Diversity matters: Unique populations of women and breast cancer screening

Cancer screening and Haitian immigrants: the primary care provider factor

BACKGROUND

Haitian immigrants, among the fastest growing immigrant communities in the United States, have low cancer screening rates. Several patient barriers have been identified and associated with low screening rates but little is known on provider barriers for cancer screening. To address this gap, we assessed the cancer screening practices, attitudes, and beliefs of primary care providers serving the Haitian community.

METHODS

We surveyed a random sample of physicians serving first generation Haitian immigrants in New York City, identified through their zip codes of practice. Participants completed a questionnaire to assess their beliefs, attitudes and practices surrounding cancer screening, and their perceptions of patient barriers to screening.

RESULTS

50 of 87 physicians (58%) consented to participate in the study. Cancer site-specific and overall cancer screening scores were created for breast, cervical, and colorectal cancer screening. 75% of providers followed breast cancer screening guidelines, 16% for cervical cancer, and 30% for colorectal cancer. None of the providers in the sample were following guidelines for all three cancer sites. Additionally, 97% reported recommending digital rectal exam and PSA annually to patients 50 years or older with no family history, and 100% to patients over 50 years old with family history.

CONCLUSIONS

The reported practices of providers serving the Haitian immigrant community in New York City are not fully consistent with practice guidelines. Efforts should be made to reinforce screening guideline knowledge in physicians serving the Haitian immigrant community, to increase the utilization of systems that increase cancer screening, and to implement strategies to overcome patient barriers.

Psychosocial influences on suboptimal adjuvant breast cancer treatment adherence among African American women: implications for education and intervention

Despite lower incidence, African American women are at increased risk of dying from breast cancer relative to their European American counterparts. Although there are key differences in both screening behavior and tumor characteristics, an additional part of this mortality difference may lie in the fact that African American women receive suboptimal adjuvant chemotherapy and may receive suboptimal hormonal therapy, therapies that are known to increase survival. The authors consider ethnic differences in the psychosocial factors that have been shown to relate to poor screening adherence and consider how they may influence adherence to breast cancer adjuvant treatment, thus the receipt of suboptimal adjuvant chemo or hormonal therapy. To this end, they review ethnic differences in cognitive, emotional, and social network variables. Psychosocial variables should be included in research designed to understand cancer disparities as well interventions that can be tailored to culturally diverse populations to improve treatment adherence.

Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis

In this paper, we review the literature on psychosocial influences on breast cancer screening and treatment adherence with an eye to identifying common cognitive, emotional, and social network factors that may lead to poor screening adherence and suboptimal treatment in the case of diagnosed breast cancer. Nonadherence to breast cancer screening and treatment guidelines can significantly and negatively impact the prospects for prevention and control of breast cancer. Psychosocial factors are an especially important focus for research, inasmuch as belief structures and psychosocial characteristics (such as patterns of emotion regulation and the quality of social relations) are modifiable and are, thus, eminently suitable to intervention.

Correlates of repeat and recent mammography for women ages 45 to 75 in the 2002 to 2003 Health Information National Trends Survey (HINTS 2003)

BACKGROUND

Most national-level mammography data are for ever-had and most-recent screening. There are few national-level data on rates of repeat, on-schedule mammography, and on the prevalence and correlates of repeat mammography. It is also important to investigate the similarity of correlates for repeat and recent mammography.

METHODS

Analyses were from data for women ages 45 to 75 in the 2002 to 2003 Health Information and National Trends Survey (HINTS 2003; N = 1,581). The two dependent variables were self-report of repeat mammography (two exams on schedule, based on an every-other-year interval) and recent mammography only (one mammogram within the past 2 years).

RESULTS

The prevalence of recent mammography was 81.6% (95% confidence interval, 79.1-84.1) and for repeat mammography was 72.2% (95% confidence interval, 69.0-75.4). An access to care variable combining insurance coverage and regular source of care was the strongest sociodemographic correlate of both mammography indicators. Most other sociodemographic variables were not associated with mammography status. Five psychosocial/behavioral variables were associated with both mammography indicators (smoking status, attention to health information, knowledge of screening interval, worry about breast cancer, and recent mood status). Correlates were very similar for repeat and recent mammography.

CONCLUSIONS

Although access to care had the strongest association with mammography, psychosocial and behavioral variables did better as a group than the sociodemographic variables. A standard set of such variables should be considered for all national surveys.

Psychosocial Correlates of Mammography Screening in Older African American Women

PURPOSE/OBJECTIVES

To explore psychosocial correlates of older African American women's adherence to annual mammography screening, including cancer fatalism, dispositional optimism, social support, knowledge of breast cancer screening guidelines, perceptions of general health, and components of the Health Belief Model (HBM), and to examine factors associated with annual mammography screening.

DESIGN

Cross-sectional survey.

SETTING

Central North Carolina.

SAMPLE

198 African American women aged 50-98 years living in low-income housing.

METHODS

Women attended group sessions at low-income housing complexes and completed questionnaires. Differences between women who had or did not have a mammogram in the previous year were explored using correlate variables associated with the HBM. Stepwise multivariable regression models were fit to explore factors associated with social support and significant components of the HBM.

MAIN RESEARCH VARIABLES

Demographics, cancer fatalism, dispositional optimism, social support, perceptions of general health, components of the HBM, and mammography in the past year.

FINDINGS

The groups did not differ by age, education, marital status, having a friend or family member with breast cancer, ever having had a clinical breast examination, self-rated health, cancer fatalism, dispositional optimism, or feelings about the seriousness of and their susceptibility to breast cancer. The groups differed significantly on mammogram-related variables, how often women should have clinical breast examinations, benefits and barriers to mammography screening, and social support. Stepwise multivariable regression analyses showed that dispositional optimism and social support were related significantly to perception of benefits; education, dispositional optimism, and cancer fatalism were related to barriers; and dispositional optimism was related to social support.

CONCLUSIONS

Older, low-income, African American women have perceived barriers to cancer screening, educational and cancer knowledge detriments, and a lack of health-related social support that may decrease adherence to mammography screening.

IMPLICATIONS FOR NURSING

The next step is to develop culturally appropriate educational interventions that increase knowledge about breast cancer and screening guidelines, enhance health-related social support, and address barriers and perhaps cancer fatalism in older, low-income, African American women.

New York City's immigrant minorities. Reducing cancer health disparities

One million newcomers arrive in the United States every year; 11.7% of the total U.S. population is foreign-born. Immigrants face cancer care and research access barriers, including economic, immigration status, cultural, and linguistic. In 2000, the Center for Immigrant Health, NYU School of Medicine, launched the Cancer Awareness Network for Immigrant Minority Populations (CANIMP), a network comprising community- and faith-based organizations, local and national government health institutions, clinical service providers, researchers, and immigrant-service and advocacy organizations. This community-based participatory program chose as its priorities high- incidence cancer sites in the overall immigrant community (colorectal, lung, breast, cervical, prostate), as well as sites with strikingly high incidence in specific immigrant groups (gastric, liver, oral). CANIMP has developed successful outreach, education, screening, survivorship, training, and research programs to decrease cancer disparities. Over 2500 at-risk community members have been reached, 25 junior minority researchers trained, 60 minority interns mentored, numerous cancer disparities research projects funded and conducted, and vital partnerships to improve cancer data developed. These initiatives serve as models to address community, systems, physician, and cancer research gaps in immigrant communities. Cancer 2006. (c) 2006 American Cancer Society.

Do Women in the Community Recognize Hereditary and Sporadic Breast Cancer Risk Factors?

PURPOSE/OBJECTIVES

To describe knowledge of hereditary, familial, and sporadic breast cancer risk factors among women in the community and to identify characteristics associated with this knowledge.

DESIGN

Descriptive, cross-sectional.

SETTING

Community settings in the San Francisco Bay Area.

SAMPLE

184 women who had never been diagnosed with cancer, were 30-85 years old (mean = 47 + 12), and agreed to complete a questionnaire in English. Participants were from diverse racial and cultural backgrounds (i.e., 43% European descent, 27% African descent, 16% Asian descent, and 14% Hispanic descent). Many (49%) were college graduates, and 24% had a median annual family income of $30,000-$50,000.

METHODS

Survey.

MAIN RESEARCH VARIABLES

Knowledge of hereditary, familial, and sporadic breast cancer risk factors and characteristics associated with this knowledge.

FINDINGS

Although most women recognized heredity as a risk factor, some did not understand the impact of paternal family history on risk. Some women did not recognize the relationship between breast and ovarian cancer, risk factors associated with the Gail model, and that aging increases risk. Education level was the most important characteristic associated with knowledge of risk factors.

CONCLUSIONS

Although age and family history are independent predictors of sporadic, hereditary, and familial breast cancer risk, women in the community could not distinguish between the three forms of the disease. Although the sample included a large number of educated women, their knowledge of breast cancer risk factors appeared incomplete.

IMPLICATIONS FOR NURSING

Advanced practice nurses should provide individualized risk assessment and education regarding breast cancer risk factors.

Differences in health and cultural beliefs by stage of mammography screening adoption in African American women

Behavioral studies show that women's stage of readiness to adopt mammography screening affects their screening rates and that beliefs about breast cancer and screening affect stages of screening. The purposes of this study were to determine, first, the relationship between particular health and cultural beliefs and stage of mammography screening adoption in urban African American women, and second, whether demographic and experiential characteristics differed by stage. Data were analyzed from 344 low-income African American women nonadherent to mammography screening who participated in a 21-month trial to increase screening. At baseline, these women were randomized into 1 of 3 groups: tailored interactive computer instruction, targeted video, or usual care. Participants were categorized by stage of mammography screening adoption at 6 months as precontemplators (not planning to have a mammogram), contemplators (planning to have a mammogram), or actors (had received a mammogram). Although demographic and experiential variables did not differentiate stages of screening adoption at 6 months postintervention, some health and cultural beliefs were significantly different among groups. Actors were more preventive-health-oriented than precontemplators and had fewer barriers to screening than did contemplators. Precontemplators had more barriers, less self-efficacy, and greater discomfort with the mammography screening environment than did contemplators or actors. These results will be useful, not to change cultural beliefs, but to guide the design of health education messages appropriate to an individual's culture and health belief system. Cancer 2007. (c) 2006 American Cancer Society.

Geographic patterns of advanced breast cancer in Los Angeles: associations with biological and sociodemographic factors (United States)

OBJECTIVE

Examination of patterns of advanced breast cancer may provide evidence needed to direct health care resources to those communities or population groups in greatest need. We assessed to what degree biologic, ethnic, and sociodemographic factors could explain such patterns within Los Angeles County.

METHODS

The proportion of cases of advanced disease among all breast cancer cases identified during 1992-1996 were analyzed using generalized linear mixed models with random census tract effects. Models included characteristics of the individual and her tumor, census tract of residence, and aggregated health districts.

RESULTS

Approximately 6% of cases, ranging from 4% for Asian to 10% for Black women, were diagnosed as advanced, exhibiting striking geographic patterns. Tumor histology and hormone receptor status were most predictive of advanced disease. Sociodemographic variables such as marital status, median income, and distance to nearest mammography unit showed additional association with risk.

CONCLUSIONS

These models explain most of the geographical patterns and eliminate differences between White and Hispanic but not Asian or Black women, identify subpopulations at high risk of advanced disease, and suggest cancer control opportunities.

Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites: Cultural influences or access to care?

BACKGROUND

Asian Americans have lower cancer screening rates compared with non-Hispanic whites (NHWs). Little is known about mechanisms that underlie disparities in cancer screening. The objectives of the current study were 1) to determine the relation between nativity, years in the United States, language, and cancer screening in NHWs and Asian Americans, independent of access to care and 2) to determine whether Asians reported different reasons than NHWs for not obtaining cancer screening.

METHODS

This population-based study included 36,660 NHWs, 1298 Chinese, 944 Filipinos, 803 Koreans, 857 Vietnamese, and 1036 Other Asians from the 2001 California Health Interview Survey. The main study outcomes were 1) self-reported colorectal, cervical, and breast cancer screening and 2) reasons for not obtaining cancer screening.

RESULTS

After adjusting for access to care, several Asian subgroups still had significantly lower rates of all types of cancer screening compared with NHWs. Adjusting for nativity, years in the United States, and English language attenuated the relation between Asian ethnicity and lower rates of colorectal and breast cancer screening. When they were asked what the most important reason was for not having each screening test, foreign-born Asians were significantly more likely than United States-born NHWs to report that they "didn't have problems/symptoms" (P < .01).

CONCLUSIONS

Nativity, years in the United States, and English language may be markers of cultural differences that are mediating cancer screening disparities. Foreign-born Asians may believe that cancer screening is in response to symptoms rather than tests that are used prior to the development of symptoms. Health education messages must consider how to communicate effectively that "cancer screening is valuable, because it finds cancer before it is advanced enough to cause symptoms."

On the importance of being ethnic: Coping with the threat of prostate cancer in relation to prostate cancer screening

The relation between coping with a possible prostate cancer diagnosis and screening behavior was examined in men from seven precise ethnic groups. Five coping styles differed in their likelihood of use across ethnic groups and had somewhat different associations with frequency of prostate-specific antigen (PSA) testing. As expected, PSA test frequency differed among men from different ethnic groups and was differentially predicted by coping styles. Analyzing the results using typical groups of White, Black, and Hispanic, rather than precise ethnic groups, obscured these results. Researchers investigating psychological variables in preventive health behaviors must analyze diversity within the framework provided by ethnic specificity. Such an approach will guide the development and provision of interventions that are more sensitive to the characteristics of specific ethnic groups of at risk men.

Prostate cancer screening behavior in men from seven ethnic groups: the fear factor

Rates of prostate cancer screening are known to vary among the major ethnic groups. However, likely variations in screening behavior among ethnic subpopulations and the likely role of psychological characteristics remain understudied. We examined differences in prostate cancer screening among samples of 44 men from each of seven ethnic groups (N = 308; U.S.-born European Americans, U.S.-born African Americans, men from the English-speaking Caribbean, Haitians, Dominicans, Puerto Ricans, and Eastern Europeans) and the associations among trait fear, emotion regulatory characteristics, and screening. As expected, there were differences in the frequency of both digital rectal exam (DRE) and prostate-specific antigen (PSA) tests among the groups, even when demographic factors and access were controlled. Haitian men reported fewer DRE and PSA tests than either U.S.-born European American or Dominican men, and immigrant Eastern European men reported fewer tests than U.S.-born European Americans; consistent with prior research, U.S.-born African Americans differed from U.S.-born European Americans for DRE but not PSA frequency. Second, the addition of trait fear significantly improved model fit, as did the inclusion of a quadratic, inverted U, trait fear term, even where demographics, access, and ethnicity were controlled. Trait fear did not interact with ethnicity, suggesting its effect may operate equally across groups, and adding patterns of information processing and emotion regulation to the model did not improve model fit. Overall, our data suggest that fear is among the key psychological determinants of male screening behavior and would be usefully considered in models designed to increase male screening frequency.

Genetics, epidemiology, and cancer disparities: is it black and white?

Epidemiologic studies attempt to understand the distribution and determinants of human disease. Epidemiologic research often incorporates information about race, ethnicity, or ancestry, usually as a self-identified race or ethnicity (SIRE) variable. Differences in the distribution and determinants of disease on the basis of SIRE may be identified in these studies. In addition, genetic and other biologic differences according to SIRE are frequently reported. If these differences are real and meaningful, they may have value in identifying disease-causative or -preventive factors, and thus may be beneficial to human health. However, the concepts of race, ethnicity, or ancestry are often poorly considered or crudely applied, particularly in genetic studies of disease etiology or outcome. Consequently, results suggesting genetic differences with respect to disease etiology or outcome across SIRE groups may not be meaningful; in fact, these differences may prove harmful if they propagate stereotypes or spurious differences. Therefore, it is critical to properly consider the meaning, definitions, and use of race, ethnicity, or ancestry in molecular epidemiologic studies.

Time spent in the united states and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation?

The current study was designed to investigate the relations between time spent in the United States and breast cancer screening in a large sample (N=915) of ethnically diverse immigrant women living in New York City. Previous research among Hispanic women has suggested that acculturation positively influences health beliefs and preventive health behaviors. However, research has not yet extended to other growing immigrant groups, including women from Haiti and the English-speaking Caribbean, and has not tested whether time spent in the United States differentially impacts breast screening across groups that are known to vary in their health beliefs. As expected, time spent in the United States was associated with a greater number of mammograms and clinical breast exams. Importantly, these relations held even when controlling for (a) age, income, education, marital status; (b) morbidity, health insurance, physician's recommendation, physical exams; and (c) ethnicity. Moreover, time spent in the United States interacted with being Haitian to predict the number of clinical breast exams. Even though Haitians were less likely to utilize breast cancer screening overall, time spent in the United States had a stronger effect on the number of clinical breast exams for Haitian women. Results are discussed in terms of the ethnic-specificity of health beliefs, how they may change over time and their implications for preventive health behaviors.

Stress versus discrete negative emotions in the prediction of physical complaints: Does predictive utility vary across ethnic groups?

Reports of stress and negative emotion are important predictors of health. However, whether discrete emotions or stress measures are more useful, whether they contribute independently to outcome, and whether they relate to health equally across ethnic groups remain unclear. In the current study, 207 US-born European American, US-born African American, Black English-speaking Caribbean, and Dominican men aged 40 years and older completed measures of somatic symptoms, trait emotions, and stress. Sadness and stress independently predicted symptom reports, even when examined concurrently, and with demographics controlled; trait anger did not predict symptoms. Moreover, the relations between trait emotions and symptoms varied across groups. Levels of sadness were associated with greater symptoms among US-born European American and Dominican men, but negatively associated among Black English-speaking Caribbean men, and the relations for anger also differed marginally across groups. The results underscore the importance of differentiating among discrete emotions and stress and considering ethnic interactions when examining reports of somatic symptomology. We suggest that the impact of psychological characteristics on health must be considered within cultural and ethnic contexts to be fully understood.

Brief report: etiological attributions for breast cancer among healthy African American and European American women

Anecdotal evidence suggests that African American women's attributions about breast cancer may differ from European American women, but empirical studies are lacking. The present study examined attributions about breast cancer made by a sample of healthy African American and European American women. The sample included 197 women (75 African American, 122 European American), with a mean age of 39.2. Overall, women were most likely to attribute the development of breast cancer to genetics, "no one", environmental poisons, diet, personal behavior and stress. European American women were more likely to attribute breast cancer to broadly external causes such as the environment, heredity and chance, while African American women were more likely to list immediate, interpersonal-level causes such as a blow to the breast, and personal behavior. Results highlight the need for attention to cultural processes in cancer prevention and control.

Breast self-examination practices among women from six ethnic groups and the influence of cancer worry

Diverse samples of women (N = 1364) from Brooklyn, New York, were interviewed regarding their breast cancer screening practices. Of interest here is the relation between cancer worry and adherence to breast self-examination (BSE) guidelines among the six ethnic groups identified--European American, African American, Haitian, Dominican and English-speaking Caribbean women. There was a significant difference in cancer worry by ethnicity. Logistic regression analysis indicated that education, cancer worry, and perceived efficacy of BSE significantly predicted adherence. Furthermore, there were significant differences among women of African descent in BSE adherence and cancer worry. These differences reflect the emerging need for researchers to empirically and methodically investigate ethnic and cultural factors, as well as emotions and affect in preventive health behaviors.