Journal of Community Health Nursing, 32: 71–88, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2015.1024541

Breast Health Beliefs, Behaviors, and Barriers Among Latina Permanent Resident and Migratory Farm Workers Michèle M. Schlehofer and Tina P. Brown-Reid Salisbury University, Salisbury, Maryland

There is a dearth of research on the breast health behaviors of migratory farm workers. This research used focus group methodology to compare the breast cancer beliefs and barriers of Latina women working as migratory farmers (n = 33) and permanent residents (n = 31). In comparison to their permanent resident counterparts, migrant farmers had low knowledge about the causes of breast cancer, and experienced significant barriers to care. Many barriers were cultural-specific, including culturally-based gender roles. These findings have significant implications for designing culturally-relevant interventions to improve access to care among this population.

Breast cancer is second only to skin cancer in prevalence among women, affecting 1 in 8 (12%) of women throughout their lifetime (American Cancer Society [ACS], 2014c), and is one of two leading causes of women’s cancer-related death (National Cancer Institute [NCI], 2014). The ACS (2014c) estimates that approximately 295,240 new cases of breast cancer will be diagnosed among US women throughout the year, and that 40,000 women will die of the disease. Early and prompt detection of breast cancer is important, as delays in diagnosis have significant negative implications for the likelihood of successful recovery (NCI, 2014). There are important benefits to detection prior to, or early in, the development of symptoms. As breast cancers that are detected in the asymptomatic stage tend to be smaller and confined to the breast, early detection offers women the best chance of surviving breast cancer (ACS, 2014b) and reduces the likelihood of partial or full removal of breast tissue during the course of their treatment (Abe, 1987; ACS, 2014a; Blackman, Bennett, & Miller, 1999; McLellan, 1988; Tabar & Dean, 2003). There are several available breast cancer screening practices (ACS, 2014a). Mammography, a low electromagnetic radiation picture of the breast, is a common procedure that can detect breast cancer in its earliest, asymptomatic stages. Research suggests that, among current detection methods, regular mammography is perhaps most effective, accounting for a 16% to 26% reduction in breast cancer mortality rates yearly in comparison to those whose breast cancer is not detected via mammogram (Kerlikowske, Grady, Rubin, Sandrock, & Ernster, 1995; United States Preventive Services Task Force [USPSTF], 2009), with one study finding that mammography reduced breast cancer’s 5-year mortality rate by almost 60% (Wojcik, Spinks, & Stein, 2003).

Address correspondence to Michèle M. Schlehofer, Department of Psychology, Salisbury University, 1101 Camden Avenue, Salisbury, MD 21801. E-mail: [email protected]

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In 2009, the USPSTF revised their breast cancer screening guidelines to recommend biennial mammograms for women, with screening starting at age 50 and lasting through age 74. Breast self-examination (BSE), or self-administered palpations of the breast to detect lump irregularities, is another common method of cancer detection. There is some controversy regarding BSE’s effectiveness, and the USPSTF (2009) does not recommend that physicians and other health professionals teach women to do BSE. Nevertheless, the ACS (2014a) and some health care providers (Mart, 2010) continue to recommend BSE as an option for women, and at a minimum suggest that women be aware of the shape, feel, and appearance of their breasts, and/or perform monthly BSEs. Further, research suggests that, despite not being officially recommended, women still perform BSEs, with approximately 43% of breast cancers discovered by women themselves via BSE or by accident (Roth et al., 2011). Despite the fact that early breast cancer detection can improve breast cancer treatment outcomes, many Latinas do not engage in early detection practices. Although Latinas are less likely to receive a breast cancer diagnosis in comparison to women of other ethnicities (ACS, 2014d; NCI, 2014), they also underutilize mammography (Emmons et al., 2011), particularly in comparison to their non-Latina White counterparts (Cokkinides, Bandi, Siegel, & Jemal, 2012; Miranda, Tarraf, & Gonzalez, 2011). Latina women also have low rates of BSE behavior in comparison to non-Latina White women (Pérez-Stable, Marín, & VanOss Marín, 1994), with some studies reporting that up to 81% of Latina women have inconsistent use of BSE (Peragallo, Fox, & Alba, 1998; Pérez-Stable et al., 1994; Skaer, Robison, Sclar, & Harding, 1996). Latinas also have a greater delay in following up abnormal mammography results in comparison to non-Latinas (Press, Carrasquillo, Sciacca, & Giardina, 2008). The result is that, when they are diagnosed, Latinas tend to be diagnosed with breast cancer at a later stage, even when controlling for various factors such as age, socioeconomic status, physician services use, and differences in detection methods (Lantz et al., 2006; Yasmeen, Xing, Morris, Chlebowski, & Romano, 2011). One recent study found that Latinas’ median delay between receiving an abnormal mammogram to receiving a cancer diagnosis was 60 days, in comparison to non-Latina White women’s 27 days (Ramirez et al., 2013). Perhaps as a result of later diagnosis, Latinas are more likely to be diagnosed with larger tumors (Miller, Hankey, & Thomas, 2002). Despite their availability, Latina women face many cultural-specific factors that may function as important barriers to, or facilitators of, breast cancer screening, the most important of which may be English language proficiency and acculturation. Not being able to speak English is associated with less knowledge of breast cancer screening guidelines (Ramirez, Suarez, Laufman, Barroso, & Chalela, 2000; Suarez, Roche, Nichols, & Simpson, 1997), less trust in doctors providing a cancer diagnosis (Kaiser et al., 2010), and less use of mammography among Latina women (Pérez-Stable, Otero-Sabogal, Sabogal, & Nápoles-Springer, 1996). Level of English language proficiency is, in part, reflective of overall acculturation to US culture. Lower levels of acculturation among Latina women has been found to be associated with a lower likelihood of engaging in BSE behaviors (Lawsin, Erwin, Bursac, & Jandorf, 2011) and mammography, unless women have access to a Spanish-speaking physician (O’Malley, Kerner, Johnson, & Mandelblatt, 1999). It is possible that less-acculturated Latinas might engage in screening behaviors at rates comparable to their more acculturated counterparts if components of the United States health care system are found to be responsive to their needs—such as culturally competent service providers and materials available in women’s native languages.

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Proxy indicators of acculturation, such as country of birth and length of residency in the United States, are also reliably related to screening behaviors, providing further (albeit indirect) support for the role of cultural factors in breast cancer screening decisions. For instance, engagement in BSE behaviors has been found to be positively correlated with length of residency in the United States among Latina women (O’Malley et al., 1999; Peragallo et al., 1998). In addition, women born in the United States have greater use of mammography than those born outside of the United States (Fink, Shapiro, & Roester, 1972) and a greater likelihood of maintaining the behavior (Song & Fletcher, 1998). It should be noted that acculturation may be confounded with socioeconomic status, as acculturation is positively correlated with both education and income (Borrayo & Jenkins, 2003). Aldridge, Daniels, and Jukic (2006) found that Latinas, in comparison to non-Latinas, were more likely to hold other demographic characteristics (such as a lack of a regular health care provider) that are associated with lower mammography use. Latina women who lack health insurance are less likely to receive mammograms (Miranda et al., 2011; Nuno, Castle, Harris, Estrada, & Garcia, 2011). Further, research has found that socio-demographic and socioeconomic factors, such as age, income, insurance status, and education, explain differences in mammography utilization among Latina populations (Fernández & Morales, 2007; Suarez, 1994). Cultural norms may also pose as barriers to breast cancer screening. Differential rates of mammography use between Latinas and non-Latina women are explained by differences in cultural characteristics (Borrayo et al., 2009). In comparison to White women, Latinas are more likely to see embarrassment and fear of the examination as barriers to obtaining a mammogram (Engelman, Cizik, Ellerbeck, & Rempusheski, 2012). Borrayo and Jenkins (2001a, 2001b, 2003) conducted a series of qualitative studies with US women of Mexican descent to identify various cultural factors involved in breast cancer screening decisions. They have found that these women hold a variety of culturally rooted beliefs that may work as barriers to care. First, many women of Mexican descent hold misconceptions that breast cancer is a symptomatic disease (Borrayo & Jenkins, 2001a, 2003). Second, Borrayo, and Jenkins (2003) found Mexican American women often hold strong beliefs that wasting money was inappropriate and a stigmatized behavior. Coupled with perceptions that breast cancer is a symptomatic disease, screening for breast cancer in the absence of symptoms by way of use of costly screening behaviors (such as mammography) is unnecessary and potentially socially unacceptable. Third, many women of Mexican descent, and particularly those who underutilize mammography, hold fatalistic attitudes (Lopez-McKee, McNeill, Bader, & Morales, 2008); these women might not screen for breast cancer to avoid a fatal illness diagnosis (Borrayo & Jenkins, 2001a; Ramirez et al., 2000). Furthermore, Latina women may hold cultural norms of female modesty, norms that suggest that exposure of one’s breasts, even to health practitioners for the purpose of cancer detection, is indecent, especially if those practitioners are men (Borrayo & Jenkins, 2001b). Finally, women in Borrayo and Jenkins’ studies (2001a, 2003) held strong beliefs that breast cancer was preventable. These women saw breast cancer as due to specific factors, such as an injury or trauma to (or manhandling of) the breast, excessive sexual activity, and improper or insufficient breastfeeding. As breast cancer is seen as being caused by specific factors, it can easily be prevented by avoidance of these factors (e.g., breast feeding children and not engaging in excessive sexual behavior). Borrayo and Jenkins’ findings suggest that these cognitions are culturally-driven, and may work in combination as barriers to obtaining mammography and of practicing BSE.

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It should be noted that these beliefs were more prevalent and pervasive among women of lower socioeconomic status and who were less acculturated (Borrayo & Jenkins, 2003), supporting conceptualization of these cognitions as being culturally driven.

MIGRATORY FARM WORKERS: AN UNDERSERVED POPULATION Among Latinas, the subpopulation of migratory farm workers are perhaps the most in need of both research attention and community health outreach (Anthony, Williams, & Avery, 2008). This population often works for extremely low wages under harsh conditions, and lacks sufficient health coverage and access to medical care (Anthony et al., 2008; Hansen & Donohoe, 2003; Robinson, 2001). Further, as Latina migratory farm workers are primarily or solely Spanish-speaking, and as many are immigrants, they are particularly likely to experience cultural and language barriers to health care (Anthony et al., 2008; Hansen & Donohoe, 2003). This community is also likely to experience a myriad of logistic concerns (e.g., transportation problems, time conflicts, lack of childcare, etc.) as barriers to care (Anthony et al., 2008). The population of migratory workers remains poorly understood, which inhibits appropriate care (McCarthy, 2000). There is a dearth of research on the healthcare needs of migrant farm workers (Anthony et al., 2008), and no research, to our knowledge, which specifically explores the breast cancer detection behaviors and beliefs of this vulnerable population. Clearly, there is a need for researchers to continue to identify and address barriers to breast cancer detection among Latinas, particularly those who work as migrant farmers. To learn more about beliefs and about breast cancer and barriers to engaging in breast cancer detection practices among Latina women, including among those who are migrant farm workers, we conducted focus groups on breast health beliefs, breast cancer detection, and barriers to engaging in detective practices among Latinas, and compared findings across subsamples of both permanent residents and migrant farm workers.

METHODS Participants Six focus groups, for a total of 64 participants, were held across a one-year period: three focus groups with Latina seasonal migrant workers (n = 33), and three groups with Latinas who live permanently in the area (n = 31). Focus groups ranged in size from four to 16 participants; the modal focus group had 11 participants. Across all groups, women were between the ages of 21 to 72 (M = 38.48; SD = 14.01). Migrant workers (M = 44.13, SD = 14.02) were significantly older than permanent residents (M = 32.07, SD = 11.24), t(59) = 3.71, p < .001. Rates of breast cancer screening behaviors were low for both migrant workers and permanent residents. Thirty percent (n = 20) of women reported that they performed BSE every month. Nine women (14%) had never performed a BSE. Of those who had performed a BSE, most (n = 25; 44.7%) reported performing their last BSE over a year ago. Of the 25 women aged 40 and older (and for whom mammography is most relevant), 13 (50.2%) had received a mammogram in the

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TABLE 1 Risk Factors for Breast Cancer Generated by Participants N (%) of Focus Groups Mentioning Risk Factor

Risk Factor

Examples

Permanent Residents

Migrant Workers

All Groups

3 (100%)

3 (100%)

6 (100%)

Social or lifestyle factors

Improper diet Hitting your breast/trauma to the breast Being overweight/not exercising Lack of personal hygiene Drug/alcohol use/smoking

Heredity

Heredity/genes Ethnicity

2 (67%)

3 (100%)

5 (83%)

Signs of breast cancer

Having lumps Tissue changes Hardening of the breasts

2 (67%)

2 (67%)

4 (67%)

Hormonal factors

Taking birth control pills Irregular periods Hormonal changes Menopause

2 (67%)

1 (33%)

3 (50%)

Screening avoidance

Not getting a mammogram Not checking one’s “blood” Not getting checked by doctors Age Getting old

1 (33%)

2 (67%)

3 (50%)

2 (67%)

0

2 (33%)

0

2 (67%)

2 (33%)

Age Motherhood-related factors

Not breastfeeding one’s baby Having children Breastfeeding a baby Having clogged breasts while breastfeeding

past year; eight (13%) had never received one. Rates of BSE performance in the past month and intentions to perform a BSE in the next 12 months did not differ between migrant workers and permanent residents, as shown in Table 1. Although 11 women (18%) had found a lump in their breast, none had received a cancer diagnosis. Eighteen women (28.1%) reported personally knowing someone with breast cancer, and two (3.1%) reported having a family history of breast cancer (defined as having a mother or sister who had been diagnosed with breast cancer). There were no differences in reporting finding a lump in one’s breast, knowing someone with cancer, or having a family history of cancer, between migrant workers and permanent residents. Participants were asked to report their perceived risk of breast cancer using Champion’s (1984) breast cancer susceptibility scale (α = .77). The scale consists of six items to assess perceived risk

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to breast cancer (sample item: I feel that I will get breast cancer sometime during my life), rated on a 7-point Likert scale ranging from 1 = strongly disagree to 7 = strongly agree. Women’s perceived risk of breast cancer was, on average, low to moderate (M = 3.86, SD = 1.88). Migrant workers had greater risk perceptions (M = 4.38, SD = 2.05) in comparison to permanent residents (M = 3.20, SD = 1.5), t(62) = 2.61, p = .011. Procedure A qualitative focus group approach was chosen as the appropriate methodology for our project for a variety of reasons. Focus group methodology helps reduce power differentials between the researcher and the participants by allowing the participants more control in the data-collection process than traditional individualist approaches (Wilkinson, 1998a, 1999), it provides a naturalistic environment in which to explore human behavior (Wilkinson, 1999), it can be empowering to participants (Harrison & Barlow, 1995), and it increases the chances that research serves the interests of marginalized populations (Mies, 1983). Further, because focus groups share features of conscious-raising groups (e.g., Fine, 1992; Wilkinson, 1998a), focus groups can lead to an increased collective consciousness among participants. The interactive nature of focus groups in health research is particularly important, as it can enhance participants’ disclosure and lead to a better understanding of participants’ own language, meaning, and agendas (Wilkinson, 1998a, 1998b). Finally, focus groups are particularly useful in increasing understanding of the perspectives of people from underserved cultural populations (Halcomb, Gholizadeh, DiGiacomo, Phillips, & Davidson, 2007). The county health department assisted in participant recruitment. To recruit participants, English/Spanish bilingual staff members of the county health department distributed recruitment flyers and made announcements to women both living in local migrant worker camps and in community organizations (such as churches) with high numbers of Latina clientele in the general area. Attendance concerns were addressed in several ways. First, we overrecruited. With a desired attendance of 5–10 people per group, we aimed to recruit 15–20 people per focus group. Once 20 people signed up for the focus group, inquiring participants were informed that the focus group was full, and placed on a wait list. To increase attendance, focus groups were held at local community-based facilities already frequented and easily accessible to the participants, such as churches and the public library. Focus groups lasted between 1 to 11/2 hr. Because all participants (permanent residents and migrant farm workers) were fluent in Spanish, and many spoke only Spanish, all focus groups were conducted in Spanish. Both facilitators were provided with 1 hr of training on the study goals and underlying methodology, the use of semistructured dialogue prompts, the importance of impartiality, active listening techniques, and how to handle difficult situations, such as situations in which no participant talks or where participants become upset when discussing sensitive topics. After signing informed consent, participants completed a short 10-min survey that asked how much at risk they felt for breast cancer (perceived risk), information on prior breast cancer detective behaviors, items to assess a family history of breast cancer, and demographic questions. Following, participants responded to a series of semistructured prompts.

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All discussions were recorded by two mini tape recorders. Two recorders were used to provide a backup in the event of a poor recording. Recording devices were positioned at opposite ends of the table to ensure audio clarity. To provide a small incentive for participants to attend, a light fare meal was provided for participants, and all participants were presented with small gift bags at the conclusion of the focus group. The gift bags contained shower hangers detailing the procedures for conducting a BSE, health and beauty products (e.g., moisturizer and bath salts), and coupons and sample products from area merchants. Most of the meals and all of the gift bag items were donated by area merchants. Focus group prompts. Participants were asked what they think causes breast cancer, what women can do to prevent breast cancer, and how effective they think preventative measures are. Second, women reported perceived barriers toward BSE and mammography. They were asked if they were easy to do, if they work, why they think some women do not do them, and how the medical community could encourage women to do them. Third, to help foster a sense of community among participants and to encourage feelings of empowerment over breast health, the women participated in a resource-sharing exercise. Women shared their knowledge of local breast health resources (e.g., places to obtain mammograms or breast cancer care centers) and any experiences with these resources. Finally, women were asked what they thought the local medical community could do to encourage both BSE and mammography. Data analysis. Audio recordings were transcribed, stripped of identifying information (such as names), and translated from Spanish to English. First, participant conversations in response to each prompt were organized in a cross-case meta-matrix. Responses were coded as whether coming from a permanent residential group or from a migrant farm worker group. Next, within each focus group, two independent research assistants identified themes at the phrase level using an inductive process. Themes were then compared across focus groups conducted with permanent residential and migrant farm workers.

RESULTS Breast Cancer Risk Factors Participants mentioned several different factors that increase one’s chances of getting breast cancer. Inductive coding resulted in classifying the risk factors participants provided into one of seven categories: social or lifestyle factors; heredity; signs of breast cancer; hormonal factors; screening avoidance; age; and motherhood-related factors. These categories, examples, and the number of focus groups in which each risk factor category was mentioned are displayed in Table 1. As can be seen in Table 1, the most frequently mentioned risk factor were those relating to social behaviors, lifestyles, or habits. Women in all six focus groups mentioned social or lifestyle factors. Between two and six lifestyle factors were mentioned in each focus group. Permanent residents and migrant workers were equally likely to mention lifestyle factors. The most common lifestyle risk factors mentioned were having a poor diet or vitamin deficiency (mentioned by all six groups), and being overweight or not exercising (mentioned by three groups). These are discussed in greater detail in the following.

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Aside from social and lifestyle risk factors, women in five of the six focus groups mentioned hereditary factors as increasing breast cancer risk. The women seemed very aware of the role of genetic risk in the development of breast cancer. However, only two groups, both comprised of permanent residents, mentioned age as a risk factor. Incorrect or Inaccurate Risk Factors Women also listed several incorrect or inaccurate risk factors for breast cancer. The social and lifestyle category elicited the highest number of incorrect breast cancer risk factors. Of the 53 risk factors women provided in the social and lifestyle category, 20 (37.7%) were incorrect. A list of incorrect social and lifestyle risk factors women provided is presented in Table 2. As can be seen in Table 2, migrant workers were three times more likely to provide incorrect risk factors. Of the 30 risk factors migrant workers generated, 15 (50%) were incorrect. Of the 23 risk factors generated by permanent residents, 21.7% were incorrect. Women mentioned that lifestyle factors such as poor diet, lack of exercise, and not maintaining personal hygiene increased breast cancer risk. Research finds that personal hygiene is not a factor that increases one’s breast cancer risk; and the impact of diet and exercise on breast cancer risk is currently inconclusive or unknown (ACS, 2014d). As an example, a permanent resident believed that breast cancer was caused by “unhealthy eating, and not exercising and not taking care of the body. If a woman does not eat healthy food, or does not understand the concept of healthy diet, or that it can be beneficial to health.” Trauma or injury to breast tissue, and having one’s breasts roughly touched were also mentioned as lifestyle factors that increased one’s risk of breast cancer. For instance, one woman (a permanent resident) stated that “one of the things that I believe (causes breast cancer) is birth control pills.” Another woman (a migrant worker), believed that “because they (husbands) touch

TABLE 2 Incorrect Breast Cancer Risk Factors, by Group Permanent Residents Having large breasts Hitting your breast Irregular periods Not checking one’s “blood” Prominent veins

Migrant Workers Being hit in the breast (2 groups) Breast implants Breast tissue changes Breastfeeding Clogged breasts when breastfeeding Eating and breastfeeding at the same time Feeling something in the breast Hard breasts Lack of personal hygiene Not cleaning one’s breasts Not cleaning one’s nipples Not doing breast self-examinations Not going to the doctor’s Not having mammograms Touching breasts too much

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our breasts in rough way, and they say that it’s not on purpose. And I think you can have some bruises inside when this happens.” In line with this, women also suggested that being a victim of domestic violence in which the breasts were injured could cause breast cancer. One woman (a migrant worker) felt that “in my country, men are used to maltreating women, sometimes by hitting her and other things. That can produce (breast cancer).” Aside from incorrect social and lifestyle risk factors, women in the various focus groups provided other risk factors that were incorrect. Women in two focus groups (both comprised of migrant workers) indicated that breastfeeding increased—not decreased—one’s chances of breast cancer. For instance, a migrant worker stated that breast cancer happens “because some women breastfeed their children, and for the remaining milk left in the breast, and because women don’t clean their breast.” Two other migrant workers in the same group subsequently expressed agreement with this statement, with one elaborating, “Well, I always thought that breastfeeding can cause breast cancer because you get your breast filled with milk and stays in your breast if you don’t empty them.” Moreover, women in four focus groups (two comprised of permanent residents and two comprised of migrant workers) mentioned signs of breast cancer as risk factors. Signs mentioned included tissue changes, breast hardening, and having breast lumps. Finally, as can be seen in Table 1, women in three focus groups (two comprised of migrant workers and one of permanent residents) stated that not getting screened for breast cancer (either by avoiding mammography or not doing BSEs) put one at increased risk of breast cancer. It is possible that women did not understand what was meant by a risk factor, or confused risk factors with symptoms of breast cancer, or confused breast cancer detection with breast cancer prevention. Barriers to BSE and Mammography An inductive coding approach was also used to code perceived barriers toward BSE and mammography into one of nine categories. The coding scheme and examples are provided in Table 3. As can be seen in Table 3, the top three barriers to BSEs were low ease of use and lack of concern over breast cancer (mentioned by women in five groups), and lack of knowledge on how to perform BSE (mentioned by women in four groups). For instance, discussing both a lack of knowledge on how to perform BSE and a lack of concern over breast cancer risk, one woman (a permanent resident) stated: I think some women don’t do them because they do not know if they don’t know what they have to do. Sometimes they don’t have understanding. They don’t know exactly how they function, how to begin. They will say, “I don’t need to because it is not in my family,” or “My family is totally healthy.”

Another woman from one of the migrant worker groups similarly addressed lack of knowledge with her comment that women do not do BSE “for lack of information, I think. Because they don’t know (how).” The lowest barrier was pain, mentioned by only one group of women (a migrant group). For mammography, the top barriers provided were a fear of breast cancer diagnosis (mentioned by women in all six groups). Lack of accessibility emerged as a top barrier (mentioned by five groups). Women mentioned that it was costly to get a mammogram and difficult logistically

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TABLE 3 Barriers to Breast Self-Examination (BSE) and Mammography

Barrier Cultural factors Easy Efficacy Embarrassment Fear Lack knowledge

Lack of concern Logistics Painful

Examples Taboo to touch breasts Husband prohibits it Not easy to do They don’t work You get false positives Embarrassing to touch or show one’s breasts Afraid of finding something Fear of cancer Don’t know how to do it Don’t know of any affordable centers Lazy Unnecessary if asymptomatic No time to do it Not enough money It hurts or is painful

Barriers to BSE: N (%) of Focus Groups Mentioning as a Barrier

Barriers to Mammography: N (%) of Focus Groups Mentioning as a Barrier

2 (33%)

4 (67%)

5 (83%) 3 (50%)

0 (0%) 3 (50%)

3 (50%)

2 (33%)

2 (33%)

6 (100%)

4 (67%)

2 (33%)

5 (83%)

3 (50%)

2 (33%)

5 (83%)

1 (17%)

4 (67%)

getting to the mammography facility. For instance, one woman (a migrant worker), stated: “When we have money, it is easy to visit any clinic or hospital. But when we don’t have any money, we postpone it until there is money available again.” A migrant worker in the same group felt that “when we are going to have my mammogram, we start worrying about how much it’s going to cost. So I check my money to see if I have enough, and if it’s enough then I go. But if not, I’ll wait.” Similarly, a migrant worker in a different group remarked, “(An)other reason they don’t get a mammogram is because of lack of money. Sometimes women don’t work, or need to pay their bills first, and they can’t. We have the money for the basics.” Yet a fourth migrant worker, in a different group, stated that women do not obtain regular mammograms because of lack of health insurance: There are companies that offer health insurance to their employers; I used to work in one that offer that benefit, and I could have access to do this exam. But now I don’t have insurance, and I haven’t been able to get a mammogram. It’s expensive, we don’t have the resources, and sometimes we don’t have the time, either.

Painfulness or fear of pain during a mammography procedure was additionally mentioned as a barrier by four groups of women (two migrant groups and two groups of permanent residents). One woman, a migrant worker, shared, “I think women don’t get a mammogram because people tell that they squeeze the breasts and that it hurts and that’s why women don’t do their mammograms.”

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Cultural Barriers Of the six focus groups conducted, participants in four groups (67%) mentioned cultural-specific barriers to breast cancer detection efforts; three groups consisting of permanent residents and one group of migrant workers. These barriers fell into one of three themes: (a) prohibitive female gender roles, (b) prioritization of health needs, and (b) language concerns. All four groups mentioning cultural barriers indicated that female gender roles were prohibitive to either doing BSE or getting a mammogram. Gender roles were seen as prohibitive in two ways. First, women expressed fear of showing one’s breast to a male health care provider during mammography. For instance, a migrant worker expressed anxiety at her first mammogram because “the first time you don’t know if it’s going to be a female or male performing the exams. That’s how I feel the first time. I wasn’t sure if a female or male was going to perform my exams.” A permanent resident additionally felt that it was “somewhat of a taboo to have to go to a doctor (and expose one’s breasts).” Second, participants in three of the focus groups mentioned that in their culture, husbands prohibit breast cancer detection behaviors. For instance, one woman, also migrant worker, stated women do not receive mammograms because “husbands don’t allow women to do it; going to the doctor and get the exams; that happens very often. Husbands don’t allow their wives to have it.” A permanent resident similarly said, “Some women don’t get it because of their husbands because they (husbands) don’t want women to show their breast.” Related to the previous quote, women in two focus groups mentioned that, for their culture, touching oneself during BSE or exposing one’s breast during a mammography procedure was taboo or shameful. For instance, one permanent resident stated that women do not do BSE because “it depends on the culture. They may not feel comfortable with touching themselves.” Women also emphasized that, in their culture, women place their health needs at a lower priority than the needs of their family. One woman, a permanent resident, stated, “They are too busy to get information . . . because they are taking care of a household; they have to get dinner on the table for their husbands; they are cleaning; they are not taking care of themselves.” Another permanent resident in the same focus group later validated this by stating: They don’t have doctors, they don’t want to go for a medical exam because when they do go, it costs them over 50 dollars. They say they have to feed their children, and they cannot afford to go to the doctor. They always put their family first and themselves last. But in the meantime, they’re being left behind in terms of health.

In terms of language concerns, participants felt that language barriers were a significant deterrent to seeking healthcare in general, and obtaining mammograms and information on BSE in particular. For instance, a permanent resident remarked that “some women don’t get them because they speak very little English, so they’re intimidated.” A migrant worker echoed this sentiment: “(We don’t go because of) the English. We make every effort to learn English, but somebody of my age it is hard to keep everything in the head.” Awareness of Existing Resources Women seemed, overall, fairly aware of existing breast health resources. Both women in the migrant worker groups and permanent residents listed area resources; women in all six focus groups mentioned between three and eight local resources. The top resources mentioned were

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the hospital, county health department, and local clinics. Four groups mentioned the local hospital’s breast cancer diagnostic center, and five groups mentioned that free mammograms could be obtained through the local health department. Only two groups (one of permanent residents, the other of migrant workers) mentioned that they could contact their primary care provider. Only one group of women (comprised of permanent residents) did not seem to explicitly know where they would go or who they would contact if they were seeking out cancer diagnostic services. Suggestions for Promoting BSE and Mammography Focus groups varied in their responses when asked what the local medical community could do to promote BSE and mammography. Of the six focus groups, only three provided suggestions for increasing breast cancer detection practices (one group comprised of permanent residents and two of migrant workers). All three groups of women suggested that more education and outreach was needed in their communities. Migrant workers, in particular, called for more educational materials (pamphlets and videos were specifically mentioned) that included women sharing their stories of breast cancer and specific directions for BSE. Migrant workers also suggested that personal, community-centered, “door-to-door” campaigns would be most effective. Migrant workers in two focus groups commented that their mobility poses a limitation to obtaining regular mammograms, and that the medical community must address these concerns. These migrant workers stated that, in some states, they have free access to mammography, and they take advantage of the access to resources and obtain the procedure. However, when they relocate to another state, they sometimes lose access to care. For instance, one woman (a migrant worker) stated that she “received the Pap smear and the mammogram in Georgia because they never charge me for anything.” Similarly, another woman (a migrant worker in a different group) stated that relocation from Florida simultaneously increased her access to mammography and made it more difficulty to get follow-up appointments: In Florida they don’t offer this kind of services that you offer (in this state), where they come and pick you up and then when you’re done they drop you off. One ends up coming to this area [Maryland] because we have more access to health care. Here one feels safer and we have more support. For instance, in a case that we get a positive results here or something happens, what are our chances, can we get surgery and treatment here or can we get it down in Florida?

In addition to these suggestions, the permanent residents also emphasized that promotion efforts be culturally relevant. They noted the need for Spanish-speaking and female doctors in the community, as illustrated by this participant (a permanent resident): “Sometimes there is nobody there that speaks Spanish, and not always we can take somebody with us to interpret. And ideally that the doctor be a female, because we are afraid of seeing a male doctor.” A second participant from a different focus group (also a permanent resident) echoed the need for materials “in Spanish for Latina women in the United States.” Latinas additionally felt that the medical community did not effectively target to their culture. For instance, one woman (a permanent resident) stated: The thing is that we have the information and doctors encourage women to do it, but because our culture is difficult. People with Latina background that come here, half of them work, and we don’t take the time to take the information with us. Probably if they created more consciousness among Latina (women), maybe we would inform ourselves better.

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Finally, one focus group, consisting of permanent residents, emphasized the use of community-based promotoras (promoters) to encourage women to obtain a mammogram. This is illustrated by the following comment, from a permanent resident: Yes, in my case, I know several women, and they will not come unless they know that I will be there. If there are familiar faces that they know, the women will be willing to come out and learn information rather than just going to someone that they don’t know. They want to feel comfortable. It is another way to reach out to the community. If they know someone there, it will be easier to get more women to come out in the community.

DISCUSSION Although Latinas are less likely to acquire breast cancer in comparison to other ethnic groups (ACS, 2014d; NCI, 2014), they have particularly low rates of mammography utilization (Cokkinides et al., 2012). Latina women face many additional, cultural specific barriers to care. This is particularly true of the Latina migrant farm worker population, who often lack sufficient health coverage and access to medical care (Hansen & Donohoe, 2003; Robinson, 2001). There is a scarcity of research examining breast health beliefs, barriers, and behaviors among this population in particular. This study sought to address gaps in the literature by conducting a series of focus groups with both Latinas who are permanent local residents and who are migrant farm workers. The goals of the study were to further shed light on the various beliefs, behaviors, and barriers to care experienced among Latina women, including those most marginalized; and to explore possible differences between Latina women who are permanent community residents, and who live as migratory farm workers. Women, both permanent residents and migrant workers, were well-informed of local breast health resources. Most were aware that free mammograms were obtainable through the county health department. This is not surprising, as the county health department has an active mammography and cervical screening program for Latinas that is well-advertised. Knowledge About Breast Cancer Despite the high level of awareness of local resources, our findings indicate a significant need for education among Latina women as to the causes of breast cancer, what factors place a woman at high risk for breast cancer, and what women can and should be doing to detect breast cancer early. Further, the findings demonstrate that educational efforts must address cultural barriers to care, particularly among the migrant farm worker population. Each of these findings is discussed in turn. Despite high knowledge of local resources, women seemed unaware of breast cancer risk factors. Although women in every focus group mentioned heredity or genetics as a risk factor, women in every focus group also mentioned that numerous variables caused breast cancer when they, in fact, did not. Commonly listed erroneous factors included trauma to the breast (getting bumped or injured), poor diet and lack of exercise, not wearing a supportive bra, and poor hygiene. Migrant women also mentioned breast feeding and having breasts clogged with milk as

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risk factors for breast cancer; when in reality, breastfeeding is preventive. Women suggested they could prevent breast cancer by improving their general health by eating healthy, exercising, and not smoking. Participants in every group also mentioned BSE and mammography as ways they could prevent breast cancer, which suggests that women might be confusing detective practices with preventive care. Prior research supports our finding that incorrect knowledge of what causes breast cancer is pervasive among some Latina populations. For instance, Saint-Germain and Longman (1993) found that over half of older Latinas believed that several attributes and behaviors, such as excessive jogging, bad diet, stress, wearing bras, or having large breasts, were significant risk factors for breast cancer—beliefs that were either overinflated or incorrect. There appears, therefore, to be an ongoing need for education regarding breast health risk factors among this population. What is now needed is research to determine whether believing that these false risk factors cause breast cancer impact breast cancer screening decisions. Believing that multiple factors cause breast cancer when they, in fact, do not might influence women’s perceptions of their risk of breast cancer or the controllability of that risk; and these perceptions might, in turn, impact breast cancer screening rates. Illustrating this possibility, Zapka, Stoddard, Barth, Costanza, and Mas (1989) found that beliefs held by Latinas that bumping of the breast caused breast cancer—beliefs held by 94% of women in their sample—were related to a greater likelihood of having their healthcare provider perform a clinical breast exam (a healthcare-provider-initiated palpation of the breast to detect for lumps). More research into how beliefs in incorrect risk factors affect the migrant worker population is warranted. Migrant workers had particularly low knowledge of breast cancer risk factors. Half of the risk factors for breast cancer that migrant workers generated were incorrect, compared to only 22% of the risk factors generated by permanent residents. There were little differences between permanent residents and migrant workers in terms of which incorrect risk factors were believed to cause cancer, with one exception: as compared to permanent residents, migrant workers were more likely to believe that breastfeeding increases breast cancer risk, rather than reduces it. Breastfeeding was mentioned as a factor that increases one’s breast cancer risk among women in two of the three focus groups with migrant workers. These migrant workers felt that milk could collect in the breast and cause breast cancer if not emptied. This finding demonstrates a need for increased awareness and education about the causes of breast cancer in this community. The fact that permanent residents also mentioned incorrect factors suggests that education need not be limited to the migrant population.

Cultural Barriers to Care When asked about BSE and mammograms, participants mentioned numerous barriers to care. Some were related to lack of knowledge (for instance, do not know how to do a BSE, did not understand reasons for mammography), fear (fear that the procedure will hurt, fear of detecting cancer), or logistical or financial barriers (e.g., do not want to take time off from work, lack of money), but many of the barriers women listed were cultural. Both the permanent residents and women residing in the migrant camps, in particular, listed multiple barriers related to cultural beliefs about male–female interactions and gender roles. For instance, women reported that touching one’s breasts was an embarrassing and a stigmatized behavior, and that these cultural

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norms decreased the chances of performing BSE. These findings are consistent with previous work (Borrayo & Jenkins, 2001b). Additionally, women commented that it is embarrassing to see a doctor for a mammogram or to perform BSE, and that their husbands do not allow them to go, and that, in their culture, women prioritize other’s needs over their own. This low prioritization of their own health care is consistent with research conducted by Borrayo and Jenkins (2003), who found that Latina women feel that wasting money on their own healthcare was inappropriate. These findings suggesting that for health outreach initiatives to be effective, they must address cultural factors and norms prohibitive of breast cancer detection. It is possible that cultural norms, such as these, which present barriers to breast cancer detection can be overcome via culturally-relevant interventions (e.g., work by Lorig & Waters, 2003, Marshall et al., 2013, and Nuno, Martinez, Harris, & García, 2011). An innovative community approach by Lorig and Walters, known as the HECO (Health Education–Community Organization) approach, has been shown to positively address cultural barriers to breast cancer screening. In the HECO approach, Latina community facilitators not only conduct workshops that address community norms and attitudes about breast cancer screening, but also demonstrate BSE over their clothing. Furthermore, the facilitators ask participants to simultaneously perform BSE (again, over clothing). Such tactics resulted not only in a significant increase in BSE, but also sanctioned the touching of the breasts, a behavior often seen as stigmatized in Latino culture (Lorig & Walters, 2003). Additional research on effective interventions that reduce cultural barriers to accessing care is warranted. Aside from cultural factors, which seemed to impact all women, the migrant workers experienced unique logistical concerns that limited their access to breast health care. These women’s frequent mobility impeded their access to consistent breast care. When living in areas with free or comprehensive medical resources, women reported being more likely to obtain mammograms and see a doctor about their breast health. However, when living in areas in which resources were lacking, their breast health fell to the wayside. Additionally, women were unsure whether and how diagnoses and medical recommendations obtained in one area of the country could be followed up once relocating to a different area. Encouraging Breast Cancer Detective Behaviors Our participants, particularly the migrant workers, had some suggestions for encouraging Latinas to engage in breast cancer detection behaviors. These included a desire for more knowledge (and detailed instructions) on teaching women how to do BSE, and health education campaigns that were culturally-relevant and provided in Spanish. Women suggested that mobile clinics, community outreach efforts, or peer health promoter (promotora) models would be most effective at motivating women in their community to engage in breast cancer detective practices.

CONCLUSIONS These findings indicate that there remains a great need for breast health education and outreach among Latinas, particularly those who are also migrant farm workers, and highlights the need for additional research. The findings emphasize the importance of culturally sensitive education

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and outreach efforts that not only inform women about breast health, but also address the multiple barriers to receiving care that exist for this population. The migrant farm workers in our sample, in particular, called for increased interventions and outreach that specifically targets the cultural and logistical barriers to care facing this vulnerable population. Based on these findings, a community-based breast health campaign using a peer health promoter (promotora de salud) model, in which migrant workers residing in migrant camps are recruited and trained to conduct breast health outreach workshops, might be one effective method of increasing these women’s knowledge of breast cancer and their breast cancer detection practices. REFERENCES Abe, R. (1987). Trial of early detection for breast cancer by itinerant mass screening. Cancer Detection Prevention, 10, 223–227. doi:10.1002/1097-0142(19850915)56:63.0.CO;2-1 Aldridge, M. L., Daniels, J. L., & Jukic, A. M. (2006). Mammograms and healthcare access among US Latina and non-Latina women 40 years and older. Family & Community Health, 29, 80–88. American Cancer Society. (2014a). Can breast cancer be found early? Retrieved from http://www.cancer.org/docroot/ CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?sitearea= American Cancer Society. (2014b). Can breast cancer be prevented? Retrieved from http://www.cancer.org/cancer/ breastcancer/overviewguide/breast-cancer-prevention American Cancer Society. (2014c). What are the key statistics about breast cancer? Retrieved from http://www.cancer. org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics American Cancer Society. (2014d). What are the risk factors for breast cancer? Retrieved from http://www.cancer.org/ cancer/breastcancer/detailedguide/breast-cancer-risk-factors Anthony, M., Williams, J. M., & Avery, A. M. (2008). Health needs of migrant and seasonal farmworkers. Journal of Community Health Nursing, 25, 153–160. doi:10.1080/07370010802221768 Blackman, D. K., Bennett, E. M., & Miller, D. S. (1999). Trends in self-reported use of mammograms (1989–1997) and papanicolaou tests (1991–1997): Behavioral risk factor surveillance system. Morbidity and Mortality Weekly Report, 48, 1–22. Borrayo, E., Hines, L., Byers, T., Risendal, B., Slattery, M. L., Sweeny, C., . . . Giuliano, A. (2009). Characteristics associated with mammography screening among both Latina and non-Latina White women. Journal of Women’s Health, 18, 1585–1594. doi:10.1089/jwh.2008.1009 Borrayo, E. A., & Jenkins, S. R. (2001a). Feeling healthy: So why should Mexican-descent women screen for breast cancer? Qualitative Health Research, 11, 812–823. Borrayo, E. A., & Jenkins, S. R. (2001b). Feeling indecent: Breast cancer screening resistance of Mexican-descent women. Journal of Health Psychology, 6, 537–549. Borrayo, E. A., & Jenkins, S. R. (2003). Feeling frugal: Socioeconomic status, acculturation, and cultural health beliefs among women of Mexican descent. Cultural Diversity and Ethnic Minority Psychology, 9, 197–206. Champion, V. L. (1984). Instrument development for health belief model constructs. Advances in Nursing Science, 6, 73–85. Cokkinides, V. E., Bandi, P., Siegel, R. L., & Jemal, A. (2012). Cancer-related risk factors and preventative measures in US Latinas/Latinos. CA: A Cancer Journal for Clinicians, 62, 353–363. doi:10.3322/caac.21155 Emmons, K. M., Cleghorn, D., Tellez, T., Greaney, M. L., Sprunck, K. M., Bastani, R., . . . Puleo, E. (2011). Prevalence and implications of multiple cancer screening needs among Hispanic community health center patients. Cancer Causes Control, 22, 1343–1349. doi:10.1007/s10552-011-9807-7 Engelman, K. K., Cizik, A. M., Ellerbeck, E. F., & Rempusheski, V. F. (2012). Perceptions of the screening mammography experience by Latina and non-Latina White women. Women’s Health Issues, 22, e395–e401. Fernández, L. E., & Morales, A. (2007). Language and use of cancer screening services among border and non-border Hispanic Texas women. Ethnicity and Health, 12, 245–263. doi:10.1080/13557850701235150 Fine, M. (1992). Disruptive voices: The possibilities of feminist research. Ann Arbor, MI: University of Michigan Press. Fink, R., Shapiro, S., & Roester, R. (1972). Impact of efforts to increase participation in repetitive screenings for early breast cancer detection. American Journal of Public Health, 62, 328–336.

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Breast health beliefs, behaviors, and barriers among latina permanent resident and migratory farm workers.

There is a dearth of research on the breast health behaviors of migratory farm workers. This research used focus group methodology to compare the brea...
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