Country of origin and prevention of breast cancer: Beliefs, knowledge and barriers☆
Highlights
► Social and cultural origins lie behind differences. ► Younger women, those from urban areas, those of high socioeconomic level and those from countries valuing prevention are more inclined to participate. ► There is a discrepancy between knowledge and behaviours in the host country. ► It is necessary to promote knowledge and access to preventive screening practices for all women.
Introduction
In Barcelona, international immigration is a new phenomenon, with a rapid increase since the end of the 20th century. In 2009, 20.3% (173,790) of the female residents in the city were born in a foreign country, whereas in 1996 this proportion was only 4.0% (Departament Estadística Ajuntament de Barcelona, 2009). The majority of these new citizens are young, come from countries which do not belong to the European Union, and do manual and/or seasonal work. If we focus on the target population of the breast cancer screening program (women between 50 and 69 years old), we find that 12% of them were born in a foreign county. The majority of these immigrants are from Latin American, Eastern European and North African countries. They are culturally diverse and belong to different realities in the city. Latin American women are part of a highly feminised group in the city, however, the women from Pakistan belong to a highly masculinised group. (Agència de Salut Pública de Barcelona, 2008).
The effectiveness of mammographic screening in reducing mortality due to breast cancer (BC) has been proven for women from 50 to 69 years old (IARC, 2008), despite current controversy (Nelson et al., 2009, Gervás and Pérez-Fernández, 2006, Gotzsche and Olsen, 2000). Consequently, the current recommendation is that all women should be informed about the possibility of early breast cancer detection, and about the benefits and risks deriving from mammographic screening, in order to enable them to take free and fully informed decisions in this regard.
Spain has a National Health System (NHS), financed mainly by taxes, which gives universal free coverage to all of the registered population. The right to a health card, with the same conditions enjoyed by nationals, is recognised for registered foreigners (with or without a residency permit), for young people, pregnant women, and emergency cases in the event of serious disease or accidents. In Barcelona, the populational BC screening program began in late 1995 in two districts of the city and it was progressively implemented throughout the entire city. It is aimed at all healthy resident women in the city (registered or not) aged 50 to 69 years, and consists of a free mammography examination every two years in the main public hospitals of the city (Agència de Salut Pública de Barcelona, 2005).
Health-related behaviours, including preventive practices, are strongly related to social and cultural factors which people experience throughout their lives. Cultural, socioeconomic and structural aspects determine lifestyles and, therefore, perceptions and attitudes towards reacting to different circumstances, including health, prevention and illness (Mota, 2008). Ethnicity and culture play significant roles in determining how an individual is likely to understand and explain cancer, which, in turn, is posited to have an impact on cancer screening behaviour (Kwok and Sullivan, 2006). Apart from the different sociocultural reality, the migration process itself determines that in many cases the priority for immigrants is to adapt to their new reality and work. Hence, attention to healthcare is sidelined as migrants focus on the more immediate concerns of adapting to life in their host country (De Andrés et al., 2002).
In Spain, although the proportion of women undergoing regular BC screening has risen, recent studies have shown that there are still inequalities related to having periodic mammographic check-ups, both in terms of social class (Puigpinós-Riera et al., 2011) and country of origin (Pons-Vigués et al., 2011). As in other countries (Lagerlund et al., 2002, von Euler-Chelpin et al., 2008, Zackrisson et al., 2007, Vermeer and Van den Muijsenbergh, 2010), preventive practices linked with BC are used less by the immigrant population.
There is some literature regarding the possible determinants of this lower participation of immigrant women, such as access to screening services, psychosocial issues and sociocultural factors (Scheppers et al., 2006, Remennick, 2006, Tejeda et al., 2009, Watson-Johnson et al., 2011). However, as far as we are aware, in a setting such as ours, i.e. multicultural and with a health care system that provides universal coverage, no qualitative studies have yet been carried out comparing different groups of immigrants with native women. The present paper tries to address this issue because previous literature focuses only on one specific community in each paper. The reason for studying this is that, although there may be aspects that are common to all cultures, there may also exist certain culture-specific factors which relate differently with the various forms of health care. Breast cancer is shrouded in fears, myths, and connotations reaching far beyond the objective clinical understanding of the disease (Remennick, 2006). For example, in a previous research on Chinese-Australian women, embedded in the women's images of cancer, the authors found factors linked with fear, mystery, contagion, and stigma (Kwok and Sullivan, 2006).
Moreover, specific actions are needed to favour equitable access to BC screening for all women. Thus a thorough understanding is needed of the perceptions, attitudes, barriers and facilitators in regard to BC prevention perceived by women of different groups living in our society. In such a situation, the use of qualitative methodologies can contribute to advances in the comprehension of the phenomenon, by listening to the women themselves (Kuper et al., 2008), and seeing the influence of culture and other structural factors related with country of origin, of socioeconomic position, and the fact of being an immigrant, in decisions made by women when it comes to undergoing mammographic controls for BC. Better understanding of the factors that ultimately influence screening is important because BC can be cured if detected in time.
The aim of the present study was to describe the concept of health prevention and identify levels of knowledge, perceived benefits and barriers, as well as the practices of early detection of breast cancer among native women and women immigrants from low-income countries, of different social classes, aged between 40 and 69 years, and residing in the city of Barcelona. The study sought to identify aspects related to cultural origins, social status and the influence of being an immigrant.
Section snippets
Methodological development
We carried out a qualitative study using a socioconstructivist perspective (Spencer et al., 2003), as it sought a sociocultural approach to the study object. Consistent with the perspective, the study was interpretative (Maxwell, 2005) and was performed in Barcelona during the years 2007 and 2008.
Participants and sampling technique
The study population consisted of women who were either native (women born in Spain), or immigrants from low-income countries, aged between 40 and 69 years, residing in Barcelona. Participants were
The concept of health prevention
The concept of health prevention held by the different cultural communities was constructed in terms of three axes: (1) “Before” vs. “now”; (2) The proactive or deterministic conception of health-disease and (3) The motives behind their care practices directed to “the others” or to “me in relation to” (Fig. 2). Throughout the results, there are examples of exact quotes of the participants.
Discussion
The most noteworthy findings of this research are described below. The concept of health prevention is a cultural construct influenced, among other aspects, by socioeconomic level, coming from a rural or urban background, and the migratory process itself. All these aspects intervene as either facilitators or barriers to early detection of BC in the host country. Hence social and cultural origins result in differences in knowledge and practices related to BC prevention. Beliefs and values of
Conclusions
The results of the present study show that the culture and place of origin (in both senses: country and rural/urban setting), social class and the migratory process itself are key factors in the concept and utilisation of preventive practices. Thus, screening programmes ought to adopt a transcultural approach, and be capable of handling diversity through educational and sensitisation activities adapted to the different realities.
Conflicts of interests
The authors declare not to have any conflicts of interest, nor financial relations with private or commercial enterprises which could have a vested interest in the findings of the present research.
Funding
This study was financed by the Grant number PI061130 of the “Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I)” of the “Instituto de Salud Carlos III-Subdirección General de Evaluación y Fomento de la Investigación” (Spain).
Acknowledgements
We would like to express our thanks to the women who have participated in the study, as well as to the cultural mediators, associations, and many other people who helped us to establish a network of contacts. The authors would also like to thank Iolanda Robles, Rocio Barbero and Edgar Maydana for their collaboration.
References (56)
- et al.
Los programas de prevención secundaria del cáncer de mama mediante mamografía: el punto de vista del médico general
SEMERGEN
(2006) - et al.
Is screening for breast cancer with mammography justifiable?“
Lancet
(2000) - et al.
How do we achieve informed choice for women considering breast screening?
Preventive Medicine
(2011) Perspectives of cervical cytology in Russia
American Journal of Obstetrics and Gynecology
(2008)- et al.
Breast and cervical cancer screening for women between 50 and 69 years of age: what prompts women to screen?
Women's Health Issues
(2003) A framework for analysing migrant health policies in Europe
Health Policy
(2009)Preventive behavior among recent immigrants: Russian-speaking women and cancer screening in Israel
Social Science & Medicine
(1999)- et al.
Barriers and facilitators related to mammography use among lower educated Mexican women in the USA
Social Science & Medicine
(2009) - Agència de Salut Pública de Barcelona, 2008. La salut de la població immigrant de Barcelona. Agència de Salut Pública...
- Agència de Salut Pública de Barcelona, 2005. Informe de l'Oficina Tècnica del Programa de Detecció Precoç de Càncer de...
Studying delays in breast cancer diagnosis and treatment: critical realism as a new foundation for inquiry
Oncology Nursing Forum
Perception of breast cancer among Arab Israeli women
Women Health
The determinants of breast cancer screening behavior: a focus group study of women in the United Arab Emirates
Oncology Nursing Forum
Breast health practices and South Asian women
The Canadian Nurse
Observación, entrevista y grupo de discusión: el silencio de tres prácticas de investigación
Revista Española de Salud Pública
Los grupos triangulares como espacios transnacionales para la producción discursiva: un estudio sobre la vivienda en Huelva
Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries?
Journal of Advanced Nursing
Salud y marginación social
Documentación Social
Socioeconomic influences on Vietnamese–Canadian women's breast and cervical cancer prevention practices: a social determinant's perspective
Social Work in Public Health
Detección temprana del cáncer de mama: creencias de salud y cribado mamográfico
Revista de Psicologia 2003
Geographic methods for understanding and responding to disparities in mammography use in Toronto, Canada
Journal of General Internal Medicine
Opportune intervention of family doctors in the programme of early detection of breast cancer
Atencion Primaria
Percepcions of breast and cervical cancer risk and screening among dominicans and puerto ricans in Rodhe Island
Ethnicity&Disease
Discourse analysis
British Medical Journal
From ethnography to intervention: developing a breast cancer control program for Latinas. Journal of the National Cancer Institute
Monographs
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This article forms part of the doctoral dissertation of Mariona Pons-Vigués at the Universitat Pompeu Fabra of Barcelona.