Health Issues for Hmong… Pinzon-Perez Health Issues for the Hmong Population in the U.S.: Implications for Health Educators Helda Pinzon-Perez, PhD, CHES The author is affiliated with the Department of Health Science at the California State University of Fresno. Contact Author: Helda Pinzon-Perez, California State University at Fresno, Department of Health Science, M/S MH 30, 2345 East San Ramon Ave, Fresno, CA, 93740-8031; phone: 559-278-5329; fax: 559-278-4179; email: [email protected] Submitted January 26, 2006; Revised and Accepted June 14, 2006 Abstract The Hmong population in the US has grown since 1975. According to the 2000 US census, there are more than 160,000 Hmong living in the US. New waves of Hmong immigrants are re-settling in the US. Over 15,000 Hmong have come to the US from Thailand as refugees since summer 2004. California, Minnesota, and Wisconsin are the States with the highest Hmong populations in the US. Minneapolis, Fresno, and Sacramento are the metropolitan areas with the highest number of Hmong residents. Health issues such as tuberculosis, hepatitis B carrier status, asymptomatic splenomegaly, sudden unexpected nocturnal death syndrome, post-traumatic stress disorder, injuries related to agricultural occupation, cardiovascular disease, diabetes, lower immunization rates, and cancer, pose major challenges for health education practitioners. Genetics, problems with access to health services, and diet-related issues appear to be important contributors for morbidity and mortality in this population. Although the Hmong born outside the US account for less than 0.5% of the foreign population in the US, they are an important group from a health education perspective. Key Words: Hmong, Cancer, Immigrants, Refugees International Electronic Journal of Health Education, 2006; 9:122-133 1 Health Issues for Hmong… Pinzon-Perez INTRODUCTION Hmong are, in descending order, Minneapolis, MN; Fresno, CA; Sacramento-CA; Milwaukee, WI; and Merced, CA. The median age for the T he US Hmong trace their cultural ancestry as Hmong is 16.1 years while for the general US an ethnic minority in China.1 They re-settled in population is 35.3 years. About 56% of the the mountainous regions of Laos, Thailand, and Hmong population in the U.S. is younger than 18 North Vietnam and came to the US as political years old. The average Hmong household size is refugees because of their involvement as US 6.27 people in comparison to 2.59 persons in the allies during the Vietnam War.2 The Hmong general population.20 living in the US come primarily from Laos. More than 200,000 Hmong left Laos as refugees Regarding educational attainment, 50.7% of since 1975 and relocated in Thailand. From Hmong adults have less than 9th grade education these, 90% have come to US.3 (7.5% for the U.S. population) and 40.4% have completed high school or higher (80.4% for the Despite their increasing numbers in the US, little general U.S. population). The median family has been written about the Hmong in the US. A income for Hmong is $ 32,076 and for US is $ few studies focus on Hmong demographics and 41,994. A total of 30.3% of Hmong living in US experiences with the educational system.4-6 derive their income from public assistance Others have emphasized gender issues,7,8 family compared with 3% in the general US population. life,9,10 and religious adaptation.11,12 A dearth The States with the highest poverty levels in has focused exclusively on the health status of Hmong populations are Alaska (70% of Hmong this population.13-18 The purpose of this article is groups) and California (50% of Hmong groups). to discuss the health status of Hmong An estimated 34.8% of US Hmong populations populations living in the US and the challenges have incomes below the poverty level as they pose for the health education practice. compared to 12% for the general US population. Income in the Hmong communities in US is Hmong Communities in the US mostly derived from working in manufacturing The number of Hmong living in US has been and agricultural jobs. Linguistic isolation difficult to determine. The data provided by the (defined as no adults speaking English well or at 2000 US Census estimates that there are 169,428 all) was 34.8% in the Hmong compared with Hmong residing in US.19 Data provided by the 4.1% in the US population.20 Hmong 2000 Census indicates that there is a total of 186,310 Hmong living in US.20 The Health Issues in the Hmong Hmong 2000 Census Study provided a Population comprehensive understanding of socio- demographic characteristics of Hmong populations living in the United States and its In the Hmong language, the word Hmong means results are based on people who identified “human being” or “free people”.21 The Hmong themselves as being Hmong. The Hmong are an agrarian society originally from China. National Development Organization indicates Thailand has been the primary area for that the previous data under-represent the resettlement for most Hmong refugees since number of Hmong people actually living in US. 1975 when US agreed to locate between 1,000 According to this organization, it is estimated and 3,000 Hmong in this Asian country. By that about 275,000 Hmong are actually residing December 1975, more than 140,000 Hmong had in US. Factors such as distrust in the migrated to Thailand as refugees.3 government, previous negative experiences related to their identification of Hmong ancestry, Traditional Beliefs and language barriers may account for this discrepancy.20 Before exploring health issues in the Hmong, it is important to understand their health beliefs According to Pfeifer,20 the states with the largest which differ from the allopathic model we are Hmong populations are California (65,095 familiar with in US. The Hmong follow an Hmong), Minnesota (41,800 Hmong), Wisconsin animist religion. They believe in the influence of (33,791 Hmong), North Carolina (7,093 spirits in all facets of life. The Hmong Hmong), and Michigan (5,383 Hmong). The community believes that life and death is a metropolitan areas with the highest numbers of continuous circle with two specific end-points International Electronic Journal of Health Education, 2006; 9:122-133 2 Health Issues for Hmong… Pinzon-Perez (birth and death). Hmong communities believe agricultural occupation, cardiovascular disease, that death is not the end of one’s existence, but diabetes, lower immunization rates, and cancer rather the beginning of a new cycle, elucidated in have been documented as major concerns for the the reincarnation process, which allows souls to Hmong population in US.25, 26 Hepatitis B carrier exist in the physical world again and again.22 status in the Hmong has reached endemic proportions. The rates of obesity and The literature suggests that the Hmong continue Hypertension among Hmong children are higher to engage in ancestral worship and soul calling. than for the general population. Among young Some Hmong believe that illness is caused by a male adults, rates of asymptomatic splenomegaly departed ancestral spirit or the loss of one of the are three times higher than for the general sick person’s souls. Therefore, it is not population of South East Asian refugees.25 surprising to find that some Hmong believe that illness is not a biological process, but rather Mental health issues are of special relevance for results from the separation of body and soul Hmong populations living in US. Of particular which may or may not be related to offending an concern is the high number of sudden and ancestor. Furthermore, ill health may result from unexplained nocturnal deaths in Hmong males the spirit wishing to depart the body it occupies recently immigrated to US.25 This phenomena in search of a better location.23 Illness, therefore, has been recently known as sudden unexpected may not be treated with allopathic medicine and nocturnal death syndrome.26 Speculations have can instead be treated by a traditional healer been made about the association of mental health called a shaman. The shaman has duties similar issues such as post traumatic stress disorder, to the ones of a psychologist, a doctor, and a depression, and post emigration stress with these minister.22 unexplained nocturnal deaths.26 It is widely believed among this population that In a study of felt health problems in the Hmong, if a shaman’s ritual of soul-calling fails to bring Yang27 indicated that participants in her study back the soul to the sick individual, the person perceived family conflicts, youth delinquency, can only get worse and eventually die.13 and mental health issues as the most important Because of these beliefs, many Hmong may have health problems in their communities. Mental difficulties understanding the concept of disease health programs that involve close family and transmission through microorganisms and they clan members seem to be a priority for the may even refuse Western-based treatments.24 Hmong. Clans are important in keeping the Home remedies and herbal treatments are highly mental and general well-being of the Hmong valued among the Hmong. community. Newly-arrived Hmong will usually move to Minnesota, Wisconsin, Ohio, North The importance of Western health care is in Carolina, and California where large clan groups general recognized among Hmong communities, live.22 The clan leader and the shaman are but traditional diagnosis and herbal or spiritual important sources of mental health support for treatments are usually first used before this community. biomedicine.22 Conflicts between biomedical practices and Hmong beliefs are important to be Oxley & Lee28 indicated that Hmong adolescents studied. For instance, surgical removal of a body perceive pregnancy as a difficult event in life part may conflict with the Hmong belief in since it involves additional responsibilities and reincarnation. In addition, Hmong people may difficulties in time management. Added be hesitant to undergo anesthesia because they responsibility was described by the participants may fear a loss of their soul while being in Oxley and Lee’s study, as having additional unconscious. After a general anesthetic, it may tasks they were not prepared for. Difficulties in be necessary to perform a soul calling ceremony time management referred to the scarcity of time in the operating room to recall the lost soul.22 to fulfill parental expectations, marriage responsibilities, and pregnancy care.28 Health Issues for the Hmong Birth rituals are important in analyzing the health Tuberculosis, hepatitis B carrier status, status of the Hmong. “In Hmong culture, asymptomatic splenomegaly , sudden mothers and mothers-in-law help at the birth, unexpected nocturnal death syndrome, post- which often occurs in the squatting position, with traumatic stress disorder, injuries related to the husband helping to cut the cord and wash the International Electronic Journal of Health Education, 2006; 9:122-133 3 Health Issues for Hmong… Pinzon-Perez newborn infant.”25 Hmong women dislike Yang27 indicated that Hmong Americans face episiotomies. A woman needing a Caesarean challenges in finding the words and appropriate section would prefer an epidural over general language to describe illnesses not known to them anesthetic because of concerns related to the loss prior to their arrival to the U.S. Examples of of one of the souls. “The placenta is required for Hmong words created to described Western reincarnation and so it is usually buried at the terms include “Taw Vwm (crazy foot=gout), Tes place of birth”.25 Vwm (crazy hand= gout), Ntshav Qab Zib (sweet blood=Diabetes), and Ntshav Siab (blood In the traditional beliefs of the Hmong, women high= hypertension)”.27 in post-partum need to keep warm. Food and clothing are given to maintain heat, particularly Family conflict, domestic violence, generation during the first three days post partum. Taking gaps, youth gangs, and poverty have been found baths and touching cold water are highly to be major health-related problems for the discouraged. Foods rich in carbohydrates, hot Hmong.27 Yang illustrated the relevance of rice, and chicken soup are given to women dealing with family conflicts by citing multiple during the first 30 days after delivery. Fish, newspaper articles related to homicide and pork, and eggs are discouraged during the first suicide in this population “The couple 10 days post partum. Cold foods such as fruits, [mentioned in a newspaper article] were vegetables, and cold drinks are not given to separated due, in part, to their cultural women in post partum. Exercise is also differences, which were described as resulting discouraged as it may cause dysfunction of from the fact that the wife was more internal organs.25 Americanized than the husband, and also in part, due to their disagreement on a decision to move Newborns are on average 200g lighter, according the family back to California”.27 to Queensland.25 Traditional rituals such as placing a necklace on the newborn before the A study of the Hmong in Fresno and the Central umbilical cord is cut, protects the baby from Valley of California indicated that lifestyle illness. In the Hmong belief system, praising the changes have increased the risk for chronic newborns may expose them to spirits who could diseases among the Hmong. This study harm the baby. This is why, it is common to documented the increasing rates of hear messages such as “you are an ugly baby” as cardiovascular disease and diabetes.29 a way to confuse the spirits and protect the newborn.25 Asian communities have reported higher rates of liver cancer associated with Hepatitis B exposure Breastfeeding for the first two years of life is when compared to other populations.16 The common in the Hmong communities, although Hmong have been found to have higher rates of bottle feeding is becoming more prevalent. “An nasopharyngeal carcinoma, gastric cancer, infant's first solid food is rice flour and water hepatic cancer, and cervical cancer. Genetics, made into gruel. This may be started as early as problems in access to health services, and diet- one month but other foods are not introduced related issues appear to be important contributors until one year. During pregnancy and lactation for cancer morbidity and mortality in this many women do not increase their caloric intake. population. In a study of cancer-related genetic Many do not include milk in their diet”.22 polymorphisms, the Hmong were found to have important risk factors associated with cancer Contraceptive use is lower in the Hmong as etiology and prognosis.16 compared to other ethnic groups in US because having several children is highly valued. A study conducted by Mills and Yang18 Contraceptive methods that suppress suggested a high incidence rate of menstruation are not commonly used because not nasopharyngeal carcinoma (NPC) among Hmong having menstrual flow is considered to be living in Central California. Her17 indicated that unhealthy and cause lack of energy, weight loss, NPC was mostly found among refugees from and paleness. Sexual intercourse is prohibited Southeast Asia who have migrated to US since during menstruation because this type of blood is 1980. Genetic and environmental factors have seen as a contaminant.25 been described as contributors to the high prevalence of NPC in the Hmong population. A study by Ng et al 30 documented a genetic risk for International Electronic Journal of Health Education, 2006; 9:122-133 4 Health Issues for Hmong… Pinzon-Perez this disease since it showed higher risk for selected by the Department of State for Hmong who have had family history of NPC. Jia resettlement in US. They are coming from the et al 31 found that the risk was higher for those Wat Tham Krabok (WTK) camp in Thailand, who have three or more family members with located 80 miles from Bangkok. An estimated NPC. 15,000 Hmong were expected to arrive to US in 2004 and 2005.37 “For many years, the US State Among possible environmental and cultural Department had not considered these Hmong factors for nasopharyngeal carcinoma is the refugees as candidates for resettlement to US. ingestion of Cantonese-style salted fish, However, in December 2003, US officials especially during childhood because shifted gears and declared that they would start carcinogenic volatile nitrosamines have been processing Hmong refugee applications from detected in Chinese salted fish.32 Hildessheim WTK, Thailand beginning February 2004. The and Levine 33 found that in addition to salted- resettlement interviews will be limited to those fish, consumption of other preserved food and Hmong refugees who are registered with the salted green mustard has been associated with Thailand government and have been living at the NPC. Buddhist Temple since August 2003… about 31 percent are expected to come to California”.38 A study of cancer in the Minnesota Hmong population indicated that compared to the The majority of the new Hmong refugees have Minessotan population, the Hmong have relocated to California, Minnesota, and increased proportional incidence ratios for Wisconsin.3 Federal, State and local programs gastric cancer, nasopharyngeal cancer, hepatic have been designed to support relocation efforts. cancer, and cervical cancer. They also had For instance, California has allocated $6 million decreased incidence ratios for prostate cancer, dollars in programs aimed to increase refugee breast cancer, Hodking disease, and melanoma.34 employment.39 Yang 35, in a review of all cancer cases in Tuberculosis (TB) has been found to be a major Hmong, Laotian, Thai, and Vietnamese between problem among Hmong refugees. This health 1987 and 1994, found that the Hmong are problem was detected among some newly particularly affected by cancers of the cervix, arrived Hmong in California and other states. stomach, leukemia, nasopharynx, and lymphoma Many of the 6,000 Hmong in Thailand are not as compared to the general population, but at the being allowed yet into the United States until same time, they also have lower rates for breast, people infected with the disease are treated. colon, and prostate cancer. Yang added that California has 20 confirmed cases of active TB Hmong populations present signs and symptoms among the 3,000 Hmong refugees who entered of cancer at an earlier age than the general the state since June 2004. 40 Public health efforts population but receive attention at late stages of adopted by health departments include the disease. tuberculosis screening and treatment. For instance, in Fresno County, more than 1,200 Mills and Yang18 found that invasive cervix refugees have been screened for TB and other cancer rates in the Hmong were unusually high. communicable diseases.40 According to these authors, many Hmong have a diagnosis and receive treatment for various The Centers for Disease Control and Prevention cancer sites when they are at an advanced stage. (CDC) announced the existence of drug resistant Some cultural factors that may account for this tuberculosis cases among Hmong refugees. situation are avoidance of Western medical care CDC indicated that upon arrival in US, with and fear of participation in screening programs. funds from the Office of Refugee Resettlement’s Mills and Yang18 have made a call for close Preventive health program, Hmong refugees are monitoring and follow up for patterns of cancer. screened and receive follow-up care in order to Other risk factors for cancer deaths in the prevent the transmission of health conditions that Hmong, as well as in the general population, are could jeopardize the public’s health.41 According tobacco use, obesity, physical inactivity, and to CDC, “standard TB screening includes a chest family history of cancer.36 radiograph (CXR) for persons 15 years of age or older, followed by sputum smears for persons New health challenges emerge now with the whose CXRs are suggestive of active TB. In latest immigration wave of Hmong refugees addition to standard TB screening, TB cultures International Electronic Journal of Health Education, 2006; 9:122-133 5 Health Issues for Hmong… Pinzon-Perez were recommended in May 2004 for Hmong providers are often caught between their desire to refugees who have signs or symptoms of TB and provide comprehensive care and their time CXR findings highly suspicious for TB, limitations for the delivery of their services. regardless of sputum smear results. Refugees Health education practitioners ought to recognize diagnosed with TB are required to complete the importance of allowing sufficient time to directly observed therapy (DOT) for TB before establish a relationship of trust, respect, and being allowed to travel to the United States.”42 A mutual cultural understanding when working delegation from St Paul visited the refugees at with the Hmong community. the Wat Tham Krabok in Thailand and analyzed their health needs. According to the report Health educators are key players in helping presented by this delegation, protein malnutrition Hmong communities acquire a level of health in children, depression, and anxiety are major literacy that allows them to understand the health health concerns for this population.43 care system in US and interact with it in a context of equality. Health educators need to According to the CDC 42, before entering US, ensure that health literacy is a reality for Hmong Hmong refugees at the Wat Tham Krabok have communities. Health practitioners may wrongly been evaluated for the Human believe that a Hmong client may be Immunodeficiency Virus (HIV), sexually understanding health recommendations. transmitted infections, Hansen’s disease According to Betancourt, “Hmong people are a (leprosy), mental disorders, and tuberculosis very happy and hospitable people. Many times in (TB). They also receive treatment of teaching situations they will constantly nod and albendazole for intestinal parasites and vaccines, say, ‘Yes.’ Keep in mind that this means, ‘Yes, I according to the age of the person, such as am listening to you,’ not, ‘Yes, I understand.”22 diphtheria and tetanus toxoids and pertussis (DTP) vaccine, tetanus and diphtheria toxoids Another challenge for health educators is the (Td), oral polio vaccine (OPV), measles-mumps- lack of familiarity and understanding of Western rubella (MMR) vaccine, hepatitis B vaccine, and medicine among some Hmong communities17. varicella vaccine. The Hmong believe that a lost soul is a principal cause of disease and see health services as means Health Education Challenges for to calling the soul back to the body.14 Health care for the Hmong in US needs to integrate the the Hmong Population in the US Hmong animist beliefs and science-based services. The benefits of this integration have The Hmong in US face many issues such as been demonstrated in Australia and in the adaptation to US culture and understanding of a Central Valley region of California. complicated health care system which, in many cases, is not congruent with their beliefs and In Australia, Hmong women are responded to practices. While Western medical principles are their desire to bury the placenta after delivery, based on the scientific method, the Hmong since disposing the placenta with regular hospital believe that health and disease are directly methods may lead to a loss soul and illness. In related to the soul and the spirit. For the Hmong, addition, arrangements are made with there is no separation between the mind and the nutritionists and health promotion specialists so body. The lack of an understanding of health Hmong women in post-partum can have access practices in US and the need for keeping their to their traditional diets such as hot rice and cultural roots have led the Hmong to seek health chicken soup. Special attention has been given in care services from traditional healers such as Australia to provide same gender health Shamans. practitioners for the Hmong population.25 Health literacy is one of the major challenges In the Central Valley region of California, The that Hmong populations pose for health MATCH coalition (Multidisciplinary Approach education practitioners. Hu24 indicated that most to Cross-Cultural Health) have a very innovative of the Hmong who have migrated to US have program called “Partners in Healing” in which little or no formal education. Older Hmong Hmong shamans and traditional healers are populations may rely on their children to invited, via the clan leader, to dialogue with communicate with health care providers and the physicians, health educators, and other health explanation of health issues.25 Health care practitioners about their methods for diagnosis International Electronic Journal of Health Education, 2006; 9:122-133 6 Health Issues for Hmong… Pinzon-Perez and treatment. Shamans and health care Vang15 made a special call to health promotion providers learn from each other and discuss ways practitioners and health educators to increase to work collaboratively. Thirty six shamans awareness levels among the Hmong of cancer- from Merced, California and surrounding regions related risk factors, so diet-related behaviors can have participated in this program. In this project, be adopted to reduce their risk. Nutritional shamans are allowed to go to selected hospitals awareness programs should be sensitive to the and other health care facilities to provide healing beliefs and needs of the Hmong community. ceremonies to restore the soul to the body, while patients are receiving concomitant medical Health educators need to become culturally services. Additional services provided by this competent in understanding the traditions and program include the training of Hmong health beliefs of Hmong groups. In Fresno, California educators, mental health interpreters, as well as a course on Traditional Healing Methods for offering Hmong music dance lessons and after- university students and health personnel, in school tutoring programs. General which Hmong shamans explain and demonstrate recommendations provided for health care their healing practices to attendees, is taught practitioners in this program include not having regularly. In this course, current and future direct eye contact with the Hmong clients and health providers become knowledgeable of the not touching their heads, since due to their Hmong traditional beliefs and explore ways to animist’s beliefs, the Hmong consider these incorporate them in the delivery of health practices to be disrespectful.45 services. Health education specialists also need to become Vang recommended that health education aware of the various federal, states, and local practitioners utilize theoretical frameworks such programs available for newly arrived Hmong as the Health Belief Model and the Theory of refugees. Examples of these programs include Reasoned Action to understand Hmong beliefs, the services provided by the IRC [International attitudes, intentions, perceptions, and behaviors. Rescue Committee], such as airport pickup, According to Vang15, these theories could help financial and logistic support for refugees to health education specialists better understand access medical care, English language classes, why the Hmong may seek health care later than school enrollment for children, and employment do other populations, and consequently design programs.46 These programs have been designed programs that enhance positive lifestyles and by the IRC with a philosophical understanding reduce cancer risk. that “…every refugee’s greatest resource in successfully making the transition to life in the The Health Belief Model and the Theory of United States is him or herself. It is our job Reasoned Action provide a framework to [IRC] to assist refugees in translating their identify underlying motives for behavioral strengths, skills and past experiences into assets change in minority populations. Barrett et al. in their new communities”.46 have exemplified the importance of these two models when working with Hmong Additional programs such as assistance with populations.47 According to these authors housing, food, clothing, and medical services are “…while providers may feel that the principles offered at the federal, state, and local level by of informed consent require an explanation of Voluntary Resettlement Agencies (VOLAGs), possible negative outcomes, Hmong patients (in Mutual Assistance Associations (MAAs), and general) do not want to hear about risks of long- community and faith-based organizations. The term morbidity or mortality and may take such Refugee Cash Assistance (RCA) program, the explanations as…’hexing’.”47 Such differences Supplemental Security Income (SSI) and the in beliefs between health care providers and State Supplemental Program (SSP) provide Hmong clients can be identified through the funds to help refugees in the process of adjusting Health Belief Model. to living in US.38 By becoming familiar with these programs and their eligibility requirements, The Theory of Reasoned action can be illustrated health education specialists could effectively in Berret et al.’s research. Berret et al. indicated explain these programs to the newly arrived that Hmong patients are more likely to look for Hmong and refer them to the appropriate treatment for acute and symptomatic illnesses, as agencies. opposed to chronic conditions such as International Electronic Journal of Health Education, 2006; 9:122-133 7 Health Issues for Hmong… Pinzon-Perez hypertension, diabetes, or hyperlipidemia.47 The Discussion & Recommendations reasoning behind these actions come from the Hmong’s perception of subjective norms in their The Hmong population in US is rapidly growing. cultural group. Subjective norms, in this case, This group has cultural beliefs and health are related to the cultural acceptance of utilization patterns that pose challenges for symptomatic treatment and health literacy issues. health education practitioners. Health disparities such as an increased incidence of various types In increasing health literacy, the use of the story of cancer, tuberculosis, and post traumatic stress cloth, known as pa’ndau in Hmong communities, disorder, among others, should be a research may be particularly useful. “The pa'ndau, priority for the health education practice. composed of applique, cross-stitches, batik, and embroidery, incorporates Hmong personal family Research oriented towards multicultural health history, village life, the death and disturbance of issues should acknowledge the diversity within war and emigration, and life in a new land. the Hmong community. Yang27 exemplified the Pa'ndau, as an art form, reflects how the medium characteristics of the various rural groups living of an old tradition is also used to tell a more in US. “The Fresno Hmong community is modern story of Hmong history and culture”.21 influenced by Fresno’s economy and social- The Hmong did not have a written language until political environment. Very few Hmong qualify the 1960’s when Christian missionaries to apply for the high skilled and seasonal jobs. standardized letters and figures for Many Hmong in the Central Valley of California communication with Hmong communities. Prior have turned to farming, but [their] agricultural to that, the Hmong communication patterns were skills have not been compatible with based on oral and pictorial representations of agribusiness in Fresno”.27 Yang added that in their life experiences. Hmong communities have Georgia, the Hmong community has adopted different dialects, among which the most Christian beliefs, while still retaining some commonly known are the dialects spoken by the animist’s ideas. The Hmong in Michigan derive “White Hmong” and “Blue Hmong,” which are their income from owning and operating the food based upon the geographical region they come industry. In the state of Washington, the Hmong from.21 The use of the story cloth in health community is highly involved in the flower education may serve as a culturally-sensitive business. In North Carolina, most Hmong own way to increase health knowledge and risk and operate egg and poultry farms. In Yang’s factors awareness among Hmong communities. words27 “Although each local Hmong American community may have developed some of its own The recommendations of Barret et al. could serve characteristics, all of them also hold many things as an appropriate summary of guidelines for in common. They all share the continuity of health educators interested in working with attempting to preserve the perceived best Hmong groups. First, Barret et al. suggest that features of the Hmong language and culture, interpretation from Hmong to English should be while they are also in the ongoing process of given in a context of mutual respect and developing a new Hmong American culture”.27 appreciation. Second, health practitioners should show a caring attitude, with a happy demeanor The diversity in this community related to and a positive attitude. Third, health educators sources of income, cultural heritage, and need to recognize that the Hmong culture is language is evidently impacting the possibilities changing and not all Hmong groups are the of the Hmong to access health care. A lack of same. This implies that health education economic resources, appropriate health programs should be designed with the information, access to technology, education, acknowledgement of such differences. Finally, and political power have placed this group in the health educators need to include the family and same disparities experienced by other minorities the clan leader in the decision-making process, in US. providing them with the tools to understand and be critical of our health care system. Building on Traditional beliefs are of special relevance when Hmong strengths and community resources is addressing issues of health disparities in this one of the major highlights of Barret et al.’s population. The Hmong may be reluctant to suggestions.47 comply with Western-based health recommendations because they conflict with International Electronic Journal of Health Education, 2006; 9:122-133 8 Health Issues for Hmong… Pinzon-Perez their view of the world. Failing to respect the traditions and beliefs from the original Hmong clients’ cultural beliefs may interfere with their and American cultures. The acculturation need to adhere to treatment health regimes.27 process in Hmong refugees and its influence in health utilization create a fertile ground for As indicated by Vang15, one of the health-related research opportunities and program design priorities in the Hmong population living in US among health education specialists and health is to expand their knowledge of risk factors practitioners in general. associated with an increased incidence of cancer cases in this population. Risk factors associated Acknowledgements with food intake and diets are examples of this need. Vang15 indicated that Hmong populations The author wants to express her gratitude to Dr. need to become aware of the risks for Miguel A. Perez and Mr. Leepao Khang for their nasopharyngeal carcinoma posed by the intake of suggestions and comments. salted fish, salted green mustard, pickled green mustard, and green mustard in brine. References Health care providers, especially those dealing with cancer care, should be bilingual and 1. Faruque CJ. Migration of Hmong bicultural. Kundstadter44 indicated that the to the Midwestern United States. major criterion used by the Hmong to select their health care providers is based on their Hmong Lanham, MD: University Press of speaking skills. Medical expertise and America, Inc.; 2002. competency for this population are secondary to linguistic needs.27 2 . Yang K. Becoming American: the Experience of Hmong Americans. A sub-population within the Hmong community that needs special attention is the group of new Ethnic Studies Review. 2001; 24(1, 2, immigrants and refugees. Care for this &3):58-84. population starts with the coverage of basic needs. 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