Teoria Cognitivo Social y Cancer de Seno - Miller 1996

8/9/2019 Teoria Cognitivo Social y Cancer de Seno - Miller 1996

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Psycholog ical Bul letin Copyright 1996 by the Am erica n Ps~ho log ical Association , Inc.

1996 , Vol . 119 , No. 1 , 70-94 0033-290 9/96 / 3 .00

Ap plying Cogn it ive Soc ial Th eory to Health Protective Behavior:

Breast Self Ex am ination in Cancer Screening

Suzanne M Miller

F o x C h a s e C a n c e r C e n t e r

Yuichi Shoda

C o l u m b i a U n i v e rs i ty

Karen Hurley

T e m p l e U n i v e r s i ty

'This ar t icle ap plies recent developments in cognit ive-social theory to heal th-protective behavior ,

ar t iculat ing a Cognitive-Social Health In forma tion Processing (C-SH IP) model . T his m odel of the

genesis and maintenanc e o f health-protect ive behavior focuses on the ind ividual ' s encodings and

construals, expectancies, affects, goals and values, self-regulatory competencies, an d the ir interac-

t ions with each o ther and the heal th-relevant information in the course of cognitive-affect ive p ro-

cessing. In processing heal th inform ation, individuals are assume d to differ in bo th the accessibil i ty

of hese mental representat ions and the organizat ion of relat ionshipsamong them . In this ar t ic le , the

mo del is app lied to analyze and inte grate the often-confusing findings on breast self-examination in

cancer screening. Implicat ion s are considered for assessments and interventions to enhance adher-

ence to complex, long-term, health-protective regimens, tailore d to the needs an d characteristics o f

the individual.

T h e r e h a s b e e n a n e x p l o s i o n o f i n t e r e s t a n d r e s e a r c h i n h e a l t h

p s y c h o lo g y in t h e l a s t d e ca d e , f u e l e d b y t h e e x c i t e m e n t o f s u c -

c e s sf u ll y a p p l y i n g b a s i c p s y c h o l o g i c a l c o n c e p t s t o u n d e r s t a n d

h o w p e o p l e d e a l w i t h h e a l t h c h a l le n g e s ( e . g . , B a u m S i n g er ,

1 9 8 7 ; G a t c h e l , B a u m , K r a n t z , 1 9 8 9 ; L a z a r u s , 1 9 9 1; H . L e v -

e n t h a l , 1 9 8 3; R o d i n S a l o v ey , 1 9 8 9 ; W e i s s , 1 9 9 2 ) . T h i s r a p -

i d l y gr o w i n g f i el d e n c o m p a s s e s d i s e a s e p r e v e n t i o n a n d e a r l y d e -

t e c ti o n , a s w e l l a s s h o r t - a n d l o n g - t e r m m a n a g e m e n t o f d i s e a s e

c o u r s e a n d c o n s e q u e n c e s ( T a y lo r , 1 9 9 0 , 1 9 9 5 ) . I t i s a l s o c o n -

c e r n e d w i t h i n d i v i d u a l d i f f e r e n c e s i n s e l e c t i n g a n d p r o c e s s i n g

i n f o r m a t i o n a b o u t h e a l t h - r e l a t e d r is k s , n e e d s , a n d s t re s s o rs .

A s t h e c o r e t o p i c s a n d i m p l i c i t g o a l s w i t h i n h e a l t h p s y c h o l o g y

h a v e b e c o m e c le a r, t h e p r o c e s s i n g o f h e a l t h - r e l a t e d i n f o r m a t i o n

Suzanne M. M iller, Division of Population Science, Fox Chase Ca n-

cer Center, Philadelphia, Pennsylvania; Yuichi Shoda, Department of

Psychology, Colum bia University; Karen Hurley, Departm ent of Psy-

chology, Temple U niversity.

P repara tion o f th i s a r t i c le was suppor ted in p a r t by Gran ts CA4659 l ,

CA58999, and CA61280 from the National Cancer Inst i tute , Grant

PBR-72 from the American Cancer Society, and Gra nts MH39349 and

MH45994 from the Nation al Inst i tute of Mental Health.

We are especially indebted to Walter Miscbel for his insightful and

constructive comm ents on man y drafts of this ar t ic le . We also thank

Paul Engstrom, Lizet te Peterson, Will iam H. Redd , Ann O'Leary, How-

ard Leventhal, Victoria Champion, C aryn Le rman, B arbara Rimer,

Mark Schwartz, Michele Rodoletz, Pagona Roussi, Megan Mills, Dan-

ika AItman, and Joanne Schwartz for their helpful feedback on ea rl ier

drafts.

Correspondence concerning this ar t ic le should be addressed to Su-

zanne M. Miller, Division of Population Science, Fox Chase Cancer

Center, 215 South Bro ad Street, 5th Floor, Philadelphia, Pennsylvania

19107. Electronic ma il may be sent to sm miUer@ fccc.edu.

70

h a s b e e n g i v e n a m a j o r r o l e . I n s t u d i e s o f t h e v a r i a b l e s t h a t a f f e c t

h e a l t h - i n f o r m a t i o n p r o c e s s in g , i n v e s t i g a t o rs w i t h i n t h e f i e ld

c a n s e l e c t f r o m a w i d e a r r a y o f c o n c e p t u a l m o d e l s a n d t e r m s

t o g u i d e t h e i r w o r k . U n d e r c l o s e e x a m i n a t i o n , h o w e v e r, m o s t

a v a i l a b le c u r r e n t m o d e l s a d d r e s s o n l y p a r t i a l a s p e c t s o r c o m p o -

n e n t s i n t h e p r o c e s s i n g o f h e a l t h - r e le v a n t i n f o r m a t i o n a n d i n d i -

v i d u a l d i f f e r e n c e s i n h e a l t h - p r o t e c t i v e b e h a v i o r . I d e a ll y , o n e

n e e d s t o p r o v i d e a c o m p l e t e a c c o u n t , f r o m s e l e c ti o n a n d e n c o d -

i n g t o t h e c o n s t r u c t i o n , e n a c t m e n t , a n d m a i n t e n a n c e o f h e a lt h -

p r o t e c t i v e b e h a v i o r p a tt e r n s . M o r e o v er , t h e s e m o d e l s t e n d t o

s h o w c o n s i d e r a b l e c o n c e p t u a l a n d m e a s u r e m e n t o v e r la p , o ft e n

d i f fe r i n g m o r e i n e m p h a s e s a n d t e r m i n o l o g y t h a n i n e s s e n t ia l

f e a t u r e s , a s W e i n s t e i n ( 1 9 9 3 ) h a s o b s e r v e d .

I t c a n b e a r g u e d t h a t t h e i n d e p e n d e n t d e v e l o p m e n t o f s im i l a r

m o d e l s t o a n a l y z e t h i s k e y t o p i c a t te s t s to t h e r o b u s t n e s s o f t h e

p h e n o m e n a a n d t o t h e u t i li t y o f t h e c o n s t r u ct s c o m m o n l y e m -

p l o y e d i n d i f f e r e n t e f f o r t s t o a c c o u n t f o r t h e m . H o w e v e r , it a l s o

m a k e s i t d i f fi c u l t t o r e l a t e f i n d in g s f r o m s t u d i es c o n c e p t u a l i z e d

i n d i f f e r e n t t h e o r e t i c a l l a n g u a g e s . I t w o u l d b e u s e f u l t o p l a c e t h e

s p e c if i c c o n s t r u c t s a n d f i n di n g s r e l e v a n t t o h e a l t h - i n f o r m a t i o n

p r o c e s s i n g i n t o a m o r e g e n e r a l fr a m e w o r k . S u c h a f r a m e w o r k

s h o u l d a l l o w o n e t o i n t e g r a t e a n d c l a r i f y t h e r e l a t i o n s h i p s

a m o n g t h e c o n s t r u c t s u s e d i n d i f f e r e n t m o d e l s w i t h i n h e a l t h

p s y c h o l o g y a n d i n c l o s e l y r e l a t e d f i e ld s t h a t d e a l w i t h o v e r l a p -

p i n g i s s u e s , i n c l u d i n g s o c i a l , p e r s o n a l i t y , c li n i c a l , d e v e l o p m e n -

t a l , a n d c o g n i t i v e p s y c h o l o g y .

F o r t h a t p u r p o s e , t h e p r e s e n t a r t i c l e b e g i n s w i t h a n o u t l i n e o f

t h e c o g n i t i v e - s o c i a l le a r n i n g t h e o r y o f s o c i al i n f o r m a t i o n p r o -

c e s s i n g a n d i n d i v i d u a l d i f f e r e n c e s ( M i s c h e l , 1 9 73 , 1 9 9 0 ; M i s -

c h e l S h o d a , 1 9 9 5 ) . R a t h e r t h a n l i m i t e d t o t h e i d e a s o f a n y

s i n gl e t h e o r i s t o r a s a s p e c if i c m o d e l o f a p a r t i c u l a r t y p e o f b e -

h a v i o r , i t w a s p r o p o s e d a s a d e l i b e r a t e l y c u m u l a t i v e g e n e r a l

f r a m e w o r k - - o r a m e t a t h e o r y - - t o i n v i t e t h e c o n t ri b u t i o n s a n d


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COGNI T IVE S OCI AL T HE ORY AND CANCE R S CRE E NING 71

domai n- spec i f ic app l i ca t i ons o f d i ve rse t heor i s ts and r e sea r ch-

e r s dea li ng w i t h va r i ous subs t an t i ve con t en t a r eas . S t r eng t hened

by a vo l umi nous body o f r e sea r ch and t heor i z i ng ( e .g . , Ban-

dur a , 1986; Can t or & Ki h l s tr om, | 98 7) a nd bu i l d i ng on ea r l ie r

cogni t ive and social l earning con t r ibut io ns (e .g. , Beck, 1976; G.

Kel ly, 1955; Rotter, 1954) , for mor e than 2 dec ades thi s cogni -

t i ve - soc i a l appr oach I has been s t i mul a t ing an i nc r easi ng l y

com prehen sive concep tual analys i s of cogni t ive , socia l , and

affect ive mediat ing processes that under l ie individual di f fer -

ences in diverse do ma ins o f beh avio r in the a reas o f personali ty ,

socia l , developm ental , and cl inical psycho logy (e .g. , Bandura ,

1977a, 1977b, 1986; Ca rve r & Scheier , 1981; Cervo ne, 1989;

Dodge, 1986; Dweck, 1990; Foa & Kozak, 1986; Foa & Riggs ,

1993; F oa , Z i nba r g , & R ot hb aum , 1992; Hor owi t z , 1991; J an is ,

1967; Mischel, 1973; Saraso n, 1979; Singer & Salovey, 1991 ).

M os t r ecen t l y , t h i s gene r a l f r amewo r k has been deve l oped

i n t o a com pr ehens i ve theor y o f pe r sona l i t y a s a cogn i t i ve -

af fective mediat ing sys tem (Misch el & Shoda, 1995) . In thi s

ar t ic le , we use thi s overarch ing cogn i t ive-social perspect ive as a

f r amewo r k t o o r gan i ze a r ev iew of t he emp i r i ca l l it e r a t u r e on

br eas t cance r s c r een i ngmf ocus i ng on b r eas t s e l f - exami na t i on

( BS E ) p r ac t i ce and adhe r encemand i l l us t r a t i ng i t s heur i s t i c

va l ue f o r t he f ie ld o f behav i o r a l medi c i ne an d hea l t h psycho l ogy

mo r e gener al ly . W e be l ieve t ha t such a u n i f y i ng concep t ua l

f r amew or k needs t o be a r t i cu l a t ed a t t h i s j unc t u r e t o p r ov i de a

com mo n l anguage and b r o ad pe r spec t i ve t ha t can f ac i li t a te the

deve l opment o f hea l t h psycho l ogy i n t o a cumul a t i ve s c i ence, 2

l inked to the c once pts and f indings of bas ic areas o f psychology.

B r e a s t C a n c e r S c r e e n i n g a s a P r o t o ty p e o r

H e a l t h P r o t e c t i v e B e h a v i o r s

W e f ocus on r e sea r ch on b r eas t cance r s c r een i ng fo r a num ber

of r easons . F ir s t, t he p r eva l ence o f b r eas t cance r mak es unde r -

s t and ing t he de t e r m i nan t s o f s c r een ing behav i o r s an u r gen t

ma t t e r. B r eas t cance r is cu r r en t l y t he m os t com mo n cance r i n

wom en and t he s econd l ead i ng cause o f a ll cance r - re l a t ed dea t hs

in the Uni ted S tates (Bor ing , Squires, & Tong, 199 2; Co unc i l

on Scienti fic Affairs , 1989) . I t is es t im ated tha t one o ut of every

n i ne w omen i n t h i s cou n t r y w i ll even t ua l l y deve l op t he d i sease

( Am er i can Ca nce r S oci et y, 1993 ) , and a n e s t i ma t ed 12 mi l l i on

wom en posses s t wo o r m or e o f the m a j or r i sk f ac t o r s f o r b r eas t

cance r ( Voge l, i 991 ) . A l t hough b r eas t cance r cann o t be p r e -

ven t ed a t p r e sen t, t he good news i s t ha t 93 o f wom en wil l su r -

vive a t l eas t 5 yea rs af ter t rea tm ent i f the disease i s detected

in i ts ear ly s tages (Am erica n Can cer Society, 199 3) . Thu s , by

i nc r eas ing com pl i ance r a t e s w i t h t he s c r een ing p r ac t i ces t ha t

faci l i t a te ear ly detect ion, heal th psychologis t s can cont r ibute

i m p o r t a n t l y t o i m p r o v i n g h e a l t h o u t c o m e s f o r w o m e n .

BSE has been prom oted for over 40 years as a low-cost cancer

screening techn ique (Eggertsen & B ergman, 1983). I t involves a

mo nthly procedure in which a w om an visual ly inspects an d m an-

ually palpates her breas t s and und erarm area in a sys tematic fash-

ion to detect lum ps, thickening, changes in contour, swell ing, dim -

pl ing o f the skin, and discharge f rom or changes in the nipple

(Am erican C anc er Society, 1987). Findings o f several studies,

both retrospective and prospective, show that breast cancer pa-

t ients who rep or ted BSE pract ice before the discovery of thei r di s-

ease present wi th smal ler tum ors an d are less likely to have axi l lary

l y m p h n o d e i n v o l v e m e n t t h a n a r e w o m e n w h o d o n o t p e r f o r m

BSE (e.g., Foster & Cos tanza, 1984; Foster et al . , 1978; Gre enw ald

et al. , 197 8; Lo ck ere t al . , 1989; Semiglazov & Moiseenko, 1987).

Nonetheless, ma ny questions rem ain ab out the sensit ivi ty of BSE

relative to other screening behaviors (especially mammography)

and a bo ut the degree to which the practice of BSE contributes to

survival rates from the disease in women who are also obtaining

m am m og ram s (Baines , 1989; Grady, 1992; O 'Ma l ley & Fletcbet ;

1987; Senie , Lesser ; Kinne, & Rosen, 1994) . H ov ~v ~ the

effectivenessof BSE depends o n whether i t is practiced regularly and

comp etent ly (GIV IO, 1991; Hugu ley & Brown, 1981; New com b et

a l ., 1991). For example, only 25-35 of wom en perform BSE at

the recommended f requency (Celentano & Hol tzman, 1983;

Cham pion, 1988; Mu rray & McMil lan, 1993) , and even fewer do

so profic iently (Celentano & H ol tzman, 1983; GIV IO, 1991; Howe,

1981; Jacob , Penn, & B rown, 1989 ; Roberts, French, & D uffy,

1984; Sheley & Lessan, 1986). I t is therefore im po rtan t to specify

the condit ions th at facil itate the regular p erform anc e of proficient

BSE and to ident ify the wom en m ost l ikely to pract ice BSE com pe-

tently and to profi[ from it .

A goo d dea l o f r e sea r ch a l r eady ex i s ts on t he psycho l og ica l

an t eceden t s and co r r e l a t e s o f adhe r ence an d f a i l u r e s t o adh e r e

t o a m ont h l y r eg i m en o f BS E . T he p r esen t a r t i c le ana l yzes t he

psycho l og i ca l p r oces ses unde r l y i ng BS E dec i s i on and adhe r -

ence , gu i ded pa r t i cu l a r l y by cogn i t i ve - a ff ec t ive sys t em t heor y

( M i sche l & S hoda , 1995) , whi ch p r ov i des a un i fy i ng f r ame-

wor k a t a b r oa d t heor e t i ca l level . T h i s f r amew or k is based on

gener a l psycho l og i ca l p r i nc i p l e s t ha t app l y t o cogn i t i ve and

emot ional process ing and individual di f ferences across diverse

con t en t do mai ns , po t en t i a l l y connec t i ng r e sea r ch i n hea l t h psy-

chology to the larger di scipline . How ever, the theory of the cog-

ni t ive-af fect ive sys tem is s t ructure d a t a metath eoret ic al level

and requi res , indeed expl ic i t ly cal l s for , speci f ic appl ica t ions to

subs t an ti ve con t en t dom ai ns .

Dr awi ng on t h i s m e t a t heor y , we a r t icu l a t e a Cogni t ive - S oc ia l

H e a l t h I n f o r m a t i o n P r o ce s s in g m o d e l ( C - S H I P ) , w h i c h w e a p -

ply to breas t cancer screening and speci f ical ly to the per for -

man ce o f BS E . T he goa l i s to ex am i ne t he u t i li t y o f the C- S H I P ,

us i ng t he s am e cons t r uc t s t o desc r i be i nd i v i dua l d i ff e r ences i n

hea l t h - p r o tec t i ve behav i o r and t o ana l yze t he psycho l og i ca l p r o -

cesses t ha t gene r a t e t hem. W e do t h i s b y t r y i ng t o c l a r i f y and

integra te the diverse and so me t imes potent ia l ly conf l ic ting

f ind ings t ha t emer ge f r om r esea r ch on t he pe r f o r m ance o f BS E .

T he f i na l s ec ti on addr es ses the i m pl i ca t i ons o f th i s f r amew or k

f or t he t ypes o f i n t e rven t i ons r equ i r ed t o p r o mo t e t he p r ac t i ce

of BS E , a s we ll a s f o r a s ses sment and f o r r e sea r ch i n o t he r do-

ma i ns o f hea l t h - p r o t ec ti ve behav i o r s .

C o g n i ti v e- S o ci a l A p p r o a c h t o H e a l t h I n f o r m a t i o n

P r oc e ss in g ( C - S H I P )

T he C- S H I P inc l udes two bas i c compo nen t s : ( a ) a s e t o f cog-

n i t ive - a f f ec ti ve un i ts i n t he hypo t hes i zed i n f o r m a t i on- pr oces s -

l Note th at the terms

social cognitive

and

cognitive social

have be-

com e virtually interchangeable n the literature (Miscbel, 1993).

2 The m ajor models in this area have recently been compared system-

atically (Weinstein, 1993 ), therefore these differencesare not ag ain re-

viewed here.


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72 MILLER, SHODA, AND HURLEY

i ng sys t em and ( b ) t he s t r uc t u r e and dynami c p r oces ses

t h r ough whi ch t hese un i t s i n t e r ac t t o gene r a t e hea l t h -p r o t ec t ive

behavior.

Choice ofMediating Units

With regard to the ch oice of mediat ing unit s , the C -SH IP incor-

porates the cumulative f indings and concepts emerging f rom cog-

nit ive and social theories o f social info rma tion pro fessin g ov er

ma ny years (e .~ , Bandura, 1986 ; Can tor & Kihls t rom, 1987;

Carver & Scheier , 1981; Dodge, 1986 ; Mischel , 197 3, 1990) .

These basic units, called cognit ive-affective units (Mischel &

Shoda, 1995), include the me ntal representations of the person 's

encoding cons tructs and strategies, beliefs, expectancies; affects,

goals, and values. The se units hav e had a long history in psychol-

ogy and play a role as variables or const ructs in on e or mo re exis t-

ing theories in the health do ma in (Glanz, Lewis, & Rimer, 1990).

Cogni tive-social theory i s not u nique in the m ediat ing uni t s i t

ident i f ies : These const ructs are common products that have

emerged over m an y years in psychology, reflecting the sha red he ri-

tage of the field as a cum ulative science. Thus , ho w people proce ss

inform ation ab ou t their health risks, prospects, an d self-protective

options greatly depends on their strategies for encoding or inter-

pret ing heal th informat ion a bou t thei r i llness s ta tes and sym ptom s

(G ritz & Bastani , 19 93; E. Leventhal, Suls, & Leventhal , 1993; H.

Leventhal , 19 70; H. Leventhal , Diefenbach, & Leventhal, 1992).

Likewise, mo st mod els of health-protective behaviors include the

expe ctancy and value cons tructs (Fischoff, Goitein, & Shapira,

1982; Rotter, 1954). T he he alth belief mo del (Becket; 1974; Jan z

& Becker, 1984; Ki rscht , 1988; H. Leventhal, Ho chb aum , & Ro -

senstock, 1960) and protect ion mot ivat ion theory (Maddux &

Rogers, 1983; Prent ice-Dun n & Rogers , 1986) em phasize the per -

son 's a t tent ion to the co st and heal th consequences for not per -

forming rec om men ded behaviors , as do subjective expected ut i li ty

theo ry (Edwards, 1954; Ronis, 1992; Sutton, 1982), the theory of

reasoned action (Ajze n & Fishbein, 198 0; Fishbein & Ajzen,

1975 ) , and the the ory of planned behavior (Ajzen, 1985; Ajzen &

Madden, 1986), al though each uses som ewh at different term s.

As t he above- c i ted mod e l s have r ecogn i zed , hea l t h - p r o tec t i ve

decis ions ref lect subjective e xpectan cies and perceived psych o-

logical costs , ra ther th an thei r object ive assessment . Be havior i s

i n f luenced by t he cons t r ua l s , expec t anc i es , and va l ues t ha t a r e

sal ient for the perso n in a sp eci f ic s i tuat ion and by the af fects or

emot i ons t ha t a r e t r i gge red when po t en t i a l l y ha r mf u l o r bene -

f ic ial consequenc es to the sel f are perceived (C. Sm i th & L aza-

r us , 1990) . T hese cog n i t i ve - emot i ona l r eac t i ons al so h i nge on

such f ea t u r es o f t he s i t ua t ion a s how i n f or ma t i on abo u t hea l t h

outcomes i s f ramed psychological ly (Rothman, Salovey, An-

tone, Keou gh, & Mar t in, 1993; Ro thm an , Salovey, Turvey, &

Fishkin, 1993; Wi lson, Pu rdon , & Wal ls ton, 1988) and on cur-

r en t moo d s t a t e ( S a l ovey & B i r nbaum , 1989) .

F ur t he r mo r e , o ne t ype o f expec t ancy , se l f - e ff i cacy- -a s ses sed

by ask i ng peop l e t o i nd i ca t e t he i r degr ee o f conf i dence t ha t t hey

can do a pa r t i cu l a r t a sk (whi ch i s desc r i bed i n de t a i l ) - - h as l ong

been r ecogn i zed a s an e spec i a ll y i mp or t an t de t e r m i nan t o f

ef for t and pers i s tence (Ban dura , 1977a, 1977b, 1978, 1981 ) . A

per son ' s be l i e f t ha t h e o r she can execu t e t he behav i o r r equ i r ed

by a pa r t i cu l a r s i t ua t ion i s e spec i al ly ge r mane f o r t he ma i n t e -

nanc e of di ff icult he al thre levant behaviors (Band ura, 1986;

O'Leary, 1985, 1992) , and i t has been shown that se l f -ef f icacy

expe ctat ions pred ict ef fective per fo rm an ce of dif ficult t asks ,

pa r t i cu l a r l y when t he p o t en t i a l ou t com e i s h i gh ly i mpo r t an t t o

t he i nd i v idua l ( L au , H ar t m an , & W ar e , 1986 ) .

T h e t y p e s o f u n it s h y p o t h e s i ze d i n t h e C - S H I P a r e s h o w n i n

Table 1. No te again tha t such u ni t s as const ruals , beliefs , expe c-

t a n ci e s, a n d v a l ue s a re c o m m o n d e n o m i n a t o r s i n m o s t c o n t e m -

por a r y mode l s abou t peop l e ' s i n t u i t i ve dec i s i on- maki ng p r o-

cesses w i th r ega r d t o h ea l t h i n f o r ma t i on . I n r ecen t yea r s , mu ch

ev i dence a l so has shown t ha t a f f ec t in f l uences soc i a l i n f o r ma-

t i on p r oces s i ng and t ha t t he p r oces s i ng o f i n f o r ma t i on i mp or -

tant to the sel f necessar i ly act ivates af fects (e .g. , Bow er , 1981;

Con t r ada , L even t ha l , & O 'L ea r y , 1990; F oa & Koz ak , 1986; C .

S mi t h & L aza r us , 1990 ; W r i gh t & M i sche l, 1982; Z a j onc ,

1980) . T hus , t he d i s t ingu i sh i ng f ea t u r e o f th i s s e t o f medi a t i ng

un i t s o r pe r son v a r i ab l e s ( M i sche l , 1973 ) i s no t i t s un i queness

bu t i t s ec lec t ic compr ehens i venes s i n t he e f f o r t t o i ncor por a t e

cum ulat ive f indings f rom diverse di rect ions over m an y years .

Processing Structure and Dynamics Organization of the

Mediating Units

M o s t i m p o r t a n t i s th e s e c o n d c o m p o n e n t o f t b e C - S H IP . L i ke

t he cogn i t i ve - a f fec t i ve sys t em t heo r y f r o m whi ch i t i s de ri ved

( M i scbe l & S hoda , 1995) , t he C - S H I P as sumes tha t i nd i v i dua ls

di f fer not only in the cogni t ive-af fect ive me diat ing u ni t s acces-

s i b le to t hem bu t a l so i n the s t r uc t u r e and dy nam i cs t ha t gove r n

t he cogn i t i ve - a f fec t i ve i n f o r m a t i on p r oces s i ng t h r ough whi ch

these un i t s interac t in the genesis of heal th-pro tect ive behavior.

T hus , i t addr es ses bo t h ( a ) t he v a r i ab l e s ( d i mens i on s ) on wh i ch

individuals imp or ta nt ly di f fer (e .g. , thei r encodings , expe ctan-

cies , values , affective s ta tes , a nd goals and values) in cogn i t ive-

a ff ec ti ve i n f o r m a t i on p r oces s i ng and ( b ) t he p r oces s i ng s t r uc -

t u r e a n d d y n a m i c s w i th i n t h e s y s t e m t h a t a c c o u n t f o r a n d u n -

der l ie these di f ferences . In the theory, for a given individual o r

typ e (e .g. , a mo ni tor , cf . Mi l ler , 1995) , thi s organiza t ion i s

bo t h s t ab le and d i s t i nc ti ve i n i t s s tr uc t u r e an d dy nami cs , w hi ch

gu i de and co ns t r a i n t he pa t t e r ns and sequences o f ac t i va ti on

amo ng t he medi a t i ng un i t s t ha t a r e gene r a t ed when r e l evan t i n -

f o r ma t i on i s p r oces sed ove r t he cour se o f t ime .

A n u m b e r o f f e a tu r e s m a k e t h i s t h e or e ti c a l f r a m e w o r k p r o m -

is ing for appl icat ion s to analyses o f heal th-protect ive behavior .

As no t ed above , t he appr o ach i s compr ehens i ve and cumul a t i ve ,

drawing o n the es tabl i shed conce pts and f indings o f the larger

f ie ld . F ur t he r mo r e , i t takes accou n t o f no t on l y t he r o l e o f cog-

n i t i on bu t a l so a ff ec t and does so a t a l l phases o f i n f o r m a t i on

pr oces s i ng f r om en cod i ng t h r ough behav i o r gene r a t ion , execu-

t i on , and l ong- t e r m mai n t enance o f d if fi cu lt bu t des i r ed behav -

ior. I t deals wi th cog ni t ive -em ot ion al process ing, as the individ-

ua l i n t e r p r e t s , t r ans f o r ms , and ac t s on t he i n f o r ma t i on , ove r

l ong t em por a l spans o f t he so r t o f t en expe r i enced when cop i ng

wi th severe threa ts o f heal th an d i l lness. I t expl ic i t ly addresses

t he execu t i on o f compl ex , l ong - t e r m behav i or s t ha t a r e d i f f icu l t

t o gene r a te and m a i n t a i n , f o r exampl e , t ha t r equ i r e pur pose f u l

delay of grat i f icat ion and sel f - regulat ion, and tha t are essent ia l

f o r m any aspec t s o f e ff ec ti ve hea l t h - p r o tec t i ve p l ann i ng and be -

havior . I t i s therefore o f di rect re levan ce to such he al th-pro tec-

t ive beha viors as se lf -screening pro ced ures fo r ear ly detect ion


4/25

COG NI TI VE SOCI AL THEORY AN D CANCER SCREENI NG 73

Ta b l e

Types of Cognitive-Affective Me diating Units in Health Information Processing

and E xecu tion o f Health-Protective Behavior

Health-relevant encodings

Strategies and constructs for encoding o f self and situations w ith regard to health and wellness, health

risks an d vulnerab ilities, and illness an d disease. Includes attentional strategies for selecting and

processing potential health-threats and dangers (e.g. , mo nitoring -bluntin g by scanning fo r and

amplifying, or avoiding an d attenuating, information abou t possible health dangers and stressors).

Health beliefs and expectancies

Specific beliefs and exp ectations activated in health inform ation processing. Includes expec tancies abou t

both outcom es (e.g. , subjective l ikelihood of one 's developing breast cancer based o n o ne's genetic

pedigree and lung cancer from smoking) and self-efficacy xpectancies (e.g., for adhering to regular BSE

in cancer screening and fo r giving up tobacco).

Affects emotions)

Affective states activated in health information processing (e.g., anxiety, depression, hop efulness, negative

feelings abo ut the self, irritability, an d anger).

Health goals and values

Desired and valued health ou tcom es and states and their subjective importance (e.g., i t is cri tical to have

healthy breas ts) and go als for health-relevant life projects (e.g., dieting an d exe rcising regularly).

Self-regulatory competencies and s kills or generating and maintaining health-protective behavior

Know ledge and strategies for dealing with specific barriers to health-protective behaviors and for

construction and mainten ance of health-protective behaviors (e.g., skills required fo r proficient breast

self-examination in cancer screening). Includes self-regulatory strategies and behavioral scripts (e.g., self-

rewards and anxiety managem ent) for executing, maintaining, an d adhering to long-term, health-

protective be havior plans a nd life projects (e.g., strategies for goal-directed delay o f gratification).

Note.

From A C ognitive-Affective System The ory o f Personality: Reconceptualizing Situations, Dispo-

sit ions, Dynamics, and Invariance in Personality Structure s; ' by W . Mischel and Y. Shoda, 1 995,

Psycho-

logical Review, 10 2, p. 253. Copyright 1995 by the A merican Psychological Association. Adapted with

permission o f the authors.

of cance~ adherence to s t r ingent d ie ts , an d smo king cessa t ion

regimens.

Finally , the app roac h a lso focuses a t tent ion on the im por ta nt psy-

chological features o f the situation as perceived a nd interp reted b y

the individual and th us m akes the psychologica l contex t a cent ra l

com pon ent in the cogni tive-af fec t ive process ing of informat ion. A s

has been de mo nst ra ted a t least a t a theore tical level (Mischel &

Shoda, 1995) , i t should al low bet ter unders tanding and pred ic t ion

no t only of overall individual differences in br oa d behav ioral aver-

ages (e .g . , the overa l l tendency to moni tor for informat ion about

heal th threa ts and dangers) but a l so of specif ic pa t terns o f Person ×

Situation interac tion (e.g. , ifA , then she mo ni tors for heal th threa ts ;

but i f B, then she avoids them ) as express ions of the sam e under ly-

ing system. T he chal lenge i s to exam ine the u t i l i ty of th is meta-

theoretical con cep tion for health-protective beha vior ~n erally , and

for BSE in Imrf icular, which i s our goal in th e next sec tion .

A p p l ic a t io n o f th e C - S H I P t o B S E

The f or ego ing a s s um pt i ons o f t he C - SH I P s ugges t tha t whe n i n -

div iduals e ncou nter Informa t ion about B SE and breas t cancer ; they

differ stably in the ease with w hic h variou s construals, expectancies,

affects, goals, and self-regulatory strategies be co m e activated. I n ad -

clifton, the theory predicts that stable differences also exist in the

s trengths a nd pat terns of the organiza t ion of in ter re la t ions thro ugh

which these me nta l representa t ions are ac tivated by par t icular types

o f BSE-r el eva nt i n f o r ma t i on a n d t h r o ugh wh i c h t he y i n t e ra c t i n

the genes is and main tenanc e o f heal th-protec t ive behavior . Thus ,

a n a ppl ic a ti on o f t he C- SH I P t o a ny p a r t i c u la r dom a i n o f he al t h -

protectiv e beha vior requires, as a first step, identifying the co nten ts

o f the cognitive-affective units th at are l ikely to b e activated in the

re levant popula t ion , in th is case when wo me n deal wi th inform at ion

abou t breas t cancer . For tha t purpose , be low w e turn to the l ite ra ture

on BSE i n c a nc e r s c r e e n i ng

T h e C - S H I P a n a l y s i s o f t h e d i s t in c t iv e c o m p o n e n t b e h a v i o r s

i nvo l ve d i n BS E d i s ti ngu i s he s t he i n t e n t i on t o do BSE ( i . e. , t he

d e c i si o n I w i ll d o B S E ) f r o m t h e e x e c u t i o n o f t h e b e h a v i o rs

t h e m s e l v e s (i .e ., t h e p e r f o r m a n c e o f B S E ) . C o n c e p t u a l l y a n d

me t hodo l og i c a l l y , t h i s d i s t i nc t i on be t we e n t he f o r m a t i on o f i n -

t e n t i o n s ( c h o i c e s a n d d e c i s i o n s) a n d t h e i r b e h a v i o r a l e n a c t m e n t

i n v i vo i s i mpor t a n t be c a us e t he y i nvo l ve d i f f e r e n t , a l be i t

c l o s e l y i n t e r a c t i n g p r o c e s s e s a nd de t e r mi n a n t s ( e .g . , Mi s c he l ,

1974 ; Mi s c he l , Ca n t o r , & Fe l dma n , i n p r e s s ) . W e t he r e f o r e c on -

s i de r t he m s e pa r a t el y , f i rs t d i s c us s i ng t he f o r m a t i on o f de c i s i ons

a n d i n t e n t io n s a n d , t h er e a ft e r, t h e i r e x e c u t i o n a n d m a i n t e n a n c e

a t t he pe r f o r m a nc e l e ve l.

F o r m a t i o n o f D e c i s i o n s a n d I n te n t i o n s t o P e r fo r m B S E

C o g n i t i v e - A f f e c t iv e M e d i a t i n g U n i t s I n f l u e n c i n g t h e

D e c i s i o n

I n ge ne r a l t he o r e t i c a l t e r ms , t h e t ype s o f c ogn i t i ve - a f f e c t i ve

m e d i a t i n g u n i t s r e l e v a n t f o r p ro c e s s i n g in f o r m a t i o n a b o u t

b r e a s t c a n c e r a n d B S E a r e i n d i c a t e d i n T a b l e 1 . I n t h e B S E r e -

s e a r c h l i t e r a t u r e , s e ve r a l o f t he s e t ype s o f un i t s ha v e be e n i nve s -

t i ga t e d a s i nd i v i dua l d i f f e r e nc e va r i a b l e s t ha t ma y i n f l ue nc e

he a l t h - p r o t e c t i ve i n t e n t i on s a nd de c i s i ons .


5/25

7 4 M I L L E R , S H O D A , A N D H U R L E Y

Encoding of health relevant information: Perceived vulnerabil

i ty

Individual d i f ferences in encoding media te the re la t ionship

between the objec tive r i sk infor ma t ion tha t the individual rece ives

and her subjec tive , perce ived vulnerabi l i ty to breas t cancer . Som e

i nd iv i dua ls a r e m or e l i kel y t o s e e he a l t h t h r e a t s e ve r ywhe r e a nd t o

s c a n f o r t he m, a t t e nd ing i n t e n t l y t o bod i l y c ue s a nd s ym pt oms ,

whe r e a s o t he rs t e nd no t t o a t t e nd t o s uc h i n f o r m a t i on a nd a c ti ve ly

avoid i t (Bars ky & K lerm an, 1983; Kel lner , 1990; Mi l ler ; 1995, in

press ; Pennebaker , 1982; Salovey & Birnb aum , 1989) . Th e impo r-

tance o f individual d if ferences in enc oding w hen proce ss ing r i sk

inform at ion i s cons is tent wi th the f inding of low corre la t ions be-

tween a wo m an ' s objec t ive r isk s ta tus and h er perce ived suscept i -

b i l i ty to breas t cancea; which has typica l ly been only in the 0 .2

r a nge ( A i ke n , We s t, Wo odwa r d , & Re no , 1994; Ca l na n & Ru t t e r,

1988 ; Ru t l e dge , Ha r t m a nn , K i nm a n , & W i n f ie l d , 1988; Sc hwa r t z

e t al ., 1995) . In a rece nt s tudy, in w hich w om en wi th a fam i l ia l

h i s t o r y o f b r e a s t c a nc e r we r e p r e s e n t e d w i t h de t a i l e d i n f o r m a t i on

abo ut the i r personal r isk , a s t r ik ing two th i rds o f the par t ic ipan ts

cont in ued to s igni ficant ly overes t imate the i r suscept ib i l i ty to the

disease af ter the r i sk coun sel ing sess ion ( Le rm an, Lustbader, e t a l .,

1995 ) . O t he r wo me n a t ob je c ti ve ly h i gh r i s k a ppe a r t o d r a ma t i -

ca l ly underes t im ate the i r vulnerabi l i ty (Kash , Hol land, Halper, &

Miller, 1992; see also Blalock, D eVellis, Atifi , & Sandier, 199 0).

C l os e e xa mi na t i on o f t he l i t er a t u re on be li ef s a bou t on e ' s pe r -

sonal r i sk of cont rac t ing breas t can cer shows tha t researchers in

t h i s dom a i n ha ve c om bi ne d d i ve rs e i t e ms a s me a s u r e s o f t he c on -

s t rua l of subjec tive vulnerabi li ty . Sam ple i tems range f rom I am

less l ike ly than the average woman to develop breas t cancer

( Ron i s & Ha r e l , 1989 ) , t o I wor r y a l o t a bou t ge tt i ng b r e a s t c a n -

c e r ( Cha m pi on , 1984 ) , t o Wh e ne ve r I he a r o f a f r i e nd o r re la ti ve

• . . ge t t ing breas t cancer, i t ma kes m e rea l ize tha t I co uld ge t i t,

too (St i l lman, 1977) . Perhap s , in par t , becau se of th is divers i ty ,

resul t s in the l i te ra ture have been mixed, such tha t some s tudies

show a pos i tive re la t ionship b e tween perce ived susceptib il ity and

BSE f r e que nc y ( Ca l na n , 1984; Cha m pi on , 1988 , 1990 ; Ron i s &

H ard , 1989; Wyper , 1990) , w hereas o thers fai l to obta in th is e f fec t

(Benne t t , Lawrence , Fle ischm ann, Gif ford , & Slack, 1983; Ch am -

pion, 1984, 1985, 1987; M urra y & McMiU an, 1993; Rut ledge ,

1987) . A m on g those tha t d o show a pos it ive associa t ion , the re la-

t ionships are typica l ly of a mo dest s ta ti s tica l m agni tude , wi th co r -

re la t ions ranging f rom 0.14 to 0 .25. These f indings are co ns is tent

wi t h r e s e a rc h i n o t he r he a l t h dom a i ns , wh i c h s hows a s ma ll , n on -

zero m ean ef fec t s ize be tween perce ived suscept ib i l i ty and screen-

ing behav iors (e.g., testicu lar self-exam, fecal occu lt blood testing,

and asy mp tom at ic venerea l d isease tes ting; Harr i so n, M ul len , &

Gree n, 1992) . 3

Ej~cacy and conf idence .

R e s e a r c h i n d i c a t e s t h a t w o m e n

d i f fe r i n t he i r s e l f - c on f ide nc e a bou t t he i r s e l f - e xa m i na t i on t e c h -

n i que a nd t he i r a b i l i t y t o u s e BSE t o de t e c t l e s i ons . A numbe r

o f s t ud i e s ha ve s h own t ha t h i gh s e l f- e f fi c a cy be li e f s ( ge ne r a l l y

a s s u m e d a s c o n fi d e n c e i n o n e ' s a b il i ty t o p e r f o r m B S E ) a r e a s -

s oc i a t e d w i t h h i ghe r l e ve l s o f BSE a dhe r e nc e ( Be nne t t e t a l . ,

1983 ; F l e t che r , M or ga n , O ' Ma l l e y , Ea r p , & De g na n , 1989 ; J a -

c ob e t a l ., 1989 ; M ur r a y & M c M i l l a n , 1993 ; Ro n i s & Ka i se r ,

1985 ; Ru t l e dge & Da v i s , 1988 ; She ppe r d , So l omon , A t k i n s ,

Fost er , & F r a nkow s k i , 1990 ; S t e f a ne k & Wi l c ox , 1991 ; S tr a us s ,

So l omon , Cos t a nz a , Wor de n , & Fos t e r , 1987 v s . Ka s h e t a l . ,

1992 ) . Howe ver , t he s e r e s u l t s a r e d i f f i c u lt t o i n t e r p r e t be c a u s e

BSE p r a c t i c e wa s a s s e s s e d r e t r o s pe c t i ve l y . On l y a ha nd f u l o f

s t ud i e s ha ve u s e d a p r o s pe c t i ve de s i gn i n wh i c h be l i e f s a bou t

one ' s s el f -e f f ic a c y a r e u s e d t o p r e d i c t t he s u bs e que n t pe r f o r -

m a n c e o f B S E . T h e s e f i n di n g s g e n e r a ll y i n d i ca t e a p o s i t i v e - - b u t

mo de r a t e - - r e l a t i on s h i p be t we e n ba s e l i ne s e l f- e f fi c a c y be l i e fs

a n d l a t e r B S E a d h e r e n c e ( C h a m p i o n , 1 9 9 0 ; C l a r k e, H i l l, R a s -

s a by , W hi t e , & Hi r s t , 1991 ; J a nz , Be c ke r , Ha e f ne r , Ru t t , &

W e i s sf e ld , 1 9 9 0 ) . 4 I n o n e s t u d y , f o r e x a m p l e , w o m e n w h o p a r -

t i c i pa t e d i n a B SE t r a i n i ng c l a s s we r e r e c on t a c t e d 1 ye a r l a t e r

( C l a r ke e t a l. , 1991 ) . Le ve l o f c on f i de nc e i n pe r f o r m i ng BS E a t

t he i n i t i a l i n t e r v i e w c o r r e l a t e d pos i t i ve l y ( r = . 19 ) w i t h f r e -

que nc y o f BSE p r a c t i c e i n t he ye a r f o l l owi ng t he t r a i n i n g c l a ss .

F r o m t he C~S HI P pe r s pe c t ive , wh e r e a s s e l f- e f fi c a c y i s a goo d

s i ng l e i n d i c a to r o f p e r f o r m a n c e , i t a l so c o n s t i t u t e s o n l y o n e a s -

p e c t o f t h e r e l e v a n t m e d i a t i n g u n i t s i n t h e p r o c e s s i n g o f h e a lt h -

p r o t e c ti v e i n f o r m a t i o n , w h o s e i m p a c t o n b e h a v i o r d e p e n d s o n

i ts r e l a ti o n t o o t h e r u n i t s a c t iv a t e d d u r i n g p r o c e s s i n g w i t h i n t h e

i nd i v i dua l ' s s y s t e m ( e . g . , o t he r e xpe c t a nc i e s a nd be l i ef s a s we ll

a s a f fe c t s, goa ls , a nd va l ue s ) . Fo r e xa m pl e , t he va l ue a n i nd i v i d -

ua l p l a c e s on he r he a l t h , he r be l i ef s a bou t t h e s e r i ous ne s s o f a

he a l t h t h r e a t , a s we l l a s he r be l i e f s i n t he e f f e ct i vene s s o f s pe c i fi c

b e h a v i o r s t o r e d u c e t h e c o n s e q u e n c e s o f t h e t h r e a t , a l l p l a y a n

i m p o r t a n t , i n t e r c o n n e c t e d r o l e ( se e a l s o B o n d , A i k e n , & S o m -

ervi l le , 1992) .

Values and goals : Perce ived cos ts an d bene f i ts.

A l t h o u g h r e -

s e a r c he r s u s ua l l y a s s um e t h a t he a l t h i s a un i ve r sa l l y va l ue d goa l ,

i n f a c t , t h i s ha s no t be e n s how n t o be t he c a s e ( L a u e t a l. , 1986 ;

Qu a d r e l & La u , 1989 ; Wa r e & Young , 1979 ) . M or e ove r , goa l s

a nd va l ue s ( e . g . , one ' s f e e l i ngs a bou t one ' s s e xua l i t y , a ppe a r -

a n c e , h e a l th , a n d m o r t a l i t y ) a p p e a r t o c h a n g e o v e r t h e l if e

c o u r s e (H o o k e r , 1 9 9 2 ; T h u r n h e r , 1 9 7 4 ) . F o r e x a m p l e , n o t s u r -

p r i s i n g l y , w h e n a s k e d t o i m a g i n e t h a t t h e y n e e d t o u n d e r g o

b r e a s t c a n c e r s u rg e ry , y o u n g e r w o m e n a r e m o r e c o n c e r n e d t h a t

t he s u r ge r y w i ll ma ke t h e m f e e l l e s s a t t r a c t i ve a nd a r e m or e c o n -

c e r ne d a bou t how o t he r s w i l l f e e l a bou t t he m ( Be nne t t e t a l . ,

1 9 8 3 ) . F u r t h e r m o r e , r e s e a rc h i n r e l a te d d o m a i n s h a s s h o w n

t h a t o l d e r p e r s o n s v a lu e t h e i r h e a l th m o r e h i g h l y a n d m e n t i o n

h e a l t h c o n c e r n s a s t h e i r m o s t - h o p e d - f o r a n d m o s t - d r e a d e d

pos s i b l e s e l ve s mo r e f r e que n t l y t ha n d o co l l e ge - a ge d i nd i v i d -

ua l s ( Hoo ke r , 199 2 ) .

Pa s t e xpe r i e nc e , o f c ou r s e , e n t e r s i n t o t he s e s ub j e c t ive c o s t -

be ne f i t c a lc u l a t i ons . Fo r e xa mp l e , a wo m a n ' s l eve l o f a nx i e t y

a b o u t f i n d in g a l u m p m a y b e l es s i f sh e h a s s u r v i v e d a n e p i s o d e

o f b r e a s t c a n c e r b e c a u s e t h i s e x p e r ie n c e w o u l d e n a b l e h e r t o

r e c o n s t r u e t h e t h r e a t i n l es s t e r r if y i n g t e r m s ( I h a d i t, a n d I a m

O K ; B e r re n b e r g , 1 9 8 9 ) . F u r t h e r m o r e , r a t h e r t h a n r e s p o n d i n g

t o t h e a n x i e t y a b o u t f i n d in g a l u m p b y a v o i d a n c e a n d d e n i a l ,

3 Similar to the BSE li terature, the research o n fear-arousing comm u-

nications in general is mixed, such that some studies find a 0-shaped

relationship between fear and adoption of, o r adherence to, health-pro-

tective behaviors, wherea s other stud ies find a positive, linear relation-

ship (see Sutton, 1982, for a review).

4 One study reported no relationship between self-efficacybeliefs and

subsequent performance (Calnan & Moss, 1984). How ev~ BSE practice

was defined in terms not only of how frequently the behavior vos per-

formed bu t also of how com petently it was performed. This combined

assessment may have dam pened the effecto f self-efficacyon BSE because

women otten overestimate he quality of heir exams (Celentano & Holtz-

man, 1983;Jacob et al. , 1989).


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COGNI T IVE S OCI AL T HE ORY AND CANCE R S CRE E NING 75

she ma y have learned thr oug h th e f i rs t episode to act ively engage

i n appr op r i a t e hea l t h - p r o tec t i ve behav i o r s ( I f I do BS E , I can

mak e su r e t ha t any f u r t he r p r ob l ems a r e caugh t ea r l y and dea l t

w i t h ) . Cons i s t en t w i t h t hese hypo t heses , women wi t h a pe r -

sona l h i s t o r y o f b r eas t cance r have been f ou nd t o be m or e l i kel y

t o pe r f o r m BS E t han t hose w ho have been t r ea t ed f o r a ben ign

( non ma l i gnan t ) b r eas t t umo r ( S t r aus s e t al ., 1987) , a l t hough

the n um be r who p ract ice BSE regu lar ly st il l fa l ls shor t o f opt i -

m um adher ence ( T ay l or e t a l. , 1984) .

Summary. A wo ma n ' s BS E i n t en ti ons and dec i s ions a r e i n -

f l uenced by he r be l i e fs t ha t a hea l t h t h r ea t ( e .g . , b r eas t cance r )

i s ser ious and personal ly re levant and that there are ef fect ive

measu r es ava i lab l e t o m i n i mi ze i t s consequences ( A i ken , W es t,

W oodw ar d , Reno , & Reynol ds , 1994) . As d ive rse mode l s o f

heal th-protect ive decis ions have noted repeatedly, the decis ion

t o pe r f o r m BS E depends , i n pa r t , on t he pe r ce i ved t r ade - of f b e -

t ween t he bene f it s and va l ue o f de t ec ti on and t r ea t me nt a s com -

pare d wi th thei r cos t s (e .g. , Becker, 1985; Procha ska, 1994) an d

com par ed w i t h t he bene f i ts o f con t i nued i nac t i on ( e .g . , avo i d i ng

t he anx i e t y p r ovoked by p e r f o r m i ng BS E ; Rogers , 1983) .

In thi s subject ive ar i thm et ic , individu al di f ferences in bel iefs

abou t t he gene r a l u ti l it y o f ea r l y de tec t i on and t r ea t me nt a l so

i mpo r t an t l y a f fec t t he dec i si on t o pe r f o r m BS E . T hose wom en

who dou b t t he u t il i ty o f medi ca l in t e r ven t i on ( B r ea s t cance r is

no t cu r ab l e ) a r e un l i ke l y t o unde r t ake BS E ( L er man e t a l . ,

1991; Sheley & Lessan, 1986 ) . L ikewise , Ronis and H arel

( 1 9 8 9 ) f o u n d t h a t w o m e n w h o b e li e v ed t h a t d e l ay e d t re a t m e n t

i nc r eased t he s eve r i ty o f b r eas t cance r ou t comes r a t ed BS E as

mo r e bene f i c ia l i n r educ i ng t he po t en t i a l s eve r i ty o f t he d i sease

and i t s t reatment . Perceived benef i t s , in turn, were re la ted to

i nc r eased f r equency o f BS E . Converse ly , w ome n wh o d i d no t

be l ieve i n t he va l ue o f ea r l y t r ea t men t pe r ce i ved f ewer bene f it s

to BSE an d were less l ikely to ex am ine the i r breas t s .

Interactions Within the Syste m: The Structure and

Dyn am ics o f Health Information Processing

The mo dest bu t s ta t i s t ical ly s igni f icant addi t ive l inea r ef fects

f ound i n t he l i t e r a t u r e r ev i ewed above a r e cons i s t en t w i t h t he

C - S H I P a s s u m p t i o n t h a t w h e n w o m e n e n c o u n t e r B S E - r el e v an t

i n f o r ma t i on , t hey d i f fe r st ab l y in t he ease w i t h whi ch va r i ous

const ruals , ex pectancies , values , and af fects bec om e act ivated.

F or examp l e , one wom an m ay have chr on i ca ll y h i ghe r l eve ls o f

pe r ce i ved vu l ne r ab i l i ty t o b r eas t cance r ( I m ay deve l op b r eas t

cance r ) , w her eas ano t he r wo man may t yp i ca l l y f ee l le s s vu l -

ne r ab l e . One w oma n may t end t o eas i l y ac t i va te pos i ti ve ou t -

com e expec t a t i ons , wher eas ano t he r i s r ead i l y pes s imi s t i c abou t

he r p r ospec t s . One woman may be mor e l i ke l y t o expe r i ence

anxious feel ings , and the other to have posi t ive feel ings when

con t em pl a t i ng BS E .

F i gur e 1 i ll us t ra t e s exam pl es o f spec if ic me nt a l r ep r esen t a -

t i ons o f t he t ypes o f cogn i t ive - a f f ec ti ve un i t s , shown i n T ab l e 1

and ident i f ied in the l i t era ture , that are potent ia l ly access ible

t o an i nd i v i dua l when encoun t e r i ng i n f o r ma t i on abou t b r eas t

cancer. Thus, i t i l lustrates a cognitive-affective do main map

( M i sche l & S hoda , 1995 ) o f t he t ypes o f men t a l r epr esen t a t i ons

l ike ly t o becom e ac t iva t ed when w omen cons i de r b r eas t cance r

and m ake dec i s ions abou t BS E . T he a r r ows i l l us tr a t e some po-

tent ia l pat terns o f re la t ions am ong these uni t s : Sol id l ines show

pos i t ive ac t i va ti on i n w hi ch t he ac t i va t i on o f on e u n i t ac t iva t e s

ano t he r ; b r oken l i nes show nega t ive ac t i va ti on i n whi ch t he ac -

t i va ti on o f on e un i t deac t i va te s ( i nh i b i t s ~ ano t he r.

A given individual i s character iz ed b y a dis t inct ive set of ac-

ces s ib l e cogn i ti ons and a f f ec t s and a s t ab l e o r gan i za ti on o f t he

as soc i a ti ons amon g t hem . F r o m t he p r esen t pe r spec t i ve , t h i s o r -

gan i za t ion , t h i s s t ab l e s t ruc t u r e , cons t r a i ns and gu i des t he dy-

nam i cs o f cogn i ti ve - a f fec t i ve hea l t h i n f o r ma t i on p r oces s i ng by

t he i nd i v i dua l. T h us , i n add i t i on t o d i f f e rences in t he chr on i c

access ibi l i ty levels of par t icula r types o f cogni t ions and af fects

(e .g. , Higgins , in press) , the theory predict s that s table di f fer -

ences w i ll a l so ex i s t be t ween peo p l e i n t he s t r eng ths and pa t t e r ns

of the o r gan i za t i on o f i n t e r r e la t i ons t h r ough whi ch t hese m ent a l

r epr esen t a t i ons a r e ac t i va t ed by pa r t i cu l a r t ype s o f BS E - r e le -

van t i n f o r m a t i on and t h r ough whi ch t hey i n t e r ac t i n t he genes is

o f hea l t h - p r o t ec t ive behav i o r. T h i s t ype o f p r oces s ing sys t em

yi e lds subs t an t ia l P e r son X S i t ua ti on , / f . . .

t h e n . . .

in-

teract ion ef fects (e .g. , i f A, she wi ll X; b ut i f B, she wi ll Y) ,

and t he t heor y p r ed i c t s t ha t t hese i n t e r ac ti ons w i ll cons t r a i n t he

level of predic tabi l i ty poss ible f rom ad di t ive , l inear an alyses of

s ingle var iables , yie lding nonz ero bu t low correla t ion s (Mischel

& Shoda, 1995; Shoda , 1 990) . Su ch correla t ions , in fact , cha r -

ac t e r i ze the em pi r i ca l l i te r a t u r e r ev i ewed above and f ound i n

the f ie ld m ore ge neral ly (Taylor, 1995 ) .

I llustrative Interactions Betwe en Health R isk

Information an d the Organization o f Cognitive-Affective

Units: Prototypic E xem plars

T h e C - S H I P e m p h a s i z e s t h a t t h e i m p a c t o f h e a l th - r el e v an t

i n f o r ma t i on depends on t he i n t e r ac t i ons among cogn i t i ve r ep-

r e sen t a t i ons and a f f ec t s t ha t b ecom e ac t i va ted i n t he sys t em.

T o i l lus t r a te t hese i n t e r ac t i ons w i t h i n t he C - S H I P f r amewor k ,

cons i de r t he e f f ec t s o f gene t ic r i sk i n f o r m a t i on a bou t b r eas t can -

ce r on t he i n t en t i on t o pe r f o r m BS E . W e f ocus on t wo pr o t o -

t yp i c exem pl a r s o f p r oces s ing t ypes cha r ac t e r i zed by r ad i ca l l y

d i f fe r en t o r gan iza t i on i n t he s t r uc t u r e o f t he ir ou t com e and

e f f icacy expec t a t i ons and a f f ect s w i t h r ega r d t o b r eas t can ce r

and t he va l ue o f ea r l y de tec t i on .

Prototypic negative expectancy organization. F i gur e 2 de -

p i c t s a p r o t o t yp i c o r gan i za t i on w i t h nega t i ve ou t come and

e f f icacy expec t anc i e s abou t b r eas t cance r and t he u t i li t y o f BS E .

O f al l t he po t en t i a l r e l a ti ons shown i n t he BS E dom ai n m ap

( F i gur e 1 ) , t hose t ha t r epr esen t t he mo r e dom i nan t p a t hways

of ac t i va t ion f o r t h i s t ype o f i nd i v i dua l a r e show n wi t h t h i ck

a r r ows . As i n t he f i r st f igur e ( and t h r ough out t h i s a r t i c le ) , so l id

a r r ows i nd i ca t e pos i t i ve ac t i va ti on , and b r oke n a r r ow s i nd i ca t e

nega t ive ac t i va ti on ( deac t i va t i on) . I t shows t ha t i f t h i s t ype o f

wom an d i scove r s t ha t she i s a t h i gh- gene t ic r i sk f o r deve l op i ng

br eas t cance r, t he ou t com e expec t ancy tha t Can ce r w il l g r ow

unde t ec t ed , and I ' l l u l t i ma t e l y d ie f r om i t i s s t r ong ly ac ti va t ed

( a r r ow 3) , i nc r eas i ng anx i e t y and depr es s ion ( a r r ow 7) .

Th e ef fect of BSE t ra in ing sessions i s to a ct ivate the self -ef f i-

cacy belief, I f I have brea s t cancer , I can f ind i t wi th B SE

( a r r o w 2 ) , w h i c h , c o m b i n e d w i t h t h e p e r c e p t io n o f p e rs o n a l

r i sk f o r b r eas t cancer , l eads t o t he expec t a t i on t ha t S oon er o r

la ter , I ' l l detect a lu m p (ar ro ws 4 and 5 ) . This , in turn, t r iggers

t he expec t ancy t ha t t r ea t ment w i l l be pa i n f u l bu t i ne f f ec t i ve

( a r r ow 9) , s i mpl y p r o l ong i ng t he pa i n w hi ch f u r t he r ac t i va te s


7/25

7 6

M I L L E R , S H O D A , A N D H U R L E Y

In fo rma t ion abo u t b reast canc er

and pe rsona l r i sk leve l

\

\

\

In fo rma t ion abou t BSE

and i ts effectiveness

1 m a y d e v e l o p b r e a s t I f I h a ve b r e a s t ca n ce r,

can cer I can f ind i t w i th BSE

Recommenda t ion

to pe r fo rm BSE

5 1

1 \ \~ 4

\

\ \ \

\ \ \ \

Ca n ce r m a y g r o w \

unde tected , and

r l l u l t ima te ly d ie f rom i t '

6 1 w i l l d o B S E r e g u l a r ly

f

f ( I n t e n t i o n t o B S E )

/

Sooner or l a t e r , lO j ,

Ill detect a lump'

I 8 1 1

' r l l ge t ear ly, effective

treatm ent, an d I' l l be 1'11b e su b j e c te d t o

~ \ cu red , exten d ing hea l thy pa in fu l bu t ine f fect i ve

\ p roduc t ive i fe t r ea tmen t , on ly to

, p r o l o n g t h e p a i n '

7 ' ~ ,, • 1 2 1 3 ~ 1 4 ,

. . . . . . . . . . ~

Anxie ty , dep ress ion

Figure 1

Dom a in m a p o f form ing in te n t ions to pe r form bre a s t s e l f- e xa m ina t ion (BSE ) , i l lus t r a ting c og-

ni t ive -a ff e c t ive uni t s po te nt i a l ly a c c e s sib le to a n indiv idua l a nd the s t ruc ture (orga niz a t ion) of r e la t ions

a m on g the m . Sol id l ine s i llus t r a te pos i t ive ( a c t iva t ing) r e la t ions f rom on e uni t to a nothe r ; b roke n l ine s

i l lus tra te negative (deactiva t ing) re la t ions .

f e el in g s o f a n x ie t y a n d d e p re s s io n a r r o w 1 3 ) a n d u n d e r m i n e s

t h e i n t e n ti o n t o p e r f o r m B S E a r r o w 1 4 ) . I n s u m m a r y , i f a

w o m a n w i t h t h i s t y p e o f c o g n i t iv e - a f f e c t i v e o r g a n i z a t i o n i s e x -

p o s e d t o g e n e t i c r i s k i n f o r m a t i o n , t h e r e s u l t i s i n c r e a s e d a n x i e t y

a n d d e p r e s s i o n a n d r e d u c e d t e n d e n c y t o p e r f o r m B S E . H o w -

e ve r, i f n o t e x p o s e d t o t h e g e n e t i c r i s k i n f o r m a t i o n , t h e i n t e n t i o n

t o p e r f o r m B S E , p r o m p t e d b y t h e re m i n d e r t o p e r f o r m B S E ,

r e m a i n s a c t i v a t e d . T h e r e f o r e , f o r t h i s t y p e o f p r o c e s s i n g o r g a n i -

z a t io n , a s i m p l e r e m i n d e r t o p e r f o r m B S E m a y b e m o s t u s ef u l,

w h e r e a s m a k i n g t h e p e r s o n a l g e n e t i c r i s k s t a t u s s a l i e n t w o u l d

b e d e t r i m e n t a l .

Prototypic po sit iv e expectancy organization I n c o n t r a s t ,

d r aw i n g o n th e s a m e c o m m o n d o m a i n m a p s h o w n i n F i g u re 1 ,

F i g u r e 3 d e p i c t s a h y p o t h e t i c a l o r g a n i z a t i o n o f B S E - r e l e v a n t c o g -

n i t io n s a n d a f fe c ts p r o t o ty p i c o f a w o m a n w i t h p o s i t iv e o u t c o m e

a n d e f f i c ac y e x p e c t a ti o n s a b o u t b r e a s t c a n c e r a n d t h e v a l u e o f

B S E . I n t h i s o r g a n i z a t i o n , i n f o r m a t i o n r e g a r d i n g h i g h - g e n e t i c r i s k

f o r b r e a s t c a n c e r d o e s n o t s t r o ng l y a c t iv a t e t h e e x p e c t a n c y t h a t

c a n c e r w il l g r o w u n d e t e c t e d a n d b e c o m e f at a l. T h e m o r e d o m i -

n a n t p a t h w a y a c t i v a te s th e e x p e c t a t io n o f b e i n g a b l e t o d e t e c t a

l u m p w i t h B S E . I n c o n t r a s t t o t h e o r g a n iz a t i on s h o w n i n F i g u r e 2 ,

t h i s e x p e c t a ti o n t h e n t r i g ~ m t h e o u t c o m e e x p e c t a n c y t h a t e a rl y,

e f f e ct i v e t r e a t m e n t w i l l b e o b t a i n e d , e n a b l i n g a h e a l t h y , p r o d u c t i v e

l i fe , w h i c h k e e p s t h e l e v e l o f a n x i e t y o r d e p r e s s i o n m a n a g e a b l e . I n

c o n t r a st , i f th i s t y p e o f w o m a n i s n o t e x p o s e d t o r i s k in f o r m a t i o n ,

t h e i n t e n t i o n t o p e r f o r m B S E i s n o t a s s t ro n g l y a ct i v a te d b e c a u s e

t h e p e r s o n a l c o n se q u e n c e s o f d e v e l e p in g c a n c e r a n d t h e u l ~ t y o f

d e t e c t i n g i t e a r l y t h r o u g h B S E a r e n o t a c t i v a t e d . T h u s , g i v e n t h i s

t y p e o f o r g a n iz a t io n , t h e i n t e n ti o n t o p e r f o r m B S E i s m o n g e r i f

t h e w o m a n i s e x p o s e d t o r i s k i n f o r m a t i o n b u t i s w e a k e r i f s h e i s

n o t e x p o s e d t o r i s k i n f o r m a t i o n , y i e ld i n g a p a t t e r n o f / f . . , t h e n

•

r e l a t i o n s h i p s t h a t i s d i r e c t l y o p p o s i t e t o t h e o n e c h a r a c t e r i s t i c

f o r t h e o r g a n i z a t i o n s h o w n i n F i g u r e 2 .

A s t h e s e i l l u s t ra t i o n s i n d i c a t e , t h e C - S H I P a n a l y s i s i n c l u d e s, b u t

g o e s b e y o n d , s i m p l e o v e r a l l d i f f e r e n c e s b e t w e e n t y p e s o f in d i v i d u -

a l s i n t h e i r g e n e r a l le v e ls o f a n x i e t y a n d t e n d e n c y t o p e r f o r m B S E .

T h u s , i t a l s o p r o v i d e s a r o u t e t o p r e d i c t f o r i n d i v id u a l s w i t h d i f f e r -

e n t t y p e s o f p r o c e s s i n g o r g a n i z a t i o n s t h e i r s p e c i f i c p a t t e r n s o f

h e a l t h - p r o t e c t i v e b e h a v i o r i n r e l a t i o n t o d i f f e r e n t t y p e s o f in f o r -

m a t i o n . I t m a k e s i t p o s s i b l e t o s p e c i f y m o r e p r e c is e l y t h e d i s t i n e -


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COG NI TI VE SOCI AL THEORY AN D CANCER SCREENING 77

I n f o r m a t i o n a b o u t b r e a s t I n f o r m a t i o n a b o u t B S E

c a n c e r a n d p e r s o n a l d s k l e v e l a n d i t s

effectiveness

1 m a y d e v e l o p b r e a e t I f I h a v e b r e a s t c a n c e r ,

c a n c e r I c a n f i n d I t w i t h B S E

R e c o m m e n d a t i o n

t o p e r f o r m B S E

1E

1'11g e t e a r l y , e f f e c t i v e - v . k . . o , , ~ . . . , . . . z

.

.

t r e a t m e n t , a n d I 'l l b e • ' - . - ~ - - ' ? ~ - . -' :- ~ i

L . . . . n - a lt h p a l f ll u I D U I[ n e ll lr e cl lv e •

cu reo , exzenaz g ne y ~ t o n ~ t a •

- - - - ' V l if e ' ~ - - - ' ~ ~ - •

~ r o o u c o • p r o l o n g t h e p a i n

• , 2 13 14

~

A n x i e t y d e p r e s s i o n

Figure 2.

Il lustrative processing structures and d ynam ics in forming intentions and decisions to perform

breast self-examination (BSE). This figure il lustrates a processing prototyp e of a wom an w ho is character-

ized by nega tive expectanc ies. Thick solid lines indicate positive (activating) relations am ong units; thick

broken lines show negative (deactivating) relations. Thin l ines i llustrate potential pathways but are n ot

salient for the particular prototype.

f ive prof i les of i f . . . t h e n . . s i t ua t i on - be ha v i o r r e l a ti ons h ip s

( e. g. , i f A , t he n s he doe s BSE; bu t i f B , s he be c om e s a nx i ous a nd

a vo i ds i t ) t ha t c ha r a c t e r i z e t he m s t a b ly ( Mi s c he l & Shoda , 1995 ) .

Specif ica lly , as was seen in the exam ples above, inform at ion a bo ut

cance r r isk s ta tus has the op posi te effec t depe nding o n the organ i -

z a t i on o f r e l a ti ons a m ong BSE- r e l e va n t c ogn i t i ons a nd a ff ec ts : Fo r

wom e n wi t h t he o r ga n i z a t i on s hown i n F i gu r e 2 , e xpos u r e t o i n -

f o r ma t i on a bou t t he i r r i sk f o r c a nc e r i s p r e d i c te d t o s t r e ng the n

t he i r i n t e n t ion t o pe r f o r m BSE; whe r e a s f o r t hos e w i t h t he o r ga n i -

z a t i on s hown i n F i gu r e 3 , t he s a me pe r s ona l r is k i n f o r m a t i on i s

predic ted t o hav e the opposi te ef fect .

Predicting the Two Opposing Effects o f R isk Information

Th e f o r e go i ng a na l y s is i n t e r m s o f t ype s o f p r oc e s s ing o r ga n i z a -

t ions is a lso cons is tent wi th , and helps to expla in , the tw o oppos ing

e ff ec ts o f r is k i n f o r m a t i on o bs e r ve d i n t he BSE l i t e ra t u r e. O n t he

one hand, be l ieving tha t one i s suscept ib le to breas t cancer has

be e n f ound t o s t re ng t he n BSE a dhe r e nc e ( Cha m pi on , 1988, 1990 ;

Ron i s & Ha r e l , 1989; Wyper , 1990 ) . O n t he o t he r ha nd , s uc h a

bel ief has a lso been fo und to inc rease the negative af fec t and anx-

i ous a r ous a l t ha t be c om e a c ti va te d , wh i c h c a n be c om e ove r whe l m-

i ng a nd t he r e by l e a ds e i the r t o a vo i da nc e o f t he be ha v i o r ( Ka s h e t

a t ., 1992; Le rm an e t a l ., 1991; Rip peto e & Rogers , 1987; St rauss

e t a t. , 1 987) or to m aladapt ive hypervigi lence ( i. e. , week ly or even

da i l y BSE; Le r m a n , K a s h , & S t e f ane k , 1994 ; S t e f a ne k & Wi l c ox ,

1991) . •

F r o m t h e C - S H I P p e r s p e c t i v e , w h e n i n d i v i d u a l s c h a r a c t e r -

i z e d b y d i f fe r e n t ty p e s o f o r g a n i z a ti o n a r e p r e s e n t i n t h e s a m e

s t udy a nd no t d i s t i ngu i s he d i n t he a na l y s i s , t he ove r a l l r e s u l t s

a r e l i k e ly t o b e i n c o n s i s t e n t a n d c o n f u s in g . T h a t i s , d e p e n d i n g

o n t h e o r g a n i z a t i o n o f th e B S E - r e l e v a n t c o g n i ti o n s a n d a f fe c ts

t y p i c a l w i th i n a p a r t i c u l a r s a m p l e o f w o m e n a s s e ss e d , t h e o v e r-

a l l e f fe c ts o f i n f o r m a t i o n a b o u t h e a l t h r i s k s o n t h e p e r f o r m a n c e

o f BSE c o u l d a ve r a ge ou t t o be pos i t i ve , ne g li g i b le , o r e ve n ne g -

a ti ve . A s r e v i e we d a bove , a nd c ons i s t e n t w i t h t he s e t he o r e t i c a l

e x p e c t a ti o n s , t h e e m p i r i c a l l i t e r at u r e i s m i x e d : W h e r e a s s o m e

s t ud i e s s how t ha t pe r c e i ve d s u s c e p t i b i l it y t o b r e a s t c a n c e r l e a ds

t o i n c r e a se d f r e q u e n c y o f B S E ( C h a m p i o n , 1 9 8 8 , 1 9 90 ; R o n i s

& Ha r e l , 1989 ; Wype r , 1990 ) , o t he r s t ud i e s f ind t ha t i t h a s no


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I n f o r m a t i o n a b o u t b r e a s t c a n c e r I n f o r m a t i o n a b o u t B S E

a n d p e r s o n a l r i s k l e v e l a n d

i t s e f f e c t i v e n e s s

1

m a y d e v e l o p b r e a s t

I f I

h a v e b r e a s t

r a n c o r ,

c a n c e r I c a n f i n d I t w i t h B S E

R e c o m m e n d a t i o n

t o p e r f o r m B S E

1 5

' C a n c e r m a y g r o w ~ 6 I w i l l do B S E r e g u l a r l y

i~tnd~itme~ate~~ndromt ~ j . . ~ ~ ( In te n tio n t o B S E )

S o o n e r o r l a te r , 1 0 / ¢ :

I ' l l d e t e c t a l u m p ' / t t

I l l'

g e t e a d y e f f e c ti v e

t z , z a ~ w ) t ~ z d I l l ~ I l l b e

s u b j e c t e d

t o

\ ~ _ m ~ , l ' -- ' ~ , ~ n ~ l ' ~ ' l~ l ~ h u p a i n f u l b u t inef fect ive

\~ ~ n d ' ~ , ' i ~ ; . . . . . . . . t r e a t m e n t , on y o

\ r - . . . . . . . ~ - - - - p r o lo n g t h e p a i n

\ l a 1

~ ' ~ A n x ie ty , d e p re s s io n

Figure3.

Il lustrative processing structures and dynamics in forming intentions an d decisions to perform

breast self-examination (BSE). This figure illustrates a woman characterized by positive expectancies.

Thick solid lines indicate positive (activating) relations among units; thick broken lines show negative

(deactivating) relations. Thin l ines il lustrate potential pathways but are n ot salient for the particular

prototype.

e f f e ct ( Be nne t t e t a l. , 1983 ; Ch a m pi on , 1984 , 1985 , 1987 ; Ru t -

l edge, 1987 ) . F r om t he p r e s e n t pe r s pe c t ive , t he s e s e e mi ng c on -

t r a d i c t i ons i n t he r e s e a r c h f i nd i ngs ma y , i n f a c t, r e f l e c t t he p r e s -

e n c e o f t h e t y p e s o f i n t e r a c ti o n s t h a t t h e C - S H I P p r e d i c ts a n d

t h a t w o u l d i n e v i t a b ly u n d e r m i n e t h e l e ve l a n d s t a b il i ty o f th e

ove r a l l c o r r e l a t i on be t we e n pe r c e i ve d vu l ne r a b i l i t y a nd BSE

pr a c t i c e , un l e s s t he r e l e va n t p r oc e s s i ng c ha r a c t e r i s t i c s o f t he

w o m e n w e r e t o b e t a k e n i n t o a c c o u n t .

Understanding the Inve rted U Shaped Relat ion B etween

N ega ti ve Ar ous a l and B SE Per fo r mance

To i l l u s tr a t e t h e e f f e c t s o f d i f f e r e n t a s pe c t s o f t he pos s i b l e o r -

g a n i z a ti o n s h o w n i n t h e d o m a i n m a p , w e h a v e u s e d t w o r a d i -

c a l l y d i f f e r e n t p r o t o t ype s , de p i c t e d i n F i gu r e s 2 a n d 3 , a s e xa m -

p l e s . I n mos t pe op l e , howe ve r , t he o r ga n i z a t i on i s no t a s e x -

t r e m e , a n d a s p e c ts o f b o t h t y p e s a r e p r e s e n t w i t h i n t h e s y s t e m .

I n s uc h a s y s t e m, he a l t h r i s k i n f o r ma t i on c a n r e a d i l y a c t i va t e

p r oc e s s e s w i t h oppo s i ng ef f e ct s , i n e s s e nc e c om bi n i ng e l e me n t s

o f th e o r g a n i z a t i o n s h o w n i n b o t h F i g u r e s 2 a n d 3 .

Suc h a s y s t e m a l s o s pe a ks t o t he c u r v i l i ne a r e ff ec ts o f r is k i n f o r -

ma r i on f oun d i n t he b r e a s t s c r e e n i ng l i te r a t u re , s uc h a s t he i n -

ver ted U -shaped re la t ionship be tw een the level of negat ive aro usal

a nd t he i n t e n t i on t o pe r f o r m B SE ( s e e a l s o J a n i s 1967; Janis &

Le ve n t ha l , 1967 ; Le r ma n & Sc hw a r t z , 1993 ) . Expos u r e t o r i s k

i n f o r ma t i on i n t h i s p r oc e s s ing s y s t e m c a n i nc r e a s e bo t h t he i n t e n -

t i on t o pe r f o r m BSE a nd t he l eve l o f a nx i e t y a bou t do i ng i t. The s e

e f f e c t s a r e de mons t r a t e d i n a s t udy by R i ppe t oe a nd Roge r s

( 1987 ) . Co ll ege -a ged wom e n we r e p r e s e n t e d w i t h e i t he r a h i gh -

t h r e a t i n f o r ma t i ona l b r oc hu r e , wh i c h v iv id ly po r t r a ye d t he s e ve r-

i t y o f b r e a s t c a nc e r a nd t he t h r e a t po s e d t o on e ' s he a l th , o r a l ow-

t h r e a t i n f o r ma t i ona l b r oc hu r e , w h i c h downp l a ye d t he s e ver it y o f

b r e a s t c a nc e r a nd i t s p r e va l e nc e a m ong youn ge r wom e n . Th e

g r ou p t ha t r e c e ive d t he t h r e a t e n i ng me s s a ge ma n i f e s t e d h i ghe r l ev -

e ls o f perce ived sever i ty o f breas t cancer; w hich, in tu rn , w ere pos-

i t ive ly associa ted wi th grea ter in tent ions to per form BSE. At the

sam e t ime, the threa te ning m essage was associa ted wi th increased

levels of anxie ty , wh ich were in turn associa ted wi th h igher levels

o f ( ma l a da p t i ve ) a vo i da n t ide a t i on ( e .g . , I t r y no t t o t h i nk a bou t

the po~ ibi l i ty o f developing breas t can cer ) . A l thoug h avoid ,ant


10/25

COGNI T IVE S OCI AL T HE OR Y AND CANCE R S CRE E NING 79

thinkin g significantly redu ced anxiety, it also resulted in decreased

intent ion to p er form BSE. As is widely known, mo derate levels of

arousal tend to enhance per formance, whereas high levels

derm ine i t (e .g. , Hebb, 1972) .

I n t he c on t ex t o f BS E , t h is ana l ys i s p r ed i c t s t ha t w omen wi t h

mod er a t e l eve ls o f wor r y w i l l be mo r e l i ke ly t o pe r f o r m r egu l a r

BSE than wi l l those who have low or high levels (e .g. , Lerman

et al ., 1991; see a l so Fajardo, Saint -G erm ain, M eake m, Rose, &

Hi l l man , 1992 ; Kas h e t al ., 1992) . T he p r ed i c t i on t ha t exces -

s iv e n e g a ti v e a r o u s a l ca n u n d e r m i n e - - r a t h e r t h a n e n h a n c e - -

BS E pr ac t ice amon g women w i t h mor e t ha n ave r age pe r ce i ved

r i sk has r ece ived cons i de rab l e empi r i ca l supp or t . F o r exampl e ,

a s tudy o f fi rs t -degree fem ale re la t ives of breas t can cer pat ien ts

f ound t ha t g r ea t e r anx i e t y an d g r ea t e r pe r ce i ved suscep t i b il i ty

p r e d i ct e d p o o r a d h e r e n c e t o t h e r e g u la r p e r f o r m a n c e o f B S E

(K ash et a l. , 199 2) . Moreover, in thi s study, wo me n who per-

f o r med BS E mont h l y t ended t o be t hose who pe r ce i ved t he i r

chances o f ge tt i ng b r eas t cance r a s moder a t e , w her eas t hose who

per ce ived t he i r chances a s h i gh nev e r pe r f o r m ed BS E .

Interact ions W ith Ind ividu al Dif ferences:

Mon i t o r ing -B l un t i ng o f Hea l t h R i s k In f o r ma t ion

T he f o r ego ing C- S H I P ana l ysi s focused on t he i n t e r ac t i on be -

t ween a pe r son ' s p r oces s ing sys t em and t he r i sk i n f o r m a t i on t o

whi ch she i s exposed . Ra t he r t han be i ng s i mpl y a t the m er cy o f

t he i n f o r ma t i on t he s i t ua t i on o f the m om ent hap pens t o supp ly ,

individuals a l so di f fer in h ow ac t ively they seek, amp l i fy, and

pr oces s d i f f e ren t t ypes o f hea l t h - re l evan t i n f o r ma t i on , a s d i s -

cussed next (Mi ller, 1989, 1995, in press) .

To illustrate, high m onitors low blun ters ) generally see health

threats pervas ively and scan for them , a t tending intent ly to bodi ly

cues, symp toms, and r i sk informat ion (Mi l ler , Comb s, & Kruu s ,

1993; Miller, Roussi , Altma n, H elm , & Steinberg, 1994 ; Miller,

Roussi , Caputo, & Kruus, 1995; Schwartz, Lerman, Miller, Daly,

& M asny, 1995) . The y tend to see themselves as fragile and vul -

nerab le and are sensit ive to cues ab ou t possible disease and i l lness,

part icularly when dealing with potential ly chronic, un con trollable

stressors (Miller, Brody, & Su mm erto n, 1988; Miller, Lein bach , &

Brody, 1989 ; Miller et al ., 1994; M uris & v an Zuu ren , 1992; Step-

toe & Vogele, 1992; van Zuure n & W olfs , 1991 ) . This co gni t ive-

at tentional focus on threat an d dan ger act ivates anxiety and pro-

longed arousal s ta tes (Ga rd, Edwards , H arr i s , & McC orm ack,

1988; Ler ma n et a l. , 1990; Mi l ler & M angan, 1983; Phipps &

Zinn, 1986; van Zuu ren, 1993; E Wardle e t a l. , 1993; J . Wardle ,

1995; J. Wardle, Pernet , Coll ins, & Bourn e, 1994).

In the face of persistent , highly severe threats, wh ich high m on -

i tors encode as par t icularly catas t rophic (L erm an et a l ., 1995; Mi l-

ler e t a l. , 19 94, 1995, in press ; Mu ds, de Jong, van Zuu ren, & ter

Horst , 1994 ; Schwartz et al ., 1 995 ; Spa rks & Spirek, 198 8; van

Zuu ren & Muris , 1993) , intrus ive ideation and acco mp anying

anxiety may become unbearable and t r igger avoidance ef for t s .

High m oni tors therefore may ul t imately tend to reso r t to ext reme

defensive strategies, such as denial and disengagement, in an in-

creas ingly d~perate ef for t to suppress and dis tance themselves

f rom awareness of thei r own int rus ive ideat ion. Low m oni tors (or

high blunters) , however, in the ext rem es tend to encode personal

r i sks by denying thei r existence and to av oid threatening cues f rom

the outset , refusing to at tend to an d assimilate info rm ation tha t is

d i sc repan t w i t h t he i r co r e be l i e f ha t t hey a r e O K - - no p r ob l em

(Miller et al ., 1993, 199 4; M ill ~ Rodoletz, Schroeder, Ma ngan , &

Sedlacek, in press) . Consequent ly, anxiety i s not arous ed and, wi th

thei r sense of nvulnerabi li ty , they m ay not f orm even the intent ion

to pract ice BSE (see a l so Salovey & Birnba um , 1989; Weinste in,

1983, 1 984, 1989) . Effective coping wi th threat should be greater

wh en individuals develop discriminativeness and flexibil ity in their

a t tent ional s t ra tegies , so they c an ass imi la te new informa t ion ( e .g.,

a l lowing them to accep t the need fo r BSE) , w i thout becom ing ob-

sessively at tun ed to the thre at an d excessively anxious.

From In tent ions to Exec ut ion an d Adherence: B eyon d

Cho ice to Health-Protect ive Action

Al t hough i n t en t i ons and dec i s ions a r e i mp or t an t s t eps i n t he

pr oces s ing o f hea l t h i n f o r ma t i on , t he C - S H I P suggest s t ha t t hey

a r e o f l imi t ed va l ue i n p r ed i c t i ng ac t ua l adhe r ence t o a r eg i m en

of r egu l a r BSE because t ha t r equ i r e s no t on l y good i n t en t i ons

bu t a l so the act ivat ion and m ainte nan ce o f ef fective sel f - regula-

t o r y s t r a teg i e s. Jus t a s m an y peop l e f i nd t ha t a New Year ' s r e so-

lut ion to ex ercise regular ly fa l ls by the wayside af ter a few shor t

weeks (Browne l l , Mar la t t , L ich tenste in, & Wilson, 1986 ) , a sig-

n i fi c a n t n u m b e r o f w o m e n f o r m t h e i n t e n t io n t o d o B S E a n d

e v e n a t t e m p t i t b u t d o n o t p e r f o r m t h e e x a m a t t h e r e c o m -

men ded f r equency .

I n f ac t , su r veys show t ha t a l t hough 70% t o 75% of wom en

r epor t p e r f o r m i ng BS E a t l ea s t once a yea r, on l y 25% t o 35%

a c t u a ll y a d h e r e t o a m o n t h l y r e g i m e n ( C e l e n t a n o & H o l t z m a n ,

1983; Cham pi on , 1988; M u r r ay & M cM i l l an , 1993) . I n one

s tudy , 61% of wom en a t t end i ng a B S E c l a ss ind i ca t ed t ha t t hey

i n t ended t o pe r f o r m BS E on a mo nt h l y bas i s in t he f o l lowing

year. However , whe n contacte d I year la ter , only 22% of he sam -

ple had a chieved th at goal (Clarke e t a l . , 1991; see a l so Salazar

e t al ., 1994) . T hu s , f o r mo s t women , the p r o b l em i s no t j us t one

o f n e e d in g t o b e c o n v i n c e d t o t r y B S E b u t r a t h e r o f m a i n t a in i n g

t he behav i o r p r o f ic i en t ly and cons i s t en t l y ove r t i me .

Dom ai n Ma p f o r BSE . Fr om In f o r ma t i on Inpu t t o

Per formance and Adherence

The chal lenge, then, i s to nar row the large gap between the

i n t en t i on t o pe r f o r m B S E cons i s t en tl y and i t s f u l fi ll men t . A

uni que con t r i bu t i on o f the p r o posed m ode l i s t ha t i t de l inea t e s

t he s e l f - r egu l a to r y p r oces s a s it ope r a t e s on t he execu t i on o f

hea l t h - p r o t ec ti ve r eg i mens , pa r t i cu l a r l y t hose t h a t a r e d i f f i cu l t

t o e x e c u t e a n d t h a t m u s t b e m a i n t a i n e d o v e r t im e . I t t h u s e n -

com passes bo t h t he dec i s ion p r oces ses t h r ough whi ch BS E i n -

t en t i ons a r e f o r m ed and t he s e l f - r egu la t o r y p r oces ses t h r ough

whi ch t hey a r e po t en t i a l l y t r ans l a t ed i n t o ac t i on , a s dep i c t ed

schemat i ca l l y i n F i gur e 4 . T hese s e l f - ma nagem ent p r oces ses a l~

c r i ti ca l because l ong- t e r m ad her ence r equ i r e s spec i a l s t r at eg i es

f o r bo t h mot i va t i ng and cu i ng BS E , whi l e s i mul t aneous l y dea l-

i ng w i t h anx i e t y , d is t r ac ti on , f r us t r a t ion , and o t he r ba r r i e r s i n

t he execu t i on o f t he r e l evan t p r ocedur es , a s d i s cussed nex t .

F i gur e 4 i l l us t ra t e s t he i n t e r ac t ions am ong t he cogn i ti ve and

affective uni t s in th e sel f - regulatory process . Specif ically, i t adds

cogn i t i ons and a f f ec t s r e l evan t f o r BSE p e r f o r m ance t o t hose

al read y ident i f ied as inf luencing BSE decis ions (F igu re 1 ) and

shows the po t en t i a l i n te r ac t i ons am ong t he m t ha t a f f ec t t he f o r -


11/25


m a t i o n o f t h e i n t e n t i o n t o p e r f o r m B S E a s w e l l a s t h e a c t u a l

p e r f o r m a n c e . T h u s , F i g u r e 4 s e r v e s a s a c o g n i t i v e - a f f e c t i v e d o -

m a i n m a p ( M i s c h e l & S h o d a , 1 9 9 5 ) o f t h e m e n t a l r e p r e s e n t a -

t i o n s p o t e n t i a l l y a c t i v a te d a s t h e p e r s o n c o n t i n u e s t o c o n s i d e r

B S E a n d t r i e s to p e r f o r m i t.

F i g u r e 4 s h o w s t h a t t h e a c c e s s i b le k n o w l e d g e f o r p e r f o r m i n g

B S E b e c o m e s a c t i v a t e d b y t h e i n d i v i d u a l ' s lo n g - t e r m i n t e n t i o n

a n d p l a n s t o p e r f o r m B S E ( a r r o w 1 7 ) , a s w e ll as b y s p e c if i c

e x t e r n a l i n p u t s s u c h a s t h e r e m i n d e r t o d o i t ( a r r o w 1 8 ) , w h i c h ,

w h e n s u f f i c ie n t l y a c t i v a t e d , g e n e r a t e s B S E p e r f o r m a n c e . A s t h e

f i gu r e in d i c a t e s, i n t e n t i o n s a n d r e m i n d e r s , o f c o u r s e , a r e n o t t h e

o n l y s a l i en t u n i t s t h a t a f fe c t t h e p e r f o r m a n c e o f B S E , a s d i s -

c u s s e d n e x t .

Activation of Cognitions and Affect During BS E

A m a j o r p r o b l e m f o r p e o p l e w h o a t t e m p t t o p r a c t i c e s c r e e n -

i n g b e h a v i o r s l i k e B S E i s t h e p e c u l i a r n a t u r e o f t h e r e w a r d s

t h e y p r o v id e . W h e n a w o m a n p e r f o r m s B S E , i t i n c r e a s e s t h e

i m m e d i a t e l i k e l i h o o d o f f i n d i n g a n a b n o r m a l i t y ( M a y e r & S o l -

o m o n , 1 9 9 2 ) . P e r f o r m i n g B S E , th e n , c a n b e a f r i g h te n i n g b e -

h a v io r , i n t h e s e n s e t h a t i t i s d e s i g n e d t o d e t e c t ~ r a t h e r t h a n t o

p r e v e n t ~ b r e a s t c a n ce r . T h u s , p e r f o r m i n g B S E ( o r i n s o m e

c a s es , e ve n t h e t h o u g h t o f p e r f o r m i n g i t ) l e a d s m a n y w o m e n t o

w o r r y e v e n m o r e a b o u t t h e p o s s i b i l i t y o f b r e a s t c a n c e r

( R u t l e d g e & D a v i s , 1 9 8 8 ) a n d a b o u t t h e s t r es s o f a f a l s e

a l a r m ( H i l l , G a r d n e r , & R a s s a b y , 1 98 5 ) . T h e m o s t d e s i ra b l e

o u t c o m e o r r e w a r d o f B S E m a y b e t o n o t f i n d a l u m p , w h i c h

m a y r e i n f o r c e a v o i d a n c e b e h a v i o r s r a t h e r t h a n c a r e f u l s e l f i n -

s p e c t i o n . I n d e e d , w o m e n w h o r e p o r t t h a t t h e y a r e a f r a i d o f

f i n d i n g a l u m p a r e l e s s l i k e ly t o p e r f o r m B

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Teoria Cognitivo Social y Cancer de Seno - Miller 1996