This study adds to the scientific literature by using systematic and semi-structured qualitative methods to explore the causal beliefs of breast and colon cancer of unaffected Latina immigrant women in the U.S. We found genetics and heredity to be important in this population’s conceptions of causes of these cancers, and interview data provided insight into this and other quantitative findings. For example, the ranking exercise required participants to decide whether genetics or heredity plays a greater role in the development of each cancer with most participants indicating that “genes/genetic factors” play a larger role than “hereditary factors” in the development of both cancers. Possibly, this was related to the fact that participants described genetics as being more immediate or having a more direct role than hereditary factors in the health of individuals. Meanwhile, respondents’ disparate awareness of the two cancer types shines light on why they see these factors differently for each cancer.
Nevertheless, we did not find that the relative importance of risk factors for breast or colon cancer was informed by a cultural consensus in this group. There are several possible explanations for the failure of the current study to identify a single cultural model. To begin, the population in this study was quite diverse in regard to age, country of origin and level of education, with a skew towards those with higher levels of eduation. Consequently, there may be culturally informed models of breast and colon cancer risk factors at play when studying more narrowly defined cultural groups. Due to sample size limitations in the current study, we were not able to conduct all possible sub-group analysis. However, our sample permitted analyses based on education (some college or higher), acculturation (low), age (under 40), age moved to the U.S. (over age 18), and country of origin (excluding South America), and none of these analyses found a shared cultural model regarding ranking of risk factors for breast or colon cancer. It is reasonable to consider that cultural consensus models may exist among Latina immigrants who share other characteristics or have multiple characteristics in common.
Other studies of cancer causal attributions among Latinos and other populations have shown that respondents tend to consider heredity to be an important factor for the development of breast and colon cancer (Schlehofer & Brown-Reid, 2015; Thomson et al., 2014; Wang, Miller, Egleston, Hay, & Weinberg, 2010). Specifically, one web-based study of 439 unaffected women (11% Hispanic) which used the Revised Illness Perceptions Questionnaire, found that heredity was ranked as the most important causal factor for both breast and colon cancer and that 84.4% of participants and 78.5% of all participants agreed or strongly agreed with heredity as a cause of breast and colon cancer respectively (Wang et al., 2010). Subgroup analysis by ethnicity showed that Hispanics fell between black and white respondents with 75% of Hispanic respondents agreeing or strongly agreeing with heredity as a cause of breast cancer. However, Hispanics had the highest level of endorsement of heredity as a cause of colon cancer, with 85% of Hispanic participants endorsing this factor. Meanwhile, an Australian case-control of 1,109 women with breast cancer and 1,633 unaffected women, found that unaffected women most commonly (77.6%) attributed breast cancer to familial or inherited factors (Thomson et al., 2014).
A previous freelisting and ranking study by Chavez et al (1995) found “family history” ranked as the top risk factor for breast cancer by U.S.-born women of Mexican descent, NHW women, and physicians but was ranked seventh and twentieth by Mexican and Salvadoran immigrant women, respectively. There were significant differences between that study and our study, but this difference in findings may indicate that beliefs around hereditary causes of cancer have shifted among Latina immigrants over the past 20 years. This makes sense because the BRCA1 and BRCA2 genes associated with hereditary breast and ovarian cancer, as well as many other hereditary cancer genes, have been discovered during that time.
Despite the evidence that Latinas do see genetics or heredity as a cause of breast and colon cancer, a review article cited various studies which have shown that Latinas have less awareness of and knowledge about genetic testing for hereditary breast cancer when compared to other racial and ethnic groups (Lynce, Graves, Jandorf, Ricker, & Castro, 2016). This was also reflected in our study with only a few highly educated participants mentioning genetic testing. Consequently, many Latinas may believe that genetics and heredity play a role in breast and colon cancer but may not be aware of their ability to be tested or take action if at increased risk.
As genetics becomes ever more integrated into cancer treatment and prevention through tumor testing and the use of polygenic risk scores, the role of genetic factors in cancer has become more central. Latina immigrants appear ready to use these tools to improve their health right along with patients of other ethnicities.
The implication in relation to our findings is that the current-day breast and colon cancer causal attributions of Spanish-speaking Latina immigrants with generally high education may not be very different from those of the general U.S. patient population. This is interesting in relation to the cancer health disparities seen in Latina patients in regard to stage at diagnosis of breast or colon cancer. The fact that the causal attributions found in our study may not differ greatly from those of other cultures suggests that differences in causal attributions do not account for these disparities. Rather, they may be due to factors in one of the other levels of the social ecological model of health commonly used as a framework for understanding and influencing public health. While causal beliefs are part of the individual level of the framework, factors at the interpersonal, institutional, community and public policy level also affect health behavior and can influence health disparities (McLeroy, Bibeau, Steckler& Glanz, 1988). It is easy to imagine language, cost, and immigration status influencing health disparities, and in the Latino community, at least one study found cultural beliefs about the propriety of breast cancer screening as a barrier to care (Schlehofer & Brown-Reid, 2015). Indeed, a meta-synthesis of U.S. Latinas’ knowledge and attitudes toward mammography reviewed qualitative research on this topic and identified common themes including barriers to mammography and facilitators or recommendations (Corcoran, Crowley, Bell, Murray, & Grindle, 2012). Lack of knowledge was identified as a barrier to screening but so were other cultural beliefs, though not beliefs about risk factors for breast cancer. Rather, embarrassment, language, lack of access to medical care, fear of being told one has cancer, and factors related to low socioeconomic status were recurrent themes across the studies analyzed (Corcoran et al., 2012). Interestingly, these systemic barriers were not mentioned as risk factors for cancer by participants in our study.
Our study showed that this group of Latina immigrants was generally less aware of colon cancer than breast cancer. Other studies have also shown low awareness of colorectal cancer among Latinos. In a study including freelisting to assess participants’ knowledge, beliefs and screening preferences in regard to colorectal cancer, only one-third of Latino participants mentioned colon cancer compared to one-half of African American participants, and no Latino participant correctly named a colon cancer screening test (Shokar, Vernon, & Weller, 2005). A survey of Latinas regarding colorectal cancer screening found that 35 of 60 respondents had not heard of colon cancer. An additional 35 participants did not respond to the question, the highest non-response rate in the survey (Warner et al., 2018).
Practice and Policy Implications
Providers and health educators need to recognize that causal attributions in the Latina population may not be so different from those found in the non-Hispanic public. Consequently, providers and educators need not greatly modify the informational content of their discussions of breast and colon cancer risk factors from that which they would present to other patients. Importantly, previously published data indicates that most Latina women interviewed in this study did not hold a fatalistic view of the role of genes in disease, but rather believe that risk factors can be modified by diet, lifestyle, and environment (Blinded for peer review). Therefore, focus on maximizing lifestyle factors to prevent cancer is a key approach. Furthermore, education should focus on overcoming some of other cultural barriers to cancer screening such as cultural beliefs about propriety and the value of preventive medicine (Corcoran et al., 2012). Meanwhile, public health investment is needed at a system level to increase access to bilingual healthcare providers and informational materials and address barriers related to socioeconomic status such as lack of transportation, insurance, and knowledge of how to navigate an overwhelmingly complicated health system. Such interventions would benefit patients of all races and ethnicities who face these challenges. The meta-synthesis by Corcoran et al. (2012) also identified physician factors, such as personability, respectfulness, and trustworthiness, as facilitators of mammography. Training physicians in active listening skills would help them demonstrate these characteristics and improve relationships with all patients but could have a particularly large effect on the most vulnerable patients. It is also important for providers to specifically and clearly recommend cancer screening to their Latina patients (Corcoran et al., 2012).
Given that Latina immigrants seem to have less awareness of colon cancer, there is a need for further educational efforts in that area. Healthcare providers and public health advocates need to inform Latina patients about colon cancer, including what it is, causes, screening mechanisms, and prevention behaviors. Based on our results, it is also important that materials emphasize that both men and women can develop colon cancer.
Limitations and Future Research
Like all studies, the current study has several limitations that should be considered. Participants in this study tended to be more highly educated than would be expected of the foreign-born Latino population in the United states. Half of participants in this study had a bachelor’s degree or higher, while nationally only 12% of this demographic holds a bachelor’s degree or higher (Ryan & Bauman, 2016). Even though the sample did include participants with less education, the overall themes identified may be less relevant to Latina immigrants with lower levels of education. Furthermore, since this population was recruited almost entirely through the NIH research networks, it is possible that these participants are generally more biomedically oriented than other Latina immigrants.
Second, no cultural consensus model was identified regarding the relative importance of the various risk factors for either breast or colon cancer. Although average rankings of each of the ranked items were used to give an overall ranking, the lack of a single model somewhat limits the significance that can be given to those rankings. While genetics and heredity stood out as having the highest average rankings and salience (particularly for breast cancer), several items had very similar average rankings, making it difficult to draw firm conclusions about their relative order. Therefore, while we may be able to see that participants generally think differently about those items with average rankings toward the top compared with those ranked toward the bottom, the significance of any difference between closely ranked items is less clear.
Given a lack of difference in causal beliefs between the Latina population and other populations, there is a need for more research into other causes of cancer disparities, including possible cultural beliefs about cancer screening or utilization of healthcare in general. Factors at the interpersonal, community, and societal levels also warrant investigation, especially since addressing systemic barriers to cancer screening and care would have implications beyond the Latino population.