Health beliefs of low-income Hispanic women: a disparity in mammogram use.
Abstract: A prominent public health disparity is the lack of mammogram screening among low-income Hispanic women. We conducted two focus groups with 12 women to identify health beliefs related to breast cancer and mammogram screening that influenced their screening intentions. Grounded theory and the health belief model (HBM) served as the theoretical bases for analyses. Each woman's medical, reproductive, and family history was used to calculate breast cancer risk. Some women acknowledged the benefits of early detection; however many lacked basic knowledge about breast cancer, breast cancer risk, and mammogram screening. Educational interventions targeting health beliefs are needed among low-income Hispanics.
Subject: Women (Health aspects)
Cancer (Diagnosis)
Breast cancer
Hispanic Americans
Mammography
Public health
Authors: Deavenport, Alexis
Modeste, Naomi
Marshak, Helen Hopp
Neish, Christine
Pub Date: 03/22/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2010 Source Volume: 25 Source Issue: 2
Topic: Event Code: 240 Marketing procedures Advertising Code: 80 Targets & Markets
Product: Product Code: E123400 Hispanic Americans; 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Accession Number: 308741500
Full Text: INTRODUCTION

BACKGROUND

According to the American Cancer Society (2006a), breast cancer is the leading cause of cancer death among Hispanic women. Obtaining a mammogram, an x-ray of the breast, is one of the best ways to detect breast cancer at early stages (CDC, 2006). The Healthy People 2010 objective for breast cancer screening is that 70% of women ages 40 and above obtain mammograms every 2 years (U.S. Department of Health and Human Services, 2000). Hispanic women, however, have the lowest rates of mammogram usage compared to women of other race/ethnicities. In 2005, the rate of mammogram screening among Hispanic women decreased from 62% to 59%, while among the poor, the rate decreased from 55% to 48% (CDC, 2009).

Reasons for the drop in mammogram screening may be due to the increase in the number of women who do not have health insurance, high co-payments, reduced perceived risk, and a lack of focus on mammogram screening in health promotion campaigns (Breen et al., 2007). Additional reasons for the disparity in screening may be due to a lack of knowledge, fear of screening, and cost (Abriaido-Lanza, Chao, & Gammon, 2004). Others have reported that demographic, socioeconomic and health system variables such as being low-income, not having a usual source of care, and not having health insurance contributed to the lower rates of mammogram usage among Hispanic women (Wells & Roetzheim, 2007; Aldridge, Daniels & Jukic, 2006). In order to decrease health disparities, additional research is needed to determine why Hispanic women underutilize mammogram screening in order to develop appropriate health promotion strategies.

Few qualitative studies have been conducted that examined perceptions related to breast cancer and mammogram screening of women who were both low-income and Hispanic (Borryao & Jenkins 2001; 2003; Moy, Park, Feibelmann, Chiang, & Weismann, 2006; Fernandez, Palmer, & Leong-Wu, 2005). Results of previous focus groups show that Hispanic women with lower incomes were less likely to get screened if they were healthy and had lower acculturation levels (Borryao & Jenkins 2001; 2003). In other focus groups, barriers to screening identified for low-income Hispanic women included poor communication with providers, pain associated with screening, lack of familiarity with screening, and having more important priorities than obtaining mammograms (Moy, Park, Feibelmann, Chiang, & Weismann, 2006; Fernandez, Palmer, & Leong-Wu, 2005).

The health belief model (HBM) has been used as a framework in various studies to promote mammogram screening (Yarbrough & Braden, 2001; Janz, Champion, & Strecher, 2002; Sohl & Moyer, 2007). The HBM is a value-expectancy model; women who believe that getting a disease such as breast cancer is possible and, that preventive actions such as obtaining mammograms might help to detect the disease early, are more likely to take action (Rosenstock, 1960). We postulated that low-income Hispanic women with higher perceived susceptibility and perceived severity toward breast cancer, as well as higher perceived benefits and self-efficacy, and lower perceived barriers, would be more likely to obtain mammograms. Obtaining qualitative information about women's attitudes and beliefs, therefore, may provide relevant information to increase mammogram intentions and utilization. Little research has been conducted using all HBM constructs, especially perceived severity for breast cancer and self-efficacy for mammogram screening, but a fair amount has been conducted on perceived barriers (Austin, Ahmad, McNally, & Stewart, 2002). After examining 16 studies employing the HBM, Yarbrough and Braden (2001) recommended conducting additional qualitative research with detailed descriptions of women's perceptions related mammogram screening. Some researchers conducting qualitative studies have opted to use grounded theory, rather than established theories such as the HBM, to code and analyze relevant themes (Strauss & Corbin, 1998; Borryao & Jenkins 2001; 2003).

STUDY PURPOSE

The purpose of this study was to obtain qualitative information about health beliefs related to breast cancer and mammogram screening among low-income Hispanic women. Second, the purpose was to calculate lifetime breast cancer risk for the women, and to compare their risk with their perceived susceptibility of getting breast cancer. Using the information generated from this study, we developed and tailored a questionnaire, based on the HBM constructs, to be used later in an experimental intervention aimed at increasing mammogram intentions. Obtaining additional information about Hispanic women's health beliefs about breast cancer and mammogram screening is essential to reduce the disparity in mammogram utilization among low-income Hispanic women.

METHOD

STUDY DESIGN

Two focus groups were conducted in order to identify knowledge, beliefs, attitudes, and practices related to breast cancer and mammogram screening. Using a qualitative research design, the health belief model (HBM) primarily served as the theoretical foundation to identify perceptions; grounded theory was also used to determine if there were any themes present aside from the HBM constructs (Rosenstock, 1960; Janz, Champion, & Strecher, 2002; Strauss & Corbin, 1998). The focus groups served as the first part of a mixed methods design aimed at identifying factors associated with mammogram usage. During the focus groups, a short survey was also conducted to determine each participant's lifetime risk of breast cancer, which was calculated using the National Cancer Institute's Breast Cancer Risk Assessment Tool (2009). Findings from the focus groups were later used in an experimental intervention among low-income Hispanic women, but that portion of the research is not described in this paper.

SAMPLE

One focus group was conducted in English and a second was conducted in Spanish in order to obtain qualitative information about participants' health beliefs about breast cancer and mammogram screening at two clinics in the county of San Bernardino, California. Both clinics assist medically underserved patients from the Family PACT (Planning Access Care Treatment) program, filling a gap in access to health care for the indigent, uninsured, and working poor (California Department of Health Services, 2006). The focus groups were conducted in both English and Spanish in order to capture the views of women who spoke Spanish as their primary language. We wanted to minimize language barriers for Spanish speakers to facilitate expression of their perceptions related to breast cancer and mammogram screening.

MEASURES

Open-ended questions were formulated using each HBM construct as a guide. The facilitator asked pre-determined follow-up questions to gain qualitative information about the participants' cues to action, perceived susceptibility and perceived severity toward breast cancer, benefits, barriers, self-efficacy and intentions to obtain mammograms, Mammogram intention was used as a proxy for actual screening behavior (See focus group questions in Appendix A). In addition, participants completed a short questionnaire assessing demographics and medical variables including questions about their medical, reproductive, and family history in order to calculate breast cancer risk (NCI, 2009). This allowed for comparison of actual breast cancer risk with perceived susceptibility to the disease. Questions used to calculate breast cancer risk included age, race/ethnicity, breast cancer history, and number of first-degree relatives who had breast cancer.

DATA COLLECTION

The two focus groups were conducted, one in English and one in Spanish, after obtaining approval from a university Institutional Review Board. Researchers recruited participants by approaching them in clinic waiting rooms and handing out informational flyers. The recruitment flyers specified whether the group would be conducted in either English or Spanish for that particular day. Patients were eligible to participate if they had an appointment at the clinic and were Hispanic females, ages 40 years and above.

Women gave consent to participate at the beginning of the focus groups, agreeing to have the conversation recorded, before any demographic information was obtained. Women who participated in the focus groups received fruit baskets and a Susan G. Komen breast cancer pins as a thank you for their participation. They also received an American Cancer Society brochure, Is it time for your yearly mammogram? (2006b) in English or Spanish to encourage them to obtain mammograms, along with information about how they may be eligible to obtain a free mammogram from the California Department of Public Health (CDPH, 2009).

DATA ANALYSES

The participants' responses were recorded and transcribed by two separate individuals. Results were initially analyzed using grounded theory to determine if any significant themes emerged, other than those from the HBM. We used various stages of analysis to examine each theme. First, we coded relevant statements and then grouped them with similar themes. Second, we categorized and organized the grouped data, and used the HBM constructs to classify the perceptions of the participants (Strauss & Corbin, 1998).

RESULTS

A total of 12 women attended the focus groups, with seven women in the Spanish-speaking group, and five women in the English-speaking group. Their ages ranged from 43 to 73 years with a mean age of 55.0 years (SD = 9.2), and a median age of 55.0 years. All women were of Hispanic descent and 58.3% were born outside of the U.S. and were Spanish-speaking. The majority (83.4%) was of Mexican descent while 16.6% self-identified as Puerto Rican or South American (Table 1). About 33.2% had a 6th grade education or below, 33.6% had between a 7th grade to a 12th grade education, and 33.2% had a high school diploma, some university, or a university degree. None of the women from either focus group previously had breast cancer; however, 42% of women had one or more first-degree relatives with a history of breast cancer. In addition, 33% previously had breast biopsies, but all results were normal. About 16.7% had never obtained a mammogram, 25% were screened every 2 or more years, and 58.3% were screened in the past year.

ACTUAL BREAST CANCER RISK

The National Cancer Institute's Breast Cancer Risk Assessment Tool (2009), based on measures of medical history, reproductive history and family history, was used to calculate the lifetime risk of breast cancer (to age 90) for each woman. The mean lifetime risk for Hispanic women in the focus groups was 6.5% (SD = 4.1) compared to the mean lifetime risk of 6.23% (SD = 1.4) for the reference group of Hispanic women of the same ages from the general population (Table 2). Thus, the mean lifetime risk of getting breast cancer in this sample was slightly higher than the mean lifetime risk for women of the same ages and ethnicity. Across both focus groups, the lifetime risk of getting breast cancer ranged from 3.8% to 19.1%, and the median lifetime risk was 5.35%. The reference group, however, had lifetime risks ranging from 3.3% to 7.8%, and a median lifetime risk of 6.45%. Overall, none of the Hispanic women in the focus groups knew their risk for getting breast cancer, nor were they aware that they were at greater risk of getting breast cancer sometime in their life compared to other Hispanic women of similar ages. Also, the few women who were aware that they might have a high risk for developing breast cancer, tended to have greater perceived susceptibility about their chances of getting breast cancer.

KNOWLEDGE ABOUT BREAST CANCER

In both the Spanish-speaking and English-speaking focus groups, many women did not have a basic level of knowledge about what breast cancer is, due to lack of information, beliefs that injury or infection can cause the disease, and perceptions that breastfeeding may result in breast cancer. Talking about breast cancer, breast health, and reproductive health was considered taboo in some families, and as a result, was not discussed. One woman believed the cause of breast cancer was from being injured: "Maybe when you hurt yourself there or when someone hurts you there (on the breast)". One woman thought that breast cancer could be caused by infections: "Perhaps (tumors) are infections that one thinks are going to go away and then one does not go to the doctor and that infection may stay there and something else may happen because of that." This reflects a view that infectious diseases such as the common cold or the flu can eventually lead to breast cancer. Some women believed that breastfeeding may cause little balls to form in the breast which can lead to breast cancer. A few women, however, did have knowledge about breast cancer and cancer prevention. One woman said, "Nutrition is important-vegetables," to prevent breast cancer. Another woman spoke about the possible cause of breast cancer: "Also hereditary who knows... who knows what it is."

PERCEIVED SEVERITY OF BREAST CANCER

Most women had medium to high perceived severity of breast cancer, but they had different fears associated with getting it and different views about their role compared to God's role in decreasing suffering. While many women considered breast cancer to be a severe disease, some women did not want to think about getting breast cancer. For instance, one woman felt that cancer was a word she never wanted anyone to mention. Another woman also expressed fear at the thought of breast cancer, "Sometimes the exams show something and I get worried..." One woman, watching her friend experience the severity of the disease, believed praying to God would decrease her friend's suffering. Utilizing religion to prevent pain or disease was a common theme in the focus groups.

PERCEIVED SUSCEPTIBILITY FOR BREAST CANCER

Women had either low or high perceived susceptibility for breast cancer. Some women had high perceived susceptibility, and as a result, took more preventive actions than others such as eating healthy, performing breast self-exams, and obtaining mammograms. Conversely, most women mentioned they did not know whether or not they were susceptible to breast cancer, while others thought they were not at risk since they had no family history of the disease. Other women with low perceived susceptibility relied on their belief in God to prevent them from getting breast cancer: "I pray to God... You are the healer. You know everything. For you nothing is impossible." One woman with high perceived susceptibility felt anxious about getting breast cancer, and often did breast self-exams and regularly attended her mammogram appointments, "I am pretty coward, every time I check myself, I find some lumps even when I do not have them." A few women realized that family history might increase one's chances for getting breast cancer. For instance, one woman mentioned, "Being Hispanic, there is a risk with heredity and I really want to have my exams done every year." While some women knew their family history of breast cancer, none of the women was aware of her own risk of getting the disease.

LACK OF KNOWLEDGE ABOUT MAMMOGRAM SCREENING

Some women were unaware about how and when to obtain mammograms. One woman did not know how to go about obtaining mammogram, and as a result, was undecided about getting one. Another woman thought that all women should obtain mammograms each year after the age of 30 years. Some women did not know that the recommended frequency to obtain mammograms, for women ages 40 years or older is every year. Given the lack of knowledge, various women felt hesitant about screening procedures.

PERCEIVED BARRIERS TO MAMMOGRAM SCREENING

Barriers to screening were that it was too expensive, aroused a fear of finding something wrong, was too embarrassing, or was too painful (Table 3). Other barriers included a lack of knowledge about screening, not remembering to schedule an appointment, and a lack of access to care. Fear associated with screening results was a major barrier. One woman said, "It's worth a lot more to know. That's what I'm afraid of." Another woman had an aunt who died from breast cancer and watched her slowly deteriorate and then pass away; as a result, she was terrified to get a mammogram because she was afraid of finding something wrong and experiencing the same outcome.

A woman who considered herself well-educated said she feared getting a mammogram each year, but obtained one because she knew it was important. Both of her children, a pharmacist and a nurse, held her hand, accompanying her to the appointment. In addition, a 69 year-old woman mentioned that she couldn't remember to get a mammogram: "I forget. I have to memorize. I am the only one taking care of my health. I need to put it (a reminder) on the refrigerator and the calendar." Other reasons for not obtaining a mammogram among some women included not taking good care of their health, or feeling embarrassed about the process of obtaining a mammogram. Pain was another barrier. One woman who had previously obtained a mammogram mentioned, "I did not want to do it because I thought that it was going to hurt me. They really squeeze your breasts hard."

Another woman explained that access to care was a problem while growing up in Bolivia; when people had cancer, high-quality care was often not available, so cancer was viewed as a death sentence. Also, a lack of transportation prevented some women from making an appointment, as they sometimes had no access to the clinic. Finally, cost was another barrier expressed. One woman said when she was living in Mexico she felt lumps in her breast, but did not have enough money to obtain a mammogram. Another woman mentioned, "Before I was having it every year, but now it is very hard. Sometimes money is not enough and my husband is on disability." After losing her job, one woman mentioned she felt alone, and did not know where to turn to obtain routine medical care such as mammogram screening.

PERCEIVED BENEFITS OF MAMMOGRAM SCREENING

Overall, most women, even those who perceived various barriers to obtaining mammograms, believed that it was worth it to get screened as they could receive knowledge about their health, take early action if a tumor was found, and felt less anxious that they would die from breast cancer. One woman explained the importance of obtaining a mammogram: "Sometimes the lumps are so small, they can only be detected with a mammogram." One woman understood the risk of allowing a tumor to go undetected, as one of her family members was dealing with breast cancer: "I think about my cousin who is losing her hair and all her suffering and that she is not going to get better. She had 6 years with the cancer and did not know."

SELF-EFFICACY TO OBTAIN A MAMMOGRAM

Many low-income Hispanic women reported that factors such as their beliefs in God, placing importance on their health, and thinking about their family members gave them confidence in their ability to obtain mammograms. One woman was grateful to God for her good health and thought she should continue to protect her health by obtaining a mammogram: "I thank God. but (now) we have to prevent." Another women commented, "...the Medi-Cal helps me" to obtain a mammogram. Some women thought that finding out the results of the test early and wanting the results to be negative motivated them to get screened. Other women felt that placing an emphasis on putting their health first empowered them to obtain mammograms, "...You have to love yourself." Some women felt that their family members gave them confidence to get screened. One woman thought about her 10-year-old granddaughter when she feared screening and decided to set a good example by getting a mammogram.

CUES TO ACTION

The women reported various cues to action that motivated them to get screened such as obtaining information, receiving reminders, and creating their own strategies to make appointments. One woman mentioned that learning about the importance of having a mammogram motivated her to get screened: "I think information is the best tool we can have." Another explained, "I just started now because they (the doctors) told me." Also, one woman scheduled her mammogram appointment on her birthday to remember get screened.

INTENTION TO OBTAIN A MAMMOGRAM

According to Ajzen (2006), intention to carry out a behavior may be denoted in terms of target, action, context, and time. The target behavior is obtaining a mammogram at a mammogram facility, while the action is planning to carry out the behavior, sometime in the next 1 or 2 years. A few women interviewed in both focus groups demonstrated intentions obtain screening within the next year. The reasons for intentions to obtain mammograms varied, but included feeling pain in the breast(s) or being due or overdue for their appointments, and not having had one before. Increasing mammogram intentions among low-income Hispanic women may help to prompt more women to obtain mammograms, decreasing the disparity in mammogram screening rates.

DISCUSSION

To our knowledge, this may be one of the first studies to examine all of the HBM constructs using qualitative methods and to examine lifetime breast cancer risk among low-income Hispanic women. Women demonstrated varying levels of knowledge about breast cancer and obtaining mammograms during the focus groups. For example, some women believed breastfeeding could lead to breast cancer. Likewise, Borrayo and Jenkins (2001) found that Mexican women with "traditional folk health beliefs" thought breastfeeding could cause the disease. We also observed that some women were unaware that the recommended age to obtain mammogram screening is 40 years and that the recommended frequency for screening is every 1-2 years. Similarly, Fernandez et al. (2005) reported that many low-income Hispanic women had misconceptions about screening and were unsure of screening recommendations. Providing additional education targeting low-income Hispanic women may help to increase awareness about the importance of and specific guidelines for mammogram screening.

While women varied in their knowledge about screening, they also had different perceptions about their perceived susceptibility and perceived severity relative to breast cancer. Most women had low perceived susceptibility of getting breast cancer, even though as a group, their risk was similar to the general population. Those who were unaware of their breast cancer risk and had no family history were less likely to obtain mammograms. Some women believed that God determined their fate, and assumed screening would not make a difference. In other studies, researchers also found low-income Hispanic women were less likely to obtain mammograms if they had no family history, felt healthy or were asymptomatic, and if they believed in fatalism (fatalismo), thinking they had no control over their destiny (Borrayo & Jenkins, 2001; Fernandez, et al., 2005). Furthermore, perceived severity among the women was medium to high, as women believed they could die from breast cancer. Champion (1999) found little difference in perceived severity among women of various race/ethnicities, and as a result, suggested using perceived susceptibility alone as a threat variable for the health belief model. High perceived severity of breast cancer, however, may lead to avoidance of screening where the fear of finding something wrong outweighs the benefit of screening. Champion, Skinner, Menon, Rawl, Geisler, and Monahan (2004) showed that high fear of breast cancer was not related to mammogram screening. Also, Fernandez, et al (2005) reported that many low-income Hispanic women failed to obtain repeat mammograms since they believed getting breast cancer was so serious that it resulted in death. Thus, if very high severity is present, including perceived severity in the HBM may not be necessary. In order to address perceived susceptibility, emphasizing more changeable perceptions, such as those related to actual breast cancer risk and addressing self-efficacy to obtain a mammogram may help to address fatalistic beliefs more effectively.

Despite cultural beliefs and obstacles related to breast cancer and obtaining mammograms, the low-income Hispanic women in our study had high perceived benefits of mammogram screening, believing they would learn about their health, and have less anxiety about the future. Some women were prompted to obtain screening because they experienced possible symptoms of breast cancer. Women also voiced barriers such as cost, fear, pain, and embarrassment. Among other women, the fear of finding breast cancer prevented them from obtaining screening, regardless of their education level. A few women mentioned that communicating about issues related to the female breasts was embarrassing, and those who were immigrants mentioned they did not receive mammograms in their countries of birth. Likewise, Moy, et al. (2006) found that Hispanic women felt that mammogram screening was not generally done in their native countries and that discussing breast health was a "taboo topic." We also found that the women experienced possible barriers in access to care due to a lack of finances or transportation to clinics. Others researcher also reported that both poverty and acculturation accounted for the lack of mammogram screening (Austin et al. 2002; Cronan et al., 2008). We found, however, that regardless of perceived barriers to mammogram screening, women with greater perceived benefits of screening were more likely to obtain mammograms

Many women had high self-efficacy in their ability to obtain mammograms. Some women developed strategies for scheduling appointments, remembered to make their health a priority, and received encouragement from their family members to focus on early detection. Having insurance such as Medi-Cal motivated many of the women to receive screening. Moy et al. (2006) found that many Hispanic women who had Medicaid or other assistance had increased confidence they could obtain screening. This indicates that lower barriers may be related to increased self-efficacy. According to Champion, Skinner, and Foster, (2000) the ability to overcome barriers related to a certain behavior, may be related to an one's level of self-efficacy to perform that behavior. Some women had increased confidence in their ability to receive mammograms because if a tumor was found, it was better to know early. Fernandez et al. (2005) also commented that low-income Hispanic women were motivated to obtain additional mammograms when prior screenings did not detect breast cancer.

Our findings suggest that while many low-income Hispanic women acknowledged the benefits of early detection, some women clearly lacked basic knowledge about breast cancer, personal breast cancer risk, and mammogram screening. Various socio-cultural characteristics such as the belief in fatalismo, being born outside the U.S., and speaking Spanish as their primary language was associated with lower mammogram usage. Many women reasoned, however that if they could afford mammograms or had insurance, it would be easier to follow screening recommendations. Thus, additional education aimed at increasing perceived susceptibility and severity of breast cancer, benefits, and self-efficacy of mammogram screening, and education aimed at decreasing perceived barriers may be needed especially in communities where Hispanic women are at 200% or below the poverty level. Also, it is important to make screening available for these women at low or no cost.

Strengths, Limitations and Implications of the Study

The primary strength of the study was that it was based on the HBM and grounded theory, providing a sound theoretical foundation. Breast cancer risk was calculated for each woman using the NCI's Breast Cancer Risk Assessment Tool. We were able to compare breast cancer risk with perceived susceptibility or perceived risk of getting breast cancer. Furthermore, themes emerged until saturation, indicating the sample size of 12 women was adequate to identify salient beliefs about breast cancer and mammogram screening. Also, data were obtained in both English and Spanish, which enabled us to reach non-English-speaking low-income Hispanic women. Finally, the study findings indicated the need for educational interventions among low-income Hispanic women. The main limitation is that women in the focus groups were selected from a convenience sample at the clinics so we cannot make causal associations or generalize about their health beliefs or intentions for screening. Also, the focus groups were conducted only among women who attended health clinics, so results do not represent women from non-clinic-attending populations who likely have other barriers to care. In addition, since there were only 12 women in the sample, it is possible that the mean for breast cancer risk was slightly elevated. The mean, however was similar to the reference, indicating that even this small sample was representative of Hispanic women of the same ages from the general population. Furthermore, a total of two focus groups were conducted, which limited the generalizability of the results. Thus, we would recommend that future researchers conduct greater than two focus groups among low-income Hispanic women, in both English and in Spanish, in order to broaden the impact of the findings.

Little research has examined low-income Hispanic women's attitudes and beliefs toward breast cancer and mammogram screening. Our study findings may therefore assist researchers and practitioners with developing culturally competent education for low-income Hispanics in order to reduce health disparities. Educational interventions targeted to HBM constructs should be developed to raise awareness of the threat of breast cancer and to increase perceived benefits, and self-efficacy and decrease barriers to screening. Thus, conducting additional studies to determine how to effectively intervene to address those perceptions is especially relevant for meeting Healthy People objectives to reduce the disparity in mammogram screening.

REFERENCES

Abriaido-Lanza, A. F., Chao, M. T., & Gammon, M. D. (2004). Breast and cervical cancer screening among Latinas and non-Latina Whites. American Journal of Public Health, 94, 1393-1398.

Ajzen, I. (2006). Constructing a TpB questionnaire: Conceptual and methodological considerations. Retrieved May 2, 2008 from http://people.umass.edu/aizen/pdf/tpb.measurement.pdf.

Aldridge, M. L., Daniels, J. L., & Jukic, A. M. (2006). Mammograms and healthcare access among U.S. Hispanic and Non-Hispanic women 40 years and. Family Community Health, 29, 80-88.

American Cancer Society (2006a). Cancer Facts and Figures for Hispanics/Latinos 2006-2008. Atlanta, GA:

American Cancer Society. Retrieved October 24, 2007 from http://www.cancer.org/downloads/STT/ CAFF2006Hisp PWSecured.pdf.

American Cancer Society. (2006b). Is it time for your yearly mammogram? [Brochure] American Cancer Society Inc.

Austin, L.T., Ahmad, F., McNally, M. J., & Stewart, D. E. (2002). Breast and cervical screening in Hispanic women: A literature review using the health belief model. Women's Health Issues, 12, 122-128.

Borrayo, E. A., & Jenkins, S. R. (2001). Feeling healthy: So why should Mexican-American women screen for breast cancer? Qualitative Health Research. 11, 812-813.

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.

Breen, N., Cronin, K. A., Meissner, H. I., Taplin, S. H., Tangka, F. K., Tiro, J. A., et al. (2007). Reported drop in mammography: Is this cause for concern? Cancer, 109, 2405-2409.

California Department of Health Services. (2006). Fact sheet on Family PACT, an overview, version 3. Office of Family Planning: CA DHS and Bixby Center for Reproductive Health and Policy: UCSF. Retrieved July 22, 2008 from http://www.familypact.org/_Resources/Documents/FS_060517_FPACTOverviewFinal. pdf.

California Department of Public Health (2009). Cancer Detection Programs: Every Woman Counts. Retrieved April 12, 2009 from http://www.cdph.ca.gov/programs/cancerdetection/Pages/ CancerDetectionPrograms EveryWoman Counts.aspx.

Centers for Disease Control and Prevention. (2006). Kinds of Screening Tests. Department of Health and Human Services. Retrieved April 25, 2007 from http://www.cdc.gov/cancer/breast/basic_info/screening. htm.

Centers for Disease Control and Prevention. (2009). Data 2010: Healthy People 2010 database. Retrieved April 14, 2009 from http://wonder.cdc.gov/data2010.

Champion, V. L. (1999). Revised susceptibility, benefits, and barriers scale for mammography screening. Research in Nursing and Health, 22, 341-348.

Champion, V. L. Skinner, C., & Foster, J. (2000). The Effects of standard care counseling or telephone/in person counseling on beliefs, knowledge and behavior related to cancer screening belief scales in African American women, Oncology Nursing Forum, 27, 1565-1571.

Champion, V. L., Skinner, C.S. Menon, U., Rawl, S., Giesler, B., & Monahan, P. (2004). A breast cancer fear scale: Psychometric development 9, 753-762.

Cronan, T. A., Villalta, I., Gottfried, E., Vaden, Y., Ribas, M., & Conway, T. L. (2008). Predictors of mammography screening among ethnically diverse low-income women. Journal of Women's Health, 17, 527-537.

Fernandez, M. E., Palmer, R. C., & Leong-Wu, C. A. (2005). Repeat mammography screening among low-income and minority women: a qualitative study. Cancer Control, (Suppl.), 77-83.

Janz, N. K., Champion, V. L., & Strecher, V. J., (2002). The health belief model. In K. Glantz, B.K. Rimer, & F.M. Lewis (Eds.), Health Behavior and Education: Theory, Research and Practice (pp. 326-332) San Francisco: Jossey-Bass.

Moy, B., Park, E. R., Feibelmann, S., Chiang, S., & Weismann, J. S. (2006). Barriers to repeat mammography: Cultural perspectives of African-American, Asian, and Hispanic women. Psycho-Oncology, 15, 623-624.

National Cancer Institute. (2009). Breast cancer risk assessment tool: Risk calculator Retrieved June 6, 2009 from http://www.cancer.gov/bcrisktool/Default.aspx.

Rosenstock, I. M. (1960). What research in motivation suggests for public health. American Journal of Public Health, 50, 295-301.

Sohl, S. J., & Moyer, A. (2007). Tailored interventions to promote mammography screening: a meta-analytic review. Preventive Medicine, 45, 252-261.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage Publications.

U.S. Department of Health and Human Services. (2000). Healthy People 2010. Understanding and improving health and objectives for improving health. (2nd ed.) Washington, DC: U.S. Government Printing Office.

Wells, K. J., & Roetzheim, R.G. (2007). Health disparities in receipt of screening mammography in Latinas: A critical review of recent literature. Cancer Control. 14, 369-379.

Yarbrough, S. S., & Braden, C. J. (2001). Utility of the health belief model as a guide for explaining or predicting breast cancer screening behaviors. Journal of Advanced Nursing, 33, 677-688.

Alexis Deavenport, DrPH, MPH, CHES Naomi Modeste, DrPH, MPH, CHES Helen Hopp Marshak, PhD, MS, CHES Christine Neish, PhD, MPH, RN, PHN, CHES

Alexis Deavenport, DrPH, MPH, CHES, is affiliated with the School of Public Health, Department of Health Education and Promotion Loma Linda University, Loma Linda, CA, 92350. Tel: (818) 620-0080. Fax: (909) 558-4741. E-mail-adeavenport@llu.edu. Naomi Modeste, DrPH, MPH, CHES, is affiliated with the School of Public Health, Department of Health Education and Promotion, Loma Linda University, Loma Linda, CA, 92350. Tel: (909) 558-474. Fax: (909) 558-0471. E-mail: nmodeste@llu.edu. Helen Hopp Marshak, PhD, MS, CHES, is affiliated with the School of Public Health, Department of Health Education and Promotion, Loma Linda University, Loma Linda, CA, 92350. Tel: (909) 558-4741. Fax: (909) 558-0471. E-mail: hhoppmarshak@llu.edu. Christine Neish, PhD, MPH, RN, PHN, CHES, is affiliated with the School of Nursing, Loma Linda University, Loma Linda, CA, 92350. Tel: (909) 558-4000, extension 45448 E-mail: cneish@llu.edu
Table 1. Focus Group Characteristics: Mammogram History and Breast
Cancer Risk Factors

                                     No.
                                   (N = 12)    %

Race/Ethnicity
  Mexican                             10      83.4
  Other Hispanic                      2       16.6
Education
  Less than 1st grade                 2       16.6
  1st-6th grade                       2       16.6
  7th-12th grade                      4       33.6
  High school diploma                 2       16.6
  Some college/college degree         2       16.6
Spanish-speaking                      7       58.3
Born Outside U.S.                     7       58.3
Mammogram History
  No                                  2       16.6
  Yes                                 10      83.4
Mammogram Frequency
  Never                               2       16.7
  Every year                          7       58.3
  Every two years or more             3       25.0
Previous Biopsy (One or More)         4       33.3
Family History of Breast Cancer       5       41.7
Age at First Period
  7-11 years                          1        8.4
  12-13 years                         7       58.3
  14 years or more                    4       33.3
Age at First Birth
  No Births                           2       16.7
  Less than 20 years                  5       41.7
  20-24 years                         3       25.0
  25-29 years                         2       16.6

Table 2. Focus Group Demographic Characteristics: Age and Breast
Cancer Risk

Variables                        Median   Mean   SD
  N = 12

Age                              55       55     9.24
5-year breast cancer risk        0.70     1.10   0.89
5 breast cancer risk compared    0.90     0.93   0.23
  w/ average person
Lifetime breast cancer risk      5.35     6.50   4.10
  (to age 90)
Lifetime breast cancer risk      6.45     6.23   1.38
  compared w/ average person

Note: Breast cancer risk was calculated using the National Cancer
Institute's Breast Cancer Risk

Assessment Tool: http://www.cancer.gov/bcrisktool/Default.aspx.

Table 3. Focus Group Results According to Health Belief Model
Constructs

Breast Cancer      * Breast cancer is a contagious disease.
  Knowledge        * "Take medications" to prevent breast cancer.

Internal Control   * You can always make time for your health. There
  for Cancer       should be no obstacles to good health.
  Prevention
Perceived          * "Also hereditary who knows.. .who knows what
  Susceptibility   it is."
                   * "I pray to God.. .You are the healer. You know
                   everything. For you nothing is impossible."
Perceived          * You can die from it
  Severity         * "I know one can suffer much. I also know that
                   if you get it in one (breast) you can get it in
                   the other. It's really bad."
Perceived          * "It's worth a lot more to do it."
  Benefits         * "I think about my cousin who is losing her hair
                   and all her suffering and that she is not going
                   to get better. She had six years with the cancer
                   and did not know".
Perceived          * Cost, fear, embarrassment, pain
  Barriers         * "Before I was having it every year, but now it
                   is very hard. Sometimes money is not enough and
                   my husband is on disability."
Self-efficacy      * "We only have one life and there is no other."
                   * ".You have to love yourself."
Cues to Action     * Even if it is economically hard you have to
                   look for information.
                   * "It will help" to have doctors, nurses or
                   clinic workers remind me.
Intention to       * I am going to run to the doctor to get a
  obtain a         mammogram.
  mammogram        * I will obtain more information from my doctor
                   about mammograms.
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.