hmong americans and healthcare inequalities and solutions. b.a
TRANSCRIPT
Hmong Americans and Healthcare Inequalities and Solutions
By
Aurea A. Berger
Senior Thesis in Asian American Studies
San Francisco State University
Professor Jonathan H.X. Lee
May 2011
© 2011 Aurea A. Berger San Francisco, California
3
ABSTRACT
The Hmong Americans are the newly added component of United States society. Due to
lack of written language, exposure to harsh living conditions in refugee camps, and war, Hmong
Americans’ adjustment to life in the United States has not been an easy process. As refugees,
most of them have to rely on welfare for cash assistance and healthcare, especially the first
generation immigrants. However, due to the existence of inequities in the US healthcare system
as well as cutbacks on welfare budgets ─ many Hmong Americans ─ are without health
insurance and are poorly served in the US healthcare system. The purpose of this research paper
is to bring awareness to the existing problem that harms the health of the Hmong American
community. Oral interviews, in-depth research, and questionnaires are used to investigate the
problem regarding the ongoing healthcare issues that affect the Hmong American community.
The findings of this research indicate that the Hmong Americans are indeed being served poorly
in the US healthcare system because of lack of interpreter service (i.e. translator), conflict
between the Hmong traditional healing methods and the Western health practices, and the lack of
understanding by the Western health providers of Hmong American culture.
HMONG AMERICANS AND HEALTHCARE 4
Hmong Americans and Healthcare: Inequalities and Solutions
This research paper explores the Hmong American community and the inequities in
healthcare in the United States. The Hmong American community is poorly served in the United
States healthcare system. Although this group is given the opportunity to be part of American
society, health disparities and inequality continue to burden their everyday lives. This research
paper will be divided in five sections. First, the racial and social positions of the Hmong
Americans will be discussed. Second, the social inequalities that exist in the Hmong American
community will be examined. Third, the chronic diseases that afflict this group will be closely
inspected, emphasizing the plight of the elderly, low income, and newly arrived immigrants.
Fourth, the quality and utilization of healthcare services will be analyzed, which would also
include access to primary and preventive care. Lastly, the health disparities and health
inequalities that impact the Hmong Americans will be summarized and recommendations will be
offered to address these problems.
Review of Literature
Who are the Hmong Americans?
After the end of the Second Indochina War in 1975, tens of thousands of Hmong refugees
immigrated to the United States. The Hmong are mountain-dwelling of people of Laos; while
most of the world’s Hmong live in China, two southern groups live in Laos, the White and the
Blue (Vang, 2011). In July 23, 1962, United States, North Vietnam, and other fourteen nations
signed the 1962 Geneva Agreement, guaranteeing the neutrality of Laos. However, the US
Central Intelligence Agency (CIA) believed it could intervene in the post-independence politics
of Laos to promote conservative, anti-Communist influences. In order to keep Laos as an asset
HMONG AMERICANS AND HEALTHCARE 5 in the war against North Vietnam, the CIA waged a secret war in Laos. Hmong soldiers in
General Pao’s “Secret Army” helped the CIA restrict the usage of the Ho Chi Minh trail as
passage to attack South Vietnam (Ely, 1990). After the US-backed regime in South Vietnam
ended in 1975, Vietnamese military allies were airlifted to the United States along with their
family.
The Hmong who came to the US lived in the mountainous regions of Laos and their
livelihood was slash-and-burn agriculture. Hmong do not have a written language. The Hmong
language is only in the form of oral communications (Vang, 2011). Being refugees, transition to
a new life caused massive anxiety, which led to stress and trauma (Ostergen, 1991; Lee, 1993).
The Hmong Americans transition to Western living is not easy. As newly arrived members of the
American society, they have to start building their new lives. As a result, the Hmong Americans
are underrepresented in the socioeconomic and racial hierarchy of the US society.
Racial and Social Positions of Hmong Americans in the US Society
As refugees, the Hmong Americans’ adjustment to life in United States has been very
harsh. There have been many barriers that led them to suffer high level of stress and cultural
shock. Upon arrival in the United States, they became concentrated in Fresno, Minneapolis,
Rhode Island, and Texas. Huping Ling presents evidence that Hmong are underrepresented in
politics, health, and business (Ling, 2008). Hmong Americans often report feeling that their lives
are empty and meaningless. Language barriers and traditional religious beliefs and rituals are
only a few of the reasons for their anxiety. Difficulty adjusting to a new culture by Hmong adult
refugees caused isolation from the main society and reluctance to take advantage of the
healthcare system (Lee, 1993). McInnis, et al (1990) argue that the Hmong are the most
HMONG AMERICANS AND HEALTHCARE 6 disadvantaged among the Southeast Asian refugees because they have large families that were
unemployable and had little education. Since their arrival in the United States, the government
has tried to disperse them to several states in order to reduce the burden to each state’s welfare
resource and to avoid conflicts with the rest of the members of the host society (Trueba, 1990).
The Refugee Act of 1980 offered welfare support to the Hmong Americans which helped them
start a new life. However, due to the country’s fluctuating economic conditions, refugees and
welfare dependents are getting negative pressure from the changing welfare policies. “With
respect to Hmong refugees, Wisconsin is an important state to examine for many reasons. It is
home to the largest Hmong refugee population in the United States. Over the past few decades,
the rapid growth of this refugee population and their unique and multiple needs have brought
challenges to the state’s welfare system” (Kretsemadas and Aparicio, 2004). In a research article
entitled, Community-Based Participatory Action research: Offering Hmong Welfare Recipients’
Voices for Dialogue and Change, Kalyani Rai presents evidence that poverty and welfare
dependency continue to plague the Hmong Americans in Wisconsin; thus, a program was
developed to increase their active participation in dialogues to mobilize their social and
economic status (Rai, 2004). Despite the studies on ways of eliminating welfare dependency, one
question remains to be answered: How will the Hmong Americans rise up from poverty if
language barriers and isolation continue to plague them as adults? For this reason, the Hmong
Americans socioeconomic inequalities remain remarkably high at present times.
Social Economic Inequalities in the US Society
In 1982, President Reagan issued a new policy initiative regarding welfare called the
New Federalism wherein the states were responsible for Aid to Families with Dependent
HMONG AMERICANS AND HEALTHCARE 7 Children (AFDC), one of the welfare programs impacting the Hmong American households.
Hmong Americans were heavily harmed by the welfare reforms. According to Mark E. Pfiefer,
“34.8% of U.S. Hmong families lived below the poverty level in 1999 compared to 12% of all
U.S. families (2005). In 2006, the poverty rate of Hmong American was 26.4% and 44.9% for
families with female as head of household and no husbands (Pfeifer, 2008). Some oral histories
were documented witnessing the serious impact of welfare reform to the Hmong American
community (Fujiwara, 2008), along with some research and studies of the Hmong American
family (Koltyk, 1998). Several Hmong American soldiers were denied benefits by Department of
Veterans Affairs, despite the fact that the US government used them in their “Secret Army” (Ely,
1990), for intelligence and combat support during the second part of the American War with
Indochina.
As with the Japanese Americans, Filipino Americans and Chinese Americans, Hmong
Americans also experienced discrimination and racism by the US Department of Housing and
Urban development. “In contrast, the large Southeast Asian population was generally reluctant to
leave public housing; Hmong residents, in particular, strongly opposed relocation. The Hmong
had only recently immigrated to the United States. Living in a tightly knit community with other
Hmong is an integral part of their cultural identity; separating clans and family through
relocation disrupts this strong connection” (Popkin, Galster, Temkin, et al, 2003, p. 189-190).
The housing, where these minorities reside, is characterized by violence and high crime rates,
poorly maintained property, and social ills. Overall, the surroundings are poor and toxic, which
contributes to the poor health and chronic diseases of the Hmong American residents in that area.
HMONG AMERICANS AND HEALTHCARE 8 Chronic Diseases that Impacts Hmong Americans
Moving to an unfamiliar place and experiencing events like war causes trauma and stress
to refugees. To be a refugee is a very sad experience for anyone. It could mean losing your
culture, identity, and physical security. The Hmong Americans suffered from the exposure to war
and refugee camp living conditions. One of the chronic diseases that plague the Hmong
Americans, especially adult male is Sudden Unexpected Nocturnal Death Syndrome (SUNDS),
wherein the cause of their death is unknown (Adler, 1991). Many of the Hmong refugees also
suffered mental health issues like Post Traumatic Stress Disorder (PTSD) and depression, due to
their exposure to combat (Choi, 2001; McInnis, Petracchi, and Morgenbesser, 1990; Prior 1994,
Lee 1993). Hypertension, obesity, tuberculosis, death due to violence, and a rare form of cancer
on nasal cavities, are some of the chronic diseases that impact the Hmong Americans (Ling,
2008; California Newsreel, 2008). If Hmong Americans are not immune to disease brought by
psychosocial adjustment, how will US society response to their demands of care? How do they
access healthcare?
Access to Healthcare and Utilization of Health
Since the Hmong arrived in the United States, their health coverage is automatically
covered by the US government. At present, in California, Hmong Americans experience limited
access to MediCal due to language barriers and computer errors in inputting Hmong information
to the database (Health Rights Hotline, 2006). There is limited access to language information
provided by MediCal; thus problems on billing and denial of care are a common issue. Also, due
to the strong beliefs of many Hmong Americans in traditional healing, misunderstanding and
contradictions between the Hmong American patient’s family and clan on the one hand, and the
HMONG AMERICANS AND HEALTHCARE 9 health provider on the other, becomes a continuing issue in accessing conventional health in the
US health care system (Cha, 2001; Mote, 2004; Koltyk, 1998; Lee, 1993). The Hmong
American’s isolation prevents them from accessing health benefits. “There were no instances in
which American friends were used for support, and only a handful of people stated that they
sought help from health and mental health services”(Lee, 1993). Training and education about
Hmong American social and cultural perception is necessary for health care providers and health
advocates; while educating Hmong Americans about Western health system and health
prevention will help make the Hmong Americans live longer and better.
In response to the continuing problem in the United States regarding the uninsured, the
federal government created the Patient Protection and Affordable Care Act. The Patient
Protection and Affordable Care Act, is part of President Obama’s Health Care Reform of 2010.
Hence, the Southeast Asia Resource Center (SEARAC), a non-profit organization whose aim is
to empower the Cambodian, Laos, and Vietnamese American community, partnered with their
community advocates in creating a program to make sure that the Southeast Asians voices are
heard and represented in the decision-making in carrying out the goal of the Affordable Care
Act. This effort is being collaborated from five states such as: California, Minnesota, Louisiana,
Maryland, and Pennsylvania, in response to the first year anniversary of the signing of the
Patient Protection and Affordable Act (SEARAC, 2010). In addition to this, Hmong American’s
advocates and community center organized the Hmong Health Collaborative ─ a program whose
aim is to harmonize Hmong traditional healings with Western health methods. For example,
Western health providers and hospitals allow the Hmong American patients to be visited and
treated by a shaman while being treated at a Western medical institution (Lee’s interview, 2011).
HMONG AMERICANS AND HEALTHCARE 10 These efforts on both parts of the government, the Hmong American advocates and communities
have improved the health prospects for Hmong Americans, but they are offset by the general
decline in social services everywhere in the US.
Health Disparities and Health Inequalities in the US Healthcare System
There are many reasons for disparities in the US healthcare system. One is that medical
research tends to lump different Asian groups together, so that health risks that affect one group,
such as ─ Hmong Americans ─ are averaged out with other groups with very different risks
(American Heart Association Scientific Statement, 2010). Similarly, social disparities in cancer
results from the lack of research regarding the impact of cancer on specific ethnic minorities.
Lack of insurance health coverage prohibit the less privileged ethnic minorities from accessing
prescreening for cancer and increases their risks of death from cancer. Researchers argue that:
The issue of heterogeneity applies equally to the underlying causes of disparities. The application of the research grid made clear that research in this area is far from one-dimensional in its findings, and can sometimes lead to surprises. For example, it is commonly thought that disparities are the result of differences in screening rates, but public health success stories in breast cancer and cervical cancer screening have all but eliminated the screening differentials - yet differences in outcome remain. Thus, researchers need to examine health status prior to diagnosis as well as the intermediate steps - diagnosis and treatment - to understand why these disparities persist (Weissman and Schneider, 2005, p.73).
Researchers need to differentiate among the challenging issues facing ethnic Chinese,
Hmong, Cambodian, and other Southeast Asian ethnicities. Furthermore, financial difficulties
put a burden in the health and life of adult people. “Nevertheless, disparities in life chances
persist within the population, with health surveys clearly showing that rates of mortality,
morbidity, and functional limitation continue to be higher for persons with limited social and
HMONG AMERICANS AND HEALTHCARE 11 economic resources as well as for racial and ethnic minorities” (Kahn and Pearlin, 2006, p. 17).
Due to poverty, low income minorities are forced to reside in an unhealthy area, with high
number of crimes and drug dealings, which causes stress that leads to serious health problems.
Likewise, Alameda County, the subject of study tracing the influence of poverty on people’s
psychological well-being,(Kahn and Pearlin, 2006), and a Hmong American family who are
residents of Richmond, a county in Alameda, California, show evidences of poverty’s impact on
health (California Newsreel, 2008).
Methods and Data
In doing this research, various sources were employed. I primarily used textbooks,
journal articles, and internet sources. As support for data gathered during research,
questionnaires and interview were also employed. The subjects for the questionnaires consisted
of five elderly Hmong Americans from Merced, California; a highly educated Program Director
of a non-profit organization that serves the Hmong Americans in Merced and one middle-age
Hmong American woman from Stockton, California. The surveys consisted of the following
eleven questions:
1. Do you have access to health insurance?
2. If you, how often do you see your health care provider/doctor/
3. How often do you see a dentist?
4. What kind of health insurance do you have?
5. If ever you have to change health insurance coverage and health care provider, do you
know whom to ask for help?
HMONG AMERICANS AND HEALTHCARE 12
6. Do you encounter difficulty in accessing the customer service hotline? If so, what are
those problems you encounter?
7. How do you rate your health at present? Please use the scale 1-5, as in: 1 =worst, 2=good,
3=better, 4= best, and 5- excellent?
8. When you get prescription for medications, do you encounter problems purchasing using
your health insurance card? If so what kind of problems?
9. How often do you visit your health care provider for check-ups?
10. Any problems that deal with accessing the health care provider network?
11. Please list any recommendations that can help improve the healthcare service provided to
Hmong Americans.
The questionnaires also requested which health insurance coverage is mostly utilized by
the Hmong Americans community, especially in the Central Valley area. The results and
findings for these questionnaires interview will be discussed in the next section. The survey was
done on a two- day visit because of the number of Hmong Americans who visit the Merced Lao
Family Community Center varies from day to day. On the last day of the researcher’s visit, Miss
Juoa Lee, Program Director of the Merced Lao Family Community Center, answered all the
questions presented to her. The interview was conducted with the goal of gathering more valid
evidences regarding the utilization of the health care system by the elderly Hmong American
community in Merced, California. Furthermore, to conduct a more factual research, one middle-
aged Hmong American woman, who is a second generation Hmong American, was also asked
to answer the health care questionnaire. Although, the human subjects for the research and
HMONG AMERICANS AND HEALTHCARE 13 interview are limited, all of the methods used in this research successfully provided factual and
good evidence for the validity of the research argument.
Analysis and Findings
The Hmong American communities are a new additional component to the Americans
society. Many studies have been done by various non-profit organizations, scholars, and medical
organizations to ease their transition. Due to lack of written language in their homeland,
acculturation and assimilation became one of the major problems encountered by the Hmong
Americans since their arrival. The objective of this research paper is to find solutions to the
problems to help Hmong Americans get better access to healthcare and maximized its benefit.
There were several questions during this research. These questions are as follows:
• What are the barriers that hinder Hmong Americans from accessing health care
benefits?
• Is being poor a hindrance to good health among Hmong Americans?
• How could the government help ease the Hmong Americans access to health care?
• Should Hmong Americans traditional beliefs be abandoned in order for them to
maximized benefit offered by Western health care medicine?
• What is the impact of health disparities and health inequalities to Hmong Americans’
health? If so, how could these problems is eliminated?
The migration of the Hmong Americans to the United States is the result of CIA’s secret war in
Laos. After the Second Indochina War ended in a communist victory, the US government was
obligated to help its Hmong allies and their dependents move to US to avoid potential reprisals
by the new Lao regime. Hence, most Hmong arrived as refugees; some relied on welfare and
HMONG AMERICANS AND HEALTHCARE 14 Refugee Act grants. Because of the extreme cultural differences between rural Laos and urban
America, Hmong refugees had a hard time adjusting to life in America. The Hmong American
adults became socially isolated from the rest of the American society because of their lack of
English proficiency. Some have found jobs but these jobs offer inadequate pay and no health
insurance coverage.
Studies found out that there were several reasons for the reluctance of the Hmong
Americans to access Western healthcare services. These are:
1. the language barrier,
2. errors inputting Hmong American data in computer databases
3. the cultural aspects of the Hmong Americans such as traditional beliefs
4. and the cultural insensitivities on the part of health care providers.
One of the reasons why Hmong Americans are hesitant to seek the help of Western healthcare
provider is the language barrier. Although, they only come to see a provider when they are
already very sick, Hmong Americans find it hard to communicate their symptoms to the provider
without a Hmong interpreter; consequently, they often do not return for follow-up appointments
or they misunderstand the instruction of the doctor. Cultural differences make it hard for the
older patients to ask questions to the doctor regarding their diagnosis or prescription. Also, if
there is an interpreter available, there is no guarantee that the interpreter is fully effective
because of the interpreter may lack the knowledge regarding the Hmong American patients’
background. Studies had been found this to be the weak point in using the interpreter method
among the Hmong Americans.
HMONG AMERICANS AND HEALTHCARE 15
To be in the bottom of the ladder of the society is also a hindrance for accessing the
healthcare system. Since they do not make enough money and work menial jobs, healthcare
insurance is hard for them to obtain; thus, access to see medical specialists is sometimes
impossible. This makes it hard for them to notice and respond promptly to cancer when it
appears. Lack of knowledge of the health field itself is another issue. Since they are poor, they do
not get the proper education to understand more about the advantage of the Western healthcare
instead on traditional beliefs in healing the illness. The Hmong traditional belief of healing is
limited to shamanic rituals, herb usage, and massages. The Hmong Americans believed that a
man’s body is composed of twelve souls. They say that a person is sick physically if he cannot
do what a normal active person does like playing, singing, working, smiling, jumping and
anything a physically active person can do. Sometimes, when a person is already too sick and all
the traditional healing were exhausted, then that’s the only time the Hmong Americans seek help
from a Western health provider for treatment.
Every time a non-profit organization or a US government department do a census or
survey, there is a problem with grouping the Asian Americans as one homogenous group. When
research are done using Asian Americans as one big group alone; then, the impact of diseases on
each subgroup are not carefully being studied and evaluated. Hence, the health disparities
become health inequalities. Health inequalities is the result of not being able to fully analyze and
seeing the results of the difference on health between socially advantage and the socially
disadvantage group or from one ethnicity to the other; thus, the socially disadvantage groups
diseases is not fully studies and causes them to suffer more due to lack of information for
treating their disease. If the different ethnicities in the US are surveyed as subgroups, then,
HMONG AMERICANS AND HEALTHCARE 16 understanding the problems and causes of their diseases will help find a better way to treat their
illnesses better. Not until the government finds a systematic way to understand and study how
each disease impact each different ethnicity; ethnic minority’s access to Western healthcare is
not really maximized.
As a result of the budget cuts in 1984, the California state government terminated the
Hmong interpretation services at various medical center and welfare services office. The
interpreter services are available on a seasonal basis and on casual occasions only. The Hmong’s
only choice is to use their children as interpreters. Since the children are less exposed to Hmong
traditional healing methods, they are often embarrassed by their elder’s preferences; often they
are reluctant to admit to accredited medical personnel that their elders use traditional methods.
At the same instance, the doctor presumed that the information provided by children is correct;
thus, they do not question the children any further at all.
Furthermore, when the University of Wisconsin partnered with the W.K.Kellogg
Foundation to study the Hmong Americans welfare recipient to self-sufficiency, they found out
that Hmong Americans, who suffered psychological problems, complained that their efforts on
behalf of the US government during the Vietnam War had been ignored. For example, they do
not receive access to counseling services. “The Hmong population in Wisconsin includes a high
proportion of adults with barriers to learning. There are Hmong welfare recipients who need
mental health counseling and training to facilitate their transition through and off welfare. They
are not provided with these essential services to meet their needs” (Kretsemadas and Aparicio,
2004).
HMONG AMERICANS AND HEALTHCARE 17
Aside from the poor communication between the Hmong American children interpreters,
the cultural differences also contribute to the difficulty in accessing healthcare by Hmong
American adults. The filial piety is a big issue among Hmong Americans. Children often do not
question the Western medical provider because of the respect for authority; thus, poor
communication is always the result, making it a problem of language barrier and lack of
interpreter services. In addition to this, the lack of medical brochures and pamphlets written in
Hmong language pertaining to diseases like hypertension and cancer impede the Hmong
Americans in accessing Western Medical treatment resulting in a more serious health condition.
When surveys are done by the United States government the minority are lumped
together as groups; thus the differences between different subgroups’ diseases are overlooked.
For example, the misclassification of ethnicity when inputting data on death certificates causes
errors in determining risk factors. When Asian Americans are surveyed, they are often lumped
together as a single “race”; as a result, differences in the incidence of illnesses that affect these
Asian American subgroups are often overlooked and not studied. It should be remembered that
different illnesses has different impact on each ethnicity.
The lack of transportation and information for accessing health coverage such as
changing the healthcare providers, are two major problems found among Hmong Americans.
Some Hmong Americans do not know whom to ask about issues of changing primary health
providers and primary dentists. The difficult experiences of Hmong Americans in dealing with
the customer service issue of Medical, a California state medical program, remains a problem for
the Hmong Americans. Sometimes, due to errors of the data entered on the computer database
often lead to termination of coverage for the Hmong Americans. Also, erroneous bills are sent by
HMONG AMERICANS AND HEALTHCARE 18 healthcare providers to Hmong Americans, not screening if they are eligible for charity and
financial assistance offered by county programs. Another added issue is the access to customer
service. The Hmong Americans have difficulty accessing healthcare benefits because of the lack
of interpreter services or customer service representatives who speak Hmong language. Due to
this issue, Hmong Americans call is left unanswered.
Based from the oral interview with Miss Juoa Lee, the Program Director of Merced Lao
Family, the Hmong American advocates in the Merced County launched a program called the
Hmong Health Collaborative. The mission of the Health Hmong Collaborative is to incorporate
the Hmong traditional healing method with the western health method in order to better serve the
Hmong Americans in the Merced and Sacramento area. Although this program was approved,
Miss Juoa Lee, still hopes that this method will be used to serve the entire Hmong American
population in the United States. In addition to this, the questionnaires results showed evidence
that Hmong Americans lack the support of the government in providing dental health insurance.
Five out of the six Hmong Americans, who filled up the questionnaires for this specific research,
do not have any dental health coverage. The reason for their lack of dental health insurance is the
elimination of the dental services by Medical of California. Dental hygiene is very essential in
maintaining our physical well-being. How could we promote a well-develop and healthy
communities if the elderly, the underrepresented, and the children are poorly serve in the United
States healthcare system? The following section shows the result of the questionnaires gathered
from among the six Hmong Americans from Merced County, California.
HMONG AMERICANS AND HEALTHCARE 19 Results from the questionnaires taken from Hmong Americans in Merced, California on March 31, 2011:
Tabulated Results for the Questionnaire
Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6
Have access with health insurance Yes Yes Yes Yes Yes Yes
Number of visit to the doctor
once in every 2-3 months
about 4-5 times per year
about 4-5 times per year
About 4-5 times per year
once every other month as needed
Number of visit to a dentist None None None None None None
Knowledge in getting help to change providers Yes No Yes No Yes Yes
Difficulties accessing customer service hotline Yes Yes Yes Yes Yes No
Problems in accessing prescription medicine No No No No No No
Number of visit for check-ups
Only when sick
about 2-3 times per year
only when sick
about 2-3 times per year
Only when sick
only when sick
Problems with accessing health network No Yes No Yes No No
Recommendations
Subject 1
Subject 2 Subject 3 Subject 4 Subject
5 Subject 6
HMONG AMERICANS AND HEALTHCARE 20
None Interpreters None
Speakers Customer Service
Representatives
Need Hmong
translators
Hence, it is for the advantage of everyone else in the United States that the government
should not cut back on healthcare system financially. If possible funding the research for health-
care should be maximized as well as education. By educating the researchers and the people of
the society about diseases and health, it is a reassurance of a healthy, happy society. As a
research, I recommend the following theory to help the easy access of Hmong Americans to US
healthcare system: The Worked-based Learning and Conventional Learning Model.
Work-based Learning Model
1. Offering health educational program and clinical training to Hmong American young
adults and Hmong American adults should be implemented such as: registered nurse,
doctors, dentist, nurse’s aide, pharmacy technicians, medical receptionist, and
medical transcriptionists; so, as they can help educate the elders.
2. Training and hiring more Hmong American adults and students as interpreters in the
health field industry is an option.
3. Offering scholarships for other Southeast Asian Americans to become interpreters
help serve underrepresented minorities will help ease the burden of minorities who
lack the English language proficiency.
4. Requiring units on continuing education to Western healthcare providers and holding
annual conferences about different ethnicities culture will help Western health
HMONG AMERICANS AND HEALTHCARE 21
providers gain knowledge and understanding of the Hmong Americans culture and
the importance of the traditional healing beliefs and practices to the ethnic minorities.
Conventional Learning Model
1. Improving the system of data entry in the government bureau’s computer database.
2. Organizing healthcare fairs in the Hmong American communities that include free
lunch and games for kids during the fair will encourage attendance to this educational
event.
3. Improving the interpreter service by hiring more Hmong American teenagers or
anyone who have knowledge of Hmong American culture.
4. Medical schools should adopt a curriculum about ethnic studies in order to help
students to be culturally-sensitive to diverse people.
This research hopes that all the above recommendations could contribute to easing the
problems of the Hmong Americans and any other underserved communities in preserving and
promoting their good health.
CONCLUSION
In the course of this research, I found out that although there are few developed programs
that help ease the problems of Hmong Americans in utilizing the healthcare system of the United
States, the Hmong Americans are overall still poorly served in the United States healthcare
system. Data gathered from interviews and questionnaires confirmed that Hmong Americans
need translators in accessing healthcare and in utilizing the western health methods. At the end of
the research, several issues were identified that continue to plague the Hmong Americans in the
United States healthcare system. First, language barrier is found to be the number one issue.
HMONG AMERICANS AND HEALTHCARE 22 Since, the first generation Hmong Americans do not speak and understand the English language,
they need translators to utilize the western health system. However, when welfare funds were cut
and California Medical cut health services, Hmong translation services were cut, making the
situation hard especially for the elderly Hmong Americans. Dental coverage was eliminated and
access to customer service hotline became a problem to the Hmong American community.
Although, several organizations like Southeast Asian Resource Center, Health Hmong
Collaborative, scholars, and other community advocates found ways to ease some of the
problems of the Hmong Americans in finding social just and equality, the Hmong Americans are
still poorly served in terms of healthcare. Not until the government will stop cutting the funds for
healthcare and education, the Hmong Americans, together with other ethnic minorities, and the
underrepresented will continue to suffer the plagued health disparities and health inequalities.
Hopefully, this research will be an eye opener to the government and to the entire American
society, to work together in finding ways in advocating and empowering the Hmong Americans
because they are Americans who possess the right to happiness, equal rights, and justice.
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1990), pp. 1093-1148. Retrieved on March 3, 2011 from Stable URL: http://www.jstor.org/stable/1228968.
Fujiwara, L. (2008). Mother’s Without Citizenship: Asian Immigrant Families and the
Consequences of Welfare Reform. Minnesota; University of Minnesota Press, (pp51-58, pp.81-89).
Health Rights Hotline. (2006). Barriers to Care: Hmong Experiences with The Sacramento
Health Care System. Retrieved on March 2, 2011 from stable URL: http://www.calendow.org/uploadedFiles/barriers_to_care.pdf.
Kahn, J., & Pearlin, L. (2006). Financial Strain Over the course and Health Among Older
Adults. Source: Journal of Health and Social Behavior, Vol. 47, No.1 (Mar.2006), pp. 17-31. Retrived on March 2, 2011 from a Stable URL: http://0-www.jstor.org.opac.sfsu.edu/stable/30040296.
Kretsedemas, P., & Aparico, A. (Eds.). (2004). Immigrants, Welfare Reform, and the Poverty of
Policy. Connecticut: Praeger Publishers. Koltyk, J. (1998). New Pioneers in the Heartland: Hmong Life in Wisconsin. Massachusetts:
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HMONG AMERICANS AND HEALTHCARE 24 McInnis, K., Morgenbensen, M., & Petracchi, H. (1990). The Hmong in America: Providing
Ethnic-Sensitive Health, Education, and Human Services. Iowa: Kendall/Hunt Publishing Company.
Mote, S.M. (2004). Hmong and American: Stories of Transition to a Strange Land. North
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Hmong National Conference in Fresno, California. April 9, 2005. Popkin, S., Laster, G., Temkin, K., Herbig, C., Levy, D., & Richer, E. (2003). Obstacles to
Desegrating Public Housing: Lessons Learned From Implementing Eight Consent Decrees. Journal of Policy Analysis and Management, Vol. 22, No. 2 (Spring, 2003), pp. 179-199. Retrieved on March 2, 2011 from Stable URL: http://www.jstor.org/stable/3325820.
Prior, S. (1984). The Significance of Gardening on the Psychosocial Adjustment of the Hmong
Elderly. California: San Diego State University. The American Community survey publishes the annual Hmong profile with detailed demographic data for the U.S. Hmong population. This data is not available at the state or smaller geographic level with the exception of the state of California. The most recent ACS profile (2006) has been posted at the Hmong Studies Internet resource Center website: http://hmongstudies.org/HmongACs2006.pdf.
Rai, K. (2004). Community-Based Participatory Action research: Offering Hmong Welfare
Recipients’ Voices for Dialogue and Change. In P. Kretsemadas & A. Aparicio (Eds.), Immigration, Welfare Reform, and the Poverty of Policy, (pp. 187-203). Connecticut: Praeger Publishers
Trueba, H., Jacobs, L., & Kirton, E. (1990). Cultural Conflict and Adaptation: The Case of
Hmong Children in American Society. Philadelphia: The Filmer Press. Vang, X. The Hmong Language. Retrived on March 23, 2011 from URL:
http://www.uwex.edu/ces/hmong/resources/documents/HmongLanguage.pdf Weismann, J. & Schneider, E. Social Disparities in Cancer: Lessons from a Multidisciplinary
Workshop. Source: Cancer Causes & Control, Vol. 16, No.1 (Feb. 2005), pp. 71-74. Retrieved on March 3, 2011 from a Stable URL: http://0-www.jstor.org.opac.sfsu.edu/stable/pdfplus/20069442.pdf?acceptTC=true
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Appendix A: Sample Informed Consent Form to Participate in a Research Project/ Survey
San Francisco State University
Informed Consent to Participate in a Research Project/Survey US Healthcare System and Hmong Americans
A. Purpose and Background The purpose of this research project/survey is to do interviews with key stakeholders in the California Central Valley who can influence key decision makers on this issue. The Investigator, Aurea Berger, is an undergraduate student at San Francisco University, conducting this study for a research project. You are being asked to participate in this research/survey because you are 1) a Hmong American 2.) a key leader in the Hmong American community and/or 3. A key leader/official who is/will be serving Asian or Hmong Americans in your community. Procedures: If you agree to participate in this research/survey, the following will occur:
• You will be interviewed for approximately 20-30 minutes about your first hand experiences in utilizing the US healthcare system. We want to hear your recommendations regarding this issue.
• The interview will be audiotape to ensure accuracy in reporting your statements. • The interview will take place at a time and location convenient to you. • This information will be used to assist me in completing a research paper regarding the
Hmong Americans and their utilization of US healthcare system. PARTICIPATION IN THIS PROJECT IS VOLUNTARY. You are free to decline to participate in this project, or to withdraw your participation at any point, without penalty. If you have questions regarding this project, you may contact Professor Jonathan Lee at (415) 338-2279 or [email protected]. Signature_________________________ Date_____________ Research/Survey Participant Signature_________________________ Date_____________ Student Investigator
Appendix B: Questionnaires for Hmong American Participants
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Questionnaires for Hmong Americans participants:
Name: _______________________ Age: _____
1. Do you have access to health insurance?
2. If you, how often do you see your health care provider/doctor/
3. How often do you see a dentist?
4. What kind of health insurance do you have?
5. If ever you have to change health insurance coverage and health care provider, do you
know whom to ask for help?
6. Do you encounter difficulty in accessing the customer service hotline? If so, what are
those problems you encounter?
7. How do you rate your health at present? Please use the scale 1-5, as in: 1 =worst, 2=good,
3=better, 4= best, and 5- excellent?
8. When you get prescription for medications, do you encounter problems purchasing using
your health insurance card? If so what kind of problems?
9. How often do you visit your health care provider for check-ups?
10. Any problems that deal with accessing the health care provider network?
11. Please list any recommendations that can help improve the healthcare service provided to
Hmong Americans.
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Appendix C: Signed Informed Consent Forms to Participate in Research Project/Survey
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Appendix D: Answers to Research Project Questionnaires/ Survey
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Appendix E: Transcript for Juoa Lee’s Interview Interviewer: Aurea Berger Location: Merced Lao Family Community Center, Merced, California Date of Interview: March 31, 2011 Interviewer: This interview is regarding the Hmong Americans dealing with the Hmong Americans and the healthcare society; wherein it talks about the issue of Hmong Americans being poorly served in the US healthcare system. I’m interviewing Miss Juoa Lee, the Program Director of the Merced Lao Family Community Center in Merced, California and today’s date is March 31, 2011. Interviewer: How are you Miss Lee? Interviewee: I’m good. Interviewer: That’s Fine! Can I ask you the first question now? Interviewee: Yes. Interviewer: My first question is: what are the common problems that the Hmong Americans encounter when they utilized their US health insurance like Medical? Interviewee: I think the biggest thing is that they do not speak the English language; so, they always need an interpreter. But, then the provider does not always provide an interpreter; so, they always have an issue, when they go see a doctor. That is why most of time they don’t go when the provider is not Hmong. So they don’t feel like going because they do not understand their medical issues. I think right now, because ………a lot of the Hmong Americans, who are our community members, are under Medical; but end up cutting a lot of services that is available under Medical; so they cannot get the service anymore. Interviewer: Like for example, the biggest hospital in this area……..even one interpreter they cannot even provide it? Interviewee: Yah!!!!They had one. Like…….I believed before they had two: one on day shift and the other on graveyard shift…… rotating. But now, since one of my partners is interpreting in the hospital and said that they cut services on Hmong interpreters. That they can just use the phone system to call and it does not help. Still, they need a person beside them to provide the interpretation. I think there is only one hospital that provides the interpretation service. Interviewer: As far as I know……from the book that I read, they had more Hmong interpretations before; but because of the fund….the big cut of the funding in welfare….
HMONG AMERICANS AND HEALTHCARE 49 Interviewee: I think…the hospital is ….like a private hospital. I don’t think it has something to do with the federal or the state funding, the main thing is that this hospital have less funds ……it’s only last week or so….that they cut the Hmong interpretation service to help them. Interviewer: How does this community center able to help Hmong Americans in safeguarding their health? Do you offer …like….education programs? Interviewee: Yes, we usually provide workshops for the Hmong Americans and we always come up with information that they can’t always get. We provide workshops. The Merced County just recently came, under the Merced Managed Care, so we invited some Managed Care group to come here and do workshops to show: what services are available, what the changes at Medical, what are the rules to advance medical care. We always have obesity workshop, nutrition workshops. We even had a toxic specialists come out, even pharmacists come out. So we have a connection so we can treat the community members who do not speak English at all. So we are like providers. Interviewers: So what age range do clients come here? Are they mostly elderly? Interviewee: Most of them are the first generations Hmong Americans. Interviewer: Oh!!!The first generations!!! Interviewee: Yah! The young folks don’t come here, the reason why the older generation come is because they believe of this office services. The young ones speak English and they do their own thing, so they don’t usually come here. Interviewer: So, (laughs), just like those four gentlemen outside, every time they come here, like…… they play game cards and watched TV? Interviewee: Yes!!!(Laughs) Interviewer: I see computers out there too. Do they use the computers also? Interviewer: Yes, we just recently bought these computers under our program and its for the elders so that they can work hard and use emails; so that they will learn how to send emails. We provide basically that they need because they don’t understand English; so that we can help them. Interviewer: Oh!!!Same thing with the Southeast Asian Community center in San Francisco, they have computers. The director told me during my interview with him last semester, that they are teaching those Southeast Asian elderly how to send emails. Interviewer: My fourth question is: Do you think that the State provides good health services to the Hmong Americans?
HMONG AMERICANS AND HEALTHCARE 50 Interviewee: The state…….just like what I am saying, the Hmong Americans here are on Medical and they cut mostly of the health services. I think that it is hard for the Hmong Americans considering that most of them are low income; because of the Hmong here are on welfare and are on Medical and cutting those services affected our community members. Yah! Interviewer: What are some issues that burden the elderly Hmong Americans utilizing the US healthcare system? Interviewee: I would say the language because ……..especially the elders who first came here, it, they don’t speak the language, and they always need somebody to go with them Even going to appointment, they don’t drive. That is always a problem to them, that’s why they always need somebody to go with them. They don’t have the transportation and they don’t know how to drive. Interviewer: I have a question with this transportation. Just like in San Mateo County, in Daly City, where I live, the San Mateo County transit has the paratransit that provides transportation for the elderly to take them to their doctor’s appointment; wherein they just pay one dollar. Don’t they have it here? Interviewee: They do but the thing is: our people don’t know how to use it. Because they don’t know how to use the system because they don’t speak the language and they are isolated. They don’t speak the language; that’s why they are always home all the time Interviewer: You mean to say they are still isolated till now? Interviewer: Yes. Interviewer: How about those elderly with kids who went to school here. Do they still feel isolated you think? Interviewer: No, but the first generation Hmong Americans who first came here and those who are not able to provide for themselves, are poor and cannot find jobs. The elderly Hmong population, who do not know how to drive and do not know the language, are still isolated. That’s why we always advocate for the Hmong community……… at least to help them come, participate and socialize with other Hmong elders. Interviewer: Do they still use the Hmong traditional healing method? Interviewer: I am going to tell you about that Interviewee: Yah! One thing that we did…because we are part of this groups the Hmong Health Collaborative, we added to the health system, for the healthcare system of the Hmong American
HMONG AMERICANS AND HEALTHCARE 51 community. What actually propose like a document to the hospital here in Merced and also in Sacramento because of the large Hmong population in this area, we could bring a shaman to the hospital to see a Hmong patient and perform those rituals. They approved it; and if the Hmong patient’s family requests the shaman’s presence, then we could bring one to the hospital to perform the ritual. Interviewer: That is good. At least they are able to adapt to it because that what the Hmong Americans believe. Interviewee: So they adapted that policy and when there is a Hmong patient there and the family request it, they will call and let the shaman perform the ritual. Interviewer: So, do they ask the patient if they need it? Interviewee: They don’t ask the patient; but only if the patient request it. Interviewer: My last question: Do you have any recommendations that could help both the Hmong Americans and the healthcare provider to better the service to Hmong Americans in the US health care system? Interviewee: Yah!!! I guess just believe in Hmong and not actually just use the western healthcare system always but incorporate the Hmong traditional healing method because Hmong Americans community in this area is big. So, just incorporate the Hmong traditional healing method also with the western health method. Interviewer: and probably more interpreters too right? Interviewee: Oh!!!! Yah!!! and more transportation for the elderly to use. Interviewer: Okay. I will end up my interview then and I really appreciate your help, Thank you for your time! Interviewee: No problem.