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Cultural Concepts of Cancer and Mammography Uptake and Adherence:Lessons from the Haitian Breast Cancer Study
Black women have the highest age-adjusted breast cancer mortality, largely due to late stage at diagnosis. Mammography can reduce breast cancer deaths through early detection. Although na-tional programs have increased prevalence of black women who have ever had a mammogram, disparities in repeat mammography have persisted even for women with health insurance, prompting suggestions that cultural factors may contribute to disparities. Demonstrations of culturally tailored interventions yield modest impacts on increasing mammography use. Empirically tested cultural explanatory models are needed to help design more effective interventions. Exist-ing models such as the health beliefs model based on the individual perspective of social cogni-tive theory have produced inconsistent predictions of mammography use. Some acute care pro-viders have adopted a framework from cultural anthropology that offers an alternative. Kleinman (1978) indicates that differences in concepts of health/ill health between the biomedical provider and the patient adversely affect their communication and adherence to recommended care. This model, however, has not been applied to racial/ethnic disparities in cancer screening in quantita-tive studies. Further, there are, few within-group studies on culture and mammography use in the black population despite its growing diversity. Haitian women face a unique challenge in com-municating with biomedical providers due to a language barrier, low education, little experience with biomedical health care systems and the concept of prevention; and a high prevalence of tra-ditional beliefs. The study’s main goal is to determine if Haitian women’s understanding of cancer influences uptake or adherence to mammography use compared to African-American or White women. The specific aims are to: 1) compare Haitian, African American, White Ameri-can, and Latina/Caribbean women on concepts of cancer; 2) determine the variance in mammog-raphy uptake and adherence explained by cancer concepts; 3) determine if concepts of cancer influence racial/ethnic differences in mammography uptake or adherence; 4) explore the rela-tionships among cancer concepts, having a usual source of care, having a consistent primary care physician and mammography use. The study design is population-based and cross-sectional, from a probability sample of 762 Greater Boston area women (The Haitian Breast Cancer Study), with 286 Haitian, 169 African-American, 144 White and 163 Latina/Caribbean partici-pants. Dependent variables are three measures of mammography uptake (mammography ever, age at first mammogram, and mammography in past 2 years) and two measures of mammogra-phy adherence (years per mammogram, mammograms per decade of life after age 40). Primary independent variables are quantitative measures of cancer concepts derived from qualitative data: 1) the extent to which cancer concepts are biomedical vs. lay; 2) faith in medicine/ biomedical providers to prevent or cure cancer. Covariates include measures of 1) social experience; 2) eco-nomic access family and other relationships; 3) health care experience and relationships. Bivari-ate analyses will compare Haitians to each of the other race/ethnic groups on these measures. Multivariate analyses will predict impact of cancer concepts on mammography uptake and ad-herence. Logistic regression will be used to predict dichotomous mammography measures and least squares regression for continuous ones. The study’s outcomes/benefits will be to: 1) pro-vide insight into the impact of women’s cancer concepts on mammography adherence; 2) extend theoretical models of culture to support effective mammography use intervention designs and research; 3) inform providers on the nature and level of knowledge required by women to facili-tate adherence to screening. This study is unique in that we will 1) study a subpopulation of black women, never studied before; 2) using measures of culturally-based cancer concepts de-rived from more accurate qualitative data and 3) extend previous research by analyzing the health/illness model quantitatively, 4) using a large, well-defined population-based sample, whose findings can be generalized to the source population.
More black women die from breast cancer than women of other ethnic groups of the same age. Based on evidence from clinical trials that mammography can reduce breast cancer deaths, breast screening with mammography every one or two years has been recommended by professional organizations such as the National Cancer Institute and the American Cancer Society as the means by which to reduce breast cancer deaths through early detection. This is because known risk factors for breast cancer such as lifelong changes in a woman’s hormones related to her re-productive history e.g. age at which a woman reaches puberty, starts having children or reaches menopause or genes cannot be altered to prevent breast cancer. National programs have in-creased access to screening mammography for all races, but the utilization according to recom-mended interval has lagged behind especially among blacks and other race/ethnic minorities. This might partly explain why mammography has contributed little to reducing deaths in the black population. The persistence of low levels of regular mammography use among black women even those who have health insurance or free mammograms has led to suggestions that cultural barriers especially beliefs and failure to communicate with biomedical providers might be contributing. Currently there is a great interest in engaging women in programs that are cul-turally tailored. These programs seem to be having some success in getting more women to par-ticipate in mammography. Designing demonstrations that are based on theory, which has been substantiated through research, has been encouraged as a way to increase effectiveness of cancer screening programs including mammography. There is currently a general lack of coherent cul-tural explanatory models that are science-based. Some researchers have questioned the cultural significance of existing models such as the health belief model (Becker, 1975) based on social cognitive theory-which highlights the role of psychological cost-benefit evaluation by individu-als. More effective culturally tailored interventions require detailed characterization of the target population. The concepts being tested in this model come from cultural anthropology based on the work by Kleinman (1978). According to Kleinman (1978), differences in the concepts of health and illhealth between biomedical providers and patients may adversely affect patient-provider communication and health care use. Haitian-American women especially those from rural-Haiti face unique challenges in communicating with biomedical providers and navigating the US health care system due to a language barrier, low education, poverty, little experience with biomedical health care system and the concept of prevention; and their traditional beliefs. Our goal is to determine if differences in cancer concepts between Haitians, African Americans and White women and if these concepts facilitate or hinder timely initiation of mammography screening and adhering to recommended amount of use over time. We will also evaluate if these concepts are altered or reinforced by having health care experience such as having a previous mammogram or relationships in the health care system such as, having a usual source of care or a regular provider. The study participants are 762 women from the greater Boston area who par-ticipated the Haitian breast cancer study and were identified using census information and in ways that gave any illegible woman an equal chance to participate. We will compare Haitian women to African-American and white women and Latina/Caribbean on each cancer concept. We will examine the influence of cancer concepts on five types of mammography use in order to determine the stability of our estimates. Our analyses will take into consideration influence of other factors including various measures of 1) social experience; 2) economic access; family and other relationships 3) health care experience and relationships. Potential benefits of this study include 1) providing tested theories that can be used to design a culturally tailored mammogra-phy screening intervention in the target population 2) providing biomedical provider information on level of knowledge/skills required to increase mammography screening among Haitian women; and 3) a possible extension of this study to other populations.