the items were studied and the
scales were formed on that basis. The first scale (what is actually

done) consisted of fair items: lying flat on back, inspecting breast

47

by pressing flat part of fingertips into breast in circles that cover
entire breast, putting arm of breast to be exanined behind head, and
squeezing each nipple gently. The second scale (what sholld be done)
consisted of these four itans and one nere, standing before a mirror
and inspecting breasts for anything unusual while holding arms over
head. The indexes of internal reliability for both of these scales
were quite high'(.76 for steps actually performed, .75 for steps that
caterehens ive BSE involves).

Confidence in cmpetence to perform breast self-examination was
measured as the five-point rating (not at all confident to very
confident) of a single item: ”How confident are you of your ability
to perform breast self-exam?”

Social influence was measured as the yes/no response to a single

 

item: “Does anyone actively encourage you to exonine yolr breasts?”
m image was measured through the Secord and Jourard (1953)
scale, as previously described in Materials (alpha= .89).

Self-esteem was measured through the Rosenberg (1965) scale, as

 

previously described in Materials (alpha= .84).

Perceived inportance of breasts was measured as the average

 

response to two questions asking the subject to evaluate the
inportance of her breasts (e.g., ”How inportant are your breasts to
your view of your body?") (alpha= .78).

Perceived attractiveness was measured as the average response to

 

three questions asking the subject to evaluate the attractiveness of
her breasts (e.g. , ”How attractive do you feel your breasts are?”)

(alpha= .76 ) .

48

The remaining items for the importance and attractiveness scales
are presented in Table 6 in the Results.

Satisfaction was measured in the sane way as the satisfaction
with other body parts in the Secord and Joirard (1953) Body Cathexis
Scale. Breasts were added as an additional itan.

Canfort with breasts was measured as the average rating given to
nine itans asking the subjet to evaluate her canfort with her breasts
in various situations (e.g., “How canfortable are ya: viewing your own
breasts?") (alpha= .85). The full scale is presented in Table 6 in
the Results.

Adolescent developnental experience was measured as the subject's
rating of one item describing her response to her early breast
developnent on a five-point scale (very negative to very positive).

Sexual experiences were measured as the mean rating of fourteen

 

questions that focus on the role breasts play in sexual activity
(e.g., "How sensitive are your breasts to sexual arousal?”) and the
inpact of sexual activities on views of the breasts (e.g., "How much
change in the consciousness of the appearance of your breasts have you
experienced?") (alpha= .83). The entire scale is presented in Table 7
in the Results.

Ebcperience of knowirg a breast cancer victim was evaluated in two
ways. The first focused on the breast cancer victim's experience
(8.9., "How difficult was it for the person to adjust to the idea that
she had breast cancer?”) and the second on the subject's response to
the experience (e.g., ”Did that experience change YOJI' awareness of
breast cancer?”) (alpha= .82, .77, respectively). The canplete scales

are presented in Table 8 in the Results.

49

Anticipated response to breast cancer and mastectany was measured

 

as the average rating to three items asking the subject to predict her
response if she were to becone a breast cancer victim (e.g., “Which of
the following best describes what ya: think your overall response
would be if yo: were to undergo a mastectany?) (alpha= .80). The

entire scale is presented in Table 8 in the Results.

 

_T_‘_e;s__t§_ _o_f_ the Hypotheses

For all four hypotheses, the sane test was used: each of the
independent variables was correlated through a Pearson product-intent
correlation procedure with reported frequency of BSE. As indicated
later in the Results section, this procedure resulted in a nunber of
significant (p<.05), but very low 5's (approximately .15). The
significance of these low correlations is a result of the large nunber
of subjects (fl=195).

An additional statistical analysis, multiple regression, was
anployed in an attempt to integrate the four hypotheses and to
ascertain how frequency of BSE could be predicted fran this group of

independent variables for this sample of yolng wanen.

RESULTS

Description of the Subjects' Instruction in and Practice of BSE

Sixty-one percent of these wanen (gr-119) indicated that they had
been taught the procedure for BSE, while 39% (_n=76) indicated that
they had not been taught BSE. The largest number learned of the
procedure by reading a panphlet or book (_11=64) and the second largest
group was taught by a doctor (_Q=Sl). It is important to note that for
this question and many of those that follow subjects were instructed
to check as many options as apply (e.g., all of the ways they have
been taught the procedure for BSE) .

Asked when they were taught the procedure, the largest number of
subjects (_n_=63) reported that the instruction had occurred between one
and three years ago. Thirty-one were taught between six months and
one year ago. (Again, subjects who had been taught BSE more than once
were asked to indicate the timing of each instruction.)

In evaluating the BSE educational program in which they had been
involved, the majority of subjects who had been taught BSE reported
that it was sanewhat adequate (_Q=53) or very adequate (g=26) (those
with nere than one were asked to rate the best program). Further
specification of the subjects' instruction in breast self-examination
is found in Table 3.

In describing their actual practice of BSE, the majority of

subjects (_r_I=116) report that they perform the procedure "when I happen

50

51

Table 3

Instruction in Breast Self-Exanination

 

 

Instructional Means* m Parcent
of all Subjects
Palphlet or book 64 32.8
Physician 51 26.2
Demonstration on television 20 10.3
Demonstration or class 18 9.2
6.7

Nurse 13

Timing of Instruction"

 

 

Within the last three nenths 9 4.6
Three to six nenths ago 10 5.1
Six nenths to one year ago 31 15.9
One to three years of ago 63 32.3
More than three years ago 16 8. 2
Evaluation of the Educational Progran“
Very adequate 26 13.3
Sanewhat adequate 53 27.2
Neutral 30 15.4
Sanewhat inadequate 6 3.1
Very inadequate 1 .5

* For these two questions, subjects were asked to "Check as many as
apply to you.” Consequently, the sums of the instructional means used
and of the timing of the instruction exceed the 119 subjects who
report being taught BSE.

** For this question, subjects were asked to rate the best program
they had been exposed to.

52

to think of it." The largest nunber fran this group (2:77) indicated
that they decide to perform BSE as a result of noticing their breasts
while showering, dressing, or looking in the mirror. Fifty-three
reported that they perform BSE as a result of “having the idea just
cone to mind." Other major stimuli for performing BSE were
experiencing breast tenderness or pain (_r_1_=50) and reading aboit breast
cancer (_r_1_=45). Further description of the stimuli for performing BSE
by the group of sporadic performers is provided in Table 4.

The wanen who report performing BSE on a routine basis (_r_1_=l9)
mainly use "a certain day in the nenstrual cycle" as their reminder
(_g=16).

The wanen who indicated that they never perform BSE (_r_1=60)
reported that the following would be necessary to their starting to
perform BSE (subjects were asked to check as many of the options as
applied to than): nere information about breast self-examination
(_n=32); nere information about breast cancer (_g=23); a consistent
reminder to perform BSE (_n=16); and nere confidence in their ability
to perform BSE: (2=15).

when asked what kind of reminder might be helpful to them in
performing BSE (again, subjects could endorse as many options as
applied), a majority of the subjects (_n=103) indicated that a reminder
fran a significant person (lover, physician, parent) would be helpful.
Other useful memory aids would be a reminder on television (2:51); a
raninder in the form of a sticker in the shower (g=51); and a reninder
throigh the mail (9338).

In answer to a question asking them to describe their reasons for

performing BSE, the largest numbers of young wanen reported that they

53

Table 4
Stimuli for Performance of Breast Self-Exanination by Sporadic
Performers
Stinuli: m krcent
Noticing bmast while showering, dressing, 77 39.5
or looking in the mirror
"Having the idea just cone to mind" 53 . 27.2
Experiencing breast tenderness or pain 50 25.6
Reading about breast cancer 45 23.1
Hearing abolt breast cancer on television 28 14.4
Talking with others about breast cancer 25 12.8
"Noticing breasts while sitting or laying 25 12.8
around without much to do"
Thinking about breasts during sexual activities 7 3.6
Receiving encouragenent from others 7 3.6

* Subjects were asked to "Check as many as apply."

54

engaged in this health behavior because of a general concern about
health (g=107), an attempt to protect thenselves fran breast cancer
(f78), and a sense of personal responsibility to perform BSE (2=44).
(For both the preceding reasons for performing BSE and the following
reasons for not performing BSE, subjects were asked to check as many
options as applied to them.)

(When asked to indicate what their reasons for ggt_performing BSE
were, the nest frequent responses involved faulty matery (33:87),
difficulty recognizing breast abnormality (9348), and lack of current
concern about getting breast cancer (gs45). Further specifications
about the reasons for performing and not performing BSE are provided
in Table 5.

These subjects report that they receive little social influence
to perform BSE. Only 42 answered the question, "Does anyone actively
encourage you t0>examine your breasts?,” affirmatively. The largest
number of those wanen received encouragenent fran their physicians (2:
25). Mothers were reported to encourage 13 of the subjects. Female
and male friends encoiraged 7 wanen each, while nurses were named by 5
subjects.

These subjects also report little knowledge of the practice of
BSE by the wanen close to then. when asked if their nethers or the
majority of their fanale friends perfonned BSE, nest subjects reported
they did not know the answer (Q; 124, in response to question about
nether's practice of BSE; n: 164, with respect to friends'
performance). Fifty-two subjects reported that theierothers do
practice BSE, while 17 indicated that their mothers do not. Nine

subjects indicated that the majority of their female friends practice

55

Table 5

Reasons for Performance and Non-performance of BSE
Given by All Subjects

 

Reasons for Performance : * 553929291 PerCent

I'm generally concerned aboit my health. ' 107 54.9

I'm trying to protect myself fran breast cancer. 78 39

I feel it is my personal responsibility to 44 22.6
perform BSE.

My breasts becone tender and that worries me, 19 9.7
so I perform BSE to check on than.

I have a family history of lumps or breast cancer. 11 5.6

It' s a habit. 11 5.6

Sansone reminds us to perform BSE. 10 5.1

Reasons for Non-performance : *

 

I don't remenbsr to do it. 87 44.6
I can't tell for sure what's normal and what's 58 29.7
abnormal in my breasts, especially because the
tissue changes.

I don't know how to perform BSE. 48 24.6

I'm not concerned about getting breast cancer 45 23.1
at this time.

I do not have a family history of breast cancer 41 21
or breast disease.

I don't feel confident enough that I perform 39 20
BSE correctly.

No one reminds ne to perform BSE. 36 18.5

I'm afraid of how I'll react if I do find sansthing 15 7.7
abnormal.

I feel uncanfortabls touching my breasts. 11 5.6

I feel that breast examination should be performed 9 4.6
by doctors and nurses.

I'm not concerned about my health at this point 6 3.1
in my life.

The tenderness of my breasts prevents ms fron 3 1.5

exanining than.

*Subjscts were instructed to check as many options as applied to then.

BSE, while 21 reported that their friends do not.

Finally, when asked how confident they are of their ability
topsrform breast self-exam, alnest half of the subjects responded that
they were not at all confident (_n=22) or not very confident (g=62).

In addition, 65 reported they were sonewhat confident, 36 were
considerably confident and 8 were very confident. Having presented
the overview of the subjects' instruction in and practice of BSE, the
results of the tests of the hypotheses follow.

Hypothesis 1: The Relationship Between Fregienty of Breast

Self-Examination
and a General Preventative Health Orientation.

 

 

 

The correlation between the Iau scale (which measured such
behaviors as eating proper foods, wearing a seat belt, and having
dental check-ups) and the frequency of BSE is not significant
(_r= .03, p> .05). Thus, the hypothesis that there is a positive
correlation between general preventive health orientation and the
frequency of practice of breast self-examination is not supported.
Hypothesis 2: The Relationship Between Awareness Of Breast

Cancer And Breast
Self-examination And Frequency Of Breast Self-examination

 

 

 

Seven variables were involved in the evaluation of this
hypothesis which broadly links frequency of BSE performance to
awareness of breast cancer and of the breast self-examination
procedure:

a) knowledge about breast cancer;

b) awareness of personal susceptibility to breast cancer;

c) awareness of perceived benefits of BSE;

d) report of procedural steps actually performed during BSE;

s) knowledge of procedural steps that should be performed

during BSE;

57

f) confidence in canpetencs to perfonn BSE;

9) social influence to perform BSE.

Because of the problem of low internal consistency with the
Stillman scales, which were anployed to measure variables a, b, and c
above, representative itens that discriminated best aneng subjects
were chosen to represent those variables. The major idea of the
questions (for entire questions, see Appendix B) and their
correlatio'us with frequency of BSE follow:

Knowlege Questions

Knowledge of the chance of a wonan (in this country) getting
breast cancer soretime during her lifetime. (E .12,
p) .05).

Knowledge that nest breast lumps are not cancerous. (_r_=.07,
E) 005) 0

Knowledge of the age at which incidence of breast cancer
increases. (_r_= .05, p) .05).

Knowledge of the increased risk for breast cancer of those
whose relatives have had the disease. (5= .17, p< .05).

The one question fran the knowledge scale that shows a
significant correlation with frequency of BSE performance is the
knowledge that relatives of breast cancer victims are nere likely to
develop the disease than others.

The items fran the benefits scale and susceptibility scales
and their correlations with reported frequency of BSE follow:
Benefits giestions

Even though it's a good idea, I find exanining/having to examine
my breasts an embarrassirug thing to do. (5 -.30, p< .001).

Exanining my breasts often makes/would make me worry
unnecessarily about breast cancer. (_r_= -.01, p) .05).

58

Susceptibility glsstions

 

My health is too good at present to even consider thinking that
I might get breast cancer. (_r_'= -.15, p< .05).

The older I get, the nere I think about the possibility of
getting breast cancer saneday. (f .07, p) .05).

If I had to think about the possibility that I might sansday get
- breast cancer, I would rate my chances as coupared with wanen as:

a. average
b. above average

c. below average
(f.09, p) .05).

One item fron the benefits scale (embarrassment about performing
BSE) and one item from the susceptibility scale (present good health)
show significant correlations with frequency of BSE psrfornuance.

The correlations between frequency of BSE and the two scales that
measured knowledge of the breast self-examination procedure were
significant (_r_= .60, p< .001 for the scale measuring what is actually
done; _r:= .31, p< .001 for the scale neasuring what should be done as
part of a conprehsnsivs breast self-examination). Thus, the part of
the hypothesis that predicted a positive correlation between frequency
of breast self-examination and knowledge about it is supported.

‘ Confidence in canpstence to perform breast self-examination shows
a significant positive correlation with the frequency of BSE (£= .16,
p< .05). q

The final variable that was tested for this hypothesis is the
impact of social influence. Only 42 of the 195 subjects reported
receiving any encouragensnt to perform BSE. A _t_-test revealed that
the means of BSE frequency for the two groups (M: 3.40 for those who
receive encouragement to perform BSE and _M_=2.30 for those who do not)

differed significantly (£= 4.04, _d_f_= 190, p< .001).

59

In sunmary, the tests of the second hypothesis suggest that there
is a positive, statistically significant correlation between frequency
of BSE and these four aspects of awareness of breast cancer and the
breast self-examination procedure: knowledge of the increased risk
for breast cancer of those whose relatives have had the disease;
reported accurate performance of BSE; knowledge of the steps involved
in couprehensive BSE; and confidence in coupetencs to perform BSE. In
addition, there are statistically significant negative correlations
between frequency of BSE and embarrasanent about BSE and lack of worry
about breast cancer due to present good health. Finally, social
infuence is associated with nere frequent perfornuancs of BSE.

Hypothesis 3: The Relationship Between Body Image, Self-Esteem and
Frequency of Breast Self-Examination

 

 

The correlation between the average body image ratirug and
frequency of breast self-examination is not significant (_F .06, p)
.05). The correlation between average self-esteem and BSE is also
non-significant (£= .001, p) .05). The third hypothesis, which
predicted a positive correlation between frequency of BSE and body
image and self—esteem, is not supported.

Hypothesis 4: The Relationship Between Positive Perceptions of and
geriences with Breasts and Frequency of Breast Self-Examination

 

 

Foir perceptions of breasts and four kinds of experiences were
evaluated for this hypothesis. The four perceptions were: inportance
of breasts, attractiveness of breasts, satisfaction with breasts, and
general confort with breasts. The itans comprising thme scales are

presented in Table 6. The correlations between these variables and

60

Table 6
Items Comprising Perceptions Scales

importance of Breasts:
How important are your breasts to you?
How important are your breasts to your view of your body?
(five point rating scale - very unimportant to very important)
(alpha= .78, N: 195)

Attract ivsness of Breasts :
How attractive do you feel your breasts are?
How attractive would nest other wouen say your breasts are?
How attractive would nest men say your breasts are?
(five-point rating scale - very unattractive to very
atractivs)
(alpha= .76, N=l95)

Satisfaction with Breasts:
Rate feelings about breasts on a five-point scale --

"wish change could sanehow be made" to "consider myself
fortunate.”

General Confort with Breasts:

How canfortable are you viewing your own breasts?

How canfortable are you touching your own breasts?

How canfortable are you viewing your friends' breasts?

How canfortable are you viewing your mother's breasts?

How canfortable are you viewing your sister's breasts?

How canfortable are you appearing nude in front of lovers?

How canfortable are you appearing nude in front of friends?

How canfortable are you appearing nude in front of your nether?
How canfortable are you appearing nude in front of your sisters?
(five point rating scale -- very uncomfortable to very canfortable)
(alpha= .85, _n= 104)

61

and reported frequency of BSE are as follows:

importance, _r= .14, p_< .05;

attractiveness, E? .02, p? .05;

satisfaction, f .02, p) .05;

general comfort, 58 .14, p< .05.

Of the four perceptions investigated, then, importance of breasts and
general confort with breasts show significant, but very small,
positive correlations with frequency of breast self-examination.

Four experiences with breasts were also investigated: response
to breast developuent, sexual experience with breasts, acquaintance
with a breast cancer victim, and anticipated response to breast cancer
and mastectany. The first experience involved one item that asked the
subject to describe her response to her early breast developuent on a
five-point scale (very negative to very positive). The items
comprising the sexual experience scale are found in Table 7.
Acquaintance with a breast cancer victim involved two scales - one
that asked the subject to report on the breast cancer victim's
experience and a second that asked the subject to evaluate the impact
of the experience on her own views. Both of those scales are
presented in Table 8, as is the final scale which neasured the
subject's anticipated response to breast cancer.

The correlations between these variables and reported frequency
of BSE are as follows:

developmental experiences, _F .04, p) .05;

sexual experiences, E? .19, pg .01;

breast cancer victim's rsSponse, 5= .18, p) .05;

impact of experience on subject, 5? .54, BK .001;

anticipated response to breast cancer, r= .09, p) .05.

62

Table 7

Items Conprising Sexual Experiences Scale
How sensitive are your breasts to sexual arousal?
(five point scale -- very insensitive to very sensitive)
How important are your breasts to you in your sexual activities?
How important are your breasts to your partner(s) in your sexual
activities?
(both five point scales -- very unimportant to very important)
Instructions for tie remaining questions:
Have your feelings about your breasts changed because of your sexual
activities? How much of each change have you experienced?
(all five point scales - nnuch less to much nere of characteristic

under consideration)

How much change in your general awareness of your breasts have you
experienced?

How much change in your consciousness of the appearance of your
breasts have you experienced?

How nuuch change in your confidence about your breasts have you
experienced?

How much change in your comfort with your breasts have you
experienced?

How much change in your respect for your breasts have you
experienced?

How much change in your pride in your breasts have you experienced?

How much change in your acceptance of your breasts have you
experienced?

How much change in your satisfaction with your breasts have you
experienced?

How much change in your awareness of sexual attractiveness of your
breasts have you experienced?

(alpha = .83, _r_u_= 181)

 

63

Table 8

Scales involving Past and Anticipated Response to Breast Cancer

Breast Cancer Victim's Experience:

 

How difficult was it for the person to adjust to the idea that she
had breast cancer? (Circle ore.) ,

How difficult was it for the person to adjust to tie removal of her
breast? It mastectany was not necessary, leave blank. (Circle
one.)

(For both questions, scale of 1 to 3 - very easy to very
difficult.) (alpha= .82, _n_= 64)

Impact of Breast Cancer Experience on Subject:

 

Did that person's experience cause any of the following attitude
changes in you? How much of each of these changes?

How much change in your awareness of breast cancer?
How much change in your fear of breast cancer?
How much change in your willingness to check for breast cancer?

How much change in your conscientiousness about examining your
breasts?

(Scales of 1 to 5 for each -- fran much less of characteristic to
much more of it.) (alpha= .77, _13= 84)

Anticipated Response to Breast Cancer:

 

Which of the following best describes what you think your
overall response would be if you were to undergo a mastectomy?
(Circle ore.)

(l=devastated, 2=quite upset, 3=upset, but assume would recover,
=not too upset, 5=grateful to be alive)

Overall, how difficult an adjustment would it be if you learned you
had breast cancer? (Circle ore.)

How difficult do you think it would be for you to adjust to the
removal of your breast? (Circle ore.)

(For both questions, scale of 1 to 4 - very easy to very
difficult.) (alpha= .80, _n= 192)

64

Of these three areas of experience, then, only sexual experience
with breasts and impact of knowing a breast cancer victim were
significantly correlated with frequency of breast self-examinations.

In summary, within the broad area of the relationship between
positive perceptions of and experience with breasts, the following
show significant positive correlations with frequency of BSE:
importance of breasts; comfort with breasts; sexual experiences with
breasts; the impact of being acquainted with a breast cancer victim.

In concluding the report of the results of hypothesis 4, it is
also important to note that much of the data from the current survey
which focused on the perceptions of and experiences with breasts was
not analyzed because of the large amount of data collected and because
those data were nere theoretically-oriented, focusing on such issues
as the effect of sexual experience on breast satisfaction. (Please
note that the questions used to elicit those data are included in the
couplets survey, which is Appendix A.) Future work with those data
may lead to greater understanding of the roles breasts play in young
wauen's lives.

Multiple Rflcress ion Analysis

 

In order to explore more fully the relationship between frequency
of breast self-examination and the group of independent variables
under study, multiple regression analysis was undertaken. Fourteen
variables were entered into the equation, the purpose of which was to
predict frequency of breast self-examination. The choice of variables
was based on three considerations: 1) the conceptual importance of
the independent variable; 2) the correlation between the independent

variable and the dependent measure (frequency of breast

65

self-examination); 3) the interbcorrelaticns among the independent
variables. Table 9 summarizes the selection process, and indicates
which of the three considerations was employed in the decision to
enter that variable or not. (Means, standard deviations and numbers
of subjects are also provided for each variable in this table.)

The following fourteen variables were, then, entered stepwise:

General Preventive Health Orientation (GPH)

Knowledge Question 1 (K01)

Knowledge Question 3 (K03)

Benefit Question 1 (301)

Susceptibility Question 1 ($01)

Reported Performance of BSE (RP)

Confidence in Competence to Perform BSE (CC)

Body Image (BI)

Self Esteem (SE)

Importance of Breasts (IB)

Response to Breast Development (RBD)

Sexual Experiences with Breasts (SEB)

Subject's Anticipated Response to Breast Cancer (SAR)

Subject's Acquaintancs with a Breast Cancer Victim (SKV)

The probability of F-to-enter (PIN) was raised to .10 because of
the exploratory nature of the study. Missing values were deleted
pairwise, leaving an‘N of 159 cases. The multiple regression equation
that is the best predictor of BSE frequency for this group of
variables utilizes the following variables: reported accuracy of
performance of BSE, the benefit question (examining breasts is a good

idea, but smbarassing to do), the susceptibility question (present

66

Table 9

Basis for Decisions to Enter Independent variables into>Multip1e
Regression Equation and Means, Standard Deviations and Number of
Subjects for Independent variables

variable

Hypothesis 1
General Preventive Health Orientation 1

Hypothesis 2

Knowledge Question #1
Knowledge Question #2
Knowledge Question #3
Knowledge Question #4
Benefit Question 1

Benefit Question 2
Susceptibility Question 1
Susceptibility Question 2
Susceptibility Question 3
Reported Performance of BSE
Ideal Performance of BSE
Confidence in Ability to Perform BSE

ha
‘
h'hlk)u)héh‘u)h‘hlhthh‘

Hypothesis 3

Body Dmage
Self-Esteem

thJ

Hypothesis 4
Importance of Breasts 2
Attractivsnsss of Breasts 3
Satisfaction with Breasts 3
General Confort with Breasts 1
Response to Early Breast Development 1
Sexual Experiences with Breasts 1,2
Response of Known Breast Cancer
Victhn
Impact of Known Breast Cancer 3
Victim's Experience on Subject
Subject's Anticipated Response to 1
Breast Cancer and Mastectomy
Subject's Knowledge of Breast Cancer 1
Victim

Basis*

 

Mean Standard

Deviation
22.66 3.73
.39 .49
.69 .46
.68 .47
.60 .49
3.01 .98
2.77 .84
3.14 .94
3.02 .82
1.97 .66
1.58 1.46
2.59 1.71
2.75 1.12
167.36 22.27
30.89 4.33
7.97 1.50
10.45 2.23
4.45 1.06
29.33 7.28
2.69 1.23
49.13 5.90
7.58 1.75
15.02 2.16
11.98 1.92
1.50 .50

* Key for basis to enter variable in regression or not

1 = conceptual as reason to enter
2 = correlation with dependent variable as reason to enter
3 =

enter

Explanations of other starred items on following page.

N

191**

195
195
195
195
195
195
195
195
195
195
195
194

169**
193

195
195
195
104**
162***
181**

64****

84****

192**

192**

interbcorrslation with other independent variable as reason not to

67

Table 9 (cont'd).

** Each of these variables is a scale consisting of multiple items.
Subject totals less than 195 reflect the nunber of subjects who
skipped one or more itens. Before entering these variables into the
regression analysis, adjustments were made so the average rating given
by subjects who responded to a significant nunber (although not all)
of the items catprising the scale (e.g., to five of the nine comfort
items) would have their average rating included. The purpose of the
procedure was to increase the umber of subjects included in the
multiple regression analysis.

*** The N of 162 reflects the 33 students who skipped the question or
endorsed the options of "unknown response" or ”appeared to respond
with mixed feelings."

**** 0f the 95 subjects who reported knowing a breast cancer victim,
varying numbers of subjects (64, 84) responded to these two sets of

questions.

68

health too good to think about breast cancer), subjects' acquaintance
with a breast cancer victim and sexual experiences with breasts. The
predicted frequency of BSE is obtained by substituting those 5
variables into the following fommula:

Predicted BSE = .803 + .539(RP) - .277(Bol) - .246(SQl) + .371(SKV) +
.355(SEB).

The multiple R for this equation is .66 which accounts for about
43.1% of the variance of frequency of BSE.

Table 10 further describes the findings of the multiple
regression equation, including the beta weights for each variable.

Table 11 (Appendix G) presents the inter—correlations of the
variables included in the multiple regression analysis.

The reported correct performance of BSE clearly daninates the
equation, accounting for 35.4% of the variance by itself. An
additional 7.7% of the variance is accounted for by utilizing these
variables: the embarrassment question (3%), the susceptibility item
(2%), acquaintance with a breast cancer victim (1.5%), and sexual

experience (1.2%).

69

Table 10

Sutmary of Multiple Regression Steps

Step variable entered multiple R
Number or continued

1 Reported Perfonmanoe .60

2 Benefit Question 1 .62

3 Susceptibility Question 1 .64

4 Knowledge of B.C. Victim .65

5 Sexual Experience .66
Significance of F change

* p < .10

** p < .05
*** p < .001

variable

General Preventive Health Orientation (GPH)
Knowledge Question 1 (K01)

Knowledge Question 3 (K03)

Benefit Question 1 (801)

Susceptibility Question 1 (SCH)

Reported Performance of BSE (RP)
Confidence in Competence to Perform BSE (CC)
Body Image (BI)

Self Esteemn(SE)

Importance of Breasts (IB)

ReSponse to Breast Development (RBD)
Sexual Experiences with Breasts (SEB)

R2

.35
.38
.40
.42
.43

Subject's Anticipated Response to Breast Cancer (SAR)

Subject's Knowledge of Breast Cancer Victim (SKV)

86.04***
48.67**
35.09**
27.80**
23.17*

Beta weights

 

-.058
-.010
-.076
-.180
-.129
.519
-.014
.031
.003
.026
-0013
.109
.044
.123

DISCUSSION

Introductim

 

The purpose of this study was to investigate the variables that
influence the frequency of breast self-examination by young wanen.
Four factors suggested by the literature were investigated: a lack of
a general preventive health orientation, difficulties with the
specific health behavior of BSE, the lack of a general positive body
image, and problens arising fran the focus on the particular body part
of the breasts.

Before proceeding with the discussion of the results, two points
about the study need to be enphasized. The first point is the size of
correlations that reached significance. Because of the large 11 (195),
small correlations (_r_= .15) attained significance (p< .05).

Obviously, the strength of those relationships is very low. Such low
correlations were expected after a personal cemunication with Lau,
who indicated that correlations of .2, .3 or less were usual in the
area of health behavior research. The low correlations are also
thought to be a result of the exploratory nature of the study; that
is, in an early stage of investigation, one is looking for prenising
areas to explore in the future, not zeroing in on already
clearly-defined influential factors.

The second point that requires emphasis is the sample of young

wanen. As indicated in the Methods section, the modal subject in this

70

71

study in 18 years old and a freshnan at a large Midwestern state
university. The results, then, are generalizable to this relatively
select group. Of particular importance is the youth of these subjects
Most of the research on breast self-exanination has involved subjects
that range in age through the young and middle adult years (18-65).
Selecting a sanple so young and so hauogeneous was purposeful in that
this particular group is seen to need information about breast
self-exanination and to be a subject population that has not been
adequately studied (personal munication with Barbara Rosnick,
American Cancer Society). The selection involves the assunption that
this particular group may show a different pattern of results fren
other samples because of its youth or because it culprises a different
cohort. Its hanogeneity with respect to age may also have
implications for the results of the study.

Overview of Subjects and their Practice of BSE

 

These young wanen are white, of Catholic or Protestant religious
preference, single, and fran suburban hares. They report being taught
BSE fron 1-3 years ago by a panphlet or a doctor. Sixty-one percent
of these college wanen report that they never do BSE or perform it
once or twice a year.

The majority of the subjects perform BSE when they think of it
(rather than on a routine basis) and indicate that they think of it
when they notice their breasts during another activity, or read about
breast cancer, or have the ”idea just cone to mind." Those subjects
who indicated that they never perform BSE cited the need for
information about the procedure and breast cancer and reminders to do

BSE as being necessary to their beginning to practice this health

72

behavior.

Investigation of the entire sample reveals that, when these young
wanen do perform breast self-exam, it is because of a general concern
about health, as an effort to protect themselves fron breast cancer,
or because of a sense of personal responsibility to perform BSE. The
young women also indicate that their lack of performance of BSE is a
result of forgetting, having difficulty discriminating breast
abnormalities, not knowing how to perform BSE, and not being worried
about developing breast cancer at this time or because it does not run
in their families.

Prediction _o_f_ m 93 Breast Self-Examination

 

 

For this sample of young wanen, frequency of breast
self-examination is best predicted by five factors: the accuracy of
their knowledge and performance of the basic steps involved in BSE,
their enbarrasenent about the procedure, their view that their present
health is too good to worry about breast cancer, their acquaintance
with a breast cancer victim, and the impact of their sexual
experiences on their views of their breasts.

As noted in the Results section, the initial factor, the reported
correct knowledge and performance of the basic steps involved in BSE,
accounts for most of the variance (35.4%, 3= .60) that. the multiple
regression equation explained. The implication of the finding appears
to be that, if the subject knows the basic steps of BSE and reports
that she actually perfonns then as she examines her breasts, the
frequency of her performance of this behavior is higher than for those
subjects who know or perform fewer of the basic steps. This result

supports the findings of Kelly (1979), Sheley (1983), and Spring and

73

Kosch (1982) that knowledge of BSE influences frequency of
performance. It may also offer some evidence for Roberts' et a1.
(1984) and Pennypacker et al.'s (1982) conclusions about the
inportance of practice in developing knowledge and proficiency of BSE.
' The second predictor of the frequency of breast self-examination,
which accounts for an additional 3% (_R_= .62) of the variance, is the
subject's degree of enbarassnent in examining her breasts.
Elbarrassment enters the equation as a negative variable; that is, its
impact causes a decline in frequency of breast self-examination. This
finding supports the conclusion about the inportance of modesty and
inhibition in non-performance of BSE reached by Howe (1981), Miller et
a1. (1980), Stillman (1977), Stronborg (1981), and Zapka and Mamon
(1982). It is interesting to note that the impact of inhibition
observed in the subjects of other studies, who represented a wider age
range, is also found with the m wanen subjects in this study.

The third predictor of frequency of breast self-examination is
the subject's view of her present health (.13= .64). It also enters the
equation as a negative variable and accounts for an additional 2% of
the variance. Its negative significant relationship with BSE is
inferred to be a result of the youth of the subjects. The lack of
these subjects' perceived susceptibility is consistent with the data
on breast cancer, which suggests that it is very uncannon under the
age of 35. This finding lends support to Edwards' conclusion ( 1980)
that her younger subjects may have been less frequent practicers of
BSE than those older because they perceive thenselves as being less
susceptible to breast cancer. It also offers support in an inverse

way for Spring and Kosch‘s (1982), Stillman's (1977), and Hallal's

74

(1982) conclusions: that is, this study shows that a lack of perceived
vulnerability has a negative impact on BSE frequency, while the
perspective fran the other studies was that increased perceived
susceptibility increased BSE frequency.

The fourth predictor, acquaintance with a breast cancer victim,
accounts for an additional 1.5% of the variance (_R= .65). This
finding is consistent with the results obtained by Senie et a1. (1981)
and Huguley and Brown ( 1981) that history of breast cancer in the
family is related to BSE frequency. As noted earlier, the issue was
broadened for this study to include knowing anyone who has had breast
cancer. It is interesting that acquaintance with a breast cancer
victim is an important variable in predicting the frequency of breast
self-examination for these young women who largely consider thenselves
free fron breast cancer. It appears that knowledge of a victim may be
a sobering reality that brings the need to protect against breast
cancer more clearly into focus. This hypothesized explanation
receives sane support from the negative significant correlation
(_r;= -.32, p< .01) between the scale that measured the inpact of
knowing a breast cancer victim and the susceptibility iten (health too
good at present to consider getting breast cancer).

The final predictor, the impact of sexual activities (3: .66),
accounted for 1.2% of the variance, bringing the total variance
accounted for by the five variables to 43.1%. The entrance of this
variable into the equation predicting frequency of breast
self-emination is thought to be a result of the current inportance
of sexual exploration and activity for this particular age group.

Fifty-three percent of these young wanen reported that they are

75

currently sexually active (defined as ”having intercourse or
oral-genital contact with a partner”), a figure that is very close to
Kallen and Doughty's (1982) finding of 55%. Eighty-three percent had
engaged in petting (stinulation of breasts and genitals) with clothes
on, while 72% had engaged in petting with clothes off. The salience
of sexual experiences for these young wanen appears to be strong
enough on the average that this variable has an inpact even on a
tangentially-related health behavior like BSE.

Having presented the five variables that entered the multiple
regression equation, the next sequent of the discussion will focus on
the relationships between frequency of BSE and the renaining
independent variables. These variables will be presented in the
clusters that forued the four hypotheses.

The Effect _o_1_3 General Preventive Health Orientation

 

 

The predicted positive association between frequency of BSE and a
preventive health orientation was not found in this sample. This
finding is inconsistent with the results obtained by Haran, et a1.
(1981), Howe (1981), and Senie et a1. (1981), who found wanen who
perform BSE more likely to engage in various other health behaviors.
Several possible explanations can be offered for these discrepant
findings. First, the measurement of general preventive health
orientation was obtained through different means in this study. As
indicated in the Methods section, the Lau scale contains both
physician-based behaviors and self-care (autonamus) behaviors. In
contrast, Senie et a1. and Haran et a1. focused on physician-based
health care only. Although Howe and Roberts investigated both kinds

of health behaviors, they did not measure the same behaviors as the

76

Iau scale does.

A second possible explanation for the difference in findings
centers on the age of these subjects. It is possible that health
behaviors may not be as salient or as highly develcped for these young
women as for the older women investigated in the other studies. It is
interesting to note that one finding of the study contradicts this
possible explanation: the majority (2:107) of these subjects report
that they perform BSE because of a general concern about health.

A third possible explanation for the difference in findings has
to do with the internal consistency of the Lau scale. As indicated in
the Methods section, the alpha for the scale was very low (.33) and
efforts to inprove it by considering different cmbinations of health
behaviors were ineffective in obtaining a more highly reliable scale.
The accuracy, then, of the scale as a measurenent of a preventive
health orientation is very questionable. Future work with a more
reliable scale is necessary before the impact of a preventive health
orientation on frequency of BSE can be ruled out for young wanen.

The Effect of Awareness _o_f_ Breast Cancer and BSE

 

 

The purpose of this area of investigation was to explore whether
or not there were specific aspects of the disease of breast cancer or
the health behavior of BSE that influenced the frequency of its
practice. (he facet of the investigation focused on breast cancer -
knowledge of it and awareness of personal susceptibility to it. A
second facet centered on the BSE procedure - knowledge of it,
awareness of its benefits, confidence in cerpetence to perform it, and
social influence to perform it.

As noted earlier, the Stillman (1977) scales, involved in the

77

tests of this hypothesis, showed poor internal consistency. Because
of that, individual questions were selected to represent the three
areas of knowledge of breast cancer, awareness of suceptibility to it,
and awareness of benefits of BSE. Generalizing from the individual
items to the broader concepts must be done very cautiously. Further
work refining scales that reliably measure these variables would be
useful.

Knowledge of Breast Cancer. Knowledge that there is an increased
risk of breast cancer for those whose relatives have had the disease
is the one aSpect of knowledge of breast cancer that showed a
sigificant positive (although low) correlation with frequency of BSE
(_r;= .17). The finding is interesting because this risk factor,
assured by many to be genetic, is one of a very few factors (along
with previous breast cancer, increase in age) that has been clearly
identified with the development of breast cancer (National Cancer
Institute, 1979). It is also interesting in that Stronborg (1981)
notes the particular importance and comnon recognition of this risk
factor. Those young wanen, then, who are aware of the familial link
for breast cancer perform BSE more frequently than those who are
unaware of the connection. Awareness of the link may, of course, be a
result of familial experience with breast cancer. Thus, this piece of
information may be confounded by such experience: that is, it may not
involve knowledge alone, but also the experience of knowing a breast
cancer victim. Investigation of the current data offers some support
for this possibility: it reveals a significant correlation (_r_= .26,
p< .05) between the scale that measured the impact of acquaintance

with a breast cancer victim and knowledge of the familial link.

78

The lack of a positive association between the remaining three
items of the knowledge scale and fmquency of breast self-examination
is also of interest. The first of those questions involves knowledge
of the chance of a woman in this country getting breast cancer
sometime during her lifetime. Interestingly, in the 6 or 7 years
between Stillman's publication (1977) and the data collection of this
study that figure changed from 9% to 11%. The correct answer, then,
also changed from 'a) Under 10 per cent” to 'b) 10-25 per cent.”
T\we1ve percent of Stillman's sample endorsed the previously correct
”under 10 per cent” response, while 39% of this sample endorsed the
currently correct "10-25 per cent” response. A higher percentage of
this sample, then, got the answer correct. Although this finding may
indicate that the current subjects are more knowledgable about this
issue, it also seems possible that choice "b" was a more likely
estimate for both groups of women. Efforts to check this hypothesized
interpretation with the Stillman data were frustrated because she does
not report the percentages of incorrect responses.

The second question asks for knowledge of the age at which
incidence of breast cancer increases. Stillman notes that options of
30th birthday (b) and 40th birthday (c) are both acceptable because
the ages of 35 and 40 are most frequently cited in the literature
(1977, p. 124). Sixty-eight percent of this satple chose one of those
two options, cotpared to 92% of Stillman's. The final question
concerned knowledge of the non-cancerous nature of most lurps found in
the breast: 70% of this sample knew that most lumps do not turn out
to be cancer, compared to 96% of Stillman's. For two of these three

questions, this sample of young women shows less knowledge than

79

Stillman's subjects and for the third the comparison is confounded by
the change in the correct answer. It appears, then, that these
college students are less knowledgeable about breast cancer than the
older women Stillman sampled; a likely explanation for the difference
is their youth, which involves both a lack of perceived susceptibility
to the disease and a lack of peer experience with the disease.

That conclusion does not, however, explain the lack of a
relationship between knowledge of breast cancer and BSE frequency.
Perhaps the equivocal information available about‘these aspects of
breast cancer engenders sufficient confusion to cloud the impact of
accurate knowledge about them. If not, it appears that knowledge of
the disease is largely unrelated to BSE frequency for these young
women. These results are not consistent with the findings of Spring
and Kosch (1982), Olenn (1981) and Stronborg (1981). They do offer
related support to Celentano and Boltzmann's (1983) finding that
knowledge of warning signs was unrelated to BSE corpetence.

Perceived Susceptibility to Breast Cancer. Of the three items

 

chosen to represent perceived susceptibility to breast cancer because
of the extent to which they discriminated among subjects, only one --
present health too good to consider thinking about getting breast
cancer -- showed a significant association with frequency of BSE.
That association is negative, indicating that the stronger one's
belief is in that view, the less frequently one performs BSE.
Discussion of that finding appears above. Investigation of the other
two susceptibility items reveals that there is not a significant
association for these young women between frequency of BSE and 1)

getting older and thinking more of the possibility of getting breast

80

cancer and 2) their estimations of their chances of getting this
disease someday. The lack of association between these items and
reported frequency of BSE seems to result from the age of these
subjects -- because of their youth, it seems probable that they have
not gotten I'old enough" to face the serious possibility of getting
breast cancer at the present time nor are they likely yet to feel

vulnerable to the disease in the future.

 

Knowledge of BSE. As discussed earlier, accurate knowledge and
performance of BSE appears to be very influentialin predicting
frequency of BSE. Further investigation of the correlations between
the two knowledge of BSE scores and the frequency of performance
reveals two interesting points. First, it is interesting to note that
in the second situation (which steps 51113119 be performed in
cotprehensive BSE) a fifth step, standing before a mirror and
inspecting breasts for anything unusual while holding arms over head,
was so highly correlated with the other four that it was included in
the scale. It is curious that subjects report knowing that step, yet
not performing it; particularly, since it seems like such an easy one
to perform. Of greater importance, perhaps, is the second point that
the scale focusing on what should be done did not show nearly as
strong a correlation with frequency of bmast self-examination as did
the first scale (_F .31, _rr- .60). It is apparent, then, that accurate
knowledge does not appear to be as influential in the frequency of BSE
as does accurate knowledge combined with perfonnance of the basic
steps of this procedure. Again, the conslusions of Roberts et a1.
(1984) and Pennypacker et al. (1982) about the importance of actual

performance of BSE in developing knowledge and proficiency is

81

underscored.

Perceived Benefits of BSE. Investigations of the subjects'

 

awareness of the benefits of BSE involved consideration of two items,
one of which showed the predicted association and one which did not.
The significant association, which was a negative one, exists between
frequency of BSE and embarrassment about examining breasts. Altholgh
the (relationship between this response and BSE frequency was examined
previously in the section on prediction of BSE, it is important to
note here that the significant negative correlation is stronger than
that for many of the independent variables in this study (_r_‘= -.30).

The second benefit item, which involved unnecessary worry about
breast cancer resulting from performance of BSE, did not show a
significant association with frequency of BSE. It seems likely, in
keeping with the results discussed above, that for these young women
the realistic evaluation that they are unlikely to get breast cancer
at this time overrides any connection that they might make between the
performance of BSE and their worry about the disease. The endorsement
of ”I'm afraid of how I'll react if I do find something abnormal" as a
reason for non-performance by only 15 subjects may support this
interpretation. The lack of worry by these young subjects contrasts
with the anxiety and worry reported by the older subjects in the
studies by Keller, et a1. (1980), Kelly (1978), Stillman (1977), and
Turnbull (1978).

Confidence in Corpetence to Perform BSE. Confidence in

 

colpetence to perform BSE resulted in the predicted positive,
significant association with frequency of BSE (_r;= .16). Confidence

is, then, a relatively important aspect of BSE performance for these

82

young women, a finding that is consistent with those of Celentano and
Holtzmann (1983), Edwards (1980), Keller et a1. (1982), Reddy (1984),
Spring and Kosch (1982), and Zapka and Mamon (1982). Further
investigation of this variable reveals that confidence also showed a
significant correlation with the reported performance of BSE (_r;= .22).
Confidence is, then, also related to accurate knowledge and

performance of the health behavior.

 

Social Influence to Perform BSE. Finally, social influence in
the form of encouragement to practice BSE is associated with
significantly more frequent performance of the procedure (means of
3.40 for those who receive it and 2.30 for those who do not differ at
the p< .001 level). Apparently, young women benefit from the interest
and concern of significant others in their practice of BSE. This
result supports Howe's (1981) investigation which revealed that lack
of social influence was associated with non-performance of BSE. It is
further supported by these students' responses to an item which asked
what kind of reminder might be helpful to then in performing BSE. A
majority (_n=103) indicated that a reminder from a significant person
(lover, physician, parent) would be helpful to then.

The Effect of ngy Image and Self-Esteem

 

 

 

As indicated in the Results section, the predicted relationships
between BSE and body image and self-esteem were not found. These
results are inconsistent with those of Scilken (1977) and Hallal
(1981), both of‘whon found significant relationships between frequency
of BSE and the related factors of body image and physical
self-concept. While the difference with Hallal's findings may be

explained by measurement techniques (she used the Tennessee

83

Self-Concept Scale physical self-concept measure), that explanation
does not hold for Scilken's study which also exployed Secord and
Jourard's Body Cathexis Scale. It seems more likely that the current
lack of findings are, again, related to the youthfulness of this
salple. Body image may be less important or less well-defined for
these young women than for the older women Scilken and Hallal studied.
Rosenbaun's (1979) comments about the revisions in body image that are
required during adolescence may lend support to the latter
possibility.

The lack of relationship between self—esteem and frequency of
BSE, which also contrasts with Hallal's (1981) findings, may again
result from differing measurement tools. She used a self-esteem score
from the Tennessee Self Concept Scale, while this study exployed the
Rosenberg Self-Esteem Scale. In addition, an argument similar to
the one above (that is, that these young women may have a less
well-defined and stable sense of self-esteem) could also be made.

A final possible explanation for the lack of significant findings
with both of these variables involves the homogeneity of the sample
with reSpect to age. Perhaps the homogeneity in age is associated
with homogeneity on these variables, and, therefore, with the lack of
significant results.

The Effect _o_f Perceptions of and Experiences with Breasts

 

 

 

This final area of investigation grew out of the possibility that
the particular body part involved in this health behavior may have
some special significance for the performance or non-performance of
BSE. Reasoning in a fashion similar to that of Scilken (1977) and

Hallal ( 1981), who hypothesized that feelings about the body as a

84

whole would affect performance of BSE, this hypothesis proposes that
feelings about and experiences with the breasts in particular might
also influence BSE frequency.

Four perceptions of breasts were investigated: importance,
satisfaction, attractiveness, and comfort. Two of those perceptions
showed positive significant (although low) correlatims with frequency
of BSE: importance of breasts (_r_= .14) and comfort with breasts (g
.14).

Importance of Breasts. The interesting aspect of the two-item
scale measuring importance of breasts is that the criteria that were
used to evaluate importance are not readily apparent. This
researcher's intuition was that, at this age of sexual exploration,
attractiveness and satisfaction would be very salient aspects of
ratings of importance of breasts. That intuition is, apparently, an
inaccurate one because efforts to combine the measures of those
variables with the measure of importance resulted in a scale of very
low internal consistency. It seem that importance must be determined
by sore aspect other than attractiveness or satisfaction, perhaps by
functioning of the breasts. Possible support for that connection may
be seen in the relatively high correlation between importance of
breasts and sexual experiences (_r_= .36, p< .001). Perhaps the
function of breasts in sexual activities as objects and scum of
arousal may be more important than attractiveness and satisfaction.

Comfort with Breasts. A significant correlation was also found
for the perception of comfort with breasts and frequency of BSE (g
.14). This study and others have found that lack of comfort, which

has been defined as embarrassment, modesty, uneasiness about the body

8S

and breasts, is associated with non-performance of BSE (Howe, 1981;
Miller, Norcross & Bass, 1980; Stillman, 1977; and Zapka & Mamon,
1982). Approaching this same issue from the opposite vantage point,
the current study also suggests that more frequent BSE is associated
with greater comfort with breasts.

Attractiveness of and Satisfaction with Breasts. The finding
that attractiveness and satisfaction are not related to‘BSE is
somewhat surprising, as suggested above. It is noteworthy that both
that both variables show significant positive correlations with body
image (_r_= .18, p< .05; 3= .29, p< .001; respectively) and that
satisfaction also shows a positive correlation with self—esteem
(_r_=.16, p< .05). The latter result supports Lerner, Orlos, and
Knapp's (1976) finding that feelings about breasts were related to
self-concept in college women.

In addition to perceptions of breasts, several kinds of
experiences with breasts were also examined: developrental
experiences, sexual experiences, and experience with breast cancer.

Developtental Experiences with Breasts. The prediction that
experience with early breast development would be associated with
frequency of BSE received no support. This prediction was based on
Benedek's (1979) evaluation of the significance of the adolescent's
response to her early breast developrent and the inference that those
early emotional responses would affect later feelings about breasts.
The lack of an association here suggests that the inference is
incorrect. Pemaps these young woten's early responses are
sufficiently in the past or sufficiently resolved that they do not

influence their current responses to their breasts, or at least their

86

current behavioral response of BSE practice.

Sexual Experiences with Breasts. The importance of which kind of

 

experience is most recent receives sate possible support from the
observed positive association between the second experience, sexual
activities, and frequency of BSE. It seems to this researcher that
for these late adolescent and young women, their current awareness of
their breasts is more likely to be focused on their role in sexual
activity than on their previols early developtent. Sexual activity
does show a significant (although low) association with the dependent
measure (_r_= .19) and also enters the prediction equation. Discussion
of this variable was presented earlier.

_E_xperiences involving: Breast Cancer. The final kind of

 

experience evaluated was the impact of another's breast cancer or
mastectomy, and anticipated response to one's own. In addition to the
simple question about acquaintance with a woman who has had breast
cancer that was entered into the multiple regression analysis, three
scales were involved in this investigation. The scale that asked the
subject to reflect on the impact of knowing that victim on her own
view of breast cancer and BSE showed a significant, positive
correlation with frequency of BSE (5= .54). The associations between
the dependent measure and the other two scales were non-significant.
Therefore, it appears that the critical variable in this area is not
the breast cancer victim's adjustment to her disease or the subject's
anticipated response to her own potential breast cancer, but the
extent to which the subject's attitudes toward breast cancer and BSE
changed as a result of knowing a breast cancer victim. Perhaps

awareness and fear of the disease increase substantially with actual

acquaintance with a person undergoing the experience and,
consequently, willingness to perform BSE conscientiously increases.
As noted earlier, this hypothesized connection receives some support
from the significant correlation (_r_= -.32) between the impact scale
and the susceptibility item (health too good at present to think about
getting breast cancer). This interpretation suggests that the
powerful impact of breast cancer and mastectomy on the victim reported
by Polivy (1975) may influence those acquainted with her. It is not,
of course, possible to establish the direction or‘even the causal
nature of the hypothesized relationship on the basis of these
correlational data. A very plausible alternate explanation may be
that those who feel susceptible to breast cancer. (or are very aware of
it) are more likely to recall their acquaintance with a breast cancer I,»
victim and retrospectively attribute their feelings of susceptibility
(or their commitment to BSE) to it. Further investigation is needed
to understand fully the impact of acquaintance with a breast cancer
victim.

L j The lack of impact of the anticipated response variable may V
again reflect the difficulty these young women appear to have in

perceiving their vulnerability to the disease.

Ca'tparison of the Results of this Study to tie Literature

 

The purpose of this study was to investigate the reasons for
performance and non-perfonnance of BSE and the variables that
differentiated performers from non-performers in a college-aged
population. The study was exploratory in that it focused on this
young population and it incorporated investigations of perceptions and

experiences with breasts into the more usual set of variables

,4

88

considered by previous researchers.

As noted in the Review of the Literature, there are few
consistent findings of variables that differentiate performers from
non-performers of BSE. / The most consistent findings are found with a
preventive health orientation, confidence in ability to perform BSE,
and embarrassment/inhibitions about examining breasts/ The first two
involve a positive relationship (increases in them are associated with
more frequent BSE): the last a negative relationship (the greater the
embarrassment, the less frequent BSE)./In this sample of young watery"
the predicted associations were found for confidence and 1 h

./
embarrassment, but not for the preventive health orientations“

// More inconsistent findings are found in the literature for the
relationship between BSE performance and knowledge of breast cancer,
perceived vulnerability to it, familial history of the disease, and
knowledge of the breast self-examination procedure/ 19.101513??? of ‘/’
young women, accurate knowledge and performance of the procedure was a
very strong differentiating variable/ A factor related to familial
history of breast cancer, acquaintance with a breast cancer victim,

was also very influential, especially as it focused on the

cousequences of that experience for the subject. Perceived

vulnerability was significantly associated in a negative direction

with BSE frequency. Finally, knowledge ofbreast cancer was
inconsistently associated with BSE frequency. A positive association

was found for only one of four knowledge questions; nauely, knowledge

of the increased risk of breast cancer if one has relatives who have

had the disease.

A final pair of variables introduced in the literature review

89

were body image and self-esteem. These variables had not been
investigated often (two studies were found for body imuage, one for
self-esteem). The predicted results were not found in this study.

Within the particularly exploratory area of perceptions of and
experiences with breasts, breast importance and the impact of sexual
activity showed significant positive correlations with BSE, while
attractiveness, satisfaction, and early breast development did not.

The major differences in results observed between the literature
in general and this study, then, are two:

1) the relationships between BSE frequency and knowledge of BSE
and acquaintance with a breast cancer victim are stronger than would
be predicted from the literature, which reveals inconsistency with
respect to these two variables:

2) the lack of a relationship between BSE frequency and a
preventive health orientation in this study is very different from the
consistent relationship found in other research.

In additim, the role of perceived susceptibility appears to have
a stronger impact on these young women than one might expect on the
basis of the inconsistent findings reported in the literature review.
More minor, but noteworthy, discrepancies involve the lack of
relationship between BSE frequency and body image and self-esteem.

The three variables where the expected relationship was not
observed — preventive health orientatiou, body imuage, and self-esteem
- have at least one explanation in common. That explanation rests on
the youth of these subjects and the decreased likelihood that they
have a clearly developed preventive health orientation, or a stable

body image or sense of self-esteem.

90

Practical Implications

Given the similarities and differences of the results of this
study in couparison to the literature in general, what practical
implications are there for young women's performance of BSE?

The major finding is that accurate knowledge and performance of
BSE are very important to its frequency for this populatiou.
Opportunities to gain knowledge of the procedure and to perform it
correctly should, then, be a central focus of the campaign for BSE
performance by young wouen. Investigation of themost effective means
of transmitting the knowledge and of promoting performance in these
young women is needed.

/It is interesting to note that knowledge of the elementary
aspects of the procedure (lying down, putting arm behind head,
pressing flat part of fingertips in circles covering whole breast, and
squeezing nipples gently) was the influential factor,» This finding
suggests the importance of stressing the basics and, perhaps, even of
simplifying the procedure. Holtzman and Celentano (1983) came to
similar conclusions. They question if 9611 of the steps for BSE need
necessarily be carried out for detection of breast abnormalities‘;(p.
1325). They also believe it would be useful to examine which
maneuvers wouen are more likely to carry out and why. After
investigating various BSE educational programs for this project and
finding saue to be both couplicated and time-consuming, the
possibility of a simpler approach has considerable appeal. The idea
of identifying the most frequently practiced maneuvers and women's
reasons for practicing those steps and building a program on that

foundation makes good common sense.

91

The impact of embarrassment on these young wouen as well as on
wauen of all ages needs to be addressed. One approach to this
difficult and affect-laden issue would involve discussing the
discomfort directly during the educational program. Pemaps talking
openly about embarrassment and hearing others' feelings would reduce
its impact. The effect of discussion on inhibition has not been
investigated, but Bond (1956) found that discussion in general can be
a useful aspect of BSE education. His educational discussion groups
showed significantly higher follow-up BSE practice rates than those in
his lecture groups. Behavioral techniques of desensitization,
modeling, and/or guided participation may also alleviate soue of the
eubarrassment. As Worden et a1. ( 1983) suggest, this sensitive
subgroup requires further study.

/Thirdly, the lack of perceived vulnerability among these young
women needs to be addressed. The major difficulty in this issue is
the epidemiology - the fact that breast cancer affects women over 35
much more often than those younger/ The rationale that has been
euployed to counteract this difficulty is the notion that it is
important to establish health behaviors early in a woman's life.
Holleb (1966) reports that “the purpose of teaching the technique
during the high school years is not to detect cancer. It is to
develOp a health habit. The muore experience they gain, the more adept
they'll be when they're older" (p. 7). Neenan and Neenan (1974)
concur and elaborate on this early health habit there:

most desirable timing for breast cancer preventiou
education would be during the woman's formative years,
namely early adolescence when the girl is highly
interested in all aspects pertaining to her body,

developuent and sex, and being at very low immediate risk

/

92

of breast cancer, is not subject to the same

barrierbbuilding anxieties as is the middle-aged

wmmmmu(pu 546).
Strouuborg (1981) sees the college health service as an "ideal" setting
for teaching BSE and Zapka and Mamon (1982) are in the process of
designirug, implementing, and evaluating a sound educational program of
BSE for college students. Stressing to young wauen the importance of
their discovering cancer through BSE (when its incidence under age 35
is very low) or focusing on establishing a habit for the future (when
they generally lack a sense of vulnerability to the disease) seem to
be relatively ineffective approaches. Reporting the epidemiology
accurately and emphasizing the importance of getting to know one's own
breasts over tflme and the unlikelihood of finding an anxiety-producing
symptom at this low-risk age may be more useful aspects of training in
BSE.

The finding of the importance of acquaintance with a breast
cancer victrm also needs to be investigated for practical
implications. Such a relationship appears to impact on the frequency
of BSE performance, perhaps because it brings the disease more clearly
into focus for these young women. One way to increase the contact
between breast cancer victimus and other wauen would be to have a woman
who.has experienced breast cancer tell her story as part of the
educational process.//Obviously, there are differences between such an
experience and the more involved contact with a victim who is a
relative or close friend,//It is not clear if a one-tame,
non-intimate, but informative, presentation would have an impact. It
seats, however, to be a possibility worth investigating.

Finally, the relationship between sexual activities and BSE

93

frequency may suggest the importance of appealing to these young
women's sexual awareness of their breasts as a motivator for BSE. It
also seeus that discussion about their sexual feelirugs and the
protection of their breasts as sexual body parts through BSE may
facilitate commitment to the procedure.

Future Research

 

Several areas of future research are suggested by these
considerations. The first is the development of scales that
adequately measure (particularly with respect to internal consistency)
general preventive health orientation, knowledge of breast cancer,
perceived susceptibility to it, and perceived benefits of BSE.

A second area focuses on investigation of the muost effective
means for transmitting information about BSE and promoting its
practice in young women. Sore of the potentially important aspects of
that investigation have been suggested above: the role of discussion
in instruction, the emphasis on the importance of getting to know
one's breasts over time, the lack of anxiety in performing the
procedure at a low risk age, the impact of a speaker who has had
breast cancer, and the appeal to the sexuality of the breasts.

A third and very important area for future work that has also
been introduced above is investigation into sensitive subgroups, like
those wouen who report that inhibitions or embarrassuent are
associated with BSE non-performance (Worden, et al., 1982). Roach and
O'Fallon (1983) extend this approach by stressing the importance of
targeting any groups of women that appear to be resistant to
performing BSE for more intensive investigatiou. One subgroup

highlighted by Stillman (1977) that is particularly intriguing is the

94

group that reports high beliefs in perceived susceptibility to breast
cancer and perceived benefits of BSE, but infrequent performance of
BSE.

A fourth area for future work that the current study anticipated
is the need to measure both proficiency and frequency of BSE. Much of
the eupirical work done before 1982 focused on frequency as the most
significant factor in BSE performance; however, recent investigators
(Holtzman 8 Celentano, 1983: Roberts, et al., 1984: Sheley, 1983) have
discovered that only a small percentage of the women in their studies
who reported frequent BSE actually knew and performed the technique
correctly. In contrast, this study revealed a strong relationship
between frequency and accurate knowledge and performance. Further
investigation of the relationship between frequency and proficiency
is, then, indicated. In addition, it is very important to note that
the measureuent of proficiency is critical to the adequate evaluation
of the efficacy of this health behavior. Fortunately, the focus on
proficiency is likely to increase because a number of the current
researchers appear to agree on the importance of measuring the quality
of performance of BSE. Scales or indexes of correct technique,
similar to that euployed in this study, have been developed and/or
utilized by Calnan, Chauberlain, and Moss (1983): Celentano and
Holtzman (1983); Howe (1980); and Zapka and Manon (1982).

A.fina1 area for future research that constrasts strongly with
the approach of the present study is introduced in a coupelling and
controversial article by Grady (1984). She argues against the focus
on characteristics of performers/non-performers in the research and

against the focus on education as the ”cure" in intervention

95

strategies. She believes that the critical factors for coupliance
with health practices most likely depend on the stimulus conditions
and reinforcement contingencies associated with the behavior.Asserting
that BSE has few intrinsic or extrinsic rewards, Grady focuses o1
stimulus control, the enhancement of cues for BSE.She reports 80%
monthly coupliance rates with subjects whose cue was an
appropriately-timed postcard reminder to perform BSE. The success of
Grady's approach and its basis in behavioral theory are impressive.
Her focus on investigating effective cues for BSE performance appears
to be a very useful, though not all-encaupassing, approach to the
issue of non-compliance. It deserves further investigation.
Summary

There are three sets of implications of this study of the factors
that influence young wouen's performance of BSE. The first is the set
of current practical suggestions for those concerned with BSE
education for college women. The second and third involve future
research directions, focusing on practical directions for the research
and on more theoretical research.

The practical suggestions for those involved in developing and
marketing BSE educational programs for college wauen are:

1) emphasize accurate knowledge of the basic eleuents of BSE;

2) promote accurate practice of BSE;

3) euploy discussion about embarrassment and behavioral
techniques aimed at alleviating inhibitions related to it;

4) euphasize the lack of anxiety involved in BSE at this
low-risk age:

5) stress the importance of getting to know one's breasts over
time;

6)

7)

8)

encourage significant people in young wouen's lives to
promote and support BSE performance;

consider having a woman who has had breast cancer tell her
story as part of the BSE educational program;

appeal to the young women's awareness of the sexual nature
of their breasts.

Future research oriented to the more practical aspects of BSE

should focus on:

1)
2)

3)

4)

measuring both proficiency and frequency. of BSE;

investigating the most effective means for transmitting
knowledge of BSE and promoting its practice in young wouen;

investigating cues for performance that would be practical
to use on a large scale;

investigating subgroups of wouen resistant to BSE and useful
strategies for promoting their practice of this health
behavior.

More theoretical research related to BSE should involve:

l)

2)

3)

4)

the accurate measurement of general preventive health
orientation and its role in BSE performance;

the accurate measureuent of breast cancer knowledge,
perceived susceptibility to it, and perceived benefits of
BSE and their relationships to BSE performance;

the relationship of this health behavior and others to body
image and self-esteem;

further investigation of the role perceptions of breasts
and experiences with then play in BSE for varying age
groups.

It was this last aspect of the current study, perceptions of and

experiences with breasts, that was new and most exploratory. Two of

the independent variables involved in the fourth hypothesis entered

the regression equation (acquaintance with a breast cancer victim and

sexual experiences) and two more showed statistically significant

97

correlations with BSE (importance of breasts and general comfort with
them). Those findings lend soue support to the idea that underlying
psychological processes play a role in the performance of BSE. This
effort to respomd to the Natin Cancer Institute's call for studies
into the ”subconscious factors that influence a woman's emotional
response to information about breast cancer and to suggestions
concerning detection processes“ (1979, p. 60) has, then, been
fruitful. Further work using the strategy of investigating women's
perceptions of and experiences with their breasts to better understand
not only BSE, but other practical and theoretical issues involved with
women and their bodies, appears to be another useful direction for

future psychological research.

APPENDICES

APPENDIX A

Survey of Women's Health Behaviors and Body Attitudes

Dear Women Students,

As the title suggests, the following survey focuses on women's
health behaviors and body attitudes. The survey, which is part of my
dissertation research, will probably take you about an hour and a half
to complete. It is the only requirement for your participation in the
study.

Through the survey, I'm interested in learning generally which
health behaviors you perform and how you feel about your body. In
addition, the survey contains questions about your attitudes. knowledge
and experience with specific health practices (for example, breast
self-examination) and your feelings and experiences with specific parts
of your body. Some of the questions focus on feelings and experiences
that people may regard as being somewhat taboo or private (for instance,
sexual experiences). I can assure you that I have asked nothing in the
survey that will not be useful in understanding the state of women's
health practices and body attitudes and that your responses will be held
in strictest confidence. To insure the anonymity of your responses,
please be sure £93 to put any identification (name, student number) on
the survey form.

Because the questionnaires are anonymous, it is not necessary for
you to sign a consent form. Please read the information on the
following page, which is usually found on the consent form, and
understand that your returning the survey to me will be evidence of
informed consent.

In closing, I would like to to ask you to complete the survey as
carefully as possible. As you probably know, research is only valuable
to the extent that it accurately reflects what people actually do or
feel. I ask, then, that you be as honest and complete in your responses
as you can be. To this end, PLEASE make any additional comments on the
questionnaire that you feel would help me better understand your
experience or point of view. Even a careful completion of the
questionnaire should take no more than an hour and a half.

Thank you for your helpl

Sincerely,

Pat Ponto

98

99

Please read this page and take it with you.

I. I have freely consented to take part in a scientific study being
conducted by Patricia Ponto, M.A., under the supervision of Elaine
Donelson, Ph.0.. Professor of Psychology.

2. The study has been explained to me and I understand the explanation
that has been given and what my participation will involve.

3. I understand that I am free to discontinue my participation in the
study at any time without penalty.

4. I understand that the results of the study will be treated in strict
confidence and that I will remain anonymous. Within these restrictions,
results of the study will be made available to me at my request. Please
contact Pat Pontc, XDepartment of Psychology after 6/l/84 for the
results.

5. I understand that my participation in the study does not guarantee
any beneficial results to me.

6. I understand that, at my request, I can receive additional
explanation of the study after my participation is completed. Please
contact Pat Ponto, 20epartment of Psychology.

7. I understand that, should the study prove upsetting to me in any
way, I am free to discuss my feelings with the researcher, who is also a
therapist. This discussion can be arranged by calling Marlene Terbush,
secretary in Department of Psychology. at 353-5981.

100

Part I. Personal Data Sheet. Please fill in the blanks as indicated.

 

l. Age ___ 2. Height ___ 3. Weight ___

A. Racial Background 5. Religious Preference
(Check one.) (Check one.)

___ White Protestant

___ Black Catholic

___ Oriental Jewish

___ Hispanic ___ Agnostic

___ Other. Please specify. Atheist

Other. Please specify.

6. How religious would you say you are? (Circle one.)
anti- not at all slightly somewhat very
religious religious religious religious religious
I 2 3 h 5
7. Number of Siblings. Place appropriate number in each blank.
___ Older brothers Older sisters
___ Younger brothers Younger sisters
8. How would you describe the area you come from? (Check one.)
___ rural
___ suburban -
___ small city (less than 250,000 people)
___ large city (more than 250,000 people)
9. Current Marital Status (Check one.)

Never married

Living with a lover
Married for the first time
Remarried

Separated

Divorced

Widowed

IO. How many children do you have ?

 

 

101

II. Body Parts. Please list ten body parts.

 

 

2.
3.
h.
5.
6.
7.
8.
9.
IO.
Part III. Health Behgviors. Please complete the questions as
indicated.
1. During the past 2h hours have you eaten: (check if yes)
Fresh fruit
Candy
Whole grain breads
Whole grain cereal
Fresh vegetables
Non-diet soft drinks
Junk food
2. Which of these statements best describes your physical activity in

general? (Check one.)

Not very active physically, usually just sitting or walking

Fairly active physically, moderate or strenuous activity several
times a week

Quite active physically, at least moderate activity every day

___ Extremely active physically, strenuous activity most days

3.

you

Do you think you weigh too much now, or has a doctor or nurse told
that you now weigh too much? yes no

Are you currently on a diet to lose weight? yes no

102

Are you doing any special exercises to lose weight?
yes no

A. When you ride in a car or truck, how much of the time do you wear a
seat belt? (Check one.)

None of the time

A little of the time
Some of the time
Most of the time

All of the time

U'I

How frequently do you brush your teeth? (Check one.)

Rarely or never

About once a week

3 or k times a week

About once a day

Twice a day

After almost every meal, including lunch

°‘|l||||

How frequently do you floss your teeth? (Check one.)

Rarely or never
About once a month
Every two weeks

Once or twice a week
3 or 4 times a week
Every day

\l

. When was the last time you visited a doctor for a regular check-up?
(0 NOT count any check-up required for admission to MSU or for
participation in athletics)? (Check one.)

Within the last 6 months

Within the past year

Within the past 2 years

Within the past 5 years

Within the past lO years

I do not go to a doctor for a regular check-up, but only when I am
k

M
O

103

8. When was the last time you visited a dentist for a regular check-up?
(Check one.)

Within the last 6 months

Within the past year

Within the past 2 years

Within the past 5 years

Within the past lO years

I do not go to a dentist for regular check-ups, but only if I have
e specific problem with my teeth or gums

3

\D

. When was the last time you had a Pap smear done? (Check one.)

Within the past 6 months

Within the past year

Within the past 2 years

Within the past 5 years

I've never or rarely had a pap smear

l0. How frequently do you examine your breasts for lumps or other
abnormalities? (Check one.)

Never

Once or twice a year
Three or four times a year
Every couple of months
Once a month

More than once a month

II. If you were to have heterosexual intercourse, would you use some
means of contraception or birth control? (Check one.)

Yes, without a doubt
___ Yes, probably
No
12. Do you currently use a birth control method? yes no

If yes, please indicate which by checking the appropriate blank(s).

Birth control pills
Intrauterine device (IUD)
Diaphragm

Contraceptive foam
Condom

Withdrawal

Rhythm

Other (Please specify.)

104

Part 1!; Family Health History. Check the space under "you" or your
parents if you KNOW that he, she or you have had any of the following
medical disorders.

.<
C

Medical Disorder Mother Father

0

High Blood Pressure

Heart Trouble

Stroke

Ulcer Disease

Kidney Disease

Arthritis

Neuromuscular Disease
(e.g., muscular dystrophy)

Seizures ___ ___ ___
Diabetes ___ ___ __.
Cancer _ _ _
Alcoholism/Drug Abuse ___ ___ ___
Mental Illness ___ ___ ___

Other. Please specify.

For the following groups of people (grandparents, other close relatives,
close friends), place the NUMBER in the blank of the persons who '
have/have had the disorder. For instance, if two grandparents

suffer/suffered from high blood pressure, put a ”2“ in the blank.

Medical Disorder Grandparents Other Close Close Friends
Relatives

High Blood Pressure

Heart Trouble

Stroke

Ulcer Disease

Kidney Disease

Arthritis

Neuromuscular Disease

Seizures

Diabetes

Cancer

Alcoholism/Drug Abuse

Mental Illness

Other. Please specify.

How trusting are you of the medical profession? (Circle one.)

very somewhat neutral somewhat very
mistrusting mistrusting trusting trusting
u 2 3 h S

105

Part My Breast Associations. List the first ten words that come to
mind when you think about breasts. (This is meant to be a free
association exercise, so please do not censor your responses. Remember
that the survey is confidential and write down the first ten words that
come to mind.)

I.

10.

Part VI. More Breast Associations.
associate with your breasts.

106

Please check those words you
Use a single check for those that stir

some (moderate) association and a double check for those that elicit

strong associations.

maternal
sexual
fulfilling
arousing
warmth
petting

milk-giving

Now, please go through the words again in the list below.

sensuous
nurturing
nourishing
gratifying
vulnerable
baby sucking

alluring

giving
powerful
protecting
womanly
soft
abundant

enfolding

In the blank

before the word, please indicate if you view that word as applying more
to the sexual role of breasts (put an "s" in the blank), the maternal
role (put an "m" in the blank), both (put a ”b" in the blank), or
neither (put an ”n" in the blank).

s-sexual
m-maternal
b-both
n-neither

maternal

sexual

fulfilling

arousing

warmth

petting

___ milk-giving

sensuous
nurturing
nourishing
gratifying
vulnerable
baby sucking

alluring

giving
powerful
protecting
womanly
soft
abundant

enfolding

107
IO

Part VII. Feelings about Body. On this page are listed a number of
things characteristic of yourself or related to you. Consider each item
listed below and decide which of the following best represents your
feelings according to the following scale. Place the appropriate number
in the blank in front of the item.

Have strong feelings and wish change could somehow be made.
Don't like, but can put up with.

Have no particular feelings one way or the other.

Am satisfied. '

Consider myself fortunate.

UTJ-‘UJN—I
IIIII

l9. shape of head
20. body build

bk. sex (female or male)
AS. back view of head

___ l. hair ___ 26. chest

I___ 2. facial complexion ___ 27. eyes

___ 3. appetite ___ 28. digestion

___ h. hands ___ 29. hips

___ 5. distribution of hair over body ___ 30. skin texture
___ 6. nose ___ 3l. lips

___ 7. fingers ___ 32. legs

___ 8. elimination ___ 33. teeth

___ 9. wrists ___ 3h. forehead

___ l0. breathing ___ 35. feet

___ ll. waist ___ 36. sleep

___ l2. energy level ___ 37. voice

___ l3. back ___ 38. health

___ lh. ears ___ 39. sex activities
___ l5. chin ___ no. knees

___ l6. exercise ___ hl. posture

___ l7. ankles ____h2. face

'___ l8. neck ___ L3. weight

___ 2l. profile ___ A6. trunk

___ 22. height ___ A7. abdomen

___ 23. age ___ 48. buttocks (seat)
___ 2h. width of shoulders ___ 49. general muscle tone
___.25. arms ___ 50. overall body

appearance
___ 5l. breasts

O

ne or more of my body features makes me a poor sex partner. (Circle
one.)

strongly disagree disagree agree strongly agree
I 2 3

108

Part VIII. Feelings about Self. The items in this section focus on
your feelings about yourself. For each item, circle the response that
most closely describes your view of yourself.

I. I feel that I'm a person of worth, at least on an equal basis with
others. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

2. I feel that I have a number of good qualities. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

3. All in all, I am inclined to feel that I am a failure. (Circle
one.)

strongly disagree disagree agree strongly agree
I 2 3

h. I am able to do things as well as most other people. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

5. I feel I do not have much to be proud of. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

6. I take a positive attitude toward myself. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

7. On the whole, I am satisfied with myself. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

8. I wish I could have more respect for myself. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

9. I certainly feel useless at times. (Circle one.)

strongly disagree disagree agree strongly agree

I 2 3

109
)2

l0. At times I think I am no good at all. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

II. I am more intelligent than the average person. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

l2. I am more likeable than the average person. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

I3. I am more assertive than the average person. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

lb. I am more emotional than the average person. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

IS. I am more conscientious than the average person. (Circle one.)

strongly disagree disagree agree strongly agree
I 2 3

16. How often do you dislike yourself? (Circle one.)

practically rarely sometimes fairly often very often
never

I 2 3 h 5

l7. When you talk in front of a class or group of persons of your own
age, how apprehensive (scared, nervous) do you usually feel? (Circle
one.)

not at all not very somewhat considerably very
apprehensive apprehensive apprehensive apprehensive apprehensive
l 2 3 It 5

l8. How confident do you feel that some day the persons you know will
look up to you and respect you? (Circle one.)

not at all not very somewhat considerably very
confident confident confident confident confident
I 2 3 h 5

110
13
I9. How often do you feel self-conscious? (Circle one.)
practically rarely sometimes fairly often very often
never

I 2 3 h 5

20. How sure of yourself do you feel among strangers? (Circle one.)

not at all not very somewhat considerably very
sure of sure of sure of sure of sure of
myself myself myself myself myself

I 2 3 h 5

2l. How confident are you that your success in your career is assured?
(Circle one.)

not at all not very somewhat considerably very
confident confident confident confident confident
I 2 3 lo 5

22. How often do you worry about how well you get along with other
persons? (Circle one.)

practically rarely sometimes fairly often very often
never
I 2 3 h 5

23. How often do you feel that you have handled yourself well at a
social gathering? (Circle one.)

practically rarely sometimes fairly often very often
never
I 2 3 h 5

2h. How uncomfortable are you when you start conversations with persons
you don't know? (Circle one.)

not at all not very somewhat considerably very
uncomfortable uncomfortable uncomfortable uncomfortable uncomfortable
I 2 3 II 5

25. Overall, how confident do you feel about your abilities? (Circle
one.)

not at all not very somewhat considerably very
confident confident confident confident confident
I 2 3 I» 5

111
lb

Part 15; Relationship History. The following questions ask you for a
description of your current and past dating relationships. Please
complete the items as indicated.

I. What phrase best describes your current situation? (Check one.)

not dating

dating occasionally, but no one in particular
dating frequently, but no one in particular
dating one person occasionally

dating one person steadily

engaged

married or cohabiting (living together)

other (Please describe.)

2. If you are dating one person steadily, engaged, married, or
cohabiting, how long have you been involved with that person? (Check
one.)

Check here if not applicable.

six months or less

six months to one year
one to two years

three to five years
more than five years

3. How would you rate the physical attractiveness of your current
partner or the average attractiveness of the people you've dated in the
last year? Circle one. Check here if not applicable.

much less slightly less as slightly more much more
physically physically physically physically physically
than I than I than I than I than I
l 2 3 A 5

A. How satisfied were you with your dating relationships during
adolescence? Circle one. Check here if not applicable.

very somewhat neutral somewhat very
dissatisfied dissatisfied satisfied satisfied
I 2 3 II 5

5. If you are not married or cohabiting, how satisfied are you with
your dating relationships now? Circle one. Check here if not
applicable.

very somewhat neutral somewhat very
dissatisfied dissatisfied satisfied satisfied
I 2 3 h 5

112
IS

6. How satisfied are you with your present marriage or cohabitation?
Circle one. Check here if not applicable.

very somewhat neutral somewhat very
dissatisfied dissatisfied satisfied satisfied
I 2 3 h S

7. How important do you think physical attractiveness is in day-to-day
social interactions for most persons? (Circle one.)

almost slightly moderately very
irrelevant important important important
I 2 3 h

8. How important do you think physical attractiveness is for most
persons in acquiring mates? (Circle one.)

almost slightly moderately very
irrelevant important important important
I 2 3 h

9. How important do you think physical attractiveness is for most
persons in acquiring sexual partners? (Circle one.)

almost slightly moderately very
irrelevant important important important
I 2 3 h

113
I6

Part 5; Knowledge 2: Breast Cancer. Please read the following
questions and circle the letter of the statement which you think is
currently true about breast cancer.

I. The chances of a woman in this country getting breast cancer
sometime during her lifetime are

a. Under l0 per cent (less than l0 women of every IOO will someday
have it.)

b. lO-25 per cent (ID to 25 women out of lOO will someday have it.)
c. 26-50 per cent (26 to 50 women out of l00 will someday have it.)
d. 5l-75 per cent (5l to 75 women out of IOO will someday have it.)
e. Over 75 per cent (More than 75 women out of IOO will someday have
it.)

f. have no idea

2. Most lumps discovered in the breast turn out to be cancer.
a. Yes b. No c. Have no idea

3. On the average, the chances of a woman developing breast cancer
begin to increase after she passes which birthday?

a. 20th b. 30th c. 40th d. 50th e. 60th f. have no
idea

A. A woman is more likely to develop breast cancer if she: (Circle as
many as you feel are correct.)

is single.

has been married, but has no children.

has been married, and has had children.

has breastfed her children.

has had a hysterectomy (surgical removal of the uterus)
has relatives who have had breast cancer.

is past menopause (change of life).

takes birth control pills.

has been hit in the breast.

have no idea.

L.—-:"(n-hGQ.OUN

5. Five-year survival rates for breast cancer victims with "early
breast cancer" are estimated at: (Circle one.)

a. 558 b. 65* c. 75* d. 852 e. 95*

114
I7

6. The number of breast cancers that are discovered by women (rather
than physicians) is estimated at: (Circle one.)

a. 552 b. 658 c. 758 d. 852 e. 952

7. At what point following mastectomy (surgical removal of the breast
because of cancer), do most women resume normal productive lives?
(Circle one.) '

a. 2 weeks b. I-2 monthsc. 3-4 months d. 5-6 months e. l year

For the following statements, indicate the extent of your agreement by
circling the number that best represents your response

8. A woman is more likely to develop breast cancer if she has had no
children. (Circle one.)

disagree disagree neither agree agree agree
strongly somewhat nor disagree somewhat strongly
I 2 3 h S

9. A woman is more likely to develop breast cancer if she has breastfed
her children. (Circle one.)

disagree disagree neither agree agree agree
strongly somewhat nor disagree somewhat strongly
I 2 3 h 5

ID. A woman is more likely to develop breast cancer if she has taken
birth control pills. (Circle one.)

disagree disagree neither agree agree agree
strongly somewhat nor disagree somewhat strongly
I 2 3 h 5

II. A woman is more likely to develop breast cancer if she has had
previous breast cancer. (Circle one.)

disagree disagree neither agree agree agree
strongly somewhat nor disagree somewhat strongly
I 2 3 h 5

l2. A woman is more likely to develop breast cancer if she has cystic

breast disease [non-cancerous cysts (lumps) in the breast]. (Circle
one.)

disagree disagree neither agree agree agree
strongly somewhat nor disagree somewhat strongly
I 2 3 h 5

115

I3. A woman is more likely to develop breast cancer if
exposed to someone with breast cancer. (Circle one.)
disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
I 2 3 I.
lh. A woman is more likely to develop breast cancer if
hysterectomy (surgical removal of the uterus). (Circle
disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
l 2 3 h

IS. A woman is more likely to develop breast cancer
in the breast. (Circle one.)
disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
l 2 3 4

l6.

exposed to radiation. (Circle one.)

disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
I 2 3 4

I7. Breast cancer cannot be prevented at this time,
detected early. (Circle one.)

disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
l 2 3 4

l8.

treatment of breast cancer. (Circle one.)

disagree disagree neither agree agree
strongly somewhat nor disagree somewhat
I 2 3 I.

IS.

diagnosis strongly influences success in treatment.

disagree disagree neither agree
strongly somewhat nor disagree
I 2 3 I.

agree

A woman is more likely to develop breast cancer '

somewhat

l8

she has been

agree
strongly
5

she has had a
one.)

agree
strongly
5

she has been hit

agree
strongly
5

she has been

agree
strongly
5

can_just be

agree
strongly
5

The removal of the entire breast is always involved in the

agree
strongly
5

The degree of development of a breast cancer at the time of

(Circle one.)

agree
strongly
5

116
19
Please note that you have only four response options from this point on.

20. If more women examined their breasts regularly, there would be
fewer deaths from breast cancer. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 3 I.

2l. My health is too good at present to even consider thinking that I
might get breast cancer. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
I 2 3

22. Whether I find a lump in my breast myself doesn't really matter
because by then it's too late anyway. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 3 h

23. Whenever I hear of a friend or relative (or public figure) getting
breast cancer, it makes me realize that I could get it, too. (Circle
one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 ' 3

2h. If I examined my own breasts regularly, I might find a lump sooner
than if I just went to the doctor for a check-up. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
I 2 3

25. There are so many things that could happen to me that it's
pointless to think about any one thing like breast cancer. (Circle
one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 3 h

117
20

26. Even though it's a good idea, I find examining/having to examine my
breasts an embarrassing thing to do. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 3 h

27. The older I get, the more I think about the possibility of getting
breast cancer someday. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
l 2 3 A

28. Examining my breasts often makes/would make me worry unnecessarily
about breast cancer. (Circle one.)

disagree disagree agree agree
strongly a little a little strongly
I 2 3

29. If I had to think about the possibility that I might someday get
breast cancer, I would rate my chances as compared with other women as
(Circle one):

3. average

b. above average (more likely that I would get it)

c. below average (less likely that I would get it)
Please explain your rating.

<§§> How many times have you examined your breasts in the last twelve
onths? (Check one.) ‘

0 times

l-2 times

3-h times

5-7 times

8-ll times

I2 or more times

118
21

Part Ll; wledge and Practice 91 Breast Self-Examination. Please
feel free to comment about any of the following questions if you wish to
add some information or feel that an explanation would help me
understand your situation more fully. Use the empty space near the
questions or the back of the paper. Please use the number of the

question to identify your comments.

,/\
(I. Have youy been taught the procedure for breast self-examination
E)? es no

(D

If ygg, answer questions 2-5. If pg, skip to question 6.
How were you taught? (Check as many as apply to you.)

By reading a pamphlet or book.

By attending a demonstration or class.
By having a doctor teach you.

By having a nurse teach you.

By seeing it demonstrated on television.
Other (Please describe.)

IIIIIIQ‘Q

If you were taught by a person(s). please indicate with a check if that
person(s) was(were) ___ male ___ female ___ both

R3;:>As part of the learning procedure, did you examine your own breasts?
~ yes no

If yes, did a professional person (doctor, nurse) observe your breast
self-exam? yes no

h. When were you taught breast self-examination? (Check as many as
apply to you).

Within the last three months.
Three to six months ago.

Six months to one year ago.
One to three years ago.

More than three years ago.

5. How would you evaluate the BSE educational program? (If you've been
taught several times, rate the best program you've been exposed to).
(Circle one.)

very somewhat neutral somewhat very
inadequate inadequate adequate adequate
I 2 3 h 5

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22

6. How many times in the last three months have you examined your
breasts? (Please be exact.)

\l
o

How often should BSE be performed? (Check one.)

every week
every month
every 3 months
every 6 months
annually

CD

Which best describes when you examine your breasts?

on a routine basis
when I happen to think of it
not at all

If you answered _p 2
(Check as many as apply.)

routine basis, what reminds you to do so?

certain day in menstrual cycle
certain day in birth control pills
certain date of month

other (Please describe.)

If you answered when l happen 32 think pi 1;, what makes you decide
to do so? (Check as many as apply.)

 

talking with others about breast cancer

reading about breast cancer

hearing about breast cancer on television

experiencing breast tenderness or pain

noticing breasts while showering, dressing, looking in mirror
noticing breasts while sitting or laying around without much to do
thinking about breasts during sexual activities

receiving encouragement from others

having the idea just come to mind

other (Please describe.)

If you answered not a; all, what would it take for you to start to
do so? (Check as many as apply.)

more information about breast cancer

more information about breast self-examination

more confidence in ability to perform breast self-examination
a consistent reminder to perform breast self-examination
other (Please describe.)

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23

If you checked the last statement ( 2 consistent reminder ), what
would be a good reminder? Please take a minute to think about this and
be as specific as you can be.

Your ideas

 

Would any of the following work for you? (Check as many as apply.)

reminder on television

reminder through mail

reminder from significant person (lover, physician, parent)
reminder in the form of a sticker in the shower or on the bathroom
murror

9. For pre-menopausal women (those still having menstrual periods), the
best time to examine their breasts is: (Check one.)

on the first day of the month

on the last day of the month

about a week before the menstrual period
about a week after the menstrual period
it doesn't matter

other. (Please describe.)

l0. Which of the following describe your reasons for performing BSE?
(Check as many as apply.)

I'm generally concerned about my health.

I'm trying to protect myself from breast cancer.

I feel it is my personal responsibility to perform BSE.

I have a family history of lumps and/or breast cancer.

Someone reminds me to perform BSE.

My breasts become tender and that worries me, so I perform BSE to
c eck on them.

It's a habit.

Other. (Please describe.)

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24

ll. Which of the following describe your reasons for not performing
BSE? (Check as many as apply.)

___ I'm not generally concerned about my health at this point in my
life.

I'm not concerned about getting breast cancer at this time.

I feel that breast examination should be performed by doctors or
nurses.

I do not have a family history of breast cancer or breast disease.
No one reminds me to perform BSE.

The tenderness of my breasts prevents me from examining them.

I don't remember to do it.

I don't know how to perform BSE.

I don't feel confident enough that I perform BSE correctly.

I can't tell for sure what's normal and what's abnormal in my
breasts, especially because the tissue changes.

I'm afraid of how I'll react if I do find something abnormal.

I feel uncomfortable touching my breasts.

Other. (Please describe.)

l2. Does anyone actively encourage you to examine your breasts?
yes no

If ypg, who?

___ physician

_ nurse

___ mother

___ female friend

___ male friend
___ Other. (Please specify.)
Does your mother examine her breasts?

yes no ___ I don't know

Do the majority of your female friends examine theirs?

yes no I don't know
l3. How confident are you of your ability to perform breast self-exam?
(Circle one.) '

not at all not very somewhat considerably very
confident confident confident confident confident
I 2 3 h 5

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25

IA. Which of the following pp ypp 92 as part of your usual breast
self-examination procedure? Check as many as apply.

____Iie flat on back ‘

'___ put arm of breast to be examined at side

___ inspect breast by pressing palm of hand into breast in circles that
cover the entire breast

___ stand before mirror and inspect breasts for anything unusual while
holding arms at shoulder height

___ bend forward from waist and look down at breasts to inspect for
anything unusual

___ inspect breast by pressing flat part of fingertips into breast in
circles that cover entire breast

___ put arm of breast to be examined behind head

‘___ squeeze each nipple gently and look for discharge

____stand before mirror and inspect breasts for anything unusual while
placing arms in front of body

___ sit up in straight back chair

___ stand before mirror and inspect breasts for anything unusual while
holding arms at side '

____squeeze each nipple vigorously and look for discharge

____stand before mirror and inspect breasts for anything unusual while
holding arms over head

___ stand before mirror and inspect breasts for anything unusual while
bending forward from waist

___ other (Please describe on reverse.)

l5. Which of the following should be done as part of a comprehensive
breast self-examination? Check as many as apply.

____lie flat on back

___ put arm of breast to be examined at side

___ inspect breast by pressing palm of hand into breast in circles that
cover the entire breast

___ stand before mirror and inspect breasts for anything unusual while
holding arms at shoulder height

___ bend forward from waist and look down at breasts to inspect for
anything unusual

___ inspect breast by pressing flat part of fingertips into breast in
circles that cover entire breast

___ put arm of breast to be examined behind head

___ squeeze each nipple gently and look for discharge

___ stand before mirror and inspect breasts for anything unusual while
placing arms in front of body

___ sit up in straight back chair

___ stand before mirror and inspect breasts for anything unusual while
holding arms at side

___ squeeze each nipple vigorously and look for discharge

____stand before mirror and inspect breasts for anything unusual while
holding arms over head

___ stand before mirror and inspect breasts for anything unusual while
bending forward from waist

‘___ other (Please describe.)

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26

I6. Which of the following are symptoms that should lead you to seek
medical attention? (Check as many as apply.)

breast tenderness

a lump, hard knot, or thickening
clear discharge from the nipple
bloody discharge from the nipple
milky discharge from the nipple
inversion of nipple

continual erection of nipple
scaly skin around nipple

scaly skin on edge of breast
rash on breast skin

dimpling or puckering of breast skin
swelling

discoloration

alteration in size

alteration in shape

l7. Do you have people to talk with if you aren't sure you're doing the

If yes, please indicate with whom you talk.

physician

nurse

mother

female friend

male friend

Other. (Please specify.)

If pp, what are the reasons that you do not discuss these concerns?
(Check as many as apply.)

I don't think about it.

I don't worry about it.

I don't know who to ask.

The topic never comes up.

I feel it is a private concern.

I would find it embarrassing to talk about.

I am too uncomfortable with my physician to discuss it.
I refer to books instead.

Other. (Please specify.)

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27

Part XII. Views 2: Breasts. The following questions focus on your
breasts and your perceptions of them and of other body parts. Please
answer the questions as accurately as possible.

I. What is your bust measurement? (Specify number and'cup size.)

2. What, in your opinion, is the ideal bust measurement for someone of
your height and body build? (Specify number and cup size.)

3. How important are your breasts to you? (Circle one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

4. How comfortable are you viewing your own breasts? (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

5. How comfortable are you touching your own breasts? (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

6. How comfortable are you viewing your friends' breasts? (Circle
one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

7. How comfortable are you viewing your mother's breasts? (Circle
one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

8. How comfortable are you viewing your sisters' breasts? Circle one.
Check here if not applicable.

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

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28

9. How comfortable are you appearing nude in front of lovers? (Circle
one.) Check here if not applicable.

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

IO. How comfortable are you appearing nude in front of friends?
(Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

ll. How comfortable are you appearing nude in front of your mother?
(Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

l2. How comfortable are you appearing nude in front of your sisters?
(Circle one.) Check here if not applicable.

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

l3. How important are your breasts to your view of your body? (Circle
one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

l4. How do you feel about your body as a whole? (Circle one.)

very somewhat neutral somewhat very
negatively negatively positively positively
I 2 . 3 4 5

l5. Would you say you tend generally to emphasize or de- emphasize your
breasts by the way you dress? (Check one.)

___ emphasize ___ de-emphasize

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29

The next few questions ask you to rank body parts on the basis of their
importance to you in various ways. To make sure the process of rank
ordering is clear, the following example of ranking school subjects is
given as an illustration. If you were asked to RANK ORDER subjects on
the basis of your enjoyment of them (l-enjoy most, 4-enjoy least) and
you like Psychology the most, English second best, Math third best, and
Physics the least, you would RANK ORDER them as follows:

_3_ Physics
_g_ English
_1_ Psychology
_3_ Math

For each of the following questions, proceed as in the example and
remember to use each ranking only once.

l6. RANK ORDER these body parts with respect to their importance to
your view of the physical pttractiveness of your body (l-most important,
6- least important). Use each ranking only once.

face

arms

legs

breasts

pubic area/vagina
buttocks (seat)

I7. RANK ORDER these body parts with respect to their important to your
view of the functioning of your body (I-most important, 6-least
important). Use each ranking only once.

face

arms

legs

breasts

pubic area/vagina
buttocks (seat)

l8. RANK ORDER the following on the basis of how upset you would feel
psychologically at the loss of that body part (I- most upset, 5- least
upset). Use each ranking only once.

leg
arm
eye
breast
teeth

127

Part XIII. 1; Breast Appearance. Describe the appearance of your

 

 

If you could change your breasts, would you? yes no

If yes, how important would it be to change them? (Circle one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

If yes, how would you change them? (Check as many as apply.)

make them smaller

make them larger

make them both the same size
make them firmer

remove hair from them

change the nipples

remove stretch marks

other (Please describe.)

If pp, why wouldn't you change them? (Check as many as apply.)

I am satisfied with my breasts as they are.

I believe in accepting my body as it is.

It's not important enough to me to change them.
other (Please specify.)

30

128
31

How attractive do you feel your breasts are? (Circle one.)

very somewhat neutral somewhat very
unattractive unattractive attractive attractive
I 2 3 4 5

How attractive would most other women say your breasts are? (Circle
one.)

very somewhat neutral somewhat very
unattractive unattractive attractive attractive
I 2 3 4 5

How attractive would most men say your breasts are? (Circle one.)

very somewhat neutral somewhat very
unattractive unattractive attractive attractive
l 2 3 4 5

g; Breast Ideal.
Do you have a view of the appearance of ideal breasts?
yes no

If yes, which of the following characteristics are part of your view of
the ideal breast. (Check as many as apply.)

medium size (34-36)

small size (30-32)

large size (38 or more)
size in proportion to body
firm

round

soft

full

other (Please specify.)

If yes, which statement best describes your view?

I have a view of the ideal breast and find that my own breasts are:
(Circle one.)

very somewhat neither somewhat very
different different different similar similar
from it from it nor similar to it to it

I 2 3 4 5

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32

If pp, which of the reasons listed below are involved in your pp; having
a view of the ideal breast? (Check as many as apply.)

I've never thought about it.

It's not very important to me.

I believe everybody's different and so are their breasts.

I believe that what's ideal varies too much with body build and

Ize.

___ I believe that "beauty is in the eye of the beholder" and,
therefore, there is no true ideal breast.

___ I believe that every woman should accept her own breasts as they are
___ Other (Please describe.)

3; Breast Development.
At what age did your breasts begin to develop?

When did your breast development begin compared to other girls in your
school class? (Circle one.)

much somewhat about same somewhat much
earlier earlier time later later
I 2 3 4 5

Was the age at which your breasts developed a significant problem for
you? _ yes _ no

For the following person/s, please choose the number of the phrase from
the eight below that best describes their response 39 your early breast
development pg ypp viewed 1;. Put that number in the blank that
precedes the name.

very positive response

somewhat positive response

neutral response

somewhat negative response

very negative response

unknown response

appeared to respond with mixed feelings

no such person/people in my life at the time

mNO‘UTPUJN—I

My mother

My father

My brothers

My sisters

My male friends
My female friends

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33

In addition to the overall response you indicated on the previous page,
did you experience any of the following emotions with regard to your
early breast development? How much of each? (Circle one response for
each emotion listed.)

 

 

Surprise
very somewhat neither somewhat very
unsurprised unsurprised surprised surprised surprised
nor unsurpised
I 2 3 4 5
Fear
very somewhat neither somewhat very
unfearful unfearful fearful fearful fearful
nor unfearful
I 2 3 4 5
gpparrpssment
very somewhat neither somewhat very

unembarrassed unembarrassed embarrassed embarrassed embarrassed
nor unembarrassed
I 2 3 4 5

Did you initiate (begin) conversations with any of these people about
your early breast development? (Check as many as apply.)

mother

father

sisters
brothers
female friends
male friends

Did any of these people initiate conversations with you about your early
breast development? (Check as many as apply.)

mother

father

sisters
brothers
female friends
male friends

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34

Did any of these people tease you about your early breast development?
(Check as many as apply.)

mother

father

sisters
brothers
female friends
male friends

If you were teased, how upsetting was the teasing to you? (Check one.)

___ extremely upsetting
___ quite upsetting
___ somewhat upsetting
___ not upsetting

Did you feel embarrassed or self-conscious with any of these people?
(Check as many as apply.)

mother

father

sisters
brothers
female friends
male friends
schoolmates
salespeople

Did any of these people appear to ignore your early breast development?
(Check as many as apply.)

mother

father

sisters
brothers
female friends
male friends
schoolmates

Which statement best describes your response to your first bra? (Check
one.)

positive feelings
negative feelings
mixed feelings
neutral feelings
embarrassed feelings
fearful feelings
surprised feelings
don't remember

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35
5; Sexual Activity. What is your sexual preference?
___ heterosexual ___ lesbian ___ bisexual ___ celibate

Are you currently sexually active (having intercourse or oral-genital
contact with a partner)? yes no

How many male sexual partners have you had?
How many female sexual partners have you had?

For each of the following romantic/sexual activities indicate how often
on the average you have engaged in the activity during the last six
months. Choose the response from the seven listed below that most
closely describes your situation and place that number in the blank that
precedes the activity. Please note that research shows that there is a
great deal of individual variation among women with respect to their
ages at the time of their first sexual experiences and the frequency of
their sexual contact.

not at all

a few times

once or twice a month

once or twice a week

three or four times a week
five or more times a week
daily or more often

NO‘U‘lJ-‘wN—I
IIIIIII

kissing

necking (stimulation of face and neck) ‘

petting (stimulation of breasts and genital areas): with clothes on
petting (stimulation of breasts and genital areas): with clothes off
stimulation of partner while lying down: clothes on

stimulation of partner while lying down: clothes off

intercourse

oral-genital contact

masturbation

other (Please describe.)

Please put your age at the time of your first experience with each of
the sexual activities in the blank in front of the term.

kissing

necking (stimulation of face and neck)

petting (stimulation of breasts and genital areas): with clothes on
petting (stimulation of breasts and genital areas): with clothes off
stimulation of partner while lying down: clothes on

stimulation of partner while lying down; clothes off

intercourse

oral-genital contact

masturbation

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36

In general, how satisfying are your sexual activities? (Circle one.)

very somewhat neutral somewhat very
dissatisfying dissatisfying satisfying satisfying
I 2 3 4 5

What is the general role of your breasts in your sexual activities?
(Check one.)

stimulated to arouse me

stimulated to arouse partner

stimulated to arouse both myself and my partner
not involved in sexual activity

other (Please describe.)

How sensitive are your breasts to sexual arousal? (Circle one.)

very somewhat neutral somewhat very
insensitive insensitive sensitive sensitive
I 2 3 4 5

How important are your breasts to you in your sexual activities?
(Circle one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

How important are your breasts to your partner(s) in your sexual
activities? (Circle one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

What are your preferred forms of stimulation of your breasts during
sexual activities? Check as many as apply. Use a double check to
indicate the type of stimulation you enjoy most.

holding

caressing

fondling

other manual stimulation (Please specify.)
kissing

sucking

licking

other oral stimulation (Please specify.)
attention to nipples

no stimulation desired

other (Please specify.)

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37
Do you inform your partner(s) when your breasts are too tender to be
touched at all or in the way that they're being touched?
yes no ‘___ do not experience that much breast tenderness

If pp, why not?

afraid of partner's response
afraid to stop partner's enjoyment
too embarrassed

no desire to inform partner

other (Please describe.)

Would you like changes in any of the following aspects of breast
stimulation in your sexual activities. Please circle the number of the
response that best expresses your feelings.

How much time and attention devoted pp breasts would you like? (Circle
one.)

much less somewhat less no change somewhat more much more
I 2 3 4 5

How much oral stimulation 2: breasts would you like? (Circle one.)

much less somewhat less no change somewhat more much more
I 2 3 4 5

How much manual stimulation 91 breasts would you like? (Circle one.)

much less somewhat less no change somewhat more much more
I 2 3 4 5

How much time and pttention devoted pp nipples would you like? (Circle
one.)

much less somewhat less no change somewhat more much more

I 2 3 4 5
How much GENTLE stimulation pi breasts would you like? (Circle one.)

much less somewhat less no change somewhat more much more
I 2 3 4 5

Other. (Please describe.)

135
38

Have your feelings about your breasts changed because of your sexual
activities? How much of each change have you experienced?

How much change in your general awareness p: your breasts have you
experienced? (Circle one.)

much less somewhat less no change somewhat more much more
aware aware aware aware
I 2 73 4 5

How much change in your conscippsness _fi he appearance pi your breasts
have you experienced? (Circle one.)

much less somewhat less no change somewhat more much more
conscious conscious conscious conscious
l 2 3 4 5

How much change in your confidence about your breasts have you
experienced? (Circle one.)

much less somewhat less no change somewhat more much more
confident confident confident confident
I 2 3 4 5

How much change in your comfort with ypur brepsts have you experienced?
(Circle one.)

much less somewhat less no change somewhat more much more
comfortable comfortable comfortable comfortable
I . 2 3 4 5

How much change in your respect for your breasts have you experienced?
(Circle one.)

'much less somewhat less no change somewhat more much more
respectful respectful respectful respectful
l 2 3 4 5

How much change in your pride 1p your breasts have you experienced?
(Circle one.)

much less somewhat less no change somewhat more much more
proud proud proud proud
I 2 3 4 5

How much change in your self-consciousness pi your breasts have you
experienced? (Circle one.)

much less somewhat less no change somewhat more much more
self- self- self- self-
conscious conscious conscious conscious

l 2 3 4 5

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39

How much change in your acceptance pi your breasts have you experienced?
(Circle one.)

much less somewhat less no change somewhat more much more
acceptant acceptant acceptant acceptant
I 2 3 4 5

How much change in your satisfaction with your breasts have you
experienced? (Circle one.)

much less somewhat less no change somewhat more much more
satisfied satisfied satisfied satisfied
I 2 3 4 5

How much change in your awareness pi sexual pttgpctiveness pi your
breasts have you experienced? (Circle one.)

much less somewhat less no change somewhat more much more
aware aware aware aware
I 2 3 4 5

Other (Please specify.)

5; Brgpst-feedingi

Were you breast-fed as an infant? ___ yes ___ no

Do you think you will breast-feed your children?

yes

no

unsure at this time

___ do not plan to have children (If you checked this response, skip to
the first question on page 42).

If pp, please check those reasons that would influence you ppi to
breast-feed. Check as many as apply. Then, skip to the first question
on page 42. ___ would be difficult to arrange schedules if employed
full-time

___ would dislike or be embarrassed about exposing breasts

___ would be inconvenient

just don't care to

other (Please describe.)

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40

If ypp, please check those reasons that would motivate you to
breast-feed. (Check as many as apply.)

contributes to baby's health and nutrition
contributes to psychological development of baby
contributes to psychological development of mother
enhances the mother-child relationship

seems to be a natural part of mothering

would be pleasurable

would be practical: cost-efficient

would be convenient

other (Please describe.)

If unsure at this time, which reasons are part of your uncertainty?
(Check as many as apply.)

need more information

question if physically capable of breast-feeding
depends on my work situation

other (Please describe.)

How important would it be to you to breast-feed your children? (Circle
one.)

very somewhat neutral somewhat very
unimportant unimportant important important
I 2 3 4 5

Please rate the degree of comfort you anticipate you would feel
breast-feeding in the following situations. Circle one response for
each situation.

In front of your partner. (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

In front of of your other children. (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

In front of your mother. (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

138

In front of your father. (Circle one.)

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In front of your sisters. (Circle one.)

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In front of your brothers. (Circle one.)

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In front of your close women friends.

somewhat

very neutral
uncomfortable uncomfortable
I 2 3

In front of your close men friends.

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In front of your in-laws. (Circle one.)

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In front of your other friends.

very somewhat neutral
uncomfortable uncomfortable
I 2 3

In public situations. (Circle one.)

very somewhat neutral
uncomfortable uncomfortable
I 2 3

somewhat

comfortable

A

somewhat
comfortable
A

somewhat

comfortable

4

(Circle one.)

somewhat

comfortable

4

(Circle one.)

somewhat

comfortable

A

somewhat

comfortable

4

(Circle one.)

somewhat

comfortable

4

somewhat

comfortable

4

very
comfortable

5

very
comfortable

5

very
comfortable

5

very
comfortable

5

very
comfortable

5

very
comfortable

5

very
comfortable

5

very
comfortable

5

4I

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42

g; Breast Cancer ppp Mastectomy.
Has anyone you've known had breast cancer? ___ yes _pp no

If pp, skip to the first question on page 44. If ypp, who? (Check as
many as apply.)

mother

grandmother

sister

close friend

other relative

close friend of mother's
other (Please specify.)

If you've known more than one person who has had breast cancer, answer
the following questions with the person whose experience you knew the
most about in mind.

How much did you know about the person's experience at the time? (Check
one.)

was aware of most of what was going on
was aware of some of what was going on
was aware of very little of what was going on
was not aware of what was going on at the time

illll

difficult was it for the person to adjust to the idea that she had
breast cancer? (Circle one.)

very somewhat neutral somewhat very
easy easy difficult difficult
I 2 3 4 5

Did that person have a mastectomy (surgical removal of the breast
because of cancer)? yes no

How difficult was it for the person to adjust to the removal of her
breast? If mastectomy was not necessary, leave blank. (Circle one.)

very somewhat neutral somewhat very
easy easy difficult difficult
I 2 3 4 5

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43
Did that person's experience cause any of the following attitude changes
in you? How much of each of these changes?
How much change in your awareness pi breast cancer? (Circle one.)
much less somewhat less no change somewhat more much more
aware aware aware aware

I 2 3 4 5

How much change in your fear pi breast cancer? (Circle one.)

 

much less somewhat less no change somewhat more much more
frightened frightened frightened frightened
I 2 3 4 5

How much change in your willingness ip check for breppi cancer? (Circle
one.) ""_"

much less somewhat less no change somewhat more much more
willing willing willing willing
I 2 3 4 5

How much change in your conscientiogsness abopi examining your breasts?
(Circle one.)

much less somewhat less no change somewhat more much more
conscientious conscientious conscientious conscientious
I 2 3 4 5

Other. (Please describe.)

Describe what you believe your response would be if you, yourself, were
to undergo a mastectomy by RANK ORDERING as many of the following
reactions as apply. Use number one for the most important reaction,
number two for the second most, number three for the third, and so on
until you have ranked all the reactions that apply ip you. Use each
ranking only once.

would feel less feminine; that I was not a whole woman
would feel uncomfortable with idea of "damaged" body
would feel concerned about sex or about lover's response
would feel alienated from others

would feel a sense of loss

other (Please explain.)

Please further describe what you believe your response would be if you
were to undergo a mastectomy by RANK ORDERING as many of the feelings
listed below as apply. Use number one to indicate the strongest

141
44

feeling, number two for the second strongest and so on until you have
ranked all the feelings that apply ip you.

___ depression
anger
guilt
___,fear
other (Please describe.)

Which of the following best describes what you think your overall
response would be if you were to undergo a mastectomy? (Circle one.)

devastated quite upset upset, but not too upset grateful
assume would to be alive
recover
I 2 3 4 5

If you were to have a breast removed, do you think you would have
reconstructive surgery (which aims to recreate the breast)?
yes no unsure at this time

If 123. describe your choice by RANK ORDERING as many of the reasons
listed below as apply. Use number one for the most important reason,
number two for the second most important reason and so on until you have
ranked all the reasons that apply ip you.

feel more normal: more of a whole woman

feel more confident about self: less self-conscious

feel more attractive: would look better in clothes

feel that the scar or loss of breast would be less noticeable to
others

___ feel more comfortable sexually

___ other (Please describe.)

142
45

If pp, describe your choice by RANK ORDERING as many of the reasons
listed below as apply. Use number one for the most important reason,
number two for the second most important reason and so on until you have
ranked all the reasons that apply ip you.

cost is too high

it would never look the same

fear of reactivating breast cancer cells
fear of surgery

other (Please describe.)

If unsure, describe your choice by RANK ORDERING as many of the reasons
listed below as apply. Use number one for the most important reason,
number two for the second most important reason and so on until you have
ranked all the reasons that apply ip you.

need more information

would depend on my age

would depend on my marital status

would depend on the amount of breast tissue removed
other (Please describe.)

Overall, how difficult an adjustment would it be if you learned you had
breast cancer? (Circle one.)

very somewhat neutral somewhat very
easy easy difficult difficult
I 2 3 4 5

How difficult do you think it would be for you to adjust to the removal
of your breast? (Circle one.)

very somewhat neutral somewhat very
easy easy difficult difficult
I 2 3 4 5

Consider the following situation:

You have breast cancer and must choose between two treatments. One
option is a mastectomy. Your physician states that this surgery has a
703 chance of eliminating your cancer. The second option is radiation.
theraPY, which your physician informs you has a 452 chance of
eliminating your cancer and would not disfigure your breast. The choice
must be made between the two because the outcome of the radiation
therapy would not be known for several months and, at that point, a
mastectomy would no longer be helpful.

I would choose the mastectomy.
I would choose the radiation therapy.

143
46

1; Experiences with Mother.

How often have you viewed your mother's breasts? (Circle one.)

never once or twice several times occasionally frequently
I 2 3 ' 4 5

How do you feel when you view your mother's breasts? (Circle one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

How comfortable do you think your mother is about her body? (Circle
one.)

very somewhat neutral somewhat very
uncomfortable uncomfortable comfortable comfortable
I 2 3 4 5

Rate your relationship with your mother when you were an adolescent
(ages l2-l7). (Circle one.)

very somewhat neutral somewhat very
negative negative positive positive
I 2 3 4 5

Rate your present relationship with your mother. (Circle one.)

very somewhat neutral somewhat very
negative negative positive positive
I 2 3 4 5

8. In the last three months, have you seen any television "spots” put
on by health groups that remind women to examine their breasts?
yes no

144
47

Do you have other significant recollections of or feelings about the
role of your breasts in your life that have not been touched on above?
It would be especially helpful to hear about those that were
particularly painful, wonderful, or interesting.

Comments about survey:

14S
48

Feedback for Survey of Women's Health Behaviors and Body Attitudes

As is probably apparent to you at this point, this survey focuses
specifically on the health behavior of breast self-examination (BSE) and
on attitudes about breasts.

The focus on breast self-examination arises from troubling
statistics which indicate that almost all women have received
instruction in BSE, but only about one-fourth practice it regularly.

The need to understand the reasons for the non-performance of BSE is
felt keenly by health educators. One purpose of this survey is to
explore psychological factors (like body image and self-esteem) that may
be involved in non-performance.

The second focus on the body part of breasts is a result of the
lack of theoretical and research information available about the role of
these important body parts in women's lives. It is generally
acknolwedged that ours is a breast-conscious society, but little has
been done to investigate the impact of that breast-consciousness. The
second purpose of this study is, then, to explore women's feelings about
and experiences with their breasts.

Significant survey results will be submitted for publication and
made available to groups involved in BSE (e.g., the American Cancer
Society). You can obtain a summary of the results by inquiring at the
Department of Psychology Office (I35 Snyder) after June I, I984 or by
writing to me ZDepartment of Psychology, Kalamazoo College, Kalamazoo,
MI 49007.

Thank you for your participation in the study. I hope that
completing the survey was an interesting experience for you and that it
increased your awareness of BSE and of the significance of your breasts.
One final note . . . the next time you visit a physician, talk with
her/him about breast self-examination.

Thank you again.

Patricia A. Ponto, M.A.

PLEASE DO NOT DISCUSS THE STUDY WITH POTENTIAL SUBJECTS.

146

APPENDIX B

Hypothesis 1 Measure: Lau's Scale for Preventive Health Orientation

Seven variables: eating, activity, pounds, seatbelt, brush, drcheck,
dencheck. Coding is assigned so that higher numbers indicate
healthier behaviors.

p. 4*, #1. Duuring the past 24 hours have you eaten: (check if yes)
Fresh fruit

Candy

Wuole grain breads

Fresh vegetables
Non-diet soft drinks
Junk food

Eating = fruit+bread+cereal+vegies-candy-pop-junk. (Number of
unhealthy foods eaten is subtracted from number of healthy foods
eaten.)

Activity

p. 4, #2. which of these staterents best describes your physical
activity in general?

(Check one.)

Not very active physically, usually just sittirug or walking (1)
Fairly active physically, moderate or strenuous activity several
time's a week (2)
Quite active physically, at least moderate activity every
day (3)
Extrerely active physically, strenuous activity most days (4)

 

Pounds
pp. 4-5, #3. Do you think you weigh too much now, or has a doctor or
nurse told you that you now weigh too much? yes no

Are you currently oru a diet to lose weight? yes no

 

Are you doirug any special exercises to lose weight? ___yes
no

Score of 4 given if subject answers no to first question, indicating
that she does not weigh too much now.

Score of 3 given if subject answers yes to first question, indicating
that she does weigh too much now, and answers yes to secoud and third
questions, indicating that she is both dieting and exercising.

Score of 2 given if subject answers yes to first question, indicating
that she does weigh too much now, and answers yes to second or third
questious, indicating that she is either dieting or exercising.

 

 

 

*page number refers to the page in the survey where the scale is found
(e.g., the Ian scale is found on pages 4-5).

147

Score of 1 given if subject answers yes to first question, indicating
that she does weigh too much now, and answers no to second and third
questions, indicating that she is neither dieting nor exercisirug.

 

Seatbelt
p. 5, #4. When you ride in a car or truck, how much of the time do
you wear a seat belt? (Check one.)

None of the time (1)
A little of the time (2)
Sore of the time (3)
Most of the time (4)
All of the time (5)

Brush
p.5. #5. How frequently do you brush your teeth? (Check me.)

Rarely or never (1)
About once a week (2)
3 or 4 times a week (3)
About once a day (4)
Nice a day (5)
After almost every meal, including lunch (6)

Drcheck

p. 5, #7. When was the last time you visited a doctor for a regular
check-up? (Do NOT cound any check-up required for admission to ISO
for participation in athletics)? (Check one.)

Within the last six months (6)

Within the past year (5)

Within the past 2 years (4)

Within the past 5 years (3)

Within the past 10 years (2)

I do not go to a doctor for a regular check-up, but only when I
am sick (1)

 

 

Dencheck
p. 6, #8. When was the last time you visited a dentist for a regular
check-up? (Check ore.)

Within the last six months (6)
Within the past year (5)
Within the past two years (4)
Within the past five years ( 3)
Within the past ten years (2)
I do not go to a dentist for regular check-ups, but only if I
have sate specific problem with my teeth or guns (1)

Scale statistics
__=l91
Alpha = . 33

General preventive health orientation is measured as the average
rating of these seven variables.

148

APPENDIX C

Hypothesis 2 Measure: Stillman's Knowledge of Bmast Cancer Scale

Four questions treated separately because efforts to combine them into
a scale resulted in very low reliabilities.

Four variables: chances, lumpcanc, chancesa, relatbc

Chances
p. 16*, #1. The chances of a woman in this country getting breast
cancer sometime during her lifetime are

a. Under 10 per cent (less than 10 wauen out of 100 will saueday have
it.)

b. 10-25 per cent (10 to 25 woren out of 100 will saueday have it.)
c. 26-50 per cent (26 to 50 women out of 100 will saueday have it.)
CI. 51-75 per cent (51 to 75 women out of 100 will saueday have it.)
e. Over 75 per cent (More than 75 woren out of 100 will saueday have
it.)

f. have no idea

A and B are scored as correct (1) because the popular literature in
recent years has quoted both 9% and 11% as the breast cancer rates.
All other options are scored incorrect (0).

Lumpcanc
p. 16 #2. Most lumps in the breast turn out to be cancer.

a. Yes
b. No
c. Have no idea

B is scored correct (1). A and C are incorrect (O).

Chancesa
p. 16 #3. On the average, the chances of a woman developing breast
cancer begin to increase after she passes which birthday?

a. 20th
b. 30th
c. 40th
d. 50th
e. 60th
f. have no idea

B and C are scored correct (1) as the popular literature is equivocal
about age of onset. A, D, E, and F are scored incorrect (0).

*page number refers to the page in the survey where the scale is found

I49

Relatbc
p. 16, #4. A woman is more likely to develop breast cancer if she:
(Circle as many as you feel are correct.)

As indicated in the complete survey (p. 16, #4.), a number of
options were provided in the original Stillman scale. This item was
the only me selected for inclusion in the present scale. It was
chosen because it differentiated adequately among subjects and was
relatively highly inter-correlated with the other three knowledge
iteuus.

f. has relatives who have had breast cancer.

This item is correct if circled, indicating that a woman is more
susceptible to breast cancer if she has had relatives who have had the
disease.

Scale Statistics
_N=l95.
Alpha=. 39.

150

APPENDIX D

Hypothesis 2 Measure: Stillman's Benefits of BSE Scale

Subjects rate each item on scale from 1 (disagree strongly) to 4
(agree strmgly).

p. 19*, #20. If more woren examined their breasts regularly, there
would be fewer deaths from breast cancer.

p. 19, #22. Whether I find a lump in my breast myself doesn't really
matter because by then it's too late anyway.

p. 19, #24. If I examined my own breasts regularly, I might find a
luup sooner than if I just went to the doctor for a check-up.

p. 20, #26. Even though it's a good idea, I find examining/having to
examine my breasts an embarrassing thing to do.

p. 20, #28. Examining my breasts often makes/would make me worry
unnecessarily about breast cancer.

Scale Statistics
_N=195.
Alpha=. 43.

Hypothesis 2 Measure: Stillman's Perceived Susceptibility Scale

p. 19, #21. My health is too good at present to even consider
thinking that I might get cancer.

p. 19, #23. Whenever I hear of a friend or relative (or public
figure) getting breast cancer, it makes me realize that I could get
it, too.

p. 19, #25. There are so many things that could happen to me that
it's pointless to think about any one thing like breast cancer.

p. 20, #27. The older I get, the more I think about the possibility
of getting breast cancer saueday.

p. 20. #29. If I had to think about the possibility that I might
saueday get breast cancer, I would rate my chances as corpared with
other woren as:

a. average

b. above average (more likely that I would get it)

c. below average (less likely that I would get it)

Scale Statistics
_N=l95.
Alpha=. 59.

*page number refers to the page in the survey where the scale is found

151

Stillman's scoring schere is as follows:

For the Perceived Benefits Scale, the first step is to re-code items
22, 26, and 28 so that the diagree strongly response receives a 4 and
the agree strongly a l. The score of 4, then, consistently indicates
the most positive view of BSE. Next, the five items are sunued for a
maximum total of 20.

For the Perceived Susceptibility Scale, iteuus 21 and 25 are recoded
so that a score of 4 consistently indicates the strougest perceived
susceptibility. Item 29 is scored so that an ”above average" response
receives a 3: "average," a 2; and "below average," a l. The scales
for five iteuus are, then, summed for a maximum total of 19 (one fewer
than the perceived benefits scale because the highest score for 29 is
3, not 4 as in the Likert items).

Stillman notes that totals of 15 or more on either scale represent a
high degree of health belief; 9-14, a moderate belief; and below 9, a
low belief.

Because of low indexes of internal consistency, Stillman's scorirug
procedure was not employed in this study. Individual items were
selected to represent the variables involved.

152

APPENDIX E

Hypothesis 2 Measure: Knowledge of Breast Self-examination Scale

There are two scales involved in this variable — what the subject
actually does during breast self—examination and what she knows should
be done during this process. The scales were derived from questions
14 and 15 on page 25 of the couplets survey. Initial reliability
checks revealed very poor alphas (.29 and .30, respectively) with all
iteue included, so the scales were shortened on the basis of
inter-item correlations. The items couprising the scale that
indicates what the subject does do (that is, reports doing) are:

p. 25*, #14. Which of the following do you do as part of your usual
breast self-examination procedure? Check as many as apply.

lie flat on back
inspect breast by pressing flat part of fingertips into
breast in circles that cover entire breast
put arm of breast to be examined behind head
squeeze each nipple gently and look for discharge

 

A score of one is given to each correct endorsement of these items.

Scale Statistics
31:195.
Alpha=.76 .

The items cauprising the second scale which indicates what the subject
believes should be done as part of breast self-examination are as
follows:

p.25, #15. Which of the following should be done as part of a
cauprehensive breast sel f-exanination? Check as many as apply.

lie flat on back

inspect breast by pressing flat part of fingertips into
breast in circles that cover entire breast

puut arm of breast to be examined behind head .

squeeze each nipple gently and lock for discharge

stand before mirror and inspect breasts for anythirug unusual
while holding arms over head.

A score of one is given to each item correctly endorsed.
Scale Statistics

Nal95.

Alpha=.75.

*page number refers to the page in the survey where the scale is found

Hypothesis 3 Measure :

p.10*, Part VII.

153

APPENDIX F

Secord and Jourard Body Cathexis Scale

Feelings about body. On this page are listed a

nuuuber of things characteristic of yourself or related to you.

Consider each item listed below and decide which of the followirug best
represents your feelings according to the following scale.

appropriate number in the blank in front of the item.

The scale is the mean rating given to the forty-six items on the 1-5

scale described below.

1==Have strong feelings and wish change could souehow be made.
2=Don't like, but can put up with.
3=Have no particular feelings one way or the other.
4=Aum satisfied.

5=Consider myself fortunate.

 

1. hair 24.
2. facial cauplexion 25.
3. appetite 26.
4. hands 27.
5. distribution of hair 28.
over body 29.

6. nose 30.
7. fingers 31.
8. elimination 32.
9. wrists 33.
10. breathing 34.
11. waist 35.
12. energy level 36.
13. back 37.
14. ears 38.
15. chin 39.
16. exercise 40.
17. ankles 41.
18. neck 42.
19. shape of head 43.
20. body build 44.
21. profile 45.
22. height 46.
23. age

Statistics Scale

p=169.

Alpha=.89.

*page number refers to the page in the survey where the scale is found

width of shoulders
arms

chest

eyes

digestion

hips

skin texture

lips

legs

teeth

forehead

feet

sleep

voice

health

sex activities
knees

posture

face

weight .
sex (female or male)
back view of head
trunk

Place the

154

APPENDIX G

Hypothesis 3 Measure: Rosenberg's Self-Esteem Scale

Subjects rate these ten iteus on a four point scale (1=strongly
disagree, 2=disagree, 3=agree, 4=strongly agree).

p. 11*, #1. I feel that I'm a person of worth, at lest on an equal
basis with others.

p. 11, #2. I feel that I have a number of good qualities.

p. 11, #3. All in all, I am inclined to feel that I am a failure.
p. 11, #4. I an able to do things as well as most other people.
p. 11, #5. I feel I do not have muuch to be proud of.

p. 11, #6. I take a positive attitude toward muyself.

p. 11, #7. On the whole, I am satisfied with myself.

p. 11, #8. I wish I could have more respect for myself.

p. 11, #9. I certainly feel useless at times.

p. 11, #10. At times I think I an no good at all.

Scale Statistics
p=l93.
Alpha=. 84.

The self-esteem score is the mean of the ratings given on the ten
items. Items 3, 5, 8, 9, 10 are recoded so that the highest ratirug
indicates greatest self—esteem (e.g., 1=4, 2:3, 3=2, 4=l).

155

APPENDIX H

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