Abstract
Introduction
Mothers and daughters share a powerful and unique bond, which has potential for the dissemination of information on a variety of women's health issues, including the primary and secondary prevention of breast and cervical cancer. This study presents formative research from a long-term project examining the potential of mother-daughter communication in promoting cancer screening among African-American women.
Methods
Thirty-two mother-daughter pairs (N = 64) completed orally administered surveys regarding their cancer knowledge, beliefs and attitudes, and barriers to care. This study compares the attitudes and beliefs of low-income, urban, African-American mothers and their adolescent daughters regarding cervical and breast cancer screening.
Results
Both mothers and daughters had fairly high levels of knowledge about breast and cervical cancer. In addition, there was a high concordance rate between mothers' and daughters' responses, suggesting a potential sharing of health knowledge between mother and daughter.
Discussion
These results have implications for selecting communication strategies to reduce health disparities, and support that the mother-daughter dyad could be a viable unit to disseminate targeted screening information.
Keywords: Mother-Daughter Communication, Cancer Prevention, Health Disparities, African-American, Cervical Cancer, Breast Cancer
Mother-daughter communication presents a unique opportunity for health promotion efforts, because the mother-daughter dyad is characterized as the most mutually supportive, cooperative, and stable relationship throughout the lifespan (Rossi & Rossi, 1990). However, research on mother-daughter communication has focused primarily on the transmission of information from mothers to daughters, and how daughters influence their mothers is not well known (Saphir & Chaffee, 2002).
Given the potential strength of the mother-daughter bond ((Rossi & Rossi, 1990; Saphir & Chaffee, 2002), mother-daughter communication has the potential to strengthen strategies targeting women’s health issues. Indeed, research supports that daughters want to have a positive impact on their parents’ health behaviors (Mosavel, Simon, & Van Stade, 2006), and mothers are willing to listen to health advice from their daughters (Mosavel et al., 2006; Washington, Burke, Joseph, Guerra, & Pasick, 2009). Mothers also report that they consult their daughters when making health-related decisions, and consider their daughters credible sources of information (Washington et al., 2009).
In the context of health behaviors, the Theory of Planned Behavior (Ajzen & Fishbein, 1980) offers theoretical insight into the potential influence of daughters and mothers on each other. Specifically, research supports that mothers and daughters view each other as important others whom they want to comply with (Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003; Mosavel et al., 2006; Washington et al., 2009). These subjective norms influence behavioral intentions, and subsequently, health behavior (Ajzen & Fishbein, 1980). Moreover, if mothers and daughters have behavioral beliefs that are aligned, it is reasonable to expect that their influence will be stronger than if there was not concordance in attitudes and beliefs (Hutchinson et al., 2003).
In this paper we focused on the promotion of health behaviors in the context of cervical and breast cancer among African-American women. Despite major improvements in access to screening resources, cervical and breast cancer disproportionately affect African-American women in the U (Barnholtz-Sloan, Patel, Rollison, Kortepeter, MacKinnon, & Giuliano 2009). Utilizing the mother-daughter relationship to deliver important health information and encourage participation in critical health screening may alleviate existing cancer disparities. As such, this paper explores preliminary data regarding (1) mother-daughter communication; (2) the concordance of African-American mothers’ and adolescent daughters’ knowledge and beliefs about breast and cervical cancer; and (3) the mother’s attitudes toward cervical and breast cancer.
Method
Participants
Thirty-two African-American mother-daughter dyads (N = 64) from low-income neighborhoods in the United States participated in the study. Recruitment was conducted using flyers, emails to community centers and conducting informational sessions at neighborhood recreational centers. Eligibility requirements included mothers or female guardians with daughters in grades eight through ten, living in the same household and self-identified as low-income. Participation was 100% for those who met the eligibility requirements. Socio-demographics of mothers and daughters are detailed in Table 1.
Table 1.
Sociodemographics of Mothers and Daughters
| Mean (SD) | Range | |
|---|---|---|
| Mothers’ Age | 45.6 (5.6) | 37–59 |
| Daughters’ Age | 14.75 (1.5) | 12–17 |
| Children per woman | 3.5 (2.2) | 1–11 |
| Percentage | ||
| Biological mother | 97% | |
| Relationship/marital status | ||
| Single | 41% | |
| Married | 31% | |
| Divorced/Separated | 28% | |
| Highest level of education completed | ||
| High school graduates | 59% | |
| Some college | 13% | |
| College graduates | 28% | |
| Employed full-time | 44% | |
| Receiving Social Security | 9% | |
| Receiving other governmental assistance | 50% | |
| Household Income | ||
| < $9,000 | 32% | |
| >$9,000 to $20,000 | 22% | |
| >$20,000 to $30,000 | 13% | |
| >$30,000 to $40,000 | 34% | |
| >$40,000 to $50,000 | 3% | |
| >$50,000 | 22% | |
| Health Insurance | ||
| Privately insured | 31% | |
| Government/State subsidized insurance | 56% | |
| Not insured | 13% | |
Measures
The survey assessed breast and cervical cancer knowledge, cancer worry, and barriers to cancer screening via open- and closed-ended responses. Items were drawn from validated surveys, for example, perceived barriers to care (Champion & Scott, 1997), cancer worry (Vickberg, Bovbjerg, DuHamel, Currie, & Redd, 2000), and perceived susceptibility (Byrd, Peterson, Chavez, & Heckert, 2004). Where applicable, we asked corresponding questions in both mother and daughter surveys. Perceptions of communication between mother and daughter were assessed by asking, “In general, do you think your daughter (mother) listens to your opinion? Responses were recorded using a 5-point scale ranging from (1) strongly disagree to (5) strongly agree. In order to test the efficacy and coherency of the survey, we conducted pilot interviews with five mother-daughter pairs from low-income families.
Procedure
After providing informed consent, mothers and daughters completed the survey separately. Because of literacy concerns, the PI (MM) administered the survey during a face-to-face interview. Mothers received $50.00 and daughters received $35.00 for their participation. This study was approved by the Institutional Review Board at [removed for blind review].
Results
Data were de-identified and reported in aggregate form. Frequencies, means and standard deviations were used to describe response patterns. McNemar- and T-test were used to describe attitude concordance between mothers and daughters. Post-hoc achieved power was computed and found to be moderate.
Cervical Cancer
Seventeen mothers (53%) reported having had a Pap smear in the past 12 months. Eight (25%) reported having had a Pap smear in the past 12 – 24 months prior to the interview and seven (22%) reported not having had a Pap smear in the past 24 months. Amongst the 22% of mothers who had not been screened, the reasons reported included no insurance (n = 4), having too many obligations (n = 3) and not going to the doctor regularly (n = 4). The mean time since the most recent Pap smear was 24.3 months (SD = 35.4); however, the median time since having one was 12 months. Mother-daughter dyads had comparable levels of knowledge and beliefs regarding cervical cancer (Table 2). Mothers’ attitudes towards Pap smears and associated challenges are outlined in Table 3.
Table 2.
Comparison of Mother’s and Daughter’s Knowledge and Beliefs Regarding Cervical and Breast Cancer
| Cervical Cancer Beliefs | |||
| Mother n (% yes) |
Daughter n (% yes) |
McNemar (df) |
|
| Cervical cancer can affect women ages 18–30 | 25 (78) | 25 (78) | 0.0 (1) |
| Do you need to worry about cervical cancer? | 19 (59) | 21 (66) | .29 (1) |
| Women over age 50 only ones to get cervical cancer | 0 (0) | 1 (3) | -- |
| M (sd) | M (sd) | t (p) | |
| Cervical cancer can be treated if found early | 1.6 (.56) | 2.1 (.82) | 2.8 (.009)* |
| Woman’s family would be severely affected if she had cervical cancer | 2.0 (1.1) | 2.4 (1.3) | 1.5 (.14) |
| To me there are other types of cancer more serious than cervical cancer | 2.4 (1.1) | 2.3 (.98) | .84 (.40) |
| Breast Cancer Beliefs | |||
| Mother n (% yes) |
Daughter n (% yes) |
McNemar (df) |
|
| Breast cancer can affect women ages 18–40 | 29 (91) | 26 (81) | 1.3 (1) |
| Do you think you can get breast cancer? | 30 (94) | 27 (84) | 1.8 (1) |
| Women over age 50 only ones to get breast cancer | 3 (9) | 0 (0) | -- |
| M (sd) | M (sd) | T (p)+ | |
| Breast cancer can be treated if found early | 1.5 (.50) | 2.0 (.82) | 2.6 (.01)** |
| Woman’s family would be severely affected if she had breast cancer | 1.8 (1.1) | 2.1 (1.3) | .87 (.39) |
| To me there are other types of cancer more serious than breast cancer | 2.8 (1.3) | 2.8 (1.1) | .10 (.92) |
Response scale for continuous variables ranges from 1 (Strongly Agree) to 5 (Strongly Disagree)
t = t-test for matched pairs
= significant at the .01 level
Table 3.
Mother’s Responses to Pap Smear and Mammogram Attitudes/Barriers Questions
| Pap Smear Questions | M (sd) | Strongly Agree n (%) |
Agree n (%) |
Neither Agree nor Disagree n (%) |
Disagree n (%) |
Strongly Disagree n (%) |
|---|---|---|---|---|---|---|
| Afraid the results of pap will show something wrong | 3.8 (1.3) | 2 (6) | 4 (13) | 5 (16) | 9 (28) | 12 (38) |
| I am embarrassed to have a pap smear | 4.2 (.94) | 1 (3) | 1 (3) | 2 (6.3) | 14 (44) | 14 (44) |
| Pap smears are painful | 3.4 (1.1) | 1 (3) | 6 (19) | 9 (28) | 11 (34.4) | 5 (15.6) |
| People delivering pap are rude insensitive | 4.4 (.61) | 0 | 0 | 2 (6.3) | 16 (50) | 14 (44) |
| Hard to find transportation to my appointment for pap smear | 4.1 (1.2) | 2 (6.3) | 2 (6.3) | 1 (3) | 12 (38) | 15 (47) |
| Having to get childcare prevents me from getting a pap smear | 4.4 (.71) | 0 | 1 (3) | 1 (3) | 14 (44) | 16 (50) |
| Pap smear least of concerns, more important problems in life | 3.5 (1.2) | 1 (3) | 7 (22) | 5 (16) | 14 (44) | 16 (50) |
| Mammogram Question | M (sd) | Strongly Agree n (%) |
Agree n (%) |
Neither Agree nor Disagree n (%) |
Disagree n (%) |
Strongly Disagree n (%) |
| Afraid results of mammogram will show something wrong | 3.3 (1.3) | 5 (15.6) | 3 (9.4) | 6 (19) | 14 (44) | 4 (13) |
| Mammograms are painful | 3.1 (1.7) | 6 (19) | 5 (15.6) | 9 (28) | 8 (25) | 3 (9) |
| People delivering the mammograms are rude insensitive | 4.1 (.89) | 0 (0) | 2 (6) | 5 (15.6) | 13 (41) | 12 (38) |
| Hard to find transportation to my appointment for mammogram | 4.0 (1.2) | 3 (9) | 1 (3) | 2 (6) | 14 (44) | 12 (38) |
| Having to get childcare prevents me from getting a mammogram | 4.5 (.57) | 0 | 0 | 1 (3) | 15 (47) | 16 (50) |
| Mammogram least of concerns, more important problems in life | 3.4 (1.2) | 2 (6) | 6 (19) | 7 (22) | 10 (31) | 7 (22) |
| Keeping my appointment to get mammogram difficult | 3.8 (1.1) | 1 (3) | 5 (16) | 3 (9) | 14 (44) | 9 (28) |
Breast Cancer
Of the 28 women eligible for mammography, 75% stated that they had a mammogram at least once and 50% reported that they had a mammogram in the last twelve months. Reasons reported for not having had a mammogram included being scared (n = 3), “not liking being touched there” (n = 1), not making the appointment (n = 2). Mother-daughter dyads had comparable levels of knowledge and beliefs regarding breast cancer (see Table 2). Mothers’ attitudes regarding mammography are presented in Table 3.
Mother-Daughter Communication
Mothers generally agreed with the query: “In general, do you think your daughter listens to your opinion?” (M=4.0, SD = .76). Daughters’ mean response to the parallel question was 3.75 (SD = 1.13). We also examined whether the communication ratings were associated with the congruence of the mother-daughter knowledge for cervical and breast cancer. Smaller discrepancies on believing breast cancer could be treated if found early (r = .48, p < .006) and whether there were more serious types of cancer than breast cancer (r = −.34, p < .05) were both associated with the daughter reporting that her mother listens to her.
Discussion
We assessed the concordance of African-American mothers’ and their adolescent daughters’ knowledge and beliefs about breast and cervical cancer. Both mothers and daughters had fairly high levels of knowledge about breast and cervical cancer. In addition, mothers had generally positive attitudes toward screening and treatment. Both mothers and daughters believed that compared to other cancers, breast cancer is the more serious cancer in the African-American community. The high concordance of mothers and daughters cancer knowledge suggests that they have access to similar sources of information, such as the mass media or social networks. Given the concordance amongst the dyads, the results suggest that there is diffusion of knowledge within the family unit, with the potential to be harnessed for health promotion purposes.
In this study, mothers and daughters reported that they believed the other to value their opinion. The mutuality of bi-directional communication, in which both daughters and mothers provide and receive health-related advice from each other, may result in enhanced closeness. Mothers in cohesive relationships with their daughters are more likely to turn to their daughters for help regarding decisions about their health and are more likely to listen to their daughters’ health-related advice (Washington et al., 2009), suggesting that bi-directional communication has an important role in establishing strong mother-daughter relationships, as well as facilitating positive health-related communication and subsequent health behaviors among mothers and daughters (Ajzen & Fishbein, 1980; Hutchinson et al., 2003).
This study has certain limitations, which limit generalizability. For example, the small, convenience sample may be unique by virtue of how they were recruited. Recruitment took place at community centers, and thus, those who participated were connected either to community services and/or resources, which may partially explain their limited experiences of barriers to receiving care. In addition, participating mother-daughter dyads may have had stronger relationships. Despite these limitations, this study makes three important contributions to health promotion: 1) as more low-income women are able to afford health insurance through subsidized government programs, more may obtain the necessary screening; 2) the lack of barriers to care reported in this study may be due to access to local community clinics, which can potentially reduce barriers to care, and; 3) mothers and daughters shared beliefs about cancer, suggesting that mother-daughter dyads may be a viable unit to disseminate targeted screening information.
Acknowledgements
The authors would like to thank the mothers and daughters who participated in this study as well as Kim Sanders, Teleange’ Thomas, Lydia Hill and Marsha Johnson, members of the mother-daughter health collaborative in Cleveland, Ohio. A special thanks to Meia Jones who assisted with recruitment.
This research was supported by Award Number K01CA132960 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National cancer Institute or the National Institutes of Health.
Contributor Information
Maghboeba Mosavel, Department of Social and Behavioral Health, Virginia Commonwealth University.
Maureen Wilson Genderson, Department of Social and Behavioral Health, Virginia Commonwealth University.
Katie A. Ports, Department of Social and Behavioral Health, Virginia Commonwealth University
Kellie E. Carlyle, Department of Social and Behavioral Health, Virginia Commonwealth University
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