Moving in between mammography: screening decisions of American Indian women in Vermont

Emotions and Narrative Reappraisal Strategies of Users of Breast Cancer Screening: Reconstructing the Past, Passing Through the Present, and Predicting Emotions

Emotional forecasting, meaning how a person anticipates feeling as a consequence of their choices, drives healthcare decision-making. Research, however, suggests that people often do not fully anticipate or otherwise grasp the future emotional impacts of their decisions. Emotional reappraisal strategies, such as putting emotions into words and sharing emotions with others, may mitigate potential undesirable effects of emotions on decision-making. The use of such strategies is important for consequential decisions, such as obtaining timely mammography screening for breast cancer, whereby earlier diagnosis may impact the success of treatment. In this study, we explored the use of emotional reappraisal strategies for decision-making regarding breast cancer screening attendance among women aged 50-69 years. Data were collected through semi-structured interviews following mammography with a reflexive thematic methodological approach employed for analysis. Results shed light on how participants' emotional response narratives were reconstructed before the mammography, felt during the mammography, and forecasted while awaiting the results. Future research should consider how individuals experience and manage their emotions as they access breast screening services.

Disparities in Mammography Screening: Analyzing Barriers to Access Using Individual Patient Perspectives and the Health Belief Model

OBJECTIVE

The objective of our study is to explore Nepali women's beliefs about access to mammography screening, and motivations to get screened or not. This work was intended to be hypothesis generating for subsequent quantitative analysis and to inform policy and decision-making to improve access.

METHODS

We conducted structured qualitative interviews among nine Nepali women in the Northeast of the United States receiving care at a local community health center and among nine white women receiving mammography care at a large academic medical center in the Northeast. We analyzed the transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach. Deductive codes were generated from the Health Belief Model which states that a person's belief in the real threat of a disease with their belief in the effectiveness of the recommended health service or behavior or action will predict the likelihood the person will adopt the behavior. We compared and contrasted qualitative results from both groups.

RESULTS

We found that eligible Nepali women who had not received mammography screening had no knowledge of its availability and its importance. Primary care physicians emerged as a critical link in addressing this disparity: trust was found to be high among Nepali women with their established primary care provider.

CONCLUSION

The findings of this study suggest that the role of primary care practitioners in conversations around the importance and eligibility for mammography screening is of critical importance, especially for underserved groups with limited health knowledge of screening opportunities and potential health benefits. Follow-up research should focus on primary care practices.

Urbanicity, Income, and Mammography-Use Disparities Among American Indian Women

INTRODUCTION

Reported breast cancer screening among American Indian women is consistently below that of White women. The last claims-based trends were from 1991 to 2001. This study updates mammography trends for American Indian women and examines the impact of race, urbanicity, and income on long-term mammography use.

METHODS

This was a multi-year (2005-2019), retrospective study of women aged 40-89 years using a 5% sample of Medicare fee-for-service beneficiaries residing in Arizona, California, New Mexico, Oklahoma, and Washington. This study used multivariable logistic regression to examine the impact of urbanicity and income on receiving mammography for American Indian women compared with that for White women. Analyses were conducted in 2022.

RESULTS

Overall, annual age-adjusted mammography use declined from 205 per 1,000 in 2005 to 165 per 1,000 in 2019. The slope of these declines was significantly steeper (difference = -2.41, p<0.001) for White women (-3.06) than for American Indian women (-0.65). Mammography-use odds across all urbanicity categories were less for American Indian women than for White women compared with those of their respective metropolitan counterparts (e.g., rural: 0.96, 95% CI=0.77, 1.20 for American Indian women and 1.47, 99% CI=1.39, 1.57 for White women). Although residing in higher-income communities was not associated with mammography use for American Indian women, it was 31% higher for White women (OR=1.31, 99% CI=1.28, 1.34).

CONCLUSIONS

The disparity in annual age-adjusted mammography use between American Indian and White women narrowed between 2005 and 2019. However, the association of urbanicity and community income on mammography use differs substantially between American Indian and White women. Policies to reduce disparities need to consider these differences.

Healthcare system distrust and the breast cancer continuum of care

PURPOSE

To identify and synthesize the literature on healthcare system distrust across the breast cancer continuum of care.

METHODS

We searched CINAHL, Cochrane, EMBASE, PubMed, PsycINFO, and Web of Science from January 1, 1990 to December 31, 2018 for all peer-reviewed publications addressing the role of healthcare system trust, distrust or mistrust in the breast cancer continuum of care.

RESULTS

We identified a total of 20 studies, seven qualitative studies and thirteen quantitative studies. Two studies assessed genetic testing, eleven assessed screening and seven assessed treatment and follow-up. Twelve studies evaluated mistrust, five evaluated distrust, and three evaluated trust. Study populations included African American, American Indian, Latina, Hispanic, and Asian American participants.

CONCLUSION

Healthcare system distrust is prevalent across many different racial and ethnic groups and operates across the entire breast cancer continuum of care. It is an important yet understudied barrier to cancer. We hope that the knowledge garnered by this study will enable researchers to form effective and targeted interventions to reduce healthcare system distrust mediated disparities in breast cancer outcomes.

Andersen's Behavioral Model to Identify Correlates of Breast Cancer Screening Behaviors among Indigenous Women

This study examined predictive models of utilization of mammograms among Indigenous women adapting Andersen's behavioral model. Using a sample of 285 Indigenous women residing in South Dakota, nested logistic regression analyses were conducted to assess predisposing (age and marital status), need (personal and family cancer history), and enabling factors (education, monthly household income, mammogram screening awareness, breast cancer knowledge, self-rated health, and cultural practice to breast cancer screening). Results indicated that only 55.5% of participants reported having had a breast cancer screening within the past 2 years. After controlling for predisposing and need factors, higher education, greater awareness of mammogram, and higher utilization of traditional Native American approaches were significant predictors of mammogram uptake. The results provide important implications for intervention strategies aimed at improving breast cancer screening and service use among Indigenous women.

A Mixed Methods Review of Education and Patient Navigation Interventions to Increase Breast and Cervical Cancer Screening for Rural Women

Reviews have assessed studies of breast and cervical cancer screening access and utilization for rural women, but none analyze interventions to increase screening rates. A mixed methods literature search identified studies of breast and/or cervical cancer prevention education and patient navigation interventions for rural women. Rural areas need greater implementation and evaluation of screening interventions as these services address the challenges of delivering patient-centered cancer care to un-/underserved communities. The lack of intervention studies on breast and cervical cancer education and patient navigation programs compared to urban studies highlights the need for validation of these programs among diverse, rural populations.

Knowledge, Attitudes, and Beliefs Regarding Breast Cancer Among American Indian Women From the Northern Plains

American Indian women have low screening mammography rates. The authors’ goal was to compare the knowledge, attitudes, and beliefs about breast cancer among Northern Plains Reservation women who had and had not received screening mammography in the previous year. Another goal was to compare response rates achieved with an immediate monetary incentive to those achieved with an incentive after survey completion. Questionnaires were mailed to 234 women who had undergone screening mammography and 266 women who had not. Respondents included 144 (62%) of women who had been screened and 127 (48%) of women who had not. Women who had not received mammography less often were aware that older age increased breast cancer risk compared to women who had had a mammogram in the previous year. Findings suggest that Northern Plains women would benefit from educational efforts and discussions with clinicians about mammography. Immediate monetary incentives appear to increase response rates.

The Design of a Multi-component Intervention to Promote Screening Mammography in an American Indian Community: The Native Women's Health Project

BACKGROUND

Breast cancer is an important public health issue among American Indian/Alaska Native (AI/AN) women in the US. This article describes the design and implementation of a culturally sensitive intervention to promote breast health among AI/AN women through a hybrid model that incorporates clinical and community-based approaches. This is one of the first studies using this model addressing breast cancer disparities among AI/AN populations in the US.

METHODS

The Theory of Planned Behavior was used as the guiding framework of the intervention and Community Based Participatory Research was the primary vehicle for the intervention planning and implementation. Three preliminary studies took place that aimed to identify qualitatively and quantitatively what deterred or encouraged AI women to get past or future mammograms. The research results were shared with community members who, through a prioritization process, identified the theoretical focus of the intervention and its corresponding activities. The priority population consisted of AI women ages 40-74, with no recent mammogram, and no breast cancer history.

RESULTS

The intervention centered on the promotion of social modeling and physician recommendation. The main corresponding activities included enhancing patient-physician communication about screening mammography through a structured dialogue, receipt of a breast cancer brochure, participation in an inter-generational discussion group, and a congratulatory bracelet upon receipt of a mammogram. Environmental and policy related changes also were developed.

CONCLUSION

Creating a theory-based, culturally-sensitive intervention through tribal participatory research is a challenging approach towards eliminating breast cancer disparities among hard-to-reach populations.

Speaking out about physical harms from tobacco use: response to graphic warning labels among American Indian/Alaska Native communities

OBJECTIVE

This study is the first to explore the impact of graphic cigarette labels with physical harm images on members of American Indian/Alaska Native (AI/AN) communities. The aim of this article is to investigate how AI/AN respond to particular graphic warning labels.

METHODS

The parent study recruited smokers, at-risk smokers and non-smokers from three different age groups (youths aged 13-17 years, young adults aged 18-24 years and adults aged 25+ years) and five population subgroups with high smoking prevalence or smoking risk. Using nine graphic labels, this study collected participant data in the field via an iPad-administered survey and card sorting of graphic warning labels. This paper reports on findings for AI/AN participants.

RESULTS

After viewing graphic warning labels, participants rated their likelihood of talking about smoking risks to friends, parents and siblings higher than their likelihood of talking to teachers and doctors. Further, this study found that certain labels (eg, the label of the toddler in the smoke cloud) made them think about their friends and family who smoke.

CONCLUSIONS

Given the influence of community social networks on health beliefs and attitudes, health communication using graphic warning labels could effect change in the smoking habits of AI/AN community members. Study findings suggest that graphic labels could serve as stimuli for conversations about the risks of smoking among AI/AN community members, and could be an important element of a peer-to-peer smoking cessation effort.

Predictors of regular mammography use among American Indian women in Oklahoma: a cross-sectional study

Background

There are significant disparities in breast cancer screening and survivorship between American Indian (AI) and non-Hispanic white women. This study aimed to identify the salient beliefs AI women from Oklahoma have on regular mammography screening, and to determine which beliefs and health- related practices are associated with past mammography screening behavior.

Methods

This study used an integrated model of the Theory of Planned Behavior as the guiding theoretical framework. Data were collected from 255 (mean age = 51 years, SD 7.64 years) AI women randomly selected from a rural Oklahoma medical clinic (response rate: 79%). Multivariate logistic regression was used to identify factors associated with self-reported past mammography within the last two years while controlling for demographic variables. Associations were summarized using odds ratios (OR), the ratio of the odds of past mammography per a 1-unit increase in continuous independent factor scales (subjective physician norm, cultural affiliation, fatalism, knowledge of mammography screening guidelines, and perceived behavior control barriers) or between groups defined by categorical variables, and 95% confidence intervals (CI).

Results

Of the participants, 65% (n = 167) reported a screening mammogram within the last two years. After adjustment for age and educational status, women with a higher total subjective-norm physician score (OR = 1.15, 95% CI: 1.06-1.24), a higher knowledge of mammography screening guidelines (OR = 1.52, 95% CI: 1.00-2.31), a family history of breast cancer (OR = 9.97, 95% CI: 3.05-32.62), or reporting an annual versus none or a single physician breast examination (OR = 5.57, 95% CI: 1.79-17.37) had a higher odds of past mammography. On the other hand, women who were more culturally affiliated (OR = 0.42, 95% CI: 0.24-0.74), perceived more barriers (OR = 0.86, 0.78-0.94), or had higher fatalistic attitudes toward breast cancer (OR = 0.90, 95% CI: 0.82-0.99) had lower odds of past mammography.

Conclusion

In the development of culturally-appropriate interventions promoting mammography among AI communities, emphasis could be put on the following: a) promoting clinic-related practices (e.g. physician recommendation, physician breast examination); b) promoting community-related practices (e.g. knowledge about mammography while eliminating fatalistic attitudes); and c) reducing environmental barriers.

Factors that influence mammography use among older American Indian and Alaska Native women

INTRODUCTION

American Indian and Alaska Native (AIAN) women have relatively high breast cancer mortality rates despite the availability of free or low-cost screening.

PURPOSE

This qualitative study explored issues that influence the participation of older AIAN women in mammography screening through tribally directed National Breast and Cervical Cancer Early Detection Programs (NBCCEDPs).

METHODS

We interviewed staff (n = 12) representing five tribal NBCCEDPs and conducted four focus groups with AIAN women ages 50 to 80 years (n = 33).

RESULTS

Our analysis identified four main areas of factors that predispose, enable, or reinforce decisions around mammography: financial issues and personal investments, program characteristics including direct services and education, access issues such as transportation, and comfort zone topics that include cultural or community-wide norms regarding cancer prevention.

CONCLUSION

This study has implications for nurse education and training on delivering effective mammography services and preventive cancer outreach and education programs in AIAN communities.

Cultural identity and patient trust among older American Indians

BACKGROUND

Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored.

OBJECTIVE

To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity.

DESIGN

Patient survey administered following primary care visits.

PARTICIPANTS

Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma.

MAIN MEASURES

Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust.

KEY RESULTS

Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9).

CONCLUSIONS

Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol

BACKGROUND

Little is known about shared decision-making (SDM) with Métis, First Nations and Inuit women ("Aboriginal women"). SDM is a collaborative process that engages health care professional(s) and the client in making health decisions and is fundamental for informed consent and patient-centred care. The objective of this study is to explore Aboriginal women's health and social decision-making needs and to engage Aboriginal women in culturally adapting an SDM approach.

METHODS

Using participatory research principles and guided by a postcolonial theoretical lens, the proposed mixed methods research will involve three phases. Phase I is an international systematic review of the effectiveness of interventions for Aboriginal peoples' health decision-making. Developed following dialogue with key stakeholders, proposed methods are guided by the Cochrane handbook and include a comprehensive search, screening by two independent researchers, and synthesis of findings. Phases II and III will be conducted in collaboration with Minwaashin Lodge and engage an urban Aboriginal community of women in an interpretive descriptive qualitative study. In Phase II, 10 to 13 Aboriginal women will be interviewed to explore their health/social decision-making experiences. The interview guide is based on the Ottawa Decision Support Framework and previous decisional needs assessments, and as appropriate may be adapted to findings from the systematic review. Digitally-recorded interviews will be transcribed verbatim and analyzed inductively to identify participant decision-making approaches and needs when making health/social decisions. In Phase III, there will be cultural adaptation of an SDM facilitation tool, the Ottawa Personal Decision Guide, by two focus groups consisting of five to seven Aboriginal women. The culturally adapted guide will undergo usability testing through individual interviews with five to six women who are about to make a health/social decision. Focus groups and individual interviews will be digitally-recorded, transcribed verbatim, and analyzed inductively to identify the adaptation required and usability of the adapted decision guide.

DISCUSSION

Findings from this research will produce a culturally sensitive intervention to facilitate SDM within a population of urban Aboriginal women, which can subsequently be evaluated to determine impacts on narrowing health/social decision-making inequities.

Breast cancer and screening in American Indian and Alaska Native women

Data relative to breast cancer among American Indian and Alaska native (AI/AN) women are limited and vary by regions. Despite national decreases in breast cancer incidence and mortality rates, declines in these measures have not yet appeared among AI/AN women. Health disparities in breast cancer persist, manifest by higher stage at diagnosis, and lower screening rates compared to other racial and ethnic groups. Disproportionately more AI/AN are younger at diagnosis. Screening beginning at age 40, improving access, annual rescreening, community education and outreach, and mobile mammography for rural areas are ways to improve these disparities in breast cancer.

Intention to receive cancer screening in Native Americans from the Northern Plains

BACKGROUND

Native Americans are disproportionately affected by cancer morbidity and mortality. This study examined intention to receive cancer screening in a large sample of Native Americans from the Northern Plains, a region with high cancer mortality rates.

METHODS

A survey was administered orally to 975 individuals in 2004-2006 from three reservations and among the urban Native American community in the service region of the Rapid City Regional Hospital. Data analysis was conducted in 2009.

RESULTS

About 63% of the sample planned to receive cancer screening. In multivariate analyses, individuals who planned to receive cancer screening were women, responsible for four or more people, received physical examinations at least yearly and had received prior cancer screening. They also were more likely to hold the belief that most people would go through cancer treatment even though these treatments can be emotionally or physically uncomfortable. About 90% of those who did not plan to receive cancer screening would be more likely to intend to receive cancer screening if additional resources were available.

CONCLUSIONS

In an area of high cancer morbidity and mortality, over one-third of screening eligible individuals did not plan to receive cancer screening. Future research should evaluate the potential for improving cancer screening rates through interventions that seek to facilitate increased knowledge about cancer screening and access to cancer screening services in the community.

Barriers to cancer screening in Hmong Americans: the influence of health care accessibility, culture, and cancer literacy

Hmong Americans face high cancer mortality rates even in comparison to their Asian American counterparts, and report low utilization of cancer screenings. To date, no study has been conducted on the cultural barriers this population faces in undergoing cancer screenings. A systematic review of the literature was conducted to examine the existing knowledge regarding the barriers to cancer screening for Hmong Americans. Potential barriers were identified from this examination to include: health access factors (type of health insurance, ethnicity of provider, low English proficiency, and years spent in the U.S.); cultural factors (belief in the spiritual etiology of diseases, patriarchal values, modesty, and mistrust of the western medical system); and cancer literacy factors (cancer and prevention illiteracy). Based on this review, potential cultural and ethnic group-specific prevention strategies and cancer health policies are discussed to address these barriers and enhance screening behavior among the Hmong.

A critical review of theory in breast cancer screening promotion across cultures

This article reviews the contribution and potential of widely used health behavior theories in research designed to understand and redress the disproportionate burden of breast cancer borne by diverse race/ethnic, immigrant, and low-income groups associated with unequal use of mammography. We review the strengths and limitations of widely used theories and the extent to which theory contributes to the understanding of screening disparities and informs effective intervention. The dominant focus of most theories on individual cognition is critically assessed as the abstraction of behavior from its social context. Proposed alternatives emphasize multilevel ecological approaches and the use of anthropologic theory and methods for more culturally grounded understandings of screening behavior. Common and alternative treatments of fatalism exemplify this approach, and descriptive and intervention research exemplars further highlight the integration of screening behavior and sociocultural context.

Views on smoking cessation methods in ethnic minority communities: a qualitative investigation

OBJECTIVE

The purpose of this qualitative analysis is to increase our understanding of minority smokers' experiences and beliefs about guideline-recommended smoking cessation treatments.

METHODS

We conducted sixteen focus groups (N=95) among current and former smokers from four ethnic minority communities in Minneapolis/St. Paul in 2005. Focus groups were conducted separately for American Indians, Vietnamese, Hmong and African Americans.

RESULTS

Participants reported little experience with counseling and views on seeking help from physicians were mixed. African American and American Indian participants expressed feelings of mistrust and negative experiences with doctors. Hmong and Vietnamese smokers viewed doctors positively but did not regard them as an important resource to help with quitting, and especially for Vietnamese, the cultural value of mental control and self-determination was seen as most important to quit smoking. Across all the groups, pharmacotherapy was rarely utilized and participants had low knowledge and poor understanding of the benefits of pharmacotherapy.

CONCLUSIONS

Personal beliefs, views toward doctors, and lack of knowledge are important determinants of the use of tobacco treatments among ethnic minority smokers. In order to increase minority smokers' utilization of evidence-based tobacco cessation treatments, effective strategies are needed to deliver accurate information about treatment from trusted sources.

Development of a culturally specific instrument for mammography screening: an example with American Indian women in Vermont

This article presents the triangulation process for translating qualitative data about mammography screening from a grounded theory study with American Indian women in Vermont, into questionnaire items based on an existing model of behavior change, the Transtheoretical Model (TTM) Stages-of-Change. Qualitative data were used to derive a theory, Moving in Between Mammography, which suggested that traditionality influenced American Indian women's screening decisions. To examine the relationship between mammography and traditionality, new items were developed for each of three key TTM constructs: Pros, Cons, and Processes-of-Change. The process for developing the new TTM-based items, as well as traditionality items specific for American Indian women living off-reservation, are presented. This article provides one example of how an instrument can be developed within a culturally competent nursing framework.