Gloria Lopez-McKee, PhD, RN
Low-income, low-health-literacy Mexican-American women exhibit poor mammography screening participation and are being diagnosed at later stages of breast cancer than are non-Hispanic white women. No instrument has been available to measure the impact of cultural and psycho-social factors on the intent to seek mammography screening participation in this population. In this article the author describes the development process of the English Mammography Beliefs and Attitudes Questionnaire (MBAQ) and the Spanish Mammography Beliefs and Attitudes Questionnaire (SMBAQ). The Theory of Planned Behavior is the theoretical framework underlying these instruments designed to measure intent to seek mammography screening in low-health-literacy Mexican-American women. The process of developing the MBAQ utilized input from low-health-literacy Mexican-American women and an expert committee. The MBAQ was translated into Spanish and assessed for content validity and reading level. In the discussion, the author explains why the MBAQ and SMBAQ are appropriate tools for use with low-health-literacy Mexican-American women to measure their intentions to seek mammography screening. Limitations of the study and implications for practice and research are presented.
Citation: Lopez-McKee, G., (November 24, 2010) "Development of the Mammography Beliefs and Attitudes Questionnaire for Low-Health-Literacy Mexican-American Women" OJIN: The Online Journal of Issues in Nursing Vol. 16 No. 1.
Keywords: breast cancer, cancer fatalism, translation of instruments, instrument development for low-health-literacy individuals, mammography screening among Hispanic women, breast cancer prevention, the Theory of Planned Behavior, health-literacy among Mexican-American women, Spanish language instruments, cultural adaptation of health instruments.
Only 38% of low-income, low-health-literacy Mexican-American women over the age of 40 have regular screening mammograms despite the availability of federally subsidized mammograms for this population. Low-income, low-health-literacy Mexican-American women are more likely to be diagnosed at a later stage of breast cancer and have lower survival rates than non-Hispanic white women (American Cancer Society (ACS), 2007; Fernandez, Palmer, & Leong-Wu, 2005; Intercultural Cancer Council (ICC), 2005; O’Brien et al., 2003).
In this article I will describe the development process of the English Mammography Beliefs and Attitudes Questionnaires (MBAQ) and the Spanish Mammography Beliefs and Attitudes Questionnaire (SMBAQ), utilizing the Theory of Planned Behavior as the theoretical framework. I designed these questionnaires to measure the intent to seek mammography screening in low-health-literacy Mexican-American women. The method used to develop the MBAQ included the utilization of input from low-health-literacy Mexican-American women and an expert committee. The MBAQ was translated into Spanish and assessed for content validity and reading level. The instruments have subsequently been revised and are currently titled the MBAQ-R and the SMBAQ-R. In the discussion section I will explain why the MBAQ and SMBAQ are appropriate tools for use with low-health-literacy Mexican-American women to measure their intentions to seek mammography screening. Limitations of the study and implications for practice and research will be presented. It is my goal that this article will motivate and guide others to develop health-related instruments or materials to facilitate health literacy among the Hispanic population.
Hispanics are composed of many different subgroups, each with different usage of Spanish language terms. One of the reasons I developed the MBAQ and SMBAQ specifically for use with low-health-literacy Mexican-American women was that health-related materials currently available in Spanish have been written to reach a generic Hispanic audience. However, Hispanics are composed of many different subgroups, each with different usage of Spanish language terms. Utilizing generic Spanish language materials that are written to reach all Hispanic subgroups may cause confusion among low-health-literacy individuals. Another reason was that millions of Hispanics in the United States (US) are classified as being Low-English-Proficient (LEP). LEP individuals are those who are classified as being unable to read or write English well enough to understand written healthcare information or navigate the healthcare system (U.S. Department of Education, 2005; U.S. Department of Health and Human Services, 2001). The confusion experienced by reading these generic materials may be adding to the problem of low-health-literacy and possibly contributing to the poor participation of Hispanics in health screening (Lopez-McKee, 2005; Meade, Calvo, & Cuthbertson, 2002).
These instruments are culturally appropriate tools for assessing how cultural and psychosocial factors impact the intentions of low-health-literacy Mexican-American women to seek mammography screening. A subsequent article will present the validity and reliability testing of these instruments.
The Theory of Planned Behavior (TPB) (Ajzen, 1985) was utilized as the theoretical framework for this study because it addresses psychosocial factors that can be used as predictors of the intention to seek mammography screening by low-health-literacy Mexican-American women. It identifies links between attitudes and behavior. The TPB is a persuasive ‘prediction’ theory which has been applied in various disciplines to predict a specific behavior.
The TPB considers behavioral determinants, such as attitudes, social norms, and perceived behavioral control, which are considered to be powerful predictors of the intention to perform a specific behavior. According to the TPB, behavior and human action is guided by three kinds of considerations: beliefs about the likely outcomes of the behavior and the evaluations of these outcomes (behavioral beliefs); beliefs about the normative expectations of others (including the cultural expectations) and the motivation to comply with these expectations (normative beliefs); and beliefs about the presence of factors that may facilitate or impede performance of the behavior and the perceived power of these factors (control beliefs) (Ajzen, 1985).
Researchers (Baron-Epel, 2009; Cooke & French, 2008; Mayo, 2001; Spurlock & Cullins, 2006) have reported that the psychosocial behavioral determinants impacting mammography screening vary between racial and ethnic groups. Baron-Epel (2009) studied beliefs, attitudes, and barriers associated with mammography use in four distinct cultural and ethnic groups in Israel, namely veteran, ultra-orthodox, and immigrant Jewish and Arab women. The author reported that subjective norms, fatalism, fear of breast cancer, and perceived effectiveness were associated with mammography in some of the population groups but not in others, and concluded that each population had a unique set of variables predicting mammography use.
Cooke and French (2008) completed a meta-analysis of 33 studies to quantify how well the TPB predicted the relationship between intentions to attend screening programs and actual screening attendance in different populations. They found that there was considerable variation between the psychosocial behavioral determinants (attitudes, perceived behavioral control, and subjective norms) and the intention to seek screening among different ethnic and cultural groups. This study emphasized the need to study the attitudes, perceived behavioral control, and subjective norms of a given population before planning an intervention for a specific population.
Mayo, Ureda, and Parker (2001) conducted a study among older, rural African-American women, examining the relationship between demographic factors and other correlates of fatalism and assessing the impact of fatalistic perceptions on participation in breast cancer screening. Fatalistic perceptions included feelings of not having control over preventing cancer and pessimism regarding the value of screening. This study found that age, race, and education may be important predictors of fatalism. The authors concluded that fatalism may be one barrier that previously has not adequately been measured so as to understand predictors of screening behaviors in these women.
Another study identifying the influence of fatalism on cancer screening in minority women was conducted by Spurlock and Cullins (2006). They studied 71 low-income, African-American women and found (a) that use of clinical breast exam and mammography was significantly related to cancer fatalism scores, and (b) that the degree of fatalism was significantly correlated with age, income, and education. This study reported that as the participants’ age increased, their perception of cancer fatalism increased; as the participants’ income and education increased, their perception of cancer fatalism decreased.
Various cultural and psychosocial factors that impact mammography screening among Hispanic women have been reported in the literature. One of the cultural factors found to contribute to poor participation in mammography screening by Hispanic women was that of fatalistic attitudes toward cancer screening.These attitudes, held by many Hispanic women, especially those who have low income and low educational levels, have a negative impact on their mammography screening participation (Deterborn, DuHamel, Butts, Thompson, & Jandorf, 2005; Fernandez et al., 2005; Lopez-McKee, McNeill, Bader, & Morales, 2008). The concept of cancer fatalism includes a number of complex variables. In a study conducted to validate the Powe Fatalism Inventory (Powe, 1995) among a Mexican-American population, themes such as ‘predestination,’ ‘pessimism,’ ‘feelings of imminent death,’ and ‘feelings of fear’ were found to surround the construct of fatalism (Lopez-McKee, 2005).
Another psychosocial factor found to impact mammography screening among Hispanic women was that of the influence of family, friends, and physicians on participation in health screening by Hispanic women. The participation rates of Hispanic woman in breast and cervical cancer screening have been found to be positively or negatively influenced the approval or disapproval of the woman’s husband or other family members to seek screening.Otero-Sabogal, Stewart, Sabogal, Brown, and Perez-Stable (2003) found that Hispanic women are influenced to participate in breast or cervical cancer screening by their physician’s recommendation for screening.
Additional psycho-social factors that have been identified in the literature as impacting Hispanic women’s participation in cervical and breast cancer screening include women’s attitudes regarding the perceived value of obtaining a mammogram, perceived risk of getting breast cancer in their lifetime, feelings of control over their own breast health, fear of getting negative results from mammography screening, religious or spiritual beliefs toward cancer; procrastination, and embarrassment (Carter, Park, Moadel, Cleary, & Morgan, 2002).
Process of Instrument Development
This study utilized a measurement research design drawing on recommendations from Mexican-American women at various points during the development process. Institutional Review Board (IRB) approval to conduct the study was obtained from the University of Texas at El Paso. The setting for this study was a mid-size city located on the U.S.-Mexico border, whose Mexican-American population was approximately 80% of the total population.
The process for developing the MBAQ and SMBAQ consisted of several steps, including: (a) development of items for the MBAQ by an expert committee; (b) translation of the MBAQ into Spanish (SMBAQ); (c) cultural adaptation of the SMBAQ to the Spanish utilized by low-health-literacy Mexican-American women in focus groups; and (d) assessment of content validity and reading level of the MBAQ and SMBAQ by the same expert committee.
Development of Items and Subscales on the MBAQ
The English version of the Mammography Beliefs and Attitudes Questionnaire (MBAQ) was developed first and then translated, culturally adapted into the Spanish that is utilized by the Mexican-American culture, and titled the Spanish Mammography Beliefs and Attitudes Questionnaire (SMBAQ). The MBAQ and SMBAQ were developed within the same timeframe in order to complete the psychometric validation of both instruments utilizing the same participants in order to determine the equivalence of the English MBAQ to the SMBAQ.
Items for the English MBAQ were developed with the help of a committee consisting of three oncology nurses who were of Mexican-American descent and bilingual in English and Spanish, and who worked with low-health-literacy Mexican-American women in their clinical practice.This committee will be hereafter referred to as the expert committee. The expert committee utilized an existing instrument, the Beliefs and Attitudes Questionnaire (BAQ), developed by Young, Lierman, Powell-Cope, Kasprzyk, and Benolict (1991), as a model for developing the items of the MBAQ.
The BAQ was selected as a model for developing the MBAQ because the BAQ also utilized the Theory of Planned Behavior (TPB) as the theoretical framework for its development. The BAQ applied the theoretical concepts from the TPB to Breast Self Exam, (BSE), and identified important “content domains” for determining a woman’s perceptions about her own breast health. The BAQ was also selected because it had demonstrated reliability coefficients (0.70 - 0.86) on different subscales of the instrument. These subscales included BSE Attitudes, BSE Perceived Behavioral Control, Behavioral Beliefs, and Normative Beliefs.
The MBAQ was developed using a five-step process outlined by Francis et al. (2004) when developing TPB questionnaires.This process is based on premises outlined by Ajzen (1985).This five-step process included:
- Selecting a behavior of interest, in this case mammography screening;
- Identifying wording of items that maintained consistency with the behavioral target; for example: “My getting a mammogram within the next 12 months would be...”
- Identifying the general attitude, social norm, and behavioral control. This was done by using statements, such as: “My getting a mammogram in the next 12 months would be...,” answered on a 4-point semantic-differential-type-scale with, for example, the following dimensions: good/bad; necessary/unnecessary; important/unimportant.
- Eliciting the salient behavioral, normative, and perceived control beliefs about the target behavior from a representative sample. This was accomplished with the use of two focus groups composed of low-health-literacy Mexican-American women.
- Actually developing the questionnaire items based on the salient behavioral, normative, and perceived control beliefs. This was accomplished with the help of the expert committee utilizing focus group input.
The expert committee examined each of the items on the BAQ to determine which of the items could be adapted to reflect some of the identified factors that were found to influence Hispanic women in seeking mammography screening. Only 25 out of the 65 items from the BAQ were identified as adaptable to mammography screening on the MBAQ. The other 40 items from the BAQ dealt with topics that were too specific to Breast Self Exam procedures and guidelines, and were not appropriate for adaptation to mammography screening. The 25 items adapted for the MBAQ were written to incorporate the most common factors impacting Mexican-American women in their decision to participate in mammography screening, as identified by the expert committee.
The 25 items adapted for the MBAQ were written to incorporate the most common factors impacting Mexican-American women in their decision to participate in mammography screening, as identified by the expert committee. The 25 items developed for the MBAQ were divided into five subscales: Subscale A, which included items dealing with attitudes toward seeking mammography screening. The items under Subscale B included behavioral intentions to seek a mammogram. Items under Subscale C included items pertaining to perceived control over getting screened for breast cancer. Items under Subscale D included items pertaining to perceived risk of getting breast cancer. Subscale E items pertained to the influence of family or physician recommendations in seeking mammography screening.
The response options of the items on the MBAQ were developed based on the recommendations by Francis et al. (2004) for the development of TPB questionnaires. Response options were structured in a semantic-differential-type scale, which measured people's reactions to stimulus words and concepts in terms of ratings on a bipolar scale. For example, adjective pairs such as valuable/worthless, harmful/beneficial, as well as good/bad were utilized. These types of adjective pairs were chosen to capture the overall evaluation of a construct.Four different response options were offered between every set of bipolar adjectives on the MBAQ, with one option being the response option of don’t know. Numerical values were assigned to each of the 4 response options on each item of the MBAQ, in order to facilitate the analysis and correlation of responses (Francis et al., 2004).
[low-literacy] individuals encounter difficulty in answering lengthy questionnaires which include a large number of response choices. Only four response options were offered for each item on the MBAQ in order to simplify the use of the instrument by low-education, low-English proficiency (low-health-literacy) Hispanic women. Research with low-literacy populations has shown that these individuals encounter difficulty in answering lengthy questionnaires which include a large number of response choices. The comprehension of written materials for use with low-literacy individuals can be improved by simplifying the language (reading level), the length and complexity of written materials, and the length and number of response options on questionnaires (Calderon, Smith & Baker, 2007; Weiner et al., 2004).
Translation of the MBAQ into Spanish (SMBAQ)
The items on the MBAQ were translated into Spanish using a model of translation (Lopez-McKee, 2005) that incorporates the view of a specific culture.The MBAQ was adapted specifically to the view of the Mexican-American culture by a series of forward-and-back translations, and reviewed by a bilingual expert committee.The cultural adaptation of the instrument was completed by incorporating the input from focus groups composed of low-health-literacy Mexican-American women.This translation model was selected for use in translating the MBAQ because it provided a systematic method for developing a Spanish-language version of an instrument adapted to a specific Spanish cultural group (Lopez-McKee, 2005). For this study, the specific cultural group included low-health-literacy Mexican-American women. This process of translation differs from “cross-cultural” methods of instrument translation, which aim to arrive at a consensus translation of an instrument that can be utilized across Hispanic subgroups, and which utilize translators and experts from several Hispanic subgroups in the translation process (Agency for Health Care Policy and Research [AHCPR], 1999); Matias-Carello et al., 2003).
Forward and backward translation of the SMBAQ. The English MBAQ was translated into Spanish (forward translation) by three independent, bilingual, and bicultural certified translators who were members of the Mexican-American culture.Another three independent, bilingual, and bicultural certified translators who were members of the Mexican-American culture but who had never seen the original English version of the original instrument developed the three back translations from Spanish to English.
Expert committee review of the SMBAQ. Each version of the three forward and three back-translations of the original instrument was then reviewed by the same expert committee who developed the items on the MBAQ. As previously mentioned, the members of this expert committee were Mexican-American, bilingual, and bicultural to the Spanish language in order to continue to incorporate the specific view of the Mexican-American culture during this phase of the development of the MBAQ.
The three bilingual/bicultural experts arrived at a consensus Spanish version of the MBAQ, which was then named the Spanish Mammography Beliefs and Attitudes Questionnaire (SMBAQ). The consensus version of the SMBAQ was derived by the three committee experts. First they individually examined each of the forward-and-back translations, making notations of which translation best represented the meaning of the English version of the instrument into the Spanish utilized by the Mexican-American culture. The three experts then worked together as a committee to arrive at a consensus version of each item on the SMBAQ that was most representative of the original intent of the items on the MBAQ. The consensus version of each item on the SMBAQ was selected by a majority vote from the same expert bilingual committee considering its likelihood of being understood by low-health literacy Mexican-American women. For example, each of the 3 certified translators who translated the MBAQ into Spanish (forward translation), considered the following item on the MBAQ into Spanish: “My getting a mammogram during the next 12 months would be...” .This item was translated by Translator #1 as, “El hacerme una mamografía en los próximos 12 meses sería…”, which translates as: ‘Getting a mammogram done in the next 12 months.’ It was translated by Translator #2 as, “El tomar una mamografía durante los próximos 12 meses será…”, which means: ‘having a mammogram taken in the next 12 months;’ and by Translator #3 as, “El someterse a una mamografía durante los próximos 12 meses sería...”, which means: ‘to undergo a mammogram in the next 12 months.’ Although all three translated versions of this ítem convey approximately the same message, the words in italics above indicate the differences in word usage.
Each expert committee member discussed the usage of each of the terms derived by each translator and reviewed the translations of the other 3 certified translators back into English (back-translation). All three committee experts decided that the first translation listed above ‘El hacerme una mamografía en los próximos 12 meses,’ most clearly represented the original intent and wording of the English versión of the ítem on the MBAQ and would be most clearly understood by low-health-literacy Mexican-American women.
Cultural Adaptation of the SMBAQ by Focus Groups
As mentioned previously under Step 4 of the 5-step process recommended by Ajzen (1985) in developing TPB questionnaires, there was a second phase for validating the salient behavioral, normative, and perceived control beliefs about mammography screening that were developed by the expert committee. This phase was accomplished with the use of focus groups composed of low-income, low-English proficiency, low-health-literacy Mexican-American women who were representative of those for whom the MBAQ and SMBAQ were developed.These focus groups, which were comprised of different participants than those who assisted in the development of the initial MBAQ, gave input relative to the appropriateness of the content of each item on the SMBAQ for use with Mexican-American women, and also on the appropriateness of the Spanish utilized on the SMBAQ for use with Mexican-American women.
The following inclusion criteria were utilized for each of the two focus groups: (a) women who self-identified as being of Mexican-American descent; (b) women who were over 40 years of age; (c) women who had an educational level less than 8th grade; and (d) women whose preferred language in writing and speaking was Spanish.This information was obtained from potential participants by the use of a demographic questionnaire.
The determination of low-health-literacy in potential participants in each focus group was completed using the two criteria of: an educational level below the 8th grade, and a statement that the preferred language when writing and speaking was Spanish. These criteria established a low English proficiency level (LEP).LEP individuals, according to the U.S. Department of Health and Human Services’ (2001) standards for assessment of low health literacy, can be considered to have a low-health-literacy level.
Focus group members were recruited either from a community center or a senior citizen center located in the city of El Paso, Texas. Women were recruited to participate in one of the two focus groups through the use of flyers posted in the community center and in the senior center utilized for this study. A total of 30 women who expressed an interest in participating were screened as potential participants, and a total of 14 women were identified who met all of the inclusion criteria to participate in this study. Participants who met all the inclusion criteria were offered a $20 gift card for participating in a two-hour focus group session. A total of eight women were recruited into the first focus group and six women were recruited into the second focus group.
Demographic characteristics of these focus group participants included 14 women who ranged in ages from 41 to 85, with a mean age of 58. All women recruited to participate in the two focus groups self-identified as being of Mexican-American descent. The majority of the 12 women had an educational level below the 6th grade. Only two women had achieved an 8th grade educational level. All the women recruited to participate in each focus group stated that their preferred language when speaking and reading was Spanish.
Each participant was asked to sign an informed consent form; all of the participants in each focus group chose the Spanish version of the informed consent. The informed consent was read to each participant by the Principal Investigator (PI), in order to mediate for any reading deficiencies they might have. Focus group members were told that the focus group session would be recorded. Participants were asked to use only first names during the session to ensure their anonymity. Participants were given the option of signing the informed consent form in either English or Spanish.
A focus group leader who had many of the same characteristics as the participants in the focus groups was selected to lead the discussions in order to increase the comfort of the participants in discussing concepts related to mammography screening. The focus group discussions for both focus groups were conducted by a trained focus group leader who was a bilingual, Mexican-American woman over the age of 40. A focus group leader who had many of the same characteristics as the participants in the focus groups was selected to lead the discussions in order to increase the comfort of the participants in discussing concepts related to mammography screening.
One focus group session was conducted at a combined community center and clinic located in one of the colonias (unincorporated communities) found in the outskirts of the city of El Paso, Texas. The focus group session was held in a private room that is typically used to hold educational activities. The second focus group session, which was conducted at a senior citizen center in the city of El Paso, Texas, was also held in a private classroom that was often used to teach arts and crafts to the seniors. The only persons who attended both focus group sessions were the focus group leader and myself as the PI. During both focus group sessions, the leader explained, in Spanish that the purpose of the focus group session was to ask each participant to give their opinion about each item on the SMBAQ with respect to the level of difficulty of the Spanish utilized on the questionnaire, whether the type of Spanish utilized on the questionnaire was the type of Spanish they commonly used, whether the participants understood what was being asked by each item on the questionnaire, and whether they thought each item on the questionnaire was appropriate to ask Mexican-American women concerning their thoughts and feelings about mammography screening.
Participants were provided with the SMBAQ, and asked to read each item as the focus group leader read each item aloud. Participants were asked to circle their response to each question on the questionnaire as the focus group leader read each item to the group. Participants were given a few minutes after the focus group leader read each item so that they could reflect and mark their answer on each item prior to discussing it with the rest of the group.
The focus group leader then asked participants to share with the group their opinion about the wording of each of the items on the SMBAQ. This included identifying any difficulty in reading and/or understanding each item. In addition, the participants were asked if the SMBAQ used the same type of Spanish they used to express themselves, and if they thought each item on the SMBAQ was asking relevant information from women who belonged to the Mexican-American culture.
Focus group members discussed suggestions for modification to the wording and appropriateness of the SMBAQ for use with Mexican-American women. Only suggestions that were mentioned by participants in both focus groups were actually incorporated into the final version of the SMBAQ.
Another example of a suggestion given by group members included modification of the wording of a question which asked if getting a mammogram would cause embarrassment. Several suggestions were made by both focus groups. For example, focus group members suggested changing the term used to refer to ‘breast cancer,’ which was originally written as cáncer de mama. Several members from both focus groups stated they preferred the use of the term cáncer del seno or cáncer del pecho when speaking about breast cancer, since they had never heard of cáncer de mama. Another example of a suggestion given by group members included modification of the wording of a question which asked if getting a mammogram would cause embarrassment. The Spanish term for embarrassment utilized in the original questionnaire was verguenza. At the suggestion of both focus groups, that term was changed to seria penoso, which also means embarrassment, but does not imply a feeling of guilt as with the word verguenza.
Women in each focus group were also asked to give their opinion about the content of each question and whether the questions on the MBAQ were appropriate to elicit thoughts and feelings they had about mammography screening. One suggestion made to the content of the questions on the SMBAQ included a question which asked what they thought was their risk of getting breast cancer in their lifetime. Several participants in each focus group indicated that this question was very confusing, since they could not predict this. Another question that several women from each focus group found confusing asked if they wanted to have direct control over their breast health. Women indicated confusion about what the question was asking because they were not sure what direct control meant.
The recordings from each focus group session were transcribed by a professional transcriptionist. The final transcription of the recordings was reviewed by the same bilingual expert committee that reviewed other phases of the instrument development and translation.Content analysis of the transcription was completed by the expert committee, and all changes suggested by both focus groups were incorporated into the final version of the SMBAQ. Items on the SMBAQ that both focus groups found to be confusing were reworded.
Content Validity Assessment and Reading Level of the MBAQ and SMBAQ
The Content Validity of the final version of the MBAQ and SMBAQ was evaluated by the same bilingual expert committee using the Lynn Content Validity Index (CVI) (Lynn, 1986). Committee members evaluated each of the items on the MBAQ and the SMBAQ. Each expert rated each of the items on each instrument according to its relevance and clarity in measuring the factors identified as impacting participation of low-health-literacy Mexican-American women in mammography screening.
The scoring system of the Lynn Content Validity Index (CVI) includes the following: items that are somewhat relevant are scored with a 2, items that are quite relevant are scored with a 3, and items that are highly relevant are scored with a 4. Only items scored with 3’s and 4’s are considered to be relevant content and thus used to calculate the actual CVI. Since all three expert committee members rated each of the items on the MBAQ and SMBAQ with either 3’s or 4’s, the MBAQ and SMBAQ were found to be content valid for use with low-health-literacy Mexican-American women. Expert ratings of an instrument as being ‘content valid’ (that is, 3 out of 3 experts rated the MBAQ and SMBAQ as being content valid), provided a Content Validity Index (or ratio) of ‘1,’ meaning that the instrument was found to be content valid (Lynn, 1986).
The reading level of the MBAQ and the SMBAQ was evaluated by the same expert committee using the Fry Graph (Fry, 1977), for the English version of the instrument (MBAQ) and the Fry Readability Adaptation for Spanish Evaluation (FRASE graph) (Vari-Cartier, 1981) for the SMBAQ. The expert committee determined that both the MBAQ and the SMBAQ had a reading level below the 6th grade level. This reading level was found to be appropriate for the MBAQ and SMBAQ to be used with LEP and low-health-literacy English- and Spanish-speaking Mexican-American women.
Revision of the subscales of the MBAQ and SMBAQ
The MBAQ and SMBAQ were developed to incorporate a reading level appropriate for use with Low English Proficiency and low-health-literacy Mexican-American women. The number of subscales on the MBAQ and SMBAQ were decreased to 3 subscales after further testing the MBAQ and SMBAQ with a sample of low-health-literacy Mexican-American women (Lopez-McKee et al. 2008).Six of the original 25 items were removed from the original MBAQ and SMBAQ because they demonstrated inadequate psychometric properties during this study. After removing these items, the two instruments were left with three subscales; the instrument names were changed to Revised MBAQ (MBAQ-R) and Revised SMBAQ (SMBAQ-R).
The three remaining subscales on the MBAQ-R and SMBAQ-R were revised to include the following: Subscale A, which now includes items dealing with attitudes toward seeking mammography screening, Subscale B, which includes items dealing with perceived control over getting screened, and Subscale C, which includes items dealing with the influence of family or physician recommendations in getting screened (See Table).
|Table. Illustration of MBAQ questions
Subscale A: (Attitudes about mammography screening)
- My getting a mammogram during the next 12 months would be:
Very Bad…………………………Very good
- My getting a mammogram during the next 12 months would be:
- My getting a mammogram during the next 12 months would be:
- My getting a mammogram during the next 12 months would be:
- My getting a mammogram during the next 12 months would be:
Subscale B: (Perceived Control over seeking mammography screening)
(Scale end points: Disagree……………………Strongly agree)
- My getting a mammogram would be very difficult to schedule.
- My getting a mammogram would be embarrassing because they have to touch my breasts.
- My getting a mammogram would make me worry about getting a diagnosis of breast cancer.
- My getting a mammogram would be unlikely because I tend to put it off.
|Subscale C: (Influence of Family and Friends in seeking mammography screening)
- Most of the people I know think I should get a mammogram once per year.
- How much do you feel you are influenced by your doctor to get a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your husband in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your friends in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your family in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your girl friend(s) in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your sister(s) in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by your daughter(s) in getting a mammogram?
Not at all……………………………………Very much
- How much do you feel you are influenced by television and advertisements in getting a mammogram?
Not at all……………………………………Very much
The Spanish version of this instrument can be obtained by emailing the author and asking for a copy of the SMBAQ.
Regarding scoring, a high score on Subscale A would indicate a negative attitude toward seeking mammography screening in the next 12 months; a high score on Subscale B would indicate that a woman feels a lack of control over getting mammography screening due to identified barriers; and a high score on Subscale C would indicate a strong influence of family and/or friends and/or physician in the decision to obtain mammography screening.
The SMBAQ was culturally adapted to incorporate the type of Spanish utilized by low-health-literacy Mexican-American women and to incorporate concepts that are relevant to Mexican-American women when seeking mammography screening.In this study two instruments (MBAQ and the SMBAQ) were developed to measure cultural and psychosocial behavioral factors impacting intentions to seek mammography screening among low-income, low-health-literacy Mexican-American women. Item development for the MBAQ and SMBAQ was guided by the Theory of Planned Behavior.
These instruments can be utilized by healthcare providers to identify factors leading to negative intentions to participate in mammography screening by low-health-literacy Mexican-American women. The MBAQ and SMBAQ provide two culturally appropriate tools for use with low-health-literacy Mexican-American women. The MBAQ and SMBAQ were developed to incorporate a reading level appropriate for use with Low English Proficiency and low-health-literacy Mexican-American women. The SMBAQ was culturally adapted to incorporate the type of Spanish utilized by low-health-literacy Mexican-American women and to incorporate concepts that are relevant to Mexican-American women when seeking mammography screening.
Limitations of this Study
One limitation of this study is that this instrument was developed and culturally adapted specifically for use with low-health-literacy Mexican-American women. The use of the MBAQ and SMBAQ may not be appropriate for use with women from other Hispanic subgroups, or with Mexican women who reside in Mexico.
Another limitation is that the cultural adaptation of the items on the MBAQ and SMBAQ was guided by input from only two focus groups composed of low-income, low-health-literacy Mexican-American women. Further input from a larger sample of English and Spanish speaking low-income, low-health-literacy Mexican-American women should be obtained in order to validate the salient cultural and socio-cognitive factors identified that influence mammography screening participation among this population.
Implications for Practice and Future Research
...the description of the process utilized to develop the MBAQ and SMBAQ can assist others in developing culturally appropriate, health-related materials to facilitate health literacy among the Hispanic population.The MBAQ and the SMBAQ are culturally appropriate tools for use by clinicians in assessing factors which most strongly impact intentions to seek mammography screening among low-health-literacy Mexican-American women. By assessing the factors that most strongly impact the decision to obtain mammography screening, healthcare providers can develop interventions to influence attitudes, to increase social support, and/or to increase women’s perceived control over obtaining mammography screening. Also the description of the process utilized to develop the MBAQ and SMBAQ can assist others in developing culturally appropriate, health-related materials to facilitate health literacy among the Hispanic population.
Future studies will need to test the psychometric properties of the revised version of the MBAQ and SMBAQ (MBAQ-R and SMBAQ-R) with 19 items, using additional samples of low-health-literacy Mexican-American women. This will be necessary to determine if deletion of the 6 items from the original instruments has improved their psychometric properties.
Future studies should adapt and test the MBAQ and SMBAQ for use with women from other Hispanic subgroups. The implementation of assessment tools which are culturally and linguistically appropriate for Hispanics may improve their healthcare outcomes, thereby decreasing the health disparities in this population. With the growing diversity of cultures in the United States, the large proportion of low-health-literacy individuals, and the need for increased cultural competence in healthcare, it is becoming increasingly important to find ways of adapting health-related instruments for research with low-health-literacy minority populations.
The implementation of assessment tools which are culturally and linguistically appropriate for Hispanics may improve their healthcare outcomes, thereby decreasing the health disparities in this population. The MBAQ and the SMBAQ were found to be content valid for use with low-health-literacy Mexican-American women. The research described in this article has provided evidence that incorporating the input from low-health-literacy Mexican-American women during the development of these two instruments helped produce instruments that are appropriate for use with this population in measuring factors which impact mammography screening.
This contribution to the literature is important because very few instruments are available to assess factors that contribute to poor mammography screening participation in this population. This study has provided a model for the design of future instruments that will facilitate health literacy among the Hispanic population.
Acknowledgement: This study was funded by the National Institutes of Health, National Center on Minority Health and Health Disparities (Grant No. P20 MD000548) through the Hispanic Health Disparities Research Center, El Paso, Texas.
Gloria Lopez-McKee, PhD, RN
Dr. Lopez-McKee is an Assistant Professor at the University of Texas at El Paso. Her research focuses on the development, translation, and cultural adaptation of health-related instruments into Spanish. She developed the Spanish version of the Powe Fatalism Inventory, a process that included the cultural adaptation of this inventory to a Mexican-American population. She also developed the English and Spanish versions of the Mammography Beliefs and Attitudes Questionnaire (MBAQ and SMBAQ) and validated these instruments with a bilingual population of Mexican-American women. She has tested all three instruments with samples of low-health-literacy Mexican-American women. Dr. Lopez-McKee earned her BSN from the University of Texas System School of Nursing at El Paso, her MSN from the University of Texas at El Paso School of Nursing and Allied Health, and her PhD in Nursing Research from the University of Houston Health Science Center School of Nursing.
Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckman (Eds.), Action-control: From cognition to behavior (11-39). Heidelberg: Springer.
American Cancer Society. (2007). Cancer facts and figures for Hispanics and Latinos 2006- Atlanta, GA. Retrieved July 20, 2010 from http://www.cancer.org/.
Baron-Epel, O. (2009). Attitudes and beliefs associated with mammography in a multiethnic population in Israel. Health Education and Behavior, 1, 1090198109339460.
Calderon, J., Smith, S., & Baker, R. (2007). A simple method for enhancing readability of patient information. Annals of Behavioral Science and Medical Education, 13(1), 20-24.
Carter, J., Park, E., Moadel, A., Cleary, S., & Morgan, C. (2002). Cancer knowledge, attitudes, beliefs, and practices of disadvantaged women in the South Bronx. Journal of Cancer Education, 17(3), 142-149.
Cooke, R., & French, D. (2008). How well do the theory of reasoned action and the theory of Planned behavior predict intentions and attendance at screening programmes? A meta-analysis. Psychology and Health, 23(7), 745-765.
Detterborn, L., DuHamel, K., Butts, G., Thompson, H., & Jandorf. (2005). Cancer fatalism and its demographic correlates among African American and Hispanic women: effects on adherence to cancer screening. Journal of Psychosocial Oncology, 22(4), 47-60.
Fernandez, M., Palmer, R., & Leong-Wu, C. (2005). Repeat mammography screening among low-income and minority women: A qualitative study. Cancer Control, 12, Suppl 2, 77-83.
Francis, J., Eccles, M., Johnston, M., Walker, A., Grimshaw, J., Foy, R.,…Bonetti, D. (2004). Constructing questionnaires based on the Theory of Planned Behavior: A manual for health services researchers. UK: Centers for Health Services Research.
Fry, R. (1977). Fry’s readability graph: Clarifications, validity and extension to level 17. Journal of Reading, 21, 241-252.
Intercultural Cancer Council. (2005). Hispanics/Latinos & cancer fact sheet. Retrieved July 22, 2010 from http://iccnetwork.org/cancerfacts/cfs4.htm.
Li, C., Malone, K., & Daling J. (2003) Differences in breast cancer stage, treatment, and survival by race and ethnicity. Archives of Internal Medicine, 163(1), 49-56.
Lopez-McKee, G. (2005). Spanish Translation, cultural adaptation and validation of power fatalism inventory among a Mexican-American population. Published doctoral dissertation, University of Houston Health Sciences Center School of Nursing.
Lopez-McKee, G., McNeill, J., Bader, J., & Morales, P. (2008). Comparison of factors affecting repeat mammography screening of low-income Mexican-American women. Oncology Nursing Forum, 35(6), 941-946.
Lynn, M.R. (1986). Determination and quantification of content validity. Nursing Research, 35, 382-385.
Matias-Carello, L.M., Chavez, G. A., Negron, G., Canino, G., Aguilar-Gaxola, S., & Hoppe, S. (2003). The Spanish translation and cultural adaptation of five mental health outcome measures. Culture, Medicine and Psychiatry, 27, 291-313.
Mayo, R., Ureda, J., & Parker, V. (2001). Importance of fatalism in understanding mammography screening in rural elderly women. Journal of Women Aging, 13(1), 57-72.
McKinney, J. & Kurtz-Rossi, S. (2000). Culture, health and literacy: A guide to health education materials for adults with limited English literacy skills. Retrieved July 22, 2010 from www.worlded.org/US/health/docs/culture.
Meade, C.D., Calvo, A., & Cuthbertson, D. (2002). Impact of culturally, linguistically, and literacy relevant cancer information among Hispanic farmworker women. Journal of Cancer Educucation,17(1), 50-54.
O’Brien, K., Cokkinides, V., Jemal, A., Cardinez, C.J., Murray, T., Samuels, A.,…Thun, M.J. (2003). Cancer statistics for Hispanics. CA: A Cancer Journal for Clinicians, 53(4), 208-226.
Otero-Sabogal R., Stewart S., Sabogal F., Brown B., & Perez-Stable E. (2003). Access and attitudinal factors related to breast and cervical cancer rescreening: Why are Latinas still underscreened? Health Education and Behavior, 30(3), 337-359.
Powe, B. (1995). Cancer Fatalism among elderly Caucasians and African Americans. Oncology Nursing Forum, 22(9), 1355-9.
Rogelberg, S., & Waclawski, J. (2001). Instrumentation design. In Bracken, Timmrek, & Church (Eds.), The Handbook of Mulstisource Feedback, (pp. 79-86). San Francisco, CA: Jossey-Bass, Inc.
Spurlock, W., & Cullins, L. (2006). Cancer fatalism and breast cancer screening in African American women. The ABNF Journal, 17(1), 38-43.
The Agency for Health Care Policy and Research (AHCPR). (1999). Consumer assessment of Healthcare providers and Systems (CAHPS) study. Cross-cultural adaptation of survey instruments: The CAHPS experience. Journal of Cross-cultural Psychology, 16, 25-49.
U.S. Census Bureau. (2002). Population characteristics. Washington, DC: U.S. Census Bureau. Retrieved July 22, 2010 from www.census.gov/.
U.S. Census Bureau. (2005). Report on the Hispanic population. Retrieved July 23, 2010 from www.census.gov/.
U.S. Congress Department of Education. (1998). Adult education and family literacy act. Retrieved July 23, 2010 from www.2.ed.gov/policy/adulated/leg/legis.html
U. S. Department of Education, National Center for Educational Statistics. (2005). Trial urban district results. Washington, DC: NCES. Accessed June 20, 2006 from nces.ed.gov/nationsreportcard/pubs/dst2007/2008455.asp.
U.S. Department of Health and Human Services (2000). Healthy people 2010: Understanding and improving health (2nd Ed.). Washington, DC: National Academic Press.
U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care. Washington, DC: National Academic Press.
Vari-Cartier, P. (1981). Development and validation of a new instrument to assess readability of Spanish prose. The Modern Language Journal, 65(2), 141-148.
Weiner, J., Aguirre, A., Ravenell, K., Kovath, K., McDevit, L., Murphy, J.,…Shea, J.A. (2004). Designing an illustrated patient satisfaction instrument for low-literacy populations. The American Journal of Managed Care, 10(11), 853-860.
Young, H., Lierman, L., Powell-Cope, G., Kasprzyk, D., & Benolict, J. (1991). Operationalizing the theory of planned behavior. Research in Nursing and Health, 14, 137-144.
© 2010 OJIN: The Online Journal of Issues in Nursing
Article published November 24, 2010
- Changing the Culture of Long-Term Care: Combating Heterosexism
Susan V. Schwinn, BSN, RN; Shirley A. Dinkel, PhD, APRN, FNP-C, ANP-C (March 31, 2015)
- Assessing and Addressing Health Literacy
Sandy Cornett, PhD, RN (September 30, 2009)
- Improving Communication With Low-Income Women Using Today’s Technology
Nancy J. Cibulka, PhD, RN, WHNP-BC, FNP-BC; Harry W. Fischer, MA; Anna J. Fischer, BFA (March 26, 2012)
- Validation of the English and Spanish Mammography Beliefs and Attitudes Questionnaire
Gloria Lopez-McKee, PhD, RN; Julia Bader, PhD (March 21, 2011)
- Disparities in Health and Health Care: Focusing Efforts to Eliminate Unequal Burdens
Dee M. Baldwin, PhD, RN, FAAN (January 31, 2003)
- Culturally Competent Nursing Care for Families: Listening to the Voices of Mexican-American Women
Sandra K. Eggenberger, PhD, RN; Jane Grassley, PhD, RN; Elizabeth Restrepo, PhD, RN (July 19, 2006)
- Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC; Billie Murray, MSN, FNP-BC; Barbara Summers, MSN, RN; Joanne Watson MSN, RN (July 23, 2010)
- Enhancing Written Communications to Address Health Literacy
Gloria Mayer, EdD, RN, FAAN; Michael Villaire, MSLM (September 30, 2009)
- Promoting Health Literacy Through Storytelling
Vivian Day, BSHCA, MHA, RN (September 30, 2009)
- More than Words: Promoting Health Literacy in Older Adults
Carolyn I. Speros, DNSc, APRN, ANP/FNP-BC (September 30, 2009)
- Health Literacy: Challenges and Strategies
Nichole Egbert, PhD; Kevin M. Nanna, MSN, RN, BC-NE (September 30, 2009)
- Understanding Cultural and Linguistic Barriers to Health Literacy
Kate Singleton, MSW; Elizabeth M. S. Krause, AB, SM (September 30, 2009)
- Electronic Personal Health Records That Promote Self-Management in Chronic Illness
Beverly Mitchell, BScN, MSN, RN; Deborah L. Begoray, PhD (July 20, 2010)
- Interweaving Policy and Diversity
Jeri A. Milstead, PhD, RN,CNAA, CNS (January 31, 2003)
- Race Consciousness and the Health of African Americans
Rosalyn J. Watts Ed.D, RN, FAAN (January 31, 2003)
- Many Faces: Addressing Diversity in Health Care
Josepha Campinha-Bacote, PhD, APRN, BC, CTN, FAAN (January 31, 2003)