HEALTH AND HEALTH CARE OF
SOUTHEAST ASIAN AMERICAN ELDERS:
Vietnamese, Cambodian, Hmong and Laotian Elders
Barbara W.K. Yee, PhD
Department of Health Promotion and Gerontology,
University of Texas Medical Branch, Galveston
Texas Consortium of Geriatric Education Centers
introduces the learner to issues in geriatric care for elders from
Vietnamese, Cambodian, Hmong, and Laotian backgrounds living in the
United States. Available information on demographics and health
risks are presented with emphasis on the effect of immigration and
refugee experiences and traditional cultures on elders’ health.
Suggestions for assessment and treatment are included, along with
information on barriers to care. The module is designed to be used
in conjunction with the Core Curriculum in Ethnogeriatrics.
After completion of
the module, learners should be able to:
- Describe major
differences in the four Southeast Asian populations and their
traditional health beliefs.
- List at least three
health risks facing elders from the respective Southeast Asian
- Evaluate the major
options for communicating with an older Southeast Asian patient
who speaks a language not spoken by the provider.
- Develop a strategy for
providing culturally appropriate health screening and education
for Southeast Asian elders for the conditions for which they are
at high risk.
- Describe the important
issues health care providers should consider in working with
elders and their families in end-of-life care.
and Background of Southeast Asians in the United States
From 1975 to 1995,
approximately 3 million people left Vietnam, Laos, and Cambodia,
including 1.75 million Vietnamese. The U.S. has resettled over 1.4
million of these Indochinese refugees, and the majority of 900,000
were from Vietnam.
In order to avoid
the social service burden experienced by Miami, Florida, during the
Cuban refugee crisis, the federal government embarked upon a plan to
widely disperse Southeast Asian refugees throughout the 50 states.
This solution was temporary for the large numbers of refugees
seeking asylum after the fall of Saigon in 1975, but was a failed
social experiment. There followed a great secondary migration of
refugees from place of first resettlement in the U.S. toward
geographic locations that became magnets for Southeast Asian
refugees. These included locations characterized by: presence of
Southeast Asian community leaders and sponsoring relatives, tropical
climates, strong socioeconomic conditions for work by non-English
speaking refugees, and established social infrastructure (e.g. Asian
grocery stores) by established Asian-American populations. (For more
information on the immigration and refugee experience, see section
Asian refugees and immigrants have the Vietnam War, refugee
experiences and acculturation issues in common, there is wide
diversity within and across the ethnic groups that comprise the
Southeast Asian population. These include: degree of Westernization
and acculturation, education and literacy in the home country;
migration history; social class and social backgrounds; English and
other linguistic skills; social supports; age at immigration, and
years in the United States.
In the 1990 census,
a total of 955,264 individuals residing in the U.S. identified
themselves as Vietnamese; the states in which the largest Vietnamese
populations resided (from largest to smaller) were California,
Texas, Massachusetts, Florida, Illinois, Virginia, Washington,
Minnesota, Maryland, New York and Connecticut. The Hmong (195,119 in
the U.S.) were settled in: California, Minnesota, Wisconsin, North
Carolina, Michigan, and Colorado. The largest Cambodian American
populations (176,148 in the U.S.) are located in: California,
Massachusetts, Pennsylvania, Washington, Minnesota, Texas, and New
York. The Laotians (135,423 in the U.S.) have settled primarily in:
California, Wisconsin, Minnesota, Maryland, Virginia and Texas. The
Southeast Asians were concentrated primarily in urban centers.
For numbers and
characteristics of elders from each of the Southeast Asian ancestry
populations, see the chart in the Introductory section of the
Asian/Pacific Islander modules. In general, Southeast Asian elders
are more likely to be in poverty, much more likely to be foreign
born, and much more likely to be classified as “linguistically
isolated” than any other ethnic minority population.
Buddhism is a common
religion in Laos, Cambodia, and Vietnam. However, a large proportion
of Vietnamese who immigrated to the U.S. are Catholic.
II. Patterns of
Asian Elders in General
There are many
cross-cutting health risks in the Southeast Asian communities. The
largest amount of empirical research deals with mental health issues
and acute or infectious health conditions. More recently, concerns
have shifted to a discussion of chronic health concerns and risk
factors for cancer, cardiovascular, cerebrovascular, and diabetes
conditions. There are no national data on health status of
Vietnamese, Cambodian, Hmong and Laotians in the U.S. Most of what
we currently know about health status in these Asian groups comes
from smaller studies, state or local statistics.
A large number of
Southeast Asian refugees suffered from mental health concerns during
the refugee experience, sudden and involuntary cultural
transplantation to a foreign culture, spending many years in squalid
refugee camps or being held in political detainee prisons in Vietnam
for a decade or more (Mollica, McInnes, Pham, et al., 1998). In
addition to the trials and tribulations of acculturation and
adaptation to Western life, there were numerous stressors prior,
during, and after refugee migration, and horrific life events during
the Vietnam War and its aftermath that may lead to depression, loss,
and trauma expressed as post-traumatic stress syndrome. The
Southeast Asian elderly appear to be at higher risk of psychological
distress than younger Southeast Asians because they have fewer
buffers and coping strategies to deal with their distress (Shapiro,
et al., 1999; Yee, 1997; Yee & Thu, 1987). Acculturation stress,
depression and mental health issues are not often incorporated into
physical health research designs for Asian and Pacific Island (API)
populations. Acculturation stressors, as measured by high cortisol
levels, may be risk factors for cardiovascular and cerebrovascular
diseases, and cancer. (Peeke & Chrousos, 1995; Schneiderman, Antoni,
Saab & Ironson, 2001). Opium or backache remedies containing opium
may continued to be used by Southeast Asian elders in the U.S. to
cope with acculturation stress (Smith & Nelson, 1991).
Han and Tran (2001) found that Southeast Asian women may be at very
high risk for osteoporosis. These authors conducted a
cross-sectional study of women born in Southeast Asia and found that
the reference values for post-menopausal Southeast Asian women were
lower than that of White women. Several predictors of high bone
mineral density were: more years of education, earlier age of
menarche, lower height, and coastal birth (seafood consumption)
among premenopausal women.
Southeast Asians are
at excess risk of high blood pressure, high total cholesterol,
cigarette smoking, and obesity (Bates, Hill, & Barrett-Conner,
1989). Overall 61% were at moderate to high risk in at least one
Expectancy. It appears that
the life expectancy has improved for Vietnamese living in the U.S.
In 1979-1989, Merli (1998) found that the life expectancy at birth
was 61.4 years for males and 63.2 for females. Hoyert and Kung
(1997) report 1992 life expectancy in seven high Asian and Pacific
Islander reporting states to be 78.8 at birth and 18.8 additional
years if a Vietnamese American lived to 65 years of age. The authors
caution that these estimates were based upon small sample sizes,
therefore may limit their generalizability.
Cancer is the leading cause of death for Vietnamese of both genders
in the United States. (Hoyert & Kung, 1997; Shinagawa, et al.,
1999). High smoking rates and exposure through passive smoking among
Southeast Asian families contributes to excess cancer rates among
this ethnic group. The SEER data (Miller et al., 1996) report excess
cancer rates for Vietnamese males in nasopharynx, liver, and stomach
cancers. The same authors report excess cancer deaths for Vietnamese
women in cervical, stomach and thyroid cancers. Vietnamese women
have the highest incidence of cervical cancer in the U.S. It appears
that much of this can be explained by lack of Pap screening,
however, other factors such as high stress levels may also
contribute to the Vietnamese women’s higher incidence of this
3. Heart Diseas.
Stroke Hypertension, and Diabetes. The second leading cause of
mortality for both Vietnamese men and women in the seven U.S. states
was diseases of the heart, and another leading cause was
cerebrovascular diseases (Hoyert & Kung, 1997). Among Vietnamese
hypertensives over 40 years of age, essential hypertension was
associated with significant increase in body mass index (BMI).
However, this figure was far lower than the defined threshold of
Occidental obesity. Insulin resistance was found despite very slight
or no excess weight among Vietnamese hypertensives (Van Minh et al.,
1997). This study suggested that thresholds established in Caucasian
populations may be an inexact predictor for the Vietnamese. Related
to the risk of cardiac and hypertension problems may be the high
rates (35%- 42%) of smoking among Vietnamese men.
Conditions. Other leading
causes of mortality for Vietnamese men included accidents and
adverse effects, homicide and legal interventions; for women they
included accidents and adverse effects, and pneumonia and influenza
(Hoyert & Kung, 1997).
A small community
study of recent Vietnamese immigrants in Boston found the following:
32% smoked (54% males, 9% females); 24% used alcohol; 17% were
depressed on the Vietnamese Depression Scale, with those older than
40 having more depression; ova parasites were found in 51%, (63% of
them required treatment); 70% tested positive on the TB test (39%
required treatment); 83% had been exposed to hepatitis B and 14%
were chronic hepatitis B carriers (Nelson, Bui, & Samet, 1997).
exposures and developmental timing (i.e., in utero, infancy,
childhood, adolescence, young, middle and elderly adulthood) of such
exposure need to be examined to determine how toxicity and
carcinogenic substances influence health of Southeast Asian elderly,
for example, dioxin levels in adipose tissue and exposure to Agent
Orange in South Vietnamese (Verger, et al., 1994).
Expectancy. Life expectancy in
Cambodia is around 47 years for men and 49 years for females (Heng,
1995). There is no life expectancy data for Cambodians in the United
States. While the major killers in Cambodia are malaria,
tuberculosis, severe anemia, undernutrition, and diarrhea, these
conditions become less health compromising with acculturation and as
chronic conditions take more prominence.
2. Mental Health.
The Cambodians are at very high mental health risk and suffer from
post-traumatic stress syndrome and depression that is exacerbated by
financial stress (Blair, 2000). The majority of Cambodians in the
United States have been touched by the genocide under Pol Pot and
the Khmer Rouge. Up to two million Cambodians died in the killing
fields from violence, starvation, and disease. Mollica, McInnes,
Poole and Tor (1998) found a dose-effect relationship of trauma to
symptoms of depression and post-traumatic stress disorder among
Cambodian survivors of mass violence.
Handelman and Yeo
(1996) found that sadness from obsessive thinking about the loss of
family members or traumatic events in the killing fields were the
root of the most common illnesses among 76 Cambodian elders in San
Jose, California. This condition (pruit chiit/ kiit chraen) produces
severe headaches with dizziness. Similarly, in a study of emotional
distress and violence among Cambodians in Long Beach, California,
and Lowell, Massachusetts, respondents experienced headaches from
"thinking too much" about the horrors of Pol Pot regime. Family
violence may be the outcome of thinking too much, and the woman's
solution would be to talk softly to the violent male. Only half of
these Cambodian women would call the police if necessary. Greater
use of alcohol, prescription drugs, especially sleeping pills, were
used to deal with the "thinking too much".
Drinnan and Marmor
(1991) found that Cambodians presenting with functional visual loss
may have conversion hysteria from wartime experiences and cultural
issues. This explanation for the emotional causes of physical
illnesses illustrates the strong holistic concept of health among
Cambodians Americans. There may be a reactivation of post-traumatic
stress disorder symptoms, behavioral indicators, self-reports of
distress, and increases in heart rate by seeing traumatic videos one
to two decades after the event (Kinzie, et al., 1998).
Health. Cambodians have high
rates of hypertension, diabetes, heart disease, stroke and seizures
accompanied by a variety of somatic complaints such as headaches,
stomach aches, dizziness and fatigue (Baughan, White-Baughan,
Pickwell, Bartlome & Wong, 1990). According to Palinkas and Pickwell
(1995), the influence of acculturation on chronic disease risk needs
to be examined, such as preference for and consumption of
traditional foods and changes in food preparation style. While
cultural preferences may remain quite traditional, use of American
food substitutes, alteration of healthy food preparation styles, and
lack of availability of traditional foods products may change
nutrition patterns that may be damaging to the health of Southeast
Many older Cambodian
women, primarily those over 50 years of age, chew betel nut quid, a
stimulant and narcotic substance that is quite addictive, with
tobacco, and red limestone paste. Chewing betel nut or its leaves
puts one at possible risk for oral squamous cell cancer that is
prevalent throughout Southeast Asia (Reichart, Schmidtberg &
Scheifele, 1996). This is a female rite of passage into adulthood,
and Cambodian older women do not view this addiction as harmful. It
appears that with acculturation, younger Cambodians have not adopted
this addictive and health damaging health habit.
often do not associate liver disease with Hepatitus B virus, only
heavy alcohol use, according to Jackson, Rhodes, Inui, and Buchwald
(1997). These authors found that about 10-15% of Asian refugees are
chronic carriers of Hepatitis B virus. Liver cancer may be a
possible negative outcome from this chronic infection.
According to Mills and Yang (1997), the Hmong have elevated rates of
cancer for the following sites: nasopharynx, stomach, liver,
pancreas, leukemia and non-Hodgkin’s lymphoma. Cervical cancer
incidence overall was elevated, and invasive cervix cancer rates
were higher than expected. Hmong also experienced advanced stage and
grade of disease at diagnosis for many cancer sites in addition to
cervical cancer. Cultural factors are implicated such as avoidance
of Western medical care, thus leading to low rates of participation
in screening programs.
Conditions In one study Hmong
were found to have significantly lower mean cholesterol level than
other Southeast Asian populations (Bates, et al., 1989).
No data are
available of the specific health risks of elders in the U.S
identified as Laotian.
Appropriate Geriatric Care: Fund of Knowledge
Two issues that are
important background knowledge for effective care of elders from
Southeast Asia are the traditional health beliefs and practices they
may have, and the historical experiences of their cohort.
A. Health Beliefs
The belief and
practices of Buddhism are widespread in Southeast Asia. Many
Buddhists believe that human suffering and hardships provide the
catalysts for change and development (Young-Eisendrath, 1998).
During difficult periods of life, people will become enlightened and
focus on how their suffering and hardships are brought about by
their own attitudes and intentions, actions and relationships.
Buddhism teaches believers that suffering is necessary to develop
personal responsibility for subjective lives and awaken thoughtful
compassion about human limitations. Illness as suffering has value
as a catalyst for change and development. Therefore, the illness and
disability journey, through pain and suffering, can provide valuable
lessons in life (Miles, 1995). Delays in obtaining relief from
illness may be a Buddhist stoic response to religious awakening.
remedies practiced by many groups throughout Southeast Asia include
herbal medicines, coin rubbing, cupping, therapeutic burning (moxibustion),
and acupuncture (Jenkins, et al., 1996). Because coin rubbing to
relieve “wind illness” produces superficial abrasions, Western
providers can misinterpret them as elder abuse.
Traditional Vietnamese believe in one or a combination of three
models of health (Tung, 1980). First, the Am-Duong model is based
largely upon Chinese traditional medicine and a belief that
illnesses are caused by imbalances in the yin (am) and yang (duong)
(Sheikh & Sheikh, 1989). Physiological imbalances can be caused by
high emotional state, external influences such as sudden climatic or
seasonal changes that block the circulation of vital energy (chi) or
blood. Acupuncture can clear obstructions.
A second organic
model sees illnesses as a function of the nervous system. For
instance, neuroses are weakness of the nerves (than kinh suy nhuoc)
and psychoses are turmoil of the nerves (than kinh thac loan).
Verbal expressions such as weak nerves may signal minor mental
disorders from anxiety, depression and mental deterioration. A nerve
tonic or tranquilizer is usually prescribed to treat such
In the third model,
a supernatural intervention is the most persistently held cause of
mental illnesses. Tien dieties have the power to protect, and errant
spirits are ancestors who have not been properly venerated by their
descendants with ancestor worship ceremonies and offerings. The
Vietnamese have spirit mediums, and sorcerers deal with the spirits.
Buddhist priests and lay monks can provide amulets and medicines for
physical ailments, as well as exorcism for spiritual ailments
The Cambodian people or Khmer culture is a combination of indigenous
folk traditions, Indian, and French influences (Zadrozny, 1955). The
majority of Cambodians adhere to Theravada Buddhism. The folk
religion centers on spirits in the natural habitats such as
mountains, ancestral spirits, and dangerous spirits or ghosts. Some
spirits are benevolent, while others are malevolent. Western medical
practices were introduced in Cambodia around 1860, however,
indigenous practitioners were the first line of defense. Western
doctors were seen only when the illness persisted. There were
indigenous practitioners who dealt with sorcery and exorcised the
evil spirits from the patient. Buddhist monks provided medical
services from spiritual to Western therapy. The causes of illness
were typically attributable to supernatural causes or natural causes
such as humoral imbalances. Spirits cause illnesses by entering the
body through the patient's food. Practitioners of black magic can
prevent or cause harm to people.
humoral imbalance come from Ayurvedic medicine in India and
Southeast Asia and its use of five basic elements -- ether, wind,
water, earth and fire to regulate bodily functions. According to
Ayurvedic thought, illness occurs when the homeostatic condition of
the humors is upset (Sheikh & Sheikh, 1989).
of ritual ceremonies to deal with the nefarious spirits and pay
homage to the benevolent spirits, moxibustion, and herbal medicines.
The Hmong are a very traditional people without a written language
prior to coming to the United States. The Hmong formed nomadic clans
who wandered in the remote and sparsely populated mountains of Laos,
used shamans, and were animistic in their folk healing beliefs. The
Hmong combine Chinese medicine and Protestant Christian beliefs, but
spirit illness and soul loss beliefs still persist in this country (Fadiman,
1997). Temporary soul loss or soul separation is considered a factor
in the majority of illnesses (Geddes, 1976). Souls can be separated
by accident or by a frightening event, or may be taken by an angered
or offended spirit. A shaman is an important leader and healer who
is the only person who can communicate directly with the
supernatural spirits; he has clairvoyant powers in traditional Hmong
Nocturnal Death Syndrome among healthy Hmong refugees has been
attributed to nightmare or attack by evil spirit that threatens to
press the life out of its terrified victim (Adler, 1995).
Hmong may not make
direct compliments or show great admiration for loved ones since
this may attract the attention of evil spirits and arouse their
envy. As a result of this envy, the evil spirits may take away the
The Hmong perceive
dementia as a natural part of aging and the lifecycle, rather than a
devastating disease that robs individuals of their identity and
autonomy (Olson, 1999). Wandering and combativeness are rare or
non-existent in the Hmong community, in spite of the fact that
demented relatives are cared for in their sons’ homes. Nursing home
placement is made for advanced dementia only when sanctioned by the
entire extended family.
Laotians are mostly literate and Buddhist. Many of the population of
Laotians in the U.S. are from Lao Mien background. Like the Hmong,
traditional Lao Mien believe that the spirit world can exert
influence over the world including, health and well being of humans.
The supernatural world consists of ancestral spirits and spirits of
animals and plants. They can be protective; however, they can also
be a major source of human affliction such as illness or accidents.
The Mien have been strongly influenced by the Chinese Taoist, and
healing practices of Lao-tsu and his priests. An individual's spirit
status in the spiritual world is dependent upon whether the person
accumulated merits during their life. The Mien believe that health
is dependent upon the status of the 12 souls that make up a person's
life force (Hwen) (Miles, 1973). These 12 souls correspond to 12
parts of the body (i.e.,eyes, ears, mouth and nose, neck, arms,
chest and upper back, abdomen and lower back, legs, left side of the
head, right side of the head, feet and hands). Illness may be
produced when malevolent ancestors express their anger by creating a
loss of hwen. Illness is created in that part of the body associated
with that lost soul.
The Mien have two
major ways of dealing with sickness. "Dia " medicine is called upon
in cases of illnesses due to hereditary factors. "Tsiang" ceremonies
are carried out to address illnesses attributed to supernatural
causes. In this latter case, Taoist grand master priests or other
priests and spirit mediums are called to deal with these illnesses.
The Mien living in
Richmond California integrated traditional healing beliefs and
practices with the use of Western health services (Gilman, Justice,
Saepharn & Charles, 1992).
Experiences of the Cohort of Southeast Asian Elders
Until April 30,
1975, there were very few Vietnamese, Cambodian, Hmong or Laotians
residing in the U.S. The fall of Saigon dramatically changed the
landscape of the Asian American population forever. It is important
for health providers to know something of the events the cohort of
elders they care for are likely to have experienced.
Over 130,000 Vietnamese left the country in 1975 in the final days
of the war, half of whom were evacuated by the U.S. military. These
Vietnamese military, government officials, and U.S. employees were
considered high risk for imprisonment. Starting in 1977, large waves
of Vietnamese refugees were created by policies pursued by the
Communist revolutionary government. In late 1978, Malaysia started
preventing Vietnamese boat people from landing, or if they landed
were towed back out to sea. Refugee drownings and horror stories of
pirate attacks created an international outcry that set the United
Nation’s refugee policy for the next decade. By the end of 1978,
about 62,000 boat people were in refugee camps across nine countries
in Southeast and East Asia. In July 1979, the United Nations
established a multilateral program to help Indochinese refugees and
displaced persons around the world. Vietnam cracked down on illegal
departures starting in July of 1979 that reduced fleeing of boat
people from 54,941 to 9,734 two months later.
The U.S. the Refugee
Act of 1980 (i.e., Immigration and Nationality Act, section 207)
dealt with the ongoing problems of Vietnamese boat people and other
Indochinese in need of resettlement. More than 80,000 Amerasian
children and accompanying family members were admitted to the U.S.
through the Amerasian Homecoming Act of 1987. By late 1980s, most of
the resettlement countries resettled top priority applicants. The
U.S. resettled some 4,600 former U.S. government employees and
another 165,000 former reeducation camp detainees and their
immediate family members. After the Southeast Asian refugees of the
1970’s became naturalized citizens, many petitioned for immigration
of their eligible family members, including many older parents who
continue to come to the U.S. as “followers of children.”
Many people leaving
Vietnam in the late 1980s came to the U.S. under approved immigrant
petitions for admittance to this country. The United Nations
sponsored a conference to establish agreements among 70 countries,
known as the Comprehensive Plan of Action for Indochinese Refugees
in June of 1989 to deal with the 100,000 Vietnamese boat people in
camps throughout Southeast Asian and Hong Kong. In 1989, 70,000
Vietnamese boat people left Vietnam. This international policy
reduced the number of disorderly refugee flights from Southeast
Asia. When the Comprehensive Plan of Action for Indochinese Refugees
ended in June, 1996, the Vietnamese in refugee camps throughout
Southeast Asia were either approved for resettlement or given
incentives to return voluntarily to Vietnam. By 1999, about 1.75
million Vietnamese had left Vietnam and been resettled. In 2000, the
U.S. included East Asian refugees in its annual refugee resettlement
ceilings of 8,000 each year.
The Welfare Reform
Act of 1996 created a lot of confusion and stress among the elderly
Southeast Asian immigrants who were caught in this reform frenzy.
Many of these Southeast Asian elders were already in poverty and had
no resources with which to support themselves when welfare funds
were withheld. [See Asian and Pacific Islander Health Forum (www.apiahf.org)
and other websites for more information.] Several congressional
remedies were enacted to address elimination of welfare and SSI
support for some elderly immigrants and refugees groups. (See Social
Security Administration site or
www.apiahf.org/new_featured/ssi.html for more details.)
The Hmong tribes had
lived in the mountainous areas of China and then Laos for centuries
before the outbreak of the Vietnam War. Hmong men were recruited to
fight for the U.S. and became a dependable and important part of the
fight against North Vietnam, incurring massive casualties. When Laos
and Vietnam fell to the communists, a few Hmong officers and their
families were flown to Thailand to safety, but an estimated 150,00
were forced to make the trek by foot pursued by communist soldiers.
Many children and adults died or were killed before reaching the
refugee campus. Some were captured and imprisoned and sent to
“reeducation” camps. After sometimes years in overcrowded refugee
campus in Thailand, thousands of Hmong were given refugee status and
transported to the U.S. and other countries such as France, Canada,
Australia, and Argentina in the late 1970s and 1980s . Because they
had maintained a relatively isolated and very self-sufficient
lifestyle based primarily on agriculture in rural mountainous areas,
most knew nothing about urban living such as indoor toilets, kitchen
appliances, or supermarkets. Their transition to the U.S. urban
culture was very abrupt and traumatic. Families were traditionally
very large, and some had been polygamous, so the resettlement meant
that family members were often separated from loved ones. Because
their language had been primarily oral rather than written, the
transition to a culture based on written words made the
acculturation even more difficult. For an excellent description of
experiences of this population, see Fadiman, (1997).
The Hmong Veterans’
Naturalization Act of 2000 eased naturalization requirements for
eligible former spouses of deceased Hmong veterans who supported
U.S. military during the Southeast Asian conflict.
Appropriate Geriatric Care: Assessment
A. Use of
A key component of cultural competence is linguistic competence. It
is defined by the Office for Civil Rights in the U.S. Department of
Health and Human Services (1999) as the " skills to communicate
effectively in the native language, or dialect of the targeted
population, taking into account general educational level, literacy
and language preferences". The director of the Office of Civil
Rights, Tom Perez, issued a guidance memorandum entitled "Title VI
Prohibition against national origin discrimination--persons with
limited-English proficiency" (www.hhs.gov/ocr/lep/).
Poor practices include: use of family or friends as
interpreters-especially children; use of untrained bilingual staff
like janitors or secretaries or community volunteers; telephone
interpretation; non-certified/untrained contracted interpreters;
limited or low quality written materials in relevant languages or
inappropriate literacy levels of translated materials. More details
can be found at the web sites
www.diversityrx.org. Jackson (1998) argues that the long term
savings in financial and human costs are enormous in spite of short
term costs since adequately trained interpreters can lessen common
issues that arise during bilingual clinical encounters such as bad
paraphrasing, impatience, lack of linguistic equivalence,
interpreter beliefs, ethnocentrism and role conflicts. Medical
interpretation is a civil rights issue and can be economically
justified by improvement of long term health outcomes. See
www.diversityrx.org for medical interpretation resources. It is
very important to provide cultural and linguistic competence in
aging services because more Southeast Asian elders are non-English
or limited English speaking in comparison to younger Southeast
(See Section on use
of interpreters in Module IV of the Core Curriculum in
Ethnogeriatrics for a comparison of different modes of providing
Research to ensure
that assessment and measurement tools are culturally competent for
the Southeast Asian population is just beginning. There are,
however, several well established and validated translated
instruments for depression:
Vietnamese Depression Scale
(Buchwald, Manson, Dinges, Keane, & Kinzie, 1993);
Hmong Adaptation of Beck
Depression Inventory (Mouanoutoua, Brown, Capelletty & Levine,
Checklist-25-Hmong version (Mouanoutoua & Brown, 1995).
scale for Southeast Asians was developed by Anderson, et al.,
(1993). This 13 item acculturation scale included two subscales:
proficiency in languages; and language, social and food preferences.
Marino, Stuart, & Minas (2000) argued that there was a degree of
independence between psychological acculturation such as self
identity, (the majority of acculturation instruments fall into this
category) versus behavioral acculturation. In addition, most
acculturation measures are heavily weighted towards English language
C. Translation of
The science of
cross-cultural equivalence of assessment tools has just begun to
examine cross-cultural equivalence in translated psychological
instruments among college and young adult samples. Unfortunately,
very little of this preliminary research has been conducted with
non-English speaking elderly. For example, Devins, Beiser, Dion,
Pelletier, and Edwards (1997) examined the psychometric equivalence
of Cantonese, Vietnamese and Laotian translations of the Affect
Balance Scale. They found that confirmatory factor analyses
indicated a good fit between the hypothesized positive and negative
affect factor model. However, there was small percentage of people
over 56 years of age in the sample [i.e., 1% (4) Vietnamese
individuals, 3.6% (7) Laotians, and 8.5% (64) Cantonese speaking
translation protocol is suggested by cross-cultural researchers (Brislin,
Lonner & Thorndike, 1973). This process includes translating the
instrument from English to the target language, then a new group of
translators would translate the document back into English.
Discrepancies between the original English version and the
back-translations are resolved by consensus and clarification to
produce conceptual equivalence. The caveat is that even under ideal
circumstances, a translated/back translated instrument may be unable
to assess concepts that have no conceptual equivalence or are
culturally bound concepts (Dunnigan, McNall, Mortimer, 1993).
D. Other Issues
For information on
eliciting elders’ perception of their conditions, sometimes called
“explanatory models of illness” and issues in the domains of
clinical assessment, see Module IV of the Core Curriculum in
Because the use of
herbal remedies is widespread among traditional Southeast Asian
elders, one issue that could be kept in mind is the possibility that
a few of herbal remedies may contain strychnine or other harmful
substances (Katz, Prescott & Woolf, 1996).
Appropriate Geriatric Care: Treatment Issues
primary health care goes beyond mere medical interpretation to
hiring bilingual/bicultural outreach staff to provide case
management, follow-up care and education of health professionals
(Jackson-Carrol, Graham & Jackson, 1996).
increases in maintaining or adopting healthy behaviors (physical
activity, nutrition, elimination of smoking, stress management),
with regular preventive physician visits and screening could
substantially improve the health of Southeast Asians. Smoking
cessation campaigns for Southeast Asian males (i.e., 72% Laotians,
35% to 42% Vietnamese, and 29% Hmong smoke) can lessen the burden of
lung and other cancers, asthma, and other respiratory conditions
among all Southeast Asian family members through exposure by passive
smoking, and eliminate smoking role models for younger members. It
appears that acculturation and adoption of unhealthy American
lifestyle habits and rejection of healthy traditional habits may be
damaging the health of Southeast Asian elderly (Yee, 1999b).
important emphasis for screening needs to be Pap smears for cervical
cancer, given the high risk for Southeast Asian women. Based on
findings on utilization (see Section VI below), recommendations
include having a female provider, spending time to establish rapport
prior to health education, support groups to discuss women's health
issues, and explaining the rationale for importance of screenings
and procedures and equipment involved. It seems important that
female physicians/health professionals carry out exams and explain
suggested that incorporation of Buddhist values and concepts into
health promotion and intervention programs might increase the
acceptability and impact of those programs (Barrett, 1997; Loue,
Lane, Lloyd & Loh, 1999).
Pham, Rosenthal &
Diamond (1999) found that Vietnamese believed Western medicine to be
“stronger, faster, and curative” while folk medicine is “weaker,
slower, but preventive”. These beliefs have major implications for
adherence to medical regimens by Southeast Asian elders. Decreasing
drug doses is a cultural response to their perceptions about these
Western medications. To the degree that this is systematically done
by older Vietnamese and other Southeast Asian patients, some
medications may not be effective.
by Cambodian patients for not adhering to the medical schedule and
dosing requirements as prescribed by their physicians were:
misunderstandings about what the medication was for; its side
effects; concerns about the powerful effects of Western medicines;
and Cambodian beliefs about pharmacokinetics (e.g., the belief that
strong stomach reactions would be produced when two medicines are
taken simultaneously (Shimada, Jackson, Goldstein, & Buchwald,
The issue of
Southeast Asian ethnicity and pharmacology needs to be explored
(Lin, Poland & Nagasaki, 1993). Cross-ethnic differences in response
to therapeutic agents have been found, but specific differences
among Southeast Asian populations were not explored.
C. Working with
Gender and age roles
are important in adaptation to aging by Southeast Asian immigrants.
The Southeast Asian gender and age roles expressed in families and
in the larger community vary by acculturation levels (Yee, 1999a).
These age and gender roles may influence family decision making.
making and intergenerational relationships vary greatly across the
Southeast Asian communities. (Yee, Huang, & Lew, 1998). Providing
orientation to the health care system and elder care services (e.g.,
Alzheimer's respite, SSI, Medicare, Medicaid), health education, and
health promotion to the entire Southeast Asian family would enhance
utilization of these services for the elderly. More acculturated
members of the Southeast Asian families can traverse the complicated
health care system and be very effective advocates for their elderly
relatives. The Southeast Asian elders are paid great deference
because they are titular heads of families. However more
acculturated family members will be the conduit to utilization of
services by elderly family members. Family interventions enhance the
effectiveness of individually targeted interventions.
Issues with Southeast Asian Families
abound in health care and end-of-life decision making. Typically
elders are more traditional. Braun, Pietsch & Blanchette (2000)
argued that culture influences a wide variety of death and dying
attitudes and medical decisions. Southeast Asian families have been
influenced by their religious and cultural philosophies, such as
Buddhist beliefs surrounding karma and reincarnation with concern
for ancestral spirits. These beliefs may lead to an avoidance of
hospitals where souls of people who died may not have a place to
rest and can create havoc upon the living. Delayed medical attention
may be the result of this avoidance of hospitals where lost souls
Organ donation would
be less likely because donors would be reborn incompletely without
all their vital organs in the next life. Decisions to donate organs
of dying elders by family members may be viewed as a sign of
disrespect and as lacking in filial piety towards the family
elder/ancestor (Nakasone, 2000). This unfilial behavior may anger
the family ancestor who may create mischief for the living. However,
the willingness to be a live or after-death donor of organs and
tissues may be increasing, especially for close relatives or
friends, with the approval by other family members (Hai, et al.,
1999). These authors also found that Vietnamese would be more
willing to donate organs and tissue if medical care was provided to
the donor's family or if there were monetary rewards for such
interventions, such as organ transplants or cardiac resuscitation,
with hospital strangers surrounding the dying person, may be
regarded as disturbing the natural ebb of life and a sign of a "Bad
death" with a great deal of negative emotions. Withdrawal of life
supports may be viewed by Southeast Asians as causing or speeding
the demise of their family elder. Palliative care with its
comforting, peaceful, and family supportive dimensions may be more
acceptable for Buddhists and other Southeast Asians. Many Vietnamese
have been influenced by Catholic, Taoist and Buddhist beliefs
regarding life and death (Ta and Chung, 1990). For instance,
Vietnamese women may not want the dying person to be told that
he/she was dying (Calhoun, 1985). There are cultural differences in
death and dying truth telling (Crow, Matheson & Steed, 2000; Muller
& Desmond, 1992). Many Southeast Asian families do not want or allow
the physician to inform dying family members of their terminal
prognosis because it would cause them to lose hope. Some do not want
to upset the loved one, others don't want to because this may bring
death sooner, or truth telling about dying may show a lack of
respect for the soon-to-be ancestor.
The issue of
advanced directives among Southeast Asian elders needs to be
examined. Vaughn, Kiyasu & McCormick (2000) found that the majority
of Chinese, Japanese, Korean, Filipino and Southeast Asian nursing
home residents were listed as “no code” on their resident charts.
Age and higher comorbidity was related to having no code indicated
on their resident charts.
VI. Access and
appear to access health care services to a lesser degree than their
Caucausian or English speaking counterparts. For instance, Kuo and
Porter (1997) found in the 1992-1994 Health Interview Survey that,
in spite of fair or poor health self reports, the Vietnamese
respondents did not see a physician as often as Caucasians. There
were a greater number of Vietnamese who knew nothing or very little
about diseases such as AIDs (Kuo and Porter, 1997) or cervical
cancer (Schulmeister & Lifsey, 1999; Yee, 1997) and preventive
behaviors/tests such as Pap smears. For instance, Jenkins, McPhee,
Bird, and Bonilla (1990) found that health knowledge regarding
cancer risks, unhealthy lifestyle behaviors, and cancer prevention
practices need to be improved among the Vietnamese. The Association
of Asian Pacific Community Health Organizations (1996) spelled out
recommendations for providing health services in API communities.
The most common reason for lack of health care access is the lack of
linguistically and culturally competent health services. According
to Cox (1986) a unique predictor of physician use among Vietnamese
elderly was satisfaction with their medical care, a finding that was
not found among Portuguese or Hispanic elders.
Health beliefs and misconceptions of disease and illness may impede
recognition of early warning signs and delay access to medical
treatment. For instance, newly arrived Vietnamese felt that
tuberculosis was an infectious lung disease with cough, weakness and
weight loss as symptoms (Carey, et al., 1997). Hard manual labor,
smoking, alcohol consumptions and poor nutrition were believed to be
risk factors. Many Vietnamese respondents incorrectly believed that
asymptomatic latent TB infection was not possible and that TB
infection always leads to disease. Nearly all respondents in this
study felt that having TB would adversely impact their work, family
and relationships, and community activities. Focus groups conducted
in Vietnam found that four types of tuberculosis were identified
(Long, Johansson, Diwan & Winkvist, 1999): 1)Lao truyen or inherited
TB that was handed down from older generations to younger through
family blood; 2) Lao luc or physical TB caused by hard work with
more of the men affected; 3)Lao tam or mental TB that is caused by
too much worrying with more women being affected by this type; and
4) Lao phoi or lung TB that is dangerous and caused by the TB germs
by transmission through the respiratory system with men more
affected by this TB. These traditional TB beliefs contribute to long
delays in TB diagnosis, increased social stigma, and social
isolation due to erroneous beliefs in transmission routes.
Fund (1995) conducted a national survey comparing the health
experiences of 1,048 African Americans, 1,001 Hispanic, 205 Chinese,
201 Korean, 201 Vietnamese and 1,114 white adults in the U.S. This
study found that Hispanic and Chinese, Korean and Vietnamese adults
said lack of insurance, health care costs, not having a regular
doctor, and less satisfaction with health care services were
associated with less care. Compared to 25% of white adults, 47% of
the Vietnamese group who had visited the doctor in the last year did
not receive preventive care services such as blood pressure tests,
Pap smears or cholesterol. Lack and lapse of insurance were bigger
problems for minority Americans and was associated with
consequences, such as not taking expensive medicines, or not taking
or delaying needed medical tests. Southeast Asians feared using
medical services during welfare reform because of potential threat
of being deported. Minority adults also had little or no choices in
where they obtained health care, a condition particularly acute
among Asian and Hispanic Americans. Barriers to care were high costs
of health care, long waits, poor access to specialty care with
language and cultural barriers. Ethnic minorities were less likely
to be satisfied with their care. Vietnamese, Mexican and Puerto
Rican adults received less preventive care such as blood pressure
tests, Pap smears, or cholesterol readings, compared to their white
women participate in health screening less than their American
counterparts (Phipps, Cohen, Sorn and Braitman (1999). The
Vietnamese and Cambodian women had poor cancer knowledge and were
unable to identify cancer prevention strategies. Greater knowledge
was associated with employment outside the home, more years of
education, and age, but not with length of time in the United
States. This study implies that limited English-speaking and
traditional Southeast Asian women are not exposed to cancer
information that appears in the English media and society. Lesjack,
Hua and Ward (1999) found that female practitioners, free screening,
and more health information improved recruitment of Vietnamese women
for cervical cancer screening.
Lifsey (1999) found that Vietnamese women believed that their risk
of cervical cancer was low. Barriers to screening were not having a
gynecologist, cost and fear of the test. Other studies found the
significant barriers for breast and cervical cancer screening among
Southeast Asian women were: embarrassment and shyness during the
physical examination in a well woman's checkup; cultural barriers
concerning being touched by a stranger and a male physician; a
belief that cancer cannot be treated; and a fear of large medical
facilities and the equipment such as used in mammography (Kelley, et
al., 1996; Mahlock, et al., 1999; Tu, et al., 2000; ;Yi, & Prows,
1996). It appears that successful programs that serve the needs of
Southeast Asian elders include the following characteristics: 1) use
of cultural lay health worker/interpreters, peer health educators,
and family/community interventions to bridge language and cultural
gaps; 2) decrease of cultural health barriers such fear of surgery
and preference for female physicians to conduct health examination
or improvement of health knowledge for chronic disease conditions
and preventive health strategies by ethnic specific videos or health
fairs; 3) use of after hours access, community based and “one stop”
integrated services (e.g., medical, mental health, social services);
4) decrease of financial and medical coverage barriers and
logistical barriers such as transportation; 5) significant
improvements in health education targeted at Southeast Asian
consumers (Cory, 1995; Free, White, Shipman & Dale, 1999; Lesjak,
Hua & Ward, 1999; Mahlock, et al., 1999; Nelson, Bui & Samet, 1997;
Pham, Rosenthal & Diamond, 1999; Siganga & Huynh, 1997; Stuer,
Case of Mr. N.
Mr. N. is a 71 year old Vietnamese former lieutenant colonel who was
imprisoned for 12 years by the Socialist Republic of Vietnam. He was
physically and emotionally tortured with stories of family members
being killed or imprisoned in other re-education camps. Mr. N. felt
lucky to be alive since 165,000 people died in Vietnam’s
re-education camps since 1975. He came to U.S. in 1989 and had
nightmares every night for the first couple of years. He feels
estranged from his family since he was imprisoned for 12 years and
his family became American strangers to him. His doctor said that he
suffered from Post-Traumatic Stress Syndrome from his long
imprisonment and torture. Now he has nightmares only when he feels
stressed out. He deals with this stress by smoking 4 packs of
cigarettes a day and drinking beer. He has a hoarse cough and
sometimes coughs up blood. His family brought him to see a physician
because his herbal medicines did not work on his cough anymore and
he cannot get to sleep at night.
Case of Mrs. K.
Mrs. K. is a 76 year old Cambodian woman who has seen a physician
twice since coming to the United States in 1978. She had
tuberculosis in 1978 and was successfully treated for TB at the
County Health Clinic. Mrs. K. has not seen a physician since 1979.
She is brought in to see a male physician at the County Health
Clinics with complaints of severe headaches with dizziness,
accompanied by her English speaking son who provides the English
translation during the medical visit. The physician notes that its
difficult to figure out what the problems may be. Notes indicate
that she talks about “thinking too much” about how many relatives
she lost under Pol Pot and the Khmer Rouge. Her medical records are
incomplete and include only a history of her TB treatment. Mrs. K.
is embarrassed to tell the male doctors, via her son, about some
vaginal blood she noticed over the last 6 months. She believes that
she is now “polluted again”. She stopped menstruating about 20 years
ago. She has never had a well woman check up. In her physical exam,
the physician noted that Mrs. K. had dark stained teeth and appears
to have oral lesions in her mouth.
Case of Mrs. V.
Mrs. V is 62 year old wife of a Hmong war veteran who helped the CIA
during the Vietnam war. They have been on welfare since coming to
the United States, but were dropped from the welfare rolls during
welfare reform. Mr. V. was a chain smoker and recently died from
lung cancer. He provided the only financial source of support for
Mrs. V. While Mr. V. was being treated for his cancer in the
hospital, the nurses wanted Mrs. V. to sign some Advanced Directives
papers she couldn’t read. Mrs. V. did not come to see her husband
everyday. Her children claim that she didn’t want to because there
are many lost souls at the hospital, and they might create problems
for her. After a week, Mrs. V. brought someone from the Hmong mutual
aid society to help with the translations. The translator provided
the translation to Mrs. V. about the advanced directive. She still
didn’t understand, but signed anyway. One day, Mrs. V. came to visit
her husband, and the doctors and nurses were pounding upon Mr. Vang
chest to resuscitate him. Mr. V. died, and Mrs. V. considered this
to be a “bad death”. Mrs. V. said that Mr. V. may be angry with her
because he died in a violent way. Mrs. V. complains to her children
that she has terrible headaches and backaches since this happened.
The physicians advise her to make ibuprofen to relieve pains. Mrs.
V. says that these medicines have not worked because the ancestor
spirit of Mr. V. was creating an illness in her head and back by
removing these two body souls. She sees a spiritual medium to do the
ceremonies to appease Mr. V.’s angered ancestor spirit.
Discussion or Written Assignment
For one or all of
the cases above, consider the following questions.
1. What would a
health provider’s problem list include for the cases above?
2. How could an
understanding of the cultural health beliefs and/or cohort
experiences assist the health care provider in giving effective
3. What kind of
treatment, management, or referrals might the health care provider
1. The large
majority of Southeast Asian elders were refugees fleeing Southeast
Asia after the Fall of Saigon in 1975. How would the refugee
experience influence their adaptation and aging in the U.S.?
2. While the
majority of Southeast Asians share the refugee experience, what
differences should be noted between Vietnamese, Cambodian, Hmong and
Laotian populations that may lead to varying degrees of adaptive
3. What are the
major health threats for Southeast Asian elders? 4. What are some
cultural health beliefs and lifestyle practices of Southeast Asian
elders? How would they influence access and utilization of health
5. What are some
strategies to improve the cultural competence of our geriatric
services for Southeast Asian elders?
6. What are some
best practice guidelines for use of language translators?
7. What are some key
issues to consider when using assessment tools to evaluate Southeast
8. What are some
end-of-life issues for Southeast Asian elders and their families?
9. What are some
important issues to consider in developing a screening program for
cervical cancer for older Southeast Asian women?
REFERENCES AND RESOURCES
Adler, A. R. (1995).
Refugee stress and folk belief: Hmong sudden deaths. Social Science
and Medicine, 40, 1623-1629.
Moeschberger, M., Chen, M. S., Kunn, P., Wewers, M. E., & Guthrie,
R. (1993). An acculturation scale for Southeast Asians. Social
Psychiatry and Psychiatric Epidemiology, 28, 134-141.
Association of Asian
Pacific Community Health Organizations. (1996). Development of
models and standards for bilingual/bicultural health care services
for Asian and Pacific islander Americans: The Language Access
Project. Oakland, CA: Association of Asian Pacific Community Health
Barrett, M. E.
(1997). Wat Thamkrabok: A Buddhist drug rehabilitation program in
Thailand. Substance Use & Misuse, 32, 435-459.
Bates, S. R., Hill,
L., & Barrett-Conner, E. (1989). Cardiovascular disease risk factors
in an Indochinese population. American Journal of Preventive
Medicine, 5, 15-20.
White-Baughan, J., Pickwell, S., Bartlome, J, & Wong, S. (1990).
Primary care needs of Cambodian refugees. Journal of Family
Practice, 30, 565-56.
Blair, R. (2000).
Risk factors associated with PTSD and major depression among
Cambodian refugees in Utah. Health and Social Work, 25, 23-30.
Braun, K. L.,
Pietsch, J. H., & Blanchette, P. L. (2000). Cultural issues in
end-of-life decision making. Thousand Oaks: Sage.
Brislin, R. W.,
Lonner, W. J., & Thorndike, R. M. (1973). Cross-Cultural Research
Methods, New York, NY: Wiley Inter-Science.
Manson, S. M., Dinges, N. G., Keane, E. M., & Kinzie, J. D. (1993).
Prevalence of depressive symptoms among established Vietnamese
refugees in the United States: Detection in a primary care setting.
Journal of General Medicine, 8, 76-81.
Calhoun, M. A.
(1985). The Vietnamese woman: Health/illness attitudes and
behaviors. Health Care for Women, 6, 61-72.
Carey, J. W., Oxtoby,
M. J., Nguyen, L. P., Huynh, V., Morgan, M., & Jeffery, M. (1997).
Tuberculosis beliefs among recent Vietnamese refugees in New York
State. Public Health Reports, 112, 66-72.
(1995). National Comparative Survey of Minority Health Care. New
York: The Commonwealth Fund.
Cory, J. (1995).
Innovative outreach and education for older Southeast Asian women
(p. 65). Paper presented at the tenth national conference on Chronic
Disease Prevention and Control, Dec. 6-8, 1995, Atlanta, GA.
Cox, C. (1986).
Physician utilization by three groups of ethnic elderly. Medical
Care, 24, 667-676.
Crow, K., Matheson,
L., & Steed, A. (2000). Informed consent and truth-telling: Cultural
directions for healthcare providers. Journal of Nursing
Administration, 30, 148-152.
Devins, G. M.,
Beiser, M., Dion, R., Pelletier, L. G., & Edwards, R.G. (1997).
Cross-cultural measurement of psychological well-being: The
psychometric equivalence of Cantonese, Vietnamese, and Laotian
translations of the affect balance scale. American Journal of Public
Health, 87, 794-799.
Drinnan, M. J., &
Marmor, M. F. (1991). Functional visual loss in Cambodian refugees:
A study of cultural factors in ophthalmology. European Journal of
Ophthalmology, 1, 115-118.
Dunnigan, T., McNall,
M., & Mortimer, J. T. (1993). The problem of metaphorical
nonequivalence in cross-cultural survey research: Comparing the
mental health statuses of Hmong refugee and generational population
of adults. Journal of Cross-Cultural Psychology, 24, 344-365.
Fadiman, A. (1997).
The spirit catches you and you fall down. New York: Farrar, Straus,
Free, C., White, P.,
Shipman, C., & Dale, J. (1999). Access to & use of out-of-hours
services by members of Vietnamese community groups in South London:
A focus group study. Family Practice, 16, 369-374.
Gilman, S. C.,
Justice, J., Saepharn, K., & Charles, G. (1992). Use of traditional
and modern health services by Laotian refugees. Cross-cultural
medicine—A decade later (Special issue). Western Journal of
Medicine, 157, 310-315.
Hai, T. B., Eastlund,
T., Chien, L. A., Duc, P. T., Giang, T. H., Hoa, N. T., et al.
(1999). Willingness to donate organs & tissues in Vietnam. Journal
of Transplantation Coordination, 9, 57-63.
Handelman, L., & Yeo,
G. (1996). Using explanatory models to understand chronic symptoms
of Cambodian refugees. Family Medicine,28, 271-276.
Heng, M. B. (1995).
Cambodian health in transition. British Medical Journal, 311,
Hickey, G. C.
(1964). Village in Vietnam. New Haven, CT: Yale University Press.
Hoyert, D. L., &
Kung, H. (1997). Asian or Pacific Islander mortality, selected
states, 1992. Monthly Vital Statistics Report, 46(1, Suppl.).
Hyattsville, MD: National Center for Heath Statistics.
Jackson, C. (1998).
Medical interpretation: An essential clinical service for
non-English-speaking immigrants. In S. Loue (Ed.), Handbook of
immigrant health (pp. 61-79), New York: Plenum.
Jackson, J. C.,
Rhodes, L. A., Innui, T. S., & Buchwald, D. (1997). Hepatitis B
among the Khmer: Issues of translation and concepts of illness.
Journal of General Internal Medicine, 12, 292-298.
N., Graham, E., & Jackson, J. C. (1996, May). Beyond medical
interpretation: The role of interpreter cultural mediators. In
Building bridges between ethnic communities and health institutions.
Seattle: Community House Calls, Harborview Medical Center.
Jenkins, C. N.,
McPhee, S. J., Bird, J. A., & Bonilla, N. T. (1990). Cancer risks
and prevention practices among Vietnamese refugees. Western Journal
of Medicine, 153, 34-39.
Jenkins, C. N., Le,
T., McPhee, S. J., Stewart, S., & Ha, N. T. (1996). Health care
access and preventive care among Vietnamese immigrants: Do
traditional beliefs and practices pose barriers? Social Science and
Medicine, 43, 1049-1056.
Katz, J., Prescott,
K., & Woolf, A.D. (1996). Strychnine poisoning from a Cambodian
traditional remedy. Journal of Emergency Medicine, 14, 475-477.
Kelly, A.W., Chacori,
M.D. M.R., Wollan, P.C., Trapp, H.M.H., Weaver, A.L., Barrier, P.
A., et al. (1996). A program to increase breast and cervical cancer
screening for Cambodian women in a Midwestern community. Mayo Clinic
Kinzie, J. D.,
Denney,D., Riley, C., Boehnlein, J., McFarland, B., & Leung, P.
(1998). Journal of Nervous Mental Disorder, 186, 670-676.
Kuo, J., & Porter,
K. (1997). Health status of Asian Americans: United States, 1992-94.
Advance Data from Vital and Health Statistics,298. Hyattsville, MD:
National Center for Health Statistics.
Lauderdale, D. S.,
Salant, T., Han, K. L., & Tran, P. L. (2001). Life-course predictors
of ultrasonic heel measurement in a cross-sectional study of
immigrant women from Southeast Asia. American Journal of
Epidemiology, 153, 581-586.
Lesjak, M., Hua, M.,
& Ward, J. (1999). Cervical screening among immigrant Vietnamese
women seen in general practice: Current rates, predictors and
potential recruitment strategies. Australia & New Zealand Journal of
Public Health, 23, 168-173.
Lin, K. M., Poland
R. E., & Nakasaki, G. (Eds.). (1993). Psychopharmacology and
psychobiology of ethnicity. Washington DC: American Psychiatric
Loue, S., Lane, S.
D., Lloyd, L. S., & Loh, L. (1999). Integrating Buddhism and HIV
prevention in the U.S. Southeast Asian communities. Journal of
Health Care for the Poor and Underserved, 10, 100-121.
Long, N. H.,
Johansson, E., Diwan, V. K., & Winkvist, A. (1999). Different
tuberculosis in men and women: Beliefs from focus groups in Vietnam.
Social Science and Medicine, 49, 815-822.
Jackson, J. C., Chitnarong, K., Sam, R., Ngo, L. S., & Taylor, N. M.
(1999). Bridging cultures through the development of a cervical
cancer screening video for Cambodian women in the United States.
Journal of Cancer Education, 14, 109-114.
Marino, R., Stuart,
G. W., & Minas, I. H. (2000). Acculturation of values and behavior:
A study of Vietnamese immigrants. Measurement & Evaluation in
Counseling and Development, 33, 21-41.
Merli, M. G. (1998).
Mortality in Vietnam, 1979-1989. Demography, 35, 345-360.
Miles, D. (1973).
Prophylactic medicine and kin units among Yao ancestor worshippers.
Mankind, 9, 77-88.
Miles, M. (1995).
Disability in an Eastern religious context: Historical perspectives.
Disability and Society, 10, 49-69.
Miller, B. A.,
Kolonel, L. N., Berstein, L., Young, J. L., Jr., Swanson G. M.,
West, D., et al. (Eds.). (1996). Racial/Ethnic Patterns of Cancer in
the United States 1988-1992 (NIH Pub. No. 96-4104). Bethesda:
National Cancer Institute.
Mollica, R. F.,
McInnes, K., Pham, T., Smith Fawzi, M. C., Murphy, E., & Lin, L.
(1998). The dose-effect relationships between torture and
psychiatric symptoms in Vietnamese ex-political detainees and a
comparison group. Journal of Nervous Mental Disorder, 186, 543-553.
Mollica, R. F.,
McInnes, K., Poole, C., & Tor, S. (1998). Dose-effect relationships
of trauma to symptoms of depression and post-traumatic stress
disorder among Cambodian survivors of mass violence. British Journal
of Psychiatry, 173, 482-488.
Mouanoutoua, V. L.,
& Brown, L. G. (1995). Hopkins Symptom Checklist-25, Hmong version:
A screening instrument for psychological distress. Journal of
Personality Assessment, 64, 376-383.
Mouanoutoua, V. L.,
Brown, L. G., Cappelletty, G. G., & Levine, R. V. (1991). A Hmong
adaptation of the Beck Depression Inventory. Journal of Personality
Assessment, 57, 309-322.
Muller, J., &
Desmond, B. (1992). Ethical dilemmas in a cross-cultural context: A
Chinese example. Cross-cultural medicine—A decade later (Special
issue). Western Journal of Medicine, 157, 323-327.
Nakasone, R. Y.
(2000). Buddhist issues in end-of-life decision making. In K. L.
Braun, J. H.Pietsch, & P. L. Blanchette (Eds.), Cultural issues in
end-of-life decision making (pp. 213-230). Thousand Oaks: Sage.
Nelson, K. R., Bui,
H., & Samet, J.H. (1997). Screening in special populations: A “case
study” of recent Vietnamese immigrants. American Journal of
Olson, M. C. (1999).
“The heart still beat, but the brain doesn’t answer.” Perception and
experience of old-age dementia in the Milwaukee Hmong community.
Theoretical Medical Bioethics, 20, 85-95.
Palinkas, L. A., &
Pickwell, S. M. (1995). Acculturation as a risk factor for chronic
disease among Cambodian refugees in the United States. Social
Science and Medicine, 12, 1643-1653.
Peeke, P. M., &
Chrousos, G. P. (1995). Hypercortisolism and obesity. Annals of the
New York Academy of Sciences, 771, 665-676.
Pham, T. M.,
Rosenthal, M. P., & Diamond, J. J. (1999). Hypertension,
cardiovascular disease, & health care dilemmas in the Philadelphia
Vietnamese community. Family Medicine, 31, 647-651.
Phipps, E., Cohen,
M. H., Sorn, R., & Braitman, L. E. (1999). A pilot study of cancer
knowledge & screening behaviors of Vietnamese and Cambodian women.
Health Care of Women International, 20, 195-207.
Reichart, P. A.,
Schmidtberg, W., & Scheifele, C. (1996). Betel chewer's mucosa in
elderly Cambodian women. Journal of Oral Pathology Medicine, 25,
Antoni, M. H., Saab, P. G., & Ironson, G. (2001). Health psychology:
Psychosocial and biobehavioral aspects of chronic disease
management. Annual Review of Psychology, 51, 555-580.
Schulmeister, L., &
Lifsey, D. S. (1999). Cervical cancer screening knowledge,
behaviors, and beliefs of Vietnamese women. Oncology Nursing Forum,
Douglas, K., del la Rocha, O., Radecki, S., Vu, C., & Dinh, T.
(1999). Generational differences in psychosocial adaptation and
predictors of psychological distress in a population of recent
Vietnamese immigrants. Journal of Community Health, 24, 95-113.
Sheikh, A. A., &
Sheikh, K. S. (1989). Healing East and West: Ancient wisdom and
modern psychology. New York: John Wiley & Sons.
Jackson, J. C., Goldstein, E., & Buchwald, D. (1995). "Strong
medicine:" Cambodian views of medicine and medical compliance.
Journal of General and Internal Medicine, 10, 369-350.
Shinagawa, S. M.,
Kagawa-Singer, M., Chen, M. S., Tsark, J. U., Palafox, N., & Mackura,
G. (1999). Cancer registries and data for Asian Americans and Native
Hawaiians and Pacific Islanders: What registrars need to know.
Journal of Registry Management,26, 128-141.
Siganga, W. W., &
Huynh, T. C. (1997). Barriers to the use of pharmacy services: The
case of ethnic populations. Journal of the American Pharmacy
Association, NS37, 335-340.
Smith, R. M., &
Nelsen, L. A. (1991). Hmong folk remedies: Limited acetylation of
opium by aspirin and acetaminophen. Journal of Forensic Science, 36,
Stuer, F. (1998).
Enhancing health programme efficiency: A Cambodian case study.
Health Policy & Planning, 13, 263-276.
Ta, M., & Chung, C.
(1990). Death and dying: A Vietnamese cultural perspective. In J. K.
Parry (Ed.), Social work practice with the terminally ill.: A
transcultural perspective (pp. 191-204). Springfield, IL: Charles C.
Tu, S. P., Yasui,
Y., Kuniyuki, A., Thompson, B., Schwartz, S. M., Jackson, J. C., &
Taylor, V. M. (2000). Breast cancer screening among Cambodian women.
Cancer Detection and Prevention, 24, 549-563.
Van Minh, H., Thanh,
L. C., Thi, B. N., do Trinh, T., Tho, T. D., & Valensi, P. (1997).
Insulinaemia & slight overweight: The case of Vietnamese
hypertensives. International Journal of Obesity Related Metabolic
Disorders, 21, 897-902.
Vaughn, G., Kiyasu,
E., & McCormick, W. C. (2000). Advance directives preferences among
subpopulations of Asian nursing home residents in the Pacific
Northwest. Journal of the American Geriatrics Society, 48, 554-557.
Verger, P., Cordier,
S., Thuy, L. T., Bard, D., Dai, L. C., Phiet, P. H., et al. (1994).
Correlation between dioxin levels in adipose tissue and estimated
exposure to Agent Orange in South Vietnamese residents.
Environmental Research, 65, 226-242.
Yee, B. W. K.
(1997). The social and cultural context of adaptive aging among
Southeast Asian elders. In J. Sokolovsky (Ed.), The cultural context
of aging (2nd ed., pp. 293-303). New York: Greenwood.
Yee, B. W.
K.(1999a). Life-span development of Asian and Pacific Islanders:
Impact of gender and age roles. In B. W. K. Yee, N. Mokuau, & Kim,
S. (Eds.), Developing cultural competence in Asian American and
Pacific Islander communities: Opportunities in primary health care
and substance abuse prevention: Vol. 5. Cultural competence series
(Special collaborative ed., pp. 91-142, DHHS Pub. No. [SMA]98-3193).
Washington DC: Center for Substance Abuse Prevention (SAMSHA),
Bureau of Primary Health Care (HRSA) and Office of Minority Health
Yee, B. W. K
(1999b). Influence of traditional and cultural health practices
among Asian women. In Agenda for research on women’s health for the
21st century. Report of the Task Force on the NIH Women’s Health
Research Agenda for the 21st Century: Vol. 6: Differences among
populations of women (pp. 150-165, NIH Publications No 99-4390),
Santa Fe, NM, July 1997, Office of Research on Women’s Health,
National Institutes of Health.
Yee, B. W. K.,
Huang, L. N., & Lew, A. (1998). Families: Life-span socialization in
a cultural context. In L. C. Lee & N. W. S. Zane (Eds.), Handbook of
Asian American psychology (pp.83-135), Thousand Oaks, CA: Sage
Yee, B. W. K., &
Thu, N. D. (1987). Correlates of drug use and abuse among
Indochinese Refugees: Mental health implications Journal of
Psychoactive Drugs, 19, 77-83.
Yeo, G. (Ed.).
(2000, October). Core curriculum in ethnogeriatrics (2nded., module
4). Stanford, CA: Stanford Geriatric Education Center. (Developed by
the members of the Collaborative on Ethnogeriatric Education,
supported by Bureau of Health Professions, Health Resources and
Services Administration, U. S. Department of Health and Human
Yi, J. K., & Prows,
S. L. (1996). Breast cancer screening practices among Cambodian
women in Houston, Texas. Journal of Cancer Education, 11, 221-225.
(1998). What suffering teaches. In A. Molino (Eds.), The couch and
the tree: Dialogues in psychoanalysis and Buddhism (pp.344-353). New
York: American Psychological Association and Work Projects
Zadrozny, M. G.
(Ed.). (1955). Area handbook on Cambodia. New Haven, CT: Human
Relations Area Files, Inc.
Bailey, S., Bennett,
P., Hicks, J., Kemp, C., & Warren, S. J. (1996). Cancer detection
activities coordinated by nursing students in community health.
Cancer Nursing, 19, 348-352.
Brock, K., Tran, D., Yau, J., & Tran-Dinh, H. (1999). Smoking and
lipid cardiovascular risk factors in Vietnamese refugees in
Australia. Preventive Medicine, 28, 378-385.
Bird, J. A., McPhee,
S. J., Ha, N., Le, B., Davis, T., & Jenkins, C. N. (1998). Opening
pathways to cancer screening for Vietnamese-American women: Lay
health workers hold a key. Preventive Medicine, 27, 821-829.
Boult, L., & Boult,
C. (1995). Underuse of physician services by older Asian Americans.
Journal of American Geriatric Society, 43, 408-411.
Cheek, J., Fuller,
J., Gilchrist, S., Maddock, A., & Ballantyne, A. (1999). Vietnamese
women and PAP smears: Issues in promotion. Austrialian & New Zealand
Journal of Public Health, 23, 72-76.
Chung, R. C., &
Bemak, F. (1996). The effects of welfare status on psychological
distress among Southeast Asian refugees. Journal Nervous Mental
Disorder, 184, 346-352.
Del Mar, C.,
Glasziou, P., Adkins, P., Hua, T., & Brown, M. (1998). Do
personalised letters in Vietnamese increase cervical cancer
screening among Vietnamese women? Australian & New Zealand Journal
of Public Health, 22, 824-825.
Frye, B. A., &
D'Avanzo, C. D. (1994). Cultural themes in family stress and
violence among Cambodian refugee women in the inner city. Advances
in Nursing Science, 16, 64-77.
Jackson, J. C.,
Oxtoby, M. J., Nguyen, L. P., Huynh, V., Morgan, M., & Jeffery, M.
(1997). Tuberculosis beliefs among recent Vietnamese refugees in New
York state. Public Health Reports, 112, 66-72.
Jackson, J. C.,
Taylor, V. M., Chitnarong, K., Mahloch, J., Fischer, M., Sam, R., &
Seng, P. (2000). Development of a cervical cancer control
intervention program for Cambodian American women. Journal of
Community Health, 25, 359-375.
Jenkins, C. N.,
McPhee, S. J., Bird, J. A, Pham, G. Q., Nguyen, B. H., Nguyen, T.,
et al. (1999). Effect of a media-led education campaign on breast
and cervical cancer screening among Vietnamese-American Women.
Preventive Medicine, 28, 395-406.
Kinzie, J. D., &
Edeki, T. (1998). Ethnicity and psychopharmacology: The experience
of Southeast Asians. In S. O. Okpaku (Ed.), Clinical methods in
transcultural psychiatry (pp. 171-190). Washington DC: American
Le Marchand, L.,
Silveraman , L., Franke, A. A., & Wilkens, L. R. (1995). Genes-diet
interactions and the high colorectal cancer risk of Japanese
Americans. Proceedings of the Annual American Association of Cancer
Research, 36, A1686.
Liang, J. (2001).
Assessing cross-cultural comparability in mental health among older
adults. Journal of Mental Health and Aging, 7, 21-30.
Marsella, A. J.,
Friedman, M. J., Gerrity, E. T., & Scurfield, R. M. (1996).
Ethnocultural aspects of posttramatic stress disorder: Issues,
research, and clinical applications. Washington D C: American
Miller, J. A.
(1995). Caring for Cambodian refugees in the emergency department.
Journal of Emergency Nursing, 21, 498-502.
Mui, A., Burnette,
D., & Chen, L. M. (2001). Cross-cultural assessment of geriatric
depression: A review of the GES-D and GDS. Journal of Mental Health
and Aging, 7, 137-164.
Mutran, E. J., Reed,
P. S., & Sudha, S. (2001). Social support: Clarifying the construct
with applications for minority populations. Journal of Mental Health
and Aging, 7, 67-78.
M., & Stewart, A. L. (2001). Use of health related quality of life
measures in older and ethnically diverse U.S. populations. Journal
of Mental Health and Aging, 7, 173-179.
National Center for
Health Statistics. (1998). Health, United States, 1998 with
socioeconomic status and health chartbook (DHHS Pub. No [PHS]
98-1232 8-0502[7/98]). Hyattsville, MD: U.S. Department of Health
and Human Services.
Pachuta, D. M.
(1993) Chinese medicine: The law of five elements. In A. A. Sheikh &
K. S. Sheikh (Eds.), Eastern & Western approaches to healing:
Ancient wisdom & modern knowledge (pp.64-90), New York: John Wiley &
Pham, C. T., &
McPhee, S. J. (1992). Knowledge, attitudes, and practices of breast
and cervical cancer screening among Vietnamese women. Journal of
Cancer Education, 7, 305-310.
Ramaswami, S., &
Sheikh, A. A. (1993). Buddhist psychology: Implications for healing.
In A. A. Sheikh & K. S. Sheikh (Eds.), Eastern & Western approaches
to healing: Ancient wisdom & modern knowledge (pp.91-123), New York:
John Wiley & Sons.
Ramirez, M., Teresi,
J. A., Silver, S., Holmes, D., Gurland, B.J., & Lantigua, R. (2001).
Journal of Mental Health and Aging, 7, 91-118.
Rice, P. L. (1995).
Pog laus, tsis coj khaub ncaws lawn: The meaning of menopause in
Hmong women. Journal of Reproductive & Infant Psychology, 13, 79-92
Rudkin, L., &
Markides, K. S. (2001). Measuring the socioeconomic status of
elderly people in health studies with special focus on minority
elderly. Journal of Mental Health and Aging, 7, 53-66.
Skinner, J. H.
(2001). Acculturation: Measures of ethnic accommodation to the
dominant American culture. Journal of Mental Health and Aging, 7,
H.,Teresi, J. A., Holmes, D., Stahl, S. M., & Steward, A. L. (Guest
eds.) (2001). Measurement in older ethnically diverse populations.
Journal of Mental Health and Aging, 7, 5-8.
Taylor, V. M.,
Jackson, J. C., Pineda, M., Pham, P., Fischer, M., & Yasui, Y.
(2000). Hepatitis B knowledge among Vietnamese immigrants:
Implications for prevention of hepatocellular carcinoma. Journal of
Cancer Education, 15, 51-55.
Teresi, J. A.
(2001). Statistical methods for examination of differential ilem
functioning (DIF) with applications to cross-cultural measurement of
functional, physical, and mental health. Journal of Mental Health
and Aging, 7, 31-40.
Teresi, J. A., &
Holmes, D. (2001). Some methodological guidelines for cross-cultural
comparisons. Journal of Mental Health and Aging, 7, 13-19.
Teresi, J. A.,
Holmes, D., Ramirez, M., Burland, B. J., & Latigua, R. (2001).
Cognitive assessment among minority elderly: Possible test bias.
Journal of Mental Health and Aging, 7, 91-118.
Tran, T. V. (1990).
Language acculturation among older Vietnamese refugee adults.
Gerontologist, 30, 94-99.
Wiecha, J. M., Lee,
V., & Hodgkins, J. (1998). Patterns of smoking, risk factors for
smoking and smoking cessation among Vietnamese men in Massachusetts
(United States). Tobacco Control, 7, 27-34.
Yeo, G. (1995).
Ethical considerations in Asian and Pacific Island elders. Clinics
in Geriatric Medicine, 11, 139-151.
- Asian and Pacific
Islander Health Forum: (www.apiahf.org;
http://www.hhs.gov/ocr/lep/ (Tom Perez)
- Immigration and
- Immigration and
Naturalization Service. This month in immigration history-July
- National Alliance for
Multicultural Mental Health, The.: A program of immigration and
refugee services of America. Lessons from the field: Issues and
resources in refugee mental health:
- Southeast Asia Resource
Action Center. 1628 16th St. NW, 3rd Floor, Washington, DC 20009,
- Southeast Asia Resource
Action Center. (2000). Southeast Asian American Mutual Assistance
Association Directory 2000: