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Breast Cancer: Relationship Between Acculturation and Barriers to Breast Cancer Screening in Southwest Florida La tinas by Patricia Patino A thesis to be submitted in partial fulfillment of the requirements for the degree of Master of Science College of Nursing University of South Florida Major Professor: Susan C. McMillan, Ph.D., A.R.N.P Cecile A. Lengacher, R.N., Ph.D. S. Joan Gregory, Ph.D., A.R.N.P. Date of Approval: December 11, 2006 Keywords: breast cancer, cancer screening, accultu ration Hispanic, Latina, health belief model Copyright 2007, Patricia Patino
Acknowledgements First, I would like to thank my committee for their support. I did not begin this journey alone. My husband and my children have been with me every step of the way, and it has been their mor al support and kind words of encouragement that have given me the strength to co ntinue. Thank you, Jose, Jose Antonio, Sonia, and Michelle. I would also like to extend particular thanks to a very special person who gave me her unconditional support and help at the time that I needed it the most. Thank you, Harriet Blymiller. Without your guidance and expert ise, the preparation of this manuscript would have been very difficult.
i Table of Contents List of Tables iii Abstract iv Chapter I Introduction 1 Statement of the Problem 2 Research Questions 3 Definition of Terms 4 Significance to Nursing 4 Chapter II Review of Literature 6 Conceptual Framework 6 Empirical Literature 7 Health Beliefs 9 Acculturation 17 Summary 20 Chapter III Methods 22 Sample and Setting 22 Instrumentation 22 Health Belief Model Scale 22 Validity and Reliability 23 Acculturation Rating Scale for Mexican Americans 24 Demographic Data Form 25 Procedures 25 Data Analysis 25 Chapter IV Results, Discussion, and Conclusions 2 7 Results 27 Descriptive Data 27 Barriers and Health Insurance 31 Barriers and Acculturation 32 Discussion 33 Descriptive Data 33 Barriers and Acculturation 34 Barriers and Health Insurance 34 Limitations to the Study 35 Conclusion 37 Implications for Research 38 References 39
ii Appendices 42 Appendix A: English HBM & Spanish Translation 43 Appendix B: Consent to Use Health Belief Model 47 Appendix C: English ARSMA-II-Scale 1 & Spanish Tra nslation 48 Appendix D: Consent to Use ARSMA II 54 Appendix E: Study Purpose & Demographics Forms 55 Appendix F: Permission to Interview 57
iii List of Tables Table 1 Participant Age-Range & Years Lived in U. S., with Means & Standard Deviations 27 Table 2 Frequency & Percentage of Participants by Language Spoken 28 Table 3 Frequency & Percentage of Participants Ha ving Annual Mammogram 28 Table 4 Frequency & Percentage of Participants Pe rforming Monthly SBE 29 Table 5 Frequency & Percentage of Participants Wi th & Without Health Insurance 29 Table 6 Frequency & Percentage of Participants by Country of Birth (N = 50) 30 Table 7 Means & Standard Deviations of Barriers I tem Scores of Latina Women (N = 50) 31 Table 8 Independent t-Test Comparing Women With & Without Health Insurance in Their Perceived Barriers Scores 31 Table 9 Descriptive Statistics of Participants: ARSMA II, Using Two Subscales, LOS & AOS, to Assess Acculturation of Participants (N = 50) 32 Table 10 Correlation Using Subscale Scores, LOS & AOS, with the Barriers Scores to Assess Acculturation of Participants 33
iv Breast Cancer: Relationship Between Acculturation and Barriers to Breast Cancer Screening in Southwest Florida Lat inas Patricia Patino ABSTRACT Despite multiple campaigns by the American Cancer S ociety, reports indicate that Latinas living in the United States who contract br east cancer are more likely than Anglos to die. These findings correlate with low particip ation in breast cancer screenings among Latinas. The objective of this study was to identif y key obstacles that influence Latinas low participation in breast cancer screenings, base d on their health beliefs, knowledge of screenings, acculturation, and socio-economic facto rs. The study was a face-to-face informal interview, co mbined with a survey questionnaire conducted at churches, social clubs a nd/or at the participants homes in a southwest Florida urban community. The sample cons isted of a total of 50 women: all of the participants were Latinas 40 years of age and o ver; they had to be fluent in Spanish or English or both. A Spanish-English bilingual indiv idual conducted a personal interview in the preferred language of each participant. The first part of the interview was to identify barriers that affect screenings. The secon d part used a survey to weigh the identified factors in order to determine their impo rtance to the participants health
v decisions. This study used a health belief model s cale to evaluate womens beliefs about breast cancer, and the benefits of screenings. The research results revealed that Latinas who part icipated in this study were acculturated to the United States culture; the larg est group of participants reported being from Colombia, followed by Cuba and Puerto Rico; on ly two of the participants were Mexican. Seventy-eight percent of the participants selfreported having yearly mammograms, and 74% performed monthly breast self e xamination BSE; 60% were bilingual; 68% had some kind of health insurance. T hese results differ from earlier studies from the western United States where the ma jority of Latinas were of Mexican or Central American origin. This suggested that Latina s from Southwest Florida are different from Latinas in other areas of the United States. A weak but significant correlation was found between acculturation and per ceived barriers to breast cancer screenings, (r 0.45, p .01); Latinas who are more acculturated perceived more barriers than those who are less acculturated. The re was not significant difference between participants who had health insurance and t hose who did not (t 0.96, p .35). The results of this study are significant for nurse s and especially for advanced practice nurses, who can assess patients knowledge about cancer in general, and breast cancer in particular when caring for Latinas; of pa rticular concern should be the evaluation of patients levels of acculturation, he alth beliefs, and understanding of the English language. Still the fundamental barrier to Latinas not bilingual in Spanish and English may be the lack of resources and informatio n in Spanish.
1 Chapter I Introduction Despite relatively low rates of breast cancer incid ence among Latina women in the United States, incidence of mortality rates fro m breast cancer are higher than those for Anglo-American women (American Cancer Society [ ACS], 2006-2008). Breast cancer is the most commonly diagnosed cancer among Latinas; an estimated 14,300 Hispanic women are expected to be diagnosed annuall y (ACS, 2005-2008). Although breast cancer is diagnosed approximately 40% less o ften among Latinas, it is frequently diagnosed at a later stage than in non-Hispanic wom en (ACS, 2002). Historically lower utilization of cancer screenings, such as mammograp hy, may contribute to later diagnosis when the disease is more advanced (OBrien et al., 2003). These differences seem contradictory, but they i ndicate a wide gap in U.S. healthcare. Higher mortality rates were persistent ly reported in relationship to Latinas low participation in breast cancer screenings when compared to that of Anglo-American women. Healthcare providers have been astounded by these reports because in spite of educational and screening programs, Latinas rates of participation remain low. The ACS (Lobell, et al., 1998) recognizes lack of participa tion in breast cancer screenings as related to diagnosis at more advanced states of the disease for Latina women and relatively high mortality from the disease (ACS, 20 06-2008). While Latinas seem to have a relatively lower susce ptibility to breast cancer, the disease does not actually discriminate among races, and all women are at risk of developing breast cancer (ACS, 2006) In fact, the American Cancer Society (2006) reported that breast cancer is the most common canc er among women in the United
2 States. Estimates by the Cancer Statistics Presenta tion, 2004, predicted that 192,200 U.S. women of all races would be diagnosed with breast c ancer in 2005; 40,200 women were expected to die. This healthcare issue is compounded by population g rowth rates. According to the United States Census (2005), the Latin populati on is growing at a rate more than three times the growth of the total U.S. population. Dur ing one year, July 2003 through July 2004, the U.S. Latin population grew by 36%, or 2.9 million people (U.S. Census Bureau, 2005). Statement of the Problem The problem, then, is clearly identifiable. The he althcare gap for screening, early diagnosis, and treatment of breast cancer in Latina women may be related to acculturation and other barriers that can be assessed through res earch. The key barriers discourage or prevent this segment of the U.S. population from pa rticipation in breast cancer care screenings that can save their lives. With the acce lerated growth in the Latin population in the United States, the need to isolate and addre ss the barriers to Latinas participation gains greater significance to the nursing professio n (Wochna et al., 2005). While research literature recognizes differences be tween cultures as obstacles to participation, the educational and screening progra ms developed to date have not decreased the differences in participation between Latina and Anglo-American women. Researchers in the nursing profession are thus chal lenged to identify and overcome key obstacles to participation through research. Such research is feasible because it involves isolating particular health perceptions. For instan ce, susceptibility may involve Latinas
3 perceptions that a woman cannot have breast cancer if she is not sick or that the disease may be a divine punishment. In other words, a woma n will not participate in breast cancer screening if she believes that cancer afflic ts only the ill and the bad. (Salazar, 1996). The research would also include variables of relati ve levels of acculturation, socioeconomics, and socio-linguistics. Good access to healthcare depends on accurate information, and many Latina women are not familiar with the risk factors because the information is not oriented to them culturally and because inadequate translation changes the meaning of some ideas. Limited proficiency in t he language used by healthcare providers also has been identified as a barrier to cancer screening. Non-Spanish speaking healthcare providers may be inconsistent in finding ways to provide information, perhaps believing it will not be understood anyway. Lower levels of acculturation may contribute to lack of knowledge and affect screening practices (OMalley, et al. 1999). The purpose of the study was to identify if there is a relation ship between acculturation and perceived barriers to participation in breast cancer screenin g for Latinas over 40 years of age. Research Questions The following research questions are addressed in t his study: 1. Is there a significant relationship between ac culturation and perceived barriers to participation in breast cancer screening among U.S. Latinas? 2. Is there a significant relationship between av ailability of insurance and perceived barriers?
4 Definition of Terms The following terms are defined for the purpose of this study: 1. Perceived barriers : perceived emotional, physical, or structural con cerns related to mammography behavior (Champion, 1999) 2. Perceived susceptibility : perceived beliefs of personal threat or harm rel ated to breast cancer (Champion, 1999) 3. A cculturation: the psychosocial adaptation of persons from thei r culture or origin to a new or host cultural environment (Mark s et al., 1987, p. 2) 4. Hispanic/Latino: a federal designation used in national and state reporting systems. For purposes of this study, the term Latina is defined as a woman who identifies herself as of Central American, Cuban, M exican, Puerto Rican, South American, or Spanish origin. In the U.S. Census 200 0, the question on Hispanic origin asks respondents if they are Spanish, Hispan ic, or Latino; as a consequence Hispanic may be of any race. Significance to Nursing The irony of the modern healthcare system is how po orly it delivers knowledge at a time when society enjoys unprecedented access to information. Language barriers may exist between healthcare providers and patients, bu t perhaps a greater barrier is the lack of knowledge regarding Hispanic/Latina health belie fs (Oliver-Vasquez et al., 1999). The American Cancer Society (2005) recognizes that Latinas have the lowest participation in breast cancer screenings and a hig her mortality from breast cancer than U.S. women as a whole; therefore, it is imperative that advanced practice nurses expand
5 and implement programs to focus on the fastest grow ing U.S. minority. The goal is to close the gap, create awareness, and increase Latin as participation in breast cancer screenings since early detection of breast cancer l eads to a better prognosis. This study may enlighten healthcare providers and help us brea k down the barriers.
6 Chapter II Review of Literature This chapter presents the background significant to the problem being studied. First, the conceptual framework is presented, follo wed by a review of research relevant to the barriers that may influence Latinas participat ion in screenings, especially in breast cancer screenings. Finally, literature related to L atinas perceived barriers to breast cancer screenings is reviewed. This is followed by a summary. Conceptual Framework The Health Belief Model (HBM) (Champion, 1993) was used for this study as one conceptual model. The HBM is often applied to breas t screenings (Champion, 1993; Foxall, Barron, & Hauck, 1997). This HBM theorized that health behaviors are based on the following concepts: barriers, confidence, heal th motivation, seriousness, susceptibility, and health motivation. The hypothes is underlying Champions HBM states that womens health beliefs about cancer influence participation in breast cancer screenings. Latinas acculturation, not language a lone, is perceived as a barrier to obtaining mammograms; the longer a women lives in t he United States, the more likely she is to participate in screenings, because she be comes more acculturated (OMalley, et al., 1999). Women who have access to free screening s are also more likely to participate in screenings (Mendalblatt et al., 2005). Finally, women who have clear understanding and knowledge of breast cancer will be more confide nt in participation in breast cancer screenings (Hansen et al., 2005).
7 In addition, the Acculturation Rating Scale for Mex ican Americans (ARSMA) establishes a framework for understanding health be haviors, and it has been used to assess acculturation as a perceived barrier related to healthcare (Cuellar & Maldonado, 1995). The hypothesis underlying ARSMA is that more acculturated women have more time to assimilate health practices and may have gr eater likelihood and opportunity of participating in breast self-examinations and breas t cancer screenings. The ARSMA theorized that health behaviors are based on the fo llowing concepts: length of time in the United States, language, ethnic identity, and ethni c interactions. Barriers are defined as perceived emotions, physica l, or structural concerns related to mammography behaviors (Champion, 1999). In an interesting article by Wochna and Buschy (2005) addressed barriers that in terfere with cancer screening in women. Barriers are classified as systematic and human System barriers are issues that include communication difficulty, low income, and l ack of transportation, insurance, and/or a primary care physician. Human barriers include lack of knowledge, low educational levels, fear of the actual screening te sts, and cultural and socioeconomic barriers. Both system and human barriers can influe nce healthcare behaviors of women relative to cancer screening, and both kinds of bar riers must be addressed in efforts to eliminate health disparities. Empirical Literature In a randomized controlled trial, Mendalblatt et al (2005) examined three factors: Latinas perceived risk of contracting breast cance r, knowledge about clinical screenings, and relative levels of acculturation. These were m ajor barriers to the intent of
8 participation in the Study of Tamoxifen and Raloxif en (STAR trial). The sample consisted of women at high risk of breast cancer (M endalblatt et al. 2005). The sample was divided into two groups: the first group was g iven a simple education counseling session consisting of a 5-to-10 minute presentation delivered by non-physician study staff. The study staff used an informational broch ure, from the National Surgical Adjuvant Breast and Bowel Project (NSABP) about the STAR Trial, which was available in both Spanish and English. The control group was given only the brochure without any presentation by staff. The outcome variable was in tent to enroll in screening; the intent was evaluated using responses that women might, pro bably, or definitely would participate if eligible versus would not participat e, unsure, or refused to participate. The ten predictor variables included perceived breast c ancer risk calculated from the Gail model, as follows: clinical screening knowledge; g eneral knowledge about breast cancer; education (high school or less, or beyond high scho ol); acculturation (country of origin and language); insurance (any or none); age; marita l status; language of the interview (Spanish or English); prior mammography (never, eve r, or recent > 2 years); and general health (excellent, very good, or good, versus fair, poor, or very poor). Perceived risk was defined by responses on a Likert-type scale. Knowle dge of the nature of clinical screening was assessed by the correct answer to mul tiple-choice questions. Language acculturation was based on responses to three items : language used at home, in speaking, and in thinking. (Mendalblatt et al., 2005). The study conducted by Mendalblatt et al. (2005) co ncluded that Latina women are interested in participation in clinical screeni ngs to prevent breast cancer although interest declined as side-effect discussion increas ed. These findings have important
9 implications as Latina women overestimated their ri sk of developing breast cancer. Education about breast cancer and their perceived r isk in screenings may increase participation. The barriers of language and accessi bility to healthcare, more than acculturation, need to be addressed by healthcare p roviders. Health Beliefs Smiley, McMillan, Johnson and Ojeda (2000) address ed the importance of educational programs to increase cervical and breas t cancer screenings among Hispanic women. This study evaluated whether health beliefs and Health Locus of Control (HLOC) of Florida Hispanics, as compared to non-His panic Caucasian women, influence participation in breast cancer screening. A conven ience sample was chosen from multiple settings to ensure inclusion of women of a ll ages from both ethnic groups. The participants who were contacted by telephone were a ddressed in their preferred language. If the women agreed to participate in the study, th e questionnaires were sent in their preferred language, or handed out at the local site A demographic instrument was used to describe the sample. The Health Screening Questionn aire (HSQ) was used to collect selfreported data about health beliefs related to breas t cancer, and health locus of control was measured with Wallstons HLOC instrument, a 16-item scale. Each sampling instrument was translated into Spani sh. The Deyo Scale, a fouritem tool, measured whether individuals were most c omfortable with the Spanish or English language, and Cronbachs alpha was applied to both the English version and the revised Spanish version. The sample was divided int o two groups. The first group was
10 composed of 57 Spanish-speaking women with a mean a ge of 54.6 years, (SD = 14.9). The second group was composed of 56 English-speakin g women with a mean age of 47.4 years, (SD = 12.9) (Smiley et al., 2000). This study by Smiley and colleagues (2000) showed that low levels of education, lack of knowledge, and acculturation were related t o low participation in cancer screenings by Hispanic women. The results showed th at Hispanic women were significantly more likely (p = 0.007) than non-Hisp anic women to believe that health is a matter of luck. Hispanic women were more likely to worry (p = 0.001) about their health. Non-Hispanic women also reported feeling m ore susceptible to both cervical (p = 0.044) and breast cancer (p = 0.000). Taken all to gether, these results suggest that the Hispanic women in the sample felt less in control o f their health than did Caucasian women (Smiley et al., 2000). Several studies recognize lack of health promotion and education as barriers to participation for minorities, in particular for Lat inas. Hansen ,Feigl, Modiano, Lopez, Escobedo, Moinpour, Pauler and Meyskens (2005) con ducted a community-based pilot study with three objectives, to: 1) assess the fea sibility of recruiting and training Hispanic female cancer survivors to perform as heal thcare educators in a promotora role, that is, a bilingual female Hispanic lay health edu cator; 2) determine whether the promotoras, after training, are willing to contact female friends and relatives to share information about cervical and breast cancer screen ings; 3) determine whether women obtain a Papsmear or mammogram after receiving canc er-screening information from a promotora.
11 This study by Hansen and colleagues (2005) was cond ucted at a San Antonio Minority-Based Community Clinical Oncology Program (CCOP), and the sample was selected from a private oncology practice. Women of Hispanic origin older than 18 years with prior history of cancer were eligible. Spanish and/or English-speaking women who were willing to complete the training course and se rve as promotoras were encouraged to enroll in the study. Twenty-two patients were invited to attend an orien tation night designed to introduce the study purpose and role of the promoto ra (Hansen et al. 2005). Of those invited, six consented to participate, and five wer e trained as promotoras during a 12week course. The workshop focused on curriculum con tent, transportation, personal safety issues, and theoretical and practical consid erations in giving health information to Hispanic women. Two Hispanic female health educator s were hired to conduct the Promotora Training Course (Hansen et al., 2005). In the study, five promotoras contacted 141 women (number ranged from 24 to 49 per promotora), to share cancer-screening information. After contact with a promotora, 50 Hispanic women obtained screenings: 21 underwent mammography (ages 25 58), and 43 received a Papsmear (ages 23 62) Documentation of screening examinations was either though postcards returned b y the patient or through review of the community health clinic records (Hansen et al., 200 5). This study failed to differentiate between women w ho obtained breast and cervical screenings after the contact with promotor as and women who intended to participate prior to contact. This study was also l imited by its small sample size, lack of comparison or control group, and the inability to t rack screening tests at low-cost or other
12 health clinics. Research has indicated that social support, a central component of the promotoras interventions, is an important predicto r of breast screenings. Several studies focus their research on knowledge o f screenings and knowledge of breast cancer risk in multicultural and multi-ethni c populations. n their study of possible barriers to Mexican-American womens participation in cancer screenings, Lobell, Bay, Rhodas, and Keske (1998) addressed knowledge of can cer, access to healthcare (economic availability), and anxiety about cancer. The sample consisted of 188 MexicanAmerican women who participated in a face-to-face s tructured interview in their preferred language. A multiple-choice survey was ad ministered by a promotora, a bilingual female Hispanic lay health educator. The median age of respondents was 28 years (mean = 36); the mean age at first childbirth was 20.3 years; and the mean number of children was 3.6. Of the sample, 69.4% had been or were currently married. The median annual income was between $10,000 and $15,00 0; and 36.7% were currently employed. The median level of education was reporte d as some high school, and 43.6% reported being able to read English. Of the sample, 98.4% spoke Spanish and 50% of the respondents spoke only Spanish. Therefore, 68% of the interviews were conducted in Spanish, the language preferred by the respondent ( Lobell et al., 1998). In the Lobell et al. (1998) study, 75% of the resp ondents had had a pelvic examination, but only 53% reported having a Pap sme ar. Of the subjects, 84% had performed breast self-examination, but only 39% rep orted doing so monthly or more frequently (p < 0.001). This study implies that acc ess to healthcare precedes positive screening behavior. Anxiety may lead to decreased s creening, but education about cancer and screenings decreases anxiety. Knowledge of risk factors among women of different
13 socioeconomic and ethnic backgrounds can be an obst acle for participation in breast cancer screenings. In a descriptive cross-sectional study in the San Francisco Bay Area, Katapodi and Aouizerat (2004) focused on identifyin g knowledge of breast cancer risk in a mixed community. The sample was composed of 184 w omen who had never been diagnosed with cancer, ages 30 to 85 years (mean = 47 12) who agreed to complete a questionnaire in English. Of the women in this stu dy, 43% were of European descent, 27% of African descent, 16% of Asian descent, and 1 4% of Hispanic descent. As many as 49% were college graduates; and 24% had a median annual family income of $30,000 to $50,000. Age, race or culture, education, incom e, employment status, health insurance status, and marital status were assessed with singl e-item questions from the Behavioral Risk Factors Surveillance System (Center for Diseas e Control and Prevention, 2002). For this study, the participants were divided into four family-histories-of-cancer groups; 1) no family history; 2) one or more family members affec ted, second-degree relative(s); 3) one affected, first-degree relative; and 4) multiple af fected family members. For the breast cancer risk factors, the researchers used the Gail model that includes age of menarche, age of first full-term pregnancy, and number of bre ast biopsies (Katapodi & Aouizerat, 2004). With five items from the Gail model, the research ers defined womens knowledge of breast cancer risk factor as the total number of situations recognized that increased the probability of developing breast canc er. Items answered affirmatively were summed to calculate each womens score for knowledg e of breast cancer risk factors and to create the Breast Cancer Risk Factor Knowledge I ndex (BCRFKI) with scores ranging from 0 to 13 (Katapodi & Aouizerat 2004).
14 The results showed no significant differences amo ng women of different races or cultures. Women of European descent were more likel y to have more education than women of African and Hispanic descent. Women of Asi an descent were more likely to be more educated than African women but not more than Hispanic women (p = 0.001). Education was significantly correlated with income only for women of African descent (r = 0.50, p = 0.001). The implications for nursing ar e that the women depend on their primary healthcare providers for risk assessment. During counseling and education, advanced practice nurses can incorporate the calcul ations of a womans risk for breast cancer by using an appropriate risk assessment mode In this study, researchers excluded Hispanic women from the community who spoke only Sp anish (Katapodi & Aouizerat 2004). Yabroff and Mandalblatt (1999) performed a meta-an alysis of well-designed patient target interventions designed to increase a dherence with mammography. The researchers used OVID with MEDLINE (1980-1989) to i dentify published English language articles on interventions to increase mamm ography utilization. Of the articles, 48 patient target studies met the criteria: four o f these studies were subsequently eliminated because they lacked concurrent control g roups. Three other studies were eliminated because the interventions were not descr ibed in sufficient detail for classification. Finally, a total of 41 studies were included. Data were classified cognitively, behaviorally, or sociologically. Among the 41 studies in the final sample, there were 63 distinct interventions to increase ma mmography utilization: a) 27 behavioral interventions; b) 21 cognitive intervent ions; c) 9 sociological interventions; and d) 5 interventions using both cognitive and beh avioral strategies. Researchers found
15 that most interventions do increase rates of screen ing. Behavioral interventions increase screenings by 12.2% compared with usual care; by 13 .0% when using multiple strategies; and by 5.6% when using a single intervention (Yabro ff & Mandelblatt, 1999). As a result overall, behavioral interventions, the ory-based cognitive interventions, and sociological patient targeted interventions app ear to be effective in increasing mammography utilization, particularly when compared with usual care. Multiple behavioral interventions and interactive theory-bas ed cognitive interventions are effective when compared with action control. In addition, the effectiveness of different types of interventions in patient subpopulations, such as mi nority or low-income women, and the cost of providing these interventions are critical areas for research in decreasing the morbidity and mortality associated with breast canc er (Yabroff & Mandelblatt, 1999). The study by Yabroff and Mandelblatt (1999) failed to recognize whether cultural sensitivity was included in any of the patient targ et studies; thus further research is needed in this area. Vasquez, Ayendez, Perez, Almodovar, and Calderon ( 2002) conducted a pilot study of health promotion programs. The sample for this study was selected from a senior center that offers services to a low-income, elderly Puerto Rican population. Ninety-four women were invited to participate; 32 m et the following criteria: 1) not having performed at least one of the breast cancer early detection practices; 2) completion of the pretest and post test; 3) attenda nce at two or more educational sessions; and 4) possession of the necessary mental and audit ory capacity as evidenced in an initial interview (Vazquez, et al., 1998). In this study, the average age of participants was 78.1 years ( 7.4), and their average schooling was 4.9 years. As regards access to healthcare,
16 75% received Medicare, Part B, and 81.3% received M edicaid, which covers mammography. For the educational sessions, the sample was divid ed into two groups: Group A consisted of 20 women; Group B consisted of 12. The education program was designed to be held in three sessions of 45 to 60 minutes ea ch. Approximately 70% of the women attended each educational session in each group, an d 50% participated in all three educational sessions. The four-year project provide d insight into personal knowledge, skills, attitudes, demographics, and external barri ers (healthcare system). The programs activities were coordinated with the government sen ior centers, the local center for diagnosis and treatment (CDT) and the regional hosp ital. A summary of the project was presented to primary care health professionals at s elected sites and published in newspapers for the communitys information (Sanchez -Ayendez et al., 1998). The program evaluation was based on a systematic a pproach that assessed all the elements affecting the achievements of the proposed goal. Data was collected four times: before, during, and after the health education sect ions, and 16 to18 weeks after the end of the health education sessions. Short-term achieveme nt was determined by changes in knowledge, beliefs, and breast self-examination (BS E) skills. Pre-tests and post tests on knowledge and health beliefs about breast cancer an d an observation check list were administered (Suarez Perez et al., 1998). The evaluation of educational sessions indicated t hat this intervention did not have the anticipated effect on clinical breast canc er examination or mammogram compliance. In fact, this study shows that breast c ancer screening programs should include not only relevant information about breast cancer risks and early detection
17 benefits but also information about barriers to pre ventive care that result from a variety of factors: beliefs, attitudes, and other personal ch aracteristics; the healthcare infrastructure and failure of physicians to perform preventive str ategies (Vazquez et al., 1998). Acculturation Acculturation has been defined as the psychosocial adaptation of persons from their culture of origin to a new or host cultural e nvironment (Marks et al., 1987). Several studies have recognized language, ethnicity, and/or acculturation as barriers influencing Latinas participation in breast screenings. When L atinas migrate to the United States from their native countries, they become acculturat ed to the U.S. mainstream lifestyle to varying degrees. Some retain their traditional beli efs and health practices, but others become more acculturated and in many cases more edu cated. Thus, healthcare providers must be careful not to stereotype patients (OMalle y et al., 1999). Most studies concluded that breast cancer screening and self-examination a re very important to the early diagnosis and treatment of breast cancer. The stud ies also recognized some cultural and racial barriers to screening participation for mino rities. Other studies also recognized socioeconomic factors, health beliefs, and accultur ation as obstacles. The following studies focus on acculturation. In a descriptive study of cancer incidence, Eschba ch, Mahnken, and Goodwin (2005) investigated whether cancer incidence among Hispanics increased with residential and economic assimilation into mainstream culture. Data from the Surveillance Epidemiologist and End Results (SEER) instrument we re collected to investigate the Hispanic cancer advantage by examining the spatial distribution of lung, colorectal,
18 prostate, female breast, and cervical cancer. Anoth er source, U.S. Census Bureau data collection, was used to estimate the population fro m which the cancer cases were derived. The study compared neighborhoods that are densely p opulated by low-income Hispanics to neighborhoods that are less populated with highe r-income Hispanics. Results showed that the incidence of breast, color ectal, and lung cancer increased as the percentage of Hispanics in the census increa sed, and as income increased. For example, in contrast to the Hispanics in the highes t income levels, the high-density Hispanic neighborhoods in the lowest income levels showed 38% fewer incidences of breast cancer and 38% fewer incidences of male colo rectal cancer (Eschbach, Mahnken, & Goodwin, 2005). To sum up, the substantial increa ses in cancer incidence among Hispanics living in ethnically heterogeneous neighb orhoods and higher-income neighborhoods suggest that the Hispanic population will lose its advantage in cancer mortality as it becomes more acculturated. (Eschbac k, Mahnken, & Goodwin, 2005). A New York City study by O'Malley, Kerner, Ayah, a nd Mendalblatt (1999) investigated whether acculturation was associated w ith breast screenings and mammograms. This studys sample represents women fr om the four largest Hispanic subpopulations of New York City as of 1992: Puerto Rican 49.5%; Dominican 19.1%; Colombian 5%; and Ecuadorian 4.5% (OMalley et al., 1997). The sample was selected from the telephone exchanges for all five boroughs of New York City. A random digitdialed technique was used to ensure coverage of hou seholds with unlisted numbers of the four ethnic groups. For this study, the groups were divided by ages: 1 8 to 44 years; 45 to 54 years; 55 to 64 years; and 65 to 74 years. Community leaders reflecting the cultural backgrounds of
19 the population were involved in the study design an d survey promotion. The instrument was developed with existing national survey items a nd then modified for use in the target populations. The participants could choose to be in terviewed in Spanish or English (Solis, Marks, & Garcia, 1990). The acculturation measure was a continuous variabl e based on a 12-item scale, which was drawn from a 26-item acculturation measur e (Cronbach alpha = .93). The 12 items asked about language and media use (televisio n, radio, books, magazines, newspapers) in Spanish and English, in a variety of situations (work, home, neighborhood, shopping), and with different people (spouses or partners, children, parents, friends). For the 12 items, there were 5 response options, as follows: 1 = only Spanish; 2 = mostly Spanish; 3 = Spanish and Englis h; 4 = mostly English; and 5 = only English. An acculturation measure with a 26-item sc ale was developed by Burnan et al. (1987) and later validated, in a shortened form, in a New York City Hispanic population by Epstein et al. (1999). The acculturation level was calculated as a mean s core of these 12 items (1 = least acculturated; 5 = most acculturated) (OMalley, et al., 1999). This New York City study concluded that 7 factors were significant: 1) relat ive acculturation; 2) having a usual source of healthcare; 3) having a relatively higher income; 4) having health insurance; 5) immigrating to the United States before the age of 16; 6) spending a greater proportion of ones life in the United States; and 7) use of Engl ish for the interview. Each of these factors was statistically significant in associatio n with greater participation in breast screenings and mammography (OMalley et al., 1999). This study concluded that recentness of immigration was associated with scree ning and was strongly co-linear with
20 acculturation, thus suggesting that targeting progr ams to areas with a high proportion of recent immigrants may be a useful way to reach less acculturated Hispanic women (OMalley et al. 1999). Summary Lower levels of acculturation may contribute to l ack of knowledge and affect screening practice. This situation, combined with limited proficiency in the language used by healthcare providers, has also been identif ied as a barrier to cancer screenings. Unless healthcare providers are able to communicate effectively, Latinas will not possess all the information they need to make intelligent h ealth promotion decisions (OMalley et al., 1999). Although cancers are the second leading cause of d eath in the developed world, Hispanics have lower incidence and mortality rates for the cancers that cause the most deaths, including breast cancer. Despite these fac ts, Latinas have a higher breast cancer rate and mortality than non-Hispanic Caucasians (AC S, 2004). Significant increases in breast cancer incidence among Latinas suggest that this population will lose the battle to cancer as long as acculturation and socioeconomic b arriers remain unrecognized and unaddressed. Thus, research should focus on isolat ing and breaking down specific barriers to Latinas participation in breast cancer screenings. Additional studies should continue to focus on all variables of the Health Be lief Model (OMalley et al., 1999). A number of studies have documented the fact that Hispanics tend to use health services less than other ethnic groups. This situat ion demonstrates the need to continue in efforts to understand the specific concerns of Lati nas, and a number of studies do
21 examine issues important to Latinas. However, the great diversity within the Hispanic community is frequently overlooked and deserves fur ther study.
22 Chapter III Methods This chapter outlines, in four sections, the resear ch methods for this study. The first section describes the sample, its selection, size, inclusions, and exclusions. The second section describes the Health Belief Model (H BM) scale, ARMSA II, and their validity and reliability. The third section covers research procedures, including protection of human subjects. The fourth and final section con tains the description of data analysis. Sample and Setting Participants in the study were Hispanic/Latina wome n from a small multicultural community of Southwest Florida, recruited from chur ches and socio-cultural clubs. Fifty women, 40 years of age and older, were included in this study. Participants had to be able to read and understand English, Spanish, or bo th. Religion and socioeconomic background were not exclusionary criteria. Finally Latinas with a history of breast cancer were excluded from the study. Instrumentation Health Belief Model Scale Three instruments were used in this study: the Bar riers Subscale of the HBM scale, the ARMSA II scale, and a Demographic Data F orm. All the instruments were translated into Spanish to ensure conceptual equiva lence. To measure concepts for this study, the revised (1999) Champion Health Belief Mo del (HBM) scale was used
23 (Appendix A). Consent for use of this instrument wa s obtained (Appendix B), and the author gave permission to revise it as necessary. The HBM has had the greatest influence in research related to prediction associated with breast cancer screening behaviors; several studies have used the HBM model to understand breast cancer screening behavio rs. The HBM model subscales measure six concepts, including perceived susceptib ility, health motivation, barriers, benefits, confidence, and seriousness (Champion 199 9). All scales were measured on a five-point Likert type scale with the following cod ing: strongly disagree (1); disagree (2); neutral (3); agree (4); and strongly agree (5) Only the barriers subscale was used in this study. Validity and Reliability. HBM scales for measuring beliefs related to breas t cancer were assessed for content validity by a pane l of three nationally known judges familiar with the HBM and breast cancer screenings. Scales were revised based upon analysis for content validity and administered to a probability sample of 581 women participating in a large intervention study. The H ealth Belief Model subscale for barriers (HBM) measure perceived barriers to breast cancer s creening. The subscale has six items. Validity was examined using LISREL (Champion, 1998) This analysis confirmed structure of the subscales. Reliability was evaluat ed for the subscale using Cronbachs alpha. Subscale alphas ranged from .75 to .88. A few items from the HBM instrument (e.g., barrier items) were modified to improve clar ity and cultural sensitivity (Champion, 1998).
24 Acculturation Rating Scale for Mexican Americans The Acculturation Rating Scale for Mexican America ns (ARSMA) developed by Cuellar et al. (1995) has 20 questions scored on a five-point Likert type scale ranging from 1 Mexican/Spanish to 5 Anglo/English (Appendix C). Dimensions include: language familiarity and usage, and ethnic interact ion differentiated into five types with the following scale: 1) very Mexicano; 2) Mexicanoriented bicultural; 3) true bicultural; 4) Anglo-oriented bicultural; 5) very Anglicized. Consent for use of this instrument was obtained (Appendix D). The ARSMA II scale measures acculturation along th ree primary factors: language, ethnic identity, and ethnic interactions. ARSMA II is a multidimensional scale that measures orientation toward Mexican culture an d Anglo culture independently using two subscales, a Mexican-orientation subscale (MOS) and an Anglo-orientation subscale (AOS). The MOS has 17 items and an alpha coefficien t of .88; the AOS has 13 items and an alpha coefficient of .83. The word Mexican was c hanged to Latinos to accommodate the mixed population in this sample. Acculturation scores can be used as continuous meas ures or to categorize subjects into different levels of acculturation. ARSMA II (A ppendix C) was slightly modified for this study by the researcher. The word Mexican was changed to Latino to accommodate the mixed population in this sample. The scale incl udes these three items: 1) place of birth; 2) years living in the United States; and 3) use of language, that is, ability to read and understand English, and the language used at ho me and at work.
25 Demographic Data Form Data were collected to describe the sample using a Demographic Data Form. This Form included the following: age, educational level marital status, and health insurance coverage (Appendix E). Procedures Permission (Appendix F) was obtained from the churc h leaders and those in charge of the community centers where data was coll ected. Approval from the Institutional Review Board of the University of Sou th Florida for the protection of human subjects (Appendix G) was obtained. All participant s received written information about the studys purpose in their preferred language (Ap pendix E). Those expressing interest in volunteering for the study were informed that pa rticipation was voluntary and that no remuneration was to be given to participants by the researcher. To ensure the understanding of those volunteering to participate, questions were answered before participants completed filling out the forms. The r esearcher interviewed fifty Latinas from the Southwest Florida community in churches, c ultural clubs, or in their homes. Data Analysis Data was analyzed to answer the research questions. A Pearson correlation was used to answer Question 1, Is there a significant relationship between acculturation and perceived barriers to participation in breast cance r screening among U.S. Latinas? Data was analyzed using an independent test to answer Qu estion 2, Is there a significant
26 relationship between availability to insurance and perceived barriers? Demographic data were analyzed using descriptive statistics.
27 Chapter IV Results, Discussion, and Conclusions This chapter represents outcomes of the study. It begins with a presentation of the results, including the demographic data, and then c ontinues with results related to each research question. The results are followed by a di scussion of the studys strengths and weaknesses, and finally, implications for future re search. Results Descriptive Data The study group (n 50) consisted only of Latina women, ages 40 years and older, with a mean age of nearly 59 years. Years l iving in the United States self reported by participants ranged from 1 to 50. Approximately 24% of participants had lived in the United States 5 years or less; 42% had lived in the United States more than 15 years (Table 1). Table 1 Participant Age-Range & Years Lived in U.S, with Me ans & Standard Deviations Number Mean Standard Deviation Subjects 50 Subject Age 58.8 6.97 Years in U.S. 15.6 13.52
28 All of the participants were fluent in Spanish; 40% of them spoke only Spanish, and 60% were bilingual, speaking both Spanish and E nglish (Table 2). The participants level of education was not included in this study. Table 2 Frequency & Percentage of Participants by Language Spoken Language(s) Number Frequency Percent Subjects 50 Spanish 20 40.0 English/Spanish 30 60.0 Overall, 22% of the Latinas in this study did not h ave yearly mammograms; 78% reported having yearly mammograms (Table 3). Of the participants, 26% reported not doing a mont hly self-breast examination (SBE); 74% reported that they do perform monthly SB E (Table 4). Table 3 Frequency & Percentage of Participants Having Annua l Mammogram Mammogram N Frequency Percent Subjects 50 No 11 22.0 Yes 39 78.0
29 Table 4 Frequency & Percentage of Participants Performing M onthly SBE Self-Breast Exam N Frequency Perc ent Subjects 50 No 13 26.0 Yes 37 74.0 A total of 32% of participants reported having no h ealth insurance. However, the majority (68%) did have some kind of health insuran ce (Table 5). Table 5 Frequency & Percentage of Participants With & Witho ut Health Insurance Health Insurance N Frequency Perce nt Subjects 50 No 16 32.0 Yes 34 68.0 Regarding country of origin, approximately 26% of t he studys 50 participants reported being from Colombia, and 18% from Puerto R ico. A little less than 30%, distributed nearly equally, reported being from Cub a, Ecuador, or Venezuela. Smaller numbers reported being from Costa Rica, the Dominic an Republic, Guatemala, Honduras, Mexico, Peru, and Uruguay (Table 6).
30 Table 6 Frequency & Percentage of Participants by Country o f Birth (N = 50) Birthplace Frequency Percent Colombia 13 26.0 Puerto Rico 9 18.0 Cuba 5 10.0 Ecuador 4 8.0 Venezuela 4 8.0 Santo Domingo 3 6.0 Peru 3 6.0 Guatemala 3 6.0 Mexico 2 4.0 Uruguay 2 4.0 Costa Rica 1 2.0 Honduras 1 2.0 For the Latina subscale, the mean of the total bar riers score was 16.3, and the standard deviation was 4.0. For the Anglo subscale the mean score was 13.5 and the standard deviation 4.5. The highest two barrier scores were Lack of privac y for BSE, with a mean score of 3.64 (SD 1.61) and Mammogram will be painful, with a mean score of 3.34 (SD 1.11). The lowest barrier scores were Doing BSE, worry about cancer (i.e., that doing BSE would make the participants worry about c ancer being a fatal disease), with a mean score of 2.80 (SD 1.16) and BSE will be embarrassing, with a mean score of 2.76 (SD 1.27) (Table 7).
31 Table 7 Means & Standard Deviations of Barriers Item Scores of Latina Women (N 50) Item Barrier Mean Standard Deviation Lack of privacy for BSE 3.64 1.61 Mammogram will be painful 3.34 1.11 Feel funny doing BSE 3.20 1.60 Mammogram takes too much time 3.04 1.06 Mammogram, worry about cancer 2.98 1.22 BSE takes too much time 2.94 1.15 Mammogram costs too much 2.90 1.71 Doing BSE, worry about cancer 2.80 1.16 BSE will be unpleasant 2.80 1.30 Mammogram will be embarrassing 2.78 1.16 BSE will be embarrassing 2.76 1.27 Barriers and Health Insurance The majority of the participants had health insuran ce (n 27; mean barriers 114.7); some had no health insurance (n 15; barriers mean 104.9). The scores in the independent t-Test scale showed no significant diff erence (Table 8). Table 8 Independent t-Test Comparing Women With & Without H ealth Insurance in Their Perceived Barriers Scores Insurance N Mean t p Barriers No 15 104 .9 -.96 .35 Yes 27 114.7
32 Barriers and Acculturation This studys objective was, first, to determine whe ther there is a significant relationship between acculturation and perceived ba rriers to participation in breast cancer screening among Latinas. The resulting Pearson corr elation coefficient was weak but significant (r 0.45, p .01). Two subscales from the ARMSA II were used t o evaluate acculturation. For the Latina subscale, the mean w as 70.4 (possible range of 17-85) with a standard deviation of 10.7 and a median of 72.0. For the Anglo subscale, the mean was 44.9 (possible range of 13-65) with a standard devi ation of 9.6 and a median of 47.9 (Tables 9 and 10). Table 9 Descriptive Statistics of Participants: ARSMA II, U sing Two Subscales, LOS & AOS, to Assess Acculturation of Participants (N 50) Latina Subscale Anglo Subscale Mean 70.42 44.94 Median 72.00 47.00 Std. Deviation 10.72 9.64
33 Table 10 Correlation Using Subscale Scores, LOS & AOS, with the Barriers Scores to Assess Acculturation of Participants N r p Latina 50 .24 NS Anglo 50 .38 .006 Discussion Descriptive Data This study found Latinas in Southwest Florida to b e different from other Latinas in the United States. The participants in this stud y were acculturated; they participate in breast cancer screenings. The majority have health insurance. Regarding country of origin, approximately 26% of the studys 50 partici pants reported being from Colombia; 18% from Puerto Rico. And a little less than 30%, d istributed nearly equally, reported being from Cuba, Ecuador, or Venezuela. Smaller num bers reported being from Costa Rica, the Dominican Republic, Guatemala, Honduras, Mexico, Peru, and Uruguay. This study is different from earlier studies done in the western United States where most of the Latina participants were of Mexican or of Central A merican origin. Other studies have also recognized differences between acculturation a nd region of origin of the participants: for instance, Lowell et al. (1988) found that in 18 8 Mexican American women, chi squared sub (111) 292.3; P<0.001.
34 Barriers and Acculturation This study analyzed the relationship between accult uration and perceived barriers to low participation in breast cancer screenings, t hat is, yearly mammograms and selfbreast examination (SBE), by Latinas in a small Sou thwest Florida geographical area. Two subscales from the ARMSA scale were used to ass ess acculturation among participants. For the Latina subscale, the median was well above the midpoint 51 (possible range of 17-85). For the Anglo subscale, the median was above the midpoint 44.9 (possible range of 13-65). The correlation bet ween the barriers scores was weak but significant; this result suggests that Latina women who were more acculturated to the U.S. culture perceived more barriers to breast canc er screening than the less acculturated women did. It is possible that Latinas who are more acculturated may have more exposure to outside influences such as health care providers, schools, and the media, while the less acculturated may not have the same e xposure. It is also possible that the ARMSA scales may not be suitable for this group. Barriers and Health Insurance Another interesting finding in this study was tha t there was no difference in perceived barriers between Latinas who had health i nsurance and those who had none. However, when asked if having a mammogram would cos t too much money, most of the participants responded agree. It is possible that the Latinas who agreed that a mammogram would cost too much are the same minority of Latinas (32%) who did not have health insurance. In any case, this studys f indings reveal important aspects to be
35 considered in the designs of health promotions and health interventions aimed at increasing breast cancer screening participation fo r the 32% who did not have health insurance: to make breast cancer screenings access ible to Latinas in hopes of decreasing mortality among those with breast cancer diagnoses. Furthermore, some women in this study self reported that doing a BSE would make them worry about cancer. Most women believed t hat breast cancer is a fatal disease and feared dire consequences should they be diagnos ed. Many participants said that if diagnosed, they would feel depressed because a diag nosis of breast cancer would be akin to a death sentence. Latinas knowledge base about cancer in general an d breast cancer in particular appears to be formed through a complex combination of information acquired formally (e.g., through schools, healthcare settings), and t hrough informal social contexts (e.g., family, acquaintances). These dynamics point to the critical importance of educating women about the high cure rates associated with ear ly detection of the disease. Still, the fundamental barrier for Latinas not bilingual in Sp anish and English is the lack of resources and information in Spanish. Limitations to the Study The study sample (n = 50) was limited to a small n umber of Latinas from one geographic area, in which many former Colombians li ve. Thus, the sample may not be representative of all Latina women in Florida. It is common practice to assume that Spanish-speaking people are all the same, but on th e contrary, cancer risk factors and occurrence vary among Latinas because of regional, behavioral, and genetic differences.
36 Latinas also differ widely in degree of acculturati on, socioeconomic status, place of origin, and health beliefs. In addition, the sampl e for this study was not randomly selected and thus allows for self-select bias. It is possible that women who consented to complete the forms were also those who tended to pa rticipate in breast cancer screenings. An unexpected finding from the study was that Lati nas in the study group do perceive barriers to breast cancer screenings. The evidence of this study is significant to nursi ng and to healthcare providers since any language barrier is one of the major obst acles for communication between patients and healthcare providers. The results sug gest that nurses and other healthcare providers may be able to make a difference in the p articipation of Latinas in breast cancer screenings to promote early detection of breast can cer by helping them to overcome perceived barriers. To do so, nurses must attain a higher level of cultural awareness than now exists. Health care provides should teach Latin as that most breast cancer can be cured if detected early. It is vital that healthcar e providers explain the advantages of early detection; in caring for Latinas, healthcare provid ers should teach Latinas that most breast cancer can be cured if detected early. It is also important to assess patients language skills and evaluate their individual healt h beliefs and levels of understanding about breast cancer. Healthcare providers should a lso teach and recommend SBE and mammograms in a way that Latina patients can unders tand. Further, information about community screening resources must be available and understandable. Communication skills tap not only technical ability to understand and be understood but also the patients willingness to assert themselves.
37 Conclusion This study suggests a significant positive relatio nship between acculturation and perceived barriers to breast cancer screening for L atinas in southwest Florida. It also suggests that Latinas who are more acculturated to the United States culture perceived more barriers to breast cancer screening than the l ess acculturated women did. Important to the study is that Latinas in Southwest Florida a re different from other Latinas living in the United States, in that a majority of the study participants were acculturated, participated actively in breast cancer screenings, and had some kind of health insurance. Several participants, however, identified specific cultural barriers that they felt interfered with participation in breast cancer scre enings. Embarrassment at revealing their bodies was a strong barrier for some but not for others. Some participants reported feeling funny about performing BSE; others said the y still find it difficult to touch their breasts. These women were taught as children that o nes body is most sacred, that it is a sin to touch oneself or reveal ones body to anothe r person. One recommendation about ways to motivate women to obtain breast cancer screenings is to create and incorporate educational health promotion programs that take into account womens cultural and social realities. Other studies have recognized the lack of health promotion as barriers to participation fo r minorities, particularly for Latinas. For instance, Henson et al. (2005) reported that minori ties who have access to community resources have a greater opportunity to participate in breast cancer screenings. Information about breast cancer screening should be not only readily available but also equitable among various U.S. populations.
38 In spite of the limitations, findings of this study have implications for educational programs aimed at increasing Latinas breast cancer screening rates. Programs should be inclusive of Latinas perceptions in order to be su ccessful. Efforts to work with womens cultural beliefs, rather than ignoring or educating away their perceptions, are more likely to influence them positively. Implications for Research Recommendations: This study can be replicated or u sed as a foundation for further research focusing on a larger sample that i ncludes Latinas from a wide range of places of origin, to better represent Latinas from all over the United States. Another interesting element for further research would be t o include education and religion as perceived barriers to Latinas low participation in breast cancer screenings. All breast cancer research results are important to the nearly 200,000 women of all origins diagnosed with breast cancer, and parti cularly to those 40,000 women who die each year with breast cancer. The unequal burden o f breast cancer among Latinas presents a significant healthcare dilemma and an im portant challenge to our nation.
39 References Anderson, L., Aspegren, K., Janzon, L., Lindholm, T ., Linell, K., & Ljubgberg F. et al. (1998). Mammographic screening and mortality from b reast cancer: The mammographic screening trial. British Medical Journal, 279, 943-948. Eschbach, K., Mahnken, J. D., & Goodwin, J. S. (200 5, January 25). Neighborhood composition and incidence of cancer among Hispanics in the United States. American Cancer Society, 10.1002 1036-1044. Retrieved October 8, 2005, from http://www.interscience.wiley.com Gail, M. H., Brinton, L. A., Byar, D. P., Corle D K., Green, S. B., & Schirer, C. et al. (1988, 1998). Projecting individualized probabiliti es of developing breast cancer for white females who are being examined annually. Journal of the National Cancer Institute Monographs, 81, 1879-1886. Hansen, L. K., Feigl, P., Modiano, M. R., Lopez, J. A., Escobedo, S. S., & Moinpour, C. M. et al. (2005, January/February). An educational program to increase cervical and breast cancer screening in Hispanic women: A So uthwest Oncology Group study. Cancer Nursing: An International Journal for Cancer Care, 28 (1), 47-53. Retrieved November 3, 2005, from http://gateway.ut. ovid.com/gwl/ovidweb/cgi Katapodi, M. C., & Aouizerat, B. E. (2004, August 2 4). Do women in the community recognize hereditary and sporadic breast cancer ris k factors?. Oncology Nursing Forum: An Official journal of the Oncology Nursing Society, 32 (3), 617-623. Lawson, H. W., Hanson, R., Bobo, J. K., & Kaeser, M K. (2000, March 31). Implementing recommendations for the early detectio n of breast and cervical cancer among low-income women. National Center for Chronic Disease Prevention and Health Promotion, 49(RR02 ), 35-55. Retrieved October 8, 2005, from http://cdc.gov/mmwr/previw/mmwrhtml/rr490a4.ht m Lobell, M., Bay, C. R., Rhodas, K. V., & Keske, B. (1998, April). Barriers to cancer screening in Mexican-American women. Mayo Clinic Foundation for Medical Education and Research, 73 (4), 301-308. Retrieved November 3, 2005, from http://gateway.ut.ovid.com/gwl/ovidweb.cgi
40 MacDonald, D. J., Sarna, L., Uman, G., Grant, M., & Weitzel, J. N. (2005, September/October). Health beliefs of women with an d without breast cancer seeking genetic cancer risk assessment. Cancer Nursing: An International Journal for Cancer Care, 280 (5), 372-379. Retrieved November 3, 2005, from http://gateway.ut.ovid.com/gwl/ovidweb.cgi Mendalblatt, J., Kaufman, E., Sheppard, V. B., Pome roy, J., Kavanaugh, J., & Canar, J. et al. (2005, November 2). Breast cancer prevention in community clinics: Will lowincome Latina patients participate in clinical tria ls? Preventive Medicine, 40 (2005), 611-618. Retrieved October 18, 2005, from http://www.sciencedirect.com OBrien, K., Cokkinides, V., Jemal, A., Caridinez, C.J., Muray, T., Samules, A., et al. (2003). Cancer statistics for Hispanics, 2003, Ame rican Cancer Society. A Cancer Journal for Clinicians 53 2008-226. Retrieved September 28, 2005, from http://caonline.amcancersoc.org/cgi/content/full/53 /4/208 O'Malley, A. S., Kerner, J., Ayah, E., & Mendalblat t, J. (1999, February). Acculturation and breast cancer screening among Hispanic women in New York City. American Journal of Public Health, 89 (92), 219-227. Retrieved September 20, 2005, from http://gateway.ut.ovid.com/gwl/ovidweb.cgi Rubistein, W. S., O'Neil, S. M., Peters, J. A., Rit tmeyer, L. J., & Sadler, M. P. (2002). Mathematical modeling for breast risk assessment: S tate of the art and role in medicine. Oncology Nursing Forum, 16, 1082-1094. Salazar, M. K. (1996, December). Hispanic women's b eliefs about breast cancer and mammography. Cancer Nursing: An International Journal for Cancer Care, 19 (6), 437-446. Retrieved October 1, 2005, from http://gateway.ut.ovid.com/proxy.usf.edu/gwl/ovidwe b.cgi? Smiley, M., McMillan, S., Johnson, S., & Ojeda, M. (2000, January 21). Comparison of Florida Hispanic and non-Hispanic Caucasian women i n their health beliefs related to breast cancer and health Locus of Contro l. Oncology Nursing Forum 27 (6), 975-984. Vazquez, M. O., Ayendez, M. S., Perez, E. S., Almod ovar, H. V., & Calderon, Y. A. (2002). Breast cancer health promotion model for ol der Puerto Rican women: Results of pilot programme. Health Promotion International, Oxford University 17 (91), 1-11. Wilmoth, M. C., & Sanders, D. (2000, September 27). Accept me for myself: African American womens issues after breast cancer. Wilmoth, 28 (5), 875-879.
41 Wochna, L. V., & Buschy, A. (2005, January/February ). Interventions that address cancer health disparities in women. Family & Community Health 28 (1), 79-89. Retrieved October 18, 2005, from http://gateway.ut.ovid.com/g wl/ovidweb.cgi Yabroff, R. K., & Mandelblatt, J. S. (1999, Septemb er). Interventions targeted toward patients to increase mammography use. Cancer Epidemiology, Biomakers & Prevention, 8 749-457. Retrieved September 10, 2005, from http://gateway.ut.ovid.com.proxy.usf.edu.gwl/ovidwe b.cgi?
43 Appendix A: English HBM & Spanish Translation T
44 Appendix A (Continued)
45 Appendix A (Continued)
46 Appendix A (Continued)
47 Appendix B: Consent to Use Health Belief Model
48 Appendix C: English ARSMA-II-Scale 1 & Spanish Tra nslation
49 Appendix C (Continued)
50 Appendix C (Continued) Since the population I am aiming are not all of Mex ican descendents I changed (Mexican to Latinos)
51 Appendix C (Continued)
52 Appendix C (Continued)
53 Appendix C (Continued)
54 Appendix D: Consent to Use ARSMA II From: permissions firstname.lastname@example.org To: Patricia P
55 Appendix E: Study Purpose & Demographics Forms
56 Appendix E (Continued)
57 Appendix F: Permission to Interview
58 Appendix F (Continued)
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b relationship betweern acculturation and barriers to breast cancer screening in Southwest Florida Latinas
h [electronic resource] /
by Patricia Patino.
[Tampa, Fla] :
University of South Florida,
ABSTRACT: Despite multiple campaigns by the American Cancer Society, reports indicate that Latinas living in the United States who contract breast cancer are more likely than Anglos to die. These findings correlate with low participation in breast cancer screenings among Latinas. The objective of this study was to identify key obstacles that influence Latinas' low participation in breast cancer screenings, based on their health beliefs, knowledge of screenings, acculturation, and socio-economic factors.The study was a face-to-face informal interview, combined with a survey questionnaire conducted at churches, social clubs and/or at the participants' homes in a southwest Florida urban community. The sample consisted of a total of 50 women: all of the participants were Latinas 40 years of age and over; they had to be fluent in Spanish or English or both. A Spanish-English bilingual individual conducted a personal interview in the preferred language of each participant.^ The first part of the interview was to identify barriers that affect screenings. The second part used a survey to weigh the identified factors in order to determine their importance to the participants' health decisions. This study used a health belief model scale to evaluate women's beliefs about breast cancer, and the benefits of screenings.The research results revealed that Latinas who participated in this study were acculturated to the United States culture; the largest group of participants reported being from Colombia, followed by Cuba and Puerto Rico; only two of the participants were Mexican. Seventy-eight percent of the participants self- reported having yearly mammograms, and 74% performed monthly breast self examination BSE; 60% were bilingual; 68% had some kind of health insurance. These results differ from earlier studies from the western United States where the majority of Latinas were of Mexican or Central American origin.^ This suggested that Latinas from Southwest Florida are different from Latinas in other areas of the United States. A weak but significant correlation was found between acculturation and perceived barriers to breast cancer screenings, (r = 0.45, p = .01); Latinas who are more acculturated perceived more barriers than those who are less acculturated. There was not significant difference between participants who had health insurance and those who did not (t = 0.96, p = .35). The results of this study are significant for nurses and especially for advanced practice nurses, who can assess patients' knowledge about cancer in general, and breast cancer in particular when caring for Latinas; of particular concern should be the evaluation of patients' levels of acculturation, health beliefs, and understanding of the English language. Still the fundamental barrier to Latinas not bilingual in Spanish and English may be the lack of resources and information in Spanish.
Thesis (M.S.)--University of South Florida, 2006.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
System requirements: World Wide Web browser and PDF reader.
Mode of access: World Wide Web.
Title from PDF of title page.
Document formatted into pages; contains 58 pages.
Adviser: Susan C. McMillan, Ph.D., A.R.N.P.
Health belief model.
t USF Electronic Theses and Dissertations.