2 3 8 S e m i n a r s in Oneology Nursing, Vol 16, No 3 (August), 2000: pp 238-247
OBJECTIVES:
To explore how culture may play
a part in breast cancer screening,
early detection, and efforts to de- crease breast mortality.
DATA SOURCES:
Journal articles published in the
past 20 years on cultural aspects
of cancer prevention and control.
CONCLUSIONS:
Research seems directed more at
discovering cultural differences
than at identifying similarities on
how culture influences breast
cancer screening and early detec-
tion. The influences of poverty
and lack of educational opportu-
nities account for much of what is
termed cultural difference.
IMPLICATIONS FOR NURSING
PRACTICE:
Improving practice through an
informed understanding of cul-
ture calls for considerable self-
education and a fundamental
refinement of care delivery.
From the Department of Physiological Nursing, School of Nursing, University of California, San Francisco.
Noreen C. Facione, PhD, RN, PNP:Assoei- ate Professor, Department of Physiological Nursing, School of Nursing, University of Cal~brtda, San Francisco; Maria Katapodi, Pdq, MSN, PhD Student in Nursing: Depart- ment of Physiological Nursing, School of Nursing, University of California, San Francisco.
Address reprint requests to Noreen C. Fac'ione, PhD, I~V, FNP, 611Y Depa~ment of Physiological Nursing, Box 0610 School of Nursing, University of CaliJbrnia San Fran. cisco, San Francisco, CA 94143-0610.
N O R E E N C . F A C I O N E A N D M A R I A K A T A P O D I
p ROFESSED beliefs about the benefits of breast cancer screening and early detect ion have become common- place in American culture, and breast cancer is no longer the sensitive topic that it was only decades ago. As we begin the 21st century, public service educa-
tion delivers information about breast cancer symptoms and mammography guidelines to most households through pr inted materials, radio, and television. Yet, early detect ion campaigns cont inue to report lower screening rates and later stage of cancer at t ime of diagnosis in some of America's subpopulations, these differences being at t r ibuted to cultural beliefs and culturally dictated behaviors. This article examines how culture may play a part in breast cancer screening, early detection, and efforts to decrease breast cancer mortal i ty (Fig 1). Even using a broad definition of culture, not all the influences on screening and early detect ion are attributable to cultural difference. ~
The complex mosaic of cultural variation is seen in the pat terned ways groups of individuals dress, eat, bargain, comfort, express humor, communica te needs, etc. Societal subcultures, such as senior citizens, African-Americans, or families living below the pover ty level, may be highly visible_ Other subcultures, such as nurses, Native Americans, or recent immigrants, are smaller or less visible. Recognizing that even members of families hold very different ideas on most subjects, a focus on culture predicts that persons who are members of the same subculture will hold generally similar beliefs, values, and expectations, and strive for
C U L T U R E A N D B R E A S T C A N C E R E A R L Y D E T E C T I O N 239
Cultural Beliefs about Cancer Risk and Cure K Culturally i Dictated Health
and Illness Behaviors
All other ] Influences on Screening and Early Detection
Each Individual's Screening and Early Detection Behavior
Stage of Disease at i Diagnosis I
I Breast Cancer Survival i
F I G U R E 1. The relationship of cultural beliefs and culturally dictated health behavior to efforts at breast cancer control,
similar goals. Within a culture, individuals share knowledge and beliefs about breast cancer. These shared knowledge and beliefs are assumed to influence participation in screening and early deteetion behaviors.
UNDERSTANDING CULTURE IN A
MULTICULTURAL SOCIETY
S Ynthesizing research reports and published observations about early detection posed great
diffieulty. The majority of the larger studies report varying rates of sereening and early detection behavior by race, ethnicity, income, age, or some other demographic identifier_ Several identifiers are measured with great ambiguity as to culture. While "black" often refers to African-Americans, blacks of other heritage and different cultural background (Caribbean, West and East African, ere) are not distinguished. Other studies describe subjects only as white and of high income and edueational level, replacing descriptions of culture with privileged class status. 2
The studies describing "Hispanic" or "Latino" samples were composed of different cultural groups. West coast studies most often included women from Mexico and Central America, while East Coast samples were more likely to inelude
Puerto Ricans and South Americans_ In our studies we have learned that Latino immigrants self-identify using the terms "white" and "black," which further complicates sample deseriptions. For this integrative discussion the categories blacks, whites, and Latinos are used.
A focus on early detection of cancer increasingly calls for cultural competence. 3,4 Meleis et aP commented that in our care delivery culture, the expectations of competent nursing care includes a sensitivity to culture, race, gender, sexual orienta- tion, social class, and economic situation. Because culture is such a pervasive influence in our lives, it is often difficult to discuss cultural difference without making eulture-eentric assumptions that have social and political implications. Even pub- lished reports of screening programs that eonsider cultural difference are written from a biomedical perspeetive on health and illness_ When we talk about monitoring breast cancer screening in terms of tracking "complianee with established guide- lines," we are making culture-centrie assumptions that persons should comply with the biomedical view on caneer screening. The biomedieal perspee- tive integrates our scientific knowledge with our beliefs and socially normative behavior and sug- gests how people should live their lives. The majority of health care providers in the United States have been trained to view health only from within the biomedical cultural model, but to make new strides toward culturally relevant outreach, it will be important to recognize the assumptions made by the model and to negotiate collaborations between this perspective and that of other cul- tures.
TRACKING BREAST CANCER SCREENING BY
CULTURAL GROUP
M onitoring mammography screening by mea- surable demographic descriptors has been
done in an effort to evaluate the effectiveness of outreach to all population groups. Data from the Risk Faetor Surveillance System indicate mammog- raphy screening gains in all surveyed states in the percentage of women aged 40 years and older, s Screening rates increased rapidly for all women aged 50 to 64 years, regardless of raee/ethnieity, income, and education level, although lower income and less-educated women continue to be screened at a lower rate_ s,6 Some geographic areas
240 FACIONE AND KATAPODI
repor t that African-Americans are still more likely to be undersc reened or not screened at all, 7-1° while data from the 1992 National Health Inter- view Survey and a 1992 survey in San Francisco Bay Area mult ie thnic communi t ies indicate that rates of self-reported breast cancer screening tests among African-American, Hispanic, and white women no longer differ significantly. 11 Differences that remain are at t r ibuted to educat ion and income levels, the recentness of immigration, and English language proficiency_
L a n g u a g e as a B a r r i e r to A c c e s s
Studies repor t that Spanish-speaking women have lower mammogr~phy screening part icipation rates. 12-17 These studies cite language barriers that limit communica t ion with providers, 13-19 nonavail- ability of explanatory reading materials, 15,~8,19 and difficulties negotiating the demands of the service delivery setting. 2°-23 Additionally, many Spanish- speaking women are immigrants who come from countries where heal th screening visits are not a familiar componen t of heal th care. ~6,18,24,25 Similar findings have been repor ted for Filipino and Korean women, a6,27 Cambodian women, 2s and Chinese-American women. 29-31 These two consid- erations have very different implications for how to direct cancer detect ion resources. The first requires only language assistance, while the second requires a larger explorat ion of utilization expectations.
The communal vocabulary and s t ructure of a language communica te the beliefs and expecta- tions that are an integral componen t of a culture. Researchers have begun to explore the structural differences of language that influence communica- tion of cancer relevant in fo rma t ionf 1,22 Transla- tion of c ommon words like "risk," "lump," and "discharge" may have very different meanings in languages other than English. "Bolita," a transla- tion of "lump," most often called forth the unders tanding of benign inflammation or cyst ra ther than the possibility of a mal ignaneyY Conversely, the word "cancer" connoted expecta- tions of death ra ther than survival. 29,32 These findings signal culturally embedded differences in meaning that were intrinsic to the languages. However, it is p remature to attr ibute these observations to culture alone without considering the influence of educat ion and poverty.
I n t e r a c t i o n s B e t w e e n E d u c a t i o n , Pover t y , a n d
C u l t u r e Table 1 displays the strategic barriers to breast
cancer screening that are related to income,
education, and immigration status ra ther than a direct result of culturally dictated behaviors and culturally shared beliefs. Navon 33 stresses the inadequacy of attributing each and every differ- enee to cultural factors when in fact they may be a result of economic or educational gaps. Education, whether formal of informal, influences the breadth of ideas available to a cultural group. Rajaram and Rashidi 34 have offered an exceptional explanation of how social networks give rise to heal th decisions
T A B L E 1. A Typology of Culture-Relevant Issues Believed to
Influence Breast Cancer Control
Strategic barriers to breast cancer screening Access to services
Availability of facilities Continuity of care Prejudice Immigration issues Spoken language Transportation Child care
Income Family annual income Public or private insurance Spendable dollars
Education Formal education Experiential learning
Culturally reinforced health and illness behaviors Modesty
Viewing the breast Touching the breast Sex role behavior
Therapies Western/Eastern medicine Scientific/folk tradition Complementary methods
Culturally embedded beliefs about cancer risk and cure Risk perception
Population vulnerability Dangers in care settings
Beliefs about cure Fatalism Perceived powerlessness
Cancer knowledge Symptom knowledge Treatment knowledge Misconceptions
C U L T U R E A N D B R E A S T C A N C E R E A R L Y D E T E C T I O N 241
within cultural groups. When the m e m b e r s of the social ne twork live in poverty, they share informa- tion about denied care delivery and the h u m a n cost of un t rea ted illness. Few would deny that pover ty inhibits breas t cancer screening and detect ion behavior. With pover ty and decreased educat ional oppor tun i ty come knowledge gaps that l imit one 's unders tanding of the potent ia l benefits of cancer screening and earlier detection. Low annual ineome remains the largest barr ier to screening m a m m o g r a p h y , 7-1°,19,a5-37 and studies of some hospital samples repor t tha t as m a n y as 45% to 60% of low-income blaek women have symp- toms for more than 6 mon ths before their initial evaluat ion visit. 3s-4°
Since income and educat ion are highly corre- lated, separat ing the effects of income and educa- tion are problemat ic . As a result, mos t studies of screening behavior have repor ted income and educat ion as interact ive influences on cance r screening and early detect ion behavior. ~s,4°-44 The observat ion tha t m e m b e r s of some cultural groups are on average less well educa ted and of lower l i teracy is well documen ted as a funct ion of educat ional opportuni ty . Audio and visual strate- gies are increasingly used to address l imited accessibil i ty to early detect ion mater ia ls for both English- and non-Engl ish-speaking groups. 45-47
Expectations of Access to Services Even the definition of adequate access to
services is de te rmined by culture, with more privileged populat ions having higher expecta t ions for care delivery. Hongvivi tana 4s provides a cross- cultural definition of access to care tha t goes beyond affordability to include availability, acces- sibility, and acceptability_ Many studies of m a m - mography util ization in samples of women f rom unders tudied groups repor t the lack of availabili ty of m a m m o g r a p h y facilities, par t icular ly in rural, isolated areas. 15,49-51 Depending on whe the r m e m - bers of a given culture (eg, Native Amer icans and Alaskans) live in outlying areas, lack of access becomes a function of their cultural group member - ship. Salazar ~s cap tured the realities of lack of geographic availability in her s tudy of Latino women, describing t h e m as dependen t on others for t ransporta t ion. Women were confined to their homes unless husbands chose to take t hem somewhere_ In the era of managed care, acces- sibility has come to m e a n an appropr ia te and t imely physic ian referral and location of ser- vices within heal th care delivery sites.r, 35,s2 Others have opera t ional ized accessibi l i ty to include
child care, t ranspor ta t ion, and t ime consider- a t i ons . 14,15,18,35,52,53
Accessibil i ty barr iers also can be related to the complexi ty and lack of personal contac t within the bureaucra t ic p rocedures of the medical system. 34 Several researchers have repor ted tha t for m a n y Latino women, immigra t ion status is a major access barrier. 1s,32 These authors have observed this influence in Latino, black, and white women who are ei ther u n d o c u m e n t e d residents or fear that their en t ry into the heal th care sys tem will endanger relatives or friends who are undocu- mented_ 32 Numerous studies reveal that having an establ ished care provider relat ionship has a gener- ally posit ive influence on breas t cancer screening rates for varying cultural groups. 5'10'27'37'53'54-57
Others have repor ted tha t Afr ican-American and Latino women ' s failure to obtain a m a m m o g r a m was related to not having received a physic ian 's r e c o m m e n d a t i o n for screening.1°,ls,37, s2,Ss
In addit ion to poverty, immigra t ion and social d iscr iminat ion are believed to account for m u c h of the differences in c ance r sc reen ing behav- ior_ 20'25,59-61 Rajaram and Rashidi 34 caut ion that the his tory of inst i tut ional rac ism in Amer ica predicates that expecta t ions of prejudicial treat- m e n t often will be a par t of a c o m m u n i t y ne twork database re levant to heal th-re la ted decisions. Researchers have repor ted the influence of preju- dice in Afr ican-American women ' s par t ic ipat ion in m a m m o g r a p h y screening. 14,62-64 In our s u r v e y of 838 Latino, blaek, and white women in the San Francisco Bay Area, the personal exper ience of prejudice in heal th care delivery was significantly related to perceived lack of access to services. = Black and Latino w o m e n repor ted exper iencing prejudice significantly more than white women in the sample. Report ing an exper ience of prejudice was significantly related to having only one m a m m o g r a m versus following screening guide- lines. While actual prejudice in the delivery of cancer screening has not been direct ly studied, 50% of the women in our sample perceived heal th care delivery as biased by race, income, or sexual or ien ta t ion2 a,65 More t ruth-seeking studies are needed of this repor ted influence on breas t cancer sereening and early detection.
MISCONCEPTIONS ABOUT BREAST CANCER
g g ~ / [ i s c o n e e p t i o n " is the t e rm used to declare ,kVl . that a belief is false when evaluated by an
establ ished criteria_ In 1980, a survey of black
2 4 2 F A C I O N E AND K A T A P O D I
Amer icans repor ted a lack of knowledge of cancer symp toms and cancer screening tests. 66 Since tha t t ime there have been m a n y articles describing knowledge abou t c a n c e r wi th in cul tura l groups, 24,2s,67-7° most focusing on the lack of
needed knowledge or misconcep t ions about can- cer. Both white and non-whi te w o m e n endorse misconcep t ions about breas t cancer , and al though misconcept ions are believed to decrease when educat ional level increases, they are not absent in well-educated women, a2,ss 80me miseoneep t ion examples are tha t a m a m m o g r a m is someth ing tha t women require only in the p resence of symptoms , 12,27,3°,58,64,71,72 tha t m a m m o g r a m s are
only needed by women who have a family his tory of breas t eaneer , j3,64 and tha t women have similar risk of breas t eaneer regardless of age. 2s,z6,ss
Another f requent ly repor ted miseoneep t ion is tha t breas t cancer can be eaused by an injury to the breas t as a result of aee ident or domest ie violence. 12,2°,26,32,34,53,67,6s,72,73 Holding such a belief
might influence early detect ion if a woman feared the need to acknowledge physical abuse to be evaluated for her symptoms . In a s tudy by Perez-Stable et al, 2° the idea tha t cancer could be caused by bruising was endorsed by 52.6% of the 884 bat ino w o m e n and 34.3% of the 510 Anglo women surveyed. Hubbell et aP 2 repor ted an even higher endo r semen t of this misconcept ion: 74% of 803 Latino w o m e n and 41% of 422 Anglo women. Such a belief m a y be surprising to m a n y in the heal th care delivery system, yet it is impor tan t to note that m a n y of the misconcept ions repor ted in non-whi te samples have ye t to be studied. 2° Other repor ted misconcep t ions center on protect ive effects against b reas t eaneer for some behaviors, including breas t self-examination, 3° m a m m o g r a - phy, 32 and breas t feeding. 12,2°,26,32,34,67,6s,72
Phillips et a174 a t t r ibuted observed miseoncep- t ions in Afr iean-Ameriean subjects to the relative lack of open discussion of b reas t cancer in the black communi ty . In our own research 29,32 we found tha t c o m m u n i t y narra t ives seemed jus t as likely to reinforee a misconcep t ion (eg, "breas t cancer lumps are never painful") as they were to be effective sources of reliable cancer control information. Evidence suggests tha t woman- to- woman eomm un i ea t i on is an impor tan t tool for the t ransmiss ion of women ' s heal th informa- tion_ 32,34,75,76 Skinner et a177 demons t ra t ed modes t gains in cancer- re la ted knowledge in the urban, Afr ican-American women, ye t some ideas critical
to screening (eg, " m a m m o g r a m s are for women who th ink they have a lump in their breasts") were still endorsed by 50% of the w o m e n after testing. However, a t tempt ing to predic t individual behav- ior based solely on cultural background can lead to s tereotyping and frequent ly flawed predictions, a4 The key issue is whe ther an individual woman has incorpora ted a culturally c o m m u n i c a t e d miscon- cept ion into her personal beliefs and whe ther this misconceived belief has implicat ions for her cancer screening behavior.
PERSONAL RISK PERCEPTION
A n u m b e r of studies have repor ted inaccura te es t imat ions of personal risk for breas t can-
cer, rr,rs but generally these err in the direct ion of higher than actual r isk percept ion, 24,68,79 a condi- tion that should foster breas t cancer screening behavior. Behavioral research on s y m p t o m ap- praisal and personal risk percep t ion 8°-s2 supports the claim tha t women who feel invulnerable to breas t cancer will be less likely to par t ic ipate in screening or to appraise a breas t s y m p t o m as a potent ia l signal of breas t cancer_ Breast self- examina t ion behavior was repor ted to be less f requent in both white and black women who felt invulnerable to breas t cancer in a s tudy by Salazar, s3 while Champion and colleagues '57,s4 studies of white and black w o m e n have consis- tent ly shown awareness of breas t cancer suscepti- bility. Lower awareness of susceptibi l i ty is fre- quent among Chinese-Americans . 29,3°,s5 Two small studies of recent ly immigra ted Chinese women repor t associating the need for prevent ive heal th behaviors with white women ra ther than them- selves, and the belief that if women reduced their level of stress and their tendencies to be bad- t empered they could prevent breas t cancer. 29,a°
A possibly related issue repor ted in a n u m b e r of studies is that m a n y Chinese-Americans believe that talking about someth ing can cause it to happen. 29,s6,87 Carese and Rhodes ss repor ted that this idea is also prevalent in the Navajo culture, which views thoughts and language as having the ability to shape reali ty and affect events. This fundamenta l cultural belief has strong implica- tions for providing early detect ion services. Appar- ent at t i tudes of invulnerabil i ty to breas t cancer in these and other studies 32,6s and the idea tha t it is possible to control the disease through thoughts and behavior cont ras t sharply with reports of over
CULTURE AND B R E A S T CANCER E A R L Y D E T E C T I O N 243
es t imat ion of risk in o ther samples 24,65,79 and require fur ther investigation.
BELIEFS AND BEHAVIORS EMBEDDED
IN CULTURE
Preserving Modesty Physical examina t ion of in t imate body parts is a
barr ier to heal th care, par t icular ly for Latino and Asian women, ls,3°,79,55-57 This bar r ie r includes a woman ' s concern for mainta ining her own expecta- tions of modes ty and the att i tudes of her male sexual par tner . Some women defer cance r screen- ing because of a strongly dictated cultural expecta- t ion requir ing tha t their breasts not be viewed or touched by others and, in some eases, them- s e lve s . 26-28'31'34,64 Concern for modes ty is also seen in cultural communi t i e s tha t espouse the Muslim faith, but the cance r screening behaviors of these women are not well reported. It m a y be tha t a culturally compe ten t approach to successful breas t cancer screening will necess i ta te modali t ies tha t do not require viewing and manipula t ing a wom- an's unc lo thed breast .
Researchers have repor ted tha t gender role dictates the suppor t women have for cancer early detect ion behavior_14,15,30,32,35,86,87 Women hid their
par t ic ipat ion in breas t cancer screening f rom their male par tners or did not seek help for s y m p t o m s because their husbands did not want a male doctor to pe r fo rm their b reas t examination.14,15,32, 57 Chi- nese, Japanese, and Latino women are expec ted to behave less au tonomous ly about heal th-re la ted decisions, 15,3°,35,56,57 with decisions about their body shared be tween husband and wife. There are no studies of p redominan t ly white and black women tha t address this issue directly, but researchers have repor ted delayed help-seeking behavior for self-discovered breas t s ym p toms by women who fear a b a n d o n m e n t by their male partners . 32,53,s9,9° Future research is needed to assess the actual cost in morb id i ty or mor ta l i ty related to male suppor t for cancer screening, early detect ion, and t r ea tmen t behavior in varying cultural populat ions. In groups in which m e n are considered barriers, a direct approach to media te these cultural at t i tudes is warranted. Most typi- cally, a cultural expecta t ion of obedience to a spouse is in conflict with ano ther cultural expecta- tion to r emain hea l thy in order to serve the needs of the family. Women who deal with these conflicting cultural expecta t ions and the anxiet ies of a potent ia l breas t cancer need direct in terven- tions to help them arrive at a personally acceptable
solution. This requires a community-based, culturally sensitive care delivery system that partners with women ' s organizat ions and suppor t agencies.
Choice of Therapies Women with late-stage breas t cancer are more
likely to use al ternat ive approaches to managing their breas t cancer symptoms . 53,65,73,89,9° The use
of c o m p l e m e n t a r y and al ternat ive therapies as par t of the r e c o m m e n d e d t r ea tmen t plan is increasing, TM but the prevalence and var ia t ion of therapies in use in Amer ica ' s diverse cultural groups is not cur ren t ly known_ In a s tudy of Anglo, Latino, and African-American women, 32 the women spoke of friends or relatives who declined surgery and sought al ternat ive therapies, were not cured, and subsequent ly died. Laws and Mayo 13 observed the use of faith healing in 25% of the Latinos in their study, but the lack of representa t ive sam- piing prohibi ts in te rpre ta t ion of thei r findings for the Latino populat ion at large. Symptomat ic women with breas t cance r often struggle to combine the directives of their heal th care provider and their c o m m u n i t y networks to decide what to do about their symptoms . Culturally c o m p e t e n t approaches to breas t cance r control in the 21st cen tu ry will require facilitating dialogues to lerant to diverse cultural perspectives_
Expectations of Cure It would be false to s te reo type m e m b e r s of any
cultural group as fatalistic in relat ion to breas t cancer. Acknowledging the s t rength of forces outside one's personal agency will only cont r ibute to the risk of advanced disease at the t ime of diagnosis if a woman believes she lacks all power in the face of a breas t cancer threat. This kind of fatalism is repor ted to be more prevalent in poor and in less-educated people. 2°,35,89,92 Many repor t
low concern for cancer prevent ion when women struggle daily to main ta in their families in the face of pover ty-s t r icken environments.9,2°,3s, 36 Studies rarely credit these women with making a general ly cor rec t a ssessment of their di lemma, given the fact tha t mor ta l i ty rates in m a n y of our poorer cultural populat ions remain unimproved. 5,35,93
These att i tudes are repor ted to be more preva- lent in black and Latino w o m e n 2°,24,65,92,94 and in older WOnlen. 22,32,65,94 Morgan et al6s studied 876
Hispanic women who were p redominan t ly born in Car ibbean countr ies but cur ren t ly living in New York_ They repor ted that 56% of their sample
244 F A C I O N E AND K A T A P O D I
believed that cancer was almost always fatal and 44% agreed with the statement that cancer cannot really be eured. In our sample of 386 Latino women 65 and in the study of 884 Latinos by Perez-Stable et al, 2° endorsement of such state- ments was closer to 25%, with both samples being born predominantly in Central America. However, representative sampling has yet to quantify the prevalence of fatalistic attitudes in these and other cultural groups.
The Concept of Prevention Women of Asian and Latino cultural groups hold
beliefs about maintaining health that differ signifi- cantly from attitudes about prevention and early detection of illness common in biomedicine. For example, in one study, Chinese women believed
that preventive health behavior should be deferred until an individual reaches 40 years of age or older or until they married and required reproductive care. 3° Attaining wellness or offsetting illness by methods that maintain balance among the body humors is an idea that is common to Chinese- Amerieans, 2s,29 Mriean-Americans, 32 Filipino- and Korean-Americans, 26 and Native Amerieans, 49 yet this is not directly congruent with biomedieal ideas. Maintaining balance involves food choiees, the use of herbs, mental exereises, and the avoidance of stress. For those cultural groups in which the traditional healing method does not prioritize the use of biomedicine, it is unusual for individuals to seek health services unless their illness has not responded to other efforts at symptom management.
StrategiCto AccessBarriers ~ Income Culturally Dictated Health and Illness Behaviors
Perceived Access versus Lack of
Access Education
Other Influences on this judgment
process?
Individually Incorporated
.3ultural Beliefs and Behaviors
Cultural Beliefs about Cancer Risk
and Cure
Judgment Process
Personal Risk Perception
Each Individual's I Screening and Early| Detection Behavior I
Stage of Disease at Diagnosis
!
Breast Cancer Survival I I
Knowledge Versus Misconceptions |
about Cancer I
FIGURE 2. Cultural components of the judgment process central to breast cancer screening behavior.
CULTURE AND BREAST CANCER EARLY DETECTION 245
JUDGMENTS TO PARTICIPATE IN SCREENING
AND EARLY DETECTION
W o m e n use i n f o r m a t i o n f rom f ami ly m e m b e r s a n d f r i ends as wel l as the i n f o r m a t i o n t h a t
t h e y r e e e i v e f rom the m e d i a a n d the m e d i c a l c o m m u n i t y w h e n t h e y m a k e d e c i s i o n s a b o u t c a n c e r s c r e e n i n g . 29,32,34,63,64,77,95-9s W o m a n - t o -
w o m a n c o m m u n i c a t i o n of c a n c e r - r e l e v a n t in fo rma- t i on is i n c r e a s i n g l y b e i n g s t u d i e d for c u l t u r a l differences in the a m o u n t of social suppor t requ i red to improve cance r screening par t ic ipat ion.
F igure 2 shows the r e p o r t e d d i r e e t effect of e d u c a t i o n a n d the i n d i r e c t effect of i n c o m e on b o t h (1) b r e a s t c a n c e r k n o w l e d g e a n d m i s c o n c e p - t ions a n d (2) p e r s o n a l r i sk p e r c e p t i o n . At t h e s a m e t i m e i t r e m i n d s us t h a t c o m m o n l y e x p r e s s e d be l ie fs a b o u t c a n c e r r i sk a n d c u r e a r e p o t e n t i a l l y inf luent ial on bo th of these as well. The mode l s tresses tha t cul tural beliefs are d iverse ly inco rpora t ed by each individual w o m a n and tha t this individual i n t e r p r e t a t i o n of c u l t u r e will m a n i f e s t as d ive r s e e x p r e s s i o n s of c u l t u r a l l y a p p r o p r i a t e b e h a v i o r .
CONCLUSION
T his d i s c u s s i o n of t h e r e p o r t e d c u l t u r a l l y r e l e v a n t i n f l u e n c e s on b r e a s t c a n c e r s c r e e n i n g
a n d e a r l y d e t e c t i o n b e h a v i o r s has b e e n brief . A n e x t e n s i v e r e f e r e n c e l is t to e n c o u r a g e r e a d e r s to e x p l o r e t h e s e r e p o r t s is i nc luded . T h e s e p u b l i s h e d r e p o r t s d o c u m e n t i n c r e a s i n g v a l u a t i o n of t h e ea r ly d e t e e t i o n of e a n e e r ac ro s s c u l t u r a l g roups . Cur -
r e n t r e s e a r c h s e e m s d i r e c t e d m o r e a t d i s c o v e r i n g
a p p a r e n t d i f f e rences t h a n a t i den t i fy ing s imi l a r i -
t ies , a n d t h e r e a re few w a r n i n g s a b o u t s t e r e o t y p -
ing i n d i v i d u a l s w h e n a p p l y i n g a n y of t he p u b l i s h e d
f indings . A s ign i f i can t l i m i t a t i o n of th i s w o r k was the t e n d e n c y to g e n e r a l i z e t h e f ind ings of sma l l
s a m p l e s t ud i e s to t h e l a rge r c u l t u r a l g roup , m a k i n g
a s s u m p t i o n s of s ign i f i can t d i f f e rences b e t w e e n g roups t h a t t h e s e a u t h o r s w o u l d v i ew as p r e m a -
ture . T h e m a j o r i t y of t h e l a rge r s tud i e s s i m p l y
r e p o r t v a r y i n g r a t e s of s e r e e n i n g a n d e a r l y
d e t e e t i o n b e h a v i o r b y race , e t h n i e i t y , i n e o m e , age,
o r o t h e r d e m o g r a p h i c iden t i f i e r . W h i l e d i f f e rences
in s c r e e n i n g a n d e a r l y d e t e c t i o n b e h a v i o r s h o u l d
be e x p l o r e d , fund ing s h o u l d be w i t h h e l d f rom
sma l l s a m p l e e x p l o r a t i o n s of t h e s e d i f fe renees a n d d i r e c t e d t o w a r d the fol lowing: (1) i n v e s t i g a t i o n s of r e a s o n i n g a n d j u d g m e n t a b o u t h e a l t h s e rv i ees u t i l i z a t i o n t h a t i n c l u d e c u l t u r a l e x p e e t a n e i e s ; (2)
h e a l t h b e h a v i o r s tud ies t h a t e x a m i n e t h e i n t e r f a c e b e t w e e n cu l tu re , e d u e a t i o n , a n d e e o n o m i e s ; a n d
(3) t h e o r e t i c a l l y b a s e d s t ud i e s of h o w be l ie f s y s t e m s o r b e h a v i o r a l n o r m s c a n be i n t e r f a c e d w i th c a n c e r c o n t r o l s t r a t eg ies .
I m p r o v i n g p r a c t i c e t h r o u g h an i n f o r m e d u n d e r - s t a n d i n g of c u l t u r e cal ls for c o n s i d e r a b l e self-
e d u c a t i o n a n d a f u n d a m e n t a l r e f i n e m e n t of c a r e de l ivery . T h e r e have b e e n c o n s i d e r a b l e ga ins in t he a p p r e c i a t i o n of c u l t u r a l d i f f e rence as an
e n r i c h m e n t of o u r c o m m u n a l cu l tu re , a n d i n c r e a s - ing k n o w l e d g e of c u l t u r a l d i f f e rence has p r o m i s e for i m p r o v i n g t h e qua l i t y of o u t r e a e h c o n c e r n i n g t h e e a r l y d e t e c t i o n of c a n c e r for all w o m e n .
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