Breast cancer affects thousands of women each year and among those diagnosed, African-American women (AAW) make up a significant proportion that are diagnosed with early onset disease, have larger tumors, greater lymph node involvement, higher mortality and lower survival rates. Studies examining factors associated with greater breast cancer morbidity and mortality in this group have suggested that they may differ from Caucasian women in terms of certain risk factors for breast cancer; however, other evidence suggests that the risk of developing breast cancer is similar among African-American and Caucasian women who have a family history of breast cancer. As such, access to genetic counseling and testing (GC/T) services would be an important part of cancer control for this group but in this fast moving area of medicine African-American women are being "left behind". It is unclear why AAW have not readily adopted these preventive services. In light of the paucity of evidence regarding explanations of underuse, it is possible that important factors such as perceived behavioral control (PBC) in the Theory of Planned Behavior may help explain African-American women's participation in genetic counseling and testing for BRCA 1/2. The goals of this mixed methods study were twofold; first, to explore levels of perceived behavioral control and general motivations regarding genetic counseling and testing for BRCA 1/2 in African-American women at moderate to high-risk for breast and ovarian cancer and second, to explore the dimensionality of the perceived behavioral control construct from the Theory of Planned Behavior (TPB) and its utility in understanding underuse of BRCA 1/2 genetics services in this group. African-American women are being "left behind". Overall, women had high levels of perceived behavioral control, low knowledge and positive attitudes towards genetic counseling and testing for BRCA 1/2. Results from the principal components analysis lent support for the dimensionality of the perceived behavioral control construct suggesting that it indeed could be thought of as made up of the constructs perceived control [P-C] and perceived difficulty [P-D]. Only perceived control was found to be associated with genetic testing intentions suggesting that it was a better predictor. Neither scale was associated with genetic counseling intentions. African-American women are being "left behind". Future research should focus on educational efforts geared towards highlighting the utility of genetic counseling in addition to genetic testing for BRCA 1/2. Theoretical implications include using two measures to assess aspects of perceived behavioral control (perceived difficulty [P-D] and perceived control [P-C]) instead of one PBC measure. Additionally, studies using the TPB model should include the constructs of spirituality and knowledge when trying to understand underuse of BRCA 1/2 genetic services in African-American women at moderate to high-risk for breast cancer. African-American women are being "left behind". / Ph. D.

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