Life is Precious - Hmong Breast Health Study

Despite more than 80 years of efforts to eliminate the disease, cancer is the leading cause of death for Asian American and Pacific Islander (AAPI) women in the United States, and breast cancer is the most common malignancy for this group. Incidence rates of breast cancer are increasing among AAPI women even as they are declining among all other racial/ethnic groups. One contributing factor is that AAPI women have some of the lowest rates of breast cancer screening among all ethnic groups. Analyses of the 2001 and 2003 California Health Interview Survey data showed that a significantly greater proportion of Asian American women, as compared with White women, have never had a mammogram.

Hmong women are among those at highest risk for health problems and underutilization of screening services because of multiple barriers to health care. These barriers include high poverty rates, low educational attainment and low literacy in both English and Hmong (which makes understanding Western biomedical terminology difficult), gender role behavior, and culturally defined health beliefs and practices that differ from Western traditions. The Hmong traditionally view disease as loss of spirit. Illness is treated by a shaman, who restores balance between the living and spiritual worlds. In contrast to the shaman's methods of diagnosis and treatment, clinical examinations and Pap tests are seen as invasive and unseemly because they require women to undress. Social and cultural differences such as these are among the many factors affecting Hmong women's access to and use of breast cancer screening services. Culturally congruent approaches are needed to increase cancer screening services through established strategies such as community-based outreach and lay health worker programs. These strategies have been shown to increase health literacy and health-promoting behaviors in Asian American and other racial/ethnic populations.

Life Is Precious is a community-based breast cancer education workshop program designed to convey to Hmong women the importance of maintaining and monitoring proper breast health. The educational sessions are conducted by trained Hmong health educators in a culturally acceptable location (i.e., temple, participant's home, or other community-based site).

The sessions use an informal conversational format and begin with Hmong games and sharing of culturally familiar foods. A visually and linguistically appropriate graphical flipchart is used to discuss basic epidemiology related to Hmong women; emotional and logistic barriers to screening; risk factors and benefits of early detection; basic information on breast self-exams, clinical breast exams, and mammograms; Pap tests; and recommended guidelines for regular screening.

A video developed for the intervention portrays two Hmong women and their families discussing the importance of screening and the different steps of doing breast self-examination, getting a clinical breast examination, and getting a mammogram, as they go through everyday life in the Hmong community. The video visually demonstrates the techniques used for each of the tests and walks the women through these procedures. A Hmong-language brochure is used to reinforce the information in the flipchart and video for younger literate family members.

An essential cultural component of the design of the program is to include Hmong men in the outreach, because they are the main decision-makers in the Hmong family and community. Men's workshops are similar to the women's, but the goals are to increase the support that men give to women in their families to get regular breast screening exams. Younger women can also be included in the education sessions because they would have a greater understanding of the need for mammograms and would help to communicate this need to the  women of screening age. 

The education workshop for participants is 1 to 1.5 hours long. Hmong health educators must complete 35-40 hours of training before conducting the workshop.

The intended audience for this intervention includes Hmong women aged 40 and over. Also, men and younger women are encouraged to attend the educational sessions to lend additional support to the older Hmong women.

Suitable settings for this intervention include a community-based organization site, a temple, someone's home, or other acceptable locations where women can gather in a comfortable and trusted setting.

The required resources for this program are--

 -Life Is Precious brochure in English and Hmong
- Life Is Precious flipchart in English and Hmong (and accompanying guidelines for use)
- "Life Is Precious: Breast Cancer Screening for Hmong Women" participant video
- Program coordinator (minimum Masters in Public Health)
- Bilingual and bicultural Hmong women and men to conduct the workshops; these health educators should have experience working with Hmong community members and leaders
- Clinical nurse oncologist (Registered Nurse) to provide an overview of breast health to the health educators

The Life Is Precious program was evaluated using a quasi-experimental cohort design with two intervention cities (Fresno and San Diego, California) and one comparison city (Long Beach, California).  A cohort of 434 Hmong women (354 from treatment communities, 80 from the comparison community) was recruited by community health educators through a door-to-door recruitment effort in pre-identified neighborhood blocks or housing complexes with high concentrations of Hmong women. Thirteen percent of the women were aged 39 or younger, 39.9% were aged 40-49, 21.2% were aged 50-59, and 26% were aged 60 or older.

In the comparison community, health outreach workers provided one-on-one and small-group workshops and used breast health education materials designed by mainstream organizations.

Face-to-face surveys were administered at baseline and 1-year follow-up. Questions were asked verbally, and the women recorded their answers on color-coded pages with colored stickers, obviating reading and writing ability for the tests. The main outcome of the study was breast cancer screening, including breast self-examination, clinical breast examination, and mammography. Women were asked if they were ever screened, when and where they were last screened, and for what reason.  Positive change in screening behavior was defined as either (1) having had no prior breast screening (breast self-examination, clinical breast examination, or mammogram) at baseline, but having appropriately performed a self-examination or having received a clinical breast examination or mammogram in the year between baseline and follow-up, or (2) having performed a breast self-examination or having received a clinical breast examination or mammogram in the year prior to baseline, and having performed or received screening again in the year between baseline and follow-up.

• Controlling for years of residence in the United States, age, marital status, language, years of education, and health insurance status, participation in the intervention group significantly predicted increases in all three breast cancer screenings. The women in the intervention group were 6.75 times more likely than women in the comparison group to have had a mammogram (p<.01), 12.16 times more likely to have had a clinical breast examination (p<.05), and 20.06 times more likely to have performed breast self-examination (p<.001).