A Validity Assessment of the Breast Cancer Risk Reduction Health Belief Scale (BCRRHBS)

Mfon Cyrus-David; Jason King; Therese Bevers; Emily Robinson

doi:10.1002/cncr.24541

Cancer. Author manuscript; available in PMC 2010 Nov 1.

Published in final edited form as:

Cancer. 2009 Nov 1; 115(21): 4907–4916.

doi: 10.1002/cncr.24541

PMCID: PMC2768118

NIHMSID: NIHMS123702

PMID: 19637346

A Validity Assessment of the Breast Cancer Risk Reduction Health Belief Scale (BCRRHBS)

Mfon Cyrus-David, MBBS, MS,¹ Jason King, PhD,² Therese Bevers, MD,³ and Emily Robinson, MD⁴

Author information Copyright and License information Disclaimer

Abstract

BACKGROUND

Women at increased risk of breast cancer (BC) are not widely accepting of chemopreventive interventions, and ethnic minorities are underrepresented in related trials. Further, there is no validated instrument to assess the health-seeking behavior of these women with respect to these interventions.

METHODS

Using constructs from the Health Belief Model, the authors developed and refined, based on pilot data, the Breast Cancer Risk Reduction Health Belief (BCRRHB) scale using a population of 265 women at increased risk of BC who were largely medically underserved, of low SES, and ethnic minorities. Construct validity was assessed using principal components analysis with oblique rotation to extract factors, and generate and interpret summary scales. Internal consistency was determined using Cronbach alpha coefficients.

RESULTS

Test-retest reliability for the pilot and final data was calculated to be r = 0.85. Principal components analysis yielded 16 components that explained 64% of the total variance, with communalities ranging from 0.50 – 0.75. Cronbach alpha coefficients for the extracted factors ranged from 0.45 to 0.77.

CONCLUSIONS

Evidence suggests that the BCRRHB yields reliable and valid data that allows for the identification of barriers and enhancing factors associated with use of breast cancer chemoprevention in the study population. These findings allow for tailoring treatment plans and intervention strategies to the individual. Future research is needed to validate the scale for use in other female populations.

Keywords: Breast cancer, chemoprevention, scale, risk reduction, health belief, validity, reliability

Introduction

In the year 2008, it is estimated that breast cancer (BC) would account for 26% of all new cancer diagnoses (i.e. 182,460 BC cases out of 692,000 cancers from all sites), and 15% of cancer deaths among women in the United States.¹ It will also be the leading cause of cancer deaths in women between the ages of 20 and 59 years.¹ A significant proportion of these deaths will be among women of minority race/ethnicity and the medically underserved.¹^,² In fact, significant disparities exist in the deaths from BC between African American and Caucasian women.²^,³ The observed disparities are said to be mediated by delays in diagnoses due to low SES with limited access to and utilization of BC prevention services⁴^–⁸, the tendency for some women of African American race/ethnicity to present with more aggressive BC phenotypes at similar stages when compared with Caucasians⁹^–¹¹, or a combination of these factors. However, the treatment of women at increased risk of BC with agents such as tamoxifen or raloxifene has been shown to reduce the risk of invasive BC by 32 to 49% in various multinational chemoprevention trials ¹²^–¹⁴, to prolong disease-free survival, and to prevent second primary BCs in patients.¹⁵^,¹⁶ In view of this incontrovertible evidence, the U. S. Food and Drug Administration approved the use of tamoxifen in 1998 and raloxifene (Evista) in 2007 for BC chemoprevention in eligible women.¹⁷^,¹⁸ Further, the majority of BCs diagnosed in African American women (over 50%), and in Latinas (over 60%) are estrogen receptor-positive (ER-+ve) ¹⁹^–²¹, and thus, are amenable to chemoprevention. Yet, few of these women who are at increased risk of BC receive these interventions (3.5%, and 6.5% in the Breast Cancer Prevention Trial and the Study of Tamoxifen and Raloxifene respectively).¹²^,¹⁴ This has been partly due to the limited inclusion of ethnic minorities in previous BC chemoprevention trials, a situation that was exacerbated in part by the lack of an adequate risk assessment tool for these populations, and limited access to information on BC chemoprevention, upon which informed decisions could have been made.

Currently, based on the search of MEDLINE from 1996 to 2008, there is no published validated instrument for assessing the health-seeking behavior of ethnic minorities and the underserved women who are at increased risk of BC with respect to the acceptance of chemoprevention. While several studies have been published on the attitudes or acceptance of chemoprevention among women at increased risk of BC²²^–³¹, the instruments employed in these studies were either not validated, or the validity and reliability data were not published, and most of these studies were not in underserved populations.²²^,²³^,²⁵^–³⁰ The existence and use of such an instrument would lead to a better understanding of the barriers and enhancing factors to the acceptance of this effective preventive option in these populations, and would lay the foundation for tailored interventions to enhance informed decision making about the receipt of BC risk assessment, chemoprevention counseling, or the interventions. This report describes the development and validation of the Breast Cancer Risk Reduction Health Belief (BCCRHB) scale, which is a multiple-choice assessment based on the conceptual framework of the Health Belief Model (HBM).³² To this end, data were collected in a population of mainly ethnic minorities and underserved women who are at increased risk of BC for testing and revising of the scale.

The use of principal components analysis to assess the construct validity of the BCRRHB scale is appropriate for deriving scores from clusters of items that are reliable representations of the latent constructs underlying the HBM (e.g., perceived susceptibility to BC). ³³^–³⁵ The estimated factor scores can then be employed in further analyses, such as in regression models predicting the level of acceptance of BC chemoprevention in the target populations.³³^–³⁵ This paper describes the validation of the scale, while the use of factor scores will be taken up in a later work.

Methods

Study Population

The assessment of the validity and reliability of the BCRRHB scale was the first specific aim of the Acceptance of Breast Cancer Chemoprevention Therapy (ABCCPT) Project, whose goal was to assess the barriers and enhancing factors for the acceptance of chemoprevention in ethnic minorities, and medically underserved women who are at increased risk of BC. The study population of the ABCCPT project is comprised of 265 women, who were mainly underserved or of self-reported minority racial/ethnic backgrounds (African Americans 38.8%, Hispanics 28.6%, or Caucasians 32.6%), at increased risk of BC, 35 to 86 years of age, and resided in the Houston Texas metropolis and its surrounding communities. They received BC prevention-related health care services such as mammograms, clinical breast examination or breast biopsies in the Ben Taub General Hospital, the Lyndon B. Johnson General Hospital and their respective affiliated clinics, and the Methodist Hospital Houston Texas between 2004 and 2006. Eligible participants were women at increased risk of BC as defined by being 60 years of age of older with no other known risk factors for BC, 35 to 59 years of age with multiple risk factors such as a family history in first-degree relatives (FDRs), history of multiple breast biopsies for benign breast diseases, the detection of a pre-malignant lesion such as lobular carcinoma in-situ, atypical ductal hyperplasia, or atypical lobular hyperplasia, early menarche (i.e. less than 12 years of age), or late first live-birth (i.e. at or after 35 years of age).³⁶^,³⁷^,³⁸ BC patients, women who had received risk assessment, chemoprevention counseling, or the intervention were excluded from the study. This was advised by the fact that these women have a higher level of knowledge of BC and chemoprevention than the target population (i.e. the underserved women of low SES, who are at increased risk of BC). Women who had limited capacity for cognitive evaluation (e.g. those with major psychiatric disorders), the terminally ill, those who were neither fluent in English or Spanish languages, those of other racial/ethnic groups (since the proportions of eligible women in these subpopulations were too small), or non-residents of the Houston Texas areas were also excluded. Women were contacted in the course of their receipt of care, and invited to participate in the study. Eligibility was ascertained using a pre-recruitment checklist, and written informed consents were obtained prior to the onset of the telephone interviews. Depending on the respondents’ preference, trained personnel conducted telephone interviews in English or Spanish, which lasted for 45 to 60 minutes. Data were collected on demographics, socioeconomic characteristics, the 48 initial items of the BCRRHB scale, and on the participants’ personal BC risk factors. The study was approved by the IRBs of the Baylor College of Medicine, the Methodist Hospital, and the Harris County Hospital District’s Research Office that oversees research compliance for the two main county hospitals — the Ben Taub General Hospital and the Lyndon B. Johnson General Hospital. Further, the questionnaire, and other study documents were translated into Spanish and approved by the IRBs prior to the onset of the surveys. All respondents were compensated ($20.00) for their participation. After a mean duration of 12 months, and using computer generated random numbers, a stratified random sample of 38 participants based on race/ethnicity (14.3% of the study population; whites, n=27; non-whites, n=11)were contacted for the re-test survey.

Instrument Development

The BCRRHB scale was developed to assess the health-seeking behavior of women who were at increased risk of BC, mainly the underserved, of low SES, or of minority race/ethnicity with respect to accepting chemoprevention. The scale items were derived from a series of 3 preliminary focus group discussions conducted on women who were at increased risk of BC, who resided in Winston-Salem NC. The report of this study has been published elsewhere.²⁴ Based on the results of the preliminary focus group discussions, further review of the literature, the HBM was deemed suitable, and its constructs used to develop the scale items.³⁹^,⁴⁰ The HBM has been used to develop various instruments for assessing the use of BC screening services⁴¹^,⁴² in similar study populations.⁴²^,⁴³ Our a priori hypotheses were that increased perceived susceptibility to BC, perceived severity of BC, perceived benefits of the intervention, perceived high self-efficacy or positive cues to actions would directly correlate with the acceptance of BC chemoprevention. Meanwhile, high perception of barriers to receiving the intervention would inversely correlate with its acceptance. We used the 5-response Likert style for all items with responses ranging from “strongly disagree” to “strongly agree” except where we used “much lower” to “much higher” as responses to items that assessed their perceived susceptibility to BC. The initial scale comprising of 52 items was validated for content by a panel of experts in clinical epidemiology, Family Practice and BC chemoprevention, two behavioral scientists, and pre-tested on a convenient sample of 40 women of diverse ethnic and socioeconomic backgrounds with similar characteristics as the study population. The review was to ensure the comprehensiveness of the contents, the appropriate use of the HBM constructs, the enhancement of the readability, and to reduce ambiguity, and eliminate redundancy. This process resulted in the elimination of 4 items, and the rewording of all retained items. The revised scale with 48 items had an eight-grade reading level according to the SMOG formula⁴⁴, and our respondents indicated that the scale items were highly readable, and all respondents completed the survey in less than an hour.

Statistical Analysis

Descriptive statistics were generated including item means, standard deviations, and ranges, frequencies, percentages, kurtosis, and skewness. Using the Factor Analysis procedure of the SPSS software version 16, we assessed the adequacy of the dataset for the factor analyses procedure through the Bartlett’s Test of Sphericity, and Kaiser-Meyer-Olkin’s (KMO) Test of Sampling Accuracy. The PROC FACTOR of the Statistical Analyses Software (SAS) program version 9.2 (SAS, Cary NC) was used to conduct the principal component analyses. The Kaiser rule of eigenvalues >1 and scree plot provided the basis for extracting the principal components. After the initial components were extracted, we used the PROMAX option of the SAS PROC FACTOR Procedure to further delineate the respective components through oblique rotation, to allow the variables to correlate under the respective factors.³⁴^,³⁵ Three items with low factor loadings (i.e. <.40) for the respective factors were excluded (see Table 3). Using the alpha option in the PROC UNIVARIATE procedure of the SAS software, we generated the Cronbach alpha reliability coefficients for the BCRRHB scale, the individual factors, and the retest survey.⁴⁵

Table 3

The principal components names, the rotated and rank-ordered factor loadings (with % variance contributed), means scale scores, standard deviations, and reliability coefficients of the Breast Cancer Risk Reduction Health Belief Scale (N=265)

Principal components	Items	Means	SD	Factor Loadings	Communality (h²)^**	% of Variance Explained	Factor Reliability
PC1^† -Motivation to accept BC chemoprevention based on high self efficacy, perceived benefits and family –related cues	Q1	23.26	3.70	0.74	0.72	10.70	0.77
	Q2			0.72	0.57
	Q3			0.67	0.60
	Q4			0.53	0.63
	Q5			0.51	0.50
	Q6			0.47	0.56
	Q7			0.44	0.68
PC2–Perception of BC chemoprevention as personally inconvenient	Q8	11.16	3.17	0.94	0.73	8.25	0.73
	Q9			0.77	0.64
	Q10			0.73	0.59
	Q11			0.41	0.65
PC3–Health care and informational access-related cues to action	Q12	14.01	2.98	0.86	0.73	5.12	0.52
	Q13			0.82	0.68
	Q14			0.76	0.65
	Q15			−0.60	0.60
	Q16			0.42	0.53
PC4–Perception of BC chemoprevention as efficacious	Q17	9.62	1.88	0.83	0.69	4.67	0.61
	Q18			0.77	0.73
	Q19			0.50	0.60
PC5–Perception of BC as life threatening	Q20	11.35	2.28	0.82	0.66	4.09	0.54
	Q21			0.70	0.65
	Q22			0.55	0.55
PC6–Concerns about poor risk-benefits ratio of BC chemoprevention	Q23	5.92	1.34	0.84	0.63	3.89	---
	Q24			0.64	0.66
PC7–Concerns about the effects of BC chemoprevention on current health status	Q25	11.82	2.22	0.87	0.71	3.65	0.53
	Q26			0.54	0.69
	Q27			0.52	0.70
	Q28			0.40	0.64
PC8–Concerns about coping with chemoprevention -related procedures and complications	Q29	6.05	1.52	0.73	0.63	3.26	0.45
	Q30			0.66	0.55
PC9–Perception of increased personal susceptibility	Q31	6.22	1.48	0.85	0.69	3.01	0.48
	Q32			0.70	0.59
PC10–Perception of the age-appropriateness and benefits of BC chemoprevention	Q33	9.26	1.52	0.82	0.65	2.75	---
	Q34			−0.46	0.73
	Q35			−0.45	0.62
PC11–Perception of personal wellness	Q36	3.21	1.10	0.91	0.75	2.64	---
PC12^† - Motivation to accept based on perceived susceptibility, and effectiveness of BC treatments	Q37	6.57	1.19	0.85	0.70	2.58	−0.65
	Q38			−0.47	0.58
PC13–Mistrust of physicians	Q39	6.80	1.26	0.69	0.63	2.45	---
	Q40			−0.66	0.61
PC14–Perception of need for longer duration of chemoprevention	Q41	9.82	1.82	0.91	0.71	2.37	---
	Q42			0.41	0.57
	Q43			0.40	0.68
PC15–Age-based perceived susceptibility	Q44	3.26	1.00	0.87	0.68	2.30	---
PC16–Perceived adequacy of health insurance coverage for BC chemoprevention	Q45	2.89	0.97	0.83	0.65	2.16	---

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^*Standardized Cronbach Coefficient Alpha

^†Abbreviations: PC, principal component; BC, breast cancer; HRT, hormone replacement therapy.

^‡No alpha coefficients were generated for principal components with less than two items.

^**Computed across all variables

Results

Study Population

The related data from all 265 participants in the Acceptance of Breast Cancer Chemoprevention Therapy study were included in this analysis. Most of the participants were 50 years of age or older (85.0%; mean age, 61.0 years), of low literacy level (65.3% had a high school education or less), of low income status (75.0% earned less than $29,000 per annum), ethnic minorities (67.5%), single (i.e. never married, divorced/separated, or widowed; 59.3%), unemployed, retired, or on disability benefits (58.8%), and the recipients of public health insurance (73.8%). (See Table 1). Of the 467 potentially eligible women who had validated contact information, 82 (17.6%) could not be reached to complete the survey due to disconnected telephones. Forty two (9.0%) were found to be ineligible due to histories of BC, or the receipt of BC chemoprevention counseling. This left 343 participants, of which 265 completed the survey, resulting in a response rate of 77.3%. According to Nunnally (1978), we have an item to respondents ratio of 1:5.6, which conveyed >90% statistical power to differentiate between various principal components.³³ Table 2 shows the means, and standard deviations of the BCRRHB scale items.

Table 1

The distribution of socio-demographic characteristics (n=265)^*

Characteristics	Number	Percent
Age (years)
<50	39	14.72
50–59	82	30.94
60–69	94	35.47
≥70	50	18.87
Education
High school or less	169	65.25
College	90	34.75
Annual household income
<$20,000	132	58.41
$20,000–$29,000	38	16.81
$ 30,000	56	24.78
Race/ethnicity
Caucasian	83	32.55
Hispanic	73	28.63
African American	99	38.82
Marital status
Married	105	40.70
Single	153	59.30
Employment status
Employed	59	22.96
Home-maker	47	18.29
Retired	78	30.35
Unemployed	33	12.84
Disabled	40	15.56
Health Insurance
Public Insurance	152	73.79
Private Insurance	54	26.21
Regular personal physician
Yes	209	87.45
No	30	12.55
# of Mammograms in the past 5 years
At least 5	237	98.75
Less than 5	3	1.25

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^*Missing numbers were excluded from the analyses.

Table 2

Descriptive Statistics of items in the Breast Cancer Risk Reduction Health Belief Scale (n=265)

Item no.	Content	Mean^*	SD^†
Q1	I am confident that I can tolerate tamoxifen therapy^‡	3.21	0.84
Q2	My family would feel better if I took tamoxifen	3.20	0.74
Q3	Taking tamoxifen would give me peace of mind.	3.31	0.91
Q4	I am sure that I will benefit from tamoxifen treatment.	3.30	0.75
Q5	I am confident that I can cope with the periodic clinic visits (twice a year) that the tamoxifen treatment will require.	3.73	0.74
Q6	I am confident that I can tolerate the hot flashes from tamoxifen therapy.	3.08	0.93
Q7	Therapy with tamoxifen can stop the progress of breast cancer.	3.43	0.83
Q8	I worry that I would forget to take daily doses of tamoxifen.	2.72	1.07
Q9	Taking daily medication would be inconvenient for me.	2.76	1.06
Q10	I am afraid of knowing my risk for breast cancer.	2.84	1.16
Q11	I would not want to take tamoxifen because it increases the risk of birth defects.	2.84	0.99
Q12	A friend told me that taking tamoxifen could reduce my risk for breast cancer.	2.35	0.98
Q13	My doctor advised me that I would benefit from tamoxifen therapy.	2.19	0.89
Q14	I heard on the media that tamoxifen can reduce the risk for breast cancer.	2.83	1.08
Q15	I have never heard of taking tamoxifen to prevent breast cancer.	3.53	1.16
Q16	I had my doctor assess my risk for breast cancer.	3.11	1.11
Q17	Taking tamoxifen may lower a woman’s chance of broken bones.	3.13	0.86
Q18	Taking tamoxifen will help lower levels of my “bad” cholesterol.	3.02	0.85
Q19	Taking tamoxifen can lower a woman’s risk of getting breast cancer.	3.47	0.80
Q20	If I was diagnosed with breast cancer, I think I would be depressed.	3.84	1.04
Q21	I would be more scared by breast cancer than by a diagnosis of heart disease.	3.35	1.14
Q22	To me, breast cancer is a life-threatening disease.	4.16	0.98
Q23	Tamoxifen has some side effects that are unacceptable to me.	3.10	0.81
Q24	My own risk of getting breast cancer is too low to take tamoxifen	2.82	0.94
Q25	I worry that tamoxifen treatment will affect my sex life.	2.78	0.84
Q26	My doctor has not advised me to take tamoxifen.	3.43	1.10
Q27	I am afraid that tamoxifen will make my health worse.	2.96	0.90
Q28	I worry that tamoxifen will make me feel like throwing up.	3.10	0.86
Q29	I would be nervous about taking tamoxifen because of the increased risk of uterine cancer.	3.08	0.97
Q30	I am not sure that I can tolerate uterine biopsies that may be required during tamoxifen treatment.	2.97	0.93
Q31	Having a history of breast biopsy would make my chances of getting breast cancer	3.06	0.93
Q32	Having a benign breast lump would make my chances of getting breast cancer	3.16	0.89
Q33	I think that these efforts to reduce a woman’s risk of breast cancer work.	3.66	0.74
Q34	I am too young to take tamoxifen.	2.57	0.95
Q35	The period of therapy (5 years) is too long.	3.03	0.98
Q36	I have always been healthy.	3.21	1.10
Q37	Having a family history of breast cancer would make my chances of getting breast cancer:	4.10	0.94
Q38	A woman may be permanently disabled after therapy for breast cancer.	2.48	1.00
Q39	I find it difficult to understand the information I received so far about breast cancer risk reduction therapy.	3.05	1.00
Q40	I trust my doctor’s advice about my breast cancer risk.	3.75	0.92
Q41	Early diagnosis and treatment of breast cancer may not always save a woman’s life.	3.60	1.07
Q42	A woman can usually perform her daily life tasks during therapy for breast cancer	3.55	0.96
Q43	The period of therapy (5 years) is too short.	2.67	0.82
Q44	Compared to other women my age, my chance of getting breast cancer is:	3.27	1.00

Q45	I am sure that I have health insurance that would pay for tamoxifen treatment.	2.89	0.97

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^*Range = 1 to 5

^†Abbreviation: SD, standard deviations

^‡Responses ranged from “strongly disagree” to “strongly agree” or “much lower” to “much higher.”

Construct Validity

Bartlett’s test of sphericity yielded a statistically significant results (P<.0001), indicating that the items shared a common variance (i.e. item correlations do not form an identity matrix), and the KMO Measure of Sampling Adequacy was .686, suggesting that the variables measured more than one component. Following the PROC FACTOR procedure, we extracted 16 principal components (see Table 3). These principal components explained 64% of the total variance, with communalities ranging from 0.50 –0.75.

Internal Consistency Reliability

Cronbach alpha coefficient for the scale items was 0.71, and 0.45 – 0.77 for the respective principal components. Following the retest survey, the Cronbach alpha reliability coefficient was 0.85.

Discussions

The BCRRHB scale was designed to measure the health seeking behaviors of women at increased risk of BC, who are medically underserved, of low SES, and mainly of racial/ethnic minority backgrounds (i.e. African Americans and Latinas). Of the 16 principal components that were extracted, nine described enhancing factors towards the acceptance of BC chemoprevention (see Table 3). These findings are consistent with the knowledge that increased perceived susceptibility to an illness, and highly perceived benefits of an intervention, work in concert with high self-efficacy and positive cues to bring about the adoption of primary and secondary prevention services for BC.⁴²^,⁴⁶ However, we also identified one additional factor the perceived adequacy of one’s health insurance coverage of BC chemoprevention. This is consistent with our a priori hypothesis and the literature, in that the lack of adequate health insurance coverage predisposes to the poor utilization of BC screening and other prevention services. ⁴⁷ Meanwhile, seven factors describe potential barriers to the acceptance of BC chemoprevention. These are the perception of the interventions as personally inconveniencing; concerns about the perceived poor risks/benefits ratios; concerns about the perceived effects of the interventions on one’s current health status; concerns about coping with intervention-related procedures or complications; perceiving oneself as always being healthy; the mistrust of one’s physicians, and the concerns about the short duration of the interventions. The concerns about the personal inconvenience of the interventions is consistent with findings from our preliminary study, where some women expressed concerns about the extra pill loads, or their ability to be compliant over the duration of the intervention.²⁴ The concerns about the risks/benefits of the interventions are in line with the fact that some potentially eligible women would have refused these interventions due to their side effects such as the increased risk of thrombo-embolic events, or uterine cancers.¹²^,¹⁴^,²³^,³⁰ The concerns about the effects of the interventions on current health status is in accordance with the fact that most eligible women are in their fourth of higher decades of life, and may be undergoing some physiologic changes such as menopause, or have cogent comorbidities (e.g. diabetes mellitus, hypertension, coronary heart disease, etc.) whose treatments may be either precluded, or interfered with by the interventions respectively.²⁴^,⁴⁸ The remaining three factors--perceiving oneself as always being healthy; the mistrust of one’s physicians, and the concerns about the short duration of the interventions are consistent with known misconceptions in similar populations such as denial of one’s susceptibility to certain illnesses⁴⁶, the mistrust of physicians due to past negative events such as the Tuskegee Syphilis Study²⁴^,⁴⁶^,⁴⁹, and folklore about disease managements.⁴⁷ These observations are particularly important with respect to BC where psychosocial factors such as unfavorable coping styles and negative emotional responses among others, predict the increased risk of death.⁵⁰

The BCRRHB scale has several strengths, namely, to the best of our knowledge, it is the first validated instrument that is designed to measure the health-seeking behaviors of women at increased risk of BC, especially, the medically underserved, those of low SES, and ethnic minorities. It is also pertinent that these persons are underrepresented in BC chemoprevention trials, while they have higher risk of death from BC.¹²^,¹⁴ In spite of the low literacy level of the study population, the scale demonstrated significant validity with 64% of the total variance explained by the extracted components, high factor loadings suggesting a high level of correlation between variables that load for the respective components, and high communalities suggesting that the items shared a common variance. With a Cronbach alpha of .71, the scale is internally consistent, and thus, reliable. The high retest reliability coefficient of .85 attests to its consistency over time. While, we desired fewer components, the larger number of components is not unexpected in a novel field of study that involves the treatment of hitherto healthy women with agents that are potentially harmful, and in a study population with a high prevalence of low literacy.²³ It is important to note that the scale would not be valid or reliable for assessing the health-seeking behavior of women of higher SES, who are adequately insured, and are at increased risk of BC, as it has not been validated in this subpopulation.

In all, the BCRRHB scale would serve to enhance the accuracy and ease of assessing the health-seeking behaviors of women who are of low SES, medically underserved, of ethnic minority backgrounds, and at increased risk of BC. The utilization of this tool would precede the development of educational interventions tailored to reduce the identified barriers, and to accentuate the enhancing factors. These would subsequently help these women make informed decisions about BC chemoprevention. Ultimately, this would help to reduce the disparate burden of BC mortality that is observed in this subpopulation. This view is consistent with the observed decline in BC mortality rate due to increased early detection, and the use of better therapies. ¹ Future research would be to revalidate this scale in a study population of potentially eligible women of middle to high SES with adequate health insurance coverage.

Acknowledgments

Support for this study was from the National Cancer Institute grant award number K22 CA100137.

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