Concept Mapping with South Asian Immigrant Women: Barriers to Mammography and Solutions

Abstract

Despite benefits of screening mammography, many South Asian (SA) immigrant women in Canada remain under screened. We aimed to elicit their experiences and beliefs about barriers to mammography and possible solutions. SA immigrant women aged 50 years or over were eligible if they never had a mammogram or had one more than 3 years ago. We employed the participatory mixed-method approach of Concept Mapping. Sixty women participated with a mean age of 58 years. Participants brainstormed 150 items which were consolidated into 67 items. After sorting and rating, cluster analysis revealed eight clusters of barriers on knowledge, fear, language and transportation, access to mammogram center, access to doctor, beliefs and practices, self-care, and family dependence. Participants discussed possible solutions, and emphasized out-reach models to address knowledge gaps and issues of language and transportation. One example was a community-based shuttle bus to screening centres, hosted by trained co-ethnic workers. The results are discussed to enhance the socio-cultural sensitivity of breast screening programs.

Appendix: Description of Cluster Content

The cluster Lack of Knowledge (10 items) had statements on: knowledge about breast cancer, risk factors, screening methods, and intervals; the process to obtain a mammogram appointment; benefits and side effects of mammograms; and details of the procedure. Other statements were about having no screening advice from providers in the countries of origin and limited access to translated information in Canada.

The cluster Fears of Cancer (10 items) included participants’ worries about the disease (e.g., poor prognosis, essential death, cancer recurrence), mammogram experience (e.g., pain, cancer diagnosis), outcomes of cancer diagnosis (e.g., psychological stress, access to counsellors, social isolation), and consequences of treatment (e.g., post-surgical spread, harm to physical beauty).

The cluster Language and Transportation (5 items) reflected women’s difficulties to travel independently to the mammogram centre, for reasons which included not knowing how to drive, complexity of public transit system, language difficulties and financial dependence on family precluding taxis as a mean to commute.

The cluster of Self-care (6 items) comprised of statements about women’s tendency to minimize one’s health care due to perceived competing demands which were either practical in nature (e.g., work) or cultural norms (e.g., modesty, preference for quality of life over quantity, self sacrifice).

The cluster Popular Beliefs and Practices (7 items) had statements about risk misperception (e.g., low susceptibility to breast cancer), preference for alternative care and limited understanding of preventive health care. The cluster with largest number of statements was Access to Doctor: preferences and ‘systems’ (15 items). Some of the statements in this cluster were participants’ socio-culturally based preferences (e.g., wish to have a female physician or visiting a doctor only when sick) and others were system-level pressures on providers or their communication skills (e.g., waiting time, short visits, ability to listen and explain). The cluster on Ease to Access Mammogram Centres (4 items) was on the distance and timings of centres and interpretation services.

In the cluster Dependence on Family (10 items), participant-generated statements primarily showing their concerns about giving “trouble” to their children by asking them to accompany for visits to mammogram centres. They felt this could compromise children’s work or add financial pressure on their children who were themselves immigrants and had employment insecurity and limited income. Other statements reflect worries about familial sanction to seek health care (e.g., husband’s permission, social restriction by children) or generational gap (e.g., risk of losing respect for elders or transfer to nursing home).