Are Religious Women More Likely to Have Breast Cancer Screening

8/9/2019 Are Religious Women More Likely to Have Breast Cancer Screening

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Are Religious Women More Likely to Have Breast Cancer Screening?Author(s): Peter H. Van Ness, Stanislav V. Kasl, Beth A. JonesSource: Journal of Religion and Health, Vol. 41, No. 4 (Winter, 2002), pp. 333-346Published by: SpringerStable URL: http://www.jstor.org/stable/27511642Accessed: 18/08/2010 03:55

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Journal of Religion and Health, Vol. 41, No. 4,Winter 2002 (? 2002)

Are Religious Women

More Likely to Have

Breast Cancer

Screening?

PETER H. VAN NESS, STANISLAV V. KASL,and BETH A. JONES

ABSTRACT The study objective was to investigate whether women who frequently attend reli

gious services are more likely to have breast cancer screening?mammography and clinical

breast examinations?than other women. Multivariate logistic regression models show that

white women who attended religious services frequently had more than twice the odds of breast

cancer screening than white women who attended less frequently (Odds Ratio (OR)=

2.61; 95%

Confidence Interval (CI) = 1.12, 6.06). The behavior of white women was different from African

American women (religious attendance-race interaction term p-value = 0.008); African American women who attended religious services frequently were possibly less likely to have breast

cancer screening (OR 0.49; CI= 0.19-1.31).

KEY WORDS: breast cancer; religion; screening; race; African Americans.

The maturity of an area of scientific research is often signaled by the appearance of a synthetic work that documents past accomplishments and identifiesas

yet unanswered questions. Epidemiological researchinto

the relation between religiousness and health now has such a vade mecum in the recentlypublished Handbook of Religion and Health by Koenig, McCullough, and Larson. The study reported here addresses one issue for which they say there is

currently little relevant research. These authors opine: "Because of the strongrelationship between religious attendance and social support, and the strong

relationship between social support and medical compliance and screening,

Peter Van News is a Postdoctoral Fellow in Epidemiology in the Department of Epidemiologyand Public Health at the Yale University School ofMedicine. He is also a Lecturer in ChronicDisease Epidemiology teaching a course entitled "Religion, Health, and Society." Prior to comingto Yale Dr. Van Ness was a professor of the philosophy of religion at Union Theological Seminaryand Columbia University in New York City. Stanislav V. Kasl, Ph.D., is a Professor in the

Chronic Disease Epidemiology Division of the Department of Epidemiology and Public Health atthe Yale University School of Medicine. Beth A. Jones, M.P.H., Ph.D., is an Assistant Professor inthe Chronic Disease Epidemiology Division of the Department of Epidemiology and Public

Health at the Yale University School ofMedicine.

333 ? 2002 Blanton-Peale Institute


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334 Journal of Religion and Health

organizational types of religious involvement probably increase the likelihood

of early cancer detection and treatment" (Koenig, McCullough, & Larson,2001). Since a previous study by two of us has investigated the relationshipbetween mammography screening and stage at diagnosis (Jones, Kasl, Cur

nen, Owens, & Dubrow, 1995), this report will concentrate on the hypothesisthat religiousness, and specifically, frequent attendance at religious services,is associated with higher rates of breast cancer screening involving mam

mography and clinical breast examinations.

In a recent study Paskett et al. investigated the associations between sev

eral measures of religiousness and rates of cervical and breast cancer screen

ing in a mostly African American sample (Paskett, Case, Tatum, Velez, &Wilson, 1999). In multivariate logistic regression analyses they reported no

significant associations between religious predictors and either Pap smear or

mammogram outcomes but they did report that being African American was

associated with a higher probability of obtaining a Pap smear. Results givenbelow present a different picture. There are several ways in which our studyovercomes limitations in the Paskett study. Ours is a statewide populationbased study. We control for important biom?dical covariables and test for in

teractions between the predictor of religious attendance and race and socio

economic covariables. Finally, the hypotheses tested are few and focused sothat results are less vulnerable to challenge on the grounds of multiple com

parisons.The primary hypothesis for this study is that frequency of religious atten

dance is positively associated with rates of breast cancer screening. A second

ary hypothesis is that levels of social support mediate the effect of religiousattendance on breast cancer screening. These two hypotheses reflect the

thinking of Koenig, McCullough, and Larson (see Diagram 1). Our own pointof view is that race and socioeconomic status may be modifiers of the religious

attendance/screening relationshipas

theyare of some other known

predictorsof breast cancer screening (Pearlman, Rakowski, B., & Clark, 1996) (Phillips& Wilbur, 1995) (Freeman, 1989). Also, our previous study of religion andbreast cancer survival in this sample showed race to be an important covariable (Van Ness, Kasl, & Jones). Accordingly, it is appropriate that we test theabove hypotheses in a data set originally assembled for the purpose of detect

ing race differences.

Methods

Population. Subject enrollment and study design have been described pre

viously (Jones et al., 1995) (Jones, Kasl, Curnen, Owens, & Dubrow, 1997).

Briefly, cases were identified through active surveillance of 22 Connecticut

hospitals. Data from the Connecticut Tumor Registry for 1984-1985 indi


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Peter H. Van Ness, Stanislav V. Kasl, and Beth A. Jones 335

DIAGRAM 1

Schematic Representation of Hypothesis of Koenig et al.

Regarding the Association of Religious Attendance and Breast

Cancer Screening

ReligiousAttendance

Breast

Cancer

Screening

Stage at

Diagnosis

cated that approximately 98% of African-American and 84% of White breastcancer cases had been diagnosed in the participating hospitals. The study

population was composed of 145 (45%) African-American women and 177

(55%) White women diagnosed with a first primary breast cancer in Connecticut between January 1987 and March 1989. All eligible African-Americanbreast cancer cases diagnosed in these hospitals were selected for possibleinterview. A White breast cancer case was randomly selected using a com

puterized random digit generator from among all eligible White breast cancer

cases, diagnosed in the same hospital, and within the same one to three week

period,as the

eligibleAfrican-American case. A 1:1 ratio of African-American

and White cases was sought in order to meet the original objective of identifying factors explaining race differences in stage at diagnosis.

Ineligibility criteria included previous malignancy (same or different site),race other than African-American or White, race unknown, and age greaterthan 79. The respondent verified race at the time of the interview. Partici

pants were interviewed in their homes using a standardized instrument, administered by trained interviewers. The instrument was a modified version ofthe questionnaire used in the National Cancer Institute (NCI) Black/WhiteCancer Survival Study and covered a wide range of demographic, health his

tory, medical care, and psychosocial factors (Ries, Pollack, & Young, 1983).

Among eligible subjects selected for enrollment the participation rate was 76

percent and did not differ significantly by race. Non-participants included

persons who refused (including physician refusals to allow contact), moved,died before they could be interviewed, or were too ill to be interviewed.


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Active surveillance identified the hospitals at which cases were diagnosed.

Hospital medical records were abstracted for each case to provide completeinformation on medical history. Photocopies of pathology, operative, and stag

ing reports, admission notes, discharge summaries, and referral correspondence were obtained. Further information was obtained when necessary from

physicians' office records. Since cases were population-based and were identified by active surveillance, and since we considered only screening ratherthan diagnostic examinations, the screening experience of breast cancer cases

should be representative of screening experience in the general population.

Predictors. Three measures of religiousness were used as predictor variables. One inquired about religious denominational preference and is re

ported here as Protestant, Roman Catholic, Pentecostal, Jewish, and no denominational affiliation. The Pentecostal grouping combines the responses"Pentecostal" or "Holiness." This combination is justified by the similar historical origins of the two groups and by their enduring emphasis on the giftsof the Holy Spirit including healing (Marty, 1997) (Raboteau, 1998). A second

measure inquired about religious attendance (less than weekly vs. weekly ormore frequently). A third, representing the respondent's religious social net

work, measured the number of congregants known personally (noneor

a fewvs. almost all).

Outcomes. The primary outcome variable was breast cancer screening status prior to diagnosis. It recorded whether or not a respondent followed publichealth recommendations that women receive periodic mammograms and breastexaminations from a physician (Breast Cancer Facts and Figures, 2000-2001,2001). A respondent was counted as having received breast cancer screeningif she answered affirmatively to both of two inquiries, one asking "Did you

have a mammogram within the last threeyears?"

and the otherasking

"Did

you have a breast exam by a doctor within the last two years?"

Covariables. The demographic covariables included in descriptive and multivariate analyses were: age (continuous); race (White vs. African American);

marital status (married vs. not married); socioeconomic status: education(


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(Jones et al., 1995) (Jones et al., 1997) (Van Ness et al.) The comorbidity

index was created from interview responses to questions regarding 22 common conditions. Specifically, respondents were asked if a doctor had told

them in the year before their diagnosis that they had any of 22 common con

ditions. The variable for self-rated health consisted of levels of poor, fair,

good, and excellent.

Respondents were asked whether or not they occasionally drank any kindof alcoholic beverage, and whether they had ever regularly smoked cigarettesfor more than six months and whether they smoked regularly when interviewed. Two medical care covariables were examined. One recorded whetheror not the

respondenthad a usual source of care.

Several questions inquiredabout a respondent's insurance coverage. An index was created from the re

sponses and then was dichotomized as those having no or poor insurance

coverage versus those having adequate insurance coverage. A social supportvariable was created to account for the mediating role proposed for it by Koe

nig et al. Respondents were identified as having a high degree of social support if they said that they knew all or almost all of the members of theircongregation and if they agreed with the statement that they were able totalk with their friends about cancer.

Statistical analysis. Hypotheses were examined using multivariate logisticregression. Predictor variables were forced into multivariate models. Controlvariables were included only if they approached significance (p < 0.25) or had

conceptual relevance. Model pruning was done in order to avoid collinearityand over-fitting. The model fitting approach used was manual backwardelimination. Linearity tests were performed for continuous variables, i.e., age,education, self-rated health, and the comorbidity index, to ensure that there

was a generally linear relationship between the predictor and outcome variables. In the absence of a linear relationship the education variable was dichotomized at 12 years.

A supplementary analysis involved a weighted logistic regression model.

Weights were assigned to each White respondent in order to compensate forthe oversampling of African Americans in the original data set. Specifically,

African American respondents received a weight of 1 and White respondentsreceived a weight of 14 in order to compensate for the fact that only some ofthe White cases of breast cancer reported in Connecticut during the enroll

ment period were randomly selected for inclusion in the study. The samplingweight of 14 for Whites is warranted given that participation rates for Afri

can Americans were somewhat lower and incidence rates of breast cancer forAfrican Americans are somewhat lower than for Whites (Kelsey & Bernstein,1996). The 1990 census records a 10.43 to 1 ratio of Whites to African Americans in Connecticut (The 1990 Census, 1990).

Stratification and clustering were not included as part of the original sam

pling design. However, control variables for the hospitals from which cases


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TABLE 1

Descriptive Characteristics of Breast Cancer Cases

in Connecticut, January 1987 to March 1989 includingUnadjusted Associations with Breast Cancer Screening

(Odds Ratios as Measure of Association)

Variable OR Variable OR

55.36

(Mean)

177

145

ReligiousDenomination

Protestant 165Roman Catholic 102Jewish 11Pentecostal 25

None 11Attendance

Weekly 168

DemographicAge

Race

White

African AmericanMarital Status

No 162Yes 160

Education (years)12 243

Income

Low 152High 133Missing 37

Occupational Rank

BelowMedian 156

Above Median 149Outcome

ScreeningNo 222Yes 93

Biom?dical

Self-Rated Health 2.78 0.81 1.47*52.5 1.00 (Mean) (S.D.)32.5 0.97 l:Poor 22 7.0

3.5 2.10 2: Fair 78 24.98.0 0.66 3: Good 159 50.83.5 3.03 4: Excellent 54 17.3

Severe Obesity44.9 1.00 No 271 84.7 1.0055.1 1.08 Yes 49 15.3 0.89

12.33 0.97** Comorbidity 2.83 2.11 1.06(S.D.) Index (Mean) (S.D.)

Behavioral55.0 1.00 Alcohol Drinker

45.0 0.74 No 92 28.9 1.00Yes 26 71.1 2.13*50.3 1.00 Smoking49.7 1.41 Never 138 43.4 1.00

Past 114 36.2 1.97*24.5 1.00 Current 65 20.4 1.0575.5 2.67** Social Support

Low 177 56.4 1.0047.2 1.00 High 137 43.6 0.8941.3 1.91* Medical Care11.5 0.81 Insurance

None/Poor 176 55.3 1.0051.2 1.00 Good 142 44.7 1.4648.8 1.79* Usual Care

No06 33.5 1.00Yes210 66.5 4.42***

70.5 ?

29.5 ?a

"This is the outcome variable for which other variables are predictors.

*p < 0.05; **p < 0.01; ***p < 0.001.

less frequently. The odds ratio for African Americans suggests that those who

attend religious services regularly are about one-half as likely to receivebreast cancer screening as are those African Americans who attend less regu

larly. Unlike the odds ratio for the Whites this last cited odds ratio does notmeet the 0.05 level of statistical significance. Again, social support is not significantly related to breast cancer screening.

When the same logistic regression model is run for a weighted sample that


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TABLE 2

Correlation Matrix of Variables Relevant to the HypothesisRegarding the Association of Religious Attendance and

Breast Cancer Screening

Variable0Religious Social

Attendance Race Support Screening

Religious Attendance

KWeekly vs.>

Weekly)

Race (White vs. AfricanAmerican)

Social Support (Low vs.

High)Breast Cancer Screening

(No vs. Yes)

1.00

0.16**

0.37***

0.02

0.16**

1.00

0.12*

-0.07

0.37***

0.12*

1.00

-0.03

0.02

-0.07

-0.03

1.00

"For these dichotomous variables the first category is coded as 0 and the second as 1.

*p < 0.05; **p < 0.01; ***p < 0.001.

approximates the 1990 ratio of Whites and African Americans in the Connecticut population, the religious attendance-race interaction term is no longersignificant because of the high proportion of Whites. (The more appropriatetest for race as an effect modifier is contained in the previously reported

model in which White and African American groups are approximately equalin size.) When the interaction term is removed, the religious attendance variable is still associated with breast cancer screening in a significant way (OR

=

2.41; 95% CI= 1.21-4.82). Again, this odds ratio mostly reflects the experi

ence of Whites who are represented heavily in the sample. This association is

maintained for White weighting ranging from 10 to 14. Thus the positiveassociation of frequent religious attendance and high rates of breast cancer

screening is present in this more representative weighted sample that accords better with the general character of the hypothesis of Koenig et al.

In order to try to understand the reasons for the religious attendance-raceinteraction two additional variables were examined. A strong positive predictor of breast cancer screening is whether or not physicians recommend that

patients receive such care (Mandelblatt, Traxler, Lakin, Kanetsky, & Kao,1992) (Vernon et al, 1992) (Stein, Fox, & Murata, 1991). (In our data the

unadjusted OR = 9.33 and the 95% CI = 4.47, 19.49; this variable is notassociated with religious attendance in the total sample and so is not a potential confounder of the religious attendance/breast cancer screening association.) In responding to the question as to whether or not they had received a

physician's recommendation for a mammogram, 68.4% of the Whites and 53.5%of the African Americans responded affirmatively (x2

=7.45, p

= 0.006).


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Peter H. Van Ness, Stanislav V Kasl, and Beth A. Jones 341

TABLE 3

Multivariate Analysis of the Association Between ReligiousAttendance and Breast Cancer Screening

Variable Odds Ratio

95%Confidence

Interval P-Value

ReligiousReligious Attendance-Race Interaction

?a ?a 0.008

Religious Attendance ?a ?ab

(


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342 Journal ofReligion and Health

Thus Whites were recommended for mammograms at a significantly higher

rate than African Americans. Furthermore,for Whites

physicianrecommen

dations were virtually the same for religious service attendees and nonat

tendees; however, for African Americans religious service nonattendees were

more likely to get physician recommendations for mammography than were

attendees (62.0% versus 50.0%). These differences are compatible with physician recommendations partially explaining the religious attendance-race in

teraction.A strong negative predictor of cancer screening is a question that measures

fatalism about the occurrence and outcome of cancer (In our data the unad

justedOR = 0.38 and the 95% CI =

0.20, 0.73;this variable is not associ

ated with religious attendance in the total sample and so is not a potentialconfounder of the religious attendance/breast cancer screening association.)Some might speculate that African American religiousness engenders greaterfatalism when women contemplate and confront breast cancer. Althoughthere may be some evidence to support it (Matthews, Lannin, & Mitchell,1994) (Lannin et al., 1998) (Gregg & Curry, 1994), this speculation is not inaccord with the overall tenor of African American Christianity that has gen

erally been an empowering force for the African American community (Lincoln & Mamiya, 1990). It is also not supported by respondents' answers to

the above-cited question measuring fatalism. Specifically, they were askedwhether they agreed with the statement "Before my illness, I thought that ifI'm going to get cancer, I'm going to get it, so I pretty much ignored it." Inanswer to this question 28.9% of Whites agreed while only 21.6% of African

Americans agreed (x2=

2.17, p= 0.141). Furthermore, among Whites 32.9%

of attendees but only 25.9% of nonattendees agreed with the fatalistic sentiments of the question. Yet among African Americans 18.2% of attendees affirmed fatalistic sentiments while 25.5% of the nonattendees did. These differences are opposite to what might explain the religious attendance-race

interaction.

Discussion

The results of this study provide some support for the hypothesis of Koenig etal. that higher levels of organized religiousness are associated with higherrates of cancer screening, thereby offering the possibility of earlier detectionand treatment. This support is qualified, though, by the role of race as a

significant effect modifier. Only Whites attending religious services frequently show the desirable outcome of increased rates of breast cancer

screening. The authors' above quoted hypothesis is further qualified by theabsence of evidence that social support is a mediator of the religious attendance/breast cancer screening association. It is possible that the measure of


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social support employed was not sufficiently detailed or appropriate to detectthis effect. Hence the lack of evidence for mediation

reportedhere does not

preclude that some other measure of social support might yield different re

sults.Additional analyses suggest that lower rates of breast cancer screening

among African Americans religious attendees are accompanied by lowerlevels of physician mammography recommendations for African American

women generally and especially for African American women attending reli

gious services frequently. On the other hand, there is no evidence that lowerrates of breast cancer screening among African American women are accom

panied by religious fatalism. In fact, African American women seemed less

likely to give fatalistic responses than White women and frequent AfricanAmerican church attendees were less fatalistic that similarly religious

Whites to a statistically significant degree.Addressing health promotion programs to religious communities is an in

creasingly common public health practice (Ransdell & Rehling, 1996). Researchers have not been quick to observe or appreciate this development; for

instance, the new Institute of Medicine report on public health interventionsextols multi-level, community strategies yet fails to mention religion or reli

gious communities in their recommendations and rarely mentions them in

accompanying commentary (Smedley & Syme, 2000). Textbook authors mostoften mention religion in the context of health promotion efforts in minoritycommunities (Emmons, 2000) (Wingood & Keltner, 1999). In their recent review of Church-Based Health Promotion (CBHP) programs Ransdell and

Rehling also report that "the majority of published papers described comprehensive programs within the African American community." Decisions to locate health promotion and screening programs in African American churchesdo not appear to be based upon clear evidence of a positive association between some aspect of African American religiousness and rates of cancer

screening. Results from this study, however, provide evidence that efforts topromote breast cancer screening might find a positive response among

Whites attending religious services frequently because they engage in breastcancer screening more than their counterparts who attend less frequently ornot at all. Further gains in breast cancer screening or in related preventivehealth practices would likely be attained if public health practitioners mountinformative and sensitive health promotion efforts for this community.

Study results also indicate the need to understand the demonstrated dis

parity in breast cancer screening rates between African Americans and Whiteswho attend

religiousservices

frequently.If the low rates of breast cancer

screening among African American women who attend religious services fre

quently are not due to some aspect of their religiousness, e.g., religious fatal

ism, but are partially explained by an aspect of the patient-physician interac

tion, e.g., low level of physician recommendations for such screening, then it


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is possible that a culturally sensitive and specific health promotion effort di

rected toward African American religious communities could be successful inraising screening rates. Efforts to measure the effectiveness of church-basedbreast cancer education programs are just beginning (Davis et al., 1994)

(Dacey Allen, Sorensen, Peterson, Stoddard, & Colditz, 2001).The major strength of this study is that the data set allows for an analysis

of racial differences in breast cancer screening behavior. A second strength of

the study is that it provides data to carry out supplementary analyses exam

ining the possible roles of physician recommendations for mammography and

fatalistic attitudes?two strong influences on breast cancer screening. The

sample size of the study is modest, limiting the ability to perform subgroupanalyses other than White/African American comparisons. Examining onlythe screening experience of women diagnosed with breast cancer might be a

limitation but in this case it allows for comparisons with other studies of thesame cohort dealing with stage at diagnosis and survival outcomes.

Acknowledgments

The authors acknowledge with appreciation the assistance of Fenghai Duan.The research was partially supported by a National Institute of Mental

Health grant MH14235-24. It was also supported by National Cancer Institute program policy grant 5-PO1-CA42101, Agency for Health Care Policyand Research grant HS 06910-01, Research Training in the Epidemiology of

Aging Grant 2-T32-Ag00153.The authors thank the following Connecticut institutions for their partici

pation in the study. Hartford Hospital, Yale-New Haven Hospital, BridgeportHospital, Waterbury Hospital, Hospital of St. Raphael, New Britain General

Hospital,Norwalk

Hospital,St. Vincent's Medical

Center,The Stamford Hos

pital, Middlesex Hospital, Mt. Sinai Hospital, St. Mary's Hospital, Lawrence& Memorial Hospital, Manchester Hospital, Greenwich Hospital Association,Veterans Memorial Medical Center, Bristol Hospital, St. Francis Hospital andMedical Center, St. Joseph Medical Center, University of Connecticut HealthCenter/John Dempsey Hospital, Park City Hospital, and William W. Backus

Hospital.

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Are Religious Women More Likely to Have Breast Cancer Screening