Ten-year changes in breast cancer knowledge,attitudes, and practices in Native Hawaiian women

Compared to women in other ethnic groups, Native Hawaiian women have the highest breast cancer mortality rates in the state of Hawai'i. Nationally, the five-year relative survival rate for Native Hawaiian women is 9% shorter than for Caucasians and all races. This poor outcome has been attributed, in part, to late-stage detection of cancer in Native Hawaiians, and data suggest that breast cancer screening rates for Native Hawaiian women are relatively low. This study examined breast cancer knowledge, attitudes, and practices (KAP) among Native Hawaiian women, reached through their friendship, community, and organizational networks. Response to an initial KAP survey in 1989-1990 was rewarded by a voucher for a free mammogram. Participation in both the survey (n = 903) and mammogram offer (n = 496) was high. The initial, Time 1 participants were resurveyed in 1999-2000, yielding a sample of 117 women who completed KAP surveys at both time points. After 10 years, changes in women's knowledge and attitudes were minimal. However, remarkable improvements in breast health practices were seen, with 62% of women reporting compliance with American Cancer Society guidelines for mammogram screening in 1999-2000, compared to only 14% in 1989-1990. Findings suggest that breast health practices can be improved through appropriate outreach; encouragement by health professionals; and policies and programs that increase access and affordability.     

Impact of a culturally appropriate intervention on breast and cervical screening among native Hawaiian women

BACKGROUND: Native Hawaiian women have the highest breast and cervical cancer mortality rates and lowest screening rates in Hawai'i. This paper summarizes impacts of a breast and cervical cancer screening intervention spearheaded by a Native Hawaiian community. METHODS: Six hundred seventy-eight randomly selected Native Hawaiian women completed two telephone surveys assessing their cancer screening behaviors: 318 women from a community that implemented an intervention, known as a Kokua Group, to provide culturally tailored education and support in a group setting and 360 women from communities without this intervention. The surveys were conducted before intervention implementation and 3 years later, 4 to 5 months after the last intervention session. RESULTS: At posttest, intervention community women reported positive changes in 4 of 12 screening activities (P < or = 0.05), while no changes were found among controls. Some women in both communities had heard about and/or participated in Kokua Groups. Hierarchical logistic regression showed that controlling for community, demographics, and pretest scores, Kokua Group knowledge or participation was a significant predictor (P < 0.05) of 9 of 12 screening-related behaviors. CONCLUSIONS: Positive changes in screening activities among women aware of the intervention support the importance of information diffusion by community consumers. Diffusion may occur beyond the boundaries of the community as defined.     

Developing a culturally responsive breast cancer screening promotion with Native Hawaiian women in churches

This article presents findings from research to develop the promotional component of a breast cancer screening program for Native Hawaiian women associated with historically Hawaiian churches in medically underserved communities.The literature on adherence to health recommendations and health promotions marketing guided inquiry on screening influences. Focus groups and individual interviews patterned on the culturally familiar practice of talk story were conducted with 60 Hawaiian women recruited through religious and social organizations.Text data were analyzed with an incremental process involving content analysis and Airhihenbuwa's PEN-3 model. Key informants and senior colleagues reviewed preliminary findings to ensure accuracy of interpretation. Findings reflect collectivist values at the intersection of indigenous Hawaiian culture and religiosity. Inclusion of messages that encourage holistic health across the intergenerational continuum of extended family and fictive kin, reinforcement from spiritual leaders, and testimonials of cancer survivors and family members may facilitate Hawaiian women's screening intent.     

Beliefs related to breast health practices: the perceptions of South Asian women living in Canada

Breast cancer is becoming a major concern for many South Asian women. Clinical observations of women from a South Asian community living in Canada revealed an under use of early detection strategies. The purpose of this qualitative ethnoscience study was to examine breast health practices from the perspective of South Asian women to provide a foundation for the development of culturally suitable breast health services for this group. Open-ended interviews were conducted with a convenience sample of 50 South Asian women over the age of 30 who had not been diagnosed with breast cancer. Adequate representation of the main religious groups (i.e. Sikh, Hindu, Muslim and Christian) was ensured through sampling techniques. Analysis of translated interviews involved identification of themes and the development of a taxonomy to represent relationships among emerging cultural themes and domains. Four central domains of beliefs related to breast health practices were identified: beliefs about a woman's calling, beliefs about cancer, beliefs about taking care of your breasts and beliefs about accessing services. These beliefs hold important implications for how health promotion strategies should be structured and offered, In particular, attention must be paid to the language that is used to talk about breast cancer, the importance of the role of the family in women's health decisions and traditions related to using narratives to share information and advice.     

A call for respect and equality for indigenous scholarship in Hawaiian health

In the State of Hawai'i, there has been steady interest on the part of Western scholarly communities in studies of indigenous Hawaiian intellectual properties. There exists an academic desire to appropriate new fields of knowledge from Hawaiian sources. This pursuit of knowledge runs the risk of increasing the sense of cultural violation already felt by many indigenous populations. If conducted using the means of colonialist intellectualism common to the academy of the dominant culture, this quest for new information will likely contribute to a legacy of spiritual and cultural violation felt by the Hawaiian people. This effort will then likely lead to a further decline in feelings of cultural integrity on the part of native populations. This endeavor will then increase the basis for the psycho-spiritual malaise that underpins the negative health statistics evidenced in Native Hawaiian populations. If present day researchers are to gain greater insight into the lexicon of knowledge available from Native Hawaiians, they will have to employ methods that provide for indigenous scholars to serve as co-researchers in this quest. If Western scholars are to gain access to Native Hawaiian knowledge, such information will more likely come as a result of healing this social wound by developing a new relationship of respect for Native Hawaiian cosmology, epistemology, and pedagogy--one wherein all parties are accepted as co-equals in the scholarly process.     

Cultural competence: a proposal for physicians reaching out to Native Hawaiian patients

Many physicians of Native Hawaiian ancestry, as well as others, have noted a cultural gap between themselves and their Native Hawaiian patients. This cultural gap could potentially lead to discordance in the physician-patient relationship, and in turn, result in less than adequate therapeutic outcomes. Native Hawaiian physicians and those who treat Native Hawaiian patients are seeking ways to improve therapeutic relationships. Developing cultural competency in Native Hawaiian physicians and those who treat Native Hawaiian patients may be expected to improve therapeutic relationships. Principles of cultural competency, including increasing awareness of self and others, enhancing one's cultural knowledge base, and developing skills to communicate effectively, could be applied to physician-patient encounters with Native Hawaiian patients. The principles and skills of cultural competency could be learned during the formal and continuing medical education process. Developing an educational system that promotes cultural competency in physicians is necessary to address the health needs of Native Hawaiians and other diverse populations in Hawai'i.     

'Imi Hale: establishing an inheritance for Native Hawaiians on cancer awareness,research and training

Native Hawaiians experience disproportionate rates of cancer incidence and mortality both nationally and in their homeland, Hawai'i. 'Imi Hale--the Native Hawaiian Cancer Awareness, Research, and Training Project, a five-year project funded by the National Cancer Institute, is aimed at reducing the burden of cancer among Native Hawaiians. The project's overall goal is to reduce cancer incidence and mortality among Native Hawaiians through the establishment of a sustainable infrastructure to 1) promote cancer awareness within Native Hawaiian communities, and 2) initiate cancer research, training, and control activities. A community-based project, 'Imi Hale emphasizes community participation, respect for cultural values, and the sharing of information, as we believe that a commitment to involve Native Hawaiians in all activities of the project will help assure that the community's awareness, training, and research priorities are addressed. In the first year of operation, cancer awareness activities included the development of culturally sensitive booklets on breast cancer and the provision of cancer education and screening for members of the Association of the Hawaiian Civic Clubs. Research and training activities included focus groups to explore the perceptions and experiences of cancer survivors, surveys to assess research priorities, the identification of Native Hawaiian researchers and the development of pilot research projects. The work of 'Imi Hale is guided by the hope that Native Hawaiians can reverse the negative effects of cancer and leave a powerful legacy and inheritance for future generations based on good health and well-being. 'Imi Hale means "to establish, as a dynasty; to acquire authority, power; to seek and establish an inheritance for one's children; and to form a friendship so close that one feels welcome in the house of the other." "By using our language for a name, we are invoking and honoring our ancestors, our culture, language and restoration as a nation."     

Knowledge, Attitudes, and Perceptions about Breast Cancer and Breast Cancer Screening Among Hispanic Women Residing in South Central Pennsylvania

The purpose of this investigation was to assess the knowledge, attitudes, and perceptions about breast cancer, and screening behaviors among Hispanic women in Pennsylvania. Eight focus groups were conducted with Hispanic women to obtain answers to the questions of interest. Results, based on content analysis, showed that cultural factors, such as family and fatalism, influence breast cancer knowledge and screening among this group. In addition, these women had some misconceptions regarding breast cancer and breast cancer detection screening. Most participants reported that they would like to receive breast cancer education in Spanish from health care providers or health educators. These results can help health professionals, including health educators, in the development of suitable breast cancer education and screening promotion programs for Hispanic women. This study was funded by the Research Council of The Penn State Capital College.     

Ka mauli o ka 'oina a he mauli kanaka: an ethnographic study from an Hawaiian sense of place

Ka Mauli O Ka 'Aina A He Mauli Kanaka: The Life of the Land is the Life of the People. A sense of place has been directly linked to spiritual well being for all indigenous peoples. Yet, there is minimal evidence that demonstrates understanding and awareness of indigenous health issues from this perspective. Health, or the lack of it, appears to be related to place or the loss of it. Issues of Hawaiian health are inseparable from issues of land, water, and atmosphere. The purpose of this research study was to explore the experience of a sense of place and its relationship to health as perceived and experienced by Hawaiian participants living in Wai'anae, Hawai'i. Thirteen adult men and women, ranging in age from 36 to 80 years, participated in this ethnographic study. Two interviews conducted with each participant addressed the research question, "What is the experience of the relationship between a sense of place and health for Hawaiians?" Participants were also asked to photograph how they experienced this relationship. The qualitative data analysis computer software, Atlas.ti, was used to assist in data analysis. The findings suggest that the relationship between sense of place and health embodies four categories: (1) relationship to akua (god, spirit), (2) relationship to natural elements, (3) relationship to self and others, and (4) belonging to a particular place. Three major traditional Hawaiian concepts, which defined how the relationship between sense of place and health are experienced, were pono, mana, and kuleana. The relationship between these concepts revealed five cultural themes. Health for Hawaiians: I. is having a spiritual connection to their ancestral place; II. relates to the past, present, and future; III. is experienced with intention and understanding; IV. means an openness to the flow and use of energy; and V. is experienced as a pu'uhonua or safe place. These themes suggest implications for Hawaiian health education, practice, and further research, including that health professionals provide care from these perspectives in order to raise the health status of Hawaiians to the highest possible level. The limitations of the study suggest the uniqueness of Hawaiian communities and diversity of cultural traditions. Although responses from other communities will be valuable, an ethnographic study of one community (i.e., Wai'anae) provides the depth to understanding its people, place, patterns, and history. This study also engaged the community in selecting the participants. This allows for active involvement in the research process, particularly for this community, which has been a victim of this process in the past. The use of photography provided an excellent medium to capture the visual aspects of "place" creating a profound image of the relationship a person has with the land. Ka Mauli O Ka 'Aina A He Mauli Kanaka: The Life of the Land is the Life of the People.     

Heterogeneity within the Asian American community

BACKGROUND: Educational interventions are grounded on scientific data and assumptions about the community to be served. While the Pan Asian community is composed of multiple, ethnic subgroups, it is often treated as a single group for which one health promotion program will be applicable for all of its cultural subgroups. Compounding this stereotypical view of the Pan Asian community, there is sparse data about the cultural subgroups' similarities and dissimilarities. The Asian Grocery Store based cancer education program evaluation data provided an opportunity to compare data collected under identical circumstances from members of six Asian American cultural groups. METHODS: A convenience sample of 1,202 Asian American women evaluated the cultural alignment of a cancer education program, completing baseline and follow-up surveys that included questions about their breast cancer knowledge, attitudes, and screening behaviors. Participants took part in a brief education program that facilitated adherence to recommended screening guidelines. RESULTS: Unique recruitment methods were needed to attract participants from each ethnic group. Impressions gained from the aggregate data revealed different insights than the disaggregate data. Statistically significant variations existed among the subgroups' breast cancer knowledge, attitudes, and screening behaviors that could contribute to health disparities among the subgroups and within the aggregate Pan Asian community. CONCLUSION: Health promotion efforts of providers, educators, and policy makers can be enhanced if cultural differences are identified and taken into account when developing strategies to reduce health disparities and promote health equity.     

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian,Alaska Native,and Native Hawaiian Communities

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts “from the ground up.” Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

     

African American Social and Cultural Contexts and Physical Activity: Strategies for Navigating Challenges to Participation

We examined the influence of social and cultural contexts on participation in recommended levels of physical activity (PA) among African American women using a grounded theory approach. Data were collected through in-depth interviews and focus groups with 15 physically active African American women. Participants described social and cultural factors that served as challenges for participation in PA. Of particular importance, participants discussed their strategies for overcoming these challenges to initiate and maintain an active lifestyle. Strategies emerged to address three main areas: lack of PA exposure, PA norms and beliefs, and hair maintenance. Understanding contextually appropriate strategies to assist African American women in long-term PA maintenance will help inform effective health promotion efforts to reduce the burden of sedentary lifestyle and chronic disease in this community of women.     

Testing the feasibility of a culturally tailored breast cancer screening intervention with Native Hawaiian women in rural churches

The authors report on the feasibility of delivering a church-based breast cancer screening intervention tailored on the cultural strengths of rural-dwelling Hawaiians. Native Hawaiian women are burdened by disproportionately high mortality from breast cancer, which is attributed to low participation in routine mammography. Mammography is proven to be an effective means for detecting disease at its earliest stages, when treatments are most likely to be successful. Culturally tailored screening programs may increase participation. Hawaiian initiatives call for screening innovations that integrate Hawaiian cultural strengths, including those related to spirituality and the extended family system. Before full-scale testing of tailored interventions, it is important to conduct feasibility studies that gauge community receptiveness to the proposed intervention and research methods. Study results establish the attractiveness and potential effectiveness of the authors' screening intervention. Recruitment exceeded targets, and retention rates were comparable to those of other randomized behavioral trials, confirming the value of reaching rural Hawaiian women through churches. Women appreciated the integrative approach of Hawaiian and faith-based values, and positive outcomes are suggested.This article may be relevant to social workers interested in culturally responsive, community-based interventions and to researchers conducting pilot studies and controlled trials of interventions adapted from evidence-based programs.     

Breast cancer screening in older African-American women: qualitative research findings

PURPOSE. The purpose of this study was to gain a better understanding of the cultural meanings that shape the breast cancer screening behavior of older African-American women. DESIGN. Qualitative research methods elicited social and cultural themes related to breast cancer screening. SETTING. Focus group interviews were conducted in the natural settings (churches, etc.) of older African-American women. SUBJECTS. Interviews were conducted with 132 members from 14 social networks of older African-American women. MEASURES. A focus group guide asked about 1) perceived risk of breast cancer, 2) behavioral intentions about breast cancer screening, 3) health seeking behavior, and 4) social support. RESULTS. For older African-American women: other health concerns are of more concern than breast cancer; age is generally not recognized as a risk factor for breast cancer; fear of finding breast cancer and its social consequences are salient barriers to mammography; they tend to rely on breast self-exam rather than mammography to detect a breast problem; cost may be more an issue of competing priorities than cost per se; the tradition is to go to doctors for a problem, not prevention; and women in their own social networks are important sources of social support for health concerns. CONCLUSIONS. These data offer explanations for mammography screening in older African-American women and emphasize the strength of naturally existing sources of social support for designing interventions to increase breast cancer screening.     

Sexual minority status and long-term breast cancer survivorship

Sexual minority women, such as lesbians, bisexuals, and women who have a woman partner face unique challenges, such as deciding on disclosing their sexual minority status to health providers. The purpose of this qualitative study was to explore the perceptions of sexual minority women who were long-term breast cancer survivors. Twenty-two sexual minority women, diagnosed with non-metastatic breast cancer between 2000 and 2005, participated in semi-structured, open-ended interviews. Interviews were audio-recorded, transcribed, and analyzed to identify emergent themes to summarize sexual minority women's perceptions of breast cancer survivorship. Participants' perceptions about the impact of their sexual minority identity on breast cancer survivorship consisted of: (1) breast cancer is a women's issue, not a lesbian issue; (2) I can manage my identity in the context of breast cancer; and (3) I am better off than heterosexual women. The authors' findings suggest a possible disconnect between sexual minority women with breast cancer who de-emphasized the importance of sexual minority status and the research community that emphasizes the importance of this status. Prior to counting on sexual minority women's interest in studies, researchers may need to educate sexual minority women about the need of breast cancer studies.     

Esperanza y Vida: a culturally and linguistically customized breast and cervical education program for diverse Latinas at three different United States sites

Breast cancer is the most common cause of cancer and the leading cause of cancer death among Latinas in the United States. In addition, Latinas experience a disproportionate burden of cervical cancer incidence, morbidity, and mortality compared with non-Hispanic White women. Lower use of breast and cervical cancer screening services may contribute to these disparities. To address the underutilization of breast and cervical cancer screening among diverse subgroups of Latinas, a peer-led education program called Esperanza y Vida ("Hope and Life") was developed and administered at 3 sites (2 in New York and 1 in Arkansas). Immigrant Latina women and their partners were educated about the importance of breast and cervical cancer screening, with the goals of increasing their knowledge about these cancers and their screening behavior. An analysis of the intervention's findings at baseline among female participants demonstrated significant sociodemographic, interpersonal, cultural, health care system, and program variability in 3 distinct geographic regions in the United States. These data indicate the need for and feasibility of customizing cancer outreach and educational programs for diverse Latina subgroups living in various U.S. regions, with implications for informing the expansion and replication of the program in other regions of the country.     

SOCIAL CONSTRUCTIONS OF BREAST CANCER

In contrast to other life-threatening diseases, in which mortality is understood as the fundamental threat, much popular and professional discourse about breast cancer focuses on such issues as the identity, body image, and self-worth of the afflicted woman. Within the Western biomedical tradition, the meaning ascribed to breast cancer has been strongly influenced by competing social interpretations. In this paper, we contend that such social constructions shape the manner in which women experience breast cancer, including their decision making in response to treatment options as well as their strategies for coping with and making sense of breast cancer illness. We argue that an appreciation of the historical and cultural contexts in which breast cancer imagery has been constructed helps to explain the confusing array of ideologies that confront contemporary women diagnosed with breast cancer.     

Social constructions of breast cancer

In contrast to other life-threatening diseases, in which mortality is understood as the fundamental threat, much popular and professional discourse about breast cancer focuses on such issues as the identity, body image, and self-worth of the afflicted woman. Within the Western biomedical tradition, the meaning ascribed to breast cancer has been strongly influenced by competing social interpretations. In this paper, we contend that such social constructions shape the manner in which women experience breast cancer, including their decision making in response to treatment options as well as their strategies for coping with and making sense of breast cancer illness. We argue that an appreciation of the historical and cultural contexts in which breast cancer imagery has been constructed helps to explain the confusing array of ideologies that confront contemporary women diagnosed with breast cancer.     

Health care utilization among women on O'ahu: implications for Native Hawaiian women

Women generally seek and use more health care services than do men. Women are also more likely to encounter financial and non-financial barriers to care than do their male counterparts. These differences are accentuated among low income and minority women. We examined health care utilization patterns among women on O'ahu using survey data, and compared those patterns among Native Hawaiian and other ethnic groups. We also provide prevalence rates for several critical women's health issues by ethnic group and explore demographic predictors for health care utilization. Although the vast majority of women have seen health care providers in the last year, ethnic and socioeconomic disparities were identified, especially with respect to our Native Hawaiian female population. A pattern for Native Hawaiian women reveals among the highest rates of depression, as well as sexual/physical/emotional abuse. Alarmingly, Native Hawaiian women are also less likely to have seen a provider in the last year, less likely to have insurance coverage, and more likely to visit emergency departments. Differences by provider type served to reinforce these disparities. In order to reduce barriers to health care utilization for Native Hawaiian women--and for all women in Hawai'i--we recommend universal insurance coverage that includes screening and counseling services. Additionally, training for health care providers is essential in order to improve culturally competent, psychological assessments of health issues for women, particularly Native Hawaiian women.     

Pilot test of a cervical cancer prevention video developed for Alaska Native women.

Cancer of the cervix is twice as likely to occur among Alaska Native women than among Caucasian women in the United State. To understand some of the factors associated with this high incidence, a random sample of 528 Alaska Native women were surveyed about their knowledge, attitudes, and behavior regarding cervical cancer and its risk factors. From the results of the Alaska Native Women''s Health Project study, the need for more public education related to cervical cancer prevention was identified. A review of existing educational resources revealed that no culturally appropriate materials related to cervical cancer had been developed for Alaska Native women. To increase Native women''s knowledge about cervical cancer and to motivate them to obtain annual Papanicolaou tests, a 12-minute videotape presentation was developed specifically for this population. The videotape portrayed Alaska Native women as role models from the community discussing cervical cancer and Papanicolaou tests and engaging in healthy lifestyles. The videotape was pilot tested with several groups of Alaska Native women. The women were surveyed before and after watching the video and were asked to rate the tape and make comments about it. The results of the posttest demonstrated a significant increase in the knowledge level of the participants. The videotape was well received because of its cultural sensitivity and appropriateness. On the basis of this study, the development of additional culturally appropriate educational materials related to cancer prevention of Alaska Native women is recommended.