African American Beliefs

Running head: HEALTH BELIEFS AND SCREENING IN AFRICAN AMERICAN WOMEN

Health Beliefs and Breast Cancer Screening in African American Women
Linda M. Frazier, RN, MSN, FNP-C
Medical College of Georgia
School of Graduate Studies

Health Beliefs and Breast Cancer Screening in African American Women Breast cancer is the most common cancer and the second leading cause of death among women in the United States. More than 211, 000 U.S. women were diagnosed with breast cancer in 2005, and at least 40, 400 women died as a result of the disease (MacDonald, Sarna, Uman, Grant, & Weitzel, 2006). Breast cancer crosses all demographic lines, affecting women of all ages, races, ethnic groups, socioeconomic strata and geographic locales. Breast cancer
is the most common cancer among African American women and one of the leading causes of cancer death in this population (Morgan, Fogel, Rose, Barnett, et al., 2005). African American women have a slightly lower incidence of breast cancer than Caucasian women, but suffer a 32% higher mortality rate as a result of the disease. One of the goals of Healthy People 2010 is to reduce the mortality rate from breast cancer and to do so a high percentage of females aged 40 years and older need to comply with screening recommendations (Stelger, Samkoff & Karoullas, 2003).
Background
Breast cancer mortality rates in the United States began to decrease in the 1990s because of increased use of screening mammography and improved breast cancer treatment.
These decreases have primarily been seen in non-Hispanic white women. Despite the abundance of health information regarding breast cancer screening and early detection, breast cancer mortality rates in African American women has changed little (Smith-Bindman, et.al., 2006). The five-year survival rate is 69 percent for African American women and 84 percent for Caucasian women (Belin, Washington, & Greebe, 2006; Tammemagi, Nerenz, Neslund-Dudas, Feldkamp, & Nathanson,
2005). Several causes have been identified, to include: differences in tumors, patient characteristics, such as obesity, that may affect prognosis; mammography use; timeliness and completeness of breast cancer diagnosis and treatment; social factors, such as education, literacy, and cultural beliefs; and economic factors, such as income level and health insurance coverage, that might affect a patient’s access to choices for breast cancer screening and treatment (Smith-Bindman et al., 2006). The focus of this paper is to explore reasons related to health and cultural beliefs, and other psychological factors that may impact screening and treatment behaviors among African American women regarding breast cancer. The impact of psychosocial factors, including cultural health beliefs have been studied and suggest health beliefs and other psychosocial factors have a direct correlation with breast cancer morbidity, mortality and survival rates. Dispelling negative health beliefs in culturally sensitive programs may impact mortality and morbidity rates in African American women and other ethnic minorities (Altpeter, Mitchell, & Pennell, 2005; Mitchell, Lannin, Mathews, & Swanson, 2002).
Discussion of the Evidence Many researchers have suggested that at least half of the difference in survival between African American women and Caucasian women is due to late diagnosis and inadequate secondary prevention (Bibb, 2001; Smith-Bindman et al., 2006). Breast-self examination and clinical breast examinations are simple and effective methods of secondary prevention of breast cancer. Mammography combined with clinical breast examinations remains the most important means of decreasing breast cancer mortality (Russell, Champion & Skinner, 2006; Earp et al., 2002; Russell, Swenson, Skelton, 2003). Although increases in mammography screening among African American have occurred, screening behaviors still vary greatly among black women and trends show that the proportions of women ever having a mammogram remains lower for African American women than Caucasian women (Erwin, Spatz, Stotts, Hollenberg, 1999; Fowler, Rodney, Roberts & Broadus, 2005). Research has shown that cultural and religious beliefs are important determinants in some African American women’s decisions to refuse mammography screening. Researchers believe that a synergistic effect of these factors exists in African American women. It also has been postulated that learned and endorsed cultural beliefs such as endurance and perseverance have given credibility to some African American women to postpone or ignore recommendations for breast screenings (Shaw, 1996; Russell, Champion, & Skinner, 2006; Russell, Perkins, Zollinger, & Champion, 2006). In Kinney, Emery, Dudley and Croyle’s (2002) study, high scores on the God Locus of Health Control scale predicated lower rates of clinical breast examination and mammography screening in African American women at high risk for breast cancer (odds ratio =88; 95% confidence interval=0.77-1.00; p< 0.05). A number of studies have also shown that fears and fatalistic beliefs of cancer result in lower screening in African Americans. The cultural interpretation of fear and fatalism is deeply embedded in the historical slavery experience. Duncan, Parrott, & Silk (2001), described “fatalism” as the result of a complex psychological cycle characterized by perceptions of helplessness, worthlessness, meaninglessness, powerlessness, and social despair. From this definition, the significance of psychosocial factors contributing to health behaviors becomes apparent. If African American women believe that increased incidence of disease is beyond the control of personal behavior, messages to promote personal behaviors may have little effect. These beliefs coupled with low socioeconomic status (SES), and oppressive forces such as long history of slavery, segregation, discrimination, substandard health care provide the environment for the emergence of cancer fatalism (Kinney, et al., 2002). Walling (2003) showed African American women were more likely than whites to report a reliance of God to cure cancer without medical intervention, fatalism that medical and especially surgical treatment would be futile, a specific belief that surgery makes cancer spread more quickly, belief that a painless lump cannot be cancer, and reliance on alternative therapies. Additionally, Shaw (1996), found a significant relationship between knowledge and posttest variables of frequency of breast self exam (BSE) and the breast cancer belief/attitudinal scales of confidence, health motivation, benefits (BSE), and barriers (BSE) in a sample of Black women. A multiple rof0. 70 which were significant at the level of 0.05 was observed. The posttest values on BSE frequency and attitudinal variables explain 50% of the individual’s posttest score, R2=0.05 Scientific evidence has confirmed that mammography is the “gold standard” for early detection of breast cancer in women aged 50 or older regardless of racial or ethnic group or SES.
These findings were confirmed in an epidemiologic report from the National Center for Health Statistics (NHS, 2001) (52 % versus 57%) (Fowler et al, 2006). Evident from 10-year tracking data from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides free or no-cost mammography screening and follow-up breast health services for women who are unemployed or employed in minimal-wage jobs without health insurance coverage. The findings showed that African American women compared to non-Hispanic, Caucasian women obtained significantly fewer mammography screenings (17% versus 60%) (Centers for Disease Control and Prevention [CDC],
2003).

Conclusion Many of the studies outlined in this discussion refer to health beliefs and their impact on health behaviors especially in African American women. Researchers conclude that customizing culturally sensitive health promotions programs aimed at eliminating breast cancer screening and mortality disparities between Caucasian and African American women is essential to bridging the gap in differences in mortality and morbidity rates for African American women. Education tailored to African American women belief systems may have an enhanced impact on decisions and thereby increase adherence to breast cancer screening recommendations. Health beliefs about screening should be assessed comprehensively before initiating education or counseling to avoid repetition of concepts and build on beliefs already present. Furthermore, tailoring health promotion to meet certain socioeconomic, psychological, and cultural factors encourage women’s optimal utilization of mammography and adherence to screening guidelines. A variety of programs have been established to meet specific cultural needs, one program called the Breast Cancer Outreach to the African American Community: The Witness Project® (WP) was started in 1991 at the University of Arkansas Medical Science Center as a response to the high mortality rate of African American women with breast cancer living in Arkansas. This innovative project was designed to reach out to low-income and rural African American women in a way the was culturally relevant to increase awareness and participation in breast screening. A community-based cancer screening program with proven effectiveness. The Mississippi River Delta region of Arkansas participants significantly increased (P< .0001) in their practice of breast self-examination and mammography (P