Exploring beliefs about cancer among American Samoans: focus group findings

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Abstract

Objective:

To evaluate answers to the following questions among American Samoans: What is cancer? What causes cancer? And what can you do to prevent cancer?

Design:

Focus groups (four with women and four with men).

Settings:

Pago Pago and the Manu’a islands, American Samoa; Honolulu, Hawaii; Los Angeles, California.

Participants:

80 self-reported Samoan men and women over the age of 18 years, selected through non-probability purposive sampling with help from Samoan community-based organizations.

Measurement:

Qualitative content analysis of focus findings to identify themes.

Results:

The concepts that cancer was not a Samoan illness, that failure to follow fa’aSamoa (the traditional Samoan way of life) could lead to cancer, and that a return to fa’aSamoa could prevent cancer were the prevalent themes in the focus groups.

Conclusion:

The value that Samoans place on fa’aSamoa, a traditional healthy lifestyle, provides insights into the design of future intervention programs aimed at improving cancer control in this population.

Introduction

Eliminating health disparities between different ethnic and socioeconomic groups in the United States (US) is one of the major goals of the Department of Health and Human Services Healthy People 2010. In order to eliminate disparities, it is important to examine what different groups know about the etiology, prevention, and treatment of disease. In this article, we will explore knowledge about cancer, a disease for which major disparities exist in morbidity and mortality rates in American Samoans [1], [2]. American Samoans are members of an important and often over-looked ethnic minority, being second only to Native Hawaiians as the largest group of Pacific Islanders in the US [3]. To put the findings into perspective, we will begin with a review of American Samoans’ traditional health beliefs, social and demographic characteristics, and what is known about the cancer-control needs of this population.

The Samoan Islands are located in the South Pacific approximately halfway between Hawaii and Australia. According to archaeological evidence, Samoan people are Polynesians who have migrated from the west (the East Indies, the Malay Peninsula, or the Philippines). The oldest known site of human occupation in Samoa dates back to about 1000 bc. The first Europeans reached Samoa in 1722. Over the years, many nations claimed authority over the Samoan Islands. In 1900, the Berlin Treaty ceded the western Samoan Islands to Germany and the eastern islands to the United States. Samoa (formerly Western Samoa) became an independent nation in 1962. American Samoa is now an unincorporated territory of the United States. Pago Pago, on the island of Tutuila, served as an important US naval base until the end of World War II. Since then, the islands have been under the administrative direction of the US Department of the Interior.

According to the accounts of early European visitors, the range of indigenous diseases on the islands was limited. Samoans lived in an environment where few endemic diseases or natural hazards existed, and the isolated nature of the islands limited contact with other groups [4]. In addition, a series of common practices among Samoans probably reduced the range of illnesses. These practices included maintaining meticulous personal hygiene, paying attention to water quality, and eating a diet consisting largely of fruits, vegetables, and seafood. Moreover, the range of natural and environmental hazards was limited. At sea, there was a chance of sailing accidents and attacks by sharks or other dangerous animals. On land, natural hazards included bites from poison ants and centipedes. However, overall, early European visitors characterized the Samoan Islands as having a relatively benign environment for its inhabitants.

When injuries or illnesses did occur, Samoans often believed that they were the results of displeasing gods or spirits (aitu) [4]. The fact that aitu had the power to cause illness gave rise to a general set of health beliefs, and Samoans translated these beliefs into practices that would identify the probable cause and the appropriate response to illness. Therefore, to treat illnesses, they attempted to identify the cause of the aitu's displeasure and to placate the deity involved. They frequently offered prayers, feasts, and valuables such as fine mats to the gods for prevention and recovery from illnesses. However, Samoans also participated in other medical practices that were not directly related to a supernatural agency. For example, early European visitors noted the use of herbal remedies for medicinal purposes and the use of scented oils for skin problems. Moreover, when missionaries later made western medicines available, Samoans rapidly accepted them and sought them out. However, they believed that these new remedies were useful only for certain types of illnesses, whereas traditional practices were useful for others. Thus, began this population's use of both traditional and western medicine that continues to this day.

The major population centers for American Samoans are the US Territory of American Samoa and a few urban areas in the US. According to the US Census, 91,029 Samoans resided in the 50 States with an additional 57,291 in American Samoa in 2000 [3]. The largest concentrations of Samoans (outside of the Territory) lived in California (approximately 30%). Most of the remainder lived Hawaii, Washington, Texas, and Utah.

Residents of American Samoa have a close-knit, communal way of life called fa’aSamoa, the Samoan way [5]. Fa’aSamoa stresses respect for everyone and in particular for the elders. The villages have a series of chiefs, including a High Chief, who has authority over the residents. Churches play an important role in American Samoan life, and most families pursue the traditional practices of prayer hour and curfew. American Samoans in California and Hawaii also tend to live in tightly knit and regionally defined communities usually establishing close ties to the local churches. Many remain bound to families in American Samoa, visit their homeland on special occasions, send monthly remittances to their families, and receive new migrants, practices that reinforce the home ties to American Samoa [6].

American Samoans tend to be younger, have higher birth rates, have fewer years of formal education, and have lower family incomes than non-Latino Whites [3]. The combination of relative youth and high birth rates results in large families and a high growth rate of the population. In California and Hawaii, Samoan families are about 50% larger than the average family. The education and income levels of American Samoans also differ from other American ethnic groups. Whereas in the US, more than 20% of the population completes college, less than 10% of Samoan men and women obtain college degrees. American Samoans also have low incomes. Approximately, 27.5% of American Samoan families have incomes below the poverty level, compared to 9.6% of the overall population.

Cancer is the second leading cause of mortality among American Samoans, and the most common cancers are similar to those of other ethnic groups [1], [2], [7], [8], [9]. For example, breast cancer is the most common cancer among American Samoan women with a proportional incidence of 26.8%, and lung cancer is the most frequently occurring cancer among American Samoan men with a rate of 25.6% [2]. Alternatively, this population has a higher proportional incidence than non-Latino Whites for other cancers including cervical cancer in women (7.2% versus 2.5%) and stomach cancer in women (5.2% versus 1.6%) and men (7.8% versus 2.6%) [2]. In addition, cancers of various types are diagnosed at a later stage in American Samoans than in the comparison group. Clearly, cancer is a major public health problem in this population.

Population-based surveys have revealed that American Samoans believe that a variety of factors may increase risk for cancer, including life style choices such as eating an unhealthy diet and environmental factors such as breathing polluted air [10], [11], [12]. For example, 65% of respondents agreed with the statement that a high-fat diet was a risk factor for breast cancer, and 80% agreed that air pollution was a risk factor for lung cancer. Moreover, the studies revealed that the majority of the population agreed that cancer could be prevented; however, use of cancer-prevention services was quite low. For example, only 64% of women had ever had a Pap smear [11] and only 33% had ever had a mammogram [12]. These rates are much lower than those for most other populations [13], [14], [15], [16].

While this quantitative data have added much to our knowledge about cancer in American Samoans, it does not provide the depth of understanding that can be obtained through qualitative studies such as focus group research. The focus group is a socially oriented research procedure that allows interaction of participants in real life situations that is not possible in most quantitative studies [17]. Moreover, focus groups allow the moderator to probe and to explore unanticipated issues. In this article, we report findings from focus groups of American Samoan men and women that provide valuable insights into the Samoan culture and that help to explain some of the results regarding cancer-control issues found in the population-based surveys.

Section snippets

Materials and methods

We conducted eight focus groups (four with women and four with men) among 80 American Samoans in three study sites, four in American Samoa (two in Pago Pago on the island of Tutuila, and two on the islands of Manu’a where the population has maintained a more traditional culture), two in Honolulu, Hawaii, and two in Los Angeles, California. We chose these sites because they contain the largest concentrations of American Samoans in the US [3]. Directors of Samoan community-based organizations

Results

Review of the transcripts revealed several major themes that were discussed during each focus group (Table 1). Several of the themes overlapped to provide answers to the following questions: what is cancer? What causes cancer? And what can you do to prevent cancer? In particular, the concepts that cancer was not a Samoan illness, that failure to follow fa’aSamoa could lead to cancer, and that a return to fa’aSamoa could prevent cancer were prevalent in the focus groups. The following discussion

Discussion

Cancer is a complicated set of diseases that are incompletely understood by the medical sciences. It is not surprising then that the general public has a relatively limited comprehension of what it is, what causes it, or how to prevent it. Indeed, several recent studies have documented culturally related beliefs about cancer that differ from the biomedical model [13], [14], [15], [16]. In order to improve cancer control, it is important to have a better understanding of these beliefs.

Our

Acknowledgements

Supported in part by grants from the National Cancer Institute (U01 CA64434 and P30 CA62203). The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the views of the funding agency.

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