摘要：Objectives. We used a community-based research approach to test a culturally based breast cancer screening program among low-income Hmong women in central and southern California. Methods . We designed a culturally informed educational program with measures at baseline and 1-year follow-up in 2 intervention cities and 1 comparison city. Measures included changes in breast cancer screening, knowledge, and attitudes. Results. Compared with women in the comparison community, women in the intervention community significantly improved their attitudes toward, and increased their knowledge and receipt of, breast cancer screenings. Odds of women in the intervention group having had a mammogram, having had a clinical breast examination, and having performed breast self-examination was 6.75, 12.16, and 20.06, respectively, compared with women in the comparison group. Conclusions . Culturally informed education materials and intervention design were effective methods in conveying the importance of maintaining and monitoring proper breast health. The strength of community collaboration in survey development and intervention design highlighted the challenges of early detection and screening programs among newer immigrants, who face significant language and cultural barriers to care, and identified promising practices to overcome these health literacy challenges. 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 cancer site for this group. 1 Although breast cancer mortality rates have declined among all other racial/ethnic groups, rates are increasing among AAPI women. 1 , 2 Low breast cancer screening rates contribute to this problem because AAPI women have the lowest screening rates among all ethnic groups. 3 – 9 Analyses of the 2001 and 2003 California Health Interview Survey data showed that a significantly greater proportion of Asian American women (in aggregate; 17.2%) have never had a mammogram compared with White women (8.1%), and a smaller proportion of Asian American women (67%) received recent mammography compared with non-Hispanic White women (78%). 8 , 10 Similar differences have been found among AAPI women in Los Angeles. 7 However, Asian Americans and Pacific Islanders include more than 57 different AAPI groups, and the smaller populations—especially Southeast Asian populations such as the Hmong—are rarely surveyed. Hmong women are among those at highest risk for health problems and underutilization of screening services because of their high rates of poverty, low educational attainment (which makes understanding Western biomedical terminology difficult), lack of English fluency, and gender-defined role behavior. 11 Notably, however, stark cultural differences in health beliefs and practices create unique barriers that result in negative experiences with the Western medical system, resulting in a lack of trust and fear of Western medicine. 12 , 13 For example, the Hmong cultural views are based in traditional animism, a belief that all elements of the earth and its creatures possess spirits or souls living in harmony. 14 Each individual holds multiple souls, and disease is believed to be caused by the loss of 1 or more of these soul spirits; thus, illness is traditionally treated by a shaman who restores balance between the living and the spiritual worlds. 15 Hmong understanding of health has no equivalent biomedical “translation.” A clinical examination, and especially a Papanicolaou test, is seen as invasive and unseemly because shamans diagnose without undressing women. Such misunderstandings with clinicians may affect the use of preventive health services. Also, because mammograms and Papanicolaou tests were not available to most of these women in their home countries, older Hmong-American women may not understand the benefits. Such social and cultural variations highlight the barriers faced by Hmong women to access and use of breast cancer screening services and underscore the need for culturally congruent approaches to increase cancer screening services through established strategies such as community-based outreach and lay health worker programs. 16 , 17 These strategies have been shown to increase health literacy and health-promoting behaviors in Asian American and other racial/ethnic populations. 18 The Life Is Precious program is the first study in the United States designed to increase the receipt of breast cancer screening examinations among Hmong women. This 3-year community collaborative research project promoted breast self-examination, clinical breast examination, and mammography use among Hmong women in central and southern California. Researchers at 2 universities collaborated with 3 community-based organizations in separate Hmong communities to implement this breast health education project: Families in Good Health in Long Beach, Stone Soup in Fresno, and the Union of Pan Asian Communities in San Diego. We hypothesized that the community-based participatory research–designed intervention would significantly improve breast cancer screening knowledge, improve attitudes, and promote screening behaviors among Hmong women in the intervention group compared with women in the control group. 19 The baseline data and methodology of the Life is Precious program are described elsewhere. 11 , 20
