Regular articleFamily and friends with disease:: their impact on perceived risk
Introduction
For many types of disease, having a family history of disease in a first-degree relative is the strongest predictor of an individual's lifetime risk of developing the disease. Relations between family history and perceived risk have been demonstrated for colon [1] and prostate [2] cancer, heart disease [3], and diabetes [4], [5]; however, the vast majority of this research has been done with women facing the threat of breast cancer (e.g., [3], [6], [7]). Research has supported the heritability of the disease, as women with a mother, sister, or daughter with breast cancer are at elevated risk [8]. Several studies have demonstrated that women are aware of the association between family history and developing the disease, as those with a family history of breast cancer perceive their personal risk for the disease to be greater than those without breast cancer in their families (e.g., [3], [6], [7]). However, the issue of how having a family history of breast cancer results in greater perceived risk for breast cancer has not drawn much research attention despite considerable data linking perceived risk to compliance with recommended breast screening behaviors [9].
Perceived risk of breast cancer, and to a lesser extent other diseases (e.g., colon cancer [3]), has been found to be substantially elevated above objectively justified levels [10], [11]. One way to explain this apparent incongruity is by considering that having a family history of breast cancer, or any other disease, can be thought of as having at least two components, i.e., (1) an objective component consisting of a recognition of shared genetic inheritance with first-degree family members, and (2) an experiential component consisting of factors like having been personally close to someone (related or not) with the disease. While it is possible that either of these components can influence perceived risk, to our knowledge their relative contribution to perceived risk has never been examined. Although the literature has not yet addressed the issue, it is reasonable to assume that the objective component is an important determinant of perceived risk. However, if simply knowing a person with the disease affects perceived risk there would be both theoretical and clinical implications. From a theoretical perspective, such data would be consistent with the gross overestimations of perceived risk for breast cancer typically reported in the literature [10], [11]. Such data would also be consistent with judgment and decision-making theory [12], according to which judgments and behaviors in cases of uncertain information are influenced by both “rational” and “irrational” heuristics. This theory is particularly applicable when full information regarding an issue (i.e., certainties) is not available [13], as is the case in many circumstances regarding personal risk of future disease. Clinically, documentation of an association between knowing a person with a disease and perceived risk would suggest that interventions to modify perceived risk must take into account social environment factors that are not typically included in genetic counseling sessions [14]. Furthermore, community approaches to risk education may wish to incorporate messages to specifically counter the contribution of irrational heuristics to perceptions of risk of disease that are relevant to promotion of health behaviors.
As noted above, the perceived health risk literature has been predominantly focused on women facing the threat of breast cancer. Relatively little research has been done to investigate whether relations between family history and perceived risk exist for other cancers, as well as whether these effects can be found in both women and men. Specifically, it is not known whether the link between family history and perceived risk for men facing the threat of prostate cancer, of which there are 189,000 cases diagnosed annually [15], is similar to that for women facing breast cancer, as these populations are rarely investigated within the same study. That is, there may be differences between men and women in how objective and experiential components of family history contribute to perceived risk. However, if a study were to exclusively focus on breast and prostate cancers, the effects of gender and disease would be confounded by design. Therefore, it would also be critical to include in such a study a cancer (e.g., colorectal) that affects both men and women to determine if these relations are consistent for both genders within the same disease context. It is also possible that relations between family history of disease and perceived risk may differ in diseases other than cancer. Erblich et al. [3] demonstrated that there is a relation between family history of heart disease and perceived risk for heart disease. However, that study focused entirely on women, and it is unclear whether these results generalize to men, and whether the contributions of objective and experiential components of family history differ. It would also be of interest to explore whether these effects generalize to other common diseases for which a link between family history and perceived risk has been suggested (i.e., diabetes [5]).
The aim of the present study, consistent with judgment and decision theory [12], was to determine if levels of perceived risk are influenced by objective as well as experiential components. To provide a first critical test of these issues, we added an assessment of a history of disease in friends and nonblood relatives to a standard family history of disease assessment commonly used in the literature [3]. We reasoned that any impact of a history of disease in friends on perceived risk could be attributed entirely to subjective experiential factors, if the effects were still seen after controlling for the contribution family history. That is, in addition to having a family history of disease, the influence of simply knowing a person with a disease on perceived risk was tested. To determine if these effects on perceived risk of disease generalize beyond women facing the threat of breast cancer, the present study also explored these relations in regard to men facing the threat of prostate cancer, and both women and men facing the threats of colorectal cancer, heart disease, and diabetes. Based on the perceived risk of disease literature, we hypothesized that (1) family history of each disease would be associated with higher perceived risk for that disease; (2) experiential components, i.e., knowing someone outside the family with the disease, will contribute to perceived risk beyond the contribution of having a first-degree relative with the disease; (3) effects of the objective and experiential components will be equivalent for both women and men; and (4) these predictors of perceived risk will have similar impacts across diseases.
Section snippets
Participants
Five hundred twenty-two participants were recruited to the study and completed a brief questionnaire and reported an absence of disease. Eighty-one percent of all potential participants who were approached (N = 644) agreed to participate. Of the decliners 9% stated that they did not have the time to participate, 5% declined due to language problems, 3% reported that they were not interested, and 2% for a variety of other reasons. As the outcome variable for the present study was perceived risk
Effects of family and friend histories on perceived risk of breast cancer among women
To determine if Friend History added to the prediction of perceived risk for breast cancer above and beyond Family History, a hierarchical regression approach was taken. As education was found to be predictive of perceived risk of breast cancer in preliminary analyses above, education was included in the regression equation to test the relations between Family History and Friend History and perceived risk of breast cancer among women. Therefore, in the hierarchical regression, education was
Discussion
Consistent with results from the perceived risk of breast cancer literature [3], [6], [7], in the present study perceived risk of breast cancer was associated with having a family history of breast cancer. The relation between having a positive family history and greater perceived risk of disease was also demonstrated for colon cancer, heart disease, and diabetes. These results are also consistent with the published literature. No effect of family history on perceived risk was found for
Acknowledgements
This research was supported in part by grants from the National Cancer Institute (Montgomery, CA87021; Bovbjerg, CA72457) and the Yeshiva University Faculty Fellowship Award (DiLorenzo). We would like to acknowledge Ms. Ora Bronner, Miriam Hirschman, and Ruth Ephron for their help in gathering these data and Ms. Dorothy Parks and Ms. Dana Spencer for their technical assistance with manuscript preparation.
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