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Exploring perceptions of facilitators that encourage breast cancer screening behavior among latina women in Los Angeles County

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Exploring perceptions of facilitators that encourage breast cancer screening behavior among latina women in Los Angeles County

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EXPLORING PERCEPTIONS OF FACILITATORS THAT ENCOURAGE
BREAST CANCER SCREENING BEHAVIOR AMONG
LATINA WOMEN IN LOS ANGELES COUNTY

by

Maribel Soto

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(STRATEGIC PUBLIC RELATIONS)

August 2012

Copyright 2012 Maribel Soto

ii

Epigraph

In 1985, the breast cancer awareness campaign started as a
partnership between the American Cancer Society and AstraZeneca’s
Imperial Chemical Industries, maker of several anti-breast cancer drugs
(American Cancer Society, “National Breast Cancer Awareness Month”).
Today, the color pink floods anything from retail stores to supermarkets year-
round in the hopes of raising awareness for the most common cancer among
women in the United States. Several people have deemed this the ultimate
awareness campaign in terms of success and with good reason. It has
managed to build widespread awareness and raise millions of dollars towards
breast cancer research. The success of the campaign may also represent
downfall because numerous critics such as sociologist Gayle Sulik, who
dedicates an entire blog on the matter called “Pink Ribbon Blues,” believe
that the pink ribbon culture has gone astray. Others criticize breast cancer
awareness for creating a potentially dangerous tunnel vision that exiles all
other severe diseases affecting women (Sulik).
My take on the situation is slightly different because not only is this a
topic that hits close to home, but I recognize that there are several kinks that
need to be worked out despite the campaign’s prevalence.
My mother was diagnosed with breast cancer when I was 12 years old.
She is an immigrant from Mexico and although she eventually mastered the

iii
English language, at the time of her late diagnosis she largely depended upon
her doctor and my eldest sister for health information. This left her
vulnerable to preventative messaging such as yearly and cost-effective
screenings, which could have resulted in a lot less physical and emotional
pain for our entire family.
With regard to overall health messaging, there are several women like
my mother who are not effectively targeted. I believe that a huge portion of
the existing health disparities in the United States is due to cultural
insensitivity and misunderstandings. In recent years, several efforts from
breast cancer advocacy groups have shed light on this issue and it has
translated into research and strategy development aimed at targeting groups
like Latinos, the largest minority group in the US.
The research findings presented in Exploring Perceptions of
Facilitators That Encourage Breast Cancer Screening Behavior Among
Latina Women in Los Angeles County give an overview and provide a plan
that can aid health professionals and communicators to appropriately target
the Latino population while breaking down the prevalent “one-size-fits-all”
notion. Ideally, I would like to encourage advocates of women’s health to not
only expand the issue of including more cultures that thrive in this ever
growing melting pot as it pertains to health disparities, but to also utilize the
breast cancer awareness campaigns, which have enjoyed success for more

iv
than two decades, and apply the lessons learned to other prevalent and not-
so-prevalent diseases and forms of cancer that affect thousands of women
each day.

Maribel Soto
Author
University of Southern California
Annenberg School for Communication & Journalism

v

Dedication

To the most resilient woman I know and my biggest inspiration – mom,
you were not only the foundation for my topic but my biggest motivator in
accomplishing what was at times a very daunting task. Your strength and
passion for life inspires me to be the best that I can be. To my sister who has
always been my biggest cheerleader and mentor – it is difficult to think how
my life would be if I didn’t have your constant support. You always believed
in me, even when I didn’t believe in myself. I love you both very much and I
only hope I’ve made you two proud. My accomplishments are yours.

vi

Acknowledgements

Writing this thesis was definitely a collective effort. I would like to
thank my friends for their constant love, patience and words of
encouragement. I am deeply touched by the overwhelming support of each
and every single one of you throughout this process. I would also like to
thank and acknowledge my committee member Laura Jackson; your work is
admirable and I am grateful at the fact that you never hesitated to be there
when I most needed guidance. A thank you is also in order for my interview
sources; your knowledge is invaluable and I appreciate the insight that I
gained from you all. And to my committee chair, Jerry Swerling, who
unknowingly forced me to step outside of my comfort zone and discover my
own strengths.

vii
Table of Contents

Epigraph

ii

Dedication

v

Acknowledgements

vi

List
of
Figures

viii

Abstract

ix

Preface

x

Introduction

1

Chapter
1:
Background

5

Chapter
2:
Literature
Review
–Cultural
Impact
on
Health
Behavior

13

Chapter
3:
Health
Communication
Experts
Weigh
In

32

Mathew
Leveque

35

Hector
Andrade

46

Laura
Min
Jackson

52

Ambrocia
Lopez

61

Chapter
4
Survey
Results

69

Method

69

Particiants

70

Results

72

Chapter
5:
Recommendations

77

Communication
Goals

77

Key
Audiences

77

Messaging
Strategy

79

Strategies

81

Tactics

83

Conclusions

87

Bibliography

89

viii

List of Figures

Figure 1: U.S. Mammography Screening Prevalence (%) 10

Figure 2: “Unidos”: Need to Focus on Latinas 13

Figure 3: Characteristics of Sample Population 71

Figure 4: Patient Attitudes & Beliefs 73

Figure 5: Social Network Experience 73

Figure 6: Accessibility of Services 74

ix
Abstract

This paper examines barriers and facilitators of breast cancer early
detection among Latina women living in Los Angeles County. The purpose of
this study is to address the discrepancy that exists between breast cancer
awareness messaging and medically underserved audiences, with specific
attention to Latina women. The research included chronicles the slow
adoption of culturally relevant educational materials. Insight from
professionals who have performed culturally relevant work and have been
successful in implementing it among the Latino population is included and
used to challenge the traditional distribution of health messaging in an ever-
growing diverse Latino population, while questioning the “one-size-fits-all”
message strategy currently in place. The author provides recommendations to
assist organizations in tailoring breast cancer education messaging for Latina
women. The ultimate goal is to encourage health professionals to use these
guidelines in conjunction with other materials that may help address other
forms of cancer and disease as well as all women.

x
Preface

Research Methodology
Qualitative primary research consisted of a series of interviews with
health public relations and communication professionals in order to form a
basis for understanding the subject. Interviewees included Matthew Leveque,
Senior Vice President at Rogers/Ruder Finn and adjunct faculty member at
the University of Southern California, Annenberg School of Journalism &
Communications; Hector Andrade, Senior Account Executive at Edelman
Public Relations; Laura Jackson, Communications Consultant and adjunct
faculty member at the University of Southern California, Annenberg School
of Journalism & Communications; and Ambrocia Lopez, Community
Outreach and Education Specialist at the Susan G. Komen Foundation,
Orange County Affiliate. Interviewees provided insight into health
communication strategies and messaging targeting the Latino population.
Additionally, quantitative data was collected from 65 self-identified Latina
women residing in Los Angeles and who’ve obtained one or more
mammograms in their lifetime.

Multicultural Health Communication
Although society is becoming increasingly multicultural, with
increasing participation of individuals representing many different national,

xi
ethnic, racial, gender, and professional cultures in political, educational,
business, and health care settings, uncertainty about how to communicate
effectively across these different cultures has made modern life increasingly
challenging (Kreps and Kunimoto 108). Respected historian and political
advisor Arthur M. Schlesinger explains that an examination of relevant
literature and social trends suggest there is a historical pattern to the ways
American society has responded to increasing cultural diversity (qtd. in
Kreps and Kunimoto 109).
For many years, perspective on cultural ideology consisted of
segmenting an entire population according to ethnic background. Recent
studies, however, tell us that variations in several cultural groups are as
diverse and different within them as they are to whites/Anglos or other
subgroups (Elder et al. 230). This is why segmentation of campaign audiences
by certain demographics such as ethnicity, compared with segmentation by
psychographic variables based on attitudes, values, and benefits are not as
effective (Backer et al. 31). However, data show that health disparities are
greatest among certain populations living in the United States, such as
Latinos.
The growth of the Latino population in the United States, with the
social and economic inequities they experience, demands continued attention
to their health needs. To bridge the health gap among individuals often

xii
created by health disparities, it is important to understand and adapt to the
evolving nature of culture, values and media habits of those who suffer the
most from lack of regular health screenings. Given the complexities
identified, a framework for targeting improvements in Latino health is
needed.
Literature has been dedicated to finding the barriers that prevent
health messaging from reaching several segments within this population;
however, little is known about the psychological and external factors that
may move these individuals towards behavioral change. It is therefore
imperative to explore these facilitators in order to complement existing
research on barriers and move effective health communication among Latino
health settings forward.

1
Introduction
Public health campaigns aim to influence a population toward
maintaining or improving its health status. In order to do this, campaign
developers must understand the link between behavior and health status for
the population of interest (Institute of Medicine 85). A sensible
communication campaign recognizes heterogeneity in its population, because
any single group characterized by general demographic variables actually
consists of diverse segments with different needs, experiences, attitudes and
behaviors (Institute of Medicine 86).
This couldn’t be truer for the Latino population, which is an inclusive
category that assumes all persons of Hispanic origin have similar needs and
experience similar barriers when using health services (Modiano et al. 35).
“Hispanic” or “Latino” is the preferred term for “a person of Cuban, Mexican,
Puerto Rican, South or Central American, or other Spanish culture or origin
regardless of race” (Office of Management and Budget). These terms are
used interchangeably throughout this paper. The reality, however, is that
while health communication efforts with Latinos need to focus on family,
cultural traditions, and the cultural value of collectivism, they must also
consider the different levels of acculturation, language, generation and
national origin (Elder et al. 227). This diverse population has a long history of

2
immigration into mature markets and has created established communities
that share a common language as well as a similar culture (Elder et al. 228).
One market that has matured into an established Latino community is
the County of Los Angeles. According to the 2010 Census, persons of Hispanic
or Latino origin accounted for 47.7 percent of the population residing in Los
Angeles. Census records track the migration of Latinos to California back to
1890, when Mexicans first came to Los Angeles. Most Latinos residing in the
county reported having Mexican ancestry. However, Los Angeles also has the
United States’ largest Central American community, including: Cuban
Americans, Puerto Ricans, Guatemalan Americans, Honduran Americans,
Salvadoran Americans, Chilean Americans, Colombian Americans, Peruvian
Americans and Nicaraguan Americans (U.S. Census Bureau). The
aforementioned intra-group diversity, then, becomes a challenge for health
professionals and communicators trying to reach this large minority
population. For example, despite the availability of reliable screening
methods and statewide programs providing free or low-cost breast cancer
screening, Latinas have lower screening rates and 26 percent are more likely
to be diagnosed with breast cancer at a later stage than non-Hispanic Whites
(Susan G. Komen Foundation, “‘Unidos’: Need to Focus on Latinas”).
Research suggests the majority of Latinas may not access and use the same
information as non-Hispanics due to language, cultural and media use

3
differences (Clayman et al.). Additionally, studies show that lower levels of
breast cancer screening among Latinas are the result of psychological and
external factors (Susan G. Komen Foundation, “’Unidos’: Need to Focus on
Latinas”).
Breast cancer is the most commonly diagnosed cancer among Latinas,
thereby making screening methods imperative (Susan G. Komen Foundation,
“’Unidos’: Need to Focus on Latinas”). Mickey RM et al. found that empirical
evidence suggests the use of screening tests in routine medical care helps
reduce cancer deaths and improve survival rates (qtd. in Ogedegbe et al. 162).
Because Los Angeles is a microcosm and home to one of the largest and most
diverse populations of Latinos in the country, this paper will observe
differences among language, cultural and media habits among Latinas living
in this city while taking a look at psychological and external barriers
associated with low breast cancer screening rates. The screening method that
will be examined throughout this study is mammography, which is
recommended annually for women beginning at 40 years of age by the
American Cancer Society (“Facts & Figures 2011-2012” 17). The benefits of
early detection of breast cancer by mammography lead to a greater range of
treatment options, including less-aggressive surgery and less-aggressive
therapy (American Cancer Society, “Facts & Figures 2011-2012” 17).

4
To complement existing data on barriers that prevent Latinas from
screening for breast cancer, this study aims to analyze factors that motivated
Latinas residing in Los Angeles to have obtained a mammogram. It is
important to observe reasons that initially encourage Latina women living in
Los Angeles to obtain a mammogram in order to find a way to duplicate these
motives, to the extent possible, with the percentage of Latinas not seeking
mammography. The goal of this paper is to position the findings from
primary and secondary research into a framework of guidelines and
recommendations for other markets seeking to target Latinas with an
effective breast cancer health communication campaign.

5
Chapter 1: Background
Breast cancer is a malignant tumor that starts in the cells of the breast
(American Cancer Society, “Facts & Figures 2011-2012” 5). A malignant
tumor is a group of cancer cells that invade surrounding tissue or metastasize
to distant areas of the body (American Cancer Society, “Facts & Figures
2011-2012” 5). The disease occurs almost entirely in women, but men can
get it as well.
The oldest description of breast cancer was discovered in Egypt and
dates back to approximately 1600 BC (Olsen 28). The so-called Edwin Smith
and George Ebers papyri is said to contain descriptions of conditions that are
consistent with modern descriptions of breast cancer, such as one where a
nameless ancient Egyptian surgeon described “bulging tumors” in the breast
and stated that “there is no cure (Olsen 28).” The medical industry has made
great advancements in breast cancer research since the time of Ancient
Egyptians, but the ultimate cure for breast cancer remains elusive. This is
partly because the disease has perplexing connections to genetic and
environmental factors.
Breast cancer typically produces no symptoms when the tumor is small
and most treatable (American Cancer Society, “Facts & Figures 2011-2012”
5). Therefore, it is very important for women to follow recommended
screening guidelines since survival rates tend to be correlated to earlier

6
detection rates. In an ideal world, women would visit their physician
regularly and get screened for breast cancer. The data, however, illustrate
that a staggering amount of women is not following the recommended
guidelines.
Excluding cancers of the skin, breast cancer is the most common
cancer among women and accounts for nearly 1 in 3 cancers diagnosed in
U.S. women (American Cancer Society, “Facts & Figures 2011-2012” 8).
Breast cancer incidence and death rates generally increase with age. Ninety-
five percent of new cases and 97 percent of breast cancer deaths occurred in
women who were 40 years of age and older (American Cancer Society, “Facts
& Figures 2011-2012” 8). In 2011, it was estimated that approximately
39,520 women would die from breast cancer (American Cancer Society “Facts
& Figures 2011-2012” 8). Only lung cancer accounts for more deaths in
women.
The National Cancer Institute estimated that approximately 2.6
million U.S. women with a history of breast cancer were alive in January
2008, of whom more than half had been diagnosed less than 10 years earlier
(American Cancer Society, “Facts & Figures 2011-2012” 8). Most of these
individuals were cancer free, while others still had evidence of cancer and
may have been undergoing treatment.

7
Relative survival rates for women diagnosed with breast cancer,
according to the most recent data obtained by the American Cancer Society,
are:
• 89% at five years after diagnosis
• 82% after 10 years
• 77% after 15 years.
The American Cancer Society suggests interpreting the abovementioned long-
term survival rates with caution, since they are based on the experience of
women treated using past therapies and do not reflect recent improvements
in early detection nor any additional advances in treatment.
American Cancer Society guidelines for the early detection of breast
cancer vary depending on a woman’s age, and include mammography among
other options (“Facts & Figures 2011-2012” 17). The American Cancer Society
recommends that women receive an annual mammogram beginning at 40
years of age and emphasize the importance of receiving regular
mammograms (“Facts & Figures 2011-2012” 17). Modern digital
mammography systems with dedicated screen-film units have been shown to
result in higher-quality images with considerably lower X-ray doses than the
general-purpose X-ray equipment used in the past (“Facts & Figures 2011-
2012” 17). The American Cancer Society details the effectiveness of
mammography:

8
Numerous randomized trials, as well as population-based screening
evaluations, have clearly shown that mammography reduces the risk
of dying from breast cancer. Early detection of breast cancer by
mammography also leads to a greater range of treatment options,
including less-aggressive surgery and less-aggressive
therapy…Mammography is the single most effective method of early
detection since it can identify cancer several years before physical
symptoms develop. It is the position of the American Cancer Society
that the balance of benefits to possible harms strongly supports the
value of regular breast cancer screening in women who are older than
40 (“Facts & Figures 2011-2012” 17).

Efforts to raise awareness of the benefits of mammography have been
made via the promotion of National Breast Cancer Awareness Month
(NBCAM), which was founded in 1985 as a partnership between the
American Cancer Society and the pharmaceutical division of Imperial
Chemical Industries (“National Breast Cancer Awareness Month”). The
aim of NBCAM has always been to promote mammography as the most
effective weapon in the fight against breast cancer (American Cancer Society,
“Facts & Figures 2011-2012” 5). As of 2011, Medicare and all new health
insurance plans were required to fully cover screening mammograms without
any out-of-pocket expenses for patients.
The National Health Interview Survey noted an increase from 29
percent in 1987 to 70 percent in 2000 for women 40 years of age and older
who reported having had a mammogram within the past two years. Breen et
al. captured trends for mammography for 2000, 2005 and 2008, and found

9
that screening rates declined by 3.4 percent between 2000 and 2005, and then
stabilized (qt. in American Cancer Society, “Facts & Figures 2011-2012” 18).
Despite progress in the availability of reliable screening methods and
an increase in statewide programs in California providing free or low-cost
breast cancer screening, invasive breast cancer incidence rates remain
highest among all invasive cancer rates in Los Angeles County (Division of
Cancer Prevention and Control). This may be due to disparities that persist
among women who have less than a high school education, have no health
insurance coverage or who are recent immigrants to the US (American
Cancer Society, “Facts & Figures 2011-2012” 17). National Cancer Institute
(NCI) defines “cancer health disparities” as follows:
Adverse differences in cancer incidence (new cases), cancer prevalence
(all existing cases), cancer death (mortality), cancer survivorship, and
burden of cancer or related health conditions that exist among specific
population groups in the United States. These population groups may
be characterized by age, disability, education, ethnicity, gender,
geographic location, income, or race. People who are poor, lack health
insurance, and are medically underserved – regardless of ethnic and
racial background – often bear a greater burden of disease than the
general population (National Cancer Institute).

A close look at cancer incidence and death statistics reveals that
certain groups in the United States suffer disproportionately from cancer and
its associated effects. One good example is people of Hispanic or Latino
origin, a population that surpasses 50 million U.S. residents and comprises
47.7 percent of the Los Angeles County population. A particularly

10
threatening disease for this population is breast cancer, the most commonly
diagnosed cancer among Latinas in the United States. As shown in Figure 1,
Latinas have lower screening rates and a greater likelihood of being
diagnosed with breast cancer at later stages than non-Hispanic whites
(Susan G. Komen Foundation, “’Unidos’: Need to Focus on Latinas”).

Figure 1: U.S. Mammography Screening Prevalence (%) among Women 40 and Older, 2011. Reprinted
from the American Cancer Society’s Breast Cancer, 2012, Retrieved January 4, 2012, from
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-
030975.pdf

11
Lower levels of cancer screening among Latinas has been primarily
attributed to financial barriers. Numbers illustrate that poor women are less
likely to have had a mammogram within the past 2 years than women at or
above the poverty level, and recent declines in mammography usage have
generally been greater among poorer women (Susan G. Komen Foundation,
“Facts & Figures 2011-2012” 18). Zambrana et al. pointed out in their study
that a disproportionate percentage of Hispanic women were low income and
also were more likely to report health insurance inadequacies and poorer
quality of life (qtd. by National Research Council 140). Interestingly, while
low income and inadequate health insurance are integral factors that are
likely to interfere with seeking regular screening, interventions directed only
at screening costs have not been particularly effective in the absence of
patient education (National Research Council 140). But inadequate financial
resources may not be the only deterrent, as wide array of literature has found
that reaching out to certain segments of the population, such as Latinos,
extends beyond financial and language issues and into cultural complexities.
Givaudan et al. explains the importance of cultural considerations in effective
health communication:
[It] determines the language used by individuals to communicate and
also determines those factors that influence the patient-provider
relationship. It affects the patient’s interpretation of disease and
health, and the way in which he/she interacts with health care
providers, and it determines the beliefs, attitudes, intentions, and
behaviors of patients toward health care (3).

12

The following chapter further explores possible barriers beyond
financial matters that may account for low screening rates among Latinas, by
taking into account the important role culture plays in health messaging. It
also consists of a literature review based on an analysis of empirical studies
addressing how culture influences the effectiveness of health messages across
different contexts. Efforts from several organizations have increased
knowledge of breast cancer screening behaviors overall and the benefits of
regular screening is beginning to reach the medically underserved Latino
population. This is also further addressed as the paper progresses.

13
Chapter 2: Literature Review
Cultural Impact on Health Behavior

“A systematic examination of the influence of culture on screening
behavior is lacking,” wrote Oetzel et al. in 2007, suggesting that for several
years, analyses of how culture influenced persuasiveness of health messages
across different contexts had been overlooked (224). Today, health
professionals and communicators recognize that without such examinations,
interventions and health information campaigns are unlikely to be successful
(Oetzel et al. 224).
In recent years, studies have helped identify several barriers that are
the product of Latino culture and values, which unfortunately may deter
Hispanic or Latina women away from seeking health-screening services.
Susan G. Komen for the Cure created a pamphlet titled “‘Unidos’: Need to
Focus on Latinas”, which highlights prevalent psychological and external
factors among Latinas (Figure 2).

Figure 2: “Unidos”: Need to Focus on Latinas, 2010. Reprinted from Susan G. Komen for the Cure

14
Discrepancies in health communication directed toward minority groups used
to be attributed to issues of language and translation, while disregarding all
other factors (Givaudan et al. 5). Since factors listed in Figure 2 give enhanced
insight on what health professionals know now about the Latina population
as it relates to their low health-screening rates, these barriers will serve as a
framework for discussion.
Recognizing that certain minority women receive fewer indicated
cancer early detection services than do the majority of women, Ogedegbe et
al. conducted a qualitative study using individual interviews with African-
American and Hispanic women to explore the factors that hinder cancer
screening behavior (barriers) and those that encourage cancer screening
behavior (facilitators) in patients (162). The authors conducted in-depth one-
on-one interviews with 187 low-income, primarily minority women in four
New-York-City-based community/migrant health centers (Ogedegbe et al.
162).
Ogedegbe et al. explored perspectives from various backgrounds with
regards to multiple cancer screening behaviors relating to cervical, breast
and colorectal cancer screening rates (163). The study found several barriers
similar to those found in current culturally relevant material. Lack of cancer
screening knowledge, patients’ perception of good health or absence of
symptoms attributable to ill health, fear of pain from the cancer test, and a

15
lack of a clinical recommendation were among the most common cited
barriers in this study (Ogedegbe et al. 162). Among the most cited facilitators
were clinician recommendations as well as personal medical history, credited
to the presence of a past or present symptom (Ogedegbe et al. 162). Patients’
responses were analyzed and grouped using standard content analysis
techniques and placed into three major categories: 1) patients’ attitudes and
beliefs, 2) their social network experience and 3) accessibility of services
(Ogedegbe et al. 164). The authors of this study emphasized that in caring for
minority and low-income women, it is important for primary care providers to
address the factors within each category before recommending cancer-
screening tests (169).
Clinician recommendation in cancer early detection surfaced as both a
barrier and a facilitator in Ogedegbe et al.’s study, thereby establishing its
importance as an influencer on patient behavior. Givaudan et al. wrote a
paper in 2002 focused on bridging the communication gap between health
providers and patients, primarily addressing written material created for the
Latino population:
Given the costs and dangers resulting from language and cultural
barriers, it is essential that written material for Latinos be adapted
linguistically and culturally. There is a serious lack of available
Spanish-written material that is acceptable and comprehensible for
Spanish-speaking individuals. Spanish-written texts are often
translated from English to Spanish with little regard or understanding
of the context in which Latinos may use certain words or images.

16
Quality of material should be evaluated on more than just reading
levels and literal translation (3).

This paper reiterated that emphasis should be placed on written
communication. One reason is that research indicates written information
offers advantages over other methods, since it is “reusable, permanent, may
be read in moments of idleness, is easy to reproduce, and transmits messages
in a consistent way” (Givaudan et al. 3). Additionally, written communication
is an essential component of human communication and is fundamental in
health-related organizations that use written material to increase patients’
knowledge and influence behavior.
In an in-depth analysis of empirical research on cultural health
promotion practices, authors Padilla and Villalobos found that all health
promotion activities practiced by healthcare professionals were filtered
through the very unique cultural interpretation of the target group (S25).
Materials and services, therefore, needed to transcend unto the population
being served in a way that culturally made sense.
In this in-depth analysis, Padilla and Villalobos addressed the
following three discoveries that surfaced: cultural expectations and beliefs
could be shared by and work complementarily in the family and the larger
social context; cultural beliefs could be a source of tension and stress as a
result of pressure in the environment; and cultural values could become less
important than other concerns, such as problems related to access when

17
dealing with the healthcare system (S27). This specific analysis focused on
Mexican American women but shed light on the complexities of cultural
values in relation to health behavior that may be worth exploring among
other Latino groups residing in the United States.
Givaudan et al. explained that handling the diverse situations that
arise from the interaction between health care providers and patients who do
not share a cultural background were “obstructed by several aspects that
bring its members together, including factors such as language,
conventionalisms and symbols which differentiate the culture from others”
(17). Problems are generated, actions are delayed, and interpersonal
relationships are impacted if there are persistent discrepancies regarding the
interpretation of information among different cultures (Givaudan et al. 17).
Additionally, poor patient–provider communication can perpetuate
psychological barriers such as fear, embarrassment, perceived discrimination
and language barriers.
Increasing patients’ knowledge, either through written or verbal
communication is important because fear of cancer, misconceptions about
invasive procedures as well as pain, and lack of knowledge about cancer and
its screening methods can easily be addressed with correct information.
Instead, they have been found to be psychological factors preventing Latina
women from obtaining mammograms (Susan G. Komen Foundation,

18
“‘Unidos’: Need to Focus on Latinas”). Interestingly, Berry et al. conducted
focus groups and reported the ensuing findings with regard to the Latino
population and health information:
 Latinos think they have insufficient information to make
decisions concerning their health
 It is difficult for them to find information about health care
 They do not consider the information they find to be very useful
 They do not trust most of the usual sources of information, such
as the American Cancer Society or the American Medical
Association, perhaps due to unfamiliarity
 They express that apart from consulting with friends, relatives
or health care providers, they would call a toll-free number to
obtain information
 They report that they are less exposed to information than the
rest of the population
 They prefer to obtain their health-related information through
personal contact with someone who is enabled to provide it, such
as a health care provider or a toll free number; other options are
pamphlets, leaflets, books, and reports
 Their trust in publications like Consumer Reports is lower with
respect to other groups, probably because these are not available
in Spanish (qtd. in Givaudan et al. 13).

The recurring perception of distrust in Berry et al.’s findings illustrates why
concerns over confidentiality, fear of deportation and perceived
discrimination serve as hindrances for Latinas seeking breast cancer
screening. For the most part, Latinos stay within a close-knit circle that is
usually comprised of family members and close friends.
Because Hispanic families stay close, they play an important and
defining role for Latinos by influencing social and individual values and
behavior. Givaudan et al. provided common perception of patterns of

19
association within the Hispanic family in their paper, which the authors
believe should be used as a frame of reference to guide health care providers
in their work with Latinos:
 Mothers generally decide if and when a family member gets
medical attention, while the male head of the family grants
permission to go to the medical center
 The head of the family, normally the eldest male, is the one who
makes decisions, although important decisions involve the whole
family
 The father or eldest male is usually the spokesperson for the
family, though this custom is often modified when the ability to
speak English is a priority
 It is common for Latino families to try to protect the patient
regarding knowledge of his/her illness, preferring to hear bad
news before the patient is informed. The family spokesperson
will generally be responsible for delivering serious information
 Families are an important source of emotional support and
patients enjoy seeing and sharing time with family members
 Family members generally distribute the patient’s daily
activities among themselves so that the patient can rest (14).

The role of family is particularly significant for women, who tend to play
care-giving roles (Padilla & Villalobos S26). In terms of screening behavior,
receiving a mammogram may not be at the top of the priority list for several
Latina women, which poses a big problem for their personal well being.
From an outsider’s perspective, the distrust of sources that might
otherwise be considered credible and the emphasis placed on giving authority
to certain members of the family can be difficult to fathom. For someone who
belongs to the Hispanic population, they may feel discouraged and feel
misunderstood or discriminated against, which can lead to the avoidance of

20
health services. Givaudan et al. wrote that communication skills are
important in order to foster trustful and useful relationships that lead to
behavior change (16). Amid diversity, cross-cultural communication is critical
because all cultures develop rules for communication (16). Givaudan et al.
expanded upon these cross-cultural rules for communication:
These rules can be referred to according to their impact on the context
(the set of stimuli surrounding communication) and the meaningful
extent of these stimuli in the communication process. These factors
increase the difficulties and challenges for communication and for
translation of texts from one language to another (16).

The use of inadequate written material and offensive or culturally
inappropriate treatment of patients only illustrates a fraction of the
communication misunderstandings that can occur between healthcare
providers and patients from different racial or ethnic groups. Recent research
recognizes that the issue of verbal and written language translation create
several complexities, and calls for a new approach for exploring health
disparities among Latinos. For example, Elder et al. explored how language
usage drives the degree to which individuals are acculturated to American
society:
[Language] may influence not only how well they respond to our
behavior change initiatives but also their selection and use of media, in
general…Acculturation may be defined as a process through which an
individual’s attitudes and behaviors shift from those of his or her
culture of origin toward those of the dominant culture. Changes that
occur in attitudes, norms, and values of individuals exposed to a new
culture are an important part of this process and may provide insight

21
into the relationship between acculturation and health-related
behaviors (230).

Additionally, Elder et al. cited data from the Pew Hispanic Center on
bilingualism among Latinos in the United States (230). According to these
findings, the 2000 Census showed that the number of Latinos speaking
Spanish at home rose from approximately 10.2 million in 1980 to 24.7 million
in 2000 (230). Amid a rise in immigration, there was clear indication that
Spanish had become an increasingly common language among U.S. Latino
households. However, the authors’ data also indicate that as Latinos move
into the second and third generation, they increasingly live in English-
dominant households.
Aside from language, education also plays a big role in effective health
communication. Kim et al. published a study that focused on African
Americans and Latinos residing in Los Angeles, which centered on combining
key ideas from the knowledge gap hypothesis and communication
infrastructure theory (393). Like knowledge about topics in other areas, the
knowledge gap hypothesis addressed that knowledge about chronic diseases
is not distributed equally among members of society (395). On the other
hand, the communication infrastructure theory pointed towards an ecological
approach to exploring the relation between community-level resources and
people’s problem-solving capacities in their everyday lives within a
neighborhood context (395).

22
The study aimed to explain the relationships among individuals’
education, access to community-based communication resources, and
knowledge of chronic diseases such as breast cancer. What this study found
was that knowledge gaps concerning chronic disease between the highly
educated and less educated may have occurred through the direct effect of
education, but also via an individual’s connection to neighborhood resources
via a third party such as promotoras.
Kim et al. conducted randomized-digit dialing telephone interviews
from June to November 2005 with 302 African Americans and 312 Latinos in
the greater Crenshaw area in Los Angeles, California (399). The surveys were
conducted in either English or Spanish, according to the participants’
language preference. Variables resulting from significantly different
demographic and socioeconomic characteristics were controlled for in all the
analyses (Kim et al. 399). Kim et al. further explains that future studies
should incorporate health specific communication resources to further
develop the relations among social economic status, access to communication
resources, and health knowledge examining (410).
In examining the knowledge gap hypothesis, Kim et al. wrote that it
“holds that the structural position of individuals, groups, and communities
either facilitates or constraints the flow of knowledge” (395). The idea behind
this hypothesis maintains that individuals, groups, and communities have a

23
better chance of accessing available information available if they are in a
“better” structural position to do so. On the other side of the spectrum, those
in a less desirable structural position will not find this information as readily
accessible. In relation to health campaigns, Kim et al. points out that the
main arguments presented by the knowledge gap hypothesis have significant
implications:
…the primary goal is to increase health issues among low
socioeconomic status groups or ethnic minorities. Even when health
campaigns are targeted towards low socioeconomic status groups, the
groups that actually benefit from the campaigns are often those with
higher socioeconomic status (Viswanath, Kahn, Finnegan, Hertog, &
Potter, 1993), thus producing the unintended consequence of
increasing the knowledge gap between high and low socioeconomic
status groups (395).

In addressing the study’s findings regarding the community
storytelling network, Kim et al. concluded that those who reside in
communities with strong storytelling networks would find it easier to make
connections than those individuals who move into an area with a weak
storytelling network (410). This suggests that health agencies consider
strengthening weak storytelling networks an important means to increasing
residents’ knowledge with regard to high risk diseases and increasing their
capacities to access health resources (Kim et al. 410). One of the
recommendations suggested a strategy to bring together the media that
residents find most important in their efforts to deal with family health
problems, which can work simultaneously to strengthen storytelling ties

24
among them as well as “increase salience of specific diseases in the
storytelling process” (Kim et al. 410). Be this as it may, previous mention of
high levels of distrust among Latino populations must not be disregarded.
“Providing Health Messages to Hispanics/Latinos”, published by
Clayman et al., focused research on the relationship between the Latino
population’s trust in and use of health information sources, including mass
media, the Internet and interpersonal channels (252). Using the 2005 Health
Information National Trends Survey (HINTS), the authors of this study
sought to test the hypothesis that Hispanics who are less comfortable
speaking English would differ from Hispanics who are comfortable speaking
English regarding levels of trust in health information sources and media use
(Clayman et al. 252). In terms of the sample, for those whose race/ethnicity
data were available, 496 respondents identified themselves as either
Hispanic or Latino and 4,103 were non-Hispanic Whites (257). The authors
pointed out the following:
Hispanics who are not comfortable speaking English may be difficult to
reach, not only because of language barriers and lower trust in media,
but also because they report relatively little use of various media
channels. These findings have important implications for health
communications towards non-native speakers of English in general
and Hispanics in particular (Clayman et al. 253).

In addition, the changing media landscape further complicates efforts
to provide health information to an entire population (Clayman et al. 254).
Clayman et al. described the amount of health information that has become

25
available via various channels and sources as well as the increase in the
platforms that disseminate information which have propagated in the past
several years (254). Webster writes that in addition to the Internet, the
number of broadcast networks and cable channels has increased significantly
as U.S. households have gained access to dozens of channels (qtd. in Clayman
et al. 253). The number of Spanish-language networks grew from 3 to 73
around the same period that the Hispanic population doubled between 1986
and 2004 (Coffey qtd. in Clayman et al. 254). The multiple ways in which
media are accessible is also noteworthy. The television set, a DVD player, the
Internet and even a cell phone are readily available should someone want to
watch an entertainment program, illustrating that although consumers of
health information may not be actively seeking such information, they can
still be exposed to it through routine use of mass media (Clayman et al. 254).
Clayman et al. recognized two very important things in their
secondary research:
Previous studies have shown that commonly used sources of health
information may vary by ethnicity (O’Malley, Kerner & Johnson,
1999), race (Nicholson, Grason, & Powe, 2003), socioeconomic status
(Hesse et al., 2005), and acculturation (O’Malley, Kerner, Johnson, &
Mandelblatt, 1999). However, it is also true that certain groups may
selectively use media outlets (such as television channels) that have
similar programming, content, and demographic targets, potentially
reinforcing existing norms and attitudes (Webster, 2005).

26
Additionally, trust becomes an important component in receiving media
messaging because it differentiates someone who listens to a health-related
message from someone who acts upon it (Clayman et al. 255).
The aim of Clayman et al.’s research was ultimately to determine if
Hispanics residing in the United States who reported differences in comfort
speaking English also reported differences in trust of sources relating to
health information (255). The authors detailed their findings as follows:
Our study shows that Hispanics who are not comfortable speaking
English have different trust and media use patterns than their
counterparts who are comfortable speaking English. The analysis
suggests that these poorer, less educated men and women might be
especially receptive to messages given through aural and visual
channels (radio messages, television, family/friends, doctors), but they
may not be receptive to text-based mediated messages such as the
Internet or in print media. However, as they report relatively little use
of both radio and TV, these approaches might have even less effect
than they would amongst heavier consumers of media. Importantly, an
analysis that grouped all Hispanics/Latinos would not have discerned
such information (Clayman et al. 261).

Incidentally, apart from inaccurate data analyses, grouping all
Hispanics/Latinos into one category may perpetuate inaccurate health
communication messaging and is therefore strongly discouraged. Latinos
vary substantially in terms of socioeconomic and legal status, their country of
origin, their region of residence within the United States, their generation
status and levels of acculturation, and psychological factors (Elder et al. 227).
Contrary to surveys that insist on treating Latinos as though they were a
homogenous group, authors write that there is now evidence that illustrates

27
each group has specific characteristics that make it different and
independent from one another (Elder et al. 227). It is implied that there is a
possible gap between efforts aimed at increasing overall cancer screening
rates and this diverse population due to generic Latino messaging
approaches. Given socioeconomic realities, regional issues, generation status,
identity, and language variations that exist among Latinos, Elder et al. point
out that “variations within this group are nearly as great as those between
them and white/Anglos or other subgroups” (231).
Latino subgroups’ distinguishing characteristics can be traced back to
highly varied experiences extending to Spanish colonization (Elder et al. 228).
Upon arrival in this country, Latino immigrants encounter varied
socioeconomic realities, some realizing middle-class status fairly quickly
while others find themselves trying to make ends meet. According to Elder et
al., these experiences may be a function of the structure of their home
countries’ educational system, as well as their native ancestry (229). Elder et
al. explain, “Mexicans are disadvantaged before they arrive because fewer
individuals have access to a secondary education compared with the
opportunities to complete high school in the United States” (229). Access to
education, in turn, affects literacy levels. Along with Puerto Ricans and
Central Americans, most Mexicans immigrate to the United States as
unskilled laborers (229). However, Cubans living in the United States have a

28
relatively stronger economic status and 74 percent have graduated from high
school (Elder et al. 228).
Aside from educational disadvantages, recent unemployment figures
for Latinos are relatively favorable, although this appears to vary by
generation status. First and third-generation Latinos have approximately the
same “employment-to-population ratio,” both substantially higher than that
of second-generation Latinos (Elder et al. 228). Several of the differences
found among Latino subgroups are arguably as great as those that have been
found among other American subgroups and can be traced back to before
Latinos became the largest American ‘minority’ (Elder et al. 229).
Also, multigenerational establishments within a state by certain
Latino subgroups, like Puerto Ricans in Miami and Mexican in California,
have helped create mature markets and reduced language and cultural
barriers when people are accessing health care services (Elder et al 230).
National identity also varies among first and second-generational
Latinos. Elder et al. explain these variations in self-identity: “A small
percentage of first-generation Latinos use the self-descriptor ‘American,’
whereas more than one-third of second-generation Latinos do so. One-fourth
of both first- and second-generation Latinos use ‘Latino’ or ‘Hispanic’ as their
primary term of self-identification” (230).

29
Elder et al. highlighted some interesting characteristics among
generational differences. For example, first-generation Latinos are more
socially conservative, as evidenced by their attitudes toward divorce,
abortion, and other social issues, which affects both the context and content
of health messages (230). In regards to health disparities, Elder et al. noted
that perception of stigmatization and discrimination from the community at
large and from the health care system were frequently reported by Latinos
(230).
The impact of discrimination against Latino immigrants may be
compounded by language, legal status, and other bases for bias,
further exacerbating their impact and resulting in considerably higher
levels of stress among minorities than among whites (231).

As described in Susan G. Komen for the Cure’s guidelines entitled
HISPANICS/LATINAS Developing Effective Cancer Education Print
Materials, the importance of inter-group and intra-group variability cannot
be overstated. Latinos are as diverse as the panorama of multi-ethnic groups
that reside in the U.S. However, they maintain common beliefs, practices and
values, “which underlie these differences and which result in wide variations
in how these beliefs, practices and values are expressed, if at all. Health care
providers should have basic knowledge of common perceptions of sickness
and health among Latinos, patterns of association within the Latino family,
and the comfort of Latinos with physical touch (Susan G. Komen,
“HISPANIC/LATINAS”).

30
Given the volume of literature that has been invested in examining
barriers for the underutilization of breast cancer screening services among
Hispanic women, several recurring barriers have been identified among
Latino subgroups and are often intertwined with other barriers. Generally,
research points to low socioeconomic status among Hispanic women, who
oftentimes also lack health insurance, have fewer years of formal education,
and higher unemployment rates. This potentially leaves them with fewer
resources to pay for medical care. The problems can be compounded by
limited knowledge about cancer-related risk factors and cancer screening
procedures (Susan G. Komen, “HISPANIC/LATINAS”).
Presently, several studies are directing their attention toward
determining which communication channels might be the most effective in
raising awareness of breast cancer screening among Latina women (Susan G.
Komen, “HISPANIC/LATINAS”). There is no use, however, in generating
content that is culturally relevant and/or understandable if it isn’t going to
generate a call to action among the targeted population.
Meanwhile, research exploring incentives and motives that determine a
woman’s decision to seek mammography is limited. Ogedegbe et al. explored
perceptions with regards to cancer screening behaviors and cervical, breast
and colorectal cancer screening rates. They also surveyed two particular
demographics: African American women and Latinas (162). Although

31
Ogedegbe et al. compiled an incomprehensive list of facilitators that
encouraged screening behavior among low-income African American and
Latina women, the study didn’t identify which facilitators weighed more in a
Latina’s decision to seek breast cancer screening (167). Also, individual
demographics weren’t explored for patterns or cross-sectional results. It also
would have been interesting to see which category (Attitudes & Beliefs, Social
Network, or Accessibility) was the most influential in encouraging breast
cancer-screening behavior.
Exploring which facilitators strongly motivate Latina women to seek
screening may help bridge a gap between what’s holding Latina women back
and the incentives that can help move them forward. It may also help create
more effective messaging that is more likely to resonate with the rest of the
Latina population who should be seeking mammography but are not. The
next chapter addresses systematic primary research that incorporates tried-
and-true approaches to overcome the barriers discussed throughout this
paper. Additionally, quantified data are presented regarding breast cancer
screening facilitators reported by Latinas who have had one or more
mammograms.

32
Chapter 3: Health Communication Experts Weigh In

Advances in health care have made extraordinary differences in the
life expectancy and level of vitality of the average American (Backer et al. 2).
Be this as it may, there are still far too many people who still do not know all
they need to know, or who may not act upon what they know. While no
societal problem of a large magnitude has a single solution, health
communication campaigns can help. Rogers and Storey define a campaign as
having four essential ingredients:
• A campaign is purposive, and seeks to influence individuals
• A campaign is aimed at a large audience
• A campaign has a more or less specifically defined time limit
• A campaign involves an organized set of communication (qtd. in
Backer et al. 4).
While designing an effective health communication campaign might seem
daunting, designers of such health communication campaigns often have
considerable expertise about the particular areas of health behavior that they
are attempting to change (Backer et al. 1). If they don’t, most will quickly
learn and readapt the strategies and messaging to the targeted population.
Following are four interviews with communication professionals who were
actively selected for the nature and scope of their work, with specific
attention paid to their experience in targeting the Hispanic population.

33
Instead of alphabetical order, the interviews are presented by specific
background in multicultural health communication as follows:
• Matthew LeVeque, a public relations veteran in his own right, has
worked on successful health education campaigns aimed at addressing
a variety of health issues ranging from smoking to obesity.
• Hector Andrade works on the widely acclaimed and award-winning
LIVESTRONG campaign, which has been very successful at increasing
awareness of available resources and services among cancer patients
and survivors in the Hispanic community.
• Award-winning communications professional Laura Min Jackson may
spend her time providing strategic communications and leadership
coaching today, but she was once responsible for running the
communications outreach of the State of California’s first Breast
Cancer Early Detection Program (BCEDP) in 1994.
• Lastly, Ambrocia Lopez spends her week actively educating and
engaging Latinas as Community Outreach and Education Specialist
for the Orange County affiliate of Susan G. Komen for the Cure.
Ambrocia’s messaging consists of emphasizing the importance of breast
health and frequent screening behavior, while demystifying cultural
misconceptions and misinformation.

34
The standard format in which the interviews are presented follow suit of
those presented in “Designing Health Communication Campaigns: What
Works?” by Backer et al. (35). Each interview is introduced with the
respondent’s name and primary organizational affiliation, a brief preamble
stating the interviewee’s background and experience in multicultural health
campaigns, followed by a transcript of the interview. Colloquial expressions
and interrupted trains of thought have been left intact, and structure was
avoided in order to allow the interviewee’s input to run its course. Initials
are used throughout the transcripts to distinguish the conversation.

35
MATTHEW LEVEQUE
Rogers / Ruder Finn

About the Interviewee

Matthew LeVeque is a public relations veteran and a full-time adjunct
professor with experience in integrated communication campaigns, public
affairs and community relations. He was senior vice president at
Rogers/Ruder Finn, where he founded and directed the firm’s internal Digital
Strategies Group and played a key communication role in California’s anti-
tobacco education campaign.
LeVeque has taught strategic public relations courses at USC
Annenberg as an adjunct instructor since 2003. The School of Journalism
Graduate Student Association recognized him as the best PR professor in the
2007–08 and 2008–09 school years, and his professional work has earned
more than 30 awards from professional organizations.

♦♦♦

MS: I am focusing on the Latino community as a whole; specifically in Los
Angeles. There has been a lot of research that says professionals who are
putting together these campaigns bunch everyone into this general Latino
community…

ML: That it’s homogenous

MS: Right, “it’s homogenous, they consist of the same beliefs, come from the
same cultural background”…

36
ML: And I would definitely disagree with that. I would definitely have
research to help you with this, but overall I would stratify…because there is
a difference between [Latinos]. Because ultimately, your communication
channels are going to vary too, who the influencers are vs. 2
nd
/3
rd
generation
that still have Spanish fluency but maybe are consuming information
primarily in English. There are different channels that you’re going to reach
them with and just the class that sort of “let’s all go to Spanish radio, TV and
print.” So I would stratify by their language preference or proficiency. I might
stratify by other generational age differences. Like is 40 to 50 age different
than 65+. I think there are tremendous differences in that generational
difference. And then…you always end up with proxies, people who influence
you.

MS: Is there a sub-segmented population who prefers TV or broadcast?

ML: There was a new law that required health care providers to bring in
translators for any language, there was like 25 languages for someone who
came into a health clinic to talk to them. Because, from the research that I
had seen, most of the Spanish speaking fluents [were] bringing their children
in to use with their doctor to discuss their medical conditions as a translator.
And that was interesting because the problem was, especially for the men
that’d have their daughter, would not want to talk about something. Because

37
it’s like if I’m having a prostate issue primarily, that’s not the kind of thing
you talk to your child about… That’s not what you sit there with your
children and say please tell him that I’m having such and such…So that’s
why they were trying, because they didn’t feel like they were getting honest
communication or necessary communication.

MS: So then, how was that hurdle overcome?

ML: Because policy was put in place, required by law now to have a
translator. There a nurse in there, a professional. That’s an interesting thing
to me because is your audience only the females that your targeting [as part
of] stratification. Or is also a consideration of thinking about the proxies and
the influencers. [Like] Hey mom, you should really go get a mammogram. It’s
really important [to see] do the daughters have a really strong influence on
mom’s preventive healthcare behavior?

That’s not similar to what I told about the smoking campaign…it’s not the
same thing, it’s an addiction. But, what are the triggers that get them to do a
quit attempt. And so you find out that it was…that’s why sometimes you
have commercials in marketing where it’s the kids talking and they’re like
Dad I love you so much. Because it’s like…I need to do this for my children, I
need to do it for such and such. If you communicate those triggers that cause

38
people to think about and moving down to quitting too, it’s the same thing as
getting people to seek the evaluation on it.

MS: So for the campaigns you worked on that dealt with raising awareness
on a certain issue, what methods of communication did you feel were the
most helpful?

ML: Budget has played a huge role on that. If you have large budgets, then
the mass media campaigns tend to be really effective because you can really
get bang in there, run commercials, get big awareness really fast. In the
ethnic communities, the upside is in the mass media market for [the] Spanish
speaking population, the media channels in Los Angeles are huge. You know,
Univision, Telemundo, and radio. Radio is gold for the Latino community
because Spanish language radio is such an important part of the culture and
the community and it transcends. You get from the really low SES to the
people that have more money, so it can be really impactful. So the mass
media tends to be most effective.

Then doing the community-based activities have also been really effective. So
we have done church-based…we’ve done advertisements in the church
bulletin…and those are very cost effective. Church outreach and those types
of groups also. Like in the obesity [campaign], we’re doing it in some of the
community centers and places like that where we pay for like running the

39
County’s message on the screens and things like that. We try to get Zumba
classes to try and get people to come and then person will talk to them about
how to feed their children and things like that. So it’s not just about coming
in there and being lectured about obesity or health problems. You’re getting
some benefit with it.

Health fairs: there are a lot of people who do these community health fairs.
They definitely do them in Spanish speaking and African American
communities. Typically, in LA county there will be a lot of health fairs. And
they’ll be in like…Compton, is not an actual African American community.
It’s a mixed of Latino and African American. Inglewood is Latino and African
American now. So, I would definitely look up health fairs on that. Any of
those health clinics also tend to be a great communication channel. Especially
for the females that are bringing in children because maybe if they’re not
doing things for themselves, they’re still bringing their children in to get
checked up or shots or anything like that. Is that a point where there in
there, and hey while you’re at it is there material? Because if you’re doing a
communication campaign, then is there posters or something…if you’re
sitting in a clinic, we look at clinics and go like the county clinics have TVs
and everything. So we’re looking to put together, like, education snippets that
go along those TVs…you’re sitting there stuck. For the outreach channels,

40
just go through, put yourself in the I’m a female in the demographic where
are there places I may be able to intersect.

I would start [with], what are the big channels on the mass are…you know
what they are…La Opinion, Telemundo, the big big mass media channels.
Then you come down, what other interception points that you might be able
to communication with that population. And you’re right, church is a…it’s not
that they’re a mass media, but the volume of it that you can get into a lot of
different churches. But it’s really a micro communication, because it was the
free snippets of…a support group or a club, that may be another point to get,
hey we have a speaker coming in to talk to us today about such and such.

MS: What are the main barriers you see when working with minority groups?

ML: Well the main barriers definitely are language and education levels and
pre-existing cultural beliefs. Then it becomes the issue of when you’re trying
to communicate these things, getting it down to a literacy level because…and
literacy level is usually problematic for many of our tougher audiences.
Because often times you will have in any of these populations you’re trying to
reach, especially the lower SES ones, Socio Economic Status ones, that have
less than high school education, and often times even less than that. You
know they’ve gone up to 8
th
grade or 7
th
grade so their reading level or their

41
comprehension level of words may be incredibly low. So there are literacy
levels, so I will have had campaigns where there are a variety of [where] you
will write things…it might be a brochure or something else where you have to
run these literacy tests against them to see what level we’re at and we’re
trying to get down to, you know, 6
th
grade or 4
th
grade level on it. What it
really comes down to, you can’t use complex words, you can’t have…So
literacy levels are a barrier…

We also have that sometimes words don’t translate well. If you’re not doing it
by somebody…I don’t translate, I always have somebody who’s native in the
tongue, you know, trans-adapt it. And especially when you’re getting down to
technical words, like diseases and things like that may be spoken about
differently. How we say it in English, how you do a translation in English is
not how people talk about it in the native language. So you definitely have to
be sensitive and aware of that too…that’s the other thing…if they’re not
specialists in the community, they have to have, I don’t want to say empathy,
but they have to be understanding of, that not everything is
homogenous…that it’s not all the same. Especially when you’re trying to
break through these difficult barriers and get people to do something that
they’re afraid to do or don’t want to do or isn’t a high priority. That could be

42
interesting, especially if you’re taking your family as high incidence of breast
cancer.

And then you’re in your 30s or 40s and you’re having kids and your family
and everything, you just don’t want to deal with it, you just don’t want to go
and find out because you want to…because people, you go to the doctor and
you find something [and it’s like all of a sudden] I learned something I didn’t
want to learn you know? The family is an important message for all cultures
and communities, definitely always the Latino community is one of the top.

Always looking for ways to incorporate family, don’t do it for yourself do it for
your…I supposed for the kids and the family situation you always want to
direct it to the mom. She’s the one, the female is the one. And then it’s down
to getting and finding channels that are going to connect. Because, again, you
have…the Socio Economic Status of people that have computers, may have
Internet connection or you can do a lot of whether it’s they’re searching for
things on YouTube or trying to get information or maybe on Facebook…and
then down the Socio Economic Status they may be less and less likely to be
on those platforms and channels or have internet access as available as we
do, having this laptop and Wi-Fi and wherever you’re going. Now the kids do
because when they go to school, the schools have internet access. But it also

43
may, is it a digital/social campaign may not be as effective but is it a mobile
campaign more effective? Because most smart phones, and you see even if
you don’t have an internet connection at home, mobile plays a very important
role in lower SES communities…

It’s always the digital divide, especially in these public education campaigns,
we’re always worried about the digital divide…we’re going to go social and
mobile and digital and then look at the data and it must be…fluents or
college educated are like 98% on the Internet and as you go down, and then it
typically was African American/Latinos were at the lower end of having a
daily or ability to get on the internet…it’s grown…if you’re getting down to
Latinos, you may want to just make a mention of it’s kind of a conundrum of
how what a great channel it is and how easy it is to get content out there that
people are going to use but then compare to other populations nationwide are
the lower SES Latinos on these channels. And you can have a conversation
about internet vs. mobile, the invention of the smart phone. It’s kind of like
back to when we’re doing the African American community or Latino
community, it’s typically we would do a radio promotion, we want to get that
sort of mass targeted conversation. And especially on the KGLA station, the
Spanish language station, I liked it better when we were doing that. Not
putting in like a pre-produced PSA or commercial but have the… radio

44
stations’ personalities, so the disc jockey or the people that are at the radio
station be the ones who are the messenger.

The research and what I’ve seen from our focus groups in the past is, they
come across as very trustable people to the members of the community so the
Spanish speaking, primary Spanish like the morning people, they consider
them trustable sources of information so they’re the ones saying look it, this
is very important for us and our community and its important for our family
and all of you, we want you to go out…that is more impactful than a pre-
recorded radio commercial…so, we try that and as part of the promotion we
always make sure we get a lot of their street team activity and community
activities so that they’re showing up at the health fairs or festivals or
whatever it may be so that the families in the community there are also then
getting their personal contact with them…remember my whole thing…the
promotion that we do with the ‘Quit Smoking’ with the LA Sparks? So we’ll
go to those community events and then try and do things that are
interactive…that stuff tends to work, just some way to get them engage and
be a part of it.

MS: Can you discuss Internet habits a little more, other than the
social/digital divide said to exist at the moment?

45
ML: Well, the digital divide is just more access to Internet, you know poor vs.
having it…and generational difference too. Although, I think that may be
changing. It used to be this young cohort that was all digital and social and
that. And now you see all the growth on Facebook and everything, it’s all in
the 55 to 85 population and now senior citizens 80+ are all coming online…so,
I don’t know how much the digital divide…but then it’s also, if you’re talking
about these Latinos that are primary Spanish speaking ones, where are they
going online? So, are they on Facebook?

46

HECTOR ANDRADE
Edelman Public Relations

About the Interviewee

As a senior account executive in the Edelman Los Angeles office, Hector is
responsible for developing and implementing multimedia campaigns for
LIVESTRONG, a nonprofit organization founded by cancer survivor and
champion cyclist Lance Armstrong, to educate Hispanic audiences about
cancer-related resources. Hector also conducts media and stakeholder
outreach for clients such as Advanced BioHealing, Miramar Labs, CareNow
and Cedars-Sinai's Maxine Dunitz Children’s Health Center.

Prior to joining Edelman, Hector worked as an independent communications
consultant, leveraging his media relations skills to help clients promote
health and wellness programs, including AltaMed, Southern California’s
premier network of community clinics and health and human services.
Hector’s work included generating awareness and increasing participation in
AltaMed’s women’s health fairs as well as its back-to-school health
screenings. At The Rogers Group (TRG), Hector contributed to the
development of media relations campaigns targeting the ever-growing Latino
community. Hector spearheaded an award-winning public education

47
campaign in partnership with Univision – an effort aiming to highlight
childhood development issues among Latino parents and caregivers.

♦♦♦

MS: Can you give me a broad overview of the campaign Edelman helped
develop for LIVESTRONG?

HA: This campaign, at its core, was to inform the public about cancer-related
resources that were not only free but culturally relevant.

MS: What were the main strategies used to drive the LIVESTRONG
campaign?

HA: Within many different strategies, it was a combination of earned and
paid media and things on the client’s side that really helped get the word out.
We were also able to raise awareness by utilizing credible spokespeople.
Research was also conducted by an independent firm called Gomez Research
in Pasadena, California.

MS: What were some of the interesting things this firm found when it
conducted focus groups?

HA: We found that in terms of the main channels of health communication,
Latinos either like to consult their doctor, or they go online and conduct a
general search on a general engine. In other words, they don’t have a specific
website they go to for health information such as the CDC or the FDA or

48
anything like that. And it varied by region. Latinos in Austin were more
likely to consult a doctor, while Latinos in New York were more likely to go
on the web and search. They were also asked about other channels of
communication. An interesting thing they found from these focus groups is
that the term ‘promotora’ resonated more with people on the West Coast,
while most New York participants did not recognize it.

MS: Can you further expand on maybe why the West Coast is more familiar
and willing to go to a promotora for health advice?

HA: I mean, I guess it makes sense. I see promotoras being predominant in
rural communities.

MS: How so?

HA: Well, look at California. There are several farm working communities.
These people migrate and don’t have access to doctors, and often times they
don’t have internet access to they’re not going online and researching health
related information.

MS: What did you find aided the most in raising awareness the availability of
cancer-related resources and services?

HA: For the Spanish-dominant, it would definitely have to be broadcast, mass
communication. TV and radio really helped us target this population. And it

49
was because we were able to find figures that this population finds to be
credible sources. One example is Univision’s Dr. Alicia Lifshitz. We were able
to conduct health segments where people watching the show could receive
more information.

MS: Can you expand on what other figures the Latino population considers
credible sources?

HA: First, they have to have credentials, they have to be health professionals
or have the title of a doctor. And the interesting thing is, the Latino
population will take advice from these doctors featured on TV or on the radio
or validate what they have to say as true. Ordinary people who have a deep
story or that the audience can relate to works in disseminating information.
However, it would not work if they were to try and give advice. It helped
LIVESTRONG to have cancer survivors speaking on behalf of the
organization because these are people saying “these are the resources I used
and are available for free for you as well” while the audience listening is
saying “well, they used all these resources maybe I should check it out as
well.”

MS: LIVESTRONG was a national campaign and so you were able to work
with different demographics. Did you see segmentation among the way
groups received or perceived health communication?

50
HA: From what we found in the Gomez research, there was segmentation.
Results varied among language, age and region. Spanish-dominant speakers
from Austin most often reported that they would turn to their physician first
for health information. Nearly all participants in New York, regardless of
primary language, reported that the Internet was their primary method for
accessing health-related information. Although participants across all groups
identified physicians as an important source of health information across all
groups, few, if any, participants reported that they would turn to a nurse,
promotora, social worker or pharmacist. And as I previously mentioned, the
term “promotora” was not recognized by most New York participants. The
research suggests that this pattern may be due, in part, to the relative
affluence of focus group participants. As a whole, the majority of participants
reported that they would conduct a key word search, instead of visiting a
particular website. Participants reported that they would search by the name
of a specific type of cancer accompanied by “symptoms” and/or “treatment.”
They didn’t have a specific website though, although the American Cancer
Society was cited in all groups. And the search engine most frequently cited
was Google, but also included MSN, About.com, Web MD and Wikipedia.

MS: One of the components of the campaign was a ‘call to action.’ Can you
expand on this?

51
HA: We basically did motivate a national “call to action.” We had a small
series of radio call-in shows. We coordinated different segments with
survivors, where they were able to share their stories and LIVESTRONG’s
resources. If people wanted, they could call in and share their questions,
comments and suggestions. We worked with promotoras, who were all at the
grassroots level engaging health fairs, having a one-to-one with survivors or
people seeking to find out more about LIVESTRONG’s resources or
transportation to and from medical centers and whatnot.

MS: The success of the campaign was huge! Was there anything administered
after the campaign concluded to see what strategies were most instrumental
in filling in the gaps in cancer information and services to empower Latino
cancer survivors to take action?

HA: It was not a component of the campaign but I definitely think it would be
a good idea, and the best way to go about this would be by following up with
the same people that initially participated in the focus groups.

52

LAURA MIN JACKSON
Laura Min Jackson – Strategic Communications & Leadership
Coaching

About the Interviewee

Laura Min Jackson is an award-winning communications professional and
consultant with 20 years+ experience in B2B, healthcare, nonprofit,
consumer goods, crisis management, and training & facilitation. Laura’s
experience includes leadership positions at established firms and start-ups,
in both corporate and PR agency settings, as well as with a county agency
and a major nonprofit organization. As a speaker and facilitator, she's worked
with many educational institutions, companies, hospitals, and domestic and
international professional associations. She's also a volunteer facilitator for
Greet The Day and AmericaSpeaks.

In addition to her consulting, Laura is an adjunct faculty member in the
graduate PR program at the Annenberg School at USC. She's also a featured
author in the best-selling “Awakening the Workplace: Achieving Fulfillment,
Connection and Satisfaction at Work. Laura is also a Black Belt-level
certified instructor of The Nia Technique, offering Nia classes, leadership and
personal development workshops throughout Southern California.

♦♦♦

53
MS: Can you provide me with a broad overview of BCEDP? Why was this
program developed when it was developed (did funding become readily
available, was there a staggering increase in breast cancer incidents, etc.)?

LMJ: The Every Woman Counts program, more formally known as the Breast
Cancer Early Detection Program, began in 1994 after funding became
available through a 2-cent excise tax on the sale of cigarettes in California. It
initially focused on providing free mammograms for qualifying women in
California, and was later extended to also include cervical cancer exams. I
don’t know what triggered the program from an epidemiological perspective,
but I do know that then-Gov. Pete Wilson’s wife, Gayle, was a big champion
in encouraging the program, and that then-Health Secretary Sandra Smolley
was a nurse and I believe also a breast cancer survivor as well. I think the
program was started in part because the State recognized the prevalence of
breast cancer in Calif., and particularly how it affected the targeted
audiences.

MS: Who was the program's targeted audience or audiences?

LMJ: Criteria were defined by the State before we won the RFP.
Women qualified for free breast cancer preventative services if they –
 were 40 years old or older
 had a low income
 had medical insurance that did not cover breast cancer screening

54
 had a high insurance deductible or co-payment
 were not getting these services through Medi-Cal or another
government-sponsored program and,
 lived in California

MS: What were the main strategies that drove the campaign's success in
reaching each targeted audience?

LMJ: This was the launch of California’s first such program and had well-
defined target audiences designated by the State. The RFP specified that we
needed to develop comm strategies/tactics that would be considered culturally
sensitive and appropriate, so we did quite a bit of primary formative research
– focus groups throughout California, involving the various target audiences
according to ethnicity. I recall that we did focus groups with Asian-
American, Latina, African-American, and low-income Caucasian groups. To
understand the patient and providers’ perspectives, we also did 1:1 and small
group meetings with regional public health professionals, and with breast
cancer survivors, particularly those who were well-known breast cancer
advocates.

MS: What barriers were encountered when addressing the Latino/Hispanic
population, if any (ex. language, specific beliefs, etc.)? Please provide as much
detail as possible.

55
LMJ: We were concerned with making sure all materials addressed the
language needs of the Latina population, so all of our communications,
including brochures and flyers, billboard, TV and radio ads, were all bilingual
English-Spanish, and any photography that was shot for promotional
materials featured a variety of multi-cultural individuals.

I don’t know if these were barriers per se, but among the “surprises” we
discovered from our focus groups was how much reticence focus group
participants expressed over the concept that they deserved self-care in the
form of self-exams and mammograms, since they felt such strong
responsibility for prioritizing the needs of their family members over their
own personal needs. This was a diametrically opposite view to the African-
American focus group participants. One message that seemed to resonate for
many of the Latina respondents was, “taking care of yourself by getting a
breast examination is another way of taking care of your family.” On a
related note, the Latina focus group participants considered both their
religious leaders (Catholic priests) and their adult children as important and
credible sources for encouraging them to get free mammograms.

Some of the Latina focus group participants expressed a misperception that
breast cancer only occurred when a woman did not breastfeed her children, or

56
when she experienced an injury to her breast. When this was further
explored, some of the participants misinterpreted the questions to mean we
were exploring their personal experiences with domestic violence. Some of the
participants became emotional while defending their male partners, and it
took additional time from the Focus Group sessions while the facilitator
clarified the misperceptions; despite this, it didn’t seem to me that all of the
ladies were completely convinced that there was no relationship between
breast injury and breast cancer.

In all of the groups, Latinas as well as the others, there were some barriers
associated with the cost of travel (unable to afford the bus fare or other
transportation to get to the screening site).

In most or all of the focus groups, at least some participants expressed
concern over the perceived pain and discomfort caused by the mammogram
machine, and the desire to delay or avoid the potential pain.

Another of the barriers, which was expressed by all of the participant groups,
was the relative priority of a mammogram, which was considered less
important relative to other more urgent or acute health issues. In some
cases, participants mentioned painful, untreated dental problems or the fact

57
that they needed new eyeglasses or help paying for medications, and that
these were more important to them in the short-term, than getting a
mammogram.

In my observation, the barrier that was most specifically associated with
Latina focus group members was a sociopolitical one that coincided with the
launch of BCEDP. At the time, Gov. Wilson had been championing an
initiative called Proposition 187, which called for elimination of public
benefits for undocumented residents. As part of Prop 187, people would be
required to show documentation proving their residency status, and there
was some suggestion of deportation if documentation wasn’t available. As a
result, we had difficulty recruiting individuals to the State-sponsored focus
groups, and some participants expressed fear and distrust once they
understood our affiliation as a State-funded program.

MS: What tactics were used to overcome these barriers, if any (ex. partnering
up with the church)? Please provide as much detail as possible.

LMJ: Check out the Google book URL listed above for lots on specifics. In
general, we worked with Hispanic Marketing specialists (a subcontractor to
our agency) to make sure our materials were culturally appropriate, and we
did qualitative pre-testing of materials and messages, as well. Some of the
outreach was done in concert with local churches in key neighborhoods,

58
essentially ecumenical outreach where we asked the religious leaders to
incorporate messages about the importance of self-care and breast
examinations in their sermons, and having the mobile mammogram unit
actually parked at some church locations so local residents could receive their
exam. We also did a “Mother’s Day” campaign, which leveraged the Latina
focus groups’ input we’d received about the importance of encouragement
from their adult children.

MS: What channels of communication do you feel aided you and your team
the most in terms of raising awareness among the Latino/Hispanic
population and why? Was it mass, interpersonal, community-based, etc.?

LMJ: We used a combination of approaches, as mandated by the State of
Calif. RFP, including paid ads (print, TV, radio, billboard) and media
relations, as well as community relations and to some degree, interpersonal
relations. The bilingual materials and the guidance from our focus groups –
the importance of religious leaders and adult children as influencers – helped
us shape the ecumenical/community outreach and a Mother’s Day program
that encouraged dialogue between adult children and their Latina moms.

We also encouraged community-level promotion by providing materials to
State-funded clinics. There was also a partnership with a small supermarket

59
chain that printed grocery bags with our logo, campaign name, statewide 800
number and key messages encouraging testing.

MS: Did you recognize any huge differences within the Latino/Hispanic
population that made it difficult to reach them as one segment and what
were these differences? If there were major differences, how were they
overcome to ensure that the program's message was reaching everyone?

LMJ: We didn’t sub-segment within the Latino population.

MS: What were some of the lessons you took away from targeting and
working with the Latino/Hispanic population?

LMJ: I learned that it’s important to suspend assumptions and that primary
research can be incredibly powerful in helping us truly learn which sources of
information were considered most credible, and what misperceptions might
be posing true barriers to access. This was vividly demonstrated when we
learned about the incorrect inference between injury and cancer risk, which
was pretty widely held among our Latina focus group participants. Even
those who didn’t necessarily believe this information, expressed familiarity
with it, although it was completely unknown by the State health workers and
our team.

MS: Are there any ways in which health communication can improve to
better communicate with minority groups? Feel free to incorporate examples
from all your work experience in this realm.

60
LMJ: The greatest professional take-away for me was one that I continue to
apply today: I got a lot more humble about my understanding of target
audiences’ priorities. Our goal, which was encouraging qualified women to
get the free breast exams, was not necessarily the population’s overall health
priority, because they were experiencing other health issues they considered
much more acute/urgent.

This work provided an invaluable lesson in how I need to suspend my
assumptions and embrace my ignorance, staying open to the research
findings, if I really want to develop effective health communications
programs that encourage positive behavior change.

61

AMBROCIA LOPEZ
Susan G. Komen for the Cure, Orange County Affiliate

About the Interviewee

Ambrocia Lopez is currently the Community Outreach and Education
Specialist for the Orange County Affiliate of Susan G. Komen for the Cure
®
.
In this role, Ambrocia facilitates the development, implementation, and
evaluation of breast health education, outreach, and special mission
initiatives focusing on Latinas. She coordinates the Speakers Bureau
Program, Wig and Hat Salon, Komen Resource Centers, Breast Self-
Awareness Presentations, Lunch and Learns and all other outreach events.
She obtained a Masters of Education from the University of California,
Irvine.

Prior to joining Komen Orange County, she worked for Healthy Smiles for
Kids of Orange County, as the Manager of Education and Outreach and was
responsible for the educational curricula, recruitment, supervision of oral
health community outreach workers and volunteers who provided health
promotion to children and their families. Ambrocia is inspired to improve her
community because she knows and understands the needs of the people from
having grown up in Santa Ana. Her ultimate goal is to help improve her
community through access to health care and education.

62

♦♦♦

MS: You helped with the preparation of the pamphlet titled “‘Unidos’: Need to
Focus on Latinas.” What tactics has Susan G. Komen used to overcome the
psychological and external factors listed on there? Please provide as much
detail as possible.

AL: Sure, I will begin with fatalism. In collaboration with the priests, what
we began doing was partnering up with Catholic churches and holding
healing masses at these Catholic churches. The priest would talk about our
messaging; provide background information to these women on our behalf
and this enabled us to gain the trust of these women. There were also times
where we synchronized our healing masses with special dates or occasions.
For example, during the month of May we would celebrate the Virgin Mary
and present her with an offering. Overall, we are there empowering them,
rallying them up to take action and take care of themselves, giving them
important information.

Our outreach efforts oftentimes are with our community partners, one of
them being the coalition called Unidos Contra Cancer del Ceno, as well as
local WICs. When mass is over, we will be there afterwards making sure they
sign up for a mammogram appointment. Our community partners will also be
set up with additional brochures and materials with information regarding
breast health and important information on cancer. We’ve also counted with

63
the support of Latino Health Access – a group of promotoras who educate on
breast health. They often go door to door or provide onsite mammography
such as at the church, community centers – anywhere we know the women
we’re targeting will easily be able to find us. This group does navigating for
Komen, schedules mammograms, and makes sure to consistently call these
women to make sure to show up to their appointment to ensure that they
plan on attending. Providing onsite mammography such as in churches or
even near their residential community also helps reduce the barrier of
transportation. We make it easy for women to find us.

In terms of the barrier concerning fear, the priest also touches upon this. He
makes sure to reassure women and along with us help rally them up and see
the importance of getting screened and taking care of one’s health.

The language barrier has been reduced significantly because of all the
culturally relevant information we have available. We have everything from
Chinese to Korean you name it. We definitely make sure to have Spanish
material with us when working with these women.

When it comes to family dynamics and putting everyone else first, we made
sure to start emphasizing the fact that these women need to take care of

64
themselves in order to be there for their families or else who’s going to be
there? This was a section of the campaign in which we heavily promoted the
catch phrase “Por ti. Por Ellos” (For you. For them.). This matter is also
emphasized in our healing masses.

I can’t say I’ve seen the issue of discrimination. However, it has been a
problem to assure these women that they don’t need to be scared because of
their legal status. It probably helps that they are able to eventually get
comfortable when they see that the women reaching out to them are Latina
as well.

Husbands can also definitely be barriers. I’ve had husbands come and tell me,
“I am never taking her back, last time they hurt her. I refuse to take her so
they can hurt her again.” However, recently I’ve seen an increase in the
numbers of calls from husbands asking for referrals for their wife. They often
call asking for the referral because their wife demonstrates some sort of
symptoms. It’s interesting to have these husbands on the phone describing
her symptoms for her. It’s good to see that they’re calling though, and are
showing an interest in their wife’s health and calling as a follow-up. The fact
that we have strong visibility also helps to overcome several barriers often

65
times. Husbands feel comfortable calling us because they trust us, they’ve
seen the name before.

External barriers have been overcome with the help of funding. We have two
sources. Every Woman Counts, for example, is a statefunded program that
provides free mammograms and services to low-income women with no
health insurance, who are over 40, and live in California. Funds help cover
diagnostics mammogram, biopsy and an ultrasound. We also have our Komen
Fund that targets women younger than 40 who may be high-risk or have
symptoms but cannot afford to be screened for breast cancer. There is also the
Breast and Cervical Cancer Treatment Program (BCCTP), which provides
needed cancer treatment to eligible individuals diagnosed with breast and/or
cervical cancer and who are in need of treatment. In terms of legal status, the
state doesn’t ask about legal status and neither will Susan G. Komen. The
only limitation of BCCTP is that they only cover women up to 18 months. So
for example, if a woman who was receiving chemotherapy during that time
then it would be suspended.

We eliminate the need for a physician referral by providing these onsite
mammography locations and signing them up for appointments ourselves.
This is important in reducing the barriers not only associated with physician

66
referral (in where women need a referral from a doctor that states they need
a mammogram), but transportation and restrictive work policies as well.

Cost is also rarely a barrier. For the most part, we are able to find them the
funds to go and get screened. Also, restrictive work policies are sometimes a
problem because employers either won’t let them take the time off to visit
their doctor or women themselves cannot afford to lose a day of work.
Between the barrier of lack of health insurance and lack of regular source of
health care of the funding available. The two state programs I mentioned
allow a mammogram every year. Every Woman Counts allows (us) to do the
biopsy and ultra sound and for high risk patients up to two mammograms a
year. For women younger than 40, we don’t provide yearly mammograms,
however hopefully after getting screened and receiving reassurance they
don’t have to come back. There will be cases, though, where the doctor will
recommend they get a mammogram every year. If this is the case, then they
will have to pay for it.

MS: What channels of communication do you feel aided you and your team
the most in terms of raising awareness among the Latino/Hispanic
population and why? Was it mass, interpersonal, community-based, etc.?

AL: Media is HUGE. When we use media, such as radio, we get a huge influx
of calls including calls from people inquiring about cancer other than breast

67
cancer. The funding at the moment isn’t there but usually mass media works
really well. Additionally, we make sure to host presentations anywhere and
everywhere we know we will reach these women. Schools, mommy groups,
supermarkets that are culturally oriented, my home, you name it and we will
go into any group that will allow us to speak.

MS: Did you recognize any huge differences within the Latino/Hispanic
population that made it difficult to reach them as one segment and what
were these differences? If there were major differences, how were they
overcome to ensure that the program's message was reaching everyone?

AL: That I’ve seen, there have been no differences among sub-segmented
groups. What really differs people is social economic status (SES), education,
income, first generation, second generation vs. first generation, etc. That’s
what really matters in terms of the differences in messaging for different
demographics.

MS: What were some of the lessons you took away from targeting and
working with the Latino/Hispanic population?

AL: The biggest thing I’ve taken away is that the best way to learn is being
out there, engaging and mingling with these women; linking to these women.
Taking note of how long it took to convince someone to sign up for a
mammogram. Really engaging these women we are targeting is important.
We also learn a lot from the community members we work with and what

68
they experience when they’re out there door to door. Having the background
is good, and data from focus groups is great, but ultimately the best way to
learn is to be out there and try new things while seeing reactions – seeing it
personally.

69
Chapter 4: Survey Results

There is an interest in analyzing the barriers surrounding lower rates
of breast cancer screening among Latinas because of all the nuances involved
in their decision-making process. Yet, less attention is paid to reasons that
motivate Latinas who regularly screen for breast cancer. The reality is,
exploring which facilitators encourage women to obtain breast cancer
screening is of the utmost importance. Los Angeles is the perfect setting, not
only because of the diversity that thrives in the city but there are several
statewide resources that provide free and low-cost screening services for
breast cancer. With such resources available, this type of study may lend
itself to illustrate facilitators that encourage women to seek mammography
where money and health insurance may not be obstacles.

Method
In order to see which facilitators are given more weight among Latina
women, a survey was developed to incorporate existing items on perceived
facilitators that encourage Latina women to seek mammography (Ogedegbe
et al. 164). More than a mere list, facilitators were placed as statements in a
matrix table that presented them on a 5-point scale. The 5-point scale
attached to the statements consisted of the following responses: “Undecided”,
“Not Influential”, “Somewhat Influential”, “Influential”, and “Very

70
Influential”. The statements were divided into three different questions,
consisting of the three separate categories to which these facilitators
belonged: 1) patient attitudes and beliefs, 2) social network experience and 3)
accessibility of services.

Participants
The target population for this survey was comprised of Latina women
residing in the greater Los Angeles area who voluntarily stated that they’d
had at least one mammogram in their lifetime. Both paper and online
instruments were available in both stand-alone English and Spanish.
Participants who completed the survey were 99 self-identified Hispanic
women age 20 or older. Because the survey was made available online, the
survey reached participants with different backgrounds across the country.
Responses in which participants listed a city of residence outside of the
County of Los Angeles and surveys that were partially complete were taken
out of the pool for analysis. One participant identified as Caucasian. This
participant was also taken out of the pool. This left the author with 65
respondents who identified as a Latina residing in the County of Los Angeles
who voluntarily reported having obtained one or more mammograms. Nine
respondents answered the survey in Spanish. The following figure defines
specific characteristics of the sample population.

71
Characteristic % (N=65)
Age Group
20-29 15%
30-39 11%
40-49 26%
50-59 26%
60-69 17%
70-79 5%
80-89 0%
90+ 0%

# of Mammograms in Lifetime
1 23%
2 9%
3 14%
4 8%
5+ 46%

Cultural Background
Belizean 0%
Costa Rican 0%
Cuban 2%
Dominican 0%
Ecuadorian 0%
Guatemalan 3%
Mexican 85%
Panamanian 0%
Peruvian 2%
Puerto Rican 0%
Salvadorean 5%
Venezuelan 0%
Other (Please specify): 8%
(Included: Chilean (2), Colombian,
N/A)

72
Characteristic % (N=65)
I was born in the United States. 43%
1-5 years 0%
6-10 years 3%
11-15 years 3%
More than 16 years 51%

Education
No schooling completed 6%
Nursery to 8th Grade 14%
Some high school completed 17%
Obtained a high school diploma or
equivalent (ex: GED)
17%
Some college/professional schooling 15%
Obtained a college degree or
professional certificate
29%
Other (please specify): 2%

Annual Household Income
Less than $10,000 22%
$10,000-$19,000 17%
$20,000-$29,000 15%
$30,000-$39,000 6%
$40,000-$49,000 3%
$50,000-$59,000 9%
$60,000-$69,000 5%
$70,000-$79,000 6%
$80,000-$89,000 5%
$90,000-$99,000 2%
$100,000 or more 11%
Figure 3: Characteristics of Sample Population

Results
The following figures present a cohesive overview of responses from all
65 respondents, divided into the three categories with statements answering

73
the following overall question, “In encouraging you to seek a mammogram,
how influential were the following factors?”

Response

Undecide
d

Not

Influential

Somewhat

Influential

Influential
Very

Influential

Mean

Personal

health/cancer

history

5
28
8
7
17
3.05

Reassurance
about

pain

3
40
10
2
10
2.63

Recommended
for

women
my
age

0
13
9
14
29
3.91

Screening
is
routine
1
11
6
20
27
3.94

Seeking
reassurance

about
health

0
9
9
21
26
3.98

Wanting
to
care
for

myself

0
9
4
15
37
4.23

Figure 4: Patient Attitudes & Beliefs

Response
Undecided
Not

Influential

Somewhat

Influential

Influential
Very

Influential

Mean

Advice
from

family
members

1
34
5
9
16
3.08

Advice
from

friends

2
32
11
10
10
2.91

Family
history
of

cancer

2
31
7
8
17
3.11

Information

from
the
media

1
25
15
16
7
3.05

Knowing

someone
with

cancer

1
23
11
13
16
3.31

Medical

recommendation

0
11
8
18
27
3.95

Figure 5: Social Network Experience

74
Response
Undecided
Not

Influential

Somewhat

Influential

Influential
Very

Influential

Mean

Availability
of

insurance

1
20
4
22
18
3.55

Affordability
of

screenings

2
20
8
20
15
3.40

Convenient

location
of

screening

services

6
21
9
13
15
3.16

Figure 6: Accessibility of Services

Regarding the general sample, the only facilitator that created a solid
mean (4.23) was associated with the response “Wanting to care for myself”,
which falls under the category of attitudes and beliefs. This contradicts
existing research that Latina women only seek the well being of their
families and do not prioritize themselves. The only other response that scored
nearly as high was “Medical Recommendation”, with a sample mean of 3.95.
This could be attributed to the fact that mammograms are generally
recommended for women who are 40 years of age or older and this particular
sample population consisted of a diverse group of ages, including 69% self-
reporting as age 40 or older.
In order to dig deeper, several cross-tabulations were created. In terms
of all of the demographic data taken into consideration, the only one that
generated potentially interesting results was “Annual Household Income”.
For example, while most participants whose “Annual Household Income” was
less than $29,000 rarely reported availability of insurance or affordability of

75
screenings as a facilitator, it was cited as important by women who had an
annual household income of $50,000 or greater. One possible reason for this
is that women with a low socioeconomic status may be covered by state
programs and funding, regardless of how little they make. For women who
reported an annual income greater than $100,000, the mean score indicating
the importance of availability of insurance and affordability of screenings was
actually the greatest at 4.43 and 4.57, respectively.
Additionally, different income groups seemed to demonstrate similar
facilitators of interest. Medical recommendation and not much else was very
important for women who had an annual household income that was less
than $29,000. Those who reported an annual household income of $30,000-
$39,000 reported medical recommendation as very important, but so were age
recommendations, routine screening and reassurance about health. Among
this same income group, wanting to care for one’s self garnered a perfect
mean of 5.00.
For those in the $40-45,000 income bracket, media was considered very
influential in conveying the importance of mammography, for reasons that
are unclear.
When sub-segmentation was conducted according to cultural
background, no significant results or differences were noted. However, 85% of

76
the sample population did identify as Mexican, making this form of cross-
tabulation inappropriate for purposes of objectivity.

77
Chapter 5: Recommendations

Communication Goals
This paper attempts to increase understanding of the importance of
recognizing cultural nuances within the Latina population when undertaking
in community campaigns that have the following communication goals:
• Increase the importance of mammograms and breast health in relation
to one’s overall optimum well being among the Latina population
• Promote free breast cancer services and information on where to learn
more about overall breast health
• Encourage health professionals such as doctors to take an active and
engaging role as public advocates of breast cancer screening as well as
in the dissemination of information about screening methods and
breast health information.

Key Audiences
• Latina Women
o Ages 18-39 – Breast cancer screening awareness is important
among this age bracket because some women have a family
history of breast cancer or are considered high risk. It’s also
possible to show symptoms early on, which should be given
medical attention as soon as possible

78
o Ages 40+ – Latina women who are at the recommended age for a
mammogram are the target audience of this health
communication model. Statistics show that not only do Latinas
have lower screening rates but also 26 percent are likely to be
diagnosed with breast cancer at a later stage than non-Hispanic
whites (Susan G. Komen Foundation, “’Unidos’: Need to Focus
on Latinas”).
• Doctors and Health Professionals – Doctors and health professionals
need to be made aware that this population weighs their input and
medical recommendations heavily.
• Spouse – Spouses also need to be educated on the importance of breast
cancer early detection to be able to provide support, knowledge, and
care for their spouse. And particularly for many Latina women, the
male spouse tends to make important decisions pertaining to everyone
in their household.
 Opinion Leaders and Influencers – Community leaders are an
important aspect of messaging distribution because the probability of
the target market listening to and internalizing the campaign
increases if they receive the information from someone with whom they
already have a personal relationship. After all, trust is a very
important factor among the Latino population.

79
Messaging Strategy
• Latina Women
o Ages 18-39 – “No one knows you better than yourself.” The
messaging here is meant to generate the important of self-
awareness and knowing to acknowledge when something doesn’t
feel right. Breast cancer symptoms are nothing to be taken
lightly.
o Ages 40+ – Given psychological and external factors preventing
Latinas from seeking mammography, the challenge will lie in
stressing the importance of one’s well being. If this campaign
isn’t successful in stressing the well being of Latinas for their
own good, it is important to emphasize a woman’s well being for
the sake of her family. The overarching message here is
validating one’s well being, and its impact on everyday life
(work, family, etc.). Breast cancer screening needs to be
embedded in the overall health of women, so that they don’t
disregard it and put it at the end of their priority list.
• Doctors and Health Professionals – Professional references as well as
research will be helpful in informing health providers on information
they may not be aware of; addressing this diverse population will make
cultural sensitivity on the part of doctors and health professionals of

80
the uttermost importance. Health providers need to be educated on the
perceived barriers and facilitators among Latina women concerning
early breast cancer detection as well. Doctors and health professionals
should also be aware of common misconceptions among the Latina
population so they can be quick to debunk them. One of them is “No
one in my family has had breast cancer, therefore I am not prone it.”
Doctors and health professionals recognize the importance of screening
for breast cancer and should therefore be passing on that message unto
the Latina population at any given opportunity, regardless of the
reason for a Latina patient’s visit.
• Spouse/Close Knit Family – The message that their significant other’s
well being is of the utmost importance, especially in order for Latina
women to continue to care for the well being of the rest of the family, is
very important. Teamwork and a sacred partnership should be
emphasized, rather than a directive from the head of household. An
individual and their spouse constitute a team when it comes to
running a household, and it is therefore important to take care of each
other in order to take care of everything else.
 Community Leaders/Organizations/Groups – “A thriving community is
made up of people who are healthy and well” is the messaging
targeting this audience. Community leaders are likely already familiar

81
with the available resources nearby and the most effective way to
utilize them. If they are proactively seeking these resources
themselves, messaging should be developed in order to guide them in
spreading the word of why it’s important to take care of one’s self.

Strategies
 Increase access to culturally appropriate information about breast
cancer, by raising knowledge of all of the resources available to women
seeking more information about breast cancer and breast cancer
screening resources. More culturally relevant information is being
produced for the Latino community and it is crucial that they know
where and how to access it.
 Employ multi-media approaches that complement overall well being
with breast health among Latina women and incorporate a
complementary social/hybrid aspect. The messaging is far more likely
to reach the various segments of the Latino population by using
several media channels and developing a strong online presence.
 Utilize a grassroots approach where community leaders and
promotoras are at the core of engaging neighboring Latina women on a
one-to-one basis.

82
 Leverage a celebrity spokesperson who either participates in breast
cancer screening to take care of her own well being or was able to use
breast cancer screening to save her life/detect something early/give her
assurance about her health. The celebrity needs to be someone who is
family-oriented and with whom Latina women can relate, such as
Adamari Lopez, a breast cancer survivor herself. Utilize ordinary
people with personal stories or who have a sentimental story in which
early detection could have saved a loved one’s life if they had placed
their well being first. Celebrities, along with everyday people, should
clearly convey where Latina women can go to get their mammogram or
seek more information on breast health.
 Capitalize on the population’s reliance for a medical referral for
mammogram to engage doctors, health professionals or other credible
spokespeople to promote the importance of obtaining a mammogram
throughout the designated market. There are several doctors affiliated
with huge Spanish broadcast networks who are considered credible
among the Hispanic population, such as Dr. Alicia Lifshitz. Doctors
could highlight the recommendation for women over 40 years of age to
seek mammography, either because of age or as a precaution.

83
Tactics
 Produce live, radio call-in shows on Spanish-language and bilingual
radio stations in the designated market. Place the radio stations’ on-air
personalities at the forefront of the message delivery, since past
research shows that the public sees them as trustworthy sources of
information and a live show is more impactful than a pre-recorded
radio commercial.
 Coordinate different radio segments with survivors and possibly
promotoras, where they can share their story, resources they used or
are knowledgeable of, which helped them or someone they know. Above
all, it would be important to encourage listeners to call in and share
their questions, comments and concerns regarding breast cancer or
breast cancer screening.
 If possible, garner additional public attention using the designated
radio station’s “street team” to engage in community activities, either
on location wherever they are, or having them participate in health
fairs or festivals where the targeted audience might be present. If
budget allowed, it might be possible to further engage the public by
using promotional items as prizes for answering questions about
breast cancer screening.

84
 Partner up with local churches in key neighborhoods. Essentially, ask
religious leaders to incorporate messages about the importance of self-
care and breast examinations into their sermons.
 Host healing masses in collaboration with priests. Not only could
religious leaders continue incorporating overall messaging to raise
awareness of breast cancer screening, but focusing on these women
with the help of priests will help campaign organizers establish
credibility in these key communities. Ideally, these healing masses
could be synchronized with special dates or occasions, in an approach
similar to what the Komen Foundation is doing in Orange County.
When mass was over, women could be encouraged to sign up for a
mammogram appointment, or mobile mammograms could be provided
on-site.
 Distribute additional information on resources about breast cancer
screenings by producing and placing ads in the church’s bulletin. This
is information people can take with them, should they not have time
when they leave church or need more time to process the messaging.
 Produce and run commercials of breast cancer screening resources in
community clinics, paying specific attention to clinics that offer free
services or host resident pediatricians.

85
 Provide state-funded clinics with additional brochures and materials
with information regarding breast health and important information
on breast cancer.
 Partner up with an organization like Latino Health Access, which is
willing to go door-to-door to sign up women for mammography
appointments or target key residential areas with Latino women,
where transportation won’t serve as a barrier.
 Utilize these partnerships to visit culturally oriented supermarkets,
mommy groups, schools, etc., where mobile mammography or a
resource table would help raise awareness among Latina women.
 Engage promotoras to interact with and encourage women at churches,
health fairs, community organizations and women’s centers. That
personal interaction is key for disseminating information on resources
available to women looking to take care of their breast health.
 Correlate PSA airings with periods during the year when people are
thinking about their overall health. This includes January, when
resolutions are common, and leading into summer, when people are
more able to be healthy and active.
 Outreach to mommy bloggers with an established voice in the Hispanic
community such as Mama Contemporania, who have knowledge of
breast health resources and pitch them the opportunity to interview a

86
health professional or a designated celebrity spokesperson. Latina
women, regardless of income and generational standing, follow fellow
Latina mommy bloggers for health tips, advice on several subjects,
deals and promotions, etc.
 Leverage the celebrity spokesperson to create an op-ed, which can then
be placed in key publications. The op-ed would contain information on
the celebrity’s personal story and additional information on breast
cancer screening resources. It would be ideal to incorporate a
practitioner’s opinion for added credibility to the op-ed.
 Develop a neighborhood action network, composed of meetings aimed
at educating Latinas on breast health throughout the designated
community.
 Procure budget-conscious advertisement in established Latino markets
often frequented by this population, such as church and grocery stores.
 Secure third party support to help build momentum around breast
cancer and screening behavior awareness.

87
Conclusions
Latinos are as diverse as the panorama of multi-ethnic groups that
reside in the US. Therefore, it is important for health care providers who are
serving Latinos to have basic knowledge of this population’s perceptions of
breast cancer health and be aware of the level of credibility and influence
they possess and are able to garner among Latinos. Furthermore, in order to
promote empathetic relationships that will facilitate trust and lead patients
to health-oriented behaviors such as more frequent breast self-exams and
regular mammograms, health care providers must always keep in mind that
human beings are unique and that factors like country of origin, education,
income level, health conditions, and past experiences may account for
important differences when dealing with breast cancer screening behavior.
When working with this population, an acceptance for cultural diversity
is essential. This can be expressed either verbally or through carefully
developed, culturally relevant, concise and easily understood education
materials (Susan G. Komen Foundation, “HISPANICS/LATINAS”). Language
is clearly a major consideration for those producing health promotion
materials for Hispanic women. For print materials to be effective, proper and
accurate use of the Spanish language is critical. This can be further
complicated by variations in lexicon and idioms that are relevant to Hispanic
groups and may be due to country of origin, regional locations within the

88
U.S., acculturation within the American culture, and other factors (Susan G.
Komen Foundation, “HISPANICS/LATINAS”). It is always recommended to
test tailored messages for accuracy, cultural variations and appropriate
literacy levels.
Given these differences, programs developed for Latino populations in
mature markets such as Los Angeles may not be directly transferable to
Latino populations in other markets. However, whether programs are
borrowed from elsewhere or developed from the ground up, the information
found throughout this paper can help guide the selection of channels,
messages, sources, and settings that have been proven successful in previous
campaigns targeting the Hispanic population.

89
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Abstract (if available)

Abstract This paper examines barriers and facilitators of breast cancer early detection among Latina women living in Los Angeles County. The purpose of this study is to address the discrepancy that exists between breast cancer awareness messaging and medically underserved audiences, with specific attention to Latina women. The research included chronicles the slow adoption of culturally relevant educational materials. Insight from professionals who have performed culturally relevant work and have been successful in implementing it among the Latino population is included and used to challenge the traditional distribution of health messaging in an ever-growing diverse Latino population, while questioning the ""one-size-fits-all"" message strategy currently in place. The author provides recommendations to assist organizations in tailoring breast cancer education messaging for Latina women. The ultimate goal is to encourage health professionals to use these guidelines in conjunction with other materials that may help address other forms of cancer and disease as well as all women.

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Asset Metadata

Creator Soto, Maribel (author)

Core Title Exploring perceptions of facilitators that encourage breast cancer screening behavior among latina women in Los Angeles County

School Annenberg School for Communication

Degree Master of Arts

Degree Program Strategic Public Relations

Publication Date 07/17/2012

Defense Date 07/17/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag breast health,Communication,health communication,latino women,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Swerling, Jerry (committee chair), Jackson, Laura Min (committee member), Parks, Michael L. (committee member)

Creator Email essence_7saz@yahoo.com,maribel_s90022@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-60969

Unique identifier UC11290383

Identifier usctheses-c3-60969 (legacy record id)

Legacy Identifier etd-SotoMaribe-962.pdf

Dmrecord 60969

Document Type Thesis

Rights Soto, Maribel

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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