319

Help-seeking intentions for breast-cancer symptoms:

A comparison of the self-regulation model and the
theory of planned behaviour
Myra S. Hunter1, Elizabeth A. Grunfeld2 * and
Amanda J. Ramirez1
1
ICRF Psychosocial Oncology Group, Guy’s, King’s and St Thomas’ Medical School,
St Thomas’ Hospital, London, UK
2
Unit of Psychology, Guy’s, King’s and St Thomas’s Medical School, Guy’s Hospital,
London, UK

Purpose. Delays in seeking help for symptoms have been found to be associated with
poorer outcome in breast-cancer patients. This study explores symptom perceptions
and health beliefs as predictors of intentions to seek medical help in a general female
population.The utility of the self-regulation model of illness cognition and the theory
of planned behaviour were examined in predicting help-seeking intentions for
potential symptoms of breast cancer in a general population sample.
Methods. A general population sample of 546 women completed a postal
questionnaire comprising items examining components of the self-regulation model
and the theory of planned behaviour. Help-seeking intention was determined by
asking participants to rate the likelihood of visiting their GP for a range of breast
symptoms.
Results. Hierarchical multiple regression analysis revealed that the cognitive
component of the self-regulation model accounted for approximately 22% of the
variance in help-seeking intention.Identity (b= 0.45, p < .001) emerged as a signiŽcant
predictor of intention to seek help. Inclusion of the components of the theory of
planned behaviour accounted for an additional 7% of the variance; the signiŽcant
predictors were attitude to help-seeking (b= 0.19, p <.001) and perceived behavioural
control (b= 0.12, p <.01).
Conclusions. Intention to seek medical help for a potential breast-cancer symptom
may be mediated, partly, by cognitive representations of the identity and
320 Myra S. Hunter et al.
consequences of breast cancer and by attitudes towards help-seeking and perceived
behavioural control. Although less than one-third of the variance was accounted for,
these results

* Requests for reprints should be addressed to Elizabeth Grunfeld, Unit of Psychology, 5th Floor, Thomas Guy
House, Guy’s Hospital, London SE1 9RT, UK (e-mail: beth.grunfeld@kcl.ac.uk).
have important implications for future research (in terms of identifying which
variables should be examined) and for the development of a model of help-seeking
behaviour in women with breast-cancer symptoms.

Breast cancer is a signi®cant health risk to women in the UK. Approximately 35,000 new
cases of breast cancer are diagnosed each year, and the UK has one of the highest mortality
rates in the world. Health education and screening programmes are aimed at increasing
early detection, but there is concern that, following self-discovery of a breast symptom,
approximately one-third of women delay for 12 weeks or more prior to presentation to a
health care provider (Richards, Westcombe, Love, Littlejohns, & Ramirez, 1999a). This is
important, as over 75% of patients present after symptoms have occurred rather than
through the National Health Service screening programme (Richards et al., 1999a).
Furthermore, evidence suggests that longer delay intervals are associated with a larger
tumour size, more advanced disease, and poorer survival (Richards, Smith, Ramirez,
Fentiman, & Rubens, 1999). To encourage changes in helpseeking behaviour, it is useful to
understand not only cognitive representations of disease and associated symptoms but also
beliefs regarding the treatment for breast cancer and the implications of seeking help.
The self-regulation model proposes that people construct cognitive representations of
an illness or disease in order to understand and cope with it (Leventhal, Nerenz, & Steele,
1984). These cognitive representations are seen to determine emotional responses and to
guide coping responses. The illness-related cognitions, or illness representations as they are
also known, comprise ®ve main components or dimensions: identity (interpretation of the
symptoms associated with the illness and of the labels attached to the illness), cause (likely
causes of the illness, which may relate to the person’s beliefs about personal risk), time-line
component (the likely duration of the illness), consequences (the perceived severity of the
illness and the potential impact on physical, psychological, and social functioning), and
cure/control (the extent to which the illness can be successfully controlled or cured).
Evidence from the ®eld of breast cancer suggests that patient delay behaviour may be
in¯uenced, at least in part, by experience of a non-lump breast-cancer symptom and by
attribution of symptoms to causes other than cancer (Burgess, Ramirez, Richards, & Love,
1998; Ramirez et al., 1999). In addition, it has been demonstrated that decisions to seek
medical help are in¯uenced not only by the presence of an atypical symptom but also by the
perceived severity and consequences of the symptom (Cameron, Leventhal, & Leventhal,
1993). Examination of the ®ve components of Leventhal’s illness representations may help
explain women’s appraisal of symptoms of breast cancer and their decisions regarding the
necessity of seeking medical help.
The theory of planned behaviour states that the intention to perform certain behaviours
is determined by two forms of beliefs (Ajzen & Madden, 1986): behavioural beliefs (attitudes
towards a particular behaviour) and normative beliefs (beliefs concerning the likely approval
or disapproval of key referents towards performing a certain behaviour). There is some
 Help-seeking intentions for breast cancer 321
evidence from qualitative studies to suggest that signi®cant others may in¯uence a woman’s
decision to seek help for symptoms of breast cancer (Burgess et al., 1998; Facione, 1993).
The theory of planned behaviour also takes account of a person’s perceived behavioural
control (how easy or dif®cult it is to perform that behaviour). Previous work employing the
theory of reasoned action (the precursor to the theory of planned behaviour that does not
include perceived behavioural control) has demonstrated that intention to delay in seeking
help for a breast symptom (among healthy women) is associated with holding positive
attitudes towards delay and with perceived social pressure to delay (Timko, 1987). The type
of favourable attitudes that Timko found to be important included beliefs that delaying
would allow one to maintain some control over, and would prevent disruption to, one’s own
or signi®cant others’ lives. As this study was based on the theory of reasoned action, it did
not examine the in¯uence of perceived behavioural control with regard to intention to seek
help.
The theory of planned behaviour has not previously been employed to examine actual
help-seeking behaviour in women with breast cancer but has been used to examine breast-
cancer screening behaviour (Rutter, 2000). Attendance at screening is a different behaviour
to help-seeking for symptoms, as it does not require the individual to interpret and attribute
symptoms, and the individual is provided with information on how, when, and where to
implement their intention. However, Rutter’s (2000) large sample study does provide a
useful comparison. The study found that attitude, perceived behavioural control, and
subjective norm were all predictors of intention to attend screening, although only attitude
and subjective norm were predictors of actual attendance behaviour.
Additional variables, outside the two models, may also in¯uence intention to seek help.
Previous work examining intentions to take hormone-replacement therapy extended the
theory of planned behaviour to include similar prior behaviour and age (Quine & Rubin,
1997). Both these additional variables and the components of the theory of planned
behaviour were found to predict intention. Similar prior behaviour in relation to help-
seeking for potential breast-cancer symptoms could include breast selfexamination
behaviour, and the present study included this variable. The aim of the present study was
to apply the self-regulation model and the theory of planned behaviour to explore women’s
interpretations and representations of potential breast-cancer symptoms and to identify
their beliefs regarding help-seeking and treatment for breast cancer. The ultimate aim was
to determine which aspects of these two theories best predict intention to seek help
promptly for potential breast-cancer symptoms.

Methods
Development of the questionnaire
The questionnaire items were developed from previous quantitative and qualitative
research with breast-cancer patients (Burgess et al., 1998; Burgess, Hunter, & Ramirez,
2001). For example, this previous work demonstrated that type of symptom and
misattribution of symptoms were key factors associated with delay among breastcancer
patients, so a range of breast changes were examined in the current study. The previous
work also identi®ed unwillingness to prioritize oneself over others, concern about talking to
322 Myra S. Hunter et al.
GPs, and being able to talk to others about symptoms as being in¯uential in the delay
process. Questionnaire items were generated from this previous work and were structured
so as to represent the components of the selfregulation model (Leventhal & Nerenz, 1985)
and the components of the theory of planned behaviour (Ajzen & Madden, 1986). All items
were piloted on a sample of healthy women who were not involved with the study or with
the health service (N = 8) to assess comprehensibility and suitability (i.e. that they did not
cause embarrassment or distress). The questionnaire was easily understood by all the
participants (in the pilot group), and there were no items that needed to be eliminated on
the grounds of poor comprehensibility or unsuitability. The questionnaire comprised two
sections.

Self-regulation model
The items in the ®rst section were based on the format of the Illness Perceptions
Questionnaire (Weinman, Petrie, Moss-Morris, & Horne, 1996), and the ®ve scales related
to the components of Lenventhal’s illness representations (Leventhal & Nerenz, 1985). The
identity scale included 12 symptoms, eight of which were potential symptoms of breast
cancer and four of which were general, non-breast-cancer-related symptoms. Participants
were required to state whether each of the symptoms was a potential symptom of breast
cancer on a 7-point scale from `de®nitely’ to `de®nitely not’. The identity scale was scored
by assigning 1 to all symptoms that were rated as symptoms of breast cancer (1±4 on the
scale) and 0 to all symptoms rated as nonsymptoms (5±7 on the scale). The scores for the
eight symptoms of breast cancer were summed to give an identity scale score (range 1±8).
Cronbach’s a for the summed scale was .71.
The four remaining scales comprised attitudinal statements and required participants to
rate their responses on a 7-point scale from `strongly agree’ to `strongly disagree’. The cause
scale comprised 14 items adapted from the Breast Cancer Risk Assessment Scale (Royak-
Schaler, Cheuvront, Wilson, & Williams, 1996). Seven of the items were established risk
factors for breast cancer, and seven were factors that people sometimes associate with
breast cancer but that are not established risk factors. Each item on the cause scale was
seen to represent a speci®c causal belief, and therefore each item was examined individually
(Weinman et al., 1996).
The time-line scale comprised three statements about the potential duration of breast
cancer following treatment. The internal consistency for this subscale (Cronbach’s a .54) was
lower than that reported for the original Illness Perceptions Questionnaire (Weinman et al.,
1996). The lower the score, the shorter was the associated time line. The consequences scale
comprised six statements regarding the physical, social, and psychological consequences of
breast cancer (Cronbach’s a .74). The higher the score, the more positive was the person’s
attitude toward the outcomes associated with breast cancer. The cure/control scale
comprised ®ve questions related to the management of breast cancer. The higher the score,
the more positive was the person’s attitude toward the controllability of the disease. The
internal consistency for this subscale was rather low (Cronbach’s a .50).
 Help-seeking intentions for breast cancer 323
Theory of planned behaviour
The items in the second section of the questionnaire were designed to measure the
constructs contained within the theory of planned behaviour and were based on the format
reported by Ajzen and Madden (1986) and as detailed in Conner and Norman
(1995).

Attitudes towards help-seeking

Five semantic differential scales (good/bad, bene®cial/harmful, pleasant/unpleasant,
wise/foolish, necessary/unnecessary) were used to assess responses towards the question
`Making an appointment to see my doctor for a symptom that might be breast cancer would
be . . .’. The scores obtained for the ®ve semantic scales were summed to produce a direct
attitude to help-seeking score. Belief-based measures of attitude towards help-seeking
were obtained by asking participants to rate (on a 7-point scale from `strongly agree’ to
`strongly disagree’) eight statements relating to the consequences of seeking help for a
potential breast-cancer symptom (i.e. `I would ®nd it easy to talk to my doctor about a
breast symptom’). The scores on the eight items were averaged to produce a belief-based
attitude to help-seeking score. The higher the score, the more positive was the attitude
toward help-seeking. Cronbach’s a for the summed scale was .57.

Subjective norm
The subjective norm measurement was based on the normative beliefs concerning three
referents: family, spouse/partner, and close friends. The strength of each normative belief
(e.g. `My family would encourage/discourage me to go to the doctor for a symptom of
breast cancer’) was assessed on a 7-point scale (`encourage’ to `discourage’). The
respondent’s motivation to comply with each referent (e.g. `In general, when making
decisions I am in¯uenced by my family’s opinions’) was assessed on a 7-point scale (from
`agree’ to `disagree’). Each normative belief was multiplied by the motivation to comply
with the referent and the sum of the products constituted the belief-based measure of
subjective norm (Cronbach’s a .68). The higher the score, the greater was the perceived
social pressure to seek help.

Perceived behavioural control

Perceived behavioural control was assessed with four items relating to the degree of
perceived control over help-seeking for a symptom of breast cancer (e.g. `There is nothing I
could do to make sure that I got help for a breast-cancer symptom’). Responses were
recorded on a 7-point scale (from `agree’ to `disagree’), and the product of the four
responses served as the measure of perceived behavioural control (Cronbach’s a .74). The
higher the score, the greater was the perceived behavioural control.
324 Myra S. Hunter et al.
Intention
Intention to seek medical help for breast-cancer symptoms was assessed in two ways,
because (1) there was an interest in seeking help for symptoms that might signify breast-
cancer, and (2) there was an interest in the intention to seek help promptly.

Symptom-based measure. Participants rated (on a 7-point scale from `de®nitely’ to

`de®nitely not’) how likely they would be to visit their doctor for each of 12 symptoms, eight
of which were potential symptoms of breast cancer and four that were general non-breast-
cancer symptoms. The intention score was calculated by assigning 1 to all symptoms where
the participant indicated that they would de®nitely visit their doctor (1±4 on the scale) and
0 to all symptoms where the participant indicated that they would de®nitely not visit their
doctor (5±7 on the scale). The scores for the eight symptoms of breast cancer were summed
to give an intention score (range 1±8). This score was used as the independent variable for
multiple-regression analysis.
Temporal-based measure. Temporal information regarding help-seeking intentions of the
participants was elicited by asking, `If you developed a symptom that you thought might be
breast cancer, how soon would you visit the doctor?’. Responses were provided on an 8-
point scale from `immediately’ to `never’. To examine differences between women who
would promptly seek help and those that would delay for a period of time, all participants
choosing `immediately’ were classi®ed as prompt helpseekers, and all other respondents
were classiŽ ed as potential delayers.

Additional variables included in the analysis

It was hypothesized that attitudes to treatment for breast cancer might in¯uence a woman’s
intention to seek help for a symptom of breast cancer. To measure attitudes to treatment,
the same ®ve semantic differential scales employed for the attitude to helpseeking measure
were used to assess attitudes towards undergoing each of four treatments for breast cancer
(surgery, chemotherapy, radiotherapy, and hormone therapy). The scores obtained for the
®ve semantic scales were summed to produce a score for the direct attitude to each form
of treatment. The scores for the four treatments were then averaged to produce a
composite score for attitudes towards treatment. Belief-based measures of attitude
towards treatment were obtained by asking participants to rate (on a 7-point scale from
`strongly agree’ to `strongly disagree’) nine statements relating to the consequences of
treatments for breast cancer (i.e. `The treatment for breast cancer is worse than the disease
itself ’). The scores for the nine items were averaged to produce a belief-based attitude to
treatment score. Cronbach’s a for the summed scale was .59.
Participants were also asked about their personal and familial history of breast cancer
and about their practice of breast self-examination, as it was hypothesized that these may
in¯uence intention to seek help for a symptom of breast cancer.

Participants
The sample was recruited from a previous study examining women’s knowledge of breast
cancer (Grunfeld, Ramirez, Hunter, & Richards, 2001), and the sample obtained was
 Help-seeking intentions for breast cancer 325
representative of the geographical, socio-economic and age distribution of the UK
population. From this original study, 781 participants provided their consent to participate
in the current study. Of these, 546 respondents completed and returned the questionnaire
(a response rate of 70%). The mean age of the sample was 47 years (range 16±86). Thirty-
®ve per cent of the sample was classi®able as professional or intermediate workers, 45% as
skilled or partly skilled, and 21% as unskilled or unemployed. The study did not examine
ethnic differences in responses, as there were too few women within each particular group
to draw meaningful conclusions. Ninety-three per cent of the sample were classi®ed as
White, 3% as Black African and Black Caribbean, 2% as Indian, Pakistani, or Bangladeshi, 1%
as Chinese, and the remaining 1% were assigned to other ethnic groups.

Analysis
The means and standard deviations for each sub-scale and the inter-correlations between
the sub-scales for each section of the questionnaire are reported. Analysis of variance was
used to examine differences between prompt help-seekers and potential delayers
(classi®ed according to responses to the temporal-based intention measure) on each of the
subscales. The symptom-based intention measure was used for all correlational analyses.
Hierarchical multiple regression was used to identify the best predictors of the symptom-
based measure of intention. To evaluate whether the addition of the components of the
self-regulation model and the components of the theory of planned behaviour accounted
for signi®cantly more variance, the formula proposed by Tabachnik and Fidell (1996, p. 144)
was applied.

Results
Responses to the temporal measure of intention to seek help revealed that 58.6% of
respondents would seek immediate help for a breast symptom, and this group was classi®ed
as prompt help-seekers. The remaining participants were classi®ed as potential delayers;
29.7% indicated that they would seek help within 1 week, 8.5% would seek help within 1
month, and 3.2% would wait for 2 months or more. Using the main intention variable (based
on the sum of intentions to seek help for individual symptoms (M = 5.34, SD = 0.85)
univariate regression analyses were carried out between intention and age and intention
and socio-economic status. Age was found to be a signi®cant predictor of intention to seek
help, F(1, 543) = 36.09, p < .001, whereas socio-economic group was not, F(1, 518) = 0.29, p
= .591.

Table 1. Mean scores (SD) for each of the sub-scales from the self-regulation model as a function of
help-seeking intention

Potential delayers Prompt help-seekers

Scale (N = 222) (N = 318)

Identity 6.5 (1.5) 6.8 (1.4)

Timeline 4.0 (1.1) 4.0 (1.3)
326 Myra S. Hunter et al.
Consequences 4.6 (1.1) 4.7 (1.3)
Cure/control 5.7 (0.9) 5.7 (0.9)

Self-regulation model
The mean scores obtained for prompt help-seekers and potential delayers on each of the
sub-scales are presented in Table 1. Potential delayers score signi®cantly lower on the
identity scale than prompt help-seekers, F(1, 542) = 5.08, p < .05, suggesting that prompt
help-seekers accurately identi®ed more symptoms of breast cancer. The mean scores for
each of the cause items are shown separately in Table 2. It can be seen that the two groups
were similar in their attributions of the risk factors for breast cancer. Family history was the
most strongly endorsed cause of breast cancer, closely followed by previous breast cancer
and smoking. The least-favoured attributions were a previous breast problem, late onset of
menses, and excess body weight. There were no signi®cant differences between the two
groups in terms of their responses on the time-line, consequences, and control/cure scales.
The inter-correlations between the self-regulation model scales are shown in Table 3
and logical (weak to moderate) relationships between the scales were apparent.
Respondents who reported a longer time course for breast cancer also reported more
negative attitudes towards the consequences of breast cancer and the controllability of
Table 2. Mean scores (SD) for the cause items from the self-regulation model (range of potential scores
1–7) (the higher the score, the stronger the causal belief)

Attribution/cause Potential delayers Prompt help-seekers

Family history 5.9 (1.5) 6.0 (1.5)

Previous breast-cancer 5.3 (1.5) 5.3 (1.6)
Bumping or bruising the breast 3.0 (1.8) 3.0 (1.9)
Smoking 5.1 (1.9) 5.4 (1.9)
High-fat diet 4.1 (1.9) 4.1 (2.0)
Older age 4.9 (1.8) 4.8 (1.9)
Alcohol consumption 3.5 (1.7) 3.6 (1.9)
Age at time of Žrst full pregnancy 5.0 (1.8) 4.8 (1.9)
Late onset of menses 2.7 (1.5) 2.8 (1.8)
Excess body weight 2.8 (1.6) 2.8 (1.8)
Late menopause 5.0 (1.5) 4.9 (1.7)
Previous breast problem 2.3 (1.3) 2.2 (1.4)
Oral contraceptives 3.9 (1.8) 4.0 (1.9)
Stress 4.3 (1.9) 4.2 (2.0)

the disease. Participants who reported a more positive attitude toward the consequences
of breast cancer were also more likely to report a greater belief in the controllability of
breast cancer. However, it was shown that participants with the greatest awareness of
breast-cancer symptoms (higher identity score) were more likely to report negative beliefs
about the consequences of breast cancer.
 Help-seeking intentions for breast cancer 327
Theory of planned behaviour
The mean scores obtained for prompt help-seekers and potential delayers on each of the
sub-scales of the theory of planned behaviour are presented in Table 4. Prompt help-seekers
scored signi®cantly higher on both the belief-based, F(1, 542) = 35.18, p < .001, and direct,
F(1, 542) = 13.94, p < .001, measures of attitude toward help-seeking. Prompt help-seekers
also reported greater perceived behavioural control regarding obtaining help for a breast
cancer symptom, F(1, 542) = 10.87, p < .01. There were no group differences in the
responses on the subjective norms scale.
The intercorrelations between the subscales can be found in Table 3. Logical
relationships were again apparent between the scales. As expected, the belief-based and
direct measures of attitude were signi®cantly correlated. Because of this, and the fact that
there were stronger correlations of intention with the belief-based measures of attitude
than with the direct measures, the direct measures of attitude were excluded from further
analysis, and therefore references to attitude correspond to the belief-based measures. The
subjective norm scores were negatively correlated with attitudes to helpseeking, suggesting
that participants with more positive attitudes to help-seeking were less likely to feel social
pressure to seek help. Examination of the correlation coef®cient, however, revealed that
this was a weak relationship.

Multiple-regression analysis
Hierarchical multiple-regression analysis was performed to examine the combined
suf®ciency of the self-regulation model and the theory of planned behaviour to explain
328 Myra S. Hunter et al.
 Help-seeking intentions for breast cancer 329
Table 4. Mean scores (SD) for each of the subscales within the theory of planned behaviour
questionnaire as a function of help-seeking intention

Potential delayers Prompt help-seekers

Scale (N = 222) (N = 318)

Attitude to help-seeking (belief-based) 5.4 (0.9) 5.8 (0.9)

Attitude to help-seeking (direct measure) 6.0 (0.6) 6.2 (0.6)
Subjective norm 92.3 (38.1) 83.9 (43.5)
Perceived behavioural control 6.4 (0.8) 6.6 (0.7)

intention to seek help for a potential breast-cancer symptom. As there were no prior
expectations as to which theory would account for the majority of variance, the theories
were entered in a logical temporal sequence based on the assumption that a woman would
®rst draw upon her beliefs and knowledge of breast cancer (as outlined in the SRM) before
drawing upon her beliefs about help-seeking behaviour (outlined in the TPB). The
components of the self-regulation model (identity, time-line, cure/control, and
consequences) were entered on the ®rst step, and the components of the theory of planned
behaviour (attitude to help-seeking, subjective norm, and perceived behavioural control)
on the second step. As shown in Table 5, the components of the self-regulation model
signi®cantly increased the explained variance to 22.1%, F(4, 536) = 23.11, p < .001. The
explained variance was again signi®cantly increased to 29.2% by the addition of the
components of the theory of planned behaviour, F(2, 500) = 6.70, p < .05. The strongest
predictor of intention to seek help was the perceived identity of symptoms, followed by
attitude toward help-seeking and perceived behavioural control (Table 5).

Table 5. Hierarchical multiple regression analysis of intention to seek help for a symptom of breast-
cancer

b in Žnal
Step/predictor R2 Adjusted R2 F equation

1. Self-regulation model .227 .221 39.41

Identity .454**

Time-line ê
Cure/control .058.021
Consequences .024

2. Theory of planned behaviour .301 .292 30.89

Attitude (help-seeking) .187**

Subjective norm ê
Perceived behavioural control
.040.122*
* p < .01; ** p < .001.
330 Myra S. Hunter et al.
Additional potential in• uences of help-seeking behaviour
It was hypothesized that personal and familial history of breast cancer, previous
breastexamination behaviour, and attitudes towards treatment for breast cancer might also
be related to intention to seek help for a potential breast-cancer symptom. Point-biserial
correlations were carried out to examine the relationship between help-seeking intention
and personal and familial history (answered as dichotomous yes/no responses). There were
no signi®cant relationships between help-seeking intention and personal history of breast
problems (rpb= .042, N = 545, p = .328), help-seeking for breast problems (rpb=ê , .069p
=,.750)N =. Bivariate linear correlations were used to112, p = .145), or familial history of
breast cancer (rpb= .014, N = 546
examine the relationship between help-seeking intention and frequency of breast
selfexamination and attitudes towards breast cancer. There was not a signi®cant
relationship between help-seeking intention and frequency of breast self-examination (r
=.038, N = 445, p = .427). However, there was a weak signi®cant negative relationship
between intention to seek help for a symptom of breast cancer and attitude towards
treatment for breast cancer (r = ê .129, N = 546, p < .01).

Discussion
The study examined the utility of the self-regulation model and the theory of planned
behaviour in explaining help-seeking intention for symptoms of breast cancer. The results
of the hierarchical multiple regression revealed that individual components of both the self-
regulation model and the theory of planned behaviour were able to predict intention to
seek help for symptoms of breast cancer but that the total variance explained by the two
models was moderate, being approximately 30%.
The proportion of estimated prompt help-seekers was higher than that found in other
studies of clinical populations (Richards et al., 1999b), and this might be explained by the
absence of the emotional response to possible breast cancer and the in¯uence of competing
demands which could not be assessed in the design of this study of well women. Therefore,
a higher proportion of the variance in help-seeking behaviour might be expected in future
studies of clinical samples.

Self-regulation model
Using the self-regulation model, differences in illness representations were identi®ed
between women intending to seek help for potential breast-cancer symptoms and between
prompt and potential delayed help-seekers. Identi®cation of symptoms as potential signs of
breast cancer (identity) was the variable within this model that most strongly predicted
intention to seek help for breast-cancer symptoms. This supports one of the main
assumptions of the self-regulation model, namely that symptoms are key factors in the
cognitive representations of health threats and in the initiation of the selfregulatory process
(Cameron et al., 1993).
There has been little research examining women’s knowledge of breast-cancer
symptoms, despite the fact that misattribution of symptoms is a well-established predictor
 Help-seeking intentions for breast cancer 331
of delay behaviour in medical situations (Cameron, Leventhal, & Leventhal, 1995; Jones,
1990; Stoller & Forster, 1994). In particular, a patient with a non-lump breast symptom is
over four times more likely to delay seeking medical help than an individual with a breast
lump (Burgess et al., 1998; Ramirez et al., 1999). A painless breast lump is the most
frequently recognised symptom of breast cancer (Grunfeld, Ramirez, Hunter, & Richards,
2001). It may be that limited knowledge of other symptoms of breast cancer leads to the
misattribution of these symptoms to a benign process, resulting in delay in seeking medical
help (Facione & Dodd 1995). In the present study, even prompt help-seekers did not identify
all potential symptoms of breast cancer. These results have implications not only for the
inclusion of symptom information in health education campaigns but also for ensuring that
the array of potential breast symptoms becomes part of a common `cancer knowledge’. It
is important to encourage people to be aware of non-lump symptoms (i.e. nipple retraction)
and that the ability to correctly identify such symptoms may have survival implications.
Time-line, consequences, and control/cure beliefs were not found to be in¯uential
predictors of help-seeking intention. This study was conducted with a sample of well
women, and it may be unlikely that they would consider the timescale of a disease when
making decisions regarding help-seeking for hypothetical symptoms. Beliefs regarding the
time course of breast cancer might be more likely to in¯uence the affective response to the
disease, as has been suggested for other illnesses (Moss-Morris, Petrie, & Weinman, 1996).
As the study was hypothetical in nature, it was not possible to measure affective response
to illness within this design. In addition, the a values for both the time-line and the
cure/control scale were rather low, and this would need to be addressed in future studies
based upon these subscales.

Theory of planned behaviour

Holding a positive attitude towards help-seeking for breast cancer was a strong predictor of
intention to seek help for breast-cancer symptoms and prompt help-seeking. These results
are in line with previous research that has demonstrated an association between less
favourable attitudes to the medical profession and increased likelihood to delay seeking
medical help (Battistella, 1971). Previous qualitative research highlighted that some women
may be hesitant to `bother’ their GP for symptoms of breast cancer, particularly if the
symptoms are ambiguous (Burgess et al., 2001). These ®ndings have important implications
for ensuring that high-risk women, in particular, are encouraged to seek help for ambiguous
symptoms.
Intention to seek help was also in¯uenced by beliefs regarding personal con®dence in
the ability to seek help for a symptom of breast cancer. The present study did not examine
in detail the in¯uences on perceived behavioural control under these conditions, but there
is evidence to suggest that some women may not prioritize their own health over perceived
competing demands (Burgess et al., 2001). Future research is necessary to elicit reasons why
some women lack the con®dence to seek help for symptoms of breast cancer.
332 Myra S. Hunter et al.
Relative sufŽ ciency of the models
The models provided a clear framework for examining variables that may in¯uence
helpseeking intentions for breast symptoms. Combined, the models accounted for almost
one-third of the total variance in intention to seek help for breast cancer symptoms, and
this is in line with the variance explained using social-cognition models for other health
behaviours (i.e. Hill, Gardner, & Rassaby, 1985). However, to explain even this relatively
moderate degree of variance provides valuable insight into the reasons why women may or
may not seek help for breast-cancer symptoms. This in turn could have a signi®cant impact
in terms of health education and informing help-seeking behaviour.
The current study did not examine the emotional component of the self-regulation
model, and it is probable that more variance would have been explained had this
component been included in a sample of women with breast-cancer symptoms

Figure 1. Hybrid model incorporating components of the self-regulation model and theory of planned
behaviour shown to be important in predicting intentions to seek help for breast-cancer symptoms.
The heavy lines show the variables that emerged as signiŽcant predictors of intention following
hierarchical multiple-regression analysis (b values are shown). The dashed lines represent signiŽcant
correlations between variables (the correlation coefŽcients are shown).

(Leventhal & Nerenz, 1984). Furthermore, unlike previous research examining screening and
treatment intentions (Quine & Rubin, 1997; Rutter, 2000), subjective norms were not found
to be a signi®cant predictor of intention to seek help among this sample. Previous research
has suggested that subjective norms are primarily of importance in situations where the
behaviour will directly affect the health of signi®cant others, for example the decision to
terminate a pregnancy (Smetana & Adler, 1980), or where the behaviour is performed
publicly, for example wearing a seat belt while driving (Wittenbraker, Gibbs, & Kahle, 1983).
Since help-seeking for a potential, possibly ambiguous, symptom of breast cancer does not
fall into either of these categories, it could be argued that subjective norms would not be a
key in¯uential variable in a decision to seek help under these circumstances. However, the
importance of social networks in help-seeking for breast symptoms has been demonstrated
previously (Burgess et al., 1998). This work demonstrated that not disclosing the discovery
of a symptom to someone within a few days was associated with increased delay and that
being prompted to seek help by someone else was associated with prompt help-seeking.
The current study forms part of a larger programme of research examining delay
behaviour for breast cancer. The study aimed to draw upon the elements of two models in
 Help-seeking intentions for breast cancer 333
order to maximize understanding of the process of help-seeking. The results suggest the
possibility of a two-component process whereby a woman appraises breast changes and,
having interpreted the change as a possible breast-cancer symptom, cognitively processes
the advantages and disadvantages of seeking help, drawing upon her health beliefs and self-
ef®cacy beliefs. Figure 1 depicts a hybrid model drawing on the components of the self-
regulatory model and the theory of planned behaviour that were found to be of signi®cance
in predicting intention to seek help for breast symptoms. The results suggest that, although
both models are useful as an initial starting point in the examination of intentions to perform
health behaviours, different types of behaviour even within the same patient group (i.e.
screening, starting treatment, and help-seeking for symptoms) may be in¯uenced by
separate components of the models. Reasons for these discrepancies have already been
discussed. The research highlights the value of utilizing multiple models in the initial stages
of research to identify key components that can be used to inform both research and policy
developments.
Inevitably, additional variables, outside the remit of the two models, will contribute to
help-seeking intentions. For example, it is likely that there is a complex, non-linear
relationship between age and health beliefs regarding breast cancer. Research is needed to
examine the usefulness of these models across different age groupings, to see which
variables exert most in¯uence at different life stages. The addition of previous behaviour has
been shown to increase the explained variance for some health-related behaviours (Quine
& Rubin, 1997). In the present study, however, breast self-examination and previous
experience of seeking help for a breast symptom were not signi®cantly correlated with help-
seeking intention. The results do suggest that some women, who hold negative perceptions
of breast-cancer treatments, may delay seeking medical help for symptoms of breast cancer.
However, this conclusion is drawn from a relatively weak correlation, and therefore further
research is needed to explain the remaining variance not accounted for by the models used
in this study. Additional variables that could be examined in future research include the
emotional component of the selfregulation model and situational factors (e.g. competing
demands). A future study is being planned, drawing upon these ®ndings with a clinical
sample of women who have recently sought medical help for breast-cancer symptoms, with
the aim of developing a health-promotion intervention.

Acknowledgements
This study was supported by a Project Grant from The Breast Cancer Campaign (charity number
299758, grant reference number 1999/96). The authors would like to thank Barzan Rahman for his
help with data collection.

References
Ajzen, I., & Madden, T. J. (1986). Prediction of goal-directed behaviour: Attitudes, intentions and
perceived behavioural control. Journal of Experimental and Social Psychology, 22, 453±474.
Battistella, R. M. (1971). Factors associated with delay in the initiation of physicians’ care among late
adulthood persons. American Journal of Public Health, 6(7), 1348±1361.
334 Myra S. Hunter et al.
Burgess, C. C., Hunter, M. S., & Ramirez, A. J. (2001). A qualitative study of delay among women
reporting symptoms of breast cancer. British Journal of General Practice, 51, 967±971.
Burgess, C. C., Ramirez, A. J., Richards, M. A., & Love, S. B. (1998). Who and what in¯uences delayed
presentation in breast cancer? British Journal of Cancer, 77(8), 1343±1348.
Cameron, L., Leventhal, E. A., & Leventhal, H. L. (1993). Symptom representations and affect as
determinants of care seeking in a community-dwelling, adult sample population. Health
Psychology, 12(3), 171±179.
Cameron, L., Leventhal, E. A., & Leventhal, H. L. (1995). Seeking medical care in response to symptoms
and life stress. Psychosomatic Medicine, 57, 37±47.
Conner, M., & Norman, P. (1995). Predicting health behaviour (pp. 121±162). Buckingham, UK: Open
University Press.
Facione, N. C. (1993). Delay versus help seeking for breast-cancer symptoms: A critical review of the
literature on patient and provider delay. Social Science and Medicine, 36, 1521±1534.
Facione, N. C., & Dodd, M. J. (1995). Women’s narratives of help-seeking for breast cancer. Cancer
Practice, 3(4), 219±225.
Grunfeld, E. A., Ramirez, A. J., Hunter, M. S., & Richards, M. A. (2001). Women’s knowledge and beliefs
regarding breast cancer. British Journal of Cancer, 86, 1373±1378.
Hill, D., Gardner, G., & Rassaby, J. (1985). Factors predisposing women to take precautions against
breast and cervix cancer. Journal of Applied Social Psychology, 15, 59±79.
Jones, R. A. (1990). Expectations and delay in seeking medical care. Journal of Social Issues, 46(2),
81±95.
Leventhal, H., & Nerenz, D. (1985). The assessment of illness cognition. In P. Karoly (Ed.), Measurement
strategies in health psychology (pp. 517±555). New York: Wiley.
Leventhal, H., Nerenz, D. R., & Steele, D. J. (1984). Illness representations and coping with health
threats. In A. Baum, S. E. Taylor, & J. E. Singer (Eds.), Handbook of psychology and health. Vol IV:
Social psychological aspects of health (pp. 219±252). Hillsdale, NJ: Erlbaum.
Moss-Morris, R., Petrie, K. J., & Weinman, J. (1996). Functioning in chronic fatigue syndrome: Do illness
perceptions play a regulatory role? British Journal of Health Psychology, 1(1), 15±25.
Quine, L., & Rubin, R. (1997). Attitude, subjective norm and perceived behavioural control as
predictors of women’s intentions to take hormone replacement therapy. British Journal of Health
Psychology, 2, 199±216.
Ramirez, A. J., Westcombe, A. M., Burgess, C. C., Sutton, S., Littlejohns, P., & Richards, M. A. (1999).
Factors predicting delayed presentation of symptomatic breast cancer: A systematic review.
Lancet, 353, 1127±1131.
Richards, M. A., Smith, P., Ramirez, A. J., Fentiman, I. S., & Rubens, R. D. (1999b). The in¯uence on
survival of delay in the presentation and treatment of symptomatic breast cancer. British Journal
of Cancer, 79(5/6), 858±864.
Richards, M. A., Westcombe, A. M., Love, S. B., Littlejohns, P., & Ramirez, A. J. (1999a). In¯uence of
delay on survival in patients with breast cancer: A systematic review of the literature. The Lancet,
353, 1119±1126.
Royak-Schaler, R., Cheuvront, B., Wilson, K. R., & Williams, C. M. (1996). Addressing women’s breast
cancer risk and perceptions of control in medical settings. Journal of Clinical Psychology in Medical
Settings, 3(3), 185±199.
Rutter, D. R. (2000). Attendance and reattendance for breast cancer screening: A prospective 3-year
test of the Theory of Planned Behaviour. British Journal of Health Psychology, 2, 199±216.
Safer, M. A., Tharps, Q. J., Jackson, T. C., & Leventhal, H. (1979). Determinants of three stages of delay
in seeking care at a medical setting. Medical Care, 17(1), 11±29.
Smetana, J. G., & Adler, N. E. (1980). Fishbein’s value ´ expectancy model: An examination of some
assumptions. Personality and Social Psychology Bulletin, 6, 89±96.
 Help-seeking intentions for breast cancer 335
Stoller, E. P., & Forster, L. E. (1994). The impact of symptom interpretation on physician utilization.
Journal of Aging and Health, 6(4), 507±534.
Tabachnik, B. G., & Fidell, L. S. (1996). Using multivariate statistics (4th ed., pp. 144). Boston: Allyn &
Bacon.
Timko, C. (1987). Seeking medical care for a breast cancer symptom: determinants of intention to
engage in prompt or delay behavior. Health Psychology, 6, 305±328.
Weinman, J., Petrie, K. J., Moss-Morris, R., & Horne, R. (1996). The Illness Perception Questionnaire: A
new method for assessing the cognitive representation of illness. Psychology and Health, 11,
431±445.
Wilcox S., & Stefanick, M. L. (1999). Knowledge and perceived risk of major diseases in middleaged
and older women. Health Psychology, 18(4), 346±353.
Wittenbreaker, J., Gibbs, B. L., & Kahle, L. R. (1983). Seat belt attitudes, habits and behaviours: An
adaptive amendment to the Fishbein model. Journal of Applied Social Psychology, 13, 406±421.

Received 9 July 2001; revised version received 25 April 2002