By David Kiefer, MD, Editor

Clinical Assistant Professor, Department of Family Medicine, University of Wisconsin; Clinical Assistant Professor of Medicine, Arizona Center for Integrative Medicine, University of Arizona

Dr. Kiefer reports he is a consultant for WebMd.

SYNOPSIS: Healthcare providers and women with recent chemotherapy for breast cancer commented on some of the stress management challenges as well as techniques that are already being used to address them.

SOURCE: Martinez Tyson DD, et al. Understanding the stress management needs and preferences of Latinas undergoing chemotherapy. J Cancer Educ 2015 May 8 [Epub ahead of print].

Summary Points

  • This qualitative research study collected information from 33 Latinas with cancer, as well as healthcare providers with experience working with that demographic.
  • Many themes emerged, including poor communication by health care providers about stress during chemotherapy, concerns about family responsibilities, and the importance of spirituality during such difficult health/disease times.

The toll that a cancer diagnosis, therapy, and follow-up take on an individual and his or her family cannot be understated. The medical literature touches on many approaches to bolster physical and mental well-being during this process, but there are gaps in the research for some demographics. The authors of this study point out a particular paucity in interventions to address cancer treatment side effects and quality of life in Latinas.

This qualitative research study was designed to understand specific “stress management and information needs” of Latinas undergoing chemotherapy, ultimately to culturally tailor a well-studied stress management intervention for this demographic. The researchers used focus groups and in-depth individual interviews to collect information, both from healthcare providers (see Table 1, column 1) and from people with a diagnosis of cancer (see Table 1, column 2). Word-of-mouth and flyers were distributed, facilitated by the Tampa Bay Community Cancer Network, to recruit study participants. In addition, a “snowball” technique was used, essentially asking current study participants if they knew anyone else who might be interested in participating in the focus groups and/or interviews.

Table 1: Inclusion Criteria for Study Participants

Health care providers

Latina patients

  • Experience with community Latina cancer patients
  • Knowledge of Latino culture
  • Knowledge of cancer patients’ needs
  • Adult
  • Latina/Hispanic as self-identified
  • Breast cancer diagnosis
  • Spanish-speaker
  • Chemotherapy treatment in last 12 months

Ten health care providers were interviewed using a semi-structured interview guide. The results from these interviews were used to develop the topics and questions for the Latina patients’ focus groups and interviews. A total of 20 Latina patients were interviewed, and four focus groups were held involving 13 Latinas. Table 2 lists some of the topics of discussion and questioning for the providers and patients. All of these interviews and focus groups were recorded with permission and transcribed. The transcriptions were then coded by the lead author to identify emergent themes. Demographic information was collected on the Latina patients with respect to years in the United States, country of origin, language(s) spoken, cancer stage at diagnosis, and presence of stress management tools during chemotherapy.

Table 2: Topics for Interviews and Focus Groups

Health care providers

Latina patients

  • Experience working with Latina cancer survivors
  • Stressors during cancer treatment
  • Experience with
    chemotherapy
  • Chemotherapy stressors
  • Stress management beliefs and techniques

The 10 providers were all women, 60% Latino, and a mixture of physicians, nurses, social workers, and support group leaders. Seventy percent had worked with Latina cancer survivors for more than 6 years. The 33 Latina patients, average age of 50, represented 10 countries, and 64% did not have any formal stress management techniques during chemotherapy. The length of time patients had been in the United States was slightly skewed to < 5 years and > 15 years (bimodal).

With respect to themes, healthcare providers honed in on logistical hurdles experienced by patients, including transportation, finances, and a lack of stress management programs, providers, or available referrals. Patients mentioned some of those same logistical issues, but elaborated by saying there was often a lack of information (in Spanish, especially) and poor communication with providers. A major area of stress for Latina patients was related to family and perceived inability to meet responsibilities or fear of causing burden, in addition to the difficulties of being away from family if their family was still in their home country.

Latina patients turned to several “techniques” to manage stress during chemotherapy. A connection to, and interacting with, family was vitally important to Latina patients. Also, patients mentioned faith, prayer, and spirituality, as well as exercise, reading, listening to music and watching television; of this list, healthcare providers only mentioned those related to spirituality, perhaps illustrating a discordance between providers’ and patients’ perceptions.

Of note, only one of 33 patients had been given information about stress management by their health care provider.

Commentary

This is a very important and interesting article, illustrating some important stress management themes relevant to a specific demographic (Latinas), but with some more general relevancy as well. If we believe these results, and the fact that the authors mention saturation of their findings with subsequent focus groups and interviews, then healthcare providers need to do a better job of addressing stress management in their Latina patients undergoing chemotherapy. Chemotherapy is not easy, often causes untoward effects, and patients would arguably benefit by having some help during the process to emerge in better physical and mental health. In this demographic, as illustrated by an extensive literature about Latino cultural beliefs,1 it would behoove healthcare providers to focus on family and spirituality/religion as their patients cope with stress and stressors.

In our own research in Madison, WI, we used similar research methods to investigate herbal medicine use in the Latino community.2 This is an effective approach for gathering general information about trends or attitudes in a particular demographic. It can lead researchers, public health experts, community organizers, and clinicians to better assess community needs, strengths, and weaknesses, just as in this research project; it answers the question “What is happening in demographic with respect to health beliefs?” From this project, we understand just that. Issues surrounding family, logistics, and communication are paramount, and many techniques were used to deal with stress, only some of which were mentioned by the healthcare providers. We clinicians can probably always improve in the patient-centered provision of care, finding out about our patient’s approaches to health and healing, and supporting it. A study like this helps to bring to light some of the general themes; it is up to us in clinic, face-to-face, to personalize our care.

One positive aspect of this study is that the researchers queried about country of origin and years in the United States, two major factors relevant to a person’s health cosmology and experience with the healthcare system. I would have liked to see some efforts at correlating those variables with the researchers’ qualitative findings. Is it more likely that someone from Mexico turn to spirituality to cope with stress than someone from Chile? The longer that someone is in the United States, is television more their “go-to” rather than family? And, how much are these choices based on country of origin as opposed to the personal experiences of each individual? These connections would be important, but the researchers didn’t comment, so we don’t know if these relationships exist.

Compared to the plethora of data about nutrition, dietary supplements, and herbal medicine, there is a relative “faith desert” in the medical literature. It was good to see the topic of spirituality finding its way into these results, corroborating what has been some intriguing research of late3 as well as some recent issues of Integrative Medicine Alert.4,5 This study touches not only on spirituality, but on the many psychosocial factors that weave together to contribute to a person’s totality of health and well-being, including community and family support. It begs the question of where the line exists between what we call integrative health/medicine and simply high-quality, whole-person provision of healthcare. Religion and spiritual practices have been in play long before these topics received a tab on the web page of the National Center for Complementary and Integrative Health.

That said, studies such as this one are a good reminder for clinicians to entertain the totality of health for all patients, perhaps especially for those with a diagnosis such as cancer. There is no downside to helping patients to engage in all aspects of their life for the healing that they need. In addition, the appearance of this multi-faceted approach to health and well-being may very well be culture specific. We all know, and this study re-affirms, that the top of the list for our Latino patients’ adjunctive cancer therapy may (or may not) differ from our Caucasian, African American, Hmong, and Asian patients; we will need to ask and be open to the answers for all of our patients, regardless of their background. At least, clinicians will want to have a basic idea of cultural preferences, not unlike those shared in a ground-breaking book about Hmong healing practices6 or any one of the multitude of sources about caring for Latino patients.1

References

  1. Juckett G. Caring for Latino patients. Am Fam Physician 2013;87:48-54.
  2. Kiefer D, et al. A pilot study of herbal medicine use in a midwest Latino population. Wis Med J 2014;113:64-71.
  3. Kim NY, et al. Effects of religiosity and spirituality on the treatment response in patients with depressive disorders. Compr Psychiatry 2015 Apr 24.
  4. Sasser H. Spiritual Care at the End of Life: Who Defines a Good Outcome? Integr Med Alert 2014;17:1-3.
  5. Sasser H. Spirituality and in vitro fertilization. Integr Med Alert 2014;17:40-43.
  6. Fadiman A. The Spirit Catches You and You Fall Down; A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux; 1997.