This course will explore current trends in cancer screening among racial and ethnic minority women, their cultural beliefs and perceptions about cancer and health care, attitudes toward cancer screening, how culture might specifically influence these attitudes, and structural, cultural, and personal/cultural barriers to cancer screening. This awareness and knowledge can assist in communicating to patients in a culturally sensitive manner and to developing culturally relevant screening promotion programs. To keep the course focused, it will only cover breast and cervical cancer screenings. As in any discussion about cultural groups, it is crucial to keep in mind that there is tremendous diversity within racial and ethnic minority groups and practitioners should be aware of the limits of their knowledge and seek assistance and consultation from cultural experts when needed.
This course is designed for all mental health and healthcare providers who may intervene to improve cancer screening adherence among racial/ethnic minority women.
NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.
NetCE designates this continuing education activity for 2 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards.
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Race and ethnicity appear to influence disparities in cancer screening among women. The purpose of this course is to increase practitioners' knowledge and awareness of how culture, race, and ethnicity influence women's behaviors and attitudes toward cancer screening.
Upon completion of this course, you should be able to:
- Define culture, race, and ethnicity.
- Explain demographic trends that lend to a multicultural landscape in the United States.
- Describe trends in diagnoses and fatalities due to cervical and breast cancer for racial/ethnic minority women.
- Explain how cultural beliefs influence racial/ethnic minority women's knowledge and beliefs about cancer and cancer screening.
- Identify barriers to cancer screening for racial/ethnic minority women.
- Discuss how cancer screening promotion can be tailored to be more culturally sensitive and relevant for racial/ethnic minority women.
- Identify culturally sensitive practice guidelines for practitioners in relation to cancer screening for racial/ethnic minority women.
Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.
Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.
Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
John V. Jurica, MD, MPH
Jane C. Norman, RN, MSN, CNE, PhD
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
- DEFINITIONS OF CULTURE, RACE, AND ETHNICITY
- RACIAL AND ETHNIC MINORITY GROUPS IN THE UNITED STATES: DEMOGRAPHIC PATTERNS
- DYNAMICS OF RACE, ETHNICITY, CULTURE, GENDER, AND HEALTH
- CANCER DIAGNOSES AND FATALITY TRENDS AMONG RACIAL AND ETHNIC MINORITY WOMEN
- IMPACT OF CULTURAL BELIEFS ON CANCER SCREENING
- BARRIERS TO CANCER SCREENING
- CULTURALLY SENSITIVE CANCER PREVENTION AND HEALTH PROMOTION MESSAGES
- LINGUISTICALLY APPROPRIATE SERVICES
- GENERAL BEST PRACTICE GUIDELINES WHEN WORKING WITH RACIAL AND ETHNIC MINORITY WOMEN
- Works Cited
- Evidence-Based Practice Recommendations Citations
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#91800: Cancer Screening Among Racial/Ethnic Minority Women
In general, cancer screening behaviors have increased in the United States over the past few decades. According to the National Health Interview Survey, approximately 29% of women older than 40 years of age reported having had a mammogram in the last 2 years in 1987; by 2010, this increased to 67% . However, what explains the 30% who have not been screened or who are underscreened? Research indicates that race and ethnicity play a role in the disparities in mammography and other cancer screenings .
The Healthy People 2020 goal for cervical cancer screening (i.e., Papanicolaou [Pap] test) is for 93% compliance with guidelines . However, some racial/ethnic groups have historically low cervical cancer screening rates. In 2009, 75% of white women 18 years of age or older had received a Pap test in the last 3 years . The rate was 80% for African American women and 75% for Hispanic women, but only 69.4% for Native American/Alaska Native women and 65.6% for Asian American women. In some ethnic subgroups, the screening rates are even lower .
Culture, race, and ethnicity influence many health dimensions, including how health information is received, where and how health services are obtained, how a health problem is defined, what type of treatment is believed to be warranted, and how symptoms are manifested and expressed . Because culture, race, ethnicity, and gender are intertwined and create intersections of power, oppression, and marginalization, this influences the health experiences of women of color [7,8]. Given the ever-increasing multicultural diversity in the United States, culturally competent and sensitive practice is essential for practitioners, and it is inevitable that practitioners will work with clients from diverse racial and ethnic backgrounds.
This course will explore current trends in cancer screening among racial and ethnic minority women, their cultural beliefs and perceptions about cancer and health care, attitudes toward cancer screening, how culture might specifically influence these attitudes, and structural, cultural, and personal/cultural barriers to cancer screening. To keep the course focused, it will only cover breast and cervical cancer screenings. As in any discussion about cultural groups, it is crucial to keep in mind that there is tremendous diversity within racial and ethnic minority groups and practitioners should be aware of the limits of their knowledge and seek assistance and consultation from cultural experts when needed.
Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [9,10]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations . Culture can also represent worldviews—encompassing assumptions and perceptions about the world and how it works . Culture helps to elucidate why groups of people act and respond to the environment as they do .
On the other hand, race is linked to biology. Race is partially defined by physical markers, such as skin or hair color . It does not refer to cultural institutions or patterns, but it is generally utilized as a mechanism for classification. In modern history, skin color has been used to classify people and to imply that there are distinct biological differences within populations . Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification. Racial characteristics are also assigned differential power and privilege, lending to different statuses among groups .
Ethnicity is also a complex phenomenon and has been defined in many different ways. Alba identified four components of ethnicity :
When ethnicity is viewed as social class, the individual's ethnicity is compared to or equated with their socioeconomic class (e.g., working class or lower class). This is most clear in ethnic enclaves, the residents of which have strong cultural and familial ties .
Ethnicity may also be associated with persecution, both political and social. Ethnic unity may serve as a tool for social change and political reform . Several famous ethnic movements took place in the 1960s, such as the unification of farm workers headed by César Chávez. Ethnicity has also been viewed as a return to traditions, characterized by a renewed interest in ethnic foods, traditional religious practices, native language, and folklore . Finally, ethnicity is also acknowledged as being a symbolic token, a way for individuals to maintain a nostalgic connection to their homeland .
The role of race, ethnicity, and culture in the development of health disparities is controversial. Although a discussion of the many causes of health disparities is beyond the scope of this course, it is important to know that it is a complex, multi-faceted issue rooted in biological vulnerabilities, differential access to resources, environmental conditions, and a range of social, cultural, and economic factors . Some of these factors will arise when discussing cancer screening among racial and ethnic minority women.
According to U.S. Census data, the minority population in the United States reached 100.7 million in 2007, which translates to 1 in 3 Americans being a member of a racial/ethnic minority group . Hawaii, New Mexico, California, the District of Columbia, and Texas are regions in the United States that consist of a "majority-minority," meaning that more than half of the areas' populations consist of individuals who are an ethnicity other than non-Hispanic white .
Hispanics are the largest minority group in the United States, and as of 2011, they numbered 52 million or 16.7% of the U.S. population . The second largest group is African or black Americans, followed by Asian Americans .
"African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or blacks as persons "having origins in any of the Black racial groups of Africa" . It includes people who indicate their race as "Black, African American, or Negro," or provide written entries such as "African American, Afro American, Kenyan, Nigerian, or Haitian." As a group, African Americans have struggled for civil rights, liberty, cultural pride, and identity, giving the term sociopolitical weight as well .
According to the U.S. Census, African Americans constitute 14% of the U.S. population, numbering at 43.9 million . By 2060, it is projected they will comprise 18.4% of the U.S. population. This group tends to be young; 30% of the African American population in the United States is younger than 18 years of age. In terms of educational attainment, 18.4% have a Bachelor's degree or higher .
The 2010 U.S. Census indicated that 14.7 million Americans identify as solely Asian . This number increases to 17.6 million when including persons of Asian and another race, which represents 5.6% of the total U.S. population . Between 2000 and 2010, Asians experienced the greatest growth compared to any other racial group at 43% . It is estimated that there will be 40.6 million Asian Americans by 2020, 9% of the U.S. population .
"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent . This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others . There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands .
Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [29,30]. The diversity of this group makes generalizations difficult.
The terms "Hispanic" and "Latino" are used to identify individuals who self-identify as having origins in Spain or Spanish-speaking countries, such as Mexico, Guatemala, Peru, Ecuador, or the Dominican Republic . The majority of the Hispanic population in the United States (65%) identify themselves as being of Mexican descent . Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian .
As noted, Hispanics are the largest minority group in the United States, including 52 million residents or 16.7% of the population . By 2050, Hispanics are expected to represent 24.4% of the U.S. population . Between 2000 and 2010, there was a 40% growth in the Hispanic population . Alabama, Arkansas, Kentucky, Mississippi, North Carolina, Tennessee, and South Carolina witnessed the most growth during this period .
The Native American population is extremely diverse. According to the U.S. Census, the terms "Native American," "American Indian," or "Alaska Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America . In the United States, there are 562 federally recognized tribal governments .
The Native American population grew 18% between 2000 and 2010 . As of 2011, Native Americans and Alaska Natives numbered 5.1 million, constituting 1.6% of the total U.S. population. By 2050, this number is projected to increase to 8.6 million, or 2% of the total U.S. population . In general, this group is young, with a median age of 31.3 years compared to the general population median age of 37.3 years. Approximately 30% are younger than 18 years of age . The states with the greatest number of residents identifying as Native American are California, Oklahoma, and Arizona .
The theory of intersectionality argues that it is not only culture, race, ethnicity, and gender (or other social constructs like social class, sexual orientation, or religion) that influence behaviors; no one single factor acts independently. Gender, culture, and race/ethnicity work synergistically to influence patterns of societal, community, familial, and individual expectations; processes of daily life; intrapsychic processes; and social interactions .
Gender is defined by existing institutions and ideologies and is imbued with views about power differentials. In terms of health care, patriarchal ideologies about women's roles can interfere with women's autonomy and decision-making behaviors regarding financial issues or even the determination of conditions severity and the need for medical attention . For example, South African women in one study reported they were not permitted by their husbands to visit women's health clinics for contraception, and some were even beaten for visiting mobile health clinics for cervical screenings without having obtained their husband's permission .
Similarly, culture influences how individuals respond to or perceive a particular health issue. The role of culture or traditionality in cancer screening is very complex, and the findings are mixed, in part because researchers have defined these terms differently. On one hand, adherence to one's cultural traditions may impede cancer screening. Some of this is due to traditional spirituality. For example, certain Native American groups believe talking about cancer will somehow invoke the spirits and cause one to get cancer . Other cultures may have strict sexual taboos and an emphasis on modesty. For example, the Chinese emphasize cultural values of sexual modesty, and knowing too much about one's body, particularly one's sexuality, is considered socially inappropriate . Similarly, Muslim immigrant women have reported privacy concerns regarding routine gynecologic prevention care . Finally, preferences for traditional medicine approaches can also influence cancer screening behaviors, particularly for many Asian women .
Yet, there have been some studies that demonstrate the positive influence of culture on cancer screening. In a study with members of the Hopi tribe of Native Americans, researchers found that Hopi women who attended cultural ceremonies were almost twice as likely to have had a mammogram in the past two years as those who did not attend .
According to the American Cancer Society, African Americans have the highest death rate and shortest survival for all cancers compared to other racial minorities in the United States, with a 16% higher mortality rate compared to their white counterparts . There are many reasons for this disparity, including socioeconomic, cultural, and institutional factors that contribute to health disparities in general for this group.
In 2013, it was projected that 176,620 new cancer cases were expected for African Americans, with 82,080 of these cases occurring in women . The leading sites of new cancer cases among African American women are the breast, lung/bronchus, and colorectum . Beginning in the 1980s, the breast cancer incidence rates among African American women increased significantly, in part because of the increased education in early detection. The incidence rates have now stabilized, and today, African American women's risk of developing breast cancer is 10% lower than white women. However, African American women tend to develop breast cancer younger (e.g., before 40 years of age) . Furthermore, the five-year survival rate for breast cancer is the lowest for African American women compared to all other racial/ethnic minority groups and white women (79% vs. 91% for white women) .
African American women have the second highest rate of cervical cancer diagnoses and the greatest associated mortality rate of all racial/ethnic groups. This disproportionate burden is believed to be related primarily to unequal access to health care extending to a lack of screening.
In the past, African American women had lower mammography screening rates than white women, but these rates are now approximately the same . However, a disparity in breast cancer mortality rates persists, and some have suggested that this may be due to lack of appropriate follow-up after an abnormal mammogram . Pap test use is slightly lower, at 80.2% for African American women compared to 81.4% of white women. In a 2011 study of African American women who frequented beauty salons in North Carolina, several demographic variables were found to predict Pap test and mammography use . African American women who had an annual household income of at least $50,000, had health insurance, were currently working, and reported being in excellent/very good health tended to have had a Pap test in the past 3 years. For mammography screening, age (i.e., 50 years or older), having health insurance, having had a Pap test, and reporting having excellent/very good health predicted having a mammogram in the past year.
Communication of mammogram results may perpetuate screening disparities among African American women. In a study comparing the adequacy of the communication of mammography results to African American and white women, African American women were more likely to report receiving inadequate communication of their results compared to white women . This was especially true when results were abnormal.
In general, Asian Americans have the lowest cancer rates of all racial/ethnic minority groups. However, it is the leading cause of death for this population, largely due to health disparities in seeking preventive care and differences in cancer site frequency. Asian American women are 30% less likely to develop breast cancer compared to white women, but they are three times more likely to be diagnosed with stomach cancer .
There is tremendous diversity within the Asian American population, and this extends to cancer rates as well. Chinese women have the highest lung cancer death rates among Asian American subgroups, and Laotian, Samoan, and Vietnamese-American women have the highest rates of cervical cancer . These three ethnic groups also have the lowest cancer screening usage rates . Korean women have the highest incidence of and mortality rates from stomach cancer, and Filipino women have the greatest breast cancer death rates .
It appears that acculturation and years of residing in the United States are variables that affect cancer rates among Asian immigrant women. For Asian women who immigrate to the United States, their risk of developing breast cancer increases six-fold, and Asian women who have lived in the United States for at least one decade have an 80% higher risk of breast cancer compared to more recent immigrants . It is speculated that this is due to the changes in diet, physical activity, and the environment.
In a 2010 study, researchers found that the gap between the highest and lowest rates of breast cancer screening among Asian American women was more than 30% . Japanese women had rates of 70.6% for mammograms within the past 2 years, but South Asian and Korean American women had rates of 40.3% and 46%, respectively.
Overall, the rates of cervical cancer screening within the last 3 years were higher than mammogram use among the Chinese, Filipina, Korean, Japanese, and South Asian women, although Korean women scored the lowest for cervical cancer screening . For both mammograms and cervical cancer screenings, having higher income, being married, being born in the United States, having health insurance, and having perceived good health predicted the likelihood of having had breast and cervical cancer screenings .
The American Cancer Society estimates that half of Hispanic men and one-third of Hispanic women will be diagnosed with cancer during their lifetime . Cancer is the leading cause of death for Hispanics, accounting for more than 20% of all deaths . In general, Hispanics have lower all-site cancer incidence and mortality rates compared to non-Hispanic whites. For example, Hispanic women are 30% less likely to develop breast cancer compared to non-Hispanic white women . However, the rates of developing stomach, cervical, liver, and gall bladder cancers are higher in the Hispanic population than among whites .
For Hispanic women, breast cancer is the leading cause of cancer-related deaths, followed by lung/bronchus cancer . Data shows that breast tumors in Hispanic women tend to be larger at diagnosis compared to their non-Hispanic white counterparts, perhaps explained by lower mammography screening rates among Hispanic women . The five-year breast cancer survival rate for Hispanic women is 86%, compared to 91% for white women . Hispanic women are 1.5 times as likely to be diagnosed with cervical cancer and 50% more likely to die from cervical cancer compared to their white counterparts .
As discussed, the breast cancer incidence is lower for Hispanic/Latina women compared to white women, but Hispanic women tend to have larger tumors and be at a more advanced stage at diagnosis. They are also more likely to have cervical cancer than white women. In a 2009 study, researchers asked Hispanic and non-Hispanic white woman whether they obtained mammograms annually according to the screening guidelines established by the American Cancer Society . Slightly fewer Hispanic women reported adhering to the guideline (42.3%) compared to non-Hispanic white women (44.6%). Hispanic women who had a family history of breast cancer, who were younger (50 to 59 years of age), who had hormone replacement therapy, and who performed regular breast self-examinations were more likely to adhere to the guidelines.
Hispanic women are also less likely to engage in cervical cancer screening compared to white women, and language barriers are a major predictor of non-utilization . Hispanic women who are proficient in English are more likely to report obtaining a Pap test within the last 3 years compared to those less proficient in English .
Screening rates for Hispanic/Latina women from lower socioeconomic areas are even lower. An estimated 36% of Hispanic/Latina women with lower incomes had received a mammogram within the past year and 55% had a Pap test within the past 3 years [63,64].
Like other racial/ethnic minority groups, age, income, employment, and health insurance predict mammography and Pap test use in this group. However, when a healthcare provider, particularly a physician, recommends a mammography and/or a Pap test, the likelihood of having received these screenings increases .
In general, cancer rates are lower for Native American women when compared to whites. However, there are some interesting racial differences among the different types of cancers. Native American women are 30% more likely to be diagnosed with kidney cancer and 150% more likely to have liver cancer compared to their white counterparts . Lung cancer is the leading cause of cancer deaths for Native American women .
Between 2004 and 2008, the breast cancer incidence rate was 77.9 per 100,000 population for Native American women, compared to 135.9 per 100,000 population for white women . However, Native American women have the third highest cancer mortality rate among racial/ethnic minority groups . Their five-year breast cancer survival rate is lower (84%) than that of white women (91%) .
Rates of cervical cancer are also higher among Native American women compared to their white counterparts. When diagnosed, they tend to be in later stages . This has resulted in a disproportionately high cervical cancer mortality rate in this population. There also appears to be regional differences for this group. Native American women living in the northern plains have the highest cervical cancer mortality rates [69,70].
Like other racial and ethnic minority groups, women from Native American populations have low mammography and Pap test rates. Level of education, health insurance status, and access to health providers all impact screening rates. In 2010, 77.2% of Native American women had had a Pap test within the last 3 years, compared to 82.5% of white women . Native American women are also least likely of all racial groups to have received a mammogram within the past 2 years, with 63.9% complying with recommendations for screening, compared to the national rate of 75.4% .
Cancer screening rates also vary based on tribal affiliations and geographic regions. In a study of 559 Hopi Indian women living on reservations, researchers found that although 95% had ever had a Pap test, only 65% reported consistent annual screenings . Younger women (18 to 24 years of age) were more likely to have had an annual Pap test compared with those older than 25 years of age. Furthermore, women with less than high school education and those who refused to be screened by a male physician were less likely to report annual screenings.
Because breast cancer is the second leading cause of death for women in the United States but is treatable if diagnosed early, the American Cancer Society has recommended annual mammography screening for women 40 years of age and older . Engaging in annual biennial screening reduces the breast cancer mortality rate by approximately 20% to 25% over a ten-year period .
Once one of the most common cancers affecting women, cervical cancer now ranks 14th among all cancers in women, and this decrease is attributed largely to improved screening practices and the introduction of the human papillomavirus vaccine . However, rates remain high among some populations due in part to limited access to or participation in screenings. The American Cancer Society recommends that women begin to receive Pap tests at 21 years of age or within three years of the onset of sexual activity [46,49]. Adherence to these guidelines would be ideal, but disparities in the use of cancer screenings exist, and the reasons are multifaceted and complex.
Beliefs about health and illness are influenced by a variety of historical, cultural, and geographical factors . Cultural norms and values affect racial and ethnic minority women's beliefs about cancer and screening, and this is especially true among immigrant populations. This section will highlight recurrent cultural themes that appear to impact beliefs about cancer and cancer screening.
Many cultures believe that language has power to shape reality and change the course of life events. For example, some Native American tribes believe that if someone talks about cancer, particularly in the first person, this can bring about cancer . Many Asian cultures also believe that speaking about taboo topics will bring about the feared event. In a study of Chinese Australian women, participants reported that thinking and speaking about cancer would bring it to fruition . In the African American community, this process is referred to as "claiming;" by discussing cancer, one takes ownership of it, and therefore, there is the possibility of it happening. Conversely, if one does not discuss illness, the possibility is significantly reduced .
Fatalism is defined as the belief that one's fate is beyond his or her individual control . This belief is common in collectivistic cultures, which place emphasis on the larger community and social forces, versus individualistic cultures, which emphasize the notion of the self, autonomy, and self-determination. Fatalism is also intertwined with religious and spiritual beliefs.
Fatalism can influence beliefs about cancer and cancer screening among racial and ethnic minority groups. African Americans, for example, may believe that cancer is part of God's will and is a predetermined course for one's destiny. Because the cancer is destined to happen, one merely needs to accept it . Similarly, Asian Indians have a belief in karma and the idea that their destinies are not theirs to control. In these cultures, cancer (or any illness) may be considered necessary to balance karma. Korean immigrants often believe that cancer is a punishment from God or spirits for not living a moral life [76,77]. For others, fatalism is rooted in philosophical beliefs regarding yin and yang. For persons who include the concept of yin/yang in their belief systems, harmony with the environment is important, which translates to accepting the events of life that are predestined to occur .
In many cultures, discussions about sex and sex-related matters are considered taboo, and sex and gender roles are often intertwined. For example, in some Hispanic cultures, particularly traditional Puerto Rican families, marianismo is highly valued. Marianismo is a cultural value that stems from the Catholic belief in the Virgin Mary as the ideal of true femininity; it is considered the female counterpart to machismo . While unmarried, women are expected to be chaste, passive, and pure, and when married, women are not supposed to demonstrate interest in sex, although having children and being a mother are prized . These ideas regarding female sexuality and women's role as enforcers of moral purity can influence beliefs about breast and cervical cancer. For example, Hispanic women are more likely than white women to believe that breast cancer is caused by breast fondling, promiscuity or having multiple sexual partners, or initiating sexual activity at an early age [49,79]. Laced with this is the belief that breast cancer is a sign of God's divine punishment for immoral behavior . Therefore, women may feel that a breast or cervical cancer diagnosis is a sign that they have engaged in immoral behaviors and be shamed at having to tell their husband or family.
This same cultural taboo about discussing sexual matters applies to many Asian cultural groups. Cultural beliefs about modesty and inappropriate public discourse make discussions about and screenings for women's cancers difficult. Many Chinese women believe that talking about breast health is inappropriate and embarrassing . A study of Korean women indicated the women never thought about breast health or breast cancer because the term "breast" is not used in everyday conversations as it would be perceived to be inappropriate . Older Korean women, in particular, associated cervical cancer with immoral behaviors. For example, these women were more likely than younger Korean women to believe that they were more susceptible to cervical cancer if they had had abortions or had multiple sexual partners or if their husbands had promiscuous lifestyles .
Nudity can also be an issue, particularly if the healthcare provider is a man. In one study, Native American women tended to object to getting fully undressed and being exposed in an examination room. Having a male stranger conduct an exam was considered intrusive by these women [81,82].
A variety of health beliefs arise in various cultures and may result in cancer screening disparities. Misconceptions regarding the causes and manifestations of cancer are particularly damaging and can be difficult to dispel.
In one study of Chinese immigrant women, participants reported that if they felt healthy, they must be healthy. If no symptoms were present, they did not believe they could have cancer . This can be particularly damaging for cancers (like breast and cervical cancers) that are treatable if identified in early stages.
In several studies, ethnic minority immigrant women reported believing that proper hygiene reduced the risk of cervical cancer . In a study of Vietnamese immigrant women, the majority believed that cervical cancer could be prevented by proper hygiene, including cleaning procedures and observances of behaviors during menstruation . A study of Malaysian women revealed similar beliefs, with the women asserting that "dirtiness" in the vagina could lead to cervical cancer and the necessity for cleaning the vulva and vagina area after sex and during menses . Older Chinese immigrant women have reported that unhygienic conditions in China caused germs that then mutated to cervical cancer .
A 2005 study involving Latina immigrant women found that the women believed that improper care of the womb could lead to infections, which could then place one at greater risk for cervical cancer . Attributing the development of cervical cancer to sexual activity during menstruation was also adhered to by some Latina women .
Some Asian cultures believe that certain foods, including deep fried foods and preserved foods (e.g., dried fish, canned foods), may cause cervical cancer . In a study of Latina women, sugar substitutes, spicy foods, and foods that have been microwaved were believed to cause breast cancer .
In a focus group study with African American women, some participants expressed fear that a mastectomy could cause cancer to spread . In another study of Haitian immigrant women, participants shared the belief that x-rays from mammography screening could cause breast cancer .
Western medicine is based on the biomedical perspective and the disease model, which focuses on biological dysfunction and symptoms . According to this model, the physician handles the care of the patient and legitimizes that a disease is present . However, many cultures do not necessarily adhere to the biomedical approach. Instead, racial and ethnic minorities tend to have a more holistic view toward health, with a community aspect to illness and healing. There are several general common denominators underlying these health beliefs. First is the belief that diseases are caused by an imbalance between oneself and one's environment, such as bodily imbalance, problems in interpersonal relationships, or even sin . In a study of Chinese women in Australia, participants attributed the etiology of breast cancer to a lack of balance in the life force that runs through the body (referred to as chi) . Thus, daily life for many traditional Chinese women involves eating a "balanced" (from the yin and yang perspective) diet that includes herbal remedies and soups and being attentive to how wind, cold, and dampness affect the body . Such practices are viewed by Chinese women as more beneficial for the prevention of cancer than obtaining annual gynecological exams . Similarly, some groups (e.g., Haitian immigrants) believe that the centrality and equilibrium of blood that runs through the body and ensuring that the blood flow remains free by adhering to the proper temperature and digesting certain foods will prevent cancer . The use of herbs and other home remedies is an initial (or preventive) solution rather than a final resort.
Because racial/ethnic minority groups often believe the causes of disease are multifaceted and holistic, there is an emphasis on the self in relation to one's social environment and network [88,91]. It is typical to find a patient's social support network involved in the illness and problem solving; community ties are incorporated into the care of the patient. For example, spiritual and religious traditions and practices may be integrated into the healing process, and community or spiritual leaders are often involved in treatment .
At the individual level, barriers to cancer screening include issues related to access to care and health literacy. Racial and ethnic minorities in the United States are significantly less likely to have health insurance, making it difficult, expensive, and inconvenient for women to obtain regular mammograms and Pap tests . Over the past decade, co-payment requirements have increased with most insurance plans, and this increase is correlated with a decrease in cancer screenings . Less than 70% of women in cost-sharing plans were screened, compared with nearly 80% of fully covered women. This disproportionately affects African American women, women with lower levels of education, and women in lower socioeconomic levels. Those who are uninsured are even less likely to receive screenings .
Lack of a regular physician can also reduce screening rates. In one study, recent immigration and lack of a regular physician were the greatest risk factors for not having a recent Pap test among minority women . Another issue is the amount of time and resources that women have to devote to their health care. In one study, Malaysian women reported being stressed by the competing demands of life, which resulted in their health being a low priority . This may be partially the result of stricter adherence to traditional gender roles, with women responsible for all home and child care. Hispanic women in focus groups discussed similar issues regarding relegating their health needs due to their daily struggles with life maintenance issues (e.g., caring for children, cooking) . Even for older women, childcare issues may remain if they are caring for grandchildren.
One qualitative study noted that cancer screening is still costly in terms of time and finances for older women because they often rely on family members for transportation, resulting in absence from work and arrangements for childcare . For many immigrants, family members attend healthcare appointments to serve as interpreters . The perceived inconvenience is exacerbated by the locations of clinics and long waits for appointments [84,96]. Creating a stable home life for their families is considered more urgent for African American women than preventive health care [96,99].
Lack of accurate knowledge about cancer and screenings also contribute to the lower rates of screening in minority populations. For example, a survey of Latina women found a common belief that breast cancer is incurable and that mammography is only necessary when symptoms emerge . As discussed, the absence of symptoms is a prevalent justification for avoiding screenings . Other women may simply be unfamiliar with mammography and how it can detect cancer. In a focus group with Filipina immigrant women, participants discussed inaccessibility of mammograms in the Philippines, where they are considered luxuries and are only available in large cities like Manila .
Degree of sexual activity also predicts Pap test and mammography use. In a study of Asian and Latina college students, Latina students who were sexually active were five times more likely to obtain breast cancer screening than their non-sexually active counterparts; Asian students were nine times more likely to obtain a mammogram if they were sexually active . Researchers posited those who are sexually active are more likely to see a gynecologist and be referred for screening.
Many racial and ethnic minorities feel that the healthcare system is marginalizing, making it difficult to access health services. A survey of Mexican immigrant women described long waits at clinics, and women who sought mammography screening reported feeling the process was impersonal and uninformative . Ultimately, these women felt they were disrespected because of their poverty, and their experiences reinforced their reluctance to seek health services.
In a focus group study with Native Hawaiian women with inadequate or no health insurance, participants were reluctant to access free screening services. This unwillingness stemmed from fears that they would be judged negatively and be discriminated against . They were also suspicious of the free services, with these fears stemming from past experiences with discrimination. Other minority groups have reported feeling like "second-class citizens" in the healthcare system .
In a focus group study with African American women about barriers to mammography screening, they expressed anxiety about the interactions with their providers . They were concerned they would be treated with disrespect and did not have much faith and trust toward their physicians; most had a history of poor healthcare encounters, particularly with failures in communication. This reinforced their negative perceptions about the healthcare system and their fears about screenings .
Another reason women may not seek medical services is general mistrust of Western medical institutions. Fears about medical incompetence and historical events involving the intentional harm of some groups, particularly African Americans, contribute to this barrier .
As discussed, the cultural values of fatalism, modesty, and manifestation through language serve as strong cultural barriers to seeking cancer screenings for many racial and ethnic minority women. The cultural value of collectivism can also serve as an impediment. Small communities (e.g., immigrant communities) make anonymity difficult, and some women may feel they will disgrace their families and be shamed if others find out about a diagnosis of cervical cancer, as this is believed to imply sexual immorality and promiscuity .
Communication patterns and styles can also inhibit racial and ethnic minority women from fully maximizing the time with their provider. For example, Asian communication styles tend to be more indirect, relying on nonverbal cues. In Japanese culture,omioyari, which refers to the cultural concept of empathy and intuition, is an important part of communication . Some Japanese women rely on physicians to sense what they need rather than inquiring directly; questioning is perceived to be asking for favors or a waste of the physician's time . In a qualitative study with Filipinas, the women indicated that they preferred a more "soft," indirect way of communicating. Among this group, being forthright and direct in communicating their needs or questions was equated with begging .
Some racial and ethnic minority women have a strong preference for a female physician or provider to conduct mammograms and/or Pap tests. Other women prefer a physician from their own racial/ethnic minority group. In one study, Hispanic women stated that they preferred to have a provider who was also Hispanic, but it was more important that the provider could speak Spanish . Asian women preferred a female provider due to their feelings of embarrassment and privacy about having a male provider touch them. Some Asian women expressed a preference for physicians with training from prestigious medical schools; this could be partially explained by the emphasis on education in Asian cultures .
Another barrier is physicians not referring racial/ethnic minority women for Pap tests or mammograms. New immigrants or those who are not proficient in English may not know where to seek screenings, and a physician referral to a specific location increases the odds of seeking preventive care. In a study with African American women, the best predictor to getting a mammogram was having had a screening in the past . Past health behaviors appear to be salient in influencing future health behaviors.
The high perceived cost of cancer screening is a barrier for many women from racial and ethnic minority groups. In a study with 897 white, African American, and Native American women, perceived cost of a mammogram, whether accurate or not, was a major barrier to screening; more than half of the women cited costs as a reason they had not sought screening . About 52% overestimated the costs associated with the test, and these women had a greater likelihood of not having a mammogram compared to those with an accurate perception of the costs .
Racial and ethnic minorities are often considered hard-to-reach, but experts have asserted that they are instead hardly reached . The one-size-fits-all model of healthcare provision is not culturally sensitive or relevant and therefore does not reach this group. When working with racial and ethnic minority groups or those who are new immigrants, it is important for practitioners to remain flexible and open to negotiation. Serving these patients involves practicing in what Donnelly calls an "in-between space—a space where the practice of Western biomedicine model, Western knowledge, and values intersect with Eastern medicine, knowledge, and values" . Simply impressing Western values regarding health and illness on minority women does not empower them to change their behaviors; instead, it reinforces their preconceived notions about the healthcare system being marginalizing .
Developing culturally sensitive and relevant health prevention education for breast and cervical cancer screenings requires active listening. Recommendations for improving cancer knowledge among racial ethnic minority women include :
More information in the relevant language(s) should be offered and disseminated through mass media (e.g., radio, television, newspapers) that target the various racial and ethnic minority groups.
Cancer community workshops can be offered in local communities.
Educational materials about cancer prevention should be available in a variety of non-English languages.
Health fairs can be offered in the community and can include free medical services.
Health information and announcements in the relevant languages can be posted in public areas (e.g., ethnic grocery stores) and also on public transportation.
When trying to reach racial/ethnic minority women, it is important to consider how mammogram and Pap test screening messages are framed . For example, the word "cancer" can evoke dread and fear for many women, with several cultures attributing the power to cause illness to the word. Similarly, some women may believe that the only "real" cancers are those in the late stages. However, if cancer screening is couched within a discussion about benign tumors, emphasizing the importance of early detection, then the message will be better received . Instead of employing the word "cancer," the terms "tumors" or "lumps" could be employed as a way to start a dialogue.
Cancer screening promotion messages should be framed within the context of holistic health maintenance. Many cultures believe that good health is the result of harmony of the mind, body, and environment, and preventive medicine can be a part of this . Mammograms and Pap tests can be discussed within the overall context of physical, spiritual, and emotional health.
When caring for minority and immigrant women, practitioners must be willing to discuss religion and spirituality and to acknowledge the connection of the mind, body, and spirit for many racial and ethnic minority groups . This may be a foreign concept for many providers practicing within the Western biomedical model which adheres to an empirically based disease model with an emphasis on diagnosing and treating disease . Practitioners should strive to become comfortable talking about prayer and taking care of one's spiritual health, which is viewed as a pathway to physical health for many racial/ethnic minority groups [74,109].
Peers and family members are often the most effective communicators of both accurate and erroneous health messages. On the one hand, they may disseminate medical information that is inaccurate or relate sensationalized anecdotes about health and remedies . Alternatively, the family and peer network is frequently the most relied upon source of health information. In one survey, Filipino American family members frequently encouraged their female relatives to seek breast cancer screenings . In many cases, a best friend, daughter, or other important person may have more power to influence a woman to obtain mammograms than a physician or husband .
Language barriers are one of the major predictors of health disparities in breast and cervical cancer screenings. In an analysis of a large study of multiethnic women undergoing menopause, the researchers found that women who indicated not being able to read or speak English at all or who were less proficient were less likely to have had breast and cervical cancer screening compared to those who could read and/or speak English. These differences could not be accounted for by other variables such as number of years residing in the United States or contact with a physician or hospital .
Obtaining cancer educational materials translated to the appropriate language can be difficult, but resources are available. One valuable service is from the Asian American Network for Cancer Awareness: Research and Training (AANCART). Co-sponsored by the American Cancer Society, AANCART provides a web tool to access translated cancer information materials in various Asian languages. The National Cancer Institute has a Spanish-language website with information about screening recommendations and patient education handouts.
In some instances, interpreters may be needed. Practitioners often consider interpreters neutral parties who communicate information back and forth, but in reality, their role can be much more complex. The role of the interpreter can be conceptualized along a continuum, with "neutral" at one end and "active" at the other . On the neutral end of the continuum are interpreters who essentially act as conduits; at the other end are interpreters who are active cultural brokers and participants in the healthcare process. Most commonly, interpreters in healthcare settings are viewed as conduits of information, which can be dehumanizing . It is implicit in the assumptions of this model that interpreters should/can all be the same, with no individuality, and that the interpretation process and experience is universal .
Another perspective is that the interpreter is an active agent, negotiating between two cultures and assisting in promoting culturally competent communication and practice and in determining a diagnosis . As co-diagnosticians, interpreters determine which medical information is valuable, seek illness-related information outside of the provider's questions, and participate in the diagnostic process by identifying symptoms the provider may not have directly asked about . In this more active role, the interpreter's behavior is also influenced by cultural variables, such as gender, class, religion, educational differences, and power/authority perceptions of the patient . Consequently, an intricate, triangular relationship develops between all three parties.
Specific qualities are necessary for interpreters to help negotiate communication between healthcare professionals, patients, and family members, including :
Ability to negotiate tension between strictly interpreting word-for-word versus being an advocate, cultural broker, and/or educator
Awareness that language and culture are two different dimensions (i.e., the interpreter and the patient/family may speak the same language but be from two different cultures)
Ability to negotiate time spent with family members and the patient
Willingness to address religious or spiritual issues that arise in the clinical encounter
Awareness of personal discomforts that may arise given the sensitive and stressful nature of the encounter
For many racial and ethnic minority women, health is holistic and multidimensional, consisting of not only the physical body but the emotional, social, spiritual, and cultural health as well . Social health refers to one being comfortable, living stress-free, and being in control of one's living environment. This may be a significant issue for immigrant women, as they live in a country in which they are constantly negotiating new systems and usually learning a new language. Impaired social health then affects their overall health . Messages about the importance of cancer screenings often focus only on physical health, which may be a small part of the holistic health perspective. The goal is not to discard the preventive methods, but rather to reframe the messages so they are relevant to the lives of racial and ethnic minority women and therefore more effective.
In collectivist cultures, individuals' roles as part of a larger group are paramount, with an emphasis placed on interdependence . There are three major elements of collectivist orientation: interdependence; familiarity, caring, and trust; and sense of obligation . The family and the church are concrete representations of this cultural norm, and they influence many behaviors, including health decisions. This translates into cancer prevention and education in that the relationship, connection, and trust between the messenger and the recipient have more importance than the message . Therefore, when practitioners deliver a health message in a personal manner that communicates that they can be trusted and that they care, the message will be viewed as more credible and is more likely be acted on. If a patient sees the same practitioner at every (or most) visit, there are more opportunities to establish a therapeutic alliance, ensuring that health behaviors are maintained.
Cancer screening messages can also be framed within the context of family commitment and well-being . For example, women may be told that mammograms and Pap tests promote family well-being and obtaining these screenings is a symbol of their pledge to the overall functioning of the family.
Styles of communication can be classified from high- to low-context . High-context cultures are those that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties . Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed . On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in a conversation . Consequently, low-context communicators listen with their ears and focus on what is being said . Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are from high-context cultures .
Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communicating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. A Chinese American male social worker may not necessarily be a high-context communicator because he is Asian. A host of factors, such as gender, level of acculturation, upbringing and socialization, education, and family immigration history, will all play a role in how one learns to communicate.
Most practitioners have been taught and socialized in a Western biomedical environment in which communication styles are direct (i.e., low-context). This is evidenced by the following common behaviors :
Asking questions to obtain more information about the medical condition
Checking for information (e.g., side-effects, symptoms)
Directing and advising (e.g., telling a patient the necessary treatment)
Summarizing (e.g., recounts of the patients' accounts of feelings)
The literature has shown that because many racial and ethnic minority patients view healthcare professionals as authority figures, they expect a direct communication style on the receiving end . However, as communicators, they do not necessarily utilize the same direct communication style and expect the professional to infer the underlying meanings of what they express.
Some experts suggest a community capacity enhancement approach to cancer prevention when working with racial and ethnic minority communities . This involves using existing community resources and ties and determining mechanisms to strengthen these links. The community capacity enhancement model can help reduce any perceived differentials in authority when "outsiders" enter into communities and begin implementing health services. In many communities, this will mean involving churches and other religious and spiritual institutions. Ministers, pastors, and church board members, such as female deaconesses, are often viewed as credible and trustworthy and can be effective communicators of breast and cervical cancer screening messages [102,122]. The "witnessing" of a survivor of breast cancer about her experiences can touch segments of the population that are considered "hard to reach" .
Despite the specific guidelines for mammograms and Pap tests and the increased education about adhering to these guidelines, racial and ethnic minority women continue to have lower rates of cancer screenings compared to their white counterparts. Cultural factors play a role in health beliefs, which then impacts health prevention behaviors, including cancer screenings. Cultural health beliefs should be honored and incorporated into the provision of services to patients either individually, within the family system, or in the community. Frequently, racial and ethnic minority communities are labeled as "hard-to-reach," but in reality they are hardly ever reached. When developing culturally sensitive intervention, prevention, and educational strategies to promote positive cancer screening behaviors, practitioners should work with the existing resources in the community in order to promote the cultural practices and beliefs and more effectively convey the importance of cancer screenings.
|African American Breast Cancer Alliance|
|Asian and Pacific Islander National Cancer Survivors Network|
|Center for Disease Control and Prevention Office of Minority Health and Health Disparities|
|Intercultural Cancer Council|
|National Alliance for Hispanic Health|
|Native American Cancer Research Corporation|
|Asian American Network for Cancer Awareness, Research, and Training (AANCART)|
|Instituto Nacional del Cáncer|
|The Office of Minority Health|
|Redes En Acción: The National Latino Cancer Research Network|
|Sisters Network, Inc.: A National African American Breast Cancer Survivorship Organization|
1. U.S. Department of Health and Human Services. Health, United States, 2011, With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: U.S. Department of Health and Human Services; 2012.
2. Schueler KM, Chu PW, Smith-Bindman R. Factors associated with mammography utilization: a systematic quantitative review of the literature. J Womens Health. 2008;17(9):1477-1498.
3. U.S. Department of Health and Human Services. Healthy People 2020. Available at http://healthypeople.gov/2020. Last accessed November 18, 2013.
4. National Center for Health Statistics. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD: National Center for Health Statistics; 2010.
5. Taylor VM, Yasui Y, Nguyen TT, et al. Pap smear receipt among Vietnamese immigrants: the importance of health care factors.Ethn Health. 2009;14(6):575-589.
6. Office of Minority Health. What is Cultural Competency? Available at http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11. Last accessed November 18, 2013.
7. Crenshaw KW. Mapping the margins: intersectionality, identity politics, and violence against women of color. In: Fineman MA, Mykitiuk R (eds). The Public Nature of Private Violence. New York, NY: Routledge; 1994: 93-118.
8. Wamala S, Ahnquist J, Mansdotter A. How do gender, class and ethnicity interact to determine health status? Gender Stud. 2009;18(2):115-129.
11. Hodge JL, Struckmann DK, Trost LD. Cultural Bases of Racism and Group Oppression. Berkeley, CA: Two Riders Press; 1975.
12. Sue DW, Sue D. Counseling the Culturally Different: Theory and Practice. 6th ed. New York, NY: John Wiley & Sons; 2013.
13. Jackson AP, Meadows FB. Getting to the bottom to understand the top. J Couns Dev. 1991;70:72-76.
15. Harawa NT, Ford CL. The foundation of modern racial categories and implications for research on black/white disparities in health. Ethn Dis. 2009;19(2):209-217.
16. Okazaki S, Saw A. Culture in Asian American community psychology: beyond the East-West binary. Am J Community Psychol. 2011;47(1/2):144-156.
17. Alba RD. Ethnic Identity: The Transformation of White America. New Haven, CT: Yale University Press; 1992.
18. Green JW. Cultural Awareness in the Human Services: A Multi-Ethnic Approach. 3rd ed. Boston, MA: Allyn and Bacon; 1999.
19. Richardson LD, Norris M. Access to health and healthcare: how race and ethnicity matter. Mt Sinai J Med. 2010;77(2):166-177.
20. U.S. Census Bureau. U.S. Census Bureau Projects Show a Slower Growing, Older, More Diverse Nation a Half Century from Now. Available at http://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Last accessed November 18, 2013.
21. U.S. Census Bureau. U.S. Hispanic Population Surpasses 45 Million, Now 15 Percent of Total. Available at http://www.census.gov/newsroom/releases/archives/population/cb08-67.html. Last accessed November 18, 2013.
22. U.S. Census Bureau. Press Release: Most Children Younger than Age 1 are Minorities, Census Bureau Reports. Available at http://www.census.gov/newsroom/releases/archives/population/cb12-90.html. Last accessed November 18, 2013.
23. U.S. Census Bureau. 2010 Census of Population: Public Law 94-171 Redistricting Data. Available at http://www.census.gov/rdo/data/redistricting_data.html. Last accessed at November 18, 2013.
24. Airhihenbuwa CO, King G. African Americans. Available at http://www.healthline.com/galecontent/african-americans. Last accessed November 18, 2013.
25. U.S. Census Bureau. Black (African-American) History Month: February 2013. Available at http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb13-ff02.html. Last accessed November 18, 2013.
26. U.S. Census Bureau. Overview of Race and Hispanic Origin: 2010. Available at http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf. Last accessed November 18, 2013.
27. U.S. Census Bureau. Asian/Pacific American Heritage Month: May 2013. Available at http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb13-ff09.html. Last accessed November 18, 2013.
28. Lee E. Asian American families: an overview. In: McGoldrick M, Giordano J, Pearce JK (eds). Ethnicity and Family Therapy. 2nd ed. New York, NY: The Guilford Press; 1996: 227-248.
29. U.S. Census Bureau. We the People: Asians in the United States: Census 2000 Special Reports. Available at http://www.census.gov/prod/2004pubs/censr-17.pdf. Last accessed November 18, 2013.
30. Lee E. Working with Asian Americans: A Guide for Clinicians. New York, NY: The Guilford Press; 1997.
31. U.S. Census Bureau. Hispanic Origin. U.S. Census Bureau, 2000 Census of Population, Public Law 94-171 Redistricting Data File. Available at http://quickfacts.census.gov/qfd/meta/long_RHI725200.htm. Last accessed November 18, 2013.
32. Pew Hispanic Center. Hispanic Origin Profiles. Available at http://www.pewhispanic.org/2012/06/27/country-of-origin-profiles. Last accessed November 18, 2013.
33. U.S. Census Bureau. Hispanic Population in the United States. Available at http://www.census.gov/population/hispanic/data/2011.html. Last accessed November 18, 2013.
34. Passel JS, Cohn D, Lopez MH. Hispanics Account for More than Half of Nation's Growth in Past Decade. Available at http://pewhispanic.org/reports/report.php?ReportID=140. Last accessed November 18, 2013.
35. U.S. Census. We the People: American Indians and Alaska Natives in the United States. Available at http://www.census.gov/prod/2006pubs/censr-28.pdf. Last accessed November 18, 2013.
36. U.S. Census Bureau. 2007 American Indian and Alaska Native Tribal Consultations: Final Report. Available at http://www.census.gov/aian/pdf/CensusFinalReport_07_color-hi_res.pdf. Last accessed November 18, 2013.
37. U.S. Census Bureau. American Indian and Alaska Native Heritage Month: November 2012. Available at http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb12-ff22.html. Last accessed November 18, 2013.
39. Ay P, Hayran O, Topuzoglu A, et al. The influence of gender roles on health seeking behavior during pregnancy in Turkey.European Journal of Contraception & Reproductive Health Care. 2009;14(4):290-300.
40. Abrahams N, Wood K, Jewkes R. Barriers to cervical screening: women's and health workers' perceptions. Curationis. 1997;20(1):50-52.
41. Olsen SJ. Cancer prevention and early detection in Native American and Alaska Native populations. In: Frank-Stromborg M, Olsen SJ (eds). Cancer Prevention in Minority Populations: Cultural Implications for Health Care Professionals. St. Louis, MO: Mosby; 1993: 3-77.
42. Hoeman SP, Ku YL, Ohl DR. Health beliefs and early detection among Chinese women. West J Nurs Res. 1996;18(5):518-533.
43. Matin M, LeBaron S. Attitudes toward cervical cancer screening among Muslim women: a pilot study. Women Health. 2004;39(3):63-77.
44. Lee HY, Ju E, Der Vang P, Lundquist M. Breast and cervical cancer screening among Asian American women and Latinas: does race/ethnicity matter? J Womens Health. 2010;19(10):1877-1884.
45. Canales MK, Rakowski W, Howard A. Traditionality and cancer screening practices among American Indian women in Vermont. Health Care for Women International. 2007;28(2):155-181.
46. American Cancer Society. American Cancer Society Guidelines for the Early Detection of Cancer. Available at http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Last accessed November 18, 2013.
47. Ryerson AB, Miller J, Eheman CR, White MC. Use of mammograms among women aged >40 years in the United States 2000–2005. MMWR. 2007;56(3):49-51.
48. National Cancer Institute. Cancer Advances in Focus: Cervical Cancer. Available at http://www.cancer.gov/cancertopics/factsheet/cancer-advances-in-focus/cervical. Last accessed November 18, 2013.
49. Mcmullin J, Alba ID, Chávez L, Hubbell A. Influence of beliefs about cervical cancer etiology on Pap smear use among Latina immigrants. Ethn Health. 2005;10(1):3-18.
50. American Cancer Society. Cancer Facts and Figures for African Americans: 2013–Available at http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036921.pdf. Last accessed November 18, 2013.
51. Susan G. Komen for the Cure. Facts for Life: Racial and Ethnic Differences. Available at http://ww5.komen.org/uploadedFiles/Content_Binaries/806-373a.pdf. Last accessed November 18, 2013.
52. Susan G. Komen for the Cure. Disparities in Breast Cancer Screening. Available at http://ww5.komen.org/BreastCancer/RacialEthnicIssuesinScreening.html. Last accessed November 18, 2013.
53. Reiter PL, Linnan LA. Cancer screening behaviors of African American women enrolled in a community-based cancer prevention trial. J Womens Health. 2011;20(3):429-438.
54. Jones BA, Reams K, Calvocoressi L, Dailey A, Kasl SV, Liston NM. Adequacy of communicating results from screening mammograms to African American and White women. Am J Public Health. 2007;97(3):531-538.
55. Office of Minority Health. Cancer and Asians/Pacific Islanders. Available at http://minorityhealth.hhs.gov/templates/content.aspx?ID=3055.
56. McCracken M, Olsen M, Chen M.S, Jemal A, et al. Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA Cancer J Clin. 2007;57(4):190-205.
57. Womenshealth.gov. Minority Women's Health: Asian Americans and Cancer. Available at http://www.womenshealth.gov/minority-health/asian-americans/cancer.cfm. Last accessed November 18, 2013.
58. Borrayo EA, Hines L, Byers T, et al. Characteristics associated with mammography screening among both Hispanic and non-Hispanic white women. Women's Health. 2009;18(10):1585-1594.
59. American Cancer Society. Cancer Facts and Figures for Hispanics/Latinos: 2012–Available at http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-034778.pdf. Last accessed November 18, 2013.
60. Office of Minority Health. Cancer and Hispanic Americans. Available at http://minorityhealth.hhs.gov/templates/content.aspx?ID=3323. Last accessed November 18, 2013.
61. Borrayo EA, Buki LP, Feigal BM. Breast cancer detection among older Latinas: is it worth the risk? Qualitative Health Research. 2005;15(9):1244-1263.
62. De Alba I, Sweningson JM, Handy CC, Hubbell FA. Impact of English language proficiency on receipt of Pap smears among Hispanics. J Gen Intern Med. 2004;19(9):967-970.
63. Fernandez LE, Morales A. Language and use of cancer screening services among border and non-border Hispanic Texas women. Ethn Health. 2007;12(3):245-263.
64. Wallace D, Hunter JB, Papenfuss M, de Zapien JG, Denman C, Giuliano AR. Pap smear screening among women 40 years residing at the United States-Mexico border. Health Care Women Int. 2007;28:799-816.
65. Nuño T, Castle PE, Harris R, Estrada A, Garcia F, Yuma Project Technical Team. Breast and cervical cancer screening utilization among Hispanic women living near the United States Mexico border. J Womens Health. 2011;20(5):685-693.
66. Office of Minority Health. Cancer and American Indians/Alaska Natives. Available at http://www.minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=52&ID=3023. Last accessed November 18, 2013.
67. Centers for Disease Control and Prevention. Cancer Among Women. Available at http://www.cdc.gov/cancer/dcpc/data/women.htm. Last accessed November 18, 2013.
68. Centers for Disease Control and Prevention. United States Cancer Statistics. Available at http://apps.nccd.cdc.gov/uscs/. Last accessed November 18, 2013.
69. Womenshealth.gov. American Indians/Alaska Natives: Cervical Cancer. Available at http://www.womenshealth.gov/minority-health/american-indians/cervical-cancer.cfm. Last accessed November 18, 2013.
70. Becker SA, Affonso DD, Beard MBH. Talking circles: Northern Plains tribes American Indian women's views of cancer as a health issue. Public Health Nursing. 2006;23(1):27-36.
71. Kaiser Family Foundation. Percent of Women Age 18 and Older Who Report Having Had a Pap Smear Within the Last Three Years, by Race/Ethnicity, 2010. Available at http://www.statehealthfacts.org/comparebar.jsp?cat=10&ind=483. Last accessed November 18, 2013.
72. Miller JW, King JB, Joseph DA, Richardson LC. Breast cancer screening among adult women—Behavioral Risk Factor Surveillance System, United States, 2010. MMWR. 2012;61(Suppl):46-50.
73. Coe K, Martin L, Nuvayestewa L, et al. Predictors of Pap test use among women living on the Hopi reservation. Health Care for Women Int. 2007;28(9):764-781.
74. Meade CD, Menard J, Thervil C, Rivera M. Addressing cancer disparities through community engagement: improving breast health among Haitian women. Oncol Nurs Forum. 2009;36(6):716-722.
75. Kwok C, Fethney J, White K. Chinese breast cancer screening beliefs questionnaire: development and psychometric testing with Chinese-Australian women. J Adv Nurs. 2010;66(1):191-200.
76. Simon CE. Breast cancer screening: cultural beliefs and diverse populations. Health Soc Work. 2006;31(1):36-43.
77. Lee EE, Tripp-Reimer T, Miller AM, Sadler GR, Lee SY. Korean American women's beliefs about breast and cervical cancer and associated symbolic meanings. Oncol Nurs Forum. 2007;34(3):713-720.
78. Comas-Diaz L. Puerto Ricans and sexual child abuse. In: Fontes (ed). Sexual Abuse in Nine North American Cultures. Thousand Oaks, CA: Sage Publications; 1995: 31-66.
79. Hall CP, Hall JD, Pfriemer JT, Wimberley PD, Jones CH. Effects of a culturally sensitive education program on the breast cancer knowledge and beliefs of Hispanic women. Oncol Nurs Forum. 2007;34(6):1195-1202.
80. Mo B. Modesty, sexuality, and breast health in Chinese-American women. West J Med. 1992;157(3):260-264.
81. Clarke HF, Rhea J, Deschamps M, Hislop G, Band PR, Atleo R. Reducing cervical cancer among First Nations women.Can Nurse. 1998;94(3):36-41.
82. Steven D, Fitch M, Dhaliwal H, et al. Knowledge, attitudes, beliefs, and practices regarding breast and cervical cancer screening in selected ethnocultural groups in northwestern Ontario. Oncol Nurs Forum. 2004;31(2):305-311.
83. Gany FM, Herrera AP, Avallone M, Changrani J. Attitudes, knowledge, and health-seeking behaviors of five immigrant minority communities in the prevention and screening of cancer: a focus group approach. Ethn Health. 2006;11(1):19-39.
84. Wong LP, Wong YL, Low WY, Khoo EM. Shuib R. Cervical cancer screening attitudes and beliefs of Malaysian women who have never had a Pap smear: a qualitative study. Int J Behav Med. 2008;15(4):289-292.
85. Hubbell FA, Chavez LR, Mishra SI, Magana JR, Burciaga Valdez R. From ethnography to intervention: developing a breast cancer control program for Latinas. J Natl Cancer Inst. 1995;18:109-115.
86. Peek ME, Sayad JV, Markwardt R. Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system. J Gen Intern Med. 2008;23(11):1847-1853.
87. White N, Lubkin I. Illness trajectory. In: Lubkin IM, Larsen PD (eds). Chronic Illness: Impact and Interventions. 8th ed. Burlington, MA: Jones and Bartlett Publishers; 2013: 53-76.
88. Hufford DJ. Folk medicine and health culture in contemporary society. Prim Care. 1997;24(4):723-741.
89. Yeo SS, Meiser B, Barlow-Stewart K, Goldstein D, Tucker K, Eisenbruch M. Understanding community beliefs of Chinese-Australians about cancer: initial insights using an ethnographic approach. Psychooncology. 2005;14(3):174-186.
90. Jackson JC, Do H, Chitnarong K, et al. Development of cervical cancer control interventions for Chinese immigrants.J Immigr Health. 2002;4(3):147-157.
91. Yeh CJ, Hunter CD, Madan-Bahel A, Chiang L, Arora AK. Indigenous and interdependent perspectives of healing: implications for counseling and research. Couns Dev. 2004;82(4):410-419.
92. Kaiser Family Foundation. Distribution of the Nonelderly with Employer Coverage by Race/Ethnicity, States (2010–2011), U.S. Available at http://www.statehealthfacts.org/comparebar.jsp?ind=148&cat=3. Last accessed November 18, 2013.
93. Trivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing on screening mammography in Medicare health plans. NEJM. 2008;358(4):375-383.
94. Schootman M, Walker MS, Jeffe DB, Rohrer JE, Baker EA. Breast cancer screening and incidence in communities with a high proportion of uninsured. Am J Prev Med. 2007;33(5):379-386.
95. Amankwah E, Ngwakongnwi E, Quan H. Why many visible minority women in Canada do not participate in cervical cancer screening. Ethn Health. 2009;14(4):337-349.
96. Ginossar T, De Vargas F, Sanchez C, Oetzel J. "That word, cancer:" breast care behavior of Hispanic women in New Mexico background and literature review. Health Care for Women International. 2010;31(1):68-87.
97. Donnelly TT. Challenges in providing breast and cervical cancer screening services to Vietnamese Canadian women: the healthcare providers' perspective. Nurs Inq. 2008;15(2):158-168.
98. Liang W, Yuan E, Mandelblatt JS, Pasick RJ. How do older Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethn Health. 2004;9(3):283-304.
99. Moy B, Park ER, Feibelmann S, Chiang S, Weissman JS. Barriers to repeat mammography: cultural perspectives of African-American, Asian, and Hispanic women. Psychooncology. 2006;15(7):623-634.
100. Wu TY, Bancroft J. Filipino American women's perceptions and experiences with breast cancer screening. Oncol Nurs Forum. 2006;33(4):E71-E78.
101. Regan PC, Durvasula RS. Predictors of breast cancer screening in Asian and Latina university students. Coll Stud J. 2008;42(4):1152-1161.
102. Ka`opua LS. Developing a culturally responsive breast cancer screening promotion with Native Hawaiian women in churches. Health Soc Work. 2008;33(3):169-177.
103. Hutson S P, Dorgan KA, Phillips AN, Behringer B. The mountains hold things in: the use of community research review work groups to address cancer disparities in Appalachia. Oncol Nurs Forum. 2007;34(6):1133-1139.
104. Sadler GR, Takahashi M, Ko CM, Nguyen T. Japanese American women: behaviors and attitudes toward breast cancer education and screening. Health Care Women Int. 2003;24(1):18-26.
105. Harle MT, Dela Cruz R, Veloso G, Rock J, Faulkner J, Cohen MZ. The experiences of Filipino American patients with cancer. Oncol Nurs Forum. 2007;34(6):1170-1175.
106. Altpeter M, Mitchell J, Pennell J. Advancing social workers' responsiveness to health disparities: the case of breast cancer screening. Health & Social Work. 2005;30(3):221-232.
107. McAlearney AS, Reeves KW, Tatum C, Paskett ED. Cost as a barrier to screening mammography among underserved women.Ethn Health. 2007;12(2):189-203.
108. Sanchez MS. Mexican American women's pathways to health. Fam Community Health. 2007;30(1):S43-S52.
109. Russell KM, Swenson MM, Skelton AM, Shedd-Steele R. The meaning of health in mammography screening for African American women. Health Care Women Int. 2003;24(1):27-39.
110. Stewart SL, Rakowski W, Pasick RJ. Behavioral constructs and mammography in five ethnic groups. Health Educ and Behav. 2009;36(5):36S-54S.
111. Jacobs EA, Karavolos K, Rathouz PJ, Ferris TG, Powell LH. Limited English proficiency and breast and cervical cancer screening in a multiethnic population. Am J Public Health. 2005;95(8):1410-1416.
112. Hwa-Froelich DA, Westby CE. Considerations when working with interpreters. Commun Disord Q. 2003;24(2):78-85.
113. Dysart-Gale D. Communication models, professionalization, and the work of medical interpreters. Health Communication. 2005;17(1):91-103.
114. Hsieh E. Interpreters as co-diagnosticians: overlapping roles and services between provider. Soc Sci Med. 2007;64:924-937.
115. Norris WM, Wenrich MD, Nielsen EL, Treece PD, Jackson JC, Curtis JR. Communication about end-of-life care between language—discordant patients and clinicians: insights from medical interpreters. J Palliat Med. 2005;8(5):1016-1024.
116. Weerasinghe S, Mitchell T. Connection between the meaning of health and interaction with health professionals: caring for immigrant women. Health Care for Women Int. 2007;28(4):309-328.
117. Pasick RJ, Barker JC, Otero-Sabogal R, Burke NJ, Joseph G, Guerra C. Intention, subjective norms, and cancer screening in the context of relational culture. Health Educ Behav. 2009;36(5supplement):91S-110S.
118. Singh NN, Mckay JD, Singh AN. Culture and mental health: nonverbal communication. J Child Fam Stud. 1998;7(4):403-409.
119. Lynch EW. Developing cross-cultural competence. In: Lynch EW, Hanson MJ (eds). A Guide for Working with Children and their Families: Developing Cross-Cultural Competence. 4th ed. Baltimore, MD: Paul H. Brookes Publishing, Co; 2011: 47-89.
120. Carlson LE, Feldman-Stewart D, Tishelman C, Brundage MD. Patient-professional communication research in cancer: an integrative review of research methods in the context of a conceptual framework. Psychooncology. 2005;14(10):812-828.
121. Smedley BD, Stith AY, Nelson AR (eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2003.
122. Bullock K, McGraw SA. Community capacity-enhancement approach to breast and cervical cancer screening among older women of color. Health & Social Work. 2006;31(1):16-25.
1. Centers for Disease Control and Prevention. Special populations. In: Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010;59(RR12):8-14. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=25578. Last accessed November 18, 2013.
2. New Zealand Guidelines Group. General principles of care. In: Management of Early Breast Cancer. Wellington: New Zealand Guidelines Group; 2009. Summary retrieved from National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=25578. Last accessed November 18, 2013.
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