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Abstract

Although health care utilization occurs in interpersonal contexts, little is known regarding how interpersonal preferences or styles among patients may be relevant. A small body of work has identified links between attachment—a dispositional style of relating to others—and patterns of health care use. The current report examined how attachment characteristics predicted the frequency of digital rectal exam and prostate-specific antigen testing in a sample of African-descent men. Four hundred and fourteen African-descent men aged 45 to 70 years completed measures of prostate screening and attachment, together with measures of traditional predictors of screening (demographics, insurance, family history, physician variables, knowledge, perceived risk, and accessibility). Consistent with predictions, dismissiveness—the most common relational style among older men—predicted less frequent prostate-specific antigen testing and digital rectal examination. However, attachment security—a comfort with intimate relationships—also predicted lower screening frequency. Identifying the interpersonal characteristics predicting screening may help identify men at risk of suboptimal health care use and guide the development of interventions suited to the normative relational preferences of current cohorts of older, African-descent men.

Keywords

attachment prostate cancer screening prostate-specific antigen digital rectal exam health care utilization emotion

Men are less likely to use health care resources than women (Courtenay, 2000). In American groups, men of African descent have lower utilization and poorer outcomes than European Americans. Historically, studies of utilization have focused on sociodemographic and structural factors, such as age (Myers et al., 2000), income and education (Steele, Miller, Maylahn, Uhler, & Baker, 2000), marital status (Merrill, 2001), and race or ethnicity (Consedine, Magai, Horton, Neugut, & Gillespie, 2005). However, such factors are difficult or impossible to modify, and while they predict, they provide little guidance for interventions (Consedine, Christie, & Neugut, 2009). Thus, understanding the psychosocial factors associated with patterns of health care utilization among men is of increasing concern.

Recently, there has been interest in possible links between attachment—a dispositional style of relating to others—and utilization (Ciechanowski, Walker, Katon, & Russo, 2002; Feeney, 1995, 2000; Hunter & Maunder, 2001). Early evidence indicates that attachment is related to both adherence and medical utilization (Ciechanowski, Katon, & Hirsch, 1999; Hunter & Maunder, 2001) as well as symptom reporting (Consedine, Fiori, Tuck, & Merz, 2013). In contributing to this body of work, the current study examined links between attachment and participation in intimate cancer screenings in a large sample of African-descent men from Brooklyn, New York.

Attachment and Health Care Utilization

Attachment theory suggests that early interactions with caregivers affect how individuals manage the threat associated with interpersonal vulnerability and relate to others throughout their lives (Bowlby, 1969; Consedine & Magai, 2003). Harsh, inconsistent, or nonresponsive caregiving results in insecure styles, whereas security results where early needs are met (Shaver & Clark, 1994). Research suggests that either three (Hazan & Shaver, 1987) or four (Bartholomew & Horowitz, 1991) styles of attachment predominate, although analyzing attachment around dimensions is statistically more robust (Fraley & Waller, 1998) and precise (Collins, 1996). In line with current practice, this report used dimensional analyses using the secure and dismissive terms as in studies of adults (Hazan & Shaver, 1987) and fearful avoidant as used by others (Bartholomew & Horowitz, 1991).

Persons high in security fundamentally believe that they are worthy of care and attention and that caregivers are capable and willing to provide support (Hunter & Maunder, 2001). This belief may underlie the finding that secure persons report better provider relationships (A. E. M. Smith, Msetfi, & Golding, 2010). Such relationships, coupled with an adaptive threat management style, imply that secure persons should be less threatened by the interpersonal vulnerability of some prostate cancer (PC) exams and thus be less avoidant of utilization.

Individuals with fearful avoidant styles have typically experienced instability in early relationships and thus failed to develop a stable interpersonal style. Fearfully avoidant individuals fluctuate between help seeking and mistrust and may request help, but then reject it. This dynamic may impair provider relationships (Hunter & Maunder, 2001) and underpin low primary care costs and utilization (Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003) among these individuals.

Finally, dismissive attachment results from early environments that encouraged self-reliance rather than seeking support from others. Dismissive individuals prioritize independence and avoid intimacy and vulnerability (Hunter & Maunder, 2001), report fewer somatic symptoms (Ciechanowski et al., 2002), are less adherent to treatment (Ciechanowski et al., 1999), and may reject medical advice (Hunter & Maunder, 2001).

In sum, when individuals are exposed to stressors, such as the threat associated with interpersonal vulnerability or health, dispositional attachment characteristics are activated (Bowlby, 1973, 1980). Given the links between attachment and threat management styles, attachment should influence if, when, and how help is sought (Hunter & Maunder, 2001). Consistent with this assertion, dismissiveness and fearful avoidance predict lower utilization (Ciechanowski, Katon, & Russo, 2000), whereas secure styles predict greater use (Feeney, 2000; Feeney & Ryan, 1994).

Attachment and Prostate Screening

Although such research represents a beginning, several areas would benefit from further work. First, attachment is conflated with demographics such as age (Fiori, Consedine, & Merz, 2011), income, ethnicity, and marital status (Mickelson, Kessler, & Shaver, 1997); few studies have controlled for these confounds. Second, given calls to examine the origins of low utilization among African American men, it may be that their normatively more dismissive profile (Consedine & Magai, 2003; Magai et al., 2001) can offer insight.

Three, PC screening has not been examined from an attachment perspective. PC is common in men and is the second leading cause of cancer-related death in men (American Cancer Society[ACS], 2007a). Incidence and mortality rates are high among African American men (ACS, 2011), and large proportions of minority men present with advanced PC (ACS, 2007b). At the time of data collection, guidelines (ACS, 2007a) suggested that African American men over the age of 45 be offered annual digital rectal examination (DRE) and prostate-specific antigen (PSA) tests, provided men were informed of benefits and limitations (R. A. Smith, Cokkinides, & Eyre, 2004). As neither test appears unambiguously effective (Andriole et al., 2009), guidelines changed in 2009 such that they no longer applied to men with a life expectancies <10 years (Wolf et al., 2010). PC mortality among African American men remains high (ACS, 2011), and data linking interpersonal styles with PC screening may provide insight into the interpersonal predictors of other intimate screenings.

From an attachment perspective, investigating PC screening in a sample of older men is a useful context in which to examine how attachment may predict health care utilization. PC screening is profoundly fear inducing (Consedine, 2012), and whereas PSA testing involves a routine blood sample, DREs require that a man allow the insertion of a finger into his anus (Winterich et al., 2009). The generic nature of PSA testing implies that they are less likely to activate attachment-linked threat management styles, whereas the high degree of threat, vulnerability, and exposure associated with DRE suggests that this screen should be more closely linked to attachment.

African American men from late middle age and later life have distinct patterns of attachment. In general, older adults are more dismissive or avoidant (Consedine & Magai, 2003; Kafetsios & Sideridis, 2006) and less preoccupied (Mickelson et al., 1997) or fearful avoidant (Fiori et al., 2011) than younger groups. Although sex differences are less consistent in older groups (Kafetsios & Sideridis, 2006), men tend to be more dismissing or avoidant (Brennan, Clark, & Shaver, 1998; Mickelson et al., 1997), and African Americans are also more dismissive (Fiori, Consedine, & Magai, 2009). Whether attachment predicts utilization in groups of older African American men is yet to be investigated.

Finally, our data allowed us to take early steps in examining possible psychological processes by which attachment may influence screening. As noted, attachment styles are rooted in how individuals manage interpersonal threat. Dismissives fundamentally mistrust others and have an intense dislike for experiences of shame and anxiety (Consedine & Magai, 2003). They are defensive and avoid situations that threaten autonomy (Bartholomew, 1990); such men may downplay PC risk and underreport anxiety (Consedine, 2012). Given that perceived risk and cancer worry predict screening behavior (Consedine, Adjei, Ramirez, & McKiernan, 2008), controlling for low perceived risk and worry among dismissives may attenuate links between dismissiveness and screening. Examining these links may highlight the specific motivations linking attachment to screening, whereby rather than being driven by fear or embarrassment, low utilization among dismissives may be in part due to low anxiety and/or an aversion to interpersonal vulnerability (Merz & Consedine, 2009).

Conversely, security is associated with more instrumental coping and support seeking (Mikulincer, Florian, & Weller, 1993), and stressors are seen as more benign (Collins & Read, 1990). The adaptive threat regulatory profile associated with security may encourage screening as a means of managing PC anxiety. Finally, fearful avoidance has links with greater anxiety, shame, and disgust (Consedine & Magai, 2003). Although anxiety generally facilitates help seeking (Hunter & Maunder, 2001), preoccupied persons see others as being unwilling or unable to provide support (Bartholomew & Horowitz, 1991), and emotions such as shame and disgust promote avoidance (Consedine & Moskowitz, 2007; Reynolds, Consedine, Pizarro, & Bissett, 2013). Fearful-avoidance should therefore predict reduced screening, but the link may attenuate once worry and fear are controlled.

Hypotheses and the Current Study

Based on prior data together with insights drawn from attachment and PC screening work, it was expected that security should predict more frequent DRE and PSA screening, whereas dismissiveness and fearful avoidance would predict less. Furthermore, the more intimate and vulnerable screen (DRE) was expected to be more closely linked to attachment. Finally, given the inherently interpersonal nature of some PC testing and the impact of attachment on threat management styles, it was expected that controlling for cancer and screening anxieties would leave the links between attachment and screening essentially unchanged.

Method

Participants

Four hundred and fourteen community-dwelling African-descent men, ranging in age from 45 to 70, living in Brooklyn, New York, from a larger (N = 533) sample formed the basis of the current report. As such, it does not include data from European American participants in the larger sample but concentrates on three distinct African-descent groups: U.S. born African Americans, immigrant Jamaicans, and immigrant men from Trinidad and Tobago. Men were recruited using a stratified cluster sampling plan. At the initial stage, tract blocks containing 25% or more of either Black or White men were identified using the year 2000 Census files. Tracts were stratified on the basis of household income (“high,” “middle,” and “low” categories) and within these categories ordered by the percentage of Black and White residents (25% to 50%, 51% to 75%, 76% or greater). Geographically representative numbers of Black and White males in each tract were derived, and trained interviewers recruited men meeting the sampling criteria. The mean age of the sample was 54.5 years. Sixty-six percent of men had a high school education or less, with a median annual income between $30,000 and $49,999. More than 80% of the men had medical insurance, a personal physician, and underwent annual examinations.

Procedures

Permission for the study was obtained from the institutional review boards of Long Island University and Columbia University; data were collected for 21 months from 2004 to 2006. Men were recruited for a “Men’s Health Questionnaire Study,” with most initial contacts made through door knocking (15.0%) and “stop and ask” (45.0%) with some “referral” based contacts (37.1%). Smaller numbers responded to advertising in local papers (1.5%) and flyer postings (1.3%). Although full data are not available, data from the door knocking portion of the sample indicate that in excess of 30% of eligible men contacted agreed to participate (see Figure 1).

Figure 1.

Flowchart showing eligibility, recruitment, and refusal rates for the proportion of the sample recruited via door knocking.

Once a man satisfying demographic criteria agreed to participate, the interviewer verified the address as fitting the geographic sampling plan. Data were collected during face-to-face interviews conducted in respondents’ homes or another location of their choice. Measures were administered in a standard order, and men were paid $50 for participation.

Measures

Background questionnaire

Elicited information regarding ethnic/nationality group, age, household income ($), years of education, relationship status (“stable relationship”; “widowed, separated, or divorced”; and “never been in stable relationship”).

Adult attachment

The 30-item Relationship Scales Questionnaire (RSQ; Griffin & Bartholomew, 1994) measures four styles of attachment (secure, fearful avoidant, dismissing, and preoccupied). Respondents rate how well each item describes their characteristic style in close relationships using 5-point scales. Because the consistency of the four subscales is often low in older samples (Consedine & Fiori, 2009; Consedine & Magai, 2003; Magai et al., 2001), and was unacceptably low in the present sample, principal components analysis with Varimax rotation was used to determine the underlying data structure.

Analyses revealed a three-factor solution discriminating three dimensions. The first two components mapped onto the secure and dismissing styles of Hazan and Shaver’s (1987) measure, whereas loadings suggested the third dimension represented fearful avoidance (per Bartholomew & Horowitz, 1991). In a manner broadly similar to other studies in diverse older samples, the secure subscale consisted of RSQ Items 3, 4, 8, 14, 15, and 30; the dismissing subscale consisted of RSQ Items 1, 2, 6, 10, 12, 19, 22, 26; and the fearful avoidant subscale consisted of RSQ Items 5, 9, 11, 13, 16, 18, 20, 21, 23, 24, 25, and 28. The α coefficients for these three subscales were .71, .68, and .86, respectively.

Insurance status and cancer history

Men reported on whether they had health insurance (Yes vs. No/don’t know), and items asked about prior diagnoses among male relatives to determine the presence or absence of a family PC history.

Physician variables

Men reported whether they had a regular physician (Yes/No) and an annual physical examination (Yes/No). Men were asked whether physicians had ever discussed their risk and/or recommended that they screen.

Prostate cancer knowledge

A 50-item PC knowledge scale was developed based on prior work (Weinrich, Weinrich, Boyd, & Atkinson, 1998), expanded in consultation with oncologists, and validated in recent work (Consedine, Horton, Ungar, et al., 2007; Gonzalez, Consedine, McKiernan, & Spencer, 2008; Lee, Consedine, Gonzalez, & Spencer, 2012; Lee, Consedine, & Spencer, 2011). Items were aggregated to form a total (α = .68).

Perceived relative risk

Men rated perceived relative PC risk with a single item indicating that their risk was less than, about the same as, or greater than that of other men. Relative metrics provide a more accurate reflection of actual risk than quantitative (absolute) measures (Woloshin, Schwartz, Black, & Welch, 1999).

Accessibility of screening

Using a 1 (Extremely accessible) to 5 (Not accessible at all) scale, men made single-item ratings regarding their ability to undergo PSA and DRE.

Prostate cancer worry and screening fear

Using a 1 (Not at all true/Never) to 5 (Always true/Always) scale, men completed six items including “I get uneasy when I think about prostate cancer” and “Prostate cancer is very frightening.” Items were aggregated to form a PC worry variable (α = .67). Similarly, screening fear was assessed with five items including “I am afraid of PC screening” and “I worry that screening procedures will hurt me somehow.” Items were aggregated to form a PC screening fear variable (α = .77).

Prostate cancer screening

Men recorded the number of PSA and DRE tests that they had undergone in the prior 10 years. This metric was used because low screening in subpopulations of immigrant men (Consedine, Horton, Ungar, et al., 2007) meant that a 12-month estimate would produce large numbers of “nonscreeners” and would not allow us to tap into patterns of PC screening. The 2-year concordance between self-report and chart measures for screening ranges from 66% for DRE (Gordon, Hiatt, & Lampert, 1993) to 74.4% for PSA (Volk & Cass, 2002). Self-reports are higher than charts (Hall et al., 2004), although many men remain unaware that PSA tests were completed (Chan, Vernon, Ahn, & Greisinger, 2004). Screening data were positively skewed (skewness = 2.18 for PSA and 2.25 for DRE) and were improved with a square root transformation.

Analytic Strategy

First, descriptive analyses were used to characterize the sample and to examine zero-order associations between attachment and other predictor variables. Second, two linear regressions on PSA and DRE frequency scores were run. Because of our interest in illuminating possible pathways linking attachment to screening, models were run in three steps. In the first step, the three attachment characteristics were entered. Next, background and health care variables were entered. Finally, established psychosocial predictor variables were entered.

Results

Table 1 presents descriptive statistics for study variables broken down by categorical attachment classification. Analysis of variance and chi-square tested group differences in age, income, marital status, PC knowledge, risk, PC worry, screening fear, and both PSA and DRE test frequency were significant. Games–Howell post hoc tests suggested that secure men were slightly older than dismissive men and that secure and dismissive men reported greater income than fearful avoidants. Dismissive men had greater knowledge than secure and fearfully avoidant men, whereas secure men had more knowledge than fearful avoidants. Secure men rated their risk as higher than dismissive men, and both secure and fearful avoidant men reported greater PC worry than dismissives. As expected, fearful avoidant men reported greater screening fear than both dismissive and securely attached men. Finally, secure men reported more frequent DRE screening than dismissives.

Table 1.

Means and Standard Deviations of Sample Demographic Characteristics by Attachment Classification and Results of ANOVA or Chi-Square.

	Categorical attachment classification
Variable	Dismissive, N = 264	Secure, N = 122	Fearful avoidant, N = 28	ANOVA or chi square	Post hoc Games–Howells
Age	52.48 (6.50)	55.25 (7.04)	55.43 (7.60)	8.31**	S > D
Median	51.5	54	55.5
Range	44-70 (26)	44-70 (26)	45-70 (25)
Income ($K), mean (±SD)	31.26 (±20.71)	34.31 (±24.39)	19.03 (±17.83)	5.65**	S, D > FA
Median	31.5	31.5	10.0
Range	148.0	148.0	57.0
Stable relationship	49.6	59.8	39.3	5.41^†
No relationship	36.4	14.8	25	19.10**
Separate, widow, divorced	14.0	25.4	35.7	12.67**
Has insurance	87.9	81.1	78.6	4.08
Insurance covers PSA	90.0	87.0	90.9	2.16
Insurance covers DRE	89.1	87.0	90.9	1.48
Positive family history	18.9	21.3	21.4	4.82
Regular physician	81.4	77	71.4	2.18
Physician discuss screening	74.6	75.4	64.3	1.55
Physician discuss PC risk	65.5	60.7	39.3	7.63*
% Annual exam	81.4	74.6	82.1	2.53
Knowledge	38.91 (4.27)	37.73 (4.53)	33.25 (5.96)	21.15**	D > S > FA
Accessibility	3.83 (1.10)	3.86 (0.94)	3.64 (1.16)	0.57
Risk	1.95 (0.70)	2.24 (0.68)	2.21 (0.83)	7.91**	S > D
PC worry	2.36 (0.83)	2.79 (0.84)	2.93 (0.82)	14.54**	S, FA > D
Screening fear	1.89 (0.73)	2.00 (0.74)	2.51 (0.88)	9.15**	FA > S, D
# PSA^a	2.91 (4.11)	4.16 (5.21)	2.46 (3.42)	3.79*
# DRE^a	2.39 (3.38)	3.41 (4.18)	2.11 (3.44)	3.65*	S > D

Note. S = secure; FA = fearful avoidant; D = dismissive; PC = prostate cancer; DRE = digital rectal examination; PSA = prostate-specific antigen.

DRE and PSA tests are summed across the previous 10 years.

†

p < .10. *p < .05. **p < .01.

Zero-Order Links Between Attachment, Demographics, Structural, and Psychosocial Factors

Dismissiveness was negatively associated with age, being in a stable relationship, and having PSA insurance cover, but was positively linked to physicians discussing PC risk (see Table 2). Dismissiveness predicted greater knowledge but less worry and less fear. Conversely, security was associated with greater age, access, perceived risk, and PC worry. Finally, fearful avoidance predicted greater age, lower income, and a lower odds of being married. Fearful avoidance was negatively linked to physician PC discussion but positively associated with perceived risk, PC worry, and PC fear.

Table 2.

Correlations Between Dimensional Attachment, Control Variables, and Screening Outcomes.

Variable	Attachment dimension
	Secure	Dismiss	Fearful avoidant
Age	.10*	−.09^†	.10*
Income	.01	−.07	−.19**
% Stable relationship^a	.01	−.11*	−.12**
% No relationship^a	−.17**	.15**	.02
% Separated, widowed, divorced^a	.18**	−.03	.13**
Insurance^a	−.07	.09	−.06
Insurance covers PSA^a	−.02	−.11*	−.04
Insurance covers DRE^a	.00	−.07	−.04
% Family history positive^a	−.00	−.02	−.03
% With regular physician^a	−.01	.06	−.04
% Physician discuss screening^a	.01	.02	−.14**
% Physician discuss own PC risk^a	.03	.11*	−.10*
% Annual exam^a	−.01	.08^†	.07
Knowledge	−.01	.22**	−.26**
Accessibility	.10*	.12*	−.03
Risk	.12*	−.06	.10*
PC worry	.24**	−.16**	.35**
Screening fear	.03	−.17**	.38**
# PSA^b	.04	−.08	.01
# DRE^b	.06	−.09	.00

Note. PC = prostate cancer; DRE = digital rectal examination; PSA = prostate-specific antigen.

Spearman’s rho.

DRE and PSA tests summed across the prior 10 years; binary variables code such that 1 = insured, insurance covers PSA/DRE, positive history, has been discussed, own risk has been discussed, annual exam.

†

p < .10. *p < .05. **p < .01.

Multivariate Predictors of PSA and DRE Screening Frequency

The initial model examining the predictors of PSA frequency was not significant, F(3, 347) = 1.66, p > .05 (see Table 3). More frequent PSA screening was associated with lower dismissiveness, β = −.11, p < .05 sr² = .01. Adding background and system variables in Step 2 produced a significant model, F(13, 337) = 10.01, p < .01, with an additional 29% of the PSA variance accounted for, FΔ(10, 337) = 14.03, p < .01. More frequent screening was predicted by greater age and income, a positive family history, having an annual exam, and a physician who discussed personal risk. Finally, the addition of psychosocial predictors in the final step also produced a significant model, F(18, 332) = 10.24, p < .01, with an additional 5% of the variance in PSA accounted for, FΔ(5, 332) = 5.46, p < .01. Dismissiveness, β = −.13, p < .01, sr² = .02, and security, β = −.10, p < .05, sr² = .01, both predicted lower screening but screening was more frequent among men who were older, of higher income, had a regular physician or annual exam, and by perceptions of greater access.

Table 3.

Raw and Standardized Coefficients From Three Steps of a Linear Regression in Which PSA Frequency Was Regressed on Attachment (Step 1) Before Adding Background and Health Variables (Step 2) and Affective/Cognitive Characteristics to the Models (Step 3).

	Step 1				Step 2				Step 3
Variables	B	SE	Beta	sr ²	B	SE	Beta	sr ²	B	SE	Beta	sr ²
Attachment
Dismissiveness	−0.22	0.11	−0.11*	0.01	−0.19	0.09	−0.10*	0.01	−0.25	0.10	−0.13**	0.02
Security	−0.03	0.10	−0.01	0.00	−0.11	0.09	−0.06	0.00	−0.18	0.09	−0.10*	0.01
Fearful avoidance	−0.03	0.10	−0.02	0.00	−0.01	0.09	−0.01	0.00	0.03	0.10	0.02	0.00
Background/health
Age	—	—	—	—	0.04	0.01	0.28**	0.08	0.04	0.01	0.28**	0.08
Income	—	—	—	—	0.00	0.00	0.17**	0.03	0.00	0.00	0.17**	0.03
No relationship	—	—	—	—	−0.21	0.12	−0.09	0.01	−0.16	0.12	−0.07	0.00
Separated, widow, divorced	—	—	—	—	−0.15	0.15	−0.05	0.00	−0.15	0.14	−0.05	0.00
Insurance covers PSA	—	—	—	—	0.53	0.18	0.15**	0.02	0.39	0.18	−0.11*	0.01
Family history	—	—	—	—	0.04	0.08	0.02	0.00	0.04	0.08	0.02	0.00
Regular physician	—	—	—	—	0.44	0.17	0.13**	0.02	0.40	0.17	0.12*	0.01
Annual exam	—	—	—	—	0.71	0.16	0.23**	0.05	0.68	0.16	0.22**	0.05
Doctor discusses PC risk	—	—	—	—	0.17	0.15	0.07	0.01	0.19	0.15	0.08	0.01
Doctor discusses PC screen	—	—	—	—	0.09	0.17	0.03	0.00	0.08	0.16	0.03	0.00
Affective/cognitive factors
Knowledge	—	—	—	—	—	—	—	—	0.00	0.01	0.00	0.00
Accessibility	—	—	—	—	—	—	—	—	0.26	0.06	0.20**	0.04
Risk	—	—	—	—	—	—	—	—	0.12	0.07	0.08^†	0.01
PC worry	—	—	—	—	—	—	—	—	0.10	0.07	0.08	0.01
Screening fear	—	—	—	—	—	—	—	—	−0.14	0.09	−0.09	0.01
Constant	2.37	0.47	—	—	−1.73	0.62	—	—	−2.40	0.84	—	—

Note. sr² = squared part correlation; PC = prostate cancer; PSA = prostate-specific antigen.

†

p < .10. *p < .05. **p < .01.

The initial DRE model was not significant, F(3, 346) = 1.89, p > .05, and DRE screening was only marginally negatively associated with dismissiveness, β = .10, p < .10, sr² = .01. Adding background and system variables in Step 2 produced a significant model, F(13, 336) = 8.38, p < .01, with an additional 23% of the variance in DRE, FΔ(10, 336) = 10.18, p < .01 (see Table 4). Adding these variables strengthened attachment-screening links with more frequent screening predicted by less dismissiveness, β = −.10, p < .01, sr² = .01, as well as greater age, income, insurance covering DRE, and having an annual exam. Adding psychosocial predictors in the final step produced a significant model, F(18, 331) = 8.50, p < .01, accounting for an additional 7% of the variance in DRE frequency, FΔ(5, 331) = 6.91, p < .01. More frequent DRE screening was predicted by lower dismissiveness, β = −.16, p <.01, sr² = .02, being older, having higher income, having insurance cover for DRE, undergoing a regular annual exam, and by greater self-reported accessibility and lower screening fear.

Table 4.

Raw and Standardized Coefficients From Three Steps of a Linear Regression in Which DRE Frequency was Regressed on Attachment (Step 1) Before Adding Background and Health Variables (Step 2) and Affective/Cognitive Characteristics to the Models (Step 3).

	Step 1				Step 2				Step 3
Variables	B	SE	Beta	sr ²	B	SE	Beta	sr ²	B	SE	Beta	sr ²
Attachment
Dismissiveness	−0.17	0.10	−0.10^†	0.01	−0.19	0.09	−0.10*	0.01	−0.29	0.09	−0.16**	0.02
Security	0.13	0.09	0.08	0.01	0.05	0.09	0.03	0.00	0.00	0.09	0.00	0.00
Fearful avoidance	−0.08	0.09	−0.05	0.00	−0.04	0.09	−0.02	0.00	0.09	0.09	0.06	0.00
Background/health
Age	—	—	—	—	0.03	0.01	0.18**	0.03	0.03	0.01	0.19**	0.03
Income	—	—	—	—	0.00	0.00	0.11*	0.01	0.00	0.00	0.13**	0.01
Single	—	—	—	—	−0.16	0.12	−0.07	0.00	−0.11	0.11	0.05	0.00
Separated, widow, divorce	—	—	—	—	−0.06	0.14	−0.02	0.00	−0.05	0.14	−0.02	0.00
Insurance covers DRE	—	—	—	—	0.61	0.17	0.19**	0.03	0.46	0.16	0.14**	0.02
Family history	—	—	—	—	0.00	0.08	0.00	0.00	−0.02	0.08	−0.01	0.00
Regular physician	—	—	—	—	0.25	0.17	0.09	0.01	0.27	0.16	0.09^†	0.01
Annual exam	—	—	—	—	0.51	0.15	0.18**	0.02	0.44	0.15	0.16**	0.02
Doctor discusses PC risk	—	—	—	—	0.15	0.15	0.07	0.00	0.16	0.14	0.07	0.00
Doctor discusses PC screen	—	—	—	—	0.28	0.16	0.11	0.01	0.23	0.16	0.09	0.00
Affective/cognitive factors
Knowledge	—	—	—	—	—	—	—	—	−0.02	0.01	−0.08	0.00
Accessibility	—	—	—	—	—	—	—	—	0.24	0.06	0.20**	0.04
Risk	—	—	—	—	—	—	—	—	0.05	0.07	0.04	0.00
PC worry	—	—	—	—	—	—	—	—	−0.01	0.07	−0.01	0.00
Screening fear	—	—	—	—	—	—	—	—	−0.26	0.08	−0.19**	0.02
Constant	1.73	0.43	—	—	−1.16	0.59	—	—	−0.70	0.80	—	—

Note. sr² = squared part correlation; PC = prostate cancer; DRE = digital rectal examination.

†

p < .10. *p < .05. **p < .01.

Discussion

Understanding the psychosocial factors associated with screening is an essential first step in targeting interventions to those for whom they might be beneficial. Attachment may be particularly relevant since most screenings occur in interpersonal contexts. PC screening offers a “quasi-experiment” to test links between attachment and utilization, since one screen is generic, less-threatening, and unlikely to trigger the attachment system (PSA), whereas the other (DRE) induces vulnerability and threat in a manner that activates the system. The present report tested associations between attachment and screening among 414 middle-aged to older men, with an eye toward clarifying the background and psychosocial factors that may account for attachment–behavior links.

Attachment and Screening: The Baseline Models

The first hypothesis, that is, security would predict greater screening, whereas fearful avoidance and dismissiveness would predict less, was partially supported. Dismissiveness was either significantly or marginally associated with lower PSA and DRE frequencies. However, the prediction that attachment would better predict DRE (relative to PSA) was not supported; with the exception of security, coefficients were similar for both models.

Given that more secure individuals are less threatened by stressors, it is not surprising that security initially predicted greater screening, perhaps because secure individuals can manage distress more effectively (Cassidy, 1994). Consistent with this view, security predicted greater perceived risk and worry, but not screening fear, implying that security is associated with a screen-facilitative pattern of risk and worry rather than a detrimental fear of screening (Consedine et al., 2008). Furthermore, security was linked to greater perceived access to screening, which, in turn, predicted greater screening. Such associations may reflect greater comfort with physicians and/or the health care system, whereby screening is experienced as more accessible because it is less threatening.

In contrast, dismissively attached individuals downplay risk (Consedine, 2012), refuse to recognize anxiety (Kobak & Sceery, 1988), and avoid threats to independence and self-reliance (Bartholomew, 1990). Given screening is facilitated by perceived risk and worry, but requires exposing oneself to a vulnerability-inducing situation, it is not surprising that dismissiveness predicted lower screening. However, because we controlled for worry and risk perceptions it is less likely that the absence of screen-facilitating emotion underlies this link. As is discussed below, it may be that a specific aversion to intimacy and vulnerability, combined with a tendency to avoid interpersonal discomfort, are responsible.

Attachment Dimensions and Screening: Links via Background and Health Variables

Despite links, prior work examining attachment and health has not typically controlled for demographic and access-type confounds. Although background factors were associated with screening (see Tables 1 and 2), adding these factors strengthened associations between dismissiveness and PSA and did not change links between dismissiveness and DRE. One possibility is that greater experience with intimate examinations among older men may counteract dispositional aversions to vulnerability. Alternately, controlling for attachment related differences in socioeconomic status (i.e., education) may also be important. Less educated persons typically work in situations that offer less flexibility in terms of scheduling and may have greater difficulty with transport or interfacing with medical systems; hence, controlling for socio-demographic confounds may clarify links between attachment and health behavior outcomes and represents a useful extension to current knowledge.

Attachment Dimensions and Screening: The Role of Psychosocial Characteristics

Similarly, adding psychosocial predictors to the models saw the ability of attachment to predict screening remain essentially unchanged. Earlier attachment research created the possibility that affective and cognitive factors might help explain the link between fearful avoidance and reduced screening, but not between dismissiveness and screening (Consedine, 2012; Consedine & Magai, 2003). There was no evidence of such processes as the betas linking dismissiveness and security to lower screening were essentially unchanged across the stages of the model. Although the demonstration is indirect, finding that these links remained after covarying with established predictors of screening suggests the links between dismissiveness and security with lower screening are unlikely a result of these factors and alternate explanations are needed.

One possibility is that low screening among dismissives stems from interpersonal fear and anxiety and a reluctance to be interpersonally vulnerable or dependent (Merz & Consedine, 2009). Studies suggest that that PC screenings, particularly those involving digital examination of the rectum, pose a serious threat to men’s masculinity (Consedine, Horton, Ungar, et al., 2007; Winterich et al., 2009). Such threats are likely to be particularly unpleasant for dismissively attached men, and it may be that this specific threat and/or their inability to effectively manage it underlies their low screening.

Applications to the Understanding of Intimate Exams Among Older Black Men

The applications of these findings can be considered in terms of benefits to both patients and providers. As longitudinal research indicates that attachment styles remain stable (Klohnen & John, 1998), interventions should focus on making screenings less threatening to insecure styles. As DREs are typically provided by a regular physician, having notes in patient files regarding their interpersonal style may inform physicians of the manner of engagement best suited to reducing threat and resulting delay, avoidance, or interpersonal tensions. Providers should be flexible and willing to accommodate dominant relational styles. Regarding dismissives, for example, actions that create privacy and interpersonal distance are likely to be helpful, such as using surnames and titles, sitting when the patient is lying down, and allowing early discharge (Hunter & Maunder, 2001). Conversely, preoccupied persons are likely to benefit from reassurance, before it is requested (Hunter & Maunder, 2001). Overall, by allowing patients to set interpersonal distances and control the “pacing” of examinations, physicians may increase their sense of control and reduce feelings of vulnerability. Equally, providers should remain aware that older men (predominantly dismissive) are less likely to request intimate procedures or report symptoms. It thus falls to the provider to encourage men to engage in screening, perhaps by alluding to the increased health-related control examinations may offer; recent work among African American women suggests that it may be possible to leverage certain cultural characteristics (such as the independence needs of African Americans) in the service of more frequent screening (Consedine, Horton, Magai, & Kukafka, 2007).

Understanding these dynamics should also benefit providers. Individuals high in fearful avoidance are likely to be emotionally demanding on physicians, and a provider’s usual strategies for putting patients at ease may be insufficient (Hunter & Maunder, 2001). These patients may manifest a combination of help seeking and rejecting behavior, coupled with an angry and demanding manner. Repeated interactions among such men may increase burden and frustration among physicians. Helping physicians to recognize patients’ basic interpersonal styles may make interactions easier and more effective, and understanding that patient behavior reflects core relational issues (rather than the physician per se) should reduce the emotional burden (Hunter & Maunder, 2001).

Conclusions, Limitations, and Future Directions

In spite of the strengths of the present study, notably the large, diverse sample, these data are not without their limitations. Data were self-reported and may be biased (Hall et al., 2004). Men may misremember screenings or, as a result of routine PSA tests in blood analysis, may not realize screening has occurred (Chan et al., 2004). Attachment styles affect memory (Mikulincer & Orbach, 1995), with dismissives tending to “forget” upsetting events, and older men may “forget” having had a DRE. More broadly, the current study design is cross-sectional meaning inferences regarding causality cannot be made. Although unlikely, it may be that screening influences attachment or the psychosocial factors in our models.

Nonetheless, given that men’s screening typically occurs in the context of relationships between patients, their social networks, and their physicians, ongoing examinations of how individual differences in relational preferences affect utilization remains a key agenda. PC screening, comprising the threatening and interpersonal DRE, along with the less interpersonally threatening PSA, constitutes an ideal vehicle for identifying and clarifying the relevance of attachment. Consistent with prior work and expectations, attachment had consistent, if complex, links to PC screening and may provide insight into the prediction of other intimate examinations. Identifying persons at risk of suboptimal health care use and developing interventions that specifically address the barriers to the timely seeking of health care remains a critical social science agenda.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received following financial support for the research, authorship, and/or publication of this article : The current report was supported by a grant from within the U54 Comprehensive Cancer Partnership between Long Island University and Columbia University (1 U54 CA1011388).

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Attachment and Health Care Utilization Among Middle-Aged and Older African-Descent Men

Abstract

Keywords

Attachment and Health Care Utilization

Attachment and Prostate Screening

Hypotheses and the Current Study

Method

Participants

Procedures

Measures

Background questionnaire

Adult attachment

Insurance status and cancer history

Physician variables

Prostate cancer knowledge

Perceived relative risk

Accessibility of screening

Prostate cancer worry and screening fear

Prostate cancer screening

Analytic Strategy

Results

Zero-Order Links Between Attachment, Demographics, Structural, and Psychosocial Factors

Multivariate Predictors of PSA and DRE Screening Frequency

Discussion

Attachment and Screening: The Baseline Models

Attachment Dimensions and Screening: Links via Background and Health Variables

Attachment Dimensions and Screening: The Role of Psychosocial Characteristics

Applications to the Understanding of Intimate Exams Among Older Black Men

Conclusions, Limitations, and Future Directions

Footnotes

Declaration of Conflicting Interests

Funding

References