South East Asian Culture in America Felicia Dreesmann, Connie Harrah , & David Hensley

1. South East Asian Culture in America Felicia Dreesmann, Connie Harrah, & David Hensley California State University, Chico February 14, 2011

2. Literature Search and Terms A literature search was conducted using the following databases: CINAHL PubMed, and Google using the following terms; culture, culture shock, cultural competence, culture and healthcare, South East Asian and culture, Hmong and culture, Mien and culture, culture and disparities, and shaman. Several selected articles are discussed and the following terms are provided as important concepts that are related to our topic on the South East Asian culture. Culture Culture is defined as the totality of socially transmitted behavioral patterns, beliefs, values, customs, lifeway, arts, and all other products of human work and thought characteristics of a population of people that guide their world view and decision-making (Prunell, 2009, p. 1). Culture Shock Culture shock refers to feelings of bewilderment, confusion, disorganization, frustration, and stupidity, and the inability to adapt to the differences in language and word meaning, activities, time, and customs, that are a part of the new culture (Murray, Zentner & Yakimo, 2009 p. 135). Cultural Competence Cultural competence is the ability of the health care provider, agency, or system to acknowledge the importance of culture on all levels (client, provider, administration, and policy) for incorporation into health care (Murray et al., 2009 p. 140). Shaman in America

3. Conceptual Framework The Roy Adaption Model (RAM) has been selected to guide our presentation. The RAM views the individual as a adaptive system in constant interaction with an internal and external environment. The environment exposes the individual to a variety of stimuli that threaten or promote one’s unique wholeness (Alligood, 2010, p. 310). For example, healthcare professionals that take the opportunity to consider there own, as well as their patients’, cultural beliefs, practices and communication styles can positively impact their patients’ ability to adapt.

4. Background: South East Asians Uprooted to America In the early 1980’s the Hmong and Mien began to immigrate to the United States with preferred refugee status after the Vietnam war where they fought along side the CIA blocking arms importation into Vietnam . Many of the older adults, who fled Laos after the war, lived much of their lives in refugee camps in Thailand separated from their community and social supports (Cobb, 2010) . Although they brought with them their language, social structure, customs, religious and health beliefs, young and old, arrived in the United States where the culture, language and socioeconomics were very different (Cobb, 2010) .One could easily conclude the myth that adversity came to a miraculous end once refugees of the South East Asian conflict arrived in the United States. However, the sense of loneliness, loss, and shame became magnified amongst refugees relocated to the United States (Sheng-Mei Ma, 2005).

5. In keeping with Roy’s Adaption Model we will explore cultural disparities and venture into a variety of South East Asian cultures to gain understanding of the population that entered the “great American melting pot” with a unique story. The culture shock that is often experienced by immigrants entering the United States will be analyzed with the focus on the elderly population. Cultural barriers that exist in providing care to Mien and Hmong Americans will be reviewed, and strategies to provide cultural competent care specific to this population will be shared. Hmong shown here playing the Qeej , a bamboo pipe instrument known worldwide as the cultural identifier for Hmong people. Hundreds of years old, it plays a pivotal role at Hmong funerals, as the sound of its chords are thought by Hmong to call the soul out of the body and into the afterworld.

6. The Big Transition • As the Southeast Asians entered the United States, they entered a world that was starkly different from their previous home. They lived in mountainous areas and were an agrarian society (Prunell, 2009). • Both Mien and Hmong have experienced a series of traumatic events: the war in Laos, the Pathet Lao takeover and subsequent Hmong persecution (including the threat of genocide), the harrowing nighttime escapes through jungles and across the Mekong River, the hardships of refugee camps in Thailand, and finally resettlement in the United States, with not only housing, income, language, and employment concerns, but also the separation of families and clans, inability to practice traditional religion, hasty conversion to Christianity, and the breakdown of the gender hierarchy, among many others (Sheng-mei Ma, 2005). • Many lacked formal education; were predominantly illiterate, lived in primitive circumstances, and had no contact with the modern world. One journalist has facetiously characterized Hmong refugees’ transition from Southeast Asia to the West as moving "from the Stone Age to the Space Age“(Sheng-mei Ma, 2005).

7. The documentary movie “The Split Horn” depicts a Hmong shaman, Paja Thao, as he struggles to maintain ancient traditions while his children embrace the American culture. Paja sees his children adapting to American society more willingly than his generation. His children are learning the English language, achieving an education, and marrying Americans outside their culture. Paja’s children talk about the guilt and distress of living in two worlds. They enjoy the America they have come to know while attempting to please older generations by honoring the culture and tradition of the homeland (Taggart, 2001). Acclimating to America

8. Cause and Effect Conceptual Inventory on Cultural Shock Causes Language and Word Meaning Differences Differences in Social Structure Differences in Cultural Practices Differences in Health Practices Culture Shock Frustration Loneliness Depression Confusion Isolation Effects Virginia Carrier-Kohlman, V., Lindsey, A.M., West, C., (2003)

9. Unpleasant feelings often associated with culture shock occur in stages and can be magnified when one moves to a culture that is very different from their own. Brink and Sanders, as cited by, Murray et al., 2009, describe four phases associated with culture shock. Honeymoon phase: This stage is characterized by excitement, exploration, and pleasure. This phase may be experienced by a short-term visitor to a new area, by a geographic move to a different location, or during initial employment in a different health care area. Disenchanted phase: Person feels stuck, depressed, irritated, and that the environment is unpredictable and no longer exotic. The normal cues for social intercourse are absent and the person is cut adrift. The person may become physically ill. Beginning resolution phase: New cultural behavior patterns are adopted. Friends are found. Life becomes easier and more predictable. Effective function phase: The person has become almost bicultural and may experience reverse culture shock on return home after living abroad or when transferring to a different health care agency. (Murray, et al., 2009, p.135-136). Phases of Culture Shock

10. Shaman Elderly Mien Janitor Societal Perfectives on the Elderly South East Asians • Cultural implication of the southeast Asian culture, ethnicity, and socioeconomic level influence the role of the older adult in family relationships and determine health practices. • Elderly Southeast Asians often state the most stressful of all adaptations to the American culture is “role loss” which may be the most corrosive to the ego. Southeast elderly Asians who were well respected and held jobs of honor such as colonels and military communications specialist are now janitors and chicken processors. Many southeast Asians state, “We have become children in this country” ( Fadiman, 1997, p. 206). • In addition, Southeast elderly Asians feel that their children have assumed some of the power that once to belong to them. The elders have taken this especially hard as the their identity has always hinged on tradition. “We have lost all control. Our children do not respect us. One of the hardest things for me is when I tell my children things and they say, “I already know that” • (Fadiman, 1997, p. 207). • Although the Hmong elders state Americanization may bring certain benefits such as job opportunities, more money and less cultural dislocation; Hmong parents are likely to view any earmarks of assimilation as an insult and a threat ( Fadiman, 1997, p. 207).

11. Religious Beliefs and Healthcare Traditional Hmong believe in animism, the belief in the spirit world and it’s link to all living things. They believe that illness can be the effect of physical and spiritual factors. Hmong believe in order to maintain good health a balance between the body and the spirit must be maintained. They also believe if their ancestors are offended illness or disease may ensue. A phenomenon called Sudden Unexpected Nocturnal Death Syndrome (SUNDS) which in the 1970s and 80s mysteriously struck Hmong and other Southeast Asian male refugees in their sleep. Some survivors claimed the attack of a Kingstonian "Sitting Ghost" (The Woman Warrior 81) on their chests, pressing air out of their lungs. Western doctors could do no more than attributing the cases to cardiac arrest in otherwise perfectly healthy men, a great number of whom reported depression and ill-adjustment to the U.S. (Munger, 1987). Health conditions common to Hmong include depression, anxiety, suicide and post traumatic stress disorder. As a result of experiences during the Vietnamese war, there flight to safety and culture stressors many Hmong continue to have nightmares and flashbacks related to the terrors they experienced in Laos. Unemployment and reversal of family roles have created additional cultural stressors. This You Tube video illustrated the culture shock encountered by Hmong males and the stress they encounter while attempting to adapt to American life.

12. South East Asian Culture and Healthcare The diversity of the United States population has resulted in the “great American melting pot”, which has brought about a need for culturally competent healthcare. Because culture has a powerful influence on health and illness, health-care providers must recognize, respect, and integrate patients’ cultural beliefs in their practice (Prunell, 2009 p.1). Literature suggests that disparities in healthcare among ethnic, social, and economic groups show that healthcare providers need to be attentive to cultural diversity. In a 2010 study, several barriers to providing healthcare to Hmong were enumerated. This study revealed barriers that resulted in misunderstanding and misinterpretation between the healthcare provider and South East Asian Americans stemmed from differences in language, religion, culture and social organizations (Cobb, 2010, p. 82).

13. Research Bridging Cultural Barriers In 2008 study, joint endeavors between researchers and the Hmong community came together to develop and test the quality of a hypertension care survey instrument. In-depth interviews were undertaken with Hmong community leaders and hypertensive patients to enrich the understanding of quality of care from the Hmong socio-cultural perspective. The goal of this study was to develop a quality care survey that would assist in yielding information to help provide culturally appropriate care to the Hmong American population. The collaborative effort at all levels within the community helped researchers and the community members to test survey instruments that was more culturally, linguistically, and socially appropriate. In addition this study, provided the means through which the Hmong population could voice their own health care needs that could be used in future research (Wong, Mouanoutoua, Chen, 2008). In the book titled, “The Challenge of Cross-Cultural Competency in Social Work “, written by Dr. Jean Schuldberg , a study conducted in 1993 refers to the recommendations of the participants of the research study concluding that, “when teaching cultural competency it is important for the teachers to name the injustices the Southeast Asians experienced and highlight our rapidly changing global community” (Schuldberg, 2005).

14. Cause and Effect Inventory for Cultural Competence Cause Overcome Language Barriers Use of Interpreter Integrations of Cultural Practices Cultural Awareness Cultural Competence Establishment of Support System New Cultural Behavior Patterns Adopted Reversal of Culture Shock Symptoms Effect Carrier-Kohlman et al. (2003)

15. Cultural Competent Care • Cultural competent healthcare practices include the consideration of others tradition, magicoreligious or biomedical beliefs and practices, individual responsibility for health, self-medicating practices and views on mental illness. • Hmong may seek westernized medical care, traditional healers or Shamans who perform rituals for healing. They may seek herbalists and take multiple treatments for the same condition. Some practice home remedies such as coining or cupping. Health care workers should not confuse the patterns of coining or cupping for abuse. • Bruising may be seen along with coining and pricking the center of the bruise may be done to release bad spirits; unsterilized sewing needles are generally used for this purpose. Healthcare workers should always encourage education regarding the use of sterilization of needles (Prunell, 2009, p. 213-214).

16. Cultural Competent Care Continued • Parents may tie strings around baby’s necks and older children and adults may have strings tied around wrists, waists, or ankles • Necklaces and strings must remain on until they fall off naturally, removing them too soon may result in soul loss • Healthcare worker should never remove strings, necklaces, or bracelets without the parents’ or patient’s permission • Some Southeast Asians utilize herbs prescribed by a herbalist Studies have indicated that these herbs may have pharmaceutical properties. Healthcare workers must always ask patients about their use of herbs • (Prunell, 2009, p. 213-214)

17. Mey Chao-Lee Mey Chao-Lee is a cultural competency coordinator for the Shasta County Health and Human Services Agency. Mey Chao- Lee fled Laos with her family as a young girl and later immigrated to America. Recently she became the first Mien to earn a master’s degree in social work from Chico State University, and has dedicated her life to helping those who share her culture. We are honored to have her here with us today to learn more about her journey to America and her Mein culture. Video with Mey can be viewed on first power point submitted using the instructions provided.

18. Sophia Questions • If you were to be uprooted from America to Laos what health practices would you want to hold on to and why? • Would you ask for a traditional American doctor to treat you or would you be willing to have a Shaman treat you? • Would you be willing to take the South East Asian traditional medications and treatments? • What could Shamans do to gain your trust? • What do you think could help break through the language barrier? • Would you want to practice your religious beliefs?