#91803: Cancer Screening Among Racial/Ethnic Minority Women

"African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or blacks as persons "having origins in any of the Black racial groups of Africa" [23]. It includes people who indicate their race as "Black, African American, or Negro," or provide written entries such as "African American, Afro American, Kenyan, Nigerian, or Haitian." As a group, African Americans have struggled for civil rights, liberty, cultural pride, and identity, giving the term sociopolitical weight as well.

According to the U.S. Census, as of 2019, 48.2 million persons in the United States identified as African American [37]. By 2060, it is projected they will number 74.5 million [37]. This group tends to be young; 30% of the African American population in the United States is younger than 18 years of age. In terms of educational attainment, 84.7% of those 25 years of age and older have a high school diploma and 19.7% have a Bachelor's degree or higher [37].

In 2019, the U.S. Census indicated that 22.9 million Americans identify as solely Asian [48]. Between 2000 and 2019, Asians experienced the greatest growth compared with any other racial group at 81% [155]. It is estimated that there will be 35.7 million Asian Americans by 2040 (10% of the U.S. population) [60]. California has the greatest Asian American population, followed by New York [48]. The largest Asian subgroup is Chinese Americans, followed by Asian Indians and Filipinos [48].

As of 2019, 22.9 million Americans identified as Asian [48]. California has the largest concentration of Asian residents (6.5 million) followed by New York (1.8 million) [138]. Chinese Americans represent the largest Asian subgroup in the United States, and it is projected that this population will grow to 35.7 million between 2015 and 2040 [32,33].

"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent [28]. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others [28]. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [29].

In 2019, 54.6% of the Asian American population 25 years or older have a Bachelor's degree or higher, compared with 30.1% of the general population [48]. The median age for this group is 33.8 years [48].

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [29,30]. The diversity of this group makes generalizations difficult.

The terms "Hispanic" and "Latino" are used to identify individuals who self-identify as having origins in Spain or Spanish-speaking countries, such as Mexico, Guatemala, Peru, Ecuador, or the Dominican Republic [31]. In 2019, there were 60.6 million Hispanic individuals in the United States [27]. The majority of the Hispanic population in the United States (63.3%) identify as being of Mexican descent [32]. The second largest group is Puerto Ricans, followed by Salvadorans, Cubans, Dominicans, Guatemalans, and Colombians [66].

In 2010, Hispanics represented 16% of the U.S. population; by 2019, they comprised 18% [176]. By 2050, Hispanics are expected to represent 29% of the U.S. population [33]. In 2019, the three states with the largest Hispanic population also had the most growth, with Texas leading at a 2 million increase, California with 1.5 million, and Florida with 1.4 million [176]. Approximately 34.5% are foreign-born. Of those 25 years and older, 14.8% have a Bachelor's degree or higher [27].

The Native American population is extremely diverse. According to the U.S. Census, the terms "Native American," "American Indian," or "Alaska Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America [35]. As of 2015, in the United States, there are 574 federally recognized tribes and 324 federally recognized reservations [177].

As of 2019, Native Americans and Alaska Natives numbered 6.9 million, constituting 2% of the total U.S. population [177]. By 2060, this number is projected to increase to 10.2 million, or 2.4% of the total U.S. population [177]. In general, this group is young, with a median age of 31 years, compared with the general population median age of 37.9 years. The states with the greatest number of residents identifying as Native American are Arizona, California, New York, Alaska, Oklahoma, New Mexico, South Dakota, Texas, North Carolina, and Montana [178]. In 2020, this group had the highest poverty rate (21.4%) of any racial/ethnic group [177].

The theory of intersectionality argues that it is not only culture, race, ethnicity, and gender (or other social constructs like social class, sexual orientation, or religion) that influence behaviors; no one single factor acts independently. Gender, culture, and race/ethnicity work synergistically to influence patterns of societal, community, familial, and individual expectations; processes of daily life; intrapsychic processes; and social interactions [38].

Gender is defined by existing institutions and ideologies and is imbued with views about power differentials. In terms of health care, patriarchal ideologies about women's roles can interfere with women's autonomy and decision-making behaviors regarding financial issues or even the determination of a condition's severity and the need for medical attention [39]. For example, South African women in one study reported they were not permitted by their husbands to visit women's health clinics for contraception, and some were even beaten for visiting mobile health clinics for cervical screenings without having obtained their husband's permission [40]. In a survey study with 768 of childbearing-age women in Nigeria, obtaining husband's permission (a common practice) was a statistically significant predictor of breast cancer screening [179]. In order for systemic change to occur, government, local traditional rulers, and community and religious organization leaders will need to be involved to reduce the stigma of cancer screening for women [180].

Similarly, culture influences how individuals respond to or perceive a particular health issue. The role of culture or traditionality in cancer screening is very complex, and the findings are mixed, in part because researchers have defined these terms differently. On one hand, adherence to one's cultural traditions may impede cancer screening. Some of this is due to traditional spirituality. For example, certain Native American groups believe talking about cancer will somehow invoke the spirits and cause one to get cancer [41]. Other cultures may have strict sexual taboos and an emphasis on modesty. For example, the Chinese emphasize cultural values of sexual modesty, and knowing too much about one's body, particularly one's sexuality, is considered socially inappropriate [42]. In another study, Vietnamese women reported being embarrassed and shy in participating in cervical cancer screening because they were socialized to believe that genitals should only be exposed to their partners/spouses [181]. In the Hmong culture, patriarchal norms can influence women's healthcare decisions for cancer screening [124]. Similarly, Muslim immigrant women have reported privacy concerns regarding routine gynecologic prevention care [43]. Indigenous Mayan women also expressed fear that rumors and gossip will ensue if they went for screening because they would be labeled promiscuous [182]. Finally, preferences for traditional medicine approaches can also influence cancer screening behaviors, particularly for many Asian women [44].

Yet, there have been some studies that demonstrate the positive influence of culture on cancer screening. In a study with members of the Hopi tribe of Native Americans, researchers found that Hopi women who attended cultural ceremonies were almost twice as likely to have had a mammogram in the past two years as those who did not attend [45].

According to the American Cancer Society, African Americans have the highest death rate and shortest survival for all cancers compared with other racial minorities in the United States [50]. There are many reasons for this disparity, including socioeconomic, cultural, and institutional factors that contribute to health disparities in general for this group. There is concern that the COVID-19 pandemic has further aggravated these disparities [183].

Cancer is the second leading cause of death for African Americans [50]. In 2019, it was projected that 202,260 new cancer cases were expected for African Americans, with 104,240 of these cases occurring in women [50]. Although the overall cancer incidence is 8% lower for African American women compared with White women, the mortality rate is 12% higher [183]. The leading sites of new cancer cases among African American women are the breast, lung/bronchus, and colorectum [50]. Beginning in the 1980s, the breast cancer incidence rates among African American women increased significantly, in part because of the increased education in early detection. The incidence rates have now stabilized. Between 2006 and 2015, the breast cancer incidence rate for African American women was 0.9%, compared with 0.4% for non-Hispanic white women [50]. The death rate for breast cancer for this group is still 40% higher than for white women [50]. African American women also tend to develop breast cancer younger (e.g., before 40 years of age) [50]. African American women tend to have later-stage diagnoses of breast cancer compared with White women [183]. Furthermore, the five-year survival rate for breast cancer is the lowest for African American women compared with all other racial/ethnic minority groups and white women (82% vs. 92%) [51; 183]. Cervical cancer rates are 30% higher among African American women than their non-Hispanic white counterparts [50]. This disproportionate burden is believed to be related primarily to unequal access to health care extending to a lack of screening.

Cancer Screening Trends Among African American Women

Race and ethnicity is a factor that has prompted concern because of a growing disparity in breast cancer mortality rates, particularly among African American women. However, the U.S. Preventive Services Task Force has found no high-quality evidence to conclude that screening African American women more often or earlier than already recommended for the overall population of women would result in fewer breast cancer deaths or a greater net benefit.

(https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening Last Accessed: December 12, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

In the past, African American women had lower mammography screening rates than white women, but these rates are now only slightly higher for African American women 40 years of age and older (69% vs. 64%) [50]. Yet, this higher rate may be due to over-reporting [50]. Similarly, Pap test use is slightly higher, at 85% for African American women compared with 83% of white women [50]. In a study of 5,060 women who had scheduled Pap test appointments at a women's health clinic in Missouri, African American women had the highest percentage of "no shows" among all racial minority participants [184]. In a 2011 study of African American women who frequented beauty salons in North Carolina, several demographic variables were found to predict Pap test and mammography use [53]. African American women who had an annual household income of at least $50,000 had health insurance, were currently working, and reported being in excellent/very good health tended to have had a Pap test in the past three years. For mammography screening, age (i.e., 50 years or older), having health insurance, having had a Pap test, and reporting having excellent/very good health predicted having a mammogram in the past year. A 2021 study found that health insurance and patient-provider communication were the two main variables that predicted breast cancer screening for African American women [185].

Overall health status may also be a factor. African American women with higher body mass indices (BMIs) are less likely to have had a Pap test compared with those with lower BMIs [126].

Communication of mammogram results may perpetuate screening disparities among African American women. In a study comparing the adequacy of the communication of mammography results to African American and white women, African American women were more likely to report receiving inadequate communication of their results compared with white women [54]. This was especially true when results were abnormal.

In general, Asian Americans have the lowest cancer rates of all racial/ethnic minority groups. There were approximately 57,740 new cases of cancer among Asian Americans, Native Hawaiians, and Pacific Islanders in 2016. Approximately 34% of these cases were breast cancer, the most common site [68]. Generally, Asian American women are 20% less likely to have breast cancer compared with non-Hispanic White women [186]. However, it is the leading cause of death for this population, largely due to health disparities in seeking preventive care and differences in cancer site frequency. Asian American women are 30% less likely to develop breast cancer compared with white women, but they are three times more likely to be diagnosed with stomach cancer [55]. They are also 2.5 times as likely to die from stomach cancer compared to their White female counterparts [186]. Compared with other racial groups, Asian and Pacific Islander women have the highest five-year breast cancer survival rates [125]. Specifically, Asian American women have a 91% survival rate following stage 0 to stage 2 breast cancer diagnoses [187].

There is tremendous diversity within the Asian American population, and this extends to cancer rates as well. Chinese women have the highest lung cancer death rates among Asian American subgroups, and Cambodian and Vietnamese American women have 40% to 70% higher rates of cervical cancer [56,68]. Asian American women have experienced an increase in breast cancer rates for the past two decades, as rates in many other groups have decreased [146]. A study of Asian American women in California found significant increases in breast cancer diagnoses in this group between 1988 and 2013, with the greatest increases noted among Korean and Southeast Asian women [146]. Korean American women reported the fourth highest incidence in breast cancer among the Asian American subgroups [188].

Filipina women also tend to be diagnosed with breast cancer at a younger age compared with other Asian subgroups (53.2 years vs. 55.1 years), and their breast cancer tends to be more aggressive at diagnosis [127]. In addition, Filipina women are least likely of all racial groups to have received a mammogram within the last two years, with 67.7% complying with recommendations for screening, compared with the national rate of 72.5% [131].

It appears that acculturation and years of residing in the United States are variables that affect cancer rates among Asian immigrant women. In a 2019 study, Asian women who have lived half or more of their lives in the United States were almost three times more likely to be diagnosed with breast compared to their U.S.-born counterparts [147]. In another study, for Asian women who immigrate to the United States, their risk of developing breast cancer increases six-fold, and Asian women who have lived in the United States for at least one decade have an 80% higher risk of breast cancer compared with more recent immigrants [51]. It is speculated that this is due to the changes in diet, physical activity, and the environment.

The American Cancer Society estimates that one-third of Hispanic men and women will be diagnosed with cancer during their lifetime [189]. In 2021, there were an estimated 176,600 new cases of cancer among this group, 54.7% of which occurred in women [189].

Cancer is the leading cause of death for Hispanics, accounting for more than 20% of all deaths among Hispanic/Latina women [189]. In general, Hispanics have lower all-site cancer incidence and mortality rates compared with non-Hispanic whites. For example, Hispanic women have a 30% lower breast cancer incidence and mortality rates than non-Hispanic White women [189].

Data show that breast tumors in Hispanic women tend to be localized and larger at diagnosis compared with their non-Hispanic white counterparts, perhaps explained by lower mammography screening rates among Hispanic women [59,150]. The five-year breast cancer survival rate for Hispanic women is 86%, compared with 91% for white women [51].

Hispanic women are 40% more like to be diagnosed and 30% more likely to die from cervical cancer than their non-Hispanic White counterparts [190].

In general, cancer rates are lower for Native American women when compared with whites. In 2020, rate of cancer diagnoses for Native American women was 6.0%, compared with 11.7% for non-Hispanic White women [192].

Breast cancer is the most diagnosed cancer among Native American women, followed by lung and colorectal cancers [152]. The breast cancer mortality rate was also slightly lower for Native American/Alaska Native women compared with white women (21.6 vs. 26.5 per 100,000) [153]. Overall, the five-year survival rate for breast cancer is 90% among this population [193]. However, there are geographical variances. For example, the breast cancer mortality rate is higher among Native American/Alaska Native women 40 to 49 years of age in Alaska compared with white women in the same area [153]. Furthermore, when they are diagnosed with breast cancer, it tends to be at a more advanced stage [154].

The rate of new cervical cancer cases for Native American/Alaska Native women in 2016 was 5.3 per 100,000 population, compared with 7.5 per 100,000 population for white women [151]. When diagnosed, they tend to be in later stages, and the cancer-related mortality rate is twice as high as that for white women [130]. This has resulted in a disproportionately high cervical cancer mortality rate in this population. The cervical cancer-associated mortality rate for 2014–2018 was 2.4 per 100,000 population for this group, compared with 2.0 for non-Hispanic White women [194]. There also appear to be regional differences for this group. Native American women living in the northern plains have the highest cervical cancer mortality rates [70].

Many cultures believe that language has power to shape reality and change the course of life events [157]. For example, some Native American tribes believe that if someone talks about cancer, particularly in the first person, this can bring about cancer [41]. Many Asian cultures also believe that speaking about taboo topics will bring about the feared event. In a study of Chinese Australian women, participants reported that thinking and speaking about cancer would bring it to fruition [75]. In the African American community, this process is referred to as "claiming;" by discussing cancer, one takes ownership of it, and therefore, there is the possibility of it happening. Conversely, if one does not discuss illness, the possibility is significantly reduced [76]. In a survey study of Muslim immigrants, some participants reported being unaware of family history of cancer, in part because information was withheld to prevent family from worrying or because speech was believed to influence health outcomes [158].

Fatalism is defined as the belief that one's fate is beyond his or her individual control [75]. This belief is common in collectivistic cultures, which place emphasis on the larger community and social forces, versus individualistic cultures, which emphasize the notion of the self, autonomy, and self-determination. Fatalism is also intertwined with religious and spiritual beliefs.

Fatalism can influence beliefs about cancer and cancer screening among racial and ethnic minority groups. African Americans, for example, may believe that cancer is part of God's will and is a predetermined course for one's destiny. Because the cancer is destined to happen, one merely needs to accept it [76,133,159]. Similarly, Asian Indians have a belief in karma and the idea that their destinies are not theirs to control. In these cultures, cancer (or any illness) may be considered necessary to balance karma. Korean immigrants often believe that cancer is a punishment from God or spirits for not living a moral life [76,77]. For others, fatalism is rooted in philosophical beliefs regarding yin and yang. For persons who include the concept of yin/yang in their belief systems, harmony with the environment is important, which translates to accepting the events of life that are predestined to occur [75].

However, it is important to remember that fatalism is a cultural theme and may not always apply; there is tremendous diversity within groups. In a focus group study with Hispanic Catholics, self-agency emerged as a prominent theme [134]. Participants reported believing that while God plays a role in determining their fate, they also maintained the importance of self-determination and personal assertiveness in the outcomes of cancer. This reinforces the notion that cultural fatalism does not necessarily connote powerlessness; rather, it is a coping mechanism [160]. Interestingly, some stress that an expression of fatalism may be way for patients to reassert individual autonomy and reject constraints placed by the medical establishment [161]. Furthermore, there may be a variety of other individual and cultural factors that mediate between fatalism and cancer screening. For example, in a study with 240 Korean American immigrant women, those who scored high in measures of fatalism were more likely to have had a mammogram in the past two years compared to those with low fatalism scores [195]. The authors found that family history of breast cancer and perceived barriers to mammogram affected the relationship between fatalism and preventive care [195].

In many cultures, discussions about sex and sex-related matters are considered taboo, and sex and gender roles are often intertwined. For example, in some Hispanic cultures, particularly traditional Puerto Rican families, marianismo is highly valued. Marianismo is a cultural value that stems from the Catholic belief in the Virgin Mary as the ideal of true femininity; it is considered the female counterpart to machismo[78]. While unmarried, women are expected to be chaste, passive, and pure, and when married, women are not supposed to demonstrate interest in sex, although having children and being a mother are prized [78]. These ideas regarding female sexuality and women's role as enforcers of moral purity can influence beliefs about breast and cervical cancer. For example, Hispanic women are more likely than white women to believe that breast cancer is caused by breast fondling, promiscuity or having multiple sexual partners, or initiating sexual activity at an early age [49,79]. In a qualitative meta-synthesis study, some Latinas reported feeling that cervical cancer screening constituted "indecorous behavior" [135]. Similarly, a study of Nepalese women found that cervical cancer screening was considered on par with promiscuity and adultery [162]. Laced with this is the belief that breast cancer is a sign of God's divine punishment for immoral behavior [79]. Therefore, women may feel that a breast or cervical cancer diagnosis is a sign that they have engaged in immoral behaviors and be shamed at having to tell their husband or family.

This same cultural taboo about discussing sexual matters applies to many Asian cultural groups. Cultural beliefs about modesty and inappropriate public discourse make discussions about and screenings for women's cancers difficult. Many Chinese women believe that talking about breast health is inappropriate and embarrassing [80]. A study of Korean women indicated the women never thought about breast health or breast cancer because the term "breast" is not used in everyday conversations as it would be perceived to be inappropriate [77]. Some women felt breasts or genitalia should not be exposed in the presence of strangers [163,164,196,197]. Older Korean women, in particular, associated cervical cancer with immoral behaviors. For example, these women were more likely than younger Korean women to believe that they were more susceptible to cervical cancer if they had abortions or had multiple sexual partners or if their husbands had promiscuous lifestyles [77].

Nudity can also be an issue, particularly if the healthcare provider is a man. In one study, Native American women tended to object to getting fully undressed and being exposed in an examination room. Having a male stranger conduct an exam was considered intrusive by these women [81,82].

Several studies have highlighted the role of male family members in women's engagement in breast and cervical cancer screening. In a qualitative study involving Latinx farm workers, some community health workers noted that convincing men to allow their wives to access cancer screening was often a necessary step to improving screening rates for this population [198]. This was related to both machismo attitudes as well as cultural taboos regarding modesty. Similarly, a 2019 study found that some Hispanic men would not allow their wives to attend gynecological exams because of their traditional views of sexuality and modesty [199]. In Ghana, some women talked about how they first needed their husbands' permission to go to screenings. Because their husbands were the key decision-makers in the area of finances, some husbands felt they could not afford screening and did not allow their wives to get screened. Furthermore, they also believed that strangers should not touch their wives [200].

A variety of health beliefs arise in various cultures and may result in cancer screening disparities. Misconceptions regarding the causes and manifestations of cancer are particularly damaging and can be difficult to dispel.

Western medicine is based on the biomedical perspective and the disease model, which focuses on biological dysfunction and symptoms [87]. According to this model, the physician handles the care of the patient and legitimizes that a disease is present [87]. However, many cultures do not necessarily adhere to the biomedical approach. Instead, racial and ethnic minorities tend to have a more holistic view toward health, with a community aspect to illness and healing. There are several general common denominators underlying these health beliefs. First is the belief that diseases are caused by an imbalance between oneself and one's environment, such as bodily imbalance, problems in interpersonal relationships, or even sin [88]. In a study of Chinese women in Australia, participants attributed the etiology of breast cancer to a lack of balance in the life force that runs through the body (referred to as chi) [89]. Thus, daily life for many traditional Chinese women involves eating a "balanced" (from the yin and yang perspective) diet that includes herbal remedies and soups and being attentive to how wind, cold, and dampness affect the body [90]. Such practices are viewed by Chinese women as more beneficial for the prevention of cancer than obtaining annual gynecological exams [90]. Similarly, some groups (e.g., Haitian immigrants) believe that the centrality and equilibrium of blood that runs through the body and ensuring that the blood flow remains free by adhering to the proper temperature and digesting certain foods will prevent cancer [74]. The use of herbs and other home remedies is an initial (or preventive) solution rather than a final resort.

Because racial/ethnic minority groups often believe the causes of disease are multifaceted and holistic, there is an emphasis on the self in relation to one's social environment and network [88,91]. It is typical to find a patient's social support network involved in the illness and problem solving; community ties are incorporated into the care of the patient. For example, spiritual and religious traditions and practices may be integrated into the healing process, and community or spiritual leaders are often involved in treatment [91].

At the individual level, barriers to cancer screening include issues related to access to care and health literacy. Racial and ethnic minorities in the United States are significantly less likely to have health insurance, making it difficult, expensive, and inconvenient for women to obtain regular mammograms and Pap tests [92]. Over the past decade, co-payment requirements have increased with most insurance plans, and this increase is correlated with a decrease in cancer screenings [93]. Less than 70% of women in cost-sharing plans were screened, compared with nearly 80% of fully covered women. This disproportionately affects African American women, women with lower levels of education, and women in lower socioeconomic levels. Those who are uninsured are even less likely to receive screenings [94]. Lack of health insurance and higher co-payment costs emerged as barriers for Hmong women engaging in appropriate breast and cervical cancer screening [124].

Lack of a regular physician can also reduce screening rates. In one study, recent immigration and lack of a regular physician were the greatest risk factors for not having a recent Pap test among minority women [95]. Another issue is the amount of time and resources that women have to devote to their health care. In one study, Malaysian women reported being stressed by the competing demands of life, which resulted in their health being a low priority [84]. In some cultures, the patriarchal social structure limits women's decision-making authority, which can negatively impact health-seeking decisions [162]. In such cases, the well-being of others may be valued above one's own [167]. In two separate studies, South Asian and Iranian women indicated that familial responsibilities did not allow time for cancer screenings [163,167]. This may be partially the result of stricter adherence to traditional gender roles, with women responsible for all home and child care. Hispanic women in focus groups discussed similar issues regarding relegating their health needs due to their daily struggles with life maintenance issues (e.g., caring for children, cooking) [96]. Even for older women, childcare issues may remain if they are caring for grandchildren. Creating a stable home life for their families is considered more urgent for African American women than preventive health care [96,99,133].

One qualitative study noted that cancer screening is still costly in terms of time and finances for older women because they often rely on family members for transportation, resulting in absence from work and arrangements for childcare [97]. For many immigrants, family members attend healthcare appointments to serve as interpreters [98]. The perceived inconvenience is exacerbated by the locations of clinics and long waits for appointments [84,96]. Health clinics that are easily accessible or known to immigrant women have been associated with an increased probability of screening [163].

Being unable to communicate well in English is a barrier in the context of obtaining transportation, locating the clinic or office, and filling out forms [124,163]. Similarly, Native American women have reported wanting information presented verbally or in simple, easily comprehendible written language [137].

Lack of accurate knowledge about cancer and screenings also contributes to the lower rates of screening in minority populations. Fear and anxiety, stemming from misconceptions, inaccurate information, and the general unknown, often impede women from adhering to screening guidelines [168]. For example, a survey of Latina women found a common belief that breast cancer is incurable and that mammography is only necessary when symptoms emerge [61]. In one qualitative study, some African American participants did not have an understanding of the difference between self-breast exam and a mammogram [159]. Others did not know where to obtain screening [200].

As discussed, the absence of symptoms is a prevalent justification for avoiding screenings [96]. Other women may simply be unfamiliar with mammography and how it can detect cancer. In a focus group with Filipina immigrant women, participants discussed inaccessibility of mammograms in the Philippines, where they are considered luxuries and are only available in large cities like Manila [100].

Degree of sexual activity also predicts Pap test and mammography use. In a study of Asian and Latina college students, Latina students who were sexually active were five times more likely to obtain breast cancer screening than their non-sexually active counterparts; Asian students were nine times more likely to obtain a mammogram if they were sexually active [101]. Researchers posited those who are sexually active are more likely to see a gynecologist and be referred for screening.

Fear is another possible barrier. In one study, 30.3% of African American women, 35.5% of Latina women, and 24.2% of Arab women stated that they believed Pap tests were very painful. This predicted the likelihood of scheduling a Pap test [138]. In another study, some African American women reported fear of pain and/or radiation associated with a mammogram [159]. Similarly, a 2022 study found that some African American women were fearful of mammograms and potential pain associated with the procedure [203]. In another study, African American reported being fearful of a breast cancer diagnosis and a wish not to know [204]. This attitude reflected the role of fatalism in individual-related barriers to screening.

Many racial and ethnic minorities feel that the healthcare system is marginalizing, making it difficult to access health services. A survey of Mexican immigrant women described long waits at clinics, and women who sought mammography screening reported feeling the process was impersonal and uninformative [96]. Ultimately, these women felt they were disrespected because of their poverty, and their experiences reinforced their reluctance to seek health services. Others talked about how providers were rude and disrespectful [204].

In a focus group study with Native Hawaiian women with inadequate or no health insurance, participants were reluctant to access free screening services. This unwillingness stemmed from fears that they would be judged negatively and be discriminated against [102]. They were also suspicious of the free services, with these fears stemming from past experiences with discrimination. Other minority groups have reported feeling like "second-class citizens" in the healthcare system [103].

Medical discrimination can adversely impact access and quality of care. In a literature review focusing on Asians and cancer care, four themes surfaced related to medical discrimination [205]:

In a focus group study with African American women about barriers to mammography screening, they expressed anxiety about the interactions with their providers [86]. They were concerned they would be treated with disrespect and did not have much faith and trust toward their physicians; most had a history of poor healthcare encounters, particularly with failures in communication. This reinforced their negative perceptions about the healthcare system and their fears about screenings [86,133].

Another reason women may not seek medical services is general mistrust of Western medical institutions. Fears about medical incompetence and historical events involving the intentional harm of some groups, particularly African Americans, contribute to this barrier [86]. General mistrust also applies to other ethnic minority groups like Korean American women. In one study, Korean American women who reported higher levels of trust with their healthcare providers were more likely to have breast cancer screening [148].

The logistics of scheduling appointments can be a barrier as well. The automated scheduling can be a challenge for those whose first language is not English, as they may have difficulty following the automated instructions [124].

The model minority myth has been proposed as a possible systemic barrier to cancer screening for Asian Americans [139]. The model minority myth is the stereotype that Asian Americans have achieved success compared with other racial minority groups largely because they have been industrious, particularly in academics. Consequently, healthcare providers may be less likely to recommend cancer screening to Asian American women because they assume they are already aware of screening recommendations or are more likely to be healthy [139].

The types of barriers may vary for women who have never had a mammography compared with those who have had a mammogram but are not on schedule [140]. In one study of women 40 years of age or older (83% African American), breast cancer knowledge predicted previous mammogram. However, structural, emotional, and communication barriers predicted whether the women were in compliance with screening schedule recommendations. For example, failure to receive a mammogram recommendation from a healthcare provider was a powerful predictor to being off-schedule [140]. Ultimately, understanding these barriers can inform interventions.

As discussed, the cultural values of fatalism, modesty, and manifestation through language serve as strong cultural barriers to seeking cancer screenings for many racial and ethnic minority women. The cultural value of collectivism can also serve as an impediment. Small communities (e.g., immigrant communities) make anonymity difficult, and some women may feel they will disgrace their families and be shamed if others find out about a diagnosis of cervical cancer, as this is believed to imply sexual immorality and promiscuity [97].

The cultural emphasis on family can also serve as a barrier to preventive care. A survey study with 401 Ugandan women found that those who had high levels of family obligation were less likely to participate in breast cancer education and screening [206]. Putting family first has also been identified as a barrier for some Hispanic women in participating in cervical cancer screening, but it can also be an enabling factor for cancer screening for others [199].

Communication patterns and styles can also inhibit racial and ethnic minority women from fully maximizing the time with their provider. For example, Asian communication styles tend to be more indirect, relying on nonverbal cues. In Japanese culture, omioyari, which refers to the cultural concept of empathy and intuition, is an important part of communication [104]. Some Japanese women rely on physicians to sense what they need rather than inquiring directly; questioning is perceived to be asking for favors or a waste of the physician's time [104]. In a qualitative study with Filipinas, the women indicated that they preferred a more "soft," indirect way of communicating. Among this group, being forthright and direct in communicating their needs or questions was equated with begging [105].

Some racial and ethnic minority women have a strong preference for a female physician or provider to conduct mammograms and/or Pap tests. For some women, female providers were associated with increased comfort and mediated modesty and embarrassment issues [199]. Other women prefer a physician from their own racial/ethnic minority group. In a study of Korean American women in Hawaii, participants expressed a desire for a female gynecologist, some even travelling back to South Korea to obtain preventive care [207]. In another study, Hispanic women stated that they preferred to have a provider who was also Hispanic, but it was more important that the provider could speak Spanish [99]. Asian and Muslim women preferred a female provider due to their feelings of embarrassment and privacy about having a male provider touch them [158]. Some Asian women expressed a preference for physicians with training from prestigious medical schools; this could be partially explained by the emphasis on education in Asian cultures [99].

Another barrier is physicians not referring racial/ethnic minority women for Pap tests or mammograms. New immigrants or those who are not proficient in English may not know where to seek screenings, and a physician referral to a specific location increases the odds of seeking preventive care. In a study with African American women, the best predictor to getting a mammogram was having had a screening in the past [106]. Past health behaviors appear to be salient in influencing future health behaviors. For immigrants who may not have legal status, they may be fearful that they will be deported if healthcare practitioners become aware of their undocumented status [135].

The high perceived cost of cancer screening is a barrier for many women from racial and ethnic minority groups. In one study, some Arab and Muslim American women identified potential financial issues as a barrier to breast cancer screening [208]. In a study with 897 white, African American, and Native American women, perceived cost of a mammogram, whether accurate or not, was a major barrier to screening; more than half of the women cited costs as a reason they had not sought screening [107]. About 52% overestimated the costs associated with the test, and these women had a greater likelihood of not having a mammogram compared with those with an accurate perception of the costs [107]. For Native American/Alaska Native women, reliance on Indian Health Services has been correlated with lack of mammogram [169]. It is possible that underfunding and understaffing of Indian Health Services may contribute to this gap.

When trying to reach racial/ethnic minority women, it is important to consider how mammogram and Pap test screening messages are framed [89]. For example, the word "cancer" can evoke dread and fear for many women, with several cultures attributing the power to cause illness to the word. Similarly, some women may believe that the only "real" cancers are those in the late stages. However, if cancer screening is couched within a discussion about benign tumors, emphasizing the importance of early detection, then the message will be better received [89]. Instead of employing the word "cancer," the terms "tumors" or "lumps" could be employed as a way to start a dialogue.

The U.S. Preventive Services Task Force asserts that cervical cancer screening may be clinically indicated in older women for whom the adequacy of prior screening cannot be accurately accessed or documented. Women with limited access to care, minority women, and women from countries where screening is not available may be less likely to meet the criteria for adequate prior screening.

(https://jamanetwork.com/journals/jama/fullarticle/2697704 Last Accessed: December 12, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Variations in screening guidelines have caused confusion among the general public. For example, the American Cancer Society recommends starting mammography at 40 years of age; however, the U.S. Preventive Services Task Force has recommended initiation at 50 years of age (unless risk factors are present) [142]. It is also important to recognize that screening guidelines should be individualized based on the specific patient's risk factors and healthcare goals. For example, estrogen-positive breast cancer tends to progress more quickly and is much more prevalent among younger African American women [142]. Knowing this, healthcare professionals may decide to recommend earlier screening in this population.

Cancer screening promotion messages should be framed within the context of holistic health maintenance. Many cultures believe that good health is the result of harmony of the mind, body, and environment, and preventive medicine can be a part of this [98]. Mammograms and Pap tests can be discussed within the overall context of physical, spiritual, and emotional health.

When caring for minority and immigrant women, practitioners must be willing to discuss religion and spirituality and to acknowledge the connection of the mind, body, and spirit for many racial and ethnic minority groups [106]. In focus groups, African American women were receptive to receiving text messages about cervical cancer and screenings that had underlying religious and spiritual content if they were aligned with their belief systems [170]. Some experts have developed workshops that educate Somali American women about breast and cervical cancer screening, with trainings specifically tailored to their cultural and religious beliefs [210]. The beliefs of Islam were woven into themes of modesty, faith practice, and preventive health care. Educating women about cancer prevention screening was promoted as being consistent with predestination and self-care was a form of respecting the will of Allah. Imams led the workshops in mosques. Ultimately, their messages were more readily accepted by the Somali American women [210]. This may be a foreign concept for many providers practicing within the Western biomedical model which adheres to an empirically based disease model with an emphasis on diagnosing and treating disease [108]. Practitioners should strive to become comfortable talking about prayer and taking care of one's spiritual health, which is viewed as a pathway to physical health for many racial/ethnic minority groups [74,109].

Peers and family members are often the most effective communicators of both accurate and erroneous health messages. On the one hand, they may disseminate medical information that is inaccurate or relate sensationalized anecdotes about health and remedies [84]. Alternatively, the family and peer network is frequently the most relied upon source of health information. In one survey, Filipino American family members frequently encouraged their female relatives to seek breast cancer screenings [100]. In many cases, a best friend, daughter, or other important person may have more power to influence a woman to obtain mammograms than a physician or husband [110]. However, some women reported that their mothers never talked about breast and cervical cancer screening, likely due to embarrassment [196,199]. Family members, friends, and peers can be important partners, because observing trusted individuals can prompt patients to engage in healthier lifestyle behaviors, such as cancer screenings [167].

For Native Americans, a tribal leader or provider may be identified to deliver health information with sensitivity to the group's communication patterns [143]. Instead, lectures with the facilitator at a podium, having participants sit in a circle, providing food and crafts, and encouraging extended family members to attend can be beneficial for this group.

For many racial and ethnic minority women, health is holistic and multidimensional, consisting of not only the physical body but the emotional, social, spiritual, and cultural health as well [116]. Social health refers to one being comfortable, living stress-free, and being in control of one's living environment. This may be a significant issue for immigrant women, as they live in a country in which they are constantly negotiating new systems and usually learning a new language. Impaired social health then affects their overall health [116]. Messages about the importance of cancer screenings often focus only on physical health, which may be a small part of the holistic health perspective. The goal is not to discard the preventive methods, but rather to reframe the messages so they are relevant to the lives of racial and ethnic minority women and therefore more effective.

In collectivist cultures, individuals' roles as part of a larger group are paramount, with an emphasis placed on interdependence [117]. There are three major elements of collectivist orientation: interdependence; familiarity, caring, and trust; and sense of obligation [117]. The family and the church are concrete representations of this cultural norm, and they influence many behaviors, including health decisions. This translates into cancer prevention and education in that the relationship, connection, and trust between the messenger and the recipient have more importance than the message [117]. Therefore, when practitioners deliver a health message in a personal manner that communicates that they can be trusted and that they care, the message will be viewed as more credible and is more likely be acted on. If a patient sees the same practitioner at every (or most) visit, there are more opportunities to establish a therapeutic alliance, ensuring that health behaviors are maintained.

Family and collectivism can play facilitator and barrier roles in cancer screening [199]. Practitioners should remember that in collectivistic cultures, the family will play a larger role on stage in decision-making. Furthermore, because cancer is serious and can be frightening, this may also lead to family tension, conflicts, and collusion (i.e., a secret agreement between two or more individuals not to share information) [145]. Cancer screening messages can also be framed within the context of family commitment and well-being to facilitate engagement [102,174,199]. For example, women may be told that mammograms and Pap tests promote family well-being and obtaining these screenings is a symbol of their pledge to the overall functioning of the family.

Styles of communication can be classified from high- to low-context [118]. High-context cultures are those that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [119]. Love and care may not always be verbally expressed but rather demonstrated through concrete actions [175]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [118]. On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in a conversation [119]. Consequently, low-context communicators listen with their ears and focus on what is being said [118]. Because of this, the use of narratives or stories in breast and cervical cancer education may be effective for these groups [129]. Stories of cancer survivors' personal experiences bring more credibility and can reinforce adherence to mammogram screening and breast self-examination recommendations [129]. Navajo Indian women test to prefer to hear personal accounts from community and family members about how they dealt with cancer, fatalism, and stigma [213]. Hmong patients, particularly older ones, tend to prefer responding in narratives to health providers' questions, which is consistent with their oral story telling traditions [214]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans, are from high-context cultures [118].

Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communicating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. A Chinese American male social worker may not necessarily be a high-context communicator because he is Asian. A host of factors, such as gender, level of acculturation, upbringing and socialization, education, and family immigration history, will all play a role in how one learns to communicate.

Most practitioners have been taught and socialized in a Western biomedical environment in which communication styles are direct (i.e., low-context). This is evidenced by the following common behaviors [120]:

The literature has shown that because many racial and ethnic minority patients view healthcare professionals as authority figures, they expect a direct communication style on the receiving end [121]. However, as communicators, they do not necessarily utilize the same direct communication style and expect the professional to infer the underlying meanings of what they express.

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for patients and their families to improve health, mental health, social, and/or family outcomes [215]. Interprofessional collaboration traverses professional boundaries and allows providers to harness the skills and knowledge of their colleagues in order to achieve a common goal [216]. Aside from improving patient care and outcomes, collaborating practitioners experience improved job satisfaction, retention, and working relationships and report higher levels of creativity [217,218,219].

Some experts suggest a community capacity enhancement approach to cancer prevention when working with racial and ethnic minority communities [122]. This involves using existing community resources and ties and determining mechanisms to strengthen these links. The community capacity enhancement model can help reduce any perceived differentials in authority when "outsiders" enter into communities and begin implementing health services. For example, doulas have been deployed to educate foreign-born women regarding cervical cancer screening. Doulas are socially accepted by the women and their families because of their role in childbirth [220]. Partnering with cultural experts and those entrenched in the community can provide insight on how to use specific practices to educate racial/ethnic minority women about cancer screenings. For example, community health workers who work with Vietnamese immigrant reported using the cultural practice of coin rubbing to build trust with their physicians. The practice in itself was innocuous but built rapport and improved patient comfort before Pap tests [221].

In many communities, this will mean involving churches and other religious and spiritual institutions. Ministers, pastors, imams, and church board members, such as female deaconesses, are often viewed as credible and trustworthy and can be effective communicators of breast and cervical cancer screening messages [102,122,174,222]. In one study, churches were determined to be a useful venue for disseminating cancer education and preventive services information for Latinas [72]. The "witnessing" of a survivor of breast cancer about her experiences may also touch segments of the population that are considered "hard to reach" [123,159].