A comparison of African American and Latina social networks as indicators for culturally tailoring a breast and cervical cancer education intervention

Abstract

As similar cancer health disparities have been documented for African American (AA) women and Latinas, it would be important to determine whether comparable interventions could be used to increase screening among these 2 culturally different populations. This paper reports research findings comparing cultural dimensions of breast and cervical cancer as they impact Latino and AA social networks and explore the feasibility of creating outreach models that may serve both groups. An existing intervention that integrates the social roles and relationships of AA women, The Witness Project®, is used as a framework for tailoring an intervention for Latino communities. Findings and data from focus groups and key informant interviews were collected from more than 120 Latinos in Arkansas and New York City. These findings are analyzed using the Pen-3 Model, categorized, and compared with previous social role and network information from AA women as reflected in the Witness Project® intervention model. The findings from this study demonstrated variations between AA women and Latinas with regard to roles and gender relationships while demonstrating similarities with regard to spiritual beliefs and attitudes toward cancer. We applied our results to culturally tailor and develop a breast and cervical cancer intervention, Esperanza y Vida™ (Hope and Life), that incorporates Latino values and social relationships. This study demonstrates that a proven education and outreach model for AA women may provide a framework for creating a culturally appropriate intervention for Latinas. Further research is needed to study the efficacy of the new model. Cancer 2007. © 2006 American Cancer Society.

Similar breast and cervical cancer health disparities exist for African American (AA) women and Latinas. For the past 3 decades, breast cancer mortality rates have been higher among AA women across all age groups (AA 34.7, white 25.9, and Latina 16.7 per 100,000).1–4 Likewise, breast cancer is the most commonly diagnosed cancer among Latinas in the United States.5, 6 With the exception of AA women under the age of 50,7 the incidence rates of breast cancer are somewhat lower for Latinas and AA women than non-Hispanic white women, and this may be due to the fact that Latinas and AAs continue to have later stage cancers at diagnosis.3, 7–9 Despite an overall decrease in the rate of new cases of invasive cervical cancer across ethnic groups, rates for Latinas are almost twice as high as those for non-Hispanic white women (Latina 15.8, AA 11.1, and non-Hispanic white 8.7 per 100,000).2

Lower screening rates for both AA and Latina women are associated with increased morbidity and mortality rates.4, 9–11 Latinas are less likely to be screened and more likely to die of both cervical and breast cancer than non-Hispanic white women,12–16 and fewer AA women than white women report ever having a mammogram across all age groups.9 Although the mammography use rate for Latinas in various regions of the United States is increasing,17 Latina screening rates, especially for Mexican women, are still significantly lower than those for non-Hispanic white or AA women.8, 16

Access to health care services impacts screening levels, and problems with access can be even more severe for Latinas than for AA women.18 In addition to having common unfavorable access factors, such as not having a routine place of care, a regular provider, and/or transportation, Latinas are less likely to have health insurance (often related to lack of documentation/being in the United States illegally) and often have English language fluency issues and limited access to bilingual providers.18–23 According to a California study,21 Latinos had less access to many types of medical care than did non-Hispanic whites. Additional studies suggest that the primary reasons for under-utilization of health services are economic factors18 and, for the undocumented, the fear of being deported.24 These findings and other reviews suggest the need to focus culturally tailored intervention research within the Latino communities to optimize use of screening and care resources.22, 23, 25

Can there be mutually shared solutions in the form of behavioral interventions for addressing these disparities in AA and Latino populations, or are the cultural variations themselves too disparate? Farqhuar et al. caution that “…although the Latino and AA communities share some fundamental challenges related to health disparities, the ways in which these two cultures identify health concerns, create solutions, and think about social capital may vary considerably.”26(p600) These authors do not specify the cultural variations, but point out that few cross-cultural coalitions exist to identify solutions to shared problems. For those Latinos who are undocumented, there may be reduced political power compared with AAs,27 and the possibility of distrust and increasing competition between AA and Latino communities for scarce resources, as some have suggested, may be problematic.26, 28, 29 Previous formative research with AA women30, 31 and Latino populations in Arkansas28 has suggested that there may be sufficient similarities in shared challenges (e.g., low knowledge levels, distrust of the medical system), values (e.g., the importance of family, God, and spirituality), and communication preferences (e.g., use of narratives, trusting personal communication from local resources) to develop comparable interventions. After recognizing the cultural variations as well as commonalities, the researchers were intrigued by the idea that one intervention model successfully adopted for AA women, called the Witness Project&® (WP), might offer a framework for an intervention for Latinas.32, 33

The WP, developed in Arkansas and replicated in over 20 states, is a breast and cervical cancer intervention for AA women, with a focus on providing a culturally appropriate survivor as a messenger within a spiritual context to provide a credible message of empowerment.30, 32–34 Lay health advisors and AA breast or cervical cancer survivors operate as teams to provide inspirational education, empowerment messages, and screening resources through church and community groups, with the goal of increasing breast self examinations, clinical breast examinations, mammography, and Pap tests. Research results demonstrated that women who participated in WP programs had significant increases in mammography (P < .005) and breast self examination (BSE) behavior (P < .0001) compared with women who did not participate in WP programs.33 The WP intervention was shown to be effective in reaching AA women, many of whom were low-income, less-educated, and aged and who may share some beliefs and barriers to screening with Latinas.32, 25

The hypothesis that an intervention like the WP could serve as a model for reaching Latinas was supported by other studies of programs that have some of the same components as the WP. A church-based model of social influence was shown to improve cancer screening and be sustained for AA and Latina women,35 and another study demonstrated shared attributes of spirituality and religiosity in both minority women subpopulations.36 A program in South Carolina used comparable lay health advisors/promotoras in a shared program for rural AA and Latina women,37 while Hansen et al. created an intervention with comparable role models by having Latina survivors as promotoras to increase breast and cervical cancer screening.38

Examining the social networks of AA women in relationship to cancer and the WP and comparing them to the role social networks play for Latinas provides a foundation for identifying and accommodating cultural variations in the development of an intervention for Latinas. Table 1, derived from a combination of research findings,30, 31 categorizes some of the specific roles that AA women often carry within their social networks. This table shows the effects illness often have on women's lives and their daily roles, how cancer specifically impacts this dynamic, and how the WP intervention builds on the positive aspects of these experiences. For example, an AA woman's role as a spiritual director may be enhanced as those around her observe how she manages her illness. Illness, specifically cancer, may be perceived as divine punishment, a belief that sends a negative message and creates a negative experience for both the individual woman and those around her. In contrast, as a survivor she is likely to be a positive demonstration of how finding cancer early can be beneficial. The WP builds on this positive message by offering outreach activities for the women as a ‘ministry’ to ‘witness’ about their experiences and serve as role models for others—a natural experience for women who serve as spiritual directors for others within their social networks.

Table 1. Social Networks of African-American Women, Illness Effects, Cancer, and Witness Project Model Intervention Design

Women's roles/Relationships	Effects of illness on lives of women	Cancer	Witness project model
Matriarchal	Threats to or change in status	(−)Family links/guilt that she may be passing on a genetic trait for cancer	Focused on and about AA Women
		(+)Women survivors can be powerful influences on others
Sister-to-sister	May change relationships—losing contacts with other women	(−)No talk rule by women about cancer	Cancer survivors serving as role models
		(+)Natural messengers to others about early detection
Nurturer/Caretakers	Change in ability to care for others/work	(−)Doesn't take time to care for herself	Take time for yourself, you're worth it; Taking care of yourself is a good message to others
		(+)Opportunity for others to take care of her
Spiritual directors	Increased attention to an illness—if she is sick, it brings attention to the need for prayer, etc	(−)May be seen as punishment	“Witnessing” as part of faith experience; role of cancer to transform their life
		(+)Witness to positive behavior change and ability to survive	Natural place to hold programs and organize outreach
Resources for information	Source of stigma, fear, myths, misinformation or improved information	(−)Spread misinformation or negative experiences	Becoming a messenger and resource for others
		(+)Credible messengers for early detection

We report here on qualitative research conducted with Latinas in 2 diverse geographic regions. These findings are analyzed in light of how breast and cervical cancer issues specifically impact social networks and relationships of Latinos as compared with AA social relations from previous research.30, 31 These findings and analyses provide a foundation for the researchers to culturally tailor the WP intervention model for Latinas.

MATERIALS AND METHODS

Between August and January 2004, 13 focus group sessions consisting of 101 women were held in New York City (NY; 7 groups) and rural and urban sites in Arkansas (AR; 6 groups). The research design also included a series of 23 key informant interviews (6 males, 17 females) in NY (n = 12) and Little Rock and DeQueen, AR (n = 11).

The participants in the focus groups and key informant interviews were selected through theoretical sampling39 to include representation of women from the population of Puerto Rican, Dominican, and Mexican women in NY, and recently immigrated Mexican women in AR. This theoretical sampling, also referred to as grounded theory in the social sciences, uses the findings and analyses from each focus group to determine the sampling and selection of questions to be included in the next focus groups. This iterative approach has been shown to maximize the generation of appropriate findings applicable to the topic.40 Sampling, focus group locations, and focus group and interview questions were informed and guided by contributions from 2 Community Advisory Boards (CABs) established in AR and NY, comprising approximately 8–10 leaders in the Latino communities in each of these states.41 More details on sampling and methods for this study is published elsewhere.41

The focus group and interview participants were recruited through churches, community organizations, existing health programs, or word of mouth. This recruitment process provided adequate representation of women 40 and older, recently immigrated, living in rural and urban communities, with a mixture of religious backgrounds. The focus groups and interviews were conducted in Spanish and/or English (as requested by the participants) by bilingual/bicultural research assistants and were tape recorded with participant permission. Educational anatomy models and posters were provided as needed to illustrate anatomical areas of the body. Each participant was asked to complete a questionnaire to provide descriptive demographic information. The group sessions lasted from one and a half to 2 hours. The interviews generally lasted 1 hour. Written informed consent was obtained from participants in NY, whereas oral consent was obtained from participants in AR. All received compensation for their time in the form of either $15 gift certificates to local discount stores (AR) or $25 cash (NYC).

There were 4 objectives to be accomplished by the focus groups and interviews. The first objective was to elicit specific information from participants regarding issues and concerns of breast and cervical cancer screening, including information on knowledge, attitudes, barriers, and myths. Second, participants were questioned regarding their own or others' experiences with the medical system, health care issues, folk medicine, and beliefs about illness. Third, the participants were queried about the role of spirituality in their lives and their relations with local churches, local community organizations, and family. Finally, there were questions to determine the extent of ethnic variation and similarity among the 3 Hispanic/Latina groups.

Analysis

Following each focus group session, the taped responses were transcribed and summarized, including direct quotes, and the text was then reviewed by the research team. This team was well-positioned to perform this analysis because it included a medical anthropologist with over 20 years of qualitative interpretive expertise and 2 Latinas. Analyses were shared with both Latino Community Advisory Boards to help ‘validate’ the findings. The responses to the focus group questions were categorized into the various dimensions of beliefs, behaviors, and culture according to the PEN-3 health education model.42 Responses were classified as 1) Perceptions—knowledge, attitudes, values, or beliefs, as stated by participants, that facilitate or hinder personal motivation and decision making to maintain or change (cues to behavioral actions) breast or cervical cancer health beliefs or practices; 2) Enablers—societal, systematic, or structural influences (resources, institutional support, socioeconomic status) that may enhance or create barriers to maintain or change these beliefs and practices; or 3) Nurturers—supportive and/or discouraging influences that a person may receive from significant others.42, 41 Then responses were further categorized into Positive, Existential (exotic), or Negative dimensions in relation to culture and behavior.42

For specific comparison with AA social networks, those responses that impacted social networks, roles of women, women's relationships, and attitudes about cancer were compared with the framework for AA social networks demonstrated in Table 1. This framework provided a direct comparison of social network categories and information from AA and Latina women. Comparing how these roles and networks might function in relationship to breast and cervical cancer directed the researchers' efforts to tailor a potential educational intervention.

RESULTS

The majority of focus group participants (84 of 101, or 83%) were of Mexican (n = 41), Dominican Republican (n = 27), or Puerto Rican (n = 16) descent. The other 17% were from various countries in Central America, including Nicaragua, Honduras, and Guatemala. Thirteen groups of women were recruited through faith-based organizations (n = 3), community-based organizations (n = 8), and word of mouth (n = 2). The average age of the women was 46 years; the amount of time in the United States ranged from 4 months to 84 years. Over 70% of the focus group participants were Catholic; 32.3% were employed; 51.5% reported incomes under $10,000; and approximately half of the participants had no insurance.

The 23 key informant interviews included Latino and non-Hispanic health providers, church leaders, and outreach workers. Their average age was 45.2 years; 47.8% were born in the United States, 82.6% were employed; 39% were Spanish speaking; and over 50% had incomes greater than $30,000. The sampling process provided a diversity of participants with a range of experiences and perceptions to inform this research. The characteristics of these samples were considered well suited to address the cultural constructs of health, cancer attitudes and behaviors, religion, spirituality, social networks, and health care access. As a more detailed discussion of the heterogeneity of this sample and the PEN-3 thematic analysis of these findings are presented in another article,41 the results presented here focus on the factors impacting social network comparisons.

Five key themes, as expressed through participant responses, directly inform the comparison of social networks as they relate to cancer education intervention design. These themes are 1) fear/distrust, especially as it related to immigration status, possibility of divorce, disease, and death; 2) lack of control/communication, often related to transportation, money, and language; 3) lack of knowledge, especially lack of understanding of anatomy, problems with seeking health care, and lack of experience with the US medical systems; 4) gender relation, social roles, as they relate to power and status; and 5) religious and spiritual issues related to health. A representative sample of quotations (translated into English) from the participants reflecting these themes are listed below and ascribed to participants in either Arkansas (AR) or New York (NY).

Fear/Distrust

I have had bad experiences that made me distrust my physician and the hospitals. (NY)

Cancer causes pain, weight loss and you lose your self-esteem. (NY)

It can mean divorce or losing your families because for a Hispanic man, a woman without a breast is not a woman. (AR)

[regarding breast cancer]…machete—you will be left without your breasts. (AR)

There are doctors that speak to you, but they intimidate you so much that you react with fear without thinking. (AR)

I heard about a woman that went to a private physician in ____. When they asked her for a social [security number] or a drivers' license and she didn't have it, they called INS. No one would go to a physician for a while after that. (AR)

There were seldom responses about positive experiences with cancer, especially from the focus group participants. Non-Latina key informants made the few positive comments. Comments reflected distrust and apprehension with the medical system, although Latinas that had lived in the United States longer tended to have better experiences with doctors, clinics, and hospitals.

Lack of Control/Communication

The one time I needed to go to the gynecologist, I didn't go because my son would be the one that would take me and the nearest gynecologist is in a town an hour away. I decided not to go because I didn't want to make him lose time from work so he could take me. (AR)

We don't feel comfortable going to the physician or a clinic because they don't have an interpreter and we have to take someone that we know with us to translate. (AR)

I had to take a friend's daughter to translate for me and I didn't feel comfortable [with her]. (AR)

Even when they do have interpreters I don't feel comfortable because I didn't feel like there were enough interpreters there for everyone and they kept having to go back and forth and didn't really spend a lot of time with just one person. And sometimes that clinic would only have male interpreters and if they had a female problem they would not tell the physician because it was a male translating for them. (NY)

Latinas, especially the most recent immigrants, did not perceive themselves or the women in their community to be in positions to control their environment or to be empowered to seek care for themselves. Many were not working outside the home and may have been undocumented. Those women who did not speak English well were not only unable to communicate with providers, but also lost control of the ability to make appropriate health care decisions and the ability to control private information about themselves. Women often also felt powerless regarding their own health because their spouses made all the decisions relating to family and home.

Knowledge

We don't know much about cervical cancer. (AR)

It seems very scary because I've heard you may have to have a hysterectomy [no knowledge of alternative treatments]. (NY)

For a young woman who has not had children, cervical cancer means they will not be able to have children [assumption that cervical cancer precludes fertility]. (AR)

Newer immigrants had no knowledge or understanding of anatomy or options for treatments. This was especially true of Mexican immigrants in AR who could not respond to some of the questions and prompts about cervical cancer without the use of drawings, pictures, and a preliminary lesson about female anatomy. These responses demonstrated that any intervention needed to include a clear presentation of facts and information on anatomy, etiology, prevention, and screening for breast and cervical cancers, as this is not common information for men or women.

Gender Relations/Social Roles

My husband gives me a hard time and does not like having someone else look at my body. (NY)

In both cases [breast and cervical cancer] there is lack of support from their partners. (NY)

Our husbands don't understand anything about women's health and sometimes it gets to the point that they even get jealous or upset if the wife has a gynecologist appointment. And the first thing the husband will ask her is not how the physician's appointment went, but did a man or a woman physician see you? (AR)

Many men treat their wives like they are not worth anything. They tell their wives that he is the man of the house and she is not allowed to work and therefore she needs to stay home all day long and take care of the children… (AR)

Some women won't have a Pap smear because their husbands don't let them go. (AR)

I usually go to my mother with problems. If not her, I'd rather keep it to myself. (NY)

[When we have problems] …We usually ask each other because we feel like we really don't have anyone or anywhere to go. So we ask each other to see if someone else has the same problem and what they did about it. (AR)

We go to neighbors and friends [for help with problems]. (AR)

Many comments regarding the women's negative experiences and perceptions related to some male behaviors and the need for encouraging a nurturing role of men for women. Female participants from the focus groups and male and female key informants suggested and supported the concept that men needed to be included in any educational or screening intervention to get optimal participation by women. Responses also indicated that female family members and trusted female friends serve as sources of information as well as confidantes.

Spirituality and Religion

The church tends to justify disease by saying we are cleansing our sins. (NY)

If you get something, that was your destiny. (NY)

Sometimes when one has cancer, you think you have it because of the way you lived your life in the past. Maybe you did something and you are paying the consequences with cancer. It is a form of punishment. (NY)

Church promotes mental, physical and spiritual health. (NY)

If a member from our church is sick, someone goes to their home to pray and help with cleaning and cooking. Church members reach out to one another. (NY)

I know someone that was trying to pass out information on STDs and the church told him that he could not do that because that was promoting sex. (AR)

Here in Arkansas the church is always open and we can get any kind of help here, not just spiritual. (AR)

[If there is a problem] I go to the Lord and pray about the problem first. (AR)

The primacy of God and spirituality was described by most participants. However, the experiences with and the perceived role of specific churches or religions varied significantly. Indeed, many of the focus group members expressed high regard for the primacy of God but also felt that they did not need to necessarily attend church. Sometimes the church or an organized religious group was portrayed as a resource; other times participants were concerned that there were potential conflicts between church teachings and messages and practices that may be considered preventive health (e.g., ‘safe sex’) or that encouraged education about female anatomy and disease. Some women expressed concern that the church might withhold health information (e.g., information about STDs) from women.

Application of Findings as They Relate to Social Roles and Networks

To apply these research findings to cancer education intervention development, these 5 themes were further analyzed as to how they apply to a social network paradigm specific to the WP model. Table 2 categorizes the findings on Latinas' roles and relationships in light of the impact of illness, specifically, breast or cervical cancer, and how an intervention design may mediate these issues.

Table 2. Social Networks of Latinas, Illness Effects, Cancer, and Intervention Design

Women's roles/Relationships	Effects of illness on lives of women	Cancer	Intervention design
Patriarchy/Disempowered women	Spouses and men control transportation for health care	(−)Fear that cancer will cause her to lose male relationships	Needs to include both men and women
	Spouses and men may resist women seeking care (especially from male providers)	(−)Inability to obtain screening	Needs to empower women while encouraging men to assist women in obtaining screenings and care
	Health issues related to female anatomy are also sexual issues	(+)Women survivors can be powerful influences for men and women
		(+)Educating and providing roles for men to be positive influences regarding cancer screening may positively influence screening behaviors
Sister-to-sister	Other women in the family or close friends will have to take care of family members	(−)Very few Latinas in their social network have any knowledge about cancer or screening.	Cancer survivors serving as role models
		(+)Women are often the health care providers (eg, curanderas, promotoras), women seek care and advice from other women regarding illness	Need increased detailed information to share about anatomy and health issues
		(+)Natural messengers to others about early detection
Nurturer/Caretakers	Change in ability to care for others and ability to work	(−)Doesn't take time to care for herself; not empowered to ask for help	Taking care of the women in the family is good for all family members
		(+)Opportunity for others to take care of her; for the man to express positive machismo	Take time for yourself, you're worth it; Taking care of yourself is a good message to others
Spirituality	Increased need for prayer and spiritual focus of all family members for prayer and seeking strength from God	(−)May be seen as punishment; the church and others may perceive cancer related to sinful living	Personal faith example as part of spiritual experience; role of cancer to transform their life
		(+)Witness to importance of maintaining individual spiritual focus and belief that behavior change (screening, seeking health care) can improve the ability to survive	Demonstration that there is no sinfulness in having cancer
		(+)Churches may be sources for information and health programs	May organize health programs through churches
Resources for information	Women may be source of stigma, fear, myths, misinformation, or improved information	(−)Spread misinformation or negative experiences	Becoming a messenger and resource for others improves social capitol of community
		(+)Credible messengers for early detection

The patriarchal nature of Latino society clearly affects the entire social network and defines certain roles and relationships for women directly. For example, Latino men may be more likely to have access to drivers' licenses and cars (especially in AR), be more likely to speak English, control access to health care through money and perceptions of appropriate care, and may even influence behavior related to screening or having certain surgical treatments. These findings suggest that an intervention design may need to include men in the educational process and find creative ways to empower women without threatening men in the Latino community.

Latinas rely upon each other (sister-to-sister) for health information as well as to assist in taking care of family members (nurturers/caretakers). Therefore, they may be comfortable serving as natural helpers or promotoras. These findings also suggest that Latino men and women can become credible resources for health information to others in the community (resources for information). This conclusion is further supported by the value placed on social capital (e.g., relations and networks of influence within a group) and reliance within a community of Latinos for many types of social, economic, political, and psychological support.26

The findings on spirituality and religion suggest that as a factor within the Latino social network, churches may or may not be perceived as appropriate venues for health or cancer education programs. However, spirituality and faith of individuals is strongly reinforced, wherein prayer is a source of power and assistance during illness and the primacy of God is a strong belief within the Latino culture.

DISCUSSION

This study examined the relationship of social roles, networks, and cancer for 2 cultural subgroups within the United States to explore the feasibility of creating outreach models that may serve both groups. As reported, both minority groups have comparable disparities in cancer screening, morbidity, and mortality in relation to non-Hispanic white populations. The qualitative findings from this study, however, clearly demonstrated differences in the sociocultural fabrics of the groups that would result in major changes to an intervention model. One of the key cultural differences was the internal distribution of power as defined by the matriarchal social system of AAs as compared to the more patriarchal system of Latinos. These differences in the sources of power and authority favor the male in the Latino society. The continuum of male/female relationship dynamics encompasses individual partner relationships where men have more capacity for decisions, interactions with male health care providers who are expected to relate to the male partner rather than the female client, and religious and church dynamics that may also be controlled by the male priest and male congregants. These sociocultural differences can be expected to have a significant impact on the cultural tailoring of a cancer control intervention.

The findings from this study support the need to focus on Latino men as well as women and their extended families. The importance of Latino men as a continual thread of influence in women's lives was present in each focus group and interview and throughout each level of analysis, confirming findings of other studies.37 Many women expressed interest in including appropriate educational information about women's health issues directed to men. They wanted to improve men's understanding of the issues, remove the fears and misunderstandings about the nature of women's examinations, enlist the men's support in acquiring resources (transportation, paying for services) for these examinations, while allowing the men to feel that they are still in control. Therefore, increasing education while maintaining control by the men might be expected to increase support of early detection and prevention plans for ‘their women.’ This acknowledged thread of male influence and the desire to co-opt this male power and influence (machismo) for the betterment of women was a universal finding with all subgroups of Latinas. This construct was very different from the foundation and source of intervention impact for the AA women and the WP.

There were diverse perspectives about how religious or church settings might be involved in educational programs. Some urban Latinas in NY indicated a preference for programs outside of a traditional religious setting or church. They recognized that the Catholic Church, specifically, has had conflicts with health issues related to women, such as pregnancy, birth control, and abortion, and that some women's health concerns are too closely related to perceived sexuality to be comfortably incorporated within the walls of a church. Likewise, the women who resided in urban areas and who had lived longer in the United States were more likely to have other social and community resources and institutions (apartment buildings, libraries, schools, social organizations, etc.) available for promoting health, and sponsoring or accommodating programs. Earlier studies, however, have indicated that churches in urban areas are still quite successful at recruiting Latinas for health programs and screenings.35 Moreover, this study confirms the importance of honoring ‘spirituality’ regardless of the specific religious affiliations.36

The rural and more recently immigrated Latinas were more likely to rely primarily on their church or religious group for socialization, community resources, guidance, and family support.28 Therefore, Latinas in rural areas were more likely to expect, desire, and be comfortable with the idea of having women's health programs in their church buildings. These findings suggest a need to review the venues for Latina interventions compared with the original WP.25 Reported findings on individual spirituality and the primacy of God were very similar between the AA and Latina women, supporting the results of another study of AA and Latino men.⁴³ The spiritual messages and church-based constructs for the Latina intervention will need to be carefully examined in the future.

The WP component of survivorship and having survivors describe or ‘witness’ about their experiences and the importance of early detection and screening was supported by this study's findings. Even though the Catholic Church does not incorporate this type of Protestant-oriented personal witness experience within the church worship services itself, participants reported that other Latinas were credible and culturally appropriate messengers for this survivorship message within the sister-to-sister approach. Participants also indicated that survivors are able to mitigate the ‘cancer = death’ perceptions. In terms of messengers, however, the participants supported the concept of men and women serving as lay health advisors, as men would be more likely to feel more comfortable with men as leaders or co-leaders of any presentations.

There are many strengths of this study that impact its usefulness. This research included rich, detailed information from both Latino women and men who would be the recipients of educational programs and early detection resources. Another strength was the diversity in geography, country of origin, and length of residence in the United States represented by the Latino participants. As the methods used a specific theoretical sampling technique to gain adequate representation of the Latinas to be the focus for future educational interventions and used the grounded theory process to develop and determine the location and nature of focus groups, the researchers suggest that these are reliable and credible qualitative results.

Limitations of the research include the fact that the findings may not be directly generalizable to Latinas in other areas of the United States, such as California, La Frontera (border areas with Mexico), or areas with predominantly Central or South American Latino populations, without further inquiry, since these groups were not strongly represented in the sample population. Likewise, there are likely to be additional system, environmental, regional, and service access challenges for Latinas that need to be examined at a local level. Investigators working with Latino community-based research must allow for intergroup variation among this highly diverse population.

Although it is doubtful that any intervention program can be effectively translated directly into use for another ethnic or cultural subgroup with the same outcomes, our findings suggest that an evidence-based intervention developed to meet the culturally specific needs and barriers to screening for AA women may provide a shared framework from which to develop an effective intervention for Latinas, with the important caveat that significant tailoring is needed to correctly ‘fit’ the social fabric of the Latino culture. As the WP is characterized by the spirituality- and church-based motto, “In church, people witness to save souls. In the WP, they witness to save lives,” the new Latina intervention based on this model, called Esperanza y Vida™ (Hope and Life), focuses more on the social fabric concerns of the Latina family by stating, “Familias saludables empiezan con mujeres saludables [Healthy families begin with healthy women].” Future research is needed to test the effectiveness of this new intervention to draw attendance of Latino men and women to programs in various communities and to improve screening behaviors.

Acknowledgements

We thank the members of the Community Advisory Boards in New York City and Arkansas, and Dulce Zamora and Ruben Arana with the Hispanic Health Program in Little Rock for their continuing contributions to the development and research for Esperanza y Vida. We are also grateful for scholarly contributions to this report from audience responses to the podium presentation of these findings at the meeting of the American Cancer Society's conference on Exploring Models to Eliminate Cancer Disparities among African American and Latino Populations held in Atlanta, GA, on April 21–22, 2005.