For the past seven years, a multidisciplinary team of UCSF researchers has attempted to understand why women choose to have or forego regular mammograms — a simple and effective tool for detecting breast cancer — and what role culture plays in that decision process.
The team, led by health disparities expert Rena Pasick, DrPH, is charting new territory by using anthropology, psychology and behavioral science to evaluate the appropriateness of longstanding elements of behavioral theory, and to examine the connections between social context and the use of mammography. “A certain set of theories has always been applied to explain mammogram use and to inform our efforts to promote regular mammography,” said Pasick, a professor of medicine and associate director of Community Education and Outreach at the UCSF Helen Diller Family Comprehensive Cancer Center. “But these theories were tested and developed with mainstream middle-class white women, and a lot of public health specialists have been questioning whether or not they are universally appropriate,” she said. To try to answer that question, Pasick and her colleagues chose to focus on Latina and Filipina women who were participating in a concurrent intervention trial of 1,463 women from five different ethnic groups. That larger study — also led by Pasick and funded by the National Cancer Institute (NCI) — was investigating whether tailored interventions would lead to an increased use of mammography and Pap smears, two tests that can detect cancer in its early stages. In the theory study, titled “Behavioral Constructs and Culture for Cancer Screening,” Pasick and her team conducted in-depth interviews about mammogram use with scholars, community gatekeepers, lay women and mother-daughter pairs of Latina or Filipina descent. “One of our key findings had to do with the behavioral theory component known as ‘intention,’” Pasick said. “We found that something as seemingly straightforward as ‘intention’ can have many different meanings other than ‘Yes, I plan to,’ and that people within a common group understand implicitly that ‘yes’ may also mean ‘no.’” For example, some women who expressed the intention to get a mammogram did not in fact plan on getting one, Pasick said. “It wasn’t that they were lying,” she said. “They were giving an appropriately respectful answer.” “We also found women who didn’t express a conscious intention to get a mammogram, but would get one because someone important to them wanted them to, such as a family member, doctor or health worker,” Pasick said. “What was important to those women was maintaining relationships and preserving the trust of those individuals.” For these women, the concept of intention was irrelevant because in many cases, their health choices were based on social and cultural processes that operate on a subconscious level, Pasick said. Therefore, the standard health behavior survey was insufficient for this group. Pasick's research team included UCSF anthropologists Nancy Burke, PhD, Galen Joseph, PhD, and Judith Barker, PhD; psychologist Regina Otero-Sabogal, PhD; and biostatician Susan Stewart, PhD. The researchers’ findings will be explored in a supplemental issue of the journal Health Education & Behavior in October. The issue will focus on “Behavioral Theory for a Diverse Society,” a theme Pasick said has received insufficient attention up to now. “I’ve worked in very diverse communities over the past 20 years and just couldn’t find research tools that adequately explained the behavior I was seeing,” Pasick said. “Anthropology and the social sciences opened up entire new ways of understanding, and I’ve been working ever since to bring in these perspectives to our research on cancer disparities.” Pasick said she hoped that “mixed methods” studies like hers would help pave the way toward a broader understanding of the role of social context and culture in human behavior. She is also working with colleagues to develop a postdoctoral training program at the UCSF cancer center to increase the number of researchers skilled in the use of both qualitative and quantitative methods. “I see that as key: increasing the number of researchers who are cross-trained and who understand the importance of teaming up across disciplines,” Pasick said. “That approach doesn’t take away from a quantitative study; in fact, it makes the study much more relevant to the real world.”