Black-White Differences in Cancer
Prevention Knowledge and Behavior
Chnstopher Jepson, PhD, Larry G. Kessler, ScD, Barty Portnoy, PhD, and
Tyson Gibbs, PhD
Introdudion
Blacks have a higher incidence ofand
mortality from cancer than Whites.1,2 This
differential presumably reflects differ-
ences in demographic factors such as ed-
ucation and income, and cognitive psy-
chological factors such as attitudes and
knowledge which influence behavior.
Although studies have shown that
Blacks tend to have lower levels of cancer
knowledge than Whites,3-5 the relation-
ship between knowledge level and cancer-
preventive behavior has not been ade-
quately documented. Some studies
indicate a relationship between knowl-
edge and behavior,6-9 while others do not
do so.10'11 At minimum, however, some
basic preexisting level of knowledge is a
prerequisite for any instrumental behav-
ior. Theories such as the Health Belief
Model,12,13 PRECEDE,14 and Fishbein
and Ajzen's theory of reasoned action15
also postulate a relationship between be-
havior and beliefs, which are presumably
based upon knowledge to some extent.
In 1987 the National Health Inter-
view Survey (NHIS)16 included a Cancer
Control Supplement assessing a variety of
demographic and cognitive psychological
factors in addition to cancer-preventive
behaviors. This made it possible to exam-
ine the extent to which such factors were
associated with Black-White behavioral
differences.
Methods
A total of 22,043 adult respondents
over the age of 18 provided data on the
1987 NHIS Cancer Control Supplement.
To increase accuracy of point estimates,
Blacks were oversampled: 3,053 respon-
dents (13.9 percent of the total sample)
described themselves as Black.
For the purposes of our analyses, the
study population was restricted to respon-
dents describing themselves as either
Black or White; Hispanics and members
of other ethnic or racial groups were ex-
cluded. This reduced the total number of
respondents to 20,088. In the analyses re-
ported here, the data are weighted (using
weights assigned by the National Center
for Health Statistics) so as to be repre-
sentative of the US population.16
We selected four measures of cancer-
preventive behavior as dependent varia-
bles. These variables are described in Ta-
ble 1.
The independent variables selected
for our analysis fell into two main
categories-demographic (race, sex, in-
come, education, age) and cognitive psy-
chological (knowledge, belief, and atti-
tude) measures. They are described in
Table 2. A detailed description is provided
in the Appendix.*
In our data analysis, we first exam-
ined Black-White differences in the de-
pendent and independent variables, and
then estimated logistic regression models
of each dependentvariable, using a special
software program, RTILOGIT,17 de-
signed specifically for use on data sets of
this type.
Results
Black-White Differences
Table 1 reveals substantial Black-
White differences in rates of diet change,
mammography, and stool blood testing;
smoking differences are essentially con-
fined to men. Table 2 shows that Blacks
scored lower than Whites on the three
knowledge measures and were less likely
to believe that cancer is preventable.
Some independent variables, such as
the knowledge measures, are continuous.
Mean Black-White differences on these
variables, shown in Table 2, appear small
but when they are dichotomized and per-
centages are compared the differences are
*Additional information on standard errors of
point estimates presented in this paper, odds
ratios, etc., are available upon request from the
first author.
From the National Cancer Institute, Bethesda,
MD. Address reprint requests to Christopher
Jepson, PhD, University of Pennsylvania
School of Nursing, Room 309, Nursing Educa-
tion Bldg., Philadelphia, PA 19104. This paper,
submitted to the Journal November 8, 1989,
was revised and accepted for publication Au-
gust 13, 1990.
American Journal of Public Health 501
Public Health Briefs

equal to or greater than those seen for the

categorical variables.
Regression Analyses
In order to determine the extent to
which knowledge-related factors could
account for the relationships between race
and cancer-preventive behaviors, we es-
timated two multivariate logistic regres-
sion models of each dependent variable.
In the first or reduced model, all indepen-
dent variables are included except for the
four knowledge-related variables (educa-
tion and the three measures of cancer pre-
vention knowledge). The second or full
model includes all of the independent var-
iables in Table 2.
Table 3 shows the coefficients (betas)
for all independent variables in the full
models of the four dependent variables.
The coefficients for race translate into the
following odds ratios (i.e. the odds of
Blacks reporting the given behavior com-
pared to Whites): for diet change, 0.94
(95% CI = 0.84,1.05); for mammography,
0.94 (95% CI = 0.77, 1.16); for stool blood
test, 1.08 (95% CI = 0.91, 1.28); for smok-
ing among men, 1.03 (95% CI = 0.83,
1.29); and for smoking among women,
0.71 (95% CI = 0.59, 0.85). Thus, in all
models except that of women's smoking,
Black-White differences in behavior do
not persist when the other predictors are
held constant.
Among women, race is not a signifi- In the reduced models ofeach depen- Discussion
cant predictor of smoking status by itself, dent variable, the betas for race are inter-
as shown in Table 1. As Table 3 shows, mediate between those shown in Table 1 Our results were generally consistent
however, Black-White differences be- and those in Table 3, and all are signifi- across all dependent variables except for
come significant in the full model. cantly different from zero. smoking status among women. By includ-

502 American Journal of Public Health Aprfl 1991, Vol. 81, No. 4
 Public Health Bnefs

*~~~~1~~~~~~69B)(n~~~~~~~~~~~~#23S)
(n.1O4~~~~~~~~~~~~~~~~~~~3)~~~.. .............5)..
eQS oW~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...
....(o1S...S (Ockp.aoD2) (~10)(~LZ07
Ap O~~~~~~~13 01Wg~ ~ ~ ~ . . ...
. . .3
.......
~~~qi~~~~~~w~~~~~ot
~~~~~~~~4AJQS4 5...
0~~~~~~~~~~~~~~~~Q1
--------S--------0-------

01~~~~~~...
................ b. ... .....

F - ~~~~~~~~~~~~~~..............
Undmr$t0............04.....O40
( 050w 013)
( 0070~~~~~~~~ (0~~~~~~~~~~~~~~~~21,Ot3) ~~~~~~~~~~0~~~01.0AS)......
$1~~~~0Q041%~~~~~~~S MS -OI# 005 OW~~~~~.......
........................................Q
$a~ ~ ~ ~ ~ ~ ~ ~ ~ o o4015340*0.m
GAS 000~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.5......... ~51

------(-17OO
............QJ4....018".013.00
(0-S--3-(GA 020--0.--0.1)( .0,03
..........................7, 1I) - ~0
Z01
D m y~~~~~~~~~~~~~~~~r~~~~~~~~~cw tw.......
............20A)
....
........ e. .......... Qi~ 0.Z 12
(OZ~~~~ "401)
P*4~~~~~~~~0A8) ("~~~~~~0A~~~ 013) (-(L04~~~~~~~~~~GA?)(011.............)
...012.OZ..L38 .0101
OW.
GAS~~~~~~~~~~~ 0.000*8 0*0~~~~~~~~~......
..................0...
..........(.. ................~1 )018~ .3a
... .. .. .. .. .. .. .....................

~~~0S~~O14...(0.......014)............................
..........0...........0....
..0 .......0 ..0 )(

...........0.. ..................)..0..........
........

~~~~~~~~~~~~~~p< 10~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~......01.........
**~~~~~~~~~~~~~~~p~

ing knowledge-related variables in the The cross-sectional nature of the measures of knowledge and attitudes, es-
analysis, Black-White behavioral differ- analysis places significant limitations on pecially if these measures assess specific
ences were eliminated. In the case of wo- the conclusions to be drawn from this concepts directly related to the behaviors
men's smoking status, when other factors study. Associations discovered in such a in question. Second, they suggest that
are controlled for, Black women become study cannot be assumed to reflect causal there may be merit in investigating the use
less likely than White women to smoke. relationships, and it is possible that other of interventions designed to narrow the
In addition to accounting for the ef- variables could account for Black-White behavioral discrepancies between Blacks
fects of race, knowledge-related variables behavioral differences as well as or better and Whites by reducing the knowledge
also displayed independent relationships than the ones we chose to examine. Nev- discrepancies. Longitudinal studies of this
with cancer-preventive behaviors. Educa- ertheless, this study is unique in that it is type should answer the question of
tion was a significant predictor in all mod- the first national study assessing the inde- whether enhancing cancer knowledge will
els. Cigarette risk knowledge also contrib- pendent effects of knowledge, beliefs, at- result in increased cancer-preventive be-
uted significantly in all cases, with its titudes, and demographic factors on haviors as a stepping stone to reductions
contribution greatest in the models of Black-White differences in cancer-pre- in cancer mortality. EC
smoking status. Fat and fiber knowledge ventive behaviors. The importance of cog-
was a significant predictor of all dependent nitive psychological factors is indicated by References
variables except smoking status; some- the fact that even the imperfect measures 1. American Cancer Society: Cancer Facts
what surprisingly, it was no more signifi- available to us eliminated the behavioral and Figures. New York: ACS, 1988.
cant for diet change than for the other de- differences. 2. Baquet CR, Ringen K, Pollack ES, et at
Cancer among Blacks and other minorities:
pendent variables. Risk factor knowledge Our findings suggest that a fuller un- Statistical profiles. DHHS Pub. No. 86-
contributed significantly only to the model derstanding of Black-White behavioral 2785. Washington, DC: Govt Printing Of-
of diet change. differences can be gained by including fice, 1986.

April 1991, Vol. 81, No. 4 American Journal of Public Health 503
Public Health Briefs

3. Michielutte R, Diseker RA: Racial differ- 8. Ho EE, Abrams C, Atwood J, Meyskens F 13. Janz NK, Becker MH: The health belief
ences in knowledge of cancer: A pilot Jr: Health attitudes and behaviors of the model: A decade later. Health Educ Q
study. Soc Sci Med 1982; 16:245-252. elderly toward dietaxy modification for co- 1984; 11:1-47.
4. Denniston RW: Cancer knowledge, atti- lon cancer prevention. In: Proceedings of 14. Green LW, Kreuter MW, Deeds SG, Par-
tudes, and practices among Black Ameri- the Annual Meeting of the American Soci- tridge KB: Health Education Planning: A
cans. In: Mettlin C, Murphy GP (eds): Can- ety for Clinical Oncology, 1986; 5:242. DiagnosticApproach. Palo Alto, CA: May-
cer among Black Populations. New York: 9. Bove PA: A study of the factors influ-
Alan R. Liss, 1981; 225-237. field Publishing, 1980.
encing women to practice breast self-ex- 15. Ajzen I, Fishbein M: Understanding atti-
5. Robinson RG, Kessler LG, Naughton MD: amination: A basis for designing a breast
Cancer awareness among African-Ameri- tudes and predicting social behavior. Engle-
cans: A survey assessing race, social sta- self-examination educational program wood Clis, NJ: Prentice-Hall, 1980; 62-77.
tus, and occupation. J Nat Med Assoc (in [Dissertation]. Kent, OH: Kent State Uni- 16. National Center for Health Statistics: The
press). versity, 1988.
10. Schlueter LA: Knowledge and beliefs National Health Interview Survey Design
6. Allegrante JP, O'Rourke TW, Tuncalp S: 1973-1984 and Procedures 1975-1983.
A multivariate analysis of selected psycho- about breast cancer and breast self-exam-
ination among athletic and nonathletic DHHS Pub. No. 85-1320. Washington,
social variables on the development of sub- DC: Govt Printing Office, 1985.
sequent youth smoking behavior. J Drug women. Nurs Res 1982; 31:348-353.
Educ 1977-78; 7:237-248. 11. Owens RG, Daly J, Heron K, Leinster SJ: 17. Shah BV, Folsom RE, Harrell FE, Dullard
7. Warnecke RB, Havlicek PL, Manfredi C: Psychological and social characteristics of CN: Survey Data Analysis Software for
Awareness and use of screening by older- attenders for breast screening. Psychol Iogistic Regression Work Assignment 74
aged persons. In: Yancik R, et al (eds): Health 1987; 1:303-313. Final Report. Research Triangle Park, NC:
Perspectives on Prevention and Treatment 12. Rosenstock IM: The health belief model Research Triangle Institute, 1984.
of Cancer in the Elderly. New York: Raven and preventive health behavior. Health
Press, 1983; 275-288. Educ Monogr 1974; 2:354-386.

..........................

... ...........
.........
......... ............... ...
........
......
.... .......

.............
................
................... ....
........

............ ......................
.. .............

........... ......... .. .......

.......

.. ............
.........
......... ........ .. ........ ....... .. ....

was
::j :::. ..............

.....
......
.......................

0:1.M.-W ...........
....................

................................. .......................................

.........

504 American Journal of Public Health April 1991, Vol. 81, No. 4