Professional Documents
Culture Documents
Yuichi Shoda
Columbia University
Karen Hurley
Temple University
'This article applies recent developments in cognitive-social theory to health-protective behavior,
articulating a Cognitive-Social Health Information Processing (C-SHIP) model. This model of the
genesis and maintenance of health-protective behavior focuses on the individual's encodings and
construals, expectancies, affects, goals and values, self-regulatory competencies, and their interactions with each other and the health-relevant information in the course of cognitive-affective processing. In processing health information, individuals are assumed to differ in both the accessibility
of these mental representations and the organization of relationshipsamong them. In this article, the
model is applied to analyze and integrate the often-confusing findings on breast self-examination in
cancer screening. Implications are considered for assessments and interventions to enhance adherence to complex, long-term, health-protective regimens, tailored to the needs and characteristics of
the individual.
has been given a major role. In studies of the variables that affect
health-information processing, investigators within the field
can select from a wide array of conceptual models and terms
to guide their work. Under close examination, however, most
available current models address only partial aspects or components in the processing of health-relevant information and individual differences in health-protective behavior. Ideally, one
needs to provide a complete account, from selection and encoding to the construction, enactment, and maintenance of healthprotective behavior patterns. Moreover, these models tend to
show considerable conceptual and measurement overlap, often
differing more in emphases and terminology than in essential
features, as Weinstein ( 1993 ) has observed.
It can be argued that the independent development of similar
models to analyze this key topic attests to the robustness of the
phenomena and to the utility of the constructs commonly employed in different efforts to account for them. However, it also
makes it difficult to relate findings from studies conceptualized
in different theoretical languages. It would be useful to place the
specific constructs and findings relevant to health-information
processing into a more general framework. Such a framework
should allow one to integrate and clarify the relationships
among the constructs used in different models within health
psychology and in closely related fields that deal with overlapping issues, including social, personality, clinical, developmental, and cognitive psychology.
For that purpose, the present article begins with an outline of
the cognitive-social learning theory of social information processing and individual differences (Mischel, 1973, 1990; Mischel & Shoda, 1995). Rather than limited to the ideas of any
single theorist or as a specific model of a particular type of behavior, it was proposed as a deliberately cumulative general
framework--or a metatheory--to invite the contributions and
Suzanne M. Miller, Division of Population Science, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Yuichi Shoda, Department of
Psychology, Columbia University; Karen Hurley, Department of Psychology, Temple University.
Preparation of this article was supported in part by Grants CA4659 l,
CA58999, and CA61280 from the National Cancer Institute, Grant
PBR-72 from the American Cancer Society, and Grants MH39349 and
MH45994 from the National Institute of Mental Health.
We are especially indebted to Walter Miscbel for his insightful and
constructive comments on many drafts of this article. We also thank
Paul Engstrom, Lizette Peterson, William H. Redd, Ann O'Leary, Howard Leventhal, Victoria Champion, Caryn Lerman, Barbara Rimer,
Mark Schwartz, Michele Rodoletz, Pagona Roussi, Megan Mills, Danika AItman, and Joanne Schwartz for their helpful feedback on earlier
drafts.
Correspondence concerning this article should be addressed to Suzanne M. Miller, Division of Population Science, Fox Chase Cancer
Center, 215 South Broad Street, 5th Floor, Philadelphia, Pennsylvania
19107. Electronic mail may be sent to sm miUer@fccc.edu.
70
71
72
73
Table 1
Affects (emotions)
Affective states activated in health information processing (e.g., anxiety, depression, hopefulness, negative
feelings about the self, irritability, and anger).
Note. From "A Cognitive-Affective System Theory of Personality: Reconceptualizing Situations, Dispositions, Dynamics, and Invariance in Personality Structures;' by W. Mischel and Y. Shoda, 1995, Psychological Review, 102, p. 253. Copyright 1995 by the American Psychological Association. Adapted with
permission of the authors.
of cance~ adherence to stringent diets, and smoking cessation
regimens.
Finally, the approach also focuses attention on the important psychological features of the situation as perceived and interpreted by
the individual and thus makes the psychological context a central
component in the cognitive-affective processing of information. As
has been demonstrated at least at a theoretical level (Mischel &
Shoda, 1995), it should allow better understanding and prediction
not only of overall individual differences in broad behavioral averages (e.g., the overall tendency to monitor for information about
health threats and dangers) but also of specific patterns of Person
Situation interaction (e.g., if A, then she monitors for health threats;
but if B, then she avoids them) as expressions of the same underlying system. The challenge is to examine the utility of this metatheoretical conception for health-protective behavior ~nerally, and
for BSE in Imrficular, which is our goal in the next section.
74
Encoding of health-relevant information: Perceived vulnerability Individual differences in encoding mediate the relationship
between the objective risk information that the individual receives
and her subjective, perceived vulnerability to breast cancer. Some
individuals are more likely to see health threats everywhere and to
scan for them, attending intently to bodily cues and symptoms,
whereas others tend not to attend to such information and actively
avoid it (Barsky & Klerman, 1983; Kellner, 1990; Miller; 1995, in
press; Pennebaker, 1982; Salovey & Birnbaum, 1989). The importance of individual differences in encoding when processing risk
information is consistent with the finding of low correlations between a woman's objective risk status and her perceived susceptibility to breast cancea; which has typically been only in the 0.2
range (Aiken, West, Woodward, & Reno, 1994; Calnan & Rutter,
1988; Rutledge, Hartmann, Kinman, & Winfield, 1988; Schwartz
et al., 1995). In a recent study, in which women with a familial
history of breast cancer were presented with detailed information
about their personal risk, a striking two thirds of the participants
continued to significantly overestimate their susceptibility to the
disease after the risk counseling session (Lerman, Lustbader, et al.,
1995). Other women at objectively high risk appear to dramatically underestimate their vulnerability (Kash, Holland, Halper, &
Miller, 1992; see also Blalock, DeVellis, Atifi, & Sandier, 1990).
Close examination of the literature on beliefs about one's personal risk of contracting breast cancer shows that researchers in
this domain have combined diverse items as measures of the construal of subjective vulnerability. Sample items range from "I am
less likely than the average woman to develop breast cancer"
(Ronis & Harel, 1989), to "I worry a lot about getting breast cancer" ( Champion, 1984 ), to "Whenever I hear of a friend or relative
. . getting breast cancer, it makes me realize that I could get it,
too" (Stillman, 1977). Perhaps, in part, because of this diversity,
results in the literature have been mixed, such that some studies
show a positive relationship between perceived susceptibility and
BSE frequency (Calnan, 1984; Champion, 1988, 1990; Ronis &
Hard, 1989; Wyper, 1990), whereas others fail to obtain this effect
(Bennett, Lawrence, Fleischmann, Gifford, & Slack, 1983; Champion, 1984, 1985, 1987; Murray & McMiUan, 1993; Rutledge,
1987). Among those that do show a positive association, the relationships are typically of a modest statistical magnitude, with correlations ranging from 0.14 to 0.25. These findings are consistent
with research in other health domains, which shows a small, nonzero mean effect size between perceived susceptibility and screening behaviors (e.g., testicular self-exam, fecal occult blood testing,
and asymptomatic venereal disease testing; Harrison, Mullen, &
Green, 1992). 3
Ej~cacy and confidence. Research indicates that women
differ in their self-confidence about their self-examination technique and their ability to use BSE to detect lesions. A number
of studies have shown that high self-efficacy beliefs (generally
assumed as confidence in one's ability to perform BSE) are associated with higher levels of BSE adherence (Bennett et al.,
1983; Fletcher, Morgan, O'Malley, Earp, & Degnan, 1989; Jacob et al., 1989; Murray & McMillan, 1993; Ronis & Kaiser,
1985; Rutledge & Davis, 1988; Shepperd, Solomon, Atkins,
Foster, & Frankowski, 1990; Stefanek & Wilcox, 1991; Strauss,
Solomon, Costanza, Worden, & Foster, 1987 vs. Kash et al.,
1992). However, these results are difficult to interpret because
BSE practice was assessed retrospectively. Only a handful of
3 Similar to the BSE literature, the research on fear-arousing communications in general is mixed, such that some studies find a 0-shaped
relationship between fear and adoption of, or adherence to, health-protective behaviors, whereas other studies find a positive, linear relationship (see Sutton, 1982, for a review).
4 One study reported no relationship between self-efficacybeliefs and
subsequent performance (Calnan & Moss, 1984). Howev~ BSE practice
was defined in terms not only of how frequently the behavior vos performed but also of how competently it was performed. This combined
assessment may have dampened the effectof self-efficacyon BSE because
women otten overestimatethe quality of their exams (Celentano & Holtzman, 1983;Jacob et al., 1989).
75
76
Recommendation
to perform BSE
,51
.....
\1
"\\~ 4
.\
\\\
\\\\
6
/
"Sooner or later,
Ill detect a lump'
lOj"
/8
11/
7 '~,,
"1'11be subjected to
painful but ineffective
treatment, only to
prolong the pain'
12
13~
.......... ~
14 ,
Anxiety, depression
Figure 1. Domain map of forming intentions to perform breast self-examination (BSE), illustrating cognitive-affective units potentially accessible to an individual and the structure (organization) of relations
among them. Solid lines illustrate positive (activating) relations from one unit to another; broken lines
illustrate negative (deactivating) relations.
77
Recommendation
to perform BSE
1E
"1 m a y develop breaet
cancer"
,!2
~ "
- v . k.. o,,~...,...z , , .
'- .-~ - - ' ? ~ - .-':- "~
palflluI DUI[ inelllrecllve
, ~ t
o n ~ ta
"prolong
~ - " - - ' ~ the pain"
"~ -
13
."
i
14
Anxiety, depression
Figure2. Illustrative processing structures and dynamics in forming intentions and decisions to perform
breast self-examination (BSE). This figure illustrates a processing prototype of a woman who is characterized by negative expectancies. Thick solid lines indicate positive (activating) relations among units; thick
broken lines show negative (deactivating) relations. Thin lines illustrate potential pathways but are not
salient for the particular prototype.
belief has also been found to increase the negative affect and anxious arousal that become activated, which can become overwhelming and thereby leads either to avoidance of the behavior (Kash et
at., 1992; Lerman et al., 1991; Rippetoe & Rogers, 1987; Strauss
et at., 1987) or to maladaptive hypervigilence (i.e., weekly or even
daily BSE; Lerman, Kash, & Stefanek, 1994; Stefanek & Wilcox,
1991).
From the C-SHIP perspective, when individuals characterized by different types of organization are present in the same
study and not distinguished in the analysis, the overall results
are likely to be inconsistent and confusing. That is, depending
on the organization of the BSE-relevant cognitions and affects
typical within a particular sample of women assessed, the overall effects of information about health risks on the performance
of BSE could average out to be positive, negligible, or even negative. As reviewed above, and consistent with these theoretical
expectations, the empirical literature is mixed: Whereas some
studies show that perceived susceptibility to breast cancer leads
to increased frequency of BSE (Champion, 1988, 1990; Ronis
& Harel, 1989; Wyper, 1990), other studies find that it has no
78
Recommendation
to perform BSE
15
"1 may develop breast
cancer"
i'~tnd~itme~atd~ndrom
e~ it"
"Sooner or later,
I'll detect a lump"
~j..~""~
10/
' /
tt
"
//
" Ill
' get eady, effective
tz,l z a ~ w )
I'll b e subjected t o
painful but ineffective
treatment, onlyto
prolong the pain"
t~zd I'll ~
~_m~,l'--"'~,~n"~l'~'l~l~hu
\~~ n d ' " ~ , ' i ~ ; " . . . . . . . .
\r- . . . . . . . ~----
'\
la
'
"
1,
Anxiety, depression
Figure3. Illustrative processing structures and dynamics in forming intentions and decisions to perform
breast self-examination (BSE). This figure illustrates a woman characterized by positive expectancies.
Thick solid lines indicate positive (activating) relations among units; thick broken lines show negative
(deactivating) relations. Thin lines illustrate potential pathways but are not salient for the particular
prototype.
effect (Bennett et al., 1983; Champion, 1984, 1985, 1987; Rutledge, 1987). From the present perspective, these seeming contradictions in the research findings may, in fact, reflect the presence of the types of interactions that the C-SHIP predicts and
that would inevitably undermine the level and stability of the
overall correlation between perceived vulnerability and BSE
practice, unless the relevant processing characteristics of the
women were to be taken into account.
Such a system also speaks to the curvilinear effects of risk informarion found in the breast screening literature, such as the inverted U-shaped relationship between the level of negative arousal
and the intention to perform BSE (see also Janis, 1967; Janis &
Leventhal, 1967; Lerman & Schwartz, 1993). Exposure to risk
information in this processing system can increase both the intention to perform BSE and the level of anxiety about doing it. These
effects are demonstrated in a study by Rippetoe and Rogers
(1987). College-aged women were presented with either a highthreat informational brochure, which vividly portrayed the severity of breast cancer and the threat posed to one's health, or a lowthreat informational brochure, which downplayed the severity of
breast cancer and its prevalence among younger women. The
group that received the threatening message manifested higher levels of perceived severity of breast cancer; which, in turn, were positively associated with greater intentions to perform BSE. At the
same time, the threatening message was associated with increased
levels of anxiety, which were in turn associated with higher levels
of (maladaptive) avoidant ideation (e.g., "I try not to think about
the po~ibility of developing breast cancer"). Although avoid,ant
79
80
immediate likelihood of finding an abnormality (Mayer & Solomon, 1992). Performing BSE, then, can be a frightening behavior, in the sense that it is designed to detect~rather than to
prevent~breast cancer. Thus, performing BSE (or in some
cases, even the thought of performing it) leads many women to
worry even more about the possibility of breast cancer
(Rutledge & Davis, 1988) and about the stress of a "false
alarm" (Hill, Gardner, & Rassaby, 1985). The most desirable
outcome or reward of BSE may be to not find a lump, which
may reinforce avoidance behaviors rather than careful self inspection. Indeed, women who report that they are afraid of
finding a lump are less likely to perform BSE regularly (Hill et
al., 1985). Discovering a benign lump during the course of BSE
actually may extinguish the behavior because it can cue excessive vulnerability and threat (Janz et al., 1990).
Excessive negative arousal when a lump is found has also
been shown to lead some women to delay seeking professional
evaluation of the abnormality (see Facione, 1993, for a review).
In short, the very act of examining one's own breasts in a clini-
\~,
'\
i
i
Rocommendation
to perform BSE
cancer"
/""\
3/
\~
llS
,
/
BSE training
and practice
,I
Reminders to
perform BSE
/1,
24
--
\
\\
\"\'\,\
\\
'/
'\~I
-~---
'Sooner or later,
( I n t e n t i o n to B S E ) _
/4
$
+ IL
17
10//
11 1
-.
',
'.
7\ ,
12
J'
14 ,~' 16/
\\
20
'~,27
. . . . 29.
/,
-- .... -
28 ..... e-i\.
~
~
"Hot', 'arousing'
reprasantati
ons:negat~v
statements about
self; anxiety-arousing
ideation
///
J
- ~,~" Anxiety,depression
Performing
~BSE
\\
~4
Behavioral scripts
and procedural
k n o w l e d g e for B S E
I I
Figure 4. Illustrative domain map: from input to intention to performance. BSE = breast self-examination. For simplicity, only illustrative feedback loops are shown (e.g., 23, 24, and 30), but conceptually such
loops are assumed throughout the system (e.g., from hot, arousing representations to the expectation "I
may develop breast cancer").
"~
81
82
to such risk cues (e.g., Lerman, Daly, Masny, & Balshem, 1994;
Schwartz et al., 1995; van Zuuren, 1993; van Zuuren & Muris,
1993; van Zuuren & Wolfs, 1991; E Wardle et al., 1993).
In conclusion, from the present perspective, the ideal self-regulatory strategy requires a flexible balance of hot and cool ideation,
of both distancing and "tuning in" of blunting and monitoring
(e.g., Chiu, Hong, Mischel, & Shoda, 1995; Christensen, Smith,
Turn~ & Cundick, 1994; Millet; Combs, & Stoddard, 1989; Miller et al., 1993; Mischel et al., in press). To adhere, the woman
must focus on the threat sufficiently to motivate action but then
focus on the necessary step-by-stop health-protective behavior. She
must cool and abstract the situation to create the psychological
distance that allows her to tune out the aversiveness and anxiety,
while concentrating on the task contingencies and encouraging her
performance and progress at each point (e.g., Meichenbaum,
1992; Meiehenbaum & Deffenbachet; 1988; Mischel et al., 1989).
To effectively maintain such behavior once initiated requires the
woman to use a complex array of self-regulatory skills. She has to
monitor her proficiency against a cleat; accurate standard that she
believes she can reasonably meet and reinforce herselfcovertly and
overtly for adherence. At the same time, she must refrain both
from distractions and from attending to interfering anxiety-inducing ideation (e.g., Meichenbaum, 1977, 1992; Meichenbaum &
Deffenbacher, 1988; Sm;ason, 1984; Sarason et al., 1986).
83
Recommendation
to perform BSE
/
1
Reminders to
perform BSE
BSE training
and practice
\\
..........
15
23
"| may develop breast
cancer"
~
4
1
\
\
\
\
\
~/
7 ~
"
"', 12
24
~
~
,
:.
,,/
\
\
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;
,"
,"
"..
.
.
L'~Uf
20
~lng
-27
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: , ' . ....
.."
"i'll be = t ~
to ~
painful but Ineffective ,"
treatment, only to
,
prolong the pain"
:
13~,
Be avioral sc 'p
,,nd . . . . ,~-ral
= ~^.~'~'M"~',~'==o= - "
- ,,.,,w,ou~o.v . . . .
%
#
".. %., : ."
-c,
repre' cer, - ~ v e sentations: task-relevant 4
/~._t~
thoughts; self-instructions;
//contingent self-rewards
rl "
regula y
(Intention to BSE)
17
10/ 11 I
"
lwdl
do BSE
//8
"Soonerorlater,
/
,
~_.~_~
%%"Hot', "arousing"
......... mpmen=uon,:,epUva
-- slatements about
~
J
4P
self; anxlety..arouMng
Ideation
~"
I I
Figure 5. Illustrative activation networks during breast self-examination (BSE) that undermine effective
performance. During BSE, hot, arousing representations are activated and undermine BSE performance
by activating negative thoughts, anxiety, and depression. Thick solid lines indicate positive (activating)
relations among units; thick broken lines show negative (deactivating) relations. Thin lines illustrate potential pathways but are not salient for the particular prototype.
84
Informationabout breast
Intormation
about BSE
cancer and personal risk level and its effliveness
Recommendation Remindersto
to perform BSE
performBSE
~18
2a
"I may develop breast
cancer"
\
"'. 4
/
jr
6
\ I ~'-'---\ J. (
7'\,,
"1 w i l l d o B S E regularly"
/ I n t e n t i o n to B S E I ,
~
.
.
" ,-,
"Soo~T~or later,
10/4
I'll detect a ump" j "
..v. . . . .
\
\
24
'O.ancermay grow
undetected, and
/
I'll ultimatelydie from it' /
[
BSE training
and practice
'>%,12
",
11 i
,'
,'
,,
"..
;
:
~'
r'
'
,""
29
,' ,
14:
/'
>/ !/
20
Performing
BSE
,,
'
",27
............
o
p
: egatlve
- - - - statementsabout
~l-
....
:'
elll,i,t o
",.
"1'11 u '
d to
be S b i l e
painful but ineffective
treatmentt only to
prolongthe pain"
13\
",
,
~,
Beh. a v i o r a l . s c r ! p t s
and proceoural
k n o w l e d e for B S E
~.i
~ 0 /
serf"anxiety arousinn
.ideation
,.
-,~,
"
///
Anxiety, depr:sion
- -
Figure 6. Illustrative activation networks during breast self-examination (BSE) that enhance effective
performance. Performance of BSE activates cool, objective representations which, in turn, activate other
cognitions and affects that maintain and enhance performance. Thick solid lines indicate positive
(activating) relations among units; thick broken lines show negative (deactivating) relations. Thin lines
illustrate potential pathways but are not salient for the particular prototype.
explore the relevance of the model for health-protective behaviors more generally.
for BSE (Figures 1 and 4). Such assessments focus on the specific cognitions and affects and their organization of relationships, activated by particular types of health-relevant information (e.g., personal breast cancer risks). This focus on context
and specific cognitions and affects that become activated in
characteristic patterns of organization contrasts with more traditional assessments. The latter describe "what the woman is
like in general" with regard to health risks in terms of such variables as generalized expectancies, or global traits, or they aggregate her overall health-relevant behaviors together to form a
broad index of her heath habits on the whole.
Instead, the C-SHIP analysis requires assessments that are
targeted as directly and precisely as possible to the underlying
cognitive-affective units and their organization in the processingOfparticular types of health information by individuals with
different types of processing structures (Lauver & Angerame,
1988). The emphasis on context and on the interaction of the
85
reflect these differences result in improved breast cancer screening outcomes (Champion & Scott, 1993; Jacob, Penn, Kulik, &
Spieth, 1992). For example, people characterized as high monitors (compared with low monitors) may differ in the types of
interventions that facilitate sustained adherence (Davis, Maguire, Haraphongse, & Schaumberger, 1994; Gattuso, Litt, & Fitzgerald, 1992; Jacob et al., 1992; Lerman et al., 1990; LudwickRosenthal & Neufeld, 1993; Miller & Mangan, 1983; Steptoe
& O'Sullivan, 1986; Watkins, Weaver, & Odegaard, 1986). As
noted previously, for high monitors, the challenge is to reduce
their tendency to overinterpret cues as threatening and to encode themselves as highly vulnerable, to decrease their negative
expectations, to enhance their self-confidence and knowledge
base, and to provide them with strategies for the modulation of
anxiety. In short, they need targeted interventions that help
them to circumvent their tendency to respond automatically by
becoming excessively anxious and ultimately denying their need
for undertaking cancer screening behaviors.
86
87
88
89
90
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Received August 5, 1993
Revision received February 16, 1995
Accepted February 20, 1995
For Psychological Bulletin, submit manuscripts to Nancy Eisenberg, PhD, Department of Psychology, Arizona State University, Tempe, AZ 85287.
Manuscript submission patterns make the precise date of completion of 1996 volumes uncertain.
Current editors Larry E. Beutler, PhD; Joel R. Levin, PhD; and Norman Miller, PhD, respectively,
will receive and consider manuscripts until December 31, 1995. Current editor Robert J. Sternberg,
PhD, will receive and consider manuscripts until February 28, 1996. Should 1996 volumes be completed before the dates noted, manuscripts will be redirected to the new editors for consideration in
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