Evaluating Teaching Techniques in the Hmong Breast and Cervical Cancer Health Awareness Project

Abstract

Background

Cancer health disparities are a reality for Hmong women who are often diagnosed at a later stage, have low literacy, and experienced care that is not culturally appropriate. Lack of attention to cultural appropriateness and literacy levels of cancer screening materials may contribute to disproportionately low levels of cancer screening among Hmong women.

Purpose

To evaluate the Hmong Health Awareness Project (HHAP), a program designed to create awareness and acceptance of breast and cervical cancer screening, and to examine participants’ perceptions of the utility of the content of the workshops.

Methods

Hmong researchers partnered with three Midwestern Hmong community centers to implement six workshops. Three teaching techniques: pictographs, videos, and hands-on activities were utilized to teach Hmong participants about cancer screening. Participants included 150 Hmong (male=30, female = 120). Teach back method was used to assess participants’ understanding of cancer screening throughout the workshops. Qualitative data were collected in focus groups to assess the feasibility of teaching methods and participants’ perceptions of the utility of the content of the workshops. Directed content analysis was used to analyze participants’ responses.

Results

The three teaching techniques were helpful in increasing the Hmong people’s understanding about breast and cervical cancer screening. Nearly all participants perceived an increased in their understanding, greater acceptance of cancer screening, and increased willingness to be screened. Men expressed support for screening after the workshops.

Conclusion

Findings can guide future interventions to improve health communications and screening and reduce diagnostic disparities among Hmong and immigrant populations.

Introduction

Hmong women experience significant cancer health disparities. They are diagnosed at a later stage of cancer than are other women in the U.S., and have cancer mortality rates 2.8 times higher than other Asian American women and 4.2 times higher than non-Hispanic white women [1,2]. Low screening rates likely contribute to these disparities. According to the Centers for Disease Control and Prevention [3], in 2010, 64.1 percent of Asian women aged 50–74 years reported having a mammogram within the past two years compared to 73.2 percent of African Americans and 72.8 percent of white Americans. Asian women who reported having had a pap test in the last three years were 75.4 percent compared to 80.1 percent for Black and 74.9 percent for White women[4]. Although the CDC has collected screening rates for Asian American women, it is an aggregate rate, making it difficult to tease out how the Hmong women compare to other Asian groups.

Lack of attention to cultural appropriateness and literacy levels of cancer screening materials may contribute to the disparity in screening rates for Hmong women. Researchers reported that few educational materials have been provided for the Hmong community and that those provided were poorly translated, lacked cultural appropriateness, and were written at an inappropriate literacy level [5].

While there may be additional barriers to screening, a better understanding within the Hmong community of the screening process and benefits to be gained might reduce these disparities. Cancer prevention education interventions that are consistent with Hmong culture and language may be helpful in promoting early cancer screening. The purpose of the current study was to evaluate three teaching techniques that were developed for a health education program called the Hmong Health Awareness Project (HHAP), a program aimed to create awareness of breast and cervical cancer screening with culturally and linguistically appropriate techniques for Hmong women and men, and to examine participants’ perceptions of the utility of the content of the workshops. Content presented will include Hmong culture and health concepts related to breast and cervical cancer, theoretical framework used to guide teaching techniques, and teaching strategies health care providers can use to provide effective health education to Hmong patients.

Hmong Culture and Health Concepts

Research has documented that culture plays a significant role in determining whether Hmong women seek breast and cervical cancer screening [3, 4, 5]. In the Hmong culture, there is a strong sense of modesty and embarrassment related to body parts and the intrusiveness of gynecologic exams [3, 6, 7]. Fear of discovering they have cancer has also been shown to prevent Hmong women from seeking cancer screening [6, 11].

Several languages related barriers are also likely influence the effectiveness of translated written materials for older Hmong. First, a study of 323 Hmong older adults found that 86% of Hmong adults reported speaking English poorly or not at all [12]. Second, Hmong language has no equivalent for many of the medical terms used routinely (such as chemotherapy) in educational materials [13]. Another important consideration is the absence, until recently, of a written Hmong language. Traditionally Hmong education occurred through a rich and elaborate oral tradition. Consequently, many older Hmong are unfamiliar with written communication, including the newly developed written Hmong language. For this reason, translating educational materials into Hmong may be ineffective.

Theory of Cultural Influence on Cognitive Styles

Based on research demonstrating that people from culturally diverse backgrounds learn differently [14], Worthley (1987) proposed four ways in which culture can influence cognitive styles including: (a) socialization practices, (b) cultural tightness, (c) ecological adaptation, and (d) language. Socialization practices refer to the extent of an individual’s autonomy [15]. For example, permissive socialization practices where experimentation is encouraged result in wider flexibility of style, in contrast to strict socialization practices with a high degree of pressure for conformity leading to less variation in style. Cultural tightness relates to traditions and routines. “Tight” cultures exhibit a high degree of pressure for conformity, while “loose” cultures focus on less precise adherence to the customary ways of doing things [15]. Ecological adaptation refers to environmentally based practices within a culture [16] such as depending primarily on agriculture and animal husbandry. Such cultures have emphasized traditional knowledge and routines in order to survive. In contrast, cultures that depend primarily on hunting and gathering require more self-reliance and flexibility required to apply skills under varying circumstances. Language refers to how knowledge is transmitted. For example, oral societies follow an enactive mode that involves observation, demonstration, and role modeling, as well as depending on situational bases within social contexts. In contrast, literate societies follow written symbols for the transmission of knowledge.

Theory of Cultural Influence on Cognitive Styles and Hmong’s Ways of Learning

Worthley’s (1987) theory can be usefully applied to educating people from traditional Hmong culture. The Hmong people were originally a tribal population living in the high mountains of Laos. The Hmong have strict socialization practices with a culture emphasizing obedience and conformity to situation-specific customs and time-honored procedures. The Hmong culture is patriarchal and family structure is organized in a way that the family is under the “authority of the male head of household” [14, pg. 13]. For example, wives are expected to be quiet, passive followers of the demands of their husbands [18]. This structure allows Hmong men to take control of many of the decisions made in the household and Hmong women are expected to support and follow the demands of the male head[19]. Thus, their traditional culture can be described as “tight” with little latitude in procedures and routines.

The Hmong people’s ecological adaptation is historically dependent on farming because their survival depended primarily on harvesting successful crops. They learned in the fields through observation and demonstration that used their tactile sensory abilities (e.g. kinesthetic learners).

The Hmong culture is oral. Skills, customs, historical knowledge and traditions are passed on orally from generation to generation, primarily focused on rote learning, memorizing, and storytelling. Moreover, the Hmong learning style is perceptual, interactive, and adapted to traditional Hmong environments and lifestyles. Group learning may result in a higher degree of achievement, perhaps because the Hmong exhibit greater self-confidence when working together. A study conducted to examine perceptual and social learning style preferences of Southeast Asian immigrant high school students, including Hmong, found that Hmong students had a preference for all perceptual styles with tactile learning scoring highest. They also expressed a clear preference for group, as opposed to individual, learning [20]. Despite this, it was not until the 1950s that the Hmong adopted a Romanized written system developed by Protestant missionary linguists [21]. However, many older Hmong do not know the written system highlighting the need for health educators to take into consideration cultural referents that influence how the Hmong learn.

To be consistent with the Hmong people’s way of learning, we proposed an education program that was consistent with preference for visual/oral communication, kinesthetic learning, and a subtle approach to the discussion of body parts. This is a novel approach to teaching which is consistent with the Hmong culture. Our teaching strategy included three visual components; (a) videos, (b) pictographs, and (c) hands on activities (kinesthetic component). Videos have been shown to be an effective tool for conveying basic information about cancer screening [22, 23] to other ethnic minorities. Videos were also chosen because they are consistent with Hmong oral culture. Pictographs have been shown to be an effective teaching tool for adults with low-literacy skills [24–26], consistent with many Hmong older adults. For example, Houts and colleagues developed pictograph-based healthcare instructions for older adults with low-literacy skills to manage cancer and acquired immunodeficiency syndrome-related symptoms and found that the pictograph-based instructions significantly improved short-term and long-term recall [27]. For our study, the use of pictographs also negated the need to use language that referred to body parts. This corresponded to the Hmong cultural norms.

Research has also documented that hands on activities are often the preferred learning style for minority groups (e.g. Latina) for health information [28]. Because hands on activities elicit social interaction/group cooperation, this corresponds well with how Hmong women have traditionally learned. Group cooperation is very much in line with Hmong social life. Cooking, gardening, shopping, and many other activities are carried out by the Hmong in small groups rather than individually. Hands on group learning activities allowed for social interaction/ group activity while also corresponding to learning techniques that the Hmong are familiar with.

Methods

This study’s purpose was to evaluate the feasibility of three teaching techniques selected for their consistency with Hmong culture and to examine participants’ perceptions of the utility of the content of the workshops. The Institutional Review Board of the University of Wisconsin-Madison approved this study. Individuals eligible to participate in this study were men and women ages 18 and older, self-identified as Hmong, who speak Hmong and agree to participate in the HHAP educational workshops.

Data Collection

Community centers with high Hmong attendance were invited to participate in the health program and were the major source for recruiting. Researchers recruited participants verbally, through personal invitations, and snowball sampling (e.g. workshop participants were asked to refer friends and relatives who they think might meet our inclusion criteria and interested in participating in future workshops). This strategy was selected because, in the Hmong culture, it is considered rude if researchers do not personally invite participants. Recruitment took place at three different community centers to allow for a heterogeneous sample including age, geographic location, and gender.

Intervention

The intervention focused on educating Hmong women and men about breast and cervical cancer screening. Men were invited to attend because they play an instrumental role in encouraging Hmong women to seek care. This is because the Hmong culture is patriarchal and Hmong women defer to their husband (Lee, 1994). The objectives of the intervention were to: (1) create awareness of breast and cervical cancer screening, (2) empower Hmong women by making it less frightening to go seek screening, and (3) assess the feasibility of the educational approach. Participants were invited to attend a set of two educational workshops, each two hours in length, and to participate in an open-ended post workshop discussion. Open-ended questions focused on participants’ perceptions of the teaching techniques. Each participant attended both workshops: one on breast cancer screening and one on cervical cancer screening. The breast cancer screening workshops were conducted from September to December 2010. The cervical cancer screening workshops were conducted from January to May 2011. The breast cancer screening workshop was presented first because it was a less sensitive topic than cervical cancer screening. The workshops were conducted in Hmong orally. However, written materials were given to those who could read and those who want to have hard copies. Written materials included the breast and reproductive anatomy documents. One Hmong student, who is bicultural and bilingual, fluent in Hmong and English, translated the documents into Hmong, and presented the information orally. To ensure that the translations were accurate, they were given to a Hmong professional translator for verification of accuracy. This resulted in a change for two words. Other handouts including the Susan G Komen shower cards had already been professionally translated into Hmong. All materials handed out were in Hmong. Handout content was primarily presented as pictographs with fewer words. The educators of the HHAP consisted of four bilingual and bicultural Hmong students enrolled in health related majors. See table 1 for better descriptions and procedure of the workshops. The procedure of the breast and cervical cancer screening workshops were the same but taught with different content.

Table 1.

Procedure Description

Procedure	Breast Cancer Workshop (September – December 2010)	Cervical Cancer Workshop (January–May 2011)
1. Set Up
2. Icebreaker Activity	Candy game: why is your name? Tell us something about you.
3. Explain agenda & goal of the workshop	Goals for the day: To recognize the importance of healthy behaviors and taking charge of one’s health through regular breast & pelvic exams To understand factors that can influence breast and cervical cancer
4. Hands on activity	What is cancer? (refer to table 2 for description of this activity)	Review: What is cancer? (in the context of cervical cancer)
5. Video	5-minute video about mammography (refer to table 2 for details)	Review: Ask participants how cells become cancerous
6. Pictograph: Preventive Strategy	Breast anatomy worksheet, Komen shower card. Powerpoint was also used to go over visuals of the breast anatomy.	Reproductive anatomy worksheet. Powerpoint was also used to go over visuals of the breast anatomy.
7. Hands on activity: Preventive Strategy	Activity with the breast model with lumps (2 models small/large)	Activity with the reproductive model & pear activity
8. Handouts: access to services	Informational handouts on breast and cervical cancer services in the community were given to participants
9. Focus group	Evaluation of the workshops

Teaching Techniques

Each of the teaching techniques was carefully selected or created to be consistent with Hmong cultural values and practices. See table 2 for description and details of teaching techniques.

Table 2.

Description of Teaching Technique Modalities

Type	Techniques	Description (Examples)
Pictographs	Use step-by-step pictographs	Self-check shower card from Susan G. Komen was used. Powerpoint included pictures of the anatomy of breast/reproductive system in the suggested language by the participants in the workshops.
Hands on activities	Facilitators demonstrated how screening procedures (e.g. Pap test) was done to allow participants to observe Allow participants to use their tactile sensory by handling the models Put participants in groups consisted of 4–5 people to elicit social interaction/group cooperation	“What is cancer?” In this activity, we used a long string to represent a breast. Then we assigned colored paper to participants representing normal, abnormal, and cancerous cells. Participants then go into the breast to demonstrate replication of different type of cells. Pap Test: We used a pelvic model to explain concepts relating to the cervix, pelvic exam, and Pap test. We used the pelvic model to demonstrate a Pap test procedure consisted of the materials including a reproductive anatomy model, speculum, and spatula Pear activity: consisted of each item similar to the reproductive organs by size. We used a color piece of paper with Hmong writing with the name of each organ. We explained the objects and its size. Then we had the participants put the pieces together to see where they think the pieces goes. Breast model activity: allowed women to handle the breast models and to practice self-exam technique and locate lumps in the breast models. We allowed enough time for all the participants to practice (approximately 15 minutes). We assisted those who needed help locating the lumps. Female Reproductive System Model: allowed women to visualize and understand their reproductive anatomy. We passed the model around so that the women could see and touch the model. This activity to enhance the women’s understanding of where the cervix is located.
Videos	Use animated characters to show procedures Storytelling of a Hmong women cancer survivor Use sensitive language to address body parts	5-minute video about mammography. The video talked the women through the breast cancer screening procedure. More specifically, the video consisted of information about what things to consider before the mammography, what the procedure is like, and how the procedure will be done. Language Examples: Instead of saying breast, we say chest [xubntiag] in Hmong ; instead of saying vagina, we say private part [chaws mos]

Videos

videos about breast and cervical cancer screening used animated characters (rather than real people) to show respect for the strong sense of modesty and embarrassment about body parts among Hmong women. The animated characters were downloaded from a Youtube clip. This Youtube clip was used for only the breast cancer screening workshop. The clip was muted and the first author recorded a voice-over in Hmong (e.g. animated woman going in for mammography procedure). To avoid embarrassment, the video narrators used sensitive, Hmong language to discuss body parts. For example, cervix was referred to as “private part’ (chaw mos, in Hmong). The clip allowed Hmong women to learn by watching and listening, through rote learning and memorizing, which is consistent with Hmong tradition. We did not use an animated video to teach about cervical cancer screening because we were concerned that it was too intrusive.

Videos were also used to reduce Hmong women’s fear of cancer. Thus, a video of a Hmong woman breast cancer survivor shared her experience with breast cancer in Hmong, emphasizing the importance of being screened and how screening helped her live a longer life. We did not use videos of Hmong women cervical cancer survivors because none exist. Most Hmong women are diagnosed with cervical cancer at later stages and do not survive. Thus, by using the video of the Hmong women breast cancer survivor, we hoped to encourage the women to seek screening. The cancer survivor videos were obtained from a Minnesotan group that produces health videos on a wide range of topics. Due to workshop time constraints we gave the video of a Hmong woman breast cancer survivor to each participant to keep and take home to watch on their own time, instead of showing it during the workshop. This approach is consistent with the oral, storytelling traditions in Hmong culture.

Pictographs

Pictographs were used to address the lack of familiarity with Westernized biomedical concepts and medical terminology. Step-by-step pictographs were used to teach the Hmong women about self-examinations of the breast and the female reproductive system, particularly understanding their external genitalia. For example, women were encouraged to use mirrors to examine their external genitalia on a daily basis, while showering, to learn about their body parts. Since older Hmong women are part of a “tight” culture that focuses on strict procedures and routines, using step-by-step pictographs such as the Susan G. Komen step-by-step self-check shower card, allowed the Hmong women to follow regimented routine and procedures of self-check and to remember how to perform a self-check. Using the pictographs of breast and reproductive anatomy, participants were asked to add labels to the body parts. Participants were able to take copies of the newly labeled pictographs home with them.

Hands on activities

The Hmong are kinesthetic learners, to accommodate learning style hands-on-models including breast and reproductive models were used. The breast model activity included teaching models of different breast size to allow participants to feel the model, practice self-exam techniques, and try to locate tumors in the breast models. The activities elicit social interaction/group cooperation among participants, which corresponds to tradition Hmong learning styles. The female reproductive system model provided a lateral/cross-section view of the female reproductive system, which included the uterus, cervix, ovum and vagina. The female reproductive system model allowed participants to visualized and understand their reproductive anatomy including the location of the cervix. See table 1 for more information.

Evaluation

The workshops were held at three community centers, where many Hmong people in the community gather. Results reported are from two of the community centers. The third center allowed us to conduct the workshops but not the evaluation. To assess the effectiveness of the workshops, focus groups were conducted at the end of each workshop to gain insight into how the Hmong experienced the intervention, how well the intervention was received, and what participants learned. Sample questions asked during the focus group were: “Tell us what you did or did not like about the teaching techniques we used. For example, did you like the videos” and “Did you find the videos, pictographs, and hands-on activities helpful?” Participant responses were also used to alter subsequent workshops. A few participants recommended including information about the types of cancer treatment; thus, we included cancer treatments in the following workshops. Participants also encouraged the usage of visuals throughout the workshops to teach them. Field notes were taken to capture the interactions between participants.

A variety of pre-test and post-test questionnaire assessments were utilized to assess knowledge of Hmong participants before and after the workshops. The first assessment technique was a four-item True/False questionnaire. Questionnaire was read aloud to participants who were directed to check a box indicating whether they thought each statement was true or false. However, participants were not familiar with this sort of format and became confused. The majority of forms were returned blank. We then tried a second assessment, where three statements were read to participants and if they thought the statement was correct they raised their hands. In this way, we could count how many individuals knew the correct response. This assessment was also not successful because of peer influence on the responses; participants were able to see each other’s response. Consequently, we were unable to compare participants’ knowledge before and after the workshops. While our teaching strategies were consistent with Hmong culture, our assessment strategies were not.

Because of the hurdles we encountered with pre-and post-workshop assessment, we decided not to continue with the pre-and post-test. Instead, we used a teach back method to assess understanding of the materials after each topic presented to the participants. The teach back method was conducted throughout the entire workshop. Radom participants were selected to answer teach back questions. Sample questions included; “At what age should a woman get a mammogram/Pap test?”; “what are the things a woman should not do before a mammogram/Pap test?”

Analysis

Directed content analysis was used to analyze participants’ responses about their perceptions of the utility of the content of the workshops [29]. Categories used to guide the content analysis include: (a) understanding of content, (b) feedback on visual aids, (c) impact of teaching techniques, and (d) feasibility of the program. All authors consisting of students, separately reviewed transcripts and coded participants’ comments into categories. Authors met to refine coding through multiple iterations to achieve consensus.

Results

A total of six cancer screening workshops (n=3 for breast and n= 3 for cervical cancer screening) were taught in ten months. Workshop participants included 150 Hmong (male= 30, female = 120) with ages ranging from 18 to 73 years old. We present responses and perceptions of participants in the breast and cervical cancer workshops in regards to the teaching techniques and the feasibility of our program overall.

Effectiveness of Teaching Techniques and Feedback from Hmong women

Increased understanding of breast and cervical content

Teaching techniques in the HHAP program enabled nearly all participants to increase their understanding of the importance of breast and cervical cancer screening. Nearly all participants demonstrated increased understanding of breast and cervical content evidenced by verbally answering the teach back questions correctly. After the workshop, one participant shared proudly, “I never knew that was how abnormal cells divided! I am glad you girls explained it very well.” Another participant shared, “Now that we have learned how to perform self-breast examinations, we need to practice doing it each month. It is important that we know how our body is like.” A few women from the first workshop also came to the second workshop at another community center. After correctly answering a teach back question, one woman said: “I know that answer because I have already been to one of your workshops before.”

Feedback on visual aids

The participants reported that the visual aids helped increase their understanding of breast and cervical cancer screening and they enjoyed the hands-on activity. One woman shared “I like the breast model activity because it really helped me know how a lump in a breast feels like. This was my first time feeling one!”

Impact of teaching techniques

Participants reported that engaging in the activities has helped reduce their fear of going in for screening. One participant expressed, “I feel not as scared to go get screening in the future.” At the completion of the workshops, men participants were very encouraging and supportive of screening. Most of the men attending encouraged the women participants, “you ladies need to go in and check annually to make sure that you are not sick. It is good to know then not know at all. Like they said, we, Hmong people always go in for help really late, and so most of the time, the doctors cannot help us. We need to start going in early. ” This is important because the Hmong come from a patriarchal society. Thus, having support from men to seek screening will likely promote screening for Hmong women.

Participants also expressed appreciation of our sensitivity to the Hmong words: breast and cervix. Many participants stated “we like how you gals used the word xubntiag instead of breast in Hmong; chaws mos instead of cervix. It helps make us less embarrassed to talk about it.”

Throughout the workshops, we observed high levels of engagement in the group interaction activities. In particular, we observed participants articulating and clarifying content with each other without asking us, taking an active role in learning the content. Participants appeared to enjoy the group activities by displaying excitement and energy. Interestingly, we noted one gender difference in one of the group interaction activities, specifically the pear activity. We observed a difference in the level of knowledge about the women’s reproductive system. Male participants displayed more familiarity and knowledge than women participants, reflected in their ability to place the reproductive pieces quicker and more accurately than the women participants. The women struggled with the location of each body part.

Feasibility of program

All participants stayed to the end of the workshop sessions and all participants who attended the first workshop on breast cancer returned for the second workshop on cervical cancer screening five months later. Many of the participants expressed the need for more educational workshops, “we need more of these workshops because the Hmong elders need to know more about their health.” Participants expressed gratitude that the workshops were conducted in Hmong. They also expressed a need for more Hmong educators. The males in the workshop requested workshops focused on screenings pertaining to them, “Can you young ladies, come back and do workshops on prostate cancer screening for us males?”

Discussion

This study evaluated the effectiveness of teaching techniques used to teach Hmong women and men about breast and cervical cancer screening education. It is clear that the Hmong’s reception of breast and cervical cancer screening information is affected by their culturally derived cognitive styles. Using (a) pictographs, (b) videos, and (c) hands-on activities teaching techniques were helpful in increasing the Hmong people’s understanding about breast and cervical cancer screening.

Behavioral preparation would increase the probability of following the physician’s recommendations. The feedback from Hmong women suggests that using culturally congruent teaching techniques were effective and have the potential to reduce distress and lead to an increase in screening rates. Johnson reported that specific characteristics of information given to patients facilitate cognitive control of emotional response to threatening stimuli [30]. Fear or embarrassment, when present, produces a variety of behaviors that sometimes facilitate and sometimes prevent performance of danger control behaviors. Researchers who have studied fear communication have suggested that when patients are given behavioral preparation for how and when to act on external threats for patients, they are better equipped to sustain control over external threats [31, 32]. Johnson and Leventhal examined the effects of accurate expectations and behavioral instructions on reactions during a noxious medical exanimation; they suggested that preparatory communication could reduce distress and increase compliance with recommended actions in a difficult, real-life setting [33]. It is possible that exposing the Hmong people to cancer information has reduced the Hmong people’s fear and/or embarrassment of getting cancer screening.

Practice Implications

There are many lessons learned from the teaching techniques used in the HHAP program that clinicians and health educators can use when working with Hmong patients on breast and cervical cancer screening education. This program supports the use of visual aids, videos, and hands-on activities in a health education program for Hmong women and men. Thus, clinicians should use visual images when teaching and/or sharing cancer screening information with Hmong people because cancer is an unfamiliar concept for them. Additionally, using a teach back method can be helpful in assessing understanding of health information instead of using pencil and paper format for Hmong people. These techniques are useful and easy to integrate into clinical practice.

Because cultural knowledge guides Hmong people’s understanding, particularly of older Hmong, teaching related to cancer screening requires a different approach. Formal instruction within Hmong culture focuses on rote learning and memorizing. Clinicians should be aware of these cultural differences when selecting methodologies to provide health education to Hmong people, regardless of the health issues. Educators/clinicians should be clear when describing the key points of breast and cervical cancer screening, be precise in their instructions, and provide step-by-step pictographs that emphasized procedure and routine.

A major limitation of this study was that we were not able to conduct a pre-and post-test knowledge assessment. However, this failure highlighted an important issue for both clinicians and researchers, that verbal assessments and feedback should be used with this population along with a one-on-one approach. Additionally, we did not evaluate whether participants actually obtained screening following our workshops. Future research could follow up on participants’ actual screening post intervention. Another limitation is that we may have overestimated the number of participants, as a few participants attended workshops on the same topic at both centers. However, this finding indicates that Hmong participants may be more willing and interested in learning about cancer screening than has previously been assumed. Because we used snowball sampling for recruitment, there is a possibility that selection bias could have occurred. Future research should identify other effective techniques for assessing the Hmong’s knowledge and explore whether the teaching strategies described here can be used with other health areas.

Conclusion

Cancer screening is an issue for Hmong women. Health care professionals are challenged to adapt their teaching style, both cultural and linguistic, to meet the needs of Hmong women. This study suggests the use of visual aids techniques including (a) pictographs, (b) videos, and (c) hands-on activities as feasible and may be a valuable tool for researchers and clinicians to increase Hmong understanding of breast and cervical cancer screening. Furthermore, these teaching techniques may be amendable for use with other low literacy adults from varied cultural backgrounds.