Experiences of Cultural Care for Improving Psychosocial Well-Being of Immigrant Adults Diagnosed with Breast Cancer: A Scoping Review

1. Introduction

Breast cancer continues to represent a significant public health concern, with an estimated 30,500 Canadian women being diagnosed, comprising 25% of all new cancer cases (Canadian Cancer Statistics, 2024; Canadian Cancer Statistics, 2023). The distribution of breast cancer cases by ethnicity and sex reveals that, from 2006 to 2016 in Canada, West Central Asian and Middle Eastern populations accounted for 31%, compared to 30.6% for African, 32.4% for South Asian, and 30.5% for East Asian individuals (Hwee & Bougie, 2021). When it comes to breast cancer deaths during the same period and demographic breakdown, the percentages were 14.9% for West Central Asian and Middle Eastern, 11.5% for African, 9.1% for South Asian, and 20.8% for East Asian populations (Hwee & Bougie, 2021). Despite recent developments in breast cancer screening, diagnosis, and treatment, there remains a significant lack of understanding regarding socioeconomic disparities and inequities in cancer outcomes. These disparities are primarily attributed to unequal access to cancer care among immigrant populations affected by cancer.

Between 2016 and 2021, Canada witnessed the arrival of 1.3 million immigrants (Statistics Canada, 2022; Government of Canada, 2023). The health of immigrants is influenced by education, employment, language, cultural differences, and differing beliefs about health (Tsai & Ghahari, 2023). The limited accessibility for immigrants can significantly impact their health, leading to critical events, such as missing cancer screenings due to language barriers (Tsai & Ghahari, 2023). Research indicates that immigrants in Canada face twice as many challenges accessing essential services, including healthcare and preventive facilities, compared to those born in Canada (Gushulak et al., 2011). Immigrant women encounter substantial obstacles related to culture, communication, and language, affecting their ability to navigate healthcare systems, establish patient-physician relationships, and comprehend healthcare information (Singh-Carlson et al., 2013). Language, beyond being a communication tool, plays a crucial role for immigrant women, especially those with English as a second language and culture such as cancer-related stigma, in conveying their healthcare and social challenges (Warmoth et al., 2017). Healthcare providers recognize the cultural stigma associated with mental health issues and help-seeking behaviours among immigrant clients (Lluch et al., 2023). Cancer care issues for immigrant women can vary due to diverse understandings of the disease, societal stigmas, and personal, social, cultural, and religious beliefs and values.

Previous literature demonstrates that professional navigators' provision of language and ethnically appropriate care has been linked to increased cancer screening rates (Muliira & D’Souza, 2016). A language barrier poses a potential threat to informed communication and decision-making processes. It thus affects the extent and quality of information, control negotiation, and establishing a trusting professional relationship with healthcare providers (Bowen, 2015; DeMoissac & Bowen, 2019). Notable patient-related barriers to cancer screening include fears, beliefs, embarrassment, anxiety, and cultural factors (Muliira et al., 2016a). A lack of proficiency in addressing language challenges can hinder women diagnosed with and treated for breast cancer from seeking necessary healthcare support and resources, which affects their psychological and emotional well-being (Singh-Carlson et al., 2018). Participants exhibit positive attitudes, yet inadequate knowledge and experience regarding cancer screening (Muliira et al., 2016b).

In the context of the psychosocial well-being of immigrant adults, integration of psychosocial care outcomes and cultural care throughout the cancer care continuum is important as it can impact work productivity and overall quality of life for individuals affected by cancer. Prior research demonstrates systematic and deliberate exclusion of immigrant adults from clinical trials, thereby exposing them to either over- or undertreatment related to the lack of data on their responsiveness to treatment, which can lead to varying reported outcomes. To our knowledge, this scoping review is the first study to examine the cultural care and psychosocial well-being of immigrant adults diagnosed with breast cancer.

1.1. Aim and Purpose

The primary purpose of this scoping review is to synthesize the published literature on experiences of cultural care for improving the psychosocial well-being of immigrant adults with breast cancer. The secondary purpose is to identify interventions to address the psychosocial well-being of immigrant adults with breast cancer. Identifying knowledge gaps and synthesizing research in this area will provide practitioners and researchers with insight into the implications of the psychosocial well-being of immigrant adults with breast cancer and indicate areas where future research and interventions are necessary.

2. Materials and Methods

2.1. Design and Method

We followed the Arksey and O’Malley (Arksey & O’Malley, 2005) approach to scoping reviews and subsequent extensions by Levac and colleagues (Levac et al., 2010); the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA, Table 6) scoping review guidelines as well as the PRISMA guidelines for reporting literature searches (Moher et al., 2015). This is an appropriate rigorous methodological approach to map the core concepts related to the scope and breadth of the literature on the psychosocial well-being of immigrant adults with breast cancer—this Joanna Briggs Institute (JBI) methodology for scoping review (Lizarondo et al., 2019) is suitable as the purpose is not to conclude, but to scope the nature of the literature and provide directions for future work.

2.2. Inclusion Criteria

We included peer-reviewed articles published in English and considered studies that included immigrant adults at least 18 years old women who have completed their breast cancer screening, diagnosis and treatment.

2.3. Exclusion Criteria

We excluded interventions outside the oncology setting, non-immigrant adults, advanced diagnosis of breast cancer, and patients currently undergoing active treatment, palliative care or end-of-life care.

2.4. Types of Studies

This scoping review considered studies that focused on qualitative methods, including, but not limited to designs such as phenomenology, grounded theory, ethnography, action research, and feminist research to provide descriptions of people’s experiences of how culture and environment influence behaviours within their context. Due to advancements in breast cancer treatment, the qualitative review was limited to articles published between January 2000 and December 2024 to ensure currency, relevance, and rigour.

2.5. Search Strategy

Following the development of our a priori protocol, we worked with a librarian and designed a comprehensive search of relevant databases to identify literature referring to the psychosocial well-being of immigrant adults diagnosed with breast cancer. We searched the following databases from 2000-2024: PubMed/MEDLINE, CINHAL, Embase, PsycINFO, Web of Science, Cochrane Library, and Google Scholar, and systematically searched by using prespecified Medical Subject Headings (MeSH) terms and keywords. The precise search strategy, including all identified keywords and index terms, was adapted for each included information source in the full review (Table 1). We used secondary search strategies to identify additional relevant studies by scanning the reference lists of relevant papers identified at the full-text screening stage.

2.6. Study Selection

All identified results were stored and loaded into the reference management software EndNote X10, and duplicates were removed. The two independent reviewers screened the article titles and abstracts for assessment against the inclusion criteria to be identified as relevant, not relevant, and maybe relevant and were determined for relevancy. The authors screened all the articles to confirm eligibility and identified potentially relevant articles. To ensure the validity of the selection criteria, in the EndNote library, the keyword searches of the article titles were deemed irrelevant to reapply the selection criteria. All relevant studies were retrieved in full text, and their citation details were independently reviewed against the selection criteria to confirm inclusion (Table 2). Any disagreements between the reviewers at each stage of the study selection process were resolved through discussion (Newman & Gough, 2020).

Assessment of bias and quality as completed for all included studies (Table 2). The JBI Critical Appraisal Checklist for Qualitative Research (JBI CAC) was used for all the qualitative studies. The JBI CAC contained 10 items, each scored as Ye, No and Unclear and the scoring for each article was 7-10 High, 4-6 Medium, 1-3 Low impact. . Q1 = Is there congruity between the stated philosophical perspective and the research methodology? Q2 = Is there congruity between the research methodology and the research question or objectives? Q3 Is there congruity between the research methodology and the methods used to collect data? Q4 = Is there congruity between the research methodology and the representation and analysis of data? Q5 = Were those delivering treatment blind to treatment assignment? Q6 = Is there a statement locating the researcher culturally or theoretically? Q7 = Is the influence of the researcher on the research, and vice-versa, addressed? Q8 = Are participants, and their voices, adequately represented? Q9 = Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body? Q10 = Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

A PRISMA diagram (Table 6) was created, showing details of studies included and excluded at each stage of the study selection process (Figure 1).

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., ... & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1-9.

2.7. Data Extraction

The COVIDENCE software was used to deduplicate reviews and to extract data on study setting and design, intervention characteristics, cultural care and psychosocial well-being description, sample characteristics, and outcomes related to cancer treatment targeted outcomes. Data extraction was transformed and coded to facilitate each element of the discussion, integrate the existing evidence, and answer the review questions (Lizarondo et al., 2019). Using the COVIDENCE software, a review matrix was generated to maximize efficiency and extract the pertinent study findings, specifically from each citation's results and discussion sections (Table 3). All study findings from the included citations were coded for analysis as textual descriptions. Qualitative data comprised themes and subthemes with corresponding quotations and narrative interpretation to answer the review questions. Two independent reviewers (M.S.D. and A.A.N.) reviewed qualitative studies and a third reviewer (A.S.) using the standardized JBI data extraction tool (Table 1) in JBI SUMARI (Porritt et al., 2014). Reviewers (M.S.D. and A.A.N.) assessed the published paper's trustworthiness, relevance, and results with the qualitative data extraction tool.

Reviewer Date

Author Year Record Number

2.8. Data Transformation

In content analysis, themes or categories were developed a priori (i.e., before integration), and then all extracted data were coded according to these categories or themes (Dixon-Woods, 2010). This coding was followed by creating tabulations of frequency counts to identify key findings (Dixon-Woods et al., 2010). This count involved transformation into textual descriptions or narrative interpretation of the qualitative results in a way that answered the review questions by repeated detailed examination.

2.9. Data Synthesis and Integration

This review followed a qualitative approach to synthesis and integration according to the JBI methodology using JBI SUMARI. This approach involved separate qualitative synthesis and integration of the resultant qualitative evidence (Tufanaru et al., 2017). Qualitative research findings were pooled using JBI SUMARI with the meta-aggregation approach (Lockwood et al., 2017). This approach involved the aggregation or synthesis of findings to generate a set of statements representing that aggregation by assembling the findings and categorizing these findings based on similarity in meaning. These categories are then subjected to a synthesis to produce a comprehensive set of synthesized findings that were used as a basis for evidence-based practice.

3. Results

3.1. Study Inclusion

A total of 2,526 articles were identified through seven database searches, and 102 articles were identified from backward and forward searches. After removing 1,182 duplicate publications, 443 titles and abstracts were screened for eligibility, and 211 articles were excluded for not meeting the criteria. After 232 full-text reviews for methodological quality, twenty-two (22) studies were included in the data analysis and synthesis (Figure 1 and Figure 2).

3.2. Participant Characteristics

Study sample sizes ranged from 10 to 5146 participants aged 18 years and older (Table 4). Most cultural care and psychosocial well-being included minority, ethnic, underserved, and low-income immigrant women.

3.3. Content Analysis

Content analysis showed two synthesized findings, and six categories based on 226 contextual statements and 113 codes (Table 5). Content analysis of experiences of cultural considerations in care revealed themes such as the development of culturally responsive care models; barriers and gaps in culturally responsive care in rural communities; and patient information, education and culturally responsive care. The findings of experiences of psychosocial well-being of immigrants revealed themes such as cultural stigma, self-perception of access, use, and role of healthcare providers; the impact of cancer and linguistically appropriate care; and challenges with psychosocial wellbeing and culturally responsive care (Table 5).

3.4. Synthesized Finding 1: Experiences of Cultural Considerations in Care

3.4.1. Theme 1: Development of Culturally Responsive Care Models

The literature highlighted the need for culturally responsive care to enhance cancer care and screening for immigrant women. Culturally responsive care is termed as intentionally recognizing, respecting, and incorporating a person's cultural background, beliefs, values, and experiences into their care and treatment (Curtis et al. 2019). Cultural issues include the lack of awareness and fear regarding cancer screening, language, barriers, and the unfamiliarity with and lack of trust in the healthcare system among Asian American women who are less acculturated and newly immigrated (Tam Ashing et al., 2003). The women's health educator's accompaniment to screening was a valued aspect during the screening experience as she provided emotional and language support to immigrant women enabling them to have the procedure explained thoroughly and ask questions via interpretation and, thereby, understanding the process of screening, findings, or need for follow-up (Crawford et al., 2015). In conjunction with understanding gender-based needs, diversity and heterogeneity within ethnic groups are also crucial for tailoring care to the specific needs of breast cancer survivors (Wen et al., 2014). These cultural differences encompass physical and emotional well-being, social network size and composition, cultural health beliefs, and doctor-patient communication (Wen et al., 2014). Numerous barriers hinder access to culturally responsive and linguistically appropriate psychosocial interventions, including limited availability, accessibility, and acceptability (Wen et al., 2014).

3.4.2. Theme 2: Barriers and Gaps in Culturally Responsive Care in Rural Communities

Research showed that participation in medical treatments (Ashing-Giwa et al., 2008) facilitated breast cancer survivorship. Experience with digital technology for health (Brennan et al., 2020) was a facilitator of breast cancer treatment. Perspectives on survivorship care plan content and delivery (Burke et al., 2016; Burg et al., 2009; Haq et al., 2013) were facilitators of breast cancer care. Screening services for women (Crawford et al., 2015) were facilitators of breast cancer care. Evolving needs throughout their cancer journey, tailoring information to patients’ needs, and transitioning to follow-up care were important facilitators of breast cancer post-treatment (Haq et al., 2013). Participants’ preconceptions and assumptions of breast cancer support groups (Green et al., 2018), engagement and empowerment (Juarez et al., 2013), use of social support and other coping behaviours (Levesque et al., 20), and educational support through professionally led support groups (Green et al., 2018; Juarez et al., 2013) were facilitators of breast cancer care. The usefulness of intervention components (Nápoles et al., 2019) and writing as a process (Gripsrud et al., 2016) were important facilitators of breast cancer treatment. The types of psychosocial distress, anxiety, and uncertainty that minority breast cancer survivors experience and the lack of adequate support and guidance emphasized the value of community-based, population-specific cancer support programs, such as the Sisters Network (Burg et al., 2009). Healthcare professionals must tailor care to meet individuals’ unique needs, beliefs, and practices from different cultural backgrounds (Ashing-Giwa et al., 2004; Haq et al., 2013). Key aspects include understanding cultural beliefs, coping strategies, family support, spirituality, and addressing barriers to healthcare access (Ashing-Giwa et al., 2004). Recognizing and adapting to the evolving needs at different stages of the cancer journey, while considering the influence of personal and social contexts, is a key facilitator in providing care (Haq et al., 2013).

3.4.3. Theme 3: Patient Information, Education and Culturally Responsive Care

The literature shed light on the need for increases diversity within the healthcare system and staffing to enhance language skills, educational programs, and cultural competence to support immigrant women (Ashing et al., 2004;Costas-Muniz et al., 2021). The fostering of a caring and trusting environment in which immigrant women can share their experiences, feelings, and concerns regarding their care is beneficial in empowering the women and further improving their psychosocial outcomes (Crawford et al., 2015). The position of the cancer care program’s role in informing and empowering patients positively impacts the quality of life of cancer patients by creating a culturally responsive care plan (Hill et al., 2013). The benefits of peer support and the integration of technology to do so (Hill et al., 2013) have positive benefits in helping patients improve their motivation, proactivity, and resilience in pursuing recovery and psychosocial well-being (Brennan et al., 2020). Chinese Australian women use strategies to adjust to their breast cancer experience, such as dietary changes, exercise, spirituality, and cognitive reframing (Levesque et al., 2020). Developing culturally responsive self-management resources for this minority group has potential empowering and beneficial results on their journey (Levesque et al., 2020). Using a mobile phone app and telephone coaching to deliver empowering and motivating care has proven beneficial (Nápoles et al., 2019). Cancer treatment significantly affects the self-efficacy, emotional well-being, and body image of Spanish-speaking breast cancer survivors, and a technology-driven intervention program helps reduce stress and enhance positivity about physical appearance and weight for the participants (Nápoles et al., 2019). Motivation and empowerment are common themes discussed as program outcomes that enable confident, individualized self-care (Nápoles et al., 2019). Despite the stigma, challenges and hardships faced by cancer survivors, the participants’ ability to try to find appropriate care and positive meaning in their experiences emphasizes their resilience (Warmoth et al., 2017). While individuals may employ diverse methods influenced by their cultural beliefs and values, the common theme of resilience reflects the concept of post-traumatic growth, referring to the positive psychosocial change experienced because of the struggle with challenging circumstances (Warmoth et al., 2017).

3.5. Synthesized Finding 2: Experiences of Psychosocial Well-Being of Immigrants

3.5.1. Theme 4: Cultural Stigma, Self-Perception of Access, Use and the Role of Healthcare Providers

Cultural identity and power are outlined as acknowledging and respecting the patient's cultural identity and background and recognizing the power dynamics and potential biases that may exist within caring relationships. Latina breast cancer survivors agreed that tailored verbal and printed education was vital during their transition process, keeping the women engaged and empowering participants to share what they learned (Juarez et al., 2013). Chinese Australian women reported difficulties with managing the side effects of treatment and noted that these side effects were disruptive to their daily lives and functioning (Levesque et al., 2019). Latina immigrant breast cancer survivors commented that the cultural change impacted their quality of life, as they often felt rushed and perceived stigma, shame, secrecy, embarrassment and a sense of urgency in terms of making medical decisions (Lopez-Class et al., 2011). Latina immigrant breast cancer survivors, even those who spoke English, faced language challenges that complicated their survivorship care, and many experienced problems with the interpretation process (Lopez-Class et al., 2011). South Asian breast cancer survivors felt that specific physical activities should be communicated so that they could overcome fatigue, depression, and weight gain during active treatment and afterwards (Singh-Carlson et al., 2013). Black and South Asian women born overseas reported needing a relative with them at appointments to enable them to understand the context of conversations with healthcare professionals (Tompkins et al., 2016). Indian and Pakistani women who were born overseas and required accompaniment to appointments often tended to fall into the lower socioeconomic position category (Tompkins et al., 2016). White British women were more inclined to engage in interactive dialogue and communication with their healthcare professionals during follow-up appointments, in contrast to Black African women who were more likely to rely on their healthcare professionals to lead the dialogue (Tompkins et al., 2016). Participants expressed a sense of identity, such as their roles as mothers, wives, and caregivers, shaped by their ethnicity, acculturation, socioeconomic status, education, cultural factors, and cultural competence (Ashing-Giwa et al., 2004). The impact of breast cancer on a woman’s sense of identity is multifaceted as they navigate their roles as mothers, wives, and caregivers; their identity becomes intertwined with their cancer experience (Ashing-Giwa et al., 2004). Cultural factors, such as ethnicity, acculturation, socioeconomic status, and education, further shape their self-perception (Ashing-Giwa et al., 2004). Coping with these identity changes and challenges due to breast cancer is an essential aspect of their psychosocial well-being and influences the care they receive (Ashing-Giwa et al., 2004). The sense of identity of cancer patients is dynamic and influenced by various factors, such as cultural perceptions of cancer, treatment, and support groups (Green et al., 2018). The culturally dynamic perceptions of support groups may challenge the sense of identity and agency, and some patients may not see themselves as belonging to a community of cancer survivors (Green et al., 2018).

3.5.2. Theme 5: Impact of Cancer and Linguistically Appropriate Care

A lack of fluency and discomfort in speaking English among Asian American women contributes to a lack of active involvement in their care (Tam Ashing et al., 2003). Latinas believed that medical staff made assumptions based on the inability to speak English and manner of dress, and Asian American survivors felt that medical staff gave more information to those who were more educated about breast cancer (Ashing-Giwa et al., 2004). There is a need for breast cancer survivors’ minority-specific considerations when providing information to patients, as patients often have information gaps, confusion, and dissatisfaction with communication from their primary care providers (Burg et al., 2009). Discrepancies in the understanding between patients and healthcare providers are a key driver of the information gaps that patients experience (Ashing et al., 2004; Burke et al., 2016). Factors such as definitions of the care received and the terminology used to capture the ongoing nature of their treatment are examples of discrepancies that display a need for linguistically appropriate care (Burke et al., 2016).

3.5.3. Theme 6: Challenges with Psychosocial Well-Being and Culturally Responsive Care

The literature highlighted various challenges in the implementation of culturally responsive care. For example, breast cancer survivors who were personally less satisfied with the survivorship care plan were less likely to share the information with the healthcare team, users did not believe that it was relevant to their current care (20%), or the user was concerned that the healthcare team would not care about the care plan (Hill-Kayser et al., 2013). Asian Americans reported limited English proficiency as a barrier to accessing health information and quality of healthcare and doctor-patient communication and medical decision-making, such as insurance and medical costs, limited time with providers, and lack of medical translation services (Wen et al., 2014). Socioeconomic and cultural factors and systemic problems in the healthcare system were the major barriers to access and quality of care among Asian American women (Ashing et al., 2004). The level of acculturation is affected by seeking medical care. Latinas born in the United States were more willing to adopt Western culture, perform self-breast exams, obtain mammograms, adhere to modern medical treatment, and be watchful of their health (Ashing-Giwa et al., 2004). The Latino community hesitates to access medical resources due to language barriers and logistical challenges associated with negotiating the complex healthcare system, what information or services to utilize, and how to find them (Ashing-Giwa et al., 2004). Also, 92% of users reported that the care plan increased their knowledge of the possible long-term and late effects of their cancer, and 84% reported that the care plan improved their knowledge of what medical tests should be done as part of the follow-up care for their cancer (Hill-Kayser et al., 2013). South American breast cancer survivors felt they should receive a list of resources, including those for reconstruction, reproduction, sexuality, nutrition, exercise, and prevention, which should be explained at discharge (Singh-Carlson et al., 2013). Women overwhelmingly said they wanted someone to talk to post-treatment and expected that their breast cancer nurse would fulfill their role (Tompkins et al., 2016). The challenges described by participants were a lack of health insurance and an unfamiliarity with the healthcare system, and a few needed to be made aware that they were eligible for health insurance (Warmoth et al., 2017). Other participants referred to difficulties in obtaining information about the medical and insurance system, such as who to approach or contact to learn more about the reimbursement process for medical expenses (Warmoth et al., 2017). Policies must address healthcare disparities and provide adequate support for cancer survivors from diverse backgrounds (Ashing-Giwa et al., 2004). Policies could involve improving access to healthcare resources, enhancing patient education about the disease, or developing support programs tailored to the needs of different ethnic groups (Ashing-Giwa et al., 2004). Latina breast cancer survivors’ experiences of stigma, shame, and embarrassment as immigrants affect their survivorship experiences (Lopez-Class et al., 2011). Factors such as language barriers, social isolation, and changes in social habits reflecting acculturation may pose additional challenges for these women (Lopez-Class et al., 2011).

4. Discussion

Based on our review of the literature, we note that experts in the field consistently raise concerns about cultural care for improving the psychosocial well-being of immigrant adults diagnosed with breast cancer. Although there is evidence for psychosocial well-being in some specific domains or aspects of care, the relationships between the psychosocial well-being of immigrant adults diagnosed with breast cancer and recommendations remain fragile. This review of the literature emphasizes the need for psychosocial well-being of immigrant adults is an ongoing issue for this population despite being highlighted. We also found that there are no interventions focused on addressing the psychosocial well-being of immigrant adults diagnosed with breast cancer.

Healthcare research to improve the cultural care of immigrant adults may be more challenging to improv access to supportive programs for immigrant women with breast cancer. Specifically, experiences of culturally responsive care, access to insurance and benefits, levels of knowledge and practices, availability of language-appropriate care, access to healthcare services, and the overall quality of care influenced the quality of life for immigrant breast cancer survivors. Immigrant women living with breast cancer perceive communication and participation, doctor-patient relationships, knowledge of services, trust, and respect as crucial elements in their experience. These women often feel vulnerable, experiencing a sense of isolation, being stigmatized, ashamed, and embarrassed, lacking information, and facing challenges related to family commitments and cultural barriers. Additionally, lower levels of education and economic gains contribute to their unique set of challenges in dealing with breast cancer (Government of Canada, 2023). Immigrant women may have to rely on community sources, volunteers, spouses, and children to access services, thus leading to a lack of decision-making, choice, and autonomy (Floyd & Sakellariou, 2017). Such changes in sociocultural behaviours and the challenges of understanding and speaking English, combined with a breast cancer diagnosis and treatment, can exacerbate feelings of worry, fear, and anxiety. These issues, along with feelings of stigmatization, may deter immigrant women from seeking adequate support and affect their ability to cope with stressors and overall well-being (Singh-Carlson et al., 2018). Social justice and health equity policies for breast cancer survivors are crucial for seeking cancer-supportive care (D’Souza et al., 2022). This health-seeking behaviour prompts co-creating and equity-oriented care requirements through culturally and linguistically responsive services. Healthcare providers must be aware of cultural values and humility that enhance cultural care and the quality of care for immigrant women (D’Souza et al., 2021). These studies do not refer to culturally and linguistically appropriate health and wellness services. There is an evident paucity of research on this topic, which prompts the need to provide community supportive care to immigrant women who are uncertain about talking with their healthcare providers due to a language hurdle.

In our review, we found that in Southeast Asian and Arab cultures, emotions are suppressed to maintain familial and societal harmony, inhibiting the individual’s capability to assert one’s beliefs through emotional expression. Breast cancer care issues could be different for immigrant women due to different perceptions of cancer-related stigma, and social, cultural, and spiritual beliefs and values. Education, access, and culture-specific barriers like breast exposure, uneasiness with one’s own body, and social, environmental, and religious beliefs influenced breast cancer screening and prevention (Racine et al., 2022). Language is a cost-effective approach to navigating cancer care. The study of sociocultural effects is critical for appraising the utility and effectiveness of cancer care plans (Singh-Carlson et al., 2018). Cultural and linguistically appropriate care is a set of policies enabling people to communicate efficiently with healthcare providers and for the most responsible person to communicate effectively with immigrants. Culture and language are important components in accessing and using healthcare and affect the person’s ability to navigate, support, communicate, and make decisions (D’Souza et al., 2023). The review findings demonstrated that some women were less informed and prepared for the physical and psychological cancer treatment-related side effects that emerged during the cancer treatment process and in the post- and long-term aftermath.

Our review also documents several challenges were identified for women with breast cancer, including a lack of knowledge (Ashing et al., 2003; Burke et al., 2016; Green et al., 2018) and insufficient information from healthcare providers about where to seek services and mental health stigma (Burke et al., 2016; Costas-Muñiz et al., 2021). Feelings of embarrassment and stigmatized about seeking services (Costas-Muñiz et al., 2021), the absence of contact with counselling professionals and psychosocial services (Costas-Muñiz et al., 2021), and feeling ill-equipped to manage follow-up care (Haq et al., 2013) were additional challenges. Language-related issues, including language barriers (Ashing et al., 2003; Warmoth et al., 2017), English language proficiency (Ashing et al., 2018), and difficulties in understanding the language, values, or background and stigma (Costas-Muñiz et al., 2021), posed challenges for women with breast cancer. Cultural changes and feeling stigmatized and ashamed (Lopez-Class, 2012; Singh-Carlson et al., 2013; Warmoth et al., 2017; Wen et al., 2013) were also identified as challenges. Unmet needs and lack of support (Brennan, Kessie, & Caulfield, 2020; Crawford et al., 2015) were noted challenges for women with breast cancer. Inadequate preparation for long-term breast cancer recovery (Burg et al., 2009) was identified as another challenge. Additionally, mental health services were perceived as too expensive (Costas-Muñiz et al., 2021), posing challenges for women with breast cancer. For immigrant women with breast cancer, issues such as lack of continuity of care, language barriers, and lack of workplace support contributed to lower satisfaction with cancer management, post-treatment, and follow-up appointments.

We identified limited English proficiency and lack of understanding about navigating healthcare services were challenging, and this caused emotional distress and potential health consequences for women with breast cancer. This scoping review has identified many categories of experiences of the cultural care of immigrant adults living with breast cancer. The primary outcome targeted was the quality of life during cancer treatment and post-treatment. In general, limited evidence suggests that cultural care and psychosocial well-being improve patient-oriented outcomes in women with breast cancer. The main barriers were accessing health information, lack of patient-physician communication and decision-making support, and lack of medical translation services, which were associated with a lack of social support and adopting recommendations.

Our work echoes recent discussions within the review and made advancements over previous reviews by conducting searches across multiple electronic databases, thereby extending the search period to 21 years. Additionally, the review included an evaluation of the quality of the research conducted. This review identified an increase in the number of cultural care and support groups for breast cancer, including the number of studies that reviewed cultural care for improving psychosocial well-being in underrepresented and underserved populations. The findings of this review indicate significant heterogeneity in terms of delivery, goals, services, healthcare providers, intended audiences, and targeted outcomes. The research that has evaluated the effectiveness of cultural care and psychosocial well-being is of moderate quality, and the findings are mixed.

To be comprehensive, we included the broader scope of the literature including studies mentioning the psychosocial well-being of immigrant adults diagnosed with breast cancer. While this diversity of methods of the included studies excluded our ability to analyze the effects of psychosocial well-being of reported outcomes and draw tangible or directional conclusions, it did allow us to meet our purpose to understand the scope of the literature, consistent with scoping review methodology, This study presents many strengths, including the breadth of information synthesized, that each title/abstract and full text was screened by at least two reviewers and inclusion of studies published in multiple languages.

5. Conclusions

Our findings highlight that psychosocial well-being has the potential to enhance cultural care for immigrant women living with breast cancer. These interventions may normalize the use of such services, provide information about their benefits and where to access them, and confirm the availability of culturally congruent counsellors and interpreters. Healthcare providers can benefit from training that emphasizes culturally responsive communication skills. Such training can teach them how to elicit psychosocial needs and knowledge gaps and address patients’ concerns effectively. Furthermore, psychosocial service providers can benefit from culturally oriented training to deliver culturally responsive services. The training should address concerns related to language interpretation within the context of psychosocial oncology services. Healthcare institutions can contribute to improving cultural competency by implementing policies, processes, and programs. This includes developing and supporting culturally responsive training for providers and support staff, maintaining a diverse workforce of bilingual language and psychosocial providers and support staff, and offering language assistance to patients and caregivers with limited English proficiency. Further strategies involve translating all materials to the patient’s preferred languages, conducting ongoing assessments of policies regarding culturally and linguistically responsive care, and fostering partnerships with the community to ensure culturally and linguistically appropriate psychosocial services. Collaboration with community clinics and programs can facilitate effective transitions of psychosocial care. Implementing a team approach, care management, continuity of care, and health navigation can address logistical, psychosocial, socioeconomic, and cultural needs. Additionally, maintaining cultural and community advisory boards can aid in planning and monitoring programs and policies, contributing to continuous improvement in cultural competency in healthcare approaches.

This study revealed several challenges that intersect to shape the access, utilization, and effectiveness of healthcare services across the cancer continuum. These challenges include pre-existing individual characteristics, interactions with healthcare facilities facilitated by physicians and healthcare providers, sociocultural expectations, and gender norms. For immigrant breast cancer survivors, experiences of culturally responsive care, insurance and benefits, lack of knowledge and practices, language-appropriate care, access to care, and quality of care collectively influence their quality of life. Factors such as a lack of knowledge about healthcare providers, contact with cancer care services, language barriers, English language proficiency, cultural factors, lack of support, unmet needs, absence of survivorship and long-term care, and the cost of extended healthcare services influence the meaningfulness of cultural care in improving the quality of life for immigrant adults living with breast cancer. In addition, a lack of understanding of the English language and navigating healthcare services leads to increased psychosocial and emotional distress for immigrant women. Establishing culturally and linguistically appropriate care is crucial for developing a trusting relationship with healthcare providers, especially for decision-making regarding treatment. While there is growing support for cultural care and psychosocial well-being in breast cancer, additional research is needed to determine the effectiveness of cultural care and psychosocial well-being in breast cancer treatment and post-treatment. Future research should compare different models of breast cancer care using patient-oriented outcomes and adhere to recommended metrics, cultural care, and psychosocial outcomes during cancer treatment and post-treatment. A more rigorous evaluation of cultural care and psychosocial well-being is needed. Studies should recruit larger, ethnically diverse samples and evaluate whether cultural care and psychosocial well-being equally benefit all ethnic groups and increase the generalizability of the findings. Future studies should include cohort-based prospective follow-ups of people with breast cancer post-treatment and track the recurrence of cancer and survival data. Future research should examine the processes by which cultural care and psychosocial well-being improve women’s goals to determine the components of breast cancer care that are most likely to be associated with timely, high-quality, and recommended treatment, post-treatment care, and survival from breast cancer.

6. Implications

This study's findings have several implications for both practice and research; as such, we offer the following recommendations.

6.1. Practice

From the practice perspective, we emphasize the importance of addressing the cultural-specific needs of breast cancer survivors, emphasizing communication and ongoing support throughout the entire continuum from screening and diagnosis to treatment and survivorship. The study proposes that culturally specific policies need to address healthcare discrepancies and provide adequate support for cancer survivors, such as improving access to healthcare resources, enhancing education and health promotion, or developing support programs tailored to the needs of different ethnic and cultural groups. The review paper suggests future directions for improving collaborations between public health, primary care, and community services. It also recommends involving culturally diverse immigrant women in the design and evaluation of cancer care services and resources. Introducing culturally responsive screening invitations tailored to encourage participation becomes imperative. Family support is important for providing transport for appointments and acting as interpreters. Spirituality support is central to enhancing spiritual beliefs and practices as a source of comfort, confidence, and coping mechanisms. This practice helps women with traditional values and support groups to recognize spiritual resources. There is a need to ensure culturally responsive, safe, equitable, affordable, and accessible care with the type of health insurance and the state of their finances, which is linked to a better quality of care. Enhancing timely access and connection to survivorship for cancer patients and their families leads to a better quality of care. Patient-physician relationships, communication, and shared decision-making are influential factors in adopting health promotion practices to improve the quality of care. Raising awareness, knowledge, and information about breast cancer treatment and follow-up affects the quality of care. There is a need for the coordination and integration of cancer-supportive care to enhance patient-oriented outcomes, psychosocial safety, information about healthcare services, and psychosocial support. Leveraging sociocultural determinants to better integrate cancer care can enhance psychosocial well-being. Therefore, cultural competence can be enhanced by increasing the uptake of formal cultural competency training among healthcare providers.

6.2. Research

For research, future practice-oriented studies should explore physical, emotional, and psychological factors that can significantly impact the quality of life during breast cancer and its treatment. For immigrant women who are breast cancer survivors, enhancing their quality of life involves integrating research and building the capacity for participation. Developing informational, educational, and awareness materials about breast cancer that are culturally responsive and linguistically tailored can be particularly helpful for this specific cultural population. Breast cancer survivors and their families may require dedicated time to engage with healthcare professionals, discussing signs of recurrence, testing for metastasis, and available treatment options. Encouraging increased family and spouse participation can be achieved through initiatives such as improving health literacy, providing counselling, offering educational programs, facilitating referrals to healthcare services, implementing cultural care, and increasing navigation in the healthcare system. Establishing a reported outcomes data platform that supports care decisions and serves as an engine for policy can actively engage individuals in their cancer care continuum. There is a notable emphasis on self-management and building the capacities of immigrant women to be better prepared for breast cancer treatment, which includes managing symptoms, handling adverse reactions, and individualizing care plans. Therefore, expanding digital health literacy solutions becomes crucial to improving access and relevance for individuals, effectively addressing the unique needs of immigrant women with breast cancer.