Recruitment strategies for cervical cancer prevention study.

OBJECTIVE: The aim of this study was to describe recruitment strategies for a single-visit cervical cancer prevention study. METHODS: From January through December 1999, low-income, predominantly Latino women were recruited to participate in a single-visit cervical cancer prevention study. For the first 6 months, all women who had ever visited one of two community-based study clinics were invited to participate (clinic registry recruitment). For the remainder of the year, recruitment was modified to be primarily inclusive of advertisements in English- and Spanish-language community newspapers and fliers left in local businesses and organizations (media campaign recruitment). Eligible volunteers were randomized to one of two study arms, usual-care program or single-visit program. All study subjects completed demographic and medical questionnaires delivered by bilingual staff. Women who declined to participate in this study were asked to provide reasons for this preference. Statistical analyses included the use of chi-square, logistic regression, and Student's t test. RESULTS: The proportion of women who agreed to participate was higher in the media recruitment group than in the clinic registry group [51% (535/1041) compared to 26% (405/1542), P < 0.001]. The no-show rate among participants solicited from the media strategy was significantly less than that from the clinic registry. There were no significant differences in the median age, number of months since the last Papanicolaou smear, incidence of abnormal Papanicolaou smear, education, or income of the subjects based on the recruitment strategy. CONCLUSION: A media-based recruitment strategy was effective for this single-visit cervical prevention study. This approach may be effective for recruitment of other low-income groups to clinical trials.

Breast cancer screening among American Samoan women.

BACKGROUND: Little is known about breast cancer screening practices or predictors of age-specific screening for Samoan women. METHODS: Through systematic, random sampling procedures, we identified and interviewed 720 adult (> or =30 years) Samoan women residing in American Samoa, Hawaii, and Los Angeles. Multivariate logistic regressions were performed to determine independent predictors for recent age-specific screening. RESULTS: Only 55.6% of women (> or =30 years) had ever had a CBE and 32.9% of women (> or =40 years) had ever had a mammogram. Furthermore, only 24.4 and 22.4% of Samoan women (> or =40 years) residing in Hawaii and Los Angeles, respectively, had an age-specific mammogram within the prior year. Independent predictors of age-specific CBE screening included age, education, health insurance, ambulatory visit, and being a resident of Hawaii or Los Angeles; those for mammography included ambulatory visit and awareness of screening guidelines. CONCLUSION: Population-based estimates of age-specific breast cancer screening among Samoan women are lower than the national objectives and those reported for other minorities. Targeted efforts that address doctor-patient communication on preventive behavior, improved access to health care services (especially in American Samoa), and focused educational awareness programs are needed to improve the dismal screening rates observed in this indigenous population.

Predictors of papanicolaou smear use among american samoan women.

To explore the rate and predictors of Papanicolaou (Pap) smear use among American Samoans, we conducted a survey of 986 randomly selected adult, self-identified Samoan women in American Samoa (n = 323), Hawaii (n = 325), and Los Angeles (n = 338). Only 46% of the women reported having a Pap smears within the past 3 years. These women were more likely than others to reside in Hawaii (odds ratio [OR], 1.7), be less than 40 years of age (OR, 2.2), be married (OR, 1.9), have more than 12 years of formal education (OR, 2.1), have an income of more than $20,000 per year (OR, 1.6), have health insurance (OR, 1.6), and have higher acculturation levels (OR, 1.9). Knowledge and attitudes about cervical cancer did not predict Pap smear screening. It is likely that the low rate of Pap smear screening contributes to the high site-specific incidence of cervical cancer among American Samoan women.

Knowledge of and attitudes about cancer among American Samoans.

The objective of this study was to determine cancer-related knowledge and attitudes among American Samoans, a population seldom studied by cancer researchers. Such information is necessary to develop culturally sensitive cancer control interventions. Specially trained personnel conducted face-to-face interviews with randomly selected respondents in the US Territory of American Samoa; Oahu, HI; and Los Angeles, CA, using a survey based on the National Health Interview Survey Cancer Control Supplement and focus group findings. The survey included questions concerning knowledge of risk factors for cancers (breast, cervical, colon, lung, stomach, and prostate), family resources (health insurance coverage, employment status, and family income), and demographic characteristics. Participants could complete the survey in English or Samoan. Analysis of data included the chi-squared test and logistic regression analysis. Participants included 1,834 noninstitutionalized English- or Samoan-speaking women and men (609 from American Samoa, 610 from Hawaii, and 615 from Los Angeles). The majority of residents had some positive attitudes about cancer prevention and treatment but often also had misconceptions about risk factors for cancer. Logistic regression analysis revealed that site of residence was an important predictor of attitudes. For example, being residents of American Samoa or Hawaii predicted that the respondents would rather not know that they had cancer (odds ratio [OR], 1.5, 2.1, respectively); that cancer can be caused by aitu, or spirits (OR, 1.9, 2.1, respectively); that cancer is a punishment from God (OR, 2.0, 2.2, respectively); and that cancer can be cured by fofo, or traditional Samoan healers (OR, 2.0, 3. 1, respectively). This study documented cancer-related knowledge and attitudes among American Samoans and set the stage for culturally sensitive interventions aimed at improving cancer control in this population. It also identified many issues that should be addressed in such interventions.

The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Improving breast cancer control among Latinas: evaluation of a theory-based educational program.

The study evaluated a theory-based breast cancer control program specially developed for less acculturated Latinas. The authors used a quasi-experimental design with random assignment of Latinas into experimental (n = 51) or control (n = 37) groups that completed one pretest and two posttest surveys. The experimental group received the educational program, which was based on Bandura's self-efficacy theory and Freire's empowerment pedagogy. Outcome measures included knowledge, perceived self-efficacy, attitudes, breast self-examination (BSE) skills, and mammogram use. At posttest 1, controlling for pretest scores, the experimental group was significantly more likely than the control group to have more medically recognized knowledge (sum of square [SS] = 17.0, F = 6.58, p < .01), have less medically recognized knowledge (SS = 128.8, F = 39.24, p < .001), greater sense of perceived self-efficacy (SS = 316.5, F = 9.63, p < .01), and greater adeptness in the conduct of BSE (SS = 234.8, F = 153.33, p < .001). Cancer control programs designed for less acculturated women should use informal and interactive educational methods that incorporate skill-enhancing and empowering techniques.

The influence of knowledge and attitudes about breast cancer on mammography use among Latinas and Anglo women.

We conducted a telephone survey of randomly selected Latinas (n = 208) and Anglo women (n = 222) to determine predictors of mammography use. The cooperation rate was 78.5%. Relatively high proportions of Latinas (61%) and Anglo women (79%) reported mammography use within the past 2 years. A logistic regression analysis revealed that knowledge and attitudes did not independently predict use. On the other hand, having health insurance, being married, and being Latino were consistent independent predictors. We conclude that mammography use among Latinas and Anglo women is increasing. However, further gains in use must address difficult barriers such as lack of health insurance.

Purity and passion: risk and morality in Latina immigrants' and physicians' beliefs about cervical cancer.

This paper examines how physicians' beliefs about risk factors for cervical cancer compare with Mexican and Salvadoran immigrant women's views (hereafter Latina immigrants). Between August 15, 1991 and August 15, 1992, we conducted ethnographic interviews with 39 Mexican immigrant women, 28 Salvadoran immigrant women, and 30 physicians in northern Orange County, California. Physicians and Latina immigrants converge on their beliefs that sexual behavior is a predominant risk factor for cervical cancer. They diverge, however, on their reasons. Latina immigrants' perceptions of health risks are embedded in a larger set of cultural values centering around gender relations, sexuality, and morality. Latina immigrants also emphasized men's behavior as risk factors. Physicians' views, on the other hand, are largely based on the epidemiology of cervical cancer risk factors. They emphasized beginning sexual relations at an early age, multiple sexual partners, and infection with sexually transmitted viruses. Some physicians, however, displayed moral interpretations of the sex-based risk factors for cervical cancer through the use of the culturally-loaded term "promiscuous" in place of "multiple sexual partners," through specific references to morality, and through characterizations of women at risk for cervical cancer. Both the physicians and the Latina immigrants in our study paid considerably less attention to socioeconomic factors. Our results have important implications for physicians who provide health care for Latina immigrants. Physicians should be clear to point out that women need not be "promiscuous" to get cervical cancer.

Undocumented Latina immigrants in Orange County, California: a comparative analysis.

"This article examines a unique data set randomly collected from Latinas (including 160 undocumented immigrants) and non-Hispanic white women in Orange County, California, including undocumented and documented Latina immigrants, Latina citizens, and non-Hispanic white women. Our survey suggests that undocumented Latinas are younger than documented Latinas, and immigrant Latinas are generally younger than U.S.-citizen Latinas and Anglo women. Undocumented and documented Latinas work in menial service sector jobs, often in domestic services. Most do not have job-related benefits such as medical insurance.... Despite their immigration status, undocumented Latina immigrants often viewed themselves as part of a community in the United States, which significantly influenced their intentions to stay in the United States. Contrary to much of the recent public policy debate over immigration, we did not find that social services influenced Latina immigrants' intentions to stay in the United States."

The influence of fatalism on self-reported use of Papanicolaou smears.

OBJECTIVE: Our objective was to examine the demographic and other predictors of fatalistic beliefs among Latinas (Hispanic women) and Anglo (non-Hispanic Caucasian) women and to assess the impact of these beliefs on the use of cervical cancer screening services. METHODS: We used ethnographic interviews and a cross-sectional telephone survey in Orange County, California. Our sample included 94 Latinas and 27 Anglo women selected through organization-based network sampling for the ethnographic interviews and 803 Latinas and 422 Anglo women randomly selected for the telephone survey. RESULTS: Latina immigrants (Latinas born outside the United States) were more likely than U.S.-born Latinas or Anglo women to have fatalistic beliefs. Immigration, education levels, and insurance status predicted fatalistic beliefs. Fatalistic beliefs were independent predictors of Pap smear use by Latinas but not Anglo women. For example, after adjusting for potentially confounding variables, Latinas who believed that fate was a risk factor for cervical cancer (odds ratio [OR] = .58), that they would rather not know if they had the disease (OR = .58), and that there is nothing one can do to prevent it (OR = .45) were less likely than others to report that they have had a Pap smear within the prior three years. Health insurance status, marital status, and immigration also predicted use of Pap smears. Insured Latinas were more likely than uninsured Latinas (OR = 2.89) to report having a Pap smear within the prior three years. In addition, married Latinas (OR = 2.32) and Anglo women (OR = 3.09) were more likely than unmarried women to report having appropriate cervical cancer screening. Finally, Latina immigrants were less likely than other Latinas to report having a Pap smear (OR = .26). CONCLUSIONS: We conclude that fatalistic beliefs are among the factors that negatively influence Latinas' use of Pap smears and that it is important for health care professionals to address those beliefs. Continued efforts are also necessary to decrease the economic and structural barriers to cervical cancer screening.

Beliefs about sexual behavior and other predictors of Papanicolaou smear screening among Latinas and Anglo women.

BACKGROUND: Latinas use cervical cancer prevention services less often than Anglo women. OBJECTIVE: To assess whether beliefs about cervical cancer influence the use of Papanicolaou (Pap) smears among Latinas and Anglo women in Orange County, California. METHODS: We conducted a telephone survey using the computer-assisted telephone interview system, randomdigit dialing, and an instrument adapted from national surveys and a previous ethnographic study. RESULTS: Participants included 1225 noninstitutionalized Spanish- or English-speaking respondents 18 years or older-803 Latinas (533 immigrants and 270 US born) and 422 Anglo women. Latina immigrants were more likely than US-born Latinas or Anglo women to believe that a variety of behaviors were risk factors for this disease. These behaviors included medically accepted risk factors such as early initiation of sexual intercourse (53% vs 41% vs 39%; P < .01) as well as unaccepted factors such as having sex during menstruation (56% vs 10% vs 3%; P < .01). Logistic regression analysis revealed that Latinas who held such beliefs were significantly less likely than others to report receiving a Pap smear within the past 3 years. Other independent predictors of Pap smear use included health insurance status, martial status, and acculturation. CONCLUSIONS: Latinas have culturally based beliefs about cervical cancer that reflect the moral framework within which they interpret diseases and that may influence their use of Pap smears. These beliefs are most prevalent among Latina immigrants. Because the known risk factors for cervical cancer are primarily related to sexual activities and because such activities are private and sensitive for many Latinas, physicians should be cautious when counseling these patients about the cause of this disease. Indeed, stressing the sexual transmission of cervical cancer could even discourage Latina immigrants from obtaining appropriate Pap smear screening.

Differing beliefs about breast cancer among Latinas and Anglo women.

To improve breast cancer control among Latinas, it is important to understand culturally based beliefs that many influence the way women view this disease. We did a telephone survey of randomly selected Latinas and non-Hispanic white (Anglo) women in Orange County, California, to explore such beliefs using questions from previous national surveys and an ethnographic study of breast cancer. Respondents included 803 Latinas and 422 Anglo women. Latinas were more likely than Anglo women to believe that factors such as breast trauma (71% versus 39%) and breast fondling (27% versus 6%) increased the risk of breast cancer, less likely to know that symptoms such as breast lumps (89% versus 98%) and bloody breast discharge (69% versus 88%) could indicate breast cancer, and more likely to believe that mammograms were necessary only to evaluate breast lumps (35% versus 11%) (P < .01 for each). After adjusting for age, education, employment status, insurance status, and income, logistic regression analysis confirmed that Latino ethnicity and acculturation levels were significant predictors of these beliefs. We conclude that Latinas' beliefs about cancer differ in important ways from those of Anglo women and that these beliefs may reflect the moral framework within which Latinas interpret diseases. These findings are important for the development of culturally sensitive breast cancer control programs and for practicing physicians.

Knowledge, power and experience: variation in physicians' perceptions of breast cancer risk factors.

Recent theory in anthropology has increasingly been concerned with issues of power. Anthropology also has a long history of interest in variation in cultural knowledge, which, we argue, benefits from attention to power relations. To show this, we examine perceptions of breast cancer risk factors among physicians. Although physicians share a general cultural model of breast cancer risk factors, variation exists, especially between university-based physicians and community-based physicians. The nature of the work performed in these two settings influences the acquisition of various sources of information and frames what is considered valid information. Similar to Foucault's argument, we find that physicians working in a university setting are more disciplined in discussing their perceptions of breast cancer risk factors, compared to community-based physicians, who move away from the centers of knowledge and power (universities).

A comparison of the methods and criteria used by traditional and primary care internal medicine programs to select residents.

OBJECTIVE: To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN: A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant's file and to score the relative importance, on a scale of -5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING: Programs at institutions (n = 54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS: Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university-administered. RESULTS: Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant's file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate's career goals and select for candidates planning to pursue primary care careers (3.9 +/- 1.4 vs 0.9 +/- 1.5, p < 0.001), enter practice (1.4 +/- 1.5 vs 0.1 +/- 1.2, p < 0.001), or serve medically indigent populations (2.7 +/- 1.5 vs 1.2 +/- 1.2, p < 0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (-1.8 +/- 2.2 vs 0.5 +/- 1.5, p < 0.001). CONCLUSION: Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate's most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent.

Structure and meaning in models of breast and cervical cancer risk factors: a comparison of perceptions among Latinas, Anglo women, and physicians.

This article reports on a study of perceptions of breast and cervical cancer risk factors among 27 U.S.-born Chicanas, 39 Mexican and 28 Salvadoran immigrants, 27 Anglo women, and 30 physicians in northern Orange County, California. In open-ended responses explaining why women might be at risk for both cancers, Latinas expressed two general themes: physical stress and trauma to the body, and behavior and lifestyle choices. Interviewees ranked the specific risk factors that they themselves mentioned. Cultural consensus of ranked data revealed that Mexican and Salvadoran immigrants had a model of cancer risks that was different from those of Anglo women and physicians. U.S.-born Chicanas were bicultural in their views, which overlapped with both Mexican women's and Anglo women's views, but less so with physicians' views. Comparing views about the two cancers revealed that general themes apply across both cancers, that Latina immigrants agreed less on the risk factors for cervical cancer than for breast cancer, and that there is a consistent pattern in the different ways Latinas, Anglos, and physicians perceive risk factors for both cancers.

Understanding knowledge and attitudes about breast cancer. A cultural analysis.

OBJECTIVE: To evaluate knowledge and attitudes about breast cancer risk factors among Latinas, Anglo-American women, and physicians. DESIGN: Ethnographic interviews employing systematic data collection methods. PARTICIPANTS: Twenty-eight Salvadoran immigrants, 39 Mexican immigrants, 27 Chicanas, and 27 Anglo-American women selected through an organization-based network sampling and a convenience sample of 30 primary care physicians in Orange County, Calif. MAIN OUTCOME MEASURES AND RESULTS: Data analysis using qualitative content analysis and quantitative cultural consensus analysis, a mathematical technique that determines the degree of shared knowledge within groups and estimates "culturally correct" answers (cultural models), was employed. The content analysis revealed different beliefs about breast cancer risk factors, particularly between the Latinas and the physicians. The cultural consensus analysis found two broad cultural models (defined as groups with ratios between the first and second eigenvalues of > or = 3 and no negative competency scores). A Latina model (ratio = 3.4), formed by the Salvadorans, Mexicans, and Chicanas, emphasized breast trauma and "bad" behaviors, including drinking alcohol and using illegal drugs as risk factors. A biomedical model (ratio = 3.0), embraced by physicians and Anglo-American women, emphasized risk factors described in the medical literature, such as family history and age. Within these broad models, each group of respondents also differed enough in their beliefs to form their own, often stronger, cultural models. CONCLUSIONS: Ethnography can provide important insights about culturally based knowledge and attitudes about disease. An understanding of the distinctive cultural models regarding breast cancer risk factors will aid future cancer control interventions.

From ethnography to intervention: developing a breast cancer control program for Latinas.

Latinas are less likely than Anglo women to have appropriate breast cancer screening for reasons that may include culturally based beliefs as well as socioeconomic factors. This study employed ethnographic methods to explore breast cancer-related knowledge, attitudes, and behaviors among Latinas, Anglo women, and physicians, tested the generalizability of the findings in a telephone survey of randomly selected women, and used the results to design a culturally sensitive breast cancer control intervention in Orange County, Calif. Respondents for the ethnographic interviews included 28 Salvadoran immigrants, 39 Mexican immigrants, 27 Chicanas (U.S.-born Latinas of Mexican heritage), 27 Anglo women, and 30 physicians selected through organization-based network sampling. Latinas had very different beliefs about risk factors for breast cancer and held more fatalistic attitudes about the disease. For example, they believed that trauma to the breast was among the most important risk factors. Results of a telephone survey of 1225 randomly selected women (269 U.S.-born Latinas, 425 Mexican immigrants, 109 other Latina immigrants, and 422 Anglo women) generally confirmed the dissimilar beliefs among Latinas and Anglo women. The findings influenced our decision to design and pilot-test a breast cancer control intervention based on Bandura's self-efficacy theory and Freire's empowerment pedagogy. The methodology and findings of this study have important implications for future cancer control research and interventions.

The value of baseline chest radiograph reports in the care of elderly patients in an emergency department.

The authors used a before/after research design to determine the impact of written reports of baseline chest radiographs (CXRs) on the care of elderly patients during 48 emergency department visits. Internal medicine housestaff completed questionnaires that included inquiries about their treatment plans for the patients both before and after they reviewed reports of baseline CXR results. The investigators compared these answers to determine the proportion of patients for whom baseline CXR reports changed patient management. In addition, three faculty reviewers used the nominal group process, a consensus analysis approach, to measure treatment changes and to estimate benefit to the patients from the alterations in management. The housestaff indicated that written baseline CXR reports caused them to change treatment plans during only 2 (4%) of the 48 visits. In both cases, they provided aggressive treatment for congestive heart failure because of baseline CXR results. The faculty reviewers could find only one case in which baseline CXR findings might have changed their management plans. Moreover, they were not convinced that the treatment changes indicated by the housestaff actually benefitted the patients. These results suggest that written reports of baseline CXRs do not improve the care of acutely ill patients in an emergency department setting.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.