Cultural Heritage: Cancer Screening and Early Detection Guadalupe Palos
UCH OF THE richness in America today can be attributed to the great cultural diversity within our borders. Our cultural backgrounds are influenced by a variety of factors such as the customs of one's homeland, especially if recently arrived from another country, the culture of a peer group, and for the poor, the culture of poverty. Being poor in this country creates social, psychological, and economic inequities that affect individuals regardless of race, age, or gender. In fact, being poor prevents impoverished individuals from accessing and using health care services. These types of barriers also keep these individuals from participating in early detection and screening activities or from seeking treatment for chronic diseases, including cancer. As a result, individuals who are economically disadvantaged become highrisk groups for certain types of cancers and, ultimately, experience higher cancer mortality rates as compared with other American groups. If we are to reverse this trend, we must first understand that an individual's cultural background consists of a combination of subcultures. Secondly, we must learn how the confluences of these subcultures affect an individual's health behavior and beliefs. Then we can develop appropriate interventions that will engage high-risk groups such as the economically disadvantaged in cancer-screening activities. In Texas, a culturally sensitive and linguistically
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From the Department of Neuro-Oncology, Section of Pain and Symptom Management, and the Department of Gastrointestinal Oncology and Digestive Diseases, University of Texas M. D. Anderson Cancer Center, Houston, TX. Guadalupe Palos, LMSW, RN, OCN: Research Nurse, Department of Neuro-Oncology, Section of Pain and Symptom Management, and Program Director of the Texas Outreach-Corpus Christi Study; Department of Gastrointestinal Oncology and Digestive Diseases. The Mujer a Mujer: Woman to Woman project was supported in part by Oncology Nursing Foundation's Lederle Cancer Public Education Award and by the Sisters of Charity of the Incarnate Word Health Care System. Address reprint requests to Guadalupe Palos, LMSW, RN, OCN, 404 Freda Ln, South Houston, TX 77587. Copyright 9 1994 by W.B. Saunders Company 0749-2081/94/1002-000555.00/0
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appropriate program entitled Mujer a Mujer: Woman to Woman was developed and implemented to reduce the mortality from cervical cancer among Hispanic women. This model program can be adapted for use by oncology nurses in other parts of the country. CULTURE Cultural diversity or the confluence of the many cultures that influence an individual's beliefs affects health behaviors along the continuum of the cancer experience. Today, clinicians recognize the importance of cultural diversity for patients and their families and how it influences communication patterns with patients. For example, potential barriers to effective patient/family teaching often result from miscommunication based on cultural differences between the patient and provider. However, the impact of these cultural differences is also affected by the health care system that provides the setting for patient-provider encounters. Each of these cultural worlds--the patient's, nurses', and health care system--has its own set of attitudes, beliefs, and behaviors. Behavioral patterns are influenced by cultural roots or heritage. Social scientists have recognized that cultural heritage is influenced by an individual's degree of acculturation and assimilation. TM In an effort to explore the various factors that influence one's cultural heritage, Spectorz formed a "heritage consistency model" that focuses on an individual's culture, ethnicity, religious preference, and socialization process. Kleinman 3 proposes a "cultural systems' model" that looks at the interaction and overlap of three social worlds: (1) the folk or ethnic medicine sector; (2) professional or contemporary medicine system; and (3) the popular or social support sector. He theorizes that an individual's beliefs, relationships, behavior, and use of health care services are influenced by these three worlds. Thus, clinicians need to know and understand how the interaction of cultural beliefs can create barriers to our patient's compliance with recommended prevention, early detection, and screening activities.
Seminars in Onco/ogy Nursing, Vol 10, No 2 (May), 1994: pp 104-113
CULTURAL HERITAGE: SCREENING AND EARLY DETECTION
THEORIES ON CULTURE, ACCULTURATION, AND ASSIMILATION
The literature shows the controversy that exists on the exact definition of the word culture. Fejos4 defines culture as "the sum total of socially inherited characteristics of a human group that comprises everything which one generation can tell, convey, or hand down to the next." Endelman and Mandel 5 define culture as "learned patterns of living, including health beliefs and behaviors, that have been handed down from generation to generation." Both definitions imply that longevity of human groups is a requirement in the development of a culture. However, recent changes in our society's philosophies require a definition that addresses the cultures of certain personal and demographic characteristics such as gender, economics, age, literacy level, physical challenges, and even geographic residence. Bates and Edwards 6 propose a definition of culture that seems to reflect these societal changes. They define culture as "patterned ways in which humans have learned to think about and act in their world". Culture, ethnicity, and ancestry are terms often used interchangeably; yet, they have different meanings. Bates and Edwards 6 view ethnicity as a subset of a larger cultural system and believe ethnic identification develops a sense of belonging to a specific group. Spector2 suggests that ancestry refers to an individual's specific nationality, group, or country from which a person, their ancestors, or parents resided before migrating to the United States. Although many culturally diverse groups share characteristics of a dominant culture, several continue to maintain their own ethnic selfidentification, values, language, and behaviors. Numerous studies have shown that two concepts, "acculturation and assimilation," influence a person's traditional (ethnic heritage) and nontraditional (dominant culture) views toward cancer and its impact on survivorship. 7-9 Thus, knowledge of how acculturation affects attitudes, beliefs, and behaviors toward cancer can also provide clues to understanding potential barriers to cancerscreening and early detection activities. Acculturation refers to changes that individuals make in their personal or cultural patterns in order to be accepted or belong to the host society, m Table 1 lists seven domains used by Milton Gordon j 1
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Table 1. Gordon's Domains of the Assimilation Process *Cultural assimilation or acculturation refers to a change in ethnic or cultural identification that follows those of the dominant culture or society. *Structural assimilation permits participation in social or civic groups, cliques, and institutions associated with the dominant culture. *Marital assimilation permits intermarriage to occur on a large-scale basis between members of the subgroup and dominant society. Identificational assimilation focuses on the development of peoplehood based on the identity of the dominant society. Attitudinal assimilation achieves complete absence of prejudice among all groups. Behavioral assimilation implies complete absence of discrimination. Civic assimilation achieves complete absence of conflict over values and power. * Must be sequentially achieved before subsequent assimilation stages can occur. Data from Gordon. ~1
to define and form three assimilation models: Anglo conformity; melting pot; and cultural pluralism. The first three domains, cultural, structural, and marital, are considered key components of the assimilation process and, according to Gordon, must be sequentially achieved before the remaining four can be achieved. Gordon 1~ theorizes that this country's assimilation process began with the New World immigrant's desire to become a part of the white AngloSaxon Protestant culture that was characteristic of English society. This Anglo-conformity model of assimilation changed with the arrival of immigrants from countries in western Europe who had different religions, languages, and cultural heritages. Although many of these immigrants had their own ethnic identity, they had a desire to conform to American values and establish a sense of belonging to "America's melting pot." As a result of the melting-pot model of assimilation, a new culture evolved that continues to be known as the "American culture." Today, many immigrants enter this country with the expectation that they will adopt American values and follow the myth of "America's melting pot." Yet in reality, many ethnic groups maintain their own unique cultural identity while still adopting those of the host society. Because many of these diverse groups continue to follow their native religions, languages, and cultures, their assimilation process
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follows that of the cultural pluralism model. This cultural pluralism model of assimilation, according to Gordon, "teaches that there is beauty in diversity."1 CORRELATES OF OUR POPULATIONS
The term cultural diversity has been used to refer to an individual's cultural or ethnic identity. Yet, this term can also apply to groups with particular personal and demographic characteristics such as gender, age, economic or educational status, sexual and other behavioral preferences, as well as physical or mental health challenges. In order to develop culturally and linguistically appropriate cancer-screening and early detection programs, clinicians need to have some background knowledge of these culturally diverse populations.
Ethnic Populations Demographic data, obtained from the 1990 US Census, indicates that this country is becoming more ethnically diverse. Census projections also show that these groups will continue to experience tremendous growth. As a result of these growth and migration patterns, by the year 2000, minorities will account for one third of the United States population. Because of recent amendments in immigration laws, Asian-Americans are currently the fastest growing ethnic group. In contrast, the Hispanic population has experienced a steady increase in its growth over the past 10 years. Hispanics also are predicted to outnumber blacks by the year 2000. Currently, however, blacks are the largest ethnic group of the United States, and Native Americans comprise the smallest of the ethnic groups. 12,13 Risk factors that contribute to the epidemiological trends found in ethnic groups are primarily associated with behavioral or environmental rather than genetic factors. Certain habits such as those associated with tobacco, alcohol use, reproductive patterns, or dietary habits seem to place ethnic groups at higher risk for certain cancers. Environmental factors, particularly occupational exposures to certain chemicals or minerals, also contribute to the high incidence and mortality rates. In addition, epidemiological migration studies conducted all over the world have generally shown that second or third generation offspring of immigrant families develop cancer at rates similar to the host country
population rather than the country of their ancestors. ~4 Consequently, data obtained from cancer epidemiological studies combined with sociobehavioral research can give additional information about protective or increased risk factors for these groups. Because of unique economic, educational, geographic, and cultural characteristics, these groups have above average morbidity and mortality rates for certain diseases, including cancer. A review of the data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program shows that overall, blacks have a 10% higher cancer incidence rate as compared with non-Hispanic whites. This group also experiences a 20% higher mortality rate and lower survival rates. Native Americans and Asian Pacific Islanders have incidence, mortality, and survival rates similar to those described for the black population. 7'~3 A meta-analysis study conducted by Michalik and Mahoney ~5 found that, overall, Native Americans have the lowest rates of cancer incidence. Yet, their data also showed that this group had the poorest survival rates. For example, female Native-American survival rates for breast cancer are lower (53%) as compared with whites (75%) and blacks (63%). Table 2 lists the leading cancers in four major ethnic groups. It is important to recognize that each of these ethnic groups have their own unique subcultures. For example, Hispanics can be categorized into Mexican-American, Puerto Rican, Cuban, and others (people from various South American countries). Similarly, Asian-Americans also are comprised of various subgroups, whereas Native Americans are descendants of numerous tribes. Hispanics tend to follow the same cancer trends for incidence and mortality rates with cervical cancer mortality rates being higher as compared with the non-Hispanic or white population. Asian-American subgroups tend to have distinct differences in their cancer trends, as evidenced by the higher rates for different cancers presented in Table 2. Yet, for blacks and Native Americans, place of residence can also contribute to the differences in cancer incidence and mortality rates. For instance, blacks experience differences based on whether they are urban or rural dwellers just as reservation and urban Native-American dwellers experience differences in their cancer trends. Cancer educators and clinicians often concentrate on
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Table 2. Leading Cancers in Four Ethnic Groups by Incidence and Mortality Ethnic Group Blacks
Asian-Americans Chinese Filipino Hawaiian Japanese Native Americans
Hispanics*
Incidence
MortalRy
Men: lung and prostate Women: breast Both genders: colorectal
Men: prostate (H), colorectal, esophagus Women: breast (H), colorectal, and cervix (H) Both genders: pancreas
Buccal cavity, nasopharynx, liver, gastric, and rectal
Both genders: Stomach (H) and nasopharynx Women: cervix (H) Colon and ovary (H)
Men: liver and lymphoma Women: thyroid Women: breast, cervix, ovary, and endometrium Both genders: stomach, pancreas, and lung Both genders: gastric, gallbladder, and rectal Both genders: gallbladder Women: cervix
Women: breast and lung Men: lung Gastric (H) Both genders: gallbladder Women: cervix (H) Men: Bronchogenic lung and colorectal Both genders: pancreas and gastric Women: cervix (H) and gallbladder
Both genders: gallbladder, liver, and gastric Women: cervix
NOTE. (H) indicates excess cancer mortality rates occur in these populations. * Incidence and mortality rates for the various Hispanic subgroups are fairly consistent and therefore were not presented by
subgroup, Data from references 12, 13, 14, and 15.
cancers that can be identified by early detection and screening activities such as breast, prostate, cervical, and oral cancers. However, information on other cancers such as gastric and gallbladder cancers that are not amenable to screening activities also can be integrated into cancer education programs. THE CULTURES OF POVERTY AND AGING
This nation's older population is of particular concern to health care providers because of their current and projected growth patterns. Census data indicates that by the year 2030, 22% of the United States population will be 65 years of age and older. US Census data on the racial and the ethnic breakdown of the older population indicates that similar growth rates are expected for ethnic populations, particularly the Hispanic population. Cancer data from SEER indicates that 50% of all cancers occur among the elderly population with higher rates observed in ethnic elders. 7'16'17 These predicted epidemiological rates and demographic projections, in conjunction with behavioral and cultural factors unique to the elderly, will have a significant impact on future cancer statistics. The "culture of poverty" concept, first introduced by Oscar Lewis is has reemerged because of the large increase in people living below the federal poverty level. The relationship between poverty and health care was summarized in the Healthy People 2000: Summary Report, which
noted that health disparities between poor people and those with higher incomes are almost universal for all dimensions of health. 19 This report also found that the incidence of cancer increases as family income decreases with lower survival rates for lower income cancer patients. 19 As a follow-up to this report, the American Cancer Society published the Report to the Nation: Cancer in the Poor, which documented the impact of limited financial resources on health status, access, and practice issues related to cancer. 2~ The findings from this report also indicated that an individual's socioeconomic status was a better predictor of cancer incidence rates as compared with ethnic differences. The overall conclusions suggested that socioeconomic factors create barriers to cancer care, which ultimately contribute to late diagnosis and treatment and poorer survival rates. According to Freeman, 21 these data suggest that racial disparities in cancer results are primarily a result of differences in economic status. 2t CULTURE, COMPLIANCE, AND CANCER SCREENING INTERVENTIONS
Traditionally, access and utilization patterns for these ethnic groups have shown under utilization of preventive health care services for various chronic diseases, including cancer, lO.22 These patterns along with other cultural factors can influence compliance with recommended diagnostic and therapeutic regimens, including preventive
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and screening behaviors. Because culture can either promote or hinder participation in cancer control activities, clinicians must understand the cultural influences on a patient's compliance or noncompliance with a recommended regimen. Compliance, according to Woldrum et al, 23 evolves from the interaction of attitude, cognition, and behavior. They define attitude as a patient's willingness to fulfill the various aspects of the prescribed plan, cognition as the individual's knowledge about their prescribed plan, and behavior as the action needed to implement the prescribed plan. Figure 1 illustrates the interrelationships of an individual's cultural environment or heritage with the various components needed to achieve compliance with cancer control activities,z3 Each of these components is influenced by the cultural and ecological worlds and their interactions with each individual's attitudes, cognition, and behavior. Hussey and Gillilan24 define compliance as the positive behavior that patients exhibit when moving toward mutually defined therapeutic goals. However, Gritz et a125use the concept of noncompliance to show that compliance is a shared responsibility between the cultural worlds of the patient, provider, and setting. They define noncompliance as encompassing not only the failure of the patient
/ \ Fig 1. The interrelationships of an individual's cultural environment with the various components needed to achieve compliance with cancer control activities. (Data from referantes 23, 25, and 30.)
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to fulfill the clinical prescription as it was intended by the practitioner but also the behavior of the provider, interactions between patient and provider, and the general setting in which these people function. Research also indicates that certain factors interact together to form, impede, and promote an individual's compliance. 25'26 The UCLA Cancer Control Science Program, a 5-year project funded by the National Cancer Institute, developed and used a six-factor model of adherence in four randomized clinical trials to identify the various factors that influence compliance or adherence. These trials focused on an individual's adherence to a specific set of guidelines applicable to a current cancer control area. A major goal of this study was to show that patient compliance was critical to the success of cancer control activities in reducing morbidity and mortality.25 Figure 2 illustrates the framework of the six-factor model; the interaction of these factors indicate how compliance can be affected at various points and levels. The authors do not indicate if the model is sequential nor do they elaborate on how cultural factors can affect the six domains. However, this study does justify the need to consider these areas as potential barriers to compliance with recommended screening and early detection activities. Although cultural factors can enhance or impede participation in cancer control activities, they are more likely to serve as barriers to cancer-screening and early detection activities among culturally diverse groups. Table 3 lists cultural factors found to influence cancer education and control activities. 2'7'9'26 Although many of these factors can be applied to most populations, culturally diverse populations with varying degrees of acculturation and assimilation will be primarily affected by language preference, education or literacy level, ethnicity, religion, and support systems. For example, Gonzalez27 found that language and selfefficacy were the strongest predictors of how frequently low-income Hispanic women participated in breast self-examination. A study of black men found that their perceptions toward early cancer detection and risk reduction activities significantly affected their health behavior, z8 A major factor affecting this group's perceptions included locus of control characterized by their pessimistic and fatalistic views toward cancer. Ante129 found that integration of western and traditional forms of
CULTURAL HERITAGE: SCREENING AND EARLY DETECTION
Effective Communication of Information
Fig 2. The framework of the six-factor model of adherence to identify factors that influence compliance or adherence. (Data from Gritz et al.~s)
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[ ~ ""1 ~
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Rapport with Health a l
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medical beliefs, healing practices, and systems were significant barriers for Native Americans seeking health care. She also found that this population often confused certain cancer-related symptoms such as skin lesions or pain with symptoms of common illnesses. THEORETICAL MODELS OF INTERVENTION
Research conducted in the fields of health education and promotion indicate that behaviors are also influenced by ecological environments. 3~ Because of the interactions between ecological environments and cultural factors, multilevel interventions that integrate a variety of health promotion models seem to be most effective in developing appropriate educational programs. Integral to each health promotion model is the application level. These levels, which are categorized into intrapersonal, interpersonal and community, institutional and policy, are found in the ecological theory of Glanz and Rimer. 3~ Figure 3 illustrates the interactions that occur across each level; there is also an explanation of each level. Leaders in behavioral oncology research recommend integrating various multilevel theoretical models to plan cancer control programs that can effectively address the diversity resulting from confluent cultures. Glanz et al3o,3~ have reviewed these models. Table 4 depicts the major theories, their levels, and examples of their application in Table 3. Cultural Factors Affecting Cancer Screening and Early Detection Beliefs and Practices Ethnic or racial identity Language preference Religious belief or taboos Socioeconomic level Age or gender Health and illness beliefs Equity and access issues
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Level of acculturation Education or literacy level Folk medicine rituals and beliefs Locus of control--fatalistic Presence or absence of social support networks Urban or rural residence Utilization patterns for preventive health
I
Client's Beliefs and Adherence Cancel~176 Regimens
'~
I
J
health education and promotion programs. These theoretical concepts are crucial in developing effective cancer intervention programs. "MUJER A MUJER": A MODEL PROGRAM
Mujer a Mujer: Woman to Woman was a multiphased program that combined educational efforts and media strategies to target Hispanic women, particularly those age 55 and over, with information on cervical cancer screening. Texas epidemiological data showed cervical cancer mortality rates to be twice as high in this group as compared with the general population. In addition, cancer intervention programs that focused on this population were few. Thus, the "Mujer a Mujer" program was developed to educate this high-risk group about cervical cancer, its early detection, and screening procedures. The overall goal of the project was to reduce
9 Intrapersonal factors: refers to an individual's knowledge, attitudes, beliefs, cultural, religious and other individual characteristics. 9 Interpersonal factors: refers to cultural, religious, and social support systems and groups such as family, friends, or peers that provide social support. 9 Community factors: refers to cultural, religious, and social standards, norms, and networks that exist on an informal or formal basis. 9 Institutional factors: refers to policias or rules that belong to formal health care delivery systems that can impede or promote screening or eady defection programs and activities. 9 Public policy factors: refers to local, state, or federal laws or policies that support or impede cancer control activities.
Fig 3. The interactions that occur across each level of the ecological theoretical model. (Data from references 30 through 36.)
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Table 4. Theoretical Models for Developing Multilevel and Culturally Appropriate Cancer Screening and Early Detection Programs Theoretical Models
Level
Modified Health Belief Model32
~ndividual/intrapersonat
Stages of Change3~ Social Cognitive Theory33
Individual/intrapersonal interpersonal
Diffusion of Innovations34
Community organization
Social Planning as
Community organization
Organizational Change3~
Community organization
Social Marketing Theoryae
Community organization
Applications To increase awareness of perceived risks. To increase the individual's self-efficacy. To assess individual's readiness to change. To use culturally appropriate role models. To use positive reinforcement or incentives. To use formal and informal leaders, norms, and values to gain support of the innovation. To obtain input from grassroots level groups to develop program goals. To increase a community's empowerment, participation, and competency. To involve policy and decision makers and implementers. To develop multimedia advocacy strategies. To develop culturally relevant media campaigns.
Data from references 30 through 36.
mortality rates from cervical cancer among Hispanic women age 50 and over. There were four phases of the program: (1) community advisory planning phase--this phase focused on establishing a community advisory group to guide the development of the plan for the recruitment and awareness phase of this initiative; (2) educational phase--the objectives of this phase were to develop culturally sensitive and linguistically appropriate materials and educational strategies to teach Hispanic women from 4 selected Catholic parishes about risk factors for cervical cancer; (3) mass media campaign this phase focused on planning and implementing a communitywide media campaign on cervical cancer using a local Hispanic television network to produce a video and a 1-hour educational program; and (4) referral campaign-objectives of this phase were to identify clinics and other health care systems that could provide cervical screening examinations to the Hispanic female population. Table 5 presents the process used to determine appropriate levels, models, and interventions for this program. A multilevel approach and a combination of models was used to address specific cultural factors identified as barriers to cervical cancer screening among Hispanic women age 50 and over. For example, the Modified Health Belief Model of Rosenstock and Becker32 was used to address the intrapersonal level or each woman's attitudes, perceived risks, and lack of knowledge toward cervical cancer and screening activities. Bandura's Social Cognitive Theory 33 model was
used to address the interpersonal process by focusing on formal and informal social support systems such as religious leaders, family, friends, and peers to serve as gatekeepers or role models. Rogers' Diffusion of Innovations, 34 Rothman's Social Planning, s5 and Novelli's Social Marketing models s6 were used to address the community level in uniquely different ways. Diffusion theory was used to gain support of Catholic churches to serve as settings for conducting the focus groups and subsequent educational programs. This theory was also used to gain support from informal and formal community leaders, including the Guadalupanas, a Catholic Church group comprised of older Hispanic women. This organization helped to recruit Hispanic women to be actresses and to obtain their guidance in the production of a video. The video featured the use of "teatro," a short play format that uses drama scripts to deliver its message. Social planning strategies were used to form an advisory council comprised of bilingual, bicultural women representing various Hispanic subgroups, professions, and grassroots communities. The women were instrumental in the validation of terminology and content of the survey, teatro's script, and educational program. Finally, social marketing theory was used to obtain advocacy support from mass-media representatives to produce a culturally sensitive and linguistically appropriate video. The 5-minute video served as a trigger for the "Mujer a Mujer" educational program. The script focused on attitudes, beliefs, and practices of Hispanic women toward cervical cancer. The
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Table 5. Schema of the "Mu|er a Mujer" Cancer Control Model Level(s) Cultural factor(s) addressed
Theorectical models Strategies used
Intrapersonal
Interpersonal
Community
Age, gender, attitudes, beliefs, locus of control, knowledge of perceived susceptibility, and seriousness of disease. HBM.
Social support systems. Religious preferences,
Acculturation, access, utilization patterns, literacy level
SLT.
DT, SP, and SM.
1. Conducted survey on perceptions and modifying factors: (ie, Women who have had a hysterectomy do not need Pap smears. 2. Designed educational program to address certain perceptions (ie, bilingual, bicultural, large print, and low literacy principles).
1. Use of influential religious leaders (ie, approval from local bishop) for priests and churches to support programs. 2. Use of graasroots leaders and gatekeepers as role models (ie, support of Guadalupanas).
1. Use of bilingual focus groups (ie, public and professional) for input on survey and video script (DT) (ie, validation of perceptions and translations). 2. Development of a Hispanic women's advisory group (SP). 3. Identification of churches with target populations with varying acculturation levels (SP). 4. Identification of mass media advocate to help produce video (SM). 5. Identification of other technical experts (SP) (ie, public health experts).
Abbreviations: HBM, Health Belief Model; SLT, Social Learning Theory; DT, Diffusion Theory; SP, Social Planning; SM, Social Marketing.
use of two "comadres" or friends discussing this sensitive topic reinforced the importance of using the natural support systems characteristic of the Hispanic culture. The video's message was delivered in Spanish but appropriately translated English subtitles also were incorporated into the video. The success of designing a program that used various models to address the intrapersonal, interpersonal, and community levels was evident by the attendance at the programs and subsequent requests for additional programs. Cultural factors such as acculturation, language preference, age, literacy level, attitudes, and utilization patterns were carefully integrated throughout the four phases of the program. In summary, the "Mujer a Mujer" program evolved as an innovative and culturally appropriate cancer prevention and early detection model for targeting a challenging subpopulation, the Hispanic elderly woman. IMPLICATIONS FOR CLINICIANS
The literature indicates that an individual is influenced by a number of diverse cultural factors and that resulting beliefs and practices can be barriers to cancer early detection and screening activ-
ities. Preliminary and limited information from programs that target high-risk populations such as the elderly or low-income women show that specially tailored screening and early detection measures increased compliance with certain screening procedures such as mammography and cervical Pap smears. 27'37-39 Before successful pilot models such as the "Mujer a Mujer" program can be replicated for specific populations, certain limitations in current cancer control program planning efforts must be initially addressed at the policy, institutional, and community level. For example, current surveillance methods for collection of comprehensive data on ethnic populations must be revised. In reviewing the epidemiological patterns of cancer among minorities, two limitations of cancer registries and data collection methods must be addressed. 14 The first limitation focuses on the national databases that collect and publish incidence, mortality, and survival rates. Currently, most data is collected from special population studies conducted by the National Cancer Institute and are based on populations living in nine SEER registry areas. The populations living in these areas may not have adequate representation or may even have overrepresentation of ethnic
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populations. A review of cancer statistics collected and published before 1970 also indicates that the majority of epidemiological data and other health indicators were categorized into black and white subgroups. These limitations imply that ethnic groups such as Hispanics, Asians, Native Americans, and others were incorrectly classified into one of the two categories. These oversights also serve as a reminder that the SEER and national health surveys such as the National Health and Nutrition Examination Survey provide data only for a limited number of subsets of the United States populations and minority groups. Thus, two major sources of epidemiological data and health indicators for the nation do not accurately represent the health status of different cultural or ethnic groups. Consequently, these limitations can result in misclassification and underreporting of cancers among these groups. Clinicians must advocate for the development of more precise surveillance methods to ensure that accurate cancer epidemiological data is used to plan educational programs and interventions. In planning culturally sensitive screening programs, clinicians often ask three questions: (1) What criteria should be used to determine whether a particular cancer-screening model integrating culturally appropriate characteristics should be replicated? (2) What criteria should be used to determine the cultural factors that should be addressed in planning interventions? and, most important, (3) What strategies should be used in planning culturally appropriate programs? Table 6 attempts to answer the last question by listing examples of culturally appropriate strategies that have been successfully integrated into cancer control programs. Many of these strategies can be used with diverse ethnic and cultural groups; however, consideration of acculturation level and other cultural factors such as religious preferences are key factors that must be evaluated before designing any type of intervention. In order to answer the first two questions, the clinician must consider the fact that there is limited research data regarding quantifiable outcomes that accurately determine whether compliance with cancer-screening activities increases when programs are tailored to meet specific cultural variations. Because of the growing need to develop culturally appropriate programs, increased efforts are under way to address these areas. It is apparent that clinicians face great
Table 6. Strategies for Developing Culturally Appropriate Cancer Detection and Screening Interventions Follow basic rules when initiating interpersonal communication such as being courteous and respectful to establish trust or confidence. Use focus groups comprised of grassroots (community) and professional individuals to validate promoters or barriers to attitudes, knowledge, and behavior related cancer and its prevention. Use influential formal and informal leaders such as religious leaders, community gatekeepers, or opinion leaders.
Integrate religious, cultural, and when appropriate, traditional (folk) medicine and healing practices, beliefs, and taboos. Involve the family, friends, and members of other influential support systems. Determine a group's preferred communication process (verbal or nonverbal) as well as language preference. Determine an individual's degree of acculturation or assimilation, when appropriate. Involve paraprofessionals such as folk healers, when and if appropriate. Integrate cultural assessments into daily nursing practice.
challenges in answering these questions. Nevertheless, they can begin to establish baseline data by designing research studies that use epidemiological methodology such as cancer prevention clinical trials or population-based surveys alone or in combination with ethnoscience qualitative research methods. CONCLUSION
The greatest challenge for all health care providers is to accept each individual as a product of diverse cultural influences and to respect each individual's cultural uniqueness, including their own. Clinicians need to realize that the term "cultural diversity" implies division and emphasizes the differences that exist among our society's people. These differences already contribute to inequity in access and utilization of health care services needed for the poor, elderly, and other vulnerable populations. As our knowledge and awareness of the confluence of cultures and their impact on oncology nursing practice increases, our society can move toward Gordon's third model of assimilation, cultural pluralism. In doing so, we will realize that, indeed, "there is beauty in diversity. ''l~ ACKNOWLEDGMENT Special thanks to LuAnn Aday, Judy Faulkenberry, Yolanda Santos, and Louise ViUejo for their encouragement and guidance.
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