Original Research: Can a Palliative Care Lay Health Advisor-Nurse Partnership Improve Health Equity for Latinos with Cancer?

PURPOSE

A palliative care infrastructure is lacking for Latinos with life-threatening illness, especially in rural regions of the United States. The purpose of this study was to develop and evaluate a community-based palliative care lay health advisor (LHA) intervention for rural-dwelling Latino adults with cancer.

METHODS

An exploratory mixed-methods participatory action research design was carried out by an interprofessional research team that included community and academic members. Fifteen Latino community leaders completed a 10-hour palliative care training program and then served as palliative care LHAs. Although 45 Latinos with cancer initially agreed to participate, four withdrew or died and six were not reachable by the LHAs, for a final total of 35 patient participants.The trained palliative care LHAs delivered information on home symptom management and advance care planning to assigned participants. Palliative care nurses led the training and were available to the LHAs for consultation throughout the study. The LHAs made an average of three telephone calls to each participant. The Edmonton Symptom Assessment System-Revised (ESAS-r) and the four-item Advance Care Planning Engagement Survey (ACPES-4) were administered pre- and postintervention to determine the intervention's effectiveness. Encounter forms were transcribed, coded, and analyzed using case comparison.

RESULTS

The major finding was that significant improvements were shown for all four items of the ACPES-4 among both the LHAs (posttraining) and the participants (postintervention). Information on advance care planning was shared with 74.3% of the 35 participants. Participants showed clinical improvement in physical symptom scores and clinical deterioration in emotional symptom scores following the intervention, although these changes did not reach statistical significance. The advisors noted that participants were anxious about how to explain cancer to children, the uncertainty of their prognosis, and medical expenses. This sample was younger than those of other cancer studies; 51.4% were under age 50 and 73.1% had at least one child in the home.

CONCLUSIONS

A community-based palliative care LHA-nurse partnership was shown to be a feasible way to engage in conversations and deliver information about advance care planning to rural-dwelling Latino adults with cancer. The positive results led to the regional cancer center's decision to select "cultural care" as its 2022 goal for maintaining its accreditation with the Commission on Cancer.

Four Kinds of Hard: An Understanding of Cancer and Death among Latino Community Leaders

Early integration of palliative care after a diagnosis of cancer improves outcomes, yet such care for Latino populations is lacking in rural regions of the United States. We used a participatory action research design with Latino community leaders from emerging immigrant communities in North Carolina to explore sociocultural perspectives on cancer and death. Thematic analysis was conceptualized as Four Kinds of Hard represented by four themes: Receiving an Eviction Notice, Getting in the Good Book, Talking is (Sometimes) Taboo, and Seeing Their Pain Makes us Suffer. These themes captured fears of deportation, coping with cancer through faithfulness, ambivalence about advance care planning, and a desire to spare families from suffering. Findings suggest strategies to improve conversations about end-of-life wishes when facing advanced illness and death. This study demonstrates the importance of training Latino community leaders to improve palliative care and bridge service gaps for Latino families living in emerging rural communities.

Emotional arousal in the making of cultural selves

The highly variable selves that ethnographers have documented cross-culturally all build upon the universal human self described by neurobiologists. The link between cultural selfhood and this neurally-based self is emotional arousal. Arousal heightens the effect of synaptic plasticity, insuring that clusters of strong associations, or cognitive schemas, result from many fewer repetitions of the arousing experience. There are identifiable types of such predictably arousing experiences cross-culturally, many occurring early in life. While susceptible to individual variation, these are typically based in kinds of experience widespread in groups. Culturally elaborated, these shared experiences result in distinctive cultural selves. The argument is illustrated at length with one of these types, disciplinary childrearing practices. Early attachment, cultural psychodynamic defenses, and several other shared, culturally variable experiences that are predictably emotionally arousing are also considered: unintended consequences of childrearing; separation from primary caretaker(s); trauma of all kinds; rituals such as initiation rites or religious conversion; and cultural idealizations of occasions, institutions, or roles.

A Multidimensional Examination of Depression among the Elderly

Data from 868 eastern North Carolina elders are used to examine the effects of variables hypothesized to moderate the impact of life strain on depression. Principal components factor analysis is used to categorize depression into subdimensions of life satisfaction, withdrawal, and general depressive affect. Although independent variables such as instrumental activities of daily living limitations as an indicator of life strain are found to affect the subdimensions, differences pertaining only to certain subdimensions of depression are found. The findings support the importance of subdimensions of depression and suggest variability among subpopulations within a primarily nonurban sample.

Health and Community-Based Service Use

Responses from personal interviews with a random sample of 2,178 adults aged 60 years and older living in their homes in eastern North Carolina were used to examine the effects of predisposing, enabling, and need indicators on differences in the use of health and community-based services separately for African American and White elders. Health services include primary care visits and visits to specialists. Community-based services were categorized into personal care services and financial assistance. Logistic regression analyses were done in an attempt to explain why African American elders are more likely than are Whites to use both kinds of community-based services, are less likely than are Whites to use specialty care, and whether there are differences by race in the use of primary care physicians. Results indicate that the odds of using financial assistance and medical care vary by race according to selected predisposing, enabling, and need characteristics. There is little difference by race, however, in the use of financial assistance services. The implications of the findings are discussed.

Difference by Race in Long-Term Care Plans

The underrepresentation of African American elders in institutional care is attributed to their greater desire for family care compared to Whites. Data from in-home interviews with 604 African Americans and Whites aged 65 and older are used to explore whether differences by race in long-term care plans substantiate this claim. Contrary to expectations, African American elders were more likely than Whites to have made long-term care plans and to include institutional as well as family care in their plans. Multivariate findings were that African American elders with more education were more likely than others to have made long-term care plans and educational attainment predicted plans for institutional care. Findings suggest that long-term care decision making is likely idiosyncratic rather than the result of careful consideration of care options in light of impending long-term care needs.

Differences in Breast Self-Examination Techniques between Caucasian and African American Elderly Women

BACKGROUND

The efficacy of breast self-examination (BSE) is controversial, recommendations to women are mixed, and reported differences by race in BSE are contrary to what is expected. We attribute this, in part, to measurement error in studies assessing the effectiveness of BSE. We assess differences by race in self-reported BSE while controlling selected sociodemographic indicators, BSE training, embarrassment, and perceived competence.

METHODS

Data are from personal interviews with 1011 women ages 50 and older, with approximately equal numbers of African Americans and Caucasians reporting that they examine their own breasts.

RESULTS

African American women are more likely than Caucasians to report examining their breasts visually, whereas Caucasian women are more likely than African Americans to report tactile examination of breast tissue, consistent with recommended BSE procedure.

CONCLUSIONS

BSE measures must be multidimensional to detect differences by race to guide interventions promoting self-detection of breast lumps, early presentation, and mortality reduction.

Religious beliefs and breast cancer screening

BACKGROUND

The mechanisms underlying a reported tendency for women who hold strong religious beliefs to seek medical help at more advanced stages of breast cancer are unknown. This study investigates further the effect of religious beliefs with other variables on breast cancer screening and the intended presentation of a self-discovered breast lump.

METHODS

The study included 682 eastern North Carolina women aged 40 and over who were interviewed in their homes about religious and other beliefs about breast cancer, screening, and intended actions with a self-discovered breast lump.

RESULTS

Principal components factor analysis results suggested that a majority of women believe that God works through doctors to cure breast cancer. We labeled this dimension "religious intervention with treatment." A minority believed that medical treatment was unnecessary because only God could cure breast cancer. We labeled this dimension "religious intervention in place of treatment." The first dimension correlated with self-reported mammography but not clinical breast examination or women's intention to delay presentation of a self-discovered breast lump. The second dimension, significantly more common in African American women who were less educated and older, correlated strongly with the intention to delay presentation of a self-discovered breast lump.

CONCLUSIONS

Belief in "religious intervention in place of treatment" may help to explain why African American women delay presentation of palpable breast lumps, contributing to advanced-stage cancer diagnosis. We suggest that clinicians and clergy work together within the context of religious beliefs to enhance early detection and survival from breast cancer.

Impacting cultural attitudes in African-American women to decrease breast cancer mortality

BACKGROUND

Over the past decade breast cancer mortality has decreased 1% or 2% per year in white women, but not in African-American women. The resulting "mortality gap" is a serious national problem, and it must be a high priority to understand the reasons for it and develop solutions.

METHODS

The literature is reviewed to elucidate reasons for the mortality gap and the current status of possible solutions to the problem. In addition, new results of large population-based surveys in North Carolina are presented that may shed light on the problem.

RESULTS

The most important reason for the mortality gap is that African-American women tend to be diagnosed with more advanced stage breast cancer than white women. This is due both to lower utilization of screening mammography and to delayed presentation for women with palpable lumps. This is related both to socioeconomic factors that influence access to medical care and to cultural factors that tend to discourage women from seeking care early for breast problems.

CONCLUSIONS

Understanding the cultural beliefs that influence patient behavior will greatly aid physicians in caring for their African-American patients, and ultimately may help reduce the racial gap in breast cancer mortality.

Beliefs about and responses to childhood ear infections: a study of parents in eastern North Carolina

Middle ear infection, also known as otitis media (OM), is a major public health problem among American children. Although clinical and epidemiological aspects of OM have been intensely studied, cultural factors that may be contributing to the problem of OM have received less attention. This article presents findings from an ethnographic study exploring beliefs about OM and responses to the illness among parents from eastern North Carolina. In-depth interviews were conducted with a convenience sample of nine mothers in order to learn more about parents' explanatory models of OM, the source of their beliefs, and how they respond to the illness. A survey instrument based on their statements was then constructed and administered to a convenience sample of 79 parents. The survey consisted of belief statements about OM, as well as questions pertaining to sources of beliefs, the home management of the disease, and the effects of the illness on families. A cultural consensus analysis of responses to belief statements indicates that parents shared a common model of OM. Beliefs about risks, symptoms, and causes of OM were similar to the current biomedical model of the illness, but their divergent beliefs about the diagnosis, prognosis and treatment of OM could lead to unnecessary use of health care services. Clinicians, family, and friends were reported to be important sources of information about OM. Parents also reported using similar home management strategies and care seeking behaviors to minimize the impact of the illness on their children and families. While these findings need to be replicated in studies with larger, more representative samples, this study suggest that ethnographic approaches may provide new insights into the cultural dimension of the problem of OM.

Increasing use of mammography among older, rural African American women: results from a community trial

OBJECTIVES

A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program, a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older.

METHODS

A stratified random sample of 801 African American women completed baseline (1993-1994) and follow-up (1996-1997) surveys. The primary outcome was self-reported mammography use in the previous 2 years.

RESULTS

The intervention was associated with an overall 6 percentage point increase (95% confidence interval [CI] = -1, 14) in community-wide mammography use. Low-income women in intervention counties showed an 11 percentage point increase (95% CI = 2, 21) in use above that exhibited by low-income women in comparison counties. Adjustment for potentially confounding characteristics did not change the results.

CONCLUSIONS

A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income, rural populations.

Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators

PURPOSE

This study assessed the extent to which community-dwelling rural older adults mismanage their prescription medication regimens and predicted mismanagement of medications from selected socioeconomic, health status, and medication profile characteristics.

DESIGN AND METHODS

Personal interviews with 499 community-dwelling adults aged 66 and over taking at least one prescription medication and living in a rural region of the Southeast. With approximately equal numbers of African American and white men and women, the SUDAAN multiple logistic regression procedure was used to predict the mismanagement of prescription medications.

RESULTS

The mismanagement of prescribed medication regimens is relatively common among older adults. Those more likely than others to mismanage their regimens are African American, younger, in poorer mental health, with more acute care physician visits, and those who find payment for their medications to be problematic.

IMPLICATIONS

The implications of the findings for what is known about the self-modification of drug regimens, targeting prescription drug cost benefits or interventions, and the limitations of the study are discussed.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population.

METHODS

In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties.

RESULTS

Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income).

CONCLUSIONS

Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Negotiating cultural consensus in a breast cancer self-help group

This article describes a shared model of the breast cancer experience negotiated by the members of a spontaneously organized breast cancer self-help group in eastern North Carolina. In the course of sharing their personal experience narratives with one another, these women worked to negotiate points of agreement among the varying sources of knowledge and oftentimes conflicting belief systems they held about breast cancer. The synthetic model they created rejected many of the assumptions underlying the dominant biomedical view of cancer "survivorship," particularly its emphasis on the autonomous individual as decision maker and its attendant male-gendered sports and military imagery--assumptions that often implicitly structured the agendas and topics discussed in the formal, medically sanctioned support groups these women found unappealing. The implications for theories about the construction of shared cultural models and for continuing efforts to design support groups to meet the needs of a diverse patient population are explored.

Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer

CONTEXT

Breast cancer mortality is higher among African American women than among white women in the United States, but the reasons for the racial difference are not known.

OBJECTIVE

To evaluate the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis.

DESIGN

Case-control study of patients diagnosed as having breast cancer at the University Medical Center of Eastern Carolina from 1985 through 1992.

SETTING

The major health care facility for 2 rural counties in eastern North Carolina.

SUBJECTS

Five hundred forty of 743 patients with newly diagnosed breast cancer and 414 control women from the community matched by age, race, and area of residence.

MAIN OUTCOME MEASURES

Breast cancer stage at diagnosis.

RESULTS

Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV disease. The following demographic and socioeconomic factors were significant predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5); never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money (OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6). Univariate analysis also revealed a large number of cultural beliefs to be significant predictors. Examples include the following beliefs: air causes a cancer to spread (OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95% CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR, 1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer (OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables were included in a multivariate logistic regression model, the OR for late stage among African Americans decreased to 1.8 (95% CI, 1.1 -3.2) compared with 3.0 (95% CI, 1.9-4.7) for race alone. However, when the belief measures were included with the demographic and socioeconomic variables, the OR for late stage among African Americans decreased further to 1.2 (95% CI, 0.6-2.5).

CONCLUSIONS

Socioeconomic factors alone were not sufficient to explain the dramatic effect of race on breast cancer stage; however, socioeconomic variables in conjunction with cultural beliefs and attitudes could largely account for the observed effect.

Coming to terms with advanced breast cancer: black women's narratives from eastern North Carolina

This paper analyzes in-depth interviews with 26 black women who entered the medical system in rural North Carolina with advanced breast disease. In these narratives, women draw on multiple sources of knowledge in order to come to terms with the diagnosis of breast cancer--a biomedically-defined disease that they often refuse to acknowledge or accept. The analysis demonstrates how women relate the meaning of their individual episodes of illness to one or more of the following sources of knowledge: an indigenous model of health emphasizing balance in the blood, popular American notions about cancer, and particular biomedical conceptions about breast disease and its treatment. These narratives provide an important window into the processes involved when individuals attempt to adapt personal experience to pre-existing cultural models, modify such models in the light of new information, and confront conflicts in their own interpretations of the meaning of a single episode of illness.

Perceptions of older adults: differences by age and sex among children in a Costa Rican community

Responses from 120 Afro-Caribbean children living in a rural Costa Rican community are used to identify two subdimensions of an index designed to measure children's perceptions of older adults. Sketches of an adult male and female at three ages are used to infer differences in subdimensions in children's perceptions by age and sex. It was found that older females are perceived by the children as more authoritative and older adult males as more affective. Ethnographic techniques are used together with the survey results to elaborate upon the findings and discuss their implications for a general modernization thesis of intergenerational relationships.

Rootwork: description of an ethnomedical system in the American South

The traditional medicine of black Americans, often labeled "rootwork," has its origins in slave culture of the antebellum South. Its continued influence on the health behavior of black Americans is reported for rural areas of the South and for poor urban areas throughout the United States. The rootwork system combines a belief in the magical causation of illness with cures by sorcery and an empiric tradition stressing the natural causation of illness with cures by herbs and medicines. Adherents of rootwork are medically pluralistic and seek help from a variety of practitioners when faced with illness. Adherents enter the clinical setting for the treatment of natural illnesses and present symptoms in accordance with traditional beliefs about the blood and "folk" categories of disease. Adherents may also consult magical practitioners, known as root doctors, for treatment of a variety of psychosocial problems.