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Fatalistic Cancer Beliefs and Information Sources
Among Rural and Urban Adults in the USA
Christie A. Befort & Niaman Nazir &
Kimberly Engelman & Won Choi
Published online: 29 June 2013
#
Springer Science+Business Media New York 2013
Abstract Fatalistic beliefs about cancer prevention can be a
significant deterrent to one’s likelihood of engaging in can-
cer prevention behaviors. Lower education and less access to
cancer information among rural resi dents may influence their
level of cancer fatalism. The purpose of this study was to
examine rural–urban differences in fatalistic beliefs about
cancer prevention and cancer information sources using data
from the 2007 Health Information National Trends Survey
(n=1,482 rural and 6,192 urban residents). Results showed
that rural residents were more likely to endorse multiple
fatalistic beliefs about cancer prevention than urban residents
even after controlling for other significant demographic cor-
relates. Urban residents were more likely to use the internet
as their primary cancer information source, whereas rural
residents were more likely to rely on print material and
healthcare providers. Future educational work to communi-
cate relevant and accurate cancer prevention information to
rural residents should consider not only information access
but also rural culture and fatalistic perspectives.
Keywords Fatalistic beliefs
.
Cancer prevention
.
Information sources
.
Rural residents
.
Urban residents
Fatalistic cancer beliefs reflect an outlook that events are con-
trolled by external forces and a sense of powerlessness over
preventing or surviving cancer . Fatalism has been conceptual-
ized as a combination of fear, predetermination, luck, helpless-
ness, and pessimism [1]. Fatalistic beliefs about surviving cancer
(i.e., “being diagnosed with cancer is a death sentence”)have
been especially prevalent among those of lower socioeconomic
status [2] and among African Americans [3]andHispanics[4].
Fatalistic beliefs about pr eventing a primary diagnosis of cancer
have been higher among those with less education [2, 4, 5], but
have not been consistently related to race/ethnicity [4, 5].
Fatalistic beliefs about cancer prevention have frequently been
operationalized with an emphasis on helplessness [5–8]. For
example, 47 % of US adults have agreed with the statement
“everything causes cancer” [5], demonstrating a high preva-
lence of fatalistic beliefs about cancer prevention.
Fatalistic beliefs about cancer prevention may be detrimen-
tal to health to the extent that they are associated with lower
engagement in cancer prevention behaviors. Individuals who
hold fatalistic beliefs are less likely to engage in cancer
screening, sunscreen use, smoking cessation, as well as fruit
and vegetable consumption and exercise [4, 5, 9, 10]. The
association between fatalistic beliefs and adoption of health
behaviors has implications for the prevention of cancer, as
well as other chronic diseases.
Although fatalism has been conceptualized as a cultural
and philosophical belief system [1], the volume of health-
related news coverage may also play a role. Health commu-
nication research suggests that information overload and
exposure to complex information may overwhelm cognitive
processing capabilities and lead to confusion or fear [11]. In
addition, low trust in health information [12] and negative
experiences with cancer information seeking (e.g., feeling
frustrated, not understanding, or having concerns about the
quality of information) are more common among those with
less education, and the latter has also been associated with
higher fatalistic beliefs about cancer prevention [6].
Few studies have examined rurality as a determinant of
fatalistic beliefs about cancer prevention [13]. Nearly 20 %
of the US population resides in a rural area, representing one
of the largest medically underserved populations in the na-
tion [14]. Rural communities have higher rates of poverty,
lower educational levels, greater percentages of patients with
chronic diseases, and poorer lifestyle behaviors [15, 16].
When diagnosed with cancer, rural residents appear to be
C. A. Befort (*)
:
N. Nazir
:
K. Engelman
:
W. Choi
Department of Preventive Medicine and Public Health, University
of Kansas Medical Center, 3901 Rainbow Boulevard, MS 1008,
Kansas City, KS 66160, USA
e-mail: cbefort@kumc.edu
J Canc Educ (2013) 28:521–526
DOI 10.1007/s13187-013-0496-7
diagnosed at more advanced stages than their urban counter-
parts [17, 18]. In addition, rural residents are less likely to
engage in cancer prevention behaviors, including cancer
screening [19], using sunscreen [ 20], and exercising [21],
and they are more likely to be obese [22]. These disparities
are related to the demographi c composition of rural areas
(especially older age and lower socioeconomic status) and
are also believed to be driven in part by cultural factors.
Access to cancer information also differs across rural and
urban settings. Rural residents appear to have less knowledge
about cancer in general [23], as well as about cancer staging
and treatment [24]. Only 55 % of rural residents have home
broadband internet access significantly less than urban resi-
dents [25]; thus, they may rely more on other sources for
cancer information. The purpose of the current study was to
examine rural–urban differences in fatalistic beliefs about
cancer prevention, cancer information sources, and trust in
health information. We also examined the unique contribution
of sociodemographic factors, cancer information sources, and
information trust to predicting fatalistic beliefs about cancer
prevention among rural and urban residents.
Methods
Data were obtained from the 2007 Heath Information
National Trends Survey (HINTS) collected from January
2008 to May 2008. The HINTS is conducted by the
National Cancer Institute and is aimed at tracking trends in
cancer-related knowledge, information seeking, attitudes, and
behaviors. It includes a nationally representative sample of
adults aged 18 years and older using a complex stratified
sampling design. The 2007 HINTS consisted of two samples:
one drawn as a random digit dial telephone survey, using a
computer-assisted telephone interview (CATI) format, and a
second random sample selected from a list of addresses from
the United States Postal Service using a mailed survey format.
African-American and Hispanic residents were oversampled
to ensure adequate representation from the two largest minor-
ity groups in the USA. Data were collected from 4,092 re-
spondents via CATI (24.2 % overall response rate) and 3,582
respondents via mail (31.0 % overall response rate).
Respondents with a history of cancer (13 % of the total sample
with no difference across rural and urban residents) were
included because prevention of new primary diagnoses and
secondary prevention remain important for this group.
Measures
Rural and urban classificat ion was based on the 2003 Rural–
Urban Continuum Code of the US Department of Agriculture
Economic Research Service, with metropolitan counties
(codes 1–3) classified as urban and nonmetropolitan counties
(codes 4–9) classified as rural. Fatalistic beliefs about cancer
prevention were operationalized with three items that have
been used in several previous studies [5–7]: “It seems like
everything causes cancer,”“There’s not much you can do to
loweryourchancesofgettingcancer,” and “There are so many
recommendations about preventing cancer, it’s hard to know
whichonestofollow.” These items were pretested with cog-
nitive interviews and included in a national pilot test of 172
adults to ensure content validity before being included in the
HINTS survey [26]. They are rated on a four-point Likert scale
from strongly agree to strongly disagree and recoded
into a dichotomous variable (strongly agree or agree vs.
strongly disagree or disagree). Each belief item was examined
separately. Primary cancer information source
was assessed
by asking “The most recent time you looked for cancer
information, where did you go first?” Response options were
collapsed into four categories: doctor/healthcare provider,
books/library/magazine/newspaper, internet, and other. Trust
in health information sources was assessed with individual
questions regarding trust in doctor, newspapers/magazines,
internet, television, government, and religious organizations.
Participants rated their trust for each source as a lot, some, a
little, or not at all. Trust was recoded as a dichotomous
variable (a lot or some vs. a little or not at all) [12]. In addition,
a trust index was created by summing across items, with a
score ≥18 representing a lot to some trust and <18 representing
little to no trust across sources. Sociodemographic variables
included gender , age (≤39, 40–49, 50–59, 60–69, or ≥70 years),
race/ethnic ity (White non-Hispanic, Black non-Hispanic,
Hispanic, or other), education level (high school or less,
some college, or college graduate or more), employment
status (yes or no), and marital status (married/living as mar-
ried, divorced/separated/widowed, or single/never married).
Statistical Analyses
Data were weighted to produce overall and stratified estimates
that would be nationally representative of the US population.
Analyses were performed using SAS (version 9.2) and
SUDAAN (Release 10.0.1, SAS-Callable Individual PC,
×64 version). Cross-tabulation procedures were used to gen-
erate prevalence estimates for primary cancer information
source, trust in health information, and fatalistic beliefs.
Wald chi-square was used to compare these variables and
sociodemographic factors across rural and urban residence.
Multiple logistic regression models were used to examine
rural–urban residence as a determinant of each fatalistic can-
cer belief controlling for sociodemographic variables, cancer
information source, and trust in health information. A separate
model was conducted for each belief item. Next, logistic
regression models were conducted, including interaction
terms between rural–urban residence and all covariates, with
separate models for each fatalistic belief as the outcome
522 J Canc Educ (2013) 28:521–526
variable. Finally, separate logistic models were conducted to
examine multivariate correlates of fatalistic beliefs within
rural and urban groups.
Results
In the weighted sample, 82.2 % (SE=0.70) was composed of
urban residents (n=6,192) and 17.8 % (SE=0.70) was com-
posed of rural residents (n=1,482). Compared to urban res-
idents, rural residents were more likely to be older, married,
White non-Hispanic, and have less education (Table 1). For
both rural and urban residents, the most common primary
cancer information source was the internet; however, com-
pared to urban residents, rural residents’ primary information
source was less likely to be the internet (44 vs. 58 %)
and more likely to be their physician (28 vs. 21 %) or
print materials (18 vs. 11 %). Compared to urban resi-
dents , rural residents were also less likely to trust informa-
tion from the internet (65 vs. 72 %), print materials (47 vs.
52 %), or government sources (70 vs. 75 %). Approximately
one third of both rural and urban residents reported high
health information trust overall, with the highest level of
trust being with their physicians (94 % reported some or a
lot of trust).
Rural residents were significantly more likely to endorse all
three fatalistic beliefs about cancer prevention. Specifically,
62 % of rural residents vs. 53 % of urban residents agreed that
“everything causes cancer,” 34 % of rural residents vs. 27 %
of urban residents agreed “There’s not much you can do to
lower your chances of getting cancer,” and 80 % of rural
residents vs. 74 % of urban residents agreed “There are so
many recommendations about preventing cancer, it’shardto
know which ones to follow.”
Multivariate correlates of each fatalistic belief about can-
cer prevention among the total sample are shown in Table 2.
Controlling for all other variables, rural residence remained a
significant and positive determinant of all three fatalistic
beliefs, including “everything causes cancer” (odds ratio
[OR]=1.77 [95 % confidence interval (CI)=1.32–2.38];
p<0.001), “prevention not possible” (OR=1.51 [95 %
CI=1.03–2.22]; p=0.02), and “hard to know which recom-
mendations to follow” (OR=1.31 [95 % CI=1.05–1.64];
p=0.04). Lower education was a significant correlate of all
three fatalistic beliefs. Older age (over 6 0 years compared to
under 40 years) was positively associated with the belief
“everything causes cancer.” Race/ethnicity showed an incon-
sistent pattern of relationships across the three beliefs.
Respondents who reported that the internet was their primary
health information source were less likely to endorse two of
the three fatalistic beliefs (“prevention not possible” and
“hard to know which recommendations to follow”) com-
pared to those whose primary source was their physician.
Finally, trust in health infor mation was not a significant
correlate of any of the three fatalistic beliefs.
Table 1 Participant characteristics by rural and urban residence
Rural
(n=1,482)
Urban
(n=6,192)
p
value
Percent SE Percent SE
Gender, % female 51.8 1.5 51.3 0.3 0.80
Age <0.001
≤39 30.2 1.8 42.4 0.3
40–49 21.5 1.4 19.9 0.3
50–59 19.9 1.3 16.5 0.3
60–69 12.9 0.7 10.2 0.1
≥70 15.6 1.1 11.1 0.2
Race/ethnicity <0.001
White non-Hispanic 83.4 1.5 65.7 0.5
Black non-Hispanic 7.9 1.3 12.1 0.3
Hispanic 5.1 0.98 14.4 0.3
Other 3.7 0.67 7.8 0.3
Education <0.001
High school or less 52.1 2.0 38.0 0.7
Some college 31.6 1.9 35.5 0.6
College degree+ 16.3 1.1 26.5 0.3
Employed, % yes 55.0 1.8 58.6 0.9 0.11
Marital status <0.001
Married/living as married 62.3 1.8 55.6 0.5
Divorced/separated/widowed 20.3 1.3 16.6 0.4
Single/never married 17.4 1.7 27.8 0.4
Primary cancer information
source
Doctor/healthcare provider 28.5 2.5 21.5 1.2 0.02
Books/library/magazine/
newspaper
18.1 2.3 10.7 0.8 0.01
Internet 43.6 2.4 57.9 1.4 <0.001
Other 9.9 1.6 9.9 0.8 0.98
Trust health information
sources
a
Trust doctor 94.0 1.1 94.0 0.5 0.98
Trust newspapers/magazines 47.0 1.7 52.1 0.9 0.004
Trust the internet 64.9 2.1 71.6 1.0 0.01
Trust television 40.5 1.7 42.7 0.8 0.23
Trust government sources 70.2 2.0 75.4 0.8 0.03
Trust religious organizations 39.4 2.2 37.4 1.0 0.43
Trust index, % high trust
b
32.2 1.9 35.1 0.89 0.18
Fatalistic beliefs about cancer
prevention
b
Everything causes cancer 61.6 1.8 53.5 1.0 <0.001
Prevention not possible 33.6 1.8 26.9 0.8 0.002
Hard to know which
recommendations to follow
80.5 1.3 74.3 0.9 <0.001
a
Percent reporting a lot or some trust
b
Percent who agree or strongly agree
J Canc Educ (2013) 28:521–526 523
When including interaction terms in the models, interac-
tions with rural–urban residence for age and primary cancer
information source were significant (p<0.05). Due to these
significant interaction terms and an interest in examining
multivariate correlates of the fatalistic belief separately for
rural and urban groups, logistic models were conducted within
rural and urban participants. Lower education remained a
significant positive correlate of all three fatalistic beliefs within
both rural and urban residents. Race/ethnicity was a significant
correlate among urban residents but not among rural residents.
Urban non-Hispanic Blacks and urban Hispanics were more
likely to endorse “prevention not possible” compared to urban
White non-Hispanics. Urban Hispanics, however, were also
less likely to endorse “everything causes cancer” compared to
urban White non-Hispanics. Among rural residents but not
urban residents, those whose primary cancer information
source was the internet had lower fatalistic beliefs for “every-
thing causes cancer” and “prevention not possible” compared
to those whose source was their physician. Among urban
residents but not rural residents, those whose primary informa-
tion source was print materials had lower fatalistic beliefs for
“everything causes cancer.”
Discussion
This is the first study to demonstrate significantly higher
fatalistic beliefs about cancer prevention in rural adults com-
pared to urban adults using a nationally representative sample.
A large body of evidence has shown that lower education is
Table 2 Multivariate correlates of fatalistic beliefs about cancer prevention, total sample
Everything causes cancer,
OR (95 % CI)
Prevention not possible,
OR (95 % CI)
Hard to know which
recommendations to
follow, OR (95 % CI)
Rural (reference=urban) 1.77 (1.32–2.38)*** 1.51 (1.03–2.22)* 1.31 (1.05–1.64)*
Gender
Male 1.0 1.0 1.0
Female 1.05 (0.85–1.29) 0.93 (0.71–1.23)
Age
≤39 1.0 1.0 1.0
40–49 1.01 (0.66–1.53) 1.10 (0.71–1.69) 1.17 (0.78–1.76)
50–59 0.76 (0.51–1.13) 0.81 (0.50–1.30) 0.73 (0.51–1.04)
60–69 0.68 (0.47–0.97)* 0.82 (0.49–1.38) 0.70 (0.45–1.08)
≥70 0.37 (0.25–0.56)*** 1.35 (0.71–2.56) 0.83 (0.55–1.23)
Race/ethnicity
White non-Hispanic 1.0 1.0 1.0
Black non-Hispanic 0.80 (0.47–1.36) 1.98 (1.29–3.03)** 1.05 (0.66–1.68)
Hispanic 0.42 (0.28–0.64)*** 2.12 (1.28–3.51)** 0.62 (0.40–0.97)*
Education
High school or less 1.84 (1.44–2.35)*** 2.07 (1.46–2.94)*** 2.00 (1.45–2.74)***
Some college 1.59 (1.24–2.04)*** 1.58 (1.12–2.22)** 1.69 (1.37–2.08)***
College degree+ 1.0 1.0 1.0
Marital status
Married/living as married 1.0 1.0 1.0
Divorced/separated/widowed 1.23 (0.97–1.56) 0.96 (0.75–1.24) 1.21 (0.86–1.68)
Single/never married 1.14 (0.89–1.46) 0.69 (0.38
–1.24) 0.79 (0.51–1.23)
Primary cancer information source
Doctor/healthcare provider 1.0 1.0 1.0
Books/magazine/newspaper 0.75 (0.54–1.05) 0.91 (0.52–1.58) 0.85 (0.58–1.23)
Internet 0.98 (0.74–1.28) 0.71 (0.52–0.96)* 0.75 (0.57–0.99)*
Other 1.01 (0.67–1.52) 0.72 (0.48–1.08) 0.87 (0.61–1.25)
Trust index
High trust 1.0 1.0 1.0
Low trust 1.01 (0.80–1.27) 1.13 (0.86–1.49) 1.10 (0.83–1.45)
*p<0.05, **p<0.01, ***p<0.001; each variable is adjusted for all other variables in the model
524 J Canc Educ (2013) 28:521–526
associated with higher fatalistic beliefs about cancer prevention
[2, 4, 5]. In this study, rural residence remained a significant
correlate after controlling for education, as well as age,
race/ethnicity, and other sociodemographic factors. Outside
of sociodemographic differences, other less studied character-
istics associated with health information access or rural culture
may contribute to fatalistic beliefs about cancer prevention in
rural communities.
The proportion of rural respondents agreeing with the three
fatalistic belief statements ranged from 34 to 80 %. Although
fewer urban respondents agreed with all three beliefs com-
pared to rural respondents, the proportion who agreed was a
similar wide range across beliefs statements. This highlights
the multidimensional nature of these beliefs. In addition, we
found race/ethnicity to be a significant correlate for only two
out of three beliefs, only among urban residents, and the
direction of the relationship was mixed. For example, urban
White non-Hispanics were more likely to agree with “preven-
tion not possible” but less likely to agree with “everything
causes cancer.” This finding also highlights the unique aspects
of these beliefs and confirms prior studies showing that fatal-
istic beliefs about cancer prevention have not been consistent-
ly related to race/ethnicity [4, 5]. In contrast, fatalistic beliefs
about surviving cancer have been consistently higher among
Hispanics and African Americans and may have stronger
ethnic and cultural origins [3, 4].
Despite the internet being the most common source for
cancer information overall, rural residents were less likely to
obtain information from the internet and less likely to trust
this information compared to their urban counterparts.
Among rural residents, those who used the internet for can-
cer information were less likely to endorse fatalistic beliefs
about cancer prevention compared to those who relied on
their physician for information. This was not the case for
urban residents. Rural internet penetration rates have
remained 10 % behind the national average over time [27],
and given the lower access to and use of the internet in rural
America, it may be a better marker for socioeconomic status,
knowledge, and beliefs among rural residents compared to
urban residents. Although the rural contingent who utilizes
the internet is expected to grow in future generations, at the
current time, lower use of and trust in internet sources for
health information among rural residents may be a barrier to
information dissemination about cancer prevention.
Despite small to moderate differences in health information
trust for three out of six sources, with rural residents reporting
lower trust in internet, print, and government sources, overall
level of trust in health information among rural and urban
residents remained similar, with approximately one third in
each group reporting high health information trust. Regardless
of their primary cancer information source, the most trusted
sources of information for both rural and urban residents were
physicians, government, and the internet. Consistent with the
2003 HINTS [12], physicians remained the most highly
trusted information source. In addition, level of health infor-
mation trust was not associated with fatalistic beliefs about
cancer prevention for either rural or urban residents. Thus,
although health information trust is associated with education
level [12], it does not appear to be related to or to mediate
fatalistic cancer beliefs. Rather, specific experiences with
cancer information seeking, such as being able to find quality
and understandable information, may be more important for
influencing beliefs about cancer prevention [6].
Other factors related to health information access in rural
communities may contribute to rural–urban differences in
fatalistic beliefs about cancer prevention. For example, de-
spite rural residents’ greater reliance on healthcare providers
for health information, they visit such providers less fre-
quently than do urban residents, further limiting their access
to health information. In addition, there are higher rates of
cancer-related morbidity in rural areas [17], and personal
health information is often discovered through social and
familial connections within small communities. Emotionally
charged news travels through social networks at a greater
volume and rate than does noncharged stories such that news
about a person’
s cancer diagnosis or poor prognosis may
spread more widely than news about those with a positive
health prognosis [28]. This phenomenon may have a prolifer-
ative effect on a person’s perception of control over being able
to combat a cancer diagnosis.
Limitations of this study include the cross-sectional de-
sign and the low overall response rates to the HINTS (24–
31 %) which somewhat limits the generalizability of the
findings. In addition, fatalistic beliefs about cancer preven-
tion were measured with three separate items rather than a
multiple item scale assessing additional dimensions of the
construct. However, the items used by the HINTS have
demonstrated const ruct validity across multiple studies [5,
6, 9]. Strengths of the study include the large nationally
representative sample which allows for comparison across
rural and urban groups.
This study highlights significant differences in fatalistic
beliefs about cancer prevention between rural and urban
communities that warrant further study. The high level of
fatalistic beliefs reported by rural residents, coupled with
poorer health status, less prevalent use of cancer screening
tests, and poorer cancer outcomes, makes focusing on the
20 % of US citizens who reside in rural communities a priority.
Targeted educational efforts may help reduce fatalistic per-
spectives about cancer prevention in rural areas. For example,
one study found that an educational video was successful in
reducing fatalistic beliefs about cancer prevention among older
rural adults [29]. The information must be packaged in a way
that can be easily understood and readily accepted by those
with fatalistic perspectives and delivered using mechanisms
that have the broadest reach such as television-based, social
J Canc Educ (2013) 28:521–526 525
media-based, and primary care clinic-based education.
Currently, only 55 % of rural residents use the internet, which
likely will result in making effective dissemination of cancer
prevention information more costly and time intensive in rural
areas. In addition, because less educated adults are the most
likely to hold fatalistic beliefs, interventions must deliver
evidence-based information in an engaging manner without
overloading recipients with too much information or over-
shooting their literacy level. In summary, future work to pro-
mote cancer prevention initiatives should identify and address
the unique cultural and fatalistic perspectives of rural commu-
nities along with limited cancer information resources to prog-
ress towards less disparate rural cancer outcomes.
Conflict of Interest The authors have no conflicts of interest to disclose.
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