Nasopharyngeal cancer (NPC) when diagnosed before Stage 3 has good prognostic outcomes. Considering that NPC is sensitive to chemo-radiotherapy and results in a two- and three-year survival rate of 84% and 78% respectively in cases of early detection [1], regular screening is important to reduce mortality. Worldwide, deaths due to NPC number 50,000 out of 86,000 cases [2] and 71% of new NPC cases are from East and Southeast Asia [3]. In Malaysia NPC is the fifth most common cancer, and the lifetime risk for males was 1 in 143 and for females it was 1 in 417 in the 2007–2011 period [4]. Most of the NPC cases were detected at Stages 3 and 4 (63% for males, 60% for females) [5], suggesting lack of awareness towards NPC symptoms.
Minimizing risk factors can reduce NPC deaths. It is widely reported among NPC researchers that Epstein-Barr virus infection, smoking, and frequent consumption of preserved food and salted fish are associated with a high incidence of NPC [6]. Non-environmental risk factors of NPC include gender, ethnicity, and family history [7]. Certain ethnic groups such as the Bidayuh [8], Cantonese [9] and Malaysian residents in Sarawak, Penang and Labuan have higher NPC incidences [5]. Exposure to formaldehyde, wood dust, smoke and chemicals may also be involved in the pathogenesis of NPC [10]. Awareness of NPC risk factors can lead to adoption of risk reducing behaviors such as screening and reduced intake of NPC-causing foods. However, taboos surrounding cancer discourage screening for early cancer detection [11, 12, 13]. However, little is known about NPC risk reducing behaviors and factors that predict these behaviors among Malaysians. Thus far, research on NPC in Malaysia are mostly clinical studies on the epidemiology of NPC [14, 15, 16, 17, 18, 19, 20, 21]. Some studies examined the knowledge of the primary care doctors on NPC [22] and social impact of NPC [23]. The present study is the first to investigate individuals’ reasons for enacting preventive or self-protective measures to reduce risk in a setting where incidence of NPC deaths is high: NPC ranks number five in cancer incidences in Malaysia period [4]. This study aimed to employ the Risk Perception Attitude (RPA) framework to predict NPC risk reducing behaviors among a group of Malaysians.
Risk Perception Attitude (RPA) Framework
The RPA framework was developed by Rimal and Real [24] based on Witte’s Extended Parallel Process Model [25] to understand the relationship between health risk perceptions and health behaviors, moderated by their efficacy beliefs. Risk perception is related to beliefs about perceived severity and perceived susceptibility, while risk prevention behaviour is related to efficacy beliefs, operationalised as the product of self-efficacy and response efficacy. Health behaviors refer to self-protective measures that individuals can take or intend to take to avoid certain diseases, including information-seeking behaviours. Based on their risk perceptions and efficacy beliefs, individuals are categorized into one of the four attitudinal groups: responsive (high risk, high efficacy), avoidance (high risk, low efficacy), proactive (low risk, high efficacy) and indifference (low risk, low efficacy). Their non-intervention study on skin cancer-related behaviours showed that the responsive group reported healthier outcomes than the avoidance group, and the proactive group reported healthier outcomes than the indifferent group [24].
The use of RPA has identified diverse risk factors influencing health behavioral intentions. For example, people who reported high levels of perceived cancer risk and strong self-efficacy were more motivated and able to engage in various health actions such as cancer-prevention diets [26], information seeking on cancer, and cancer screening [27, 28, 29]. Besides efficacy beliefs, other studies found that non-environmental risk factors moderated breast cancer risk perceptions and intention to undergo mammography screening such as rural-urban locality, religion, social-cultural beliefs [30], family history [31], age [32], and health literacy [33]. Spiritual health locus of control, for example, influenced American women’s perceived risk and efficacy, which resulted in several health outcomes: message acceptance, talking about breast cancer, information seeking and behavioural intentions [34]. In addition, cancer fatalism, mistrust of health care providers, and previous negative experiences with the medical system have also been found to be associated with people’s invariable attitudes towards cancer precautionary measures such as cancer screening and adherence to health care recommendations [35]. In their review of the field concluded that the causal relationship between people’s health risk perceptions and their health behaviours is “more tenuous” than expected, given the “discrepanc(ies) in (research) findings” while some studies found a positive connection between people’s perceptions of health risks and their health-related precautionary behavior, others discovered otherwise [27]. They further argued that the causes for these discrepancies could be attributed to researchers’ own failure to take into account the various moderators that may influence the causal link between risk perception and health behavior. Consistent with the RPA and the findings of studies that have employed this framework, we hypothesise that – efficacy beliefs, in addition to various modifying factors, will predict NPC risk reducing behaviors.