Context: Breast cancer is the most common form of cancer found in women today. The incidence of breast cancer is increasing in the United States. Hispanics have been found to be at greater risk of mortality due to late-stage breast cancer detection.
Purpose: The focus of this study was to determine, through community-based participatory research, the attitudes, beliefs, and actions, that agricultural farm workers adopt to encourage or discourage their sexual partners to engage in early detection breast cancer strategies.
Methods: A total of 50 rural male Latino farm workers participated in focus groups conducted in Spanish. Participants discussed seven major questions. Data was analyzed using Nud*ist, a computer software for qualitative data analysis.
Findings: The results of this study indicated that rural Latino farm working males are willing to support their sexual partners’ initiatives for early detection of breast cancer but do not have enough knowledge about this disease, do not have communication tools to address this issue at the family level, have economic constrains, and have cultural and religious beliefs that may interfere with their sexual partners’ decision to have breast-self examinations, clinical breast exams, and mammograms.
Conclusions: Latino males could play a major role in breast cancer early detection. Recommendations for practitioners working with rural Latino communities include incorporating community-based research models in which Latino males could become empowered and more conscious about the positive impact they may have on the health of their female partners.
Key words: Farm workers, Latino males, rural health, breast cancer, early detection
Breast cancer prevention is currently one of the top priorities among public health professionals. Breast cancer is the most common form of cancer found in women today. The incidence of breast cancer has increased from one in 20 women to a current ratio of one in eight women (Breastcancer.org).
Among Hispanic women, breast cancer is the leading cause of cancer death (16%), followed by lung (13%), and colon and rectum cancers (11%). Hispanics comprise an estimated 12.5% of the population and are the fastest growing minority group in the United States. Hispanics have been found to be at greater risk of mortality due to late-stage breast cancer detection (O’Brien K. et.al.).
The limited research literature on the role of Latino males in the prevention of breast cancer among their sexual partners, motivated the development of this study. This research project was conducted with a community-based approach. This form of research is appropriate for Hispanic/Latino populations because it involves the active participation of local organizations and community representatives.
The purpose of this study was to identify the role Latino males play in early detection of breast cancer in Latina women living in the rural Central California Valley, as measured in their attitudes, beliefs, and actions towards their sexual partners’ compliance with breast-self examination, clinical examination, and mammography.
To date, few studies have attempted to recognize how Latino males could become active partners in the prevention of breast cancer. The positive or negative influence Latino Males can have on their partners’ decision to adopt breast cancer early detection strategies is still yet to be explored.
This study attempted to 1) determine the knowledge levels of male Latino farm workers about breast cancer and early detection strategies such as breast self examination, clinical examination, mammography; 2) determine the attitudes and behaviors of male Latino farm workers that may encourage or discourage their sexual female sexual partners to practice breast self examination every month, get an annual clinical exam, and get a mammogram according to pre-established health screening recommendations, and 3) actively involve community members in health-related research.
Review of Literature
Population-based studies show that Hispanic women are more likely to be diagnosed at a later stage than non-Hispanic whites (Intercultural Cancer Council). Routine mammography screening and clinical breast examinations can lead to early detection of breast cancer and improve survival of women who have breast cancer (Laws MB, Mayo SJ, 1998). Breast Cancer is the most common malignancy and the leading cause of cancer deaths among Hispanic women (National Cancer Institute). A call for more research on cancer prevention and early detection among rural Hispanic women has been currently proposed by researchers and practitioners (Berskowit, Ivory, and Morris, 2002, and Ricketts, 2002).
It is well known that regular breast cancer screening increases early detection and significantly reduces breast cancer mortality. Therefore, it is of concern that Hispanic women are less likely to report the use of breast cancer screening than women in the general population (Ramirez et.al., 2000a).
Although there is evidence that older minority women may feel scared about breast cancer, a paucity of information exists regarding the screening knowledge and practices of this segment of the population. Most of the work to date has been regional in nature and has involved limited samples (Ramirez, et.al., 2000b). Hispanic women are not complying with preventative screenings for breast cancer at the optimal level and deserve further study to determine whether their sexual partners may be a point of access to screening.
There is limited research on the role that Latino males could play on cancer prevention and early detection. A study by Flores and Mata (1995) attempted to identify how Latino males could have an influence on their sexual partners’ health-seeking behaviors, especially regarding breast cancer and cervical cancer screening. This research focused on Latino males’ concept of machismo, masculinity, and conjugal decision-making. This study addressed Latinos’ attitudes, values, and behaviors about health, their knowledge and experience with their partners’ health-seeking efforts, and specific health-care screening practices. Flores and Mata’s study involved the development of focus groups with Latino males from a wide range of educational, occupational, language preference, age, residential, and acculturation backgrounds.
This study’s key findings suggested that for Hispanic women, preventative health measures can be greatly enhanced by understanding the husband’s knowledge base and attitudes regarding his wife’s health and health-seeking efforts. These health-seeking efforts should be understood, in light of the husband’s own conceptions of health, his knowledge and attitudes about his spouse’s beliefs about her health status, and how these beliefs change and evolve over the life course. Flores and Mata stated that by promoting measures of social support regarding breast cancer and cervical cancer screening via the husbands, health practitioners could enhance and promote women’s health. Flores and Mata emphasized the importance of continuing with this line of research and made a call for further studies on the impact that spouses could have on the development of health-seeking behaviors among Latinas.
Community-based research has been defined as a ‘collaborative inquiry that is dedicated primarily to serving the needs of community organizations’ (Paul, 2006). In this type of research, the representatives from local entities, members of the community, faculty, and students form a partnership to collaborate in the solution of community problems. Each of the members of this partnership brings skills and expertise and all partners are teachers and learners (Paul, 2006). Community-based research with Hispanic/Latino populations in the U.S has been scarce, particularly for the study of breast cancer prevention.
The focus of this study was, through the use of community-based research, to gather data to bolster the core understanding of the role Latino partners could play in the prevention of female breast cancer. This qualitative study attempted to generate grounded theory that could be further explored through quantitative or qualitative means. This research intended to provide data to practitioners working with rural populations, to understand the important role males could play in disease prevention among Latinas. This role was defined in terms of the attitudes, beliefs, and actions that agricultural farm workers adopt to encourage or discourage their female sexual partners to adopt early detection breast cancer strategies.
The research process started with dialogues with representatives from Migrant Head Start, which was the community organization involved in this research project, to identify the health education priorities among Hispanic/Latinos farm workers. After this, Migrant Head Start representatives had consultative interactions with its populations about their needs to discuss cancer-related issues. Community representatives expressed their concerns about breast cancer and their need to learn more about it. The need for including working males in this research was consulted with the participants since they could potentially play an important role in breast cancer prevention. With this in mind, a research team was established and composed of Migrant Head Start representatives, community members, faculty, and students.
The study involved the development of seven focus groups with a total sample of 50 participating Latino males from a rural area in the Central Valley of California. Focus groups have been identified as very efficient methods for cross-cultural understanding of health behaviors, particularly among populations with limited literacy levels. The central idea to using focus groups in community-based research with low-literacy populations is that the group process allows participants to explore their ideas and viewpoints, and make them more accessible to the researcher than do other methods of inquiry (Kitzinger, 1995).
Focus groups have been amply used in community-based research. They have served as a medium to motivate each of the research partners (organizations’ representatives, community members, faculty, and students) to actively participate in the identification of problems and alternatives for solution. Focus groups are used in community-based research to create an environment of trust and open dialogue.
The focus groups were lead by a male Hispanic researcher with a Masters in Public Health and assisted by a male undergraduate student with health science background. Criteria for participation in this study included: 1) being a male older than 18 years old, and 2) being Latino descendant of up to third generation. Approval by the Committee for the Protection of Human Subjects at the participating institution was granted prior to collection of data.
To encourage participation, the focus groups were conducted in the office of the Migrant Head Start located in the geographical area of study. Male participants in this study were recruited through various Migrant Head Start centers throughout Fresno County.
A seven-question instrument was used to identify the participant’s role in the prevention of breast cancer with their female partners. The instrument was translated to Spanish and used in the focus groups. The following questions were used in the meetings:
- What do you know about breast cancer?
- What do you think about your wife or sexual partner practicing breast self-examination? Breast self-examination is an exam that women can practice by themselves. In this exam, a woman has to touch her breast in different locations with the intention to identify any abnormal mass present in the breast. It is recommended once a month.
- What do you think about your spouse having a mammography? A mammography is an exam prescribed by a doctor or a health care practitioner that helps in the identification of any tumor or abnormal mass present in the breast. For this exam, women have to uncover their breast and allow the health professional to place the breast in an appropriate manner in front of the machine so the exam can be taken appropriately.
- What do you think about your spouse having a breast exam by a physician or a health practitioner? In this kind of exam, a doctor, nurse or other health care professional has to touch the breast of the woman in various locations in order to identify any abnormal mass in the breast. This exam is done in the consulting room at a health care center or any other health organization.
- What do you think Latino men do to discourage their wives or sexual partners from having breast cancer screenings?
- What do you think Latino men do to encourage their wives or sexual partners to have breast cancer screenings?
- What difficulties did you find answering the previous questions?
All focus groups were conducted in Spanish and lasted approximately 60 minutes. To keep an environment of trust and comfort, the focus groups were conducted by Hispanic males. The male research assistants participated in an intensive training to develop their skills on qualitative health research and to discuss bilingual and bi-cultural considerations.
Written consent was obtained from participating males prior to collection of data. To increase understanding of the consent form, each item was read and explained to the participants. After conclusion of each focus group, the research participants received an educational session on breast cancer and were given visual materials to share with their spouses and family.
The demographic data was analyzed through the Statistical Package for Social Sciences (SPSS). Demographic data included the age of the participants, educational level, previous courses on breast cancer, and family history of breast cancer.
Content-analysis was used for the responses to the focus groups. Responses were also analyzed using Nud*ist, which is a computer software for qualitative data analysis. Focus groups were transcribed and translated from Spanish to English. After all focus groups were conducted, the written notes and demographic questionnaires were analyzed to determine trends and identify major themes.
The analysis of the demographic data through SPSS showed that the age of the participants ranged from 18 to 67 years old, with the majority of participants (75%) being of age 28 to 33. An estimated 30% of the participants had some elementary school education, 30.6% completed elementary school, 15.2% had some secondary school, 21.2% completed secondary school, and 3.0% had some college or university education. The majority of participants (97%) had not participated previously on courses related to breast cancer education. Regarding family history of breast cancer, 91% indicated no history of breast cancer, 6% indicated having a history of breast cancer in their families, and 4% did not respond to this question.
The responses to the questions in the focus groups were grouped by themes for this article. The common themes for question #1, ‘What do you know about breast cancer?’ showed that participants, had misconceptions about the etiology of breast cancer such as understanding breast cancer as a problem generated by constantly touching the breast. Participants recognized breast cancer as a health problem exclusively for females. No knowledge about breast cancer in males was expressed in the participating group. Participants mentioned that their knowledge about breast cancer came primarily from having seen or heard commercials on radio and television.
For question #2, ‘What do think about your wife or sexual partner practicing breast self-examination,’ participants expressed concern about breast cancer as being a serious illness. Acceptance of breast self-examination varied by educational level of participants. Participants with educational attainment of less than elementary school expressed concerns about this practice because according to their perceptions, constantly touching the breast may lead to the development of tumors. Participants with elementary school or less also indicated their concerns about self-breast examination as a practice that may go against their religious principles because of the sexual connotation that this practice may have. Participants with higher educational attainment considered it to be an acceptable screening tool for women. Participants also mentioned that they would like to be kept informed about their spouses’ health.
For question #3, ‘What do you think about your spouse having a mammography,’ participants expressed a lack of knowledge about this exam. Participants indicated they see a mammography as important and positive if prescribed by a health care provider. Participants also expressed concerns about the cost of this exam. They stated that they would like to know more about how a mammography is performed.
In question #4, ‘What do you think about your spouse having a breast exam by a physician or a health practitioner,’ participants expressed concerns. Some participants indicated that male physicians and health care practitioners could be unethical and could touch their spouses in an inappropriate manner. Female health practitioners were more acceptable for a clinical exam. Some participants would prefer their spouse to have a mammography instead of a clinical exam, and perceive male ego as a barrier for women to receive adequate clinical exams.
For question #5, ‘What do you think Latino men do to discourage their wives or sexual partners from having breast cancer screenings,’ participants expressed that ‘machismo’ (a male-centered approach to decision-making) was the main reason for Latino males to discourage their spouses to have breast cancer screenings. Actions identified by participants as discouraging for breast cancer screening included not allowing time for women to go to the doctor and not recognizing the importance of screening methods to maintain the health.
For question #6, ‘What do you think Latino men do to encourage their wives or sexual partners to have breast cancer screenings,’ participants indicated at the moment very few actions are taken by Latino men. Examples of those actions were motivating their spouses to go to health care facilities and having open communication with their spouses about their health. Participants expressed interest in talking to their sexual partners and family about breast cancer screenings but did not know how to start a conversation on this topic. They also expressed concerns about economic limitations to access these types of screening. Participants suggested creating ‘clubs of Peers for Health/Compadres por la salud’ in which males could educate other Latino males about the prevention of breast cancer. They would like to receive further education about breast cancer prevention and screening.
For #7, ‘What difficulties did you find answering the previous questions,’ participants indicated that the questions were not difficult to understand and considered the focus group session informative. Question # 3 related to mammograms was recognized as the most difficult one since some of the participants had limited knowledge about this exam. They indicated that these questions were clear enough to be used in future studies. Participants indicated that through the questions used in this study, they became more aware of the importance of breast cancer screening for their spouses or sexual partners.
The results of this study indicated that rural Latino farm working males are willing to support their sexual partners’ initiatives for early detection of breast cancer but do not have enough knowledge about this disease, do not have communication tools to address this issue at the family level, have economic constrains, and have cultural and religious beliefs that may interfere with their sexual partners’ decision to have breast-self examinations, clinical breast exams, and mammograms.
The data suggested that the majority of the participants perceive cancer as being a serious illness and consider the breast cancer prevention exams to be good for women. Sources of information about cancer among participants included television and radio messages. These messages have increased their level of awareness about breast cancer among females. No knowledge about male breast cancer was present among the participants in this study.
Participants mentioned that they would like to be kept informed about their spouses’ health. Research participants stated that they would like to know more about how mammography exams are performed and the importance of this diagnostic technique in the prevention of breast cancer.
Participants mentioned machismo as one of the main issues in discouraging their spouses to have breast cancer screening. Machismo was defined in this study as the decision-making process centered on the male figures of the family.
Participants also indicated that Latino males can motivate their spouses to attend regular breast cancer exams and have open communications about their spouses’ health exams. Participants were willing to talk to their daughters and wives to encourage them to have self and clinical breast exams, but did not know how to start the conversation about this particular issue. An important consideration is that in order for a discussion on breast cancer prevention and early detection to happen, participants need more educational opportunities in which they can learn how to address this important issue in the family environment. Participants also suggested the creation of peer education groups in which males can talk to each other about the importance of breast cancer prevention.
Limitations of this study included that participants were asked to complete some forms, such as the consent form, and answer to demographic questions, which could have inhibited their full participation since they may have been intimidated by the formality of the process. The focus groups modality and the meeting times may also have had an effect in the participants’ responses. Focus groups require a verbal expression of personal thoughts and feelings in front of other people, which may limit the participants’ willingness to share. In addition, the focus groups met from 6:00 p.m. to 7:00 p.m. These times could have influenced the participants’ readiness to provide input since they came straight from work and may have been tired. An additional limitation could be the participants’ lack of familiarity or relationship with the focus group facilitators. This could have influenced the participants’ willingness to provide responses that reflected their real experiences and not the responses expected by the facilitators.
The role of Latino males in the prevention of breast cancer among their female sexual partners is crucial. Involving Latino males in the prevention of breast cancer may significantly contribute in Latino women’s decision to adopt screening practices for breast cancer.
Community-based research is an important approach to motivate participants’ active involvement in health education efforts. This type of research allows for the development of educational programs and curriculums on breast cancer prevention that empower Latino males to become actively involved in the care of their spouses’ breast health. This study needs to be replicated in a larger scale to determine the consistency of the results among other Latino populations.
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About the Authors:
Helda Pinzon-Perez is an Associate Professor at California State University, Fresno. Her research interests are focused on the health issues of migrant, rural and farm working Latino communities. Contact Information: Helda Pinzon-Perez, Ph.D., Department of Health Science, M/S MH 30, California State University- Fresno, Fresno, CA 93740-8031; firstname.lastname@example.org.
Jose Antonio Gonzalez is a graduate of the Master’s in Public Health Program at California State University, Fresno. He is currently working with HealthNet. His research interests are centered on issues of rural male populations.
Special gratitude is owed to Ms. Inez Rodriguez and staff at the Migrant Head Start Program for their assistance and support to this research project. This article was written with support from the ‘Faculty Increase Productivity’ Program at California State University, Fresno.