Culture as an influence on breast cancer screening and early detection.

OBJECTIVES: To explore how culture may play a part in breast cancer screening, early detection, and efforts to decrease breast mortality. DATA SOURCES: Journal articles published in the past 20 years on cultural aspects of cancer prevention and control. CONCLUSIONS: Research seems directed more at discovering cultural differences than at identifying similarities on how culture influences breast cancer screening and early detection. The influences of poverty and lack of educational opportunities account for much of what is termed cultural difference. IMPLICATIONS FOR NURSING PRACTICE: Improving practice through an informed understanding of culture calls for considerable self-education and a fundamental refinement of care delivery.

Perceived risk and help-seeking behavior for breast cancer. A Chinese-American perspective.

Delay in the diagnosis and treatment of breast cancer diminishes a woman's chance of survival. How do women decide whether and when to seek an evaluation of breast symptoms that may signal breast cancer? Prior studies of African-American, white, and Latino women have described a number of critical factors associated with making the judgment to delay, but at this writing, there have been no studies factors influencing Chinese-American women. By means of focus group methods in English, Mandarin, and Cantonese, a sample of 45, predominantly first-generation Chinese-American women explained their understanding of breast cancer risk and their likelihood of delaying versus seeking evaluation of self-discovered breast symptoms. There was much congruence with the ideas of other American women despite the differing cultural heritage. Unique to these Chinese Americans was a sense of invulnerability to breast cancer, a linking of cancer to tragic luck, and the predominant likelihood of delay. To preserve modesty and to conserve wealth and time, many study participants favored using Chinese medicine and delaying Western therapies. This study suggests ways by which health care providers must approach guidelines for breast cancer early detection in this population.

Breast cancer screening in relation to access to health services.

PURPOSE/OBJECTIVES: This study examined mammography screening and breast self-examination (BSE) in relation to perceived access to health services to identify persistent barriers to earlier detection. DESIGN: Community-based, cross-sectional, survey, and interview. SETTING: More than 80 nonhealthcare-related, women's group settings in northern California. SAMPLE: Convenience sample of 838 black/African American, Latina/Hispanic, and Caucasian/Anglo women varying in age, annual family income, sexual orientation, and educational history. METHODS: Survey and interview (in English or Spanish) by on-site research assistants facilitating participation of women with limited reading capability. MAIN RESEARCH VARIABLES: Perceived access to services, breast cancer screening behaviors, acculturation and spoken language, habits of use, perceived prejudice in health delivery, available economic resources, and other social and behavioral variables reported elsewhere. FINDINGS: Healthcare habits, the perception of prejudicial treatment in health service delivery, spoken language, and three different measures of financial capability explained a large degree of perceived access to services. Perceptions of a lack of access to services were related to decreased mammography screening participation and to decreased BSE behavior. CONCLUSIONS: Participation in cancer screening depends on real economic access and previous health service delivery experience. BSE behavior may be influenced by lack of money to pay for healthcare services, and experienced prejudice in healthcare delivery appears to have a lasting influence on mammography screening behavior. IMPLICATIONS FOR NURSING PRACTICE: Tolerance and culturally sensitive service delivery coupled with economic access to both screening and necessary treatment will be vital to eliciting women's complete participation in attaining desired earlier detection goals for breast cancer.

Narratives of breast symptom discovery and cancer diagnosis: psychologic risk for advanced cancer at diagnosis.

In spite of cancer screening programs, women continue to present with advanced breast cancer. How do women decide whether and when to seek an evaluation for self-discovered symptoms? This study examined 104 narratives told by 80 Anglo-, Latina-, and African-American women who participated in 1 of 16 community-based focus groups. The women's narratives contained powerful thematic messages about breast cancer and their expected behavior in the event of a self-discovered breast symptom. Narrative explanations that predicted an increased likelihood of advanced disease at diagnosis included these factors: incorrect symptom attributions and risk estimations; reluctance to consider the threat posed by the symptom; failure to tell another person about the symptom; and expectations of abandonment by male partners, deportation, prejudice, and refusal of treatment due to poverty. Stories of advanced breast cancer also told of reliance on alternative healing, concerns about overwhelming family resources, and extreme modesty that inhibited obtaining a physical examination. Interventions aimed at earlier detection of breast cancer must connect with the beliefs and assumptions embedded in these narratives, provide pragmatic solutions for perceived constraints on seeking evaluations of self-discovered symptoms, and explore the use of community narratives to confirm the value of early detection of breast cancer.

Helpseeking for self-discovered breast symptoms. Implications for early detection.

PURPOSE: Most breast cancer symptoms are discovered by women themselves, and at least one third of these women will be aware of their symptoms for 3 months or more before seeking an initial provider evaluation. The authors identify personal, social, and environmental influences on women's intention to seek an immediate provider evaluation (helpseek) versus to delay evaluation of a breast symptom that worried them. DESCRIPTION OF STUDY: Black women (N = 352) from the San Francisco Bay are women's organizations, community settings, and churches formed this convenience sample. Participants ranged across age, income, and educational levels. The survey contained 10 scales that measured health behavior variables, including new and existing scales augmented by items derived from prior interview and focus group investigations. RESULTS: Women of younger age and lower income were significantly less likely to intend to seek an evaluation for self-discovered breast symptoms. Single and partnered women were less likely to seek a provider evaluation than married or widowed women. Perceiving negative consequences of delaying, having previous habits of healthcare utilization, perceiving access to services, and feeling fearful were positively related to the intention to seek evaluation of breast symptoms. Holding fatalistic beliefs about getting breast cancer or dying and perceiving constraints to seeing a provider negatively influenced helpseeking intention. Racism in the healthcare delivery system was perceived, but was not a significant influence on helpseeking intention. A multiple linear regression model containing these variables explained 46% of the variance in helpseeking intention. CLINICAL IMPLICATIONS: This study shows that the intent to helpseek is not merely a matter of education and economics, but is dependent on a complex picture of personal, social, and economic factors. Gynecologic and primary care providers should consider this and the potential influences on helpseeking in the women for whom they provide cancer screening and early detection services. History taking should be expanded to assess women's ideas about the consequences of delaying evaluation of self-discovered breast symptoms, their sense of vulnerability to breast cancer, the constraints on cancer early detection they may be feeling related to role obligations, their economic or strategic limitations to accessing services, the pressures they may feel to hide a breast cancer symptom, or their own tendency to interpret the breast symptom as not threatening. Healthcare providers should not assume that helpseeking for breast symptoms is an automatic behavior for all women. Rather, providers should assess whether a women is the one in three who will delay the evaluation of a breast cancer symptom she discovers herself for months or years.

Comparison of methods to determine the prevalence and nature of oral mucositis.

PURPOSE: Chemotherapy-induced oral mucositis may cause considerable patient morbidity. Its prevalence has been reported as ranging from 30% to 39%, although a prevalence as high as 75% has been reported with 5-fluorouracil. This variation may be a function, in part, of the methods of measurement used across different studies. The first purpose of this study was to determine the prevalence of oral mucositis in a sample of 127 patients receiving specific chemotherapy. The second purpose was to compare different instruments and techniques for assessing oral mucositis. DESCRIPTION OF STUDY: A longitudinal design was used to collect data at four monthly chemotherapy cycles during drug nadir. The methods of measuring oral mucositis included interview (conducted monthly x 4); Eiler's Oral Assessment Guide (monthly x 4); Chemotherapy Knowledge Questionnaire and Behavior Checklist (both at the fourth month); Self-Care Behavior Log (ongoing over 4 months); and medical record review (collected at 4 months). RESULTS: The mucositis prevalence in this one sample ranged from 30% to 69% depending on the method of measurement. The use of multiple instruments and techniques captured a clinical picture of oral mucositis far more detailed than published reports--a picture not revealed with any one instrument or technique. The chart record severely underdocumented the prevalence of mucositis compared to the interview. This discrepancy could reflect under-reporting by the patients, inadequate history taking at provider visits, or perhaps the documentation of only the more severe mucositis or mouth problems in the medical record. CLINICAL IMPLICATIONS: Clinicians and researchers must choose their method of measurement carefully in relation to the purpose of assessment. For subjective tolerance of symptoms, the interview technique may be most useful. To test interventions, the use of a quantitative rating instrument is desirable. Intervention studies using multiple measures may require a combination of subjective and objective measures.

Assessment design issues for evaluating critical thinking in nursing.

The assessment of graduating students' critical thinking skills and habits of mind challenges and rewards those who approach the task from a critical thinking perspective. The article identifies and discusses issues in the design of authentic assessments of critical thinking as an educational outcome predictive of competent professional judgment in nursing practice. Authentic assessment implies a multiple methods design that addresses the diverse contexts within which judgments must be made by professional nurses. Most important, it implies a concern for validity and reliability of measurement, selection of appropriate data points, and attention to a number of logistic and practical concerns.

Women's narratives of helpseeking for breast cancer.

One-third of women with self-discovered breast cancer are symptomatic for 3 months or more before seeking evaluation. Few studies examine women's accounts of this important time. Using narrative analysis in the style of Labov and Waletzky, breast cancer cases from a larger mixed-tumor sample of patients receiving chemotherapy were examined for the details of breast cancer symptom discovery and the events relevant to the timing of diagnosis and treatment. The majority (56.3%) of women in the sample sought evaluations within days, many proceeding to immediate diagnosis. Factors cited by women as influencing the delayed timing of initial provider evaluation were that they attributed the symptoms to a benign process, and they perceived gender role-related constraints. Many women in this younger-aged sample had false-negative mammographic examinations, and many reported receiving false reassurance from providers on initial consultation visits. Women who delayed evaluations sought them only as symptoms advanced.

Critical thinking disposition as a measure of competent clinical judgment: the development of the California Critical Thinking Disposition Inventory.

Assessing critical thinking skills and disposition is crucial in nursing education and research. The California Critical Thinking Disposition Inventory (CCTDI) uses the Delphi Report's consensus definition of critical thinking as the theoretical basis to measure critical thinking disposition. Item analysis and factor analysis techniques were used to create seven disposition scales, which grouped the Delphi dispositional descriptions into larger, more unified constructs: open-mindedness, analyticity, cognitive maturity, truth-seeking, systematicity, inquisitiveness, and self-confidence. Cronbach's alpha for the overall instrument, the disposition toward critical thinking, is .92. The 75-item instrument was administered to an additional sample of college students (N = 1019). The alpha levels in the second sample remained relatively stable, ranging from .60 to .78 on the subscales and .90 overall. The instrument has subsequently been used to assess critical thinking disposition in high school through the graduate level but is targeted primarily for the college undergraduates. Administration time is 20 minutes. Correlation with its companion instrument, the California Critical Thinking Skills Test, also based on the Delphi critical thinking construct, was measured at .66 and .67 in two pilot sample groups.

Role overload and health: the married mother in the waged labor force.

Women are joining the waged labor force in ever increasing numbers, raising the proportion of women who hold multiple roles. Each of these roles frequently place significant time and labor demands on women, causing researchers to speculate on a subsequent negative effect on women's health. Research studies paint colorful images of today's working, married mother but have only begun to identify risks to women's health that might be associated with the increased demands associated with multiple roles.

Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay.

Patient delay in seeking help for breast cancer symptoms and provider delay in treating those symptoms combine to decrease a woman's potential for breast cancer survival. This paper reviews the literature on patient and provider delay published since 1975. Meta-analysis of 12 studies using common definitions of patient delay estimates that 34% of women with breast cancer symptoms delay help seeking for 3 or more months. Provider delay appears to be both under researched and underestimated. This review identifies the factors that have been advanced as contributing to patient and provider delay, evaluating the support for each of these reported findings. Theory-based hypotheses emerging from the reviewed studies highlight foci for future investigations.

The Triandis model for the study of health and illness behavior: a social behavior theory with sensitivity to diversity.

The Triandis model of social behavior offers exceptional promise to nurse researchers whose goal is to achieve cultural sensitivity in their research investigations. The model includes six components: consequential beliefs, affect, social influences, previous behavioral habits, physiologic arousal, and facilitating environmental resources. A directed methodology to include culture-relevant items in the measurement of each of these model components allows researchers to capture the diverse explanations of health and illness behavior that might pertain in diverse populations. Researchers utilizing the model can achieve theory-based explanations of differences they observe by gender, race/ethnicity, social class, and sexual orientation. The Triandis model can provide studies to target variables for future intervention studies, as well as highlight areas for needed political action to equalize access to and delivery of nursing care.