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Increasing the cultural competence of health care providers serving Minnesota's diverse populations
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Common health equity issues for Hmong 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.
More Hmong people live in St. Paul than in any other U.S. metro area.
Hmong in Minnesota
Nearly 64,000 Hmong lived in Minnesota, according to the 2010 Census. Minnesota is home to the second-largest population of Hmong in the U.S. and St. Paul has more Hmong than any other metro area. More than half of the Hmong population in the U.S. was born in America.
The Hmong in Minnesota primarily arrived from Laos. They began immigrating to the U.S. in 1975, fleeing genocide and political persecution after the Vietnam War. In their native lands, most Hmong were farmers. Hmong Americans have tapped into their agricultural heritage and make up more than 50 percent of all the farmers in the Twin Cities metropolitan farmers markets.
Four-fifths of Hmong Minnesotans speak a dialect of Hmong at home, either white or green dialects. Half of the Hmong-language speakers say they speak English “less than very well.” Elders, especially women, are less likely to speak English well. Scholars suggest the Hmong written language was lost in the 1600s due to persecution. Until the late 1960s, it was not a written language and has few medical terms.
Hmong in Minnesota face several disparities in health outcomes and care delivery compared to the overall population. 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 Hmong-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.
The Hmong community in Minnesota is diverse. Many aspects of Hmong-Minnesotan culture reflect the culture of the general U.S. population and generational differences impact social practices. Hmong often maintain the tradition of being family-oriented. Hmong elders commonly support and take care of their grandchildren.
Hmong are organized into 18 clans, determined by ancestral lineage. Each person has a last name that represents the clan to which they belong. When a woman marries, she keeps her maiden name. Some Hmong maintain traditional culture, speak mostly Hmong, and live and work within a close-knit Hmong community that adheres to the clan system more than others. Younger Hmong Minnesotans are more assimilated into American culture than elders.
The traditional Hmong religion blends animism with shamanism. Many Hmong are associated with a Christian church, some practice a mix of traditional beliefs and Christianity, and others do not practice a faith.
“Eat until you are stuffed”
Many acculturated Hmong have replaced traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension. However, many Hmong food traditions are practiced in Minnesota, such as inviting people to eat together; eating a balanced meal of rice, vegetables, and meat; eating fresh foods rather than processed foods; nuclear and extended families cooking and preparing food together; men fishing and hunting animals to share with family and relatives; and family members growing their own gardens of fresh vegetables and herbs.
During cultural rituals and celebrations, a large feast is planned by the hosts who may invite extended families to attend and prepare food. It is considered generous and shows prosperity among relatives. These celebratory meals include more fattier meats. It is a custom to encourage guests to “eat until you are stuffed,” as a gesture of hospitality. Guests often eat large amounts to show respect to their hosts.
Generally, you can find some families eat fewer traditional meals and more “American” foods. Rates of diabetes and obesity have risen in the Hmong population since coming to the U.S. and adopting American diets. Hmong 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 (MDH) advises health care professionals to encourage their patients to replace some fish in their diet with alternative protein sources.
Hmong people often are very polite and may say “yes” even when they do not understand their clinicians. Hmong Americans commonly use herbal medicines and clinicians should discuss the use of alternative medicines with their patients. A study in the Twin Cities identified 37 medicinal plants used by Hmong Americans.
Traditionally, Hmong believe that an illness has either a spiritual or physical cause. In addition to using Western medicine, some Hmong will call on a shaman, religious leader, to perform healing ceremonies for illness that may have a spiritual cause. Illness may be caused by evil spirits, a curse from an unhappy ancestor, or because the spirit has left the body.
Many Hmong in Minnesota live with mental health issues, although they may lack understanding about mental health illnesses and treatment. Anxiety, clinical depression, and posttraumatic stress disorder are the most common, especially for those who faced cultural destruction and genocide and were forced to flee their homeland. 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 already caused by discrimination, torture, and loss of homeland.
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. Traditionally, after death a person’s soul must return to the place he/she was born, before traveling on to the afterlife. Funerals today will typically start in the morning on a Friday, continuing without stop until the burial on Monday. Rituals during the days-long ceremony are meant to ensure safe passage.
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