Increasing the cultural competence of health care providers serving diverse populations
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 provided. 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.
Hmong (the H is silent) in the US
represent a small Southeast Asian minority group of people who immigrated
to the US at the end of the Vietnam War.
According to US Census 2005 American
Community Survey data, the majority
of Hmong live in California (65,345),
Minnesota (46,352), and Wisconsin (38,814). Hmong people originally lived
in the mountains of South China, Laos,
Vietnam, Burma, and Thailand.
Social structure
Hmong are organized into 18 clans determined by ancestral
lineage. They have large, extended families and practice traditional ceremonies to
remember their ancestors. Clan leaders are the key decision makers. Each person has a
last name that represents the clan they belong to. When a woman marries, she keeps her
maiden name. The Hmong language, Hmoob (Hmong in English), has many dialects,
although most Hmong speak either White Hmong or Green Hmong. Hmong was not a
written language until the late 1960s and has few medical terms.
Diet
Traditional staples of the Hmong diet are rice, noodles, fish, meat, and green vegetables with hot chili sauces. Hmong tend to eat the same types of food at each meal, with very little fruit or dairy products. Hmong people often prefer hot dishes and drink hot or warm water. Traditionally, a sick person must eat hot food with certain vegetables. Within 30 days of childbirth, Hmong mothers usually eat only warm foods.
Religion
The Hmong shaman is a religious leader who makes all decisions related
to spiritual healing and conducts religious ceremonies. The shaman acts as a medium
between the visible world and an invisible spirit world, and practices rituals for healing,
divination, and control over natural events. Since coming to the US, a number of
Hmong have become Christian.
Medical care
Chronic diseases common among the Hmong population include chronic obstructive pulmonary disease, diabetes, congestive heart failure, and hypertension. The adoption of a Western diet and sedentary life style has lead to a dramatic increase in the prevalence of diabetes. A lack of roughage in the diet has resulted in chronic constipation and diarrhea among many Hmong. Refugees 30 years of age or older may have long-term effects from malnutrition and exposure to yellow rain and other war zone chemicals. Many refugees have intestinal parasites, tuberculosis, anemia, depression, and post traumatic stress syndrome.
Although Hmong have been exposed to Western medicine since the 1950s, they traditionally view illness from a holistic perspective, with perfect health being a balance between the spirit and the body. Good health comes from the souls living within each person. When a person is ill, they seek the help of a shaman to determine if the cause of the illness is within the realm of the spirit. Spiritual causes require religious remedies. Traditional spiritual causes of illness may include evil spirits or because one’s own spirit has left the body. A person may be ill because an ancestor or evil spirit is unhappy with them or their family or because someone cursed the family or offended the family’s ancestors or spirits. The sick person may accept either the appropriate Hmong medicine or treatment, or the Western approach.
Some Hmong people will not communicate dissatisfaction
with the quality of health care they receive. If they are dissatisfied with their care, they may refuse care and turn to traditional treatments. Older Hmong may listen attentively to health professionals, but avoid direct eye contact, which is considered to be rude.
Many Hmong practice spiritual healing, which involves
retrieving the lost soul from another plane of existence.
They may consider an illness or an invasive surgical
procedure to be the cause of soul loss. Hmong may conduct
healing ceremonies in the hospital or in the home. Herbal
medicine and traditional healing practices are often widely
used before a person seeks Western medical remedies.
A person also may use traditional herbal treatments as
complements to Western treatments and practices. Surgery
is usually not acceptable to older Hmong people unless
laboratory or other tests identify a disease. Blood transfusions
and organ donation also are considered unacceptable.
Recent immigrants are unaccustomed to doing things at specific times. In their native lands, farmers organized their
activities around sun up and sun down. Appointment times need to be written down and fully explained. Take advantage of the following tips to help you provide the most appropriate, culturally competent care for your Hmong patients:
- Demonstrate respect to Hmong patients by asking how they would like to be addressed. Hmong do not call each other by their first name. They address one another by their title, such as aunt, uncle, brother, etc. (The medical record is filed under first and last name.)
- Maintain physical distance during an initial encounter. As trust develops, Hmong patients become comfortable shaking hands. Not using direct eye contact with the opposite sex demonstrates respect. Saying “no” to a Hmong patient demonstrates disrespect.
- Involve the patient and family in the care plan and in obtaining consent signatures.
Ask the patient, “In what language do you prefer to discuss your health with us?” Use trained medical interpreters rather than family members. Never use children as interpreters.
- Ask patients what they believe is causing their illness. Be aware that Hmong health beliefs are intermingled with spirituality. Schedule longer appointments for Hmong patients, and take the time to explain care options.
Explain the long term consequences of not taking care of chronic illnesses, and the need to take medications even when they are feeling well.
- Ask elderly patients, “Who in your family can help you do this?” Solicit support from adult children in caring for their elderly parents.
- Educate patients about the safety of non FDA-approved foreign medications. Ask if they use herbs or medications from Thailand, China, Laos, or France.
- Provide the patient and family with current knowledge about an incurable disease. Explain that a cure has not yet been discovered for this disease. Hmong people sometimes feel they do not receive the same treatments
others receive that could cure them.
- Review instructions orally and ask patients to repeat
them back to you. Hmong may say “yes,” but still do not understand. Explain by comparing a condition or disease
to a familiar household process such as using heat to
control room temperature.
- Explain your telephone triage system. You may need to
make appointments for some patients and to call them
before their next scheduled appointment.
- Provide educational materials in Hmong and English.
The patient, family member, or someone else at home
may be able to read at least one of the languages.
Death and dying
Traditional Hmong view life as
a continuous journey, rather than the Western perspective
of life as a journey with a beginning and an end. They
believe that death is merely a phase people go through
when passing from this plane of existence to the next. They
believe people are destined to live to a certain age. When
that age is reached, it is time for the person to depart.
Hmong believe the spirit will reincarnate.
Religious ceremonies conducted on behalf of a dying
person are intended to make the person happier. The
deceased is dressed in fine Hmong clothes to demonstrate
to the community and family that the person has lived a
good life, will be missed, and will make a proper entrance
into the next world.
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.
Culture Matters DVD Training - Hmong. Stratis Health's DVD series offers insights into the beliefs and norms of three of Minnesota’s prevalent cultures: Hispanic/Latino, Hmong, and Somali. DVDs available for purchase; facilitator discussion guides available at no cost. CEU credit available.
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