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Correlates of compliance with mammography screening guidelines among low-income Latinas: An exploratory study

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Correlates of compliance with mammography screening guidelines among low-income Latinas: An exploratory study

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Content CORRELATES OF COMPLIANCE WITH MAMMOGRAPHY
SCREENING GUIDELINES AMONG LOW-INCOME LATINAS: AN
EXPLORATORY STUDY
by
Lorena Michelle Teran
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
PREVENTIVE MEDICINE (HEALTH BEHAVIOR RESEARCH)
May 2004
Copyright 2004 Lorena Michelle Teran
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UMI Number: 3140562
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DEDICATION
This dissertation is dedicated to my parents, Fernando and Susana Teran, for their love
and devotion to their children, to Eric and Stephan Teran, for being the most caring
brothers, and to Luis Orjuela, for his endless support.
In memory of Maria Elena Echeverria, a victim of breast cancer, who was the most
inspiring individual I have ever met.
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ACKNOWLEDGMENTS
An enormous and heartfelt thanks to my mentor and friend, Dr. Karen Belkic, for
her countless hours of guidance, dedication, encouragement, and patience throughout my
doctoral studies.
My sincere gratitude and thanks to Dr. Lourdes Baezconde-Garbanati for being an
excellent role model as a researcher and human being, and for providing me with positive
energy while challenging my limits.
Thanks to Dr.Karen Belkic and Dr.Lourdes Baezconde-Garbanati I was able to
achieve my research and educational goals. The care, concern, and tools they gave me
are priceless.
A special thanks to Dr. Clyde Dent for bringing me into the program and always
being there to help me and share his expertise.
My thanks to Dr. Jennifer Unger and Dr. C. Anderson Johnson for being so
helpful and supportive while offering me so many opportunities to conduct research.
My sincerest appreciation to Dr. Lourdes Baezconde-Garbanati, Dr. Karen Belkic,
Dr. C. Anderson Johnson, Dr. Clyde Dent, Dr. Jennnifer Unger, and Mel Barron for
serving on my dissertation committee.
Thank you Mamy Barovich for always being available to resolve so many types
of issues, and for providing me with information and advice to make it through the
program.
I am truly grateful for all the wonderful people I had the pleasure of working with
at the University of Southern California, especially Greg Molina, Jolanda Lisath, Jenny
Zogg, Yaneth Rodriguez, Anamara Ritt-Olson, Monica Alvardo, and Dr. Robin Clark.
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TABLE OF CONTENTS
DEDICATION.............................................................................................................. ii
ACKNOWLEDGEMENTS........................................................................................ iii
LIST OF TABLES....................................................................................................... vi
LIST OF FIGURES..................................................................................................... vii
ABSTRACT................................................................................................................. viii
I. INTRODUCTION............................................................................................ 1
II. BACKGROUND AND SIGNIFICANCE..................................................... 2
III. CONCEPTUAL MODEL............................................................................... 15
IV. RESEARCH QUESTIONS AND HYPOTHESES..................................... 19
V. METHODOLOGY............................................................................................ 20
Data Source......................................................................................................... 20
Sample.................................................................................................................. 21
Data Collection Procedure............................................................................... 22
Measures.............................................................................................................. 23
Data Analysis...................................................................................................... 28
VI. RESULTS............................................................................................................. 30
Response Rate................................................................................................... 30
Demographic Characteristics......................................................................... 32
Univariate Analysis.......................................................................................... 36
Reliability Analysis.......................................................................................... 43
Biviariate Analysis............................................................................................ 48
Multivariate Analysis....................................................................................... 51
Summary of Results from Bivariate and Multivariate Analysis................ 54
VII. DISCUSSION......................................................................................................... 56
Limitations......................................................................................................... 60
From Research to Practice............................................................................... 62
Intervention Strategies...................................................................................... 64
International Perspective.................................................................................. 69
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VIII. CONCLUSION................................................................................................... 71
REFERENCES................................................................................................................ 73
APPENDICES
A. Consent Form............................................................................................. 85
B. Breast cancer screening questionnaire (English version).................... 86
C. Breast cancer screening questionnaire (Spanish version).................... 100
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LIST OF TABLES
Table la. Participation for entire sam ple................................................................ 31
Table lb. English Language Participants................................................................. 31
Table lc. Spanish Language Participants................................................................31
Table 2a. Demographic Characteristics of Sample.................................................33
Table 2b. Demographic Characteristics for Latinas...............................................34
Table 2c. Demographic Characteristics for non-Latinas........................................35
Table 3 a. Univariate Data for the Entire Sample.................................................... 37
Table 3b. Univariate Data for Latinas......................................................................39
Table 3c. Univariate Data for Non-Latinas.............................................................41
Table 4a. Scales for Entire Sample........................................................................... 44
Table 4b. Scales for Latinas...................................................................................... 45
Table 4c. Scales for non-Latinas............................................................................... 46
Table 5. Correlation Matrix of Scales.....................................................................48
Table 6. Bivariate Analysis: “t” test (only Latinas).......................................... 49
Table 7. Significant Differences between Latinas and non-Latinas................ 50
Table 8. Chi-Square Tests (without continuity correction) for Latinas.............50
Table 9. Correlations for Latina group....................................................................50
Table 10a. Multivariate Regression Analysis (Entire Sample)................................52
Table 10b. Multivariate Regression Analysis (Only Latinas)..................................53
Table 10c. Multivariate Regression Analysis (Only non-Latinas)..........................53
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LIST OF FIGURES
Figure 1 Heuristic framework for compliance with mammography
among Latinas.............................................................................................16
Figure 2 Barriers for adherence to mammography screening guidelines 47
Figure 3 Heuristic framework for compliance with mammography
among Latinas (Modified model)......................................................... 55
Figure 4 Structure of the AMIL program personnel..............................................68
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ABSTRACT
Purpose. Breast cancer is the most commonly diagnosed cancer and the leading
cause of cancer deaths among Latinas, which underscores the necessity o f improving
breast cancer screening compliance. Latinas have lower breast cancer screening rates and
are less likely to comply with mammography screening guidelines compared to White
women. The objective of this study was to conduct exploratory research necessary to
understand the factors associated with nonadherence to regular screening mammography
among Latinas.
Methods. This study was cross-sectional, based on a representative sample of
low-income women who called the Breast Cancer Early Detection Program (BCEDP)
referral line in Los Angeles County. The BCEDP provides breast cancer screening and
detection services to women who are uninsured or underinsured and are 200% below the
federal poverty level. A 45-minute telephone survey in Spanish or English was
administered to a sample of 115 women from the BCEDP. Cultural, cognitive, and
psychosocial determinants of rescreening were examined. Descriptive statistics, bivariate
tests, and multiple linear regression were used to analyze the data.
Results. Sixty five percent of Latinas surveyed had a mammogram within the last
year. The most common barrier for Latinas not to receive a mammogram was lack of
attention to their own health due to family being their first priority. Regression analysis
revealed that among Latinas, cultural factors such as familism and fatalism were
predictors of regular mammography, but not health care provider recommendation.
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In contrast, health care provider recommendation was a significant predictor for non-
Latinas, yet familism and fatalism were nonsignificant.
Conclusions. These findings provide insight into how intervention programs for
Latinas may be more effective by incorporating cultural factors at the individual, family,
provider, and community level. Recommendations for possible interventions strategies
are made in both national and international settings.
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Chapter 1
INTRODUCTION
Latinos in the United States are the fastest growing segment of the U.S.
population and are the largest minority group in the United States, (U.S. Census Bureau,
2003) with approximately 5 million Latinas over the age of 40 residing in the country
(U.S. Census Bureau, 2002). Hence, it is important to consider the large and growing
Latina population in terms of mammography screening, given that they are less likely to
participate in breast cancer screening and even more unlikely to be rescreened for breast
cancer on a regular basis (Suarez & Pulley, 1995). Furthermore, early detection is
particularly important for Latinas due to breast cancer incidence rates increasing faster
among Latinas than any other group of women in the U.S. (National Cancer Institute,
1999). Breast cancer is now the leading cause of cancer deaths among Latinas (O’Brien,
Cokkinides, & Thun, 2002), which underscores the necessity of improving screening
compliance and access to appropriate breast cancer treatment for Latinas.
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Chapter II
BACKGROUND AND SIGNIFICANCE
Breast Cancer
Breast cancer is the most commonly diagnosed cancer in women and the second
leading cause of cancer-related deaths in the United States. For 2003 it was estimated that
211,300 new cases of breast cancer would be diagnosed and 39,600 of those women
would die from the disease (American Cancer Society, 2002). Eighty-five to 100% of
breast cancer deaths occur among women diagnosed with stage II, III, or IV breast cancer
(Frisell et al., 1991; Andersson et al., 1988), and Latinas rank highest for mammography
reports of stage III and IV breast cancer (Li, Malone, & Daling, 2003). The National
Breast and Cervical Cancer Early Detection Program found in a comparison of breast
cancer abnormalities across different races and ethnicities that Latinas ranked second
highest with 6.3% of mammogram results being abnormal (May, Lee, Richardson,
Giustozzi, and Bobo, 2000). These results are from low-income women without
insurance coverage - those most at risk for underscreening.
In Latinas, the mortality rate increased 100% over 30 years and the incidence
rate rose by 56% over 19 years, while for non-Hispanic Whites the mortality rate and
incidence rate increased by 30% and 15%, respectively (Eidson, Becker, Wiggings, Key,
& Samet, 1994). The alarming increase in incidence and mortality rates for breast cancer
among Latinas, coupled with late stage diagnosis, is a disconcerting public health issue.
Latinas undergo fewer initial and regular mammograms and consequently are more likely
to be diagnosed at a more advanced stage o f breast cancer when fewer treatment options
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are available resulting in a poor prognosis (Gilliland, Hunt, Key, 1998). They are more
frequently diagnosed at a later stage even when they knew about cancer, its warning
signs, and have adequate access to health care, indicating that underlying psychosocial
determinants may be involved (Zaloznik, 1997; Soto, Behiens, & Rosemont, 1990).
Breast Cancer Screening and Rescreening
Currently, one of the most effective methods of reducing breast cancer mortality
is through a yearly screening consisting of a clinical breast exam and mammogram
(American Cancer Society, 2003). Support for the effectiveness of breast cancer
rescreening among women ages 50-69 was found in several randomized trials which
provide strong evidence that regular clinical breast exam and mammography reduce
mortality for breast cancer (Humphrey, Helfand, Chan, & Woolf, 2002; Tabar et al.,
2003; Duffy et al., 2002; Tabar et al., 2001). Randomized mammography screening trials
showed up to a 30% mortality reduction (White, Urban, & Taylor, 1993), and as much as
a 40% drop in mortality from breast cancer could be attributed to mammography and
clinical breast exam over a five-year period (Miller and Champion, 1993). With respect
to breast cancer screening for women between the ages of 40-49, mortality was reduced
by 16-24% (Evans, 2000; Fletcher et al., 1993; Tabar et al., 1996). The benefits of breast
cancer screening in reducing mortality in the population can be achieved only if
screening guidelines are followed, a large proportion of women receive screening
examinations regularly, and appropriate follow-up is done on abnormal or suspicious
findings (Day, Williams, & Khaw, 1989). However, Latinas are less likely to benefit
because of the numerous barriers they must overcome such as, lack of health insurance,
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fear, and cultural and systemic barriers (Garcia, 1995; Laws and Mayo, 1998; Elwood et
al., 1998) that may delay or prevent a timely diagnostic resolution.
Overall rates for breast cancer rescreening are still too low in the United States for
a reduction of 40% in mortality to be realized, as this would require 65% to 90% of
women ages 50-69 to have a mammography screening on a regular basis (The Workshop
Group, 1989). Even though studies have demonstrated that participation rates are
initially high, rates tend to decline after repeated screenings. A study by Zapka and
colleagues (1992) found 48% of women ever had a mammogram while only 20% had a
regular mammogram, and several studies indicate that less than 25% of women follow
recommended breast cancer screening guidelines for at least 2 consecutive years
(Champion, 1994; Miller and Champion, 1996; Zapka, Stoddard, Maul, and Costanza,
1991).
In comparison to studies with minority populations, studies among White women
have generally reported higher rates of initial and regular mammography. In particular,
Latinas have lower rescreening rates compared to White and African American women
(Centers of Disease Control, 2002; Gilliland, Rosenberg, Hunt, Stauber, & Key, 2000).
The most recent statistics indicate that 72% of White women and 68% of Black women
had a mammogram within the past 2 years compared to 63% of Latinas 50-64 years of
age (CDC, 2002). Estimates for regular mammography are much lower: the annual
mammography rate for non-Latina White women was at 46% whereas Latinas had a rate
of 40% (Gilliland et al., 2000).
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Disparities
Disparities exist in breast cancer screening and rescreening among ethic groups,
especially among Latinas. Several studies conducted in the United States have reported
that Latinas are at high risk of being underscreened (Rakowski, Rimer & Bryant, 1993;
Calle, Flanders, Thun & Martin, 1993; Song & Fletcher, 1998). This may be partially
attributed to Latinas being disproportionately represented in three of the most consistent
predictors for mammography under use - lack o f health insurance, low-income, and low
education level (Calle et al., 1993; Zapka, Stoddard, Costanza, Greene, 1989; Stein, Fox,
& Murata, 1991). A quarter of Latinos, compared to 8 % of Whites, have income levels
below the poverty line and have a lower education level, as well as lack health insurance
more frequently than non-Latinas (U.S. Census Bureau, 2000;Goldsmith, 1993; Munoz,
1988). Low-income and lack of health insurance creates a priority among Latinas of
addressing urgent health needs rather than preventive services such as, screening for
breast cancer. This dilemma is accentuated in rural areas, among Latinas between 45-64
years o f age (Baezconde-Garbanati, Portillo, & Garbanati, 1999), among undocumented
and only Spanish-speaking women who are more likely to be uninsured (Stein & Fox,
1990; Chaves, Cornelius, & Jones, 1985).
Furthermore, Mexican American women have fewer medical visits compared to
other Latino subgroups (Solis, Marks, Garcia, & Shelton, 1990). This makes it less likely
for them to have the opportunity to receive a recommendation for a mammogram from a
physician. Although numerous studies report that regular use of the health care system
and physician recommendation increases mammography screening, several studies show
physicians tend to make fewer recommendations for mammograms to patients who are
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Latinas, only speak Spanish (Fox & Stein, 1991), and are of low-income (Gemson,
Elinson, & Messeri, 1998). Subsequently, Latinas are less likely to receive a
recommendation from a health care professional compared to White women (Caplan,
Wells, & Haynes, 1992), partially due to their high rates of being uninsured and language
barriers with providers. Poor communication with physicians, lack of cultural
competence and sensitivity by healthcare professionals, and access barriers all contribute
to health disparities among Latinas (Woloshin, Bickell, Schwartz, Gany, & Welch, 1995;
Vermeire, Heamshaw, VanRoyen, & Denekens, 2001; Rutledge, 2001; Canto et al.,
2000; Geiger, 2001).
Breast Cancer Screening Factors
The determinants of breast cancer screening have been extensively examined
among White women and to a much lesser degree among Latinas (Burton, Warren, Price,
& Earl, 1997; Philips et al., 1998; Stoddard et al.,1998; Fulton, Rakowski, & Jones,
1995). Given that the literature on breast cancer rescreening among Latinas is scarce, the
following is a critical review of the determinants of breast cancer screening among
women in general. From the general literature we can extrapolate lessons learned as they
may apply to Latinas.
Studies have revealed that socioeconomic status, having a usual source of care,
health insurance, and a physician recommendation, contribute to breast cancer screening
for Latinas and non-Latinas (Calle et al., 1993;Zapka et al., 1989;Rakowski et al.,
1993;0’Malley, Mandelblatt, Gold, Cagney, & Kemer, 1997; Hubbell, Mishra, Chavez,
& Valdez, 1997). Apart from the previously mentioned predictors of breast cancer
screening, other factors have been found to be associated with lack of mammography
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screening among Latinas; the most salient are, low English proficiency, short duration of
residency in the United States, lack of knowledge about screening guidelines, fatalistic
attitudes, and fear (Skaer, Robinson, Sclar, & Harding, 1996; Lee & Vogel, 1995;
Bastani, Kaplan, Maxwell, Nisenbaum, Pearce, & Marcus, 1994; Fox & Roetzheim,
1994).
Demographics
Overall, the most common measure in the screening literature is demographics.
Age is particularly important, because several studies on mammography screening with
women over the age of 50 found that women were more likely to be screened if they were
younger, married, and had higher socioeconomic status (Solomon, Mickey, Rairikar,
Worden, & Flynn, 1998; Hayward, Shapiro, Freeman, & Corey, 1988; Calle et al.,1993;
Phillips et al., 1998; Bastani, Marcus, Hollatz, & Brown, 1991). Among Latinas the
relationship between age and mammography screening varies. One study reported that
Latinas over the age of 65 were less likely to be screened for breast cancer using
mammography (Calle, 1993), while another study found that Latinas in a younger age
bracket (over 50 years of age) were the least likely to have a mammogram (Hedeggard,
Davidson, & Wright, 1996).
Demographics as a predictor of breast cancer screening have produced different
results for Latinas compared to White women. Latinas who had children were more likely
to be screened for breast cancer (Morgan, Park, & Cortes, 1995). In contrast, a study
done with predominantly White women found that having fewer children and less than
three household members were positively associated with adherence to screening
guidelines (Phillips et al., 1998).
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Acculturation and Other Cultural Factors
Latina immigrants face additional barriers in mammography screening use. For
instance, Latinas who reside in the United States for a shorter period of time are usually
less acculturated and are less likely to obtain a mammogram (Blackman, Bemnett, &
Miller, 1999; Balcazar, Castro, & Krull, 1995). However, the relationship between
acculturation and breast cancer screening among Latinas is inconsistent. A number of
studies found that higher acculturation levels did not predict mammography use (Perez-
Stable, 1995: Suarez, 1994; Elder et al., 1991), yet other studies have found that less
acculturated Latinas had the lowest levels of mammography use (Stein & Fox, 1990;
Solis et al., 1990). The conflicting findings are partially explained by Suarez (1994) who
found that measures o f acculturation that rely solely on language proficiency were not
positively associated with mammography utilization when socioeconomic variables were
controlled (Suarez, 1994). Because lack of language proficiency is related to reduced use
of health care services (Stein & Fox, 1990), then acculturation may be acting as a proxy
variable for socioeconomic status when it is not controlled.
Less controversial is the relationship between cultural values and obtaining a
mammogram. The cultural value offamilism, which emphasizes the immediate and
extended family as a source of support, belonging, identity, and purpose, was positively
associated with engaging in breast cancer screening among a sample of Mexican
American women over the age of 40 (Suarez et al., 1995). A report from a study that
used a multidimensional measure of acculturation indicated that after controlling for
socioeconomic status, only traditional family attitudes predicted mammography use. The
Mexican American women in the study who had the strongest traditional family attitudes
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were more likely to have received a mammogram (Suarez, 1994). Familism may also
give somewhat of an indication of how much social support the participant may have.
According to a study done in 1997 by Pearlman and colleagues, women who do not have
social support and cannot discuss their health concerns with members from their social
network were less likely to have favorable attitudes towards mammography,
Another cultural factor that may have a role in breast cancer screening is fatalism.
Fatalism is the belief that an individual cannot alter his/her fate (Perez-Stable, Otero-
Sabogal, Sabogal, Hiatt, & McPhee, 1992). Fatalism may lead a Latina to think that there
is little she can do to change her fate, as a result she may be less inclined to obtain a
mammogram. High fatalism scores have been associated with lower screening rates
among Latinas of Caribbean origin (Laws and Mayo, 1998), and fatalism has been found
to be more prevalent among Mexican American women (Suarez, 1997;Perez-Stable et al.,
1992).
Familism and fatalism are the two cultural values/factors that have been most
examined in the breast cancer screening literature, yet not in the rescreening literature.
An array of cultural factors, which include machismo/marianismo, respeto, and
personalismo, have been tested across health behaviors (Unger et al., 2002; Sabogal,
Marin, Otero-Sabogal, Van Oss Marin, & Perez-Stable, 1987; Molina, Zambrana, &
Aguirre-Molina, 1994). Future studies on mammography use among Latinas should
incorporate other cultural values and factors that have not been examined in the breast
cancer rescreening literature such as, respeto (respect for authority) and personalismo
(warm and personal way of relating to an individual) as well as, familism and fatalism.
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Breast Cancer Beliefs and Attitudes
Several studies have found misconceptions regarding cancer beliefs among Latina
women (Fulton, Rakowski, & Jones, 1995; Morgan, Park, & Cortes, 1995; Chavez,
Hubbell, McMullin, Martinez & Mishra, 1995). A study done by Morgan and colleagues
(1995) revealed that 58% of women surveyed thought that it was possible for a hard
knock to the breast to become cancer, 44% agreed that cancer cannot really be cured, and
30% believed that surgery could cause cancer to spread. In concordance with Morgan’s
investigation, Chavez and coworkers (1995) found that Mexican immigrants ranked
injury to the breast as a stronger risk factor for breast cancer than family history. Another
study conducted with a sample of Latinas residing on the East Coast of the United States
helps to further elucidate the beliefs and knowledge that are held by these women (Fulton
et al., 1995). Respondents in the study were more likely than non-Hispanic Blacks and
Whites to agree with the statements, “Once you have a couple o f mammograms in a row
that show no problems, you don’t need any more mammograms” and “If your doctor
gives you a breast exam, then you do not need to have a mammogram.” Furthermore,
Latinas were less likely to agree with the statements, “If you have questions about
mammograms, you try to get the facts to answer them” and “Mammograms are now a
very routine medical test ” (p.478). These inaccurate beliefs and attitudes held by Latinas
are influential in the decision to obtain a mammogram. The combination of lack of
information and culture may help form these erroneous beliefs among Latinas.
Barriers
Embarrassment, fear, difficulties arranging a time, painful mammograms, and
negative experiences with doctors, nurses, and/or staff are barriers that have been found
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to impede breast cancer screening (Elwood et al., 1998). For Latinas the most common
barriers cited as deterrents of breast cancer screening were fear o f cancer, embarrassment,
and pain (Lobell, Bay, Kelton, Rhoads, & Keske, 1998; Roetzheim, Van Durme,
Brownlee, Herold, Woodward & Blair, 1993). Cultural and language barriers may also
hinder patient-provider interactions among Latinas. A qualitative study conducted in
California reported that Latinas felt providers do not understand them and are insensitive
(Garcia, 1995). Future quantitative studies need to validate this finding and analyze it in
the context of rescreening.
Health care practices among Latinas have also been examined in the breast cancer
screening literature. Latina women use alternative forms of healing significantly more
compared to non-Latinas (Laws and Mayo, 1998), and Latinas of Mexican descent are
more likely to use home remedies and care by other family members rather than seeking
professional care (Gordon, 1994). Women who revert to home remedies may not feel
they need a mammogram; hence, these alternative forms of healing could act as a barrier
towards mammography use.
Perhaps one of the greatest barriers of breast cancer screening would appear to be
the cost associated with receiving a mammogram, however, this may not always be the
case. A study done in the state of Washington examined breast cancer screening in a
managed care environment and all the services related to the program required no out-of-
pocket cost. Nevertheless, the removal of the financial barrier did not create an increase
in breast cancer screening rates (Tu, Taplin, Barlow, & Boyko, 1999). Similarly, cost is
not always cited as a barrier to obtain a mammogram for Latinas (Dibble, Vaoni, &
Miaskowski, 1997). A study on motivation for mammography use found that a free
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mammogram was not a sufficient incentive for Latinas to receive an initial mammogram
(Viet, 1999). Even though there have been improvements in reducing financial barriers to
receiving an annual mammogram, there are still many other barriers that may account for
the low rescreening rates, particularly among Latinas. Perez-Stable and colleagues (1994)
found that even when financial barriers are taken into account, Latinas are less likely to
receive cancer screenings.
One of the strongest predictors for mammography is physician’s recommendation,
and no controversy exists as to the importance of physician recommendation in
mammography screening among White women (May, Kiefe, Funkhouser, & Fouad,
1999; Rimer, Trock, Engstrom, Lerma & King, 1991; Pearlman et al., 1997; Phillips et al,
1998). Physician recommendation may be important among Latinas due in part to the
cultural value of respeto (Chong, 2003; Marin and Marin, 1991). Respeto in the Latino
community is an appreciation for authority figures and expertise. Moreover, the
importance of physician recommendation may have been heightened due to changes in
guidelines to annual mammography screening for 40-49-year-old women. Modifications
in recommendations for women in this age group may have lead to some confusion for
women who previously thought they did not need a mammogram until age fifty.
Subsequently, many interventions have sought to increase screening rates by targeting
physicians to emphasize and increase mammography recommendation.
Rationale for the current study
This study intends to address a gap in the breast cancer rescreening literature
among Latinas. The few studies that have included Latinas have limited
representativeness of the Latina population due to small sample size. In addition, the
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findings in the literature are inconsistent, most of the studies are self-report data (no
objective measures), the constructs vary in their conceptualization thus there is a lack of
comparable instruments, a lack o f culturally based theoretical models, and problems with
bias.
Most of the studies that have included Latinas have only examined demographic
characteristics as predictors of breast cancer rescreening. A study conducted in the state
of Washington that included African American, White, Asian, and Latina women, who
were sampled from a free breast and cervical cancer screening program for low-income
women(Song & Fletcher, 1998), showed that older age, Latina ethnicity, and no prior
history of a mammography screening were significantly associated with low breast
cancer rescreening; yet, they did not test if risk factors vary by ethnicity. Research
suggesting that rescreening may vary by ethnicity (Stein & Fox, 199: Calle et al., 1993;
Tortolero-Luna, Glober, Villarreal, Palos, & Linares, 1995) and other factors previously
mentioned, such as cultural values and breast cancer beliefs and attitudes, indicate that
further inquiry into this area is warranted, because it suggests that Latina women are at
risk for especially low rescreening rates.
Few of the aforementioned constructs have been included in rescreening studies
among low-income Latinas, and there are no published articles that have investigated the
psychosocial, cultural, and cognitive determinants of low compliance with breast cancer
screening guidelines among low-income Latina women. In addition, consensus on the
predictors of mammography among Latinas has not been reached. Thus, it is important
to understand which constructs account for the low rescreening rates among Latinas. The
lack of research with Latinas on compliance with mammography screening guidelines in
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conjunction with the increasing breast cancer incidence and mortality rates is a serious
public health concern. Therefore, this research is aimed at seeking possible explanations
as to why low-income women do not adhere to screening guidelines, given that currently
mammography is the best option in the fight against breast cancer. In order to achieve a
greater insight into this urgent public health issue among Latinas, a model was developed
based on theory and the breast cancer screening literature.
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Chapter III
CONCEPTUAL MODEL
The unique aspects of the theoretical model (See Figure 1) presented here are that
it incorporates the Theory of Planned Behavior (Ajzen, 1985) and is culturally based.
Studies on breast cancer rescreening among Latinas have not explored theoretical
frameworks such as the Theory of Planned Behavior. The theory helps provide
conceptual clarity, and in combination with the culturally based components of the
proposed model provides a good “model fit” in terms of the Latino cultural experience.
Albeit, future studies may discover other determinants of low rescreening rates, this is a
parsimonious model that, according to our current knowledge, could determine why
Latinas engage in an initial screening, but not subsequent screenings.
The components of the Theory of Planned Behavior (Ajzen, 1985) are intention,
attitudes, subjective norms, and perceived behavioral control. Intention to screen is the
immediate determinant of behavior, and is a function of a person’s attitude toward the
behavior and perception of the social norm concerning the behavior (Baker et al., 1996).
Attitudes consist of the perceived advantages and disadvantages of having a
mammography on a regular basis. Subjective norms might encourage women to attend
screening, given that motivation to receive a mammogram may stem from the knowledge
that other women participate in screening. Both attitudes and subjective norms have been
found to predict intention and participation in mammography screening programs
(Montano & Taplin, 1991), and in several studies intention has been found to be a
significant predictor of mammography (Rakowski et al., 1993; Montano & Taplin, 1991;
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Figure 1. Heuristic framework for compliance with mammography among Latinas
Culturally based theoretical model
Past Clinical j
Breast Exam and j -
Self Breast Exam :
Perceived
Behavioral
-------- ►
Control
Barriers/Facilitators
-General
-Knowledge
-Provider
-Breast Cancer Early
Detection Program
-Health Practices and Care
-Social Support
r
Intention
Subjective
Norm
Beliefs
Attitudes
Regular
Mammogram
Cultural
Factors
-Familism
-Fatalism
Demographics
-Age
-Marital Status
-Education
-Number of
Children
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Baumann, Brown, Fontana, & Cameron, 1993; Lechner, Vries, & Offermans, 1997). In
addition, perceived behavioral control, which refers to the degree of control an
individual has over a target behavior, has been found to contribute to the prediction of
both intention and behavior. Perceived behavioral control may empower low-income
women to obtain a regular mammogram, and could play a particularly important role in
increasing the low rescreening rates among Latinas. Comparison o f the Theory of
Planned Behavior with the Theory of Reasoned Action has shown that adding perceived
behavioral control to the attitudes and social norm variable of the Theory of Reasoned
Action significantly improves prediction of behavioral intentions (Godin & Kok, 1996;
Millstein, 1996). The construct of perceived behavior control has not been examined
among Latinas in regards to compliance with mammography screening guidelines.
The Theory of Planned Behavior appears to pay little attention to how much
cultural factors and ideologies play a role in behavior. Thus, cultural factors such as
familism and fatalism are added to the model. Fatalism was not included in the Theory
of Planned Behavior as part of attitudes partially due to the conceptualization of attitudes.
The attitudes construct is specific to breast cancer screening while the fatalism construct
is a cultural factor applicable to various circumstances.
Several other variables in the model have been proposed as additional explanatory
factors. An important variable for understanding intention and future behavior is a
woman’s past screening behavior (Sutton, 1994). Past behavior with respect to breast
cancer screening has been found to be predictive o f mammography use and compliance
(Beaulieu, Beland, Roy, Falardeau, & Hebert, 1996; Lechner et al., 1997), and regular
clinical breast exam has been found to be strongly associated with mammography
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compliance (Hagoel, Ore, Neter, Shiffoni, & Rennert, 1999; Seow, et al., 1997; Solomon,
et al., 1998). To account for past screening behavior, self and clinical breast exams are
included in the model as other predisposing factors that might influence intention.
Barriers and facilitators are also included in the model to help gain an
understanding of what role these variables have in rescreening among Latina women.
Emphasis is placed on a variety of barriers that minority women may encounter. Lastly,
demographics are part of the model because several studies in the screening literature
have found them to be predictive, albeit the findings are contradictory. This study seeks
to clarify those inconsistencies.
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Chapter IV
RESEARCH QUESTIONS AND HYPOTHESES
1) How well does the heuristic framework and culturally based theoretical model for
breast cancer rescreening predict mammography intention and mammography
behavior among women over the age of 40?
a) Latinas who rate high on familism and fatalism, have more children and
are married, have fewer barriers and more facilitators, and have high
intentions to be screened, will be more likely to have a regular
mammogram (rescreened).
b) Intention will mediate the relationship between the components of the
Theory of Planned Behavior (attitudes, subjective norms and perceived
behavior control) and regular mammogram use.
c) Women who regularly engage in other types of breast cancer screening
behavior such as self and clinical breast exams will be more likely to
obtain regular mammograms.
2) Are there significant differences for Latinas vs.non-Latinas in terms of model
variables?
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Chapter V
METHODOLOGY
Data Source
This is a cross-sectional study based on a representative sample of the women
who called the Breast Cancer Early Detection Program referral line in Los Angeles
County (BCEDP) from January 1997 to December 1998. The BCEDP provides and/or
refers breast cancer screening and diagnostic services to women who meet the eligibility
requirement of being uninsured or underinsured and are 200% below the federal poverty
level. The BCEDP referral line and program information were disseminated to Los
Angeles County residents via local media campaigns, community organizations, clinics,
and individual practitioners.
Specifically, the Los Angeles Partnership works at the community level
establishing a system o f diagnostic, screening and follow-up services to local underserved
women, and facilitates the development of education, support, and treatment services.
The Partnership seeks to implement strategies to reduce barriers and empower women
with information, support, and advocacy.
In light of the fact that overall rescreening rates of low-income women in Los
Angeles County and through out the state of California are low and in need of
improvement, the BCEDP aims to increase the number of low-income women who
receive breast screening and rescreening. The rescreening rate from the BCEDP's Los
Angeles partnership was 23% and 22% for the state of California (Partnered for Progress,
1999), and the Los Angeles Partnership’s concern of the low rescreening rates prompted
interest in conducting a study on this issue. Subsequently, the Los Angeles Partnership
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facilitated the process of acquiring the telephone numbers and relevant information of
potential study participants from the BCEDP.
Another community organization involved in this rescreening study was the
Encore Plus program. This program provides breast and cervical cancer screening along
with counseling, information, and moral support to women who do not have access to
health screenings. The Encore Plus program helped with the recruitment of the
participants for the pilot test. Both the Encore Plus program and the Los Angeles
Partnership had the opportunity to provide feedback at every stage of the questionnaire
development.
Sample
One thousand nine hundred and sixty-four (1,964) women from Los Angeles
County over the age of 40 contacted the BCEDP referral line from January of 1997 to
December of 1998 and were eligible for services. O f those women, 640 were randomly
selected using Statistical Analysis System (SAS).
A pilot test with a group of women (N-40) from the YWCA of Glendale was
conducted in order to obtain feedback regarding the questionnaire. They were recruited
from the Encore Plus free mammography screening program. These women were similar
to the women from the BCEDP in being ethnically diverse, low-income, uninsured or
under-insured, and over the age of 40. Results from the pilot test helped ensure that the
questionnaire was relevant to the experience of low-income women, i.e. face validity.
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Data Collection Procedure
Participants were contacted for the administration of the survey via telephone.
The survey was developed in English and translated into Spanish; the translation-back-
translation method was used to ensure equivalence between the two versions. The
institutional review board at the University of Southern California approved the study,
and verbal informed consent was obtained at the beginning of the survey. The surveys
were administered over the telephone in order to eliminate any literacy problems as well
as limitations, and three attempts to reach each participant were made. In order to
increase our probability of contacting each participant, the survey was offered by trained
female interviewers to the participants in their preferred language, and personalismo was
incorporated. Personalismo was incorporated by using a culturally and gender sensitive
approach that expressed concern for the participant and for the well being of her family.
Choca defines personalismo as a warm and personal way of relating to an individual, and
Peniagua states that Mexican Americans tend to relate more to people than to
impersonal relationships (Choca 1979; Peniagua 1994). Participation among Latinas in
health-related studies may be improved by a culturally and gender sensitive approach,
characterized by personalismo (Teran, Belkic, and Johnson, 2002). We also followed
Ekblad, Belkic, and Eriksson’s (1996) approach to avoid problems surrounding scale
equivalence by emphasizing the importance of choosing the best answer to each inquiry.
In addition, participants had the opportunity of scheduling a time when it was
most convenient for them to complete the survey. However, if a participant refused to
engage in our research study, the interviewer inquired about the possible reasons for non
participation. At that point the interviewer had the opportunity to clarify any
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misconceptions regarding the study. Participants did not receive actual financial
compensation, instead they were given small tokens of appreciation for their participation
such as a grocery gift certificate for $10 (donated by the Breast Cancer Early Detection
Program).
Measures
The lack of validated scales for Latinas stems from the paucity of breast cancer
rescreening research in this population. Although the barrier and beliefs constructs are
not validated measures, they have been used with Latina populations. The cultural values
measures have demonstrated construct validity and reliability (Cuellar, Arnold and
Gonzales, 1995), yet have not been used in breast cancer rescreening studies among
Latinas. For several constructs, shortened versions were used due to the requirements of
the community organizations for the questionnaire to be concise. The attitudes,
subjective norms, and perceived behavioral control scales were newly created for this
study.
Demographics
Education and job status were assessed, but income was not measured due to this
being a very low-income sample (200% below poverty level), established by the BCEDP
criteria. Age, marital status, and number of children were documented. Ethnic origin, the
ethnicity with which the participant most identifies, and age of arrival to the United
States (if foreign bom) were also included in the questionnaire.
Acculturation and Other Cultural Factors
Four items from the short form of the Marin et al. acculturation Scale (1987) were
used to assess language use and preference. Marin and colleagues (1987) found that the
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short form of the scale is valid and reliable (Cronbach’s a= .90). Some o f the items from
the scale that were used are, “In general, what language do you read and speak?” and
“What language do you usually think?” The response options range from “only English”
to “only another language” on a 5-point scale.
The 5-item fatalism scale that was used is from the Cuellar et al. (1995) study.
An example from the scale is, “People die when it is their time, and there is not much that
can be done about it.” Items were rated on a 4-point scale ranging from “strongly agree”
to “strongly disagree.” The same method used in Unger and colleagues’ (2002) study
was used to choose the five fatalism items. This method involves using the five items
with the highest factor loadings from the fatalism scale that did not load highly on any
other scale (Unger et al., 2002)
The questions used for familism are from Cuellar et al. (1995 ) familism scale.
Two of the questions read, “Relatives are more important than friends” and “ I expect my
relatives to help me when I need them.” Items were ranked on a 4-point scale, ranging
from “strongly disagree” to “strongly agree.” The two items with the highest loadings
were chosen from this scale.
Beliefs
The questions used for the beliefs scale are from Futon et al. (1995), who used the
scale with a Latina population, but reliability or validity was not established. Five
dichotomous items measured erroneous beliefs: getting a mammogram causes cancer,
you only need a few mammograms and not regular mammograms, mammograms are
ineffective, mammograms are unnecessary in the absence of symptoms, and unnecessary
if a clinical breast exam is performed. An example of one of the questions is, “Do you
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agree that if you have a few mammograms in a row that show no problem, then you don’t
need to have regular mammograms?”
Attitudes
Two questions assessed attitudes about mammography. The attitudes towards
mammography were embarrassment and fear. Response options ranged from “very
much” to “not at all.” One of the questions read, “Even though it’s a good idea, you find
that having your breast examined is embarrassing.”
Subjective Norm
The following item was created to be a proxy measure for subjective norm, “Do
you know other women who receive regular mammograms?” The response options were,
“no” to “yes, many.”
Perceived Behavioral Control
A proxy measure for perceived behavioral control was created with two items.
The items measure how much the participant would want to know if they had cancer and
how much she feels cancer could be cured if it was caught early. For example, “If you
were to have cancer, you would want to know about it.”
Intention to be Rescreened
Intention for breast cancer rescreening was measured with two questions that
assessed the likelihood that a woman will obtain a mammogram during the next year.
One question measured intention at 6 months and the other at one year. Specifically,
respondents were asked, “How likely do you think it is that you will receive a
mammogram in the next year?” Intention to receive an annual mammogram was assessed
on a 4-point scale ranging from “very likely” to “very unlikely.”
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Barriers/Facilitators
-General
Dichotomous items that measured barriers for mammography were administered
to women who the called the BCEDP referral line, but did not have an initial screening
(YWCA, 1998). The most common barriers cited were lack of importance and
forgetfulness. Items used in this study include, but not limited to, proximity of the clinic,
time issues, transportation problems, and illness.
- Satisfaction with BCEDP
Because these women have been in contact with the BCEDP in the past, it is
useful to find out what type of experience they had, what problems they may have
encountered, and how those factors influenced regular mammography use. We inquired
about problems with the results, problems with the doctor or staff at the clinic or office,
problems with the doctor trying to bill them for the free service, and an open ended
section for the respondent to indicate any specific problem. In addition, a question
regarding any positive experiences with the BCEDP program and how likely they would
be to recommend the BCEDP program to a friend was asked.
-Medical Provider's recommendation
One question was used to measure whether or not a health professional
recommended a mammogram. The question was, “Did any medical professional
explain the importance of receiving a mammogram regularly?” Response options ranged
from “very much” to “not at all.”
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-Health Practices and Care
A question related to reliance on alternative medicine and on Western medicine
was included. The item was, “Do you use herbs or natural remedies for healing or
medicinal purposes.” Queries related to health care were, “Do you generally have a
regular health check-up, or do you only go to the doctor/clinic when you are sick, or do
you never see a doctor?” and “To what extent will your religious beliefs influence your
decisions about seeing a doctor or getting medical tests?”
Physical activity was measured with the following question, “How physically
active are you during a typical day?” The response options were, “very little, I’m mainly
standing or sitting,” “a little, but I do walk for up to 30 minutes or more on most days,” “I
walk 30 minutes or more on most days,” and “I do exercise, dance, or play sports (at least
1-2 times per week).”
-Knowledge of screening guidelines
The following question measured how knowledgeable the participant was on
mammography screening guidelines, “How often should a woman get a mammogram?”
Response options were, “once in her life,” “every 3-5 years,” “every 2 years,” and “every
year.” Knowledge of risk factors was measured with the following dichotomous items:
having some in the family with breast cancer, not having faith in god, and injury to the
area.
-Social Support
The three items that measured instrumental and emotional aspects of social
support are from the Teran, Belkic, and Johnson study (2002), which derived the scale
from House and Kahn (1985) and tested it with a sample of Latinas in Southern
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California (Cronbach’s alpha=.67). The items were, “I see friends and/or family with
whom I can chat,” “Do you have someone with whom you can confide in or share your
feelings?” and “Do you have someone who can help you solve problems?” Response
options were “yes”, “to some extent” and “no.”
Clinical and Self-Breast Exam
One question measured on a continuous scale assessed clinical breast exam,
“When was the last time that you received a clinical breast exam?” Response options
range from "within 6 months" to "more than 25 months.” Self- breast exam was
measured with the following question, “How often do you perform a self breast exam?”
Response options ranged from “never” to “every month.”
Breast Cancer Rescreening
The dependent variable for breast cancer rescreening was measured with the
question, "When was the last time that you received a mammogram?" Response options
range from "within 6 months" to "more than 25 months." Two additional questions,
“How many times have you received a mammogram since you called the BCEDP referral
line in 1997 or 1998?” and “How often do you receive a mammogram?” were asked to
establish cross-validation o f compliance with regular screening mammography.
Data Analysis
Descriptive statistics, frequencies, correlations, t-tests, and chi-square tests were
used to analyze the data. Multi-item scales were created by adding several items
together. For normally distributed independent and dependent variables, multiple linear
regression was used. Regression analyses was used to identify significant predictors of
regular breast cancer screening and controlled simultaneously for potential
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confounders. In order to distinguish ethnic differences in regular mammography use,
stratified analyses using non-collinear independent variables for Latinas and non-Latinas
were examined. Age and education were controlled for in all regression analysis.
Intention was assessed as a potential mediator according to the following
conditions: the four independent variables (past screening, perceived behavioral control,
subjective norms, and attitudes) have a significant effect on annual mammogram, the
independent variables have a significant effect on the mediator, the mediator has a
significant effect on regular mammogram, and when both the mediator and independent
variables are included in the model, the mediator would be significant but the
independent variables lose significance or have a decreased beta coefficient. Moderation
was also tested.
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Chapter VI
RESULTS
Comparison of Samples
The women who participated in our study did not significantly differ from the
remaining women enrolled in the BCEDP. Our sample is representative o f the overall
BCEDP sample on age and ethnicity. Forty-nine percent of BCEDP clients were between
the ages of 40-49 while 46% of the women in our study were in that age bracket, and
65% of the BCEDP clientele were Latinas while 66% of our sample consisted of Latinas.
Response Rate
We attempted to reach 640 randomly selected women by telephone, however, 215
of the telephone numbers were invalid due to disconnection and wrong numbers and 288
could not be located after several attempts. Twenty-two women explicitly refused to
participate. A total of 115 women completed the survey. The response rate for the entire
sample was 67%, based on 172 reachable women (See Table la). Table lb and lc
describes the break down for English and Spanish speakers. The response rate for English
language participants was 52% and 75% for Spanish language participants. Chi-square
analysis reveals significant difference (p<.01) between English and Spanish on
participation.
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Table la. Participation for Entire Sample (N=640)
Reachable (N-172)__________________________
Frequency Percent
Survey Completed 115 66.8%
Call Back 35 20.4%
Refusal 22 12.8%
Unreachable (N=468)
Frequency Percent
Disconnected 80 17.1%
Busy Signal 16 3.4%
Wrong Number 135 28.8%
Not Home 237 50.7%
Table lb. English Language Participants (N=250)
Reachable (N=60)______________________________
Frequency Percent
Survey Completed 31 51.7%
Call Back 19 31.7%
Refusal 10 16.6%
Unreachable (N=190)
Frequency Percent
Disconnected 46 24.2%
Busy Signal 5 2.6%
Wrong Number 53 27.9%
Not Home 86 45.3%
Table lc. Spanish Language Participants (N=390)
Reachable (N=l 12)_____________________________
Frequency Percent
Survey Completed 84 75.0%
Call Back 16 14.3%
Refusal 12 10.7%
Unreachable (N=278)
Frequency Percent
Disconnected 34 12.2%
Busy Signal 11 4.0%
Wrong Number 82 29.5%
Not Home 151 54.3%
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Demographic Characteristics
Table 2a summarizes some of the demographic characteristics of the entire
sample. Sixty six percent of the women were Latinas and 33% were non-Latinas.
Slightly under half of the women were between the ages of 41-49 and approximately half
were over the age of 50. The majority of women had 3 or more children, and over half
were married. Sixty percent were employed, and 58% had a regular medical check-up.
However, for 43% of them medical visits were “financially very hard". Table 2b
describes the demographic characteristics for Latinas. Approximately half were between
the ages of 41-49. The majority of Latinas had less than a 9 years of education, and 68%
had a job. For almost half of the Latinas a medical visit would be “financially very
hard.” Over 60% were married, and over 80% had 3 or more children. Table 2c shows
the demographic characteristics for non-Latinas. Again, approximately, half of the non-
Latinas are between the ages of 41-49; however, only 64% had three or more children
and over three-quarters had 9 or more years of education.
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Table 2a. Demographic Characteristics of Sample (N=l 15)
FREQUENCY PERCENT
Age
41-49 52 45.2
50-59 48 41.7
60-69 13 11.3
70 or more 1 .9
Missing 1 .9
Marital Status
Married 62 53.9
Divorced 17 14.8
Single 18 15.6
Widowed 13 11.3
Other 4 3.5
Missing 1 0.9
Number of Children
1 11 9.6
2 15 13.1
3 51 44.3
4 33 28.7
5 or more 3 2.6
Missing 2 1.7
Education
Up to 4 years 13 11.3
Between 5 and 8 years 29 25.2
Between 9 and 12 years 28 24.3
Between 13 and 16 years 35 30.4
More than 17 years 9 7.9
Missing 1 0.9
Job
Yes 70 60.9
No 44 38.2
Missing 1 0.9
Ethnicitv
Latina 75 65.3
White 23 20.0
African-American 9 7.8
Asian/Pacific Islander 2 1.7
Other 4 1.7
Missing 2
Medical Check-Up
Regular check-up 67 58.2
Only when sick 40 34.8
Never see a doctor 8 7.0
Medical Visit
All expenses covered 35 30.4
A fee would be assessed 30 26.1
Financially very hard 50 43.5
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Table 2b. Demographic Characteristics for Latinas (N=75)
FREOUENCY PERCENT
Age
41-49 36 48.0
50-59 29 38.7
60-69 9 12.0
70 or more 1 1.3
Marital Status
Married 48 64.0
Divorced 6 8.0
Single 10 13.3
Widowed 8 10.7
Other 3 4.0
Number o f Children
1 4 5.3
2 9 12.0
3 28 37.4
4 30 40.0
5 or more 3 4.0
Missing 1 1.3
Education
Up to 4 years 13 17.3
Between 5 and 8 years 27 36.0
Between 9 and 12 years 20 26.7
Between 13 and 16 years 12 16.0
More than 17 years 3 4.0
Job
Yes 51 68.0
No 24 32.0
Medical Check-Up
Regular check-up 47 62.7
Only when sick 23 30.7
Never see a doctor 5 6.7
Medical Visit
All expenses covered 21 28.0
A fee would be assessed 19 25.3
Financially very hard 34 45.4
Missing 1 1.3
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Table 2c. Demographic Characteristics for non-Latinas (N=34)
FREOUENCY PERCENT
Age
41-49 15 44.1
50-59 15 44.1
60-69 4 11.8
70 or more 0 0
Marital Status
Married 13 38.2
Divorced 10 29.5
Single 6 17.6
Widowed 4 11.8
Other 1 2.9
Number of Children
1 6 17.6
2 6 17.6
3 20 58.9
4 2 5.9
5 or more 0 0
Education
Up to 4 years 2 5.9
Between 5 and 8 years 6 17.6
Between 9 and 12 years 21 61.8
Between 13 and 16 years 5 14.7
More than 17 years 0 0
Job
Yes 18 52.9
No 16 47.1
Medical Check-Up
Regular check-up 17 50.0
Only when sick 15 44.1
Never see a doctor 2 5.9
Medical Visit
All expenses covered 13 38.2
A fee would be assessed 8 23.5
Financially very hard 13 38.2
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Univariate Analysis
Tables 3a - c show the descriptive statistics for all continuous and semicontinous
variables. Means, standard deviations, medians, and normality (skewness cut-off
value=1.3 and kurtosis=-2.0) are displayed for the entire sample and stratified by group.
Latinas had a higher mean average (M==3.3) for performing a self breast exam, but a
lower mean average (M-2.0) for receiving a clinical breast exam compared to non-
Latinas (M=2.8 and M=2.5, respectively). For the entire sample and Latinas all
variables were normally distributed, except for intention at one year. A log
transformation was performed to create a normal distribution for intention at one year for
the entire sample, Latinas, and non-Latinas. A log transformation was also used in the
non-Latino group for religious influence on medical decision.
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Table 3a. Univariate Data for the Entire Sample
VARIABLE
DESCRIPTION
MEAN ±SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Age
1= <40 2.7 3.0 Yes
2=41-49 .71 .71
3= 50-59 (2-5) -.13
4= 60-69
5= >70
Education 3.0 3.0 Yes
1 = <4 years 1.16 -.10
2= 5-8 years (1-5) -.94
3= 9-12 years
4= 13-16 years
5= 17 or more years
Number of Children 3.0 3.0 Yes
1=0 .96 -.52
2=1 (1-5) -.07
3=2
4=4-5
5= 6 or more
Health care provider Yes
recommendation 2.0 2.0 1.0
l=Very much .93 -.33
2=To some extent (1-4)
3= A little
4= Not at all
Clinical Breast Exam 2.2 2.0 Yes
1= Within 6 months 1.35 1.0
2= Within 12 months (1-5) -.25
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
Self Breast Exam 3.1 4.0 Yes
1= Never 1.07 .86
2= 6 months-1 year (1-4) -.63
3= Every few months
4= Every month
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Table 3a (continued). Univariate Data for the Entire Sample
VARIABLE
DESCRIPTION
MEAN ± SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Religious Influence on Medical 2.9 4.0 Yes
Decisions 1.30 -.654
1= Very Much (1-4) -1.39
2= To a large extent
3= A little
4= Not at all
Intention 6 months
1= Very likely 2.2 2.0 Yes
2= Likely 1.15 .48
3= Unlikely (1-4) -1.2
4= Very unlikely
Intention 1 vear 1.6 1.0 No
1= Very likely .79 1.54
2= Likely (1-4) 2.24
3= Unlikely
4= Very unlikely
Number o f Mammograms in last 3-4 3.0 3.0 Yes
vears 1.0 -.68
1=0 (1-4) -.77
2= 1
3=2
4= 3
Last mammogram 2.6 2.0 Yes
1= Within 6 months 1.53 .61
2= Within 12 months (1-6) -.65
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
38
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Table 3b. Univariate Data for Latinas
VARIABLE
DESCRIPTION
MEAN ± SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Age
1= <40 2.7 3.0 Yes
2=41-49 .75 .83
3= 50-59
4= 60-69
5= >70
(2-5) .06
Education 2.5 3.0 Yes
1= <4 years 1.08 -.10
2= 5-8 years
3= 9-12 years
4= 13-16 years
5= 17 or more years
(1-5) -.94
Number of Children 3.3 3.0 Yes
1=0 .92 -.65
2=1
3=2
4=4-5
5= 6 or more
(1-5) -.22
Health care provider 1.6 1.0 Yes
recommendation .85 1.0
1= Very much
2=To some extent
3= A little
4= Not at all
(1-4) -.45
Clinical Breast Exam 2.0 2.0 Yes
1= Within 6 months 1.25 1.2
2= Within 12 months
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
(1-5) .46
Self Breast Exam 3.3 4.0 Yes
1 = Never 1.00 -1.1
2= 6 months-1 year
3= Every few months
4= Every month
(1-4) .02
39
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Table 3b (continued). Univariate Data for Latinas
VARIABLE
DESCRIPTION
MEAN ±
SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Physical Activity 2.7 3.0 Yes
1= Very little .86 -.35
2= Walks up to 30 minutes/day
3= Walks > 30 minutes/day
4= Actively exercises
(1-4) -.39
Religious Influence on Medical 2.7 3.0 Yes
Decisions 1.36 -.28
1= Very Much
2= To a large extent
3= A little
4= Not at all
(1-4) -1.8
Intention 6 months 2.2 2.0 Yes
1= Very likely 1.24 .40
2= Likely
3= Unlikely
4= Very unlikely
(1-4) -1.5
Intention 1 year 1.7 2.0 No
1= Very likely .84 1.34
2= Likely
3= Unlikely
4= Very unlikely
(1-4) 1.60
Number o f Mammograms in last 3-4 3.2 3.0 Yes
years 1.0 -1.01
1=0
2= I
3= 2
4= 3
(1-4) -.14
Last mammogram 2.6 2.0 Yes
1= Within 6 months 1.55 .75
2= Within 12 months
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
(1-6) -.75
40
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Table 3c. Univariate Data for non-Latinas
VARIABLE
DESCRIPTION
MEAN ± SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Age
1= <40 2.7 3.0 Yes
2=41-49 .68 .52
3= 50-59
4= 60-69
5= >70
(2-4) -.70
Education 3.8 4.0 Yes
1= <4 years .74 -.70
2= 5-8 years
3= 9-12 years
4= 13-16 years
5= 17 or more years
(2-5) .91
Number of Children 2.5 3.0 Yes
1=0 .86 -.70
2=1
3=2
4=4-5
5= 6 or more
(1-4) -.41
Health care provider 1.8 1.0 Yes
recommendation 1.0 .96
l=Very much
2=To some extent
3= A little
4= Not at all
(1-4) -.43
Clinical Breast Exam 2.5 2.0 Yes
1= Within 6 months 1.5 .65
2= Within 12 months
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
(1-5) -.99
Self Breast Exam 2.8 3.0 Yes
1=Never 1.17 -.37
2= 6 months-1 year
3= Every few months
4= Every month
(1-4) -1.4
41
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Table 3c (continued). Univariate Data for non-Latinas
VARIABLE
DESCRIPTION
MEAN ±
SD
(ACTUAL
RANGE)
MEDIAN
NORMAL DISTRIBUTION
SKEWNESS < 1.3
KURTOSIS < 2.0
Physical Activity
1= Very little
2= Walks up to 30 minutes/day
3= Walks > 30 minutes/day
4= Actively exercises
2.7
1.1
(1-4)
3.0 Yes
-.15
-1.4
Religious Influence on Medical
Decisions
1= Very Much
2= To a large extent
3= A little
4= Not at all
3.6
.93
(1-4)
4.0 No
-2.1
3.4
Intention 6 months
1= Very likely
2= Likely
3= Unlikely
4= Very unlikely
2.2
1.09
(1-4)
2.0 Yes
.54
-.94
Intention 1 year
1= Very likely
2= Likely
3= Unlikely
4= Very unlikely
1.3
.69
(1-4)
1.0 No
2.3
5.9
Number o f Mammograms in last
3-4 years
1=0
2= 1
3= 2
4= 3
2.8
1.08
(1-4)
3.0 Yes
-.34
-1.2
Last mammogram
1= Within 6 months
2= Within 12 months
3= Within 18 months
4= Within 24 months
5= > 25 months
6= Never
2.7
1.47
(1-5)
2.0 Yes
.48
-1.15
42
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Reliability Analysis
Reliability testing revealed that the language acculturation and fatalism scales had
good levels of internal consistency (See Table 4a and 4b). The very low Cronbach’s
alpha of .22 for the belief items and .41 for the knowledge items indicated that these are
poor scales that do not hold together; therefore, we will use single item variables for
bivariate and multivariate analysis. The attitudes, perceived behavioral control (PBC),
and BCEDP scale items had very low variance. For example, 100% of the respondents
felt that breast cancer could be cured if it is caught early and 96% would want to know if
they had cancer (PBC items). Thus, we could not use these measures in any statistical
analysis, consequently, we could not test the Theory of Planned Behavior and had to
discard the constructs pertaining to the theory.
As shown in Table 4b, the newly developed scale of language discrepancy was
derived from the short version language acculturation scale and reflects the degree to
which the mother’s predominant language differs from the language spoken at home. All
scales, except for language acculturation in Latinas, were normally distributed. A log
transformation was used to normalize the language acculturation scale.
43
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Table 4a. Scales for Entire Sample
COMPONENTS DESCRIPTION
(POTENTIAL
RANGE)
MEAN ± SD
(ACTUAL
RANGE)
SKEWNESS
AND
KURTOSIS
CRONBACH
a
Social
Support
-Chat with
friends
-Has confidant(s)
-Has help solving
problems
Additive:
Lowest score-
Highest
Support
(3-9)
4.4 1.5
(3-9)
1.0
.23
.54
Language
Acculturation
-Language
spoken at home
-Language for
reading
-Language for
thinking
-Language for
talking to friends
Additive:
Highest score-
Predominance of
English
(4-20)
11.25
6.6
(4-20)
.35
-1.6
.97
Familism -Relatives
important than
friends.
- Expect relatives
to help when
needed
Additive:
Highest score-
Lowest familism
(2-8)
4.0
1.41
(2-8)
.262
-.663
.53
Fatalism -Enjoy life now
-People die when
it’s their time
-Live for present
-Not wise plan
too far ahead
-Can’t change
future, in hands
o f God
Additive:
Highest score:
Least fatalistic
(5-20)
9.79
3.0
(5-17)
.29
-.69
.75
44
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Table 4b. Scales for Latinas
COMPONENTS DESCRIPTION
(POTENTIAL
RANGE)
MEAN ± SD
(ACTUAL
RANGE)
SKEWNESS
AND
KURTOSIS
CRONBACH
a
Social
Support
-Chat with
friends
-Has
confidant(s)
-Has help
solving
problems
Additive:
Lowest score-
Highest
Support
(3-9)
4.67 1.6
(3-9)
.79
-.196
.58
Language
Acculturation
-Language
spoken at home
-Language for
reading
-Language for
thinking
-Language for
talking to
friends
Additive:
Highest score-
Predominance
of English
(4-20)
7.68
4.4
(4-20)
1.66
-2.19
.93
Familism -Relatives
important than
friends.
- Expect
relatives to help
when needed
Additive:
Highest score-
Lowest
familism
(2-8)
3.92
1.38
(2-7)
.35
-.78
.54
Fatalism -Enjoy life now
-People die
when it’s their
time
-Live for present
-Not wise plan
too far ahead
-Can’t change
future, in hands
of God
Additive:
Highest score:
Least fatalistic
(5-20)
8.89
2.50
(5-15)
.41
-.29
.65
45
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Table 4c. Scales for non-Latinas*
COMPONENTS DESCRIPTION
(POTENTIAL
RANGE)
MEAN + SD
(ACTUAL
RANGE)
SKEWNESS
AND
KURTOSIS
CRONBACH
a
Familism -Relatives
important than
friends.
- Expect
relatives to help
when needed
Additive:
Highest score-
Lowest familism
(2-8)
4.20
1.50
(2-8)
.27
-.26
.53
Fatalism -Enjoy life now
-People die
when it’s their
time
-Live for present
-Not wise plan
too far ahead
-Can’t change
future, in hands
o f God
Additive:
Highest score:
Least fatalistic
(5-20)
11.7
3.3
(5-17)
l (
*4^ L *
O
.77
* Social support and language discrepancy were not included in the table, because social
support had an unacceptable Cronbach a (.03) and language discrepancy was an
irrelevant measure for non-Latinas who only spoke English.
Mammograms and Clinical Breast Exam
Sixty-one percent of the women who were surveyed had a mammogram and 72%
had a clinical breast exam within the last year. Sixty-five percent of Latinas received a
mammogram in the last year and 81% had a clinical breast exam. Cross-validation of
endpoints was established between the variable number of mammograms in the last 3
years and time since last mammogram (r=.59).
In this sample, 81% of the women would return to the site where they had their
previous mammogram, and 78% knew someone who had breast cancer.
46
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Barriers
The most frequently barrier cited by all women who did not receive an annual
mammogram was financial difficulties. However, for Latinas the most common barrier
was, “My family is my first priority and I ended up not taking care of my own health.”
The second most common barrier for the whole sample and for Latinas was that they lost
the information from the BCEDP on how to obtain a free mammogram (See Figure 2).
The most important barrier ranked was financial difficulties followed by putting their
family first.
Figure 2. Barriers for adherence to mammography screening guidelines
Barriers for annual mammograms
70%
60%
50%
40%
30%
20%
10%
0%
47
□ Entire Sample
□ Latinas
Fam ily F irst Priority F inancial D ifficulties L ost P ro g ra m
Inform ation
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Biviariate Analysis
A matrix of Pearson correlations for the entire sample is presented in Table 5, and
correlations within the Latina group are shown in Table 9. For Latinas, familism was
significantly correlated with fatalism, language acculturation, social support, and
education. The results of the t-tests (See Table 6) revealed several significant bi-variate
relations for yearly last mammogram: clinical breast exam, familism, and number of
mammograms. Significant differences were found between Latinas and non-Latinas on
education, number of children, and self-breast exam (See Table 7). Additional bivariate
analyses include chi-square tests (See Table 8) that indicate intention at 6 months to be
significantly associated with religious influence on medical decisions, knowledge of
erroneous risk factor, and yearly last mammogram.
Table 5. Correlation Matrix of Scales
FAMILISM FATALISM LANGUAGE
ACCULTURATION
SOCIAL
SUPPORT
Familism 1 .194* .186' .154
Fatalism 1
.419**1
-.048
Language
Acculturation
*
1 -.249**^
Social
Support
1
* = P<.05
**=P<.01
1 The positive correlations are due to scoring, but are in fact inverse associations
2 The negative correlation is due to scoring, but is in fact a positive association.
48
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Table 6. Bivariate Analysis: “t”test (only Latinas)
GROUPING
VARIABLE
MEAN +/- SD OF
GROUPS
T (P LEVEL)
EQUAL
VARIANCES
ASSUMED
T (P LEVEL) EQUAL
VARIANCE NOT
ASSUMED
Yearly
Mammogram
Yes: 3.46+/-.80
No: 2.35+/-1.1
4.4 (p= 000) 3.7(p=.001)
— Yearly Last Mammogram
GROUPING
VARIABLE
MEAN +/- SD OF
GROUPS
T (P LEVEL)
EQUAL
VARIANCES
ASSUMED
T (P LEVEL) EQUAL
VARIANCE NOT
ASSUMED
Clinical Breast
Exam
Yes : 1.53 +/-.65
No: 2.96+/-1.56
-5.6 (p=.000) -4.47 (p=.000)
-Yearly Last Mammogram
GROUPING
VARIABLE
MEAN +/- SD OF
GROUPS
T (P LEVEL)
EQUAL
VARIANCES
ASSUMED
T (P LEVEL) EQUAL
VARIANCE NOT
ASSUMED
Familism Yes: 3.63+/-1.16
No: 4.42+/-1.60
-2.4 (p=.02) -2.2 (p=.03)
— Knowledge of risk factor-family
GROUPING
VARIABLE
MEAN +/- SD OF
GROUPS
T (P LEVEL)
EQUAL
VARIANCES
ASSUMED
T (P LEVEL) EQUAL
VARIANCE NOT
ASSUMED
Clinical Breast
Exam
Yes: 2.25+/-1.33
No: 1.52+/-.90
2.4 (p=.02) 2.7 (p=.007)
49
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Tabic 7. Significant Differences between Latinas and non-Latinas
VARIABLE T VALUE P LEVEL
Education -7.25 .000
Number o f Children 4.40 .000
Self Breast Exam 2.16 .03
Fatalism -2.81 .000
Table 8. Chi-Square Tests (without continuity correction) for Latinas
VALUE SIGNIFICANCE FISHER’S
EXACT TEST
SIGNIFICANCE
Intention 6 months * Religious
influence on medical decisions
6.41 .01
Intention 6 months * Knowledge
of erroneous risk factor-faith
4.06 .05
Intention 6 months * Yearly Last
Mammogram
8.57 .01
Table 9. Correlations for Latina group
FAMILISM
Fatalism .28*
Log of Language Acculturation .25*
Social Support .25*
Education
* P<.05
** P<.01
***p<0Q0
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Multivariate Analysis
The multiple regression models presented are the most parsimonious models that
explain the largest amount of variance. Results from the regression analysis for the entire
sample revealed that the significant predictors for women who receive an annual
mammogram were having more children, having a health professional explain the
importance of regular mammograms, having a clinical breast exams, strong value of
familism, and an absence o f fatalism. Age and education were included as control
variables to ensure that these demographic variables would not confound the results (See
Tables 8a-c). Language acculturation was also controlled for in the multiple regression
analysis that included Latinas.
Separate multiple linear regression analysis for Latinas and non-Latinas revealed
a slightly different set o f predictors, given that having a medical professional explain the
importance of regular mammograms and number of children were only significant for
non-Latinas and familism and fatalism were only significant among Latinas. Clinical
breast exam remained significant in Latinas and non-Latinas (See Tables 10b and 10c).
51
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Table 10a. Multivariate Regression Analysis (Entire Sample)
ADJUSTED
R2 FOR
MODEL
F OF
MODEL
SIG.
OFF
INDEPENDENT
VARIABLES
STANDARDIZE
D P
COEFFICIENT
OF VARIABLE
SIGNIFICANCE
OF
p COEFFICIENT
.48 13.11 0.000 -Clinical Breast .589 .000
Exam
-Familism .213 .006
-Fatalism -.256 .002
-Flealth Provider .223 .003
Recom
mendation
-Number of
Children -.211 .008
-Age
-.078 .274
-Education
-.060 .573
-Language
Acculturation .012 .905
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Table 10b. Multivariate Regression Analysis (Only Latinas)
ADJUSTED
R2 FOR
MODEL
F OF
MODEL
SIG.
OFF
INDEPENDENT
VARIABLES
STANDARDIZED
P COEFFICIENT
OF VARIABLE
SIGNIFICANCE
OF
p COEFFICIENT
.37 7.79 0.000 -Clinical .547 .000
Breast Exam
-Familism .250 .025
-Fatalism -.279 .008
-Age -.134 .168
-Education .062 .611
-Language .015 .896
Acculturation
TablelOc. Multivariate Regression Analysis (Only non-Latinas)
ADJUSTED
R2 FOR
MODEL
F OF
MODEL
SIG.
OFF
INDEPENDENT
VARIABLES
STANDARDIZED
p COEFFICIENT
OF VARIABLE
SIGNIFICANCE
OF
P COEFFICIENT
.66 15.09 0.000 -Clinical .634 .000
Breast Exam
— Health .400 .000
Provider
Recom
mendation
-Number of -.211 .039
Children
-Age .047 .634
-Education -.156 .123
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Summary of Results from Bivariate and Multivariate Analysis
An inverse correlation was found between familism and education as well as,
between familism and language acculturation. Those who had less education and lower
levels of acculturation had more familism. On the other hand, familism was positively
correlated with social support and fatalism. Women who had more social support and
fatalism were more likely to have higher familism scores. Familism, fatalism, and
clinical breast exam were predictors of yearly last mammogram, after controlling for age
and education. Latinas who knew that family history of breast cancer was a risk factor
were more likely to have a clinical breast exam. Number of mammograms in the last 3-4
years and intention at 6 months were significantly associated with yearly last
mammogram. A significant association was detected between knowledge that not having
faith in God was not a risk factor for breast cancer and intentions at 6 months. Not letting
religious beliefs influence medical decisions was also significantly associated with
intention at 6 months.
54
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Figure 3. Heuristic framework for compliance with mammography among
Latinas (Modified model)
Significant interrelations among independent variables, and those, which in turn, predict
the outcomes of interest for Latinas.
p < .0 0 0
p<.05 Yearly Last
Mammogram
Familism
Clinical
Breast Exam
p< .01
.25* .28* p< .01
p<.01
Intention
6 months
p<.01
p<.05
Education
Social
Support
Fatalism Language
Acculturation
(Log)
Knowledge- of
erroneous risk
factor-faith
Knowledge-
of risk
factor-family
Number of
mammograms in
last 3-4 years
Health Care-
Religion
influences medical
decisions
*p < .05; * * p < .0 1 ; * * p < .0 0 0
A heavy line indicates a significant multivariate predictor and a thin line indicates a
significant bivariate association.
1 The positive correlations are due to scoring, but are in fact inverse associations
0 = Negative association
55
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Chapter VII
DISCUSSION
The results from this study corroborate findings from other studies on
mammography among Latinas in California (Ramirez et al., 2000; CDC, 2000). Ramirez
and colleagues randomly selected working residential telephone numbers from San
Diego, California and found mammography rates for Mexican women to be 61%,
(Ramirez et al., 2000) similarly we found 65% for our predominantly Mexican sample.
Nonetheless, these estimates of mammography may be upwardly biased to some degree,
because neither study reached those Latinas with the lowest incomes who may be less
likely to own a telephone.
Not only are mammography and clinical breast exam percentages similar to other
studies, but also the cultural values predictive of last mammography in this study are in
concordance with Suarez and Pulley’s finding (1995). This study along with Suarez and
Pulley’s study affirms that Latinas with a strong sense offamilism are more likely to
obtain mammograms. Our study’s unique contribution of revealing the significant finding
of familism and fatalism in relation to rescreening establishes the importance of cultural
values in not only initial screening but also in regular screening. Given that we
performed a very brief assessment of familism, replication of these preliminary results
from this exploratory study is needed with a well-developed familism scale with good
internal reliability.
Results from the univariate analysis show that the Latinas in our study have low
levels of language acculturation and social support. These low levels of social support
may be due to 89% of the Latinas in our study being bom in Latin America (primarily
56
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from Mexico) and that first generation Mexican-American women have fewer relatives
nearby compared to women of second and third generation (Schaffer and Wagner, 1996).
They also had significantly fewer years of education and significantly more children
compared to non-Latinas. The low levels of acculturation and education place these
Latinas at higher risk to be non-compliant and yet, according to our results it appears that
familism acts as a protective factor in terms of compliance with screening guidelines. A
borderline significant interaction between familism and education ((3.=-.21 p-.07)
indicates that Latinas who have lower levels of education but high familism are more
likely to engage in regular mammography, and a marginally significant interaction
between language acculturation and familism ((3= -.21, p=.07) reveals that Latinas who
have low acculturation and high familism are also more likely to have regular
mammogram. Taken together, the findings from our study encourage future
investigations to explore this hypothesis with a larger and more diverse sample of
Latinas.
In terms of the interrelationships (Figure 3) we find that clinical breast exam,
familism, and intention at 6 months are significantly associated with yearly last
mammogram. Intention at 6 months may be a better predictor of mammography than
intention at one year because it is a shorter time interval and Latinas tend to be more
present time oriented. It may be easier for them to assess how likely they are to have a
mammogram in the next 6 months than in a year when unforeseen events could change
their intention. We also find that women who have knowledge of the erroneous risk
57
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factor for breast cancer and do not let religious beliefs influence decisions to see a doctor
or receive medical tests are more likely to have intentions to have a mammogram in 6
months.
The findings from the present study corroborate several studies that reported no
significant relationships between breast self exam and mammography compliance (Seow
et al., 1997; Schofield, Cockbum, Hill, & Reading, 1994), but did find a significant
relationship with clinical breast exam (Hagoel et al., 1999;Seow et al., 1997). Therefore,
we were able to confirm our hypothesis, in both bivariate and multivariate analysis that
women who engage in clinical breast exam are more likely to obtain regular
mammograms. Increasing the likelihood of receiving a clinical breast exam, was being
more knowledgeable that having a family member with breast cancer increases their risk
of breast cancer.
On the other hand, the results did not support our hypothesis of intention as a
mediator. Intention in this study does not mediate the relationship between past
screening behavior or subjective norms and regular mammogram use. We were not able
to test the other components of the Theory of Planned Behavior due to a lack of variance.
Nevertheless, we did find support for our hypotheses that there are differences in the
predictors for obtaining regular mammograms for Latinas vs. non-Latinas.
58
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It is interesting to note that the survey completion rate was higher among Spanish
speakers (75%) compared to English speakers (52%). We believe this is partially due to
our approach o f incorporating personalismo into our survey administration.
Personalismo has been used in several other studies and interventions to increase
participation and involvement of the Latino community (Teran et al., 2002; Cuellar et al.,
1995).
A particular challenge was tracking low-income women. Over 70% of the sample
was unreachable. A potential explanation for the difficulty in tracking these women may
be due to all the telephone numbers for the potential participants in the study being 3-4
years old, and mobility rates of Latinas being 33% higher than for Whites. Participation
rates for unreachable women could be improved by sending a correspondence that
conveys personalismo to potential participants (emphasizing the importance of their
participation in efforts to improve the health of Latinas) prior to telephone interviews
(Teran et al., 2002). Insight into detailed reasons for nonparticipation could be gained
from semi-structured interviews with low-income women from the community.
O f the women we were able to track, only 22 explicitly refused. On several
occasions a male would refuse participation for the woman being contacted, hence
negating us the opportunity to speak to the potential participant. Other reasons for
refusals were did not speak English or Spanish, death, sick from cancer, or moved to
Mexico.
Also, distrust of medical research among low-income Latinas can hinder
participation. They may feel that they are not truly being told what their participation in
the study entails; it will be more difficult, take more time, or work than originally
59
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presented. These women may have negative connotations of research by assuming they
may be taken advantage of or may be deceived. Suspicion of the intention of the
researcher and possible research queries may be concerns that will intimidate low-income
women from becoming involved with the study. They may also have questionable legal
status and fear that participating in the study may jeopardize their time in the United
States. Low-income women who have low education levels may not participate because
they lack understanding regarding the type of research. Lastly, low-income women may
have heavy work and family demands with fewer resources to alleviate their burden
which may not permit them to participate in a survey.
Limitations
Due to the exploratory nature of the study conducted, several limitations are
inherent in this study. First of all, this is a cross-sectional design; consequently, this
study cannot ascertain directionality or causation. It cannot provide evidence for spatial
relationships nor threats to internal validity such as testing, instrumentation, statistical
regression, and selection. Even though causal inference cannot be drawn, we can still
learn about the correlates of compliance among Latinas given the exploratory nature of
this study. Also, conclusions can be made only in a tentative way, pending further
investigation.
Secondly, these data are limited to BCEDP clients from Los Angeles County;
therefore, the results cannot be generalized to all low-income women in Los Angeles
County because we did not have true random assignment. The participants from the
BCEDP program were an appropriate group to recruit into this study because of the
objectives of the research study. The assumption being that this sample of convenience
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is, “representative of a larger population or differ in systematic ways that can be
understood and explained. It is a big assumption, but a generally necessary one in health
research (Grady and Wallston, 1998).” This threat to external validity must be taken into
consideration, because we under represent certain segments of the low-income Latina
population in Los Angeles County and over represents Latinas that may be more
proactive about their health. These women had the initiative to call the BCEDP referral
line and may be more health oriented; this group of women is therefore not characteristic
of the general low-income population in Los Angeles, for whom compliance with
mammography screening and rescreening guidelines is likely to be poorer. Selection bias
is present because the women voluntarily participate in this study on breast cancer
screening and may have better than expected experiences with mammography than the
general low-income population of women. Hence, the results obtained may be an
overestimation of the true mammography rates for low-income women who do not
contact the BCEDP referral line, because low-income women in the general population
may not exhibit this self-motivation. Selection bias may also impact upon internal
validity. For example, the Latinas in our study may be a group of women who may not
feel that physician recommendation is as important. Thus, caution should be used when
generalizing these findings to other populations, since self-selection bias limits the
internal and external validity of these findings.
Thirdly, our data is exclusively self-report and our mammography rates may be
higher due to a socially desirable response. The mammography rates in this study were
not validated and may not be as accurate as rescreening rates obtained with objective
measures such as medical records. For instance, the rates from the BCEDP are from
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medical records and produce a more conservative estimate (annual rescreening rate of
23%). It is possible that higher estimates based from self-report data are due to
“telescoping” of the time interval between mammograms. Studies that have compared
self-reported annual mammography rates with radiology records have found self-reported
data to be 20% higher (Gilliland, 2000). Future studies with individuals of Mexican
descent, who have been found in other studies to give socially desirable responses (Ross
& Mirowsky, 1984), should include a social desirability scale such as the Marlow-
Crowne Social Desirability Scale short form (Cronbach’s alpha=.58).
Fourthly, this is a retrospective study which introduces recall bias, and previous
studies have found that women tend to underestimate the amount of time since their last
mammogram (Degnan, Harris, Ranney, Quade , Earp, & Gonzalez, 1992). Moreover, the
participant’s ability to report their experience may be affected by how they view the
BCEDP program.
Lastly, we were unable to test the complete culturally based theoretical model that
was proposed in this study. Specifically, our inability to test the constructs of the Theory
of Planned behavior considerably limits our originally proposed model; however,
siginifcant insight can be attained by the data driven heuristic framework for compliance
among Latinas. Further research is necessary to establish measures for the Theory of
Planned Behavior that are culturally appropriate for Latinas and can subsequently be
validated among Latina populations.
From Research to Practice
Our results from the regression analysis indicates that interventions geared at
increasing rescreening rates for Latinas should focus on the importance of the family
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(familism) and its relation to breast cancer rescreening. In other words, interventions
should seek to help women understand that annual mammograms are beneficial to her
and most importantly to her family, because compliance with screening guidelines will
help detect breast cancer early and increase her chance for survival dramatically, which in
turn allows her to take better care of her family. Through this study we also found that
one of the greatest barriers for a Latina is that she will put her family first and does not
have time to receive a mammogram annually; therefore, interventions should help women
understand that by receiving a mammogram she is truly putting her family first.
Perhaps physician recommendation for annual mammograms to Latina patients
could be more efficacious if components of familism were included. Several
interventions have focused on physician reminders to increase screening compliance
(Pearlman, 1997;Weinberg, 1997, Mayer, 2000; Taplin 1994), however, among the
Latina population interventions at the community level that weave familism into their
program have not been implemented.
Interventions focusing on non-Latinas women should still emphasize the
importance of recommendation of a regular mammogram by a health professional.
Our study in conjunction with several other studies has found that recommendation of
regular mammograms by a medical professional as being tremendously important in
motivating a woman to engage in annual mammograms (Champion, 1992, Glanz et al.,
1992, Pearlman et al., 1997, and Phillips et al., 1998). Populations with high percentages
of non-Latinas should implement programs that create health care provider awareness
regarding the significant impact their recommendation has on compliance with
mammography guidelines.
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Intervention Strategies
The following recommendation for a future intervention was developed as a
multicomponent community-based intervention for Latinas. Annual Mammograms in
Latinas (AMIL) would incorporate cultural appropriateness and sensitivity based on the
model proposed from the results of this study (the acronym can be modified if screening
recommendations or technology changes). Given that Latinas have limited access to
information and are a difficult population to reach (Navarro et al., 1998), the strategy
would be to approach breast cancer screening as a family issue rather than just a women’s
issue. It is not enough to send out informational booklets on breast cancer screening, as
implemented in the past (Bastani et al., 1994). A study conducted with women over the
age of 40 residing in Los Angeles by Bastani et al. found no significant difference
between the group of women who received a booklet via mail and the control group
(Bastani et al., 1994). The optimal intervention for Latinas incorporates several
approaches, ranging from tailored individualized outreach to group and family
presentations.
Studies have found that Latinas respond well to personal or small group
interaction with women who resemble them (Hiatt et al., 2000; Castro et al., 1995).
Hence, Promotoras or peer health workers would provide health education, referrals for
screening, and act as the liaison between the research team and the community of
targeted Latinas. In AMIL, the Promotora would encourage and persuade Latinas within
the community to obtain mammograms on a yearly basis. They would educate while
understanding and reinforcing the common identity shared with the Latinas. By utilizing
the Promotoras the lack of understanding or indifference toward the Latina cultural
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health perspective by health care providers is ameliorated. Culturally competent services
are crucial in order to improve patient adherence by increasing the understanding
between physician and patient. When patients receive information in their preferred
language and when health care providers take into account patients’ cultural beliefs and
practice then patient centeredness and quality care are achieved (Hurtado, Swift, &
Corrigan, 2001). A culturally competent physician is aware of how cultural health beliefs
and practices influence a person’s health seeking behavior and is able to arrange medical
procedures in a culturally sensitive manner (Chin, 2000)
Promotoras understand Latino beliefs regarding how to seek health care and treat
illness. In addition to sharing the language, attitudes, and beliefs of the target community,
Promotoras selected from the community would be 1) actively involved in their
community 2) have leadership potential 3) show an interest in participating in a breast
cancer prevention program (Castro et al., 1995). Overseeing the group of Promotoras
would be the Promotora director (See figure 4). She would help shape the Promotoras
skills through role playing that emphasizes the importance of the positive aspects of
familism while highlighting the negative effects of fatalism. Training would include
guest lectures, sample activities to use with participants, and group discussion on how to
resolve potentially difficult questions or situations. Another vital role for the director of
the Promotoras would be to bridge the gap between the Promotoras and researchers. She
would coordinate the efforts between the Promotoras and researchers, so that protocols
are developed to collect quality data while ensuring that a culturally sensitive intervention
could be maintained.
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The intervention efforts would include health education on the recommended
screening guidelines for the whole family. Mother-daughter workshops/events and
outreach that includes husbands/boyfriends would reinforce familism. These workshops,
events and other types of outreach would be lead by Promotoras. By using Promotoras
the program ensures that interventions would disseminate breast cancer screening
messages in a culturally appropriate manner and would promote familism while
countering fatalism. Since Promotoras are from the target community and would
establish a relationship with the participants in the intervention, it would be more
effective to have the Promotora recommend and send reminders for screening on an
annual basis. This may be especially relevant for Latinas given the finding in our study
that indicates health care provider recommendation is not a predictor of mammography.
A possible explanation for the lack of a significant finding in regards to recommendation
may stem from Latinas’ distrust of health care professionals (Fox and Stein, 1991).
In all aspects of the intervention personalismo will be incorporated. Personal
relationship between the Promotoras as well as with the community members is vital
when working with the Latina population. Whereas interventions focusing on White
women may find it sufficient to target physicians in order to increase screening
recommendations, interventions for Latinas must explore other culturally appropriate
avenues, and create program material with collaboration from those who have substantial
knowledge and working experience with the Latino community.
Intervention Possibilities
1) Beauty salon- one-on-one brief educational session while waiting for or
getting service. A brief baseline questionnaire would be administered to
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establish annual mammography use, fatalism, familism and barriers. After the
session the telephone number of the participant would be acquired and the
surveys would be sent back to the research team to analyze. After the analysis
is complete, the results would be sent back to the Promotoras to use in a brief
telephone intervention with the participant. The telephone intervention would
help reinforce familism while weakening fatalism. The Promotora would also
offer solutions to overcome the barriers to obtaining an annual mammogram
(e.g. help with scheduling an appointment).
2) Promotora created parties- would include the whole family and consist of
educational classes, games, prizes, and referrals.
3) Fotonovela- especially designed to address identified barriers such as, “My
family is my first priority and I ended up not taking care of my own health”
and financial difficulties. The cultural values offamilism and fatalism would
be woven into the storyline. Promotoras, that members from the community
could identify with, would be the actors.
4) Birthday card- with the AMIL logo and reminder for a free annual
mammogram as well as an invitation to call the Promotoras with any
questions, concerns, or problems regarding mammograms.
5) Family events- Particularly helpful would be the incorporation of familism as
a mechanism for outreach to Latinas with high risk o f breast cancer. By
including the extend family, such as grandmother, aunts, and cousins, the
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message of annual screening would be conveyed in a family context with a
deeper understanding of the importance of mammography.
Figure 4. Structure of the AMIL Program Personnel
Assistants Student
Assistants
Research
Director
Promotora
Director
Production
Director
Promotoras
Principal
Investigator
BCEDP
-Referral to
mammography site
YWCA Encore Plus
Program
-On site
mammography
Evaluation
A crucial component of the intervention program will be process and outcome
evaluations using qualitative and quantitative methods. Process evaluation will give the
program implementers an opportunity to assess the performance and intensity of the
instruction given by the Promotoras, and to determine which parts of the program
worked. Promotoras will be given a pretest prior to receiving the training and a post-test
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after completing the training to assess their levels of knowledge and skill attainment. To
monitor and evaluate the quality of information given to participants during the
workshops or events, the Promotora director will develop a content checklist. The
checklist will be completed by the Promotoras at the end of each workshop or event.
Also, workshops will be randomly video taped and evaluated to assess for the quality,
quantity, and accuracy o f information being taught in the workshop sessions. The results
will be shared with the members from the research team to make adjustments if necessary
and with the Promotoras for the purpose of strengthening their skills. The outcome
evaluation design will be a quasi experimental approach using nonequivalent control
group, pretest-post-test. Knowledge, attitude, values, intention and behavior will be some
of the constructs used to measure program effectiveness. Qualitative information will be
gathered through focus groups and semi-structured interviews to provide insight on
participants’ experiences and program process (Dignan and Carr, 1992).
International Perspective
The relevance of this research study may extend to minority women in other
countries. The incidence and mortality rates in Mexico are increasing and a significant
proportion of women in Latina America are being diagnosed for breast cancer at a late
stage (Schwartsmann, 2001; Tovar-Guzman, Hemandez-Giron, Lazcano-Ponce, Romieu,
and Avila, 2000). Hence, breast cancer interventions that cater to Latina cultural values
are vital to early detection. For minority populations in other countries, cultural values
should be considered when designing intervention programs and trying to increase
mammography among minority ethnic groups. To begin with, studies should be
conducted in other countries that have growing minority population to discover the
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cultural values that are most salient. We cannot assume that the predictors are the same
for minority women as for women in the dominant culture. A personalized letter or
greeting card could be sent that informs the woman of the concern for their health and
invites them to participate in screening and rescreening mammography. The letters sent
should be customized to reflect the appropriate cultural values, and care should be taken
to ensure that all mailings appear friendly and inviting, so that it is not feared or
discarded.
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Chapter VIII
CONCLUSION
As was emphasized, the lack of research with Latinas on compliance with
mammography screening guidelines in conjunction with increasing breast cancer
incidence and mortality rates is a serious public health problem and underscores the need
for such exploratory investigations as a crucial first step for further investigations of
mammography adherence among low-income Latinas. Results from this study and
implementation/evaluation o f AMIL can help inform policy geared towards increasing
rescreening mammography among Latinas
This research follows the recommendation Baezconde-Garbanati and colleagues
(1999) made regarding improving Latina health through greater involvement not only
from the research community but through the development of partnerships with
community-based organizations. The collaborative efforts of the BCEDP and Encore Plus
lead to a partnership between the research community and community-based organization
to improve the breast cancer rescreening rates of Latinas. The BCEDP has served
108,853 women between 1994-1998, and continues to increase the number of women
screened in Los Angeles County (Partnered for Progress, 1999). Nevertheless,
improvements in rescreening rates are vital for the program to be successful in achieving
its mission to decrease breast cancer mortality in California. This study helped shed light
on the determinants of rescreening for breast cancer among women who contacted the
BCEDP referral line that can be used to make improvements within the Partnership to
increase compliance.
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Future longitudinal studies with a large representative Latina population, multiple
measures of cultural values, and objective measures are urgently needed to confirm our
findings. This would provide insight prior to screening and following screening on
cultural and psychosocial factors, which at the present time is nonexistent in the breast
cancer rescreening literature, and would help better determine the varying predictors
among low-income Latinas and breast cancer rescreening behavior. Nevertheless, the
results generated from this study helped its main purpose, which is to guide the design of
culturally tailored interventions by incorporating cultural values such as familism and
fatalism, so that Latinas will be screened regularly in order to avoid late stage diagnosis,
and ultimately to reduce cancer mortality through compliance with screening
recommendations.
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REFERENCES
Ajzen, I. (1985). From intention to actions: A theory of planned behavior. In J.
Kuhl & J.Beckman (Eds.), Action -control: From cognition to behavior. Heideleberg:
Spriner.
American Cancer Society (1997). American Cancer Society guidelines for the
early detection of breast cancer: Update 1997. CA: a Cancer Journal for Clinicians, 47,
150-153.
American Cancer Society (2003). Breast Cancer Facts and Figures 2003-4.
Retrieved March 12,2003, from http://www.cancer.org/downloads/STT/CAFF2003
BrFPWSecured.pdf.
American Medical Association (1999). Report 16 of the Council on Scientific
Affairs(A-99). Mammographic Screening for Asymptomatic Women. Retrived April 8,
2003 from http://www.ama-assn.org/ama/pub/article/2036-2346.html.
Andersson, I., Aspegren, K., Janzon, L., Landberg, T., Lindholm, K., Linell, F.,
Ljungberg, O., Ranstam, J., & Sigfusson, B. (1988). Mammographic screening and
mortality from breast cancer: the Malmo mammographic screening trial. British Medical
Journal. 297, 943-948.
Baezconde-Garbanati, L., Portillo, C.J., & Garbanati, J.A. (1999). Disparities in
health indicators for Latinas in California. Hispanic Journal of Behavioral Sciences.
21,302-329.
Balacazar, H., Castro, F.G., & Krull, J.L. (1995). Cancer risk reduction in
Mexican American women: The role of acculturation, education, and health risk factors.
Health Education Quarterly, 22, 61-84.
Baker, S., Morrison, D., Carter, W., & Verdon, M. (1996). Using the theory of
reasoned action (TRA) to understand the decision to use condoms in an STD clinic
population. Health Education Quarterly. 23, 528-542.
Bastani, R., Kaplan, C.P., Maxwell, A.E., Nisenbaum, R., Pearce, J., & Marcus,
A.C. (1994). Initial and repeat mammography screening in a low-income multi-ethnic
population in Los Angeles. Cancer Epidemiology. Biomarkers and Prevention. 4, 161-
167.
Bastani, R., Marcus, A.C., & Hollatz-Brown, A. (1991). Screening
mammography rates and barriers to use: A Los Angeles County survey. Preventive
Medicine. 20, 350-363.
73
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Baumann, L.J., Brown, R.L., Fontana, S.A., & Cameron, L. (1993). Testing a
model of mammography intention. Journal of Applied Social Psychology. 23, 1733-
1756.
Beaulieu, M.D., Beland, F., Roy, D., Falardeau, M., & Hebert, G. (1996). Factors
determining compliance with screening mammography. Canadian Meidcal
Association Journal. 154, 1335-43.
Blackman, D.K., Bennett, E.M., & Miller, D.S. (1999). Trends in self-reported
use of mammograms (1989-1997) and Papanicolaou test (1991-1997)-Behavioral Risk
Factor Surveillance System. Morbidity and Mortality Weekly Report, 48,1-24.
Burton, M.V., Warren, R., Price, D., & Earl, H. (1997). Psychological predictors
of attendance at annual breast screening examinations. British Journal of Cancer. 77,
2014-2019.
Calle, E. E., Flanders, W.D., Thun, M.J., & Martin, L.M. (1993). Demograhpic
predictors of mammography and pap smear screening in US women. American Journal
of Public Health. 83, 53-60.
Canto, J.G., Jeroan, A.J., Kiefe, K.I., Fincher, C., Farmer, R., Sekar, P., Person,
S., & Weissman, N.W. (2000). Relation of race and sex to the use of reperfusion therapy
in medicare beneficiaries with acute myocardial infarction. New England Journal of
Medicine. 342,1094-1100.
Caplan, L.S., Wells, B.L., and Haynes, S. (1992). Breast cancer screening among
older racial/ethnic minorities and Whites: Barriers to early detection. Journal of
Gerontology. 47,101-110.
Castro, F.G., Elder, J., Coe, K., Tafoya-Barraza, H.M., Moratto, S., Campbell, N.,
& Talavera, G. (1995). Mobilizing churches for health promotion in Latino
communities: Companeros en la salud. Journal of the National Cancer Institute
Monographs. 18, 127-135.
Center for Disease Control and Prevention (2002). Fast Stats Mammography.
Retrived October 27, 2002 from http://www.cdc.gov/nchs/fastats/mammogram.htm.
Center for Disease Control and Prevention (2000). Behavioral Risk Factor
Surveillance System. Retrived June 6,2003 from http://apps.nccd.cdc.gov/brfss/race.asp?
cat=WH&yr=2000&qkey= 1984&state=C A.
Champion, V. L. (1992). Compliance with guidelines for mammography
screening. Cancer Detection and Prevention. 16, 253-258.
74
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Champion, V.L. (1994). Relationship of age to mammography compliance.
Cancer. 74, 329-335.
Chavez, L.R., Cornelius, W.A., & Jones, O.W. (1985). Mexican immigrants and
utilization of U.S. health services: The case of San Diego. Social Sciences and Medicine.
2, 93-102.
Chavez, L.R., Hubbell, F.A., McMullin, J.M., Martinez, R.G., & Mishra, S.I.
(1995). Structure and meaning in models of breast and cervical cancer risk factors: A
comparison of perceptions among Latinas, Anglo women, and physicians. Medical
Anthropology Quarterly. 9, 40-74.
Chin, J.L. (2000). Viewpoint on cultural competence: Culturally competent health
care. Public Health Reports. 115,25-33.
Choca, P.R.(1979). Dysfunctional Mexican-American family patterns and
strategies for intervention. In: P.P. Marin (Ed.), La frontera perspective, providing
mental health services for Mexican Americans. Tucson, AZ: La Frontera Center Inc.
Collette, J.H., Day, N.E., Rombach, J.J., & DeWaard F. (1984). Evaluation of
screening for breast cancer in a non-randomized study by means of a case-control study.
Lancet. 1,1224-1226.
Cuellar, I., Arnold, B., & Gonzales, G. (1995). Cognitive referents of
acculturation : Assessment of cultural constructs in Mexican Americans. Journal of
Community Psychology. 23, 339-356.
Day, N.E., Williams, D.R., & Khaw, K.T. (1989). Breast cancer screening
programmes: The development of a monitoring and evaluation system. British Journal of
Cancer. 59, 954-958.
Degnan, D., Flarris, R., Ranney, J., Quade, D., Earp, J.A., & Gonzalez, J. (1992).
Measuring the use of mammography: two methods compared. American Journal of
Public Health. 82. 1386-1388
Dibble, S.L., Vaoni, J.M. & Miakowski, C. (1997). Women’s attitudes towards
breast cancer screening procedures: Differences by ethnicity. Women’s Health Issues. 7,
47-54.
Dignan, M.B. and Carr, P.A. (19921. Program Planning for Health Education and
Health Promotion. Phildadephia, PA:Lea and Febiger.
75
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Duffy, S.W., Tabar, L., Chen, H.H., Holmqvist, M., Yen, M.F., Abdsalah, S.,
Epstein, B., Frodis, E., Ljungberg, E., Hedborg-Melander, C., Sundbom, A., Tholin, M.,
Wiege, M., Akerlund, A., Wu, H.M., Tung, T.S., Chiu, Y.H., Chiu, C.P., Huang, C.C.,
Smith, R.A., Rosen, M., Stenbeck, M., & Holmberg, L. (2002). The impact of organized
mammography service screening on breast carcinoma mortality in seven Swedish
counties. Cancer. 95, 458-469.
Eidson, M., Becker, T.M., Wiggins, C.L., Key, C.R., and Samet, J.M.(1994).
Breast cancer among Hispanics, American Indians and non-Hispanic whites in New
Mexico. International Journal of Epidemiology. 23, 231-237.
Ekblad, S., Belkic, K., & Eriksson, N.G. (1996). Health and disease among
refugees and immigrants. A quantitative review approaching meta-analysis, implications
for clinical practice and perspectives for further research. (Rep No. 267). National
Institute for Psychosocial Factors and Health, Department of Stress Research, Karolinska
Institute, WHO Psychosocial Center.
Elder, J.P., Castro, F.G., de Moor, C., Mayer, J., Candelaria, J., I., Campbell, N.,
Talavera, G., & Ware, L.M. (1991). Differences in cancer-risk related behaviors in
Latino and Anglo adults. Preventive Medicine. 20, 751-763.
Elwood, M., McNoe, B., Smith, T., Bandaranayake, M., Adam, H., & Doyle, T.
(1998). Once is enough-why some women do not continue to participate in a breast
cancer screening program. New Zealand Medical Journal, 111, 180-184.
Evans, A.(2000). Beneficial effects of screening women aged 40-49. European
Journal of Cancer, 36, S43.
Fletcher, S.W., Black, W., Harris, R., Rimer, B.K., & Shapiro, S. (1993). Report
on the international workshop on screening for breast cancer. Journal of the National
Cancer Institute. 85, 1644-1656.
Fox, S.A. & Roetzheim, R.G. (1994). Screening mammography and older
Hispanic women. Cancer, 74, 2028-2033.
Fox, S.A. & Stein, J.A. (1991). The effect of physician-patient communication on
mammography utilization by different ethnic groups. Medical Care, 29, 1065-1082.
Frisell, J., Eklund, G., Hellstrom, L, Lidbrink, E., Rutqvist, L.E., & Somell, A.
(1991). Randomized study of mammography screening— preliminary report on mortality
in the Stockholm trial. Breast Cancer Research Treatment, 18.49-56.
Fulton, J.P., Rakowski, W., & Jones, A.C. (1995). Determinants of breast cancer
screening among inner-city Hispanic women in comparison with other inner-city women.
Public Health Reports, 118,476-482.
76
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Gemson, D.H., Elison, J., & Messeri, P. (1998). Differences in physician
prevention practice patterns for White and minority patients. Journal of Community
Health, 13, 53-64.
Garcia, R.E. (1995). L.A.Countv Breast Cancer Early Detection Program-
Partnered for Progress. Summary findings of focus groups conducted with various ethnic
groups and special populations. Los Angeles, CA: Partnered for Progress
Geiger, H.J. (2001). Racial stereotyping and medicine: The need for cultural
competence. Canadian Medical Association Journal, 164, 1699-1701.
Gilliland, F.D., Hunt, W.C., & Key, C.R. (1998). Trends in the survival of
American Indian, Hispanic, and Non-Hispanic White cancer patients in New Mexico and
Arizona, 1969-1994. Cancer. 82, 1769-1783.
Gilliland, F.D., Rosenberg, R.D., Hunt, W.C., Stauber, P., & Key, C.R. (2000).
Patterns of mammography use among Hispanic, American Indian, and non-Hispanic
White women in New Mexico, 1994-1997. American Journal of Epidemiology. 152,
432-437.
Glanz, K., Resch, N., Lerman, C., Blake, A., Gorhcov, P. M., & Rimer, B. K.
(1992). Factors associated with adherence to breast cancer screening among working
women. Journal of Occupational Medicine. 34,1071-1077.
Godin, G., & Kok, G. (1996). The theory of planned behavior: A review of its
application to health-related behaviors. American Journal of Health Promotion. 11, 87-
98.
Goldsmith, M.F. (1993). Hispanic/Latino health issues explored. Journal of the
American Medical Association, 269,1603.
Hagoel, L., Ore, L., Neter, E., Shifroni, G., & Rennert, G. (1999). The gradient in
mammography screening behavior: A lifestyle marker. Social Science Medicine. 48,
281-290.
Hayward, R.A., Shapiro, M.F., Freeman, H.E., & Corey, C.R. (1988). Who gets
screened for cervical and breast cancer? Results from a new national survey. Archives of
Internal Medicine. 148, 1177-1181.
Hedegaard, H.B., Davidson, A.J., & Wright, R.A. (1996). Factors associated with
screening mammography in low-income women. American Journal of Preventive
Medicine. 12, 51-56.
77
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Hiatt, R.A., Pasick, R.J., Stewart, S.S., Bloom, J., Davis, P., Gardiner, P.,
Johnston, M., Luce, J., Schorr, K., Brunner, W., & Stroud, F. (2001). Community-based
cancer screening for underserved women: design and baseline findings from the breast
and cervical cancer intervention study. Preventive Medicine. 33, 190-203.
House, J. & Kahn, L. (1985). Measures and concepts of social support. In: S
Cohen, L Syme (Eds.), Social Support and Health (p.85). New York: Academic Press.
Hurtado, M.P., Swift, E.K., & Comigan, J.M. (Eds.). (2000). Envisioning the
national healthcare quality report. Washington, DC: National Academy Press.
Hubbell, F.A., Mishra, S.I., Chavez, L.R., & Valdez, R.B. (1997). The influence
o f knowledge and attitudes about breast cancer on mammography use among Latinas and
Anglo women. Journal of General Internal Medicine. 12, 505-508.
Humphrey, L.L., Helfand, M., Chan, B.K., & Woolf, S.H. (2002). Breast cancer
screening: a summary of the evidence for the U.S. Preventive Services Task Force.
Annals of Internal Medicine. 137, 347-360.
Laws, M.B. & Mayo, S.J. (1998). The Latina breast cancer control study, year
one: Factors predicting screening mammography utilization by urban Latina women in
Massachusetts. Journal of Community Health, 23. 251-267.
Lechner, L., Vries, H., & Offermans, N. (1997). Participation in a breast cancer
screening program: Influence of past behavior and determinants on future
screening participation. Preventive Medicine. 26, 473-482.
Lee, J.L. & Vogel, V.G. (1995). Who uses screening mammography regularly?
Cancer Epidemiology. Biomarkers and Prevention. 4, 901-906.
Li, C.I., Malone, K.E., & Daling, J.R. (2003). Differences in breast cancer stage,
treatment and survival by race and ethnicity. Archives of Internal Medicine. 163, 49-56.
Lobell, M., Bay, R.C., Kelton, V.L.,Rhodes, M.A., & Keske, B.(1998). Barriers to
cancer screening in Mexican American women. Mavo Clinic Proceedings. 73, 301- 308.
Marin, G., Sabogal, F., VanOss Marin, B., Otero-Sabogal, R., & Perez-Stable,
E.J. (1987). Development of a short acculturation scale for Hispanics. Hispanic Journal
of Behavioral Sciences. 9,183-205.
May, D.S., Kiefe, C.I., Funkhouser, E., & Fouad, M.N. (1999). Compliance with
mammography guidelines: Physician recommendation and patient adherence. Preventive
Medicine. 28, 386-394.
78
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
May,D.S., Lee, N.C., Richardson, L.C., Giustozzi, A.G., & Bobo, J.K. (2000).
Mammography and breast cancer detection by race and Hispanic ethnicity: Results from
a national program. Cancer Causes and Control. 11, 697-705.
Mayer, J.A, Lewis, E.C., Slymen, D.J., Dullum, J., Kurata, H., Holbrook, A., &
Elder, J. Patient reminder letters to promote annual mammograms: A randomized
controlled trial. Preventive Medicine. 31,315-322.
Miller, A. M. & Champion, V. L. (1993). Mammography in women <50 years of
age: Predisposing and enabling characteristics. Cancer Nursing, 16, 260-269.
Miller, A.M. & Champion, V.L. (1996). Mammography in older women: One
time and three-year adherence to guidelines. Nursing Research. 45, 239-245.
Millstein, S. (1996). Utility of the theories of reasoned action and planned
behavior for predicting physician behavior: A prospective analysis. Health Psychology.
15, 398-402.
Molina, C., Zambrana, R.E., & Aguirre-Molina, M. (1994). The influence of
culture, class, and environment on health care. In C.W. Molina & Aguirre-Molina (Eds),
Latino Health in the US: A Growing Challenge (pp.25-43). Washington, DC: American
Public Health Association.
Montano, D.E. & Taplin, S.H. (1991). A test of an expanded Theory of
Reasoned Action to predict mammography participation. Social Science Medicine. 32,
733-741.
Morgan, C., Park, E., & Cortes, D.E. (1995). Beliefs, knowledge, and behavior
about cancer among urban Hispanic women. Journal o f the National Cancer Institute
Monographs. 18, 57-63.
Munoz, E. (1988). Care for the Hispanic poor: A growing segment of American
Society. Journal of the American Medical Association. 260,2711-2712.
National Cancer Institute (1999). Screening Mammograms 1999. Retrieved
December 21, 2001 from www.cancemet.nci.nih.gov.
National Cancer Institute (2002). Cancer Facts. Retrieved October 27, 2002, from
www.cis.nci.nih.gov/fact/5_6.htm.
Navarro, A.M., Senn, K.L., McNicholas, L.J., Kaplan, R.M., Roppe, B., & Camp,
M.C. (1998). Por la Vida model intervention enhances use of cancer screening tests
among Latinas. American Journal of Preventive Medicine. 15, 32-41.
79
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
O’Brien, K., Cokkinides, V., & Thun, M. (2001). Cancer Facts and Figures for
Hispanics 2000-2001. Retrieved April 1, 2003, from http://www.cancer.org/docroot/
STT/stt_0_2001 .asp?sitearea=STT&level=l.
O’Malley, A.S., Mandelblatt, J., Gold, K., Cagney, K.A., & Kemer, J. (1997).
Continuity of care and the use of breast and cervical cancer screening services in a
multiethnic community. Archives of Internal Medicine. 157, 1462-1470.
Partnered for Progress (1999, November). BCEDP Quality Indicator Report
(Issue No. 4). Los Angeles, CA: Author.
Pearlman, D.N., Rakowski, W., Clark, M.A., Ehrich, B.R., Goldstein, M.G.,
Woolveronton, H., & Dube, C.E. (1997). Why do women’s attitude toward
mammography change over time? Implications for physician-patient communication.
Cancer. Epidemiology. Biomarkers and Prevention, 6, 451-457.
Peniagua, F.A. (1994). Assessing and treating culturally diverse clients: A
practical guide. Thousand Oaks, CA: Sage Publications.
Perez-Stable, E.J., Otero-Sabogal, R., Sabogal, F., Haitt, R.A., and McPhee, S.J.
(1992). Misconceptions about cancer among Latinos and Anglos. Journal of American
Medical Association. 268, 3219-3223.
Perez-Stable, E.J., Otero-Sabogal, R., Sabogal, F., McPhee, S.J., & Hiatt, R.A.
(1994). Self-reported use of cancer screening tests among Latinos and Anglos in a
prepaid health plan. Archives of Internal Medicine. 154,1073-81.
Perez-Stable, E.J., Sabogal, F., & Otero-Sabogal, R. (1995). Use of cancer-
screening tests in the San Francisco bay area: Comparison of Latinos and Anglos.
Journal of the National Cancer Institute Monographs. 18, 147-153.
Phillips, K.A., Kerlikowske, K., Baker, L.C., Chang, S.W., & Brown, M.L.
(1998). Factors associated with women’s adherence to mammography screening
guidelines. Health Services Research. 33, 29-53.
Rakowski, W., Rimer, B. K., & Bryant, S. A. (1993). Integrating behavior and
intention regarding mammography by respondents in the 1990 national health
interview survey of health promotion and disease prevention. Public Health Reports. 108,
605-624.
Ramirez, A. G., Talavera, G. A., Villarreal, R., Suarez, L., McAlister, A.,
Trapido, E., Perez-Stable, E., & Marti, J. (2000). Breast cancer screening in regional
Hispanic populations. Health Education Research. 15, 559-568.
80
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Rimer, B.K, Trock, B., Engstrom, P.F., Lerman, C., & King, E. (1991). Why do
women get regular mammograms. American Journal of Preventive Medicine. 7, 69-74.
Roetzheim, R.G., Van Durme, D.J., Brownlee, H.J., Herold, A.H., Wooward, L.J.,
& Blair, C. (1993). Barriers to screening among participants of a media-promoted breast
cancer screening project. Cancer Detection and Prevention, 17, 367-377.
Ross, C.E. & Mirowsky, J. (1984). Socially-desirable responses and acquiescence
in a cross-cultural survey of mental health. Journal of Elealth and Social Behavior. 25,
189-197.
Rutledge, E.O. (2001). The struggle for quality in healthcare continues. Journal
of Healthcare Management. 46, 313-326.
Sabogal, F., Marin, G., Otero-Sabogal, R., Van Oss Marin, B., & Perez-Stable,
E.J. (1987). Hispanic familism and acculturation: What changes and what doesn’t.
Hispanic Journal of Behavioral Sciences. 9, 397-412.
Schaffer, D.M. & Wagner, R.M. (1996). Mexican American and Anglo single
mothers: The influence of ethnicity, generation, and socioeconomic status on social
support networks. Hispanic Journal of Behaviorl Sciences, 18, 74-86.
Schofield, P.E., Cockbum, J., Hill, D.J., & Reading, D. (1994). Encouraging
attendance at a screening mammography program: determinants of response to different
recruitment strategies. Journal of Medical Screening, 1, 144-149.
Schwartsmann, G. (2001). Breast cancer in South America: Challenges to
improve early detection and medical management o f a public health problem. Journal of
Clinical Oncology. 19, 118S-124S.
Seow, A., Straughan, P.T., Ng, E.H., Emmanuel, S.C., Tan, C.H., & Lee, H.P.
(1997). Factors determining acceptability o f mammography in Asian population: A study
of women in Signapore. Cancer Causes and Control, 8, 771-779.
Skaer, T.L., Robinson, L.M., Sclar, D.A. & Harding, D.H. (1996). Cancer
screening determinants among Hispanic women using migrant health clinics. Journal of
Health Care for the Poor and Underserved. 17, 338-54.
Solis, J. M., Marks, G., Garcia, M., & Shelton, D. (1990). Acculturation, access to
care, and use of preventive services by Hispanics; Findings from HHANES 1982-1984.
American Journal of Public Health. 80,11-19.
Solomon, L.J., Mickey, R.M., Rairikar, C.J., Worden, J.K., Sc Flynn, B.S. (1998).
Three-year prospective adherence to three breast cancer screening modalities.
Preventive Medicine. 27, 781-786.
81
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Song, L. & Fletcher, R. (1998). Breast cancer rescreening in low-income women.
American Journal of Preventive Medicine. 12, 128-133.
Soto, M.A., Behrens, R., & Rosemont, C. (Eds.). (1990). Healthy People 2000:
Citizens Chart the Course. Washington, D.C.: National Academy Press.
Stein, J.A. & Fox, S.A. (1990). Language preference an indicator of
mammography use among Hispanic women. Journal of the National Cancer Institute. 7,
1715-1716.
Stein, J.A., Fox, S.A., & Murata, P.J. (1991). The influence of ethnicity,
socioeconomic status, and psychological barriers on the use of mammography. Journal of
Health and Social Behavior. 32,101-113.
Stoddard, A.M., Emier, B.K., Lane, D., Fox, S., Lipkus, I., Luckman, R.,
Awrunin, S., Sprachman, M., & Urban, N. (1998). Underusers of mammogram
screening: Stages of adoption in five U.S. subpopulations. Preventive Medicine. 27,
478-487.
Suarez, L. (1994). Pap smear and mammogram screening in Mexican American
women: The effects of acculturation. American Journal of Public Health, 84, 742-746.
Suarez, L. & Pulley, L. (1995). Comparing acculturation scales and their
relationship to cancer screening among older Mexican American women. Journal of the
National Cancer Institute Monographs, 18,41-47.
Suarez, L., Roche, R.A., Nichols, D., & Simpson, D.M. (1997). Knowledge,
behaviors and cervical cancer among older low-income Mexican-American women.
American Journal of Preventive Medicince. 12, 137-142.
Sutton, S.R. (1994). The past predicts the future: interpreting behavior-behavior
relationships in social psychological models of health behavior. In D.R. Tutter
and L.Quine (Eds.). Social Psychology and Health-European Perspectives, 71-88.
Tabar, L., Fagerberg, C.G., Gad, A. (1985). Reduction in mortality from breast
cancer after mass screening with mammography. Lancet. 1, 829-832.
Tabar, L., Larsson, L., Andersson, I., Duffy, S.W., Nystrom, L., Rutqvist, L.E.,
Alexander, F., Baines, C.J., Miller, A.,B., Bjurstam, N., Chen, H., Day, N.E., Fagerberg,
G., Frisell, J, Immonen, P., Forids, E., Paci, E., Shapiro, S.,Thurfjell, E., Wall, S., &
Burhenne, L.W. (1996). Breast cancer screening with mammography in women aged 40-
49 years. International Journal of Cancer. 68, 693-699.
82
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Tabar, L., Vitak, B., Chen, H.H., Yen, M.F., Duffy, S.W., and Smith, R.A.
(2001). Beyond randomized controlled trials: organized mammographic screening
substantially reduces breast carcinoma mortality. Cancer. 91,1724-1731.
Tabar, L., Yen, M.F., Vitak, B„ Chen, H.H., Smith, R.A., Duffy, S.W. (2003).
Mammography service screening and mortality in breast cancer patients: 20-year follow-
up before and after introduction of screening. Lancet. 361, 1405-1410.
Taplin, S.H., Anderman, C., Grothaus, L., Curry, S., & Montano, D. (1994).
Using physician correspondence and postcard reminders to promote mammography use.
American Journal of Public Health. 84, 571-574.
Teran, L.M., Belkic, K.L., Johnson, C.A. (2002). An exploration of psychosocial
determinants of obesity among Hispanic women. Hispanic Journal of Behavioral
Science. 24, 92-103.
The Workshop Group (1989). Reducing deaths from breast cancer in Canada.
Canadian Medical Association Journal. 141, 199-201.
Tortolero-Luna, G., Glober, G.A., Villarreal, R., Palos, G., & Linares, A. (1995).
Screeening practices and knowledge, attitudes, and beliefs about cancer among Hispanic
and non-Hispanic White women 35 years old or older in Nueces County, Texas. Journal
of the National Cancer Institute Monographs. 18,49-56.
Tovar-Guzman,V., Hemandez-Giron, C., Lazcano-Ponce,E., Romieu, I., &
Avila, M.H. (2000). Breast cancer in Mexican women: An epidemiological study with
cervical cancer control. Saude Publica. 34, 113-119.
Tu, S.P., Taplin, S.H., Barlow, W.E., & Boyko, E.D. (1999). Breast cancer
screening by Asian-American women in a managed care environment. American Journal
of Preventive Medicine. 17, 55-60.
Unger, J.B., Ritt-Olson, A., Teran, L., Huang, T., Hoffman, B.R., & Palmer, P.
(2002). Cultural values and substance use in a multiethnic sample of California
adolescents. Addiction Research and Theory. 10, 257-279.
US Census Bureau (2000). The Hispanic population in the United States: 1999.
Current Population Reports, Series P20-527. Retrived April 13,2003 from
http://www.census.gov/prod/2000pubs/p20-527.pdf.
US Census Bureau (2002). Hispanic population in the United States 2002 March
CPS. Retrived March 13, 2004 from http://www.census.gov/population/www/socdemo
hispanic/ho02.html.
83
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
US Census Bureau (2003). 2003 Statistical Abstract of the United States. Retrived
March 13, 2004 from http://www.census.gov/prod/www/statistical-abstract-03.html.
U.S. Preventive Services Task Force (2002). Recommendations and Rationale:
Screening for Breast Cancer. Retrieved April7, 2003 from http://www.ahrq.gov/clinic
/3rduspstf/breastcancer/brcanrr.htm.
Vermeire, E., Heamshw, H., VanRoyen, P., & Denekens, J. (2001). Patient
adherence treatment: Three decades of research. A comprehensive review. Journal of
Clincial Pharmacy and Therapeutics. 26, 331-342.
Viet, C. T. (1999). Motivating mammography adherence in elderly Latinas: A test
of three mathematical models of decision making. Medical Decision Making. 19,448-
465.
Weinberg, A. D., Cooper, P.H., Montague, L., & Kripalani, S. (1997). Screening
behaviors and long-term compliance in a breast cancer screening program. American
Journal of Preventive Medicine, 13, 29-35.
White, E., Urban, N., & Taylor, V. (1993). Mammography utilization, public
health impact, and cost-effectiveness in the United States. Annual Review of Public
Health. 14, 605-633
Woloshin, S., Bickett, N.A., Schwartz, L.M., Gany, R„ & Welch, H.G. (1995).
Language barriers in medicine in the United States. Journal of the American Medical
Association, 273, 724-728.
Young Women's Christian Association (1998). BCEDP 800 Number Follow-Up.
Los Angeles, CA : Partners for Progress.
Zaloznik, A.J. (1997). Breast cancer stage at diagnosis: Caucasians versus
Hispanics. Breast Cancer Research and Treatment. 42, 121-124.
Zapka, J.G., Hosmer, D., Costanza, M.E., Harris, D.R., & Stoddard, A. (1992).
Changes in mammography use: economic, need, and service factors. American Journal of
Public Health, 82,1345-1351.
Zapka, J.G., Stoddard, A.M., Costanza, M.E., & Greene, H.L. (1989). Breast
cancer screening by mammography: Utilization and associated factors. American Journal
of Public Health. 79. 1499-1502.
Zapka, J.G., Stoaddard, A., Maul, L., Costanza, M.E. (1991). Interval adherence
to mammography screening guidelines. Medical Care. 29, 697-707.
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APPENDICES
A. Consent Form
Script
Hello, my name is ___________________ . I am calling from__________. We are
conducting a survey about women and mammograms. You were chosen to participate in
this study because you are a female who contacted the Breast Cancer Early Detection
Referral Line.
Procedure:
If you decide to participate, we will ask you over the telephone questions about you, your
health, health care experience and how it has affected your life. The survey will be
completed during this telephone call. This survey will help us to understand the
experience of women like you, so that we can design ways to make mammograms work
more smoothly for Latinas.
Risks
There are minimal risks associated with completing this survey. You may be a little
uncomfortable or uneasy about some of the questions and/or inconvenienced by the
amount o f time spend on the phone answering the questions on our survey.
Benefits
The information that we receive from you will help us to determine how to design
effective breast cancer prevention programs for Latinas.
Confidentiality
All of the information that you give me will be held in the strictest confidence and will be
used only by the persons involved in this study. After we finish speaking to you, no one
will be able to identify your answers with your identity.
Withdrawal Statement
You may decide to stop participating in the survey at any time during the telephone call.
Participation
Would you agree to participate in this survey? Yes No____
Instructions
It is important that you understand that there are no right or wrong answers to any of
these questions. However, if there is anything that you do not understand, just let me
know, and I will be happy to explain it to you. We would like you to answer all of the
questions that we ask you, but if there are some questions you do not wish to answer, we
can skip them.
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B. Breast cancer screening questionnaire (English version)
ID #_______
Would you agree to participate in this survey? Y es No
The following questions are about your health practices.
1. Do you generally have a regular health check-up, or do you only go to the doctor/clinic
when you are sick, or do you never see a doctor?
1) Regular check up
2) Only when sick
3) Never see a doctor
2. If one of your family members needed medical help
1) He or she could see a doctor and all or nearly all of the expenses would be covered
2) He or she could see a doctor but there would be a fee
3) This would be financially very hard
Please answer the following questions in regards to your clinical breast exams and
mammogram(s).
3. Have you had breast problems?
1) Yes
2) No
4. How often do you perform a self breast exam?
1) Never (Skip to 5)
2) Every six months to a year (Ask #4a)
3) Every few months (Ask #4a)
4) Every month (Ask #4a)
4a) Who taught you how to do your self breast exam? ________________
5. When was the last time that you received a clinical breast exam (a clinical breast exam
is when a doctor or nurse examines your breasts to check for lumps)?
1) Within the last 6 months
2) Within the 12 months
3) Within the last 18 months
4) Within the last 24 months
5) More than 25 months
6) Never (Skip to question #14)
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6. Did the Breast Cancer Early Detection Program (the program that provides free
mammograms) pay for your last clinical breast exam?
1) Yes
2) No, 6a. Who paid for the exam?
3) I don’t know
7. When was the last time that you received a mammogram (a mammogram is when an x-
ray of the breast is taken by a machine that presses against the breast while the picture is
taken)?
1) Within the last 6 months (Skip to question #9)
2) Within the 12 months (Skip to question #9)
3) Within the last 18 months
4) Within the last 24 months
5) More than 25 months
6) Never (Skip to question #14)
8. How likely is it that you will receive a mammogram within the next 6 months?
1) Very likely
2) Likely
3) Unlikely
4) Very unlikely
9. How many times have you received a mammogram since you called the BCEDP
referral line in 199___ ?
1) Never (Skip to #14)
2) Once
3) Twice
4) Three times
10. Did you have to go to one site for your clinical breast exam and then to another site to
receive your mammogram?
1) Yes
2) No
11. Would you return to the site where you received your last mammogram?
1) Yes
2) No, 11a. Why n o t?____________________
12. How often do you receive a mammogram?
1) Every year
2) Every two years
3) More than two years
13. Have you been uncertain about when you should receive your next mammogram?
1) Yes 2) No
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(Skip to #18 if the respondent has had a mammogram in the last 2 years)
If you have not received a mammogram within the last 2 years, please answer the
following questions about why you did not receive a mammogram.
14. In a few words, what is the single main reason you have not received a mammogram
in the last 2 years? _________________________ _______________________________
15. Did the doctor or staff do, or not do something, that made it hard for your next
mammogram?
1) No (Skip to #16)
2) Yes
15a. If yes, what is the biggest problem you think of in regards to the doctor or staff?
Now I am going to read you a list of reasons and please tell me all that apply to you.
16. Did any of the following reasons influence your decision not to get a mammogram
this year? Please respond yes or no.
( yes=l no=0)
a. My family is my first priority and I ended up not taking care of my own health.
b. The previous mammogram was painful
c. Concerned about radiation
d. Overall the last mammogram you received was a bad experience
e. It was difficult to get a mammogram because the services were far from where
you live
f. You felt that waiting for the results of your mammogram produced too much
anxiety and worry
g. You had to wait too long in an office or clinic before getting your mammogram?
h. If you went to the doctor’s office or clinic for a mammogram you would lose pay
from work?
i. The hours to receive a mammogram were inconvenient?
j . You had to wait too long to get an appointment for a mammogram?
k. It was not necessary for your age
1 . Did you have a problem receiving a mammogram because your health care
providers did not speak your preferred language?
m. Getting a mammogram was difficult because you needed someone to take care of
your children?
n. It was not important
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0 . You forgot
p-
You had no time
q-
Transportation problems
r. Illness
s. Provider would not make the appointment
t. Provider left the program
u. You had your own insurance/doctor
V. You lost the information from the BCEDP
w. You did not qualify for a free mammogram
X. You did not want a mammogram
y-
You had too many other worries
z. Financial difficulties
aa. You were afraid
bb. Mammograms are ineffective
cc. Other reasons
Now, I am going to read you the reasons you listed for not receiving a mammogram
and I would like you to tell me the three most important reasons.
17a. 1._________________________________________________
17b. 2._________________________________________________
17c. 3._________________________________________________
Please tell me whether or not you think that the following concepts increase a
woman’s chance of getting breast cancer.
18. Injury to the area (like getting hit in the chest)
1) Yes
2) No
19. Not having faith in God
1) Yes
2) No
20. Having someone in her family with breast cancer
1) Yes
2) No
21. Getting a mammogram causes cancer
1) Yes
3) No
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Please answer the following questions to the best of your knowledge.
22. How likely do you think it is that you will receive a mammogram in the next year?
1) Very likely
2) Likely
3) Unlikely
4) Very unlikely
23. How often should a woman get a mammogram?
1) Once in her life
2) Every 3-5 years
3) Every 2 years
4) Every year
24. How important is it to you to receive a mammogram regularly?
1) Very Important
2) Important
3) Don’t care
4) Not very important
5) Not important at all
25. Do you know other women who receive regular mammograms?
1) No
2)Yes, a few
3) Yes, many
26. Can breast cancer be cured if it is caught early?
1) Yes
2) No
27. If you were to have cancer, you would want to know about it?
1) Yes
2) Maybe
3) No
28. Do you worry about getting breast cancer?
1) Yes
2) A little
3) No
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29. Where or whom do you turn to when you have health concerns? Please tell me all
that apply(Yes=l No=2)
1)
Female relative
2)
Comadre
3)
Husband
4)
A close friend
5)
Male relative
6)
Doctor/nurse
7)
Church
8)
Books
9)
Internet
10) Other
30. Do you agree that a breast lump can go away on its own?
1) Yes, I agree
2) No, I do not agree
31. Do you agree that mammograms are necessary in the absence of symptoms?
1) Yes, I agree
2) No, I do not agree
32. Do you agree that if your doctor gives you a breast exam, then you don’t need a
mammogram?
1) Yes, I agree
2) No, I do not agree
33. Do you agree that if you have a few mammograms in a row that show no problem,
then you don’t need to have regular mammograms?
1) Yes, I agree
2) No, I do not agree
34. Did any medical professional explain the importance of receiving a mammogram
regularly ?
1)Very much
2)To some extent
3)A little
4)Not at all
35. Has breast cancer ever been diagnosed in any of your family member such as your
mother, sister, grandmother, or aunt?
1)Yes
2)No
3)Don’t know
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36. Have any of your friends, co-worker or other relative been diagnosed with breast
cancer?
1) Yes
2) No
For each statement tell me AT THIS TIME IN YOUR LIFE how you feel.
37. Even though it’s a good idea, you find that having your breasts examined is
embarrassing.
1) Very much
2) To some extent
3) Very little
4) Not at all
38. When you see or hear a news story about cancer, you usually skip it.
1) Always
2) Sometimes
3) Hardly ever
4) Not at all
39. Even though it’s a good idea, you find that getting an examination for cancer scares
you.
1) Very much
2) To some extent
3) Very little
4) Not at all
40. Do you feel that the treatment for breast cancer is worse than the disease
1) Very much
2) To some extent
3) Very little
4) Not at all
The next questions are about the BCEDP program (the program that
provides free mammograms).
41. Why did you call the BCEDP referral line?
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42. Was the information and the services that Breast Cancer Early Detection Program
offer easy to understand?
1) Yes
2) Not really
3) No
43. Would you recommend the program to a friend?
1) Yes
2) No
If not, why? Was it because you had...
43a. 1) Problems with obtaining your results
43b. 2) Problems with the doctor trying to bill you for the service
43c. 3) Other problems with the doctors or staff
43 d. 4) Another type of problem___________________
44. What would you improve about the Breast Cancer Early Detection Program?
Now, I would like to ask you some questions about your life.
45. What is your current marital status?
1) Married
2) Divorced
3) Single / Never married
4) Widowed
5) Other _ _ _ _ _ _ _ _ _
46. How old are you?
1) 40 or younger
2) 41-49
3) 50-59
4) 60-69
5) 70 or more
47. How tall are you? feet inches
48. How much do you w eigh? lbs.
49. How many children do you have?
1) 0
2) 1
3) 2-3
4) 4-5
5) 6 or more
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50. How many years of education have you received?
1) Up to 4 years
2) Between 5 and 8 years
3) Between 9 and 12 years
4) Between 13-16 years
5) More than 17 years
51. Do you have a job (besides your work at home)?
1) No
2) Yes
44a. If yes, what type of w ork__________ _
44b. If yes, how many hours per week
1 )1 ess than 40 hours per week or
2)40 hours or more per week
52. How do you describe yourself?
1 ) Latina/Hispanic
2) African-American/Black (Skip to question #54)
3) White (Skip to question #54)
4) Asian/Pacific Islander (Skip to question #54)
5) Other_______________ (Skip to question #54)
53. Where were you bom?
1 ) Mexico
2) Central America
3) South America
4) Caribbean
5) United States (Skip to question #55)
6) Asia/Pacific Islands
7) Other_____________________
54. If you were not bom in the United States, how old were you when you first moved to
the United States?
1 ) I was bom in the United States
2) Less than 5 years
3) 6-15yearsold
4) 16-25 years old
5) 26-36 years old
6) 37-50 years old
7) 50 years or older
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55. In general, what language do you read and speak? (Start with option 5)
1)
Only another language other than English
2)
Another language better than English
3)
Both Equally
4)
English better than another language
5)
Only English
56. What language do you usually speak at home?
(Start with option 5)
1)
Only another language other than English
2)
Another language better than English
3)
Both Equally
4)
English better than another language
5)
Only English
57. In which language do you usually think?
(Start with option 5)
1)
Only another language other than English
2)
Another language better than English
3)
Both Equally
4)
English better than another language
5)
Only English
58. What language do you usually speak with your friends? (Start with option 5)
1)
Only another language other than English
2)
Another language better than English
3)
Both Equally
4)
English better than another language
5)
Only English
59. I see friends and/or family with whom I can chat ?
1)
Yes
2)
To some extent
3)
No
60. Do you have someone with whom you can confide in or share your feelings?
1)
Yes
2)
To some extent
3)
No
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61. Do you have someone who can help you solve problems?
1) Yes
2) To some extent
3) No
The following questions are about your health and health practices.
62. Would you say your health at the time is...
1) Excellent
2) Good
3) Fair
4) Poor
63. Do you use herbs or natural remedies for healing or medicinal purposes?
1) Yes
2) No
64. How physically active are you during a typical day?
1) Very little, I’m mainly standing or sitting
2) A little, but I do walk for up to 30 minutes on most days
3) I walk 30 minutes or more on most days
4) I do exercise, dance o play sports (at least 1-2 times per week)
The next questions are about your religious beliefs.
65. To what extent will your religious beliefs influence your decisions about seeing a
doctor or getting medical tests?
1) Very Much
2) To a large extent
3) A little
4) Not at all
66. How would you say you feel spiritually?
1) Excellent
2) Good
3) Fair
4) Poor
Please answer the following questions about your beliefs and opinions
67. Some equality in marriage is a good thing, but by and large the father ought to have
the main say in family matters
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
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68. Relatives are more important than friends
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
69. I expect my relatives to help me when I need them.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
70. It is more important to enjoy life now than to plan for the future.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
71. People die when it is their time, and there is not much that can be done about it.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
72. We must live for the present. Who knows what the future may bring.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
73. It is not always wise to plan too far ahead because many things turn out to be a matter
of good and bad fortune anyway.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
74. It doesn’t do any good to try to change the future because the future is in the hands of
God.
1) Strongly Agree
2) Agree
3) Disagree
4) Strongly Disagree
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Now I would like to ask you a few questions about feelings you may have had in the
past 7 days
75. Did you feel depressed?
1)
None of the time
2)
Sometimes
3)
Most o f the time
4)
All o f the time
76. Did you feel lonely?
1)
None of the time
2)
Sometimes
3)
Most of the time
4)
All of the time
77. Did you cry a lot?
1)
None of the time
2)
Sometimes
3)
Most of the time
4)
All of the time
78. Did you feel sad?
1)
None of the time
2)
Sometimes
3)
Most o f the time
4)
All of the time
Please answer these next questions to the best of your knowledge.
79. Have you recently heard more about mammograms in the media or your community?
1)Yes
2)No (Skip to question #81 )
80. Has this influenced you to get an annual mammogram?
1)Yes
2)No
This next question is an opportunity for you to express any comments or suggestions
regarding mammograms or this survey
81. Please tell me any com m ent, questions or suggestions...
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Now I would like to give you a few brief reminders about mammograms:
1) Mammograms do not cause breast cancer.
2) Not having faith in God and injury to the breast does not increase your risk for
breast cancer.
3) There is a very good chance that breast cancer can be completely cured, if it is
detected early
4) Monthly self breast examines and annual clinical breast exams and mammograms
are recommended for early detection of breast cancer.
THANK YOU VERY MUCH FOR YOUR TIME AND COOPERATION!!!!
Please select from the following stores for you $10 gift certificate.
Could I please verify you address, so that I can send your gift certificate to the store of
your choice.
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c. Breast cancer screening questionnaire (Spanish version)
ID #_____________
Acepta participar en este estudio? Si No
Las siguentes preguntaras son sobre su salud
1. Usted generalmente mantiene un chequeo regular de salud o solamente va al
medico/clinica cuando esta enferma? Usted va ha:
1) Chequeo regulares
2) Solo va cuando esta enferma
3) Nunca ve un medico
2. Si uno de los miembros de su familia necesita ayuda medica que pasaria:
1) Podria ir a ver a su medico y todos o casi todos los gastos estarian cubiertos
2) Podria ver a un medico pero le costaria
3) Seria economicamente muy dificil
Por favor responda a las siguientes preguntas de acuerdo a sus examenes clinicos del
seno y mamografi'a.
3. Ha tenido algun problema con sus senos?
1) Si
2) No
4. Con que frecuencia se hace usted un autoexamen de los senos (un exam del seno por si
misma).
1) Nunca (Pase al #5)
2) Cada 6 meses a un ano. (Preguente #4a)
3) Cada 2 o 3 meses. (Pregunte #4a)
4) Cada mes (Pregunte #4a)
4a. Quien le enseno a hacerse un examen de los senos por si
misma?________________________________
5. Cuando fue la ultima vez que usted recibio un examen clinico del seno ( un examen
clinico del seno es cuando un medico o enfermera chequeo anormalidades en sus senos)?
1) Durante los ultimos 6 meses
2) Durante 12 meses
3) Durante 18 meses
4) Durante 24 meses
5) Mas de 25 meses
6) Nunca (Pase al #14)
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6. El programa de temprana deteccion de cancer del seno (el programa que provee
mamografias gratis) pago por su ultimo examen clinico del seno?
1) Si
2) No, 6a. Quien pago por el examen?_ _
3) No sabe
7. Cuando fue la ultima vez que usted se hizo una mamografia (una mamografia es
cuando le toman un rayo X de los senos con una maquina que presiona los senos mientras
que se toma una foto)
1) Durante los ultimos 6 meses (Pase al #9)
2) Durante 12 meses (Pase al #9)
3) Durante 18 meses
4) Durante 24 meses
5) Mas de 25 meses (Pase al #14)
6) Nunca (Pase al #14)
8. Que probable piensa usted que es el hacerse una mamografia en los siguientes 6
meses?
1) Muy probable
2) Probable
3) No probable
4) Para nada probable
9. Cuantas veces se hecho una mamografia desde que llarno en 199 al programa de
temprana deteccion de cancer del seno
1) Nunca (Pase al #14)
2) Una vez
3) Dos veces
4) Tres veces
10. Tuvo que ir a cierto lugar para el examen del seno y a otro lugar diferente para la
mamografia?
1) Si
2) No
11. Regresaria al lugar donde se hizo la ultima mamografia?
1) Si
2) No, 11a. Porque no? ______ _
12. Con que frecuencia se hace una mamografia?
1) Cadaano
2) Cada dos anos
3) Mas de dos anos
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13. Se ha sentido insegura de cuando debe hacerse la proxima mamografia?
1) SI
2) _No
(Pase al #18 si la partlcipante se ha hecho una mamografia en los ultimos 2
anos)
Si usted no se ha realizado una mamografia durante los ultimos 2 anos, por favor
conteste las siguientes preguntas acerca de las razones por las que no se ha
hecho una mamografia.
14. En pocas palabras, cual es la razon principal que no se ha hecho una mamografia en
los ultimos 2 anos?
15. Los medicos o el personal de la clinica hicieron o no hicieron algo para que sea dificil
hacerse una siguente mamografia?
1) No
2) Si
15a. Cual fue el problema mas grande con el medico o la gente que la atendio?
Ahora le voy a leer una lista de razones y por favor digame todas las que
aplican a usted.
16. Cuales son las razones que influieron que usted NO se haga una mamografia este
ano? Por favor responda si o no (si— 1, no=0)
a. Su familia es su prioridad mas grande y termina siendo que no cuida de su
propia salud
b. Su anterior mamografia fue dolorosa
c. Lepreocupa laradiacion
d. Su anterior mamografia file una mala experiencia
e. Fue dificil porque los servicos para obtener una mamografia quedaban
demasiado lejos de donde usted vive
f. Penso que el tiempo de espera de los resultados de la mamografia le
producirian demasiada ansiedad y preocupacion
g. Tenia que esperar mucho tiempo en una oficina o clinica antes de recibir la
mamografia
h. Si iba a la oficina del medico o a una clinica para la mamografia perderla
pago en su trabajo
i. El horario en que se hacen las mamografias eran inconvenientes?
j . Tenia que esperar mucho tiempo para obtener una cita
k. No era necesario para su edad
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1 . Tuvo problemas al hacerse una mamografia porque no le atendieron en su
idioma
m. Hacerse la mamografia era dificil porque necesitaba de alguien que cuide a
sus niflos
n. No era importante
o. Seolvido
p. No tuvo tiempo
q. Problemas para transportarse
r. Enfermedad
s. No le dieron cita
t. Su medico no participo en el programa de temprana deteccion de cancer del
seno
u. Tenia su propio seguro medico
v. Perdio la information que le dio el programa de temprana deteccion de cancer
del seno
w. No califico para una mamografia gratis
x. No quiso una mamografia
y. Tenia otras preocupaciones
z. Dificultades economicas
aa. Tuvo miedo
bb. Mamografias son ineficaces
cc. Hay otra razon___________________
Ahora le voy a leer las razones por las cuales usted dijo que no se hizo una
mamografia y por favor digame la tres razones mas importantes.
17a. 1._________________________________________________
17b. 2._________________________________________________
17c 3._________________________________________________
Digame por favor si las siguientes razones aumentan o no la posibilidad de que
usted obtenga cancer del seno.
18. Herida en el area (como recibir un golpe en el pecho)
1) Si
2) No
19. Falta de fe en Dios
1) Si
2) No
20. Que alguien en su familia tenga cancer
1) Si
2) No
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21. El hacerse una mamografia produce cancer
1) Si
2) No
Responds por favor a las siguientes preguntas lo mejor que pueda.
22. Que probabilidades hay que usted reciba una mamografia en este ano?
1) Muy probable
2) Probable
3) No probable
4) Para nada probable
23. Con que frecuencia necesita una mujer (de su edad) hacerse una mamografia?
1) Una vez en la vida
2) Cada 3-5 anos
3) Cada 2 anos
4) Cada ano
24. Que importante es para usted hacerse anualmente una mamografia?
1) Muy importante
2) Importante
3) No le importa
4) No muy importante
5) Completamente innecesario
25. Usted conoce a otras mujeres que reciben mamografias regularmente?
1) No
2) Si, pocas mujeres
3) Si, muchas mujeres
26. Cancer al seno se puede curar si se encuentra a tiempo.
1) Si
2) No
27. Si hubiera la posibilidad que usted tenga cancer, quisiera saberlo?
1) Si
2) Talvez
3) No
28. A usted le preocupa que le pueda dar cancer del seno?
1) Si
2) Un poco
3) No
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29. A quien acude cuando tiene preocupaciones acerca de su salud? Por favor di'game
todas la respuestas que aplican a usted. (Si=l, No=0)
1) Pariente familiar que sea mujer
2) Comadre
3) Esposo
4) Una amiga
5) Pariente familiar que sea hombre
6) Medico/enfermera
7) Iglesia
8) Libros
9) Internet
10) Otro________________
30. Esta usted de acuerdo que una protuberancia (una bola) en el seno puede desaparecer
por si solo?
1) Si estoy de acuerdo
2) No estoy de acuerdo
31. Esta usted de acuerdo que necesita una mammografia aunque no tenga sintomas.
1) Si estoy de acuerdo
2) No estoy de acuerdo
32.Esta listed de acuerdo que si su medico le hace un examen del seno, entonces no
necesita una mamografia.
1) Si estoy de acuerdo
2) No estoy de acuerdo
33. Esta listed de acuerdo que una vez que usted a tenido algunas mamografias que
salieron normales ya no necesita mamografias regularmente.
1) Si estoy de acuerdo
2) No estoy de acuerdo
34. Ha habido algiin profesional medico que le ha explicado la importancia de recibir una
mamografia anualmente?
1) Si, mucho
2) Un poco
3) No
35. Alguna vez ha sido encontrado cancer al seno en algiin miembro de su familia como
su madre, hermana, abuela, o tia?
1) Si
2) No
3) No sabe
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36. Usted tiene alguna amiga, familiar o companera de trabajo que ha tenido cancer del
seno?
1) SI
2) No
Responda a cada frase como se siente EN ESTE MOMENTO DE SU VIDA.
37. Aunque es una buena idea, a usted le da pena que le examinen los senos.
1) Siempre
2) A veces
3) Casi nunca
4) Nunca
38. Cuando usted presencia o escucha nuevos casos de cancer, usted usualmente los
ignora.
1) Siempre
2) A veces
3) Casi nunca
4) Nunca
39. Teme usted una prueva del cancer.
1) Siempre
2) A veces
3) Casi nunca
4) Nunca
40. Usted siente que el tratamiento de cancer del seno es peor que la enfermedad?
1) Siempre
2) A veces
3) Un poco
4) Nunca
Las siguientes preguntas tienen que ver con el programa de temprana deteccion del
cancer del seno (el programa que provee mamografias gratis)
41. Porque llamo a la linea del programa de temprana deteccion de cancer del seno?
42. Fue facil entender como funcionaba y que ofrecia el programa de temprana deteccion
del cancer del seno?
1) Si
2) Mas o menos
3) No
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43. Recomendarla este programa a una amiga?
1) Si (Pase a la pregunta #44)
2) No
Porque no?
Fue porque tuvo...
43a. 1) Problemas con los resultados
43b. 2) Problemas con el medico o con el personal de la clinica o la oficina
43c. 3) Problemas con el medico porque ha tratado de cobrarle los servicios
43d. 4) Otro tipo de problema ________ __
44. Que haria listed para mejora el programa de temprana deteccion de cancer del
seno?
Responda ahora preguntas sobre su vida.
45. Cual es su estado civil?
1) Casada
2) Divorciada
3) Soltera / Nunca se ha casado
4) Viuda
5) Otro_______________
46. Que edad tiene?
1) Menor de 40
2) 41-49
3) 50-59
4) 60-69
5) 70 o mas
47. Cual es su estatura? pies pulgadas
48. Cuanto pesa usted? libras
49. Cuantos hijos tiene?
1)0
2)1
3) 2-3
4) 4-5
5) 6 o mas
50. Cuantos anos de education a recibido usted?
1) Hasta4 anos
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2) Entre 5 y 8 anos
3) Entre 9 y 12 aflos
4) Entre 13 y 16 anos
5) Mas de 17 anos
51. Tiene usted un trabajo (a parte de su trabajo como ama de casa)?
1)No
2) Si
51a. Por favor especifique que es su trabajo__________________
51b. 1)___ Trabajo menos de 40 horas a la semana
2 ) Trabajo 40 horas o mas a la semana
52. Como se describiria usted?
1) Latina / Elispana
2) Africa-Americana / Negra (Pase al # 54)
3) Blanca (Pase al #54)
4) Asiatica (Pase al #54)
5) Otra _
53. En que region nacio?
1) Mexico
2) Centro America
3) Sudamerica
4) Caribe
5) Los Estados Unidos (Pase al #55)
6) Asia / Islas del Pacifico
7) Otro lugar______________________
54. Que edad tenia cuando vino a los Estados Unidos por primera vez?
1) Menos de 5 anos
2) 6-15 anos
3) 16-25 anos
4) 26-36 anos
5) 37-50 anos
6) 51 anos o mas
55. En general, que idioma usted lee y habla?
1) Solo Espanol
2) Espanol mejor que Ingles
3) Ambos iguales
4) Ingles mejor que Espanol
5) Solo Ingles
56. Que idioma usualmente habla en su casa?
1) Solo Espanol
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2) Espanol mejor que Ingles
3) Ambos iguales
4) Ingles mejor que Espanol
5) Solo Ingles
57. En que idioma usted piensa usualmente?
1) Solo Espanol
2) Espanol mejor que Ingles
3) Ambos iguales
4) Ingles mejor que Espanol
5) Solo Ingles
58. Que idioma habla usualmente con sus amigas?
1) Solo espanol
2) Espanol mejor que Ingles
3) Ambos iguales
4) Ingles mejor que Espanol
5) Solo Ingles
59. Usted ve a sus amigas o familiars con quien puede charlar?
1) Si
2) Mas o menos
3) No
60. Tiene usted alguien en quien pueda confiar y compartir lo que siente?
1) Si
2) Mas o menos
3) No
61. Tiene usted alguien que le puede ayudar a resolver sus problemas?
1) Si
2) Mas o menos
3) No
Las siguentes preguntaras son sobre su salud y sus practicas de salud.
62. Usted diria que su salud en este momento es:
1) Excelente
2) Buena
3) Mas o menos
4) Mala
63. Usted usa hierbas o remedios naturales para curacion o para propositos medicinales?
1) Si
2) No
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64. Cuanta actividad flsica hace usted en un dia tipico?
1) Muy poquito, generalmente esta sentada o parada
2) Un poquito, camina hasta 30 minutos casi todo los dias
3) Camina mas que 30 minutos casi todos los dias
4) Hace ejercicio, baila o juega deportes 1 o 2 veces por semana
Las siguientes preguntas tienen que ver con sus creencias religiosas
65. Hasta que punto sus creencias religiosas influyen en sus decisiones de ver un medico
o recibir examenes medicos?
1) Bastante
2) Mas o menos
3) Un poco
4) Nada
66. Como cree que se siente espiritualmente?
1) Excelente
2) Bien
3) Mas o menos
4) Mai
Por favor conteste las siguentes preguntas sobre sus opiniones
67. Algo de igualdad en el matrimonio es bueno, aunque en la mayor parte el padre tiene
la ultima palabra.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
68. Familiares son mas importantes que los amigos.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
69.Yo espero que mis familiares me ayuden cuando lo necesite.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
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70. Cree usted que es mas importante disfrutar la vida en este momento que planear para
un futuro?
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
71. La gente muere cuando le llega la hora, y eso es algo que no se puede hacer nada.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
72. Se debe vivir el presente, quien sabe lo que el futuro pueda traer.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
73. No siempre es prudente planear con mucha anticipation, porque muchas cosas
pueden dar un giro y convertirse en buena o mala fortuna de igual manera.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
74. No es bueno tratar de cambiar el futuro porque esta en manos de Dios.
1) Completamente de acuerdo
2) De acuerdo
3) Desacuerdo
4) Completamente de desacuerdo
Ahora quisiera preguntarle algunas preguntas acerca de sentimientos que haya
tenido en los ultimos 7 dias .
75. Se ha sentido deprimida?
1) Nunca
2) Algunas veces
3) Mayor parte del tiempo
4) Todo el tiempo
111
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76. Se ha sentido sola?
1) Nunca
2) Algunas veces
3) Mayor parte del tiempo
4) Todo el tiempo
77. Ha llorado bastante?
1) Nunca
2) Algunas veces
3) Mayor parte del tiempo
4) Todo el tiempo
78. Se ha sentido triste?
1) Nunca
2) Algunas veces
3) Mayor parte del tiempo
4) Todo el tiempo
Por favor responda lo mejor que pueda a las siguentes preguntas
79. Usted ha escuchado mas acerca de mamografias en la television o su comunidad.
1) Si
2) No (Pase a la pregunta #81)
80. Esto la ha influenciado para hacerse una mamografia?
1) Si
2) No
Esta pregunta es una oportunidad para que usted exprese cualquier comentario o
sugerencia acerca de las mamografias o este cuestionario.
81. Tiene usted comentarios, preguntas o sugerencias ...
Para su informacion recuerde:
1) Mamografias no causan cancer del seno.
2) El no tener fe en Dios no causa cancer del seno.
3) Una herida al seno no incrementa el riesgo de cancer al seno.
112
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4) Hacerse un autoexamen de los senos mensualmente, y un examen del seno clinico
y una mamografia anualmente es recomendado para detectar cancer del seno
temprano
MUCHAS GRACIAS POR SU TIEMPO Y COOPERACION!!
Por favor seleccione de esta lista de tiendas para su certificado por $10.
Necesito verificar su direction para poder mandarle su certificado.
113
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Asset Metadata

Creator Teran, Lorena Michelle (author)

Core Title Correlates of compliance with mammography screening guidelines among low-income Latinas: An exploratory study

School Graduate School

Degree Doctor of Philosophy

Degree Program Preventive Medicine - Health Behavior Research

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

Tag education, health,health sciences, medicine and surgery,health sciences, public health,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Belkic, Karen (committee chair), Baezconde-Garbanati, Lourdes (committee member), Barron, Mel (committee member), Dent, Clyde (committee member), Johnson, C. Anderson (committee member), Unger, Jennifer (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-529116

Unique identifier UC11335654

Identifier 3140562.pdf (filename),usctheses-c16-529116 (legacy record id)

Legacy Identifier 3140562.pdf

Dmrecord 529116

Document Type Dissertation

Rights Teran, Lorena Michelle

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 au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA