Health Education Research, Vol. 14, No. 3, 315-325,
June 1999
© 1999 Oxford University Press
Lay beliefs about the preventability of major health conditions
Epidemiology Unit, South Western Sydney Area Health Service, Locked Mail Bag 17, Liverpool, NSW 2170,
1 Centre for General Practice Integration Studies, School of Community Medicine, University of NSW, NSW 2052 and
2 South Eastern Sydney Area Health Promotion Unit Joynton Ave, Zetland, NSW 2017, Australia
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Abstract |
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Beliefs about the extent to which health problems can be prevented reflect an understanding that preventive measures can reduce adverse health events and the level of control individuals perceive that they hold over the factors that affect their health. A population survey of 1659 people conducted in 1995 in south western Sydney, Australia, found that only child drownings, tooth decay, skin cancer, and burns and scalds were considered all or mostly preventable by more than 50% of the sample. The majority of respondents did not believe that heart attacks, cervical cancer, high blood pressure, serious road injury, lung cancer and asthma deaths were all or mostly preventable. Logistic regression analysis showed that people born in an English speaking country, those with more than 10 years of education and men were significantly more likely to recognize a number of key conditions as highly preventable. The findings suggest that, in spite of the range of prevention efforts in Australia to date, these are not matched by strong beliefs within the community that prevention is possible. Communication of the opportunities and methods for prevention needs to be improved, particularly among certain population groups. The findings also indicate a need to examine social and environmental factors which are potentially reducing confidence, and subsequently the adoption of preventive behaviours.
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Introduction |
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Health promotion and prevention programs are an increasingly important part of the Australian health system. In the goals and targets developed in recent years to guide national health improvement efforts prevention strategies were included as central to reducing major problems such as cardiovascular disease, cancer and injury (Commonwealth Department of Human Services and Health, 1994
). This was not surprising in light of the strong evidence for the relationship between these problems and preventable risk factors such as smoking, nutrition, moderate exercise, sun protection and the presence of environmental safeguards. However, while there has been a continued increase in knowledge and activity relating to prevention among health professionals, there has been little research concerning the extent to which public awareness and confidence about prevention has risen. Questions that have not been addressed include: `Is there a high level of confidence in the lay community about the prevention of disease and injury?', `What are the differences in beliefs about the preventability of various health conditions?' and `Do different sections of the population hold different beliefs about the preventability of certain health conditions?'.
For those concerned with developing and refining health promotion programs prevention beliefs provide an indicator of the uptake of prevention messages and acceptance that preventive action is worthwhile. Several studies have examined beliefs about the extent to which problems like high blood pressure and cancer can be prevented in order to determine the need for education campaigns and to investigate additional factors that may be related to behaviours (Kumanyika et al., 1989; Jepson et al., 1991; Bostick et al., 1993). A theoretical context for these beliefs can be drawn from the Health Belief Model (Rosenstock, 1974) and the locus of control construct in Rotter's social learning theory (Langlie, 1978; Allison, 1991). An important construct in the Heath Belief Model, after perceived vulnerability to a disease and its perceived severity, is the belief that successful action can be taken to stop its occurrence. The locus of control construct concerns whether individuals feel in control of the events they experience. In this regard, beliefs about preventability may reflect whether individuals feel that they have the capacity to control or prevent the occurrence of disease outcomes.
Weinstein (Weinstein, 1984) investigated the beliefs underpinning perceived susceptibility to, and controllability of diseases and injuries. He found a positive correlation between the number of personal actions and psychological factors that individuals related to their susceptibility to diseases and injuries, and whether or not those events were considered controllable. A notable finding in this research was that personal actions and psychological factors were viewed with an optimistic bias, i.e. as reducing rather than increasing susceptibility to risk. A negative association was found between the number of hereditary factors mentioned in relation to disease and the level of perceived controllability. Weinstein's (Weinstein, 1984) research also highlighted the differing thought patterns associated with various health conditions, with the balance of risk-creating factors (personal actions, heredity, physical/physiological factors, the environment, psychological factors) varying in relation to each problem.
Research in the area of risk perception points to factors which may determine whether individuals consider a health threat to be related to preventable risk factors. Denscombe (Denscombe, 1993) states that, at the most basic level, individuals may not absorb or properly comprehend the risk information they receive. They may also assess the level of risk to them suggested by information, e.g. about the link between smoking and lung cancer, using different criteria to those held by health professionals. Such criteria may include the level of fear generated by the outcome, the ease with which the danger can be imagined and whether the risk is commonplace or rare. Another process Denscombe (Denscombe, 1993) identifies is whether the individual is motivated to reduce their risk once he or she has assessed its level. This may be determined by factors such as the level of tolerance to that risk in the individual's cultural or social setting, if the risk has resulted from voluntary action or not, and the costs and benefits for them of avoiding the risk.
A fatalistic attitude towards disease and illness may determine whether a health problem is considered preventable or not. The work of Davison et al. (Davison et al., 1991) in the area of coronary candidacy indicates that a reasonably accurate grasp of the range of risk factors for heart attack may be offset by a belief that ultimately it is chance or fate that determines whether one experiences such an event. Pill and Stott (Pill and Stott, 1987) in a study involving working class mothers in Wales found that only one-third of the sample believed that aspects of their day-to-day behaviour were relevant to their health status, lending support to the concept of working class fatalism. These authors emphasized, however, that such apparent fatalism could be a realistic assessment based on actual experience and reinforced by the prevailing attitudes in their social group.
The increase in prevention activity that has characterized recent developments in the Australian health system is premised on the belief that preventable risk factors play a major role in causing various adverse health events, and that it is possible to reduce these risk factors and achieve health improvements. Measurement of prevention beliefs in the population tests whether the public has adopted these assumptions. Previous research suggests that beliefs about preventability relate to knowledge of preventable risk factors, weighting of these compared to other factors not considered preventable and the broader sense of control that individuals have in relation to their health. Given that increasing the control that individuals have over the factors affecting their health is central to the aims of health promotion, we propose that prevention beliefs may provide a useful indicator of progress in this field.
This paper presents results of a population health survey conducted in south western Sydney, Australia, which investigated beliefs about the preventability of a range of health conditions that have been identified as major causes of morbidity and mortality in this country (Nutbeam et al., 1993). Using data from a large population-based sample and contrasting beliefs about the preventability of a number of major health conditions (circulatory diseases, cancer, injury and various chronic conditions) this builds upon previous research in this area of health beliefs. The degree of accuracy of the beliefs identified is estimated through comparison with expert opinion regarding the preventability of the conditions in question. Given that the region in which the study was conducted contained significantly higher proportions of unemployed, low income earners and migrants with poor levels of English compared to Australia as a whole, we also examined the link between social factors and beliefs about prevention. While these findings are primarily descriptive, we seek to interpret them in the context of the current health promotion programs in Australia and previous research about health beliefs and attitudes. The implications for health promotion in this region of Australia are highlighted.
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Methods |
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Survey design
The population health survey was designed to be administered by telephone. Questions relating to health risk factors, preventive behaviours, usage and ratings of health services, and demographic characteristics were drawn from validated instruments developed elsewhere (National Centre for Health Promotion, and Health Promotion Branch, NSW Health Department, 1995
). Several new items were included concerning access to health programs and facilities, health priorities, and beliefs and attitudes concerning health maintenance. Beliefs about the preventability of various health conditions were measured by asking: `How possible do you think it might be to prevent certain health problems for people living in your area?', with a five-point scale for reply: `totally or mostly preventable', `sometimes preventable', `rarely ever preventable', `not preventable' and `don't know'. This question was asked in relation to skin cancer, lung cancer, cancer of the cervix, high blood pressure, heart attacks, diabetes, child drowning, burns and scalds, serious road injury, tooth decay, and asthma deaths. These conditions were selected because they were identified as priorities in the Goals and Targets for Australia's Health in the Year 2000 and Beyond (Nutbeam et al., 1993).
Sampling
The South Western Sydney Area Health Service was stratified into five areas, consisting of four discrete local government areas (LGAs) and a fifth region which was a combination of three small semi-rural LGAs. The electronic telephone directory was used to select a random sample of 600–700 households in each region. The desired sample size was 1800. These households were sent a letter informing them of the study, followed by a telephone call to administer the survey. In each household the interviewer asked to speak to the person who was over 18 years of age and who had the most recent birthday.
Survey implementation
The survey was conducted in late 1995 using a Computer Assisted Telephone Interviewing system. Up to six call backs were allowed in order to make contact with the selected respondent in each household. Interpreters were available to conduct interviews in the most common languages among migrants in the region—Arabic, Vietnamese, Cantonese and Mandarin.
Respondents
In total 1659 interviews were carried out representing a response rate of 55.8%. Table I shows the characteristics of respondents. The mean age was 43.8 years. There was a higher proportion of females (60.9%). Almost one-quarter (23.9%) reported usually speaking a language other than English at home. More than half (53.9%) had not completed more than 10 years of schooling.
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An index of relative socioeconomic disadvantage developed by the Australian Bureau of Statistics (Australian Bureau of Statistics, 1993a
) was used to calculate the socioeconomic status of the areas in which respondents lived. This uses data from the 1991 Population Census of Australia about economic resources of households, education and occupation. A rating of 1000 in this index is average for Australia as a whole. For the purposes of analysis two categories of socioeconomic status were created: suburbs with a rating of 980 or less and those above 980. A cut-off point below 1000 was necessary because the socioeconomic level of the region was generally lower than the Australian average. A little less than half of respondents (46.1%) were in the lower category.
Data analysis
Data were analysed using SPSS PC+ version 6.1, SAS version 6.10 and Excel version 5.0. Responses about the preventability of various conditions were allocated to one of four categories: totally or mostly preventable, sometimes preventable, rarely or never preventable and don't know. Stepwise logistic regression with a 95% confidence interval was conducted using age, sex, educational level, language spoken at home and socioeconomic status as explanatory variables in order to measure the associations between demographic characteristics and beliefs about prevention.
Estimates of actual preventability
Evidence from the literature was used to estimate the actual preventability of the conditions referred to in the survey. They were rated `all or mostly preventable' if 50–100% of cases were considered preventable, `sometimes preventable' for 20–49% and `rarely or never preventable' for the range 0–19%. A variety of literature was considered in assigning these ratings. This included review articles demonstrating the relationship between health conditions and preventable risk factors, and evidence concerning the effectiveness of prevention strategies. Table II shows the major methods of prevention and the estimated actual preventability of the conditions examined in the study.
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Results |
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Comparison of beliefs about the preventability of health problems
Table III
shows how preventable the respondents considered the different health problems. Of the three cancers, skin cancer was most often rated as all or mostly preventable (61.7%), followed by lung cancer and cancer of the cervix. Cancer of the cervix was the health condition about which there was greatest uncertainty, with 28.8% of respondents unsure whether it could be prevented. It was also the type of cancer most commonly rated as rarely or never preventable (16.3%).
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Relatively low proportions of respondents believed that the three circulatory conditions (high blood pressure, heart attacks and diabetes) were all or mostly preventable. Most respondents believed each of these conditions to be sometimes preventable: heart attacks (44.2%), high blood pressure (39.1%) and diabetes (30.3%). Diabetes was regarded as the least preventable of all health problems, with over one-quarter of respondents rating it as rarely or never preventable.
Child drownings was believed to be the most preventable type of injury with 66.5% believing that it was all or mostly preventable. Among the three injury types, it was followed by burns and scalds, and serious road injury in relation to the proportions who considered these all or mostly preventable. Most respondents (40.1%) considered serious road injury to be sometimes preventable and 14.8% believed this was rarely or never preventable.
Among the remaining conditions tooth decay was believed to be all or mostly preventable by 67.8% of respondents, ranking it as the condition considered to be most preventable overall. Most people (34.7%) regarded asthma deaths as sometimes preventable, while a substantial proportion did not know about the potential for their prevention (22.7%).
Relationships between prevention beliefs and demographic variables
Table IV shows adjusted odds ratios with 95% confidence limits for the associations between gender, age, ethnicity (language usually spoken at home), education and socioeconomic status, and beliefs that the listed health conditions were all or mostly preventable.
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Ethnicity was the most important factor explaining variations in beliefs about prevention. People who usually spoke English at home were significantly more likely than non-English speaking people to believe a number of conditions were all or mostly preventable, including: cervical, lung and skin cancer; burns and scalds; child drownings; and tooth decay.
Educational attainment and gender were also important. People with more than 10 years of education (compared to those educated to a level of year 10 or lower) were more likely to believe that skin cancer, child drownings, tooth decay and asthma deaths were all or mostly preventable.
Women were significantly more likely than men to consider cervical cancer all or mostly preventable. Conversely, they were less likely to regard lung cancer, high blood pressure, heart attacks and serious road injury as highly preventable.
The only conditions where prevention beliefs varied according to socioeconomic status were skin and lung cancer, with people from higher socioeconomic status areas significantly more likely to regard these as all or mostly preventable.
Age was not a significant factor except in the case of child drownings, where a significantly higher proportion of people 55 years and younger regarded this as all or mostly preventable compared to those who were older.
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Discussion |
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The results reveal differences in the level of confidence within the community about the prevention of various health conditions. They also show that beliefs about prevention are related to demographic factors, which may prove useful in the more effective delivery of health promotion programs.
Only child drowning, tooth decay, skin cancer, and burns and scalds were correctly identified as all or mostly preventable by more than 50% of respondents. An interesting feature of child drowning, tooth decay, and burns and scalds is that they are causes of morbidity and mortality where people under 14 years are at major risk (Nutbeam et al., 1993). There may be greater concern about these risks, and hence awareness about their prevention, because they do not have an aspect of voluntarism or personal responsibility attached to them (Denscombe, 1993). Another distinguishing feature of both tooth decay and skin cancer is that there has been longstanding commercial advertising of products to prevent these problems (toothpaste and sun cream). Skin cancer has also received extensive media attention as a public health threat over the last 10 years because Australia has the highest rate of melanoma in the world. The effectiveness of these campaigns has been shown in recent evidence about improved rates of sun protection among key groups such as adolescents (Sanson-Fisher, 1994).
It is of particular concern that preventability was under-rated by respondents for six of the conditions which are major causes of morbidity and mortality in Australia. These included: heart attacks, lung cancer, high blood pressure, serious road injury, cervical cancer and asthma deaths. Given the importance of these conditions it is worth considering the factors affecting the perceptions of their preventability.
A perception of heart attacks as unforeseeable, chance events may have contributed to beliefs about their prevention. Based on their research into beliefs about coronary candidacy Davison et al. [(Davison et al., 1991), p. 14] state:
A strong element of the public image of heart disease (and of sudden fatal heart attack in particular) is that it is a random killer. In the course of our field investigation we have observed that, even though most of our informants professed the opinion that heart disease is to some extent preventable or postponable, the idea that it could happen to anyone (at any time) is omnipresent.
Aside from chance, these authors also identified a range of risk factors within the lay epidemiology of heart disease that have little or no scope for control, including hereditary heart troubles, psychological predisposition and work or family stresses. Calnan (Calnan, 1987), in his ethnographic work among women, found that beliefs about the role of stress and strain, which were seen as unavoidable aspects of surviving in modern society, contributed to the most uncertainty among working class women about the preventability of heart disease. In this sense, a weak belief about heart attack prevention may reflect an assessment that social circumstances do not allow individuals to do anything about the forces which put them at risk.
Weinstein's (Weinstein, 1984) research found that in regard to blood pressure hereditary factors were more often identified as increasing personal susceptibility than for any other condition. This suggests that the lack of recognition that high blood pressure was all or mostly preventable may arise from a perception that this problem has a physiological origin beyond the scope of personal action. It is also worth recognizing that this has rarely been addressed in community-wide health promotion activities as a problem in its own right, with its own behavioural determinants. It is not possible to judge whether this is an issue of neglect by health promoters or a conscious decision to avoid complicating their messages by attempting to convey the intermediate role played by high blood pressure between factors like obesity, salt intake, lack of exercise and cardiovascular problems.
In light of the high profile of the issue of smoking in the media in Australia it was surprising that less than half of respondents considered lung cancer all or mostly preventable. This poses a question about the level of uptake of information about the link between smoking and lung cancer. While data is not available to answer this for south western Sydney, a population survey in South Australia reported by Baghurst et al. (Baghurst et al., 1992) found that almost all respondents identified smoking as the most important risk factor for lung cancer. Even if the level of awareness in south western Sydney is somewhat less than this it would appear that knowledge about smoking as a cause of lung cancer does not necessarily lead to a belief that this condition is highly preventable. Calnan's (Calnan, 1987) study found an awareness, particularly among middle class women, about the link between smoking and lung cancer, but a belief that not smoking just increased one's chances of avoiding lung cancer. Some women referred to cases where people who did not smoke developed lung cancer, reflecting a degree of uncertainty about the strength of this relationship. As with heart attacks there may be a belief that chance or other factors outside of one's control play a role in cancer causation.
In spite of an extensive and high profile prevention effort, and considerable achievements over the last 30 years, most respondents (40.1%) rated serious road injury as sometimes preventable. Traffic injuries and fatalities are notable as an area of public health activity where the effects of prevention programs are subject to constant scrutiny, primarily through media coverage of the road toll. The fact that media awareness campaigns and high profile police activities appear to have an incremental rather than a dramatic effect may underlie uncertainty about their effectiveness. Another dimension of road injuries is that one's level of risk is partially determined by the behaviour of others, no doubt lowering the sense of control that individuals feel over this outcome.
The pattern of beliefs about preventing cervical cancer must be viewed in light of the fact that this condition only affects women. Almost 44% of men gave a `don't know' response in regard to its preventability, with only 20.9% rating it as all or mostly preventable. Yet, upon examination of the scores for women, the proportion who considered cervical cancer all or mostly preventable was still just 32.2%, with 19.2% giving a `don't know' response. The most likely explanation for this is a lack of awareness about pap smear testing and its efficacy. Breast cancer, which is the primary cause of cancer mortality among women in Australia (Australian Bureau of Statistics, 1995) has achieved a far higher public profile than cervical cancer. While cervical cancer contributes to considerably less mortality, its level of preventability is high and these findings indicate that this is not being communicated effectively to the public.
The most common response given about asthma deaths was that these are `sometimes preventable' (34.7%) with 22.7% giving a `don't know' answer. This is likely a reflection of the pattern of asthma education in Australia to date, which has primarily been directed to asthmatics and concentrated on the ongoing management of asthma as a chronic condition rather than preventing the possible fatal outcomes associated with it. The National Asthma Campaign was only established in the early 1990s (Comino et al., 1995), and more resources and time are required for its public education strategies to achieve a high level of penetration. Given that proper recognition of severe asthma symptoms and early action in seeking appropriate care are key steps in preventing deaths (National Health and Medical Research Council, 1988) this finding indicates the need to promote greater awareness of the risks of asthma and steps that can be taken to prevent harm.
While most respondents believed that diabetes was sometimes preventable, which is consistent with the available evidence, what emerged strongly was the high proportion of people who did not know how preventable this condition was (27%). This suggests that they may have felt they do not have adequate information to make a judgement about the prevention of this condition or that the information they have received has been unclear so that their level of uncertainty remains high.
While the data is drawn from a population-based survey, it is important to acknowledge obvious limitations to the generalizability of these findings. The response rate to the survey was 55.8% and some sections of the population were under-represented. Men, for instance, were not adequately represented among respondents (38.9%). While almost one-quarter of the sample (23.9%) usually spoke a language other than English at home, this was less than the proportion in the south western Sydney region at the 1991 Census [33.4% (Australian Bureau of Statistics, 1993b)]. There were higher proportions of people in the older age groups in the sample compared to the region generally: 23.4% aged 18–30 in the study compared to 31% in the base population; 24.6% who were 31–40 compared to 23.1% in the region; 26.5% aged 41–55 compared to 24.4%; and 25.4% compared to 21.5% who were aged 56 and over (Australian Bureau of Statistics, 1993b). Data were not available to indicate the extent to which the education levels and socioeconomic status of area of residence of people in the sample were representative.
In terms of demographic patterns in prevention beliefs the strongest associations were along the lines of ethnicity, gender and educational attainment. People who spoke a language other than English at home were significantly less likely to hold accurate beliefs about six of the conditions that were mostly preventable. The two most obvious explanations for this are the dominant use of English in information dissemination and a shorter period of exposure to prevention messages. Social and cultural factors must also be given consideration. As Reid and Trompf (Reid and Trompf, 1990) state, non-English speaking immigrants typically have the highest rates of poverty and unemployment in Australia, other than the Australian Aborigines, and must cope with the pressures associated with limited social networks and lack of English competency. Information about health risks, particularly those of a long-term nature, may generate relatively little concern for these people who are dealing with more immediate problems. Douglas and Wildavsky (Douglas and Wildavsky, 1982) also point out that the choice of risks which generate concern and action is the product of shared beliefs and values that are integral to various cultures and forms of social organization. Such risk perceptions may arise partly from shared experiences, such as originating from an environment where problems such as skin cancer may not present a major threat. While this study did not allow examination of the patterns of prevention belief among specific ethnic groups, the need to address the way that health problems are perceived within various cultural frameworks must be recognized (Bunton et al., 1991).
Beliefs about whether conditions were all or mostly preventable were distinguished by gender in five cases, with women significantly less likely than men to regard heart attacks, high blood pressure, serious road injury and lung cancer as all or mostly preventable, but more likely to rate cervical cancer this way. This finding is surprising in light of research which has observed women to hold a variety of key responsibilities relating to the health of families (Graham, 1984), which could be expected to include holding information about health risks. This pattern of prevention beliefs indicates that susceptibility may influence one's attention to information about health risks and their prevention, as for each of these five conditions the strength of prevention beliefs held by each gender is correlated to the risk of experiencing the problem (Australian Bureau of Statistics, 1995).
Accurate prevention beliefs were more strongly associated with educational attainment than with socioeconomic status of area of residence. People with 10 or more years of education were significantly more likely to rate skin cancer, child drowning, tooth decay and asthma deaths as all or mostly preventable, while those in the higher socioeconomic category were more likely to give skin cancer and lung cancer this rating. To the extent that either demographic characteristic represents social class, this data gives limited support to the notion that people from lower class backgrounds are more likely to hold fatalistic views about their health. In the case of educational attainment, which showed the stronger relationship, further investigation is required to determine if these beliefs reflect a lack of risk factor awareness among these groups or of resources and opportunities to act upon the information that they have received. These data, together with the findings in relation to ethnicity, raise the question of whether health promotion programs are adequately reaching the more disadvantaged segments of the population.
Overall, the apparent lack of confidence among respondents about the extent to which most of the health issues presented in this survey could be prevented is a major concern. There is a need for further investigation of the factors that are undermining public beliefs about the preventability of conditions that are priorities for health improvement at the national and state level, especially heart attacks, lung cancer, high blood pressure, motor vehicle injuries, cervical cancer and diabetes. While better communication of the preventive benefits of personal health behaviour may be necessary, the social patterns of prevention beliefs found here affirm the need to better understand the social and cultural factors affecting the health perceptions of various groups and to adapt health promotion programs accordingly. These findings, descriptive in nature, point to where some of this work should begin. The links that we have attempted to draw with research into related areas of health beliefs, such as personal susceptibility, risk perception and fatalism, suggest useful leads which need to be followed up with empirical research in relation to specific health conditions.
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Received on July 29, 1997; accepted on April 26, 1998
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 L. B. Trifiletti, A. C. Gielen, D. A. Sleet, and K. Hopkins Behavioral and social sciences theories and models: are they used in unintentional injury prevention research? Health Educ. Res., June 1, 2005; 20(3): 298 - 307. [Abstract] [Full Text] [PDF]
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Z. Philips, S. Johnson, M. Avis, and D. K. Whynes Human papillomavirus and the value of screening: young women's knowledge of cervical cancer Health Educ. Res., June 1, 2003; 18(3): 318 - 328. [Abstract] [Full Text] [PDF]
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A. Chapple Vaginal thrush: perceptions and experiences of women of South Asian descent Health Educ. Res., February 1, 2001; 16(1): 9 - 19. [Abstract] [Full Text] [PDF]
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B. Kahan and M. Goodstadt The Interactive Domain Model of Best Practices in Health Promotion: Developing and Implementing a Best Practices Approach to Health Promotion Health Promot Pract, January 1, 2001; 2(1): 43 - 67. [Abstract] [PDF]
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