BBA 3210, Business Law 1 Course Learning Outcomes for.docx

BBA 3210, Business Law 1
Course Learning Outcomes for Unit II
Upon completion of this unit, students should be able to:
4. Demonstrate research skills using all modalities available for
legal issues.
4.1 Describe what administrative law is and where it is derived.
4.2 Differentiate between the two principal varieties of agency
rule making.
4.3 Classify the limitations placed on agency powers.
4.4 Describe law and its sources.
4.5 Identify the key elements of the judicial process, including
the parties involved and the places
where disputes are heard.
4.6 Differentiate the various forms of jurisdiction.
8. Analyze business ethics in legal matters.
8.1 Recognize the importance of ethics to business management.
8.2 Discuss ethical scenarios using the WH framework.
9. Explain the need for promoting business social responsibility.

Course/Unit Learning
Outcomes
Learning Activity
4.1, 4.2, 4.3, 4.4, 4.5, 4.6
Unit Lesson
Chapter 4, pp. 59–75
Unit I and II Assessment
8.1, 8.2
Unit Lesson
Article: “Ford Pinto: A Pre Law Case-Study in Product
Liability”
Unit II Assignment
9
Unit Lesson
Unit II Assignment
Required Unit Resources
Chapter 2: Business Ethics and Social Responsibility, pp. 13–24
Chapter 4: Administrative Law, pp. 59–75
In order to access the following resource, click the link below.
The reading below is helpful in expanding your knowledge

when completing the Unit II Assignment. This
article briefly goes over the Ford Pinto case and the impact it
had on Ford and the automobile manufacturing
industry.
Ford Pinto: A pre law case-study in product liability [Blog
post]. (2013, January 11). Retrieved from
http://www.regisuniversity.org/ford-pinto-a-pre-law-case-study-
in-product-liability/
UNIT II STUDY GUIDE
Administrative Law, Business
Ethics, and Social Responsibility
http://www.regisuniversity.org/ford-pinto-a-pre-law-case-study-
in-product-liability/
UNIT x STUDY GUIDE
Title
Unit Lesson
Administrative Law
Introduction: This unit goes beyond the various sources of law

covered in Unit I, including constitutions, laws
passed by legislatures, and laws that administrative agencies
pass. Understanding administrative law
requires knowledge of the creation of administrative agencies,
their primary function, and their everyday
application. All are very important to a business manager.
In brief, administrative law involves the substantive and
procedural rules created by administrative agencies—
entities created by the legislative branch—to carry out specific
duties. These agencies have hearings (agency
“trials”) in which an administrative law judge (ALJ) presides
over the hearing.
An example of the importance of administrative law is the case
mentioned in Chapter 4 which starts on
page 59. A group of private organizations petitioned the
Environmental Protection Agency (EPA) to require
that it regulate carbon dioxide from automobile emissions. After
hearings and comments from the public, the
EPA refused to regulate, saying they did not have the legal
authority to do so. The matter was appealed and
eventually went to the U.S. Supreme Court. The Bush White
House filed an amicus curie brief, arguing that
the EPA was attempting to force the automobile industry to
reduce emissions. The Alliance of Automobile
Manufacturers came to the EPA’s defense, arguing that the EPA
as well as the states had no authority to
regulate automobile emissions.
In a 5-4 decision, the U.S. Supreme Court disagreed, holding
that the Clean Air Act authorizes the EPA to
regulate greenhouse gas emissions from new motor vehicles in
the event that the EPA forms a “judgment”
that such admissions contribute to climate change. Moreover,
the Court held that the Clean Air Act’s definition

of air pollutant includes carbon dioxide. As a result of the
Court’s decision, many are now calling for national
standards on emissions from automobiles (Massachusetts v.
EPA, 2007).
Administrative Agencies: Agencies are created by Congress to
do work that is too specific, burdensome, or
outside the expertise of legislative bodies. Enabling legislation
specifies the name, functions, and specific
powers of the administrative agency. Congress approves passing
of this legislation, resulting in a statute that
specifies the name, functions, and specific powers of the
administrative agency, and the agency is
empowered to act.
Agencies have three processes to carry out their mandates—rule
making (procedural, interpretive, and
legislative), the executive power to investigate possible
violations of rules or statutes, and adjudication. The
EPA case above is an example of the EPA’s interpretation of its
own administrative responsibility.
The Administrative Procedure Act (APA) passed by Congress is
a major limitation on how agencies are run.
Prior to this, agencies had the power to decide how they carried
out rule making, investigations, and
adjudications. Agencies could decide on their own how to make
rules, conduct investigations, and hold
hearings and trials. The APA established specific guidelines on
the formation of rules.
Following the formal guidelines of the APA, there are two
common types of rules—informal and formal—that
agencies can generate. The rules are published in the Federal
Register. Agencies primarily use informal rule
making. The process of formal rule making is illustrated in

Alexis Perez v. John Ashcroft (2002). In this case,
the court ruled that all substantive rules (i.e., rules that create
law) must be implemented through formal rule-
making procedures established by the APA.
Agencies have broad and expansive powers that are kept in
check by political, statutory, judicial, and
informational limitations. Judicial limitations are arguably the
biggest constraint on agency power. An
individual or business that believes itself harmed by an
administrative rule may challenge that rule in federal
court after all administrative procedures are exhausted
(Kubasek, Browne, Herron, Dhooge, & Barkacs,
2016). Specifically, the petitioner must do all that is possible
within the administrative agency before taking a
matter to federal court.
In Massachusetts v. EPA (2007), the EPA had resisted
regulating greenhouse gases, arguing that carbon
dioxide and similar gases are not pollutants under the Clean Air
Act, and, therefore, the agency had no
UNIT x STUDY GUIDE
Title
regulatory power over them. Ultimately, the Supreme Court
decided otherwise and determined the EPA has
authority to regulate greenhouse gases as air pollutants under

the Clean Air Act.
The informational limitations on agencies are defined by the
Freedom of Information Act (FOIA), the
Government in the Sunshine Act, and the Privacy Act of 1974.
These acts serve to provide transparency in
government activities, including agencies. Electronic Privacy
Information Center v. National Security
Administration (2011) determined limits on FOIA requests.
There are over 100 federal agencies and countless state
agencies. Each state has its own analog of the EPA.
The federal EPA delegates authority to each of the state
environmental protection agencies for enforcing
environmental protection laws. If the state agency fails to
enforce these laws using their delegated authority,
the federal EPA will enforce them.
Business Ethics and Social Responsibility
Earl Warren (March 19, 1891–July 9, 1974), American jurist
and politician, served as the 30th Governor of
California and later served as the 14th Chief Justice of the
United States (1953–1969).
The concepts of business law must be illustrated with real-life
examples in order to be meaningful to citizens
and institutions. It is safe to speculate that the leadership from
all of those institutions all passed a business
law class at some point in their career development. One of the
lessons to learn is that it is not enough to
simply memorize the law or court case decisions. It is most
important to understand the reason for the law
and the practical application of that reasoning.
Ethics addresses the issues of right and wrong and the

implications for conduct, including the actions of
individuals and businesses. Chief Justice Warren’s quote
implies a strong connection between law and ethics.
The legality of a decision is the minimum standard that must be
met. The law both affects and is affected by
evolving ethical patterns.
Ethics is the study and practice of decisions about what is good
or right. Business ethics is the use of ethics
and ethical principles to understand and solve potential ethical
threats in a business environment.
Every community has its own values—positive abstractions that
capture the sense of what is good or
desirable. The community has the right to these expectations in
regard to business actions within their
community. These underlie social responsibility. Understanding
the concept of values is necessary to use the
who-how (WH) framework for ethical business decisions.
Kubasec et al. (2016) described that the WH framework
provides practical steps for responding to an ethical
dilemma. The W refers to who (i.e., the stakeholders) would be
affected. This can be challenging as the
interests of one group of stakeholders (e.g., shareholders) may
conflict with the interests of others (e.g.,
customers or future generations). The H refers to how the
ethical decisions are made. Often, traditional
guidelines, such as the Golden Rule (“Do unto others as you
would have done to you"), are used. Guidance is
also provided by considering the test of public disclosure—the
consequences of the decision becoming
public. A third test is the universalization test—if action X is
taken, would the world be a better place if others
did the same?

References
Alexis Perez v. John Ashcroft, 236 F. Supp. 2d 899 (2002).
Electronic Privacy Information Center v. National Security
Administration, 795 F. Supp. 2d 85 (2011).
Kubasek, N., Browne, M. N., Herron, D. J., Dhooge, L. J., &
Barkacs, L. (2016). Dynamic business law: The
essentials (4th ed.). New York, NY: McGraw-Hill Education.
Massachusetts v. E.P.A., 549 U.S. 497 (2007).
Breast Cancer in Hispanic Populations
NR502: Proposal
Session,
NOTE: This is a template and guide. Delete all highlighted
materials.
Running head: Breast Cancer in Hispanic Populations1
Breast Cancer in Hispanic Populations1
Breast Cancer in Hispanic
Populations

Note that there is no heading that says Introduction. The
paragraph or two that follows the title on the first page of your
text is assumed to be your introduction. Your introduction
follows the title of your paper (note that the title is not bolded).
You should start your introduction with a powerful statement or
two to stimulate interest. You should identify the purpose of
your paper. Remember that formal papers are in third person, so
no I, me, we except in specified areas. The introduction should
include the purpose of the project and the Methods (Literature
review). 1 page
Significance of the Practice Problem
Start this section with identification of the practice problem.
This section should also answer the question “why is this
important?” You should address the significance to the
patient/client (e.g., pain, suffering, quality of life, impact on
income potential, etc.), the family, healthcare system (e.g.,
impact on cost or delivery systems), and society (e.g., cost of
care, need for healthcare policy). Discuss the incidence and/or
prevalence and include the financial impact if possible. You
might discuss the impact on length of stay, readmission, home
health care requirements, disability and/or mortality. Also, you
should address any quality, safety, legal, and ethical
implications. This discussion must be substantiated by citations
from professional literature. 1page
Research Question
Which are the determinants for a higher incidence of breast
cancer in the Hispanic population compared with African
Americans?
Objective
1. To identify which are the determinants for a higher incidence

of breast cancer in the Hispanic population compared with
African Americans.
2. To establish the incidence of Breast Cancer in the Hispanic
population and African Americans.
3. To analyze if those determinants are modifiable or not.
Theoretical Framework
This section should include the theoretical framework that
supports your MSN Project. Describe the theory or model that
served as the foundation for your project. This may be a nursing
theory. KOLCABA'S THEORY OF COMFOR. 2 paragraphs
Synthesis of the Literature
Synthesize at least 15 primary research studies attached and/or
systematic reviews; do not include summary articles. This
section is all about the scientific evidence rather than someone
else’s opinion of the evidence. Do not use secondary sources;
you need to get the article, read it, and make your own decision
about quality and applicability to your question even if you did
find out about the study in a review of the literature. The
studies that you cite in this section must relate directly to your
research question. This is a synthesis rather than a study-by-
study review. Address the similarities, differences, and
controversies in the body of evidence. One paragraph per article
(15 in total, the synthesis can be obtained from the abstract) 15
paragraphs 4PAGE
Practice Recommendations
So. . . using available evidence, what is the answer to your
question? This section is for you to summarize the strength of
the body of evidence (quality, quantity, and consistency), make
a summary statement, and based on your conclusions drawn
from the review, give a recommendation for practice change
based on scientific evidence. This would logically be the
intervention of your PICOT question. You might want to design

an algorithm and include it in as a figure. Perhaps you found
substantiation for usual practice, and you recommend
reinforcement and education regarding this best practice. What
you found on the articles 1PAGE
Project Description
The keywords that I will use for my search are: ……….
The results obtained from the study will contribute to
identifying ………..
Discussion and Implications for Nursing and Healthcare
Discuss the conclusions you can make from the project
evaluation results: review and answer your PICOT question.
Examine, interpret, and qualify the results. Discuss internal
validity and limitations of the project evaluation. Take into
account sources of potential bias and other threats to internal
validity, the imprecision of measures, and other limitations and
weaknesses of the evaluation (adapted from APA, 2010, p. 35).
Describe the implications of your project and the project
evaluation on nursing practice and healthcare. Do not overstate
the significance. Identify the impact on the appropriate
microsystem. Include any recommendations you have as a result
of this project and project evaluation. Also, include what you
might recommend with replication of this project and project
evaluation and your potential next steps for this practice
problem.1PAGE
Summary and Conclusion
The conclusion should start with a statement regarding the
intent of the paper and your achievement toward that intention.
Remember that the introduction is a preview, and this section
should contain a summary. 2 PARAGRAPH
When completed your summary and conclusion, do not include a
categorical conclusion, which means, that you should not
mention the results of your literature review, otherwise, this
would give the impression that your project has ended. It must
include the importance of what has been reviewed so far, and
the need to finalize the literature review in order to have a more

conclusive result.
References
Remember that this is a reference list rather than a
bibliography. A bibliography is everything you read to prepare
the paper but a reference list is only what you cited. If there is
not a citation for a reference, it should not be here. PLEASE
make sure that your references here and your citations
throughout the paper are in APA format. Take the time to make
sure that they are correct. We have already formatted the paper
for you with this template.
Karen Reifenstein, PhD, RN,
Matt Asare, PhD, MPH, MBA, CHES,
and Sandra M illon-Underwood, PhD, RN, FA AN

Abstract: Lack o f adequate participation by African American
and Hispanic zoomen in breast can-
cer genetic research studies sustains a knowledge gap in our
understanding o f new and innovative
scientific advances and outcomes in breast cancer
research/genomics. The purpose o f this study is
to suggest strategies to increase African American and Hispanic
women's participation in breast
cancer genetic research. A review o f literature reveals that
historical, com m unity involvement,
cultural, discrimination/stigmatizations concerns, and economic
factors may impact participation
in breast cancer genetic research investigations. Future research
investigations should involve
members o f the minority com munity as recruiters,
acknowledge anticipated historical concerns
up-front, address anticipated concerns o f
discrimination/stigmatizations, and recognize and
respect a person's culture and try to work within it when
attempting to recruit minority women
for breast cancer genetic research.
Key Words: African-American Women, Hispanic Women,
Breast Cancer Genetic Research,
Participation, Strategies
W omen a n d B reast C ancer R esearch
Introduction
Significant differences exist in breast cancer (BC) incidence a n
d m o rta lity rate s b e tw e en A frican American, Hispanic,
and Caucasian w om en (CW).
W hile the incidence of BC for African Am erican wom en
(AAW) is not higher com pared to CW, the incidence rate
for AAW is higher than H ispanic w om en (HW) from
the m ost recent data available (2016), 132.7 per 100,000

com pared to 128.2 per 100,000 (H ow lader et al., 2019).
Notably, while BC m ortality for CW had a substantial
decline from 1975-2016 (decreasing from 31.8 per 100,000
to 19.6 per 100, 000), AAW's BC m ortality rates changed
little during this same period (29.5 per 100,000 compared
to 27.3 per 100,000) (H ow lader et al., 2019). For HW, BC
m ortality declined significantly from 2000-2016, decreas-
ing from 16.8 p e r 100,000 to 13.9 p e r 100,000 (H ow lader
et al., 2019).
Breast cancer genetic research can offer potential
health benefits to m any w om en. More targeted and in-
dividualized treatm ent approaches m ay be obtained as
a result of new and innovative scientific advances in BC
research/genom ics (Lee & Naiem, 2012). Furtherm ore,
some BC racial disparities (e.g., m ortality rates), m ay be
further reduced as a result of current genetic research.
Karen R eifenstein, PhD, RN, corresponding author,
University o f Rochester, School o f Nursing. The author
may be reached at: [email protected]
Matt Asare, PhD, MPH, MBA, CHES, Department of
Public Health, Robbins College o f Health and Human Sci-
ences, Baylor University, [email protected] Sandra
M illon-Underwood, PhD, RN, FAAN, University of
Wisconsin-Milwaukee, College o f N ursing, [email protected]
uwm.edu.
However, in order to take advantage of potential m edi-
cal/genetic benefits, individuals from under-represented
groups m ust participate in BC genetic research. Some
investigators report that there is a contentious a nd com-
plicated association betw een the concepts of ethnicity and
race and genomics (Lee & Naeim, 2012). The form ation
of large biological sample collections that have been used
to study the role of genetics in various diseases has in-

creased debates regarding the potential im pact of genetic
research on vulnerable ethnic and racial groups. One
aspect of these debates includes individuals w ho have
expressed concerns related to the discriminatory potential
of genetic research/ genetic testing. Another aspect relates
to individuals w ho are concerned that benefits of genetic
research will not be distributed equitably if vulnerable
groups do not participate in biobanks because of w or-
ries about possible discrim ination (Goldenberg, Hull,
Wilford, & Sharp, 2011; Lee & Naeim, 2012). Concerns
of discrim ination was also found by other investigators
w ho w anted to assess AAW's perceptions and aw are-
ness of counseling and testing for BRCA 1 /2 (Adams,
Chrisotopher, Williams, & Sheppard, 2015). Suther and
Kiros (2009) pointed out that concerns regarding possible
stigm atization, discrim ination, and privacy breaches,
m ay cause individuals to avoid participation in research
and genetic related services.
Clinical trials (CT) offer potential significant benefits
to a variety of patients including m inority w om en diag-
nosed w ith BC. Reifenstein and Asare (2018) previously
reported that both w om en and m inorities have been u n -
derrepresented in CTs, and this underrepresentation has
perpetuated health disparities in racial / ethnic minorities
and continues to w iden the chasm betw een racial/ethnic
m inorities and the majority population. C om padre et
al. (2018) also noted that AAW are underrepresented in
cancer genetic research.
Journal of Cultural Diversity • Vol. 26, No.3 Fall 2019
mailto:[email protected]

Search Strategy
A structured approach was used to docum ent the
search strategy for this research review. A comprehensive
review of PsychoINFO, Cochrane Library, PubMed, Ovid
Medline, and CINAHL databases was conducted and the
review period is published studies between 2006 and 2018.
Key words used to identify articles included AAW, AAs,
BC genetic research, cancer genetic research participation,
BC clinical trials, Latina women (LW), Latinos, BC genetic
research participation, and lack of participation. Articles
were narrowed down by reading the titles. Those titles
which did not relate to BC genetic research participation
were dropped. Abstracts of the articles were read and
the following inclusion criteria were used in making the
final selection of articles. Inclusion criteria were: (1) only
published articles in refereed journals; (2) studies reported
in English; (3) studies conducted in the United States (4)
studies that were related to BC genetic research; (5) m ul-
timedia (Twitter; Facebook-publicly available posts) for
discussions related to BC genetic research participation
(6) studies that published the final results and not merely
baseline results or descriptions, and (7) had a study popula-
tion of adults (older than 18 years). All those studies that
did not meet the listed criteria were excluded from review.
Participation in Clinical Research
Involving underrepresented and underserved popu-
lations in research such as genetic research and CTs is
needed to make improvements in cancer treatment and risk
reduction strategies (Quinn, Mcintyre, & Vadaparalmpil,
2011). This is indeed a significant challenge as less than 2
percent of cancer studies funded by the National Institutes
of Flealth (NIH) include enough minority participants to
meet their own goals (Fluff, 2016). Unfortunately, minor-

ity participation in CTs has historically been quite limited.
Most recently, a review of National Cancer Institute (NCI)
sponsored or co-sponsored CTs during the month of Janu-
ary, 2013 indicated that AA's and Flispanics each had the
lowest CT participation at 1.3% (Chen, Lara, Dang, Pater-
niti, & Kelly, 2014 ). This is indeed very concerning, as
2013 census data showed Caucasians comprising nearly
63% of the population w ith AA's at 13% and Flispanics at
17% http: / / www.indexmundi.com/facts / united-states /
quick-facts/ all-states/w h i te-not-hispanic-population-
percentage#map. In 2016, only about 3% of genetic re-
search participants were of African and Fhspanic descent
and were even less represented at only 0.54% (Popejoy &
Fullerton, 2016). Despite these very low participation rates,
some authors insist that AAs and Flispanics are interested
in participating in clinical research (George, Duran, &
Norris, 2014; http ://k h n .o rg /n ew s/latin o s-left-o u t-o f-
clinical-trials-and-possible-cures /) and in genetic research
(Sanderson, et al, 2013; Smith et al., 2018, Chalela, Munoz,
Kipling, Kakalamani, & Ramirez, 2018, Sheppard et al.,
2018; John, Sangaramoorthy, Koo, Whittemore & West,
2019). However, their willingness to participate may be
untapped as some researchers have pointed out that minor-
ity individuals are not given an invitation to participate in
CTs even when the disease being investigated primarily
affect the minority population (h ttp s://s p h .u m d .e d u /
sites / default / files / files / http_www_hormone_org_Pub-
lic_clinical_trials_content_loader.pdf).
Factors in M aking a D ecision to Participate in Breast
Cancer Genetic Research
Given the increased attention on health disparities and
genetics, it is imperative to include AA and HW in research
that examines how individuals decide to participate in
BC genetic research. Genetic research presents itself in a

sociopolitical context, which may ultimately affect how
minorities understand this information and affect their
willingness to participate in research related to genetics
(White, Koehly, Omogbehin & McBride, 2010).
Very lim ited studies have been conducted in this
research area (Lee & Naeim, 2012; Underwood, Busch,
Kelber, Stevens, & Townsend, 2013). Most of the research
that was uncovered focused on inherited BC susceptibil-
ity and genetic testing for this susceptibility in non-Latino
Caucasians (Yeomans -Kinney, Gammon, Coxworth,
Simonsen, & Maritza, 2011). When related research was
found, information about individual ethnic groups was
unable to be determined because the number of subjects
were too small (Streicher et. al., 2011), or the data was
presented only in an aggregate narrative form at that
did not specify if the respondent was male or female, or
Latina, or AA (Sanderson, et al., 2013). Efforts to capture
conversations regarding BC genetic research participation
on multi-media platforms (e.g., Twitter - publicly available
posts) from AA and FTW were challenging. Ponce, Glenn,
Shimkhada, Scheitier, and Ko (2017), also reported chal-
lenges locating high-volume discussions on BC barriers on
Facebook and Twitter in their work related to challenges
and barriers to BC care in California. They believed that
these conversations/discussions were likely occurring in
non-publicly accessible social media platforms and chat
sites, or privately in Facebook groups. This author agrees
with the aforementioned assessment of limited discussions
found on social media.
Using hashtags such as #breastcancergenetics and
#breastcancer on Twitter (publicly available posts) this
investigator also found limited relevant results similar to
Ponce and colleagues (Ponce, et al., 2017). However, Twit-
ter chats and BLOGS were found on the Living Beyond

Breast Cancer website (h tt p ://w w w .lbbc.org/). Some of
the information found on Twitter chat within tJus website
was coping with BC related fatigue and insomnia, breast
reconstruction, and communicating with your children
regarding BC. However, in a BLOG story (http: / /www.
lbbc.org/n o d e /6470) on this website, information from a
woman of unknown ethnic background who participated
in a HER2 targeted clinical trial was shared. She reported
a few concerns (e.g., experimentation) about participating
in the CT. Such concerns were expressed as "...but I felt
like I would be a guinea pig and that the hospital and the
pharmaceutical company w ouldn't have my best inter-
ests at heart" (http://w w w .lbbc.org/node/6470). These
concerns are similar to those reported by AAW and LW
regarding BC genetic research.
London et al. (2015) evaluated factors associated with
168 LW for their willingness to participate in a BC CT.
Findings indicated that helping family members, (e.g., if
the family member had cancer) helping someone else that
they knew had cancer, and monetary compensation were
factors that would make them willing to be in a CT.
A desire "to help" also was mentioned by all 6 focus
groups comprised of AAs, Hispanics, and Caucasians in re-
search that assessed attitudes toward genetic research par-
http://www.indexmundi.com/facts
http://khn.org/news/latinos-left-out-of-clinical-trials-and-
possible-cures
http://khn.org/news/latinos-left-out-of-clinical-trials-and-
possible-cures
https://sph.umd.edu/
http://www.lbbc.org/

http://www.lbbc.org/node/6470
ticipation and data sharing (Lemke, Wolf, Hebert-Beime,
& Smith, 2010). In other research, 57 % of Hispanics, 62 %
of AAs indicated that it w as very im portant to participate
as a volunteer in a clinical trial to im prove the health of
others w hen deciding to participate in a CT (http: / / www.
saludtoday. com / blog / poll-minority-populations-support-
clinical-trials-but-participation-rem ains-low / . African
Am erican w om en com m ented "your research will help
future generations" w hen m aking a decision to participate
in a genetic research study (Smith et al., 2018). A nother in-
vestigator reported that Latinos are willing to participate in
CTs, especially to help treat their ill children (https: / / www.
usatoday.com / story / new s / 2017 / 07 / 24 / kaiser-latinos-
le ft-o u t-c lin ic a l-tria ls-a n d -p o ssib le -c u re
s/103956714/.
Ceballos et al. (2014) study revealed that Latino partici-
pants valued biom edical research as som ething that could
potentially help themselves, their families, other Latinos,
and the community.
Using a cancer registry approach, Pal, Rocchiio, Garcia,
Rivers, & Vadaparam pil (2011) assessed factors associated
w ith the recruitm ent of AAW for a study on inherited BC.
The m ost frequently cited reason for study participation
w as to learn m ore about personal cancer risk and risks to
family (46%), followed by w anting to learn more about
cancer research (24%), the convenience of study participa-
tion itself (18%), physician or other health care professional
(5%), incentives provided by studies (3%) past positive
experience w ith other research studies (3%), and recogniz-
ing someone on the study brochure (2%).
Trust seems to be a factor that LW consider w hen de-

ciding w hether to participate in cancer genetic research.
Quinn, et al. (2011) reported on challenges in recruiting
Mexican w om en for cancer genetics research, uncovering a
sense of distrust of health research among potential partici-
pants at a health fair. Additionally, it has been reported that
LW are less likely to trust m edications and have concerns
related to being treated as a guinea pig w hen deciding to
participate in a CT (http: / / www.expressnews.com / news /
local / article / Researchers-encourage-Hispanic-women-to-
join-9643084.php.
It appears that this sense of distru st am ong Latinas
essentially m irrors the p erceptions of AAW and their
p articipation in clinical research. Linden et al. (2007)
revealed th at m any AAW w ere suspicious ab o u t the
fun d in g sources for research studies and did not tru st
the recruitm ent efforts in such studies. Smith et al. (2007)
found an overall lack of trust in researchers and healthcare
systems am ong AAW. Distrust of research studies also was
reported by Rivers et al., (2017) in their interesting study,
w hich assessed the inform ation needs of AAW regarding
participation in cancer CTs. Huff (2016) also reported that
there is m istrust of the m edical system related to earlier
research injustices in her w ork regarding diverse popula-
tions in genetic research. Ulrich et al., (2013) noted a lack
of trust am ong HW and m en as a barrier to pardcipating in
biomedical research. Ochs-Balcom, Rodriguez, and Erwin
(2011) evaluated how beliefs, perceptions, and know ledge
in the AA com m unity im pact willingness to participate in a
fam ily-based genetic epidem iology study. An elem ent of
d istrust also seem ed to be apparent in this research as the
w om en expressed a great deal of concern regarding con-
fidentiality of data. O ther barriers uncovered in the data
were the possibility of having to provide a blood sam ple
and lengthy time com m itm ents for com pleting research

study requirem ents.
R odriguez, Torres, a n d Erw in (2013) e v a lu a te d the
feasibility of com m unity-based approaches for engaging
m em bers of the Latino com m unity in biospecim en dona-
tion for cancer genomic research. Findings revealed that
a m onetary incentive w ould influence their decision to
participate in a biospecim en donation, as w ould a recom -
m endation from their physician.
McDonald et al. (2012) assessed beliefs and attitudes
regarding participation in cancer genetic research am ong
AA's. F indings revealed th a t p a rticip a n ts considered
legal, social, and ethical issues w hen deciding to partici-
pate in cancer genetic research. For example, participants
expressed that they w ould consider factors such as the
potential to experience negative side effects, the extent to
which study sponsors (e.g., pharm aceutical company) and
researchers were trusted, and possibility of exploitation.
Participants also indicated they w ould consider inform a-
tion provided regarding study details, such as w ho has
access to the study data, w hether or not subjects w ould
have access to results w hen the study ended, and the p ro -
cedures involved in study participation. A prim ary factor
in subjects' decisions regarding participating in cancer
genetics research was the potential benefit of the study.
Personal benefits, as well as those to AA's and the public
were factors that participants w ould think about w hen
deciding w hether to participate in research. Subjects also
considered the logistics of a study (e.g., study participation
length and m onetary compensation).
A particularly interesting study by U nderw ood et al.
(2013) exam ined factors associated w ith the participation
of AA's in health-related genetic research. Results of
this study indicated that participants w ith higher levels

of know ledge regarding inheritable diseases/conditions
and genetics, prior involvem ent in a health-related study,
and an understanding of the risks, benefits, and utility of
genetic testing were more apt to report a willingness to
participate in health-related genetic research. The inves-
tigators noted that nearly all of the participants in their
study were supportive of health related genetic research,
b u t m ost revealed that they had "never been asked". In-
terestingly, Rodriguez et al. (2013) found that a m ajority of
subjects in their study about community-based approaches
for engaging Latinos in biospecim en donation for cancer
genomic research had not previously donated any type
of biospecimen. W hen participants were further queried
about this, they revealed that the reason for this was never
being asked to do so. M ost recently, AAW reported that
they were less apt to be in research studies because they
were never asked to participate (Smith et al., 2018).
The w illingness of AA's to p articip ate in precision
m edicine research w as evaluated by Halbert, McDonald,
Vadaparam pil, Rice & Jefferson (2016). Results indicated
that more than two thirds of the participants (69%) w ould
be "v ery /so m e w h a t unlikely or neutral" that they w ould
p a rtic ip a te in a g o v e rn m e n t-sp o n so re d study, w
hich
involved providing a check swab and responding to a
questionnaire, which w ould provide data that w ould be
used in another study, and w ould not provide results to
participants. M ost participants (86%) believed that the
results of participating in cancer genetic research w ould be
used to help future generations. Reasons for not participat-
http://www.expressnews.com

ing in cancer genetic research included: a) if the participant
did not know w ho w ould be able to access their personal
inform ation (60 % unlikely to participate); b) difficulty in
getting to the study site (63% unlikely to participate); c) if
the study results w ould not be m ade available to them (59%
unlikely to participate); and d) participation in a study for
a long length of time (48% unlikely to participate).
A n interesting qualitative study evaluated com m unity
perceptions of genomic research am ong 91AA, Latino, and
Caucasian participants (Isler, Sutton, Cadigan, & Corbie-
Smith, 2013). Findings revealed that m ost participants had
concerns related to research that addressed health dispari-
ties. M istrust of the governm ent, researchers, and fear of
m edical abuse w ere some of the concerns that w ere m en-
tioned by AA's and Latinos. For some Latino participants,
m istrust was closely linked to deportation fears regarding
family m em bers w ho are undocum ented imm igrants.
N odora et al. (2016) evaluated biospecim en donation
and data sharing am ong FIW w ho had undergone a breast
biopsy at a safety net hospital. The investigators noted that
the potential for increasing participation of diverse ethnic/
racial groups and u n derserved people can be obtained
by partnerships am ong hospitals, safety-net clinics, and
academic institutions, w hich will be crucial for precision
m edicine efforts.
A lthough partnerships am ong clinics, hospitals, and
acad em ic in s titu tio n s w ill be im p o rta n t in precisio n
m edicine efforts, other factors also should be considered
for increasing particip atio n of H ispanic indiv id u als in
health-related research. For example, Q uinn et al. (2011)
noted that language, cultural barriers, and m isunderstand-
ing of the consent process w ere some of the barriers that

HW encountered w hen participating in health research.
Furtherm ore, the authors noted that the m anner in which
cancer is spoken about in Hispanic families and the socio-
cultural aspects of cancer m ay influence research participa-
tion rates. It has been suggested that some Hispanics m ay
w ant to include family m em bers in their decision to p a r-
ticipate in research and they m ay place m ore im portance
on faith than scientific data (https: / / w w w .linkedin.com /
pulse / three-ways-increase-hispanics-particpation-clinical-
trials-batista). Prior research also indicates that AAW
acknowledge the im portance of family input w hen making
a decision to participate in a cancer clinic trial (Rivers et
al., 2017). Q uinn et al. (2011) pointed out that sensitivity
issues such as building trust, targeting their needs, and
providing education w ithin the context of the Hispanic
culture is crucial. This m ay include research assistants
having bilingual training on the standards for culturally
and linguistically appropriate care (https: / / www.linkedin.
c o m / p u ls e / three-w ays-increase-hispanics-particpation-
clinical-trials-batista).
A Framework for Understanding Participation in Breast
Cancer Genetic Research
Scientific investigations in this research area have had
limited guidance from theoretical frameworks / models (see
Table 1). A theoretical fram ew ork that m ay be particularly
appropriate in this research is the socioecological m odel
(SEM) (Salihu, Wilson, King, Marty, & W hiteman, 2015;
Suther & Kiros, 2009). The (SEM) can be very helpful for
addressing potential obstacles ( e.g., language or literacy
barriers) that m ay be encountered in study recruitm ent/
participation and retention. In this m odel, factors and
behaviors are assessed from a m ultilevel view such as in-
trapersonal (attitudes, beliefs, knowledge), interpersonal

(cultural acceptance and social norms), institutional and
com m unity (equal access to services and identification of
resources), and policy (laws regarding discrim ination and
confidentiality). Each level is influenced and reinforced
by behaviors and factors from the other levels of influence
(Suther & Kiros, 2009). In extending this m odel to m inority
w om en and BC genetic research, this m odel w ould con-
sider BC genetic research participation as an outcom e of
interaction/interrelationship am ong a variety of factors/
behaviors at intrapersonal, interpersonal, institutional and
community, and policy levels. For example, if potential
study participants express d istru st/su sp ic io n of medical
research as a barrier to participation in BC genetic research,
a thorough and on-going open com m unication by the re-
searcher and trained team m em bers should ensue about
the im portant role of H um an Subjects Review Boards in
the protection of research subjects.
Discussion
M any of the factors that affect participation of AA's
in general BC clinical research/trials are also found to be
factors affecting m inority participation in BC genetic re-
search. The aforem entioned studies indicate factors such
as trust in health care systems and researchers, m onetary
com pensation for research participation, culture, fear of
m edical abuse, physician recom m endations, inp u t from
family m embers, and altruism are all influences that m ay
affect m inority w om en's decisions in deciding w hether to
participate in BC genetic research. It is critical that research-
ers extend an invitation to AAW and LW for participation
in BC genetic research. Prior research has revealed that
m any individuals from under-represented groups have not
been asked to participate in genetic research, although they
are supportive of this type of research. Recognition of po-
tential concerns about breaches of privacy, discrimination,

and stigm atizations is param ount, as they m ay negatively
im pact participation in genetic research and genetic-related
services (Suther & Kiros, 2009). Continued efforts m ust be
sustained in safe-guarding genetic inform ation provided
by participants, so that trust can be established and m ain-
tained betw een potential participants and the research
comm unity. D oing this sh ould be helpful in assuring
participants that their contributions will only be used to
advance science, and ultim ately help them as well as oth-
ers. A lthough scientific w ork has been conducted in this
research area, so m uch w ork still needs to be done. More
descriptive and intervention research should be conducted
to shed light on how AAW and LW ultim ately decide to
participate in BC genetic research, and eventually targeting
those factors significant to large groups of m inority wom en
will be critical. The elucidation of those factors will enable
us to learn m ore about im proving care through patient
engagem ent in scientific research and im prove diversity
in our research studies.
Strategies to Enhance Subject Participation
Scientific know ledge acquired in clinical studies can
hopefully translate to im proving cancer disp arities in
these vulnerable groups. If new scientific know ledge is
to be developed regarding BC genetics am ong AAW and
Journal of C ultural Diversity • Vol. 26, No.3 Fall 2019
http://www.linkedin.com/
http://www.linkedin
LW, then it becomes im portant to form ulate strategies that
will encourage AAs and Latinos to participate in clinical
studies.

1. As revealed by Reifenstein and Asare (2018), acknowl-
edging anticipated historical concerns up front - espe-
cially the Tuskegee Study- m ay be helpful in reducing
potential participants' uneasiness. This may be aided
by directly acknow ledging barriers to involvem ent
a n d p a rtic ip a tio n in cancer research (Somayaji &
Gates Cloyes, 2014), program s, and trials. M aintain-
ing an open dialogue about subjects' concerns m ay
provide ongoing opportunities for the researcher to
discuss research subject protection issues (e.g., confi-
dentiality, w hether or not subjects w ould have access
to study results). If this open dialogue is done in a
culturally sensitive m anner, subjects will feel valued
and protected. Taking the time to carefully explain
study procedures (e.g., inform ed consent) w ould also
be helpful in building a sense of trust betw een study
participants and the research team.
2. Interventions that are designed to m ore effectively
inform , recruit, involve, a n d su p p o rt the decisions
of m inorities willing to participate in health-related
genetic research is critical (U nderw ood et al., 2013).
U nderw ood et al. (2013) agrees that w ithout this type
of approach, current participation trends for these m i-
nority groups will rem ain the same. Using this type of
approach also m ay be helpful in m aking participants
feel that research team m em bers care and value them.
Issues such as m otivations regarding research p a r-
ticipation, and how different ethnic and racial groups
assess harm s and benefits, are crucial to designing
com m unity engagem ent strategies, m essages regard-
ing research, and recruitm ent plans (Isler, et al., 2013).
3. Com m unity involvem ent in recruiting AAW and LW
for research studies can often be critical for success.

Ewing, Thom pson, and Ricks-Santi (2015) pointed
o u t th a t c o m m u n ity -b a s e d rese a rc h efforts have
p ro v id e d success in the recru itm en t of m inorities
in prior w ork. Smith et al. (2018) found success u …
Symptom Experience, Management, and Outcomes According
to Race and Social Determinants Including Genomics,
Epigenomics,
and Metabolomics (SEMOARS + GEM): an Explanatory Model
for Breast Cancer Treatment Disparity
Maura K. McCall1 & Mary Connolly1 & Bethany Nugent1 &
Yvette P. Conley1 & Catherine M. Bender1 &
Margaret Q. Rosenzweig1
# The Author(s) 2019
Abstract
Even after controlling for stage, comorbidity, age, and
insurance status, black women with breast cancer (BC) in the
USA have
the lowest 5-year survival as compared with all other races for
stage-matched disease. One potential cause of this survival
difference is the disparity in cancer treatment, evident in many
population clinical trials. Specifically, during BC
chemotherapy,
black women receive less relative dose intensity with more dose
reductions and early chemotherapy cessation compared with
white women. Symptom incidence, cancer-related distress, and
ineffective communication, including the disparity in patient-
centeredness of care surrounding patient symptom reporting and
clinician assessment, are important factors contributing to racial
disparity in dose reduction and early therapy termination. We
present an evidence-based overview and an explanatory model

for
racial disparity in the symptom experience during BC
chemotherapy that may lead to a reduction in dose intensity and
a
subsequent disparity in outcomes. This explanatory model, the
Symptom Experience, Management, Outcomes and Adherence
according to Race and Social determinants + Genomics
Epigenomics and Metabolomics (SEMOARS + GEM), considers
essential factors such as social determinants of health, clinician
communication, symptoms and symptom management, geno-
mics, epigenomics, and pharmacologic metabolism as
contributory factors.
Keywords Breast cancer . Symptom . Social determinants .
Treatment disparity . Chemotherapy . African-American . Dose
intensity
Introduction
Breast cancer (BC) incidence is similar among black and white
women [1], except for younger black women aged 45 and
under, who have higher incidence rates [2]. Yet black women
die from BC at a rate 42% higher than white women [1, 3] and
are more frequently diagnosed at later disease stages and with
aggressive triple-negative (estrogen, progesterone, HER2/neu)
tumors [2]. This increase is particularly true in BC, confirmed
when a meta-analysis reported a 1.22 odds ratio for a negative
effect of African-American ethnicity on BC mortality [4].
These negative outcome differences persist after controlling
for disease stage and tumor type, comorbidities, age, and insur-
ance status, which leaves the underlying cause of this disparity
unexplained [5, 6]. Receiving ≤ 85% of prescribed BC chemo-
therapy is associated with poor outcomes [7–9]. Racial
* Margaret Q. Rosenzweig

[email protected]
Maura K. McCall
[email protected]
Mary Connolly
[email protected]
Bethany Nugent
[email protected]
Yvette P. Conley
[email protected]
Catherine M. Bender
[email protected]
1 University of Pittsburgh School of Nursing, 3500 Victoria
Street,
Pittsburgh, PA 15261, USA
https://doi.org/10.1007/s13187-019-01571-w
Journal of Cancer Education (2020) 35: –428 440
August 2019Published online: 8
http://crossmark.crossref.org/dialog/?doi=10.1007/s13187-019-
01571-w&domain=pdf
http://orcid.org/0000-0003-2276-9673
disparity in cancer treatment is documented [10] and is a po-
tential source of the racial variance in survival rates [3, 11–17].
Suboptimal adherence to chemotherapy treatment is a mul-
tifactorial problem, which involves much more than the pa-
tient herself. The International Society for Pharmacoeconom-
ics and Outcomes Research defines medication compliance/
adherence as “the degree or extent of conformity (most appro-
priately a percentage) to the recommendations about day-to-
day treatment by the provider with respect to the timing, dos-

age, and frequency” [18]. Most often, studies investigating
cancer treatment adherence focused on oral cancer treatments
and have not included factors other than the patient’s role in
adherence. The term “adherence” or “compliance” carries
some traditionally pejorative connotations, implying that the
choice to receive less than full-dose treatment is always pa-
tient initiated. In BC treatment, the choices regarding less than
full adherence to prescribed BC intravenous chemotherapy are
most often initiated by the clinical staff rather than the patient.
Treatment decisions such as capping chemotherapy dosing at
a body surface area (BSA) of 2.0 [19, 20] instead of treating to
full body weight or the clinician’s subjective treatment deci-
sions based on the categorization of certain women as “poor
chemotherapy candidates” allowed a differential treatment ap-
proach that was potentially racially biased [21]. The standard-
ization of chemotherapy dosing according to BSAwithout any
or minimal cap for overweight and obese patients [22] and the
standard use of national treatment guidelines in medical on-
cology [23] may now more closely regulate the clinician’s
discretion during initial treatment prescription, limiting
the clinician’s autonomy in prescribing nonstandard ther-
apy or first cycle reduction. Perhaps these changes are
reflected in recent studies, including our own, reporting
on racial disparity in the initiation of chemotherapy. Slight
to no racial disparity was found in the clinician’s prescrip-
tion or the patient’s initiation of prescribed chemotherapy
[24], but racial disparity in receiving full-dose, timely
treatment across the chemotherapy continuum was noted
[25–31].
The Symptom Experience, Management and Outcomes
According to Race and Social determinants (SEMOARS)
model was developed to address factors associated with the
disparate receipt of chemotherapy. In this model, the explora-
tion of these adjuvant BC chemotherapy receipt variables
stresses the importance of the person within a social and en-

vironmental context.
The SEMOARS + GEM Model
The development of the SEMOARS model, with the addition
of Genomics, Epigenomics, and Metabolomics (GEM)
(Fig. 1), enables rasearchers to examine the variables contrib-
uting to the hypothesized explanatory model [32–41]. The
SEMOARS + GEM model identifies crucial factors that con-
tribute to racial disparity in dose reduction and early chemo-
therapy termination. These factors include symptom pheno-
type and intensity, symptom reporting and management, and
social determinants of health. In addition, the biologic vari-
ables of genomics, epigenomics during BC chemotherapy,
and chemotherapy metabolism are modeled. The purpose of
this paper is to provide a presentation and explanation of this
model with relevant science. We will explore each variable in
the model (Fig. 1) and provide current supporting evidence
(Table 1).
Social Determinants of Health The model begins with the
patient (within the context of her social and physical environ-
ment) initiating BC chemotherapy. Social determinants of
health associated with increased symptom experience and in-
tensity are considered integral and specific to each patient.
Race/ethnicity, age, income, education, zip code, allostatic
load, comorbidity, and self-efficacy/belief in prescribed med-
ication are social determinants of health that may be associat-
ed with increased symptoms resulting in dose reductions, che-
motherapy holds, and early therapy cessation [68–74]. The
following sections provide a review of evidence of these as-
sociations to date.
Race/Ethnicity Racial and ethnic differences in treatment de-
livery and symptoms are documented [75–77]. Black women

experience more chemotherapy delays compared with white
women [47, 78]. Symptoms may be a causative factor. For
example, minority women describe more symptom intensity
and distress BC treatment [79, 80]. In a recently completed
study of 140 black women receiving adjuvant BC chemother-
apy, nearly all (99%) black women initiated chemotherapy,
and almost 40% received a reduction in dose intensity, early
cessation, or delay associated with symptoms and cancer-
related distress [32].
Age Evidence regarding the influence of age on symptom
distress is contradictory. Older women are more likely to re-
ceive a lower chemotherapy dose intensity, due to fewer pre-
scriptions and more dose reductions than younger women,
with a subsequent decrease in overall survival [8, 42, 43].
Most studies adjust for age in their analyses, and when exam-
ined as a factor related to symptoms, age produced mixed
results. Older age was associated with increased long-term
peripheral neuropathy in docetaxel regimens [50] and more
overall toxicity, such as chemotherapy-induced bone marrow
toxicities [81]. Conversely, younger women experience an
increase in symptoms related to cognitive function [82].
Miaskowski et al. examined factors across multiple tumor
typesassociatedwithincreasedsymptomdistressduringcan-
cer chemotherapy and found younger age, female sex, low
social support, and socioeconomic status to be characteristic
J Canc Educ (2020) 35: –428 440 429
of the symptom grouping for greater symptom severity, sug-
gesting multiple factors, including age, are related to symp-
toms experienced [54].
Income/Education/Zip Code Indicators of socioeconomic sta-

tus, including income, education level, and zip code, affect
women’s experience of BC chemotherapy and overall treat-
ment. Lower-income women are more likely to report symp-
toms after treatment [34] as well as a financial burden, and
black women report a greater financial burden than white
women after controlling for socioeconomic status [44].
Education level, which is often correlated with socioeconomic
status, was inversely related to chemotherapy symptoms, with
better-educated women reporting a lower symptom burden
[45] and being less likely to receive a chemotherapy dose
reduction [22]. Additionally, black women with less education
were more likely to report perceived discrimination and dis-
parities in their care [59].
Zip code may be used as a surrogate measure of socioeco-
nomic status, such as income, education, and employment, in
addition to the geographical region. For example, Griggs et al.
found that when compared with the Northeastern region of the
USA, patients in the Southern region had greater odds of re-
ceiving a reduction in their chemotherapy dose [22].
Financial, educational, and geographic factors influence
symptoms and BC treatment intensity.
Allostatic Load Allostatic load is an algorithmic risk factor
representing cumulative stress exposure causing persistent,
severe psychological and physical symptoms for any illness,
specifically cancer. Geronimus et al. used the term
“weathering” to characterize the effect of cumulative stress
from multiple stressors on US blacks in their residential, oc-
cupational, and other environments [83]. Thus, among black
and low-income women, there is increasing concern about the
impact of a lifetime of accumulated stress on illness outcomes,
including BC outcomes [84, 85]. The impact of the full range
of childhood and cumulative adult-life stress exposure has not
yet been studied in relation to cancer-related symptoms.

Comorbidity Black women with BC have more comorbid con-
ditions [86] than white women has implications for BC out-
comes. For example, hypertension accounted for 30% of ra-
cial survival disparity for one BC cohort [56]. An 18% in-
creased risk of death was observed with each additional co-
morbid condition [57]. Comorbidities may interfere with treat-
ment and are associated with chemotherapy delays [47, 87]. A
meta-analysis concluded that patients with comorbidities had
lesser odds of receiving chemotherapy and greater odds of
toxicity [88]. The precise means by which comorbidities in-
crease symptom incidence and distress and influence chemo-
therapy intensity is not clear.
Beliefs and Communication The belief that medication is nec-
essary and efficacious, in addition to the concern over possible
harmful effects, can influence whether a patient will carry out
a prescribed treatment [58]. Concern may result from mistrust
among black patients in a traditionally white health care sys-
tem or belief among black women that health care providers
are not sufficiently culturally sensitive to address specific con-
cerns [59, 60, 89, 90]. Communication is essential to estab-
lishing trust in the provider-patient relationship and was neg-
atively correlated with medical mistrust among black women
with BC [59]. The communication patterns between clinician
Fig. 1 The SEMOARS + GEM
explanatory model
J Canc Educ (2020) 35: –428 440430
Table 1 Influence of social determinants of health, symptom
experience, genomics and epigenomics on outcomes during
breast cancer chemotherapy

Age
Griggs et al. [26]
Sample N=1403
Black 361
Low-acculturated Hispanic 186
High-acculturated Hispanic 183
Non-Hispanic white 673
Multivariable logistic regression
o Increased age had lesser odds of receiving chemotherapy: OR
0.91 (95% CI 0.90–0.92)
Inwald et al. [42]
Sample N=3463
Bavaria, Germany, no race data reported
Frequency
o Women >70 years old were treated less frequently with
chemotherapy + endocrine therapy
(6.9%) than 50-69 years old women (28.3%)
Owusu et al. [43]
Sample N=689
White 643
Minorities 46
Chi-square
o Women >75 years old (9%) received less chemotherapy
compared with 65 to ≤75 years
(28%; p < .0001)
Sandy & Della-Fiorentina [8]

Sample N=308
Sydney, Australia, no race data reported
Multivariable regression with backwards selection
o Women age ≥ 65 years old had greater odds of having a dose
reduction adjusted OR 8.36;
95% CI 2.40–29.08; p= .001
Income/insurance
Griggs et al. [26]
Sample N=1403
Black 361
Multivariable logistic regression
• Medicaid versus other insurance lesser odds of receiving
chemotherapy OR 0.59; 95% CI,
0.37–0.95
Wells et al. [24]
Sample N=99
Black 51
White 48
Logistic regression
• Medicaid/no insurance versus private/private+Medicare*
related to adherence to
chemotherapy: β= –2.111;
• Adjusted OR 0.121; p= .016

Financial toxicity
Wheeler et al. [44] Multivariable logistic regression predicted
risk for black women compared with white
Sample N=2494 • Financial barrier adjusted risk difference
13.09 (SE 1.50) p < .001
• Insurance loss adjusted risk difference 3.37 (SE 0.83) p <
.001Black 49%
White 51%
Education and symptoms
Prigozin et al. [45]
Sample N=51
Pearson’s r:
o Education and total symptom scores were inversely related rs=
–0.41; p < .01
Race and adherence
Griggs et al. [26]
Sample N=1403
Black 361
Multivariable logistic regression receipt of chemotherapy
compared with non-Hispanic white
women
• Black women (ns) OR 0.83 95% CI 0.64–1.08
• Hispanic low acculturated women OR 2.00; 95% CI 1.31–3.04

• Hispanic high acculturated women OR 1.43; 95% CI 1.03–1.98
Wells et al. [24]
Sample N=99
Black 51
White 48
Chi-square
• No difference in adherence to chemotherapy between black
and white patients: χ2= 2.627,
p= .10
K. Smith et al. [46]
Sample N=121
Black 21
White 98
Relative Risk
• Modification of chemotherapy treatment in black versus white
women: RR= 1.56; p= .04
• Black women received reduced cumulative doses of adjuvant
chemotherapy: RR= 2.49; p= .03
J Canc Educ (2020) 35: –428 440 431
Table 1 (continued)
Fedewa et al. [47]
Sample N=107,587
White 69.75%
Black 11.52%
Hispanic 4.57%
Asian 2.84%

Other minorities 11.32%
Multivariate regression results
• Greater risk of delay in black women (6.78% versus white
3.59%):
60-day delay RR= 1.36; 95% CI, 1.30–1.41
90-day delay RR= 1.56; 95% CI, 1.44–1.69
• Greater risk of delay in Hispanic women (6.91% versus white
3.59%):
60-day delay RR= 1.31; 95% CI, 1.23–1.39
90-day delay RR= 1.41; 95% CI, 1.26–1.59
Check et al. [48] Generalized Linear Model Step-wise
Regression with cancer-specific physical well-being and
1) race 2) clinical and demographics 3) interpersonal processes
of care for black women:Sample N=4002 (N=2740 for 6-month
timepoint)
Black 316
White 2672
Hispanic 498
Asian 516
• At baseline, interpersonal processes of care domains for
compassion (β= 0.40; p= .02),
elicited concerns (β= 0.59; p= .0009), and explained results (β=
0.46; p= .002) were
positively associated with physical well-being and
discrimination due to race was
negatively associated (β= –0.58; p= .005)
• Black and white women differences in physical well-being
widened at 6 months (β= –0.99; p=
.02)

Newman et al. [4] Pooled meta-analysis of breast cancer
mortality in black compared with white women:
Sample 14 studies
N=52,474
Black 10,001
White 42,473
• Random effects for mortality OR 1.215; 95% CI 1.13–1.30
• Adjusted for socioeconomic status OR 1.27; 95% CI 1.17–1.38
Symptom/severity
Simon et al. [49]
Sample N=126
Black 27.8%
White 65.1%
Independent sample t test chemotherapy induced peripheral
neuropathy (CIPN) black women
experienced and reported more CIPN compared with white
women:
• Sensory scale: 28.6 versus 14.4, p < .002
• Motor scale: 25.0 versus 15.6, p < .012
• Autonomic scale: 24.3 versus 13.4, p < .014
• Reported CIPN: 82.9% versus 67.1%Yee et al. [32]
Sample N=121
Black 100%
Pearson Correlation
• Full dose chemotherapy at midpoint with:
o Symptom distress at baseline r= 0.243; p= .007; mid-chemo
course r= 0.187, p= .042; and
completion r= 0.180, p= .050
o Total number of symptoms at baseline r= –0.225, p= .014
• Full dose chemotherapy at endpoint with:

o Total number of symptoms at baseline r= 0.189; p= .039
Bandos et al. [50]
Sample N=1512
Multivariable ordinal logistic regression
• Women ≥50 were more likely to experience long term
peripheral neuropathy OR 1.34; 95%
CI 1.10–1.65; p=.005
Gnerlich et al. [51]
Sample N=243,012
Cox regression
• Younger (<40 years old) were more likely to die with Stage 1
(adjusted HR 1.44; 95% CI
1.27-1.64) or Stage 2 (adjusted HR 1.09; 95% CI 1.03–1.15)
than women older than 40
Gaston-Johansson et al. [52]
Sample N=30
Black 100%
Chi-square
• Symptoms increased at midpoint of chemotherapy and then
decreased or remained the same
at completion. For example, worst pain χ2= 7.81, p= .027
Schneider et al. [53]
Sample N=1779
African descent 213
European descent 1566
Logistic regression with Cox hazard ratio
• Compared with other races, patients of African descent had

increased risk of taxane-induced
peripheral neuropathy (TIPN) grade 2-4 HR 2.1; p= 5.6 × 10-16
and grade 3-4 HR 2.6;
p= 1.1 × 10-11
Symptoms and race/ethnicity
Eversley et al. [34]
Sample N=116
White 30%
Black 30%
Latina 25%
Other minorities 15%
Breast cancer survivors
Comparing race/ethnicity:
o Latina reported more symptoms (μ= 2.5) than black (μ= 1.5)
or white (μ= 1.2; p < .01)
o Black (91%) and Latina (93%) reported more pain (white
54%; p < .001)
o Latina (89%) reported more depressive symptoms compared
with black (38%) and white
(40%; p < .001)
Least Squares Regression for total number of symptoms:
o Income β= –0.397 p= .003
o Mastectomy β= 0.340 p= .005
o Chemotherapy β= 0.340 p= .026
o Latina β= 0.340 p= .004
Miaskowski et al. [54]
Sample N=582
Latent Class Analysis yielded 3 trajectories for symptoms:
o “All High” 13.9% of patients

J Canc Educ (2020) 35: –428 440432
Table 1 (continued)
Breast, gastrointestinal, gynecological, or lung cancer
patients undergoing chemotherapy
o Younger age F= 6.07; p= .002 (low versus moderate and high)
o Less education F= 5.00; p= .007 (low versus moderate and
high)
o Minorities χ2= 8.81; p= .012 (low versus moderate and high)
o Lower income KW= 22.81; p < . 0001 (low and moderate
versus high)
o Breast cancer χ2= 11.17; p= .083
o More comorbidities F= 38.99; p < .0001 (low versus moderate
versus high)
o Lower reported functional status F= 38.73; p < .0001 (low
versus moderate versus high)
o “Moderate” 50% of patients
o “Low” 36.1% of patients
o Fewer females χ2= 24.39; p < .0001 (low versus moderate and
high)
o More married/partnered χ2= 10.80; p= .005 (low versus high)
Comorbidities and cancer
Leach et al. [55]
Sample N=1527
Black 18.1%
White 50.5%
Prevalence and Linear Regression:
o Compared with breast cancer survivors, fewer comorbidities
were reported by prostate

cancer survivors β= –1.22; p= .0001; as well as colorectal
cancer survivors β= –0.62;
p= .0243 and ovarian cancer survivors β=–0.55; p= .042
o Compared with white cancer survivors, black cancer survivors
reported fewer comorbidities
β= –0.89; p= .0112
o Breast cancer survivors reported having experienced more
comorbidities (5.8; 95% CI 5.4–
6.2) than survivors of other cancers
Comorbidity and adherence
Fedewa et al. [47]
Sample N=107,587
Black 11.52%
Hispanic 4.57%
Asian 2.84%
White 69.75%
Multivariate regression results
Greater risk of delay compared with no comorbidity:
• 60-day delay 1 comorbidity RR= 1.09; 95% CI, 1.04–1.14
≥2 comorbidities RR= 1.32; 95% CI, 1.21–1.45
• 90-day delay 1 comorbidity RR= 1.13; 95% CI, 1.34–1.23
≥2 comorbidities RR= 1.32; 95% CI, 1.10–1.60
Comorbidity and survival
Braithwaite et al. [56]
Sample N=1254
Black 416
White 838
Logistic regression with Cox hazard ratios

• Hypertension increased risk of mortality after adjusting for
age and race HR 1.33 95% CI
1.07–1.67
Klepin et al. [57]
Sample N=329
Black 11%
White 87%
Other minorities 1%
Unknown 1%
Multivariable logistic regression for overall survival
• Total number of comorbidities HR 1.18; 95% CI 1.06–1.33; p
< .01
Beliefs and adherence
Gatti et al. [58]
Sample N=275
Black 86.2%
White 5.1%
Multivariable logistic regression on medication adherence in
general
• Negative beliefs about medication is a predictor of low
adherence adjusted OR 2.12; 95% CI
1.3–3.7; p=.006
Spirituality and patient-reported outcomes
Gaston-Johansson et al. [52]
Sample N=30
Black 100%
Correlation

• Negative religious coping correlated with psychological
distress r= 0.6; p < .05, anxiety r=
0.51; p < .05, and depression r= 0.65; p < .01
Interpersonal communication and mistrust
Sutton et al. [59]
Sample N=210
Black 100%
Multiple linear regression
• Low rating of chemotherapy communication was associated
with greater medical mistrust
high school or less p=.02
Tucker et al. [60]
Sample N=298
Black 100%
Mediation analysis
• Trust mediated the role of cultural sensitivity in the domains
of provider competence/
confidence, provider sensitivity/interpersonal skill, and
provider respect/communication
with patient satisfaction
J Canc Educ (2020) 35: –428 440 433
and patient, described as the patient centeredness of care
(PCC), coded and scored through a 23-item checklist, may
be an important explanation for racial differences in commu-
nication during BC clinical visits. Rosenzweig’s team de-
scribed a prospective, comparative pilot study qualitatively

coded for PCC during the clinical visit of women undergoing
BC chemotherapy and compared by race. Twenty-four clinical
visits were recorded in a sample of five black and five white
women undergoing BC chemotherapy. Overall for each PCC
item, the mean clinician visit scores for black women were
higher (worse PCC) than the mean clinician visit scores for
white women. Significant differences were found in 27% of
the PCC items. The higher scores were evident for three of the
four subscales “Invest in the Beginning,” “Elicit the Patient’s
Perspective,” and “Demonstrate Empathy” [91].
Table 1 (continued)
Jiang et al. [33]
Sample N=101
Black 100%
Multiple linear regression
• Perceived better physician interpersonal communication was
positively associated with
beliefs in the necessity of chemotherapy β= 0.057; p= .007
Genomics and taxane-induced peripheral neuropathy (TIPN)
Schneider et al. [61]
Sample N=213
Black 100%
Gene-based case control statistical analysis (SKAT)
• SET binding factor 2 (SBF2) was associated with TIPN p=
4.35 × 10−6
Hertz et al. [62]
Sample N = 411
White discovery cohort 209

Black replication cohort 107
Log-rank test and Cox proportional hazards
• In European-American discovery cohort, CYP2C8*3 genotype
increased risk of grade 2+
neuropathy for each allele HR =1.95; 95% CI 1.06–3.58; p =
.031
• In African-American replication cohort, no homozygotes were
found, but one allele of
CYP2C8*3 increase TIPN risk HR = 3.30; 95% CI 1.04–10.45;
p = .043
Baldwin et al. [63]
Sample N = 1126
White discovery cohort 855
Black replication cohort 154
White replication cohort 117
Ordinal logistic regression
o In the white (European) discovery cohort, FGD4 was
associated with TIPN HR 1.57; 95%
CI 1.30–1.91; p = 2.6 × 10−6
o The white replication cohort was similar HR 1.72; 95% CI
1.06–2.80; p = .013
o The black replication cohort was also associated HR 1.93;
95% CI 1.13–3.28; p = 6.7 × 10−3
Abraham et al. [64]
Sample N = 1303 samples from several trials
White 100%
Unconditional logistic regression and likelihood ratio test
o ATP-binding cassette, subfamily B (ABCB1) was associated

with decreased odds of TIPN
OR 0.47; 95% CI 0.28–0.79; p = .004
o Tubulin Beta 2A Class IIa (TUBB2A) was also associated
with increased odds of TIPN OR
1.80; 95% CI 1.20–2.72; p = .005
Apellaniz-Ruiz et al. [65]
Sample N = 146
White 100%
Cumulative dose analysis and additive model
o Ephrin Receptor A5 (EPHA5) was associated with TIPN HR
2.3; 95% CI 1.6–3.9; p = .0074
1.9; 95% CI 1.2–2.9; p = .0063
1.9; 95% CI 1.1–3.2; p = .0012
Boso et al. [66]
Sample N = 113
White 100%
Multivariate logistic regression
o Excision repair cross complementation group 1 (ERCC1) was
associated with TIPN p = .006
Epigenomics and chemotherapy
Smith et al. [67.]
Sample N = 61
Black 25
White 36
Linear regression (MethLAB)
o CpG sites with change in methylation after chemotherapy
versus no chemotherapy included

o cg26077811 β = −.074, p = 3.65 × 10−9
o cg18942579 β = −.161, p = 1.65 × 10−8
o cg12054453 β = −.154, p = 2.75 × 10−8
o cg16936953 β = −.168, p = 3.26 × 10−8
o cg05438378 β = −.089, p = 7.78 × 10−8
o cg25446789 β = −.085, p = 7.84 × 10−8
o cg01409343 β = −.138, p = 9.88 × 10−8
o cg13518625 β = −.051, p = 9.98 × 10−8
Where studies categorized race as other or nonwhite (likely
grouped due to the sample size), we used the terms minorities or
other minorities
ns, not significant; OR, odds ratio; HR, hazard ratio; CI,
confidence interval; RR, relative risk; SE, standard error; SD,
standard deviation; β, beta; μ,
mean; KW, Kruskal-Wallis; χ2 , chi-square; RR, risk ratio;
“white” was used in some cases when European ancestry was
indicated
*Health insurance variable was a surrogate for
income/socioeconomic class
**Only measured number of sessions, not dose. Adherence
divided into 100% attendance or less than 100% and was
defined by patient factors: missed
appointments, cancellations, no shows, etc.; no delays or
discontinuations by the provider were noted

J Canc Educ (2020) 35: –428 440434
Symptom Phenotype and Intensity
For all women, once the chemotherapy dosing is calculated
and initiated, follow-up doses may be decreased, held, or
discontinued if patients exhibit symptoms of toxicity. There
is a pattern during chemotherapy that symptoms increase from
pre-chemotherapy to mid-therapy but stabilize after chemo-
therapy treatment midpoint to completion [32, 52], suggesting
a symptom tolerance among patients. Associations between
the ability to receive ≥ 85% of the prescribed treatment course
and symptom distress, severity, and the total number of symp-
toms at pre-chemotherapy are reported [32]. Minority patients
were more likely to belong to the high-symptom group when
symptom severity was categorized into low, moderate, and
high [54]. Other variables to consider in racial symptom and
treatment disparity include baseline genomics and temporal
epigenomic changes that may be associated with symptom
phenotype and treatment response.
Genomics and Epigenomics of Symptoms
and Chemotherapy Metabolomics
Thoughsocialdeterminantsofhealtharefactorsrelatedtodisparity
in dosing and completion of chemotherapy, they do not fully …
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2020
Breast Cancer Knowledge, Attitude, and Screening Practices
among Hispanic/Latino Women among Hispanic/Latino Women
Harrindra Seepersaud
Walden University
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Walden University
College of Health Sciences
This is to certify that the doctoral study by
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Nancy Rea, Committee Chairperson, Public Health Faculty

Dr. Tina Cunningham, Committee Member, Public Health
Faculty
Dr. Kai Stewart, University Reviewer, Public Health Faculty
Chief Academic Officer and Provost
Sue Subocz, Ph.D.
Walden University
2020
Abstract
among Hispanic/Latino
Women
By

Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Public Health
Walden University
May 2020
Abstract
Nearly 1 out of every 8 women will develop breast cancer
during her lifetime, making
breast cancer the most common noncutaneous malignancy in

women, particularly among
the Hispanic/Latino population. Hispanic/Latino women are
more likely than non-
Hispanic/Latino women to be diagnosed with breast cancer after
the disease has
progressed to a fatal stage. This quantitative study measured
how knowledge, attitude,
and screening practices affect the prevalence and outcomes of
breast cancer cases among
Hispanic/Latino women while controlling for socioeconomic
status factors, using social
cognitive theory as a framework. This research uses secondary
data analysis of a cross-
sectional survey study, the 2014 Health Information National
Trends Survey, which
collected pertinent breast cancer health information on the
Hispanic/Latino population in
the United States. Descriptive characteristics were derived from
a sample population of
3,677, a logistic regression analysis model was used to compute
crude odds ratio and
confidence interval. The findings revealed that Hispanic/Latino
women had a positive
attitude toward information sources such as physicians and

medical facilities; however,
the findings indicate Hispanic/Latino women had negative
attitude when these
individuals lacked information sources. There were notable
differences in how frequently
Hispanic/Latino women access screening practices, due to
income, knowledge, culture,
and attitudes toward a health condition like breast cancer. The
findings revealed an
opportunity for health professionals to promote breast cancer
awareness by educating
Hispanic/Latino women about the importance of screening
practices and behavioral
compliance to reduce their late-stage diagnoses of breast cancer.
among Hispanic/Latino
Women
By

Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Public Health
Walden University
May 2020
Dedication
I want to dedicate this doctoral degree to my parents, Ravi
Seepersaud and
Seewantie Seepersaud, who have supported my educational
goals and aspirations
throughout my entire academic career. Also, I would like to
thank my two siblings,
Ravindra Sepersaud and Kamini Seepersaud, for their wisdom
and support throughout

my educational path. Finally, I would also like to thank my
girlfriend, Sudha Janaki
Raman, for her support and advice throughout the process.
Acknowledgments
I would like to thank Dr. Amany Refaat, Dr. Tina Cunningham,
Dr. Nancy Rea ,
and Dr. Kai Stewart, for their knowledge, wisdom, and efforts
in helping me get through
this doctoral study process.
i
Table of Contents
Section 1: Introduction to the Study
...............................................................................................
. 1
Background
...............................................................................................
................................ 1

Problem Statement
...............................................................................................
................... 10
Purpose of the Study
...............................................................................................
................. 14
Research Questions and Hypotheses
....................................................................................... 15
Theoretical Foundation for the Study
...................................................................................... 17
Nature of the Study
...............................................................................................
................... 19
Literature Search Strategy
...............................................................................................
........ 19
Definition of Key Variables
...............................................................................................
..... 20
Definition of Terms
...............................................................................................
.................. 22
Assumptions
...............................................................................................
............................. 23
Scope and Limitations
...............................................................................................

.............. 24
Significance, Summary, and Conclusions
............................................................................... 26
Literature Review
...............................................................................................
..................... 29
Breast Cancer Occurrence in Hispanic/Latino Women
........................................................... 30
Hispanic/Latino Women’s Screening Practice and Attitude
................................................... 33
Section 2: Research Design and Data Collection
........................................................................... 45
Introduction
...............................................................................................
.............................. 45
Research Design and Rationale
...............................................................................................
45
Methodology
...............................................................................................
............................ 46
Threats to Validity
...............................................................................................
.................... 62
Data Approval
...............................................................................................

.......................... 63
Summary
...............................................................................................
.................................. 66
ii
Section 3: Presentation of the Results and Findings
...................................................................... 67
Introduction
...............................................................................................
.............................. 67
Data Collection of Secondary Data Set
................................................................................... 69
Results and Findings
...............................................................................................
................ 70
Summary
...............................................................................................
.................................. 86
Section 4: Application to Professional Practice and Implications
for Social Change ................... 88
Introduction
...............................................................................................
.............................. 88

Discussion of Interpretation of the Findings
........................................................................... 88
Conclusion
...............................................................................................
.............................. 100
References
...............................................................................................
..................................... 101
Appendix A: Consent Form (First Mailing)
................................................................................ 123
Appendix B: Participant Study
...............................................................................................
..... 124
1
Section 1: Introduction to the Study
Background
Cancer is defined as a group of conditions that cause cells in the
body to change

and grow in an uncontrolled manner (American Cancer Society,
2017). Most cancers
occur sporadically and are caused by somatic mutations
(American Cancer Society,
2017). Cancers arise when the cells in a particular region of the
body grow out of control
(American Cancer Society, n.d.), and can be classified as
malignant or benign (Centers
for Disease Control and Prevention [CDC], 2017a). Breast
cancer is a condition in which
a cancerous growth occupies the breast tissues. Breast cancer
can originate in different
regions of the breast, and the type of breast cancer a woman
acquires depends on which
cells in the breast become malignant (CDC, 2017a). The most
common form of breast
cancer invasive ductal carcinoma, whereby cancer cells develop
within parts of the breast
tissue outside of the duct (CDC, 2017a). The second-most
common form of breast cancer
is invasive lobular carcinoma, in which cancer cells spread from
the lobules to nearby
breast tissues (CDC, 2017a).

Breast cancer has become a major global public health issue
(Nuño, Castle,
Harris, Estrada, & García, 2011). It affects women of all
demographics in both developed
and developing countries (Banegas et al., 2012). Nearly one out
of every eight women
will develop breast cancer during their lifetime. Worldwide,
more than one million
women are diagnosed with breast cancer each year, of which
more than 410,000 will
succumb to the disease (Curao, 2011). Indeed, breast cancer has
become the most
widespread form of cancer among women worldwide, in both
advanced and developing
2
countries, with estimated mortality ranging from 6 to 29 per
100,000 (Demchig, Mello-
Thoms, & Brennan, 2017).
As of 2017, breast cancer was the fifth most common cause of
cancer-related
death, with 410,000 deaths per year in women (Demchig et al.,
2017). Studies have

shown that various predispositions and other factors increased
the risk of breast cancer,
including genetics, body mass index (BMI), reproductive
factors, alcohol intake, diet,
level of physical activity, knowledge, behavior, and screening
practices (Demchig et al.,
2017, 2013). The incidence of breast cancer varies from country
to country; however,
breast cancer rates are significantly higher in developing
countries than in developed
countries (Demchig et al., 2017).
Alexandraki and Mooradian (2010) reported breast cancer to be
the most common
form of non-cutaneous malignancy among United States women,
noting that it was
particularly prevalent among Hispanic/Latino women
(Alexandraki & Mooradian, 2010).
Hispanics/Latinos are the second-largest demographic in the
United States behind non-
Hispanic whites (NHWs) (Siegel et al., 2015). In the United
States, the incidence of
breast cancer is significantly higher among Hispanic/Latino
women, a phenomenon

attributed to a vulnerability arising from cancer inequality.
These individuals face
considerable barriers to accessing the required levels of health
care and
disproportionately reside in conditions of poverty (Siegel et al.,
2015).
Because the Hispanic/Latino population is increasing in the
United States, breast
cancer among women in this demographic has imposed a
significant financial burden
(Ekwueme, Allaire, Guy, Arnold, & Trogdon, 2016). Breast
cancer has increased
3
markedly in both incidence and prevalence among
Hispanic/Latino women over time
(National Cancer Institute [NCI], 2015). In 2012, breast cancer
was diagnosed in
approximately 17,100 Hispanic/Latino women and caused 2,400
deaths among this
demographic (Breastcancer.org, 2018; CDC, 2017a). Invasive
breast cancer is the most
diagnosed cancer in Hispanic/Latino women in the United

States, accounting for 19,800
new cases and 2,800 deaths in 2015 (American Cancer Society,
n.d.).
In this study, I examine how factors such as knowledge,
attitude, perceptions,
observations, and screening practices are associated with breast
cancer differences in
Hispanic/Latino women. These factors were the primary
variables for the study; essential
to evaluate because they involve distinct elements that can
prevent Hispanic/Latino
women from getting screened for breast cancer (Aparicio-Ting,
& Ramirez, 2003).
Screening participation, strong knowledge, and positive
attitude/perceptions are essential
factors in minimizing the occurrence and reoccurrence of breast
cancer, along with
maintaining the welfare of Hispanic/Latino women (Aparicio-
Ting, & Ramirez, 2003;
Banegas et al., 2012). Hispanic/Latino women have shown low
participation rates in
preventive cancer care (Hurtado-de-Mendoza; Aparicio-Ting, &
Ramirez, 2003), and
tend to hold negative attitudes/perceptions toward breast cancer

(Aparicio-Ting, &
Ramirez, 2003). Limited culturally sensitive breast cancer
prevention education and poor
communication have contributed to Hispanic/Latino women
from various subgroups and
economic scales to be less aware of the screening tests available
to them (Costas-Muñiz
Hunter-Hernández, Garduño-Ortega, Morales-Cruz, & Gany,
2017). Income, health
coverage status, education level, and attitude were the most
consistent predictors of
4
preventive screening behaviors amongst Hispanic/Latino
women. However, breast cancer
screenings relied heavily on the type and quality of information
available that describes
the risks in this population (Salinas, Byrd, & Martin, 2018).
Hispanic/Latino women’s
broadly negative attitude toward breast cancer is due to their
low self-efficacy and
misconceptions regarding their diagnosis of this disease
(Salinas et al., 2018; Chavez-

Korell et al., 2012)
The independent variable attitude was essential to explore in
this study because
fatalistic attitudes and beliefs prevent Hispanic/Latino women
from accessing breast
cancer screening services (HealthDay, 2010). Hence, women
from this racial group are
more likely than NHW women to believe that breast cancer is
not preventable
(HealthDay, 2010). As such, death rates caused by breast cancer
are higher among
Hispanic/Latino women (HealthDay, 2010). Numerous studies
have established a
statistically significant correlation between fatalism and
diminished use of breast cancer
screening services (HealthyDay, 2010). Improving breast cancer
diagnosis, screening
utilization, and mortality outcomes are required for
Hispanic/Latino women to improve
their understanding and prognosis of their condition (Healthy
Day, 2010).
Research results indicate that an increase in health awareness,
consistent

education, and screening practices can significantly change
knowledge and beliefs about breast cancer (Hall, Pfriemer, &
Wimberley, 2007). A
higher proportion of Hispanic/Latino women experience a lower
quality of life (QoL)
than women from other racial groups; an observation that is
associated with late-stage
breast cancer diagnosis in Hispanic/Latino women (Graves et
al., 2012). Such lower
5
quality in the life of Hispanic/Latino women was due to their
later stage diagnosis of
breast cancer (Graves et al., 2012). Women of Hispanic/Latino
descent initiate breast
cancer treatments later in life compared to women from other
racial/ethnic groups (Kouri,
He, Winter, & Keating, 2010). Fatalistic views, a lack of health
knowledge, and low use
of preventive practices have stopped Hispanic/Latino women
from maintaining a higher
quality of health (Bowen et al., 2007; Kouri et al., 2010). In this

study, I examine the
extent to which screening practice, health literacy, and attitudes
have predisposed
Hispanic/Latino women to diagnoses of advanced breast cancer.
Livaudais et al. (2010) explained that low levels of knowledge
about, and
negative associations with, breast cancer screening affect
Hispanic/Latino women’s use
of early detection practices (EDPs). Consequently, such women
experienced delays when
initiating treatment and care after their breast cancer diagnosis.
My quantitative study
revealed that Hispanic/Latino women had a poorer perception
and lower awareness of the
importance of breast cancer screening than NHWs did. As a
result, increasing
Hispanic/Latino women’s knowledge of cancer and propensity
to engage with EDPs may
improve breast cancer diagnoses and outcomes in this
population at an earlier stage. The
working hypothesis of my quantitative study examines the
extent to which knowledge
about breast cancer differs between Hispanic/Latino women and
women of other races.

In this quantitative research study, I provide a perspective on
the epidemiology
and risk factors, as well as the barriers that were preventing
Hispanic/Latino women from
attaining a better QoL (Borrayo et al., 2009). My study differs
from previous studies due
to my focus on Hispanic/Latino women’s lack of knowledge and
resources implicated in
6
breast cancer diagnosis and treatment. I aimed to gain a detailed
understanding of how
the behavior of Hispanic/Latino women influenced their
likelihood of getting screened
for breast cancer (Borrayo et al., 2009; Flynn, Betancourt, &
Ormseth, 2011). This
research is unlike other studies, which have focused little, if at
all, on how attitudes,
perceptions, and screening can influence the incidence of breast
cancer in
Hispanic/Latino women. In this study, I measure the difference
in knowledge, attitude,

and screening practices among Hispanic/Latino women and
women from other races.
Limited availability of health information has impacted the
attitude and screening
practices of Hispanic/Latino women and their use of cancer-
related resources (Haile et
al., 2012; Patterson, 2010). I use the social cognitive theory
(SCT) as the prime
theoretical framework for this study to examine how
Hispanic/Latino women’s health
knowledge affects their willingness to undertake preventive
breast cancer measures. I
designed the research questions in this study to evaluate the
differences in knowledge,
attitude, and screening concerning breast cancer among
Hispanic/Latino women, and
their likelihood of being screened for breast cancer. I aimed to
establish whether
differences in knowledge, attitude, screening practice were
influencing the diagnosis of
breast cancer among Hispanic/Latino women. I used secondary
data analysis of a cross-
sectional study that collected data through survey
questionnaires and phone calls for

inclusion in the Health Information Trends Surveys (HINTS)
database. The findings of
this earlier study had revealed that household income, age,
knowledge group, and
race/ethnicity all significantly affected the incidence of breast
cancer in Hispanic/Latino
7
women (Hunt, 2016). This was true for those who were less
likely to be diagnosed with
breast cancer when the cancer remained localized (Hunt, 2016;
Haile et al., 2012).
Importantly, Hispanic/Latino women were vulnerable to cancer-
related
inequalities, especially breast cancer that resulted from
disproportionate levels of poverty,
failure to have a mammogram, cultural approaches, and barriers
to health care (Siegel et
al., 2015). Hunt (2016) found that breast cancer was the most
diagnosed cancer in
Hispanic/Latino women, as well as the primary cause of
premature death in this group.
Far too often, preventive breast cancer care has gone unnoticed

for Hispanic/Latino
women, leading to later diagnoses and a higher mortality rate
(Huffingtonpost, 2012;
Saint-Germain, & Longman, 1993). Previous studies found more
favorable outcomes
when the disease was detected in its initial stages and followed
by early intervention.
However, Hispanic/Latino women were often diagnosed with
breast cancer later, when
the cancer had almost reached the metastatic stage that is less
responsive to treatments
(Ashing-Giwa et al., 2004; Hunt, 2016).
All women aged 50 or above are required to have a mammogram
every one to
two years in the United States (Seely, & Alhassan, 2018;
Livaudais et al., 2010). The
American Cancer Service (ACS) recommends that women aged
45–54 years undertake
breast cancer screening annually (Seely, & Alhassan, 2018).
The development of breast
cancer growth is faster in premenopausal women than
postmenopausal women (Seely, &
Alhassan, 2018). However, in 2010, the National Health
Interview Survey (NHIS)

reported that only 58.8% of Hispanic/Latino women aged 40–64
had a mammogram
within the preceding two years, a proportion that has declined
further in recent years
8
(Livaudais et al., 2010). Hispanic/Latino women often face
numerous barriers to
obtaining their first mammogram and undergoing breast cancer
screening every one to
two years (Hunt, 2016). Consequently, these women are more
likely to be diagnosed with
breast cancer after the disease had metastasized (Hunt, 2016).
Further, these women
usually only had irregular access to treatment options and
interventions (Livaudais et al.,
2010).
Numerous risk factors contribute to Hispanic/Latino women’s
irregularity in
seeking mammography screenings (Nuño et al., 2011). In turn,
these can affect the
frequency with which women receive a breast cancer diagnosis

at a fatal stage (Nuño et
al., 2011). When compared to NHWs, Hispanic/Latino women
have less access to
preventive services because of their generally lower income
(Livaudais et al., 2010).
Moreover, Hispanic/Latino women face considerable limitations
regarding their ability to
access health insurance coverage (Livaudais et al., 2010). More
significantly, low levels
of health knowledge and awareness about cancer, along with
cultural beliefs, reduce the
likelihood of breast cancer screening and engagement in
preventive behavioral practices
among Hispanic/Latino women (Livaudais et al., 2010). Such
barriers have created and
caused considerable disparities in the early and subsequent
stages of diagnosis (Rauscher,
Allgood, Whitman, & Conant, 2012). In particular,
psychological barriers such as fear of
pain related to the mammography, along with the fear of being
diagnosed with cancer,
have prevented U.S. Hispanic/Latino women from seeking
mammography screening
(Rauscher et al., 2012). Behavioral factors such as disease

screening practices, physical
health beliefs, individual perceptions about breast cancer, and
timely adherence to
9
guidelines also contribute to differences in breast cancer
survival rate among
Hispanic/Latino women (Molina, Thompson, Espinoza, &
Ceballos, 2013). These factors
had also created irregularities in mammography screenings
among these women (Hunt,
2016; Molina et al., 2013).
Molina et al. (2013) reported that early-stage breast cancer
detection and
prognosis improved with adherence to screening guidelines. As
Molina et al. (2013)
explained, this consideration is important for Hispanic/Latino
women because of their
different rates of breast cancer examinations (BCEs) and
mammograms (Molina et al.,
2013). Barriers to communication also gave rise to negative
experiences throughout the

breast cancer continuum, possibly affecting rates of breast
cancer mortality (Molina et al.,
2013). In turn, these negative experiences have contributed to
the development of
negative perceptions of breast cancer screening and
mammography among
Hispanic/Latino women. Healthcare providers are less inclined
to recommend
mammography screenings to Hispanic/Latino women than they
are to NHWs (Molina et
al., 2013). Concurrently, Hispanic/Latino women are less likely
to understand the
recommended follow-up care procedures. As a result, these
women are less likely to
adhere to follow-up care after receiving an abnormal
mammogram test result (Molina et
al., 2013). These behaviors are likely to be a function of lower
levels of health literacy,
linguistic barriers, relatively higher costs of treatment, and
negative attitude toward mammography screenings (Kadivar,
Kenzik, Dewalt, & Huang,
2016; Molina, 2013).

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