A Holistic and Community-Based Service Program Promoting Mental Health among Latina Breast Cancer Survivors and Informal Caregivers.

This report discusses the components and uptake of a holistic-health community-based service program designed to promote mental health among Latina breast cancer survivors and their caregivers. Salud Holística para la Mujer's (SAHOM) strategic plan tackled all phases of the mental health prevention continuum and of the cancer care continuum.

Complementary and Alternative Medicine Use in Patients With Cancer and Immigration Background.

PURPOSE: Studies have shown that patients with cancer are more likely to use complementary and alternative medicine (CAM) than noncancer patients for symptom relief and hope. We aimed to evaluate factors of race, ethnic groups, and immigration status in attitude of patients with cancer in seeking out CAM. PATIENTS AND METHODS: This is a prospective questionnaire study where information on demographics, cancer information, race/ethnicity, immigration duration, and psychosocial factors was correlated with the CAM use in a community cancer center located in the borough of Brooklyn, at New York City. RESULTS: Among 658 patients, the prevalence of CAM use was 66.11%. CAM use was 71.98% in females and 54.34% in males (P = .113 × 10-4). Patients of African descent had higher CAM use (72.73%) than the White patients (63.53%; P = .0371). There was no difference of CAM use between the US born (68.77%) and the immigrants (63.98%, P = .199) as a whole; however, comparing with the US born (66.50%), Asian-born immigrants had lower CAM use (53.77%, P = .0161), whereas Latin-American born had a numerical trend toward higher CAM use (74.83%, P = .0608). The number of years of living in the United States was not associated with more CAM use. Prayer and spirituality was the most common CAM subtype used (25.91%). There was no difference in CAM use in the respective non-White ethnic groups whether they were US born or non-US born. CONCLUSION: In this cohort of patients with cancer enriched with immigration background, CAM use was the highest in African American patients. The use of CAM in the non-White patients was associated with their ethnic background, regardless whether they were US born or not. Cultural roots appeared to be a strong influencing factor for the usage of CAM.

Racial and ethnic differences in perinatal depression and anxiety.

BACKGROUND: Findings on racial and ethnic differences in perinatal depression/anxiety are mixed. METHODS: We assessed racial and ethnic differences in depression, anxiety, and comorbid depression/anxiety diagnoses in the year before, during, and the year after pregnancy (n = 116,449) and depression severity during (n = 72,475) and in the year after (n = 71,243) pregnancy among patients in a large, integrated healthcare delivery system. RESULTS: Compared to Non-Hispanic White individuals, Asian individuals had lower risk of perinatal depression and anxiety (e.g., depression during pregnancy relative risk [RR] = 0.35, 95 % confidence interval [CI]:0.33-0.38) and postpartum moderate/severe (RR = 0.63, 95 % CI:0.60-0.67) and severe (RR = 0.66, 95 CI:0.61-0.71) depression but higher risk of moderate/severe depression during pregnancy (RR = 1.18, 95 % CI:1.11-1.25). Non-Hispanic Black individuals had higher risk of perinatal depression, comorbid depression/anxiety, and moderate/severe and severe depression (e.g., depression diagnoses during pregnancy RR = 1.35, 95 % CI:1.26-1.44). Hispanic individuals had lower risk of depression during pregnancy and perinatal anxiety (e.g., depression during pregnancy RR = 0.86, 95 % CI:0.82-0.90) but higher risk of postpartum depression (RR = 1.14, 95 % CI:1.09-1.20) and moderate/severe and severe depression during and after pregnancy (e.g., severe depression during pregnancy RR = 1.59, 95 % CI:1.45-1.75). LIMITATIONS: Information on depression severity was unavailable for some pregnancies. Findings may not generalize to individuals without insurance or outside of Northern California. CONCLUSIONS: Non-Hispanic Black individuals of reproductive age should be targeted with prevention and intervention efforts aimed at reducing and treating depression and anxiety. Asian and Hispanic individuals of reproductive age should be targeted with campaigns to destigmatize mental health disorders and demystify treatments and systematically screened for depression/anxiety.

Pediatricians' role in healthcare for Latino autistic children: Shared decision-making versus "You've got to do everything on your own".

LAY ABSTRACT: Latino parents may choose to use complementary health approaches, such as vitamins, supplements, and special diets, for their autistic children. However, they might not tell their pediatrician about their complementary health approach use if they worry that the pediatrician will disapprove or judge them. This fear, along with pediatricians' lack of autism knowledge, creates barriers to "shared decision-making" between parents and pediatricians. Shared decision-making is a process where families and healthcare providers collaborate and exchange information in order to come to an agreement about treatment options. In our qualitative study with 12 bilingual Latino families of autistic children, we interviewed and observed families to learn about their experiences with both conventional healthcare (their pediatrician) and complementary health approaches. Our study results describe the parents' different pathways to an autism assessment, a process that is sometimes called the "diagnostic odyssey." The parents reported that conventional healthcare met their needs for their child's physical health but not for their child's developmental challenges. The parents who used complementary health approaches for their autistic children were more frustrated about a lack of autism information from pediatricians than those who did not use complementary health approaches. Finally, we describe two examples of successful shared decision-making between parents and pediatricians. We conclude that pediatricians who are able to talk about complementary health approaches with Latino families may help to facilitate shared decision-making and reduce healthcare disparities for Latino autistic children.

Gender Differences in Self-Efficacy for Diabetes Self-Management Among Hispanics: The Mediating Role of Perceived Support and Depressive Symptoms.

PURPOSE: The purpose of this study is to examine the extent to which perceived support and depressive symptoms might interfere with Hispanic patients' ability to manage their diabetes and whether these effects vary by gender. METHODS: Data were collected from a cohort of 232 Hispanic men and women with type 2 diabetes mellitus (T2DM). Conditional process analysis was used to test a moderated mediation model of the time-lagged processes associating gender, diabetes support, and depressive symptoms with reported self-efficacy after 3 months. RESULTS: Increased depressive symptoms were associated with lower self-efficacy, but the conditional effects varied among men and women. The index of moderated mediation was significant, indicating that among women, the indirect effect of depressive symptoms on self-efficacy was contingent on lower levels of perceived support. Among men, increased depressive symptoms were directly associated with declines in self-efficacy and were not conditional on perceived support. CONCLUSIONS: Results of the study have important implications for gender health equity. Mental health screening and an assessment of support needs may be important for determining appropriate complementary therapies when treating Hispanic women with chronic conditions such as diabetes. Attention to possible differences in gender-specific mental health needs could lead to improved self-management, better glycemic control, and more equitable health outcomes.

Evaluating Patient and Family Experience Among Spanish-Speaking and LatinX Patients: a Scoping Review of Existing Instruments.

INTRODUCTION: LatinX populations are rapidly growing in the USA, but still report lower levels of patient centered care and satisfaction when compared to their non-LatinX white counterparts. This review encompasses literature which describes patient experience instruments that (1) evaluate LatinX experience, (2) have validated Spanish versions, or (3) measure language-concordant care experiences. METHODS: A scoping review of literature in Ovid Medline, CINAHL, and PsycINFO was conducted. Articles were excluded if they were not applicable to the health care industry, did not include a patient experience instrument, or did not include LatinX or Spanish-speaking individuals within their study population. Data extraction was performed for concepts measured, study size, population, health care setting, and languages validated. RESULTS: This review identified 224 manuscripts. Of these, 81 met full inclusion criteria and represented 60 unique instruments. These covered six categories: general patient experience (43%, n = 26/60), experiences of discrimination/mistrust (12%, n = 7/60), cultural factors (10%, n = 6/60), patient-provider relationship (10%, n = 6/60), and communication (8%, n = 5/60). The remaining instruments measured multiple categories (17%, n = 10/60). Just over one third of instruments (n = 24, 5 pediatric, 19 adult) were validated in Spanish and an additional 14 (23%) were validated in English alone. Finally, 4 (7%) instruments were identified which were developed for use in a language concordant setting. CONCLUSION: Many instruments were identified which evaluate LatinX patient experience; however, none was both validated in Spanish and measured in all key categories of experience described above. Additionally, few instruments were developed for holistic evaluation of patient experience in pediatric or language concordant care settings.

Creating community: Expanding access to psychosocial programs for Latina breast cancer survivors.

OBJECTIVE: Breast cancer survivors often derive benefits from psychosocial interventions, but less is known about Latina women's experiences. Given the disproportionately high disease burden faced by Latina survivors, it is critical to examine ways to enhance access for this population. Thus, the present study aimed to (a) examine women's perceptions of factors associated with effective delivery of a psychosocial program designed for Spanish speaking women with limited access to care, and (b) identify the mechanisms by which the program enhanced women's psychological well-being. METHODS: In a qualitative study, in-depth interviews were conducted with 15 immigrant Latina breast cancer survivors who previously received psychosocial services at a community-based organization. Grounded theory was used to analyze the data. RESULTS: Through open, axial, and selective coding, we arrived at the core category achieving a sense of community. The psychosocial program promoted access and enhanced women's psychological well-being by creating a sense of community among participants. This was facilitated by three primary aspects of service provision: access factors, a holistic approach to health, and therapeutic factors imparted through a biweekly support group. CONCLUSIONS: Psychosocial services promoted a sense of community among Latina breast cancer survivors while reflecting their cultural values and unique psychosocial needs. Findings may guide the development of interventions to increase access to care, enhance health outcomes, and create and maintain a sense of community among medically underserved populations.

When Engagement Leads to Action: Understanding the Impact of Cancer (Mis)information among Latino/a Facebook Users.

Latinos/as - the largest minority group in the U.S. - are avid Facebook users, making this an opportune tool to educate on the uptake of cancer prevention and screening behaviors. However, there is a dearth in scholarship exploring how Latinos/as engage with and act upon health content encountered on social media, which may be influenced by cultural values. This qualitatively-driven, mixed-methods study explores how Latinos/as engage with and act upon cancer prevention and screening information (CPSI) on Facebook. During one-on-one, in-depth interviews, participants (n = 20) logged onto their Facebook account alongside the researcher and discussed cancer-related posts they engaged with during the past 12 months. Interview questions included the reasons for engagement, and whether engagement triggered further action. Interviews were analyzed thematically. In parallel, a content analysis of the CPSI posts identified during the interviews was conducted. The majority of CPSI posts participants engaged with contained food-related content and visual imagery. Engagement was most common when individuals had personal relationships to the poster, when posts included videos/images, and when posts contained content promoting the curative properties of popular Latin American foods. Engagement often led to information-seeking and sharing, discussing content with others, and/or changing health behaviors. Findings highlight the importance of adequately contextualizing how cultural values influence the ways in which Latinos/as engage with and act upon CPSI on Facebook, which may lead individuals to bypass evidence-based procedures. Multi-pronged efforts are necessary to adequately leverage social media to empower Latinos/as to partake in behaviors that effectively reduce cancer health disparities.

Cultural Health Beliefs and Practices Among Hispanic Parents.

Parents' beliefs about and approaches to their child's health vary with culture and change within cultures over time. To provide an updated understanding of folk and traditional medicine (FTM) among Hispanic parents in the United States, we surveyed 200 caregivers identifying their child as Hispanic in a pediatric primary care clinic about their cultural health beliefs and practices. Overall, 84% of participants believed in ≥1 folk illness, with foreign-born participants more likely than US-born to endorse folk illness beliefs. Eighty-three percent had used cultural remedies for their children. Of those, although just 15% had discussed such practices with their child's provider, 86% would feel comfortable doing so. No demographic factors predicted use of cultural remedies/healers or comfort talking to providers. Beliefs and practices related to FTM are prevalent among Hispanic parents and cannot be predicted using demographics; providers should routinely ask all families about FTM.

Patient perspectives on how to demonstrate respect: Implications for clinicians and healthcare organizations.

OBJECTIVE: Clinicians and healthcare organizations are ethically obligated to treat patients with respect, yet it is not clear what actions best demonstrate respect to patients. This exploratory qualitative study aimed to understand what actions on both an individual and organizational level effectively demonstrate respect for primary care patients. METHODS: We conducted semi-structured telephone interviews with primary care patients in an integrated healthcare delivery system in Oregon and an integrated safety net health system in Colorado who were participating in a genomics implementation research study of a hereditary cancer screening program. We systematically coded interview transcripts using a coding framework developed based on iterative review of the interview guide and transcripts. We further analyzed the data coded with sub-codes relating to patients' experiences with respect in healthcare using a descriptive content analysis approach. RESULTS: We interviewed 40 English-speaking (n = 30, 75%) and Spanish-speaking (n = 10, 25%) patients. Most interviewees identified as female (n = 35, 88%) and either Hispanic/Latino(a) (n = 17, 43%) or White or European American (n = 15, 38%). Interviewees identified two categories of efforts by individual clinicians that demonstrate respect: engaging with patients and being transparent. They identified five efforts by healthcare organizations: promoting safety and inclusivity, protecting patient privacy, communicating about scheduling, navigating financial barriers to care, and ensuring continuity of care. CONCLUSIONS: Our findings suggest that patients' experiences of respect depend on efforts by individual clinicians as well as healthcare organizations. Our findings offer insight into how clinicians can build stronger partnerships with patients and how organizations can seek to promote access to care and patient safety and comfort. They also illustrate areas for future research and quality improvement to more effectively respect patients.

If we offer, will they come: Perceptions of yoga among Hispanics.

OBJECTIVE: Yoga is underutilized by the Hispanics. This study examined perceptions of benefits and barriers to yoga among Hispanic adults, to provide information that may increase their participation in this practice. SETTING: Participants were recruited from a Community Center serving low-income Hispanics. DESIGN: Self-administered cross-sectional questionnaires assessing benefits and barriers to yoga were conducted in Spanish and English. Fisher's exact test was used to examine perceptions of yoga by gender, age, and prior experience. RESULTS: Participants (ages 18-85, 65 % women, n = 121) reported several benefits to yoga. Hispanic women, individuals 65 y or older, and those with prior experience, perceived more benefits. Barriers to yoga also differed by demographics. Men reported that time and the perception that they would have to do unrealistic pretzel-like poses as deterrents to yoga practice; younger individuals perceived yoga to be boring, and those with no experience perceived lack of flexibility and feeling like an outsider in class, as barriers to yoga. The most common barrier, across subgroups, was the cost associated with yoga practice. The majority of participants reported being willing to attend yoga classes if offered at a low cost. CONCLUSION: Perceived barriers related to yoga reflect a lack of knowledge about yoga and what it entails and the cost of classes. Despite these barriers, Hispanic adults from a low-income population said they would be willing to attend yoga classes if offered at a low cost. Understanding and addressing these barriers can help researchers and health practitioners improve diversity in yoga classes and research.

Examining Associations between Community Health Worker-Rated Health and Mental Health among Latino Adults with Chronic Disease.

Latinos with chronic disease often experience comorbid depression, but confront barriers to mental health treatment. Community health workers (CHWs) develop trusting relationships with the communities they serve, and may be uniquely positioned to identify Latinos with mental health care needs. Research has not examined whether their rating of clients' health is indicative of their mental health. This mixed-methods study examines CHWs' appraisals of Latino adults' health and their relation to mental health outcomes, and explores factors informing CHWs' rating of health status. The current study utilized baseline data from the Linking Individual Needs to Community and Clinical Services (LINKS) study. We assessed associations between CHW-rated health (CHWRH), or rating of health status as poor-excellent, and mental health outcomes with multilevel linear regression modelling. We qualitatively analyzed CHWs' written perceptions of participants' health status to understand what influenced their health rating. The quantitative results showed that CWHRH was significantly related to depressive symptoms and emotional problems severity. The qualitative results showed that CHWs took a holistic and ecological approach in rating health. The findings suggest that CHWRH could be indicative of mental health among Latino adults. Further studies investigating CHWRH as an independent indicator of mental health are warranted.

Development of a cognitive behavioral therapy with integrated mindfulness for Latinx immigrants with co-occurring disorders: Analysis of intermediary outcomes.

Objectives: Transdiagnostic interventions have been increasingly used in the management of a variety of mental health and substance use conditions, and in the context of chronic stress. We discuss the development and evaluation of the Integrated Intervention for Dual Problems and Early Action (IIDEA), a 10-session manualized intervention that includes cognitive therapy and mindfulness practice designed to improve symptoms of anxiety, depression, posttraumatic stress, and co-occurring substance use problems. Methods: In this secondary analysis of a randomized-controlled trial of IIDEA conducted with an international sample of immigrant Latinx in the United States and Spain, we evaluate intermediate outcomes-mindful awareness, working alliance with clinician and illness self-management-and integrate statistical findings with results from qualitative interviews with participants. Results: The IIDEA intervention group showed higher levels of mindful awareness, illness self-management, and working alliance over an enhanced treatment as usual control group (usual treatment plus scheduled assessments) and qualitative data offer insights into the importance of therapeutic alliance and integration of mindfulness practice with cognitive therapy management skills. Conclusions: Findings suggest that skills related to the studied intermediary outcomes can be helpful for Latinx immigrants experiencing circumstances of ongoing exposure to adversity and traumatic stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Hispanic Parental Beliefs and Practices in the Management of Common Childhood Illnesses: A Review of the Literature.

Introduction: Hispanic parents are more likely to perceive common childhood illnesses as serious and needing immediate attention compared with other groups. The purpose of this review is to describe the factors that influence Hispanic parental management of common childhood illnesses. Method: A systematic search of PubMed, PsycINFO, and Cumulative Index of Nursing and Allied Health Literature was conducted. Studies were screened and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Results: Fifteen studies met the inclusion criteria for synthesis. Key findings include the following: (a) parental fears around common illnesses, (b) belief in folk illnesses, (c) use of traditional healers and remedies, (d) family members as a source of health information, (e) medical pluralism, and (f) barriers to care. Conclusion: Hispanic parents simultaneously engage both biomedical and folk spheres of treatment. More current research is needed to understand Hispanic beliefs and practices and to formulate culturally sensitive interventions in this population.

Mexican Traditional Medicine: Application of a Traditional and Complementary Medicine System to Improve Opioid Use Treatment in Latinos.

Background: Initially considered a primarily rural, White issue, opioid use and overdose rates have risen faster for Latinos (52.5%) than for White, non-Hispanics (45.8%) from 2014 to 2016. With an estimated 45% to 65% of Latino immigrant families using Mexican traditional medicine (MTM) practices before seeking Western medical services, these practices could be used as a method to increase access to care and improve outcomes. Practice Model: Although not well known, MTM is founded on a defined set of theoretical tenets that comprise a whole medical system as defined by the National Center for Complementary and Integrative Health. Whole medical systems are characterized as complete systems of theory and practice that develop independently and parallel allopathic medicine. Classifying MTM as a whole medical system to encourage further research and utilization of traditional and complementary medicine (T&CM) practices could help improve health outcomes for Latino patients. Specific T&CM practices that could be used in opioid treatment integration to decrease stigma and increase treatment utilization are then discussed. Conclusion: Incorporating T&CM practices will allow more effective, culturally competent and culturally sensitive health care provision for Latino immigrants in the United States to decrease stigma, improve health care outcomes, and address disparities in opioid use treatment.

Perceptions of Health Promotion and Maintenance Among Latinos in Faith Communities.

Faith communities provide a place for Latino congregants to discuss health information. A pilot study using focus groups and semistructured interviews explored how Latino faith community members define the meaning of health and examined their perceptions and attitudes surrounding health promotion and maintenance. Four themes emerged that reflect participants' health beliefs, with faith as a uniting force. Results support the faith community as a means of fostering health promotion for Latinos.

Vitamin D Deficiency and Sleep Quality in Minority Pregnant Women.

PURPOSE: To examine if vitamin D deficiency was associated with poor sleep quality in a sample of African American and Hispanic pregnant women. We also examined if race moderates the relationship between serum 25(OH)D levels and sleep quality among participants in this sample. STUDY DESIGN AND METHODS: Using a cross-sectional design, a sample of 115 African American and Hispanic pregnant women were enrolled from a federally qualified health center in the Midwest. Women completed questionnaires and had blood drawn for serum 25(OH)D levels between 24- and 32 weeks gestation. The questionnaires included demographic characteristics, the Pittsburgh Sleep Quality Index, and dietary vitamin D and calcium intake. RESULTS: The overall regression model indicated that the predictors explained 17% of variance in sleep quality (F(5, 103) = 4.10, p = .002, R = 0.17). Serum 25(OH)D levels were significant predictors of sleep quality after controlling for covariates (i.e., race, maternal age, prepregnancy body mass index, gestational age at data collection). Race did not moderate the association between serum 25(OH)D levels and sleep quality among women in this sample. CLINICAL IMPLICATIONS: Pregnant women should be screened for vitamin D deficiency. Women who have vitamin D deficiency should be provided vitamin D supplementation. Vitamin D supplementation may be a simple solution to enhance sleep quality at this critical time in a woman's life.

Depressive Symptoms and Resilience among Hispanic Emerging Adults: Examining the Moderating Effects of Mindfulness, Distress Tolerance, Emotion Regulation, Family Cohesion, and Social Support.

Emerging adulthood has been described as a difficult stage in life and may be particularly stressful for Hispanic emerging adults who are disproportionately exposed to adversity and chronic sociocultural stressors. To better prevent and treat depressive disorders among Hispanic emerging adults, more research is needed to identify and understand modifiable determinants that can help this population enhance their capacity to offset and recover from adversity and sociocultural stressors. As such, this study aimed to (1) examine the association between resilience and depressive symptoms among Hispanic emerging adults, and (2) examine the extent to which intrapersonal resources (e.g., mindfulness, distress tolerance, emotion regulation strategies) and interpersonal resources (e.g., family cohesion, social support) moderate the association between resilience and depressive symptoms. To examine these aims, 200 Hispanic emerging adults (ages 18-25) from Arizona (n = 99) and Florida (n = 101) completed a cross-sectional survey, and data were analyzed using hierarchical multiple regression and moderation analyses. Findings from the hierarchical multiple regression indicate that higher resilience was associated with lower depressive symptoms. Findings from the moderation analyses indicate that family cohesion, social support, and emotion regulation strategies (e.g., cognitive reappraisal and expressive suppression) functioned as moderators; however, mindfulness and distress tolerance were not significant moderators. Findings from this study add to the limited literature on resilience among Hispanics that have used validated measures of resilience. Furthermore, we advance our understanding of who may benefit most from higher resilience based on levels of intrapersonal and interpersonal resources.

Long-Term Effect of a Nonrandomized Psychosocial Mindfulness-Based Intervention in Hispanic/Latina Breast Cancer Survivors.

Background: There is a paucity of research on the long-term impact of stress-reduction in Hispanic/Latina breast cancer (BC) survivors, a growing minority. In this article, we assess the long-term efficacy of an 8-week training program in mindfulness-based stress reduction (MBSR) on quality of life (QoL) in Hispanic BC survivors. Methods: Hispanic BC survivors, within the first 5 years of diagnosis, stages I to III BC, were recruited. Participants were enrolled in bilingual, 8-week intensive group training in MBSR and were asked to practice a- home, daily. They were also provided with audio recordings and a book on mindfulness practices. Patient-reported outcomes for QoL and distress were evaluated at baseline, and every 3 months, for 24 months. Results: Thirty-three self-identified Hispanic women with BC completed the MBSR program and were followed at 24 months. Statistically significant reduction was noted for the Generalized Anxiety Disorder measure (mean change -2.39, P=0.04); and Patient Health Questionnaire (mean change -2.27, P=0.04), at 24 months, compared with baseline. Improvement was noted in the Short-Form 36 Health-related QoL Mental Component Summary with an increase of 4.07 (95% confidence interval = 0.48-7.66, P=0.03). However, there was no significant change in the Physical Component Summary. Conclusions: Hispanic BC survivors who participated in an 8-week MBSR-based survivorship program reported persistent benefits with reduced anxiety, depression, and improved mental health QoL over 24 months of follow-up. Stress reduction programs are beneficial and can be implemented as part of a comprehensive survivorship care in BC patients.

Praying to win this battle: Cancer Metaphors in Latina and Spanish Women's Narratives.

This study closely examines 51 breast cancer narratives Latina and Spanish women wrote for other patients to illuminate how they conceptualize their health, with insights for addressing health disparities. Using discourse analysis of the role of language and culture in health care communication, this study focuses on the use of metaphors in the narratives. This provides revelations about the cultural and linguistic aspects of how the writers conceptualize their disease. Building on past research on metaphor use in cancer discourse in the English language, this study reveals the prevalence of metaphors comparing cancer to combat, or more generally, violence (e.g., "my battle against cancer"), or a journey (e.g., "my path with cancer"). Writers used this metaphorical language to offer advice to others with cancer and to mark their membership in a larger community of people with cancer. We also find that Spanish women use metaphors more frequently than Latinas and that they differed in their metaphorical portrayals of cancer. This research uncovers culturally embedded themes that are central to how women with cancer think about the disease, such as the prominence of spirituality in Latinas' metaphorical constructions, a pattern not evident in Spanish women's narratives.