African American women and breast cancer: notes from a study of narrative

Qualitative Research and Cancer Nursing: A Guide for Novice Researchers

OBJECTIVE

To introduce the cancer nurse to qualitative research.

DATA SOURCES

A search of published literature including articles and books was conducted to inform the article using University libraries (University of Galway and University of Glasgow) and CINAHL, Medline, and Google Scholar databases using broad terms, including qualitative research, qualitative methods, paradigm, qualitative, and cancer nursing.

CONCLUSION

It is important for cancer nurses wishing to read, critically appraise, or undertake qualitative research to understand the origins and different methods employed in qualitative research.

IMPLICATIONS FOR NURSING PRACTICE

The article is of relevance for cancer nurses globally who wish to read, critique, or undertake qualitative research.

Healthy Sisters: A Feasibility study of a health behavior intervention for women of color breast cancer survivors

There is strong evidence for the need to educate and empower women of color breast cancer survivors (WCBCS) to adopt healthy lifestyle behaviors. The purpose of this study was to explore feasibility and preliminary efficacy of a culturally grounded lifestyle intervention on functional ability, quality of life, and health behaviors. A community-based sample of WCBCS was recruited from two inner cities, with encouragement to invite a partner. There were 30 WCBCS and 10 partners who participated in the 6-week interactive intervention. Data were collected at baseline, end of intervention and 3 and 6 months. There was significant improvement in healthy lifestyle behaviors (p = 0.041), physical activity (p = 0.003), nutrition (p = 0.007), and stress management (p = 0.010) for WCBCS and, for partners, improvements in healthy lifestyle behaviors (p = 0.041), nutrition (p = 0.007), and health responsibility (p = 0.034).

"Being connected" The experience of African American women with breast cancer: A community-based participatory research project: Part I

The objective was to understand the breast cancer experience of African American (AA) women using a community-based participatory research framework. Qualitative data were collected from five focus groups with 29 participants in four urban cities. "Being Connected" was the major theme that explained the importance of people in their lives as they coped with the diagnosis, treatment, and life after therapy. Faith, talking, information, support, and living with changes were important factors in the process. The breast cancer experience was situated with the AA culture and community and unique aspects were identified for clinical practice in the care of these women.

“Nobody Ever Asked Me Before”: Understanding Life Experiences of African American Elders

With the unprecedented growth in the African American elderly population, there exists an urgent need to prepare nurses to deliver culturally competent care. The purpose of this study was to increase the knowledge available about the cultural heritage, worldviews, and life experiences of African American elders. Reminiscence interviews were conducted with African American elders living in a medium-sized northeast urban community. Data were analyzed using Spiegelberg’s phenomenological method. The following themes emerged: (a) nobody ever asked me before, (b) stories of discrimination, (c) coping with discrimination, (d) the hurt of discrimination, and (e) self-discoveries. Nurses, through the use of reminiscence, can gain insight into the cultural heritage, worldviews, and life experiences of African American elders and improve their ability to deliver culturally competent care to this population.

The Meaning of Survivorship as Defined by African American Breast Cancer Survivors

Background: While there is an abundance of cancer survivorship research among various racial/ethnic groups, there is a paucity of research on survivors of African descent. To date, the meaning of survivorship has not been reported exclusively among African American breast cancer survivors (AABCS). Purpose: The purpose was to describe and understand the meaning of survivorship among community-dwelling AABCS, mostly recruited from breast cancer support groups. Method: Using a qualitative descriptive approach, an open-ended questionnaire explored the meaning of survivorship among 155 AABCS. An analysis of the content was performed. Results: Among AABCS, survivorship meant having a strong spiritual base, thriving, being resilient, and being altruistic. The survivors self-identified with and embraced the term survivor.Conclusions: These results provide an important understanding of the perspectives and meaning of survivorship among AABCS and may assist in developing cancer survivorship care plans that are relevant, responsive, patient centered, and culturally appropriate.

Psychosocial interventions addressing the needs of Black women diagnosed with breast cancer: a review of the current landscape

BACKGROUND

Poorer health outcomes and lower survival rates have been well documented among African American/Black (Black) women diagnosed with breast cancer. Black women are 41% more likely to die from breast cancer than White women despite a lower incidence rate. Apart from pharmacotherapy, psychosocial interventions are recommended by the Institute of Medicine as standard medical care for breast cancer patients at all phases of treatment. The current review is the first attempt to systematically evaluate the literature on the influence of psychosocial interventions for Black women diagnosed with breast cancer.

METHODS

This systematic review aimed to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive computerized literature search of CINAHL, PsycINFO, PubMed, and Web of Science was conducted to obtain relevant studies.

RESULTS

Interventions demonstrated improved mood, decreased distress, increased ability to cope with intrusive thoughts and cancer-related stress, personal growth, and improved social well-being. However, aspects unique to this population require additional scientific inquiry. Over 80% of empirical interventions focused on Black women diagnosed with breast cancer have been concentrated on the posttreatment phase. There is a paucity of work at the time of diagnosis and during treatment.

CONCLUSIONS

To address gaps in the scientific literature, more work is needed to better understand how psychosocial interventions can improve the health trajectory for Black women diagnosed with breast cancer particularly in the areas of seeking help and support, identifying culturally acceptable methods for engaging support networks, and identifying best practices for enhancing coping skills.

A systematic review of barriers to early presentation and diagnosis with breast cancer among black women

OBJECTIVE

To explore barriers to early presentation and diagnosis with breast cancer among black women.

DESIGN

Systematic review.

METHODS

We searched multiple bibliographic databases (January 1991-February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (≥18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible.

RESULTS

We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (≥10 years) with newer ones (<10 years) to determine changes over time. In older studies, delaying factors included: inaccessibility of healthcare services; competing priorities and concerns about partner abandonment. Partner abandonment was studied in older studies but not in newer ones. Comparisons of healthy women and cancer populations revealed differences between how people perceive they would behave, and actually behave, on finding breast abnormality.

CONCLUSIONS

Strategies to improve early presentation and diagnosis with breast cancer among black women need to address symptom recognition and interpretation of risk, as well as fears of the consequences of cancer. The review is limited by the paucity of studies conducted outside the USA and limited detail reported by published studies preventing comparison between ethnic groups.

A pilot randomized study of skills training for African American cancer survivors

This study tested the efficacy of a psychosocial group intervention for African American breast cancer survivors based on the Cancer Survival Toolbox with the specific aim of decreasing distress and improving aspects of psychosocial functioning and quality of life. This pilot study utilized a randomized, repeated measures, experimental design. The study sample (N = 71) consisted of an intervention group (n = 23) of cancer survival skills training for 6 weeks and a control group (n = 48). The study could not confirm that cancer skills training in a psychoeducational group setting had a positive effect on decreasing stress or improving aspects of psychosocial functioning and quality of life.

Perceived risk for breast cancer and its relationship to mammography in Blacks, Hispanics, and Whites

A challenge for health behavior science is to develop theory and best practices that take cultural diversity into account. Using data from Black, Hispanic, and White respondents to the 2003 Health Information National Trends Survey, we examined racial/ethnic differences in: (1) breast cancer risk perceptions/worry; (2) the associations between perceived risk/worry and ever having received a mammogram; and (3) perceived risk/worry and having had at least 2 mammograms over a 4-year period (consecutive mammography). Compared to White race/ethnicity, Black race/ethnicity was associated with lower perceived absolute risk and comparative risk for developing cancer. For the sample as a whole, higher perceived risk (both absolute risk and comparative risk) and worry predicted greater odds of mammography use; however, this was not true for Hispanics. In stratified analyses, perceived risk and worry were not associated with mammography use for either Hispanics or Blacks whereas they were for Whites; however, this interaction effect was significant only for Hispanics vs. Whites. Results support the need for formative research to identify determinants of health behavior prior to cancer prevention message planning for diverse audiences in order to accommodate racial/ethnic differences not only in the level of perceived risk, but also the association between risk perception to behavior change in that community.

Peer-based models of supportive care: the impact of peer support groups in African American breast cancer survivors

PURPOSE/OBJECTIVES

To examine the impact of support groups among African American breast cancer survivors (BCSs).

RESEARCH APPROACH

A qualitative research study.

SETTING

Community health and cancer centers and churches.

PARTICIPANTS

62 African American BCSs.

METHODOLOGIC APPROACH

Focus groups were conducted with African American BCSs to share their experiences with peer-based support groups. A brief questionnaire was administered and assessed demographics, medical history, and support group impact.

FINDINGS

Survivors emphasized that a culturally embedded focus was essential for their participation in a cancer support group. The survivors underscored that cultural-based groups are rooted in the spiritual, linguistic, experiential, and historical contexts of the intended constituents. The peer-based support groups provided multilevel functions, including emotional, social, spiritual, informational, and financial support, as well as patient navigation. The groups' activities fostered personal development and a call to community advocacy that included prevention education and research engagement.

CONCLUSIONS

The unique strengths of grassroots community-based support groups are that they are culturally consonant, peer-based, and responsive to cancer-related and personal needs. The contribution and value of those multifaceted peer-based groups expand the paradigm of supportive care, extending the net of psychosocial care to underserved and underrepresented cancer survivors.

INTERPRETATION

Research provides the critical foundation to lead and articulate the studies necessary to bridge peer- and professional-based care to ensure the psychosocial needs of increasingly diverse survivors are met.

Correlates of depressive symptomatology in African-American breast cancer patients

PURPOSE

This study assessed the levels of depressive symptomatology in African-American women with breast cancer compared to those of women without breast cancer and examined demographic, psychosocial, and clinical factors correlated with depression.

METHODS

A total of 152 African-American women were recruited from Washington, DC and surrounding suburbs. Breast cancer patients (n = 76 cases) were recruited from a health care center and women without cancer were recruited from health fairs (n = 76 comparison). We assessed depression, psychosocial variables (ego strength and social support), and sociodemographic factors from in-person interviews. Stage and clinical factors were abstracted from medical records. Independent sample t test, chi square test, analyses of variance, and multiple regression models were used to identify differences in depression and correlates of depression among the cases and comparison groups.

RESULTS

Women with breast cancer reported significantly greater levels of depression (m = 11.5, SD = 5.0) than women without breast cancer (m = 3.9, SD = 3.8) (p < 0.001). Higher cancer stage (beta = 0.91) and higher age (beta = 0.11) were associated with depression in the breast patients, explaining 84 % of the variance. In the comparison group, ego strength and tangible support were inversely associated with depressive symptoms, accounting for 32 % of the variance.

CONCLUSIONS

Women with more advanced disease may require interdisciplinary approaches to cancer care (i.e., caring for the whole person).

IMPLICATIONS FOR CANCER SURVIVORS

Depression is often underrecognized and undertreated in African-American breast cancer patients. Understanding the factors related to depression is necessary to integrate psychosocial needs to routine cancer care to improve survivors' quality of life.

"A Breast Ain't Nothing but a Sandwich": narratives of Ella, an African American social worker breast cancer survivor

Breast cancer mortality rates continue to increase among African American women making it imperative to develop culturally tailored programs to help reduce these rates. In this study, narratives of Ella an African American breast cancer survivor who is also a social worker were constructed. Prevalent themes were self-identity, perceptions of women living with cancer, and the socialization of African Americans in cancer prevention. Her perspective as a survivor and social worker offers insight on how the intersection of race and gender impacts breast cancer survival and has implications for future research in cancer awareness among African Americans.

Coping skills among African-American breast cancer survivors

Women with a diagnosis of breast cancer, particularly African-American women, face multiple barriers to survival. Although research exists regarding the unique barriers faced by African-American breast cancer survivors, there has been little research into the various coping needs or coping strategies used among African-American women. The purpose of this article is to provide information from an exploratory study of data investigating the coping skills of 30 African-American women diagnosed and treated for breast cancer. Quantitative data was collected via a self-report questionnaire based on the pretest of the Breast Cancer Survivors Toolbox. The study sample was evaluated to determine overall coping skills followed by an analysis of individual categories of coping skills (e.g., communication, information seeking, negotiating, social support systems, cultural norms). Although limited by the non-random sampling technique and self-report, the results of the study support the need for further research regarding the use of interventions and strategies tailored to improve coping skills used by this population.

Cultural differences in use of an electronic discussion group

This article describes how 121 women newly diagnosed with breast cancer used a computer mediated discussion group to cope with their diagnosis. These data are part of a larger data set from a randomized clinical trial assessing the impact of a computer-based system called CHESS (the Comprehensive Health Enhancement Support System) on health outcomes. The larger study found significant improvement in health outcomes for those in the experimental group (those receiving CHESS), especially for women of color. Since discussion group is by far the most heavily used service of CHESS, one might conclude that these benefits (both overall and greater for women of color) should be attributed to amount of discussion group use. This study looks at how women of color and Caucasian women used the CHESS discussion group over the period of the study. Content analysis of messages in the discussion group showed that women of color used the discussion group differently from Caucasian women-they used it less frequently but their messages were more focused on breast cancer, suggesting they used discussion group more instrumentally.

Participant evaluation of teleconference support for African American women with breast cancer

BACKGROUND

African American women with breast cancer face obstacles such as transportation and family obligations when attending standard support groups. Teleconference support circumvents barriers such as transportation to participation, but few evaluations have been reported about teleconference support.

OBJECTIVE

The purpose of this article was to describe the format of a teleconference group and to provide a descriptive account of the participants' feedback about a teleconference group intervention.

METHODS

A descriptive design was used. Participants completed the Overall Support Group Evaluation tool at the end of the 10th group session.

RESULTS

Teleconference group participants' feedback indicated that they perceived they had gained knowledge about breast cancer and coping. The participants expressed that the group helped them to reach out and ask for support and improved family and work relationships. Also, participants rated the group highly for the presence of therapeutic factors. On a scale of 1 to 4, with 4 being the highest, mean scores ranged from 3.97 to 3.56.

CONCLUSIONS

The participants gave high ratings of satisfaction in terms of knowledge gained, leadership style, and benefits. The participants perceived that the group increased their knowledge about cancer, improved family connections, and increased their ability to deal with their cancer.

IMPLICATIONS FOR PRACTICE

Using teleconferencing technology to deliver a support group to African American breast cancer patients is a beneficial method to reach a disadvantaged population that may be unable to attend face-to-face groups.

Adaptation of a Psycho-Oncology Intervention for Black Breast Cancer Survivors: Project CARE

Black women are traditionally underserved in all aspects of cancer care. This disparity is particularly evident in the area of psychosocial interventions where there are few programs designed to specifically meet the needs of Black breast cancer survivors. Cognitive-behavioral stress management intervention (CBSM) has been shown to facilitate adjustment to cancer. Recently, this intervention model has been adapted for Black women who have recently completed treatment for breast cancer. We outline the components of the CBSM intervention, the steps we took to adapt the intervention to meet the needs of Black women (Project CARE) and discuss the preliminary findings regarding acceptability and retention of participants in this novel study.

I'm a Jesus girl: coping stories of Black American women diagnosed with breast cancer

Breast cancer continues to be the most diagnosed cancer for all women, excluding non-melanoma skin cancer, in the United States. Incidence rates are 1 in 8 for an American woman being diagnosed. Moreover, statistics indicate that every 13 min an American woman dies from complications related to breast cancer. Despite all the gains made in the area of cancer research, Black American women continue to have a 67% higher mortality rate than their White counterparts. There is no preparation for a diagnosis of breast cancer. Upon hearing the words: you have breast cancer, a woman's life is forever altered. The woman's initial reactions of denial and/or anger yield to strategic responses. These responses may strengthen the woman's resiliency both during and following treatments. Research indicates that Black Americans, specifically Black American women, exhibit greater religiosity/spirituality than do other racial/ethnic groups. In addition, the use of religiosity/spirituality by Black Americans increases during a crisis. This qualitative study examines how religiosity/spirituality was utilized as a coping mechanism by a group of Black American women following their diagnoses of breast cancer.

An examination into audience targeting and the use of storytelling or statistical evidence on breast cancer websites

OBJECTIVE

This research sought to address the presence of information targeting low literacy, racially diverse, non-English speaking, and age diverse audiences on breast cancer websites. In addition, this study documented the utilization of evidence strategies, either statistics or storytelling, for these audiences.

METHODS

This research examined these relationships on 157 breast cancer websites through content analysis.

RESULTS

Nearly half of websites did not contain any of the elements targeting diverse literacy, racial/ethnic, language, and age audiences. Websites with multiple languages were more likely than monolingual websites to use statistics, and websites with low literacy sections were less likely than others to do so. Websites with ethnic or racial diversity and age diversity were more likely than other websites to use first person storytelling about breast cancer.

CONCLUSION

Current breast cancer websites demonstrate promising use of targeting specific audiences and employing evidence strategies prescribed as effective by past research, however there is room for improvement.

PRACTICE IMPLICATIONS

Tip sheets for incorporating audience targeting, readability, and storytelling should be created for health organizations to use in the process of developing their websites, as these constructs were found only sparingly on the assessed sites.

Ethnicity and cultural models of recovery from breast cancer

OBJECTIVE

Recovery narratives describe the culturally shared understandings about the ideal or desirable way to recover from an illness experience. This paper examines ethnic differences in recovery narratives among women participating in breast cancer support groups in Central Florida, USA. It compares groups serving African-American, Latina, and European American women, with the objective of better understanding the appeal of ethnic-specific illness support groups for culturally diverse populations.

DESIGN

A mixed-method study design combined qualitative and quantitative measures, including in-depth interviews, participant observation at support group meetings, collection of printed documents, and a structured survey.

RESULTS

Core elements of the recovery narrative drew from the dominant societal cancer discourse of optimism and personal transformation through adversity; however, important ethnic differences were evident in the meaning assigned to these themes. Groups gave distinctive salience to themes of faith and spirituality, empowerment through the migration experience, and becoming a better person through the journey of recovery.

CONCLUSION

The findings suggest that ethnic cancer support groups draw upon dominant societal discourses about cancer, but they espouse distinctive recovery narratives that are consonant with the groups' cultural models of illness. Similarity between ethnic members' individual recovery narratives and that of the group may contribute to the appeal of ethnic illness support groups for culturally diverse populations.

African-American caregivers' breast health behavior

This study utilizes a stress and coping framework which includes cognitive appraisal, personal and environmental resources, coping and stress to examine factors related to African-American caregivers' breast cancer screenings, including mammograms, clinical examinations and self-examinations. Using data from the Black Rural and Urban Caregivers Mental Health and Functioning Study, we performed separate logistic regressions for each type of breast cancer screening. Results reveal that having a regular doctor checkup (coping), care recipients having a cancer diagnosis (cognitive appraisal, and living in urban areas (environment resources) are associated with receiving a mammogram. Having greater income, having at least a high school degree (both personal resources) and having a regular doctor checkup (coping) are associated with receiving a clinical examination. Increased caregiver strain (stress), being 40 years old or older, social support (coping) and living in rural areas are associated with performing a self-examination. Targeting African-American caregivers, particularly in rural areas, for increased education on the importance of receiving breast cancer screenings is crucial to addressing health disparities. Making resources available, encouraging caregivers to get a clinical examination and a mammogram and directing public education toward caregivers are important points of intervention.

Challenges of illness in metastatic breast cancer: A low-income African American perspective

Objective:

Disparities in breast cancer survival and treatment for African American and low income women are well documented, yet poorly understood. As care for women with metastatic breast cancer (MBC) evolves to a chronic care model, any inequities in optimal treatment and management of symptoms must also be identified and eliminated. The purpose of this study was to explore how race and income status influence women's experiences with MBC, particularly the management of symptoms, by describing the perceived challenges and barriers to achieving optimal symptom management among women with MBC and exploring whether the perceived challenges and barriers differed according to race or income.

Method:

Quantitative techniques were used to assess demographics, clinical characteristics, symptom distress, and quality of life and to classify women into groups according to race and income. Qualitative techniques were used to explore the perceived challenges, barriers, and potential influences of race and income on management of symptoms in a prospective sample of 48 women with MBC.

Results:

Commonalities of themes across all groups were faith, hope, and progressive loss. Low-income African American women uniquely experienced greater physical and social distress and more uncertainty about treatment and treatment goals than the other delineated racial and economic groups.

Significance of results:

There are many commonalities to the challenges of illness presented to women with MBC. There are also interesting, emerging thematic racial and economic differences, most compelling among the low income African American women with resultant practice and research implications.

Psychosocial issues facing African and African American women diagnosed with breast cancer

Breast cancer is a global issue. The World Health Organization estimates that approximately 1.2 million people will receive a diagnosis of breast cancer each year. Breast cancer continues to be the most diagnosed cancer for all women, after skin cancer, both within the United States and worldwide. Although the incidence of breast cancer among African and African American women is lower than that of European and White American women, their mortality rate is significantly higher. Findings indicated the common denominators for African, African American, and Caribbean women regarding breast cancer are that (1) they present at younger ages, (2) they present having advanced-stage tumors, (3) they are often from lower socioeconomic levels, and (4) they lack knowledge regarding causes and treatment of breast cancer. Social workers in their roles as researchers and advocates can identify gaps within the health care system that adversely impact these women. As policy makers and educators, social workers can design interventions to ensure that the needs of these women and their support system are fulfilled.

'If it almost kills you that means it's working!' Cultural models of chemotherapy expressed in a cancer support group

It has long been recognised that cancer is an extraordinarily culturally charged disease. However, while studies have provided valuable insights into the embodied experience of cancer, far less research exists on cancer patients' and survivors' perceptions of the treatments they receive and the meanings they assign to these treatments. This paper focuses specifically on chemotherapy--a highly feared form of treatment that is often popularly depicted to be worse than the experience of cancer itself. Drawing on ethnographic fieldwork over an 8-month period at a cancer support group in western Canada, this article explores patient perceptions of adjuvant chemotherapy. I argue that a widespread cultural model of chemotherapy exists that emphasises the value of suffering as a means of tracking treatment effectiveness and the possibility of cure. However, this framework diverges from biomedical understandings of treatment in important respects, with implications for patient anxiety levels during treatment and their subjective assessments of the future risk of recurrence. Overall, research findings highlight the need to pay closer attention to the meanings patients assign to cancer treatments and call for further research in this area.

Punjabi immigrant women's breast cancer stories

The breast cancer experiences of Punjabi immigrant women, who represent the most populace group of South Asians in Canada, need to be understood in order to inform culturally appropriate cancer services. The purpose of this qualitative study was to explore women's stories of breast cancer in order to uncover how they made sense of their experiences. Interviews with twelve Punjabi immigrant women who had breast cancer within the last 8 years were available for this study. The four storylines that emerged from the ethnographic narrative analysis were: getting through a family crisis, dealing with just another health problem, living with never-ending fear and suffering, and learning a "lesson from God." A minor theme, "being part of a close-knit family," highlighted the family context as the most pronounced influence on the women's experiences. These findings provide valuable insights into how women's experiences of breast cancer were shaped by the intersections of culture, family, community, cancer treatments, and interactions with health care professionals.

Ethnocultural women's experiences of breast cancer: a qualitative meta-study

A growing number of studies have been conducted that explore the breast cancer experiences of women from diverse ethnocultural groups. To advance knowledge and provide a foundation for future research, a synthesis was conducted of 15 qualitative research studies focusing on women from ethnocultural groups diagnosed with breast cancer. A qualitative meta-study approach was used that included analysis of the theoretical orientations and methodological approaches underlying the research, and an interpretive synthesis of research findings. Ethnocultural groups represented in the studies included Asian American, Aboriginal, Hispanic, and African American women. The synthesis revealed diverse experiences within and among these ethnocultural groups represented in 5 major themes: (a) the "othered" experience of a breast cancer diagnosis, (b) the treatment experience as "other," (c) losses associated with breast cancer, (d) the family context of breast cancer experiences, and (e) coping with cancer through spirituality and community involvement. The integration of findings from the 15 studies also revealed how methodological and theoretical approaches to conducting this research influenced understandings of the experiences of breast cancer. Further experiential breast cancer research with ethnocultural groups is needed, as well as the use of research methods that illuminate the ways that ethnicity, class, age, and gender relations are played out in healthcare settings.

Urban voices: The quality-of-life experience among women of color with breast cancer

Objectives:Research on the health-related quality of life (HRQL) among women of color (i.e., Hispanics and African Americans) with breast cancer suggests that they may be at elevated risk for a variety of physical and psychosocial sequelae. The context in which these women perceive, experience, and respond to these HRQL challenges can provide important information for planning a culturally appropriate palliative care treatment plan.

Methods: In an effort to understand the quality of lifeexperienceafter breast cancer among women of color, this study describes the nature and impact of physical, emotional, and menopausal symptoms among African American (n= 8) and Hispanic (n= 12) breast cancer survivors based on qualitative data gathered through semistructured interviews. Themes were identified and categorized into six HRQL domains: physical (e.g., pain, nausea), psychological (e.g., sadness, irritability), cognitive (e.g., memory problems), sexual (e.g., decreased desire), social/functional (e.g., financial strain, social distress), and spiritual/existential (e.g., increased faith, spiritual coping), with high interrater reliability (kappa = .81).

Results:For both groups, physical issues had a major impact on HRQL, with psychological issues being additionally salient for Hispanic women. Most (88%) African American women voiced positive changes in their faith after diagnosis whereas 50% of Hispanic women viewed faith as an important way of coping with breast cancer.

Significance of results:This research broadens our understanding of the experience of breast cancer among ethnic minority women, and in turn, offers some key directions for guiding the development of culturally tailored HRQL interventions.

The Delay and Worry Experience of African American Women With Breast Cancer

PURPOSE/OBJECTIVES

To examine the delay in seeking treatment and worry experiences of African American women with breast cancer.

DESIGN

Descriptive, correlational.

SETTING

Urban northeastern United States.

SAMPLE

60 African American women diagnosed with breast cancer.

METHODS

Consenting participants completed the worry subscale of the Ware Health Perception questionnaire and a Demographic and Illness-Related Information Sheet during a one-hour personal interview. Data analysis consisted of descriptive statistics and Pearson correlations.

MAIN RESEARCH VARIABLES

Delay in seeking treatment, worry about breast cancer and symptoms, and sociodemographic characteristics.

FINDINGS

Contrary to the literature, participants reported short patient and provider delay. As a result of little variability in delay, predicting those for whom worry was a deterrent or a motivator to seek prompt treatment was not possible.

CONCLUSIONS

Although delay does exist, African American women with sociodemographic characteristics similar to white women who do not delay are likely to have similarly short symptom durations. Further study to determine who is helped and who is hurt by worry and other possible intervening factors would be useful. Including biologic characteristics such as tumor staging and hormone receptor information in future studies would allow for a closer examination of stage at diagnosis and biologic influence.

IMPLICATIONS FOR NURSING

Interventions with African American women cannot assume that delay exists. Strategies that consider both individual and cultural group differences are essential to the early seeking of a diagnosis and treatment for breast cancer symptoms among African American women.

African American Couples Merging Strengths to Successfully Cope With Breast Cancer

PURPOSE/OBJECTIVES

To explore the process of coping with breast cancer among African American women and their spouses.

DESIGN

Exploratory, qualitative study using grounded theory methods.

SETTING

Large metropolitan area in the mid-Atlantic United States.

SAMPLE

12 African American couples (N = 24).

METHODS

African American women and their spouses were asked to complete a background data sheet and participate in a face-to-face semistructured interview. Qualitative data were audiotaped and transcribed verbatim. Themes were identified using the constant comparative method. Quantitative data were analyzed with descriptive statistics.

MAIN RESEARCH VARIABLES

The process of coping with breast cancer among African American couples.

FINDINGS

The basic social concern was living through and beyond a breast cancer diagnosis. The core variable was merging strengths to cope with and survive a breast cancer diagnosis. Six main categories emerged to describe how African American couples actively worked together to cope with a breast cancer diagnosis: walking together, praying together, seeking together, trusting together, adjusting together, and being together.

CONCLUSIONS

African American couples described the importance of combining their strengths and working together as a couple to cope with a breast cancer diagnosis.

IMPLICATIONS FOR NURSING

Nurses must understand the importance of developing culturally sensitive and culturally relevant interventions to assist African American couples with effectively coping with a breast cancer diagnosis. When providing care to African American couples, nurses should incorporate the six categories of walking, praying, seeking, trusting, adjusting, and being together to help couples cope with the various phases of the breast cancer experience.

Psychosocial Responses in Breast Cancer Survivors

OBJECTIVES

To review the evidence on psychosocial responses in breast cancer survivors (BCS); identify factors that influence those responses; and propose patterns of psychosocial functioning that may provide a framework for assessment and intervention.

DATA SOURCES

Research articles/abstracts; literature reviews.

CONCLUSION

The majority of breast cancer survivors demonstrate a pattern of recovery. Age, information, communication, social and emotional support, family, and degree of symptom distress are known factors influencing QOL outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Assessment of psychosocial functioning is essential to identify needs and risk factors. Interventions should be targeted to meet informational needs, promote effective communication, manage uncertainty, control symptoms, enhance social and emotional support, and address cultural differences.

Family support of immigrant Punjabi women with breast cancer

Women with breast cancer have been found to rely heavily on family members for providing support during their illness experiences. There has been limited research on ethnocultural families' experiences of illness and how these families respond to a diagnosis of breast cancer. This study examined the experiences and responses of family members of immigrant Punjabi women diagnosed with breast cancer. Through interviews with 19 Punjabi women diagnosed with breast cancer and 18 family members, key practical and emotional support strategies were described. Recommendations for culturally appropriate, family-centered models of care are provided that acknowledge breast cancer as a family event.

Research institute for nurse scientists responds to the challenge to expand and strengthen research focused on breast cancer in African American women

In an era where scientifically derived 'evidence' is used as a basis for nursing practice, it is imperative that nurses have a breadth of knowledge relative to the fundamentals of nursing science; knowledge of the current standards of nursing and medical practice; and knowledge of the characteristics, needs, concerns, and challenges of diverse consumer and patient population groups. Yet, while a significant body of 'evidence' that describes the experiences and needs of African American women across the breast care continuum has been generated, research suggests that there is a need to expand and strengthen this body of science. This report presents an overview of a decade of research focused on breast cancer among African American women and describes an initiative funded by the Susan G. Komen Breast Cancer Foundation to expand and strengthen nursing science that aims to reduce and/or eliminate excess breast cancer morbidity and mortality among African American women. Cancer 2007. (c) 2006 American Cancer Society.

Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer

Breast cancer treatment can have a profound influence on a woman's physical, psychological, social, and spiritual well-being. Anxiety, depression, anger, fatigue, and fear of recurrence are common responses to a diagnosis of breast cancer and undergoing breast cancer treatment. Women develop their own coping strategies for the pain and other effects of treatment. However, it is unclear whether there is a relationship between adaptation to pain and psychological distress during breast cancer treatment. Findings from the present study reveal that breast cancer patients who have better pain coping strategies also have lower levels of anxiety, fatigue and depression. These results suggest that pain coping interventions may reduce fatigue and psychological distress among women with breast cancer.

Standardized versus open-ended assessment of psychosocial and medical concerns among African American breast cancer patients

Standardized quality of life measures have been developed and used primarily with Caucasian and middle-class cancer patients. This study assessed the ability of several widely used standardized measures to capture the concerns and problems of 89 African American breast cancer patients. Concerns and problems were assessed using both an open-ended format and standardized measures. The degree of overlap in responses from these two formats was examined. The most frequently reported problems in the open-ended format included physical (43%), financial (40%), and worry about others (30%). Overall, standardized measures had significant overlap with open-ended concerns and problems. The Cancer Rehabilitation Evaluation System-Short Form subscales/items were associated with corresponding open-ended physical, financial, and social problems (R2 change = 0.07-0.16, p's < or = 0.02), the Interpersonal Support Evaluation List-Short Form was associated with open-ended social problems (R2 change = 0.11, p = 0.004), and the Mental Health Inventory was associated with open-ended psychological distress problems (R2 change = 0.08, p = 0.01). One category of open-ended problems, worry about others, was not captured by standardized measures. With the exception of associations between open-ended physical problems and psychological distress measures, there were few significant correlations between standardized measures and dissimilar problem categories. These findings suggest that the standardized measures in this study reflected the concerns and problems of African American breast cancer patients. Additional studies are needed to evaluate the utility of other widely used standardized measures that have not been developed or standardized among non-white samples.

Closing the divide: diverse populations and cancer survivorship

Currently, there is a "divide" between cancer survivorship initiatives and minority participation. The level of participation is nearly nonexistent in many cancer support and control initiatives. Cancer survivorship resources that facilitate access to treatment, psychosocial interventions, clinical trials, and research are key components to eliminating this divide. Differences in cancer results among minority populations are caused by several factors, including biologic reactions to environmental activities, socioeconomic status, perceived beliefs and notions of medical professionals, a lack of resources to participate in cancer support groups, and having personal contact with cancer survivors. Health professionals, advocates, and researchers hold the key to opening more opportunities for the improvement of cancer survivorship among minorities. The belief that "one size fits all" is unrealistic. These beliefs can influence participation in innovative clinical trials, decisions about treatment, emotional responses, and social support relationships. To help ensure participation in these programs, researchers and health workers must understand the role of social and psychosocial implications and results of the assessment, strategies, and sustainability that must be included in the development stage of any cancer support and survivorship initiatives. For this article, the authors examined mechanisms that can be used by cancer-control researchers and program staff to limit the divide between cancer survivorship initiatives and minority participation. They identified three strategies that must be used to address this divide effectively: the inclusion of minorities in clinical trials, intervention studies, treatment, and research programs; the development of culturally sensitive environments; and the ability to sustain minority participation. In summary, cancer survivorship includes many components that are developed individually and collectively to formulate sound strategies for including minorities in cancer-control initiatives. These programs should go beyond basic support groups and should include research studies, clinical trials, and alternative treatments for increasing cancer survival rates and quality of life among minorities. The divide can be addressed only through a proactive initiative that brings cancer survivorship initiatives and minority communities together in full partnership.

Testing a model of symptoms, communication, uncertainty, and well-being, in older breast cancer survivors

Among older, long-term breast cancer survivors, symptoms from previous treatment can generate uncertainty about whether they represent co-morbid conditions, recurrence, or normal aging. This uncertainty can result in emotional distress and thoughts of recurrence. Communication with health care providers may help women reduce uncertainty and improve both emotional and cognitive well-being. To assess the influence of symptoms, uncertainty, and communication with providers on well-being, data from 203 Caucasian and African American survivors, 5-9 years post treatment, were tested using structural equation modeling. Symptoms, age, and uncertainty had the strongest influence on well-being, regardless of race. There was an unexpected positive association between patient-provider communication and thoughts of recurrence. Descriptive analysis revealed that 52% of women were unable to achieve their desired decision-making role with health care providers.

Triggers of uncertainty about recurrence and long-term treatment side effects in older African American and Caucasian breast cancer survivors

PURPOSE/OBJECTIVES

To examine the sources of uncertainty in older African American and Caucasian long-term breast cancer survivors by focusing on frequency of triggers of uncertainty about cancer recurrence and physical symptoms linked to long-term treatment side effects.

DESIGN

In the context of a larger randomized, controlled treatment-outcome study, data were gathered from 10 monthly follow-up telephone calls by nurses.

SETTING

Rural and urban regions of North Carolina.

SAMPLE

244 older women (mean age = 64 years); 73 African American women and 171 Caucasian women who were five to nine years after breast cancer diagnosis.

FINDINGS

The most frequent triggers were hearing about someone else's cancer and new aches and pains. The most frequent symptoms were fatigue, joint stiffness, and pain. Although no ethnic differences occurred in the experience of symptoms, Caucasian women were more likely than African American women to report that their fears of recurrence were triggered by hearing about someone else's cancer, environmental triggers, and information or controversy about breast cancer discussed in the media.

CONCLUSIONS

Illness uncertainty persisted long after cancer diagnosis and treatment, with most women experiencing multiple triggers of uncertainty about recurrence and a range of symptoms and treatment side effects.

IMPLICATIONS FOR NURSING

Nurses can help cancer survivors to identify, monitor, and manage illness uncertainty and emotional distress.

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.

Disparities across the breast cancer continuum

OBJECTIVE

We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.

METHODS

We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.

RESULTS

Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.

CONCLUSION

A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

African American women's breast memories, cancer beliefs, and screening behaviors

African American women experience higher breast cancer mortality and lower survival rates compared with white women of comparable age and cancer stage. The literature is lacking in studies that address the influence of past events on current health behaviors among women of diverse cultural groups. This qualitative exploratory study used participant narratives to examine associations between women's memories and feelings concerning their breasts and current breast cancer screening behaviors. Twelve professional African American women, aged 42 to 64 years, shared stories about memories and feelings regarding their breasts. Codes grouped together with related patterns and recurrences revealed categories that encompassed the language and culture of the participants. The categories identified were Seasons of Breast Awareness, Womanhood, Self-Portraits, Breast Cancer and Cancer Beliefs, Breast Cancer Screening Experiences, and Participants' Advice for Change. These categories provide direction for further exploration of barriers to health promotion practices among African American women and women in general.

African American women coping with breast cancer: a qualitative analysis

PURPOSE/OBJECTIVES

To determine how African American women cope with breast cancer.

DESIGN

Descriptive and exploratory study.

SAMPLE/SETTING

66 African American women diagnosed with breast cancer were interviewed in the southeastern United States.

METHODS

Data were collected through tape-recorded interviews using a semistructured interview guide. Data were analyzed by content analysis and frequency distributions.

MAIN RESEARCH VARIABLES

Coping strategies used by women to adapt to a diagnosis of breast cancer.

FINDINGS

Coping strategies described by African American women included relying on prayer, avoiding negative people, developing a positive attitude, having a will to live, and receiving support from family, friends, and support groups.

CONCLUSION

Spirituality played a major role in these African American women coping with breast cancer. Supportive networks also served as a vital asset throughout the breast cancer experience. Participants discussed the need for culturally sensitive breast cancer support groups.

IMPLICATIONS FOR NURSING

Nurses must recognize coping strategies that African American women with breast cancer use. Healthcare professionals need to develop culturally sensitive breast cancer support groups. Throughout the breast cancer experience, nurses must assess communication patterns among African American families. Nurses should serve as healthcare advocates for African American women with breast cancer.

Breast cancer survivorship: are African American women considered? A concept analysis

PURPOSE/OBJECTIVE

To apply Rodger's (1989) evolutionary view of concept analysis to the term "cancer survivorship" with a heightened focus on breast cancer and African American women.

DESIGN

Qualitative, concept analysis.

DATA SOURCES

50 references from the disciplines of nursing and medicine.

DATA SYNTHESIS

This analysis revealed that the concept of cancer survivorship is unique, evolving, and based on the meaning individuals give to a diagnosis of cancer and their experiences of living beyond the diagnosis.

CONCLUSIONS

The concept of breast cancer survivorship can be operationally defined as the process of living through the cancer experience beyond a breast cancer diagnosis. A crucial need exists to explore the meaning of cancer survivorship among African American women as a basis for culturally competent care.

IMPLICATIONS FOR NURSING

Nurses and other healthcare professionals must comprehend the meaning of breast cancer survivorship and its implications for cancer survivors. The meaning of cancer survivorship to African American and ethnic minority women must be explored. Culturally relevant cancer survivorship education and care should be provided for African American women and other cancer survivors of ethnic minorities as well as those involved in the women's social and healthcare world. Nurses and healthcare professionals must continue to advocate for health policies to improve the lived experiences of all cancer survivors.

Cancer survivorship research among ethnic minority and medically underserved groups

PURPOSE/OBJECTIVES

To review the current state of knowledge about the impact of cancer on ethnoculturally diverse and medically underserved survivors.

DATA SOURCES

MEDLINE, CancerLit, and Psychlit searches from 1966-present were conducted to locate articles about survivorship outcomes among minority and underserved populations.

DATA SYNTHESIS

65 articles were identified and grouped into one of four content areas: physiologic; psychosocial; health services, patterns of care, and quality of care; and health-promoting behaviors and lifestyles.

CONCLUSIONS

Despite limited information, researchers found a consistent theme: the need to recognize and address the socioeconomic and cultural variables that affect adaptation to and survival from cancer among diverse groups of survivors.

IMPLICATIONS FOR NURSING

The researchers found specific variations in risk for, response to, and recovery from cancer that provide direction for changes in nursing practice that may reduce the burden of cancer in these often vulnerable populations.