The disparities between African American women and other races in regard to the incidences of and mortality from breast cancer are alarming. Studies have shown that minority communities are less likely to take advantage of preventative and detection care like breast cancer screening. Other studies find that a number of factors, outside of race and ethnicity play a role in this. Ultimately, approaching the topic from a holistic understanding and acknowledgement of the ways in which a person’s full background influence their values, beliefs, and decisions and present barriers to action – cultural sensitivity, namely – is essential to reversing these disparities.
In “African-American Women, Self-Breast Examination and the Health Belief Model: Implications for Practice,” author Josephine McCaskill, PhD., APN, FNP, BC examines the fact that African American women, despite having lower incidence rates of breast cancer have a higher mortality rate, and the fact that findings show that “the adherence to recommended breast cancer screening guidelines is frequently reported to be lower in the African American population” (McCaskill p. 33). McCaskill begins by discussing the epidemiology of breast cancer, noting that it is “the most common form of cancer, resulting in significant deaths among African American women.” She discusses its origins, cell growth, and disparities among populations. Particularly, among women who are ages fifty and older, the mortality rate for African American’s is 77% higher than that of their white counterparts (McCaskill p. 33). Further, “younger women are more likely to have higher grade and aggressive tumor basal like breast cancer subtype – making treatment outcomes more problematic” (McCaskill p. 33). These disparities are attributed to the fact that white women tend to adopt early detection practices more openly and with more commitment than African American women. This is alarming, considering that aside from prevention “early detection of breast cancer through screening is the best option available to all women” (McCaskill p. 33).
McCaskill then moves on to discussion of self-examination as a preventative method that, along with mammograms, has assisted in decreasing the percentage of cancers found by women from 80% to 35% today (McCaskill p. 34). However, African American women are still the least likely to participate in these detection measures, thus lessening the likelihood that cancer will be found early enough to reduce the likelihood of mortality.
The health belief model weighs heavily into this discussion as well, because of the insight it delivers into the health behavior of individuals. This model examines preventive health behavior like diet and exercise, sick role behaviors like compliance with medical regimens laid out by a doctor, and clinic use including visits to physicians. The model reveals how values and beliefs affect participation in each of these behaviors. More importantly, “there are four main constructs of the HBM that relate to readiness to take action, including perceived susceptibility, perceived severity, perceived benefits, and perceived barriers” (McCaskill p. 34). The knowledge surrounding these is framed within the context of demographics, personality, ethnicity, and socioeconomic status. McCaskill took this mental construct into account in her studies.
McCaskill, in conclusion, found that considering the health belief model and the African American community’s lack of commitment to preventative measures, “nurses practice must be guided by research findings” (McCaskill p. 35). The familiarity they have with patients and their backgrounds, along with nurses’ knowledge, positions them as the most effective for “designing community outreach programs that optimize African American’s participation in” these preventative and detection measures (McCaskill p. 36). Further, “survivor advocates, social networks, and church-based support” are all essential to successfully increasing black women’s participation in preventative and detection care (McCaskill p. 36).
Authors David Litaker and Anne Tomolo also discuss the disparities in breast cancer screening, but do so from the perspective of income and insurance status among other factors. These authors use data from a cross-sectional survey of 2231 residents between the ages of 50 and 69 years old in Ohio. Aside from the background of racial characteristics, these authors examine how urbanization, the proportion of female-headed households, the number of primary care physicians per capita, managed care activity, and county designation affected the data on the women’s participation in breast cancer screening. The authors found that “the proportion of age-eligible women screened for breast cancer was 61.9% and county screening rates varied from 12.9% to 100%” (Litaker & Tomolo, 2007; p. 36). Further, a lack of completion of high school, lower family income, and absence of continuous insurance, a usual source of care, or current employment were also found to contribute to lower occurrences of breast cancer screening adherence. While the previous article emphasized the health belief model in explaining why African American women take advantage of preventative and detection practices, this study finds that “contextual characteristics” are instrumental in affecting use of these measures and thus in increasing the “risk for delayed breast cancer diagnosis” (Litaker & Tomolo, 2007; p. 36).
More specifically, this study cites much of the same research and statistics regarding the severity of breast cancer incidences in the united states and the lack of commitment to screening as preventative and detective measures. This study, however, took many factors into consideration, and pulled data from the Ohio Family Health Survey of 16,000 respondents. They assessed bivariate associations between women’s backgrounds – including income, insurance, and steady care – and reports of actually having used mammograms using a chi-square test of significance and found that “several characteristics were associated with a lower probability of having been screened for breast cancer by mammography in the preceding 12 months” (Litaker & Tomolo, 2007; p. 39). These included a combination of characteristics contributing to low socioeconomic status and having a steady source of care or continuous insurance. One implication of their study is that these characteristics that have been identified as contributing to not using preventive and detective care can be used to strengthen community-based intervention.
Both of the previous studies pointed to personal characteristics as contributing to a lack of use of preventative and detective care and recommended that they be considered in the creation of community-based intervention programs by nurses. A third, entitled “Cultural Sensitivity and Health Promotion: Assessing Breast Cancer Education Pamphlets Designed for African American Women” by (2007) Kimberly Kline puts these insights into practice. Kline frames her work by discussing how “cultural influences are extremely salient for health educators because culture shapes perceptions and practices with regards to health, illness, and medicine and mediates responses to health information,” as corroborated by the previous studies (Kline, 2007; p. 84). She aims to “discover the implications for cultural sensitivity of the rhetorical choices in breast cancer education materials developed specifically for African American audiences” by using the PEN-3 model of cultural sensitivity (Kline, 2007; p. 86). This model “explained that to centralize culture in health interventions, three dynamically related and interdependent domains of health beliefs and behavior should be taken into account,” namely cultural identity, relationships and expectations, and cultural empowerment ((Kline, 2007; p. 86). The method Kline uses is rhetorical criticism, from an interpretive and generative approach, of pamphlets. She found that “although messages were not inaccurate, they were constituted by rhetorical choices that emphasized racial-ethnic differences to support an argument in favor of mammography, but conversely obscured many racial and cultural differences when addressing mammography barriers and facilitators” (Kline, 2007; p. 88). This is evidence of a lack of real cultural sensitivity to the aspects of minorities’ lives that play a major role in their ability and commitment to using these preventative and detection measures like breast cancer screening. Further, “the emphasis on individual responsibility and potential personal empowerment is consistent with a Western ideology that” erases structural and institutional barriers to action.
Thus, if the aforementioned disparities are to be addressed and lessened, materials and cultural intervention must not only recognize cultural differences at the level of the disparity, but must also acknowledge the differences that prevent and discourage action taking. Messages that “recognize and respond to cultural values and concerns,” though challenging, must be developed instead. Only by recognizing these difference and their effects at every level of decision making can change in this system take place. Each of these articles centers on the cultural effects, and this is a solution.