Cultural Barriers to Early Breast Cancer Detection Among African Immigrants in California Yewoubdar Beyene, PhD, UCSF

Background: African Immigrants in the US Immigrants from the continent of Africa are the most recent immigrant population in the US and steadily growing. Data from the 2000 Census shows a surge in African migration to the United States over the past twenty years (229%). The largest groups are from Nigeria (18.4%), followed by Ethiopia (14.3%), and Egypt (12.5%). Currently, over three million African immigrants are estimated to live in the U.S, more than 60% of whom are between years old. Like many other immigrants, African immigrants tend to settle in urban areas and the majority live in California and on the East Coast.

Breast Cancer in Africa Breast cancer is the second most common malignancy of women in the region. Women diagnosed with breast cancer in African countries seem to be a decade younger than their counterparts in the West. The disease is most often advanced to stage III an IV at the time of diagnosis.

Lack of Health Data on African immigrants in the US Lack of discrete population data for African immigrant populations. - Data on blacks include both foreign-born and US- born. - On the few occasions when foreign-born data exists on black populations, there is usually no distinction among cultures. The health of African immigrants differs in many ways from the health of U.S. born blacks with a long generational, social and cultural history of living in the US. Area of dissimilarity concerns: - cultural beliefs - practices toward health.

Understanding health risks, managing illness, and utilization of health services are more strongly influenced by cultural beliefs and practices than by race. Immigrants bring their specific cultural heritage to the host country with dramatically different beliefs, values, and customs about health and illness, often contrasting with those of their adoptive country. Consequently, many immigrants are impervious to public health education about diseases that appear in American media.

Beliefs and Risk of Breast Cancer among African Immigrants University of California, BCRP 5PB-0027 Objectives: To identify culturally specific factors that influence African immigrant women’s: -understanding of breast cancer symptom presentations - perceived risks - barriers to early detection - access to knowledge of early detection - acceptance of breast cancer screening guidelines

Study Design Focus group interviews with 20 key informants. In-depth interviews with 100 African immigrant women, age ranged from The participants for this study were recruited from a convenience sample of African immigrants from Nigeria, Ghana, Sierra Leone, Congo, Ivory Coast, Cameroon, Burundi, Ethiopia, Eritrea, Kenya and Uganda.

Findings Barriers to early detection screening: Cultural Beliefs Lack of knowledge and Invisibility Lack of Access to Health Care

BARRIERS TO EARY DETECTION SCREENING CULTURAL BELIEFS ● Fear of dying -cancer is a death sentence ● Fear of finding cancer  Modesty - Cultural taboo of self breast examination  Stigma - Disclosure would jeopardize social standing and marriage for the family members.  Mastectomy - disfigurement and physical disability  Reincarnation – a need to keep the body intact LACK OF KNOWLEDGE  Lack of knowledge about treatment options  Invisibility-Lack of perceived risk  Misinterpretation of media health information LACK OF ACCESS TO HEALTH CARE ●Lack of health insurance ●Lack of culturally tailored health forum

Cultural Beliefs Not wanting to know if one has cancer Delay in seeking medical advice unless sick (No pain, no symptom and no need to see a doctor) Faith- Everyone dies of something why find out early; If you talk about an illness and you worry about it you are bound to get it

Stigma- belief that cancer is hereditary: –Disclosure of cancer diagnosis would jeopardize social standing and marriage possibilities. –Fear of mastectomy because of strong cultural stigma of disfigurement and physical disability. –Modesty about touching ones breast, undressing in front of others.

Lack of Knowledge and Invisibility Lack of representation It is not about me Lack of perceived risk (belief that breast cancer is an American disease) Misinterpretation of media breast cancer information: - information on family history and risk of breast cancer is misaligned to validate the cultural beliefs that breast cancer is inherited and therefore, reinforces stigma.

Lack of Access to Health Care Lack of health insurance 73% of the women interviewed never had mammography. 80% did not have health insurance and use emergency rooms and health clinics. They don’t want mammography because they don’t have insurance. Even if the mammography is free the uninsured African immigrant women feel that they don’t have the money to follow through.

Lack of culturally tailored health forum Unlike other ethnic groups, African immigrant communities in the US do not have any existing social structures targeted specifically to their needs in the area of health promotion and disease prevention. Services provided to other ethnic minorities are not accessible to immigrants from sub-Saharan Africa because of : *social *cultural *linguistic differences

Remarks African immigrant women in this study were found to hold health beliefs regarding susceptibility to cancer that were congruent with their country of origin rather than with their country of residence. Lack of access to medical care compounded by cultural beliefs and patterns of health care seeking behaviors, such as delay in seeking medical advice unless sick, not sharing or discussing health problems with others and communication problems with health care personnel, are barriers to breast cancer early detection efforts among immigrant population. Moreover, the lack of a reliable census of African immigrant populations in the US is a particular problem in addressing health risks in these communities. The statistical aggregation of African immigrants with native-born African Americans causes serious setbacks in disease prevention efforts in these immigrant communities.