November 2007, Volume 34, Number 6

 

Article

Effects of a Culturally Sensitive Education Program on the Breast Cancer Knowledge and Beliefs of Hispanic Women

Cathy P. Hall, MSN, RN, OCN®, John D. Hall, PhD, LP, SPS, NCSP, Judith T. Pfriemer, MSN, RN, Paige D. Wimberley, MSN, RN, and Craig H. Jones, EdD

 

 

Purpose/Objectives: To determine the effectiveness of a multifaceted, culturally sensitive, and linguistically appropriate breast cancer education program for Hispanic women.

 

Design: Experimental (post-test only, control-group design).

 

Setting: The parish hall of a Roman Catholic Church in northeastern Arkansas.

 

Sample: 31 Hispanic women aged 25–56 residing in northeastern Arkansas.

 

Methods: The experimental group received a multifaceted, culturally sensitive, and linguistically appropriate breast cancer education program; the control group received general nutritional information. Both groups completed the Breast Cancer Knowledge Test and Breast Cancer Screening Belief Scales so that the researchers could measure dependent variables. Data were analyzed with t tests.

 

Main Research Variables: Knowledge of and beliefs about breast cancer.

 

Findings: The experimental group scored significantly higher on the Breast Cancer Knowledge Test than did the control group. The control group scored significantly higher than the experimental group on the barriers to mammography scale and the benefits of breast self-examination scale of the Breast Cancer Screening Belief Scales.

 

Conclusions: The multifaceted, culturally sensitive, and linguistically appropriate breast cancer education program appeared to be responsible for increased knowledge of breast cancer and reduced barriers to mammography.

 

Implications for Nursing: Education may change Hispanic women’s knowledge and beliefs about breast cancer. An intervention designed and implemented by nurses can play a significant role in meeting the strong need for culturally sensitive and linguistically appropriate breast cancer educational programs for Hispanic women. Such programs should focus on helping Hispanic women understand their personal risks related to breast cancer and reduce barriers they perceive to early screening and detection.

 

Key Points

 

·         Hispanics are the largest and fastest-growing minority group in the United States.

·         Hispanic women have a higher mortality rate from breast cancer than do non-Hispanic Caucasian women. The increased mortality is caused, in part, by later diagnosis in Hispanics.

·         Hispanic women significantly underutilize breast screening services; underutilization is related to lack of appropriate education.

·         Multifaceted, culturally sensitive, and linguistically appropriate breast cancer education programs can enhance Hispanic women’s knowledge of the disease and increase early detection.

 

Hispanics are the largest and fastest-growing minority in the United States (Population Resource Center, 2002). The U.S. Census Bureau (2003) estimated the Hispanic population to be 38.8 million. In 2000, the group constituted 12.6% of the total population. By 2010, the percentage is projected to rise to 15.5%, with steady increases in the following years (U.S. Census Bureau, 2004). Hispanics are more likely to reside in the western and southern United States than in other parts of the country (Ramirez & de la Cruz, 2003). Arkansas has the fastest growth rate in the nation, with 127,000 Hispanics comprising 4.4% of the state’s population (Lee, 2006). Most of the individuals have arrived since 1993 (Southern Regional Educational Board, 2005).

 

Breast cancer is the most frequent solid tumor in U.S. women, constituting the second-leading cause of cancer death. Differences in survival rates for the disease exist among racial and ethnic groups. Compared to non-Hispanic Caucasian women, Hispanic women have a higher risk of cancer death, partially because the disease is diagnosed at later stages (Boyer-Chammard, Taylor, & Anton-Culver, 1999; Frost et al., 1996). Among Hispanic women, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death. An estimated 1,740 Hispanic women died from breast cancer in 2006 (American Cancer Society, 2006).

 

Breast Cancer Screening of Hispanic Women

 

Hispanic women greatly underutilize breast cancer screening services (American Cancer Society, 2006; Bazargan, Bazargan, Calderon, Husaini, & Baker, 2003; Fulton, Rakowski, & Jones, 1995; Goel et al., 2003; Jibaja et al., 2000; National Cancer Institute, 2006; Saint-Germain & Longman, 1993; Salazar, 1996; Wong, 2000; Zambrana, Breen, Fox, & Gutierrez-Mohamed, 1999). Infrequent mammography use and delayed follow-up for abnormal screening results contribute to the high mortality rates for Hispanics (American Cancer Society).

 

Consistent with the Health Belief Model (HBM) (Rosenstock, 1966; Rosenstock, Strecher, & Becker, 1988), the underutilization of breast cancer screening services by Hispanic women is linked to limited knowledge. A number of studies have found that Hispanic women’s knowledge about breast cancer has a strong positive association with obtaining screening (Hubbell, Chavez, Mishra, & Valdez, 1996; Longman, Saint-Germain, & Modiano, 1992; Saint-Germain & Longman, 1993). In addition, culturally based beliefs among Hispanic women reduce use of breast cancer screening services. Thus, foreign-born Hispanic women who are less acculturated to the United States are less likely to receive mammograms (Borrayo & Guarnaccia, 2000; Goel et al., 2003; O’Malley, Kerner, Johnson, & Mandelblatt, 1999) and are less likely to practice correct breast self-examination (BSE) (Peragallo, Fox, & Alba, 2000). Fulton et al. (1995) found that Hispanic women were unlikely to perceive themselves as susceptible to breast cancer and often believed that the disease is incurable. Hispanic women are more likely than non-Hispanic Caucasian women to believe that breast trauma, breast fondling, and multiple sexual partners increase risk. Hispanic women also are more likely to believe that the disease is God’s punishment for immoral behavior. Many Hispanic women believe that breast cancer inevitably leads to death. As a result, they do not want to discuss breast cancer, are reluctant to know whether they have it, and are fearful of telling their husbands if they develop the disease (Luquis & Villanueva Cruz, 2006). Thus, fear and fatalism serve as significant barriers to screening for Hispanic women (Carpenter & Colwell, 1995; Huerta, 2003; Rahman, Mohamed, & Dignan, 2003; Salazar, 1996). 

 

Mammography

 

Hispanic women are less likely to receive screening mammograms than non-Hispanic Caucasian or African American women (Darling, Nelson, & Fife, 2004). Many Hispanic women have never heard of mammography (Cockburn, Murphy, Schofield, Hill, & Borland, 1991; Skaer, Robison, Sclar, & Harding, 1996), and those who have often believe that mammograms are unnecessary except for diagnostic purposes, such as evaluating breast lumps (Hubbell et al., 1996; Skaer et al.). Some Hispanic women believe that mammograms are not routine medical tests and that two consecutive normal mammograms negate the need for further mammography (Fulton et al., 1995). Hispanic women with such poor functional health literacy or the inability to understand and act on health information (Andrus & Roth, 2002) are the least likely to undergo mammography (Guerra, Krumholz, & Shea, 2005). In addition, lack of health insurance and costs associated with the procedure are deterrents to Hispanic women obtaining mammograms (Bazargan et al., 2003; Fulton et al.; Gorin & Heck, 2005; Salazar, 1996; Skaer et al.; Zambrana et al., 1999).

 

Breast Self-Examination

 

BSE is an important early-detection tool for women (Taylor, 2002). An estimated 65%–75% of women are independently responsible for detecting their own breast tumors (Arndt et al., 2003; Facione, Miaskowski, Dodd, & Paul, 2002). Although the efficacy of BSE instruction has been questioned, the American Cancer Society recommended that women be informed about the potential benefits, limitations, and harms of BSE (Smith, Cokkinides, & Eyre, 2004). Furthermore, Susan G. Komen for the Cure continues to endorse monthly BSE for women beginning at age 20. Others note that, even though it is of limited effectiveness in detecting breast cancer in its earliest stages, BSE still has advantages. For example, nurses and healthcare professionals easily can teach BSE to women, no financial costs are associated with the practice, and it may help reduce mortality from the disease (Peragallo, Fox, & Alba, 1998, 2000).

 

Hispanic women are less likely to perform BSE than are non-Hispanic Caucasians (Borders, Warner, & Sutkin, 2003). In addition, Hispanic women’s knowledge of BSE often is lacking. Peragallo et al. (1998) noted that 44% of the participants in their study were unable to correctly answer any questions on a basic BSE knowledge test. Palacios and Sheps (1992) found that approximately one-fourth of Hispanic women in their study did not know how to perform BSE. Two other studies have confirmed that a significant portion of Hispanic women are not proficient in the technique (Coe et al., 1994; Fitzgibbon, Gapstur, & Knight, 2003).

 

Specific personality constructs are correlated with whether Hispanic women perform BSE (Coe et al., 1994). For example, Chrisler (1993) found that Hispanic women with an external health locus of control (i.e., women who believe that their health is controlled by external forces such as luck or fate) are less likely to perform BSE than those with an internal locus of control (i.e., who believe that they can affect their health through their own actions). High self-efficacy also is positively correlated with knowledge of how to perform BSE and actual practice of the method (Carpenter & Colwell, 1995; Gonzalez, 1990).  

 

Breast Cancer Education Programs for Hispanic Women in the United States

 

Breast cancer programs that focus on risk factors, behavior changes, and screening should reduce the death rate for Hispanic women (Cancer in Mexican American Women, 2006). A small but growing number of empirically validated breast cancer education programs exist for Hispanic women in the United States (Cancer in Mexican American Women; Fitzgibbon et al., 2003). Mishra et al. (1998) used a quasiexperimental design to evaluate the effectiveness of an educational program with Hispanic women based on Bandura’s (1997) self-efficacy theory and Freire’s empowerment pedagogy. The program focused on skill enhancement and empowerment. Participants in the experimental group had greater knowledge, skill, and self-efficacy in performing BSE than did those in the control group. Jibaja et al. (2000) evaluated the impact of a computer-based breast cancer educational program for high-risk Hispanic women. The program used a culturally sensitive, linguistically appropriate soap-opera format. Women randomly assigned to the experimental condition demonstrated greater knowledge and more accurate beliefs than those randomly assigned to a control condition. Valdez, Banerjee, Fernandez, and Ackerson (2001) evaluated the effectiveness of an interactive multimedia breast cancer education program based on Bandura’s (1986) social learning theory with low-income Hispanic women. The program was delivered through a touch-screen kiosk in the participant’s language preference. Information about breast cancer and barriers to screening and mammography was provided via a combination of video, animation, photos, music, and audio. At a four-month follow-up, approximately 40% of the participants who had obtained or scheduled a mammogram since receiving the intervention attributed the decision to their participation in the program. In a similar study, the same researchers examined the effectiveness of a multimedia breast cancer education program based on Bandura’s social learning theory. Low-income Hispanic women were assigned randomly to an experimental or control group. Women in the experimental group exhibited greater knowledge and were more likely to seek information about mammograms than were women in the control group (Valdez, Banerjee, Ackerson, & Fernandez, 2002). Finally, Darling et al. (2004) implemented an educational outreach program in Spanish with Hispanic women through a bilingual outreach coordinator. The coordinator visited community centers, churches, and health clinics to present culturally appropriate information about breast cancer. During the first six months of the program, the number of women obtaining mammograms rose by more than 200%. 

 

Although several researchers have attempted to provide appropriate programming for Hispanic women, Hispanic women’s lack of participation in screening is caused, in part, by breast education programs being insensitive to special, culturally based concerns (Million-Underwood, Sanders, & Davis, 1993). Thus, a strong need exists for culturally and linguistically appropriate interventions pertaining to breast cancer with Hispanic women living in the United States. Similar to those for women in other minority groups, the programs should involve the community and be infused with cultural knowledge (Oncology Nursing Society, 1999). Program materials should be culturally sensitive (Smiley, McMillan, Johnson, & Ojeda, 2000), presented in Spanish, and at appropriate reading levels (Perez-Stable, Sabogal, Otero-Sabogal, Hiatt, & McPhee, 1992). Additionally, programs should be implemented in a familiar environment (e.g., churches) using community facilitators or liaisons from the same cultural group. Finally, nurses should work collaboratively with researchers in higher education to ensure rigorous evaluation of the effects of the programs.

 

The purpose of the current study was to determine the effectiveness of a multifaceted, culturally sensitive, and linguistically appropriate breast cancer education program based on the HBM for Hispanic women in Arkansas. Two hypotheses were tested. The first was that participants in the experimental condition would exhibit greater knowledge of breast cancer than those in the control condition. The second hypothesis was that participants in the experimental condition would display more adaptive beliefs regarding mammography and BSE than those in the control condition. The program was modeled after a successful intervention designed to teach breast cancer screening to African American women in Arkansas (Hall et al., 2005). Hall et al. found that participants in the experimental group who received the program possessed more knowledge about breast cancer, had a better understanding of risk or susceptibility associated with developing the disease, and were more confident in their ability to successfully perform BSE than those in the control group.

 

Theoretical Model

 

The HBM has been applied frequently to breast cancer screening. In recent years, the HBM has been used in studies involving Hispanic women (e.g., Fulton et al., 1995; Smiley et al., 2000). The model proposes that screening behaviors result from personal decisions that are based on perceived susceptibility, perceived seriousness, benefits and barriers to action, and confidence (Champion & Scott, 1997). A person’s knowledge of cancer and risk influences perceived susceptibility and seriousness. Participation in screening results from the belief that certain behaviors will benefit the person and surpass any barriers. Finally, confidence, or self-efficacy (Bandura, 1986, 1997), specific to engaging in screening behaviors such as BSE, functions to increase the likelihood of engaging in health-promoting behavior (Champion & Scott; Mishra et al., 1998).

 

Methods

 

Prior to conducting the study, the researchers obtained approval from the Institutional Review Board at Arkansas State University. To maintain confidentiality, subjects did not record their names or other direct identifying information on any of the questionnaires.

 

Setting

 

The study was carried out in the parish hall of a local Roman Catholic Church. The priest gave permission for the study. The nun who was primarily responsible for working with the Hispanic population in the church and the director of the local Hispanic community center assisted in announcing the program and encouraged women to attend.

 

Participants

 

To be included in the study, a participant had to be a woman of at least 18 years of age who identified herself as being of Hispanic background. The participants were recruited through an announcement in local English and Spanish newspapers describing the free breast cancer education program. Written announcements in Spanish also were delivered to Hispanic businesses, local churches that had a substantial number of Hispanic members, and the area Hispanic community center. The announcements offered child care, door prizes, and lunch. Informed consent was obtained from all participants before initiation of the study.

 

The sample consisted of 31 Hispanic women aged 25–56 years living in northeastern Arkansas. The average age was 36 years (SD = 7.38). The mean number of years of education completed was 7.72 (SD = 3.72) with a range of 2–16 years. The median income level was $13,500 per year, with 84% earning less than $20,000 per year and 44% earning less than $10,000 per year. Statistical analysis revealed no significant differences between the experimental and control groups in terms of age, education, or income. With regard to health status variables, 59% reported being in good to excellent health, 35% reported fair health, and 7% reported poor health. Only 24% had a physician, and only 48% reported having regular checkups. In addition, only 24% had ever had a mammogram, only 45% had received a clinical breast examination in the prior year, and only 52% performed BSE. None of the participants had been diagnosed with cancer, and only one had received a breast biopsy.

 

Design

 

An experimental post-test–only, control-group design (Campbell & Stanley, 1963) was employed. A pretest was not administered to the participants because of time constraints and concerns about reactivity. Participants in the experimental group (n = 15) received the multifaceted, culturally sensitive, and linguistically appropriate breast cancer education program. Participants assigned to the control group (n = 16) received a program on nutrition. Participants were assigned randomly to the groups immediately before implementation of the program. Immediately after measurements were collected, participants in the experimental program received the nutrition program and those in the control group received the breast cancer education program. Thus, all participants had access to both programs.

 

Researchers achieved randomization by first printing the study instruments on different colors of paper (pink for experimental and blue for control). The instruments then were sealed in large manila envelopes with a demographic questionnaire attached to the outside. The envelopes were ordered randomly and placed on a table where participants entered the church hall. Upon entry, participants were asked to choose an envelope from the table. After completing the demographic questionnaire, participants opened the manila envelope and were directed to the appropriate group based on the color of the instruments. This was done so that women who arrived together were less likely to feel that they were being separated arbitrarily.

 

Educational Program

 

The educational program was presented by a university nursing faculty member who had completed the Susan G. Komen Breast Cancer Foundation breast health course and undergraduate nursing students. A multimedia format was used to provide readable, culturally sensitive information and materials. Hispanic interpreters were obtained from the local Hispanic community center. Interpreters translated all spoken program information from English to Spanish. Printed materials and media were provided in Spanish. The materials did not exceed a seventh-grade reading level. All visual aids featured Hispanic women. All educational materials were obtained from the Susan G. Komen Breast Cancer Foundation.

 

The program was divided into two parts. The first was delivered via large-group instruction and played the Spanish version of selected sections from the Susan G. Komen Breast Cancer Foundation (2003–2006) interactive Web site “Anatomy of Breast Cancer.” The Web site uses animation to present some of its program content. Topics from sections I and XII were shown and included information on incidence, mortality, general risk factors, personal history with cancer, lifestyle-related risk factors, screening recommendations, breast cancer facts, and screening examinations. Next, participants viewed the Susan G. Komen Breast Cancer Foundation (2004b) videotape titled, “Cáncer del Seno: Guia de Deteccion Temprana (“Breast Cancer: Your Guide to Early Detection”).

 

The second part of the educational program, which immediately followed the large-group instruction, consisted of small-group sessions led by a presenter who was assisted by an interpreter. The interpreter translated all information about BSE from the presenter. Each participant received a shower card designed for Hispanic women that gave directions for performing BSE titled, “Pasos Para el Autoexamen del Seno” (“Steps to Breast Self-Examination”) produced by Susan G. Komen Breast Cancer Foundation (2004c). The presenter provided the content of the shower card to the participants verbatim. Participants retained the cards at the conclusion of the program. Additionally, participant modeling was used to teach correct BSE. Each presenter first demonstrated proper BSE using a breast model. Next, each participant was required to demonstrate proper BSE and detect at least one lump using the model. Finally, each participant was given a “Beads for Life” key chain. The aid, which the participants were allowed to keep, consisted of beads of various sizes that are analogous to breast tumors detected at different points in their development using available screening methods. Each presenter discussed the significance of the tool and explained the accompanying script, written in Spanish, which noted the size of breast tumors detected by various screening techniques (i.e., untrained in BSE, occasional BSE, regular BSE, first mammogram, subsequent mammograms). The educational program concluded with each participant receiving a Spanish version of a booklet published by Susan G. Komen Breast Cancer Foundation (2004a) titled, “Breast Cancer: What Every Woman Needs to Know.”

 

The total length of the program was approximately 40 minutes. The control group received a program about nutrition, also lasting approximately 40 minutes. Collection of the study measurements occurred immediately following the programs. Hispanic interpreters assisted in data collection, which took approximately 30 minutes, as needed.

 

Treatment Integrity

 

Treatment integrity, the extent to which a program is implemented properly, was measured by trained observers who read along with the program scripts to determine whether each presenter delivered the content as listed on selected portions of the Web site, shower card, and key chain. Observers also used a checklist in one of the small groups to determine whether the participants correctly demonstrated BSE on the model and detected lumps. Overall, treatment integrity associated with the program was 98%.

 

Instruments

 

Each participant completed a demographic questionnaire. Knowledge of breast cancer was measured by the Breast Cancer Knowledge (BCK) Test (McCance, Mooney, Smith, & Field, 1990). Adaptive beliefs regarding mammography and BSE were measured by the Breast Cancer Screening Belief Scales (BCSBS) (Champion & Scott, 1997). The three instruments had been translated into Spanish. The demographic questionnaire was written at a sixth-grade reading level. The translation of the BCK Test was at the seventh-grade level, and the translation of the BCSBS was at the eighth-grade level. The levels are the same as those of the English versions.

 

The BCK Test is based on Stillman’s (1977) Knowledge Questionnaire and has been recommended for evaluating the effectiveness of educational programs designed to promote early detection of breast cancer (McCance et al., 1990). It contains 18 items with an internal consistency (coefficient alpha) of  0.81 on the English language version. Content validity was established through expert opinion. A high score on the instrument is associated with greater knowledge. Coefficient alpha for the Spanish translation used in the current study was 0.72, indicating sufficient internal consistency.

 

The BCSBS (Champion & Scott, 1997) is based on the HBM and consists of 47 items that comprise six scales: (a) susceptibility, (b) benefits of mammography, (c) benefits of BSE, (d) barriers to mammography, (e) barriers to BSE, and (f) confidence. All of the items on the BCSBS are rated on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). High scores on the susceptibility, benefits of mammography, benefits of BSE, and confidence scales are associated with increased breast cancer screening. Conversely, low scores on the barriers to mammography scale and barriers to BSE scale are associated with early detection. Internal consistencies for the English-language version of the instrument are 0.83 for susceptibility, 0.65 for benefits of mammography, 0.69 for benefits of BSE, 0.85 for barriers to mammography, 0.83 for barriers to BSE, and 0.90 for confidence. Test-retest reliabilities for the English-language version over an unspecified time interval ranged from 0.40–0.68. Construct validity for the scales was assessed and supported through confirmatory factor analysis. Coefficient alphas for the Spanish translation used in the current study were 0.92 for susceptibility, 0.70 for benefits of mammography, 0.36 for benefits of BSE, 0.80 for barriers to mammography, 0.84 for barriers to BSE, and 0.88 for BSE self-efficacy. Thus, all of the scales except benefits of BSE had sufficient internal consistency. Although analyses are reported for benefits of BSE to maintain the integrity of the BCSBS, the findings for that scale should be interpreted with caution.

 

Data Analysis

 

The results were analyzed with t tests using SPSS version 14.0 (SPSS Inc.). Because directional hypotheses were involved, statistical significance was evaluated at the 0.05 level using one-tailed tests. Degrees of freedom vary for some tests because some participants did not respond to all items.

 

Results

 

Breast Cancer Knowledge

 

The mean scores on the BCK Test were 12.92 (SD = 2.40) for the experimental group and 10.53 (SD = 3.41) for the control group. The difference was statistically significant, t(27) = 2.17, p < 0.05 one tailed. Fisher exact tests indicated that the experimental and control groups differed significantly (p < 0.05) on four of the BCK Test items. Women in the experimental group were more likely than those in the control group to know that postmenopausal women should perform BSE once a month (86% correct versus 46% correct), that regularly feeling the breasts is one of the most effective methods of cancer detection (100% correct versus 73% correct), that women should begin BSE at 20 years of age (100% correct versus 67% correct), and that looking at the breasts in a mirror is an important part of BSE (100% correct versus 60% correct).

 

Barriers to Screening

 

The mean scores on the BCSBS are presented in Table 1. Only two of the differences were statistically significant. Thus, the hypothesis that participants in the experimental condition would display more adaptive beliefs about mammography and BSE than those in the control condition was supported only partially. As predicted, the control group perceived greater barriers to mammography than did the experimental group, t(26) = 1.88, p < 0.05 one tailed. Three individual items contributed significantly to the difference (p < 0.05 one tailed). Women in the control group were more likely than those in the experimental group to believe that they could not remember mammography appointments (–X = 2.47 versus 1.36) and that having a mammogram would be painful (–X = 2.93 versus 1.93). Women in the control group also were more likely to fear finding out that something is wrong (–X = 4.53 versus 3.50). Contrary to prediction, the control group perceived greater benefits to BSE, t(27) = 2.18, p < 0.05 two tailed. However, analysis of individual items revealed no statistically significant differences. Analysis did reveal that responses in the experimental and control groups were uniformly high (i.e., all 4s and 5s) except for one participant in the experimental group who assigned a 1 to four of the five questions. Thus, the difference between the groups appears to be the result of a ceiling effect on the scale, possibly caused by response bias. 

 

Discussion

 

The breast cancer education program for Hispanic women implemented in this study was multifaceted, culturally sensitive, and linguistically appropriate. A major objective of the program was to increase Hispanic women’s knowledge of breast cancer because, consistent with the HBM, more knowledge of breast cancer has been associated with greater mammography use, more frequent clinical breast examinations (McCance et al., 1990), and more frequent BSE (Champion, 1987; Dickson et al., 1986; Gray, 1990; Mamon & Zapka, 1986; Reeder, Berkanovic, & Marcus, 1980; Rutledge, Barsevick, Knobf, & Bookbinder, 2001).

 

Women who received the educational program exhibited greater knowledge of breast cancer than did those in the control group. Participants in the experimental group perceived barriers to mammography according to the BCSBS; however, no between-group differences existed on barriers to BSE, benefits of mammography, confidence, or susceptibility. Small sample size may have contributed to the nonsignificance of group differences on those variables. Thus, the researchers detected an indication of some success on the second objective of the program, to reduce specific beliefs that serve as barriers to breast cancer screening. The women who received the program exhibited reduced fear of physical discomfort or pain, perceived inability to remember appointments, and fear of diagnostic results. The finding is important because previous research has shown that fear of diagnostic results is a major barrier to screening in Hispanic women (Taplin & Montano, 1993).

 

The finding that women in the control group perceived greater benefits of BSE was unexpected. The extremely high scores on the scale in both groups and the low internal consistency indicate that the result is more likely a result of measurement problems than the effect of the educational program. Previous research has shown that response sets such as extreme responses, acquiescence, and socially desirable responses may be more frequent in Hispanic samples (Hui & Triandis, 1989). Thus, the women in the sample may have been biased to say positive things about BSE.

 

Although unrelated to the research hypotheses, the translation of the BCK Test and the BCSBS into Spanish for the study is important. The researchers were able to obtain translations of the instruments without affecting reading levels and, for the most part, retained acceptable internal consistencies. Thus, the instruments appear to be valuable tools for assessing breast cancer knowledge and beliefs of Hispanic women.

 

Limitations

 

The study has several limitations. First, the term “Hispanic” refers to a number of diverse subpopulations. Whether the findings of the study would generalize to Hispanic women of different backgrounds is unknown. In addition, the sample was a convenience sample of women willing to attend an advertised intervention at a local church. Replication of the program is needed to evaluate the generalization of the intervention. Second, future research should compare the program to alternative interventions to evaluate relative efficacy and cost efficiency. Third, although knowledge and beliefs can be predictors of screening, actual screening behaviors were not examined. Studies that examine differences in obtaining mammography and actual performance of BSE are needed. Fourth, although the translations of the BCK Test and the BCSBS showed acceptable reading levels and internal consistencies, the validity of the measurements with Hispanic populations was not evaluated. The BCK Test and the BCSBS appear to be amenable to Spanish translation, although the psychometric properties of the Spanish versions of the instruments will require additional research specific to their reliability and validity. Fifth, although the reading levels of sixth- to eighth-grade for written materials was appropriate for most members of the sample, some participants had educational levels as low as second grade. Thus, a few participants may have had difficulty with the written materials.  

 

Implications for Nursing Practice

 

Nurses must play an important role in making breast cancer education accessible to underserved populations (Olsen & Frank-Stromborg, 1993). Providing breast cancer screening to Hispanic women in the United States is challenging; increasing knowledge and changing faulty beliefs associated with screening are needed to increase mammography and BSE in the population. Educational programs for the women, however, must be culturally based and linguistically appropriate to be successful. In addition, careful evaluation of the effectiveness of programs is necessary. Program success can be increased through collaborative partnerships with the community (e.g., local churches, Hispanic community centers) and with researchers in higher education to increase participation and ensure proper evaluation, respectively (Meade & Calvo, 2001). Group education is a viable and acceptable way to bring advances in breast cancer prevention to large groups of women (Snyder et al., 2003), and multimedia technology can present messages in a sensory-rich environment (Street, Van Order, Bramson, & Manning, 1998).

 

The present study involved the successful use of all of those resources. In addition, the specific educational materials used in the investigation are readily available through Susan G. Komen for the Cure, making replication of the program possible without the need to develop special materials. Thus, the study shows that providing multifaceted, culturally sensitive, and linguistically appropriate breast cancer education programs for Hispanic women can be accomplished successfully within the scope of nursing practice.

 

The authors gratefully acknowledge Patty Abraham, RD, Karen Blachly, RD, Gina Gomez, Kenny Adams, LPN, Crystal Turner, LPN, Brandi Workman, LPN, Krista Sutton, LPN, Marissa Mangrum, LPN, Ashley Carter, LPN, Carol Hammett, LPN, Jessica Chisem, LPN, Twan Nguyen, Sister Elaine Willett, Reverend Mark Wood, Ronald Blachly, MD, Ernesto Lombeida, PhD, Hispanic Community Services, Inc., and the Blessed Sacrament Catholic Church in Jonesboro, AK, for their assistance with the study.

 

References

 

American Cancer Society. (2006). Cancer facts and figures for Hispanics/Latinos 2006–2008. Retrieved September 23, 2006, from http://www.cancer.org/downloads/STT/CAFF2006Hisp

PWSecured.pdf

 

Andrus, M.R., & Roth, M.T. (2002). Health literacy: A review. Pharmacotherapy, 22, 282–302.

 

Arndt, V., Sturmer, T., Stegmaier, C., Ziegler, H., Becker, A., & Brenner, H. (2003). Provider delay among patients with breast cancer in Germany: A population-based study. Journal of Clinical Oncology, 21, 1440–1446.

 

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

 

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman.

 

Bazargan, M., Bazargan, S.H., Calderon, J.L., Husaini, B.A., & Baker, R.S. (2003). Mammography screening and breast self-examination among minority women in public housing projects: The impact of physician recommendation. Cellular and Molecular Biology, 49, 1213–1218.

 

Borders, T.F., Warner, R.D., & Sutkin, G. (2003). Satisfaction with health care and cancer screening practices among women in a largely rural region of West Texas. Preventive Medicine, 36, 652–658.

 

Borrayo, E.A., & Guarnaccia, C.A. (2000). Differences in Mexican-born and U.S.-born women of Mexican descent regarding factors related to breast cancer screening behaviors. Health Care for Women International, 21, 599–613.

 

Boyer-Chammard, A., Taylor, T.H., & Anton-Culver, H. (1999). Survival differences in breast cancer among racial/ethnic groups: A population-based study. Cancer Detection and Prevention, 23, 463–473.

 

Campbell, D.T., & Stanley, J.C. (1963). Experimental and quasi-experimental designs for research. Chicago: Rand McNally.

 

Cancer in Mexican American Women. (2006). Retrieved September 23, 2006, from http://cancercontrol.cancer.gov/womenofcolor/mexican.htm

 

Carpenter, V., & Colwell, B. (1995). Cancer knowledge, self-efficacy, and cancer screening behaviors among Mexican-American women. Journal of Cancer Education, 10, 217–222.

 

Champion, V.C. (1987). The relationship of breast self-examination to Health Belief Model variables. Research in Nursing and Health, 10, 375–382.

 

Champion, V.L., & Scott, C.R. (1997). Reliability and validity of Breast Cancer Screening Belief Scales in African American women. Nursing Research, 46, 331–337.

 

Chrisler, J.C. (1993). Commentary on role of locus of control beliefs in cancer screening of elderly Hispanic women. AWHONN’s Women’s Health Nursing Scan, 7(5), 11.

 

Cockburn, J., Murphy, B., Schofield, P., Hill, D., & Borland, R. (1991). Development of a strategy to encourage attendance for screening mammography. Health Education Research, 6, 279–290.

 

Coe, K., Harmon, M.P., Castro, F.G., Campbell, N., Mayer, J.A., & Elder, J.P. (1994). Breast self-examination: Knowledge and practices of Hispanic women in two southwestern metropolitan areas. Journal of Community Health, 19, 433–448.

 

Darling, C.M., Nelson, C.P., & Fife, R.S. (2004). Improving breast health education for Hispanic women. Journal of the American Medical Women’s Association, 59, 171, 228–229.

 

Dickson, G., Parsons, M.A., Greaves, P., Jackson, K.L., Kronenfeld, J.J., Ward, W.B., et al. (1986). Breast self-examination knowledge, attitudes, and practice behaviors of working women. AAOHN Journal, 34, 228–232.

 

Facione, N.C., Miaskowski, C., Dodd, M.J., & Paul, S.M. (2002). The self-reported likelihood of patient delay in breast cancer: New thoughts for early detection. Preventive Medicine, 34, 397–407.

 

Fitzgibbon, M.L., Gapstur, S.M., & Knight, S.J. (2003). Mujeres felices por ser saludables: A breast cancer risk reduction program for Latino women. Preventive Medicine, 36, 536–546.

 

Frost, F., Tollestrup, K., Hunt, W.C., Gilliland, F., Key, C.R., & Urbina, C.E. (1996). Breast cancer survival among New Mexico Hispanic, American Indian, and non-Hispanic white women (1973–1992). Cancer Epidemiology, Biomarkers and Prevention, 5, 861–866.

 

Fulton, J.P., Rakowski, W., & Jones, A.C. (1995). Determinants of breast cancer screening among inner-city Hispanic women in comparison to other inner-city women. Public Health Reports, 110, 476–482.

 

Goel, M.S., Wee, C.C., McCarthy, E.P., Davis, R.B., Ngo-Metzger, Q., & Phillips, R.S. (2003). Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care. Journal of General Internal Medicine, 18, 1028–1035.

 

Gonzalez, J.T. (1990). Factors relating to the frequency of breast self-examination among low-income Mexican-American women: Implications for nursing practice. Cancer Nursing, 13, 134–142.

 

Gorin, S.S., & Heck, J.E. (2005). Cancer screening among Latino subgroups in the United States. Preventive Medicine, 40, 515–526.

 

Gray, M.E. (1990). Factors related to practice of breast self-examination in rural women. Cancer Nursing, 13, 100–107.

 

Guerra, C.E., Krumholz, M., & Shea, J.A. (2005). Literacy and knowledge, attitudes and behavior about mammography in Latinas. Journal of Health Care for the Poor and Underserved, 16, 152–166.

 

Hall, C.P., Wimberley, P.D., Hall, J.D., Pfriemer, J.T., Hubbard, E.M., Stacy, A.S., et al. (2005). Teaching breast cancer screening to African American women in the Arkansas Mississippi River

Delta. Oncology Nursing Forum, 32, 857–863.

 

Hubbell, F.A., Chavez, L.R., Mishra, S.I., & Valdez, R.B. (1996). Differing beliefs about breast cancer among Latinas and Anglo women. Western Journal of Medicine, 164, 405–409.

 

Huerta, E.E. (2003). Cancer statistics for Hispanics, 2003: Good news, bad news, and the need for a health system paradigm change. CA: A Cancer Journal for Clinicians, 53, 205–207.

 

Hui, C.H., & Triandis, H.C. (1989). Effects of culture and response format on extreme response style. Journal of Cross Cultural Psychology, 20, 296–309.

 

Jibaja, M.L., Kingery, P., Neff, N.E., Smith, Q., Bowman, J., & Holcomb, J.D. (2000). Tailored, interactive soap operas for breast cancer education of high-risk Hispanic women. Journal of Cancer Education, 15, 237–242.

 

Lee, T. (2006). Hispanic population growing fastest in Arkansas. Retrieved September 23, 2006, from http://asbdc.ualr.edu/enews/article.asp?aid=723

 

Longman, A.J., Saint-Germain, M.A., & Modiano, M. (1992). Use of breast cancer screening by older Hispanic women. Public Health Nursing, 9, 118–124.

 

Luquis, R.R., & Villanueva Cruz, I.J. (2006). Knowledge, attitudes, and perceptions about breast cancer and breast cancer screening among Hispanic women residing in south central Pennsylvania. Journal of Community Health, 31, 25–42.

 

Mamon, J.A., & Zapka, J.G. (1986). Breast self-examination by young women: Characteristics associated with frequency. American Journal of Preventive Medicine, 2, 61–69.

 

McCance, K.L., Mooney, K.H., Smith, K.R., & Field, R. (1990). Validity and reliability of a breast cancer knowledge test. American Journal of Preventive Medicine, 6, 93–98.

 

Meade, C.D., & Calvo, A. (2001). Developing community-academic partnerships to enhance breast health among rural and Hispanic migrant and seasonal farmworker women. Oncology Nursing Forum, 28, 1577–1584.

 

Million-Underwood, S., Sanders, E., & Davis, M. (1993). Determinants of participation in state-of-the-art cancer prevention, early detection/screening, and treatment trials among African-Americans. Cancer Nursing, 16, 25–33.

 

Mishra, S.I., Chavez, L.R., Magana, J.R., Nava, P., Valdez, R.B., & Hubbell, F.A. (1998). Improving breast cancer control among Latinas: Evaluation of a theory-based education program. Health Education and Behavior, 25, 653–670.

 

National Cancer Institute. (2006). Cancer in Mexican American women: Key points. Retrieved September 23, 2006, from http://cancercontrol.cancer.gov/womenofcolor/mexican.html

 

Olsen, S.J., & Frank-Stromborg, M. (1993). Cancer prevention and early detection in ethnically diverse populations. Seminars in Oncology Nursing, 9, 198–209.

 

O’Malley, A.S., Kerner, J., Johnson, A.E., & Mandelblatt, J. (1999). Acculturation and breast cancer screening among Hispanic women in New York. American Journal of Public Health, 89, 219–227.

 

Oncology Nursing Society. (1999). Multicultural outcomes: Guidelines for cultural competence. Retrieved March 20, 2007, from http//www.ons.org/clinical/documents/pdfs/multicultural2.pdf

 

Palacios, C., & Sheps, S. (1992). A pilot study assessing the health status of the Hispanic American community living in Vancouver. Canadian Journal of Public Health, 83, 346–349.

 

Peragallo, N.P., Fox, P.G., & Alba, M.L. (1998). Breast care among Latino immigrant women in the U.S. Health Care for Women International, 19, 165–172.

 

Peragallo, N.P., Fox, P.G., & Alba, M.L. (2000). Acculturation and breast self-examination among immigrant Latina women in the USA. International Nursing Review, 47, 38–45.

 

Perez-Stable, E.J., Sabogal, F., Otero-Sabogal, R., Hiatt, R.A., & McPhee, S.J. (1992). Misconception about cancer among Latinos and Anglos. JAMA, 268, 3219–3223.

 

Population Resource Center. (2002). Executive summary: A demographic profile of Hispanics in the U.S. Retrieved October 2, 2006, from http://www.prcdc.org/DemographicProfileofHispanics.pdf

 

Rahman, S.M., Mohamed, I., & Dignan, M.B. (2003). Assessment of perceptions related to breast cancer prevention and behavioral practices in medically underserved women. Journal of Multicultural Nursing and Health, 9, 30–39.

 

Ramirez, R.R., & de la Cruz, G.P. (2003). The Hispanic population in the United States: March 2002. Retrieved October 8, 2006, from http://www.newsdesk.umd.edu/pdfHispanicCensus2002.pdf

 

Reeder, S., Berkanovic, E., & Marcus, A.C. (1980). Breast cancer detection behavior among urban women. Public Health Reports, 95, 276–281.

 

Rosenstock, I.M. (1966). Why people use health services. Milbank Quarterly, 44, 94–127.

 

Rosenstock, I.M., Strecher, V.J., & Becker, M.H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15, 175–183.

 

Rutledge, D.N., Barsevick, A., Knobf, M.T., & Bookbinder, M. (2001). Breast cancer detection: Knowledge, attitudes, and behaviors of women from Pennsylvania. Oncology Nursing Forum, 28, 1032–1040.

 

Saint-Germain, M.A., & Longman, A.J. (1993). Breast cancer screening among older Hispanic women: Knowledge, attitudes, and practices. Health Education Quarterly, 20, 539–553.

 

Salazar, M.K. (1996). Hispanic women’s beliefs about breast cancer and mammography. Cancer Nursing, 19, 437–446.

 

Skaer, T.L., Robison, L.M., Sclar, D.A., & Harding, G.H. (1996). Knowledge, attitudes, and patterns of cancer screening: A self-report among foreign born Hispanic women utilizing rural migrant health clinics. Journal of Rural Health, 12, 169–177.

 

Smiley, M.R., McMillan, S.C., Johnson, S., & Ojeda, M. (2000). Comparison of Florida Hispanic and non-Hispanic Caucasian women in their health beliefs related to breast cancer and health locus of control. Oncology Nursing Forum, 27, 975–984.

 

Smith, R.A., Cokkinides, V., & Eyre, H.J. (2004). American Cancer Society guidelines for the early detection of cancer 2004. CA: A Cancer Journal for Clinicians, 54, 41–52.

 

Snyder, L.A., Soballe, D.B., Lahl, L.L., Nehrebecky, M.E., Soballe, P.W., & Klein, P.M. (2003). Development of the breast cancer education and risk assessment program. Oncology Nursing Forum, 30, 803–808.

 

Southern Regional Educational Board. (2005). SREB fact book on higher education: Arkansas featured facts. Retrieved September 23, 2006, from http://www.sred.org/main/EdData/FactBook/2005StateReports/Arkansas05pdf

 

Stillman, M.J. (1977). Women’s health beliefs about breast cancer and breast self-examination. Nursing Research, 26, 121–127.

 

Street, R.L., Van Order, A., Bramson, R., & Manning, T. (1998). Preconsultation education promoting breast cancer screening: Does the choice of media make a difference? Journal of Cancer Education, 13, 152–161.

 

Susan G. Komen Breast Cancer Foundation. (2004a). Breast cancer: What every woman needs to know [Item No. 806-445SP]. Dallas, TX: Author.

 

Susan G. Komen Breast Cancer Foundation. (2004b). Cáncer del seno: Guia de deteccion temprana [Video, Item No. 806-11301-SP]. Dallas, TX: Author.

 

Susan G. Komen Breast Cancer Foundation. (2004c). Pasos para el autoexamen del seno [Shower card, Item No. 806-301]. Dallas, TX: Author.

 

Taplin, S., & Montano, D.E. (1993). Attitudes, age, and participation in mammographic screening: A prospective analysis. Journal of the American Board of Family Practice, 6, 13–23.

 

Taylor, G.A. (2002). Effects of a culturally sensitive breast self-examination intervention. Outcomes Management, 6, 73–78.

 

U.S. Census Bureau. (2003). U.S. Census Bureau guidance on the presentation and comparison of race and Hispanic origin data. Retrieved September 28, 2006, from http:/www.census.gov/population/www/socdemo/compraceho.html

 

U.S. Census Bureau. (2004). Projected population of U.S. by race and Hispanic origin 2000–2050. Retrieved September 28, 2006, from http://www.census.gov/ipc/www/usinterimproj/natprojtab01a.pdf

 

Valdez, A., Banerjee, K., Ackerson, L., & Fernandez, M. (2002). A multimedia breast cancer education intervention for low-income Latinas. Journal of Community Health, 27, 33–51.

 

Valdez, A., Banerjee, K., Fernandez, M., & Ackerson, L. (2001). Impact of a multimedia breast cancer education intervention on use of mammography by low-income Latinas. Journal of Cancer Education, 16, 221–224.

 

Wong, A.M. (2000). Risk assessment survey of breast cancer among prenatal Hispanic clients at Prince George’s Hospital Center. Maryland Nurse, 2, 9.

 

Zambrana, R.E., Breen, N., Fox, S.A., & Gutierrez-Mohamed, M.L. (1999). Use of cancer screening practices by Hispanic women: Analysis by subgroup. Preventive Medicine, 29, 466–477.

 

Cathy P. Hall, MSN, RN, OCN®, is an assistant professor of nursing in the Department of Nursing, John D. Hall, PhD, LP, SPS, NCSP, is a professor of psychology and counseling in the Department of Psychology and Counseling, Judith T. Pfriemer, MSN, RN, and Paige D. Wimberley, MSN, RN, are assistant professors of nursing in the Department of Nursing, and Craig H. Jones, EdD, is a professor of psychology and counseling in the Department of Psychology and Counseling, all at Arkansas State University in Jonesboro. This study was funded by a grant from the Northeast Arkansas Clinic Charitable Foundation, with additional funding from the College of Nursing and Health Professions at Arkansas State University. (Submitted February 2006. Accepted for publication April 3, 2007.)

 

Author Contact: Cathy P. Hall, MSN, RN, OCN®, can be reached at chall@astate.edu, with copy to editor at ONFEditor@ons.org.

 

Digital Object Identifier: 10.1188/07.ONF.1195-1202