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Common health equity issues for Cambodian populations
Cultural competence is the ability to recognize and understand the role culture plays in health care and to adapt care strategies to meet patient needs.
Get to know patients on an individual level. Each person’s preferences, practices, and health outcomes are shaped by many factors. Generalizations in this material may not apply to your patients.
Cambodians in Minnesota
60% of Cambodian immigrant parents who endured the Khmer Rouge regime have experienced mental illness.
Minnesota is home approximately 8,000 Cambodians, with many living in St. Paul and Edina. The Twin Cities area had the sixth largest Cambodian population in the U.S., with Los Angeles having the largest. Cambodia is located in Southeast Asia, between Thailand and Vietnam. It was a colony of France from 1853 to 1953. Its people are also referred to as Khmer or Kampuchean. The Khmer, the largest ethnic group in Cambodia, make up 70 percent of the population.
The majority of Cambodians arrived in Minnesota during the mid-1980s. Most Cambodians came to the U.S. as refugees fleeing the violence and genocide of the Khmer Rouge regime and civil war. Many Cambodians lived in refugee camps in Thailand for years waiting for the opportunity to be resettled. In 2013, more Cambodian Americans were foreign-born (59%) than born in the U.S. (41%).
Cambodians speak Khmer, Chinese, Vietnamese, and French. The Khmer have a complex system of pronouns and terms of address that distinguishes between royalty, monks, age, and acquaintance. Some Cambodians may prefer same sex interpreters. Sompeah is a gesture of greeting with both palms brought together with fingers pointed upward. The higher the sompeah, the higher the status of the person being greeted.
According to Pew Research Center analysis in 2015, 39 percent of foreign-born and 91 percent of U.S.-born Cambodians indicated that they speak English proficiently.
Limited health data is available about Cambodian-Americans. Some health issues could be biologically tied to race; many are tied to social inequities, including poverty. When included in the data for Asian-Americans, the true picture of Cambodian-American health may be missed.
Social determinant disparities
Social determinants of health are economic and social conditions that influence the health of people and communities. Recent refugees often have high rates of poverty, which can result in lack of preventive health care and limited health choices.
The Cambodian community in Minnesota is diverse. Many aspects of Cambodian-Minnesotan culture reflect the culture of the general U.S. population and generational differences impact social practices. Throughout history, the Khmer culture has been influenced by Thailand, Laos, China, and India. Traditionally, Khmer are considered respectful and polite, and speak softly, often communicating carefully and indirectly.
Khmer often raise large families, with extended family members living together or nearby. Data from the 2015 American Community Survey indicated that 41 percent of Cambodian Americans lived in multigenerational households. Men are generally recognized as head of the family—although roles are changing as Khmer become acclimated to American society and values. Women have traditionally been responsible for the family’s finances. They are the traditional caregivers, and also often work outside the home. Infant care is characterized by almost constant attention to the child. Children are instructed early to respect the authority of parents and older siblings. Elders are respected and important in decision making. They often take care of their grandchildren. Traditional arranged marriages are not a common practice. Divorced women and single mothers may be viewed with less respect, especially by elders.
Cambodians practice Buddhism, Islam, Cham, Christianity, or animist religions. In Minnesota, the two largest Cambodian Buddhist temples are located in Hampton and Rochester. The most important cultural symbol of the Khmer is the ancient temple Angkor Wat in Cambodia. Classical dance, also an important national symbol, ties in costume and gesture to recreate the bas-reliefs in the temple Angkor Wat.
The Khmer culture has a strong taboo against public touching between men and women. To Buddhists, the head is the most important part of the body and one does not touch another person’s head, not even a child’s. While seated, it is considered impolite to point the soles of one’s feet toward another person.
Many acculturated Cambodians have replaced traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension. Staples of the traditional Khmer diet include rice, fish, meat, vegetables, and fruit. Breakfast is often rice porridge or rice noodles. Lunch and dinner may include broth with fish or meat and vegetables, or vegetables eaten with a fermented fish-based paste, and stir-fried vegetables with chopped meat. Meals often are eaten in shifts according to status, with adult men and guests eating first and women last. Devout Buddhists refrain from alcohol.
Many Khmer believe in the inherent properties of balancing hot and cold foods. Food is deemed either hot, cold, or neutral. For example, chicken is hot, vegetables are cold, and rice is neutral. People who eat a traditional Cambodian diet eat rice at all three meals and prefer warm tea or water to drink. Most Khmer do not use ice and rarely consume dairy products. Many are lactose intolerant.
Special elaborate dishes are prepared for festivals, including curries, spiced fish sauces, stir fries, and sweets. At temple festivals, each family brings special dishes that are ritually presented to the monks. After the monks have eaten, the remaining food is eaten by the lay community. Monks cannot eat after noon.
Khmer often attribute good health to equilibrium, adopting the Chinese philosophy of balancing hot and cold described previously. Khmer who subscribe to traditional beliefs attribute illness to natural or super natural powers. Illness may be considered punishment for sins committed in a past life. Many believe evil spirits or ancestors cause mental illness.
Common health problems for older refugees who came to the U.S. 30 years ago include nutritional deficits, hepatitis B, tuberculosis, malaria, HIV/AIDS, and post-traumatic stress disorder, a result of war and the brutality of the Khmer Rouge in Cambodia.
Khmer who consume large quantities of fish taken from Minnesota lakes and rivers are at risk of exposure to mercury and PCBs. The Minnesota Department of Health advises clinicians to encourage their patients to replace some fish in their diet with alternative protein sources.
Khmer may use traditional healing practices and hold healing ceremonies at home before they seek Western medical treatment. Rather than asking general questions about pain or symptoms, clinicians are advised to ask their Khmer patients very specific questions. They may reject the value of preventive care, screening, and early detection.
Khmer are known for enduring pain stoically. Common traditional treatments for pain include herbal medicines, Tiger Balm, acupuncture, acupressure, cupping, coining, and moxibustion. In cupping and coining, cutaneous hematomas are made on the face and trunk by pinching and pulling the skin to release excessive air, by rubbing oiled skin with a coin or spoon, or by cupping— heating air in a cup with a flame, then placing the cup onto the skin. As the air cools, it contracts and pulls on the skin, leaving a purple mark. Moxibustion, often combined with acupuncture, is the process of making circular superficial burns on the skin with ignited incense or other material placed directly on the skin.
Health care providers should be aware of the effects of dermabrasive procedures used by patients that leave marks on the skin—and not misinterpret the marks as a sign of physical abuse.
Approximately one in five of all adults in the U.S. experiences mental illness in a given year. Cambodian refugees experience high levels of post-traumatic stress disorder (PTSD) and depression, due to mass executions, violence, and refugee experiences. An estimated, 60 percent of parents who went through the Pol Pot regime have mental health issues. Discrimination, torture, relocation, and loss of cultural heritage have resulted in direct and historical trauma to Cambodian Minnesotans. The effects of historical trauma are being studied. Older immigrants are less likely to have English skills which may increase the loneliness, isolation, and depression.
End of life
When discussing end of life issues with any patient, health care providers need to understand preferences based on personal and family views. Families of most Cambodian patients prefer to discuss end of life issues with the physician, protecting the patient from the knowledge of a poor prognosis. In the hospital, many family and friends may visit patients and often like to sleep in the patient’s room. Khmer may fear surgery and giving blood due to the belief that these procedures will result in heat loss. Many patients prefer to die at home with family care and community support. When a person dies at home, the body may be kept in the home for 24 hours to allow for visitation and ceremonies.
Buddhists believe they will return in another life and should prepare for death calmly and thoughtfully. The family and monks may wash and shroud the body. Monks recite prayers and burn incense. Due to belief in rebirth, Buddhists rarely allow organ donations or autopsy.
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