Screening pleas now culture-focused

Psychologists are developing programs to encourage more ethnic minorities to seek cancer care.

By Lisa Rabasca
Monitor staff

While it's always been difficult to get people to go for cancer screenings, it has been more troublesome to persuade ethnic minorities to undergo such tests, largely due to socioeconomic barriers, psychologists say.

Studies show, for example, that Hispanic women are less likely to have heard of Pap smears than African-American or white women, and fewer African-American and Hispanic women than white women know that Pap smears should be done annually. Similarly, African-American and Hispanic women are less likely to comply with follow-up cancer treatment than white women.

Now, psychologists are working with health-care providers to encourage ethnic minorities to seek cancer screenings and to comply with cancer treatment when diagnosed.

Building on 'kokua'

In Hawaii, psychologists at the Cancer Research Center of Hawaii worked with community leaders in Waianae, to test a community-based intervention to encourage native Hawaiian women to seek cancer screenings. The National Cancer Institute (NCI) funded the study.

The intervention builds on the Hawaiian value of kokua, which means "helping others without expecting help in return," says Carolyn Gotay, PhD, an associate professor at the Cancer Research Center at the University of Hawaii. The intervention encouraged groups of native Hawaiian women to meet to discuss the benefits of a Pap smear and mammogram. After the intervention, they were urged to share what they had learned with their mother, sisters, aunts and friends to encourage them to receive cancer screenings.

About 600 randomly selected native Hawaiian women living in the community where the intervention took place and in a nearby community that didn't participate in the intervention were asked about their cancer screening practices before and after the intervention. Although only a handful of these women had actually taken part in a kokua group, cancer screening rates increased in the community that participated in the intervention. This increase reflects the diffusion of information about cancer screenings from kokua group participants into the community as a whole, says Gotay.

While community-based interventions that incorporate cultural values may help persuade ethnic minorities to seek cancer screenings and treatment, low-income, newly-immigrated minorities are much harder to reach. Socioeconomic barriers such as illiteracy, cost of treatment and lack of transportation and child care often keep them from obtaining cancer screenings.

A low-income Hispanic immigrant is less likely to get a Pap smear or mammogram than a Hispanic women born in the United States, believes Regina Otero-Sabogal, PhD, associate adjunct professor at the Institute for Health and Aging at the University of California, San Francisco and associate director of the prevention science program at the Northern California Cancer Center in Union City, Calif. In fact, she says, there are often more similarities across all immigrant groups than within different ethnic groups.

Otero-Sabogal and her colleague, Rena Pasick, PhD, are testing this theory through a randomized controlled trial funded by the NCI. The study targets 1,500 low-income, multiethnic women, ages 45 to 74, in Alameda County, Calif. Each woman in the intervention group will receive an individually tailored health guide and letter written in her native language, incorporating themes that reflect the cultural characteristics of her ethnic group and the woman's personal barriers to having a mammogram and Pap smear, says Otero-Sabogal.

An example of the message in the health guide for Hispanic women is, "To enjoy a healthy life with your loved ones, take care of your health." One of the messages for Chinese women is, "Good health and best wishes in the year of the rabbit," while a message for African-American women is, "Loving yourself is taking care of yourself."

The tailored health guides will be sent to the women every six-months during the three-year intervention and will include where and when they can obtain cancer screenings. Women who can't read will receive an audiotape of the health guide.

Community health-care workers from each ethnic community will call the women three months after the first letters are sent. One-on-one counseling also will be available to address individual concerns about cancer screenings. For example, Otero-Sabogal says, sometimes women don't get tested because they're embarrassed or they're afraid it will be painful.

After a year, the community health-care workers will be phased out and the women will be encouraged to call a multilingual telephone help-line for screening information. During the last six months of the study, the help-line will be eliminated and the women will be directed to community resources.

Otero-Sabogal hopes the study will demonstrate that, with appropriate cultural tailoring, one intervention can be implemented across ethnic and language groups rather than having to use a different program for each ethnic group.

The next step

Getting ethnic minorities to participate in cancer screenings is only half the battle. Those diagnosed with cancer also need to regularly participate in treatment, and levels of treatment adherence are often much lower for poor, immigrant populations than for middle-class white populations, says Beth Meyerowitz, PhD, professor of psychology at the University of Southern California in Los Angeles.

Many cancer treatments have high rates of success when they are followed exactly as prescribed, she says, but if a patient misses even a few sessions, the treatment's effectiveness decreases. Charles Cleeland, PhD, is working on an intervention to help Hispanic and African-American patients better control their pain. A pilot study by Cleeland found that those who went to clinics that served minority outpatients were three times more likely to receive inadequate care for cancer-related pain than those in other settings.

The reason was usually poor pain assessment, caused by communication problems or lack of time for a careful evaluation, says Cleeland, the McCullough professor of cancer research at the MD Anderson Cancer Research Center at the University of Texas in Houston.

The pilot study also found that ethnic minorities are often unwilling to report pain because they believe the physician is in a hurry, or they're afraid to take stronger painkillers or they fear the pain is increasing because their illness is getting worse.

"It became clear that it was important to educate, prepare and empower the patient to be his own advocate," says Cleeland. "The patient has to be willing to communicate and he or she has to have some skills to know what to say and how to get the physician's attention."

Cleeland developed an intervention that teaches these skills, now being tested through an NCI-funded randomized clinical trial of 500 patients at hospitals in Houston and Miami. Patients are shown a video that explains how to use a zero to 10 system to rate their pain as well as describe the exact location, character and quality of their pain. Patients are also given written material about taking painkillers, controlling side effects such as constipation and addressing fears of addiction.

"No one at these clinics is going to sit down with the patients and tell them what they need to know about their pain because there's not enough time," says Cleeland.

And, perhaps that's the root of the problem, says Meyerowitz of California.

"We don't have to fit patients into the round hole of the medical system," she says. "People who work with cancer patients need to learn about different cultural approaches and what type of impact they can have on patients."

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