July 2006, Volume 33, Number 4
American Women’s Perceptions
and Experiences With Breast Cancer Screening
Tsu-Yin Wu, PhD, RN, and Joanna Bancroft, BSN, RN
Purpose/Objectives: To determine information about Filipino American women’s perceptions of breast cancer, the most frequently diagnosed cancer and number-one killer of Asian American women, and their experiences with screening.
Design: A qualitative, exploratory approach with focus groups.
Setting: Suburban Filipino American communities in the midwestern
Sample: 11 Filipino American women aged 45–80 years who shared their experiences with breast cancer screening.
Methods: Focus groups were conducted, and the meetings were recorded on audiotape, transcribed, and analyzed using constant comparison techniques.
Main Research Variables: Breast cancer screening, experiences, motivators, and barriers.
Findings: Avoidance was the main theme for Filipino American women in
dealing with a cancer diagnosis in the Filipino American culture. Facilitators
of Filipino American women’s screening practices were support from family
members, recommendations from familiar physicians, health insurance
reinforcement, and personal attributes of physical symptoms, family history,
past diagnosis, and health literacy. Barriers identified were different
mind-sets and healthcare systems in the
Conclusions: Results of the focus group discussions provide useful information about facilitators and barriers that affect Filipino American women’s screening practices.
Implications for Nursing: The findings of the study can be used to develop tailored interventions for addressing culturally specific barriers and promoting screening practices in the Filipino American community.
· Cultural beliefs and attitudes affect women’s experiences and decisions regarding cancer screening practices, yet most studies in Asian American populations have used the quantitative approach, and sociocultural aspects of screening behaviors have been examined less frequently.
· Filipino American women preferred having female and familiar healthcare providers perform cancer screening. They also appreciated support from their significant others, which motivated them to get screened regularly.
awareness of breast cancer screening modalities that are recommended in the
Cultural beliefs and values about cancer and cancer screening shape and inform decisions about whether to engage in screening behaviors. To date, few qualitative studies have examined the cultural beliefs and values of Filipino Americans related to breast cancer screening practices. Previous survey-based studies have reported on use of and attitudes toward breast cancer screening among Filipino American women (Ko, Sadler, Ryujin, & Dong, 2003; Maxwell, Bastani, & Warda, 1997, 2000). The results of a randomized trial among Filipino American women indicated that screening rates for breast and cervical cancer did not differ between experimental and control groups at baseline and follow-up (Maxwell, Bastani, Vida, & Warda, 2003). The authors urged healthcare professionals who attempt to improve adherence to cancer screening in immigrant populations to consider culturally specific outreach methods.
The purpose of the current qualitative study was to explore views about
breast cancer and screening practices from the perspective of Filipino American
women in the midwestern region of the
The term Asian American represents a diverse
population in the
In addition, Tu, Taplin,
Barlow, and Boyko (1999) found that breast cancer
screening programs are less successful and underused by ethnic communities.
Therefore, to develop effective interventions to reduce healthcare disparities
among various ethnic groups, healthcare professionals must recognize the
specific cultural beliefs and values and different health needs of each group.
Filipino Americans are the second-largest Asian subgroup in the
Focus group methodology was used to explore the shared meaning of breast cancer and experiences of breast cancer screening among 11 Filipino American women. The method was chosen for data collection because the interaction of a group provides a social context for the development of each participant’s ideas so participants will be able to stimulate and refine thoughts and perspectives (Krueger, 1988; Morgan, 1988; Owen, 2001). In addition, researchers are able to obtain data with greater depth than with individual interviews (Morgan & Krueger, 1994).
Groups were kept small, with fewer than five participants in each session (for a total of three sessions), to allow each woman to share her thoughts with an adequate amount of time. Each session, lasting about two hours, was held in a nonthreatening environment in which participants were able to exchange their views without being judged. The methods effectively gathered information about Filipino American women’s views about breast cancer and their current and past practices of breast cancer screening.
Inclusion criteria were that participants self-identify themselves as
Filipino American, speak either English or Tagalog,
and be aged 40 years or older. Twelve women were recruited from the
metropolitan area of southeastern
The primary investigator developed an unstructured interview guide for the study, which was reviewed and validated by two cultural experts and one consultant. The final interview guide was developed with seven questions (see Figure 1) after revisions were made according to the feedback received during the review.
The study was approved by the affiliated university’s institutional review board. Each focus group began with the introduction of the roles of the primary investigator and the moderator, the purpose of the study, and a review of the guidelines for participation. Written informed consent was obtained. Each focus group session was recorded on audiotape (with permission obtained at the beginning of the session), and field notes were taken to document additional comments, facial expressions, and interactions among participants. During the sessions, the participants were encouraged to ask questions and additional questions were posed to clarify responses. Each session lasted 90 minutes to two hours and allowed discussions to be completed. Participants received $25 gift certificates as incentives, and refreshments were served.
Audiotapes were transcribed and verified before data analysis. Verbatim transcripts of audiotapes and field notes served as the primary data for analysis. Data were analyzed by identifying and organizing themes in the text, as recommended by Morgan and Kreuger (1998). The two authors independently reviewed each transcript, coded each line of the transcripts, and analyzed for themes based on the questions asked. The moderator’s notes were used to gain more understanding and assist in interpreting the women’s responses. Next, the two authors met to compare the coding results, discuss emerging themes, clarify differences, and resolve inconsistencies. Consensus was reached about the categories under each theme, and decisions were made about which comments fit into each category. Concepts that were salient and repeated in the text were identified and kept in preliminary data analysis. To validate the findings from the first two focus group meetings, a preliminary summary was prepared and discussed with the participants in the third focus group and with a key community informant who was familiar with the issues of Filipino American women. After the third focus group meeting, major themes discovered in the final data analysis were presented, with quotations from the transcripts supporting the themes.
The final sample included 11 women with a mean age of 56.9 years (SD =
10.4 years, range = 45–80 years) (see Table 1).
Most women (82%) in the sample were married, and two were single. All of the
participants were born in the
Analysis of the three focus group meetings yielded three major themes: perceptions and experiences with breast cancer, motivators to obtain breast cancer screening, and barriers to obtaining breast cancer screening. Under each theme, categories were created to describe the diverse experiences and beliefs that the women discussed.
Perceptions and Experiences With Breast Cancer
Avoidance of discussing the topic: In the stories the women shared, avoidance was one of the major themes in dealing with a cancer diagnosis in the Filipino culture. Six women with different backgrounds spoke about use of the word cancer and how most people did not use it when someone was diagnosed. Often, alternative words such as tumor, lump, “the sickness,” or mass were used to refer to a diagnosis (see Table 2). Fear was another major reason for avoiding the word cancer. The majority of the women talked about the finality of a diagnosis and that a lot of them assumed the worst. The women told dramatic stories about people they knew who were diagnosed with cancer. Examples of the women’s explanations as to why the word cancer was not used: “I think it is too final and too brutal to hear the word.” “You know, we avoid the word cancer. I think [be]cause it really scares most people. The word cancer evokes the real scary.”
Information-sharing process: In the sample
of Filipino American women, six of 11 women had relatives diagnosed
with breast cancer or breast-related benign diseases, and one woman reported
having a personal diagnosis of breast cancer and another having a lump in her
breast. The Filipino American women
described the process of bringing up the diagnoses of breast cancer to their
relatives or friends as either delaying or withholding communication to their
loved ones. A participant who was a survivor said that her diagnosis was
malignant but that her relatives withheld the information from her. Other
participants also reported that their relatives or friends with breast cancer
were not told about their cancer diagnoses until much later in treatment or
until they completed treatment. For example, one woman talked about her cousin,
who still resided in the
Motivators to Obtain Breast Cancer Screening
Subjects expressed different but related perceptions that motivated them to perform breast cancer screening. The perceptions were categorized as family support, recommendations from familiar physicians, health insurance reinforcement, and personal attributes (see Table 3).
Family support: Participants reported that family members served as major sources of information about breast cancer and other topics related to health and diseases. Participants often received encouragement from family members to undergo certain medical procedures. They spoke about family and friends having a positive impact on the initiation of breast cancer screening activities by advising them to perform mammography screening or insisting that they go to a doctor when symptoms occurred. One woman talked about her brother who was a physician. She explained that he took it upon himself to educate his family and tell them the importance of screening every year. The encouragement was a major force for her to get her yearly mammogram and clinical breast examination and to perform monthly breast self-examination. Another woman stated that her husband helped to encourage her to see a doctor yearly for a physical so that she could be in the best of health.
Recommendations from familiar physicians: Two common factors identified that facilitated women to participate in screening were working with physicians whom they knew, preferably women, particularly in taking care of their breast health, and physicians who spoke their own language. Women spoke frequently about their healthcare providers in relation to screening and that they were more comfortable with female physicians. One woman explained, “In the breast, I want a female doctor, but in other ways, for example, in some parts or other parts, it may be male, but [with] the breasts, I want a female.” Most of the women also preferred a Filipino American doctor, although it did not seem as important as the need for a female physician. One of the stated advantages of cultural similarity is that a woman could speak her native tongue with a physician, which brings a sense of comfort to the meeting. One woman stated, “He knows our practices, and I told him that it’s okay. . . . I can talk to him in my own language.” Although the physician happened to be male, the statement shows the importance of the provider-patient interaction and sharing the same culture and language.
Health insurance reinforcement: Another woman described how her health maintenance organization (HMO) encouraged her to get a mammogram, which helped her to make the decision to get the procedure. One of the ways the HMO motivated its customers to get screened was a penalty method.
My first mammogram was when I was 35. And that was just a requirement of the health organization, the HMO that I was with. [The HMO] has such good health maintenance practices with their members that if you didn’t go for their screenings, they gonna kick you out of the insurance plan.
Later in the focus group, she admitted that it was the best motivator
for her, because she never would have had the mammogram otherwise. Results from
the focus groups showed that policy reinforcement from health insurance is one
of the economic factors that motivate Filipino
American women to participate in mammography screening in the
Personal attributes: Several personal attributes, including physical symptoms, family history, prior diagnosis, and knowledge about breast cancer, emerged as factors that prompted the women to obtain breast cancer screening. In several instances, the same attribute could serve either as a motivator or barrier to breast cancer screening.
In all three focus group meetings, the women talked about the modalities
(e.g., mammography, clinical breast examination) that are promoted in the
What motivates me to do a self-exam [is] if I feel something different. Then I compare both sides. Like by chance, I saw myself in the mirror and see why is that [breast] lower than the other [breast] and then start examining.
In contrast, several participants said that if they did not feel anything different or painful, then they would not get screened.
Family history: Focus group participants reported that they performed breast self-examination or other types of screening procedures if they had a family history of breast cancer or had friends with breast cancer. One woman’s experience with her sister’s diagnosis helped prompt her to get screened. When asked about the motivation, she said, “Because of our history, family history, I want to be sure that I’m not one of them, and I don’t want to be one of them.” Though family history was a strong motivator, it also was a barrier. One woman said that she did not get screened because she had no family history, even though she was told that people do not have to have family history to get breast cancer.
Prior diagnosis: A prior diagnosis of cancer or a benign tumor was a major motivator for breast cancer screening for several women. One woman who was a survivor said that she continued to get screened because of her history. “Well, maybe it’s because of my past experience, because I don’t want it to be, to return.”
Health literacy: Knowledge of breast cancer screening played an important part in the women’s participation in some or all types of breast cancer screening. In particular, those who worked in health care (i.e., nurses and nurses’ aids) were more knowledgeable about the three screening modalities and seemed to possess the skills to perform breast self-examination. Most of the women who were nurses or in medical fields continued to perform breast self-examinations after they learned how. The experiences that they had in the healthcare field and the patients they encountered helped them to stay current with screening guidelines and recommendations. One woman explained it simply: “I know what happens if you don’t do it.”
Barriers to Obtaining Breast Cancer Screening
Through the focus groups, the barriers to breast cancer screening were
categorized as a different mind-set and healthcare systems in the
Different mind-set and healthcare
systems in the
In all three focus groups, women mentioned that
mammograms are a luxury for women in the
Participants whose occupations were not health related generally lacked
comprehensive and accurate knowledge about the purpose of the three screening
modalities (i.e., breast self-examination, clinical breast examination, and
mammography) used in the
In terms of breast self-examination, the women were unfamiliar with the term. Six women had heard of the examination but were not fully aware of all of the components (e.g., technique, frequency) to perform breast self-examination properly. The participants with medical backgrounds who had exposure to various degrees of health education had better awareness of the techniques and frequencies, but some discrepancies existed in the actual application of the screening. Lack of education and confidence with breast self-examination was a reason for some women to not perform it on a monthly basis; one woman expressed that she did not feel that she really knew it. Others spoke about the frequency of their breast self-examinations, which ranged from almost every day to once a month. Most of the women commented that they felt more comfortable with letting a physician examine them because doctors know what to look for in breast tissue. They said that they needed more education about how to do it to feel more comfortable.
Unpleasant experiences with mammography: Focus group participants associated mostly negative feelings with mammography. Five women reported negative reactions related to discomfort, pain, and uneasiness of the examination. One woman said, “To me, I feel that it’s demeaning to be pulled and smashed in that part of my body, so I don’t like it.” Another woman commented, “I think the word cancer and pain are associated with the mammogram.” The vivid statement shows the negative aspects of mammography.
The women’s fear of cancer and how the fear affected their perceptions
about breast cancer screening were reflected in several scenarios. One woman’s
remarks touched on why she responded to breast cancer screening as she did. She
stated, “I don’t want to know. I am just afraid. I know so many things that
happened in health-care-wise cause I work in the
hospital.” Often, several women spoke about mammograms being associated with
already having cancer. One woman said, “When I hear that word [breast cancer],
it makes me afraid. I’m afraid . . . cause once I
heard that you go to get a breast cancer screening, it means that I have it.”
Another woman also made a statement that reinforced a similar mind-set: “People
at home also do not go, undergo this test, because sometimes if you are
thinking about this test, it usually comes out positive. And they think you get
the disease because you have the test done.” The statement is a great example
of the use of mammography in the
Cultural beliefs about breast health: Culture’s
unspoken traditions and beliefs caused some of the women to feel uncomfortable
with touching or exposing their bodies or talking about their breasts. The
length of time since immigrating to the
Difficulties accessing services: The women also shared other issues related to their participation in screening, including scheduling, transportation, and community resources. Finding time to schedule appointments for mammography was reported to be a main barrier for women who worked five to six days a week or had busy family schedules. For example, the opportunity for one woman to get time off work during weekday hours was almost impossible. She said that the only day she could go was on Sundays, when doctors’ offices and clinics are not open. Forgetfulness also was associated with scheduling problems and not getting any type of breast cancer screening.
Lack of transportation or limitations on driving made going to a physician difficult. One woman could drive only short distances and was not able to drive herself to visits. This raised another barrier: finding someone to transport her.
Lack of knowledge about agencies in the area to help with medical expenses and resources was a significant barrier for new immigrants. When asked about certain agencies or federal programs for breast and cervical cancer screening that were available, most of the women were unfamiliar with them.
Focus groups were useful for gaining insights into the range of views
that Filipino American women held about breast cancer and breast cancer
screening. The themes identified in the discussions came from the participants’
past experiences in the
The women in the focus groups held specific views from their Filipino
culture about breast cancer and ways to deal with a diagnosis of breast cancer;
often, their experiences were closely related to family members. Sensitivities
about using the words cancer and breast cancer need to be addressed. The
finding is in accord with findings of Bottorff et al.
(1998) regarding beliefs related to breast health practices among southern
Asian women in
Family members who are employed in the medical profession play an important role in helping their families to deal with health issues. The support of significant others such as spouses and healthcare providers was fundamental to women’s participation in screening activities.
The findings of the current study provide important insights regarding
the perceptions of Filipino American
women about breast cancer and screening. The findings, however, must be viewed
in light of potential limitations of the study. The sample size was relatively
small, and the convenience sample focused on women who had immigrated to the midwestern
In addition, the focus group discussions were conducted on the culturally sensitive topic of breast cancer. Despite the research team’s effort to develop a good rapport with the women, the researchers were concerned about some women providing the “right” answers instead of sharing their true views.
Elements that serve as facilitators to screening also can become barriers to screening, not only when they are absent but also depending on the perceptions of individuals. For women who are looking for physical changes or signs that they need to be screened, healthcare professionals must recognize the need to educate them about the purpose and importance of early detection in breast cancer even when symptoms are absent. The messages should be tailored when communicating to Filipino American women that breast cancer screening such as mammography enables women to find cancer at early stages despite the absence of symptoms so they can get early treatment to increase their chances of a longer life expectancy. Culturally appropriate educational interventions need to be developed based on research findings so healthcare providers can communicate with Filipino American audiences with consideration of their cultural views, negative thoughts, and misconceptions.
The findings of the study also suggest that Filipino American women should be better educated about current
recommendations for the three modalities for breast cancer screening and about
the skills and knowledge to perform breast self-examination properly. As the
researchers found in the focus groups, healthcare education in cancer detection
and control has been evolving in the
Cultural beliefs, including barriers to screening, differ among ethnic groups (Miller & Champion, 1997; Wu, Brady, Chen, & Hergert, 2006). Healthcare professionals should be aware of facilitators and barriers to breast cancer screening among Filipino American women to plan effective, tailored interventions. Barriers that are constraints to cancer screening for Filipino American women should be addressed carefully, with consideration for cultural sensitivity. Nurses and other healthcare professionals can provide alternatives to women who have scheduling, transportation, or financial constraints that interfere with their medical care.
The cultural, social, and healthcare-system factors related to breast cancer screening as identified by the Filipino American women who participated need to be addressed. Nurses and healthcare professionals should be cognizant of such factors to improve the quality of service to Filipino American women. Instead of translating health education materials into different languages, key strategies include tailoring health education messages to their specific needs and cultural beliefs to empower the women with necessary resources and information.
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Digital Object Identifier: 10.1188/06.ONF.E71-E78