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<run head>The National Cambodian American Town Hall Meeting
<run author>Kuoch et al.
<T>The National Cambodian American Town Hall Meeting: A Community Dialogue on “Eat,
Walk, Sleep” for Health
<author>Theanvy Kuoch, MA, LPC1, Mary Scully, RN, CS1, Heang Kim Tan, BA3,
Thiruchandurai V. Rajan, MD, PhD2, and Julie Wagner, PhD2
<info>(1) Khmer Health Advocates; (2) University of Connecticut Health Center; (3) Society for
New Communications Research, Inc./Health Justice CT
<abstract subhead>Abstract
<abstract>Background: The 2009 National Cambodian American Town Hall Meeting was a
public–private partnership convened to address long-term health issues related the Cambodian
holocaust. Goals for participants were to dispel myths about diabetes; goals for the partnership
were to build research capacity and to strengthen relationships.
Methods: Partners collaborated on all aspects of the meeting which was held in Khmer by
bridged videoconferencing in 10 sites and webinar at 5 sites across the United States over a 3hour period. EAT, WALK, SLEEP for Health (EWS), the National Cambodian American
Diabetes Project program, provided the framework for the meeting.
Results: Pre and post surveys were completed by 323 participants. Modest improvements were
seen in participants’ belief that they could improve their own and their community’s health,
although significant barriers remained. Participants and community partners evaluated the
meeting positively.
Conclusions: The meeting is a model for other populations, and results inform future work.
<abstract subhead>Keywords
2
<abstract>CBPR, metabolic syndrome, refugee, Cambodian
Submitted 2 January 2013, revised 18 July 2013, accepted 2 July 2013
<N>The main wave of Cambodian immigration to the United States occurred in 1975, when
refugees fled the Cambodian holocaust led by the Khmer Rouge. These communities resettled in
small pockets across the United States.1 They have suffered from high rates of persistent
posttraumatic stress disorder and depression,2 as well as poor access to services for medical and
mental health problems3 and associated disability.4 Since the 1990s, there has been shared
concern among community agencies serving Cambodian Americans regarding the population’s
rates of diabetes, stroke, liver disease, and early mortality.5 Documenting and intervening on
these medical problems has been hampered by a lack of resources, and a population that is
spread across the country and wary of involvement in mainstream programs owing to a history of
systematic persecution. A lack of data on the national level has limited the ability of community
agencies to garner funding to address these concerns. Means are sorely needed to efficiently
gather health data and deliver health promotion campaigns in this widely dispersed and very low
literacy population.
Community-based participatory research (CBPR) was used to connect and mobilize the
fearful, socially isolated, and economically disenfranchised members of these communities for a
national meeting.6 The 2009 National Cambodian American Town Hall Meeting was convened
to address the community’s health and mental health issues related to trauma. The goals of the
meeting for participants were to dispel myths about diabetes and to instill hope regarding the
prevention and management of diabetes. The goals of the meeting for the partnership were to
socialize partners to the research process, and to strengthen relationships among community
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agencies and between community leaders and participants. This paper reports the process of
planning, conducting, and evaluating the meeting.
<A>Methods
<B>Formation of Partners
<N>The National Cambodian American Health Initiative is a coalition of Cambodian leaders
from across the country that was formed in 2003. In 2006, it convened a community forum to
inform the development of diabetes educational materials. The 2006 forum was a 6-hour factfinding event that brought together 410 Cambodian community members and experts on
Cambodian health from 12 states to discuss the health issues of survivors.7 The Cambodian
Heritage Museum and Killing Fields Memorial of Chicago, Illinois, hosted the event, which
linked seven sites by bridged videoconferencing and webcast.
To prepare for the 2009 meeting reported herein, sites from the 2006 forum held a series
of conference calls, and efforts were made to reach out to additional agencies. The National
Cambodian American Health Initiative engaged 14 agencies. Any agencies that wished to be
involved were invited to do so; three additional sites joined the partnership. Partners were
community-based organizations, federally funded community health centers, federal health
programs, and private businesses, and included more than 15 Cambodian-serving organizations
and health clinics. Funding came from the Centers for Disease Control and Prevention, the
National Diabetes Education Program, the Racial and Ethnic Approaches for Community Health
across US Program, and the Office of Refugee Resettlement Torture Victim Program. Polycom,
Inc., and HB communications provided technical support for the meeting.
<B>Technical Preparation
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<N>A bridged videoconference can be thought of as a traditional conference call, but with the
addition of live video. Ten sites used bridged videoconferencing at the meeting. For the meeting,
a split screen was used in which the speaker was seen in a large section of the screen while other
participants were still seen simultaneously. The Community Health Center in Danbury,
Connecticut, hosted the event by providing access to their network and use of their
videoconferencing system.
Sites that were not able to connect by bridged videoconferencing provided access to a
webinar. A webinar allows the viewer to watch the live conference, but not interact with it. Five
meeting sites provided webinar viewing for community members.
<B>Preparation of Partners
<N>The National Cambodian American Diabetes Project worked extensively with partners
before the meeting to assist in preparations. The technical director for Khmer Health Advocates
was responsible for setting up and testing the technology for the meeting. Polycom provided the
necessary software for videoconferencing for sites that did not have equipment. Site setup and
testing took more than 60 hours and represented an unfunded commitment from the partner sites.
<B>Content Development
<N>The speaker at the Town Hall Meeting was Dr. Lim Keuky. Dr. Keuky was born and raised
in Cambodia and earned a doctorate degree in Pharmacology and a DEA in Endocrinology from
the University of Paris. He was a consultant to the United Nations Development Program in
Cambodia and the World Health Organization focusing on diabetes and is currently the Director
of the Diabetes Association of Cambodia. He is trilingual and was able to speak with personal
and professional expertise in lay Khmer language using cultural idioms and kinship terms.
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Dr. Keuky spoke for 15 minutes, and for the remainder of the 3-hour meeting he
responded to questions. All partners were invited to submit questions from community members
to Dr. Keuky that would help to guide the narrative of the meeting. One volunteer from each site
asked one question. These were submitted in advance and considered in the preparation of
surveys. Thus, the meeting was thematic but not highly structured.
Content from EWS8 provided the framework for Dr. Keuky’s presentation and his
responses to questions. EWS is a bilingual Khmer/English, manualized, educational toolkit for
community health workers that includes props, pictures, handouts, and a spoken format CD (a
computer interface that reads aloud pre-recorded content for those who cannot read text). The
approach of EWS emphasizes personal action to prevent and control chronic illness through
traditional Cambodian concepts rooted in Buddhism.
<B>Measures
<N>The development of the survey was a key function of the meeting. This is because one goal
of the National Cambodian American Health Initiative is to increase research capacity in the
Cambodian community. The aim was to ensure that Cambodians were involved in developing,
evaluating, and collecting data so that Cambodians could direct research activities in their own
communities. Because 90% of the educated population was killed by the Khmer Rouge, and
because local agencies are overwhelmed with service delivery, there is a need to build human
resource capacity for research. Thus, in addition to collecting data per se, we also aimed to
socialize partners to the research process.
Domains of interest (e.g., self-reported diseases) were identified by leaders from each
site, and survey questions were developed in an iterative process with the larger partnership. Two
predominant themes of questions submitted by the partnership were, “I have diabetes, am I going
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to die?” and “Can I improve my health even though I am sick now?” Questions were written in
English, translated into Khmer, and backtranslated into English by a bilingual individual who
had not seen the original English.
Survey questions included age, gender, ethnicity, and subjective health status. We used
the format from the Behavioral Risk Factor Surveillance System for self-report of physiciandiagnosed conditions (e.g., diabetes, posttraumatic stress disorder). Other questions included
health-promoting behaviors (e.g., exercise and diet), health beliefs (e.g., trust of Western vs.
traditional medicine), and an evaluation of Dr. Keuky’s presentation. Participants were also
asked about intentions to change health behaviors, and barriers to health behavior change. No
HIPAA identifiers were collected. Pre and post surveys were not coded; thus, individual-level
responses at pre and post timepoints could not be linked. Evaluation of the survey data was
approved by the University of Connecticut Health Center Institutional Review Board.
<B>Survey Administration
<N>Community members were invited to attend the meeting by word of mouth and posters at
Cambodian establishments around the respective sites. There was no incentive for attendance or
completion of the pre–post surveys. At each site, six volunteer community health workers
administered the pre and post surveys. The surveys were conducted on site immediately before
and after the conclusion of the 3-hour meeting. Surveys were printed in and conducted in both
Khmer and English. Participants who requested it could have the survey questions read to them
by a volunteer. These volunteers were trained by program staff regarding the purpose of the
survey, how to socialize participants to the survey, and the voluntary and anonymous nature of
the survey. Only attendees who were physically present at one of the ten bridged
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videoconferencing sites participated in pre and post surveys; there were no surveys available for
those attending by webinar.
<A>Results
<B>Participants
<N>Table 1 provide for participant characteristics. Of approximately 400 attendees, 378
completed the pre survey, and 323 completed the post survey (an average of 38 and 32 per site).
Mean age 54.5 years (SD, 14.0); 93.7% described their ethnicity as Cambodian and 4.1% as
Cambodian American. Sixty-five percent were female, which reflects the greater proportion of
women in the Cambodian-American population. More than one half of participants reported one
or more chronic illnesses; 31.7 % reported diabetes.
<T>Table 1
<B>Response to EWS
<N>Table 1 shows pre and post survey results. Compared with before the meeting, after the
meeting the percent of people who believed they could improve their own health increased by
14%. The most common health behavior intentions included limiting rice intake, increasing
physical activity, and talking to a doctor about sleep problems. Common barriers to self-care
included needing assistance, needing information, and lack of resources. A high percentage of
participants (89.2%) reported that they believe that EWS can help to them stay healthy.
The percent of people who believed they could improve their community’s health
increased by 10%. Commonly endorsed methods for doing so included referring friends and
family for help, distributing health information, and contacting their Cambodian association. The
most common barriers to these actions included lack of knowledge, lack of transportation, and
fear.
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<B>Evaluation of the Town Hall Meeting
<N>Table 2 shows evaluation of the meeting. The vast majority of participants rated the meeting
as good to excellent (96%). Dr. Keuky was warmly received. Nearly all (94%) rated the
discussion as good to excellent, and the majority said that the length of the meeting was just right
(66%). However, almost half (42%) wanted to talk but did not get the chance.
<T>Table 2
<B>Dissemination
<N>After the meeting, data were analyzed and sent to partners in a six-page written summary
statement and data tables aggregated by site. In addition, community health workers were given a
single page, 10-bullet summary and were encouraged to share the information with their clients.
<A>Discussion
<N>The main finding reported herein is that the National Cambodian Town Hall Meeting was a
successful public–private partnership that employed traditional health messages and high-tech
delivery for addressing chronic disease and trauma among resettled Cambodian refugees.
Conducting the meeting through this mechanism brought together geographically isolated
communities, increased the self-efficacy of local organizations regarding use of technology and
conduct of research, and increased efficiency by sharing resources.
The fact that the meeting was so well received by participants may be owing to several
factors. Although the reach was highly dependent on technology, the keynote speaker was live,
in person, and interactive with the audience. We believe that this human dimension to the hightech delivery was central to the program’s success. EWS itself was developed using a CBPR
process, and thus the content of the meeting was highly relevant to participants. Messages were
also delivered in an appropriate linguistic and cultural context. Moreover, messages were
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delivered by a highly respected and trusted leader of the community, Dr. Keuky. It should be
noted that a substantial minority did report that they wanted to speak during the meeting, but did
not have the chance. This feedback suggests that, despite fear, this community will communicate
given the appropriate setting. Future endeavors should do more to ensure that participants have a
chance to speak, such as through email, a chat room, or blog. Literacy issues in the population,
the inability of many community health workers to read Khmer, and access to technology may
limit these possibilities, although spoken-format technology is promising. Khmer Health
Advocates and the National Cambodian American Health Initiative are currently testing the use
of “spoken-format” questionnaires delivered by hand-held mobile devices.
We found a modest increase in the participants’ belief in their ability to improve their
own health. A high percentage (89.2%) of participants reported that they believe that EWS can
help them to stay healthy. Health beliefs are important in determining health behaviors, such as
medication compliance, diet, and physical activity.9 Beliefs about controllability are even better
predictors of health behaviors than perceived barriers to treatment.10 They are also stronger and
more consistent predictors of outcomes than other psychosocial measures.11 It should be noted,
however, that participants continued to report contextual barriers to improving their own and
their community’s health. Thus, programs such as EWS, although promising, will only be truly
successful if contextual barriers are also addressed.
Partnerships that attempt to feed CBPR data back to the community face numerous
challenges.12 We returned aggregated findings to the sites. We also returned simplified data that
were then shared with and explained to participants via community health workers. Anecdotal
accounts suggest that seeing the evidence of a large number of participants across the country
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decreased a sense of isolation by making participants feel like part of something larger than
themselves or their local community.
<B>Continuity of Partnership
<N>Partnerships established through the meeting have been successfully maintained. The
partnership meets face to face annually and has applied for three national grants since the
meeting. The partnership has also worked together to formulate a national service delivery model
called Cambodian American Medical Home Program, which addresses many of the barriers to
care reported by meeting participants.
The partnership has also benefited from the socialization to the research process that they
experienced through the meeting. For example, a community-based research project has since
been undertaken to determine the feasibility of using computer tablets with spoken format for
data collection from Cambodians in six states.13 Five of the six sites in this spoken-format
research project were part of the 2009 Town Hall Meeting.
<B>Limitations
<N>First, all data were self-reported, and pre and post surveys were not linked. Those who
attended but chose not to complete the surveys, or who chose to complete only pre but not post
surveys may have created bias in the results. The use of community volunteers may have created
demand characteristics.
<B>Future Directions
<N>The meeting serves as one example of a CBPR approach to mobilizing marginalized
communities. Addressing chronic illness in Cambodian Americans is challenging, because local
populations are small, their health issues are complex, and there is a wide cultural divide
between Western and traditional health beliefs and healing strategies. Resources for refugees in
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general are dwindling at the national level, and are often allocated to high population density
areas, leaving the needs of smaller communities unaddressed. The ability to connect
communities and speak with a unified voice makes the needs of even these smaller communities
more influential on policy and funding directives. Videoconferencing is one way to do so. In the
3 years since the Town Hall Meeting, videoconferencing has become cheaper, faster, more
reliable, more sophisticated, and more readily available. The 2009 Meeting required outside
vendors to provide bridged videoconferencing. Now, the partnership has created its own capacity
for bridging meetings. Use of this tool to gather data and deliver culturally sensitive and
inherently human interventions could be generalizable to other small and widely dispersed
underserved groups.
<A>Acknowledgments
<N>The authors thank the staff and administration of the following organizations for their
contributions to this process: Cambodian Association of America, United Cambodian
Community, Friends of Mount Carmel, Cambodian Family of Santa Ana, Immigrant and
Refugee Community of Oregon, Cambodian Association of Illinois, Cambodian Association of
Minnesota, Alliance of Multicultural Community Services of Houston, Cambodian Association
of Greater Philadelphia, Cambodian Mutual Assistance Association of Lowell, Metta Clinic of
the Lowell Community Health Center, Social Economic Development Center For South East
Asians. Special thanks to Dr. Deborah Jeffrys of Polycom, Inc., who coordinated the use of the
telecommunications equipment and software and to David Marinelli of HB Communications for
his technology support and troubleshooting efforts.
12
Funding for this study was provided by the National Diabetes Education Program, Office
of Refugee Resettlement Services for Victims of Torture, REACH US project of the Centers for
Disease Control.
<A>References
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Community Survey [cited 2013 Apr 26].Available from: Factfinder2.census.gov
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Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005;294:571-9.
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Wagner J, Burke G, Kuoch T, Scully M, Armeli S, Rajan TV. Trauma, healthcare access,
and health outcomes among Southeast Asian refugees in Connecticut. J Immigr Minor Health.
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Mirza M, Heinemann AW. Service needs and service gaps among refugees with
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Wong EC, Marshall GN, Schell TL, Elliott MN, Babey SH, Hambarsoomians K. The
unusually poor physical health status of Cambodian refugees two decades after resettlement. J
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<table number>Table 1. <table title>Cambodian American Health Survey Responses Measured
Pre-Meeting (n = 378) and Post-Meeting (n = 323)
<table>
Survey Question
PrePost-Meeting, n
Meeting,
(%)
n (%)
Can you read this form without any help? (Yes)
272 (72.0)
If you read this form without any help, can you read it in
Khmer?
212 (77.9)
English?
91 (33.5)
Do you have the ability to improve your health? (Yes)
248 (65.6)
255 (78.9)
What will you do to improve your health?
Limit my rice to one bowl per meal
262 (81.1)
Walk 30 minutes 6 times a week
173 (53.6)
Walk 30 minutes 3 times a week
155 (48.0)
Get help from my doctor if I cannot sleep
164 (50.8)
Talk with my family and friends about preventing diabetes
157 (48.6)
None
5 (1.5)
What are some reasons you would not try?
I don’t have the resources
157 (48.6)
I think that it is my Karma
125 (38.7)
I think I need help to improve my health
175 (54.2)
I think I need more information
143 (44.3)
I don’t have any energy to help myself
93 (28.8)
I don’t care if I die
70 (21.7)
None
45 (13.9)
Do you have the ability to help your community to improve
180 (47.6)
188 (58.2)
their health? (Yes)
What are some things you will do for your community?
Talk to my Cambodian organization about how I can help
192 (59.4)
Talk to other people about where they can get help
213 (65.9)
Distribute information about diabetes, stroke, and mental
162 (50.2)
health
Talk to my doctor about diabetes and stroke in Cambodians
146 (45.2)
Advocate for community health workers (more helpers)
137 (42.4)
None
14 (4.3)
What are some reasons you would not try?
I don’t think anything will help
82 (25.4)
I don’t know enough
174 (53.9)
It’s hard for me to get out of my house
116 (35.9)
It’s not my job
52 (16.1)
I am afraid
112 (34.7)
I need help to organize
108 (33.4)
None
21 (6.5)
15
“EAT, WALK, SLEEP for Health” can keep me healthy.
(Agree)
288 (89.2)
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<table number>Table 2. <table title>Participant Evaluation of the Town Hall Meeting (n = 323)
<table>
Questions and Possible Responses
n (%)
How would you rate the meeting as a whole?
Poor
5 (1.5)
Fair
8 (2.5)
Good
88 (27.2)
Very good
76 (23.5)
Excellent
130 (40.2)
How would you rate Dr. Lim Keuky’s presentation?
Poor
5 (1.5)
Fair
4 (1.2)
Good
73 (22.6)
Very good
112 (34.7)
Excellent
115 (35.6)
How would you rate the audience survey?
Poor
4 (1.2)
Fair
15 (4.6)
Good
105 (32.5)
Very good
82 (25.4)
Excellent
90 (27.9)
How would you rate the national discussion?
Poor
5 (1.5)
Fair
12 (3.7)
Good
118 (36.5)
Very good
79 (24.5)
Excellent
86 (26.6)
What did you think about the length of the meeting?
Too long
70 (21.7)
Too short
28 (8.7)
Just right
214 (66.3)
Did you want to talk but did not get a chance?
Yes
136 (42.1)