Research Letter
Results
Perceived Ambiguity, Fatalism, and Believing Cancer Is More Prevalent Than Heart Disease
To control for bias in variance estimates due to the complex sampling design, jackknife replicate weights were employed. Univariate logistic regressions identified significant predictors of perceived prevalence. Significant univariate predictors (po0.05) were entered simultaneously in a final multivariable regression model (Table 1). Approximately 44% agreed or strongly agreed that cancer was more common than heart disease. Higher perceived relative cancer prevalence was associated with lower education level but not age, race, smoking status, numeracy, personal risk perception, or cancer experience. The ambiguity and fatalism measures (and frustration in seeking cancer information) were significantly associated with believing that cancer is more prevalent. In multivariable analyses, the perception that everything causes cancer was the most predictive item. Misperceptions were related to exercise intentions but no other behaviors.
Introduction In most subpopulations, heart disease incidence is higher than cancer incidence,1 yet laypeople may think the reverse given extensive cancer exposure2 such as the “pink ribbon” campaign and celebrity deaths (e.g., Peter Jennings3). People often overestimate their own cancer risk4 and thus may also overestimate its relative prevalence. Such misperceptions could promote underuse of preventive interventions for cardiovascular disease and overuse of cancer risk reduction strategies. Concomitantly, laypeople perceive cancer messages as highly ambiguous (defined in decision science as lacking in reliability, credibility, or adequacy5) and fatalistic. In one study,6 72% of U.S. citizens believed there were too many cancer prevention recommendations and 47% agreed that everything causes cancer. These beliefs are associated with greater perceived risk and cancer worry.7 We used a nationally representative sample to assess whether such beliefs are related to misperceptions about relative prevalence. We also explored how these misperceptions might be related to demographics and riskrelated behavior.
Methods Data were collected from 3,376 U.S. adults in 20122013 via the National Cancer Institute Health Information National Trends Survey (HINTS) and analyzed in 2013. The sample included 51% women, 75% whites, 41% with high school education or less, 58% never smokers, and 75% with own or family cancer history. Questionnaires were randomly mailed to residential addresses and completed by the adult with the next birthday. Relative prevalence perceptions were assessed with: How much do you agree or disagree with the following statement: In adults, cancer is more common than heart disease (1¼strongly agree through 4¼strongly disagree). Perceptions of ambiguity and fatalism were assessed on the same scale with How much do you agree or disagree with each of the following statements: It seems like everything causes cancer, There’s not much you can do to lower your chances of getting cancer, and There are so many recommendations about preventing cancer, it’s hard to know which ones to follow. Standard measures assessed sample demographics; personal cancer risk perceptions; cancer experience; health behaviors; cancer information seeking (including frustration when doing so); and numeracy (HINTS downloadable at hints.cancer.gov/docs/HINTS_4_Cycle_2_ English.pdf).
Discussion Many U.S. citizens, including the highly educated, erroneously believe that cancer is more common than heart disease. Cancer experience and attitudes about personal risk appear unrelated to prevalence perceptions, as does age even though older individuals have more experience with both diseases. Individuals who perceived cancer as more prevalent were more likely to engage in exercise but not other behaviors related to both diseases such as healthy diet and physical activity. Perceptions of cancer message ambiguity and fatalism may underlie misperceptions of cancer prevalence. Other work shows that people misunderstand the relative prevalence of different cancers, perhaps for similar reasons.8 Although more work is needed to establish causality, these findings suggest the need to design cancer messages not only to be less ambiguous but to explicitly present health risks in the context of other health risks— consistent with the finding that people are often more responsive to comparative than absolute information.9 Of course, such an approach would need to be tailored for subpopulations with higher cancer risk. One limitation is that respondents may have focused on mortality rather than morbidity and may have used a narrow definition of heart disease. Although heart disease prevalence is higher across all adult age groups,1 cancer accounts for more deaths in those aged o85 years.10 Nevertheless, if the misperception about prevalence is pervasive, further research should consider whether it is consequential and how it might be addressed.
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2014;46(4):e45–e47 e45
e46
Klein et al / Am J Prev Med 2014;46(4):e45–e47
Table 1. Results from univariate and final logistic regressions predicting the belief that cancer is more common than heart disease Univariate logistic regression
Final logistic regression
Predictora
OR (95% CI OR)
p
OR (95% CI OR)
p
Gender (51% women)
1.09 (0.70, 1.69)
0.694
Age (M¼46.64, SD¼16.64)
1.00 (0.99, 1.01)
0.886
Less than HS (13%) versus college (29%)
1.82 (1.18, 2.80)
0.007
3.34 (1.61, 6.93)
0.002
HS (28%) versus college (29%)
1.96 (1.46, 2.61)
0.000
1.15 (0.69, 1.91)
0.584
Some college (30%) versus college (29%)
1.29 (0.92, 1.81)
0.134
1.26 (0.75, 2.12)
0.383
White (76%)
1.00 (0.95, 1.06)
0.991
Smoker (19%) versus never smoker (59%)
0.83 (0.55, 1.24)
0.348
Former smoker (23%) versus never smoker (59%)
0.81 (0.62, 1.05)
0.105
Cancer diagnosis (8%)
0.89 (0.69, 1.14)
0.337
Family members with cancer (67%)
0.97 (0.82, 1.16)
0.747
Numeracy (14, M¼1.10, SD¼0.31)
1.07 (0.75, 1.52)
0.716
Lifetime cancer risk (absolute risk) (15, M¼2.73, SD¼0.83)
1.09 (0.96, 1.24)
0.197
Lifetime cancer risk (comparative risk) (15, M¼2.79, SD¼0.88)
1.02 (0.84, 1.23)
0.852
It seems like everything causes cancer (14, M¼2.27, SD¼0.96)
0.80 (0.71, 0.90)
0.000
0.70 (0.58, 0.85)
0.001
There are so many different recommendations about preventing cancer it’s hard to know which ones to follow (14, M¼2.07, SD¼0.87)
0.72 (0.62, 0.84)
0.000
0.78 (0.59, 1.04)
0.091
There’s not much you can do to lower your chances of getting cancer (14, M¼2.94, SD¼0.89)
0.78 (0.68, 0.89)
0.001
0.92 (0.74, 1.15)
0.468
Cancer information seeking, frustration (14, M¼2.99, SD¼0.97)
0.82 (0.67, 1.00)
0.046
0.97 (0.73, 1.31)
0.864
Cancer information seeking, easy to understand (14, M¼3.00, SD¼0.91)
0.72 (0.60, 0.88)
0.002
0.80 (0.59, 1.07)
0.125
t
p
d
Linear regressions Outcome
β
Exercise intentions (13, M¼1.78, SD¼0.85)
0.04
2.85
0.006
0.10
Soda consumption intentions (13, M¼2.03, SD¼0.89)
0.05
0.33
0.746
0.01
Vegetable consumption intentions (13, M¼1.99, SD¼0.84)
0.04
0.53
0.596
0.02
Fruit consumption intentions (13, M¼2.12, SD¼0.86)
0.05
0.87
0.390
0.03
Weight management intentions (13, M¼2.01, SD¼1.17)
0.09
1.59
0.716
0.05
Sunscreen use (15, M¼3.45, SD¼1.41)
0.09
0.37
0.117
0.01
Mammography (16, M¼3.29, SD¼2.13)
0.04
0.26
0.792
0.01
a
For 14 scales, 1¼strongly agree through 4¼strongly disagree; for 15 scales, 1¼very unlikely through 5¼very likely; for exercise, vegetables, and fruit, 1¼increase, 2¼maintain, and 3¼haven’t paid attention; for soda and weight, 1¼decrease, 2¼maintain, and 3¼haven’t paid attention; for sunscreen, 1¼never through 5¼always; for mammography, 1¼1 year ago or less, 2¼more than 1, up to 2 years ago, 3¼more than 2, up to 3 years ago, 4¼more than 3, up to 5 years ago, 5¼more than 5 years ago, and 6¼never had a mammogram. HS, high school
www.ajpmonline.org
Klein et al / Am J Prev Med 2014;46(4):e45–e47
William M.P. Klein, PhD Rebecca A. Ferrer, PhD Kaitlin A. Graff, BA Annette R. Kaufman, PhD, MPH National Cancer Institute, NIH, Bethesda, Maryland Paul K.J. Han, MD, MPH Maine Medical Center, Portland, Maine E-mail: [email protected]. http://dx.doi.org/10.1016/j.amepre.2014.01.003 No financial disclosures were reported by the authors of this paper.
References 1. CDC, National Center for Health Statistics. National Health Interview Survey. Atlanta GA: CDC, 2012. www.cdc.gov/nchs/data/hus/2012/044.pdf.
April 2014
e47
2. Gottlieb N. The age of breast cancer awareness: what is the effect of media coverage? J Natl Cancer Inst 2001;93(20):1520–2. 3. Portnoy DB, Leach CR, Moser RP, Alfano CM, Kaufman AR. Reduced fatalism and increased prevention behavior following two high-profile lung cancer events. J Health Commun 2014:In press. 4. McCaul KD, O’Donnell SM. Naïve beliefs about breast cancer risk. Women’s Health 1998;4(1):93–101. 5. Ellsberg D. Risk, ambiguity, and the Savage axioms. Q J Econ 1961;75: 643–69. 6. Niederdeppe J, Levy AG. Fatalistic beliefs about cancer prevention and three prevention behaviors. Cancer Epidemiol Biomarkers Prev 2007;16(5):998–1003. 7. Han PKJ, Moser R, Klein WMP. Perceived ambiguity about cancer prevention recommendations: relationship to perceptions of cancer preventability, risk, and worry. J Health Commun 2006;11(S1):51–69. 8. Jensen JD, Scherr CL, Brown N, Jones CL, Christy K. Public perception of cancer survival rankings. Health Educ Behav 2013;40(6):721–9. 9. Mussweiler T. Comparison processes in social judgment: mechanisms and consequences. Psychol Rev 2003;7(3):165–85. 10. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58(2):71–96.
Results
Perceived Ambiguity, Fatalism, and Believing Cancer Is More Prevalent Than Heart Disease
To control for bias in variance estimates due to the complex sampling design, jackknife replicate weights were employed. Univariate logistic regressions identified significant predictors of perceived prevalence. Significant univariate predictors (po0.05) were entered simultaneously in a final multivariable regression model (Table 1). Approximately 44% agreed or strongly agreed that cancer was more common than heart disease. Higher perceived relative cancer prevalence was associated with lower education level but not age, race, smoking status, numeracy, personal risk perception, or cancer experience. The ambiguity and fatalism measures (and frustration in seeking cancer information) were significantly associated with believing that cancer is more prevalent. In multivariable analyses, the perception that everything causes cancer was the most predictive item. Misperceptions were related to exercise intentions but no other behaviors.
Introduction In most subpopulations, heart disease incidence is higher than cancer incidence,1 yet laypeople may think the reverse given extensive cancer exposure2 such as the “pink ribbon” campaign and celebrity deaths (e.g., Peter Jennings3). People often overestimate their own cancer risk4 and thus may also overestimate its relative prevalence. Such misperceptions could promote underuse of preventive interventions for cardiovascular disease and overuse of cancer risk reduction strategies. Concomitantly, laypeople perceive cancer messages as highly ambiguous (defined in decision science as lacking in reliability, credibility, or adequacy5) and fatalistic. In one study,6 72% of U.S. citizens believed there were too many cancer prevention recommendations and 47% agreed that everything causes cancer. These beliefs are associated with greater perceived risk and cancer worry.7 We used a nationally representative sample to assess whether such beliefs are related to misperceptions about relative prevalence. We also explored how these misperceptions might be related to demographics and riskrelated behavior.
Methods Data were collected from 3,376 U.S. adults in 20122013 via the National Cancer Institute Health Information National Trends Survey (HINTS) and analyzed in 2013. The sample included 51% women, 75% whites, 41% with high school education or less, 58% never smokers, and 75% with own or family cancer history. Questionnaires were randomly mailed to residential addresses and completed by the adult with the next birthday. Relative prevalence perceptions were assessed with: How much do you agree or disagree with the following statement: In adults, cancer is more common than heart disease (1¼strongly agree through 4¼strongly disagree). Perceptions of ambiguity and fatalism were assessed on the same scale with How much do you agree or disagree with each of the following statements: It seems like everything causes cancer, There’s not much you can do to lower your chances of getting cancer, and There are so many recommendations about preventing cancer, it’s hard to know which ones to follow. Standard measures assessed sample demographics; personal cancer risk perceptions; cancer experience; health behaviors; cancer information seeking (including frustration when doing so); and numeracy (HINTS downloadable at hints.cancer.gov/docs/HINTS_4_Cycle_2_ English.pdf).
Discussion Many U.S. citizens, including the highly educated, erroneously believe that cancer is more common than heart disease. Cancer experience and attitudes about personal risk appear unrelated to prevalence perceptions, as does age even though older individuals have more experience with both diseases. Individuals who perceived cancer as more prevalent were more likely to engage in exercise but not other behaviors related to both diseases such as healthy diet and physical activity. Perceptions of cancer message ambiguity and fatalism may underlie misperceptions of cancer prevalence. Other work shows that people misunderstand the relative prevalence of different cancers, perhaps for similar reasons.8 Although more work is needed to establish causality, these findings suggest the need to design cancer messages not only to be less ambiguous but to explicitly present health risks in the context of other health risks— consistent with the finding that people are often more responsive to comparative than absolute information.9 Of course, such an approach would need to be tailored for subpopulations with higher cancer risk. One limitation is that respondents may have focused on mortality rather than morbidity and may have used a narrow definition of heart disease. Although heart disease prevalence is higher across all adult age groups,1 cancer accounts for more deaths in those aged o85 years.10 Nevertheless, if the misperception about prevalence is pervasive, further research should consider whether it is consequential and how it might be addressed.
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2014;46(4):e45–e47 e45
e46
Klein et al / Am J Prev Med 2014;46(4):e45–e47
Table 1. Results from univariate and final logistic regressions predicting the belief that cancer is more common than heart disease Univariate logistic regression
Final logistic regression
Predictora
OR (95% CI OR)
p
OR (95% CI OR)
p
Gender (51% women)
1.09 (0.70, 1.69)
0.694
Age (M¼46.64, SD¼16.64)
1.00 (0.99, 1.01)
0.886
Less than HS (13%) versus college (29%)
1.82 (1.18, 2.80)
0.007
3.34 (1.61, 6.93)
0.002
HS (28%) versus college (29%)
1.96 (1.46, 2.61)
0.000
1.15 (0.69, 1.91)
0.584
Some college (30%) versus college (29%)
1.29 (0.92, 1.81)
0.134
1.26 (0.75, 2.12)
0.383
White (76%)
1.00 (0.95, 1.06)
0.991
Smoker (19%) versus never smoker (59%)
0.83 (0.55, 1.24)
0.348
Former smoker (23%) versus never smoker (59%)
0.81 (0.62, 1.05)
0.105
Cancer diagnosis (8%)
0.89 (0.69, 1.14)
0.337
Family members with cancer (67%)
0.97 (0.82, 1.16)
0.747
Numeracy (14, M¼1.10, SD¼0.31)
1.07 (0.75, 1.52)
0.716
Lifetime cancer risk (absolute risk) (15, M¼2.73, SD¼0.83)
1.09 (0.96, 1.24)
0.197
Lifetime cancer risk (comparative risk) (15, M¼2.79, SD¼0.88)
1.02 (0.84, 1.23)
0.852
It seems like everything causes cancer (14, M¼2.27, SD¼0.96)
0.80 (0.71, 0.90)
0.000
0.70 (0.58, 0.85)
0.001
There are so many different recommendations about preventing cancer it’s hard to know which ones to follow (14, M¼2.07, SD¼0.87)
0.72 (0.62, 0.84)
0.000
0.78 (0.59, 1.04)
0.091
There’s not much you can do to lower your chances of getting cancer (14, M¼2.94, SD¼0.89)
0.78 (0.68, 0.89)
0.001
0.92 (0.74, 1.15)
0.468
Cancer information seeking, frustration (14, M¼2.99, SD¼0.97)
0.82 (0.67, 1.00)
0.046
0.97 (0.73, 1.31)
0.864
Cancer information seeking, easy to understand (14, M¼3.00, SD¼0.91)
0.72 (0.60, 0.88)
0.002
0.80 (0.59, 1.07)
0.125
t
p
d
Linear regressions Outcome
β
Exercise intentions (13, M¼1.78, SD¼0.85)
0.04
2.85
0.006
0.10
Soda consumption intentions (13, M¼2.03, SD¼0.89)
0.05
0.33
0.746
0.01
Vegetable consumption intentions (13, M¼1.99, SD¼0.84)
0.04
0.53
0.596
0.02
Fruit consumption intentions (13, M¼2.12, SD¼0.86)
0.05
0.87
0.390
0.03
Weight management intentions (13, M¼2.01, SD¼1.17)
0.09
1.59
0.716
0.05
Sunscreen use (15, M¼3.45, SD¼1.41)
0.09
0.37
0.117
0.01
Mammography (16, M¼3.29, SD¼2.13)
0.04
0.26
0.792
0.01
a
For 14 scales, 1¼strongly agree through 4¼strongly disagree; for 15 scales, 1¼very unlikely through 5¼very likely; for exercise, vegetables, and fruit, 1¼increase, 2¼maintain, and 3¼haven’t paid attention; for soda and weight, 1¼decrease, 2¼maintain, and 3¼haven’t paid attention; for sunscreen, 1¼never through 5¼always; for mammography, 1¼1 year ago or less, 2¼more than 1, up to 2 years ago, 3¼more than 2, up to 3 years ago, 4¼more than 3, up to 5 years ago, 5¼more than 5 years ago, and 6¼never had a mammogram. HS, high school
www.ajpmonline.org
Klein et al / Am J Prev Med 2014;46(4):e45–e47
William M.P. Klein, PhD Rebecca A. Ferrer, PhD Kaitlin A. Graff, BA Annette R. Kaufman, PhD, MPH National Cancer Institute, NIH, Bethesda, Maryland Paul K.J. Han, MD, MPH Maine Medical Center, Portland, Maine E-mail: [email protected]. http://dx.doi.org/10.1016/j.amepre.2014.01.003 No financial disclosures were reported by the authors of this paper.
References 1. CDC, National Center for Health Statistics. National Health Interview Survey. Atlanta GA: CDC, 2012. www.cdc.gov/nchs/data/hus/2012/044.pdf.
April 2014
e47
2. Gottlieb N. The age of breast cancer awareness: what is the effect of media coverage? J Natl Cancer Inst 2001;93(20):1520–2. 3. Portnoy DB, Leach CR, Moser RP, Alfano CM, Kaufman AR. Reduced fatalism and increased prevention behavior following two high-profile lung cancer events. J Health Commun 2014:In press. 4. McCaul KD, O’Donnell SM. Naïve beliefs about breast cancer risk. Women’s Health 1998;4(1):93–101. 5. Ellsberg D. Risk, ambiguity, and the Savage axioms. Q J Econ 1961;75: 643–69. 6. Niederdeppe J, Levy AG. Fatalistic beliefs about cancer prevention and three prevention behaviors. Cancer Epidemiol Biomarkers Prev 2007;16(5):998–1003. 7. Han PKJ, Moser R, Klein WMP. Perceived ambiguity about cancer prevention recommendations: relationship to perceptions of cancer preventability, risk, and worry. J Health Commun 2006;11(S1):51–69. 8. Jensen JD, Scherr CL, Brown N, Jones CL, Christy K. Public perception of cancer survival rankings. Health Educ Behav 2013;40(6):721–9. 9. Mussweiler T. Comparison processes in social judgment: mechanisms and consequences. Psychol Rev 2003;7(3):165–85. 10. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58(2):71–96.
