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Cambodians in Minnesota

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Common medical issues and cultural concerns of Cambodian patients

Social structure

Cambodian people are also referred to as Khmer or Kampuchean, and speak Khmer, Chinese, Vietnamese, and French. Throughout history, the Khmer culture has been heavily influenced by Thailand, Laos, China, and India. The Khmer have a complex system of pronouns and terms of address that distinguishes between royalty, monks, age, and acquaintance. A major part of etiquette involves knowing and using these systems. 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. The Khmer are generally respectful and polite, and speak softly, often communicating carefully and indirectly. Within the Khmer culture, there is a strong taboo against public touching between men and women.

Khmer often raise large families, with extended family members living together or nearby. 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.

Although gender roles have become increasingly interchangeable between men and women in the U.S., in Cambodia, men and women performed traditional duties according to gender. Men fished, plowed, threshed rice, made and repaired tools, and cared for cattle. Women seeded the rice fields, cleaned the home, washed and mended clothes, and did the shopping.

Marriage traditionally is arranged by the parents of the bride and groom or by someone acting as their representative, although neither the groom nor the bride is forced to take a marriage partner. Specialists in reading horoscopes typically are consulted about the appropriateness of a wedding. The groom pays bride-wealth to the family of the bride to buy jewelry or clothing for the bride or defray costs of the wedding.3,4,5

Diet

Staples of the 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 males 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.

Religion

Cambodians practice Buddhism, Islam, Cham, Christianity, or animist religions. Most Cambodians are Theravada Buddhists, one of the two major branches of Buddhism. Followers of Theravada, meaning the “Doctrine of the Elders,” adhere to the earliest surviving record of Buddha’s teachings. Buddha is believed to have lived and taught in northeastern India during the fifth century B.C. In Cambodia, Theravada Buddhist monks can be seen in saffron robes walking in procession in the early mornings and going from door to door to ask for food. Only men can enter the monkhood.

The most important cultural symbol of the Khmer is the ancient temple Angkor Wat in Cambodia. Classical dance, also an important national symbol, tries in costume and gesture to recreate the bas-reliefs in the temple Angkor Wat. In Minnesota, the two largest Cambodian Buddhist temples are located in Hampton and Rochester.

Medical care

Khmer often attribute good health to equilibrium, adopting the Chinese philosophy of balancing hot and cold. 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.

End-of-life care

Most patient’s families 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.3,4,5

Cambodians in Minnesota

According to the U.S. Census Bureau’s American Community Survey, in 2009, 275,379 American citizens of Cambodian heritage resided in the U.S.1 An estimated 8,000 Cambodians live in Minnesota.2

Formerly known as Kampuchea, Cambodia faces the gulf of Thailand and is bordered by Thailand, Laos, and Vietnam. Between 1969 and 1973, Cambodia was invaded by the U.S. and Vietnam, with more than 2 million Cambodians made refugees by the war. By 1975 the country was faced with famine, and the Communist Khmer Rouge (Red Khmer), heavily influenced by China, took power. The Khmer Rouge regime was responsible for the deaths of 1.7 million people by execution, starvation, and forced labor. In 1979, the U.S. government settled 150,000 refugees, with the largest Cambodian-American populations settling in California, Massachusetts, Washington, Texas, and Minnesota.3,4,5

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.

Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.

In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than non-minorities even when access to insurance and income is accounted for. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.

Resources for Cambodians

United Cambodian Association of Minnesota. UCAM supports the adjustment of Cambodians in Minnesota to American society through social services and cultural support. Its main programs focus on elders, families, youth, health, and legal services. Programs also serve low income people from many cultures. Central to the UCAM mission is providing Cambodians the skills they need to achieve long-term economic stability.


Wilder Southeast Asian Social Adjustment Program. Wilder Services provides culturally specific mental health programs for Cambodian, Hmong, Laotian, and Vietnamese immigrants living in the Twin Cities.

Sources:
1. U.S. Census Bureau’s American Community Survey, 2009, viewed January 18, 2012
2. Minnesota State Demographic Center, viewed January 18, 2012
3. Cambodian Americans, viewed March 24, 2010
4. Cambodian Information Center, viewed March 24,2010
5. United Cambodian Association of Minnesota, viewed March 24, 2010