Fear of negative appearance evaluation and attitude towards mammography: Moderating role of internal health locus of control,cancer worry and age

Introduction

Breast cancer is a principal form of cancer and a prevalent malignancy among women¹ accounting for 25% of all female cancer globally.² In Iran specifically breast cancer is reported as the most common malignancy among women.³ Strong evidence shows that breast cancer screening and mammography screening tend to reduce mortality rate through early detection.^4-7 This has attracted researchers to study the barriers to mammography screening.

While there is a growing body of research on a barriers such as lack of knowledge, fear of breast cancer diagnosis,^8,9 possible pain experienced during mammography, low self-efficacy, lack of health motivation, lack of access to health-care, and lack of physician referral,^10-12 research on the role of fear of negative evaluation on mammography screening is scarce. Due to its consequences,^13-15 fear of negative evaluation would be an important detrimental factor in women’s mammography screening. Thus, this study attempts to examine if the more specific fear of negative appearance evaluation (FNAE) affect women’s attitude toward mammography screening.

Moreover, this study goes one step further and investigates the mechanism behind this relationship by introducing three moderators that may weaken or strengthen the relationship between FNAE and attitude towards mammography screening.

Controlling for country specific sociocultural influence, this study focuses on Iran women along three additional major reasons. First, body and physical appearance dissatisfaction is prevalence among Iranian women^16,17 which leads to their lower self-esteem and strong desire for plastic surgery.¹⁸ Second, Iranian women have shown low tendency to undertake regular breast cancer and mammography screening.^10,19,20 Third, breast cancer is the most prevalent chronic disease among Iranian women²⁰ and the peak age of incidence is ten years earlier than developed countries.²¹

This research contributes to the growing interest among researchers in explaining the mechanism that shapes attitudes towards mammography screening by focusing on Iranian women who have no prior breast cancer screening experience. Therefore, to fill the gap in the knowledge, the current study aims to investigate the moderating role of internal health locus of control, breast cancer worries and age in the relationship between FNAE and attitude towards mammography among Iranian women without breast cancer screening experience.

Materials and Methods

Results

The mean age of the participants was 40.06 (SD = 8.83). The sample was mainly from urban areas (95.5%), married (80.7%), unemployed (59.0%), and had diploma and above qualification (78.8%) and insurance coverage (84.9%). In terms of the reported BMI, 307 participants (37.3%) fell into normal weight, followed by 290 (35.2%) in underweight, 163 (19.81%) in overweight, and 63 participants (7.7%) into the obese group. Table 1 reports a summary of the participants’ socio-demographic characteristics.

Next, the factor structure was developed and validated by performing CFA. By following the modification indices, four pairs of the items’ measurement errors of ABCSPS were allowed to freely covary. Moreover, four items of ABCSPS and two items of internal health locus of control were deleted as they loaded weakly on their respective constructs. The revised measurement model had a good fit (χ²(199) = 585.763, P < 0.001, χ²/df = 2.944, goodness-of-fit index (GFI) = 0.939, comparative fit index (CFI) = 0.951, incremental fit index (IFI) = 0.951, normed fit index (NFI) = 0.927, standardized root mean square residual (SRMR) = 0.036, and root mean square error of approximation (RMSEA) (90% confidence interval (CI)) = 0.049 (0.044–0.053)). All item loadings were greater than 0.5 and significant (z-value between 9.941 and 28.296). Table 2 reports the results of the assessment of the constructs. The CR and Cronbach’s alpha of all constructs was greater than 0.7 indicating a good construct reliability and convergent validity.⁵⁵ This study also estimated AVE of the constructs. AVE of FNAES (0.477) and ABCSPS (0.454) were slightly less than 0.5. However, according to Malhotra and Dash⁵⁶ “AVE is a more conservative measure than CR. On the basis of CR alone, the researcher may conclude that the convergent validity of the construct is adequate, even though more than 50% of the variance is due to error.” (p. 702). Moreover, AVE of each construct was greater than its ASV and MSV establishing discriminant validity of all constructs.⁵⁷

The results after controlling for the effect of education level and insurance coverage are reported in Table 3. There was a significant positive relationship between FNAES and ABCSPS that was used to measure negative attitudes towards mammography (β = 0.144, P  < 0.001) providing support for H1. As ABCSPS is a measure of negative attitudes towards mammography, the significant positive relationship supported that FNAE is a barrier to take mammography, and therefore the relationship between FNAE and attitude towards mammography screening is negative and significant.

Also, the interaction of FNAES with internal health locus of control (β = -0.128, P  < 0.05), breast cancer worry (β = -0.090, P  < 0.05), and age (β = -0.095, P  < 0.05) was significant which provided support for H2, H3, and H4 respectively. More specifically, the results indicated that the three moderators tested in this research dampened the positive relationship between FNAES and ABCSPS (negative attitudes towards mammography). Figure 1 shows the results of the assessment of the structural model. The conditional relationship between FNAES and ABCSPS showed that for the low (SD = -1) and medium (SD = 0) levels of the moderators, the relationship between FNAES and ABCSPS is positive and significant. However, for higher levels of the moderators (SD = +1), this study could not find any significant relationship between FNAES and ABCSPS. Figure 2shows the relationship between FNAES and ABCSPS as a measure of negative attitudes towards mammography for low and high values of the moderators. The model explained 10% of the variance of attitudes towards mammography.

Figure 1. Structural model assessment results. Abbreviations: ABCSPS: Attitude toward breast cancer screening procedures scale, FNAE: Fear of negative appearance evaluation.

Figure 2. The conditional relationship between FNAE and ABCSPS. P values for the interaction of FNAE and Internal health locus of control, FNAE and Breast cancer worry, and FNAE and Age are 0.000, 0.015 and 0.007 respectively.

Discussion and Conclusion

This study attempts to fill the gap in the literature related to the association between FNAE and women’s attitudes towards mammography screening. The moderating effects of internal health locus of control, breast cancer worry, and age on this relationship were tested.

The results showed a positive relationship between FNAES and ABCSPS scale which measures negative attitude towards mammography. The findings provide evidence that women’s FNAE by others can act as a barrier for mammography screening. This may be due to the fact that mammography screening requires physical examination of their body and exposure of their body to a medical professional. These results provide empirical evidence for the conceptual framework developed by Ridolfi and Crowther.⁴⁵ They stated that “women experiencing body shame may avoid cancer screenings performed by a physician for fear that they will be negatively evaluated on the basis of the perceived flaws in their physical appearance” (p. 154). In this study, women with no past mammography screening experience showed a strong relationship between FNAE and attitude towards mammography screening. This corroborated with past studies on the association between body image and screening behavior.^58-61 The results of a study by Chait et al⁵⁸on 93 women indicated that those with higher satisfaction with overall appearance and evaluating themselves as attractive reported more frequent skin self-examination. Clark et al⁶⁰ showed that body image concern was one of the barriers to perform cancer screening for both men and women.

This study also provided support for the moderating effect of internal health locus of control, breast cancer worry, and age on the relationship between FNAE and attitudes towards mammography. More specifically, internal health locus of control, breast cancer worry, and age weakened the FNAE-attitudes towards mammography link. The findings show that FNAE could more likely act as a barrier towards positive mammography behavior in women who were less likely to have a sense of control over their health status, who were less worried about the prospect of contracting the disease, and who were younger.

Women who have a disposition toward internal health locus of control are more likely to actively participate in their own health care and health-related information seeking and as a result, they are more likely to have higher levels of awareness and self-efficacy for cancer screening which in turn may improve their attitudes towards cancer screening and mammography.^1,62 Moreover, the findings lend support to the notion that being worried about cancer may have benefits, having a positive effect on women’s attitude towards cancer screening and prompting them to engage in screening behaviors such as mammography.^37,41 Furthermore, due to the prevalence of cancer in older women,⁴² women who were older tend to have higher awareness and self-efficacy for breast cancer screenings and mammography. Also, they may be more susceptible to more peer and medical professional encouragement to undertake mammography. These may buffer the negative effect of the FNAE on their screening attitudes and as a result they may be more likely to undertake mammography regardless of their FNAE.⁴⁵

The moderating effect of internal health locus of control, cancer worry, and age adds to our understanding of the relationship between FNAE and mammography screening behavior among women who have not had any prior mammography screening experience. This is a major contribution and it is useful for health policy and practices strategies that are aimed at early detection of breast cancer among women.

Ethical approval

The study protocol and the consent form were approved by the ethical committee of the first author’s institution. All participants provided informed consent. The purpose of the study was explained to the participants and they were assured that all responses are anonymous, and participation in this study is voluntary. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Competing interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This study was funded by an extension of Taylor’s University Research Grant (TRGS/ERFS/1/2015/TBS/014).

Authors’ contributions

SPS involved in the conceptualization of the study, data collection, methods, results, and discussion. ASA and FSO involved in the introduction section. NN involved in the discussion. FSO and NN involved in editing the work..

Acknowledgments

We thank all participants, Mastoureh Afshari, Khadijeh Irani Tehrani, Nahal Naghavi, and Fatemeh Irani Tehrani for their support.

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