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Evidence Based Practice: Breast Cancer Screening in Ethnic Groups, Research Paper Example

Pages: 9

Words: 2450

Style guide: Journal of Clinical Nursing

Author guide retrieved from: http://www.wiley.com/bw/submit.asp?ref=0962-1067&site=1

Abstract

Aims. To review the evidence for breast cancer awareness and screening among women of various ethnicities to determine the best practices for a variety of ethnic groups, including African American, Latina, Chinese, Turkish, and Jordanian women.

Background. Cultural awareness is critical in dealing with patients, and various ethnic backgrounds have differing knowledge of and willingness to use breast cancer screening tests; by identifying the cultural differences nurses can be more aware of those cultural sensitivities.

Design. Descriptive literature review.

Methods. A convenience sample of papers were reviewed which identified in databases which were published in the past five years in major professional journals which addressed the issues of specific ethnicity and how that ethnicity affects women’s perceptions of breast cancer, particularly with respect to screening tests (i.e., mammograms and self examinations).

Results: The issues that are culturally and ethnically sensitive falls into several areas: lack of knowledge about breast cancer and breast self examination; lack of access to healthcare providers and a mistrust of them; a concern for personal modesty in discussing breast health issues.

Conclusion: Sensitivity to the key issues uncovered in this review are important, with lack of knowledge of breast cancer and breast self examination being key to correct to improve breast cancer screening rates.

Relevance to clinical practice. By providing nurses with an understanding of how various ethnic groups perceive breast cancer and breast cancer screening techniques, improved communications with patients and increased execution of cancer screening practices.

Key words: cancer, critical review, information delivery, breast cancer, nurse, cancer screening.

Introduction

Women of various ethnic groups have different attitudes toward illness and medical practices. In particular, when the illness entails a system that impacts their perceptions of their sexuality and/or ability to live up to their culture’s expectations of wife and mother, different cultures can impose differing attitudes toward screening for such diseases and treating those diseases. Because cultural norms differ significantly, it is important that nurses understand how best to communicate with women from a variety of cultures to ensure compliance with recommended screening procedures and treatment protocols.

One disease that has been well studied with respect to ethnicity is breast cancer, and the standard screening processes to detect breast cancer, specifically breast self-examination (BSE), and mammograms. This study attempts to correlate these studies and present a useful guide to working with women of different ethnicities and cultures that takes into account the cultural sensitivities of the patients.

Methods

A descriptive critical review was used to generate the results. The papers reviewed were published between 2007 and 2011.

Articles chosen for review were based on questions:

Did the article present information about attitudes toward breast cancer screening based on one or more identified ethic or cultural background?
Was the study published 2007 or later?
Did the study provide guidance for improving the compliance rate of breast cancer screening or treatment for women from one or more ethnic groups?

Databases were searched using search terms such as “breast cancer screening ethnic” and “breast cancer screening multicultural” in various combinations. A convenience sample of a dozen papers were chosen for inclusion.

Once selected, the articles were reviewed and summarized. Categories included the ethnicity of the women in the sample set, the location of the test (i.e., Australian, Britain, U.S.), sample size, and methodology of the data collection. Papers were excluded if they failed at any of the following criteria:

Paper did not report results explicitly by ethnicity of participants.
Paper were purely descriptive with no quantitative data.
Paper lacked conclusions regarding dealing with cultural differences among patients.
Paper published prior to 2007.

Papers with a quantitative or mixed quantitative/qualitative design were preferred.

Results

The results of the literature review are summarized in the table on pages 5-9 of this report. The table assesses each study and provides a brief summary of the key information from that article.

Authors (year)	Study design	Sample size and ethnicity	Instruments used	Main findings	Content of information provided
Alkhasawneh (2007)	Descriptive study of knowledge and proficiency with BSE and early detection of breast cancer	395 female nurses in various healthcare facilities in Jordan	Researcher-developed knowledge test of breast cancer and BSE	Nurses knowledge of need for early detection poor, and few practice monthly BSE	Limited knowledge among Jordanian healthcare workers about breast cancer; continuing education essential, female healthcare workers preferred source of info for patients. 75% of breast cancer patients diagnosed in late stages in Jordan.
Conway-Phillips et al. (2009)	Critical literature review of papers published 1997-2007.	Papers with population exclusively of African-American women or inclusively if findings reported by ethnicity.	Various.	Research revealed that misperceptions, fear, and fatalism persist in African-American women with respect to breast cancer. Barriers to care and screening include cultural attitudes, health care accessibility, lower social status, and earlier negative experiences with healthcare.	Addressing fears and misconceptions about breast cancer is essential in dealing with this population. It is also important to understand differences in access to health care and distrust of healthcare providers.
Graves et al. (2008)	Mixed study on perceptions of risk of breast cancer.	450 Latina women older than 35, mostly from Central & South America in Washington DC area; most were married and uninsured.	In-person interview with questions on socio-demographics, language use (acculturation), cancer worry, breast cancer knowledge, perceived risk; Gail model risk & medical history to assess actual risk	26% considered themselves at high risk, and 24% reported “higher than average” risk; only 6% had objectively higher risk. 29% did not comply with mammography guidelines;	In Latinas, while most overestimated their personal risk, being older, being better acculturated, knowing more about breast cancer, and having insurance made them more compliant. Younger Latinas should be targeted for increased breast cancer knowledge, particularly those with no insurance.
Kara &Acikel, (2009)	Cross-sectional comparative study of health beliefs and BSE practices.	196 Turkish nursing students and their mothers (n=196).	Personal data form and Chapman’s Health Belief Model	Nursing students were more likely to perform BSE than their mothers.	Compliance with screening guidelines associated with higher education, youth, fewer perceived barriers. Older Turkish women should be targeted for improved knowledge of breast cancer.
Kudadjie-Gyamfi et al. (2010)	Cross-ethnicity survey.	308 women, 44 in each of 7 ethnic groups: US born African Americans, US born European Americans, Puerto Ricans, and Hispanic, Dominican, Haitian, and Eastern European immigrant groups.	Survey on medical history questions, access to care, coping style using a vignette based on “imagine you’ve been diagnosed with breast cancer.”	Patterns of screening rates consistent with coping styles; problem solving and social support consistent with compliance; avoidance coping style not consistent.	Cultural styles of problem solving and social support are associated with compliance with screening across ethnicities; avoidance is associated with non-compliance. In terms of ethnicity, race is more important than cultural background.
Kwok et al. (2009)	Validation of psychosocial survey of beliefs, knowledge and attitudes toward breast cancer and screening.	292 Chinese-Australian women (22 to 78 years).	Researcher developed questionnaire for Chinese-Australian women.	Factors affecting low compliance in this cultural group include fatalistic attitude (breast cancer is a death sentence), feeling well=being well, and modesty concerns.	Cultural barriers and cultural beliefs need to be addressed when dealing with this population.
Price et al. (2010)	Longitudinal study (1989-2004) comparison of breast and bowel cancer screening uptakes in England	72,566 women invited to breast and bowel cancer screening, 3539 of them South Asian which were split into Hindu-Gujarati; Hindu-Other, Muslim, Sikh, South Asian-Other cultural groups..	Medical response of women who had been invited to participate in bowel and breast cancer screening.	While 86% of total cohort did at least one of two screenings, only 74% of Asians did so; only 30% of Asians completed both screenings (59% of non-Asians). For all but Muslim, most Asians accepted breast cancer only; in Muslims, refusal of both screenings was most common response.	English literacy rate of Muslims was rated as “very low” or “poor”; a combination of strategies is needed to overcome barriers to participation.
Underwood et al (2008)	Descriptive study of attitudes and risks of breast cancer as discussed between women and healthcare providers.	Selected sample of 16 African American women age 40 or older with close female relative diagnosed with breast cancer prior to menopause	Semi-structured interviews.	The women were very knowledgeable about breast cancer, primarily as a direct result of their relatives’ experiences with the disease, but is not necessarily indicative of actual BSE or other screening by the women.	Discussions of these knowledgeable women with healthcare providers were limited and their practice of BSE also inconsistent with their understanding of the risks of their developing breast cancer themselves.
Wancai et al. (2010)	Critical literature review of use of complementary and alternative medicines (CAM) in breast cancer recovery and prevention.	11 papers published between 1990 and October 2009	Variable.	CAM usage was mostly with biological supplements (herbal), more than the whole medical system. The main source of information for CAM therapies comes from families and friends.	The use of CAM—or providing information about such therapies—for ethnic patients can help bridge the gap with ethnic patients.
Yavan et al. (2010)	Mixed study on breast cancer awareness and attitudes toward screening.	188 women in Ankara who applied for a gynecological examination.	Semi-Structured questionnaire.	Very few Turkish women perform BSE, most claiming “I don’t know how.” Most women profoundly overstated risk of developing breast cancer with error increasing as patient aged.	Use of breast cancer screening increased with perception of risk, educational status; addressing need for further education in young Turkish women about breast cancer.

Discussion

Key issues uncovered in the literature search are noted as issues with access to medical care, issues of mistrust of healthcare providers (including insurers), issues of an unwillingness to address concerns about breasts (i.e., modesty), and issues of a lack of knowledge about breast cancer and its risks.

Issues of lack of knowledge about breast cancer. This was the most common factor in nearly all ethnic groups. Women tended to overestimate their personal risk of developing cancer on the one hand, and to assume that if they felt fine, they must be fine. This factor is a problem for all of: African American (Conway-Phillips et al. 2009, Underwood 2008), Chinese (Kwok et al., 2009), Jordanian (Alkhasawneh, 2007), Latina (Graves, et al., 2008), and Turkish women patients (Kara & Acikel 2009, Yavan et al. 2010) .

Issues of mistrust or lack of access to healthcare providers. This actually represents two separate issues that were seen in conjunction in several papers. The lack of access to healthcare providers is a reflection either of lack of health insurance (or very poor coverage insurance), or in lack of money to pay for insurance co-payments or other patient-costs for screening. The lack of access to healthcare in general can result either from living in a remote area, not having a personal physician, or other general lack of healthcare facility. This was noted as a problem for African American (Conway-Phillips et al. 2009, Underwood 2008) and Latina (Graves, et al., 2008)women in particular. Mistrust of healthcare providers (including insurers) was especially noted in African American women (Conway-Phillips et al. 2009, Underwood 2008).

Issues of modesty, unwillingness to address breast health issues. This is of particular importance with women who were Muslim (Price et al., 2010), and those from Jordan (Alkhasawneh, 2007), China (Kwok et al., 2009), Turkey (Kara & Acikel 2009, Yavan et al. 2010), and African American women (Conway-Phillips et al. 2009, Underwood 2008).

Finally, many of those with breast cancer often resort to CAM to address their breast cancer concern and prevent a recurrence of the disease. Such CAM approaches are also more compatible with other cultures. Since studies show that women rarely discuss CAM with their healthcare providers (Wancai, et al., 2010), a knowledgeable and sympathetic discussion of this approach may reduce mistrust of the healthcare system.

Conclusions

The key areas that should be addressed when working with multicultural patients and breast cancer include ensuring that women are properly educated about the disease, understand their realistic risks and risk factors for it, and understand the importance of catching the disease early. Women from non-Western societies and African American women frequently held a view that a diagnosis of breast cancer is a “death sentence” whereas it is highly treatable if diagnosed in early stages of the disease.

Yet it is also clear that simple education of these ethnicities is insufficient to improve breast cancer screening compliance; the Underwood study (2008) noted that even women who had close female relatives diagnosed with breast cancer before menopause, and who were highly educated in the disease, did not comply with BSE recommendations, nor did they generally discuss their risk factors with their healthcare providers.

Clinical nurses may be able to improve the compliance of their multicultural female patients with recommended screening guidelines by increasing their sensitivity and understanding of the issues the patients have with such processes

References

Alkhasawneh, I. M. (2007). Knowledge and practice of breast cancer screening among Jordanian nurses. Oncology Nursing Forum, 34 (6), 1211-1217.

Conway-Phillips, R., Millon-Underwood, S. (2009). Breast cancer screening behaviors of African American women: a comprehensive review, analysis, and critique of nursing research. ABNF Journal, 20 (4), 97-101.

Graves, K. D., Huerta, E., Cullen, J. Kaufman, E., Sheppard, V., Luta, G. Isaacs, C., Schwartz, M. D., Mandelblatt, J. (2008). Perceived risk of breast cancer among Latinas attending community clinics: risk comprehension and relationship with mammography adherence. Cancer Causes and Control: CCC, 19 (10), 1373-1382.

Kara, B., Acikel, C. H. (2009). Health beliefs and breast self-examination in a sample of Turkish nursing students and their mothers. Journal of Clinical Nursing, 18 (10), 1412-1421.

Koutsopoulou, S. Papathanassoglou, E. D., Katapodi, M. C., Patiraki, E. I. (2010). A critical review of the evidence for nurses as information providers to cancer patients. Journal of Clinical Nursing, 19 (5-6), 749-765.

Kudadjie-Gyamfi, E.K., Magai, C. & Consedine, N.S. (2010). The obscuring object of race: Clinical breast exams and coping styles in ethnic subpopulations of women. British Journal of Health Psychology, 15 (Pt 2), 289-305.

Kwok, C., Fethney, J., White, K. (2009). Chinese breast cancer screening beliefs questionnaire: development and psychometric testing with Chinese-Australian women. Journal of Advanced Nursing, 66 (1), 191-200.

Price, C. L., Szczepura, A. K., GUmber, A. K., & Patnick, J. (2010). Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England. BMC Health Services Research, 10, 103-111.

Underwood, S. M., Richards, K., Bradley, P. K., & Robertson,E. (2008). Pilot study of the breast cancer experiences of African American women with a family history of breast cancer: implications for nursing practice. ABNF Journal, 19 (3), 107-113.

Wancai, A., Armer, J. M., Stewart, B. R. (2010). Self-care agency using complementary and alternative medicine (CAM) among breast cancer survivors. Self-Care, Dependent-Care & Nursing, 18 (1), 8-18.

Yavan, T., Akyuz, A., Tosun, N. Iyigun, E. (2010). Women’s breast cancer risk perception and attitudes toward screening tests. Journal of Psychosocial Oncology, 28 (2), 189-201.