Introduction

Cancer health disparities are influenced by a combination of factors including social conditions and policies, institutional context, social context, social relationships, physical context, individual demographics, individual risk factors, biological responses, and biological/genetic pathways [1]. These population-level characteristics can be collectively referred to as Social Determinants of Health and are an important target of public health interventions. Of the various models that have attempted to elucidate the mechanisms through which Social Determinants of Health occur, the Health Belief Model (HBM) is one of the most widely used frameworks.

The Health Belief Model (HBM) identifies beliefs that predict an individual’s likelihood of engaging in health preventive behaviors [2–4]. Belief constructs of the HBM including perceived susceptibility, perceived severity, perceived benefits, and perceived barriers have been found to predict mammography and CRC screening adherence [4–6]. Related constructs such as negative attitudes and beliefs about cancer (e.g., cancer is automatically associated with death, not much can be done to prevent cancer) have been linked to increased rates of cancer incidence and mortality, lower economic status, and lower education level [7,8]. These fatalistic beliefs along with poor health literacy contribute to decreased engagement in preventative cancer care such as eating a healthy diet, using sun protection, avoiding tobacco, and following cancer screening guidelines [9–11]. Furthermore, negative emotions and attitudes are linked to an array of health consequences including anxiety, poor adherence to treatment, use of drugs and alcohol, disordered eating, and poor exercise [12–14].

Health beliefs are influenced and modified by factors such as age, gender, ethnicity, personality, socioeconomics, and knowledge [4]. However, studies about how cancer beliefs and behaviors vary in individuals who have a family member with cancer have yielded variable results. Some studies have found that while those who have a family member with cancer are more likely to participate in cancer screening, they are not any more likely to engage in other preventative behaviors such as smoking cessation, increasing physical activity, or changing their diet [15,16]. Intergenerational behavioral factors may be responsible for this finding. For instance, individuals with parents who smoke or eat unhealthy diets may be more likely to adopt these same behaviors [15].

Other evidence suggests that those with family history of cancer are more knowledgeable about screening guidelines, but their engagement with screening may lead them to believe that they no longer need to adopt lifestyle modifications [17]. Padamsee et al. (2020) found that the type of experience a person has with family history of cancer may affect their attitudes and behaviors towards cancer [18]. For example, women with close and traumatic experiences of cancer were more likely to engage in aggressive preventive actions, including surgery and chemoprevention, despite not having any known genetic mutations [18]. The link between family history of cancer, cancer knowledge, and cancer attitudes and beliefs remains unclear, but it is necessary for people to accurately understand their cancer risk and the important role that lifestyle factors play in reducing risk.

The purpose of the current study was to determine whether having a family history of cancer is associated with beliefs and attitudes about cancer and knowledge about cancer screening. We hypothesized that participants who reported a first-degree relative (FDR) with cancer had more negative beliefs and attitudes about cancer. In addition, we expected that family history of cancer would influence knowledge about cancer screening. Findings from this study would suggest a need for cancer prevention strategies that are informative about familial risk and increased education about the benefits of other modifiable cancer risk factors such as lifestyle changes.

Methods

Data were collected from the Community Initiative Towards Improving Equity and Health Status (CITIES) project, part of an initiative by the National Cancer Institute (NCI) to assess population health in 15 NCI-designated Cancer Center catchment areas [19]. The CITIES project surveyed Ohio residents within the catchment area of The Ohio State University Comprehensive Cancer Center (OSUCCC), the state of Ohio. Sampling and data collection for this project have been detailed in previous studies and is summarized below [19,20]. Depending on the method of survey administration, participants provided verbal or written informed consent. This project was approved by the OSU Institutional Review Board in February 2017.

Results

Table 1 shows a demographic summary of the sample population (n = 603) for participants with and without a FDR with cancer. Overall, 32.01% were ages 51–65 years, 24.05% were ages 21–40 years, 22.55% were ages 41–50 years, and 21.39% were ages 66–74 years. More than half the sample was female (63.02%), predominantly white (65.17%), and the majority were married or living as married (66.33%). Additionally, 45.27% of participants were college graduates, 35.82% obtained a high school education or less, and 18.91% had technical school or some college. For household income, 39.47% of the sample earned $75,000 or more, 31.84% earned $35–74,999, and 28.69% earned less than $35,000. Related to financial security on present income, 42.12% indicated that they were living comfortably, 37.98% reported that they were getting by, and 19.9% indicated that they found it difficult. Most of the sample had health insurance (59.2% private, 30.85% public) and 9.95% were uninsured. For the CABs score, 62.69% scored between 11–15, 19.24% scored between 16–20, and 18.08% scored between 5–10.

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Table 1. Demographic summary of participants with and without a first degree relative (FDR) with cancer.

https://doi.org/10.1371/journal.pone.0287629.t001

Compared to participants without a FDR with cancer, participants with a FDR with cancer were older (p < 0.001), more likely to be white (p < 0.001), less likely to be single (p = .03), more likely to make $75,000 or more (p = .01), and more likely to have health insurance (p < 0.001). For CABs, participants without a FDR with cancer were more likely to score between 5–10 (22.37% vs. 13.96%) and less likely to score between 16–20 (16.27% vs. 22.08%) as compared to participants with a FDR with cancer (p = .01).

Table 2 presents the backward model selection used to examine the association between CABs with other variables. As compared to participants ages 21–40, participants ages 51–65 and ages 66–74 were respectively 1.74 times and 2.31 times more likely to have positive CABs (OR = 1.74, 95% CI = (1.07–2.81), p = 0.04; OR = 2.31, 95% CI = (1.34–3.97), p = 0.01). Compared to married or living as married participants, divorced, widowed, or separated and single or never married participants were respectively 48% and 58% less likely to have positive CABs (OR = 0.52, 95% CI (0.33–0.81), p = 0.35; OR = 0.42, 95% CI = (0.26–0.69), p = 0.04). As compared to participants with a high school education or less, college grads were 2.81 times more likely to have positive CABs (OR = 2.81, 95% CI = (1.92–4.11), p < 0.001).

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Table 2. The association of family history of cancer and demographic characteristics on cancer attitudes and beliefs.

https://doi.org/10.1371/journal.pone.0287629.t002

Table 3 presents the backward model selection of participants’ knowledge about the correct age to begin CRC screening. Participants ages 51–65 were 4.55 times more likely to know the correct age to begin CRC screening when compared to those ages 21–40 (OR = 4.55, 95% CI (2.64–7.85), p < 0.001). When compared to participants earning $<35k annual income, those earning $75k+ were 2.81 more likely to know the correct age to begin CRC screening (OR = 2.81, 95% CI = (1.26–3.29), p = 0.05).

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Table 3. The association of family history of cancer and demographic characteristics on knowledge of correct age to begin colorectal cancer screening.

https://doi.org/10.1371/journal.pone.0287629.t003

Table 4 presents the backward model selection of female participants’ knowledge about the correct age to begin mammography. As compared to participants ages 21–40 years of age, participants ages 51–65 and ages 66–74 were respectively 3.67 times and 3.69 times more likely to know the correct age to begin mammography (OR = 3.67, 95% CI (1.27–10.62), p = 0.01; OR = 3.69, 95% CI (1.12–11.45), p = 0.02).

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Table 4. The association of family history of cancer and demographic characteristics on knowledge of correct age to begin mammography (female participants only).

https://doi.org/10.1371/journal.pone.0287629.t004

Discussion

In this study, we first examined the relationship between having a family history of cancer and CABs. We hypothesized that participants with a FDR with cancer would have more negative attitudes and beliefs about cancer. Out of 603 participants, about half (n = 308) reported having a FDR with cancer. Contrary to our hypothesis, more participants without a FDR with cancer scored negatively (5–10) on the CABs scale, and more participants with a FDR with cancer scored positively (16–20) on the CABs scale. However, participants with a FDR with cancer were not significantly more likely to have positive CABs. These findings are in contrast with a previous study which found that women with a FDR with breast cancer had more negative attitudes about breast cancer [23]. The difference in results could be due to the wide variety of experiences among participants with a FDR with cancer that were not taken into account. A previous study on women with a family history of breast or ovarian cancer found that the nature of their experience with family history of cancer affected cancer attitudes and health decisions [18]. Another factor to consider is that participants without a FDR with cancer may still have close experiences with cancer in other relatives or close friends [24,25].

In our analysis of the demographic variables of CABs, we found that older, more educated, and married participants were more likely to have positive CABs while younger, less educated, and single participants were less likely to have positive CABs. These findings are consistent with the HBM which identifies demographic variables affecting health beliefs and attitudes which in turn affect health behaviors and health outcomes [3,25]. Previous research has shown that single people have worse overall health outcomes and higher mortality as compared to married people, possibly due to differences in social support [26,27]. Protective effects of marriage in terms of improved survival rates have also been observed in certain cancers [28–30]. These findings suggest that marital status may affect health through effects on attitudes and beliefs, consistent with the HBM [2,3,31]. Older and more educated adults may also be more likely to have positive CABs due to increased knowledge about cancer screening and prevention.

However, it remains unclear whether attitudes about cancer translate into increased uptake of cancer prevention strategies. Studies have shown that women with a FDR with breast cancer experienced increased worry, increased perception of susceptibility, increased fear of breast cancer, and decreased perception of mammography barriers [23,32–34]. Negative CABs translated to increased uptake of cancer screening in some studies [23,35] while other studies did not find a difference in cancer screening uptake based on family history, regardless of perceived susceptibility and attitudes [32,33,36,37]. Another study found that family history of cancer was associated with increased cancer screening uptake but not other health promotive behaviors [38]. In general, all groups underestimated their breast cancer risk in relation to actual calculated risk, and engagement with cancer prevention was suboptimal [23,33,34]. Similar underestimation of cancer risk was found in studies of individuals with family history of colorectal cancer [39].

We also predicted that knowledge about cancer screening would differ between those with and without a FDR with cancer. Contrary to our hypothesis, cancer screening knowledge was unrelated to FDR cancer status. Rather, we found that older participants ages 51–65 years of age and participants earning more than $75,000 per year were more likely to know the correct age for beginning CRC screening. Older female participants were also more likely than younger female participants to know the correct age to begin mammography. A similar study found that older individuals were more likely to engage in early detection screening for breast cancer as compared to younger individuals, regardless of family history status [40]. These findings about breast and colorectal cancer knowledge may be due to current screening guidelines and the fact that older adults receive more targeted recommendations about breast and CRC screening [41]. Further research could examine cancer knowledge in younger adults by asking questions about Pap tests or skin cancer prevention which are health actions that are recommended beginning at a younger age [42]. Several studies have found that educational interventions based on the HBM can improve health knowledge and uptake of preventive health behaviors—including cancer screening [43–45].