HMONG ELDER’S SOCIAL AND CULTURAL BARRIERS TOWARD
SEEKING WESTERN HEALTHCARE
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Chue Neng Xiong
SPRING
2012
HMONG ELDER’S SOCIAL AND CULTURAL BARRIERS TOWARD
SEEKING WESTERN HEALTHCARE
A Project
by
Chue Neng Xiong
Approved by:
__________________________________, Committee Chair
Dr. Serge Lee, Ph.D., MSW
____________________________
Date
ii
Student: Chue Neng Xiong
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
__________________________________, Graduate Coordinator, _________________
Dale Russell, Ed.D., LCSW
Date
Division of Social Work
iii
Abstract
of
HMONG ELDER’S SOCIAL AND CULTURAL BARRIERS TOWARD
SEEKING WESTERN HEALTHCARE
by
Chue Neng Xiong
This research study explores the social and cultural barriers that Hmong elders faced in
seeking western healthcare. It is the understanding of the researcher that Hmong elders
lack adequate healthcare; therefore contributing to the gab in healthcare disparity among
the Hmong population. To explore the barriers to Hmong elders’ resistance of western
healthcare, the researcher conducted interviews on 50 Hmong participants who were 60
years of age or older living in the greater Sacramento region. The researcher recruited
participants using the snowball sampling procedure and conducted the interviews in the
Hmong dialect using a survey consisting of open-ended and closed ended questions. .
The study indicated that there is still a strong cultural and religious influenced especially,
among those who are still traditional in their religious belief when it comes to their health
seeking behaviors.
____________________________, Committee Chair
Dr. Serge Lee, Ph.D., MSW
_______________________
Date
iv
DEDICATION
I would like to dedicate this project to my loving parents Lao Xiong and Nhia
Yang for their constant support, to my precious grandparents See Vue Xiong and Pha
Moua for their unconditional love and support of my children, and finally my wonderful
hard working wife Mai Chang and three adorable children Andy Xiong, Angelina Xiong
and Alex Xiong. Thank you all for being there for me and giving me the energy and
courage to continue my educational dream.
v
ACKNOWLEDGEMENTS
First, I would like to thank my parents, Lao Xiong and Nhia Yang for their
unconditional love, encouragement and financial support throughout my entire
educational career. Dad, it is because of your hard work and inspiration that has helped
me succeeded this far in the pursuit of my educational dream. I greatly appreciate the
time that you spend day and night working to make sure that your family especially, your
children are able to attend school.
Next, I would like to thank my grandparents See Vue Xiong and Pha Moua for
their endless support and love for me and my children while I’m at school. I understand
that it is because of your precious time and energy taking care of my children that I am
able to concentrate in school. Thank you so much for all the things that you two have
done for me.
Next, I would like to give special thanks to my precious wife Mai Chang and all
my three children Andy Xiong, Angelina Xiong, and Alex Xiong for being there for me
during stressful times and standing by my side. I appreciate the fact that you all have
come into my life and given me the most inspiring reasons to continue my education. I
cannot find enough ways to tell you all how grateful I am to have everyone in my life.
Lastly, I would like to give my sincere thanks to my wonderful advisor Dr. Serge
Lee. I cannot imagine myself being able to complete the thesis project if it was not for
your consistent guidance and support. Despite all the other things that you are busy with,
you have put a lot of effort in helping me on this research project. Thank you.
vi
TABLE OF CONTENTS
Page
Dedication ..................................................................................................................... v
Acknowledgments....................................................................................................... vi
List of Tables ................................................................................................................ x
Chapters
1. THE PROBLEM…………………………………………………. .........................1
Introduction ........................................................................................................1
Background of the problem ...............................................................................3
Statement of the Research Problem ...................................................................4
Purpose of the Study ..........................................................................................5
Theoretical Framework ......................................................................................5
Assumptions.......................................................................................................7
Justification ........................................................................................................8
Definition of Terms............................................................................................8
2. LITERATURE REVIEW ......................................................................................10
Introduction ......................................................................................................10
Healthcare Disparity in America .....................................................................11
Western Concept of Health ..............................................................................13
Healthcare Accessibility ..................................................................................15
Hmong Origin Theories ...................................................................................16
vii
Hmong and the Secret War of Laos .................................................................18
Refugees in a New Land ..................................................................................20
Clan and Family Structures ..............................................................................22
Demographics ..................................................................................................24
Shamanism and Alternative Healing ...............................................................25
Hmong Health Concept....................................................................................28
Healthcare Challenges for Hmong ...................................................................31
Conclusion .......................................................................................................33
3. METHODOLOGY ................................................................................................35
Research Design...............................................................................................35
Data Collection Procedures..............................................................................35
Protection of Human Subjects .........................................................................37
Instrumentation ................................................................................................40
Data Analysis ...................................................................................................41
Limitations .......................................................................................................42
4. DATA ANALYSIS ................................................................................................44
Introduction ......................................................................................................44
Section 1: Demographics .................................................................................44
Section 2: Social Factors ..................................................................................50
Section 3: Cultural Beliefs and Healthcare Practices ......................................54
Significant Findings .........................................................................................59
5.
CONCLUSION AND RECOMMENDATION ...................................................64
viii
Introduction ......................................................................................................64
Summary ..........................................................................................................65
Social Work Implications ................................................................................68
Recommendations for Future Research ...........................................................69
Conclusion .......................................................................................................71
Appendix A. Interview Questions...............................................................................72
Appendix B. Oral Consent to Participate in the Research Study................................77
Appendix C. Human Subjects approval form .............................................................78
References ....................................................................................................................79
ix
LIST OF TABLES
Tables
Page
1.
Table 1. Age of participants ............................................................................. 45
2.
Table 2. Gender of participants ........................................................................ 46
3.
Table 3. Able to Speak Thai ............................................................................ 46
4.
Table 4. Able to speak Laotian ........................................................................ 46
5.
Table 5. Marital status...................................................................................... 47
6.
Table 6. Religious preference .......................................................................... 48
7.
Table 7. Amount of time living in the U.S. ..................................................... 49
8.
Table 8. Number of Children ........................................................................... 50
9.
Table 9. Attend school in Laos ........................................................................ 51
10.
Table 10. Number of years attended school..................................................... 51
11.
Table 11. Insurance/Income ............................................................................. 52
12.
Table 12. Children with degree ........................................................................ 53
13.
Table 13. Decision making .............................................................................. 54
14.
Table 14. Children help decide medical care ................................................... 54
15.
Table 15. Take advice from Physician ............................................................. 55
16.
Table 16. Take advice from Shaman ............................................................... 55
17.
Table 17. Take advice from herbalist .............................................................. 56
18.
Table 18. Take advice from someone who had the illness before ................... 56
19.
Table 19. When you are sick, who do you seek for help first? ........................ 57
x
20.
Table 20. Do you think prescription medications do more harm than good? .. 57
21.
Table 21. Do you think your inability to speak English is a barrier? .............. 58
22.
Table 22. Prefer a primary care physician that speaks Hmong........................ 58
23.
Table 23. Comfortable with a Hmong physician ............................................. 59
24.
Table 24. Decision making and gender............................................................ 61
25.
Table 25. Time in the U.S and taking advice from a physician ....................... 61
26.
Table 26. Healthcare preference and religious preference ............................... 62
27.
Table 27. Healthcare preference and having Medi-Cal ................................... 63
xi
1
Chapter 1
THE PROBLEM
Introduction
Healthcare among minority elders are becoming a major issue facing the United
States, especially, with the increasing population of older Americans. According to Byrd,
Fletcher, and Menifield (2007), minority elders will make up about 50% of the overall
elderly population by the year 2050. This is half of the total elderly population here in the
United States, which includes several main groups such as African Americans, Hispanics,
Pacific Islanders and Asian descent. This could mean that healthcare disparity among
half of the elderly population could put a burden on taxpayers in the long run. Research
has shown that minority elders are less likely to receive routine medical care and tends to
receive lower quality of care compare to their white counterparts (Baldwin, 2003).
Among a portion of the minority elders who are experiencing health disparity, are former
elderly Hmong refugees. It is no wonder why Hmong elders experienced such high
health problems such as tuberculosis, hepatitis B carrier status, sudden unexpected
nocturnal death syndrome, posttraumatic stress disorder, injuries related to agricultural
occupation, cardiovascular disease, diabetes, lower immunization rates, and cancer
(Pinzon-Perez, 2006). Since Hmong elders have a higher health challenge and less likely
to seek medical attention , they are most likely will experience higher rates of inadequate
treatments and lacking the quality of care that they should get compare to other groups.
As a member of the Hmong community, it has been the researcher’s
understanding that many of the Hmong elders usually lacks adequate access to healthcare
2
and most of the time resorts to using traditional healings as a way of finding cure for
whatever their illness may be (Lee & Pfeifer, 2010). Healthcare disparity is of an
important issue that the researcher is interested in, especially when it comes down to the
fact that many Hmong elders are dying from treatable diseases such as hypertension and
cancers. Some of these diseases could have been easily treatable, especially if they were
detected in the earlier stages. The researcher has personally witnessed a relative who
would rather not see his doctor and prefer traditional healings from herbal medicines and
spiritual healings through a shaman. Another relative also came down with tuberculosis
and was reluctant to see his doctor. When he did, it was when he had depleted all of his
alternative options such as asking the help of a shaman and herbalist. Even after he was
able to see his primary care physician, the differences between eastern and western
culture created mistrust, leaving him hesitant to take the prescribed medications given to
him. Partially, the physician might have been a bit ignorant of Hmong cultural values;
hence, the physician was not willing to listen and make sense of the Hmong patient’s
perspective on the illness.
Over the years, the researcher have found himself questioning the cultural and
socioeconomic factors that might have hindered Hmong elders from seeking medical care
from western healthcare providers. For this reason, the researcher was wondering what
cause their hesitation. How could the lack of utilizations of western medical care
correlate with the Hmong’s traditional cultural values and their previous medical
practices and beliefs? The researcher believes that being able to identify these cultural
3
barriers would make it possible for health and human service professionals to intervene,
in turn, proper medical care programs can be setup to serve this group of population.
Background of the problem
The documentation of healthcare disparity is extensive, but there has not been
any thorough examination of the issue. The Center for Diseases Control and Prevention
(CDC, 2010), reported that there has been little done in terms of trying to solve the issue
of healthcare disparity among majority and minority Americans. Seeing healthcare
disparity as a problem, the federal government’s Healthy People 2020 program has
included this issue as part of its goal in eliminating and improving the overall health of all
groups. According to Byrd et al. (2007), minority elders are less likely to receive a good
quality routine care compared to their White counter parts. Since many elders within the
ethnic minority population are reluctant to seek care and distrust western medical practice
due to cultural beliefs; it leaves them vulnerable to a higher risk of diseases and lower
quality of care from medical professionals. Dhami (2009), states that ethnic minorities
will have a higher rate of developing wide range of conditions, with poorer health
outcomes. Former Hmong refugees being a portion of this minority population are no
exceptions.
Hmong are one of the most recent arriving refugees to the United States from
Southeast Asia following the Vietnam War. The exposure of Hmong elders within this
population to western healthcare providers and the U.S healthcare system creates cultural
challenges in seeking healthcare and the accessibility of the health system. Pinzon-Perez,
(2006) stated that the medical model of western healthcare are not congruent to the
4
traditional practices of the Hmong’s cultural belief. The difference in cultural belief
creates misunderstanding and misperception of the healthcare system here in the United
States among former Hmong refugees, especially the elders. These cultural barriers
stands in the way of receiving timely and appropriate healthcare needs; thus, contributed
to the overall healthcare disparity among minorities in this country.
Statement of the Research Problem
The increasing healthcare disparity among Hmong elders creates challenges in
closing the healthcare gaps among minorities in the United States. With basic
understanding of the Hmong’s cultural belief and as a member of the Hmong community,
it is this researcher’s recognition that the lack of cultural and social awareness by
healthcare professionals is associated with the current healthcare disparity within this
population. To help bridge the healthcare gaps, this study will be focus on the cultural
and social factors that are barriers to seeking western healthcare among Hmong elders in
the greater Sacramento region. Some of the cultural and social factors being explore in
this study will include but not limited to cultural barriers, language barriers, lack of health
insurance, poverty, rate of acculturation and lack of education. Even though there have
been numerous studies on cultural and social barriers among other minority groups in
their association to the disparity of healthcare; however, there has not been much studies
done specifically about the older Hmong population here in the United States. There is a
definite need to identify the barriers that are the roadblock of Hmong elders’ inability or
reluctance to utilize the healthcare system here in this country.
5
Purpose of the Study
The primary purpose of this research project is to explore and obtain information
pertaining to the cultural and socioeconomic factors that are barriers in seeking western
healthcare for former elderly Hmong refugees. This will provide the necessary
understanding and awareness for western healthcare professionals to efficiently be able to
address the ongoing disparity of healthcare within this population. It will allow social
workers and medical professionals alike to see the reasons why Hmong elders are
reluctant to seek health treatments from western healthcare providers. In grabbling with
this issue, it will open up a clearer picture of the gaps in healthcare disparity among
minority elders in this country.
The second purpose of this study is to increase the cultural sensitivity of
healthcare professionals in working with Hmong elders in the greater Sacramento regions
and other parts of the country. The hope is that by being more culturally sensitive, it will
open up more opportunities for professionals to work collaboratively with this population
in addressing their health needs. At the same time to allow opportunity for the
incorporation of Hmong traditional healings as a dual process in treating illnesses within
this population. The researcher hope that with a holistic approach to healthcare,
professionals can adequately decrease the gap of healthcare disparity and encourage
Hmong elders to increasingly utilize the healthcare system in the United States.
Theoretical Framework
In order to understand how the cultural and socioeconomic factors impact the
decision among Hmong elders toward seeking western healthcare and how it correlates
6
with healthcare disparity among this population; the researcher will utilize the ecological
perspective (McCleroy, Bibeau, Steckler, & Glanz, 1988) as the overall guiding principle
of this study. It will be follow by the empowerment theory and health belief model,
which will help give a holistic explanation of the meanings behind Hmong elders’
perception and resistance to western health treatments.
The conceptual framework of ecological perspective is based on the fact that
one’s environment has an impact on one’s life, which includes multiple levels such as
micro, mezzo, and macro level of the social environment (McCleroy et al, 1988).
Through the use of this theoretical frame work, it allows the researcher to see how taking
into consideration the holistic factors such as living environment, cultural beliefs,
practices, family structure, social network and social status could have an impact on
Hmong elder’s reluctance to seek western medical care. The understanding of the
ecological perspectives is crucial for other professionals to understand the cultural and
socioeconomic systems in which Hmong elders are embedded.
The empowerment theoretical framework (as cited by Shriver, 2011) is based on
the process in which individuals have the ability and power to improve their own lives, if
given the necessary resources. This framework will help explain the feelings of
powerlessness among former Hmong refugees who came to this country not speaking the
language and living in a society that differs dramatically from what they are used to. I
hope that with this research it will allow social workers and medical professionals to
utilize this theory and help empower this population through collaboration and cultural
awareness. When Hmong elders feel that their inputs matter and that their cultural
7
practices means something in the medical field, it would empower them to feel more
comfortable in seeking western healthcare.
The health belief model explains that “people will engage in health-related
behaviors if they believe that a negative health condition can be avoided, expect that
taking a recommended action will avoid a negative health condition” (Hutchison, 2008,
pp. 53). To put this in context of health related behaviors, it is the desire to avoid illness
and belief that a certain type of heath related behaviors will lead to prevention of illness
or lessen the degree in which it can negatively influence the individual (Janz & Becker,
1984). Through this frame work, it allows the researcher to see why many Hmong elders
will turn to cultural practices and see that this type of health behaviors will lessen the
degree of illness compare to seeking western healthcare treatment, which Hmong elders
sees as making the situation more complicated.
Assumptions
This study examines the cultural and social barriers affecting older Hmong
individual’s reluctance to seek medical attention from western healthcare providers;
therefore, the researcher assumes Hmong elders are resistant to seeking help from their
primary care physician when they are ill. The researcher assumes that culture and social
status are the influencing factor that hinders Hmong elders’ ability to seek western
healthcare services. Considering this, the researcher assumes that Hmong elders’
underutilization of the healthcare system here in this country directly contributes to the
overall healthcare disparity within this population.
8
Justification
This research is important to social work because it will allow social workers
working with this population to get an understanding of the factors contributing to the
lack of access to healthcare and high rates of health challenges among this population.
This population being an ethnic minority group and recent refugees makes them
vulnerable, so addressing the issue of healthcare disparity among this population would
allow social workers to carry out their core value of social justice. Since social workers
strive to ensure access to services and equality for all people, this research would enable
social workers and other medical professionals to explore and address proper social
service programs in collaboration with the medical field that could allow for better
healthcare access among former Hmong refugees. To be culturally sensitive is to be
holistically accepting of people’s differences and allowing for incorporation of alternative
ways of seeing healthcare; therefore, healthcare disparity among any group is a social
injustice and it is the duty of social workers to make sure all groups of people have equal
opportunities and access to healthcare.
Definition of Terms
1. Healthcare: the preservation of mental and physical health by preventing or
treating illness through services offered by the health profession
2. Hmong: An ethnic group traditionally living in mountain villages in southern
China and adjacent areas of Vietnam, Laos and Thailand; many have immigrated
to the United States as refugees.
3. Disparity: The lack of similarity or equality; inequality; difference.
9
4. Elder: An older person who is consider to be 6o years or older.
5. Poverty: The state or condition of having little or no money, goods, or means of
support; condition of being poor; indigence.
6. Shaman: A spiritual healer who performs traditional rituals and is believed to
possess the ability to communicate with the spirit world (Vue, 2002).
7. Herbalist: Individual who employs herbal medicines to treat both physical and
mental ailments (Cha, 2003).
10
Chapter 2
LITERATURE REVIEW
Introduction
In this chapter, the researcher examines existing literature review, focusing on
different themes that will help provide basic understandings to the healthcare disparity
among Hmong elders. This chapter is divided into three major themes. The first section
is mainly focused on healthcare disparity in the United States, which includes: (1)
Healthcare disparity in America; (2) Western concept of health and (3) Healthcare
accessibility. The second section emphasized on the history of the Hmong people and
their origin, which includes: (1) Hmong origin theories; (2) Hmong and the Secret War in
Laos; (3) Refugees in a new land; (4) Family structures and; (5) Demographics. The third
section is mainly focused on the Hmong culture and perception of healthcare, which
includes: (1) Shamanism and alternative healing; (2) Hmong health concepts, (3) and
healthcare challenges within the Hmong population.
HEATHCARE IN THE UNITED STATES
There has not been much research done about Hmong elders and their healthcare
in this country, so this section mainly covered the overall healthcare disparity and
utilization in the United States. The section examined accessibility of western healthcare
and the barriers they faced in seeking healthcare. It briefly covers some of the different
western concepts of health and the health model that dictates the health system here in the
United States. The section provided basic understanding to the underlying health
problems that minorities faced in this country.
11
Healthcare Disparity in America
The topic of healthcare in the United States has been an ongoing debate among all
Americans. The United States continues to remain one of the industrialized nations that
does not provide healthcare to all of its citizens (Rashford, 2007). Racial disparities have
been documented extensively and still are a major political agenda especially, the socalled Healthy People 2020. The objective of the Healthy People 2020 is to eliminate
healthcare disparities that determine eligibility based on social, economic and
environmental factors. With the cost of healthcare beyond the reach of many Americans,
lower class Americans will find themselves, unable to afford for adequate healthcare. As
stated by Reinhard and Relman (1986), the American health system is run by the law of
economics, where healthcare is essentially based on one’s ability to pay. People that are
unable to pay for their healthcare will have to rely on the basic care provided by the
government through Medicare. Good healthcare should not be dependent on one’s ability
to pay and it makes no exception for a resourceful nation as the United States to lack a
basic necessity such as healthcare for its’ citizens.
According to Congressman Jesse Jackson (as cited by Williams, 2007), he
reported that in 2005 the federal government spends over one quarter of the federal
budget on healthcare cost alone. Fiscal healthcare spending during that year was over $2
trillion, yet the United States has one of the highest uninsured rates of about 16%. High
spending rates and with many Americans without health insurance really generates
concerns about the huge gap in healthcare disparity among minority groups. Based on a
study done by Johns Hopkins Bloomberg School of Public Health and University of
12
Maryland, Mr. Hopkins reported that the federal government’s pricey expenditure of
$229.4 billion from 2003 through 2006 attributed to the cost of racial healthcare disparity
(La Veist, Gaskin, & Richard, 2009). By ignoring the disparity in healthcare, it has cost
the government more money in the healthcare industry than expected. This could mean
that by addressing healthcare disparity, it could potentially help safe unnecessary
spending. According to a study reported by the National Conference of State
Legislatures, the Joint Center for Political and Economic Studies found that the federal
government could have reduced medical expenditure by about $229.4 billion between
2003 and 2006, if it had eliminated healthcare disparity among minorities.
Healthcare disparity has always been part of American’s long racial history with
its roots from the time of slavery (Williams, 2007). Since many of the slaves of African
descents were seen as part of an inferior race, those ideologies have guided the health
treatments of racially different groups (Williams). Despite the huge improvements in our
health system, there are still disparities in access across ethnic and racial groups in the
United States (Zuvekas, & Taliaferro, 2003). When closely examining all the facts,
Whites still have the highest insured rates and are at a higher rate to have private
insurance (Zuvekas, & Taliaferro). One major social root to healthcare disparities in this
country is the reliance of one’s social hierarchy in relationship to their accessibility to
healthcare. Barr (2007), states that it is in one’s social, economic and cultural
circumstances that people will be able to find the secrets of longevity and good health.
Barr states further that since economic means is a main component of the health system,
the question of who shall live relies heavily on one’s social hierarchy. This is no wonder
13
why minorities in this country who are on the lower end of the economic spectrum, are at
the highest risk from lacking adequate healthcare.
As a group, Asian Americans, Native Hawaiians and Pacific Islanders are the
ones that are most likely uninsured; especially, noting the fact that many of the Asian
Americans are employed in non-healthcare coverage jobs (Kaiser & APIAHF, 2008).
This leads to a lesser degree of one’s capability to seek health treatment; thus, leading to
higher array of health problems. The number one leading cause of death for minorities
are chronic diseases, with heart disease and cancer ranking first among Asians and
Pacific Islanders (Williams, 2007). It is reported that Asian American women with breast
cancer is 1.4 to 1.7 times higher than those of their White counter parts (Chappell, 2007).
According to Jang et al, this is because Asian American women have a very low
screening rate. The Agency for healthcare Research and quality (AHRQ) reported that
Asian Americans received worst quality of healthcare when compared to Whites for
about 20 percent of measures (AHRQ, 2010).
Western Concept of Health
American medicine during the nineteenth century was highly pluralistic. It was a
time when western physicians depended heavily on techniques such as bleeding, leeching
and cupping (Baer, 2001). According to Baer the different medical systems were divided
based on religious affiliation and thus became the heterodox and orthodoxy. During this
time, physicians treated disease through administering remedies like antimony,
purgatives, and often encouraged diarrhea as a means of letting out any poisonous
substances (Baer). It wasn’t until the late 1900’s that the modern day medical system
14
begin to emerged as a success and most desired approach to healthcare. Baer further
elaborated that even though biomedicine has always been popular, it never fully
established hegemony since other alternative medicines still exist during this time.
Based on the definition of health from the World Health Organization (WHO), the
organization defined health as “being in the state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity”. However, in the sense of
policies and the ability for developed countries like the United States to achieve such
health stance is difficult (Barr, 2007). Using the medical model, which is solely
grounded in a biomedical perspective, western concept of health is guided by one’s
understanding that health is a physical state. Barr explained that from this perspective,
illness is characterized by the presence of abnormal signs or symptoms. This concept
defines that if western health professionals identify no abnormal signs, than an individual
would be consider as healthy. According to Nordenfelt (2006), contemporary view of
health has been to determine illness and disease from a scientific point of view; therefore,
the detection of illness can only be obtain through observation and scientifically validated
procedures. This would mean that any observations taken other than from a scientific
approach would not be taken into consideration as symptoms of illness.
In the United States, the biomedicines are considered the most dominative system
within the medical field (Baer, 2001). Since medical model dominates the medical field,
it leaves other forms of alternative healing very little space. According to Baer, the rise
of biomedicine during the late nineteenth century in the fullest sense is a reflection of the
rise of capitalism.
15
Healthcare Accessibility
Despite the fact that this country has one of the best healthcare systems and
equipment, a huge portion of the United States population lacks access to a good quality
healthcare (Williams, 2007). Since the United States is inhabited by a huge array of
different racial groups, the inability to speak English could hinder one’s access to
healthcare. Language barriers have been linked to people’ ability to effectively utilized
healthcare and a number of studies have shown the connection between language barrier
and low numbers of health visits (Yeo, 2004). With diverse groups of minorities, it is
important to be able to communicate effectively with different groups. A research
indicated that providers and patient’s communication has a direct impact on patient’s
satisfaction and health outcome (Betancourt, Green, Carrillo, & Ananeh-Firempong,
2003). Based on a research conducted by Ponce, Hays, and Cunningham (2006), older
adults who had limited English speaking ability were 1.68 to 2.49 higher risks at access
to care and health status.
Based on a study done by Betancourt et al. (2003), they found that one major
component that had been an obstacle in providing healthcare accessibility to minority
groups is the organizational barriers. To a certain degree the leadership and workforce of
health professionals does not reflect the general composition of racial and ethnic groups.
Betancourt et al. asserted that despite the fact that African Americans and Latinos make
up 28 percent of the population, which represented only three percent of medical school
faculties.
16
It is found that cultural differences are a major barrier to the accessibility of
healthcare among minorities. Since one’s culture greatly effects how an individual’s
ability to make sense of his/her health conditions or illnesses, treatments provided by
professionals could be culturally inappropriate; therefore, potentially hindering
accessibility and effectiveness of interventions (Schaafsma, Raynor, & Berg, 2003). By
definition, most minority groups fall at the low socio economic status, with limited
education; thus, influencing their knowledge of healthcare and information pertaining to
treatments (Schaafsma et al). Reyes (2001) stated that poor education and poverty can
result in one’s inability to gain access to a quality healthcare. This is why it could be
potentially difficult to minorities especially, older minorities who are uneducated to gain
proper access to healthcare.
HMONG HISTORY
This section focused on the history of the Hmong people from the past to the
present, with emphasis on who the Hmong people are and their status in the United
States. It briefly examines the demographics of Hmong in this country.
Hmong Origin Theories
The Hmong is an ethnic group found throughout Southwestern China and
Southeast Asia such as Thailand, Vietnam, Burma and Laos (Lee, 2007). The Hmong
people have a long difficult history and many of the oral history that passed down from
generation to generation has mentioned China as a core origin. However, scholars and
the Hmong people have multiple theories describing the origin of where the Hmong truly
came from. Based on literatures and the research of scholars, the Hmong people have a
17
very long history, spanning over five thousand years, dating back to 2497 B.C. (Quincy,
1995). It is proposed that there are four theories of origin, explaining where the Hmong
came from (Thao, 2004).
According to Savina, one of the early missionaries who encountered the Hmong
people indicated that Hmong might have originated from a land behind China (Patch,
1995). Savina claimed that Hmong folk stories are similar to those from the bible such as
the great flood and the Towel of Babel; thus, linking the Hmong with an origin in
Mesopotamia (Lee, 2007). According to Quincy, Savina indicated that it is the Aryans
that had forced the Hmong out of the area, indicating the reason for their migration to
China.
According to another theory, the Hmong have settled in the southern regions of
the basin of the Yellow River before the Chinese (Mottin, 1980). Research shows that
most of the ancient roots of Hmong heritage are found throughout modern day provinces
of Yunna, Guizhou, Sichuan, and Hunan (Chan, 1994). According to Lee, an origin in
China makes the most sense, especially with the DNA traces that is available. It is
believed that the Hmong people had a king named Sonom, who was brutally killed by the
Chinese emperor following his surrender that peace would come (Hamilton-Merritt,
1993; Quincy, 1995). It is believed that King Sonom sparked a very long war with the
Chinese emperor and became a symbol of heroism and resistance to Chinese oppression
(Hillmer, 2010). Yet, with this believed, it is highly criticized by Ententmann (2005),
stating that Sonom was never Hmong and the Jinchuan Wars had had nothing to do with
the Hmong people; thus, renouncing the accuracy of the stories behind King Sonom.
18
Even though there are conflicting beliefs of King Sonom and its relationship to the
Hmong people; however, there are written records dating way back to 2479 B.C.,
indicating that there is a group of people known as Miao by the Chinese (Patch, 1995).
The word “Miao” refers to modern day Hmong and is seen by many Hmong people
outside of China as a demeaning term (Lee, 2007). As Hmong begin to migrate out of
China and into neighboring countries to the south such as Thailand, Vietnam and Laos,
their identity towards the term “Miao” changed. Later during the American involvement
in Southeast Asia, it officially changed to Hmong, meaning free people.
Hmong and the Secret War of Laos
Due to persecutions and oppressions from the Chinese government, the ethnic
Hmong migrated south to neighboring countries such as Thailand, Burma, Vietnam and
Laos between 1810 and 1820 (Hamilton-Meritt, 1993; Mottin, 1980; Patch, 1995). Out
of all the countries, there is a larger population of Hmong who settled in Laos. Most of
them settled in small villages throughout the northeastern portions of Laos (Hillmer,
2010). Hamilton-Meritt explained that in Laos, the Hmong people practiced slash and
burn farming as a mean of living and never quite integrated with the low land Laotians.
When the Hmong began coming to neighboring Vietnam and Laos, the French had
already established a strong colonial role (Smalley, Vang, & Yang, 1990). The Hmong
was peaceful with the French and submitted to their rule of Laos. However, with harsh
treatments and high taxation, a majority of the Hmong population in Laos rose up and
fought against the French in 1919 under the leadership of Paj Chai (Quincy, 2000). The
war that Paj Chai fought with the French was a harsh and brutal war, but it eventually
19
ended with his death. For the most part, the Hmong people assisted the French during
World War II and all the way until the end of French colonialism in Laos (Chan, 1994).
Fearing for the domino effects of communism takeover of Laos, the United States
decided to send in American CIAs to recruit the Hmong. The Hmong formed the
backbone of the fighting force against Communist North Vietnamese on behalf of the
United States (Quincy, 2000). It is during this time, that Vang Pao emerged as a heroic
leader for the Hmong people because of his ability to lead the Hmong people against the
well-equipped Pathet Lao Army and North Vietnamese Amy (Hamilton-Meritt, 1993).
At the peak of the conflict in Lao, the small Hmong guerilla force grew from a few
thousands to approximately 30,000 soldiers (Kaufman, 2004). By the time the war was
coming to an end, so many Hmong soldiers have been loss that thirty percent of the new
recruits were consisted of fifteen and sixteen year old boys (Fadiman, 1997). It is
estimated that around 40,000 Hmong lives were loss because of their direct involvement
in the conflict (Lee & Pfeifer, 2005). Hamilton-Meritt asserted that the Hmong assisted
the American CIA and fought hard for more than ten years until the withdrawal of U.S
forces in 1975.
The Americans following their defeat in the Vietnam War left behind the Hmong
people. The Hmong were on their own to defend against the victorious Pathet Lao Army
and North Vietnamese Army. Since many of the Hmong had assisted the Americans
during the war, the Communist Pathet Lao government targeted them as traitors (Vang,
2005). Fearing for their own lives and their families, a majority of the Hmong who had
been with General Vang Pao left Laos.
Following General Vang Pao’s departure to
20
Thailand, nearly 40,000 Hmong men and women made their way slowly out of the
country (Fadiman, 1997). Many of them eventually made their ways through the
treacherous jungles of Laos and arrived in Thailand as refugees. For those families that
did not make it to Thailand, many had either been ambushed or killed by Pathet Lao
soldiers. Those that remain behind in Laos faced harsh treatments and death; thus, many
of them joint the Hmong resistance group known as Chao Fa (Hamilton-Meritt, 1993).
Refugees in a New Land
As the secret war in Laos ended, refugee camps were set up in Thailand to
accommodate Hmong refugees by the late 1970s. One of the best-known camps was Ban
Vinai (Lee & Pfeifer, 2010). By 1976, Hmong refugees were allowed to enter the United
States in huge numbers, estimating at over 10,000 in 1979 and reaching a peak of 27,000
in 1980 (Lee & Pfeifer, 2005). Even though the United States and other Western
countries have opened the doors to Hmong refugees, many of the Hmong were hesitant to
take the opportunity to migrate to western countries. As Hillmer (2010) puts it, “I always
used to think they were the most deserving refugee population, yet the ones that wanted
to come the least (pg.195).” Since so many of the Hmong refugees still had hopes of
returning to Laos, it was difficult for them to take the option of migrating to a different
country. Hillmer stated that it is in the refugee camps that many of the young Hmong
professionals in Western countries today grew up. One must credit the experiences of the
Hmong during this crucial period in their history as a period of grief and loss, but also a
period of hope. The huge majority of Hmong eventually entered the United States and
21
many of them have resided in California, Minnesota, Wisconsin and other states until this
day.
Life as new refugees in the United States was not easy at all for many of the older
Hmong who did not speak English or understood American culture. According to
Fadiman (1997), many Hmong lost their pride of self-sufficiency, especially living in the
United States and having to rely on assistance. In America, many of the Hmong lost their
way of life. They no longer were able to practice slash and burn farming nor have Air
America drop them food like during the war (Chan, 1994). Fadiman explained that the
Hmong were used to living in mountains and their exposure to urban life and separation
from traditional supports exhibited high levels of stress and depression among the Hmong
population. America felt so different to many of the older Hmong population that many
of them yearn to return to Laos. Hillmer (2010) indicated that during the 1970s and
1980s one could easily senses the energy surrounding the Hmong’s desire to return to
Laos. For the most part the Hmong people in the United States have persevered and have
improved greatly in the areas of education and political participation. One of the most
subversive social changes that took placed in the United States was the greater freedoms
of Hmong women in America. Chan elaborated that in traditional Hmong society, the
women should always be submissive to the husband’s chain of command; however, the
taste of freedom in America gave Hmong women more rights.
Besides all the other conflicts that Hmong faces in the United States, they also
continued to face major religious conflict within the Hmong communities. There are
disagreements among Hmong Christians and those who are still traditional (Thao, 2006).
22
Many of the traditional practices such as shamanism and other rituals were met with
harsh enforcements from the local neighbors and law enforcements. Thao explains of a
case where the neighbor called the local police on a Hmong shaman while he was
performing his rituals. Things like this happen all the time and in a way create fears and
frustrations among Hmong shamans, feeling like they do not have a sense of freedom to
practice their own cultural beliefs. Besides religious conflicts, Hmong Americans also
faced a sense of disconnection from the youth that grew up here in the United States.
Thao further stated that some of the Hmong elders’ concerns are younger children and
their rebellious behaviors toward parents and Hmong traditions. Many of the older
parents feel that they have no authority to discipline their children and feel a sense of
hopelessness (Thao).
Yang (2001) concluded that through hundreds of years of adversity, the Hmong
have bred a strong spirit of independence and success. As many of the older generations
who have been a part of the Vietnam War era are dying off; the questions is will the
Hmong people be able to overcome their own internal challenges and continue to be a
successful group within the melting pot of this country.
Clan and Family Structures
Traditionally Hmong are divided into patrilineal clans. Kinship in the Hmong
society is to establish some sort of guidance on cultural traditions within each clan (Thao,
2006). According to Lee & Pfeifer (2010) there are eighteen Hmong clans consisting of :
Chang, Chue, Cheng, Fang, Her, Hang, Khang, Kong, Lee/Ly, Kue, Lor, Moua, Pha,
Thao, Vang, Vue, Xiong and Yang. Within each clan group, decisions are made based on
23
a hierarchical scale where the oldest male makes the decision with consultation to other
male members of the clan (Johnson, 2008). In the patrilineal systems, when a woman
marries, she moves in with her husband’s family and becomes a part of the husband’s
kinship (Fang, 2008). Johnson explains that in these kinds of systems, women generally
do not have any rights to make decisions; therefore, the husband or oldest son must be
consulted for major decision-making. For the purpose of major medical decisions, the
head of the household, which is the husband, must also consult the clan leader for
recommendations (Lee & Pfeifer). For example if a physician diagnosed a major illness
for a family member, the head of the household must set up a clan meeting to allow clan
leaders and elders to discuss the final decision. This is why Johnson indicated that a
Hmong person’s identity is based on his/her membership of a family or clan.
Thao (2006) explains that clan memberships are established through marriages, so
when the woman marries, they keep their own clan name, but the child inherits their
father’s clan name. Thao further explains that once a male figure marries and has a kid,
he is considered a man. According to Yang (1993), women are not allowed to be
involved in any kinds of politics, even though sometimes the discussion directly affects
them. To a certain degree, the Hmong people see marriage as a way of building
connection to different clan groups (Tatman, 2004). It is considered taboo for a Hmong
individual to married within his/her own clan and once a woman is married, it is a taboo
to divorce the husband (Lee & Pfiefer, 2010).
Moua (2003) emphasized that there are two functions for marriage and the first
reason is for procreation and economic production within the family. The second
24
function is to create reciprocal economic and political ties. In the Hmong tradition, when
a man marries a woman, he will have to pay the woman’s parents a set dowry amount.
To many Hmong parents, they viewed the dowry as payments for the pains they endured
giving birth to the child and raising her to adulthood. According to Moua, in the Hmong
tradition, there is also the possibility of arranged marriages; however, in the United States
Hmong parents no longer practiced arrange marriage any longer. In the Hmong culture,
there are two ways that a man and woman could get married and the first is through
begging. This is when the groom’s family requests the bride’s parents for permission
(Moua). The Second is through regular courtship, which is the most common way for
most people.
Demographics
Based on the U.S. Census (2010), the Hmong American Partnership estimated
that there are about 260,076 Hmong in United States, with approximately 91,224 residing
in California, 66,181 in Minnesota, 49,240 in Wisconsin, 10,864 in North Carolina, 5,924
in Michigan, and the rest scattered throughout the other states. According to the U.S.
Census (2010), Asian Americans in Sacramento County made up a total population of
203,211, with Chinese American at 39,865, Filipino at 41,455, Japanese at 10,708,
Korean at 6,049, Vietnamese at 25,030, Asian Indians at 26,560, and other Asians at
53,544. Even though there are no actual numbers indicating the total amount of Hmong
population in this result, the U.S. Census (2000) reported the Hmong population in
Sacramento County at about 17,646. A research done by Fong and Kim-Ju (2006)
informed that Hmong has one of the fastest growth rates of 164.5 percent in Sacramento.
25
Using the 2000 U.S. Census, Niedzwiecki, Yang, and Earm (2003) reported that there are
approximately 6,415 Hmong elders fifty-five years and older living in California.
When compared to other Asian Americans, Hmong and Laotian have the lowest
percentage of at least a bachelor’s degree, with Hmong being at 4.8 percent and Laotian
3.2 percent (Fong & Kim-Ju, 2006). The study reports that 31.5 percent of all Hmong
elders sixty-five and older were living under the poverty line in 1999; thus, 5.2 percent of
them were receiving social security income and 10.1 percent public assistance
(Niedzwiecki et al). According to Lee and Pfiefer (2010) based on the 2008 American
Community Survey, there is an estimated 25 percent of Hmong families living under the
federal poverty line compared to the overall 9.5 percent of the total U.S population.
HMONG CULTURE AND RELIGIOUS PRACTICES
This section examined the cultural aspects of the Hmong people and the effects on
their perception of health and wellbeing. It looked at the alternative traditional healthcare
practices that the Hmong people utilized besides the mainstream medical model. This
section helps expanded better insights into Hmong elders’ view of their illnesses.
Shamanism and Alternative Healing
The Hmong people still have a very strong sense of their spiritual beliefs and
unlike the western versions of well-being, one’s spiritual well-being is connected to the
overall health of each individual (Gerndner, Xiong, & Cha, 2006). Hmong continues to
practice shamanism within their communities as part of a healing process to cured
sickness and chase away the evil spirits (Helsel, Mochel, & Bauer, 2004). Helsel et al.,
further stated that many times Hmong Shamans are resentful of western medical
26
professionals, especially when they feel a sense of disrespect from the medical
community. One good example of the traditional practices clashing with western medical
healthcare is the case of Lai Lee in Fadiman’s 1997 The Spirit Catches You and You Fall
Down. Here you have a Hmong girl whose parents had a different perception of the
child’s illness compare to the western concept of health and illness; thus, created
misunderstanding and confusion in the treatment of the child’s illness. The result was
resistance to all treatments requested by western physicians. There are approximately 70
percent of the Hmong population in the United States still practicing traditional
animalism and Shamanism, with one third of them being Christians (Lee & Pfeifer,
2010).
The Hmong people believe that in order to be a shaman, one must be chosen and
through the chosen process, the individual becomes encroached with what the Hmong
calls “dab neeb-da neng” (Cha, 2003). Here the chosen individual will become very sick
and he/she must accept the calling for his/her well-being. The Hmong believed that
shamanism was passed down from generation to generation, originating from the very
first shaman by the name “Shi Yee” (Fadiman, 1997). Shi Yee threw upon his skills and
talents to the Hmong people, allowing them to carry on his healing. Some of the
equipment’s used by the shaman includes a gong, gong stick, finger bells, a sword and a
shaman bench (Pinzon-Perez, Moua, & Perez, 2004).
The Hmong strongly believe that a shaman could communicate with the spirit
world and that the spiritual world coexists with the physical world (Lee & Pfeifer, 2010).
It is known that shaman has the power to find souls that have been lost and bring them
27
back to the person (Cha, 2003). Usually when someone is sick, the individual’s family
will call upon the shaman to perform a ritual. The ritual involves the shaman covering
his/her face with a black cloth and going into a trance; thus, allowing the shaman to
contact the spirit world (Helsel, et al, 2004). Unlike a western medical doctor who
focuses on physical illness, the Hmong Shaman is a respected healer, whose mean focus
is to do spiritual healing (Fontaine, 2000). As part of the process of healing and trying to
appease the angry spirits, the shaman usually sacrifices an animal such as a big, chicken
or a cow (Pinzon-Perez et al, 2004). The sacrificed animals are then cooked and invited
relatives and friends will join and enjoyed a nice meal as part of the healing process
(Vang, 2005).
Besides shamanism, Hmong traditional practice also relies on the use of
traditional herbal medicines to treat illnesses and injuries. Hmong people have always
lived far away from modern medical facilities; thus, they have become used to utilizing
different variety of herbal medicines. Many of these herbal medicines come from natural
plants found throughout Laos and China (Cha, 2003). Traditional herbs continued to be
popular among Hmong elders, especially among women, who continue to passed down
their knowledge to others they trust (Corlett, Dean, & Grivettie, 2003). According to
Capps (1994), even though Hmong have incorporated some of western healthcare
procedures into their lives, a majority of the Hmong population continues to utilize a type
of medical pluralism where they incorporate different healing procedures from traditional
shaman, to herbal medicines and western medical treatments as needed.
28
Hmong Health Concept
Hmong people have a very different conceptual view of their overall health status
compared to western concepts. In Laos, Hmong was never much exposed to modern
medicine, the complexity of the human body parts and its functions are unknown to them
(Johnson, 2002). Even though Hmong people have adopted different practice of health
treatments from other people and beginning to accept some forms of western health
concept, a majority of the Hmong population continues to rely heavily on traditional
health concepts as a mean to understand illnesses. The lack of words for chronic diseases
within the Hmong language further complicates the difference in health and health
concepts among the Hmong population and western providers (Plotnikoff, Numrich, Wu,
Yang, & Xiong, 2002).
The Hmong people view their health from a holistic perspective, taking a strong
consideration of both spirits and their physical body. The Hmong describes a healthy
person to be one who is outgoing, active and happy (Rairdan & Higgs, 1992). Hmong
believes that sickness are caused by spirits, imbalance of one’s souls, germs, wind, bad
food and water, which is very similar to that of the Chinese’s concepts of yin and yang
(Culhane-Pera, Her, & Her, 2007). Plotnikoff et al. explains that traditionally, Hmong
understood diseases as an imbalance of souls, spirits and person. Unlike western
biomedical concept where illness is associated with a physical feature or cause by a type
of virus; the Hmong’s concept of illness relies heavily upon spiritual means. Henry
(1999) gave a good case example of how parents of Hmong children with measles
explained the causation for the illness. Henry stated that many Hmong parents asserted
29
the cause of measles as being caused from the seasonal cycle and the bad spirits that
roams in the air. Hmong believe strongly in the different types of spirit internally and
externally that can influence one’s well-being. Some of those spirits includes ancestral
spirits, house spirits, spirits that resides in the natural world such as regions and estates,
as well as evil spirits that roamed in the night (Cha, 2003).
According to Culhane-Pera, Vawter, Xiong, Babbitt and Solberg (2003), there are
many types of spirits that causes illnesses such as ancestral sprits, household spirits, evil
wild spirits and unsettled ghosts. It is believe that one must provide adequate worships
to ancestors, especially from the father’s side of the family. Hmong believes that a
person can become sick if ancestors are not properly attended to especially, if a deceased
elder is not given a proper burial. According to Bosher and Pharris (2009), those
deceased elders would create distress and sickness to family members and in this case a
shaman will be ask to perform rituals with burnt offering of monetary papers to appease
the restless ancestral spirits. Culhane-Pera et al., asserts that wild spirits bring illnesses in
many different forms and most are done by stealing one’s soul. Culhane-Pera et al.,
further explains that people usually dies if the shaman’s power is unmatched to those of
the evil spirits causing the illness.
Another strong belief in the cause of illness among people is what Culhane-Pera
et al., calls social etiologies such as stressful social interactions and curse. In this case,
illnesses are either cause through talking to other human beings or with spirits. For
example, a person could become sick or give birth to a disable child if he or she mocks or
makes fun of other people who are disabled (Culhane-Pera et al.). There are also
30
personal etiologies that Hmong belief influences one’s health, which Culhane-Pera et al.,
strongly emphasis as not following Hmong traditional food custom. Culhane-Pera et al.,
explains that after a woman goes through delivery and she does not follow the expected
routine of eating only boiled chickens, restraining from sex and physical activities, future
illnesses with headache, joints and back problems could be associated with the failure to
observe postpartum customs.
Hmong’s view of life is seen as a continuous circle of birth and rebirth with two
worlds, one being the spiritual world and the other being the physical (Plotnikoff et al.,
2002). It is the coexistence of these two worlds that Hmong believe each individual
person has three souls. Culhane-Pera et al. (2003), explains that since life and death are
joined in a continuous circle, humans are able to travel between these two worlds either,
through birth or death. When a person dies, one of them will journey to the ancestral
world, while one will remain in the home as guardians and the other remaining at the
gravesite (Her, 2005). Since the Hmong people strongly believe in a person having more
than one soul, it is the understanding that souls and one’s physical body function as one
unit in order for a person to remain healthy. According to Hickman (2008), soul calling
(Hu Plig) is a common technique used to call back lost souls. Hmong usually utilized
soul calling when an individual becomes traumatized and it is assumed that they lost their
soul. Soul calling is used as a healing process as well as a preventive approach such as
during a ceremony to honor a newborn or one’s graduation (Hickman).
According to Hickman, three factors indicate an illness as purely the cause of
spiritual means such as the regularity, longevity and spiritual visions or manifestation. If
31
the illness indicates any of these factors, most Hmong will associate them with the cause
of spirits. For example, Hickman explains that if a headache occurs around the same
time every day or an illness has been present for quite some time and it is not cure
through western medicine; then, most Hmong will affiliate it with spiritual caused. This
would mean that they would most likely seek traditional healing instead of seeing their
primary care physician. Based on a research done by Plotnikoff et al. (2002), it is found
that out of the 22 participants, one’s perception of the cause of illness will determine the
type of health treatments; therefore, individuals utilized a shaman for spiritual illness and
a physician for physical illness such as high blood pressure and dizziness.
Healthcare Challenges for Hmong
Since Hmong people are not used to western medical practices and retains a huge
portion of their own cultural background, it has been difficult for the overall Hmong
population to adjust to the American Healthcare system here in the United States.
According to Pinzon-Perez (2006), Hmong faced health issues of Tuberculosis, hepatitis
B carrier status, sudden unexpected nocturnal death syndrome, and post-traumatic stress
disorder. One of the major concerns is of the high reported incidences of cancer among
Hmong Americans. Pinzon-Perez found that many of the Hmong with a diagnosis of
cancers did not received treatment until later into the advance stages, which was
contributed to the avoidance of western medical care. It is reported that the mortality rate
of stomach cancer for Hmong Americans is 3.5 times higher than the rest of the Asian
groups. This again correlates with the fact that Hmong Americans tends to received later
stage treatments (Lee & Vang, 2010). The high rate of cancer mortality rates among
32
Hmong has to do with their low screening rates. Based on Lee and Vang’s finding, the
percentage of Hmong women undergoing mammography was 30 percent compared to 49
percent of Korean American women.
It is found that a healthcare challenge among Hmong Americans is heavily
dependence on public insurance such as Medi-Cal and Medicaid. Lee and Vang (2010)
found that consumers with public insurance had only a limited pool of healthcare
providers and many of the Hmong reported feeling stigmatized from using Medicaid. It
makes sense why those that had private insurance felt more comfortable to seek medical
attention comparing to those that relied on public insurance. Another potential challenge
for Hmong is the level of acculturation. According to Maxwell, Bastani, and Warda
(2000) Filipino and Koreans were more likely willing to participate in screening if they
had spent a longer time in the United States. Even though there are no research done on
behalf of the Hmong people to see if acculturation will have an impact; it could be a
possibility that with more time, Hmong will be more willing to undergo screening.
Among other challenges, Health literacy is one of the major challenges posed to
the Hmong population here in the United States (Pinzon-Perez, 2006). Since Hmong
who had migrated here had no prior educations, many of them find themselves in a state
of hopelessness when it comes to communicating with health professionals. Rairdan and
Rae (1992) indicated that Hmong are only familiar to healthcare directly related to the
exact symptoms of their illness; thus, any other preventive or tests will be avoided.
According to Lee and Vang, this is probably why Hmong American’s attitude towards
preventive healthcare in the absence of symptoms is viewed as unnecessary. One other
33
major challenge identified by Lee and Vang was Hmong’s mistrust of western medical
systems. The research indicated that the mistrust had to do with Hmong’s unfamiliarity
with the western healthcare systems. Since Hmong are new to the healthcare systems,
they are very suspicious as to how much can the health system benefit them.
Conclusion
Healthcare disparity among minorities in this country has affected the quality of
care that all Americans deserve to receive. It is important that communities and leaders
from all disciplines work together as a team to tackle the inequality in healthcare. It is
crucial that we properly addressed the issue of healthcare disparity so that the federal
government will not have to spend thousands of dollars. Based on the literatures, there is
sufficient evidence to show that healthcare disparity is a problem among minorities and
that western concept of health dramatically differs from many of the diverse racial groups
found throughout the United States, especially among the Hmong population.
The Hmong people are recent arrivals from Southeast Asia to this country and
many of them carried with them their rich cultural traditions. Even though they have
faced challenges in adapting to the new environment of this country, they are also slowly
acculturating with the new cultures found here. Since many of the older Hmong
Americans are unable to speak English and lack the educational means to seek healthcare
in this country, one must remember to consider older Hmong’s cultural and spiritual
perception of health when providing culturally sensitive healthcare services. It is
important that anyone working with the Hmong population should try to understand
Hmong’s concept of health and wellness, especially when trying to diagnose a Hmong
34
individual. Through culturally sensitive work with an opened mind will allowed for a
smooth transition of effective health treatments for the Hmong people; thus, eliminating
the healthcare disparity among Hmong and other minorities in the greater Sacramento
region.
35
Chapter 3
METHODOLOGY
Research Design
This research project applied an exploratory research design. The researcher
collected the data through a quantitative and qualitative research method. The general
research study was administered through a series of interview questionnaire consisting of
open-ended and closed-ended questions. According to Rubbin and Babbie (2010), an
exploratory research is appropriate when one wants to conduct research on a study,
relatively new or test the feasibility of undertaking a more careful study. Even though
there has been studies done about the Hmong community and issues related to social and
cultural factors affecting their health seeking behaviors; however, there has been little
research specifically on the older Hmong population and the barriers encountered by
them in accessing western medical healthcare. Due to the limited research available on
Hmong elders, the researcher utilized research that has been done on the general Asian
population to provide better insights into the overall issue of social and cultural barriers
to western healthcare. The research project explored, investigated and analyzed factors
that may have been an influencing factor in Hmong elders’ willingness to seek healthcare
from western medical providers.
Data Collection Procedures
After the researcher was able to secured approval from the Committee for the
Protection of Human Subjects, the researcher started calling potential participants whom
the researcher knew. All interview sessions were conducted at the participant’s home and
36
most were done during the weekend due to time constraint on the part of the researcher.
The researcher was able to conduct data collection on fifty Hmong participants who were
60 years or older and currently residing in the greater Sacramento region. There are a
total of 28 females and 22 male participants interviewed by the researcher. The
researcher recruited all the participants using convenience and snowball sampling.
Through this process, the researcher was able to interviewed individual Hmong elders
whom the researcher already knows. The majority of participants were referred by
friends and relative of those that had already been interviewed by the researcher. All
participants were contacted by way of phone and permission to conduct the interview was
given through oral consent over the phone. The majority of the participants were not
proficient in the English language, so consent to participate and administering of the
interview questionnaires were all done in the Hmong dialect. Since the majority of them
were not literate in English or Hmong, no written translations of the interview
questionnaires were made.
The researcher took the following steps and procedures to conduct the research
appropriately: 1) the researcher contacted the participant and asked for permission to be
interview for the project, 2) the researcher explains the research concept, purpose, and
objective in the Hmong dialect to all potential participants over the phone, 3) those that
were willing to participate were asked to orally consent to be a participant of the research
project, 4) Once the participant gave permission to be interview, the researcher scheduled
an appointment with the participant over the phone. For those that were scheduled a few
days ahead, the researcher made friendly phone calls the night before to confirm
37
interview appointments, since many of the seniors tend to forget. 5) Once the researcher
meets with the participant at his/her home, the researcher introduces himself and briefly
re-explained the research concept, purpose and objective. the researcher explained to the
participants that all the collected data will be confidential, which means all materials
collected on behalf of them will not be shared with anyone except with the thesis advisor
for the purpose of this research, 6) the researcher informed all participants of their rights
to terminate their participation at any time during the research process, 7) the researcher
conducted the whole interview process in the Hmong dialect and interpreted each
questions to the participants. Since each of the questions had to be interpreted in
different ways within the Hmong dialect to allow participants to have a clear
understanding of what’s being ask; therefore, each interview took about a good 20 to 30
minutes. The interview time varies depending on how talkative the individual participant
is. 8) After the interview, questionnaires were conducted with each participant, the
researcher provided contact information of the researcher and thesis advisor, 9) at the end
of each interview, the researcher provided the participants with local community
resources in case the interview created distress or discomfort for the participants. Since
the committee for protection of human subject assigned the project as minimal risk, the
researcher expected there to be no major concerns or discomfort on the part of the
participant because of their participation in the research interview.
Protection of Human Subjects
The researcher filled out the Protection of Human Subjects application with the
assistance of the thesis advisor Dr. Serge Lee. The researcher submitted the human
38
subject application multiple times to the thesis advisor and made multiple corrections to
the wordings and procedures of the steps to protect all participating subjects. The first
time the human subject application was submitted to Dr. Lee for review, it came back
with suggestions to modify the consent forms to oral consent. Dr. Lee explained that
most of the participants would be least likely willing to participate if signature was
required; therefore, the researcher changed the written consent form into an oral consent.
With the oral consent, participants would just have to orally consent without signing any
forms.
The second time, Dr. Lee suggested that since most of the participants in the
Hmong community knows each other, the researcher needed to make sure other
participant’s participation in the research be kept confidential. The researcher modify the
wordings in question three of the human subject application so that if any of the
participants happen to ask about other member’s, the researcher will not share
participant’s information with any of the participating subjects. The third time that the
human subject application was resubmitted to Dr. Lee for review, minor formatting and
the correct form of the human subject application was suggested. Once the changes were
made, the only major concern was the interview questionnaire. Dr. Lee assisted the
researcher in modifying the wordings and structure of the questionnaires to be
understandable by the participating subjects. The questionnaire started with 41 questions
and due to the content of certain questions and the lengthy questions, it was cut down to
29 questions. Once the questionnaire was approved by Dr. Lee, both the human subject
application along with the interview questionnaire and consent form was submitted for
39
review by the Committee for Protection of Human Subjects in the Social Work
department.
The Committee for Protection of Human Subjects in the Division of Social Work
at California State Sacramento reviewed and responded back to the researcher on Dec. 7,
2011 with three conditions that needed to be modified before the human subject
application was approved. The first condition was to make sure there are procedures set
aside to protect the identity of all participating subjects especially, since the researcher
will know most of them. To make this correction, the researcher went ahead and stated
that no names or identity of individual participants will be collected, even if names were
given, it will not be recorded or shared with anyone. The second condition was to fix
minor grammatical errors, which the researcher quickly fixed all the indicated errors.
The final condition was for the researcher to modified question 9 on the interview
questionnaire since most elder participants are assumed to have some sort of health
insurance in the United States. After all required conditions were fixed; the researcher
resubmitted the human subject application to Dr. Lee for review and signature.
The Committee for Protection of Human Subjects at California State University,
Sacramento, approved the research project and indicated it to be at “minimal risk.” It
was approved on Dec. 12, 2011 with reference number 11-12-045. The protection of
human subject is crucial to the research; therefore, the researcher took all steps necessary
to protect the safety and identity of all interviewed subjects. As part of the agreement
with the Protection of Human Subjects, the researcher did not collect any identifiable
information and securely kept all collected materials in a highly secure cabinet. All
40
research was done according to the approved guidelines of the Protection of Human
Subjects application.
The researcher believed that the questions asked in the interview would not do
any physical harm to the participants since they are not required to perform any physical
task as part of the research. When it comes to psychological harm, the researcher does
not believe that participants will react in a discomfort way or emotionally impacted from
the questions asked.
Instrumentation
The researcher utilized an interview questionnaire consisting of 29 questions that
included opened and closed ended questions. All of the questions in the interview
questionnaire were develop by the researcher with the exception of the demographic
portion, which was adapted from models of previous student researchers. Most of the
ideas in developing the questions were based on literature reviews that had indicated
certain criteria such as health insurance, acculturation and language as barriers to health.
The questionnaire started with a total of 41 one questions, but with the inputs and
assistance of the thesis advisor Dr. Lee, most of the questions were modified and
eliminated in order to be direct and inclusive of both Christians and traditional
participants. Due to the limited nature and time of the study, the researcher did not
perform a validity nor reliability test on the questionnaire before administering them to
all the participants. The researcher realized that this puts a major limitation on the
outcome of the overall research project.
41
The questionnaire is consisted of three major sections. The first section of the
interview questionnaire is consisted of 8 closed ended questions on the demographics of
the participants, with 1 opened ended question on employments. This section is to help
the researcher identify the origin, age and gender groups of all participants participating
in this research project.
The second section is consisted of 11 questions, with 10 closed ended questions
and 1 opened ended question. The questions in this section are designed to assess for the
social factors of the participants in this study. The section asked questions about
education, employment, income, medical insurance and decision making to allow insights
into the social factors that might be barriers in seeking western healthcare.
The third section included 9 closed ended questions on cultural belief of the
participants. The design of the questions in this section is to measure the cultural factors
that might have an impact whether or not a participant will seek medical care from
western physicians. All of these questions combined will assist the researcher to see if
there are any association between the participant’s demographics, social factors and
cultural beliefs as it relates to barriers in seeking healthcare from western medical
providers.
Data Analysis
The researcher utilized the SPSS computer software program for the statistical
analysis of the data collected from the research project. Descriptive statistics were used
to summarize, present and describe the data that was collected. As part of the descriptive
statistics, tables and measures of central tendency were utilized to provide representation
42
of the data for each of the different sections in the interview questionnaires.
The
researcher used chi-square to compute and see if there was any association between the
amounts of time participants had been living in the United States and the participant’s
willingness to seek healthcare from a primary care physician. Cross-tabulation was also
used to distinguish the relationship between gender and decision making person in the
family. The researcher further utilized cross-tabulation to analyze the relationship
between gender, religious preferences, and the participant’s willingness to seek help from
a primary care physician first.
Limitations
The researcher identified multiple limitations to this study. First, the study was
only based on a limited number of fifty Hmong elders in the greater Sacramento region;
therefore, the number is not large enough to establish a strong finding in order to relate it
to other Hmong elders in other parts of the country. Second, all participating Hmong
elders are not fluent in English; therefore, all question had to be translated into the
Hmong dialect, making it difficult to explain each question and how much of the elders
actually understood the full meaning of what is being ask. Since the questionnaire was
not tested for validity or reliability, it is unsure how accurate the intended outcome would
be. The fact that many of the elder participants were willing but hesitant to answer some
of the questions, the researcher felt that some of the participants might not have been
fully honest on some of their answers to certain questions. In addition, because the
procedure used to recruit participant was based on a snowball sampling, it limits the
43
degree of a randomly selected research group; therefore, opinions could have been
limited to a small selected group instead of random participants in the community.
44
Chapter 4
DATA ANALYSIS
Introduction
This chapter explores and presents the results obtained from the 29 interview
questions that were administered to 50 Hmong elders living in the greater Sacramento
Region. To reiterate, this is an exploratory study on the social and cultural barriers that
prevents Hmong elders from seeking western healthcare, so better access to and a more
culturally sensitive healthcare treatments can be provided to this population group. The
first section of this chapter will examine the demographic portion of the research using
descriptive statistics to present a visual representation of the results collected from the
study. The rest of the survey materials, including section 2 and section 3 will also be
examined using descriptive statistics. The following questions from section 3 of the
questionnaire are analyzed using cross-tabulation to see if there are any relationships with
the participant’s social factors or demographics. 1) When you get sick, who do you seek
for help first, 2) When you are sick, who do you most likely take healthcare advise from,
3) Do you think that your inability to speak English is a barrier in seeking help from
American Doctors, and 4) if your primary care physician was Hmong, would you feel
more comfortable seeking medical care from him/her?
Section 1: Demographics
Based on the results, the age of all 50 participants varies between 60 and 89 years
of age. There are 20% (n=10) between 60 and 64 years of age, while the highest
concentration of all the participants are in the 65 to 69 year old range with a total of 34%
45
(n=17). The second highest concentration which is 26% (n=13) falls between the age of
70 and 74 years old. The rest of the participants are between the age of 75 to 79 at 12%
(n=3), 80 to 84 at 6% (n=3) and 85 to 89 at 2% (n=1) (see table 1).
Table 1
Age of Participants
Valid 60-64
65-69
70-74
75-79
80-84
85-89
Total
Frequency
10
17
13
6
3
1
50
Percent
20.0
34.0
26.0
12.0
6.0
2.0
100.0
Valid
Percent
20.0
34.0
26.0
12.0
6.0
2.0
100.0
Cumulative
Percent
20.0
54.0
80.0
92.0
98.0
100.0
Out of all the participants that participated in the research there are a total of 44%
(n=22) who are male and 56% (n=28) who are female. The researcher expected to have
more female participants than male participants because of the researcher’s experience
with the Hmong community. The researcher understands that Hmong males tend to
decline research more often than Hmong females. The outcome of gender participants
coincides with the researcher’s expectation (see table 2). Out of the 50 participants 20%
(n=10) indicated that they spoke Thai and 38% (n=19) stated that they can speak Laotian
(see table 3 & 4). This is interesting because the researcher would assume that most of
the participants would be able to speak Laos; however, the results showed that the
majority are able to speak Thai. It could be that those who are able to speak Laos can
46
speak Thai because of the similarity of the language; however, since there are also a few
of the participants who are recent refugees coming from Thailand in 2004 and 2005;
these could be the ones making up the majority of those who could speak Thai.
Table 2
Gender of Participants
Frequency Percent
Valid Male
Female
Total
22
28
50
44.0
56.0
100.0
Valid
Percent
44.0
56.0
100.0
Cumulative
Percent
44.0
100.0
Table 3
Able to Speak Thai
I speak Thai
Valid Yes
No
Total
Frequency Percent
10
20.0
40
80.0
50
100.0
Valid
Percent
20.0
80.0
100.0
Cumulative
Percent
20.0
100.0
Valid
Percent
38.0
62.0
100.0
Cumulative
Percent
38.0
100.0
Table 4
Able to speak Laotian
I speak
Laotian
Valid Yes
No
Total
Frequency Percent
19
38.0
31
62.0
50
100.0
47
When asked to see the marital status of the participating subjects, 64% (n=32)
responded that they are currently married, with a small 2% (n=1) who responded as being
single. Obviously with the participating subjects being of older age, the results shows
30% (n=15) of participants as widows. This could also be that many of them probably
loss their loved one during the secret war in Laos and was never remarried. There was
only a small 4% (n=2) who considered themselves divorced (see table 5). The result
overwhelmingly shows that older Hmong adults have a very small percentage of divorced
within their family and this could be because of the traditional belief of the Hmong
culture in regards to marriages. Older Hmong adults tend to stay within their marriages
no matter what happens, unlike those of the younger generation.
Table 5
Marital Status
Valid Married
Single
Divorced
Widowed
Total
Frequency Percent
32
64.0
1
2.0
2
4.0
15
30.0
50
100.0
Valid
Percent
64.0
2.0
4.0
30.0
100.0
Cumulative
Percent
64.0
66.0
70.0
100.0
As part of the demographic portion of the interview, participants were asked to
identified their religious preference and out of the overall participating subjects, there
were an overwhelming 70% (n=35) participants who identified themselves as being
Shamanism. The rest of the other participants consisting of 30% (n=15) responded as
being Christians. No other religious preference was identified even though there were
48
other types of religious beliefs different from the ones identified here in this research
project. This does not show that majorities of Hmong are Shamanism, but only shows
that a majority of those that happen to have been recruited to be participants in this
research came from the traditional belief of Shamanism (see table 6). Since the research
was done through a snowball sampling; therefore, random sampling was absent from the
recruitment process. It could be that most of the people interviewed by the researcher
only know more of those who are still traditional compare to those who have been
converted to Christians.
Table 6
Religious Preference
Frequency Percent
Valid Shamanism
Christianity
Total
35
15
50
70.0
30.0
100.0
Valid
Percent
70.0
30.0
100.0
Cumulative
Percent
70.0
100.0
To get an ideal of how long many of the participants had been living in the United
States, all participants were asked to indicate the amount of years they have been living in
this country. Table 7 shows that most of the participants had been living in the country
for about 21 to 25 years, which is 32% (n=16) of the total participants. The second group
consisted of 28% (n=14) who indicated that they have only lived in the country between
6 to 10 years, which these participants were presumably part of the most recent arriving
Hmong refugees to this country in 2004 and 2005. The third group which is 22% (n=11)
indicated that they have resided within the country between 26 to 30 years, making them
49
the folks who have been in the United States the longest of all the 50 participating
Hmong elders. These groups of participants are probably those who came right after the
end of the Vietnam War. The 18% (n=9) of the remaining Hmong elders stated that they
have been here between 16 to 20 years (see table 7).
Table 7
Amount of time living in the U.S
Valid 6-10
16-20
21-25
26-30
Total
Frequency Percent
14
28.0
9
18.0
16
32.0
11
22.0
50
100.0
Valid
Cumulative
Percent
Percent
28.0
28.0
18.0
46.0
32.0
78.0
22.0
100.0
100.0
To have an idea of the family size of the participating Hmong elders, the
researcher asked the participants to list the number of children that they had. A majority
of them, which is 50% (n=25) have between 4 to 6 kids and the average mean is about 4
kids. This result seems about right with what the researcher has observed in the Hmong
community. It is not a surprise to the researcher that 24% (n=12) of the participants
indicated having between7 to 9 children, which was common among Hmong families.
Since many of these older Hmong adults grew up in Laos, the belief of the benefits of
having a huge family strongly influences their family sizes. There was a total of 20%
(n=10) whom stated that they have between 1 to 3 children. The last remaining few of
6% (n=3) had between 10 to 12 children, which was quite a high number of children (see
table 8).
50
Table 8
Number of Children
Frequency Percent
Valid
Cumulative
Percent
Percent
Valid 1-3
10
20.0
20.0
20.0
4-6
25
50.0
50.0
70.0
7-9
12
24.0
24.0
94.0
10-12
3
6.0
6.0
100.0
Total
50
100.0
100.0
Section 2: Social Factors
To get an idea of the socio economic and educational backgrounds of the Hmong
elders, the researcher asked all participants to indicate rather or not they had some form
of education in Laos. Results indicated that out of the 50 Hmong elders, only 18% (n=9)
responded that they had some form of education in Laos. The other 82% (n=41) stated
they had no education at all. The 18% (n=9) that had an education, only 16% (n=8) was
in school between 1 to 3 years and only 2% (n=1) indicated going to school between 4 to
6 years. Since the 82% (n=41) had indicated that they did not have any form of education
in Laos, they did not check the number of school years, leaving the results as missing (see
table 9). It is not a surprise that an overwhelming majority of the participants did not
have some form of education because in Laos it was impossible for a majority of the
51
Hmong ethnic groups to be able to obtain any kind of formal education. For those that
were able to attend school, it was probably because their family had money.
Table 9
Attend school in Laos
Valid Yes
No
Total
Frequency Percent
9
18.0
41
82.0
50
100.0
Valid
Percent
18.0
82.0
100.0
Cumulative
Percent
18.0
100.0
Table 10
Number of years attended school
Frequency Percent
Valid
1-3
4-6
Total
Missing 999
Total
8
1
9
41
50
16.0
2.0
18.0
82.0
100.0
Valid
Percent
88.9
11.1
100.0
Cumulative
Percent
88.9
100.0
When it comes to the type of insurance that the participants had, all 50
participants indicated having both Medi-Cal and Medicare coverage with an
overwhelming 100% (n=50). The result shows that 100% of the participants are not
currently working and receives SSI as their main sources of income (see table 11). Since
many of the participants did not work while in this country, it is not a surprise that all of
the participants in this group are on Medi-Cal and Medicare as their main source of
health insurance. Even for those that did work a few years, it was not long enough for
52
them to receive any social security income. This result indicates that none of the
participants had any private insurance to cover their healthcare and is dependent on
governmental health coverage.
Table 11
Insurance/Income
Frequency Percent
Valid SSI
50
Valid
Percent
100.0
Cumulative
Percent
100.0
100.0
Valid
Percent
100.0
Cumulative
Percent
100.0
I have Medi-care
Valid Yes
Frequency Percent
50
100.0
I have Medi-Cal
Valid Yes
Frequency Percent
50
100.0
Valid
Percent
100.0
Cumulative
Percent
100.0
When the Hmong elder participants were asked to report children of theirs that
have obtained a college degree and based on table 10, 32% (n=16) indicated having at
least one children with a college degree. The majority of the participants consisting of
68% (n=34) had no children who had completed a college degree (see table 12). This
result shows that a huge percentage of the children belonging to these participants lack a
formal college degree in this country. This could be associated with the fact that many of
these older Hmong adults have not been here as long as other Asian groups.
53
Table 12
Children with degree
Valid Yes
No
Total
Frequency Percent
16
32.0
34
68.0
50
100.0
Valid
Percent
32.0
68.0
Cumulative
Percent
32.0
100.0
100.0
When it comes down to who makes the decision in the household, 42% (n=21) of
respondents indicated that they make most of the decision, while 58% (n=29) indicate
they did not make the decision in the household. This could be that majorities of the
participants are female and females tend to make less decision within the Hmong family
structure (see table 13). However, a strong majority of 98% (n=49) indicated that most of
their children are involved and helps decide on their medical care. There was only a 2%
(n=1) who responded that their children does not help with health care decisions (see
table 14). This indicates that the children of these participants are highly involved in their
healthcare needs and further supports the fact that Hmong are very family oriented. The
researcher understands that individual Hmong elders even if they are the head of
household, they will still consult relatives and their grown children for advices and
decision-making. The result fits in with the researcher’s experience with local Hmong
family especially, dealing with major health concerns. It has always been that Hmong
elders will consult their families first before deciding on any major healthcare
procedures.
54
Table 13
Decision making
Valid Yes
No
Total
Frequency Percent
21
42.0
29
58.0
50
100.0
Valid
Percent
42.0
58.0
Cumulative
Percent
42.0
100.0
100.0
Table 14
Children help decide medical care
Valid Yes
No
Total
Frequency Percent
49
98.0
1
2.0
50
100.0
Valid
Percent
98.0
2.0
Cumulative
Percent
98.0
100.0
100.0
Section 3: Cultural Beliefs and Healthcare Practices
To see where most of the participants in the research were seeking healthcare
advice from, the participants were asked to identify rather or not they seek advice from a
primary care physician, a shaman, a herbalist or someone who had suffered from a
similar illness. A strong majority of the participants 70% (n=35) indicated seeking
advice from their primary care physician (see table 15). There were 62% (n=31) stating
that they also seek advice from a shaman (see table 16). Table 17 shows a strong 82%
(n=41) of participants responded that they take advice from a herbalist and with 74%
(n=34) saying that they take advice from someone who has suffered from a similar illness
(see table 18). This indicates that a strong majority of the participants are pluralistic in
55
their approach in seeking healthcare advice. This is evidence in the day-to-day practice
of many Hmong adults and coincides with the literature review in chapter 2 on how
Hmong utilize a pluralistic approach in seeking healthcare for themselves. This is no
wonder why Hmong people will seek help from their physician, at the same time take
herbal medicines, and seek help from a shaman or prayers from a priest.
Table 15
Take advice from Physician
Valid Yes
No
Total
Frequency Percent
35
70.0
15
30.0
50
100.0
Valid
Percent
70.0
30.0
100.0
Cumulative
Percent
70.0
100.0
Valid
Percent
62.0
38.0
100.0
Cumulative
Percent
62.0
100.0
Table 16
Take advice from Shaman
Valid Yes
No
Total
Frequency Percent
31
62.0
19
38.0
50
100.0
56
Table 17
Take advice from herbalist
Valid Yes
No
Total
Frequency Percent
41
82.0
9
18.0
50
100.0
Valid
Percent
82.0
18.0
100.0
Cumulative
Percent
82.0
100.0
Table 18
Take advice from someone who had the illness before
Valid Yes
No
Total
Frequency Percent
37
74.0
13
26.0
50
100.0
Valid
Percent
74.0
26.0
100.0
Cumulative
Percent
74.0
100.0
Respondents were asked to see who they would most likely seek help from first if
they were sick, and based on table 17, 36% (n=18) indicated that they would seek help
from a Hmong shaman first. Out of the 50 participants, 48% (n=24) would most likely
seek help from a primary care physician first, while the remaining 16% (n=8) would
prefer help from a herbalist first (see table 19). The results indicated that there are little
over 50% of the participants whom are still seeking help from traditional ways such as
shaman and herbalist for their healthcare needs. This could point to the fact that many
Hmong adults are still dependent on traditional ways of seeking healthcare and are still
resistant to seeking help from their primary care physician as their first contact point.
57
Table 19
When you are sick, who do you seek for help first?
Valid Hmong Shaman
Folk herbalist
Frequency Percent
18
36.0
8
16.0
Primary care
physician
Total
Valid
Percent
36.0
16.0
Cumulative
Percent
36.0
52.0
100.0
24
48.0
48.0
50
100.0
100.0
All participants were asked to see how they felt about medications and an over
whelming majority of 66% (n=33) felt medications were harmful to them. The remaining
34% (n=17) indicated that medications were more helpful then harmful (see table 20).
This was not a surprise to the researcher because the researcher understands that a
majority of older Hmong individuals do not completely follow the recommendations of
their physicians.
Table 20
Do you think prescription medications do more harm than good?
Valid Yes
No
Total
Frequency Percent
33
66.0
17
34.0
50
100.0
Valid
Percent
66.0
34.0
100.0
Cumulative
Percent
66.0
100.0
When asked to see what the participants would considered as barriers to seeking
healthcare needs from western medical doctors, an over whelming 100% (n=50) indicated
58
that the lack of English proficiency as a major barrier to healthcare (see table 21). The
result shows that language barrier is a major roadblock for Hmong elders when it comes
to seeing their primary care physicians for healthcare needs. Also based on the results in
table 20, 100% (n=50) stated that they would prefer a physician that speaks the Hmong
language with 86% (n=43) feeling more comfortable is the physician was Hmong (see
table 22). This could indicate that if most physicians can speak the Hmong language if is
a Hmong person, more of the Hmong elders will likely seek help from their physicians
more often. Only a small percentage of 14% (n=7) did not feel comfortable having a
Hmong physician (see table 23).
Table 21
Do you think that your inability to speak English is a barrier?
Valid Yes
Frequency Percent
50
100.0
Valid
Percent
100.0
Cumulative
Percent
100.0
Table 22
Prefer a primary care physician that speaks Hmong
Frequency Percent
Valid Yes
50
100.0
Valid
Percent
100.0
Cumulative
Percent
100.0
59
Table 23
Comfortable with a Hmong physician
Valid Yes
No
Total
Frequency Percent
43
86.0
7
14.0
50
100.0
Valid
Percent
86.0
14.0
100.0
Cumulative
Percent
86.0
100.0
Significant Findings
As the purpose of the research is to look at the cultural and socio-economic
factors that prevent Hmong elders from seeking western healthcare, it is crucial to look at
the relationships between gender and the variable that makes the decisions in the family.
In this, case cross-tabulation shows that male participants made up 95 % (n=21) of those
who said they are the ones making the decisions, while 100% (n=28) of the female
participants said no (see table 24). When computed to see if there are any significant
relationships between the numbers of years one has been here in the United States and
one’s willingness to seek a primary care physician for help first; table 25 shows that there
are no significant relationship between how long the Hmong participants had been in the
country and their willingness to take healthcare advice from a western physician (r=-.173,
p>.228). This is surprising because the researcher expected that with longer time,
acculturation of western culture would influence one’s acceptability of western
healthcare.
One other factor that was look at closely was religion preference in relation to
seeking help from a primary care physician when the participants are sick. The cross-
60
tabulation in table 26 shows that of the 35 participants who preferred shaman as their
religious preference, 51% (n=18) would seek help from a shaman. As for those who are
Christians, 60% (n=9) indicated that they would seek help from a primary care physician
first (see table 26). Even though the numbers of shaman participants and Christians are
slightly imbalance, the result shows that those who are Christians rely more upon the help
of their primary care physicians.
Since a majority of the literature review indicated that the type of insurance has an
impact on rather or not people will utilize healthcare services; however, the results from
this research indicated that healthcare coverage is not a major factor in predicting the
participant’s willingness to seek help from a physician. Table 27 shows that of the 50
participants who had both Medi-Cal and Medicare, only 48% (n=24) would seek
healthcare from a physician, while the other 36% (n=18) would seek a shaman first and
16% (n=8) would seek a folk herbalist. This reinforces that Hmong elders continued
utilize a pluralistic approach to healthcare despite having healthcare coverage.
61
Table 24
Decision making and gender
When it comes to
decision making, do
you make them?
Total
Yes
Count
No
Count
What is your gender?
Male
Female
21
0
95.5%
.0%
1
4.5%
22
100.0%
Count
Total
21
42.0%
28
29
100.0% 58.0%
28
50
100.0% 100.0%
Table 25
Time in the U.S and taking advice from a physician
How long
have you
been in the
U.S?
How long have you
been in the U.S?
Pearson
Correlation
Sig. (2-tailed)
N
I take advice from a
Pearson
Primary care physician Correlation
Sig. (2-tailed)
N
I take advice
from a
Primary care
physician
1
-.173
50
-.173
.228
50
1
.228
50
50
62
Table 26
Healthcare preference and religious preference
When you are sick,
who do you seek for
help first?
Total
Hmong Shaman
Count
Folk herbalist
Count
Primary care
physician
Count
Count
What is your religious
preference?
Shaman Christian
18
0
51.4%
2
5.7%
15
42.9%
35
100.0%
Total
18
.0% 36.0%
6
8
40.0% 16.0%
9
24
60.0% 48.0%
15
50
100.0% 100.0%
63
Table 27
Healthcare preference and having Medi-Cal
When you are sick,
who do you seek for
help first?
Hmong Shaman
Count
% within I have
Medi-Cal
Folk herbalist
Count
% within I have
Medi-Cal
Primary care
Count
physician
% within I have
Medi-Cal
Total
Count
% within I have
Medi-Cal
a. No statistics are computed because I have Medi-Cal is a constant.
I have
Medi-Cal
Yes
18
36.0%
Total
18
36.0%
8
16.0%
8
16.0%
24
48.0%
24
48.0%
50
50
100.0% 100.0%
64
Chapter 5
CONCLUSION AND RECOMMENDATION
Introduction
In this chapter, the researcher summarized the major findings that are associated
with the research purpose, which is to examine the cultural and socio-economic factors
that prevent Hmong elders from seeking western healthcare. The chapter will first
present a summary of the findings ranging from the demographics to the potential social
and cultural barriers found through the research interviews. This is followed by brief
recommendations for professionals in working with the older Hmong population,
specifically for those residing within Sacramento County. The researcher have found
himself questioning the cultural and socioeconomic factors that might have been
influential for Hmong elders in their access to western healthcare; therefore, has inspired
the researcher to explore the underlying cultural and socio-economic factors that are
barriers to Hmong elders in seeking western healthcare. The researcher believes that
having an understanding of the cultural and socioeconomic factors behind Hmong elders’
health seeking behaviors. It will not only allow Hmong elders better access to healthcare
treatments; but to also bring broader awareness to the medical field in order to be more
culturally sensitive; therefore, able to adequately address the problem of healthcare
disparity among this population. The hope is that it will improve Hmong elder’s
utilization of the healthcare system; therefore, lessening the healthcare disparity gap
among this population and better treatment outcomes and diseases prevention among
elderly Hmong immigrants in the United States.
65
Summary
Based on history, Hmong people are the most recent arriving refugees from
Southeast Asia and according to Lee and Pfeifer (2005), the majority of Hmong refugees
started arriving here to this country in the mid to late 1970’s. The research indicated that
of all the 50 participants, those that had been here the longest consisting of 22% (n=11)
have been here between 25 to 30 years, which coincides with about the right time when
Hmong refugees were arriving here in the mid to late 1970’s. The research indicates that
a majority of participants lack formal education as evidence in the response to question
10 asking participants to see if they attended school in Laos. Only 18% (n=9) attended
school in Laos, not to say that of the 18% (n=9), only 2% (n=1) had attended at least 4
years or longer of school. The rest of the 16% (n=8) had only attended between 1 to 3
years of school. This goes to show that many of the older Hmong adults who grew up in
Laos lack formal education and therefore are not highly educated compare to other
people. The lack of an education could be a social factor that prevents Hmong elders
from utilizing western healthcare, which according to the Center for Diseases Control and
Prevention (CDC, 2010), education plays a role in access to quality healthcare.
The study further indicates that healthcare coverage is not a major factor in rather
or not a Hmong elder would seek health services from a primary care physician since all
participants had Medi-Cal and Medicare as their primary health insurance. Even though
according to Reyes (2001), health insurance is a primary indicator of access to healthcare,
however, the results from this study shows that despite have health coverage, there are
only 48% (n=24) of the participants who would seek help from a physician first. This
66
could mean that health coverage is not a concern for the other 50% who are not seeking
help from a physician. It would take more detail exploration in this area to find out more
about the reasons for these other half of the participants who are utilizing traditional
practices besides their primary care physician despite having Medi-Cal and Medicare.
It is surprising that when the researcher looked at the amount of time spend in the
United States and the participant’s willingness to seek healthcare services from their
primary care physician, there is no significant relationship between these two variables.
It could be that the ratio of those being here over 20 years and those who are recent
within the last 7 years are scattered; therefore impacting the results to have an
insignificant relationship. The researcher predicts that if there were a strong balance
between those participants who were here over 20 years and those who were under 7
years, the results would be able to produce a better picture of whether or not it has a
major impact on health seeking behaviors.
Although about 70% (n=35) of the participants were still practicing shamanism
while the other 30% (15) were Christians, the data shows that over half of those still
practicing shamanism would rather seek healthcare from a shaman first. As for those
who were Christians, a majority of them consisting of 60% (n=9) would seek help from a
primary care physicians. This result shows that the Christian participants were more
willing to rely on their primary care physicians for their healthcare needs. This indicates
that the participant’s cultural practices in terms of religious belief have an impact on
whether or not they will seek healthcare from a western physician or from traditional
ways.
67
Considering decision making within the households of Hmong elders as an
important component in deciding healthcare utilization, the researcher looked at gender
and the relationship to decision making and to no surprise, an overwhelming 96% (n=21)
of male participants indicated being the decision maker of their household. This shows
that male figures are the prominent decision makers and their opinions on either
themselves or a family member’s healthcare decision matters. As Culhane-Pera et al.
(2003), indicated that Hmong men have more status and power over women; thus,
making most of the decision within their own family. However, the research further
indicates that even though the male participants overwhelmingly makes their own
decision, 98% (n=49) of all the participants stated that their children also helps to decide
their medical care. The result indicates that decisions regarding medical care are not
made alone by the male participants, but are also impacted by the decisions of the
participant’s children; therefore, it is a family matter when it comes to any medical
decisions. According to Culhane-Pera et al., when social, political or health problem
arises, Hmong men turn to their family and extended family members for assistance,
which supports the results found in this research.
One major finding from this research was the strong indication of language as a
barrier to seeking healthcare from western health providers. According to the data, all 50
participants mark language as a major obstacle in obtaining healthcare services from their
primary care physician. This shows that many of them are not fluent in the English
language and is uncomfortable seeking healthcare services if they do not understand their
health providers. Besides this, the results also indicated that all 50 participants also
68
would like to have a physician that is Hmong or at least speaks Hmong so they could
understand. One major finding that was not a surprise to the researcher was the question
on the benefits of prescription medications. Based on the result, 66% (n=33) of the
participants agreed that prescription medications does more harm than good, which could
explain the reason for the inconsistent consumption of medication based on physician
recommendations. The researcher understands that a majority of Hmong elders does not
follow through with taking their prescribed medications and will not take it throughout
the whole duration that is recommended.
Social Work Implications
It is important that professional social workers working with the Hmong
population especially, the elders should constantly be aware of the cultural sensitivity of
the topics at hand when discussing issues regarding major health concerns. It is crucial
that social workers working at the micro level have a basic understanding of Hmong
elder’s concept of health and illnesses and should be cautious at how responses from
health professionals and the individual’s healthcare experience can impact his/her health
seeking behaviors. Through cultural awareness training and social worker’s willingness
to listen empathetically to individual’s unique perspective, despite cultural competency
will enhance social worker’s ability to advocate on behalf of their Hmong clients.
While it is important to be culturally competent working with Hmong clients, it is
important that social workers become the voices of their clients and bring about changes
at the macro level through educational awareness and policy changes in the healthcare
arena. Social workers could influence policies that would provide culturally sensitive
69
treatments to Hmong clients in western healthcare settings and enhance the
communication between physicians and their Hmong patients. It could be as simple as
recognizing the pluralistic utilization of health treatments among Hmong elders;
therefore, developing less restricted policies that incorporates to a certain extent,
traditional healings in a medical setting.
Recommendations for Future Research
One important factor that was strongly indicated in this study was the issue of
language barriers, which many of the participants felt was an issue when dealing with
western physicians. The recommendation from this is to have in existence a culturally
appropriate healthcare interpretation system. The interpretation system would provide
well-trained culturally sensitive individuals to help translate for those participants who do
not speak English fluently. It is also not just a matter of having an interpreter, but as
cited in Culhane-Pera et al. (2003), providers should also acquire some language skills
that would allow them to communicate respect to this group of population. By having
more culturally sensitive interpreters’ available and culturally appropriate
communications between professionals and participants, it would potentially have a
positive impact on the relationship and trust of older Hmong adults.
Since religious belief and cultural practices play a major role in influencing
participant’s health seeking behaviors, it is crucial that professionals working with
Hmong elders should have a basic understanding of the health concepts and religious
beliefs of their Hmong patients. Understanding how a Hmong elder views the cause of
his/her, illness would allow professionals to see their Hmong patient’s perspective and
70
not have to force their own conclusions onto their patients. The recommendation is to
develop a manual that would provide all health concepts and health beliefs among the
Hmong people in regards to the causations of disease and ways of curing sickness within
their cultural beliefs.
Based on this study, the results also indicated that Hmong elders are very
pluralistic in their approach in seeking healthcare; therefore, professionals should
consider this and should not deny or insult these practices. It is crucial that professionals
work hand in hand with their Hmong patients and show their respects towards these other
alternative traditional healthcare practices. The recommendation is to develop a system
in place where hospitals and other healthcare settings would allow traditional healers to
provide healthcare assistance as supplemental treatments alongside western medical care
for Hmong patients.
This exploratory research still has a lot of question that were not answer and only
touched the surface of the issues concerning the cultural and socio-economic barriers that
prevents Hmong elders from seeking western healthcare. It would take a more detail
research of the specific cultural barriers and a larger sampling size in order to have a
clearer understanding of the barriers. An example of possible future studies could be a
more detail research of the specific Hmong concepts of health and illness in the United
States. Through a thorough research on this topic, it could potential open up more
questions and understanding of the impact it has on Hmong’s health seeking behaviors.
71
Conclusion
Although individual Hmong participants in this research study come from a
similar cultural background, they all have different religious beliefs and opinions that
influence their perception of health and wellbeing. It is important that even though many
of them might believe in the same religion or cultural experiences, they all are unique in
their own ways and should not be assuming to have common opinions in terms of seek
healthcare from western providers or relying on tradition healthcare practices such as a
shaman and herbalist.
As the research indicates, there is still a strong cultural and religious influence
especially, among those who are still traditional in their religious belief. Therefore,
professionals must continue to maintain a respectful and culturally sensitive approach in
assisting older Hmong adults with their healthcare needs in order to provide effective
health treatments for this population. Utilizing a holistic approach in either the social
work or health professional field would be a beneficial approach in working and
understanding this population and their health needs.
72
APPENDIX A
INTERVIEW QUESTIONS
73
Interview Questions
Introduction
The purpose of this interview questionnaire is to acquire information pertaining to the
social and cultural factors that influences Hmong elders’ reluctance in seeking western
healthcare. The information collected will only be used for developing the interviewer’s
thesis paper and all information collected on behalf of this project will be strictly
confidential.
Please respond to all questions to the best of your knowledge.
Demographics:
1. What is your age? _____
2. Gender: Male_____, Female______
3. Besides the Hmong language, what other languages do you speak?
Thai
Others (Please specify)
Laotian
4. What is your current marital status? Married_____, Single_____, Divorced_____,
Widowed_____.
5.
What is your country of Origin? Thailand_____, Laos_____, Vietnam_____,
Others (Please specify)_____
6. What is your religious preference? Shamanism_____, Christianity_____,
Buddhism_____, Others (please specify)_____
7. Overall, how many children do you have?
8. How long have you been in the United States? _____Yrs.
9. List any current or past employments that you have had after arriving in the
United States?
74
Social Factors
10. Did you attend school in Laos?
1. Yes
2. No
11. If yes, how may schooling years did you completed? _________/years
12. Are you currently employed?
1. Yes
2. No
13. If not currently employed, your source of income? ____________/type of income
14. What kind of health insurance do you have?
1.
Medicare
2.
MediCal
3.
Private (Please specify)
4.
None
15. Do you have any children with a college degree?
1.
Yes
2.
No
16. If Yes, how many of your children have college degree (Associate degree or higher).
____________/No. of children
17. When it comes to decision making, do you make most of the decision?
1.
Yes
2.
No
18. When it comes to taking care of medical needs, does your children help decide the
types of healthcare treatment for you?
1.
Yes
2.
No
19. Do you have transportation when you need to visit your primary care physician?
75
1.
2.
Yes
No
20. Do you considered yourself knowledgeable about the healthcare system in the United
States? (Please explain)
Cultural beliefs and Healthcare Practices
21. Do you have a Western primary care physician?
1.
Yes
2.
No
22. When dealing with illness, do you also consult Hmong shaman for recommendation?
1.
Yes
2.
No
23. When you get sick, who do you seek for help first? (Mark any that apply)
1.) Hmong healer (Shaman) _____
2.) Folk herbalist ____
3.) Primary care Physician ____
4.) Others (Please specify)_____
24. When you
that apply)
1.
2.
3.
4.
5.
are sick, who do you most likely take healthcare advice from? (Check all
Primary care physician
Hmong shaman
Herbalist
Someone who has recovered from a similar illness
Others (Please specify)
25. Have you had an experience where you were sick, but your primary care physician
was not able to diagnose your sickness?
1.
Yes
2.
No
76
26. Do you think prescription medications do more harm than good?
1.
Yes
2.
No
27. Do you think that your inability to speak English is a barrier in seeking help from
American Doctors?
1.
Yes
2.
No
28. Would you prefer to have a primary care physician that speaks Hmong?
1.
Yes
2.
No
29. If your primary care physician were Hmong, would you feel more comfortable
seeking medical care from him/her?
1.
Yes
2.
No
77
APPENDIX B
Oral Consent to Participate in the Research Study
I, Chue Xiong, a Masters of Social Work student over at California State
University of Sacramento would like to invite you to participate in my research. The
purpose of this research is to explore the difficulties experienced by Hmong elders while
seeking healthcare from western medical doctors. I realize that there is a healthcare
disparity among the Hmong elder population and through this project, I hope to find out
why Hmong elders are reluctant to see western medical doctors for their healthcare needs.
This research will not benefit you directly, but would help social workers and American
Doctors to recognize the cultural differences within the Hmong community and hopefully
will use the information in this research to better reach out to the older Hmong
populations.
This is voluntary so you are not obligated to participate and there will be no
monetary gifts or goods of any kind given to you, but your participation will be greatly
appreciated by me. There will be a total of 29 questions that you will have to answer and
it is estimated to take you about 50 to 60 minutes. Each of the questions will be explain
thoroughly to you. If you feel uncomfortable during the interview process or afterward,
and would like to end your participation, please let me know and I will discard the data
collected from you.
Your participation in this research will be strictly confidential, which means that
all information collected from you will be kept in a locked cabinet; therefore, only my
research advisor and I will be able to access it. I will ask that you do not give your name,
address or any identifiable information. There might be a few personal questions that may
make you feel uncomfortable; therefore, I do have local community resources that will be
given to you if you do need to talk to someone. If you have any questions or concerns,
you can reach me at (916) 524-7538 or my research advisor Dr. Lee at (916) 278-5820.
I would greatly appreciate it if you would be willing to participate in this research,
so will you like to be a participant?
78
APPENDIX C
Human Subjects approval form
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
TO:
Chue Xiong
Date: 12/12/2011
FROM: Committee for the Protection of Human Subjects
RE: YOUR RECENT HUMAN SUBJECTS APPLICATION
We are writing on behalf of the Committee for the Protection of Human Subjects from
the Division of Social Work. Your proposed study, “Hmong elder’s social and cultural
barriers toward seeking western healthcare.”
__X_ approved as _ _
_EXEMPT _ __ NO RISK __X__ MINIMAL RISK.
Your human subjects approval number is: 11-12-045. Please use this number in
all official correspondence and written materials relative to your study. Your
approval expires one year from this date. Approval carries with it that you will
inform the Committee promptly should an adverse reaction occur, and that you
will make no modification in the protocol without prior approval of the
Committee.
The committee wishes you the best in your research.
Professors: Jude Antonyappan, Teiahsha Bankhead, Maria Dinis, Serge Lee, Kisun Nam,
Francis Yuen.
79
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