Tuesday, November 3, 2009

Perspectives of African American, Amish, Appalachian and Latina Women on Breast and Cervical Cancer Screening

Low-income and minority women are less likely to be screened for breast and cervical cancer and less likely than others to be diagnosed at an early stage in the cancer's growth. We consulted women and providers to understand how social, economic, and health care environments affect screening among African American, Amish, Appalachian, and Latina women, and to outline possible solutions. Women participated in 31 focus groups. Providers completed a mail survey (n=168) and follow-up interviews (n=12). We identified barriers women face: not always following recommendations; feeling intimidated during appointments; having incorrect information about risks, screening guidelines, and programs; and receiving information in ways they cannot understand or accept. Women indicated a strong desire for accurate information and, like the providers, identified strategies for reducing barriers to screening. In the terms of a social ecological model, our results point to three avenues along which to approach cultural competence: 1) policy, 2) health care provision, and 3) clinical care.
Early detection of breast and cervical cancer has a high probability of preventing death, yet researchers consistently report that women in low-income and minority populations—including African American, Latina, and Appalachian women—are less likely than other women to obtain cancer screening and more likely to be diagnosed at a later stage.1–4 Amish women may also be less likely than others to obtain cancer screening, although data are not available. This study, funded by the Pennsylvania Department of Health, focused on these ethnic/cultural groups in an effort to provide guidance for improving their health care.
Researchers have shown that certain factors act as barriers to early screening for all women (e.g., lack of a regular care provider, lack of a doctor's recommendation, cost of health care/insurance, inconvenience, lack of English proficiency, and lack of social support).4–7 Although low-income and minority women are more likely to have breast and cervical cancer screening when their health care providers recommend it, physicians recommend screening less often to women who are poor, are less educated, or lack health insurance.2 Survey and qualitative data indicate differences in the screening practices of women from diverse ethnic backgrounds.4,8–11
Community and cultural perspectives about barriers may be best explored using qualitative methods, particularly focus groups, which can allow group members to voice their concerns, thoughts, and feelings in their own words and language of origin. However, little has been published about the influence of cultural values and attitudes on screening among minority and rural women from their own perspectives. Facione and Giancarlo,12 using focus group research, demonstrated the power of cancer narratives as a way for African American and Latina breast cancer survivors to give meaning to their experiences. Kenney et al.,11 also using focus groups, found that participants had incomplete knowledge of a free screening program and their eligibility. Borrayo and Jenkins10 used focus groups in Texas, finding that the Mexican American women participants did not recognize a need for screening when they felt healthy. Baldwin9 clarified, using focus group data, the fundamental importance of an Afrocentric worldview in framing messages to African American women concerning breast and cervical cancer screening.9 In Canada, Van Til, MacQuarrie, and Herbert13 established through focus groups with women ages 45 to 70 that personal experiences, including fears and lifestyle, contribute to low screening rates. However, these studies are among very few that express the views of the women themselves about how to improve screening among low-income and minority women.
As the U.S. population becomes more diverse and minority populations grow, delays in cancer detection impose an increasing burden, not only on individuals and their families, but also on the nation's economy. To succeed, early detection programs must be culturally competent, meaning that their design includes deliberate modification of health care environments to serve patients of various cultural backgrounds more effectively.14–16 Theory-based strategies for change require specific data from particular groups.

The objectives of this study are 1) to understand how the social, economic, and health care environments affect breast and cervical cancer screening among African American, Amish, Appalachian, and Latina women and 2) to outline possible solutions that reflect the views of women and health care providers.
This study was conducted in terms of social ecology,17 which posits that individuals are affected by multiple dimensions of their environment, including the interpersonal, organizational, community, and public policy dimensions. The conceptual framework is the PRECEDE model, because it includes several of these dimensions, provides a ready-made tool for devising health promotion activities,17 and has been used before to study cervical cancer screening.7 In this model, quality of life and health are affected by two interdependent factors: (1) environment, including the social and cultural context, and (2) behavior and lifestyle, as influenced by predisposing, enabling, and reinforcing factors.17 One or more of these factors must be affected if health promotion activities are to bring about change.

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