Common medical issues and cultural concerns of Hmong patients
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. Hmong do not call each other by their first name. They address one another by their title, such as aunt, uncle, brother, etc. Hmong have large, extended families and practice traditional ceremonies to remember their ancestors. The clan leaders are generally the key decision makers for families. The Hmong language, Hmoob (Hmong in English), has many dialects. Until the late 1960s, it was not a written language and has few medical terms. In their native lands, most Hmong were farmers. They organized their activities around sun up and sun down and were unaccustomed to doing things at specific times.2,3
Staples of a traditional Hmong diet are rice, noodles, fish, meat, green vegetables, and hot chili sauces. Hmong tend to eat the same types of food at each meal, with very little fruit or dairy products. Meat and vegetables are usually stir fried, steamed, or boiled. Hot dishes and hot or warm water are preferred. Traditionally, sick persons or expectant mothers eat only hot or warm food.
Most Hmong are animists. Animists believe
in non-human entities as spiritual beings. The Hmong
shaman is a religious leader who acts as a medium between
the visible world and an invisible spirit world. The shaman
conducts religious ceremonies and makes all decisions
related to spiritual healing. Hmong may seek the help of
a shaman when ill to determine if the cause of the illness
is within the realm of the spirit. Spiritual causes require
religious remedies. Illness may be caused by evil spirits, a
curse from an unhappy ancestor, or because the spirit has
left the body. An illness or invasive surgical procedure is
believed to be the cause of soul loss. Since coming to the
U.S., a number of Hmong have become Christian.
Adoption of a Western diet and sedentary lifestyle have lead to a dramatic increase in obesity, diabetes, hypertension, heart disease, and stroke in the American Hmong population. Other areas of concern for this population include congestive heart failure, chronic obstructive pulmonary disease, and chronic constipation and diarrhea.
In addition, many 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 advises health care professionals to encourage their patients to replace some fish in their diet with alternative protein sources.
According to the Refugee Health Report, many Hmong refugees immigrated to the U.S. with intestinal parasites, viral hepatitis, tuberculosis, anemia, depression, and post-traumatic stress disorder. Refugees 30 years of age or older may show long-term effects from malnutrition and exposure to yellow rain and other war zone chemicals.4
Research has shown that Hmong do not generally practice preventive health care and do not fully understand the importance of diet and physical activity in daily life. They also tend to lack understanding of the concepts of germs, asepsis, and immunizations, as well as diseases such as diabetes.5
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. A sick person may accept the traditional approach, the Western approach, or a combination of both approaches to treatment. Families often use herbal remedies and may conduct healing ceremonies in the hospital and in the home. Surgery, blood transfusions, and organ donation usually are not acceptable in this culture. Some Hmong even believe that certain Western medicines may poison them, rather than help them.
Take advantage of the following tips to help you provide the most appropriate, culturally competent care for your Hmong patients:
- Demonstrate respect by asking patients how they prefer
to be addressed.
- Maintain physical distance initially.
- Ask your patients in what language they prefer to discuss their health. Use trained medical interpreters; never use children or other family members as interpreters.
- Ask your patients what they think is causing their illness.
- Be aware that older people may listen attentively, but avoid direct eye contact, which is considered to be rude.
- Involve the patient and family in developing a care plan
and in obtaining consent signatures.
- Explain the long-term consequences of not taking care of chronic illnesses, and the need to take medications even when feeling well.
- Solicit support from adult children in caring for their elderly parents.
- Inquire about foreign medication use. Advise patients about possible safety issues associated with non FDA-approved foreign medications.
- Provide current knowledge about an incurable disease to the patient and family. Explain that a cure has not yet been discovered for the disease. Hmong people may 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 patients may say “yes,” but still not understand. Explain by comparing a condition or disease to a familiar household process such as using heat to control room temperature.
- Schedule longer appointments for Hmong patients, and
take the time to explain care options.
- Write down and fully explain appointment times. You may need to make appointments for some patients and call them before their next scheduled appointment. Explain your telephone triage system.
- Provide educational materials in Hmong and English. The patient or someone else at home may be able to read at least one of the languages.
Death and dying
Unlike the Western perspective of life as a journey, with a beginning and an end, traditional Hmong view life as a continuous journey. Most believe that death is merely a phase people go through when passing from this 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.
Hmong in Minnesota
At the end of the Vietnam War in 1975, thousands of Hmong (the H is silent) people immigrated to the U.S. A Southeast Asian minority group, the Hmong originally lived and farmed in the mountains of South China, Laos, Vietnam, Burma, and Thailand.
According to the 2010 U.S. Census, 245,807 Hmong people reside in the U.S., with the largest population living in California (91,224). Minnesota’s Hmong population is 66,181, reflecting a 46 percent increase since 2000. The largest Hmong community in the nation is in St. Paul, with 29,662 residents. Minneapolis has 7,512 Hmong residents. More than 53,000 Hmong live in Hennepin and Ramsey counties combined.
In the last 10 years, nearly 13,000 Hmong residents have moved to the suburbs. Washington County showed an influx of 3,764 Hmong residents and Anoka County showed an influx of 3,280 during that period.1
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.
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.
Additional reading specific to caring for diverse populations.
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.
Hmong Quick Reference Card. This card inlcudes Hmong words for hello, thank you, and goodbye, the 18 Hmong clan names, and tips for working with Hmong adults and children. The file is designed to be printed two sided and cut into four cards to share with staff. (2-page PDF)
Video Clips on Faith, Culture & Identity Perspectives in Hmong Communities. Sometimes communities have their own way of thinking and talking about end of life issues. Use thse videos to support community-based conversations regarding end-of-life care planning. Produced by Honoring Choices Minnesota.