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
 

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

Culture, Religion & Spirituality

Participants in cross-cultural presentations often ask how to separate an individual’s cultural beliefs and behaviors from those that are based on the person’s religion. The best answer to this very complex question is to think of culture and religion as being two sides of the same coin – it may not be very useful to struggle with separating them (unless you are a theologian or philosopher).

When interacting with patients and their families, religion can be a touchy subject. It isn’t always exactly clear where health care and religious practices intersect. According to Brick Johnstone, professor of health psychology at the MU School of Health Professions, “Some professionals may feel uncomfortable obtaining information about patients’ religious beliefs, (but) it is no different than inquiring about their sexual or psychological beliefs, substance abuse, etc…”  (See MU Center Link below)

In this Dimensions of Culture article, and as part of the cross-cultural communications “toolkit” we have developed for providers and other health care professionals, we suggest six key areas of intersection between a patient’s health care and cultural-religious beliefs. We also delineate five health events of particular interest in cross-cultural health care, suggesting examples of associated cultural-religious tenets from various faiths. Finally, resources for more specific in-depth cultural-religious information appear at the end of the article.

Six Key Areas Where Health Care and Cultural-Religious Beliefs Intersect

Communication with Spiritual Leaders: The need for adequate language interpreters in health care settings is uniformly addressed, but it is also imperative for people to be able to communicate with leaders of their faith community. These influential figures can help interpret what is happening on a spiritual level during a health crisis for patients and their families. For example, in the Catholic faith, a person may gain great strength and peace from the sacrament  of the sick being administered by a priest. In Judaism, it is important to know the variations in practice among Orthodox, Conservative, and Reformed traditions. Religious leaders can clarify which tenets cut across the branches of their faith in matters ranging from birth control to life support. In the Muslim faith, it is considered a taboo topic to talk about death with a patient; a religious leader may be a crucial intermediary in conversations between doctors and second-degree male relatives deciding to whether to immediate family members about a terminal illness.

Religious leaders assist individuals in making connections between their “inner life or spirit” and their communal, social, and cultural reasons for practicing a formal religion. ” Collaboration with the leaders of a faith community can result in strongly positive outcomes for a patient and family.(2)

Gender: It is ethically egregious not to be aware of gender-specific rules for patient care that are extremely important in many faith traditions – for example, among Orthodox Jews and Muslims. It may be forbidden to be touched by someone of the opposite gender. Male Muslims should be examined by men and only female nurses and doctors should examine Muslim women.

Modesty: Nakedness is anathema to members of some faiths, notably Muslims. Health care situations, including hospitalization, do not lessen this sensitivit, especially for women and elderly people. Requirements for putting on a hospital gown may be met with opposition. Studies indicate that concerns about modesty contribute to health disparities among certain segments of the population. Asian women, in particular, if they are very traditional, may often avoid seeking care if a physical examination is necessary.

Diet: Concerns about dietary restrictions are most important in hospital settings where patients have little control over what they are served. Still, general awareness of food taboos predicated by culture/religion is important for all health care providers. Doctors in private practice settings and clinics need to be aware of how dietary restrictions affect patient compliance and should know to ask, for example, if a Hindu patient is vegetarian. Some do eat meat, but do NOT eat pork or beef. Eggs may not be allowed. Hindus and Muslims may both observe strict fasting. Mormons follow a dietary code that prohibits tea, coffee, and cola drinks. It is not as important to try to memorize specific dietary rules as it is to understand something about the beliefs driving the rules. For example, where fasting is practiced, it is related to a widely-held belief that physical cleansing is associated with spiritual cleansing.

Sacred objects: Be they amulets, figurines, portraits of saints, crosses, intaglios – sacred object should be allowed in a patient’s physical space and on the body. All caution should be taken to safeguard them. They should not be removed (or even moved) without talking with the patient/family. Evil eye pendants or charms are common worldwide. In Mexico they are very common, and should never be removed, especially from babies, without permission of family members. Similarly, Sikhs wear a steel bracelet on the right wrist that – like a wedding ring – should not be removed unless absolutely necessary. Called a Kara, this bracelet is a symbol of unbreakable attachment to God. It is in the shape of a circle which has no beginning and no end.
Sacred Time: In our Dimensions of Culture trainings we talk a great deal about how people’s concepts of time vary by culture. In addition to differences between clock time and “fluid” time, health care providers should be aware of sacred time. What day does the patient and family observe as a day of rest? It is Friday for Muslims, Friday at sunset until Saturday at sunset for Jews and Seventh-day Adventists, and Sunday for Christians. Institutions should post calendars that note the holidays for all traditions served. Meetings with families should not be scheduled on these dates, and office appointments should be offered on days other than sacred days. Clergy within certain faith traditions can provide the dates for holidays, like Ramadan, that shift year to year.

Possible Health Events and Associated Cultural-Religious Tenets

(Based on Table 5-1 presented in Rachel Spector’s “Cultural Diversity in Health and Illness” listed in resources below. )

• Use of Birth Control- Sterilization may be forbidden. In some circumstances, Jews may seek rabbinical consultation before deciding about the use of birth control. People of some other faiths may only use natural means of preventing pregnancy.
• Circumcision – Male: In some cultures, males must be circumcised after birth, during childhood, or around puberty as part of a rite of passage. Jewish law states circumcision is mandatory. In Islam it is either recommended or obligatory – worldwide 70% of circumcised males are from the Muslim world. It is also prevalent in parts of Southeast Asia, Africa,the United States, the Phillipines, Israel, and South Korea. Female: While individual Muslims, Christians, and Jews practise FGM, it is not a requirement of any religious observance. Judaism requires circumcision for boys, but does not allow it for girls. Islamic scholars have said that, while male circumcision is a sunna, or religious obligation, female circumcision is preferable but not required, and several have issued a fatwa against Type III FGM. WHO Global Map of Male Circumcision WHO on Female Circumcision

• Surgery (including Cesarian) In some faiths surgery is acceptable with the exception of abortion. In others, all invasive procedures are avoided. In the Hmong culture people fear soul loss during surgery.  A Muslim woman may avoid a cesarian because she believes only Allah can decide whether a baby is born. Jehovah’s witnesses are not opposed to surgery but the administration of blood during surgery is strictly prohibited.
• Use of Blood and Blood Products – Typically no restriction except for Jehovah Witnesses and possibly Christian Scientists
• Autopsy – Tenets about autopsy range from being permitted for medical or legal purposes only to actually being required by law.
• Organ Donation – Forbidden by Jehovah’s Witnesses. For many who follow Judaism this is a complex issue requiring rabbinic consultation.

Summary

Health care providers may sometimes be uncomfortable talking about cultural-religious health beliefs and behaviors with patients and families. This article has suggested six key areas of intersection between a patient’s health care and their cultural-religious beliefs to assist in these important conversations. In addition, five health events of particular interest in cross-cultural health care were presented. Discovering the broader context of a patient’s life is critical to providing responsive care and assuring good health outcomes.  Resources for more specific in-depth cultural-religious information appears below.

PDF Version of Article

Resources

• MU Center on Religion and the Professions, funded by the Pew Charitable Trusts.

• Testerman, John K. Md, Ph.D. “Spirituality vs. Religion: Implications for Health Care” by John K. From lecture given at 20th Annual Faith and Learning Seminar June 1997.
• Kennedy, Maria MD. “Role of Patient’s Religion in Delivery of Culturally-Responsive Care.” MD Anderson Cancer Center Chaplaincy Department
• Spector, Rachel E., “Cultural Diversity in Health and Illness” (7th Edition) July 19, 2008 Publisher: Prentice Hall; 7 edition (July 19, 2008)Language: English

Could this kind of information could be useful as a quick reference guide before an office visit with a patient/family from another country? If the information is used to suggest possible differences in communication styles between cultures, then yes.  Being aware, for example, that some cultures prefer indirect communication and may avoid sustained eye contact is important. This fact might help make sense of how a patient/family member is behaving during an office visit. As always, the information can’t be applied too rigidly. I wrote an email to the developer suggesting they help users avoid stereotyping by keeping in mind the great variation in adherence to cultural norms. I didn’t get an reply. The app is FREE and worth checking out if you have an iPhone.

What is Heritage Consistency?

The term heritage consistency is used to describe how much or how little a person’s lifestyle reflects his or her traditional culture. If one is very “consistent” with their heritage,  then one maintains more of the core values, beliefs, attitudes, and behaviors of one’s cultural heritage. If one is more “inconsistent,” then he or she deviates from that cultural heritage. Usually, the more one acculturates to American society, the less consistent they are with their original culture.  Asking questions that reveal heritage consistency is an important means of zooming in on the individual patient’s experience which helps avoid stereotyping.

Three Key Factors Related to Heritage Consistency

Especially when working with immigrants and refugees, it is important to determine three key factors related to heritage consistency: socialization, acculturation, and assimilation into the dominant U.S. culture.  Though close in meaning, the three are distinct.

Socialization: The process of being raised within a culture and acquiring the characteristics of that group. Formal K-12 education in the U.S. is a key means of socializing children in our society.

Acculturation:  This is the process of becoming a competent participant in the dominant culture. Acculturation is necessary to survival so it is involuntary. The degree to which one becomes acculturated and the speed of the process are affected by an individual’s circumstances and choices. Children, who can easily avail themselves of socialization via public schools, tend to acculturate quickly in the U.S. They have an easier time learning a new language. Grandparents, on the other hand, often acculturate slowly. They find adaptation more stressful and thus are often less willing to engage the dominant culture. They may seek the safety of their own close-knit ethnic communities, even resisting learning the language of their new country. Finally, literacy – in one’s native tongue as well as the language of the new country – affects the acculturation process.

Assimilation – Very much like acculturation, assimilation refers to the extent of identification with the dominant culture. Beyond becoming a competent participant in the dominant culture, an assimilated person chooses to identify with the members of the dominant culture. Behaviors that indicate this include marrying into the dominant culture, engaging in the civic activities of the dominant culture, living and working within dominant-culture communities, and so on. “The process of assimilation is complete when the “foreigner” is fully merged into the dominant cultural group.” (McLemore, 1980, p. 4)2

Many European Americans today – Irish Americans, Italian Americans, French Americans, etc. – are disconnected from their cultural heritage. Exploring the assimilation experience of one’s forebears can be very eye-opening. America’s history is truly a history of immigration, acculturation and assimilation (with notable exceptions/variations).

Indications of Heritage Consistency

The following list of questions can help establish heritage consistency for a particular patient/family. Used skillfully, they reveal attitudes about health and illness as well as important family dynamics. For older children and adolescents, it can be especially stressful straddling two cultures. These questions can be especially helpful in facilitating discussion about acculturation and assimilation with bi-cultural children struggling with identity confusion.

1. Did the person’s childhood development occur in the person’s country of origin or in an immigrant neighborhood in the United States?
2. Do extended family members encourage participation in traditional religious or cultural activities?
3. Is the individual’s family home within their ethnic community?
4. Does an individual/family frequently visit the country of origin or return to the “old neighborhood” in the United States?
5. Was/ is the individual raised in an extended family setting?
6. Has the individual’s name has been Americanized?
7. Was the individual educated in a school with a religious or ethnic philosophy similar to the family’s background?
8. Does the individual engage in social activities primarily with others of the same ethnic background?
9. How fluent is the individual in the family’s language of origin?
10. Does the individual possess personal pride about his/her cultural heritage?

(This list adapted from Cultural Diversity in Health and Illness, 7th Edition)

Summary:

Along with the socio-economic factors of poverty, literacy, and health literacy, culturally responsive care takes into account the heritage consistency of individual patients within the context of family dynamics. In an effort to avoid applying cultural generalizations too rigidly, providers explore the indicators of cultural consistency with their patients from different cultural backgrounds to understand how closely each individual adheres to the traditional culture in which they were raised.  Deviations in attitudes and life experiences affect each person’s health beliefs and behaviors including their ability and/or willingness to comply with the treatment plan their doctor recommends.

Sources:

• The 12 questions to use for indications of heritage consistency are adapted from the Cultural Diversity in Health and Illness by Rachel E. Spector. 7th Edition,
• Heritage consistency is a concept developed by Estes and Zitzow (1980) “The degree to which one’s lifestyle reflects his or her respective tribal culture.”

The Diversity of “Black” Experience

It’s helpful to make a distinction in terminology – “blacks” can be defined as all persons of African descent, whose genealogical connection is to Africa, and in particular West Africa. However, because skin color and culture are not the same thing, when discussing cultural beliefs and practices among this group, the term African American best refers to “blacks” in the United States, people whose sociocultural roots are in the North American experience, but who are of African descent. When applying this definition, it should become obvious that skin color is not the best indicator; people of African descent can have very light complexions. Many are of combined heritages. It is particularly important not to generalize about the African American experience when meeting with patients and families. Seeing the individual in each encounter is, as always, most important.

Social Structure

Many aspects of African American culture today reflect the culture of the general US population. However, the structure in African American families is often extended to include non-related “family” members or “fictive kin.” The family may be matriarchal, although father or mother may take on the decision-making role. For African Americans, women more than men tend to remain unmarried, and more women have been educated at the college level.

Respect for Elders

In general, the older generation is more conservative, may have a more traditional view of gender roles, and may shun interracial dating and marriage. Elders are respected and often provide care for their grandchildren. Institutionalization of elders has historically been avoided, with sons and daughters taking on the family caretaker role.

Diet & Health Disparities

Studies in health disparities show residents of disadvantaged neighborhoods often have little to no environmental support for healthy behaviors which increases their risk for health disparities. For most African Americans and others residing in low-income neighborhoods, the abundance of fast food chains (fast food companies have specifically targeted African American communities as a growing market for their products), high-priced food marts, and a lack of access to healthy affordable foods contributes to the prevalence of obesity and chronic illness. Convenience and cost have an especially strong influence on low-income individuals’ likelihood of adopting healthy dietary behaviors; fresh fruits and vegetables and lean meat are more expensive than packaged processed foods. Similarly, lack of transportation can be a pressing problem for low-income families, something middle class Americans of all ethnic groups are spared. If you have to take a bus to do real grocery shopping, it is more likely you will rely on the corner 7-11 for convenience food.

Obesity, especially in children, is an enormous problem across America. National programs to improve diet quality and the overall health, especially among African Americans and other minority groups, have been initiated. Body and Soul: A Celebration of Healthy Eating and Living for African Americans offers information targeted to African Americans on eating a healthy diet rich in fruits and vegetables. (PDF of Body & Soul Manual— Body and Soul was a collaborative effort among two research universities, a national voluntary agency (American Cancer Society), and the National Institutes of Health to disseminate and evaluate under real-world conditions the impact of previously developed dietary interventions for African Americans.)

Religion

African Americans often have strong religious affiliations, especially with Christian denominations—notably Baptist and Church of God in Christ. However, many follow Islam. Maintaining good health is often correlated with good religious practice. Many churches maintain a health ministry through which congregations and parish nurses support good health with flu shots, blood pressure checks, and health education.1 Research has shown that the affluent among all social groups tend to move away from their communities of origin, and to become less traditional, whereas the poor are more likely to follow traditional cultural and religious practices.2,3

Asking About Religion and Spiritual Matters

According to Dr. Terri Richards, keynote speaker at a recent noon conference for the Department of Community Pediatrics’ residents at the University of Colorado School of Medicine, it can be very important to find out about a patient’s religion or faith. However, asking your patient directly “What religion do you practice?” or “What is the faith you follow?” is not as effective as asking more indirectly about where an individual turns for support in difficult times. Often times, the answer to this question among African Americans will be church. “I go to church every Sunday” or “My child wasn’t feeling well enough to make it to church on Sunday.” Encourage the patient to elaborate. This opens up an avenue for further exploration of how a person’s faith informs their health beliefs and behaviors. Also, because our formative experiences are so long-lasting, it may be helpful to learn not just what the patient’s religious and cultural affiliation is now, but what the beliefs of the family of origin were.

Trust & Medical Care

African Americans are becoming increasingly health conscious, seeking health screenings and treatments, although health literacy in this population tends to vary by generation. Older African Americans may be suspicious of clinicians, because of experiences of past generations of African Americans with health care.  Even African American parents today have heard about the Tuskegee experiments on African Americans, so they may be a little reserved or suspicious until it is apparent that their health care provider is friendly, wants to listen, and is interested in them.  There may be reluctance to share personal or family issues, so building a trusting relationship is absolutely crucial.

Child Rearing

African Americans describe their approach to child rearing as being less permissive than Americans of European descent. For example, telling a child that he is “in time out” may not seem as effective as giving a spanking, and culturally spanking is not frowned upon. The American Academy of Pediatrics suggests that parents be encouraged to develop methods other than spanking for managing undesirable behavior in their children. However, among African Americans, studies show a preference for using “harsh” or “authoritarian” forms of discipline that include physical punishment. This does not mean to suggest that abuse is considered acceptable among African Americans. Culture must be taken into account in childrearing. “Because parenting occurs in a socio-cultural context, recommendations about what constitutes an effective approach to discipline may not be generalizable to all populations among or between similar cultures. 4,5

Death and Dying

When considering the ways different cultures respond to death and dying, it is important to look at three variables: heritage consistency (the extent to which a person’s lifestyle identifies with traditional cultural values an reflects their cultural roots), social class, and spirituality.

Generally speaking, in the African American experience, spirituality is a fundamental part of how many people process and reconcile the experience of death. African Americans tend to believe in the sanctity of life and rely on a strong sense of community and family at times of loss. Family-centered consensus is valued in decision-making and there’s often a strong need for extended family to gather at a time of death; the family should be informed of an impending death so that extended family members who live out of state can be notified.

Many African Americans have a holistic view of death and dying so that birth and death are understood to be part of a cycle or continuum. At the same time, many older African Americans, who believe that death is God’s will, may also tend to believe that life support should be continued as long as necessary. Cremation is generally avoided in this community and organ donation may be viewed by some as a desecration of the body.6

In medical settings, the spiritual aspects of caring for people who are dying have often been neglected. So much emphasis is placed on the physical care of the dying that spirituality is often overlooked, and health care providers do not always recognize that this should be an integral part of the continuum of care. In hospital settings, one way to accomplish this is to offer the support of the hospital chaplain. Naturally, it would be ideal to involve clergy from a person’s own faith community, but if that is not possible, then certainly make sure that the hospital chaplain is available as an integral part of the care team.

Conclusions

Understanding a patient’s practice of cultural norms can allow providers to more quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities among African Americans 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. Again, get to know your patients on an individual level. Generalizations in this material may not apply to your patients. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions.

PDF of this Article

References

1 www.stratishealth.org African American  cultural guide

2. Barrett RK. Sociocultural Considerations for Working with Blacks Experiencing Loss and Grief. In Living with Grief: How We Are—How We Grieve, K Doka (ed.). Washington DC: Taylor & Francis Publishers, Inc., 1998, 83-96.[Return to International Perspectives]

3. Perry H. Mourning and Funeral Customs of African Americans. In Ethnic Variations in Dying, Death, and Grief, DP Irish, KF Lundqust & VJ Nelson (eds.). Washington: Taylor & Francis Publishers, Inc., 1993, 51-65.[Return to International Perspectives]

4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2568462/pdf/jnma00178-0030.pd

5. Larzelere RE. A review of the outcomes of parental use of nonabusive or customary physical punishment. Pediatrics. 1996 Oct;98(4 Pt 2):824–828. [PubMed]

6. Barrett RK, Heller KS. Death and dying in the black experience: An interview with Ronald K. Barrett. Innovations in End-of-Life Care. 2001;3(5), www.edc.org/last acts

If your American family story is like mine…

your ancestors were probably voluntary immigrants to this country, not refugees. My maternal grandfather came over from Poland at the turn of the last century, knowing eight languages, but not one of them English. He was thirteen, alone, with just a note hung around his neck with a destination written on it. In honor of his memory, I wanted to help another newcomer to the United States, and that is why  I volunteer to teach English as a Second Language (ESL) in the Colorado Refugee English as a Second Language Program (CRESL) at Emily Griffith (http://www.refugee-esl.org).

A person doesn’t choose to be a refugee. It happens to you.

Refugees have been forced to flee their homeland, and through the United States refugee resettlement program, have found refuge in our country.  By official definition, a refugee is any person who is outside his/her country of nationality, and is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, and membership in a particular social group, or political opinion.

Women refugees are often isolated at home.

The refugees in the CRESL in-home tutoring program are overwhelmingly women who are to unable to attend the regular ESL classes for various reasons – perhaps health issues or small children at home or cultural and religious issues that forbid women from appearing in public without being chaperoned by a male family member. The in-home tutoring program was established to aid these women in learning English and becoming acculturated so that they are not isolated. They learn the English language and American cultural ways so that they can ride the bus and do their own grocery shopping, go to their children’s school appointments, rent an apartment, and basically live day to day in an American city.  Also, as I discovered firsthand, learning English is crucial in helping these women refugees access much-needed health care.

Literate in three languages, zero health literacy.

I was first assigned to tutor a woman in her mid forties named *Fatima. In some ways Fatima shares similarities with my grandfather, as she is literate in three languages but speaks no English. She and her family also share his courage and desperate longing, maybe you could say a determined optimism, for something better.

I was considered very lucky as a tutor; my student knew how to read and write in several languages, one of them Russian, a rather complex language. And, she was used to living in large cities. Often refugees are illiterate and from rural areas. Literacy made it much easier to teach a second language and familiarity with urban, modern living meant many of the tasks of teaching daily skills could be skipped. Thankfully, I wouldn’t have to pantomime why one should put chicken in a freezer or refrigerator to keep it fresh.

Fatima lives with her husband and two teenage sons. She also has a married daughter in Ohio. Fatima and her family are Muslims and would be considered rather liberal. For example, Fatima wears a head covering, but it looks more like a large headband that does not cover her head like a traditional Islamic head covering.

The doctor suspects cancer.

One day Fatima asked for my help arranging a follow-up visit to a health clinic. Her teeth and gums were in terrible condition, due in large part to her time in a refugee camp. She was unable to eat solid food and continued to lose weight. It turned out her gums were so inflamed and full of sores that she had previously gone to the clinic on an emergency basis where the doctor, suspecting cancer, had done a biopsy.

I was able to assist her with scheduling the second appointment. Upon her request, I also went with her and her son to that appointment.  She wanted me to stay with her during the actual visit, and I did. Thankfully she didn’t have cancer, but she was in a great deal of pain and had been for months. The clinic sees and serves many people. They are overwhelmed. What I had to explain to Fatima was that although she was in terrible pain, and although her mouth looked so bad that they had initially thought it might be cancer, they could not see her for dental care for at least 6 months. Further, they would not give her help with pain management while she waited for dental treatment.  After a brief statement from the doctor and the interpreter I was left trying to explain this.  My pantomime skills – never any good to start with, and any dexterity I had paging through the English- Russian dictionary, were inadequate to explain the situation. But with her experience as a refugee Fatima grasped the totality of the situation more completely and more quickly than I did.  “No money, too many people, has to wait.”

Family culture can be a health care barrier.

Our overburdened public health care services weren’t the only challenge I would have to navigate to find Fatima the care she needed immediately. I was in for a real “cross-cultural awakening.” After searching the internet for a few hours I found that the University of Colorado School of Dental Medicine runs an emergency dental clinic (open Mondays – Fridays sessions at 10 a.m. and 2 p.m.) that was open and available to Fatima. Yes, they assured me, if I got there early I could get Fatima into one of the slots that next day.  But I had to convince Fatima’s two young sons, since her husband was out of town, to let their mother receive the emergency dental care she needed. One of the sons would need to get up early enough to accompany us to the clinic because Fatima was not allowed to go anywhere without a male member of the family. We finally negotiated to have one of the sons would go with us, but only to an afternoon session; we would have to hope that one of the afternoon slots might be open. Also, I assumed I would drive,  but oh no! Her son had to drive us because no woman could be allowed to drive. I am thankful that we made it without being stopped for his myriad traffic infractions.

Eventually, Fatima had all her teeth pulled, got dentures, and is much happier and pain free.  Not long after, her family moved to Ohio to find work and to be closer to her daughter’s own growing family. I miss Fatima – her laugh and good spirits and her attempts to teach me a bit of Russian.  But I am pleased for her that her loneliness is eased with having her daughter close by.

I learned more than I ever imagined working with Fatima, maybe more than she did. I learned that for a refugee trying to get health care there are both obvious and invisible barriers. Language differences and the financial limitations of both the refugee and the care providers themselves  are easy to see. It was the cross-cultural barriers that caught me by surprise. This woman’s culture, her values, beliefs, and attitudes from a remote area of Turkey, determined whether or not a she could leave her house to visit an emergency clinic or choose a safe convenient method of transportation to get herself there.

Perhaps your American family’s story is more like Fatima’s than mine. At the very start, I imagined the refugee I would be tutoring would have much in common with my maternal grandfather. Well, Fatima shares some traits with him, indeed. As I noted earlier,  she and her family share his courage and determination to build better life in a new country. But Fatima, being a woman and being Muslim, has a much harder road to travel here with a unique set of barriers she must struggle to overcome.

It is common for non-native speakers of English, especially those who speak an Asian language as their mother tongue, to respond to negative questions in a way that reverses the meaning of their answer. For example, if I ask, “She didn’t eat breakfast this morning?” a native English speaker would say “no” meaning, no she didn’t eat breakfast this morning. But a Chinese person learning English, for example, might answer as if there was no negation: “Yes, that is correct. She didn’t eat breakfast this morning.”

Another Example: “Didn’t you take the medicine?” If I answer with “yes” it means “Yes, I took the medicine.” But some non-native speakers of English will answer: “No, it is not true that I didn’t take the medicine”.

A question tag is the “mini-question” at the end of a phrase like: “Snow isn’t black, is it?” Again, non-native speakers often will answer with “Yes” (meaning “Yes, I agree with you that snow is not black.”

It is best when communicating across cultures to avoid negation in forming questions. In some instances, the context of the questions will immediately prove there’s been missed communication between two people: “Men don’t have babies, do they?” Yes. (Huh???) But in other situations, context won’t help: “Didn’t you give the child the medicine as I explained?” Yes! (It is true that I didn’t.)

The Better Way To Ask: “When did you give the child the medication? (notice I did not start that question with DID because that can lead to a head nod and we want a full answer. “Is snow black?” No. (Unless, of course, you’ve lived through a winter in Chicago where the snow stays on the ground so long it does turn black. Isn’t that true?)

As an interculturalist and educator, I help people acquire skills to make them better cross-cultural communicators. I naturally discourage using lists of culture facts as an oversimplified approach to a very complex subject. Using lists of dos and don’ts will tend to obscure the all important context driving any interaction between people of different cultures.

This leads me to the following quote by Edward T. Hall, anthropologist and cross-cultural researcher: “The essence of cross-cultural communication has more to do with releasing responses than sending messages. And it is most important to release the right responses.” What could be more crucial to taking accurate patient histories, making diagnosis and treatment plans?

Eliciting the right responses begins with asking quality questions.

In past months, the University of Colorado’s Department of Pediatrics’ Cross-cultural Healthcare Committee set about fine tuning a set of key questions to support cross-culturally responsive care. Though there are already questions/acronyms used in health care to remind providers about cross-cultural issues (LEARN, BASIC, etc.) our department’s questions are geared specifically to pediatrics. These questions are grouped under the following headings: seeing the individual in each encounter; beliefs about what causes illness; family dynamics and decision making; seeking treatment & using remedies; understanding/acceptance; and special situations (modesty concerns, death and dying).

The efforts of the Cross-cultural Healthcare Committee were largely focused on finding the best wording for these questions, so it is important to pay attention to their phrasing. It is also crucial to understand the rationale behind each category as well as the individual questions themselves. Why, for example, is it important to understand the impact of family dynamics on a particular patient? Especially when the patient is a child, family hierarchy is going to determine decision making. How many generations of one family are living in the same house? Who will be administering medications to a sick child – grandma, older siblings?

Being able to release quality responses from patients from any culture is a communication skill that comes with experience. Having a set of strategically designed questions at the ready can help providers be more diligent in accessing the cultural implications of a case during  encounters with patients and families. The questions may take more time up front, but will lead to fewer misunderstandings and better diagnosis, saving precious time in the long run.

These questions are not intended to be used as a check list which would render them about as useful as fact lists; the context of each encounter will determine what information is most important for a provider to obtain. These key questions are intended as a way of drilling down to deeper levels of context. That’s where the individual patient’s experience is found. That’s where real communication can happen so that the patient experiences truly responsive care.

Key Cross-cultural Care Questions
 

In this article we will take a look at Latino culture specifically, keeping in mind that a wealthy Cuban American who has been in the United States for many years will likely have cultural values that are markedly different from a recent immigrant to the US from Mexico.

Definitions: Latino vs. Hispanic

The term Latino denotes all persons living in the United States whose origins can be traced to the Spanish-speaking regions of Latin American, including the Caribbean, Mexico, Central American, and South America. ( Flores 2000) The term Hispanic was created by the U.S. federal government in the early 1970s in an attempt to provide a common denominator to a large and highly diverse population with connection to the Spanish Language. It is often considered a somewhat narrow indicator by those who prefer the term Latino. Interestingly, “Hispanics” are a race to the United States Department of Justice when it enforces provisions of the civil rights laws, but Hispanics are not a race to the Bureau of the Census.

A Collectivist Culture With Strong Family Values (Familismo)

Latinos tend to be highly group-oriented. A strong emphasis is placed on family as the major source of one’s identity and protection against the hardships of life. This sense of family belonging is intense and limited to family and close friends. People who are not family or close friends are often slow to be given trust. The family model is an extended one; grandparents, aunts, cousins, and even people who are not biologically related may be considered part of the immediate family. The term Latinos use to describe their supreme collective loyalty to extended family is familismo. Financial support of the family by the individual and vice versa is important and expected. The decisions and behavior of each individual in the extended family are based largely on pleasing the family; decisions are not to be made by the individual without consulting the family. Failure of the clinician to recognize familismo can potentially lead to conflicts, non-compliance, dissatisfaction with care and poor continuity of care.  Familismo can delay important medical decisions because extended family consultation can be time consuming. To gain the trust and confidence of the Latino patient/parent, it is important to solicit opinions from other family members who may be present and give ample time for the extended family to discuss important medical decisions.

A Hierarchical Culture That Values Respecto

The term power distance is used in the field of intercultural communications to compare the extent to which less powerful members of a society accept that power is distributed unequally.  When power distance in a society is high, people tend to believe that everyone has their rightful place and they understand that not everyone is treated equally.  When power distance is low, people believe that everyone should have equal rights and the opportunity to change their position in society. In Latin American cultures, people tend to expect status differences between members of a society which is very different from U.S. American culture. Latinos place a high value on demonstrating respecto in interactions with others, which literally translates into respect. Respecto means that each person is expected to defer to those who are in a position of authority because of age, gender, social position, title, economic status, etc. Healthcare providers, and doctors especially, are viewed as authority figures. Thus, Latino patients/parents will tend to demonstrate respecto in healthcare encounters. They may be hesitant to ask questions or raise concerns about a doctor’s recommendations, being fearful that doing so might be perceived as disrespectful. They may nod to demonstrate careful listening and respect when a doctor is talking, rather than agreement about treatment.
Respecto is also expected on a reciprocal basis by Latinos when dealing with healthcare professionals. This is especially the case when a young doctor is treating an older Latino patient. It is important to approach Latino patients/parents in a somewhat formal manner, using appropriate titles of respect (Senor [Mr.] and Senora [Mrs.] and appropriate greetings [good morning or good afternoon]. This is especially true with older Latinos. U.S. Americans are recognized the world over as being highly informal. We jump to a first name basis with strangers almost immediately, signaling a collapse of status differences by doing so. Good intentions aside, people from many traditional cultures will not appreciate this informality. It will make them uncomfortable and may even be seen as rude behavior in certain situations.

Hierarchy in Latino Families

Latino families are often stratified based on age and sex. Generational hierarchy is expected – grandparent, child, grandchild. The oldest male (direct relative) holds the greatest power in most families and may make health decisions for others in the family. Latino men traditionally follow the ideal of machismo. They are expected to be providers who maintain the integrity of the family unit and uphold the honor of family members. Many Latino females, at least publically, are expected to manifest respect and even submission to their husbands, though this compliance varies by individual and is affected by acculturation in the U.S. Women follow the ideal of marianismo which refers to the high value Latino women place on being dedicated, loving and supportive wives and mothers. They are responsible for teaching Latino children culture and religion and for being ready to help those in need both in the family and community. It bears repeating that upward mobility, education and other societal factors are changing the above, but in isolated communities and among new immigrants, little has changed.

Latinos and Uncertainty Avoidance/Fatalismo

“A basic fact of life is that time goes only one way. We are caught in a present that is just an infinitesimal borderline between past and future. We have to live with a future that moves away as fast as we try to approach it, but onto which we project out present hopes and fears. In other words, we are living with an uncertainty of which we are conscious.” (Hofstede 2001)

Because human beings display a variety of cultural attitudes about controlling external forces, our attitudes about time, destiny and fate can be dramatically different.  In US American culture, we struggle to accept things as they are which creates high levels of stress and anxiety in our lives.  Our inner urge to be busy is directly correlated to a need to control life’s uncertainty and feelings of powerlessness toward external forces.  We focus on the individual as the locus of control in decision making and put little faith in fate or karma. We also exhibit an adversarial relationship to time, constantly needing to control the time shortage we face. We believe that multi-tasking is an important skill to develop and we rely heavily on technologies to help us do things like check our email while eating breakfast.
Latinos, by comparison, often have a strong belief that uncertainty is inherent in life and each day is taken as it comes. The term fatalismo is often used by Latinos to express their belief that the individual can do little to alter fate. This mindset manifests in health beliefs and behaviors in significant ways.  Latino patients are more likely than whites to believe that having a chronic disease like cancer is a death sentence. They may prefer not to know if they have cancer, and may believe that cancer is God’s punishment. As a result of fatalismo, Latino patients may be less likely to seek preventive screenings and may delay visiting a western doctor until symptoms become severe. They may avoid effective therapies for cancer and other chronic diseases, especially radical new treatments and invasive procedures. (Flores 2000)
It makes sense that a culture tolerant of uncertainty tends to have a relaxed attitude towards time. Many Latinos definitely treat time as flexible and do not value punctuality the way their healthcare providers may expect them to. In fact, within the Latino community, not being on time is a socially accepted behavior. This explains a tendency for Latino patients/parents to show up late for healthcare appointments fully expecting to be able to see their provider. Similarly, Latinos are more accepting of certain levels of chaos and don’t expect orderly processes. The western medical model, with its focus on data gathering and tracking, and its insistence on adhering to specific appointment procedures, may seem unduly regimented to less acculturated Latinos, especially those who are new immigrants.

Task vs. Relationship/Simpatia and Personalismo

If U.S. Americans are time and task-oriented, Latinos tend to be more focused on relationship. The word simpatia means “kindness” and refers to an emphasis on politeness and pleasantness even in the face of stress. Latinos expect that healthcare providers demonstrate simpatia and personalismo which translates into “formal friendliness.” Latinos may read the neutral or businesslike affect of western doctors as negative. If the physician seems hurried, detached and aloof, the Latino patient/parent may experience resentment and be dissatisfied with care. This of course reduces the likelihood of compliance with the doctor’s recommendations for treatment and follow-up. A physician should be attentive, take their time, show respect, and if possible communicate in Spanish. Physical gestures such as handshakes or even placing a hand on the shoulder help to communicate warmth. Latinos also expect their healthcare provider to exhibit confidence.

Conclusion

Healthcare providers need to be familiar with the normative cultural values affecting interactions with their patients from different cultures. While it is impossible to know everything about every culture, clinicians can learn about important cultural values by using published references, consulting colleagues from other ethnic groups, and speaking to interpreters and community members. It is also important to learn to ask patients questions in a culturally sensitive way, understanding that fear of making mistakes in communicating with them blocks the exchange of vital information.

The information provided here about Latino culture is meant to assist clinicians by providing a general framework. No hard and fast rules about interacting with Latino patients and families are being offered because they would lead to stereotyping. A cross-cultural mindset requires understanding one’s own health beliefs and behaviors first and then applying that baseline of understanding as a means of making effective comparisons across cultures. Clinicians should keep in mind that individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on an individual’s health beliefs and behaviors. All these factors challenge one’s ability to understand and treat patients in cross-cultural settings, but meeting those challenges can be vital in reducing health disparities for Latino Americans in the U.S.

Sources Referenced for this Article
1. Hofstede, GH. Cultures Consequences. Second Edition 2001
2. Flores G. Vega LR. Barriers to Health Access for Latino Children: a review. Family Med 1998:30:196205
3. www3.Baylor.edu/Charles_Kemp/Hispanic_health.htm

In my free time, I like nothing more than a thought-provoking read. Ali’s book Nomad, a follow-up to her memoir, Infidel, is certainly this kind of book. In the words of a NY Times op-ed columnist who reviewed it, “Since Hirsi Ali denounces Islam with a ferocity that I find strident, potentially feeding religious bigotry, I expected to dislike this book. It did leave me uncomfortable and exasperated in places. But I also enjoyed it.”

Ali is at her best when she is telling her powerful story, and as a reader interested in learning about other cultures, I found her insights into tribal life in Somalia very informative. Her explanation of the challenges of integrating Muslim immigrant communities into Western societies was useful as well. As an interculturalist and educator, I recommend the book to others for these aspects. I also discovered the term designer tribalism in Nomad, and added yet another book to my wish list: “The Culture Cult” by Roger Sandall.

Author Ayann Hirsi Ali, a self-professed “infidel”, did indeed provoke a lot of questions with this portrait of her family. Though the word infidel means literally “one without faith,” I find this woman to be a cultural nomad who has struggled, but succeeded, because she does have strong faith -  in herself.