Providing Healthcare to Hmong Patients and Families

Who Are the Hmong People in America? The Hmong (pronounced hmung with a very soft h) in the United States are a relatively small southeast Asian minority group who began living here at the close of the Vietnam war. Due to their unique cultural beliefs and indigenous practices, Hmong refugees settled in the United States often present a unique set of challenges to healthcare professionals. As a people, their adaptation to our western model of healthcare delivery is often slow, hindered by particularly strong traditional beliefs, culturally-based patterns of communication, limited English proficiency, and a deep distrust of governments. Their history as a marginalized people fleeing persecution as war refugees has made them an insular people. Indeed, history has taught them to mistrust outsiders and large impersonal institutions, i.e. hospitals.
(An Important History Note: Due to their support of the CIA’s efforts in Laos during the Vietnam War, the Hmong had to flee retribution when the communists gained power in that country after the US military pulled out. The United States finally gave the Hmong preferential refugee status in the early 1980s.1)

Today, the US has the fourth largest population of Hmong. There are an estimated 6,000,000 in China, 787,000 in Vietnam, 315,000 in Laos, and between 200,000 and 250,000 in the US.2

As of the last census, California, Minnesota and Wisconsin had the largest Hmong populations. Colorado was sixth on the list with an estimated 3,859 Hmong. 3

 

A Very Youthful Community

2000 census data showed the median age of the Hmong population being 16, while the average for the overall US population was 35. Similarly, census data showed 56% of Hmong in the U.S. were under 18 years of age compared to 25% for the overall US population. The average Hmong household size was 6 persons compared to the average overall US population household size of 2.5. 4

 

Diversity Within the Hmong Community

Though a relatively small and close knit ethnic minority in the U.S., there is considerable diversity within Hmong communities in the US.

 

Diversification factors include:

Religion: Though an estimated 70% still practice traditional Hmong religion, a significant number are Christians. Many combine belief systems. 5

 

Language & Dialects: The Hmong have their own language, called Hmoob (Hmong in English). It has many dialects. However, most Hmong speak either white or green Hmong, referencing the colors in their traditional clothing. (The green is sometimes called blue.) These dialects are different in the way, for example, that British and American English are different. Hmong language was not a written language until the late 1960s when Christian missionaries came up with a writing system that allowed translation of the Bible. The Hmong language has few medical terms. Older Hmong may tend to use metaphor when expressing themselves, and this can make it difficult for healthcare professionals in the US to understand them without a capable interpreter.

Clans: The central unit of political and social organization in Hmong communities is the clan. Clans are determined by ancestral lineage (great, great grandfather) and which traditional ceremonies they practice. If families practice the same ceremonies, then they probably belong to the same ancestor. Hmong families tend to be large and extended; the entire clan is “family.” A Hmong man stays in his clan for life, but a woman marries into the clan of her husband’s family. Mutual assistance is expected between clan members. According to one Hmong proverb, “One stick cannot cook a meal or build a fence.” Clearly, collective identity is central to the Hmong way of life.

 

Family Dynamics and Healthcare

Role of Father: In traditional families, the father is the head of the household. When healthcare professionals encounter a more acculturated Hmong family in the U.S., they will likely see more balance of power between mother and father.

Role of Mother: Traditionally, Hmong mothers nurture and take care of the children. They are responsible for the household. Succeeding generations are giving Hmong women increased respect outside the domestic realm. It is often women who will converse with healthcare providers, but men usually will make decisions related to healthcare.

Role of Elderly Hmong: The elderly get the most respect of all members of the family and are consulted when important decisions need to be made. They help discipline the younger children. The elderly remain with the family throughout their life. Grandmothers may or may not actually be present during healthcare visits, but they typically make key decisions about managing illness in the family.

Clan Leader: Each clan has a leader. All adult members of a Hmong clan help in selecting their leaders; a leader must be deemed honest, respectful, and capable of making wise decisions. The leader helps make important decisions whenever there is a problem, such as a divorce, illness, or death in the family. The leader is often the person in the clan who decides whether to go forward with a surgery or whether to resuscitate a patient. He calls people together to discuss issues and then he informs the clan members of his decision. Many clan leaders are very powerful indeed.

Religious Leader: A clan leader is often assisted in decision-making by a religious leader called a shaman. Some Hmong shamans are very powerful. They may make the decisions related to spiritual healing. (The book The Spirit Catches You and You Fall Down is an excellent resource for understanding the clan dynamics in healthcare situations involving a sick child.)

 

Verbal/Non-Verbal Communications

High Context Communicators: Hmong may not communicate dissatisfaction with regards to the quality of their healthcare directly. They may not feel comfortable speaking up, asking questions, etc. Instead, they may politely refuse care and go somewhere else for treatment. Older Hmong are often accustomed to speaking in metaphor, telling a story in answer to a question. The story is important. Concentrated listening on the part of the provider is extremely important, as is asking for clarification of a story’s intended meaning.

Avoid Addressing Hmong Women by their first name. Use Ms./Mrs. and a last name.

Eye Contact: Hmong people tend to listen attentively to healthcare professionals, but will often avoid direct eye contact because it is considered rude in their culture.

Be Aware of Your Body Language:
Use a normal tone of voice. Be aware of body language. Hmong who don’t speak English fluently will listen intently and interpret what is being said by tone of voice and body language.

 

Hmong Sense of Time Control

Many Hmong originally came from agrarian societies which tend to relate to time as cyclical, repetitive, and slowly advancing. Some Hmong individuals who are less acculturated to the U.S. may still be unaccustomed to functioning via American “clock time.”

• Information about healthcare appointments needs to be written and carefully explained.

• Allow extra time to get consent forms signed as it may involve discussion with Hmong elders and family members.

• Remind Hmong parents about scheduled immunizations for kids. It is helpful to reiterate that immunizations are part of preventive care, a concept unfamiliar in the traditional Hmong medicine tradition.

 

Beliefs About Illness Causation

Traditional Hmong view illness from a holistic perspective. Perfect health is a balance between the spirit and the body. Illness is seen as having either spiritual or physical causes. Typical physical causes are exposure to environmental factors and unsuitable dietary practices including hot/cold food imbalances. Physical illness is treated with various traditional curatives and/or western medical care. Spiritual causes of illness include:

• Evil spirits that are unhappy with the ill person

• Loss of one’s own spirit (an ill person has lost their soul)

• Unhappy ancestors (Perhaps someone has done something to offend the family’s spirits or ancestors. An example might be forgetting to provide food to needy ancestors or forgetting to make offerings of paper money. Those in the real world offer paper money by burning it; it is converted to silver and gold in the spirit world.

• A curse upon the family by someone

• (Note: Some Hmong accept western concepts of illness causation along with their culture’s traditional view)

 

Spiritual Healing and Soul Loss

Hmong believe good health depends on souls living in each person. These souls govern the body. Illness or an invasive procedure of any kind can cause soul loss. Spiritual healing rituals are common, often conducted in the home or even in the hospital. Spiritual healing involves retrieving the lost soul from another plane of existence. The practice of soul calling during ritualistic ceremonies is performed by a shaman.

 

Preventive Care

Many Hmong, especially older ones, focus on treating illness when it occurs, but do not have an understanding of preventive medicine or of chronic disease requiring daily treatment even when symptoms are not experienced. Similarly, these are often people who have no concept of germs causing disease. Younger Hmong who are raised in the US will naturally be much more familiar with these concepts and will be more likely to value preventive medicine. They will understand that immunizations are required when children enter schools. As cross-generational conflicts are common in refugee communities, it is important that healthcare professionals in the US understand the importance of respect – younger Hmong must demonstrate respect for the opinions of Hmong elders to maintain familial harmony.

 

Traditional Treatments

Many Hmong continue to use traditional herbal treatments. Others will use herbal treatments as complements to western treatments. Traditionally, someone who is sick is required to eat hot food and certain vegetables. Hmong prefer hot chicken and rice. They drink hot or warm water. Within 30 days of childbirth, Hmong mothers will usually only eat warm foods.

 

Caring for a Sick Child in a Hmong Family

Sick children are often put on a strict dietary regimen, such as eliminating vegetables and only feeding a diet of rice and chicken. Chicken must be boiled, not fried. Herbal medicines are added to the meal in small amounts. Other treatments for physical illness include cupping, coining, and moxibustion. Treatment for illness of a spiritual nature involves religious ceremonies, wearing amulets, or food/animal sacrifices.

 

Immunizations

Traditionally not acceptable. Hmong believe it is not a good idea to put something into their bodies. If a person is immunized or has surgery, he/she will be reincarnated with less than a complete body or a body with something foreign in it. However, most Hmong parents will have their children immunized once they know it is required for school or other activities.

 

Surgery

Usually not acceptable. Opening the body allows the soul to escape; soul loss is one of the Hmong’s greatest health concerns. However, in some cases, with the support of the clan shaman and leader, the Hmong are willing to consider surgery.

 

Organ Donation/ Blood Transfusions

Traditionally, both are unacceptable. Younger Hmong, however, are more accepting of these medical procedures.
Blood Tests: Hmong accept blood tests. But they may question why they have to have blood taken more than once in one visit or why a large volume of blood is needed.

 

Practical Tips to Achieve Positive Health Outcomes for Hmong patients

Build trust: Building trust from the very outset is essential with the Hmong. Providers need to be open to the family’s suggestions. Show respect for the family by listening.

Privacy Concerns: Hmong share information among certain clan members. All staff and all interpreters in healthcare settings must honor the privacy of patients and their families. This policy needs to be communicated to the Hmong.

Alternative Medicines/Herbs/Healing: Ask what care, if any, is already under way? What herbal treatments are being used? What is the source of the herbs?

Should You Inform the Patient Directly: Before sharing information regarding a serious diagnosis with a Hmong patient consult the family. If may be a necessary to hold a conference if there is a major problem or surgery is needed. A conference may need to involve all important family decision-makers including clan leader and shaman. Consider the location. Hold the session in a conference room, not in the patient’s room.

Use Hmong Interpreters: Be aware that even if the patient/parents speak English, other important other decision-makers may not. Provide a Hmong interpreter.

Explain Explain! The Hmong may be fearful and distrustful at the outset. Be very clear about details of the patient’s condition and intended care (but be sure to talk to important family decision-makers before informing a patient of bad news).

• Explain why many immunizations are needed.
• Explain what a chronic disease is; asymptomatic does not mean cured
• Repeat information about medicines.
• Explain purpose of blood withdrawals. Explain what the test is and why so much blood is needed.

 

Conclusion

It is hoped that the information in this article will help guide doctors, nurses and other healthcare professionals in developing culturally responsive practices and interventions for Hmong children and their families. It is important not to apply the general information about the Hmong culture presented in this article too rigidly to individuals; there is great variety to be found in people affiliated with any cultural group. Each individual identifies with his or her cultural heritage to a greater or lesser degree, depending on personality and unique life experiences.
More articles on cross-cultural communications for health care professionals can be found at
www.dimensionsofculture.com
 

“Providing Health care to Hmong Patients and Families” by Marcia Carteret, Copyright © 2012. All rights reserved.

 

Additional Suggested Resources

Patricia Nuttall “Hmong Healing Practices Used for Common Childhood Illnesses”. Pediatric Nursing. Findarticles.com 05 Dec., 2011.

Judy Leaver “Joining Hands Across a Cultural Divide” Copyright 2009 www.Jleaver.com

www.hmongnet.org

www.hmongcenter.org

www.hmongstudies.org

www.learnabouthmong.com
 
Footnotes for census statistics in this article

1, 2, 4, 5 Presentation by Txong Pao Lee and Mark E Pfeifer Ph.D, Hmong Cultural and Resource Center Saint Paul, MN www.hmongcenter.org. 2006

3. United States Census 2010


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