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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 Karen 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 than 10,000 Karen people live in Minnesota, most of them in St. Paul. St. Paul is home to the largest Karen community in the nation.
Karen in Minnesota
Karen (pronounced k’REN) people are an ethnic minority from the nation of Burma (also known as Myanmar). Karen refugees, who fled oppression from the Burmese government, began arriving in Minnesota in the early 2000s, with large numbers arriving starting in 2005. Today more than 10,000 people of Karen descent live in Minnesota. St. Paul is home to the largest Karen community in the U.S. The Burmese American population is:
In their native home in the Karen State in Burma, the Karen are largely subsistence farmers who work small plots to raise vegetables and rice.
The Karen people have three main languages: S'ghaw (pronounced Skaw) Karen, Eastern Pwo Karen, and Western Pwo Karen. S’ghaw Karen is the most commonly spoken and understood. In a Wilder study, 80 percent of Karen reported they speak English “only a little bit” or “not at all.” Burmese is the language of the military who continue to attack the Karen and drive them from their traditional lands. Thus, Karen people may be uncomfortable with a Burmese translator.
Limited health data is available about Karen-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 Karen-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.
Karen families are often large, and many generations may live together. The society is matriarchal, and women and men are considered equal, and girl and boy children equally prized. Men become members of the wife’s clan when a couple is married. Traditionally, the Karen do not use surnames. For example, married couples do not share a last name. This can cause confusion in the U.S., where last names are used as important identifiers.
Smoking is traditional in Karen society. Some children start as young as 10 years of age. Karen also use chewing tobacco, pipe tobacco and cheroots. Harmful alcohol use has risen in the Karen population as people left traditional village life and were dislocated to refugee camps and resettled.
Many Karen feel ill at ease when confronted with American communication styles. Loud speech, direct address, and Western body language, such as direct eye contact, are considered impolite. Karen people demonstrate respect by standing back and folding their arms in front when speaking. Disagreement is avoided and direct displays of anger are considered shameful.
Making and sticking to strict schedules is difficult for many. Karen do not come straight to the point. Many other subjects might be discussed first.
As Karen acculturate, they replace traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension. Traditional food consisted of rice, vegetables, and meat or fish. Karen cuisine features many spices including turmeric, ginger, garlic, lime, and cardamom. A traditional meal might feature a large bowl of rice, and smaller amounts of meat or fish as well as vegetables and flavorings or spices such as fermented fish pastes and chilies, garlic, ginger.
Most Karen come from rural areas and had little experience with going to doctors. Western medicine is accepted by most, but many are reluctant to speak openly with doctors. One strategy to help ensure better care is to have Karen case workers follow up with patients after the visit, to allow the patients to ask questions or clarify what the doctor said. Karen patients may be reluctant to question or contradict what the doctor says, as doctors are often held in high regard. Asking open-ended questions is a good strategy to provide Karen patients with the opportunity to voice concerns or issues with a doctor’s orders.
Approximately one in five of all adults in the U.S. experiences mental illness in a given year. Many Karen refugees in Minnesota were exposed to torture and war trauma. As a result, they experience post-traumatic stress disorder (PTSD), depression, and various physical ailments. Like many patients with a history of trauma, Karen people are often reluctant to discuss this history. A 2014 screening of Karen people in Minnesota found:
Discrimination, torture, relocation, and loss of cultural heritage have resulted in direct and historical trauma to Karen 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. Almost all Karen in the U.S. are Christian and may follow the traditions of their faith.
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