According to the World Health Organization (WHO), breast cancer is the world’s most prevalent cancer—there were 7.8 million women at the end of 2020 who were diagnosed with breast cancer in the past five years, and 2.3 million women diagnosed in 2020 alone. While breast cancer treatment can be highly effective, especially when the cancer is identified early, large ethnic and racial disparities in breast cancer education, screening, and treatment persist today.

SIS professor Maria De Jesus’s recent research, published in Women’s Health Reports, investigated the efficacy of mobile health (mHealth) intervention strategies related to breast cancer knowledge and screening among low-income Latina immigrants. We spoke with her to learn more about this research.

You also can read the full original article, “A Mobile Health Breast Cancer Educational and Screening Intervention Tailored for Low-Income, Uninsured Latina Immigrants,” with access provided by American University Library.

What is mobile health, and why are mHealth intervention strategies important for health knowledge, behavior, and outcomes and reducing barriers to heath care?

The WHO defines mHealth as the “use of mobile and wireless technologies to support the achievement of health objectives.” mHealth intervention strategies, therefore, provide health information and interventions outside of the traditional clinic setting, relying on mobile technologies such as apps, smartphones, and tablets. mHealth is a rapidly expanding field in the digital health sector and has the potential to transform health service delivery across the globe. Certain factors are driving the increased use of mHealth, including rapid advances in mobile technologies and applications and the continued growth in coverage of mobile cellular networks.

According to the International Telecommunication Union (ITU), there are now over 5 billion mobile phone subscribers, with over 70 percent of them residing in low- and middle-income countries. The penetration of mobile phone networks in many low- and middle-income countries surpasses other infrastructure, such as paved roads and electricity. Increasingly high speeds of data transmission, alongside cheaper and more powerful handsets, are transforming the way health services and information are accessed, delivered, and managed. With increased accessibility comes the possibility of achieving more equity, for example, by increasing access to health knowledge and reducing barriers to health care.

What ethnic and racial disparities in breast cancer persist today? Why did you decide to focus this research on low-income uninsured Latina immigrants specifically?

Breast cancer is the most common cancer diagnosed worldwide and the leading cause of cancer mortality in women. Tremendous progress has been made in breast cancer care, as evidenced by steadily rising overall survival rates observed in the past three decades, largely due to earlier detection of disease with screening mammography and advances in treatment. However, these outcome benefits are not universal. A study by Heer et al. (2020) in The Lancet Global Health revealed that countries with a low Human Development Index (HDI) faced a greater burden of breast cancer for both new cases and deaths compared to higher income countries. Moreover, while countries with a very high HDI had the highest breast cancer incidence, countries with low and medium HDI had the highest mortality.

Although the greatest burden of breast cancer now falls on low HDI countries, some countries with a high HDI reveal cancer inequities. Even within the United States—a country in the very high human development category—racial/ethnic identity is still one of the stronger predictors of breast cancer mortality, with Black women dying at a higher rate than White women. Breast cancer inequities reveal a 40 percent higher mortality rate, younger age distribution, greater advanced-stage distribution, and an increased risk of aggressive disease among Black women. The intersection of race, poverty, and social, economic, and structural factors—which are often referred to as the social determinants of health—drives these inequities. These inequities will likely be further exacerbated by diversion of resources from chronic non-communicable diseases to communicable diseases during and following the COVID-19 pandemic.

Social determinants also significantly influence cancer disparities because they impact nearly every aspect of care, including access to insurance, preventive care, and treatment. Latinas in the US have a higher incidence of breast cancer than their counterparts living in Latin America. While breast cancer screening has increased across all racial and ethnic groups in the US, Latinas are still more likely to be diagnosed with late-stage breast cancer, partially due to lower rates of screening mammography or lack of follow-up on abnormal screening results. This delay results in more advanced breast cancer at the time of diagnosis, which contributes to higher breast cancer mortality rates. Latinas are disproportionately affected by multiple obstacles to care— including low income, low health literacy, long travel distances to screening sites, limited access to care, no paid medical leave, and lack of health insurance—which is reflected in the lower rates of screening mammography among this group.

This study investigated the efficacy of mHealth intervention strategies to determine which was more likely to increase breast cancer knowledge and screening among the participants. What did your study reveal about the intervention strategies studied?

Surprisingly, the results of this study revealed that the percentage of mammography adherence did not differ among the three intervention groups—mobile phone educational messages, mobile text educational messages, and the control group (standard mail). All three intervention strategies are equally effective in contributing to the increase in knowledge and mammography adherence. One plausible explanation for the results is that the actual method of communication is not what ultimately matters in increasing screening mammography rates and breast cancer knowledge among Latina immigrants. The key issue in promoting breast cancer knowledge and the uptake of screening mammography among Latinas is how the messages are constructed and who the messenger is, rather than which communication method is adopted to deliver the messages.

The automated educational messages sent to all the participants—regardless of method of communication—were personalized, linguistically and culturally tailored, and provided relevant and clear information to the audience, purposefully targeting information gaps related to breast cancer and prevention. In addition, the educational messages in the intervention incorporated a faith- or family-based component, as these elements were identified as essential in the development of the message during the formative focus groups. The other takeaway is that we need to reduce the barriers to screening mammography encountered by low-income, uninsured Latina immigrants if we want to reduce cancer inequities.

This study was designed and implemented with your community partner, Nueva Vida, a nonprofit, community-based organization that provides free cancer screenings and comprehensive and culturally competent services to Latinas with cancer or at risk for developing cancer. Why was it important to draw on a community-based research approach in this study?

Community-based participatory health research is an approach that emphasizes the active role of communities in highlighting and addressing the issues that matter to them. This approach seeks to empower communities and promotes changes in practice and policy with an aim to foster health equity. Whereas traditional research views a community as a place to conduct research “in,” a participatory and community-engaged research approach views community as a unit of identity to conduct research “with,” beyond just the recruitment phase. The principles of this approach are based within the premise of co-learning, where both community and academic partners’ strengths and capacity needs are acknowledged. Through this approach, the hierarchy of knowledge that prioritizes academics over community is replaced instead with knowledge democracy, which values each partner.

For me, it was extremely important to partner with Nueva Vida and to adopt a community-based research approach in this study for several reasons. First, the approach recognizes that Nueva Vida and the women served are the experts in their own right on how these cancer inequities are directly impacting them and the larger Latinx community. Second, it appreciates the complexity of cancer inequities by acknowledging that no one sector, discipline, or organization can achieve health equity alone. Change, instead, requires collective effort of multiple partners—academia, community, and other sectors—to tackle barriers and make an impact across the social determinants of health, and ultimately, to promote health equity.

How will the results of this study enhance cancer prevention efforts among underserved populations?

The research has ended, yet to this day, I still receive phone calls from uninsured Latinas in the greater Washington, DC, metropolitan area inquiring about how they can obtain a free mammography screening. Clearly, there continues to be an access issue for many of these women. This research has implications for reducing these inequities by prioritizing equal access to quality breast cancer prevention and treatment, not only as a public health issue but also as a human rights issue. This project followed my previous research with this community that identified breast cancer screening barriers among Central American and Mexican immigrant women.

Based on the results of this study, the key to increasing breast cancer knowledge and screening adherence among underserved, ethnically diverse populations lies in the provision of culturally and linguistically tailored breast cancer and screening education delivered by a patient navigator or another trusted source of information. A breast cancer preventive intervention program that uses the individuals’ preferred method of communication and is combined with a free or low-cost mammogram holds promise to be an effective method in reaching underserved populations with high breast cancer burdens.