Abstract
Information seeking is an active health behavior that influences cancer fatalism; however, people commonly experience challenges in accessing high-quality and actionable health information that is personally relevant. This is especially common among older and rural adults who have a high cancer risk. The purpose of this study was to examine the theoretical assumption that enhancing perceived confidence to overcome health information seeking challenges will alleviate cancer fatalism. In 2017, 895 adults from a large southeastern medical university’s cancer catchment area participated in a random digit dial survey. Participants were Millennials (18–35; 19%), Generation X (36–51; 23%), Baby Boomers (52–70; 40%), and Silent Generation (71–95; 16.9%) who had equal representation across metro (78.9%) and non-metro (21.1%) counties. Younger generations (Millennials and Generation X) held stronger fatalistic cancer beliefs (“It seems like everything causes cancer,” “When I think about cancer, I automatically think about death”) than older generations. Most participants believed that precautionary efforts exist to reduce their chances of getting cancer, which was strongest among individuals residing in metro counties. In controlling for generation and rural-urban residence, individuals who experience challenges in the process of accessing health information have stronger fatalistic beliefs about cancer prevention; however, this relationship was most pronounced among individuals with confidence to ultimately obtain information that they need. This study contributes to evidence for health information equity in combatting fatalistic cancer beliefs. Findings have important implications for the optimized dissemination of culturally-adapted cancer education and skills-based training to efficiently access and evaluate relevant cancer education.
Keywords: cancer fatalism, rural health, health information equity, health literacy
INTRODUCTION
Fatalistic beliefs about cancer include pessimistic and deterministic thoughts about the perceived lack of control in its prevention [1] and hopelessness about an inevitable death upon a diagnosis [2]. Cancer fatalism is associated with greater engagement in high-risk behaviors, including tobacco use, less consumption of fruits and vegetables, and avoiding chronic illness screenings and delayed diagnosis [1, 3]. Ironically, fatalistic beliefs about cancer cultivate a self-fulfilling prophecy. By not taking active steps to alleviate the burden of cancer, people inadvertently increase their personal risk despite the belief that there is little personal agency to effect these chances. Identifying methods to combat fatalistic cancer beliefs is a public health priority, as people with less cancer fatalism report greater behavioral intentions and health decision-making that are central to primary, secondary, and tertiary cancer prevention [4].
Individuals who actively seek health information are less likely to report fatalistic cancer beliefs [5], whereas those passively exposed to health-related content from the media report more perceived cancer fatalism [6]. Active health information seeking is a dynamic and interactive process where content is negotiated among diverse resources (e.g., Internet, healthcare providers, family/friends) to reinforce, challenge and to reconstruct beliefs that inform knowledge acquisition [7, 8]. From a health literacy perspective, a person’s ability to successfully seek and obtain health information is crucial in informing their future health beliefs and behaviors [7, 9]. Research demonstrates that the relationship between health literacy (i.e., the degree that a person can access, understand, evaluate, and apply health information) and engaging in cancer-related health information seeking is partially explained by fatalistic cancer beliefs [9]. Nearly 37–58% of people feel frustrated during the health information seeking process and have concerns about the quality of information they find throughout this process [10]. To date, however, limited research has examined how challenges in the process of obtaining health information contributes to fatalistic cancer beliefs.
The protective nature of active health information seeking on alleviating fatalistic cancer beliefs may not always be consistent in regard to age and geographic region. As compared to older adults, younger adults are more frequent health information seekers but they have a stronger perception of cancer fatalism [9]. Also, rural regions comprise a greater proportion of older adults and a culture that inadvertently condones cancer risk behaviors (e.g., tobacco use); however, rural adults are infrequent information seekers and hold strong fatalistic cancer beliefs [11]. One explanation that is that health information seeking abilities vary according to socio-cultural values and belief systems of communities [12]. It is known that older adults and individuals residing in rural regions generally have low health literacy [13, 14]; however, limited empirical attention has examined how the health information seeking abilities of these vulnerable subgroup of the population influences fatalistic beliefs about cancer.
The purpose of this study was to examine how perceived challenges and confidence in health information seeking are associated with fatalistic cancer beliefs. We hypothesize that having confidence in the ability to obtain needed health information will attenuate the relationship between perceived challenges in health information seeking and fatalistic cancer beliefs. A secondary aim of this study was to explore whether cancer fatalism and perceived health information seeking challenges and confidence varied according to age generation and rural-urban geographic context. Consistent with foundational recommendations to combat cancer fatalism with culturally-adapted health promotion efforts [2], results of this study have important implications for understanding the role of health information seeking in managing fatalistic cancer beliefs across diverse generations and rural-urban cultural contexts [4].
METHODS
Sample and Procedures
In 2017, a cross-sectional random digit dial (RDD) survey was conducted in 22 counties within a large southeastern academic medical university’s catchment area. A series of items from the Behavioral Risk Factor Surveillance System (BRFSS) [15] and Health Information National Trends Survey (HINTS) [16] were included in the surveillance of socio-demographics and health needs, behaviors, information seeking strategies of the catchment area. RDD recruitment procedures were followed, in which 15 attempts for a landline and 6 attempts for a mobile phone were made. Calls were made on day-evening-weekend rotations. People who agreed to participate were over the age of 18 years old and provided a verbal waiver of consent. Our secondary analysis of the surveillance data examines relationships between a select set of variables that have theoretical underpinnings to health outcomes related to cancer. The original RDD survey and this secondary analysis was approved by the authors’ Institutional Review Board (IRB) human subject review committee.
Measures
Socio-demographic characteristics were captured, including age, gender, race/ethnicity, socioeconomic status, and county. Age (in years) was recoded and categorized into four generations based on 2019 estimates [17]: Millennials (18–35), Generation X (36–51), Baby Boomers (52–70), and Silent Generation (71–95). To assess geographic region, participants were asked to state the county in which they reside. The 2013 Rural-Urban Continuum Code (RUCC) [18] defined each county, which were dichotomized as metro (codes 1–3) or non-metro (codes 4–9) counties to test our hypothesis.
Information seeking experiences were measured with items that capture preferred source of information and perceived (a) confidence in obtaining needed health information and (b) challenges in health information seeking [10, 16]. Perceived confidence was assessed with a single item (“How confident are you that you could get health-related advice or information if you needed it?”) on a 5-point Likert-type scale (1 not at all confident, 5 completely confident). The instrument used to assess health information seeking challenges includes four items from the Information Seeking Experiences Scale, which have been adopted by the Health Information National Trends Survey (HINTS) [16] to measure cognitive and affective barriers during a health information search [10, 19]. These items assess the degree of effort and frustration that is exerted to get information as well as their concern for being able to comprehend information and evaluate its quality. Items were anchored on a 4-pt Likert-type scale (1 strongly disagree, 4 strongly agree) and data yielded adequate internal consistency (α = .77).
Fatalistic cancer beliefs were measured with three items on a 4-point Likert-type scale (1 strongly disagree, 4 strongly agree) [16]. Items included: “It seems like everything causes cancer,” “There’s not much you can do to lower your chances of getting cancer,” “When I think about cancer, I automatically think about death.” Items yielded suboptimal internal consistency (α = .61), despite an exploratory factor analysis showing that these items fit a unidimensional model. Following practices of other social scientists [1, 9], these items were examined independently rather than as a scale.
Data analysis
We conducted all analyses with SPSS v26. One-way analysis of variance (ANOVA) were conducted to determine if fatalistic cancer beliefs and perceived health information seeking abilities significantly varied by generation and geographic region. The Hayes SPSS PROCESS Macro [20] was used to conduct linear regression analyses that examine how the moderating effect of health information seeking challenges and confidence on cancer beliefs. Three analyses were conducted with the following DVs: “It seems like everything causes cancer,” “There’s not much you can do to lower your chances of getting cancer,” and “When I think about cancer, I automatically think about death.” The primary IV in each analysis was perceived challenges in health information seeking. The interaction term was the mean-centered product of perceived confidence to obtain needed health information and perceived challenges in the health information seeking process. Covariates in models included generation (1 = Silent Generation; 0 = Younger Generations) and geography (1 = Metro; 0 = Non-Metro Counties).
RESULTS
Sample Characteristics
Participants from 15 counties in the catchment area completed the survey, with most (n = 784; 87.6%) residing as counties categorized as metro (n = 706 or 78.9% with 250K-1M population and n = 78 or 8.7% with <250 population). Nearly 80% (n = 717) of participants reported having looked for health or medical information. Table 1 shows that over half of the participants reported an age consistent with the Baby Boomer (52–70 years old; 40%) and Silent Generation (71–95; 16.9%). Generations were equally represented across metro and non-metro counties, X2 (3, 887) = 2.72, p = .52. Consistent with the catchment area’s racial/ethnic demographic profile, participants in this study were predominantly non-Hispanic (n = 830; 92.7%) and White (n = 660; 73.7%). However, a significant proportion identified as Black/African American (n = 180; 20.1%). Unlike the relatively low socioeconomic status of the catchment area, nearly 70% had at least some college experience and 18% (n = 157) earned less than $20K/year.
Table 1.
Socio-demographic characteristics of the sample, N = 895
| Variable | n (%) |
|---|---|
| Age Generations | |
| Millennials (18–35) | 170 (19.0) |
| Generation X (36–51) | 204 (22.8) |
| Baby Boomers (52–70) | 362 (40.4) |
| Silent Generation (71–95) | 151 (16.9) |
| Missing | 8 (0.9) |
| Gender | |
| Female | 502 (56.1) |
| Male | 393 (43.9) |
| Missing | N/A |
| Racea | |
| White | 660 (73.7) |
| Black/African American | 180 (20.1) |
| American Indian or Alaska Native | 48 (5.4) |
| Asian | 23 (3.5) |
| Native Hawaiian or Other Pacific Islanders | 3 (0.3) |
| Refused/Missing | 12 (1.3) |
| Ethnicity | |
| Hispanic | 56 (6.3) |
| Non-Hispanic | 830 (92.7) |
| Missing | N/A |
| Annual Income | |
| Less than $10K | 56 (6.3) |
| $10K to $14,999 | 47 (5.3) |
| $15K to $19,999 | 54 (6.0) |
| $20K to $34,999 | 132 (14.7) |
| $35K to $49,999 | 114 (12.7) |
| $50K to $74,999 | 149 (16.6) |
| $75K to $99,999 | 104 (11.6) |
| $100K to $199,999 | 121 (13.5) |
| $200K or more | 28 (3.1) |
| Missing | 90 (10.1) |
| Education | |
| Less than 8 years | 7 (0.8) |
| 8 through 11 years | 44 (4.9) |
| 12 years or completed high school | 186 (20.8) |
| Post high school training (not college) | 32 (3.6) |
| Some college | 224 (25.0) |
| College graduate | 227 (25.4) |
| Postgraduate | 164 (18.3) |
| Missing | 11 (1.2) |
| County by Rural-Urban Continuum Categoryb | |
| Metro: 250K-1M population | 706 (78.9) |
| Metro: <250K population | 78 (8.7) |
| Urban: 20K+, adjacent to metro area | 52 (5.8) |
| Urban: 2.5K-19.9K, adjacent to metro area | 59 (6.5) |
| Rural: <2.5K, not adjacent to metro | 1 (0.1) |
| Missing | N/A |
Note.
Percentages do not add up to 100% as participants could select multiple races;
Rural (<2.5K, not adjacent to metro) was combined with Urban (2.5K-19.9K adjacent to metro) for primary analyses.
Primary sources of health information included the Internet (n = 487; 67.9%) and healthcare providers (n = 122; 17%). Exploratory chi-squared analyses found no statistically significant difference in the likelihood that participants from metro and non-metro counties primarily used the Internet (68.1% and 66.7% respectively; p = .80) or healthcare provider (16.4% and 21.8% respectively; p = .23).
Fatalistic Cancer Beliefs: Generational and Geographic Differences
About half of the sample strongly or somewhat disagreed that everything causes cancer (n = 418; 46.9%) and that cancer automatically makes them think about death (n = 480; 53.8%). However, nearly 80% (n = 714) strongly or somewhat disagreed that not much can be done to reduce their risk of cancer.
Participants reporting an age consistent with the Millennial generation were more likely to believe that everything causes cancer (M = 2.80; SD = .90), as compared to Generation X (M = 2.52; SD = 1.0; p < .05; 95% confidence interval [CI] = .02, .55), Baby Boomers (M = 2.43; SD = 1.0; p < .001; 95% CI = .13, .61), and Silent Generation (M = 2.03; SD = .93; p < .001; 95% CI = .48, 1.05), F (3, 881) = 16.95, p < .001. In contrast, Generation X participants were more likely to automatically think about death when they think about cancer (M = 2.61; SD = 1.13), as compared to Baby Boomers (M = 2.33; SD = 1.10; p < .05; 95% CI = 2.21, 2.45) and the Silent Generation (M = 2.25; SD = 1.09; p < .01; 95% CI = 2.07, 2.42), F (3, 880) = 4.74, p < .01. The belief that not much can be done to lower chances of getting cancer did not vary by generation.
Cancer fatalism also varied by county residence, but only for one belief. The belief that there is not much that can be done to decrease the chances of cancer was lower in metro counties (250K-1M people; M = 1.77; SD = .92) as compared to urban counties with 2.5K-19.9K people (not adjacent to metro; M = 2.22; SD = 1.08; p < .01; 95% CI −.78, −.12) in the catchment area, F (3, 886) = 5.96, p < .001.
Health Information Seeking Confidence and Challenges: Generational and Geographic Differences
Perceived challenges in health information seeking were relatively low (M = 2.06; SD = .76). Participants either strongly or somewhat disagreed that it took a lot of effort to get health information (n = 458; 64.1%), they felt frustrated during the search (n = 522; 73.2%), and that information was hard to understand (n = 564; 79%). A smaller proportion said they were not concerned about the quality of the information (n = 353; 49.6%). Participants reported an above average degree of confidence to obtain health-related advice or information if they needed it (M = 3.73; SD = .99). Specifically, the majority indicated that they were completely (n = 182; 25.4%), very (n = 247; 27.6%), or somewhat (n = 221; 24.7%) confident in being able to do so. As expected, a negative correlation existed between perceived challenges and confidence to access health information (r = −.38; p < .001).
Perceived health information seeking confidence differed among individuals according to their rural-urban geographic residence, F (3, 713) = 3.46, p < .05. Individuals in metro counties (250K-1M people) had a greater degree of confidence in their ability to obtain needed health information (M = 3.76; SD = .98) than those residing in metro counties with less than 250K people (M = 3.39; SD = 1.02; p < .05; 95% CI = .03, .72). Interestingly, individuals in non-metro counties with 2.5K-19.9K people (M = 3.64; SD = 1.06) had a significantly higher degree of perceived confidence than individuals in metro counties where less than 250K people reside (p < .05; 95% CI = .03, 1.09). Perceived challenges in the health information seeking process did not statistically vary by generation or rural-urban geographic residence.
Multiple Linear Regressions
Table 2 shows the results of regression analyses examining how perceived challenges in the health information seeking process is associated with fatalistic cancer views at three levels of perceived confidence to obtain needed health information (Low = −1SD; Average = M; High = +1SD). All analyses include generation and rural-urban geographic residence as covariates.
Table 2.
Multiple linear regression analysis of perceived health information seeking on three cancer fatalism beliefs
| “It seems like everything causes cancer.” |
“There’s not much you can do to lower your chances…” |
“When I think about cancer, I automatically think death.” |
||||
|---|---|---|---|---|---|---|
| Predictor Variables | b (SE) | 95% CI | b (SE) | 95% CI | b (SE) | 95% CI |
| Information Seeking Challenges | .22 (.05)*** | .12, .32 | .20 (.05)*** | .11, .29 | .20 (.06)*** | .09, .32 |
| Information Seeking Confidence | −.02 (.04) | −.09, .06 | −.08 (.03)* | −.15, −.02 | −.10 (.04)* | −.19, − .02 |
| Confidence*Challenges | .10 (.05)* | .01, .19 | .12 (.04)** | .05, .20 | .06 (.05) | −.04, .16 |
| Generationa | −.43 (.10)*** | −.62, −.24 | .16 (.09)† | −.01, .33 | −.13 (.11) | −.34, .08 |
| Geographyb | −.26 (.12)* | −.48, −.03 | −.19 (.10)† | −.40, .01 | −.14 (.13) | −.40, .12 |
| N | 695 | 695 | 695 | |||
| R2 | .07 | .06 | .04 | |||
| F Statistic | 10.27*** | 9.27*** | 6.13*** | |||
Note.
p < .05,
p < .01,
p < .001,
p < .10;
Generation (1 = Silent Generation; 0 = Millennial, Generation X, Baby Boomers);
Geography (1 = Metro County; 0 = Non-Metro County);
“It seems like everything causes cancer.”
Individuals who report challenges in health information seeking had an increased likelihood of this fatalistic belief (b = .22; SE = .05; p < .001). Although perceived confidence in obtaining needed health information was not statistically significantly associated with this belief, the interaction between perceived confidence and challenges in health information seeking did yield statistical significance (b = .10; SE = .05; p < .05). Figure 1 shows that the relationship between perceived challenges in the information seeking process and this fatalistic cancer belief was strongest among those with high (b = .32; SE = .07; p < .001) and average (b = .22, SE = .05; p < .001) confidence to ultimately obtain any health information they need. The relationship was not statistically significant for those with low perceived confidence (b = .12; SE = .07; p = .07).
Figure 1.
The relationship between intrinsic barriers to health information seeking and two fatalistic cancer beliefs by 3 levels (−1SD, M, +1SD) of perceived confidence in health information seeking.
“There’s not much you can do to lower your chances of getting cancer.”
Perceived challenges in the health information seeking process (b = .20; SE = .05; p < .001) and less confidence to obtain needed health information (b = −.08; SE = .03; p < .05) were statistically significantly associated with an increased likelihood of this belief. The interaction between perceived confidence and challenges did yield statistical significance (b = .12; SE = .04; p < .01). Figure 1 shows that this relationship is strongest at high (b = .32; SE = .06; p < .001) and average (b = .20, SE = .05; p < .001) levels of confidence in obtaining needed health information. This relationship was not statistically significant at low levels of confidence (b = .07; SE = .06; p = .23).
“When I think about cancer, I automatically think death.”
Perceived challenges in the health information seeking process (b = .20; SE = .06; p < .001) and confidence to obtain needed health information (b = −.10; SE = .04; p < .05) were associated with an increased likelihood of this belief. Unlike the prior two fatalistic beliefs centralized around cancer prevention, interaction between these variables on this fatalistic belief about survivorship was not statistically significant.
DISCUSSION
The purpose of this study was to examine how perceived challenges and confidence in health information seeking are associated with fatalistic cancer beliefs. Results support tenets of behavior change theory [21] and health literacy perspectives [7], in that alleviating perceived challenges in the health information seeking process is critical to combat fatalistic cancer prevention beliefs across generations and rural-urban regions. Results have important implications for optimizing access to cancer prevention education with content that is salient to diverse age groups residing in rural and urban regions.
Similar to existing research [9], younger adults (Millennials and Generation X) held negative beliefs about the perceivably unavoidable causes of cancer and their potential to succumb to it, as compared to older adults (Baby Boomers and Silent Generation). Again, similar with prior research [11], individuals in metro regions were more likely than their non-metro counterparts to believe in precautionary actions that could lower their chances of getting cancer. However, it should be noted that nearly 80% of the sample, regardless of age and geographic residence, held this belief. As such, individuals generally hold positive beliefs about possible action to alleviate personal cancer risk, signaling an opportunity for intervention. Given this evidence, there is an empirical need for research to explore specific actions that individuals across generations and rural-urban residences believe are effective and feasible in lowering their cancer risk. Such evidence will inform culturally-adapted messages that uniquely address fatalistic cancer beliefs across generations and uniquely promote cancer prevention in rural-urban contexts.
Despite evidence supporting that older and rural adults generally have limited health literacy [13, 14], our study found that perceived challenges throughout the process of health information seeking were considerably low and did not vary by generation or rural-urban county residence. As expected, perceived confidence in the ability to obtain any needed health information was highest among individuals residing in metro counties with 250K-1M residents. However, individuals in non-metro counties (not adjacent to metro locations) had a higher degree of confidence than individuals in metro counties with less than 250K residents. This finding suggests that confidence in accessing needed health information is a determinant of rural-urban health information equity. According to behavior change literature [21], confidence in the ability to perform a behavior is one of the strongest predictors of future action. In an effort to facilitate rural-urban health information equity, research is needed to examine how confidence in accessing cancer information is uniquely cultivated across these regions. In the current study, individuals from metro and non-metro counties were equally likely to use the Internet as a primary health information resource. Future research must examine how rural-urban adults differ in their online health information seeking skills, as well as their preferred type and source of online cancer information.
Finally, this study confirmed that fatalistic cancer beliefs are independently reinforced by health information seeking challenges and low confidence in being able to get health information when it is needed. Unfortunately, we were unable to confirm our hypothesis that confidence in being able to obtain health information would attenuate the relationship between health information seeking challenges and fatalistic cancer beliefs. Rather, the positive relationship between perceived health information seeking challenges and cancer fatalism was strongest among individuals with a high degree of confidence to obtain health information. Interestingly, the theorized protective mechanism of confidence in being able to obtain health information only existed when perceived challenges in health information seeking process were low. Findings demonstrate that an important aspect of combatting fatalistic beliefs about cancer prevention is not simply cultivating confidence in the ability to obtain cancer information; rather, there is a need to facilitate individuals in their quest to find high-quality, useful, and personally relevant information.
Results of this study have especially important practical implications. In clinic-based care and through public health campaigns, people are often provided a website or brochure to learn more about a condition or behavior on their own time. Directing patients to health resources may facilitate confidence in having access to health information that is relevant to their situation; however, it does not necessarily protect them from experiencing challenges in extracting and comprehending information from the resource. This may explain why the public, which generally reports frustration in accessing high-quality and actionable health information [10], has a high degree of cancer information overload and avoidance [22, 23]. Results of this study support the importance of future research in (a) disseminating cancer prevention messages that infiltrate aspects of the rural-urban culture to different generations, and (b) continuing to enhance skills to effectively navigate and evaluate online information from diverse channels (e.g., government sites, social media, apps) and sources (e.g., providers, known and anonymous peers).
Strengths and Limitations
The results of this cross-sectional survey are correlational and cannot infer causation. As a secondary data analysis, we were unable to adapt survey items. A primary goal of the medical university-sponsored surveillance of its cancer catchment area is to compare outcomes at the state and national levels; therefore, items were not adapted to cancer-specific language. This study employed RDD recruitment, a population-based epidemiologic method; however, data from some rural counties were not represented. Future research is needed to confirm that confidence and challenges in health information seeking within the cancer context yields similar results, especially in predominantly rural regions.
Conclusion
Perceived challenges experienced throughout the health information seeking process is a strong contributing factor of cancer fatalism. Individuals who are confident in their ability to obtain health information but experience challenges throughout its process are most likely to have fatalistic cancer beliefs, particularly in regard to cancer prevention. Cancer fatalism was strongest among younger adults; however, the belief that precautions could be taken to reduce the chances of getting cancer was evident, especially among those residing in metro counties. This study has important implications for combating fatalistic cancer beliefs by improving the process by which people acquire health information. Two recommendations, which are grounded in the perspective of health information equity, include enhancing patients’ skills in accessing and evaluating health information on the Internet and optimizing the dissemination of culturally-adapted cancer education.
Funding Acknowledgement:
Research reported in this publication was supported by the National Heart, Lung, and Blood institute of the National Institutes of health under Award Number F32HL143938.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
REFERENCES
- [1].Niederdeppe Jeff and Gurmankin Andrea Levy. 2007. Fatalistic beliefs about cancer prevention and three prevention behaviors. Cancer Epidemiology, Biomarkers, and Prevention 16: 998–1003. [DOI] [PubMed] [Google Scholar]
- [2].Powe Barbara D. and Finnie Ramona. 2003. Cancer fatalism: The state of the science. Cancer Nursing 26: 454–467. [DOI] [PubMed] [Google Scholar]
- [3].Wigfall Lisa T. and Friedman Daniela B.. 2016. Cancer information seeking and cancer-related health outcomes: A scoping review of the Health Information National Trends Survey literature. Journal of Health Communication 21: 989–1005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4].Cohen Miri. 2013. Cancer fatalism: Attitudes toward screening and care In Psychological aspects of cancer, ed. Carr Brian I. and Steel Jennifer, 83–99. Boston MA: Springer Publications. [Google Scholar]
- [5].Valera Pamela, Lian Zi, Brotzman Laura, and Reid Andrea. 2018. Fatalistic cancer beliefs and information seeking in formerly incarcerated african-american and hispanic men: Implications for cancer health communication and research. Health Communication 33: 576–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Ramondt Steven and Ramirez A. Susana. 2017. Fatalism and exposure to health information from the media: examining the evidence for causal influence. Annals of the International Communication Association 41: 298–320. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [7].Paige. Samantha R, Stellefson Michael, Krieger Janice L., Anderson-Lewis Charkarra, Cheong JeeWon, and Stopka Christine. 2018. Proposing a transactional model of electronic health (eHealth) literacy. Journal of Medical Internet Research 20: e10175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Ramirez Artemio, Walther Joseph B., Burgoon Judee K., Sunnafrank Michael. 2002. Information-seeking strategies, uncertainty, and computer-mediated communication. Human Communication Research 28: 213–28. [Google Scholar]
- [9].Kobayashi Lindsay C. and Smith Samuel G.. 2016. Cancer fatalism, literacy, and cancer information seeking in the American public. Health Education and Behavior 43: 461–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Arora Neeraj K., Hesse Bradford W., Rimer Barbara K., Viswanath K, Clayman Marla L., Croyle Robert T.. 2008. Frustrated and confused: The American public rates its cancer-related information-seeking experiences. Journal of General Internal Medicine 23: 223–228. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Befort Christie A., Nazir Niaman, Engelman Kimberly, Choi Won. 2013. Fatalistic cancer beliefs and information sources among rural and urban adults in the USA. Journal of Cancer Education 28: 521–526. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Anker Ashley E., Reinhart Amber Marie, and Feeley Thomas Hugh. 2011. Health information seeking: a review of measures and methods. Patient Education and Counseling 82: 346–54. [DOI] [PubMed] [Google Scholar]
- [13].Chesser Amy K., Nikkie Keene Woods Kyle Smothers, and Rogers Nicole. 2016. Health literacy and older adults: A systematic review. Gerontology and Geriatric Medicine 2: 1–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Zahnd Whitney E., Scaife Steven L., and Francis Mark L.. 2009. Health literacy skills in rural and urban populations. American Journal of Health Behavior 33: 550–557. [DOI] [PubMed] [Google Scholar]
- [15].Centers for Disease Control and Prevention. Behavioral risk factor surveillance system: Overview of BRFSS 2016. Https://WwwCdcGov/Brfss/Annual_data/2016/Pdf/Overview_2016Pdf.2017 https://www.cdc.gov/nchs/data/databriefs/db20.pdf. Accessed 29 July 2018.
- [16].National Cancer Institute. Health information national trends survey. HINTS; https://hints.cancer.gov. Accessed 30 September 2019. [Google Scholar]
- [17].Dimock Michael. 2019. Defining generations: Where Millennials end and Generation Z begins. Pew Research Center; https://www.pewresearch.org/fact-tank/2019/01/17/where-millennials-end-and-generation-z-begins/. Accessed 2 August 2019. [Google Scholar]
- [18].National Cancer Institute. Rural-Urban Continuum Code - SEER Datasets. https://seer.cancer.gov/seerstat/variables/countyattribs/ruralurban.html. Accessed 2 August 2019.
- [19].Paige Samantha R., Elizabeth Flood-Grady Janice L. Krieger, Stellefson Michael, and Miller M. David. Measuring health information seeking challenges in chronic disease: A psychometric analysis of a brief scale. Chronic Illness. https://www.ncbi.nlm.nih.gov/pubmed/30889966. Accessed 8 April 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Hayes Andrew F. 2017. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press. [Google Scholar]
- [21].Jones Christina L., Jensen Jakob D., Scherr Courtney L., Brown Natasha R., Christy Katheryn, Weaver Jeremy. 2015. The health belief model as an explanatory framework in communication research: Exploring parallel, serial, and moderated mediation. Health Communication 30: 566–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [22].Jensen Jakob D., Carcioppolo Nick, King Andy J., Scherr Courtney L., Jones Christina L., and Niederdieppe Jeff. 2014. The cancer information overload (CIO) scale: Establishing predictive and discriminant validity. Patient Education and Counseling 94: 90–6. [DOI] [PubMed] [Google Scholar]
- [23].Loiselle CG. 2019. Cancer information-seeking preferences linked to distinct patient experiences and differential satisfaction with cancer care. Patient Education and Counseling 102: 1187–93. [DOI] [PubMed] [Google Scholar]