OBJECTIVES:
Women from minority groups have been traditionally under served in mammography. The most common barriers facing this community are insufficient education concerning personal health care and little or no access to familiar, locally based heath care providers.
We are beginning to surmount some of these obstacles by providing government funded, neighborhood based, free breast screening and establishing community outreach programs to minority neighborhoods. But even when minority patients are able to gain access to conveniently located, low-cost mammography, language and/or cultural barriers make it difficult for them to receive full benefit from the procedure. It is of great urgency that the experiences and values of minority women be better understood so we can provide them with full use of prevention and early detection services.
BEFORE THE SCREENING Our medical care system is modeled on middle class values and middle class education levels. Many low-income minority patients are completely unfamiliar with mammography. Our patient needs careful explanation and education about screening from someone who understands her language AND her socio-cultural background.
Minority women tend to wait for a crisis before seeking health care. The concept of preventive action is foreign to them. One way of emphasizing the need for early detection and prevention in these communities is to stress the importance of their lives on the lives of their children and grandchildren. Point out that keeping their health by early detection and intervention will keep them with their families longer. It will help keep them productive and active in the community for many happy years.
Many minority women have no idea that they are at risk from breast cancer. The perception is that breast cancer is a ‘white woman’s’ disease. They do not recognize themselves in the health promotions. The concept of increased risk to women of color must be reinforced before the screening begins so that our patient will relate to what is happening to her.
In many minority communities there are important taboos concerning anyone other than a spouse touching a woman’s breast. This patient must be carefully informed before the procedure that the mammographer will be touching and maneuvering her breasts. She must know that she will have to disrobe. It is important to tell her why all this is to take place. Always politely ask permission before any touching or positioning of the breast begins.
Fear of pain during mammography is widespread among minority women. They have extraordinary concerns about this. Even though, statistically, minority patients related less pain during mammography than their Caucasian counterparts. Therefore, even if the fear seems unfounded, it is important to take extra time and precautions when explaining the amount of pressure and the importance of breast compression to women from minority communities.
DURING THE SCREENING Self-introduction and discourse with minority women must be handled discretely. When calling a minority patient her given name should never be used without the patient’s permission. Introduce yourself formally, using your first name, last name and title. Always use a formal greeting such as ‘Miss’, “Mrs.” or ‘Ms.’ and never resort to slang expressions such as ‘sweetie’, ‘dearie' or ‘sweetheart’. Many ethnic groups interpret this behavior as a racial or cultural slur. When greeting your patient always start with some polite introductory inquiry into the weather, the health of her family or children. Make any request to disrobe quiet polite and discrete. A gentle “Would you mind removing your blouse and bra for a few moments?” is considered respectful.
It is a common belief among minority groups that the use of any x-ray equipment will cause cancer. It is also widely held that pressing or excessive manipulation of the breast will cause ill health of various sorts including cancer. She must be assured that the mammogram will not cause any breast problems and that the mammographer will make every effort to be quick, efficient and sensitive.
The technologist must be prepared to see and accept cultural practices different from her own. Tips of acupuncture needles, circular suction cup marks from ‘steam cups”, freely injected silicon, tattooing, ritual scarring or tiger balm plasters are all common practice within certain communities. React to these customs with respect and treat your patient with dignity.
Women of various ethnic backgrounds may be hypersensitive about the size or shape of their breast tissue. It doesn’t matter whether your patient thinks she is too big or too small. It doesn’t matter whether she feels she is too tall, too short, too fat, too thin, too simple or too sick. We must treat EVERY patient as if she is the easiest client we have ever had. Take all the responsibility for doing the test. Never suggest that the patient is making it difficult. Just keep up a continuous stream of confidence boosting conversation. Speak softly, pleasantly and congenially; your attitude will travel through your voice.
Among the refugee community we may find a serious barrier to breast examination that we thank heavens, do not have to deal with often. Many women from refugee backgrounds have suffered rape, humiliation, abuse and torture. These women have braved great anxiety just to get to your facility they deserve all the respect and quiet dignity we can muster. Treat these patients gently; do not rush them through. Try to give them as much time and explanation as they need to get used to the idea of the test. Don’t push them beyond their tolerance. Have a list of counselors and help groups available but do not force information on them. Allow them to back out of the examination and try again later if necessary. Be alert to all the body language, don’t force eye contact, be receptive and always use appropriate family and friends for support if available.
Finally, many ethnic societies have a pathological fear of the word ‘CANCER’. In some cases the word itself is so disruptive that it inhibits the entire mammogram. Rather than compromise the whole breast imaging session, I suggest using ‘breast health’, ‘preventative testing’ or ‘early detection of problems’. In most situations, open and honest dialogue about cancer, its detection and prevention is the best way. However, if the mere word is going to drive your patient out of the department in panic, use a milder alternative.
AFTER THE SCREENING Because so many minority women have such a limited knowledge of mammography, there may be a distorted perception of what happens after a screening mammogram. These women may think that the mammographer will come and tell immediately if she has cancer or not. If nothing is said she may misinterpret that to mean the test was negative, or worse, positive and run in frenzy to her physician. It is important to have a chat with this type of patient before she leaves the department and make sure she is comfortable with what happened to her and what will happen next.
Ideally, after the mammogram, there should be a meeting with the mammographer, the interpreter, the patient and her family to explain the facility’s physician reporting system and follow-up procedures. She should understand when and how her next appointment should be made and whom she can contact for information or further explanation.
CONCLUSION:
Every woman deserves individual attention, an appreciation of past experience, respect for her distinct belief systems and clearly conveyed instructions and explanations. Women from culturally diverse communities present us with a challenge in this area. With a little time, sensitivity and armed with the knowledge we need to deal with these patients we can make their medical experience valuable and pleasant.
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