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INTRODUCTION
Demographic changes in the Seattle area are having a profound impact on the local health care delivery system. Health care providers need to hear from ethnic communities about their experience in trying to access health care. Offering culturally appropriate care requires being open to the perceptions, realities and expectations of a community that may be different from one's own.
The Cross-Cultural Health Care Program (CCHCP) in Seattle, WA works with health care providers, interpreters and community-based organizations to address these needs. Established in 1992, the CCHCP is funded by a grant from the W.K. Kellogg Foundation. This "Voices of the Communities" profile is one of a series developed by the CCHCP. The profiles and an earlier survey of 22 underserved ethnic communities are part of the CCHCP's effort to provide a forum for underserved communities to interact with the health care community. These profiles were developed by and in consultation with members of the profiled community.
Location and traditional life
Cambodia borders Thailand, Laos and Vietnam in the southeastern part of Asia. Most Cambodians traditionally lived in small villages near waterways and worked in agriculture. The nuclear family is more common as the family unit than the extended family. However, in rural areas, extended families often live together for financial reasons. The family is likely to be self-sufficient, owning land and a home, and raising rice, vegetables and livestock for food. Traditional values include a strong family identity, respect for ancestors and the past, and a desire for smooth interpersonal relationships. The roles of both males and females are respected.
Language
Khmer (also known as Cambodian) is Cambodia's language. Because of historical ties to the culture of India, the language has many words similar to Sanskrit. Few people, especially in rural areas, attended school. For this reason, many Cambodians never learned to read or write.
Religion
Theravada Buddhism has been the primary religion, although Christianity and animism are also found. For many centuries, Buddhist monks lived and taught in every community.
History
The political framework of the country has long been unstable. In 1975, the Khmer Rouge movement overthrew the government and established a reign of terror lasting until 1979. Between 20 and 40 percent of the population was executed or died of disease and starvation. Cambodian culture was largely destroyed.
Cambodians who managed to escape remained in refugee camps for years. Over 180,000 Cambodians sought refuge in the United States. Cambodians arrived in poor health because of extreme deprivation of food, shelter and medical care. The most common diseases were tuberculosis, hepatitis B and intestinal parasites. Many also suffer from post-traumatic stress disorder related to their political persecution.
Population size and residence
Over 5,600 Cambodian refugees live in King County. Most live in south Seattle (White Center, Holly Park, High Point, Rainier Vista, Rainier Valley, Mt. Baker and Park Lake).
Employment and family life
A few refugees who had formal education and were professionals in Cambodia have found well-paying jobs or established their own businesses in Seattle. However, because of language barriers and lack of education, many Cambodians are unemployed or work at two or three low-paying jobs.
Families fortunate enough to have their own homes often live together in extended families. For those in public housing, regulations limit the number of family members per apartment. Often parents or older relatives are in housing apart from the family, sometimes in a different part of town. The traditional gender roles of Cambodian families also have broken down because of the need for all adults to work outside the home or because of limited English.
Language
Most Cambodians speak Khmer at home. Elders continue to speak only Khmer. When interpreters are needed, nationality is not of concern to most Cambodians, but most prefer same-gender interpreters.
Religion
Most of Seattle's Cambodian population is Buddhist, although some are Christians. There are Buddhist temples in the Beacon Hill area and in White Center.
Community organizations
The Khmer Community of Seattle/King County offers a variety of services, including classes on cultural expectations and on such institutions as courts and schools. Help also is available to fill out job or public assistance applications. The Family Center of Southwest Seattle offers classes in Cambodian language and culture for children.
Medical care
Cambodians deal with illness through traditional medicine and self-medication, often using more than one treatment for the same illness. In Cambodia, they have access to over-the-counter drugs at low cost but have few hospitals and physicians. Western medicine is available in urban areas, but the cost is high. Western medicine may be tried only when all known remedies have failed.
Traditional healing
The traditional forms of treatment are herbal remedies, dermal techniques, hot-cold balance and rituals. Dermal techniques include cupping, pinching or rubbing, also known as "coining." These techniques are used to relieve headaches, muscle pains, sinusitis, colds, sore throat, coughs, diarrhea or fever. In hot-cold theory, illness is caused by a change in the natural balance between hot and cold elements in the universe. The patient adjusts drugs, herbs and foods to restore balance and harmony. If these remedies are not effective, rural Cambodians will seek help from a traditional healer.
Some illnesses are thought to be the result of evil spells cast by someone else, mistakes the patient made in various rituals, or the patient's neglect of rituals or spirits. Traditional or spiritual healers will be called in for these illnesses.
Mental health
Severe emotional disturbance and mental illness is usually attributed to possession by malicious spirits, to bad karma from misdeeds in past lives or to inherited bad luck. Mental illness is usually denied and feared and brings great shame to the patient's family.
Maternal and child health
Family planning is uncommon in Cambodia; most women have many children. Some herbal medicines are thought to prevent pregnancy. In the cities, some women use birth control pills. During pregnancy and for childbirth, women seek help from a midwife and elders. The first month after childbirth is a time for a woman to regain her strength. She lies on a bamboo bed with a constant fire underneath, does not bathe, and drinks and eats only certain things. Other women care for the baby during this time. Most women breast-feed their babies; breast-feeding in public is common.
Traditional healing
Cambodians in Seattle use both traditional and Western medicine in combination or succession. Fresh herbs are hard to obtain, however. Cupping, pinching and rubbing are practiced by many local Cambodians. Some will go to the Buddhist temple to get rid of bad spirits.
Medical care and providers
Some Cambodians in Seattle see Chinese doctors, since they use herbs as a treatment. Some see Vietnamese doctors, who, they say, require few tests and minimal physical examinations but will dispense medications freely, which is important to Cambodians. Many Cambodians are hesitant to let Western medical providers know that they are using other forms of health care because they think the provider will disapprove.
Western health care is confusing and overwhelming for many Cambodians. Language and cultural barriers, crowded waiting areas, multiple interviews, mysterious procedures and the somewhat abrupt behavior of health personnel all make obtaining health care an unpleasant experience. Western health care practices such as appointments and preventive health care are not familiar to most Cambodians.
Cambodians expect to receive medications for every illness because it makes them feel that something is being done. If none is dispensed, they will find another provider. Medications are taken only as long as the individual feels sick. If there are any side effects, the patient will decrease the dose. Cambodians expect drugs to relieve a problem fairly quickly, so may not continue taking medications for a chronic illness such as hypertension.
Procedures that are feared and not understood include blood draws, X-rays and surgery. Many Cambodians believe blood draws are very painful and will make them weaker because blood is not replaced. X-rays are thought to destroy red blood cells and lower life expectancy. Many Cambodians are extremely frightened of any kind of surgery since it was traditionally used only as a last resort.
Maternal and child health
Cambodian women are very modest and will avoid annual exams because they know pelvic and breast exams will be included. Generally, they prefer women health care providers. In Seattle, women who have just had a baby cannot take the usual month to rest but must return to work, school or taking care of the household. Although breast-feeding is common in Cambodia, many Cambodian women in Seattle believe that breast-feeding is only for poor people or is inappropriate to do in public. Some start feeding their baby rice soup as early as age six weeks.
Social customs
In Cambodia, it is not polite to have eye contact with someone who is older or is considered a superior. Although Cambodians in Seattle tend not to follow this custom, it is well to be aware of it. To Cambodians, it is very insulting to touch another person's head since this is the most important part of the body and the place where the spirit is found. Feet are the least valued part of the body, so it is insulting to point them at someone.
Mental health
Cambodian refugees often suffer from depression and post-traumatic stress syndrome. Many are not able to understand what they are suffering from as there are no comparable terms in Khmer. Many do not take prescribed anti-depressants out of fear of becoming addicted or going to sleep and never waking up. Some find help going to the temple to be blessed, from support groups or from the Asian Counseling Center.
Suggestions
Profile prepared by: Linda Wetzel, University of Washington School of Nursing, and Jennifer Huong.
This profile was originally developed by the House Calls project of Harborview Hospital in Seattle, under a grant from the Opening Doors Initiative of the Robert Wood Johnson Foundation.
References include:
Boehnlein, J. (1987). Clinical relevance of grief and mourning among Cambodian refugees. Social Science and Medicine, 25(7): 765-72.
Buchwald, D., Panwala, S., & Hooton, T. (1992). Use of traditional health practices by southeast Asian refugees in a primary care clinic. The Western Journal of Medicine, 156(5): 507-11.
Caranzaro, A., and Moser, R.J. (1982). Health status of refugees from Vietnam, Laos, and Cambodia. Journal of the American Medical Association (JAMA), 247(9): 1303-08.
Chung, R.C., and Kagawa-Singer, M. (1993). Predictors of psychological distress among southeast Asian refugees. Social Science and Medicine, 36(5): 631-39.
D'Avanzo, C.D., Frye, B., & Froman, R. (1994). Stress in Cambodian refugee families. IMAGE: Journal of Nursing Scholarship, 26(2): 101-05.
Erickson, R.V., and Hoang, G.N. (1980). Health problems among Indochinese refugees. American Journal of Public Health, 70(9): 1003-06.
Frye, B.A., and D'Avanza, C. (1994). Themes in managing culturally defined illness in the Cambodian refugee family. Journal of Community Health Nursing, 11(2): 89-98.
Kemp, C. (1985). Cambodian refugee health care beliefs and practices. Journal of Community Health Nursing, 2(1): 41-52.
Keyes, C. (1990). Buddhism and revolution in Cambodia. Cultural Survival Quarterly, 14(3): 60-63.
Kinzie, J.D., Fredrickson, R.H., Ben, R., Fleck, J., & Karls, W. (1984). Post traumatic stress disorder among survivors of Cambodian Concentration Camps. American Journal of Psychiatry, 141(5): 645-50.
Kulig, J.C. (1988). Conception and birth control use: Cambodian refugee women's beliefs and practices. Journal of Community Health Nursing, 5(4): 235-46.
Kulig, J.C. (1989). Childbearing beliefs among Cambodian refugee women. Western Journal of Nursing Research, 12(1): 108-18.
Kulig, J.C. (1994). "Those with unheard voices": The plight of a Cambodian refugee woman. Journal of Community Health Nursing, 11(2): 99-107.
Mattson, S. (1993). Mental health of southeast Asian refugee women: an overview. Health Care for Women International, 14: 155-65.
Messner, M.M., and Rasmussen, N.H. (1986). Southeast Asian children in America: the impact of change. Pediatrics, 78(2): 323-29.
Mollica, R.F., Donelan, K., Tor, S., Lavelle, J., Elias, C., Frankel, M., & Blendon, R.J. (1993). The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA, 270(5): 581-86.
Mollica, R.F., Wyshak, G., and Lavelle, J. (1987). The psychosocial impact of war trauma and torture on southeast Asian refugees. American Journal of Psychiatry, 144(12): 1567-72.
Muecke, M.A. (1983). Caring for southeast Asian refugee patients in the USA. American Journal of Public Health, 73(4): 431-38.
Muecke, M.A. (1983). In search of healers-southeast Asian refugees in the American health care system. The Western Journal of Medicine, 139(6): 835-40.
Muecke, M.A., and Sassi, L. (1992). Anxiety among Cambodian refugee adolescents in transit and in resettlement. Western Journal of Nursing Research, 14(3): 267-91.
Pike, D. (ed.). (April-June 1990). Indochina Chronology, 9(2): 23.
Song, C. (1986). The struggle continues: immigration and resettlement. In B. Levy and D. Susott (eds.), Years of Horror, Days of Hope: Responding to the Cambodian Refugee Crisis, (pp. 305-10). Millwood, N.Y., New York City, and London: Associated Faculty Press, Inc.
Story, M., and Harris, L.J. (1989). Food habits and dietary change of southeast Asian refugee families living in the United States. Journal of the American Dietetic Association, 89(6): 800-03.
U.S. Committee for Refugees (1989). Refugee Reports. (Publication No. 001-465) Washington, D.C.
Vickery, M. (1990). Cultural survival in Cambodian language and literature. Cultural Survival Quarterly, 14(3): 49-52.
This is a condensed version of the profile. For the complete profile and survey reports, please contact the Cross-Cultural Health Care Program, (206) 860-0329.
This "Voices of the Communities" profile was made possible by a grant from the SAFECO Corporation
.January 1996