There are limited data on how subjective and cultural norms (e.g., perceived discrimination) affect the “art of care” (e.g., patient-provider relationships) and how the art of care may impact mammography adherence among Latina immigrants. We found that Latina immigrants reporting less discrimination and higher trust in providers were more satisfied with their health-care relationships. In turn, Latinas with higher satisfaction in their health-care relationships had higher rates of mammography adherence. Overall, the rates of adherence to recent screening in this low income, immigrant population were high.
Latinas in the US underutilize mammography,2,13,18,60,61
and foreign-born Latinas have even lower usage rates.14,18,62–63
However, the rate at which Latinas in our study underwent recent mammography (73%) was higher than that reported in a national study of Latinas (59%)63–64
and much higher than rates in other studies of Latina immigrants (39–47%).13
Our results may partially reflect the fact that most of the women had access to health care and/or health information and that the region includes several low-cost screening services. However, access factors were less significant in our study after considering satisfaction and other measures of the “art of care.”
Our results confirm other studies of non-Latina groups that show that factors related to the art of care in patient-provider relationships influence the use of preventive services,20,37,54,65–67
and that it is particularly important to Latinas.45,48,55,68
For example, in a qualitative study by Moy and colleagues, trust and the quality of the patient-physician relationship determined whether Latinas followed their physicians’ mammography recommendation.69
Most of the women in our study reported mid to high satisfaction with their health-care relationships, with 43% reporting very high satisfaction. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships. Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence, controlling for other factors.
Though communication has been cited as important in Latinas’ decisions about mammography screening and cancer treatment,55,66,69
studies have noted that Latinos may experience communication problems because of limited language concordance with their health-care providers.68,70–71
However, in our study, most women reported good to excellent communication with providers. This result may be due to the fact that most Latinas in our study received care from clinics that predominately serve Latinos and have bilingual administrative and medical staff.66,70
Thus, these women may have been better able to effectively communicate with their providers than Latinas receiving care from non-Spanish-speaking providers in other studies.
Foreign-born Latinos experience more difficulty obtaining culturally competent care38,41,72–73
and are more likely to report discrimination by health-care providers than are US-born Latinos.42
Approximately 41% of the sample reported that they experienced health-care discrimination. Thus, health-care disparities regarding preventive services (i.e., mammography use) may be due in part to distinctive discrimination experiences of minorities.18,20,42
Latinas’ perception of discrimination or bias in health care has been cited as a barrier to mammography use,74
and Latina breast cancer survivors reported perceptions of bias within the US health-care system because of language issues and a lack of respect for their culture.38,75
Beyond language concordance, Latinas have emphasized the value of having a Latino provider for cultural-concordance.69
We did not assess cultural, racial, or gender concordance between patients; this will be important to examine in future research in this population.
Important contributions of this study include the focus on an understudied population, use of bilingual cancer control staff, adaptation of a theoretical model for use with an underserved population, and very high response rates. We also provided information regarding the reliability of several scales not previously validated in studies of Latinas. Given that few studies have documented mammography patterns among Latinas from Central and South America, this study provides useful information to address issues in this growing population.
This study also has several limitations. First, mammography adherence was based on self-reports, often resulting in overestimates.76
However, previous studies comparing assessment measures concluded that self-reporting of mammography use is highly consistent with actual mammography use as recorded in medical charts or insurance claims, even in low income groups.77
Additionally, participants had access to a Latino health network with primarily bilingual staff, Latino providers, and/or Latino health information sources, creating a unique population subgroup. Mammography use may be different among Latinas without access to such clinics or health information sources. Thus, our study likely underestimates the needs of Latinas for mammography programs.
Thirdly, with the cross-sectional design, we were unable to determine the cause and effect between satisfaction with health-care relationships and adherence to mammography. Yet, our results suggest that satisfaction with health-care relationships is likely a mediator between perceived discrimination and mammography adherence. Future clinical research may examine this mediation effect to validate our findings. Fourth, we dichotomized the satisfaction variable rather than using a continuous score since a high proportion of our participants reported that they were satisfied in their relationships. The skewed distribution of the scale may have been attributed to social desirability (e.g., Latinos’ high respect for their providers). This may also reflect that some women (e.g., foreign-born and those with limited education) find Likert formatted scales difficult to understand.78
Dichotomizing this variable is likely to reduce statistical power. However, the association of satisfaction as a dichotomous variable and mammography adherence was very robust, suggesting that the true relationship may be even stronger than captured using a categorical definition.
Finally, subjective norms and attitudes pertaining to health-care access do not exclusively consist of experiences of discrimination or perceived racism, and may also include a broader range of cultural factors. Limited scales exist for assessing cultural factors related to mammography adherence in Latinas, and these may not reflect values such as familisma
(respect for the family), collectivism (vs. individualism), fatalism, spirituality, and respect for authority. Selected cultural domains have demonstrated importance among Latinas seeking preventive care,79–81
so an expanded capacity to measure cultural constructs would be an important future research priority. Other factors such as patient knowledge of breast cancer prevention and family history may also impact mammography adherence and will be important to assess in future surveys with Latinas.82–83
Overall, we found that Latina immigrants with higher satisfaction in their patient-provider relationships were more likely to adhere to mammography recommendations. Patient-provider relationships are complex and are likely to vary based on several factors (e.g., availability of providers, place of care, etc.). Thus, identifying strategies to strengthen these relationships for Latinas will be an important area for future work.