PERCEPTIONS OF HEALTH CARE AMONG HMONG AMERICANS
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
Stacy Thang Yang
SPRING
2012
© 2012
Stacy Thang Yang
ALL RIGHTS RESERVED
ii
PERCEPTIONS OF HEALTH CARE AMONG HMONG AMERICANS
A Project
by
Stacy Thang Yang
Approved by:
__________________________________, Committee Chair
Serge C. Lee, Ph.D.
____________________________
Date
iii
Student: Stacy Thang Yang
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
Division of Social Work
iv
________________
Date
Abstract
of
PERCEPTIONS OF HEALTH CARE AMONG HMONG AMERICANS
by
Stacy Thang Yang
The Hmong immigrated to America as a result of various life threatening conditions that
prevented them from being able to live an ordinary life. Despite the huge population of
Hmong who have settled in California, Minnesota, Wisconsin and Michigan, they still
experience challenges when utilizing the modern health care system and its services.
This study explores Hmong Americans’ perceptions toward both traditional and modern
health care and their utilization of these services. Participants in this study were Hmong
American adults who are former refugees and immigrants from Laos and Thailand. The
findings of this research study reveal that there are indeed challenges and obstacles that
have prevented Hmong Americans from utilizing modern health care, as well as its
services, such as different philosophies toward health and illness, providers’ lack of
understanding about the Hmong’s cultural beliefs and/or practices, and lack of sufficient
English comprehension skills to communicate with health care providers.
_______________________, Committee Chair
Serge C. Lee, Ph.D.
_______________________
Date
v
DEDICATION
I would like to dedicate the completion of my Master’s Project to my mother,
Zang Thao (Zaag Thoj) for her insurmountable struggles and sacrifices that she has
endured while being both a mother and a father figure for all her children, and for raising
me to be the decent person that I am today. If not for her genuine heart, unwavering
support, patience, determination, and perseverance, my life path would have been very
different today. Words cannot express my gratitude for what she has done for me, and I
am forever grateful that I have a strong mother like her in my life.
Mom, I know that you are battling with cancer at this current time, but with your
resiliency and strong spirits you will be able to overcome your illness. I believe in your
courage and ability to fight against your illness, and there is no doubt that a strong person
like you will be able to do so. No matter how the future unfolds, I will be by your side to
provide my support, encouragement and unconditional love. Mom, I love you very much
and I have no doubt that you will get better soon.
vi
ACKNOWLEDGEMENTS
First of all, I would like to thank my father, Txawj Tooj Yaaj, for his love,
struggles, and sacrifices that he has endured in bringing my family and I to America,
where we were given the opportunity not only to receive an education, but to also pursue
higher education. Father, although you are not able to celebrate and witness my
accomplishments (obtaining a Master’s degree), I know that you would have been proud
of me as is my mother and siblings too.
My deepest appreciation is extended to my parents Nkaaj Muas Yaaj and Zaag
Thoj for their unconditional love, support, encouragement and for always emphasizing
the importance of education. If not for both of your continual inspirations and believing
in me, I would not be where I am today. Thank you very much and I love you both
dearly!
To my grandparents, Tsaav Kum Yaaj and Phuab Xyooj, for their nurturing,
guidance, and love. Thank you grandma (Phuab Xyooj) for your patience in teaching me
how to sing traditional Hmong songs (Lug Txaj). Grandma, although you are no longer
here to witness my achievement, I know that you would have been proud of me as is the
rest of the family.
To my siblings, JeFong, Lou, Zoua, Sheng, Jenny, Julie and Melody, and my
sister-in-law, Xe for their encouragement, support and love that they all have provided
me throughout my educational years. I would not be where I am today without your
vii
countless patience and understanding, especially when I am not able to help around the
house. I love you all very much!
I would like to express my appreciation to my thesis advisor, Dr. Serge C. Lee,
for his patience, guidance and support throughout this research project. Without his help
and support, I would not have completed this research project.
To Jamie Brezinski for her encouragement, patience and understanding. Thank
you for your genuine heart, friendship, emotional support and for being my partner in
“crime” throughout our two-years in the graduate program, which I truly appreciate.
I would like to thank my writing tutor David Reynolds for his time, effort, and
patience while supporting me in completing my thesis.
Lastly, I would also like to convey my appreciation and thanks to all the Hmong
participants who voluntarily participated and contributed to this research project. Without
their support and willingness to share their views of both traditional and modern medical
care, as well as their utilization of such services, this research project would not have
been possible.
viii
TABLE OF CONTENTS
Page
Dedication .......................................................................................................................... vi
Acknowledgements ........................................................................................................... vii
List of Tables .................................................................................................................... xii
Chapter
1. THE PROBLEM ............................................................................................................. 1
Introduction ........................................................................................................... 1
Background of the Problem ................................................................................... 2
Rationale ................................................................................................................ 6
Theoretical Framework ......................................................................................... 7
Limitations............................................................................................................. 9
Definition of Terms ............................................................................................... 9
2. REVIEW OF THE LITERATURE .............................................................................. 10
Introduction ......................................................................................................... 10
An Overview of Health Care ............................................................................... 11
History of the Hmong .......................................................................................... 12
Hmong Cultural Beliefs and/or Practices as Related to Modern Health Care .... 14
Prevalence Rates of Illnesses .............................................................................. 16
Education ............................................................................................................. 18
Language ............................................................................................................. 19
ix
English as a Second Language ............................................................................ 21
Mistrust in Providers ........................................................................................... 21
Decision Making ................................................................................................. 22
Mental Health ...................................................................................................... 23
Current Health Care Policies and Procedures ..................................................... 24
Common Health Care Models Practiced by Asians ............................................ 27
Types of Hmong Health Care .............................................................................. 29
Local Health Care Programs and Services Serving the Hmong Community...... 34
Summary ............................................................................................................. 35
3. METHODS ................................................................................................................... 36
Introduction ......................................................................................................... 36
Research Design .................................................................................................. 36
Data Collection Procedures ................................................................................. 37
Research Subjects ................................................................................................ 39
Instrumentation .................................................................................................... 39
Human Subject Protection ................................................................................... 40
Data Analysis Plan .............................................................................................. 41
4. RESULTS ..................................................................................................................... 42
Introduction ......................................................................................................... 42
Demographic Characteristics .............................................................................. 43
Key Findings Related to the Research Purpose................................................... 51
x
Qualitative Responses by the Participants........................................................... 64
5. CONCLUSION AND IMPLICATION ........................................................................ 73
Introduction ......................................................................................................... 73
Summary ............................................................................................................. 73
Conclusion ........................................................................................................... 74
Implications for Social Work Practice ................................................................ 78
Recommendations for Service Providers ............................................................ 80
Recommendations for Future Research .............................................................. 82
Appendix A. Consent Form .............................................................................................. 85
Appendix B. Questionnaires in English ............................................................................ 87
Appendix C. Questionnaires in Hmong ............................................................................ 95
References ....................................................................................................................... 103
xi
LIST OF TABLES
Table
Page
1. Table 1 Age Category of Participants ........................................................................... 43
2. Table 2 Sex of Participants ........................................................................................... 43
3. Table 3 Birthplace of the Participants ........................................................................... 44
4. Table 4 Marital Status of Participants ........................................................................... 44
5. Table 5 Highest Level of Education ............................................................................. 45
6. Table 6 Where Education was received ........................................................................ 46
7. Table 7.1 Numbers of Years Participants Have Lived in the U.S. ............................... 46
8. Table 7.2 Numbers of Years Participants Have Lived in the U.S. ............................... 47
9. Table 8 How Well Do You Understand English? ......................................................... 48
10. Table 9 How Well Do You Speak English? ............................................................... 49
11. Table 10 How Well Do You Read in English? ........................................................... 49
12. Table 11 How Well Do You Write in English? .......................................................... 50
13. Table 12 Religious Preference .................................................................................... 50
14. Table 13 Family Member for Treatment Decision ..................................................... 52
15. Table 14 Most Likely to be First Person to Help When a Family Member Becomes
Ill ................................................................................................................. 53
16. Table 15 Ever Reluctant to Utilize Modern Medical Care in the Past........................ 53
xii
17. Table 16 Encountered Problems or Concerns with Previously Sought Modern
Medical Care ............................................................................................... 54
18. Table 17 Modern Medical Doctor Knowledgeable of Cultural Background ............. 54
19. Table 18 Felt Disrespected by a Modern Medical Doctor .......................................... 55
20. Table 19 Felt Devalued by a Modern Medical Doctor ............................................... 55
21. Table 20 Modern Medical Doctors Have Knowledge/Understanding of Cultural
Beliefs/Practices .......................................................................................... 56
22. Table 21 Sought Help From a Traditional Healer Such as a Shaman ........................ 56
23. Table 22 Sought Help From a Healer/Soul Caller ...................................................... 57
24. Table 23 Sought Help From an Herbalist ................................................................... 57
25. Table 24 Sought Help From a Modern Medical Doctor ............................................. 58
26. Table 25 Has Your Understanding of Illness Changed in Recent Years .................... 58
27. Table 26 (a) How Well Understands English * Highest Level of Education ............. 59
28. Table 26 (b) Symmetric Measures .............................................................................. 60
29. Table 27 (a) How Well Understands English * Ever Reluctant to Use Modern
Medical Care in the Past .............................................................................. 61
30. Table 27 (b) Chi-Square Tests .................................................................................... 61
31. Table 28 (a) Ever Reluctant to Use Modern Medical Care in the Past * Sought Help
From a Modern Medical Doctor .................................................................. 62
32. Table 28 (b) Chi-Square Tests .................................................................................... 62
xiii
33. Table 29 (a) Has Your Understanding of Illness Changed in the Past Years *
Encountered Problems/Concerns with Previously Sought Modern Medical
Care ............................................................................................................. 63
34. Table 29 (b) Chi-Square Tests .................................................................................... 63
xiv
1
Chapter 1
THE PROBLEM
Introduction
The United States is a culturally diverse society which is home to a large
population of immigrants and refugees from around the world. Thousands of these
immigrants and refugees have settled in the U.S. for various reasons including economic
advancement, educational opportunities, and flight from religious and political
persecution (Warmer & Mochel, 1998). Hmong Americans began emigrating to the U.S.
from Laos after the Vietnam War ended in 1975, entering the US as political refugees.
The 2000 U.S. Census Bureau enumerated the Hmong population to be 186, 310, with the
largest concentration of Hmong in California at just over 65, 000, followed by Minnesota
(41, 800), Wisconsin (33, 791), North Carolina (7, 093) and Michigan (5, 383).
However, it is believed that the Hmong people may have been under counted for the
census, as many Hmong may have identified themselves as Laotian while others retain
their identity as Hmong (Pfeifer & Lee, 2004). According to the 2010 census, the total
Hmong population is estimated to be 245, 807, which has increased by approximately 60
thousand from the 2000 census (U.S. Census Bureau, 2010).
In the United States, the medical care trend has shifted first from inpatient care to
outpatient care to preventive health care, which has allowed the scope of health services
to broaden. As a result, it has included not previously considered related medical care
such as weight-reduction programs, counseling, birthing classes, and lifestyle and stress
2
management instead of relying solely on formal services such as physicians and hospitals
(Ma, 1999). Thomas (1993) defines health care as any means that may have direct or
indirect association with safeguarding, maintaining, and/or improving the health status
which involves activity such as visiting the physician and/or selecting an appropriate diet
or exercise (as cited in Ma, 1999). Medical care is the provision of care to all, which is
medically authorized by doctors that rely on clinical emphasis of the “germ theory” and
the biomedical model (Ma, 1999).
Although the Hmong have settled in the United States for more than thirty years,
they still encounter barriers and challenges as a result of their different cultural beliefs
and practices regarding health and illness when accessing and receiving services from
modern health care. Warmer and Mochel (1998) explain that American health care
providers do not look at the individual as part of a broader social setting; instead they
focus on the disease and illness of the individual. In contrast, when a Hmong is sick, the
family seeks an herbalist first, and if those remedies fail the shaman becomes the
preferred form of treatment approach for physical or mental ailments. The Hmong
believe that when illness becomes untreatable, it is caused by their ancestors or evil
spirits. Western health care models become the last source of care for some Hmong
individuals and families.
Background of the Problem
Modern health care views illnesses as having organic or psychological causes;
however, disease in traditional Hmong health care is believed to be understood as a
3
disruptive interaction of souls, spirits and persons, which are balanced and dynamic in
nature (Platnikoff, Numrich, Wu, Yang & Xiong 2002). As Uba (1992) and Parker and
Kiatoukaysy (1999) state, traditional Hmong believe that the primary cause of illness is
“soul loss,” and a person is believed to have a certain number of souls. It is believed that
“a person’s soul may leave the body when he or she is depressed, lonely, has experienced
a personal loss, or is frightened” (Parker & Kiatoukaysy, 1999, p. 512). As a result of the
Hmong’s cultural practices and beliefs about the body and the soul, there have been
clashes between the Hmong and Western health care practitioners, and problems in how
services were viewed by some Hmong. Although some doctors and healthcare
practitioners may feel that Hmong patients are neglecting to follow through with western
healthcare’s guidelines, often times this is due to cultural differences rather than
compliance issues.
Upon entering the United States, refugees and immigrants are provided with
health examinations to identify potential medical conditions, such as active TB, mental
health issues, HIV/AIDS, and other conditions that may pose a danger to themselves and
others. There are many significant health issues among refugees and immigrants, and
over 70% of refugees in California were found to have at least one significant health
problem. The Hmong, in particular, are found to have high incidences of hypertension,
kidney stones, and diabetes, especially among the elderly population, who have little or
no English language skills (Allen, Matthew & Boland, 2004). Other major health
concerns, identified by the Queensland Government (2003) and Nicholson (1997), among
4
the Hmong population include tuberculosis, cardiovascular disease, hepatitis B carrier
status, asymptomatic splenomegaly, sudden unexpected nocturnal death syndrome,
diabetes, and posttraumatic stress disorder (as cited in Pinzon-Perez, 2006). Furthermore,
the Queensland Government (2003) found that Hepatitis B carrier status has reached
endemic portions within the Hmong population, and that their rates of asymptomatic
splenomegaly are three times higher than that of general Southeast Asian population (as
cited in Pinzon-Perez, 2006). In addition, there have been higher rates of nasopharyngeal
carcinoma, gastric, hepatic and cervical cancer found in the Hmong population.
Important contributors for cancer mobility and mortality in the Hmong population are due
in part to genetics, problems with accessing health care services and diet-related issues
(Pinzon-Perez, 2006).
Despite the prevalence of these health problems that the Hmong encounter within
their communities, they appear to have conflicts when communicating with health care
professionals, and utilizing modern health care. As a result, a majority of Hmong
Americans fail to follow through and/or comply with orders from doctors and other
health care professionals. The Spirit Catches You and You Fall Down by Fadiman (1997)
is an example of the disconnect that discusses the collision of two different cultures, a
Hmong family and the staff at a Merced hospital, when a Hmong girl named Lia Lee is
diagnosed with epilepsy. The treatments required for Lia’s epilepsy became a struggle
for her family as a result of the Hmong’s cultural beliefs about the body and the soul.
The hospital failed to recognize the family’s strong cultural beliefs of shamantic healing
5
rituals, which caused miscommunication and misunderstanding between the family and
the hospital in regards to the necessary treatments for Lia. As a result of their strong
rooted cultural beliefs about the sources of illness and appropriateness of treatments,
Lia’s family preferred to seek a shaman first before utilizing modern health care.
Another case story, which is found in Healing by Heart: Clinical and Ethical
Case Stories of Hmong Families and Western Providers by Cullhane-Pera, Vawtex,
Xiong, Babbitt and Solberg (2003), demonstrated a doctor’s lack of understanding of the
Hmong’s cultural beliefs and a family’s desire to perform khawv koob (magic healing), as
well as the parents’ refusal to allow life-saving biomedical treatments to treat their son,
Neng’s fever. Neng is a three-month-old boy whose parents brought him to see his
doctor and asked the doctor for medicine to reduce his fever because of a cold that he
had. Even though Neng had a fever of 103°F and was fussy, he was easily consoled. As
a result of the doctor’s concern of possible bacterial meningitis or bacterial infection in
the blood, Neng’s parents were told they needed to draw Neng’s blood, get a urine
sample with a catheter, and lumbar puncture to identify whether there was any indication
of bacteria in his blood, urine, or spinal fluid. Neng’s parents were alarmed at the
doctor’s evaluation, and they refused the doctor’s recommended interventions. Despite
the risk of Neng dying from meningitis or bacteremia, the family still refused and wanted
to take him home. A security guard was immediately called by the doctors to escort
Neng’s parents to the emergency room, a police hold was obtained and a court order was
issued for Neng to undergo treatment. By the time Neng’s grandparents arrived, Neng
6
was alert and playful as his temperature had decreased to 100.8° F. Neng’s grandfather
wanted to take Neng home for khawv koob but the doctor refused, wanting to examine
Neng’s blood and spinal fluid. While the security guard was distracted, the family took
Neng and drove away in a car. The police came to Neng’s home, but Neng was nowhere
to be found. Because of this traumatic cultural encounter with the doctor, Neng’s parents
questioned “Why did the doctors want to do such awful things to their son when he was
not very sick? Why did the doctors treat them like dogs, without rights and
responsibilities toward their beloved son?”(Culhane-Pera, Vawter, Xiong, Babbitt &
Solberg, 2003, p. 118). Consequently, the culture gap created tension and
misunderstanding between Neng’s parents and the doctor in providing effective
treatments for Neng’s fever.
Rationale
As a Hmong woman who immigrated to America as a young child, the author of
this study has encountered and seen many challenges that prevented Hmong families,
including my own family, from successfully accessing the modern health care system. I
have noticed the different cultural belief systems, the insufficient understanding of the
English language, the lack of healthcare professionals’ cultural competency, and different
views and understanding of approaches and treatments within modern health care.
The author’s interests are to understand perceptions that Hmong Americans have
in regards to modern health care, as well as barriers and/or challenges that may have
prevented Hmong families from seeking and utilizing modern medicine or its services.
7
More importantly, this author hopes to gain a better understanding of the reasons behind
the Hmong’s cultural beliefs and practices, in order to increase health care professionals’
and social workers’ knowledge when working with the Hmong population and to
improve the relationship between practitioners and Hmong patients. Moreover, this
author’s intent is to create a friendly and understanding environment in which the Hmong
feel comfortable in expressing and addressing their concerns in regards to health and
illness in relation to their cultural beliefs.
The results that the author is hoping to find are that the influence of Hmong
Americans’ cultural beliefs, their lack of knowledge about treatment procedures, their
lack of a sufficient understanding of the English language, and modern health care
professionals’ lack of cultural awareness and understanding are the contributing factors to
Hmong Americans’ challenges when utilizing modern health care.
Theoretical Framework
The Ecological perspective and cultural competency approach will be utilized in
this research project. The ecological perspective identifies the individual/person as an
active agent in his or her environment (Schriver, 2004). This perspective is an integrative
framework that takes into account the individual’s environmental factors, enabling the
individual to transition, maneuver and develop as the individual comes into contact with
different systems. It also emphasizes the importance of relationships, adaptations,
interactions, and the behavior of the individual in his or her environment as related to
oppression (Kirst-Ashman & Hull, 2006; Robbins, Chatterjee & Canda, 2006). The
8
ecological perspective’s core focus has to do with the interrelatedness between the
environment and the individual. Similarly, the Hmong are interconnected with their
cultural beliefs regarding the cause of illness and treatment procedures which are viewed
differently from modern health care practices.
Dill (1999) defines the cultural competency approach as “the experiential
awareness of the worker about culture, ethnicity, and racism; knowledge about historical
oppression and related multicultural concepts; development of skills to deal effectively
with the needs of the culturally diverse client” and the continuous acquisition of
knowledge regarding multicultural skills (as cited in Schriver, 2004, p. 126). According
to this approach, not having an understanding of the theoretical foundation of cultural
competence can potentially affect how professionals provide and deliver care to
clients/patients of diverse cultures. The lack of cultural competency within modern
health care has created barriers and challenges for Hmong American families who are
seeking medical treatments and are attempting to comply with medical advices. Because
of the complexity of Hmong Americans’ cultural beliefs and/or practices as related to
health and illnesses, it is imperative that these two approaches are taken into
consideration. These approaches will enable health care providers and health
professionals to gain a better understanding and be culturally sensitive to Hmong
Americans’ cultural beliefs and/or practices, as well as the many challenges that they may
have endured while settling in America.
9
Limitations
Only 30 Hmong Americans participated in this research study and a majority of
those participants are in Sacramento County. Therefore, data collected and issues
discussed and analyzed in this study may not be generalized to the larger Hmong
population in the United States. Secondly, some participants felt they did not know how
to respond to the questions that were being asked or were fearful that the study might
intrude into their private lives. Lastly, a majority of the Hmong Americans who
participated in this research study are 61 years of age or older, which limits the views and
perceptions that younger Hmong American individuals have toward both modern and
traditional health care.
Definition of Terms
Nocturnal Death Syndrome:
Adler (1995) describes nocturnal death syndrome as being “attributed to a
nightmare or attack by an evil spirit that threatens to press the life out of its
terrified victim” (as cited in Yee, 2011, p, 8).
Khawv Koob (magic healing):
Cha (2003) explains that magical healing “is performed to frighten, negotiate
with, or trick the spirits into leaving the patient alone, and to relieve pain,
swelling, vomiting, and bleeding, and it is, by and large, men who learn and
practice this technique” (p. 115).
10
Chapter 2
REVIEW OF THE LITERATURE
Introduction
There are more than 30 million immigrants and refugees currently living in the
United States; however, they often have difficulty getting appropriate health care services
(The Robert Wood Johnson Foundation, 2011). Further, they encounter high rates of
chronic health problems and poor access to adequate health care (Asgary & Segar, 2011).
In the United States immigrants and refugees have distinct legal statuses, and may be
entitled to access different levels of public benefits, such as health insurance
(Massachusetts Department of Public Health [MDPH], 2007). Allen, Matthew and
Boland (2004) state that legal immigrants are those admitted for humanitarian reasons,
which include refugees and asylums. According to the Refugee Act of 1980, a refugee is
defined as a person who fears persecution from their own country/homeland due to their
race, nationality, or political opinion (Hsu, Davies & Hansen, 2004). An immigrant, on
the other hand, is defined as a resident who has gained legal permanency under the U.S.
immigration law (MDPH, 2007). Asgary and Segar (2011) defined asylum as an
individual who applies for protection and has been granted permission by their host
country government. Asylees and refugees are similar except that Asylees receive their
status post immigration to the U.S. (MDPH, 2007). Due to limited information on
Hmong immigrants and refugees, this author plans to incorporate relevant literature on
other closely related Southeast Asian immigrant groups.
11
This chapter reviews previously conducted research about Hmong Americans’
perceptions of traditional and modern health care, as well as utilization of services.
Furthermore, the review of literature will examine significant findings, and it will include
the following themes: 1) an overview of health care; 2) history of the Hmong; 3) Hmong
cultural beliefs and/or practices as related to modern health care; 4) prevalence rates of
illnesses; 5) education; 6) language; 7) English as a second language; 8) mistrust in
providers; 9) decision making; 10) mental health; 11) current health care policies and
procedures; 12) common health care models practiced by Asians; 13) types of Hmong
health care; and 14) local health care programs and services serving the Hmong
community.
An Overview of Health Care
Kleinman (1978) clarified that the Western health care system has a distinct
biomedical viewpoint in which practices are “based upon particular Western explanatory
models and value orientations, which in turn, provide a very special paradigm for how
patients are regarded and treated” (as cited in Warmer & Mochel, 1998, p. 6). As Specter
(1994) asserted, biomedical view is believed to have no alternative forms of healing
and/or healers. This is the belief that Western biomedicine is remotely superior to other
medical system in the world (as cited in Warm & Mochel, 1998). As a result of these
insensitive beliefs about the principles of causation, diagnosis, and treatment of disease,
Western biomedicine’s considerations of cultural differences are nonexistent (Warmer &
Mochel).
12
Biomedicine focuses on the germ theory of disease, as well as the biomedical
model, in which causes of diseases are determined through the use of blood tests and
other diagnostic procedures (Ma, 1999; Warmer & Mochel, 1998). Sperstad and Werner
(2004) stress that there are philosophical differences between Hmong culture and the
Western world regarding causes of illness. Unlike Western germ theory, the Hmong
believe that illness may be caused by four major forces: natural, supernatural, social, and
personal. As Warmer and Mochel (1998) state, most non-Western cultures believe that
the causes of illness are the result of soul loss, spirit possession, or breach of taboo rather
than germ theory.
History of the Hmong
The Hmong in Asia. The Hmong, which translates “free men,” are a tribal group
from the mountainous regions of Laos (Raidan & Higgs, 1992). According to Parker and
Kiatoukaysy (1999), the Hmong are believed to have left China about 400 years ago to
resettle in Burma, Laos, Thailand, and Vietnam. Since the Hmong only resided in the
mountains, and lived in isolation, they were without a language and had no formal
schooling until 1951. Xiong (1994) and Duchon (1993) state that even after schooling
was made available for some Hmong it was provided in the Laotian language because the
Hmong’s written language was not yet developed by missionaries until the 1950s in Laos
and Thailand (as cited in Parker & Kiatoukaysy, 1999).
After the French withdrew from Laos, Vietnam and Cambodia in the late 1950s,
the United States Central Intelligence Agency (U.S. CIA) arrived in Laos and learned that
13
the Hmong were suitable for military use. As a result of the Hmong’s bravery and
reputation as military personnel among the French, they were recruited, trained, and
armed as guerillas for the United States Army’s secret war in Laos. More than 30, 000
Hmong were recruited to support the anticommunist government in Laos and fight along
the Ho Chi Minh Trail to prevent the Communists from passing through Laos into South
Vietnam. The Hmong soldiers not only fought on the ground and directed air strikes by
American pilots, but they also rescued American pilots when they were shot down by the
Vietcong in Northern Vietnam and Northern Laos (Xiong, 1994; Fadiman, 1997).
The Hmong in the U.S. In 1975 the U.S. CIA withdrew from the Vietnam War,
and, as a result, the Communist Pathet Lao took over (Parker & Kiatoukaysy, 1999). See
(2003) reported that nearly two thirds of the Laotian Hmong soldiers died from
starvation, disease, and combat resulting from the war. After Laos came under the
control of Communist rule, the Hmong’s economic social stability was severely disrupted
(Xiong, 1994). In spite of the Hmong’s strong collaboration and alliance with the U.S.,
the Hmong were abandoned by the U.S. and isolated themselves within the high
mountainous regions Laos to avoid retaliation from the Communists (Xiong, 1994;
Hamilton-Merritt, 1993). As a result of being targeted by the Communists, the Hmong
left their homeland and crossed the Mekong River into Thailand and settled in refugee
camps (Rairdan & Higgs, 1992; Perez & Cha, n.d). After many years of settlement in the
refugee camps in Thailand, the Hmong had to be relocated to a different place due to the
closing of the refugee camps. The only solution for the Hmong residing in the refugee
14
camps was to immigrate to the United States, as agreed to by the American government
during the Hmong’s collaboration with the U.S. CIA during the Vietnam War. The
Hmong immigrated to the United States from the 1980s through 1995 because of the
closing of the refugee camps in Thailand. They eventually settled in other Western
countries, including Australia and France, but the majority remained in the United States
(Johnson, 2002).
Hmong Cultural Beliefs and/or Practices as Related to Modern Health Care
Practitioners are often frustrated with ethnic patients who do not seek regular or
preventive care. This leads to the misconception by practitioners that minority groups do
not care about their health; however, practitioners fail to recognize that minority groups
have different beliefs, priorities, and access to regular health screenings. Furthermore,
many people are reluctant to seek medical care unless necessary, as it interferes with their
daily life. For example, oftentimes Hmong immigrants believe that discussing a health
problem which they don’t have may potentially increase its likelihood of occurring. As a
result of different beliefs about health, diabetes may not be detected at an early stage, but
may only be detected when care is sought for other problems. Having a heavier
physique, which Western health care considers unhealthy, is a sign of good health among
ethnic groups such as the Navajo and Utes who believe it is indicative of health and
happiness, and some Chinese see it as an indication of blessing relating to wealth and
prosperity (Tripp-Reimer, Choi, Kelley & Enslein, 2001).
15
Although biomedicine is a minor part in Hmong ideologies of health and illness, it
is minimally considered for treatment of certain illnesses and injuries. According to
Hurlinch, Holtan and Munger (1986) and Kirton (1985), biomedicine, in some cases, has
its part in Hmong health care; however, it is thought to be potentially dangerous (as cited
in Capps, 1994). A common fear among Southeast Asian Refugees is invasive medical
procedures such as venipuncture because it does not exist in the Hmong traditional
medical practice. For example, venipuncture brings about the fear of disturbing the
balance between hot and cold within the body such as drawing of blood for medical
purposes. Southeast Asian Refugees associate the drawing of blood with the military
need for blood that was given to American troops. However, this is a misconception
among refugees who lack the education, knowledge, and awareness that the body can
compensate and reproduce the amount of blood lost in the body. Western medicine is
generally classified as hot, and perceived as very effective, which often times is too
effective for Southeast Asians’ physiology (Muecke, 1983).
Due to the lack of understanding that Hmong have regarding invasive procedures,
medical attention and a hospital stay may be avoided. For example, the Hmong fear
surgical treatment of diseases because it could weaken spiritual health, souls may leave
the body during surgery, or it may leave the soul miserable or unwhole in the next
reincarnation (Her & Culhane-Pera, 2004; Cobb, 2010). Many Hmong also take issue
with end of life decisions about organ donation, as it is believed that the donor may be
reborn in the next life without all of their vital organs. Furthermore, a family member’s
16
donation of the dying elder’s organs is viewed as a form of disrespect that may anger the
ancestor, who, in turn, may create mischief for those who are still living (Yee, 2011).
Prevalence Rates of Illnesses
There are many health issues among Southeast Asian Americans, particularly
within the Hmong American population. Mills, Yang and Riordan (2005) found that
during 1988-2000, cancer incidence of the stomach, liver, cervix and nasopharynx was
elevated among Hmong in California, compared to non-Hispanic whites. Mills and Yang
(1997), conducted a study using reported cancer data from the Cancer Registry of Central
California (CRCC), found that the age-adjusted cancer-incidence for liver cancer among
the five cases found in this study was 7.1 per 100,000 amongst the Hmong population.
This is in between the rate for the All Races group and the Asian/Other group. The rate
for age-adjusted cancer-incidence for all cancer sites combined was 275 per 100,000 in
the Hmong population, which was slightly higher than in the Asian/Other groups, yet not
as high as in the All Races Combined group of 380 per 100,000. However, overall the
rates of prostate, breast, lung, and colorectal cancers were much lower in the Hmong than
other Asian Pacific Islanders. Another cancer study done by the Wisconsin
Comprehensive Cancer Control Program (WCCCP) and the Wisconsin United Coalition
of Mutual Assistance Association (WUCMAA) report that in this study cancers are
diagnosed among Hmong at later stages in comparison to Caucasians. During 1995 to
2007, only 27% of Wisconsin’s Hmong who had cancer were detected at the early local
stage, compared with 46% for whites. Hmong patients tend to be diagnosed with cancer
17
at younger age than whites, even though that diagnosis tends to find the cancer at a more
advanced stage (Foote & Matloub, 2010). Mills and Yang (1997) affirm that cultural
factors that may have contributed to advanced stages of cancer is due in part to avoidance
of Western medical care, as well as fear of participation in screening programs.
Yang, Mills and Riordan (2004) reported that cervical cancer is the second
leading cause of fatality among women around the world, and is another prevalent cancer
among Hmong women. In an earlier study conducted by Mills and Yang (1997), they
found that the rate of cervical cancer age-adjusted cancer-incidence among Hmong
women was found to be higher than the Asian/Other group; however, it was about the
same rate as for the All Races Combined group. Nevertheless, the Hmong have a
considerably higher rate of invasive (at all sites) cervical cancer, compared to the All
Races Combined group and/or the Asian/Other group. In another study that looked at
early detection Pap test screening among Hmong women, Fang, Lee, Stewart, Ly, and
Chen (2010) found that 74% of Hmong women in this study indicated they had ever had
a Pap test, while 61% of the total participants indicated they were screened in the past
three years. Additionally, the result of Hmong women with abnormal Pap tests or who
did not know their test results was10%. Lack of awareness issues, such as never having
heard of the test or not knowing the test was needed, were among the reasons listed for
never having been screened, which was the main reason for never having been tested.
Hepatitis B virus (HBV) has been identified as a human carcinogen and has
caused 60-70% of liver cancer worldwide, causing approximately 700,000 people deaths
18
each year from liver cancer or liver disease (DHHS-OMH, 2011). According to Sheikh
et al., (2011), chronic HBV is prevalent in the Asian-Pacific region. Furthermore, they
found that among 534 Hmong age 18 and over in Fresno County approximately “one out
of every six Hmong immigrants screened was infected with HBV” (p.1). Of the 534
screened Hmong in this study, nearly 62.4% indicated they were not vaccinated or were
unsure of their vaccination status, as well as having no primary care physicians to provide
further treatment and/or preventive measures to stop the transmission of HBV to their
families (Sheikh et al., 2011). According to Grytadal et al., (2009) and Shiraki (2000),
studies have suggested that transmission of HBV was due in part to vertical transmission
from mother to newborn, especially among those with low vaccination rates (as cited in
Sheikh et al., 2010). As a result of low vaccination rates, many children remain
unvaccinated while many adults are chronically infected with hepatitis B throughout the
world, including in the U.S, despite the availability of the HB vaccine since 1982
(DHHS-OMH, 2011).
Education
Chung and Lin (1994), report that Hmong and Cambodians are less educated and
have low literacy in both their native language and English, as compared with Laotians
and Vietnamese. The Hmong and Cambodians were the least exposed to Western ideas
and concepts in their homeland, compared to Vietnamese and Laotians (as cited in Hsu et
al., 2004). Mattson (1993) describes two waves of Southeast Asian immigrants: the first
wave was more likely to be university educated, high-ranking, and wealthy compared to
19
the second wave which was more likely to be illiterate in their own language, unfamiliar
with Western technology, and live on subsistence farming and fishing (as cited in Hsu et
al., 2004). Tanjasiri et al., (2007) point out during a needs assessment among 200
Hmong women that literacy levels were remarkably low: 46% did not speak any English,
71% could not read any English, 50% could not read in Hmong, and 71% could not read
in Lao. These findings demonstrated that Hmong have the lowest literacy rate and
educational attainment among their Southeast Asians counterparts.
Language
The language barrier is contributing factor to the difficulty Southeast Asian
immigrants have accessing the health care delivery system. A large number of Southeast
Asian refugees have limited understanding of the English Language. Because physicians
and health care professionals typically do not know Southeast Asian languages, this
creates a major obstacle when providing care to Hmong Americans (Cobb, 2010). The
Hmong language is called Hmoob, and is pronounced Hmong in the English Language.
According to the U.S. Census Bureau 2000, 58.6% of Hmong households reported they
do not have family members who speak English well, and only 4.4% of Hmong
households actually reported English as their only spoken language in the home (as cited
in Cobb, 2010). As a result, family, friends, and interpreters often help families who
have limited English proficiency, however, due to the lack of medical vocabulary or
terms available in the Hmong Language, interpreters oftentimes create as many problems
as they solve (Chang, Feller & Nimmagadda, 2009; Warmer & Mochel, 1998; Cobb,
20
2010). For example, the Hmong language does not have medical terminology to describe
symptoms and signs, as well as certain internal organs in the body because they were not
common knowledge in Laos. This can lead to “frequently committed stereotypical
errors” such as omissions, editing, substitutions and the interpreters’ unwillingness to
provide quality interpretation as a result of an unpaid burden, which may add to crucial
mistakes or problems during the translation processes (Chang et al., 2009; Warmer &
Mochel, 1998).
Children’s Hospitals and Clinics of Minnesota (2002) further explain that
complicating communication issues are due in part to the fact that the Hmong had not had
a written language until the late 1960s (as cited in Cobb, 2010). However, this written
language was developed by missionaries and based on the Latin alphabet (Xiong, 1994).
As a result of this, older Hmong refugees are not able to read or write in their own
language so written materials available for Hmong patients are somewhat useless (Cobb
2010). Parker and Kiatoukaysy (1999) and Johnson (2002) state that the Hmong
language lacks compatibility with Western language, as they do not have the same
concept of understanding of anatomy, physiology, various system of illnesses and/or
treatment procedures (as cited in Perez & Cha, n.d.). According to Xiong (1994), today in
Western countries only about 20% of Hmong people can read and write in Hmong,
typically those who have converted to Christianity.
21
English as a Second Language
Not having an understanding of the English language is a fundamental problem
for immigrants and refugees, as it prevents them from making vital connections with
other communities in this country. Focus group participants reported in the Robert Wood
Johnson Foundation study that they face language difficulty when they see a doctor, at
the public library, at their child’s school, and when they are lost and seeking directions.
For example, due to the language barrier, an Arab immigrant was not given medication or
treatment while she was in the hospital emergency room after she fainted. This was due
to her inability to communicate about her health condition with the providers (Robert
Wood Johnson Foundation, 2006). In addition, many Southeast Asians avoid seeking
Western health care due to their inability to clearly communicate their symptoms and
concerns to the physicians. According to Van Deusen (1982), about 40% of Southeast
Asians have difficulties in obtaining medical services due to not being familiar with the
process of making appointments, language problems, and not understanding the physician
(as cited in Uba, 1992).
Mistrust in Providers
Uba (1992) points out that Southeast Asians will only seek Western Healthcare
after traditional remedies are sought out and have failed due to the negative experiences
that patients encounter with Western health care. Johnson (2002) shared a story of a
sobbing elderly woman and her negative experience while waiting in the emergency
room with thoughts of dying and enduring dreadful pain. The elderly woman stated she
22
saw the American doctor treating other patients in the emergency room with respect, but
when the American doctor came to her, she felt he began to mock her by mimicking her
demeanor of distress and crying sounds. While many refugees agreed that health
professionals are nice and most have done their best, others felt that doctors acted out of
monetary interest not care for patients. Similarly, an immigrant woman stated, “They
don’t pay much attention to immigrants, see us fast just to finish and don’t listen”
(Asgary & Segar, 2001, p. 509) because they know we are undocumented. Moreover,
some participants believed that legal citizens’ health information was protected at a
higher standard compared to non-citizens (Asgary & Segar, 2001).
Decision Making
The Hmong culture places a high emphasis on the value of family and the clan
system, which often includes medical decisions made by the family and/or clan leaders
(Barrett et al., 1998). The Center for Cross-Cultural Health (1998) notes that medical
care decisions are generally not made solely by the Hmong individual alone (as cited in
Parker & Kiatoukaysy, 1999). The husband generally makes all the welfare decisions for
the family such as health care and finances in a traditional Hmong family household.
Traditionally, a family’s overall welfare is the responsibility of the husband, while the
wife provides care for the children and in-laws, in addition to other household duties.
They further explained that the spouse, in this case the husband, also gains approval from
grandparents, adult siblings and great uncles, as well as clan leaders in clinical decision
making situations (Parker and Kiatoukaysy (1999). According to the Center for Cross-
23
Cultural Health (1998), decision making is often a shared process amongst families, clan
leaders and others in their immediate community, an integral part of the Hmong culture
especially in times of crises (as cited in Parker & Kiatoukaysy, 1999). However, this is
often difficult for doctors when recommending patients to make quick medical decisions
in times of emergency. For instance, in a case that involved a Hmong patient who needed
an emergency Caesarian section in the middle of the night, the doctor was told to notify
the clan before any medical decision was made by the patient, even though the patient
grew more sick (Barrett et al., 1998). This form of decision making includes families
asking questions to gain a better medical understanding and learn available options,
which requires a great deal of patience and understanding from the physicians, as well as
other health care professionals (Parker & Kiatoukaysy, 1999).
Mental Health
Many immigrants and refugees arriving in America have developed various
mental health illnesses, but they are rarely given the opportunity to identify then and
receive services (Walter, 2001). A study was done by Asgary and Segar (2011) using
focus groups and comprehensive interviews with 35 refugee asylum seekers. They found
that participants failed to recognize psychiatric symptoms as a result of abuse or mental
illness when accessing care. Although one participant was found to have received
services, she did not refill her antidepressant prescription because she did not understand
the need for a refill, could not afford to pay for a follow up exam, and disliked the minor
side effects that she encountered. Mental illness was a major obstacle in seeking care, as
24
it was considered a burden of shame and stigma to share psychological trauma or
histories of abuse with providers. As Sperstad and Werner (2004) and Culhane-Pera and
Xiong (2003) emphasize, Hmong refugees in particular had endured many years of
deprivation under communist control. Many suffered incarceration while in the refugee
camps, faced death and disabilities, were bombed in their homes and repeatedly fled to
the jungle, witnessed the rape and murder of family members, and risked drowning in the
Mekong River to escape Laos. Culhane-Pera and Xiong (2003) describe the profound
after effects on the Hmong as“…suffer[ing] from depression, posttraumatic stress
disorder, and culture shock. They share a sense of alienation, vulnerability, and
powerlessness--which often translate into self-protective mistrust of others’ intentions”
(p. 26). This affected the well-being of Hmong refugees because social policies and
implementation labeled them as pathologised individuals (Watters, 2001).
Current Health Care Policies and Procedures
The ability to provide cross-cultural medical treatment is critical, especially as
U.S. medical providers interact with consumers from different cultural and linguistic
backgrounds. It is imperative to take into account culturally and linguistically diverse
patients as culture and language are important factors in providing health care services
(U.S. Department of Health and Human Services [DHHS], Office of Minority Health
[OMH] (2001). However, if linguistically and culturally diverse medical personnel are
not accessible, it may hinder how refugees and immigrants develop trust and respect for
Western medicine. This is why effective communication such as knowing the patients’
25
medical history, current needs, beliefs and personal heath practices is necessary in order
to prevent miscommunication, the possibility of being misdiagnosed, and inappropriate
usage of medical services (co-dependency of emergency room) from taking place
(Burgess, 2004). The National Standard for Culturally and Linguistically Appropriate
Services in Health care (CLAS) was established to address the most immediate and
necessary need for foreign born individuals. CLAS was developed by the U.S.
Department of Health and Human Services, Office of Minority Health (New Mexico
Department of health, n.d.). Most importantly, CLAS’ purpose is to address the needs of
culturally and linguistically diverse populations who experience disproportionately
inferior access to health services (DHHS-OMH, 2001). According to Burgess (2004),
CLAS standards are directed at health care groups, but individual providers are
encouraged to incorporate the same standards in order to accommodate a culturally and
linguistically diverse population.
The Refugee Act of 1980 created The Federal Refugee Resettlement Programs to
provide refugees with effective resettlement assistance, as well as to support them in
achieving economic self-sufficiency soon after their arrival in the United States (DHHS,
2010). The enactment of the Refugee Act of 1980 would not have been possible if there
were no modifications to the Immigration and Nationality Act of 1965,which enacted
“…a seventh immigration preference under the newly adopted hemispheric quotas system
permitting 6 percent of all ordinary immigrants to enter as refugees” (Leibowitz, 1983, p.
164). The Refugee Act of 1980, as stated by Leibowitz (1983) was considered the most
26
comprehensive law enacted in the United States concerning refugee admissions and
resettlement. The enactment of The Refugee Act of 1980 addressed four significant
provisions: (1) To establish federal policy for the continuation of the admission of
refugees; (2) To redefine the term refugee to meet the international U.N. Convention
definition; (3) To establish the asylum principle in U.S. statutory law; and (4) To
establish the idea of resettlement assistance for refugees. This enactment provided a
mechanism for how to allocate federal funds to refugees, as well as how to reimburse
local governmental agencies, states, and private voluntary agencies for related refugee
expenses and/or disbursements (Leibowitz, 1983).
The Immigration and Reform Control Act (IRCA) of 1986 was signed into law on
November 6, 1986 to address provisional immigration regulations into the U.S., as well
as to address vulnerable undocumented immigrants’ plights in American society. This
act offers employers sanctions to legally hire undocumented workers and to expand
federal enforcement of undocumented aliens at the U.S borders (U.S. Citizenship and
Immigration Services, 2011).
The current health care act signed into law by President Barack Obama on March
23, 2010 is called the Patient Protection and Affordable Care Act of 2011 (ACA). This
comprehensive health reform has “…provisions to expand coverage, control health care
costs, and improve health care delivery system” (The Henry J. Kaiser Family Foundation,
2010, para. 1). Under the ACA, U.S. citizens and legal residents are required to have
health insurance. Through the American Health Benefit Exchange, individuals can
27
purchase premium and cost-sharing coverage for individuals/families with income
between 133% and 4900% of the federal poverty level, as well as allowing small
businesses to purchase separate Exchanges of coverage. This act will allow U.S. citizens
and legal residents to have qualifying health care coverage (The Henry J. Kaiser Family
Foundation, 2010).
Common Health Care Models Practiced by Asians
Traditional Medicines. Traditional medicines are often used in Taiwan, China,
Japan, and other Asian countries (Ma, 1999). Herbal medicines are popular and are
mainly prescribed by older women with knowledge about their use. In the US, herbal
medicine is limited by the availability of herbs even though herb gardens are still kept
among some people in Richmond. A study done amongst the Mien population in
Richmond confirms that herbal medicines were found to treat 12% of reported illnesses,
particularly for respiratory symptoms. While three (21%) of the participants in the study
indicated they grow their own herbal ingredients and only one (5%) reported that herbal
medicines were obtained in Chinatown (Gilman, Justice, Saepharn & Charles, 1992). It
was found in a survey study conducted in Houston by Chan and Chang (1976) that
Chinese medicine was commonly used as a form of home treatment. 93% of respondents
stated they used Chinese drugs for self-treatment, while the remaining 7% had no
association with Chinese drugs (as cited in Ma, 1999). The extensive use of herbal
medicine as a healing approach is a common practice among Chinese and other Asian
groups in the Houston community. The popularity of traditional medicine is due in part
28
to the fact that it has no adverse side effects due to the naturalness of the herbal
medicines (Ma, 1999).
Traditional healers. As a result of the minimal exposure that refugees had toward
modern medicine in their homeland, services of traditional healing by traditional healers
had been utilized for centuries. In particular, the Hmong and Iu Mein seek out help from
traditional healers before they turn to Western medicine, as their traditional healing
rituals have served them well for thousands of years (Warmer & Mochel, 1998). As
stated by Lemoine (1982), Mein is also called “Iu Mein or Yao” which are a highland
group of people who inhabit the hills of Vietnam, Thailand, Laos, Burma, and China (as
cited in Gilman et al., 1992). For instance, the Mien also practices healing that involves
the calling of traditional spirits or ancestors except the use of home remedies and herbal
medicine as related to humoral theory of interventions. Not only was traditional healing
practiced among the Hmong and Mein, but also among other groups such as the Somali
Bantu from Kakuma camp in Kenya. They believe that some illnesses may be the result
of being cursed or targeted by evil spirits. As a result, they will not seek medical
attention; however, they will seek a traditional healer to eradicate the curse and/or to cast
out the spirit (Burgess, 2004). Many of the immigrants and refugees are confident and
have trust in these rituals. Consequently, they are suspicious of Western biomedicine
such as medical procedures, diagnostic tools, and treatment plans (Warmer & Mochel,
1998).
29
Cupping/Coining. According to Canino and Spurlock (2000), Southeast Asian
Refugees employ indigenous practices such as cupping, coining, and moxibustion which
are traditionally used to heal minor illnesses. These practices may leave bruises, marks,
or scars that can be interpreted as a form of child abuse. The practice of cupping is
defined as placing a small heated cup on the skin of the individual. These healing
practices will result in the emergence of circular red bruises on the surface of the
individual’s skin. Coin rubbing is also known as “Cia cio” which requires constant
rubbing of warm oil on the skin with a coin or spoon. Because of the repetitive linear
rubbing, bruises may appear to be symmetrical and linear looking (as cited in Hsu et al.,
2004). Moxibustion, according to Feldman (1987), consists of various acupuncture tools
such as sticks of incense or other materials burned at specific therapeutic points near or
on the skin. These practices may result in the skin appearing red or burning (as cited in
Hsu et al. 2004).
Types of Hmong Health Care
The pluralities of biomedicine are included in Hmong medical culture and are
available in the country of Laos. In Laos the Hmong first encountered biomedicine
through their contact with Westerners during the Southeast Asian War. There are a
number of biomedical resources that are available in Thailand such as mobile clinics,
locally based clinics and other hospitals located in Chiang Mai and Chiang Ria, as well as
in the refugee camps in Thailand (Capps 1994). However, these health care facilities
located in the lowland areas are scarce and not easily accessible to the Hmong.
30
The Hmong’s traditional religious beliefs are based on animism, including spirits,
souls, birth, and death which are parallel to other animistic cultures around the world.
Additionally, in traditional Hmong communities, all aspects of life such as births, deaths,
illnesses, funeral, kinship relations, and appropriate relationships between people are
intertwined with animistic beliefs and values (Culhane, Vawtex, Xiong, Babbitt &
Solberg, 2003). Life to the Hmong is believed to coexist between the physical and
spiritual worlds, and birth and rebirth are joined in a continuous circle of life (Plotnikoff
et al., 2002; Sperstad & Werner 2004).
Shamanism. The shaman (txiv neeb) is a spiritual healer who has the ability to
communicate directly with the supernatural spirits and has “clairvoyant powers” in the
Hmong culture (Cobb 2010, p. 80; Cha, Vue & Carmen, 2004; Yee, 2011). Shamanism
(ua neeb), according to Eliade (1964), is “a range of traditional beliefs and practices
pertaining to communication with the spirit or metaphysical world” (as cited in Capps,
2011). The role of the shaman is to leave the material world to identify the spiritual
causes of illness, communicate with the spiritual world for the purpose of separation of
souls (weakness, fright or soul loss) as souls are easily detachable in the young or old, or
actions of malicious or generous spirits which are not seen in the human world, and to
retrieve the wandering or lost souls and reunite them with the ill person’s body (Cobb,
2010; Plotnikoff et al., 2002; Capps, 2011). As state by Bliatout (1986) and Helsel et al.,
(2004), the shaman’s fundamental goal is to restore harmony between the spiritual and
the physical world when a person is ill or distressed, as soul loss (poob plig) is a common
31
apprehension among Hmong individuals who may seek treatment from a txiv neeb for
their symptoms rather than biomedicine (as cited in Capps, 2011).
There are two main types of traditional Hmong shamans. The first type is called
neeb muag dawb, which must be chosen by the neng (shaman) spirits based on the
person’s circumstance, fate or destiny, and not just the desire to become one. The second
type is called neeb muag dub, which is one’s desire to become a shaman. Only
traditional shamans (neeb muag dawb) will be discussed; however, both neeb muag dawb
and neeb muag dub’s processes and practices are similar. The process of a neeb muag
dawb is accomplished through making the individual seriously ill, appearing in dreams or
refusing to allow the individual to become better, unless the individual agrees to become
a shaman at the request of the neng spirits (Cha, Vue, & Carmen, 2004; Quincy 1995). A
txiv neeb is expected to be capable of diagnosing and treating illness, as they are
responsible for two things: first, to join forces with the patient in fighting for life and
health; and, second, to restore the patient’s wholeness by bringing back the wandering
soul or souls. The txiv neeb serves as a bridge between the physical and the spiritual
world for the individual’s physical and spiritual well-being (Cha et al., 2004). The txiv
neeb serves people of both sexes and of all ages, and can treat a variety of symptoms
perceived as spiritual illness such as depression, chronic pain and infertility (Her &
Culhane-Pera, 2004).
Soul caller. Soul calling (hu plig) is a very common ceremony in the Hmong
culture, and people become familiar with it at a young age. Anyone can perform the soul
32
calling ceremony, but craft skills must be learned from a soul caller. A shaman can also
perform the soul calling ceremony as well (Hickman, 2007; Her & Culhane-Pera, 2004).
A soul caller (tus hu plig) performs a ceremony which sacrifices chickens or eggs in
order to call the soul/s back to the ill person’s body for reasons such as being frightened,
or falling from the body (poob plig), fatigue, pallor, or dry lips (Kruger, 2002; CulhanePera, K.A. & Xiong, 2003). It is considered a serious situation when souls are lost
because it requires certain measures to call the lost souls back to the ill person’s body and
to restore good health (Bliatout, 1991; Kruger, 2007; Her & Culhane-Pera, 2004; Cha et
al., 2004). According to Her and Culhane-Pera (2004), incense and chanting are involved
during this soul-calling (hu plig) ceremony where the soul caller lures the lost souls to
return to the body with loving words and promises of a good life. Oftentimes the missing
or lost soul may have wandered away to nearby places or it may have wandered too far to
a place where spirits and other disembodied beings exist. If the soul cannot be easily
retrieved by hu plig or the situation becomes complicated, the shaman (txiv neeb) must be
called upon to solve the complicated problems through the performance of shamanism
(ua neeb) (Cha et al., 2004; Hickman, 2007).
A soul-calling ceremony is not only performed when an individual becomes ill,
but it is performed as a preventive measure and for good health, three days after a baby is
born, whenever someone will take a long journey, and for recently married newlywed
couples. For example, during the Hmong New Year, a soul calling ceremony usually
takes place for the entire family which is to prevent wandering souls from becoming lost.
33
Although this ceremony can be performed by anyone, it is usually performed by a
shaman, an elderly person, or other healers (Cha et al., 2004; Kruger, 2007).
Herbalist. Herbalists (kws tshuaj) provide treatments for illnesses that are due to
natural causes, but not illnesses that are spiritually based. Women are generally the
practitioners who diagnose and treat illnesses; very few are men. Some herbalists may
have helping spirits (dab tshuaj), and were trained under a well known specialist. Plants
are collected from Asia or grown by herbalists and other herbalists, which are made into
poultices or teas to treat a variety of ailments or illnesses. Herbal remedies typically
involve the use of plants and roots found in the mountains of Laos when treating stomach
problems (Her & Culhane-Pera, 2004; Hickman, 2007). Health problems within the
expertise of the herbalist include infertility, headaches, diarrhea, menstrual irregularity
and impotence. A study conducted by Duffy, Harmon, Ronard, Thao, Yang, and Herr
(2004), found that women were responsible for preparing and growing plants.
Furthermore, herbal medicine can be used for treating food poisoning and other digestive
illness, broken bones, as well as an energy imbalance (as cited in Krueger, 2007). In
addition, Hmong herbalists consult and use herbs from the Chinese, and have adopted
other homeopathic practices such as cupping (Hickman, 2007). Cupping and coining are
used when physical illnesses are considered less severe. To draw out fever and pain,
cupping is used to suction the skin. In contrast, scraping the skin to draw out evil spirits is
called coining. However, to Western providers, this may be mistakenly considered
physical abuse due to the bruising that occurs with both rituals (Kruger, 2007).
34
Magic Healer. Magic healers (tus ua khawv koob) work with naturally based
illnesses and are not chosen by the spiritual world like the txiv neeb. However, tus ua
khawv koob use the same spiritual chanting language as the txiv neeb to call upon helping
spirits with incense through blowing air and water onto the sick person’s body (Her &
Culhane-Pera, 2004; Hickman, 2007). Magic (khawv koob), for example, is widely
known to fix broken bones much quicker than the cast the hospital places on the
individual (Hickman, 2007). Further, these healers are skilled at attending to burns, eye
infections, wounds, and hyperstartle (ceeb) in children, as well as childhood fevers that
are accompanied by rashes (ua qoob). Some healers have claimed to have the ability to
remove kidney stones from the individual’s body or stones are placed in the patient’s
body through black magic (Her & Culhane-Pera, 2004). According to Faderman (1998),
a healer named Nao Kao Xiong shared a few examples of his healing that impressed
Western doctors. For example, he stopped a women’s uncontrolled bleeding after she
underwent surgery and he was called by the patient’s family. He tied a “sher qeng”
around the patient’s neck with a healing khaws koob that he performed. An x-ray was
done the following morning and the x-ray showed that the bleeding had stopped (as cited
in Krueger, 2007).
Local Health Care Programs and Services Serving the Hmong Community
There are several local health care programs and services in the greater
Sacramento region that serve the Hmong population. The following Community-based
organizations (CBO) are non-profit organizations that currently provide health care
35
education and services to the Hmong population: Health Right Hotline, Independent
Assistance for Health Care Consumers, Valley Vision, Hmong Women's Heritage
Association, Hmong Health Collaborative, Sacramento Asian Assistance Center, Asian
Resources, Asian Community Nursing Home, and Asian Pacific Community Counseling
Center.
Summary
Although Hmong Americans have settled in the United States for many years,
they still encounter challenges when utilizing and accessing modern health care. Some of
these challenges are due to different cultural beliefs and practices, limited understanding
of the Western biomedicine, different perspectives on health and illness, and traumatic
histories that prevented Hmong Americans from receiving the best possible care when
interacting with the U.S. health care system. Despite the many policies and procedures
that are in place to assist immigrants and refugees, particularly Hmong Americans, they
lack sufficient English comprehension skills to navigate or communicate with health care
providers. As a result, it creates challenges and obstacles for many Hmong Americans in
receiving adequate health care.
36
Chapter 3
METHODS
Introduction
This chapter will discuss the research design, data collection procedures, research
subject, and instrumentation used in this study. The chapter will also discuss the data
analysis plans in completing the research process, as well as the safeguards undertaken to
protect human subjects in the study.
Research Design
To reiterate, this research project is an exploratory study, both qualitative and
quantitative in nature that explores views and perceptions about modern medical care,
decision making, and comprehension of both traditional and modern medical care. Rubin
and Babbie (2011) assert that an exploratory study is a form of research that examines
new interests, especially when areas of interest are relatively understudied. The purpose
of this research is to explore views and perceptions Hmong Americans have toward both
traditional and modern medical care, and their utilization of such services. The study’s
rationale is to gain a better understanding of the reasons behind Hmong cultural beliefs
and practices and, more importantly, to increase health care professionals and social
workers’ knowledge and understanding when working with Hmong Americans in
California, Sacramento County.
Quantitative and qualitative research methods were applied throughout this
research study. Quantitative methods were applied to demographic characteristics
37
including age, sex, marital status, highest level of education and religious preference.
Open-ended questions were asked regarding the utilization of health care services in
traditional and modern medical care, as well as medical providers’ knowledge and/or
understanding of Hmong Americans’ cultural belief system. The intent was to focus on
Hmong individuals’ understanding of illness and the importance of integral decision
making among families, clan leaders, and immediate community leaders.
Data Collection Procedures
The data collection process began on July 5, 2011, a few weeks after the
application for the Protection of Human Subjects was reviewed and approved by the
Committee for the Protection of Human Subjects at California State University,
Sacramento, Division of Social Work. The author informed the Sacramento Community
Clinic prior to the data collection process. The research participants were selected
randomly to participate in this research study, as they all were either new or existing
patients of Sacramento Community Clinic who appeared to be in good health, friendly,
and approachable. After the patients were called into their rooms, the author approached
the prospective participants individually to maintain confidentiality by gently knocking
on each patient’s door, and asked if the author could have a couple seconds to speak to
the prospective participants. Once the author was granted permission to speak to the
prospective participants, the author then introduced herself, explained the purpose of the
study, informed the prospective participants that the author was granted permission from
Sacramento Community Clinic to conduct the research project, spoke about its voluntary
38
nature and asked if the patients would be interested in participating in this research study.
Once the prospective participants agreed to participate in this research study, the author
then asked if the prospective participants wanted to complete the interview process
afterward or whether an appointment needed to be made for a different time. Those
prospective participants who were able to complete the questionnaire survey immediately
after their doctor visit were escorted by the author to the conference room, and those who
were not available were provided with an appointment based on their availability.
Before consent was obtained from the individual, the author provided an
introduction statement regarding the purpose of the study, the importance of
confidentiality, and how confidentiality would be maintained throughout the study, as
well as the voluntary nature of the study. Prospective participants were informed that no
incentives (financial or otherwise) would be offered in exchange for their participation.
A written oral consent was read and explained in the Hmong language, as a majority of
participants did not have a sufficient understanding of the English language (written or
oral). In addition, the consent form included a list of resources and additional contact
information if additional counseling were needed after participation in this study. After
the survey questionnaires had been completed by the participants, the author answered
any additional questions the participants may have had and thanked them for their time
and participation in this research study.
39
Research Subjects
Participants in this research study were Hmong American adults who were former
refugees and/or immigrants from Laos and Thailand. The author conducted a total of 31
surveys, of both males and females age 21 and over. It took approximately 60 minutes
for participants to complete the questionnaire survey. However, one of the subjects did
not answer the majority of the questions so the author decided not to include the survey in
the author’s data collection. At the time of the study, participants were individual adults
who were either new or existing patients of Sacramento Community Clinic. Participation
in this study was completely voluntary, and no incentive (financial or otherwise) was
offered to the participants. All completed survey questionnaires were kept confidential
and secured in a locked file cabinet, and no one other than the author and her thesis
advisor had access to it. In addition, the author informed participants that if in any case
the author decided to use any specific quotes or examples, the author would make sure
that the identity of the source used would not be identified. This researcher took notes
during all interviews. All completed questionnaire surveys were destroyed after data
entry was entered and analysis was completed.
Instrumentation
This project employed a survey questionnaire, consisting of a total of forty-nine
questions, to explore views and perceptions that Hmong Americans have toward both
traditional and modern medical care, and their utilization of such services. The questions
were developed by the author with assistance from the author’s thesis advisor Dr. Serge
40
Lee. The survey questionnaire in this study encompassed both closed-ended and short
answer questions that explored views and perceptions of demographic characteristics,
decision making, perceptions of modern medical care, understanding of traditional and
modern medical care, cultural, and traditional beliefs, as well as utilization of health care
services. The set of questions were written in both English and the Hmong language, but
were asked verbally in the Hmong language. The author did not have her questionnaire
pretested. These questionnaires were constructed with the hope that they would benefit
professional social workers, the Hmong community, health care professionals, and
anyone who would be interested in conducting further studies about perceptions that
Hmong Americans have regarding contemporary health care modalities.
Human Subject Protection
The Protection of Human Subjects was completed according to the required
protocol by California State University, Sacramento. The author completed the
Protection of Human Subjects with the assistance of the author’s project advisor, Dr.
Serge Lee. Then the Protection of Human Subject application was turned into the
author’s thesis project advisor for review. Once changes were made and reviewed to the
author’s project advisor, the author submitted the Protection of Human Subjects
application for review to the Committee for the Protection of Human Subjects of the
Division of Social Work of California State University, Sacramento. The Committee
notified the author of the approval of the research proposal, however, with conditions.
Once the necessary changes were made as instructed by the Committee and reviewed
41
again by the author’s project advisor; the application was resubmitted for final approval.
The study was approved on May 13, 2011. The Human Subject’s approval number for
this research is: 10-11-112. The approval number expires one year from the date it was
approved. After approval was granted, this author began her data collection on July 5,
2011. This research proposal was approved at minimal risk, though some participants
might have a strong reaction to modern medical health care questions due to the
mistreatment and misunderstandings of modern medical doctors toward them. The
author also ensured that subjects who were willing to participate in this research signed a
consent form (See Appendix A).
Data Analysis Plan
The data was processed through the program IBM Statistical Package for Social
Sciences (SPSS), version 19. Descriptive statistics, content analysis and statistical
analysis were all employed to analyze the data. Descriptive statistics of frequencies were
used to capture the demographic characteristics and key variables of the study population
(e.g. age, highest level of education, decision making, and understanding of illness).
Cross-tabulations were utilized to examine any further significant relationships between
different variables. Charts and tables were utilized to provide a graphic summary of the
quantitative analysis. Further, Microsoft Office Word 2010 was also used to analyze and
compile the qualitative portion of participants’ responses.
42
Chapter 4
RESULTS
Introduction
This research project explored views and perceptions of both traditional and
modern medical care among Hmong Americans, as well as utilization of such services.
The selected population for this study was Hmong Americans who were either seeking
care or current patients of Sacramento Community Clinic. The survey questionnaire used
in this study encompassed both closed-ended and open-ended questions that explored
demographic characteristics, decision making, perceptions and understanding of both
traditional and modern health care, cultural and traditional beliefs, as well as utilization
of health care services. A total of 31 participants were interviewed; however, one of the
survey questionnaires was not counted, as a majority of its survey questions were not
answered. Therefore, the total number of participants was 30.
43
Demographic Characteristics
Table 1
Age Category of Participants
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
21-28
5
16.7
16.7
16.7
29-36
3
10.0
10.0
26.7
37-44
3
10.0
10.0
36.7
45-52
6
20.0
20.0
56.7
53-60
5
16.7
16.7
73.3
61 or over
8
26.7
26.7
100.0
30
100.0
100.0
Total
Table 1 represents the age distribution of 30 Hmong American adults from
Sacramento County, California who participated in this research study. Due to the small
sample size, age distributions were as follows: five (16.7%) were between the age of 21
to 28, three (10.0%) were between the ages of 29 to 36, three (10.0%) were between the
ages of 37 to 44, six (20.0%) were between the ages of 45 to 52, five (16.7%) were
between the ages of 53 to 60, and eight (26.7%) were age of 61 or over. Looking at the
frequency distribution, the majority of participants are 61 or over.
Table 2
Sex of Participants
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Male
12
40.0
40.0
40.0
Female
18
60.0
60.0
100.0
Total
30
100.0
100.0
44
Among the 30 participants, twelve (40.0%) were male and the remaining eighteen
(60%) were female. Unfortunately, the sample distribution was not evenly distributed as
participants were randomly selected to participate in this project.
Table 3
Birthplace of the Participants
Cumulative
Frequency
Valid
Percent
Valid Percent
Percent
U.S.
5
16.7
16.7
16.7
Outside of U.S. (Thailand)
3
10.0
10.0
26.7
Outside of U.S. (Laos)
22
73.3
73.3
100.0
Total
30
100.0
100.0
When asked about their birth place, the participants reported their country of birth
as illustrated in Table 3 above. Among the 30 participants in this study, five (16.7 %)
indicated they were born in the US, while the others were born outside of the U.S with
three (10.0%) born in Thailand and twenty-two (73.3 %) born in Laos.
Table 4
Marital Status of Participants
Cumulative
Frequency
Valid
Married
Percent
Valid Percent
Percent
18
60.0
60.0
60.0
Separated/Divorced
2
6.7
6.7
66.7
Widowed
4
13.3
13.3
80.0
Single
6
20.0
20.0
100.0
Total
30
100.0
100.0
45
Marital status for participants is illustrated in Table 4. Eighteen (60.0%) of the
participants are married, two (6.7%) are separated/divorced, four (13.3%) are widowed,
and six (20.0%) are single. More than half of the participants in this study are married.
Table 5
Highest Level of Education
Cumulative
Frequency
Valid
Less Than High School
Percent
Valid Percent
Percent
21
70.0
70.0
70.0
Some College Units
6
20.0
20.0
90.0
Associate or Community
1
3.3
3.3
93.3
2
6.7
6.7
100.0
30
100.0
100.0
College Graduate
College Graduate
Total
Table 5 shows the participants’ response to the highest level of education attained,
with twenty-one (70.0%) participants reporting less than a high school education. Six
(20.0%) participants reported some college units were completed, one (3.3%) received an
associate or community college degree, two (6.7%) indicated they graduated from
college, and no participants indicated that they have obtained a post-graduate degree.
46
Table 6
Where Education Was Received
Cumulative
Frequency
Valid U.S.
Percent
Valid Percent
Percent
10
33.3
33.3
33.3
Outside of U.S.
4
13.3
13.3
46.7
More Than One Country
1
3.3
3.3
50.0
None
15
50.0
50.0
100.0
Total
30
100.0
100.0
As seen in Table 6, the study asked the participants where they received their
education. Ten (33.3%) of the participants indicated they received their education in the
U.S., followed by four (13.3%) who studied outside of U.S., while the remaining fifteen
(50.0%) reported “none,” meaning that they did not receive any formal education at all.
Table 7.1
Numbers of Years Participants Have Lived in the U.S.
N
Mean
Total Number of Years in U.S.
30
Valid N (listwise)
30
23.8667
Std. Deviation
7.32842
Table 7.1 represents the numbers of years participants have lived in the U.S.
ranging from 6 to 35 years with a standard deviation of 7.328 and an overall mean of
23.86.
47
Table 7.2
Numbers of Years Participants Have Lived in the U.S.
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
6
2
6.7
6.7
6.7
15
1
3.3
3.3
10.0
17
2
6.7
6.7
16.7
18
1
3.3
3.3
20.0
19
2
6.7
6.7
26.7
20
3
10.0
10.0
36.7
22
1
3.3
3.3
40.0
23
2
6.7
6.7
46.7
24
1
3.3
3.3
50.0
25
2
6.7
6.7
56.7
28
1
3.3
3.3
60.0
29
1
3.3
3.3
63.3
30
6
20.0
20.0
83.3
31
3
10.0
10.0
93.3
32
1
3.3
3.3
96.7
35
1
3.3
3.3
100.0
30
100.0
100.0
Total
Table 7.2 shows that study participants have lived in the U.S. for a long time,
with 11 (36.6%) participants having lived here for over thirty years, and 22 (73.2%)
having lived here longer than 20 years. Only two (6.7%) participants have lived in the
U.S. less than 15 years.
48
Table 8
How Well Do You Understand English?
Cumulative
Frequency
Valid
Percent
Valid Percent
Percent
Do not understand it well
12
40.0
40.0
40.0
Somewhat understand it
11
36.7
36.7
76.7
Understand it well
3
10.0
10.0
86.7
Understand it very well
4
13.3
13.3
100.0
30
100.0
100.0
Total
When looking at the ability to understand English in Table 8 above, twelve
(40.0%) participants reported they do not understand English well, while eleven (36.7%)
reported they somewhat understand English, followed by three (10.0%) who indicated
they understand English well, and four (13.3%) stated they understand English very well.
As presented in Table 9, thirteen (43.3%) participants indicated that they do not
speak English well at all, ten (33.3%) stated they somewhat speak English well, two
(6.7%) reported they speak English well, and only five (16.7%) participants reported they
speak English very well.
49
Table 9
How Well Do You Speak English?
Cumulative
Frequency
Valid
Percent
Valid Percent
Percent
Do not speak well at all
13
43.3
43.3
43.3
Somewhat speak it well
10
33.3
33.3
76.7
Speak well
2
6.7
6.7
83.3
Speak very well
5
16.7
16.7
100.0
30
100.0
100.0
Total
Participants were asked to indicate how well they can read English in Table 10.
Of the 30 participants who participated in this study, more than half, or (56.7%, n=17)
stated they do not read well at all, while seven (23.3%) participants reported they
somewhat well, followed by one (3.4% ) participant who reported reading English well,
and only four (13.8%) reported they read English very well. In addition, one participant
did not respond to this question.
Table 10
How Well Do You Read in English?
Cumulative
Frequency
Valid
Do not read well at all
Valid Percent
Percent
17
56.7
58.6
58.6
Somewhat read well
7
23.3
24.1
82.8
Read well
1
3.3
3.4
86.2
Read very well
4
13.3
13.8
100.0
29
96.7
100.0
1
3.3
Total
Missing
Percent
System
50
Cumulative
Frequency
Valid
Do not read well at all
Valid Percent
Percent
17
56.7
58.6
58.6
Somewhat read well
7
23.3
24.1
82.8
Read well
1
3.3
3.4
86.2
Read very well
4
13.3
13.8
100.0
29
96.7
100.0
1
3.3
30
100.0
Total
Missing
Percent
System
Total
In response to how well participants write in English as presented in Table 11,
seventeen (56.7%) participants revealed they do not write well at all in English, seven
(23.3%) reported they somewhat write well in English, one (3.3%) writes English well,
and five (16.7%) participants reported they write very well in English.
Table 11
How Well Do You Write in English?
Cumulative
Frequency
Valid
Do not write well at all
Percent
Valid Percent
Percent
17
56.7
56.7
56.7
Somewhat write well
7
23.3
23.3
80.0
Write well
1
3.3
3.3
83.3
Write very well
5
16.7
16.7
100.0
30
100.0
100.0
Total
Table 12
Religious Preference
Cumulative
Frequency
Percent
Valid Percent
Percent
51
Valid
Shamanism
23
76.7
76.7
76.7
Christianity
7
23.3
23.3
100.0
30
100.0
100.0
Total
Participants were asked to indicate their religious preference in Table 12. The
results show that in terms of religious preference, twenty-four (76.7%) participants stated
their religious preference is Shamanism while seven (23.3%) indicated their religious
preference is Christianity. No participants indicated a different religious preference other
than Shamanism and/or Christianity.
Key Findings Related to the Research Purpose
This section will analyze and identify the key findings based on the participants’
responses to the “yes” and “no” survey questionnaires.
In response to who makes the decision regarding modern medical care
when it comes to treating illness among family, Table 13 revealed that twelve (40.0%)
participants revealed that modern medical decisions are made by fathers when it comes to
treating illness, two (6.7%) participants reported that decisions regarding treating illness
is made by mothers. Two (6.7%) participants stated decisions regarding modern medical
treatment when it comes to treating illness are made by siblings, three (10.0%)
participants reported that decisions are made by elders in the family while one (3.3%) left
decisions to the clan leader. Ten (33.3%) participants indicated “other,” which indicates
that medical decisions are made collectively among family members when it comes to
treating an illness.
52
Table 13
Family Member for Treatment Decision
Cumulative
Frequency
Valid
Percent
Valid Percent
Percent
Father
12
40.0
40.0
40.0
Mother
2
6.7
6.7
46.7
Siblings
2
6.7
6.7
53.3
Elders in the family
3
10.0
10.0
63.3
Clan leader
1
3.3
3.3
66.7
Other
10
33.3
33.3
100.0
Total
30
100.0
100.0
The results in Table 14 shows the results of participants who were asked to
indicate who is most likely to be the first person that they go to for help when a family
member becomes ill. Of the 30 participants, six (20.0%) reported the shaman is the first
person they will go to for help when a family member becomes ill, one (3.3%) participant
reported he/she will first seek a healer/soul caller for help while two (6.7%) reported they
will first seek an herbalist, thirteen (43.3%) indicated a western physician is the first
person from whom they will seek help when a family member becomes ill, and eight
53
(26.7%) indicated other as the first person to seek help from when a family member
becomes ill. Although the literature and studies have reported that modern health care
treatment is often the last source of care for some Hmong individuals and families.
According to this study Western or modern medical health care is actually the first choice
that Hmong Americans seek help from when a family member becomes ill.
Table 14
Most Likely to be First Person to Help When a Family Member Becomes Ill
Cumulative
Frequency
Valid
Percent
Valid Percent
Percent
Shaman
6
20.0
20.0
20.0
Healer/Soul Caller
1
3.3
3.3
23.3
Herbalist
2
6.7
6.7
30.0
13
43.3
43.3
73.3
Other
8
26.7
26.7
100.0
Total
30
100.0
100.0
Western Physician
Table 15
Ever Reluctant to Utilize Modern Medical Care in the Past
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
11
36.7
36.7
36.7
No
17
56.7
56.7
93.3
2
6.7
6.7
100.0
30
100.0
100.0
Refused
Total
In terms of Hmong Americans’ reluctance to utilize modern medical health care
in the past, among the 30 participants, eleven (36.7%) revealed they had been reluctant to
54
utilize modern medical health care in the past, while seventeen (56.7%) stated they had
never been reluctant to utilize modern medical health care in the past. This result
indicated that more than half of Hmong Americans surveyed had never been reluctant to
utilize modern medical health care in the past.
Table 16
Encountered Problems or Concerns with Previously Sought Modern Medical Care
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
13
43.3
43.3
43.3
No
16
53.3
53.3
96.7
1
3.3
3.3
100.0
30
100.0
100.0
Refused
Total
As shown in Table 16, only thirteen (43.3%) participants indicated they
encountered problems or concerns when they previously sought modern medical care
while sixteen (53.3%) stated they did not encounter problems or concerns, and one
(3.3%) participant refused to respond to this question.
As seen in Table 17, the study asked the participants if their modern medical
doctors are knowledgeable about their cultural background. A large majority (70.0%,
n=21) of participants stated that their doctors are knowledgeable about their cultural
background, followed by seven (23.3%) participants who reported their doctors are not
knowledgeable about their cultural background.
Table 17
55
Modern Medical Doctor Knowledgeable of Cultural Background
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
21
70.0
70.0
70.0
No
7
23.3
23.3
93.3
Refused
2
6.7
6.7
100.0
30
100.0
100.0
Total
As the result indicated in Table 18, eleven (6.7%) of the participants stated they
felt disrespected by a modern medical doctor while nineteen (63.3%) reported that they
never felt disrespected by a modern medical doctor.
Table 18
Felt Disrespected by a Modern Medical Doctor
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
11
36.7
36.7
36.7
No
19
63.3
63.3
100.0
Total
30
100.0
100.0
When asked if participants have ever felt devalued by a modern medical doctor in
recent years as illustrated in Table 19 below, eight (26.7%) participants had felt devalued
by a modern medical doctor in recent years while more than half (60.0%, n=18) indicated
they have not felt devalued by a modern medical doctor in recent years.
Table 19
Felt Devalued by a Modern Medical Doctor
Frequency
Percent
Valid Percent
Cumulative Percent
56
Valid
Yes
8
26.7
26.7
26.7
No
18
60.0
60.0
86.7
4
13.3
13.3
100.0
30
100.0
100.0
Refused
Total
As presented in Table 20, nearly all (93.3%, n=28) of the participants reported
that it is necessary for modern medical doctors to have knowledge and understanding of
their cultural beliefs and/or practices, while only two (6.7%)indicated it was not
necessary for modern medical doctors to have knowledge and understanding of their
cultural beliefs and/or practices. This finding revealed that modern medical doctors’
knowledge and understanding of Hmong’s cultural beliefs and/or practices is highly
imperative, especially when treating Hmong individuals.
Table 20
Modern Medical Doctors Have Knowledge/Understanding of Cultural Beliefs/Practices
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
28
93.3
93.3
93.3
No
2
6.7
6.7
100.0
30
100.0
100.0
Total
The results in Table 21 indicated more than half (70.0%, n = 21) of the
participants had sought help from a traditional healer such as a shaman, while nine
(30.0%) have never sought help from a shaman. This implies that traditional healers such
as a shaman are is highly utilized in the Hmong culture.
Table 21
57
Sought Help From a Traditional Healer Such as a Shaman
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
21
70.0
70.0
70.0
No
9
30.0
30.0
100.0
30
100.0
100.0
Total
Table 22
Sought Help From a Healer/Soul Caller
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
20
66.7
66.7
66.7
No
10
33.3
33.3
100.0
Total
30
100.0
100.0
As illustrated in Table 22 above, twenty (66.7%) participants indicated they have
sought help from a healer/soul caller while ten (33.3%) participants reported they have
never sought help from a healer/soul caller. However, this finding may not be entirely
accurate as only seven participants stated that their religious preference was Christianity,
or this could be due in part to participants not wanting to provide further explanation
when they indicated “yes” to this question.
In Table 23 below, two-third (66.7%, n = 20) have sought help from an herbalist
while ten (33.3%) have never sought help from an herbalist.
Table 23
58
Sought Help From an Herbalist
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
20
66.7
66.7
66.7
No
10
33.3
33.3
100.0
Total
30
100.0
100.0
In response to whether participants have ever sought help from a modern medical
doctor, Table 24 shows that all but one (96.7%, n = 29) of the participants stated they
have sought help from a modern medical doctor while only one (3.3%) participant
indication that he/she has never sought help from a medical doctor. This finding
revealed that Hmong Americans sought help from modern medical doctors at a higher
rate, when compared to seeking help from a shaman (70.0%, n=21), a healer/soul caller
(66.7%, n=20), and/or an herbalist (66.7%, n=20).
Table 24
Sought Help From a Modern Medical Doctor
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
29
96.7
96.7
96.7
No
1
3.3
3.3
100.0
30
100.0
100.0
Total
Table 25
Has Your Understanding of Illness Changed in Recent Years
Frequency
Valid
Percent
Valid Percent
Cumulative Percent
Yes
19
63.3
63.3
63.3
No
7
23.3
23.3
86.7
59
Refused
Total
4
13.3
13.3
30
100.0
100.0
100.0
In response to whether participants’ understanding of illness has changed in
recent years, especially among those who were born and raised in Laos or Thailand,
Table 25 shows that more than half (63.3%, n = 19) of the participants stated that their
understanding of illness has changed in recent years while seven (23.3%) participants
indicated that their understanding of illness has not changed in recent years.
Table 26 (a)
Crosstabulation
How Well Understands English * Highest Level of Education
Highest Level of Education
Associate or
How Well
Do not understand
Count
Understan
it well
% of Total
Somewhat
Count
understand it
% of Total
Understand it well
Count
ds English
% of Total
Total
Understand it very
Count
well
% of Total
Count
% of Total
Less Than
Some
Community
High
College
College
College
School
Units
Graduate
Graduate
Total
12
0
0
0
12
40.0%
.0%
.0%
.0%
40.0%
9
2
0
0
11
30.0%
6.7%
.0%
.0%
36.7%
0
3
0
0
3
.0%
10.0%
.0%
.0%
10.0%
0
1
1
2
4
.0%
3.3%
3.3%
6.7%
13.3%
21
6
1
2
30
70.0%
20.0%
3.3%
6.7%
100.0%
60
26 (b)
Symmetric Measures
Asymp. Std.
Value
Error
a
Approx.
Approx. T
b
Sig.
Ordinal by
Kendall's tau-c
.551
.113
4.889
.000
Ordinal
Spearman Correlation
.781
.073
6.612
.000c
Interval by
Pearson's R
.856
.043
8.745
.000c
Interval
N of Valid Cases
30
a. Not assuming the null hypothesis.
b. Using the asymptotic standard error assuming the null hypothesis.
c. Based on normal approximation.
The Spearman Correlation indicates that there is not a significant relationship
between highest level of education and how well the participants understand English
(Spearman = .781, p > .073). As table 26 (a) shows, participants that have less than high
school level of schooling tend to not understand English well (40%). Only two
participants graduated from college and stated that they understand English very well
(6.7%). However, Table 27 (a-b) show that understanding English is not associated with
Hmong being reluctant to use modern medical care (chi-square = 3.452, df = 6, p > .750).
61
Table 27 (a)
Crosstabulation
How Well Understands English * Ever Reluctant to Use Modern Medical Care in the
Past
Ever Reluctant to Use Modern
Medical Care in the Past
Yes
How Well
Do not understand Count
Understands
it well
% of Total
English
Somewhat
Count
understand it
% of Total
Understand it well Count
% of Total
Understand it very Count
well
% of Total
Total
Count
% of Total
No
7
0
12
16.7%
23.3%
.0%
40.0%
4
6
1
11
13.3%
20.0%
3.3%
36.7%
1
2
0
3
3.3%
6.7%
.0%
10.0%
1
2
1
4
3.3%
6.7%
3.3%
13.3%
11
17
2
30
36.7%
56.7%
6.7%
100.0%
Chi-Square Tests
Asymp. Sig. (2df
Total
5
Table 27 (b)
Value
Refused
sided)
62
Pearson Chi-Square
3.452a
6
.750
Likelihood Ratio
3.617
6
.728
Linear-by-Linear
1.245
1
.265
Association
N of Valid Cases
30
a. 10 cells (83.3%) have expected count less than 5. The minimum
expected count is .20.
Table 28 (a)
Crosstabulation
Ever Reluctant to Use Modern Medical Care in the Past * Sought Help From a Modern
Medical Doctor
Sought Help From a
Modern Medical Doctor
Yes
Ever Reluctant to Use
Yes
Count
Modern Medical Care in
the Past
% of Total
No
Count
% of Total
Refused
Count
% of Total
Total
Count
% of Total
No
11
0
11
36.7%
.0%
36.7%
16
1
17
53.3%
3.3%
56.7%
2
0
2
6.7%
.0%
6.7%
29
1
30
96.7%
3.3%
100.0%
Table 28 (b)
Chi-Square Tests
Asymp. Sig. (2Value
df
Total
sided)
Pearson Chi-Square
.791a
2
.673
Likelihood Ratio
1.162
2
.559
63
Linear-by-Linear
.262
1
.609
Association
N of Valid Cases
30
a. 4 cells (66.7%) have expected count less than 5. The minimum
expected count is .07.
Table 28 (b) also shows that modern medical care doctors’ knowledge are not
associated with reasons why Hmong patients are reluctant to use modern medical care
(chi-square = .791, df = 2, p > .673). Similarly, Table 29 (a-b) show that the Hmong’s
knowledge of illness in past years are not associated with health problems encountered by
them (chi-square = 7.234, df = 4, p < .124).
Table 29 (a)
Crosstabulation
Has Your Understanding of Illness Changed in the Past Years * Encountered
Problems/Concerns with Previously Sought Modern Medical Care
Encountered Problems/Concerns
with Previously Sought Modern
Medical Care
Yes
Has Your
Yes
Understanding of
Illness Changed in
Count
% of Total
No
the Past Years
Count
% of Total
Refused
Count
% of Total
Total
Count
% of Total
Table 29 (b)
No
Refused
Total
8
11
0
19
26.7%
36.7%
.0%
63.3%
3
4
0
7
10.0%
13.3%
.0%
23.3%
2
1
1
4
6.7%
3.3%
3.3%
13.3%
13
16
1
30
43.3%
53.3%
3.3%
100.0%
64
Chi-Square Tests
Asymp. Sig. (2Value
df
sided)
Pearson Chi-Square
7.243a
4
.124
Likelihood Ratio
4.918
4
.296
Linear-by-Linear
.203
1
.652
Association
N of Valid Cases
30
a. 7 cells (77.8%) have expected count less than 5. The minimum
expected count is .13.
Qualitative Responses by the Participants
Participants’ responses. The following section presents findings based on survey
responses of participants which include open-ended and closed-ended questions.
However, some closed-ended questions asked participants to provide an explanation to
their “yes” or “no” responses in the next question that followed.
Perspective on modern medical care. Participants were asked to provide their
general perceptions about modern medical care. There were some common themes that
emerged from participants’ responses to this question. Among the responses provided,
participants reported modern medical care is considered beneficial when they are
provided with medication to treat illnesses such as fever, headache and stomach pain.
Others perceived modern medical care as fact, science and technology. Some feel that
modern medical care has some good and bad benefits depending on the condition of the
illness. While others feel that because they do not speak English modern medical care
doctors do not want to provide them with quality services and medications.
65
Ever reluctant to utilize modern medical health care in the past. Of the
participants who answered “yes” to whether they have ever been reluctant to utilize
modern medical health care in the past, reported that modern medical doctors do not treat
them well when they do not have an interpreter with them, and that it takes more time and
longer for them to schedule a medical appointment, as they do not speak the English
language. Others expressed that they do not believe what modern medical health care
professionals said about their illnesses, as it is based on fact and not their illnesses. Some
feel that their illness is not a result of disease, but of soul and/or spirit loss so they will
seek traditional health care first. For example, a participant shared that his wife went to
the hospital to get a pregnancy test done, but the doctor told her she was going to die that
night so she was forced to stay overnight at the hospital. Another participant revealed
that while she was 7 months pregnant she was admitted to the hospital for a fever of 109
°F, she was later diagnosed with having H-pylori. On the other hand, those participants
who stated “no” to this question expressed that they believe and have trust in modern
medical care. Others stated that modern medical care will be able to tell them what is
going on with their health. An older participant shared, for instance, that “…as I age,
modern medical care will be able to help me with my illness.” Another participant stated
“Because I do not know the real cause to my illness so I need to seek modern medical
care first then seek traditional health care. Another one stated “I grew up in America so
western medicine seems to work best for me.”
66
Encountered problems/concerns with previously sought modern medical care. As
for problems or concerns with previously sought modern medical care, participants stated
“yes” that they have encountered problems and/or concerns when modern medical care
forced them to undergo certain procedures that had no connection or association with
their illness, but as a result of their inability to understand and speak English. Others
believed it was their “ntsuj plig” (soul/spirit) and not an illness. One frustrated
participant stated “the doctor told me that my dad had cancer on his neck, arms, and groin
just based on his assumption, and not on any test results.” Another participant stated that
the doctor wanted to do surgery to remove his wife’s uterus, but he said “no” because he
had never heard of such a thing as cancer. Participants who stated “no” to this question
revealed that they have never encountered problems/concerns with previously sought
modern medical care, and feel that modern medical doctors just do what they have to do
and that modern medical care is good. A participant, for instance, stated “Because there
are rules and regulations that doctors must follow when treating patients.”
Modern medical doctor knowledgeable of cultural background. In terms of
modern medical doctors’ knowledge about the Hmong’s cultural background, a majority
of participants indicated that some doctors are aware of their cultural background and
have allowed them to perform rituals for individuals when necessary. A participant
shared that when his daughter-in-law fell and hit her stomach while she was still
pregnant, the doctor asked if the family would like to perform any ritual to help her.
Another participant stated that sometimes doctors allow them to use their traditional
67
beliefs and/or practices before submitting to modern medical care. Of those who stated
“no,” they believe that modern medical doctors need to understand their cultural
background before treating their illnesses and/or diseases, and some were not sure if their
doctors were even knowledgeable of their cultural background at all. One participant
stated “some doctors never heard of Hmong people before.” Another participant reported
“if they (doctors) were knowledgeable about my culture then they would have allowed
me to seek other alternatives.”
Ever felt disrespected by a modern medical doctor. According to those
participants who had indicated they were disrespected by a modern medical doctor, they
stated doctors do not want to listen to what they have to say about their illness or care for
them. For example, a participant explained an incident where he was told by the doctor
that his little brother had cancer two days after being kicked in the eye. Another felt
disrespected when the doctor told her that her daughter was going to die as a result of the
rashes on her body. Those who never felt disrespected by a modern medical doctor
indicated modern medical doctors whom they have met have been grateful and
understanding toward them. They reported doctors also talk nicely to them, which means
that they are being respected by modern medical doctors.
Ever felt devalued by a modern medical doctor in recent years. Participants who
felt devalued by a modern medical doctor in recent years reported that doctors did not
listen to their needs and illnesses. Others stated that because they do not have an
education, doctors talk mean to them. For example, a participant reported that she took
68
her husband to the doctor, and the doctor said to her that he is not sick, but only faking
his illness to qualify for benefits. Of those who indicated they never felt devalued by a
modern medical doctor, they stated they were treated well.
Last time sought help from a modern medical provider such as a doctor. At the
time of the interview a majority of participants indicated that they had recently sought
help from a modern medical doctor. For example, more than half of the participants
stated the last time they sought help from a medical doctor was within the last month.
There were only three participants who stated the last time they saw a medical doctor was
a year ago and another one stated three years ago. This implies that a majority of Hmong
Americans do seek help regularly from a modern medical doctor.
Modern medical doctors have knowledge and understanding of cultural beliefs
and/or practices. In terms of cultural competency with the Hmong population, a majority
of the participants stated “yes” it is necessary for modern medical doctors to have
knowledge and understanding of their cultural beliefs and/or practices in order for doctors
to treat and understand their illnesses. Those participants who indicated “yes,” stated that
understanding the Hmong’s cultural beliefs and/or practices allow doctors to become
more open minded to alternative treatments that are available in their culture. While a
few revealed modern medical doctors do not need to know or understand their cultural
beliefs and/or practices in order to treat their illnesses.
Ever sought help from a traditional healer such as a Shaman. In response to
whether participants have ever sought help from a traditional healer such as a shaman, a
69
majority of participants indicated “yes” that they have utilized a shaman. Participants
reported that the benefit of seeking help from a shaman is that he or she is able to restore
the individual’s soul and/or spirit back to its body. After the soul is restored it makes the
individual feel better, and the shaman is able to get rid of evil spirits. For example, a
participant indicated that the shaman is always the first person on her mind while another
reported that if you feel fatigue prior to the shaman’s performance, you will feel better
after the performance is completed.
Ever sought help from a Healer/Soul Caller. Participants who answered “yes” to
having sought help from a healer/soul caller stated that the benefit of seeking a
healer/soul caller is to bring the individual’s soul back to its body, as a result of being
frightened (poob plig) or scared by something. Others indicated that the spirit and the
soul are very important to the Hmong. For instance, a participant revealed that when she
got into a car accident, it made her very scared. She got sick after her car accident
because she lost her soul at the place where the accident took place. A soul caller had to
perform a spiritual calling ceremony to bring her soul back to her body, as a result of her
soul loss. The participant stated she felt better and had the energy to do her usual
activities afterward. Another participant stated a soul caller is able to help call the soul
that was lost back to the “virtual or real world” and back into the physical body.
Ever sought help from an Herbalist. According to participants who have sought
help from an herbalist, they stated the benefit of seeking help from an herbalist is that it is
70
very helpful in treating fever and rashes, but it must have no association with the evil
spirit. Another benefit is using herbal medicines to massage painful areas of the body.
Ever sought help from a Modern Medical Doctor. Almost all participants reported
they have sought help from a modern medical doctor; however, they did not all provide
any explanation as to the benefits of using a modern medical doctor. Those participants
who provided explanations regarding the benefits of seeking help from a modern medical
doctor expressed that modern medical doctors are able to prescribe medications to treat
their illnesses such as fever, headache and/ or stomach pain. While others revealed that
modern medical doctors are able to use the latest technologies to evaluate and pinpoint
exactly where the disease is located and how big in size it has become. A participant, for
example, articulated that modern medical doctors have helped improve and prolong her
life because of the illness that she has and that she has been taking medications for 9
years.
Suggestions for the Hmong community after seeking traditional health care, and if
illness is still present. In terms of providing suggestions for the Hmong community after
traditional health care has been exhausted, almost all participants indicated modern
medical care must be considered and not disregarded it. This implies that Hmong
Americans are more likely and more willing to seek modern medical care only after
traditional healthcare is exhausted for the individual’s illness.
Value of traditional medicine. Regarding the value of traditional medicine, a
majority of participants found traditional medicine to be very valuable. Many
71
participants reported that traditional medicine is good for the soul and mind. A
participant, for example, expressed that she had witnessed the benefit of using traditional
medicine. While another participant stated “Traditional medicine is as valuable as
modern medicine, the only difference is that modern medicine has the modern tools to
assess my illness such as x-ray machines.”
Understanding of illness. Although five people did not respond to this question
regarding their understanding of illness, those participants who responded to this question
interpreted the understanding of illness as related to the soul being lost (poob plig)
especially when the soul has wandered off to other places beyond the human world.
Other participants associated the understanding of illness to the soul, body and physical
self of the individual. For instance, a participant shared that illness could be in the mind,
soul and/or body. Further, some participants attributed the understanding of illness to the
processed food that is being consumed by individuals which causes chemical imbalances
in the body. A participant revealed that “In Laos, the food that we eat is organic, but
now, many of the food that we eat here have fertilizer/pesticides, which makes our health
bad.”
Understanding of illness changed in recent years. Of the participants who
answered “yes” to whether their understanding of illness has changed in the recent years
said it was due in part to the existence of hospitals and advanced technologies. A
majority of participants expressed that in Laos there were no hospitals so only traditional
rituals and medicines were used to treat illnesses and there were no alternative options
72
like a hospital. Other participants stated their understanding of illness has changed as a
result of the food that is being consumed in the United States. For instance, a participant
reported liking organic versus chemical food.
Those participants who stated “no” suggested that their understanding of illness
has not changed in the recent years, as the only difference is the existence of hospitals
and advanced technologies. Illness, according to these participants, is a mixture of
spiritual, physical, mental and other factors. For example, a participant shared his belief
that traditional shamanism can set your mind at ease, but western medicine is the only
way to treat your body’s illness. Another participant stated “Traditional shamanism
cannot treat diabetes, high blood pressure and a broken leg, only western medicine can.
On the other hand, only shamanism will set your mind at ease if you feel that spiritually
something is wrong. In conclusion, you need both in the Hmong community. You
should never disregard both types of treatments.”
73
Chapter 5
CONCLUSION AND IMPLICATION
Introduction
This chapter will present a summary of the research project findings regarding
views of both traditional and modern health care among Hmong Americans. In addition,
conclusions of the overall research key findings and the literature review will be
compared and contrasted. Lastly, implications for social work practice,
recommendations for service providers as it relates to two theoretical frameworks
presented in Chapter 1, as well as recommendations for future research will be discussed.
Summary
According to data gathered from both quantitative and qualitative questionnaires,
it was confirmed that Hmong Americans still have not abandoned their cultural beliefs
and/or practices, and they are still a very traditional group of people. The Hmong
refugees are a nomadic group of people who left their homeland as a result of their
collaboration with the United States during the Vietnam War in the 1960s. Although the
Hmong have settled in the United States for more than three decades, they still encounter
barriers when accessing and utilizing the modern health care system and its services.
Many of the barriers are as a result of the cultural and traditional beliefs that are currently
being practiced within the Hmong community. Also, many Hmong lack the education
and/or do not have a sufficient understanding of the English language, which prevents
them from being able to understand treatment procedures or to simply follow through
74
with advice from health professionals. On the other hand, health care professionals also
lack the training and education to become culturally sensitive practitioners in effectively
meeting the needs of Hmong Americans. As a result, it creates greater
miscommunication and mistrust between healthcare professionals and the Hmong people.
As tensions increase, Hmong Americans become more reluctant to seek modern medical
treatments and/or services even when they become ill. This leads them to seek traditional
modalities including shamanism, herbalists, healer/soul caller and healing practices.
Conclusion
Key findings. The author examined the highest level of education attained by the
30 participants of this research study, as well as where they received their education. The
findings in Table 6 showed that half (50.0%) had never received any form of education,
and 33.3% indicated they received their education in the U.S, followed by 13.3% outside
of U.S while only 3.3% stated more than one country. In addition, Table 5 revealed that
of the 30 participants, 93.3% of them received less than a high school education and/or
had never received a college degree, while only 6.7% had received a college degree. This
implies that not having an education is a contributing factor, as it prevents Hmong
Americans from having sufficient knowledge and understanding of the modern health
care system. These findings proved to be consistent with the data from the literature
review, as Chung and Lin (1994) reported that Hmong Americans are one of the groups
who are less educated and have lower literacy rates compared to Laotians and
Vietnamese.
75
English as a second language is another theme that emerged from this study in
regards to understanding, speaking, reading, and writing in English. The finding in Table
8 revealed that 76.6% of participants either did not understand or only somewhat
understood English well while only 23% reported they either did understand English or
understood English very well. Table 9, showed that 76.6% of participants indicated they
either did not speak or only somewhat spoke English well, followed by only 23.3% who
either did not read or only somewhat read English well. Table 10 indicated that 80.0% of
participants either did not write or only somewhat wrote English well, and only 16.6%
indicated they either read or read English very well. Lastly, Table 11 results showed that
80.0% of participants either did not write or only somewhat wrote well in English,
followed by only 20.0% who reported they either write or write very well in English. Not
having the ability to understand, speak, read and write in English are major factors, as it
prevents Hmong Americans from being able to communicate their symptoms and
concerns to health care providers. This finding is similar to the literature review, as a
large number of Southeast Asian refugees have limited understanding of the English
language (Cobb, 2010). Furthermore, the finding from the 2000 U.S Census Bureau
showed that over 50% of households reported they do not have family members who
speak English well, while only 4.4% of households reported English as their only spoken
language in the home (as cited in Cobb, 2010). It is imperative that Hmong Americans
have an understanding of English in order to effectively communicate and access the
modern health care system successfully.
76
Another considerable theme is decision making. Participants indicated that
decision making is mostly made by fathers when it comes to modern medical treatment.
Table 13 revealed that 40.0% of decision making regarding modern medical treatments
are made primarily by the father, but are still made in conjunction with such persons as
the mother, siblings, clan leaders and others. This finding coincides with the literature
review, as fathers generally make all the welfare decisions in the household. However,
fathers also base their decision making on the opinions of grandparents, siblings, and clan
leaders. Because decision making is a shared process in the Hmong culture, it usually
takes longer for the family to make quick medical decisions when a medical procedure is
needed for an ill Hmong individual (Parker and Kiatoukaysy, 1999).
Another finding is regarding who would most likely be the first person to seek
help from when a family member becomes ill. Table 14 shows that 43.3% of participants
reported they would seek help from a Western physician first when it comes to illness,
while 30.0% indicated that they would first seek tradition health care such as a shaman, a
healer/soul caller or an herbalist, followed by 26.7% of participants who reported others
(e.g. husband and son, father, mother, and siblings, and son and daughter in law). In
contrast, the literature review indicated that modern medical health care models are the
last source of care for some Hmong individuals and families (Warmer & Mochel, 1998).
However, this research study found that modern doctors are most likely the first person
(health care provider) sought by Hmong families when an illness arises.
77
Another key finding is cultural competency, which asks participants about their
modern medical doctors’ knowledge of their cultural background. Table 17 revealed that
that 70.0% of participants who reported doctors who are knowledgeable of their cultural
background, followed by 23.3% reported their doctors are not knowledgeable of their
cultural background, while 6.7% refused to answer the question. Of the 30 participants
who indicated that their modern medical doctors are knowledgeable of their cultural
background, six expressed that some doctors have allowed them to perform rituals for
Hmong individuals when necessary. For example, one participant shared that doctors
sometimes allow him to use his traditional beliefs and/or practices before agreeing to
modern medical care. In contrast, other participants stated their modern medical doctors
are not knowledgeable of their cultural background. For instance, one participant
reported that some doctors had never heard of Hmong people before. Another participant
explained that if her doctor was knowledgeable of her cultural background, then he
(doctor) would have allowed her to seek other alternatives.
In contrast, another a question also asked if participants thought it was necessary
for modern doctors to have knowledge and understanding of their cultural beliefs and/or
practices. A majority (93.3%) of participants indicated it was necessary for modern
doctors to have knowledge and understanding of their cultural beliefs and/or practices,
while the other 6.7% indicated it was not necessary for doctors to have knowledge and
understanding of their cultural beliefs and/or practices. Participants who indicated it was
necessary for their doctor to have knowledge and understanding of their cultural beliefs
78
and/or practices stated that in order to treat and understand their (Hmong Americans)
illnesses, doctors must have knowledge and understanding of their cultural beliefs and/or
practices. Similarly, the literature review shows that Hmong Americans still rely heavily
on their traditional beliefs and practices of shamanism, soul calling, and traditional
remedies.
The findings related to understanding illnesses are not only significant, but
coincide with data found in the literature review as illness is viewed as a distraction of
souls and spirits, which are balanced and dynamic in nature (Platnikoff et al., 2002).
According to this research finding, participants interpreted the understanding of illness as
related to the soul being lost (poob plig), especially when the soul has wandered off to
other places beyond the human world, while others attributed the understanding of illness
to the body and physical self of the individual, as well as the soul. As stated by Uba
(1992) and Parker and Kiatoukaysy (1999), traditional Hmong believe that the primary
cause of illness is soul loss. This implies that Hmong Americans, although, a majority
have been in the U.S. for more than twenty years, are still a very traditional group of
people.
Implications for Social Work Practice
Although the health care system in the United States is complex and
multidisciplinary in nature, health care professionals have not yet been able to fully help
Hmong Americans ease their difficulties when utilizing modern health care. This is due
in part to healthcare providers’ lack of cultural competency skills. Because of their
79
difficulties and challenges with the modern medical health care, this research study is
intended to gain a better understanding of the reasons behind Hmong cultural beliefs and
practices and, more importantly, to increase health care professionals’ and social
workers’ knowledge and understanding when working with Hmong Americans.
Moreover, this author’s intent is to create a friendly and understanding environment in
which the Hmong feel comfortable expressing and addressing their concerns in regards to
health and illness in relation to their cultural beliefs.
The implications for social workers at the micro level includes understanding
Hmong Americans’ evolution of sociocultural upbringing, geographical environment,
familial factors that impact how they view and understand modern health care systems, as
well as their utilization of services, as it relates to the ecological perspective mentioned in
Chapter 1. The ecological perspective allows health care providers and others to
understand the range of physical, emotional, and environmental factors that have affected
the well-being of Hmong individuals. Health care professionals and social workers must
be culturally sensitive and competent in respectfully affirming the worth and dignity
(NASW, 2005, p. 8) of Hmong Americans as a group whether or not health care
professionals agree with what has been expressed to them. In addition, they must have a
basic knowledge and understanding of the different life threatening situations that Hmong
Americans have encountered in order to understand their struggles and challenges while
settling in the United States. Further, it is crucial for service providers to acknowledge
the language and cultural differences, religious beliefs, and other diverse features that are
80
found within the Hmong American population.
Social work implications at the mezzo level include changing larger systems, such
as communities and organizations. By doing this, social workers will be able to address
the necessary skills and training in order to promote greater cultural competency within
modern health care system to address barriers that Hmong Americans encounter as they
utilize modern health care services. Lastly, on a macro level, health care professionals
and social workers must be able to develop community programs to evaluate the
strengths and assets that Hmong Americans have within their communities and
neighborhoods to bring about greater change with local initiatives. As a result of social
workers’ proactive skills and knowledge, they will be able to empower Hmong
Americans as well as to strengthen the relationship between healthcare professionals and
Hmong Americans who struggle with understanding the modern health care system, as
well as utilization of services. Most importantly, the constant and continual education
and training in the ecological perspective, practice in human diversity and cultural
competency are vital skills needed in working collaboratively with diverse group of
people within the U.S.
Recommendations for Service Providers
As indicated in this research study, even though the average Hmong American has
settled in the United States for 23.8 years, they are still a very traditional group of people
due to their distinct perceptions of health and illness, as well as their traditional cultural
beliefs and/or practices. Therefore, it is imperative that service providers (doctors, health
81
professionals and educators) receive sufficient training and education on how to address
Hmong Americans’ concerns regarding health and illness. By having a better
understanding about Hmong Americans’ health care beliefs and/or practices, it will
enable health care providers to relate sensitively to meeting the needs of Hmong
Americans. As a result, it will enable Hmong Americans to be more willing to seek and
utilize modern medical care, and illnesses will likely be detected at earlier stages
compared to later stages.
Another recommendation is that health care academia should adopt culturallysensitive approaches in order to assist and provide the necessary care for diverse people,
especially for Hmong Americans. Service providers who are culturally competent and
sensitive regarding Hmong Americans’ social and cultural perceptions and practices will
be able to address Hmong patients’ needs and concerns, which will decrease the
likelihood of creating tension and miscommunication between Hmong patients and health
care providers and professionals.
Further recommendation is that health care providers and professionals should view
themselves as advisers and presenters of information, and not authoritarian figures to
their patients and families. Hmong patients favor providers with a caring and respectful
demeanor; therefore, patients’ cultural beliefs and/or practices, as well as decision
making processes, must be taken into consideration before a patient agrees to medical
procedures. This is due in part to the fact that the Hmong are a patriarchal culture, where
decisions are made primarily among male family members and/or male clan leaders.
82
Lastly, medical providers also need to learn about Hmong Americans’
understanding of causation to illness, patterns of communication, decision making,
cultural beliefs and/or practices, traditional medicine, and healings practices when
treating illnesses. This requires an acknowledgment of cultural differences and
similarities between traditional Hmong and biomedicine perspectives.
Recommendations for Future Research
As a result of the findings, it is important that future research focus on
longitudinal studies of Hmong Americans’ views of both traditional and modern medical
health care and how it has changed over the years. In addition, a larger sample size
throughout different regions including counties, cities and states are suggested for future
study and must be considered in order to gain more in-depth understanding of Hmong
Americans’ views of both traditional and modern medical care, as well as its utilization
of services. Furthermore, future study should focus on younger Hmong Americans’
views of both traditional and modern health care, as a majority of participants in this
research study consisted of participants’ ages 61 years of age or older.
Another intriguing future research topic would be to compare and contrast
perceptions of newly arrived Hmong refugees from Wat Tham Krabok, an area located in
Thailand, and the first and second wave of Hmong refugees to both traditional and
modern health care
Lastly, another future research suggestion is to focus on the level of acculturation
and assimilation of Hmong Americans to see if their views of both traditional and
83
western healthcare will yield a different or more significant result, compared with this
author’s findings.
84
APPENDICES
85
APPENDIX A
Consent Form
I, Stacy Thang Yang, a social work graduate student at California State University,
Sacramento is conducting a research study to explore perceptions of Hmong Americans
have toward traditional and modern health care, and their utilizations of such services.
The study’s rationale is to gain a better understanding of the reasons behind Hmong
cultural beliefs and/or practices and, more importantly, to increase health care
professionals and social workers’ knowledge and understanding when working with
Hmong Americans in Sacramento County.
Your participation in this study will take approximately 40-50 minutes and is
strictly anonymous. My questions will not collect any personal information from you
such as name, address, phone number, or social security number. Verbal consent will be
required from you before participating in the study. You will be asked to complete a set
of questions exploring views and perceptions that you have toward traditional and
modern medical care, and your utilizations of such services. I will interview or
administer my questionnaire to you at a private room at Sacramento Community Clinic.
Those participants who have difficulty with transportation coming to the scheduled
appointments, the author will ask if she could conduct the interview at the participants’
homes. However, interviews will only be conducted at the participants’ homes after
permissions have been granted from the participants. In addition, any information
collected from you will be kept confidential and secure in a locked file cabinet, and no
one other than me and my advisor will have access to the information. Furthermore, all
completed survey questionnaires will be destroyed once the study is completed.
In my views, this research project is considered to have minimal risk. However,
some participants such as yourself may have a strong reaction to certain modern medical
care, as a result of your experiences with modern medical care or negative experiences
with your doctor. Your participation in this research project is completely voluntary, and
you have the right to withdraw or may skip any questions if you are not comfortable
answering at any given time without penalty.
After participating in my research project, in case you have addition questions, I
will provide my email address (faithfulyang@yahoo.com) and a contact phone number
(916-393-xxxx), as well as my thesis advisor’s (Dr. Serge Lee) email address
(lees@saclink.csus.edu) and his contact phone number (916- 278-5820). Additionally, I
am providing you with a list of referral sources and their contact phone numbers where
you can receive additional counseling services should you feel the need for it after your
participation in this study. Sacramento Community Clinic has granted me permission to
86
approach you at this facility. If you have any questions please contact Sacramento
Community Clinic at 916-428-3788 or 916-924-7988.
If you consent to what described above, please sign your name here
__________________________________ indicating that you agree to participate in this
research study.
Thank you,
Stacy Thang Yang
1).
Hmong Women’s Heritage Association
2251 Florin Road, #104
Sacramento, CA 95822
Office: 916-394-1405
Fax: 916-392-9326
2).
Asian Pacific Community Counseling Center
5330 Power Inn Road, Suite A,
Sacramento, CA 95820,
Phone: 916-383-6783
Fax: 916-383-8488
3).
Asian Resource
709 Stockton Blvd.
Sacramento, CA 95824
Office: 916-454-1892
Fax: 916-454-1895
4).
Southeast Asian Assistance Center
5625 24th Street
Sacramento, CA 95822-2233
Office: 916-421-1036
Fax: 916-421-6731
87
APPENDIX B
Questionnaires in English
1. What is your age category?
a.
b.
c.
d.
e.
f.
21-28
29-36
37-44
45-52
53-60
61 or over
2. Sex
a. Male
b. Female
3. Where were you born?
a.
b.
In the United States
Outside of the United States. If outside of the United States, please specify
country: __________________________
4. What is your marital status?
a.
b.
c.
d.
Married
Separated/Divorced
Widow
Single
5. What is your highest level of education?
a.
b.
c.
d.
e.
f.
Less than high school
High school graduate
Some college units
Associate or community college graduate
College graduate
Post-graduate
88
6. Where did you receive your education?
a. United States
b. Outside of the United States. If outside of the United States, please specify
country: __________________________
7. Numbers of years you have lived in the United States: ______________________
8. How well do you understand English?
a.
b.
c.
d.
Do not understand
Somewhat understand
Understand well
Understand very well
9. How well do you speak English?
a.
b.
c.
d.
Do not speak at all
Somewhat speak
Speak well
Speak very well
10. How well do you read in English?
a.
b.
c.
d.
Do not read at all
Somewhat read
Read well
Read very well
11. How well do you write in English?
a.
b.
c.
d.
Do not write
Somewhat write
Write well
Write very well
12. What is your religious preference? Would you say…
a. Shamanism
b. Christian
c. If other, please specify: __________________________
89
13. For your family, when it comes to treating illness, who makes decisions regarding
modern medical treatment? Would you say…
a.
b.
c.
d.
e.
f.
______Father
______Mother
______Siblings
______Elders in the family
______Clan leader
If other, please specify: __________________________
14. When a family member becomes ill, who is most likely to be the first person you
go for help? (Please select only one source/person). Would you say…
a.
b.
c.
d.
e.
Shaman
Healer/soul caller
Herbalist
Westerner physician
If other, please specify: _________________
15. In the event that a designated family member is not available to make modern
medical care decisions for you/the family, who is most likely to make such
decisions?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
16. What do you think about modern medical care? Please briefly describe your
general perceptions about this type of medical practice.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
17. Have you ever been reluctant to utilize modern medical health care in the past?
a. ________Yes
b. ________ No
c. ________ Refused
90
18. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
19. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
20. In case you had previously sought modern medical care, have you ever
encountered problems or concerns with this type of medical care?
a. _______ Yes
b. _______ No
c. _______ Refused
21. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
22. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
23. In your view, was your modern medical doctor knowledgeable about your cultural
background?
a. _______ Yes
b. _______ No
c. _______ Refused
24. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
91
25. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
26. Have you ever felt disrespected by a modern medical doctor?
a. ________ Yes
b. ________ No
c. ________ Refused
27. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
28. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
29. Have you ever felt devalued by a modern medical doctor in recent years?
a. ________ Yes
b. ________ No
c. ________ Refused
30. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
31. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
32. When was the last time you sought help from a modern medical provider such as
a doctor?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
92
33. Do you feel that it is necessary for modern medical doctors to have knowledge
and understanding of your cultural beliefs and/or practices?
a. ________ Yes
b. ________ No
c. ________ Refused
34. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
35. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
36. Have you ever sought help from a traditional healer such as a shaman?
a. ________ Yes
b. ________ No
c. ________ Refused
37. If yes, could you provide a brief explanation as to the benefits of shamanism?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
38. Have you ever sought help from a healer/soul caller?
a. ________ Yes
b. ________ No
c. ________ Refused
39. If yes, could you provide a brief explanation as to the benefits of a healer/soul
caller?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
93
40. Have you ever sought help from an herbalist?
a. _________ Yes
b. _________ No
c. _________ Refused
41. If yes, could you provide a brief explanation as to the benefits of an herbalist?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
42. Have you ever sought help from a modern medical doctor?
a. _________ Yes
b. _________ No
c. _________ Refused
43. If yes, could you provide a brief explanation as to the benefits of a modern
medical doctor?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
44. Suppose that, after a Hmong person seeking help from a shaman, a healer/soul
caller, and an herbalist, and if the illness is still present, what suggestions do you
have for the Hmong community?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
45. In your view, how valuable is traditional medicine?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
46. In your view, what is your understanding of illness?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
94
47. In case you were born and raised in Laos or Thailand, has your understanding of
illness changed in past years?
a. ________ Yes
b. ________ No
c. ________ Refused
48. If YES, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
49. If NO, please explain:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
95
APPENDIX C
Questionnaires in Hmong
1. Koj lub noob nyoog yog nyob ntawd li cas?
a.
b.
g.
h.
i.
j.
21-28
29-36
37-44
45-52
53-60
61 or over
2. Koj yog:
a. Txiv neej
b. Poj niam
3. Koj yug rau qhov twg?
a.
b.
Teb chaws Meskas
Tsis yog teb chaw Meskas. Thov qhia saib koj yus rau teb chaw twg:
__________________________
4. Koj:
a.
b.
c.
d.
Muaj txiv los yog muaj poj niam lawm
Sib nrauj lawm
Poj ntsuam, yawg ntsuag
Tsis tau muaj txiv tsis tau muaj poj niam
5. Koj kawm ntawv txog qib twg:
a.
b.
c.
d.
e.
f.
Kawm tsis tau tag thawj qib
Kawm tag thawj qib
Kawm me ntsis qib siab
Kawm tas ob xyoo qib siab (Associate Degree)
Kawm tag qib siab
Kawm dhau qib siab
96
6. Koj kawm ntawv nyob teb chaw twg?
a. Teb chaws Meskas
b. Tsis nyob rau teb chaws Meskas. Thov sau lub teb chaws ntawd npe:
__________________________
7. Koj nyob teb chaws Mekas tau pes tsawg xyoo lawm?
__________________________
8. Koj nkag siab lus Meskas ntau npaum li cas?
a.
b.
c.
d.
Tsis nkag siab li
Nkag siab thiab
Nkag siab zoo
Nkag siab zoo heev
9. Koj txawj hais lus Meskas npaum li cas?
a.
b.
c.
d.
Tsis txawj hais lus Meskas li
Txawj hais lus Meskas thiab
Txawj hais lus Meskas zoo
Txawj hais lus Meskas zoo heev
10. Koj txawj nyeem ntawv Meskas npaum li cas?
a.
b.
c.
d.
Tsis txawj nyeem li
Txawj nyeem me ntsis thiab
Txawj nyeem zoo
Txawj nyeem zoo heev
11. Koj txawj sau ntawv Meskas npaum li cas?
a.
b.
c.
d.
Tsis txawj sau ntawv li
Txawj sau ntawv me ntsis thiab
Txawj sau ntawv
Txawj sau ntawv heev
12. Koj txoj kev ntseeg yog dab tsis? Koj yuav hais tias yog…
a. Coj kev cai qub
b. Coj kev cai tshiab
c. Lwm yam, thov qhia: __________________________
97
13. Ntawm koj tsev neeg, hais txog kev mob nkees, leej twg yog tus yuav sawv cev
thiab txiav txim hais txog kev kuaj mob rau sab Meskas? Koj yuav hais tias yog…
a.
b.
c.
d.
e.
f.
______ Leej txiv
______Leej niam
______Cov kwv los cov muam
______Cov neeg laus hauv yus tsev neeg
______Tus thawj coj hauv koj xeem
Lwm yam, thov qhia: __________________________
14. Yog koj tsev neeg ib tus twg muaj mob, koj yuav mus cuag leej twg ua ntej?
(Thov khij ib yam xwb). Koj yuav hais tias yog…
a.
b.
c.
d.
e.
Txiv neeb
Tus kws khawv koob/hu plig
Kws tshuaj ntsuab
Kws tshuaj Meskas
Lwm yam, thov qhia: _____________________
15. Thaum tus neeg sawv cev thiab txiav txim hais txog kev mob nkeeg tsis khoom
los yog tsis nyob lawm, leej twg yog tus yuav los sawv cev?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
16. Koj txoj kev xav zoo li cas rau kev kuaj mob sab Meskas xwb? Thov qhia me
ntsis koj txoj kev xav rau sab kev kuaj mob.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
17. Puas tau muaj tej lub sij hawm yav tas los uas koj tsis xav mus ntsib kws kho mob
Meskas?
a. ________Muaj
b. ________ Tsis muaj
c. ________ Tsis kam teb
98
18. Yog muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
19. Yog tsis muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
20. Yog yav tas los koj tau ntsib kws kho mob Meskas, koj puas tau ntsib teeb meem
los yog muaj kev txhawj xeeb dua li?
a. _______ Muaj
b. _______ Tsis muaj
c. _______Tsis kam teb
21. Yog muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
22. Yog tsis muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
23. Ntawm koj txoj kev xav ne, koj tus kws kho mob Meskas puas paub txog koj keeb
kwm?
a. ________ Paub
b. ________ Tsis paub
c. ________ Tsis kam teb
24. Yog paub, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
99
25. Yog tsis paub, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
26. Koj tus kws kho mob Meskas puas tau uas tej yam saib tsis taus koj dua los li?
a. ________ Muaj
b. ________ Tsis muaj
c. ________ Tsis kam teb
27. Yog muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
28. Yog tsis muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
29. Ob peb xyoos tas los no, koj tus kws kho mob Meskas puas tau saib koj tsis muaj
nuj nqis?
a. ________ Muaj
b. ________ Tsis muaj
c. ________ Tsis kam teb
30. Yog muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
31. Yog tsis muaj, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
32. Zaum tas los no, koj mus ntsib koj tus kws kho mob Meskas yog thaum twg?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
100
33. Koj puas xav hais tias nws tseem ceeb heev uas koj tus kws kho mob Meskas
paub txog thiab to taub txog koj tej kab lig kev cai?
a. ________ Tseem ceeb
b. ________ Tsis tseem ceeb
c. ________ Tsis kam teb
34. Yog tseem ceeb, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
35. Yog tsis tseem ceeb, thov piav me ntsis los:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
36. Koj puas tau mus nrhiav kev pab los ntawm ib tus txiv neeb (kev ua neeb ua yaig)
dua li?
a. ________ Tau lawm
b. ________ Tsis tau li
c. ________ Tsis kam teb
37. Yog nrhiav kev pab lawm no, koj sim qhia seb kev ua neeb ua yaig muaj txiaj
ntsim li cas?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
38. Koj puas tau mus nrhiav kev pab los ntawm ib tug neeg txawj khawv koob/hu plig
dua li?
a. ________ Tau lawm
b. ________ Tsis tau li
c. ________ Tsis kam teb
101
39. Yog nrhiav kev pab lawm no, koj sim qhia seb kev ua khawv koob/hu plig pab
muaj txiaj ntsim li cas?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
40. Koj puas tau nrhiav kev pab los ntawm ib tus kws muab tshuaj ntsuab dua li?
a. _________ Tau lawm
b. _________ Tsis tau li
c. _________ Tsis kam teb
41. Yog nrhiav kev pab lawn no, koj sim qhia seb kev siv tshuaj ntsuab muaj txiaj
ntsim li cas?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
42. Koj puas tau mus nrhiav kev pab ntawd ib tus kws kho mob Mesksa dua los li?
a. _________ Tau lawm
b. _________ Tsis tau li
c. _________ Tsis kam teb
43. Yog tau nrhiav kev pab lawm, koj sim qhia txog tias tus kws kho mob Meskas
muaj txiaj ntsim li cas?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
44. Yog thaum ib tus neeg mob tau txais kev pab los ntawm ib tus txiv neeb, ib tus
kws khawv koob/hu plig, thiab ib tus kws muab tshuab ntsuab tiabsis nws tus mob
tsis zoo. Koj muaj lub tswv yim li cas los qhia koj haiv neeg Hmoob?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
45. Nyob ntawm koj txoj kev xav, hmoob tshuaj ntsuab muaj nuj nqes npaum li cas?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
102
46. Nyob ntawm koj txoj kev xav, koj to taub thiaj nkag siab li cas txog txoj kev mob
nkees?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
47. Yog koj yug los loj hlob nyob rau Nploj Teb los Thaib Teb, koj txoj kev to taub
thiab nkag siab txog kev mob nkeeg puas tau hloov pauv li?
a. ________ Hloov lawm
b. ________ Tsis tau hloov
c. ________ Tsis kam teb
48. Yog hloov pauv lawm, thov qhia hais tias hloov li cas:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
49. Yog tsis tau hloov pauv, thov qhia tias yog li cas thiaj tsis hloov pauv:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
103
REFERENCES
Allen, M., Matthew, S., & Boland, M. (2004). Working with immigrants and refugee
populations: Issues and Hmong case study. University of Illinois Press, 53(2),
301-328.
Asgary, R. & Segar, N. (2011). Barriers to health care access among Refugee Asylum
Seeker. Journal of Health Care for the Poor and Underserved. 22, 506-522.
Barrett, B., Shadick, k., Schilling, R., Spencer, L., Rosario, S., Moua, K. & Vang, M.
`
(1998). Hmong/medicine interactions: Improving cross-cultural health care.
Family Medicine, 30(3). 179-1984.
Bliatout, B.T. (1991). Hmong healing practitioners. Hmong Forum, 2, 58-65.
Burgess, A. (2004). Health challenges for refugee and immigrants. In Refugee Reports: A
News Service of Immigration and Refugee Services of America, 25(2), 1-20.
Capps, L.L. (1994). Change and continuity in the medical culture of the Hmong in
Kansas City. Medical Anthropology Quaterly, 8(2), 161-177.
Capps, L.L. (2011). Ua Neeb Khu: A Hmong American healing ceremony. Journal of
Holistic Nursing, 29(2), 98-106.
Cha, D., Vue, M. Z. & Carmen, S. (2004). Field guide to Hmong culture. Madison, WI:
Madison Children's Museum. Retrieved from
http://csumc.wisc.edu/cmct/HmongTour/howwedidit/HMONG_FIELD_GUIDE_
WEB.p df
104
Chang, M., Feller, E., & Nimmagadda, J. (2009). Barriers to healthcare access in the
Southeast Asian community of Rhode Island. Medicine & Health, 92(6). 310313.
Chung, R.C. & Lin, K. (1994). Help-seeking behavior among Southeast Asian refugees.
Journal of Community Psychology, 22, 109-120.
Cobb, T.G. (2010). Strategies for providing cultural competent health care for Hmong
Americans. Journal of Cultural Diversity, 17(3), 79-83.
Culhane-Pera, K.A. & Xiong, P. (2003). Hmong culture: Tradition and change. In K. A.
Culhane-Pera, D. E. Vawter, P. Xiong, B. Babbitt & M.M. Solberg (Eds.).
Healing by heart. Clinical and ethical case stories of Hmong families and
Western providers (pp. 11-68). Nashville: Vanderbilt University Press.
Culhane-Pera, K. A., Vawter, D. E., Xiong, P., Babbitt, B. & Solberg, M. M. (2003).
Healing by heart: Clinical and ethical case stories of Hmong families and
Western providers. Nasville: Vanderbilt University Press.
Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her
American doctors, and the collision of two cultures. New York: Farrar, Straus,
and Giroux.
Fang, D. M., Lee, S., Stewart, S., Ly, M. Y. & Chen, M. S. (2010). Factors associated
with pap testing among Hmong women. Journal of Health Care for the Poor and
Underserved, 21, 839-850.
105
Foote, M. & Matloub, J. (2010) Determining practices for reporting Hmong cancer cases
in Wisconsin special supplement: Cancer incidence data for Hmong. Surveillance
Brief, 6(4), 1-4.
Gilman, S. C., Justice, J., Saepharn, K. & Charles, G. (1992). Use of traditional and
modern health services by Laotian refugee: In cross-cultural medicine a decade
later. Western Journal of Medicine,157(3), 310-315.
Johnson, S. K. (2002). Hmong health beliefs and experiences in the Western health care
system. Journal of Transcultural Nursing, 13, 126-132.
Hamilton-Merritt, J. (1993). Tragic mountains: The Hmong, the Americans, and the
Secret Wars for Laos, 1942-1992. Indiana: Indiana University Press.
Henry J. Kaiser Family Foundation. (2010). Summary of new health reform law. Focus
on Health Reform. Retrieved December 115, 2011 from
http://www.kff.org/healthreform/upload/8061.pdf
Her, C. & Culhane-Pera, K. A. (2004). Culturally responsive care for Hmong patients:
Collaboration is a key treatment component. Postgraduate Medicine,116(6), 3946.
Hickman, J. R. (2007). “Is it the spirit or the body?”: Syncretism of health beliefs among
Hmong immigrants to Alaska. Napa Bulletin, 27, 176-195.
Higgs, Z.R. & Rairdan, B. (1992). When your patient is a Hmong refugee. The American
Journal of Nursing, 96(3), 52-55.
106
Hsu, E., Davies, C.A. & Hansen, D.J. (2004). Understanding mental health needs of
Southeast Asian refugees: Historical, cultural, and contextual challenges. Clinical
Psychology Review. 24, 193-213.
Krista-Ashman, K. K. & Hull, G. H. Jr. (2006).Understanding Generalist Practice.
Belmont, CA: Brooks/Cole.
Kruger, L. (2007). Wisconsin Hmong experiences with hemodialysis. Thesis Master of
Career and Technical Education at University of Wisconsin, Menomonie.
Lee, H. Y., Lytle, K., Yang, P. .N., & Lum, T. (2010). Mental health literacy in Hmong
and Cambodian elderly refugees: A barrier to understanding, recognizing, and
responding to depression. International Journal of Aging and Human
Development, 71(4), 323-344.
Leibowitz, A. H. (1983). The Refugee Act of 1980: Problems and congressional
concerns. The American Academy of Political and Social Science, 467, 163-171.
Ma, G. X. (1999). The culture of health: Asian communities in the United States.
Westport, Connecticut, Bergin & Garvey.
Massachusetts Department of Public Health [MDPH]. (2007). Chapter 16: Refugee and
immigrant health care. Retrieved December 12, 2011 from
http://www.maclearinghouse.com/SchoolHealthManualSite/schoolhealthmanual/P
DF/Chapters/Chapter16_D.pdf
Mills, P. K. & Yang, R. (1997). Incidence in the Hmong of Central California, United
States, 1987-94. Cancer Causes & Control, 8(5), 705-712.
107
Mills, P. K., Yang, R., & Riordan, D. (2005). Cancer incidence in the Hmong in
California, 1988-2000. Cancer, 104(12 Suppl), 2969-2974.
Muecke, M. A. (1983). In search of healers-Southeast Asian refugees in the American
health care system. Western Journal of Medicine, 139(6), 835-840.
National Association of Social Workers [NASW]. (2005). NASW standards for social
work practice in health care setting. Retrieved from
http://www.naswdc.org/practice/standards/NASWHealthCareStandards.pdfRefug
ee
New Mexico Department of health. (n.d.). Culturally and Linguistically Appropriate
Services (CLAS) Toolkit. Retrieved from http://nmdohcc.org/files/DRCLAS%20instrument%20final%208-18-09.pdf
Office of Global Health Affair. (2004). Background on potential health issues for Hmong
refugees from Wat Tham Krabok, Bethesda, MD: U.S. Department of Health and
Human Services.
Parker, M. & Kiatoukaysy, L.N. (1999). Culturally responsive health care: The example
of the Hmong in America. Journal of the American Academy of Nurse
Practitioners, 11(12), 511-518.
Perez, M. A. & Cha, K. (n.d). Diabetes knowledge, beliefs, and treatments in the Hmong
population: An exploratory study. Hmong Studies Journal, 8, 1-21.
108
Pfeifer, M.E. & Lee, S. (2004). “Hmong population, demographic, socioeconomic, and
educational trends in the 2000 census.” Hmong 2000 Census Publication: Data
and Analysis. Saint Paul, MN: Hmong Cultural Center and Washington D.C.:
Hmong National Development, 3-11.
Pinzon-Perez, H. (2006). Health issues for the Hmong population in the U.S.:
Implications for health educators. International Electronic Journal of Health
Education, 9, 122-133.
Platnikoff, D. A., Numrich, C., Wu, C., Yang, D. & Xiong, P. (2002). Hmong
shamanism: Animist spiritual healing in Minnesota, Minnesota Medicine, 85(6),
29-34.
Rairdan, B. & Higgs, Z. R. When your patient is a Hmong refugee. American Journal of
Nursing, 92(3), 52-55.
Robbins, S., Chatterjee, P., & Canda, E. (2006). Contemporary human behavior theory:
A critical perspective for social work. Boston: Allyn and Bacon.
Robert Wood Johnson Foundation. (2011). The immigrants and refugees new arrivals
advocacy project: Expanding legal advocacy to increase the access of immigrant
and refugee children to education and health services. Retrieved December 12,
2011 from http://www.rwjf.org/files/research/63239vp1.pdf
Robert Wood Johnson Foundation. (2006). Living in America: Challenges facing new
Immigrants and Refugees. Retrieved on December 12, 2011 from
http://www.policyarchive.org/handle/10207/bitstreams/21623.pdf
109
Rubin, A. & Babbie, R. (2011). Research method for social work. Belmont, CA:
Brooks/Cole
Schriver, J. (2011). Human behavior and the social environment (5th Ed). Needham Hts., MA:
Allyn and Bacon.
See, P. (2003). Awareness points for interacting with Hmong/Southeast Asian students
[Handout]. Retrieved March 13, 2011, from
http://www.uwec.edu/asc/Tutors/Awarepts/AsAmStu.pdf
Sheikh, M.Y., Mouanoutoua, M., Walvick, M.D., Khang, L., Singh, J., Stoltz, S. & Mills,
P. K. (2011). Prevalence of hepatitis B virus (HBV) infection among Hmong
immigrants in the San Joaquin Valley. Journal of Community Health, 36, 42–46.
doi: 10.1007/s10900-010-9283-0.
Spector, Rachel E. (2009). Cultural diversity in health and illness (7th edition). Upper
Saddle River, NJ: Pearson Prentice Hall.
Sperstad, R. A. & Werner, J. S. (2005). Coming to the cultural “in-between”: Nursing
insights from a Hmong birth case study. Journal of Obstetric, Gynecologic, &
Neonatal Nursing, 34 (6), 682-688.
Tanjasiri, S. P., Kagawa-Singer, M., Foo, M.A., Chao, M., Linayao-Putman, I., Nguyen,
J., . . . Valdez, A. (2007). Designing culturally and linguistically appropriate
health interventions: The “Life is precious” Hmong breast cancer study. Health
Education & Behavior, 34(1), 140-153.
110
Tripp-Reimer, T., Choi, E., Kelley, L.S., & Enslein, J.C. (2001). Cultural barriers to
care: Inverting the problem. Diabetes Spectrum, 14(1), 13-22.
Uba, L. (1992). Cultural barriers to health care for Southeast Asian refugees. Public
Health Reports, 107(5), 544-548.
U.S. Census Bureau. (2000). Census 2000 demographic profile highlights. Retrieved
from
http://factfinder2.census.gov/faces/nav/jsf/pages/searchresults.xhtml?ref=ci&refre
sh=t
U.S. Census Bureau. (2010). 2010 American Community Survey 1-Year Estimates.
Retrieved from
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid
=ACS_10_1YR_S0201&prodType=table
U.S. Citizenship and Immigration Services. (2011). Immigration Reform and Control Act
of 1986 (IRCA). Retrieved from
http://www.uscis.gov/portal/site/uscis/menuitem.5af9bb95919f35e66f614176543f
6d1a/?vgnextchannel=b328194d3e88d010VgnVCM10000048f3d6a1RCRD&vgn
extoid=04a295c4f635f010VgnVCM1000000ecd190aRCRD
U.S. Department of Health and Human Services [DHHS] Office of Minority Health
[OMH]. (2001). National standards for culturally and linguistically appropriate
services in health care. Retrieved from
http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
111
U.S. Department of Health and Human Services [DHHS] Office of Minority Health
[OMH]. (2011). Hepatitis data/statistics. Retrieved from
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=541
U.S. Department of Health and Human Services [DHHS] Office of Minority Health
[OMH]. (2008). Chronic Hepatitis B in Asian Americans, Native Hawaiians
and Other Pacific Islanders: Background. Retrieved from
http://minorityhealth.hhs.gov/templates/content.aspx?ID=7240
U.S. Department of Health and Human Services. (2010). The Refugee Act. Retrieved
from http://www.acf.hhs.gov/programs/orr/policy/refact1.ht
Vue, C. B. (2008). Historical and contemporary overview of General Vang Pao and
higher education attainment of the Hmong people. Thesis. Master of Social Work
at California State University, Sacramento.
Warmer, M. E. & Mochel, M. (1998). The Hmong and health care in Merced, California.
Hmong Studies Journal, 2(2), 1-30.
Watters, C. (2001). Emerging paradigms in the mental health care of refuges. Social
Science and Medicine, 52, 1709-1718.
Xiong, J. L. G. (1994). Attitudes of Hmong toward surgery: A comparative study.
Thesis, Master of Social Work at California State University, Sacramento.
Yang, R. C., Mills, P. K. & Riordan, D. G. (2004). Cervical cancer among Hmong
women in California, 1988 to 2000. American Journal of Preventive Medicine,
27(2), 132-138. Doi:10.1016/j.amepre.2004.04.003.
112
Yee, B. W. K. (2011). Health and health care of Southeast Asian American elders:
Vietnamese, Cambodian, Hmong and Laotian elders. Department of Health
Promotion and Gerontology. 1-26.