Preferred term. Hmong, which means human being in Hmong language.
History of immigration. Immigration began in 1975 after Vietnam War. New immigrants have continued to enter U.S. as late as 1995, sponsored by family members who immigrated earlier.
Hmong people found in Southeast Asian area of southern China, Laos, Vietnam, Burma, and Thailand. Thought to be indigenous people of Yellow River area of China. Ten to live in high mountainous areas in Southeast Asia. Because of geographical isolation, have retained own unique language and customs. Life in homeland rugged: no running water or electricity. Life expectancy shorter.
The Hmong in U.S. are originally from Laos but may have lived many years in Thailand refugee camps. During Vietnam War, fought for U.S. Central Intelligence Agency against Communists. When war ended, they were targeted for genocide by Communists who controlled Laos. Many Hmong were killed or injured in military onslaughts and biological/chemical warfare.
After immigration to U.S., a second migration occurred in which families and clans reunited. Migration continues as Hmong families move to areas of U.S. with employment opportunities.
Literacy assessment. Written Hmong language not developed until 1950s. Most older Hmong have no formal schooling and are not literate in their own language or in English. Young people will be literate in English but may not be able to read Hmong or Lao although there is an effort in Hmong community to teach young people to speak and read their traditional language.
Nonverbal communication. Hmong people very polite and reticent. Very aware of disrespectful and prejudicial behavior, but will not protest to health care professional. Consider prolonged, direct eye contact rude. Physical affection and touching not done in public but health care professionals touching may be accepted as: the way Americans are." Tend to communicate indirectly and try to present positive image. Many will not say "no" outright but will say "I'll think about it" when they don't wish to do something. "Yes" can mean "yes," but may also mean "I hear you;" it does not necessarily mean affirmative response.
Use of interpreters. Many Hmong will want their own trusted relatives who are bilingual to be present. Hmong interpreters employed by hospital or institution considered loyal to hospital and may be distrusted. Children rarely good interpreters because they lack adequate Hmong language skills. For many families, however, young bilingual adults most likely working and it may be difficult or impossible for them to bring in an adult interpreter. Hmong men and women may not discuss or admit to intimate problems to an interpreter of opposite sex.
Hmong language structure considerably different from Indo-European languages. When working with interpreters, important to give entire sentence, paragraph, or thought, so they know intent of message necessary for accurate interpretation. Hmong language lacks many terms comparable to English and has almost no medical terms. Procedures may be interpreted in most rudimentary way and/or erroneously.
Hmong people have great respect for authority and "saving face" is important. Interpreter may not understand what you have said but may not tell you. Ensuring that interpreter understands your questions is first step to accurate communication with patient. Interpreter may not want to interpret comments considered rude in Hmong culture.
Also, interpreter of one sex may feel it is not proper to discuss some topics with patient of opposite sex. Before interpreting takes place, talk with interpreter to assess the level of comfort with the planned questions and discussion.
Greeting. Handshakes, smiles, and introductions appropriate. Most older Hmong women usually retain their own surname after marriage. Younger women may have adopted husband's surname. Do not refer to Hmong patients by their first names; use Mr. or Mrs. and last name. Calling a married woman by first name considered inappropriate and disrespectful to her husband.
Orientation toward time. Many older Hmong individuals are present-oriented. Calendars and clocks rarely used in rural Laos and many Hmong born in Laos do not know their actual birthdates. May birthdates assigned in refuges camps, resulting in some erroneous ages, so people may actually be younger or older than their stated age.
Keeping appointment times has been difficult. Hmong patients may arrive early in morning on day of their medical appointment. This occurs less often as children serve as socializers to Western system. Social events within Hmong community may start several hours after stated time.
Consents. Many Hmong people suspicious of consent forms if they cannot read them and are afraid that form does not contain what was explained orally. Rumors persist in Hmong community that American doctors "practice" on Hmong people because Hmong are uneducated about Western medical system. May be suspicious of health care professional's motives, especially of care provided by students.
Surgery rarely available to Hmong in Laos so they are especially afraid of surgical procedures. Patient will often want family members (usually male elders) to review consent forms before signing. This can lead to considerable delays before treatment can begin since elders may not be readily available. Lack of elder availability may also be used as delaying tactic when family either needs more time to make decision or doe not want procedure or surgery, yet does not want to directly state their decision. (See Communication).
Privacy. Hmong families tend to be large, and privacy within family often lacking. Many will not feel comfortable sleeping in hospital alone, but will want another family member with them at all times. Hmong folktales warn that evil befalls Hmong person who goes out alone.
Adult women are modest and will not feel comfortable having a physical examination. Purpose of examination must be clearly explained before consent can be obtained. Women often will refuse pelvic examinations by male health care providers but will more likely accept them from female practitioner.
Concerns of a private nature may not be freely revealed unless asked directly. If interpreter of opposite sex, patient may deny that problem exists. However, males are especially sensitive to topics such as impotence and will deny this problem even in presence of male Hmong interpreter. Sensitive information can sometimes be obtained if question first presented with explanation that "this is a common problem for all people who have your diagnosis, and I am wondering if this might be a concern of yours also?"
Serious or terminal illness. Hmong people present positive attitude in presence of serious ill family members. May visit someone they know is dying and say that they're sure the patient will "get well soon." Considered inappropriate to speak of impending death to someone with fatal diagnosis. This may be due to traditional belief that evil spirit may be cause of illness and if complications or potentially fatal outcomes spoken about in front of patient, evil spirit will then know what to do.
This cultural perspective problematic in Western medical system where Patient's Bill of Rights states that patient has right to knowledge regarding his or her diagnosis. Hmong people may be so shocked by abruptly present information that they may leave and never return. Better to discuss sensitive issues with family first and ask them how best to convey this information to patient.
Activities of Daily Living
Modesty. Hmong women's perspectives regarding their bodies can vary considerably. Older women modest regarding their genital but because of past breastfeeding experiences, may not be concerned with baring their breasts. Some older women may forget to button their blouses and not be concerned about exposure. Men are modest but accept examination of their genitals by female health care professionals as appropriate to their problems.
Skin care. Bathing infrequent in Laos due to water being available only from well or steam. In U.S., daily bathing more commonly expected.
Hair care. Women does not shampoo daily if hair very long (common in this culture).
Nail care. No known restrictions
Toileting. No known restrictions or concerns
Special clothing/amulets. Traditional Hmong people may wear amulets at neck, wrists, and/or ankles. These may be gold necklaces, or bracelets, string, fabric bands, or chains. Small amulet pouches may be attached. These thought to have special powers to hold the soul in and keep evil spirits out, and should not be removed without permission.
If Hmong person has had shaman ritual to treat illness, blood of sacrificed animal may be placed on clothing. Parts of animal (such as nails or teeth) may be placed in pocket on their back or sewn onto clothing. May not want this clothing removed since its purpose is to have spirit of dead animal protect ill person. (Note: Christian Hmong do not practice shaman healing rituals.)
Self-care. When ill, Hmong person expects female family members to provide care. Women primary caregivers, and daughters-in-law are expected to provide care for in-laws.
Usual meal patter. Hmong usually eat two to three meals a day. If person customarily eats two meals per day, first meal is usually about 9 or 10 am and second in late afternoon or early evening. Same types of foods eaten at each meal.
Food beliefs and rituals. Hmong people eat special foods when ill or not feeling well, such as plain boiled rice soup which may contain small amounts of chicken. Hmong suspicious of store bought chicken and meat, believing these contain unhealthful chemicals. Many prefer to kill their own live chickens and animals or to purchase meat fresh. Appearance of chicken (e.g., color of chicken feet) enters into their beliefs regarding benefit of that chicken as healing food.
Usual diet. Rice main stable alone with small amount of meat, fish, and green vegetables. Noodle dishes and soups also favorites. Large amounts of MSG often used by some people. Food usually bland but hot chili condiments and salty sauces may be added at table to individual taste. Fruit rarely eaten. Sweets and soda adopted as American favorites.
Fluids. Women have special prohibitions during pregnancy, birth and postpartum, and menstruation. Iced drinks may be avoided; may request warm water or weak tea.
Food prohibitions. (See Food beliefs and rituals.) Dairy products such as milk and cheese rarely eaten by adults, but ice cream enjoyed.
Food prescriptions. (See food beliefs and rituals.)
Pain. Hmong people traditionally grew and used opium for its analgesic properties. Expect same relief from Western medicines. Medications readily accepted but instructions regarding dosage may not be followed; may continue to take more in an effort to find relief from pain. Opium still used by some Hmong in the U.S.
Dyspnea. Lung disease common among older Hmong, and considerable lung disease noted in opium smokers. This is accepted as part of life, and rarely complained about.
Nausea/vomiting. Gastrointestinal disturbance common, and individual will freely discuss distress and request relief from symptoms.
Constipation/diarrhea. Constipation occurs frequently due to poor intake of roughage but may not be reported to health care professional unless specifically asked. Diarrhea is distressful and Hmong will ask for medication to control it.
Fatigue. Fatigue often presenting symptom of depression.
Depression. Posttraumatic stress disorder is common. Marital discord often expressed as depression in Hmong women who feel helpless to change their situation. Hmong men become depressed due to physical limitations from war injuries and sense of powerlessness since immigrating to U.S. Unemployment high for older adults due to lack of fluency in English.
Self-care symptom management. Home remedies, including cupping, coining, massage, pinching, herbs, and shaman rituals often will be tried before going to Western health care practitioners, (See Home and folk remedy section for more information.)
Birth Rituals/Care of the New Mother/Baby
Pregnancy care. Prenatal care becoming more widely accepted although some mothers may not enter the system until third trimester because they are embarrassed by examinations. Hmong women have as many as 10 to 12 pregnancies. Labor can progress very rapidly for multiparous women.
Labor practices. Labor practices will vary. Some women will prefer to walk about and other will lie in bed.
Role of the laboring woman during birth process. Hmong women often quiet during labor although behavior may vary. Women do not want to be examined and having multiple caretakers will increased mother's anxiety.
Role of the father and other family members during birth process. Traditionally father delivered baby by reaching under skirt of squatting mother. Fully exposure of genital area not done. If problems, in-laws might assist since married couple usually lived with them. Since immigration and practice of birthing in hospitals, father usually present but assistance in labor and delivery will vary. Some men will not want to be present. Father usually at hospital and expects to make all decisions related to surgical options.
Vaginal vs. cesarean section. Vaginal delivery preferred, and cesarean section often refused. Most Hmong women are very small and, because of improved nutrition, babies becoming quite large. Cephalopelvic disproportion increasing, with growing need of cesarean section.
Breastfeeding. Breastfeeding decreasing and bottle feeding becoming standard within Hmong community even though breastfeeding encouraged by health care professionals. Many Hmong women think American women do not breastfeed since they never see this behavior in public.
Birth recuperation. New mother remain on restricted chicken/white rice diet for 30 days after delivery. No other foods allowed during this time. Can drink warm water ( no ice water) and tea made with loose tea (no tea bags). Chicken initially boiled and later may be roasted or fried, depending on mother's preferences and beliefs. Chicken must be fresh, preferably killed by father. Store-bought chicken may be used if fresh not available. Rice must be soft and white. At end of 30 days, regular diet resumed.
Problems with baby. Mother-in-law assists new mother in child care and if problems occur that cannot be solved by mother or mother-in-law, male family elders will be consulted.
Male and female circumcision. Neither practiced in Hmong community.
Preparation. Elders of family/clan will meet regarding any decisions that must be made about dying person. In Hmong culture, immediate family members and female relatives may not have exclusive decision-making power, even though they may be "next of kin" by medicolegal standards.
Traditional Hmong religious beliefs say that when someone dies, this person will go to next world with same appearance they have at time of death. If someone dying at home, family would dress dying person in finest traditional Hmong clothing so he/she would enter next world well dressed. Considered shameful to enter next world poorly dressed or unclothed. Nurses can aid traditional family when person is near death by allowing them to dress loved one in traditional clothing.
Home vs. hospital. Dying either at home or hospital may be acceptable for Hmong families. Decisions always based on what they regard as best for dying person.
Special needs. Do not remove amulets from body. Shaman rituals may be performed in attempt to cure dying person. These rituals must be performed in home and would be considered less effective in hospital. After death, specific rituals performed in funeral home to help send person's spirit to heaven.
Care of body. Body usually prepared for burial by family at funeral home. Family believes person will suffer if hard objects buried with body; may ask that indwelling metal plates, bullets, and shrapnel be removed from body. Person cannot be buried with buttons, zippers, or metal closures on clothing, and screws and nails will be removed from inside coffin. Traditional Hmong or Western clothing will be placed on body with extra finery placed in coffin. No Hmong metal amulets or jewelry buried with body.
Attitudes toward organ donation. Traditional Hmong usually will not donate organs because they believe one of body's three spirits stays with body; therefore, body needs to stay whole. Hmong who are Christians, however, believe that body and soul are separate and may consent to donation.
Attitudes toward autopsy. (See Organ donation.)
Composition/structure. Hmong families, large, patrilineal, with well-organized hierarchy of decision making. Eldest male relative considered head of family. Father, followed by eldest son, head of individual family. There are 18 Hmong clans, and all members of clan have same last name. All clan members considered related and prohibited from marrying on anther, even though close biological relationships do not exist. Cousins in father's clan considered brothers and sisters. Sons expected to marry and bring wives to live in family home. Daughters marry and become part of husband's clan although may retain birth clan's name as surname. Men may have more than one wife. Married Hmong style not registered by the State. Gays and lesbians are not acknowledged by Hmong.
Decision making. Women my express opinions, but men make final decisions. If woman's husband gone, eldest adult son expected to make decisions for mother unless she has remarried. Many decisions made through family meetings and if head of family lives another state, decision making can be an arduous process.
Spokesperson. Spokesperson most likely someone who speaks English, but might not have decision-making power.
Gender issues. Women considered subservient to men. Sons expected to always remain with family clan and daughters expected to leave home and join husband's clan. Most Hmong prefer sons so their sons can care for them in their old age. Hmong men may take a second wife if first wife does not bear sons. Couples who have only daughters may continue to have children in attempt to have son.
Caring role. Women are caretakers during health and illness. When woman considered potential mate for son, her reputation as "hard worker" considered part of her value as bride. After marriage, she is expected to cook and clean for family. This role expectation persists, even though daughter-in-law may have job or go to school. Mothers-in-law take over many child-rearing responsibilities. Daughters-in-laws expected to care for in-laws during illness.
Expectations of and for children. Children expected to obey parents and other siblings. Decisions may be made for children regarding schooling and choice of careers. These decisions felt to be in best interest of family; individual's desires subservient to needs of family.
Expectations of and for elders. Elders take on child-rearing roles when they are no longer able to work outside the home. Older people held in great respect in Hmong community and looked to for advice.
Expectations of adults caring for children and elders. See above.
Expectation of visitors. When Hmong person is ill, all family members expected to go to hospital to visit. If someone doesn't go, it is thought they do not love ill person and they would be socially censured within community. Some Hmong families are quite large and extended family members have close times, hospital can be overwhelmed by visitors.
Primary religious/spiritual affiliation. A recent study found that 75% of Hmong people practiced traditional religion which is animistic. Traditionalists believe that body has three souls. When someone dies, one soul goes to heaven, one stays with the body, and one is reincarnated. Traditionalists practice ancestor worship and believe that ancestral spirits can protect them or can cause harm if spirits are not honored sufficiently.
Many Hmong also practice Buddhism or Christianity with membership to various churches such as Catholic, Missionary Alliance, Baptist, Mormon, and others. Hmong who are Christians may use all traditional medical practices except shamanism which is practiced by those who retain animist beliefs.
Usual religious/spiritual practices. For Hmong who retain traditional beliefs, a shaman is necessary to communicate with spirit world. During this ritual, family members gather at home and shaman rides imaginary horse to spirit world to learn why person is ill and what sacrifice required to make person well again. Healing ceremony then conducted, usually involving sacrifice of chicken, pig, or cow. Purpose of sacrificing animal is to send its spirit to other world in place of ill person's spirit that has been stolen or wandered away. Animal's spirit may also be expected to protect person from further harm. Amulets are applied at time of ceremony, intended to continue protective powers for as long as person wears them.
Use of spiritual healing/healers. See above.
Causes of physical illness. Hmong believe illness can have natural or supernatural etiologies, although infectious disease etiologies are beginning to be understood. Traditional causes of illness caused by an ancestral spirit in attempt to get person's attention and remind them that honoring ceremonies have not been sufficiently performed. Christian Hmong may have illness beliefs similar to other Westerns or feel that illness is "God's will." Hmong recently converted to Christianity may consider illness retribution from ancestral spirits for abandoning traditional ways.
Causes of mental illness. There is no word for mental illness in Hmong except a word that would mean "crazy" in English. Depression common and not hidden. Some individuals who have nightmares attribute them to spirit visits from dead relatives.
Causes of genetic defects. Genetic defects thought to be caused by spirits because parents did something wrong. Child accepted without stigma although marriage may be more difficult since appearance an important factor in mate selection.
Sick role. Ill people expect family members to care for them. Family relationships can be strained by prolonged illnesses of insufficient help. Patients may resist self-care practices. For example, family members may be expected to administer insulin injections.
Home and folk remedies. Several methods used, intended to release evil spirits or illness-causing toxins from body. These are all similar in their primary purpose: to cause an ecchymotic area through which illness passes. Darkness of ecchymotic area also considered an indicator of seriousness of illness. These methods performed on skin over area of pain to locate pain for health care professional. Methods include:
Cupping - cotton or tissues burned in a small glass jar. After flame is out, jar is placed over painful area and remains until air within jar has cooled, producing a vacuum and a round ecchymotic area.
Coining - Using spoon or coin (anything with round edge), skin is stroked lightly until an ecchymotic area appears, an oval bruise with an irregular border.
Pinching - Skin in pinched until a bruise appears, usually narrow and may be found between eyes of person with headache.
It is common practice to puncture ecchymotic area to express blood, thereby removing toxin causing illness. Puncture often done with sewing needle, rarely sterilized. One needle may be used on several individuals.
Herbs commonly used in Laos and still used today in U.S. May traditional herbs not available here but some imported from Laos. Chinese herbs also popular.
Acceptance of procedures. Generally, invasive procedures not well accepted. Some individuals do not want blood drawn when feeling ill because they think it will make them "too sick." Many complain if they have "too many" blood tests because they do not believe blood is regenerated. Others will request blood tests because they think they feel better afterward.
Care seeking. Home remedies and traditional medicine practices often will be tried before going to Western physician, sometimes allowing disease processes to be become well advanced. Preventive medicine practices such as PAP smears gaining greater acceptance.
Concept of health. Health equated with being able to perform expected routines. Great distress occurs when someone cannot perform usual duties.
Health promotion and prevention. Not a priority in Hmong community if health promotion considered from Western perspective. Hmong practice some behaviors and avoid others because of widespread beliefs that certain Western foods or medical procedures will cause harm.
Most Hmong parents will have children immunized. To insure compliance with immunization schedule, may need reminders by telephone or mail.
Screening. Screening generally done on sick visits. Most will not come in just for screening.
Source: Lipson, Juliene G., Dibble, Suzanne L., Minarik, Pamela A. Culture & Nursing Care: A Pocket Guide. The Regents. 1996