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Karen People in Minnesota

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Increasing the cultural competence of health care providers serving diverse populations

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 accounted for. 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.

Nearly 4,000 Karen (pronounced kuh REN) refugees live in Minnesota. Karen refugees are from Myanmar (formerly Burma, and still referred to as Burma by the Karen people) and refugee camps in Thailand. St. Paul is home to the largest Karen refugee population in the U.S.

An ethnic minority in Burma, which is located in Southeast Asia between India and China, the Karen people constitute more than one-fourth of Burma's population. They arrived in Burma more than 4,000 years ago and have lived primarily in the eastern hill country and in western Thailand. Since 1962, Burma has been a military dictatorship.

Karen people have been fighting for independence from Burma for the past 60 years. The military has tortured, raped, and killed many thousands of Karen people. Many have died under conditions of forced labor and month-long walks to refugee camps. In 1989, Burma was renamed Myanmar, but because of its negative military overtones, most minority ethnic groups, like the Karen, refuse to use the new name. The Karen are often referred to as the indigenous people, or hill tribes, of Burma. Red Karen include several groups, including the Padaung or Kayan, famously recognized for the neck rings worn by women of the tribe. White Karen include the Sgaw and Pwo Tribes. Karen people from Burma identify themselves with their ethnic group; they do not refer to themselves as Burmese. The Karen population consists of smaller subgroups of people who speak different dialects. A common interpretation problem is expecting one person from Burma to understand another. Because the cultural rift between Karen and ethnic Burmese runs very deep, Karen often prefer no interpretation assistance rather than assistance from another ethnic group.

Social structure

The Karen are known for their friendliness, hospitality, traditional red or blue woven shirts and dresses, and festival dances. Many men display elaborate, extensive tattoos, which represent character and protection against harm.

Karen people are often recognized for the brass neck rings worn by women from the Padaung or Kayan tribes. The neck rings distort the growth of their collarbones and make them look as if they have long necks. The rings do not actually stretch their necks, but squash the vertebrae and collar bones. A woman may have 20 or more rings around her neck. This practice may begin when girls are five or six years old.

Traditionally, Karen people do not have surnames—which can cause some confusion in a health care setting. They normally address each other by terms that denote kinship. Men and women are considered equal in this community. They trace their lineage through the mother and maternal ancestors. Parents, children, and grandparents often live under the same roof. In Burma, most Karen were farmers and have little education.

Karen people avoid confrontation and don't usually like talking about themselves. Public displays of anger and other negative emotions are considered shameful. They often communicate indirectly. Rather than coming straight to the point, they may discuss other subjects first and may say "no" as a demonstration of modesty. Although Karen people don't engage in public displays of affection, women are often physically affectionate with each other, naturally holding hands or hugging a female visitor. Men may hold hands with one another. Unmarried women and men do not touch, although handshaking is common when greeting Westerners, regardless of sex.

Dress is usually conservative, with women wearing sarongs and both men and women carrying woven shoulder bags. Shoes are usually removed and left at the door. Women may sit with their feet faced away from others. When walking between others, it is considered polite to bend over so that one's head is not above others. Stepping over people or passing things over others is considered impolite. Many Minnesota organizations support these new arrivals, including the Karen Organization of Minnesota and the Karen Community Minnesota. Several churches and many Karen already living in Minnesota help new immigrants find food, clothing, social services, and housing. Other organizations that support the Karen people in Minnesota:

Diet

Meals are served in family groups that may also include neighbors. A large container of rice is accompanied by smaller bowls of meat or fish, vegetables, chillis, fermented fish paste, and other foods and spices. In Minnesota, when Karen refugees arrive, they receive welcome packages of rice, other traditional foods, and a rice cooker from the Karen community.

Religion

In the U.S., most Karen are Evangelical Christians, with a small percentage of Buddhists and Animists. Karens make up the majority of the congregation of St. Paul's First Baptist Church, where they participate in choirs and bands. The church helps the newly resettled refugees connect with American Baptist-USA and Cooperative Baptist Fellowship churches throughout the
U.S. so that they can reconnect with families across the country and around the world.

Medical care

In theKaren people seem to prefer a warm, yet business like approach from their health care providers. Providers are often evaluated by the Karen people from the moment of first contact.

While many Karen hold traditional beliefs about health and illness, they tend to believe that Western medicine can cure anything. Many became familiar with Western medical practices from traveling medical staff when they were living in refugee camps. Like many groups from Southeast Asia, Karen may attribute illness to imbalance in the natural forces of wind, fire, and water. Many believe the abdomen is significant in causing and understanding illness. Menstrual flow is highly significant among women.

Infectious diseases are the greatest health problem for Karen immigrants. Other health risks include posttraumatic stress disorder (as a result of war, torture, and rape), malnutrition, injuries, chronic mental health problems, hypertension, diabetes mellitus 2, and anemia.

Chewing a derivative of the betel nut stimulates the nervous system and is common among women and men. Although it helps relieve dental pain, it is associated with submucosal fibrosis, oral leukoplakia, and squamous cell carcinoma.

Providers are advised to choose the simplest treatment routine possible for this population, explain prescribed medications, and ask the patient to repeat or demonstrate the treatment routine. Printing the treatment plan on a separate sheet of paper is helpful. Even if the patient does not read, he or she may have a neighbor who does. Follow-up and home visits may be required. Patient education should include:.

  • Signs and symptoms of common illnesses
  • Taking medications correctly
  • How to take a temperature
  • Hygiene and self care
  • Dental care
  • When to call or see a provider

Enf of life

Most Karen people in the U.S. are Christian and may acknowledge death according to the practices of their churches. For Buddhists, death marks transition from this world to the next. Karma the deceased accumulated during life begins a process of determining the next in a series of rebirths.

Death provides an opportunity to assist the deceased into a new existence. Ceremonies honoring the deceased can be held for up to 100 days after death as a reminder of life's impermanence. A monk may offer a sermon on behalf of the deceased, and survivors may hold an almsgiving ceremony to relieve suffering and assist in rebirth. The corpse is cremated to allow the spirit to escape.

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.

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