Journal of Community Health Nursing
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women Barbara A. Frye To cite this article: Barbara A. Frye (1991) Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women, Journal of Community Health Nursing, 8:1, 33-44, DOI: 10.1207/s15327655jchn0801_4 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0801_4
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JOURNAL OF COMMUNITY HEALTH NURSING, 1991,8(1), 33-44 Copyright @ 1991, Lawrence Erlbaum Associates, Inc.
Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women Barbara A. Frye, DrPH, RN Downloaded by [Deakin University Library] at 08:35 07 November 2015
Lorna Linda University
The recent immigration of larger numbers of refugees from various regions of the world has presented a challenge to the health-care system. There are marked perceptual differences between recent immigrants and health-care providers in such areas as the definition of kinds and causes of diseases, illness behaviors, treatment modalities, and patterns of health-care decision making and accessing of care. Understanding these perceptual differences from the perspective of cultural themes is a useful crosscultural tool for nursing. Among Cambodian refugee women in the described study, the overarching theme in understanding and managing illness is the concept of equilibrium. Health-related behaviors were in congruence with the described traditional belief structure. However, a pragmatic theme dictated a blending of traditional and scientific healing practices. The need for language and cultural comfort was the primary theme in accessing care and selecting care providers. This study has implications for the significant role of the nurse as crosscultural educator and cultural interpreter to American health-care providers. The United States is increasingly a pluralistic society populated by ethnic minorities and recent immigrants. Since 1975, almost one million refugees, mostly from Southeast Asia, have entered the U.S. In addition, there have been large waves of immigrants from Mexico, Central America, and Eastern Europe (Holley, 1986; Montero, 1979; Office of Refugee Resettlement, 1985). Adding a new dimension to the American society, these recent arrivals have presented a challenge to the health-care system. A frustrating aspect for American healthcare providers is the radically different world view of these multiple cultural groups. Perceptual differences include varying definitions of kinds and causes of diseases; behaviors to avoid when ill; appropriate kinds of treatment; patterns of accessing care and selecting care providers, including traditional healers; and patterns of decision making within the family. As an area of research, there is limited study on decisionmaking processes utilized by ethnic minorities seeking health care in the U.S. The majority of such studies have been done among populations in other countries. ~ 9_haraIt-b-sav& J = ~ E ~ .&.iw F am= If one seeks to understand the p r ~ s nf ethnic minority group, the critical element is to identify the cultural theme driving the behavior. Requests for reprints should be sent to Barbara A. Frye, DrPH, RN, School of Public Health, Lorna Linda University, Lorna Linda, CA 92354.
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Frye REVIEW OF THE LITERATURE
The literature suggests that there are four common themes that influence healthcare decision making. These themes are: 1. Beliefs about disease causation.
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2. The pragmatics of the situation. 3. Language and cultural factors. 4. Farnilism.
Beliefs About Disease Causation
Fabrega and Manning (1979) made a comparative study of 179 Mayan Indian, Mestizos, and Latino women in San Cristobal, Mexico, analyzing illness episodes, severity, and perceived treatment options in this medically pluralistic setting. The women were randomly selected from the three ethnic groups populating this southern provincial city in Mexico. The initial interview gathered retrospective and crosssectional data, and the women were then followed bimonthly for 1 year. The more affluent Latino women had the most frequent illnesses, although illnesses were the least severe and of shortest duration. Fabrega and Manning found that the decision to seek biomedical care was most frequent among the Latinos, with the Mestizos and Mayans utilizing spiritual healers and curanderos. The Latinos prescribed to the biomedical theories of disease causation, whereas the Mestizos and Mayans believed in the moral and psychosocial causes of illness. The conclusion of this study was that belief about disease causation was the principle factor in the decision to seek care. The Pragmatics of the Situation
In Medical Choices in a Mexican Town, Young (1981) described the health-care decision-making process among the Mestizo population of Pichataro, a rural Tarascan community in West Central Mexico. The purpose of their study was the development of a model of preferred treatment choice. The model was then applied to 323 actual illness episodes, correctly accounting for 91% of preferred treatment choices. Although the preferred method of treatment in most instances was biomedical care, traditional care was used most frequently because of the inaccessibility and high cost of biomedical care. The initial study of Pichataro, and a subsequent comparative study of Pichataro and the neighboring town of Uricho, indicated that the decision process in treatment seeking in a pluralistic setting is mostly a pragmatic reflection of accessibility and cost of care (Young, 1981; Young & Garro, 1982). Frye (1986) found similar results in a nonrandom study of 14 middle-income Indochinese refugee families in Southern California. Although traditional remedies
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were stated to be most efficacious, the majority of respondents stated that, if given a choice, they would select biomedical care because it works quickly, and it is more convenient in the U.S.Cost of care was not a major factor with this study group. Auerbach's (1982) study also supports the pragmatic view. Auerbach studied the health-care decision-making process with childbirth among the women of KsarHellal, a medically pluralistic town in Tunisia, North Africa. Factors found to affect decision making were cost of care, normalcy of the pregnancy, and anxiety avoidance. Biomedical care was selected primarily when normalcy of the pregnancy was in question. High cost and separation from other children and preference for the home environment were factors that kept these women from accessing biomedical care. Their reluctance to utilize biomedical obstetrical care was not grounded in their belief system, but rather in the pragmatic factors of cost and cultural comfort. When the pregnancy was perceived as presenting a life-threatening situation, the considerations of cost and comforts of home were put aside in favor of survival. Language and Cultural Factors
In a study of 19 Latin American immigrant families on the U.S. eastern seaboard, Ailinger (1977) found that familism, language, and culture were the most influential factors in health-care decision making. Using focused interviews, self-recording by respondents, and participant observation as methods of data collection, she found that the initial decision for most problems was made by the individual. However, if the problem became serious, the bilateral kinship network collectively made the decision for care. Close friends of the family were also influential in the decisionmaking process. If the problem escalated to a very serious state, the family would allow only a Spanish-speaking physician of Hispanic origin to treat the sick family member. This decision held, even though Anglo English-speaking physicians were in closer proximity. Pearson (1986) reported similar findings among Indochinese refugees in Boulder, CO, in regard to the effort to find physicians with linguistic and cultural closeness. Familism
According to Heller, Chalfant, Quesada, and Rivera-Worley (1981), familism, which is the collective force of the family, is a significant factor in health-care decision making: The role of familism in health-seeking behavior has only been studied in its broadest perspective. An important question for future research concerns the role played by familism as a communication network in the process of decision making concerning health-care seeking behavior among both lower and middle-class populations. (p. 541)
Heller et al. (1981) studied 100 middle- and lower-income women in Durango, Mexico. These researchers found that a high degree of familism was positively related to the utilization of biomedical care, regardless of socioeconomic level. Heller
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et al. proposed that strong family ties acted as a buffer against feelings of alienation when accessing biomedical care. In another study of the effect of familism on health-care decision making, Abasiekong (1981) studied attitudes regarding the importance of family concurrence versus individual decision making prior to hospitalization of a family member. His study was conducted in the Uyo Division of Cross River State, rural Nigeria. The study population consisted of 450 families with a total of 3,270 hospitalizations. Abasiekong found that 61% of the families strongly supported the belief that the family, rather than the ill members, should decide whether to allow hospitalization. Support for the family's decision over the individual's decision was inversely related to educational level and directly related to age. He summarized his findings as follows: An individual is not socially defined as a sick person until his claim is validated by his associates. Only when his relatives and friends accept his condition as an illness can he obtain exemption from the performance of the normal daily tasks. Since illness directly affects an entire group, it is only logical that the group should be expected to participate in the decision that must be made. (p. 49)
PROFILE: THE CAMBODIANS
Among the most cryptic and traumatized ethnic populations in the U.S. are the Cambodian refugees. From the war-torn villages and camps of southeast Asia, these recent immigrants are primarily concentrated in California and the Northwest. Over 140,000 in number, they are a young to middle-age population who have survived the Cambodian holocaust under 4 years of the murderous Khmer Rouge reign (Holley, 1986; Office of Refugee Resettlement, 1985). The Cambodians have not been assertive in seeking health care in America. This lack of assertiveness has been attributed to high levels of depression, lack of English language abilities, and a cultural bias toward avoidance of confrontive situations (Blanchard, Yao, McAlpine, & Hurt, 1986; Boehnlein, 1987; Kemp, 1985; Muecke, 1983b; Rosenberg & Givens, 1986). Further, there is widespread misunderstanding among American health-care providers of Cambodian concepts of disease causation and traditional health modalities (Falvo & Achalu, 1983; Frye, 1989; Rosenberg & Givens, 1986). Yet, the Cambodian refugee population has been targeted as the southeast Asian population at highest risk for physical and psychosocial health problems (Boehnlein, 1987; Duncan, 1987; Kinzie & Fleck, 1987; Meinhardt, Tom, Tse, & Yu, 1984; Mollica, Wyshak, & Lavelle, 1987). In one epidemiological study of refugees in Santa Clara County, CA, the Cambodians were found to be the least educated, sickest, and most depressed across all ages (Meinhardt et al., 1984). The major physical illnesses have been tuberculosis, anemia, parasitic diseases, malnutrition, sequelae of malaria, and hepatitis B (Catanzara & Moser, 1982; Meinhardt et al., 1984; Muecke, 1983a).
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Psychosocial concerns include suicide, clinical depression, somatization, and posttraumatic stress syndrome (Blanchard et al., 1986; Boehnlein, Kinzie, Ben, & Fleck, 1985; Bowlan & Bruno, 1985; Kotva, 1984; Meinhardt et al., 1984; Nolan, Elarth, & Barr, 1988). Youth have been identified as an especially high-risk group. Emotional problems in southeast Asian youth are generally presented psychosomatically (Messer & Rasmussen, 1986). The frequency of intentional drug overdose among young Cambodian women is a problem of major concern (Blanchard et al., 1986; Nolan et al., 1988). Cambodian world view is rooted in Buddhist philosophy which espouses the need to maintain equilibrium in one's life. Equilibrium results from noncompetitive behavior; respect for individuality; nurturance toward the weak, especially children and the elderly; and peaceful co-existence with the natural world. The culture stresses individual accountability for behavior and holds out the promise of a continued and improved life through reincarnation. Basically the culture says that if one is good (i.e., follows the Buddhist eight-fold path to righteousness), and does good (i.e., makes "merit" through good deeds), one will receive good (i.e., an improved reincarnated state; Ebihara, 1968; Frye, 1989; Whitaker, 1972). Health is considered a state of equilibrium and illness occurs when equilibrium is disturbed. Such disturbances are viewed holistically as affecting body, mind, and spirit. The result of such disturbances is a state of internal "bad wind." Equilibrium can be restored if the bad wind is released from the body through "coin rubbing," the practice of massaging the skin with eucalyptus oil and a heated coin. By creating reddened abrasions on the skin, it is believed that the bad wind can escape. Disequilibrium and resulting bad wind are caused by exposure to environmental forces such as high velocity winds or by imbalances of "hot" and "cold" states in the body. The body can be brought back into equilibrium by the appropriate windreleasing or oppositional treatment. For instance, childbirth which is considered a cold state must be managed with hot treatments such as liberal intake of meat, salt, wine, and hot pepper. Also, the postpartum women is restored to equilibrium by placing a charcoal burner under her bed, a practice known as "mother roasting." Hypertension, on the other hand, is a hot state and must be treated with cold foods like fruits and vegetables (Fishman, Evans, & Jenks, 1988; Frye, 1989; Kemp, 1985; Kulig, 1988; Marcucci, 1986; Martin, 1983; Ong in Bowlan & Bruno, 1985).
CULTURAL THEMES IN HEALTH-CARE DECISION MAKING
In a qualitative study of health-care decision making, Frye (1989) examined cultural beliefs and health-seeking behavior among 30 Cambodian refugee women in Southern California. The purpose of the study was to identify the cultural themes basic to health-care decision making among this population. Variables studied included perceived kinds and causes of diseases, behaviors to avoid when ill, appropriate treatments, patterns of accessing care and selecting care providers, and patterns of decision making in the family.
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Utilizing in-home interviewing in Khmer, the Cambodian language, data was gathered on beliefs about health and illness. Subsequently 226 illness episodes among 157 family members were tracked over an 8-month span. Beliefs were then compared to behaviors and to four hypothesized cultural themes: (a) beliefs about disease causation, (b) the pragmatics of the situation, (c) language and cultural factors, and (d) familism.
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Beliefs About Disease Causation Traditional belief defined the perceived kinds and causes of illnesses in this study. Illnesses in infants and children were perceived to be caused by traditionally defined sources of disequilibrium-"wind illness" resulting from exposure to environmental forces like high winds as well as states of dietary imbalance. The young were perceived to be highly vulnerable and there was much expressed fear of child mortality. Menstrual irregularities in adolescent girls were perceived to be caused by "weak blood," a state of disequilibrium. Childbearing women were perceived to be highly vulnerable and at risk for death. Pregnancy was defined as a cold state and the parturient woman was at high risk for the culturally defined disease "toa." Toa, an extreme cold state results in collapse after childbirth. It results from failure to adhere to equilibrium promoting practices during the childbearing cycle. Adult men and the elderly were perceived to be susceptible to the condition called "thinking too much," a state of excessive rumination about unhappy or tragic memories. It reflects a state of disequilibrium in which sad thoughts predominate over pleasant thoughts. Among the Cambodians in this study, wind illness, weak blood, toa, and thinking too much are culturally defined illnesses having varying causes but all resulting in a state of disequilibrium. Avoidance behaviors are the actions one takes when ill to prevent further suffering. In this study, the described illnesses and subsequent avoidance behaviors for these illnesses closely paralleled the perceived causes. For instance, there were many cases of upper respiratory infection and flu among the children. Perceived as wind illness resulting from the winter winds, these conditions were treated with coin rubbing to release the bad wind. Concurrently the child was kept inside to avoid all contact with the wind. If the child had to be taken outside, he or she was bundled heavily. Menstrual irregularity (weak blood) in adolescent girls was treated with herbal tea boiled with a nail and avoidance of cold foods like fruit. The affected girl was encouraged to eat hot foods like meat, suggesting a cultural understanding of the link between diet and anemic states. There were multiple treatments and avoidance behaviors for toa, centering on the concept of equilibrium. Toa, as a state of extreme coldness, was managed with oppositional treatment such as eating hot foods after childbirth and mother roasting. Avoidance behaviors included avoidance of emotional stress and sexual intercourse. All distressing conversation was to be avoided including any discussion of neonatal complications.
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Thinking too much as a culturally defined illness and state of disequilibrium was treated privately with family and spiritual support. Family members, especially the women, had responsibility for providing a therapeutic milieu including "talking sweet to the person thinking too much," not nagging him, and making him laugh. He was also encouraged to seek spiritual support from the Buddhist monk of Christian pastor as appropriate. When thinking too much, the affected person had to avoid alcohol and solitude. The woman was responsible for ensuring that man or the elder complied with these cultural avoidance behaviors especially the intake of alcohol. In this study of Cambodian women, the cultural theme of belief about disease causation held for the definition of kinds and causes of illnesses, avoidance behaviors when ill, and some treatments. Pragmatics of the Situation
However, there was a pragmatic mixing of traditional treatments with scientific medicine especially with the infants, children, and adolescents. Often the children were receiving coin rubbing, traditional herbal teas, antipyretics, and antibiotics simultaneously. There was close adherence to the traditional practices among childbearing women, suggesting the strength of the cultural beliefs surrounding childbearing. They sought limited prenatal care and hospital admissions for birthing. However, in emergency situations with women or children, scientific care was readily sought. Examples of such cases in this study included febrile convulsions in an 8-month-old infant with measles, spontaneous abortion in a grand multipara, and chest pains in an elderly woman. Psychologically defined illness, such as thinking too much, was treated within the family and the ethnic community, although diagnosed posttraumatic stress syndrome was treated with a mixture of traditional and scientific approaches. Language and Cultural Factors
In spite of being surrounded by a large number of primary and tertiary facilities within a 10-mile radius, almost exclusively, the participants and their families in this study accessed care in distant settings of linguistic and cultural comfort. The exceptions to this pattern were emergencies as just described. Most of the informants reported driving 60 to 80 miles to seek culturally acceptable care. Physicians were chosen based on language and cultural factors. A few physicians either spoke Khmer or had a Khmer translator. More commonly, the non-Khmer speaking physician was accessed based on recommendation of a Cambodian friend. Continuation with the physician was based on feelings that the physician had a caring attitude and was making an effort to understand the Cambodian ways. There are very few elderly traditional Cambodian healers, Kru Khmer, available in America. In this study, treatment was provided either by a physician or by the woman in
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TABLE 1 Cultural Themes in Health-Care Decision Making Among Cambodian Women
Ttaditional Beliefs Kinds of Illness Causes of Illness Avoidance Behaviors Treatment Decision-making patterns Pragmatics Treatment-mixture of scientific and traditional modalities Language and Culture Access to care Selection of care providers Familism None
the family using traditional Cambodian remedies. The cultural theme of language and cultural factors held for access to care and the selection of care providers. Familism
Familism was hypothesized as a cultural theme in the Cambodian health-care decision-making pattern. Farnilism was not shown to be a cultural theme. The mother in the family was perceived to be the decision maker in nearly all situations with the children and the adolescents. The father had a central role in decision making when there were long-term, chronic problems with the children. There was an individual decision-making pattern in health-care matters among the adult men and women and the elders, reflecting the cultural bias toward respect for individual accountability. Among this study population, the cultural themes operating in health-care decision making included beliefs about disease causation, pragmatics, and language and cultural factors (see Table 1). IMPLICATIONS FOR NURSING PRACTICE
The World Health Organization (WHO) strongly supports the development of care giving strategies which build on cultural strengths of a population. Such culturally sensitive care promotes self-reliance and self-esteem (WHO Technical Report, 1983). Central to the Cambodian culture is the concept of equilibrium. When illness occurs, the culture promotes restoration of equilibrium through prescribed treatments and adherence to defined avoidance behaviors believed to contain the disease process. This goal of restoration of equilibrium is the core on which nursing care can be planned for the Cambodian patient and family. Cultural Theme: Beliefs About Disease Causation
The classification of kinds and causes of illness by the Cambodians differs from the classification scheme utilized by the professional nurse. Nonetheless, there is a common element. The Cambodian explanation of equilibrium is the nursing concept of
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homeostasis. Examples of especially important ways of maintaining homeostasis are protection from the winds and ingestion of foods to restore balance. These practices are based in deeply rooted beliefs about the interaction and integration of the body, mind, and spirit. The nurse is in a key position to explain this cultural expression of homeostasis to other health-care providers. lladitional treatments and avoidance behaviors are ways that a culture tries to protect its sick members. In the Cambodian culture this protective behavior is shown through encouraging certain foods. Hot food is given to the parturient woman to protect her from toa. This food is strengthening, iron-rich food. Cold food is given to a hot or hypertensive person. Cambodian cold foods are foods high in fiber and low in sodium, the foods which promote energy and decrease blood cholesterol. Protective behavior is also shown through touch. Coin rubbing involves a substantial amount of touch. It is a relatively harmless procedure which usually only causes vasodilation. It has the effect of a massage. These protective behaviors are the ways of the people to restore equilibrium. The nurse as an advocate, can encourage American health professionals to avoid interference with these traditionally based practices unless obvious harm is resulting. Cultural Theme: Pragmatics in the Situation
The Cambodians cling to traditional treatment as it provides a sense of comfort and control over illness, especially when that illness is experienced in an alien culture. It seems reasonable to expect rather than to be surprised by this clinging to the traditional explanations and remedies. Yet the Cambodians have also demonstrated considerable acceptance of scientific treatment, pragmatically merging both systems. The Cambodians are a people who have barely escaped extinction. Their selfreliance and self-esteem capabilities have been severely tested. They have emerged as an immigrant people capable of integrating new ways with old ways. At this point in their history, they need the support, not the criticism, of the health-care community in this integration process. The nurse is in a key position to interpret this merging of cultures and practices to other health-care providers. Cultural Theme: Language and Cultural Factors
The Cambodians in this study indicated that the key factor in accessing health care was language and cultural comfort. Even if a language barrier was present, they would continue with a selected care provider if there was an attitude of caring and willingness to learn about the Cambodian ways. The Cambodians have taken many steps toward learning American ways. The nurse, as interpreter of the culture, can adapt care and encourage adaptation of care to include Cambodian ways including nonconfrontive and highly personalized approaches. This kind of flexibility will perhaps encourage the Cambodian patient to seek routine health care locally, not just in emergency situations.
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Health-Care Decision Making
In this study, the mother was the primary health-care decision maker for all ages of children. Adults showed an individual decision-making pattern consistent with the Cambodian cultural value of individual accountability for behavior. The Cambodian culture highly values interpersonal relationships, built on collaboration and mutual support. If decision-making patterns are respected and not challenged, the Cambodian patient and family is likely to reciprocate with smiling compliance. Violation of these decision-making patterns is likely to be met with indirect, resentful noncompliance. One Cambodian woman described her experience as follows: In my country I felt so special when I had my first two babies. I had them in my own home and my mother was with me. She took very good care of me and I got to decide what I wanted. I had good food, a warm bed, all my friends visiting me and plenty of rice wine. When my third baby was born in the refugee camp, it was hard but the nurse was so kind to me. She gave me plenty of hot food and my bed was warm. Here in America I was so afraid I would get toa and die because everything is so cold-the beds, ice water, the wrong kinds of food after delivering a baby. The nurses told me to eat lots of fruits and vegetables, but that is cold food! They wouldn't let me make any decisions. They wouldn't even let my other children come and play with the new baby. That is very important. Otherwise how will their spirits get to know each other? So I just smiled at the nurses but I did not listen to them. SUMMARY The Cambodians are adapting to the American ways while still holding firmly to their culture. Such cultural identity provides security and a sense of equilibrium. With the Cambodian patient, providing culturally sensitive nursing care centers on supporting the concept of equilibrium. In this endeavor, the nurse plays multiple roles advocate, culture broker, educator, and friend. REFERENCES Abasiekong, E. (1981). Familism and hospital admission in rural Nigeria-A case study. Social Science and Medicine, 1563 45-50. Ailinger, R. (1977). A study of illness referral in a Spanish-speaking community. Nursing Research, 26(1), 53-56. Auerbach, L. (1982). Childbirth in Iitnisia: Implications of a decision-making model. Social Science and Medicine, 16, 1499- 1506. Blanchard, P., Yao, J., McAlpine, D., & Hurt, R. (1986). Isoniazid overdose in the Cambodian population of Olmsted County, Minnesota. Journal of the American Medical Association, 256, 3 13 13133. Boehnlein, J. (1987). Clinical relevance of grief and mourning among Cambodian refugees. Social Science and Medicine, 25, 765-772. Boehnlein, J., Kinzie, J., Ben, R . , & Fleck, J. (1985). One year follow-up of post traumatic stress dis-
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order among survivors of Cambodian concentration camps. American Journal of Psychiatry, 142, 956-959.
Bowlan, J., & Bruno, E. (1985). Cambodian women's project: Proceedings from the Conference on Cambodian mental health. New York: American Friends Service Committee. Catanzaro, A., & Moser, R. (1982). Health status of refugees from Vietnam, Laos, and Cambodia.
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Journal of the American Medical Association, 247, 1303-1 307. Duncan, J. (1987). Cambodian refugee use of indigenous and western healers to prevent or alleviate mental illness. Unpublished doctoral dissertation, University of Washington. Ebihara, M. (1968). Svay: A Khmer village in Cambodia. Unpublished doctoral dissertation, Columbia University, New York. Fabrega, H., & Manning, P. (1979) Illness episodes, illness severity and treatment options in a pluralistic setting. Social Science and Medicine, 138 41-51. Falvo, D., & Achalu, D. (1983). Differences in perceptions of health status and health needs between refugees and physicians providing care. Health Values, 7(5), 2Q-24. Fishman, C., Evans, R., & Jenks, E. (1988). Warm bodies, cool milk: Conflicts in postpartum food choice for Indochinese women in California. Social Science and Medicine, 26, 1125-1132. Frye, B. (1986). Health beliefs of selected Southeast Asian cultures. Unpublished manuscript, Loma Linda University School of Public Health, Loma Linda, CA. Frye, B. (1989). The process of health care decision making among Khmer immigrants. Unpublished doctoral dissertation, b m a Linda University, Loma Linda, CA. Heller, P., Chalfant, H., Quesada, G., & Rivera-Worley, M. (1981). Class, familism and utilization of health services in Durango, Mexico: A replication. Social Science and Medicine, 15A, 539-541. Holley, D. (1986, October 27). Refugees build a haven in Long Beach. Los Angeles Times, pp. 1-4. Kemp, C. (1985). Cambodian refugee health care beliefs and practices. Journal of Community Health Nursing, 2, 41-52. Kinzie, J., & Fleck, J. (1987). Psychotherapy with severely traumatized refugees. American Journal of
Psychotherapy, 41, 82-94. Kotva, L. (1984, November 7). Monk Lok San on Cambodians' dreams. City Pages, pp. 5, 7. Kulig, J. (1988). Childbearing among Cambodian refugee women. Canadian Nurse, 84, 46-47. Marcucci, J. (1986). Khmer refugees in Dallas: Medical decisions in the context of pluralism. Unpublished doctoral dissertation, Southern Methodist University, Dallas. Martin, M. (1983, June). Elements de medecine traditionnelle Khmere [Elements of traditional Khmer medicine]. Seksa Khmer, pp. 135-17 1. Meinhardt, K., Tom, S., Tse, P., & Yu, C. (1984). Santa Clara County Health Department Asian health assessment project. San Jose: Santa Clara County Health Department, Division of Mental Health Services. Messer, M., & Rasmussen, N. (1986). Southeast Asian children in America: The impact of change. Pe-
diatrics, 78, 323-329. Mollica, R., & Wyshak, G., & Lavelle, J. (1987). The psychological impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572. Montero, D. (1979). VietnameseAmericans: Patterns of resettlement and socio-economic adaptation in the United States. Boulder, CO: Westview Press. Muecke, M. (1983a). Caring for Southeast Asian refugee patients in the USA. American Journal of
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Office of Refugee Resettlement. (1985). Refugee Reports, 5, 23-24. Rosenberg, J., & Givens, S. (1986). Teaching child health care to Khmer mothers. Journal of Commu-
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World Health Organization Technical Report, Series 690. (1983). New Approaches to health education in primary health care. Geneva: Author. Young, J. (1981). Medical choices in a Mexican town. New Brunswick, NJ: Rutgers University Press. Young, J., & Garro, L. (1982). Variations in the choice of treatment in two Mexican communities. Social Science and Medicine, 16, 1453-1465.
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Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women Barbara A. Frye To cite this article: Barbara A. Frye (1991) Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women, Journal of Community Health Nursing, 8:1, 33-44, DOI: 10.1207/s15327655jchn0801_4 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0801_4
Published online: 07 Jun 2010.
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JOURNAL OF COMMUNITY HEALTH NURSING, 1991,8(1), 33-44 Copyright @ 1991, Lawrence Erlbaum Associates, Inc.
Cultural Themes in Health-Care Decision Making Among Cambodian Refugee Women Barbara A. Frye, DrPH, RN Downloaded by [Deakin University Library] at 08:35 07 November 2015
Lorna Linda University
The recent immigration of larger numbers of refugees from various regions of the world has presented a challenge to the health-care system. There are marked perceptual differences between recent immigrants and health-care providers in such areas as the definition of kinds and causes of diseases, illness behaviors, treatment modalities, and patterns of health-care decision making and accessing of care. Understanding these perceptual differences from the perspective of cultural themes is a useful crosscultural tool for nursing. Among Cambodian refugee women in the described study, the overarching theme in understanding and managing illness is the concept of equilibrium. Health-related behaviors were in congruence with the described traditional belief structure. However, a pragmatic theme dictated a blending of traditional and scientific healing practices. The need for language and cultural comfort was the primary theme in accessing care and selecting care providers. This study has implications for the significant role of the nurse as crosscultural educator and cultural interpreter to American health-care providers. The United States is increasingly a pluralistic society populated by ethnic minorities and recent immigrants. Since 1975, almost one million refugees, mostly from Southeast Asia, have entered the U.S. In addition, there have been large waves of immigrants from Mexico, Central America, and Eastern Europe (Holley, 1986; Montero, 1979; Office of Refugee Resettlement, 1985). Adding a new dimension to the American society, these recent arrivals have presented a challenge to the health-care system. A frustrating aspect for American healthcare providers is the radically different world view of these multiple cultural groups. Perceptual differences include varying definitions of kinds and causes of diseases; behaviors to avoid when ill; appropriate kinds of treatment; patterns of accessing care and selecting care providers, including traditional healers; and patterns of decision making within the family. As an area of research, there is limited study on decisionmaking processes utilized by ethnic minorities seeking health care in the U.S. The majority of such studies have been done among populations in other countries. ~ 9_haraIt-b-sav& J = ~ E ~ .&.iw F am= If one seeks to understand the p r ~ s nf ethnic minority group, the critical element is to identify the cultural theme driving the behavior. Requests for reprints should be sent to Barbara A. Frye, DrPH, RN, School of Public Health, Lorna Linda University, Lorna Linda, CA 92354.
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Frye REVIEW OF THE LITERATURE
The literature suggests that there are four common themes that influence healthcare decision making. These themes are: 1. Beliefs about disease causation.
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2. The pragmatics of the situation. 3. Language and cultural factors. 4. Farnilism.
Beliefs About Disease Causation
Fabrega and Manning (1979) made a comparative study of 179 Mayan Indian, Mestizos, and Latino women in San Cristobal, Mexico, analyzing illness episodes, severity, and perceived treatment options in this medically pluralistic setting. The women were randomly selected from the three ethnic groups populating this southern provincial city in Mexico. The initial interview gathered retrospective and crosssectional data, and the women were then followed bimonthly for 1 year. The more affluent Latino women had the most frequent illnesses, although illnesses were the least severe and of shortest duration. Fabrega and Manning found that the decision to seek biomedical care was most frequent among the Latinos, with the Mestizos and Mayans utilizing spiritual healers and curanderos. The Latinos prescribed to the biomedical theories of disease causation, whereas the Mestizos and Mayans believed in the moral and psychosocial causes of illness. The conclusion of this study was that belief about disease causation was the principle factor in the decision to seek care. The Pragmatics of the Situation
In Medical Choices in a Mexican Town, Young (1981) described the health-care decision-making process among the Mestizo population of Pichataro, a rural Tarascan community in West Central Mexico. The purpose of their study was the development of a model of preferred treatment choice. The model was then applied to 323 actual illness episodes, correctly accounting for 91% of preferred treatment choices. Although the preferred method of treatment in most instances was biomedical care, traditional care was used most frequently because of the inaccessibility and high cost of biomedical care. The initial study of Pichataro, and a subsequent comparative study of Pichataro and the neighboring town of Uricho, indicated that the decision process in treatment seeking in a pluralistic setting is mostly a pragmatic reflection of accessibility and cost of care (Young, 1981; Young & Garro, 1982). Frye (1986) found similar results in a nonrandom study of 14 middle-income Indochinese refugee families in Southern California. Although traditional remedies
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were stated to be most efficacious, the majority of respondents stated that, if given a choice, they would select biomedical care because it works quickly, and it is more convenient in the U.S.Cost of care was not a major factor with this study group. Auerbach's (1982) study also supports the pragmatic view. Auerbach studied the health-care decision-making process with childbirth among the women of KsarHellal, a medically pluralistic town in Tunisia, North Africa. Factors found to affect decision making were cost of care, normalcy of the pregnancy, and anxiety avoidance. Biomedical care was selected primarily when normalcy of the pregnancy was in question. High cost and separation from other children and preference for the home environment were factors that kept these women from accessing biomedical care. Their reluctance to utilize biomedical obstetrical care was not grounded in their belief system, but rather in the pragmatic factors of cost and cultural comfort. When the pregnancy was perceived as presenting a life-threatening situation, the considerations of cost and comforts of home were put aside in favor of survival. Language and Cultural Factors
In a study of 19 Latin American immigrant families on the U.S. eastern seaboard, Ailinger (1977) found that familism, language, and culture were the most influential factors in health-care decision making. Using focused interviews, self-recording by respondents, and participant observation as methods of data collection, she found that the initial decision for most problems was made by the individual. However, if the problem became serious, the bilateral kinship network collectively made the decision for care. Close friends of the family were also influential in the decisionmaking process. If the problem escalated to a very serious state, the family would allow only a Spanish-speaking physician of Hispanic origin to treat the sick family member. This decision held, even though Anglo English-speaking physicians were in closer proximity. Pearson (1986) reported similar findings among Indochinese refugees in Boulder, CO, in regard to the effort to find physicians with linguistic and cultural closeness. Familism
According to Heller, Chalfant, Quesada, and Rivera-Worley (1981), familism, which is the collective force of the family, is a significant factor in health-care decision making: The role of familism in health-seeking behavior has only been studied in its broadest perspective. An important question for future research concerns the role played by familism as a communication network in the process of decision making concerning health-care seeking behavior among both lower and middle-class populations. (p. 541)
Heller et al. (1981) studied 100 middle- and lower-income women in Durango, Mexico. These researchers found that a high degree of familism was positively related to the utilization of biomedical care, regardless of socioeconomic level. Heller
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et al. proposed that strong family ties acted as a buffer against feelings of alienation when accessing biomedical care. In another study of the effect of familism on health-care decision making, Abasiekong (1981) studied attitudes regarding the importance of family concurrence versus individual decision making prior to hospitalization of a family member. His study was conducted in the Uyo Division of Cross River State, rural Nigeria. The study population consisted of 450 families with a total of 3,270 hospitalizations. Abasiekong found that 61% of the families strongly supported the belief that the family, rather than the ill members, should decide whether to allow hospitalization. Support for the family's decision over the individual's decision was inversely related to educational level and directly related to age. He summarized his findings as follows: An individual is not socially defined as a sick person until his claim is validated by his associates. Only when his relatives and friends accept his condition as an illness can he obtain exemption from the performance of the normal daily tasks. Since illness directly affects an entire group, it is only logical that the group should be expected to participate in the decision that must be made. (p. 49)
PROFILE: THE CAMBODIANS
Among the most cryptic and traumatized ethnic populations in the U.S. are the Cambodian refugees. From the war-torn villages and camps of southeast Asia, these recent immigrants are primarily concentrated in California and the Northwest. Over 140,000 in number, they are a young to middle-age population who have survived the Cambodian holocaust under 4 years of the murderous Khmer Rouge reign (Holley, 1986; Office of Refugee Resettlement, 1985). The Cambodians have not been assertive in seeking health care in America. This lack of assertiveness has been attributed to high levels of depression, lack of English language abilities, and a cultural bias toward avoidance of confrontive situations (Blanchard, Yao, McAlpine, & Hurt, 1986; Boehnlein, 1987; Kemp, 1985; Muecke, 1983b; Rosenberg & Givens, 1986). Further, there is widespread misunderstanding among American health-care providers of Cambodian concepts of disease causation and traditional health modalities (Falvo & Achalu, 1983; Frye, 1989; Rosenberg & Givens, 1986). Yet, the Cambodian refugee population has been targeted as the southeast Asian population at highest risk for physical and psychosocial health problems (Boehnlein, 1987; Duncan, 1987; Kinzie & Fleck, 1987; Meinhardt, Tom, Tse, & Yu, 1984; Mollica, Wyshak, & Lavelle, 1987). In one epidemiological study of refugees in Santa Clara County, CA, the Cambodians were found to be the least educated, sickest, and most depressed across all ages (Meinhardt et al., 1984). The major physical illnesses have been tuberculosis, anemia, parasitic diseases, malnutrition, sequelae of malaria, and hepatitis B (Catanzara & Moser, 1982; Meinhardt et al., 1984; Muecke, 1983a).
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Psychosocial concerns include suicide, clinical depression, somatization, and posttraumatic stress syndrome (Blanchard et al., 1986; Boehnlein, Kinzie, Ben, & Fleck, 1985; Bowlan & Bruno, 1985; Kotva, 1984; Meinhardt et al., 1984; Nolan, Elarth, & Barr, 1988). Youth have been identified as an especially high-risk group. Emotional problems in southeast Asian youth are generally presented psychosomatically (Messer & Rasmussen, 1986). The frequency of intentional drug overdose among young Cambodian women is a problem of major concern (Blanchard et al., 1986; Nolan et al., 1988). Cambodian world view is rooted in Buddhist philosophy which espouses the need to maintain equilibrium in one's life. Equilibrium results from noncompetitive behavior; respect for individuality; nurturance toward the weak, especially children and the elderly; and peaceful co-existence with the natural world. The culture stresses individual accountability for behavior and holds out the promise of a continued and improved life through reincarnation. Basically the culture says that if one is good (i.e., follows the Buddhist eight-fold path to righteousness), and does good (i.e., makes "merit" through good deeds), one will receive good (i.e., an improved reincarnated state; Ebihara, 1968; Frye, 1989; Whitaker, 1972). Health is considered a state of equilibrium and illness occurs when equilibrium is disturbed. Such disturbances are viewed holistically as affecting body, mind, and spirit. The result of such disturbances is a state of internal "bad wind." Equilibrium can be restored if the bad wind is released from the body through "coin rubbing," the practice of massaging the skin with eucalyptus oil and a heated coin. By creating reddened abrasions on the skin, it is believed that the bad wind can escape. Disequilibrium and resulting bad wind are caused by exposure to environmental forces such as high velocity winds or by imbalances of "hot" and "cold" states in the body. The body can be brought back into equilibrium by the appropriate windreleasing or oppositional treatment. For instance, childbirth which is considered a cold state must be managed with hot treatments such as liberal intake of meat, salt, wine, and hot pepper. Also, the postpartum women is restored to equilibrium by placing a charcoal burner under her bed, a practice known as "mother roasting." Hypertension, on the other hand, is a hot state and must be treated with cold foods like fruits and vegetables (Fishman, Evans, & Jenks, 1988; Frye, 1989; Kemp, 1985; Kulig, 1988; Marcucci, 1986; Martin, 1983; Ong in Bowlan & Bruno, 1985).
CULTURAL THEMES IN HEALTH-CARE DECISION MAKING
In a qualitative study of health-care decision making, Frye (1989) examined cultural beliefs and health-seeking behavior among 30 Cambodian refugee women in Southern California. The purpose of the study was to identify the cultural themes basic to health-care decision making among this population. Variables studied included perceived kinds and causes of diseases, behaviors to avoid when ill, appropriate treatments, patterns of accessing care and selecting care providers, and patterns of decision making in the family.
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Utilizing in-home interviewing in Khmer, the Cambodian language, data was gathered on beliefs about health and illness. Subsequently 226 illness episodes among 157 family members were tracked over an 8-month span. Beliefs were then compared to behaviors and to four hypothesized cultural themes: (a) beliefs about disease causation, (b) the pragmatics of the situation, (c) language and cultural factors, and (d) familism.
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Beliefs About Disease Causation Traditional belief defined the perceived kinds and causes of illnesses in this study. Illnesses in infants and children were perceived to be caused by traditionally defined sources of disequilibrium-"wind illness" resulting from exposure to environmental forces like high winds as well as states of dietary imbalance. The young were perceived to be highly vulnerable and there was much expressed fear of child mortality. Menstrual irregularities in adolescent girls were perceived to be caused by "weak blood," a state of disequilibrium. Childbearing women were perceived to be highly vulnerable and at risk for death. Pregnancy was defined as a cold state and the parturient woman was at high risk for the culturally defined disease "toa." Toa, an extreme cold state results in collapse after childbirth. It results from failure to adhere to equilibrium promoting practices during the childbearing cycle. Adult men and the elderly were perceived to be susceptible to the condition called "thinking too much," a state of excessive rumination about unhappy or tragic memories. It reflects a state of disequilibrium in which sad thoughts predominate over pleasant thoughts. Among the Cambodians in this study, wind illness, weak blood, toa, and thinking too much are culturally defined illnesses having varying causes but all resulting in a state of disequilibrium. Avoidance behaviors are the actions one takes when ill to prevent further suffering. In this study, the described illnesses and subsequent avoidance behaviors for these illnesses closely paralleled the perceived causes. For instance, there were many cases of upper respiratory infection and flu among the children. Perceived as wind illness resulting from the winter winds, these conditions were treated with coin rubbing to release the bad wind. Concurrently the child was kept inside to avoid all contact with the wind. If the child had to be taken outside, he or she was bundled heavily. Menstrual irregularity (weak blood) in adolescent girls was treated with herbal tea boiled with a nail and avoidance of cold foods like fruit. The affected girl was encouraged to eat hot foods like meat, suggesting a cultural understanding of the link between diet and anemic states. There were multiple treatments and avoidance behaviors for toa, centering on the concept of equilibrium. Toa, as a state of extreme coldness, was managed with oppositional treatment such as eating hot foods after childbirth and mother roasting. Avoidance behaviors included avoidance of emotional stress and sexual intercourse. All distressing conversation was to be avoided including any discussion of neonatal complications.
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Thinking too much as a culturally defined illness and state of disequilibrium was treated privately with family and spiritual support. Family members, especially the women, had responsibility for providing a therapeutic milieu including "talking sweet to the person thinking too much," not nagging him, and making him laugh. He was also encouraged to seek spiritual support from the Buddhist monk of Christian pastor as appropriate. When thinking too much, the affected person had to avoid alcohol and solitude. The woman was responsible for ensuring that man or the elder complied with these cultural avoidance behaviors especially the intake of alcohol. In this study of Cambodian women, the cultural theme of belief about disease causation held for the definition of kinds and causes of illnesses, avoidance behaviors when ill, and some treatments. Pragmatics of the Situation
However, there was a pragmatic mixing of traditional treatments with scientific medicine especially with the infants, children, and adolescents. Often the children were receiving coin rubbing, traditional herbal teas, antipyretics, and antibiotics simultaneously. There was close adherence to the traditional practices among childbearing women, suggesting the strength of the cultural beliefs surrounding childbearing. They sought limited prenatal care and hospital admissions for birthing. However, in emergency situations with women or children, scientific care was readily sought. Examples of such cases in this study included febrile convulsions in an 8-month-old infant with measles, spontaneous abortion in a grand multipara, and chest pains in an elderly woman. Psychologically defined illness, such as thinking too much, was treated within the family and the ethnic community, although diagnosed posttraumatic stress syndrome was treated with a mixture of traditional and scientific approaches. Language and Cultural Factors
In spite of being surrounded by a large number of primary and tertiary facilities within a 10-mile radius, almost exclusively, the participants and their families in this study accessed care in distant settings of linguistic and cultural comfort. The exceptions to this pattern were emergencies as just described. Most of the informants reported driving 60 to 80 miles to seek culturally acceptable care. Physicians were chosen based on language and cultural factors. A few physicians either spoke Khmer or had a Khmer translator. More commonly, the non-Khmer speaking physician was accessed based on recommendation of a Cambodian friend. Continuation with the physician was based on feelings that the physician had a caring attitude and was making an effort to understand the Cambodian ways. There are very few elderly traditional Cambodian healers, Kru Khmer, available in America. In this study, treatment was provided either by a physician or by the woman in
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TABLE 1 Cultural Themes in Health-Care Decision Making Among Cambodian Women
Ttaditional Beliefs Kinds of Illness Causes of Illness Avoidance Behaviors Treatment Decision-making patterns Pragmatics Treatment-mixture of scientific and traditional modalities Language and Culture Access to care Selection of care providers Familism None
the family using traditional Cambodian remedies. The cultural theme of language and cultural factors held for access to care and the selection of care providers. Familism
Familism was hypothesized as a cultural theme in the Cambodian health-care decision-making pattern. Farnilism was not shown to be a cultural theme. The mother in the family was perceived to be the decision maker in nearly all situations with the children and the adolescents. The father had a central role in decision making when there were long-term, chronic problems with the children. There was an individual decision-making pattern in health-care matters among the adult men and women and the elders, reflecting the cultural bias toward respect for individual accountability. Among this study population, the cultural themes operating in health-care decision making included beliefs about disease causation, pragmatics, and language and cultural factors (see Table 1). IMPLICATIONS FOR NURSING PRACTICE
The World Health Organization (WHO) strongly supports the development of care giving strategies which build on cultural strengths of a population. Such culturally sensitive care promotes self-reliance and self-esteem (WHO Technical Report, 1983). Central to the Cambodian culture is the concept of equilibrium. When illness occurs, the culture promotes restoration of equilibrium through prescribed treatments and adherence to defined avoidance behaviors believed to contain the disease process. This goal of restoration of equilibrium is the core on which nursing care can be planned for the Cambodian patient and family. Cultural Theme: Beliefs About Disease Causation
The classification of kinds and causes of illness by the Cambodians differs from the classification scheme utilized by the professional nurse. Nonetheless, there is a common element. The Cambodian explanation of equilibrium is the nursing concept of
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homeostasis. Examples of especially important ways of maintaining homeostasis are protection from the winds and ingestion of foods to restore balance. These practices are based in deeply rooted beliefs about the interaction and integration of the body, mind, and spirit. The nurse is in a key position to explain this cultural expression of homeostasis to other health-care providers. lladitional treatments and avoidance behaviors are ways that a culture tries to protect its sick members. In the Cambodian culture this protective behavior is shown through encouraging certain foods. Hot food is given to the parturient woman to protect her from toa. This food is strengthening, iron-rich food. Cold food is given to a hot or hypertensive person. Cambodian cold foods are foods high in fiber and low in sodium, the foods which promote energy and decrease blood cholesterol. Protective behavior is also shown through touch. Coin rubbing involves a substantial amount of touch. It is a relatively harmless procedure which usually only causes vasodilation. It has the effect of a massage. These protective behaviors are the ways of the people to restore equilibrium. The nurse as an advocate, can encourage American health professionals to avoid interference with these traditionally based practices unless obvious harm is resulting. Cultural Theme: Pragmatics in the Situation
The Cambodians cling to traditional treatment as it provides a sense of comfort and control over illness, especially when that illness is experienced in an alien culture. It seems reasonable to expect rather than to be surprised by this clinging to the traditional explanations and remedies. Yet the Cambodians have also demonstrated considerable acceptance of scientific treatment, pragmatically merging both systems. The Cambodians are a people who have barely escaped extinction. Their selfreliance and self-esteem capabilities have been severely tested. They have emerged as an immigrant people capable of integrating new ways with old ways. At this point in their history, they need the support, not the criticism, of the health-care community in this integration process. The nurse is in a key position to interpret this merging of cultures and practices to other health-care providers. Cultural Theme: Language and Cultural Factors
The Cambodians in this study indicated that the key factor in accessing health care was language and cultural comfort. Even if a language barrier was present, they would continue with a selected care provider if there was an attitude of caring and willingness to learn about the Cambodian ways. The Cambodians have taken many steps toward learning American ways. The nurse, as interpreter of the culture, can adapt care and encourage adaptation of care to include Cambodian ways including nonconfrontive and highly personalized approaches. This kind of flexibility will perhaps encourage the Cambodian patient to seek routine health care locally, not just in emergency situations.
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Health-Care Decision Making
In this study, the mother was the primary health-care decision maker for all ages of children. Adults showed an individual decision-making pattern consistent with the Cambodian cultural value of individual accountability for behavior. The Cambodian culture highly values interpersonal relationships, built on collaboration and mutual support. If decision-making patterns are respected and not challenged, the Cambodian patient and family is likely to reciprocate with smiling compliance. Violation of these decision-making patterns is likely to be met with indirect, resentful noncompliance. One Cambodian woman described her experience as follows: In my country I felt so special when I had my first two babies. I had them in my own home and my mother was with me. She took very good care of me and I got to decide what I wanted. I had good food, a warm bed, all my friends visiting me and plenty of rice wine. When my third baby was born in the refugee camp, it was hard but the nurse was so kind to me. She gave me plenty of hot food and my bed was warm. Here in America I was so afraid I would get toa and die because everything is so cold-the beds, ice water, the wrong kinds of food after delivering a baby. The nurses told me to eat lots of fruits and vegetables, but that is cold food! They wouldn't let me make any decisions. They wouldn't even let my other children come and play with the new baby. That is very important. Otherwise how will their spirits get to know each other? So I just smiled at the nurses but I did not listen to them. SUMMARY The Cambodians are adapting to the American ways while still holding firmly to their culture. Such cultural identity provides security and a sense of equilibrium. With the Cambodian patient, providing culturally sensitive nursing care centers on supporting the concept of equilibrium. In this endeavor, the nurse plays multiple roles advocate, culture broker, educator, and friend. REFERENCES Abasiekong, E. (1981). Familism and hospital admission in rural Nigeria-A case study. Social Science and Medicine, 1563 45-50. Ailinger, R. (1977). A study of illness referral in a Spanish-speaking community. Nursing Research, 26(1), 53-56. Auerbach, L. (1982). Childbirth in Iitnisia: Implications of a decision-making model. Social Science and Medicine, 16, 1499- 1506. Blanchard, P., Yao, J., McAlpine, D., & Hurt, R. (1986). Isoniazid overdose in the Cambodian population of Olmsted County, Minnesota. Journal of the American Medical Association, 256, 3 13 13133. Boehnlein, J. (1987). Clinical relevance of grief and mourning among Cambodian refugees. Social Science and Medicine, 25, 765-772. Boehnlein, J., Kinzie, J., Ben, R . , & Fleck, J. (1985). One year follow-up of post traumatic stress dis-
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Bowlan, J., & Bruno, E. (1985). Cambodian women's project: Proceedings from the Conference on Cambodian mental health. New York: American Friends Service Committee. Catanzaro, A., & Moser, R. (1982). Health status of refugees from Vietnam, Laos, and Cambodia.
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Journal of the American Medical Association, 247, 1303-1 307. Duncan, J. (1987). Cambodian refugee use of indigenous and western healers to prevent or alleviate mental illness. Unpublished doctoral dissertation, University of Washington. Ebihara, M. (1968). Svay: A Khmer village in Cambodia. Unpublished doctoral dissertation, Columbia University, New York. Fabrega, H., & Manning, P. (1979) Illness episodes, illness severity and treatment options in a pluralistic setting. Social Science and Medicine, 138 41-51. Falvo, D., & Achalu, D. (1983). Differences in perceptions of health status and health needs between refugees and physicians providing care. Health Values, 7(5), 2Q-24. Fishman, C., Evans, R., & Jenks, E. (1988). Warm bodies, cool milk: Conflicts in postpartum food choice for Indochinese women in California. Social Science and Medicine, 26, 1125-1132. Frye, B. (1986). Health beliefs of selected Southeast Asian cultures. Unpublished manuscript, Loma Linda University School of Public Health, Loma Linda, CA. Frye, B. (1989). The process of health care decision making among Khmer immigrants. Unpublished doctoral dissertation, b m a Linda University, Loma Linda, CA. Heller, P., Chalfant, H., Quesada, G., & Rivera-Worley, M. (1981). Class, familism and utilization of health services in Durango, Mexico: A replication. Social Science and Medicine, 15A, 539-541. Holley, D. (1986, October 27). Refugees build a haven in Long Beach. Los Angeles Times, pp. 1-4. Kemp, C. (1985). Cambodian refugee health care beliefs and practices. Journal of Community Health Nursing, 2, 41-52. Kinzie, J., & Fleck, J. (1987). Psychotherapy with severely traumatized refugees. American Journal of
Psychotherapy, 41, 82-94. Kotva, L. (1984, November 7). Monk Lok San on Cambodians' dreams. City Pages, pp. 5, 7. Kulig, J. (1988). Childbearing among Cambodian refugee women. Canadian Nurse, 84, 46-47. Marcucci, J. (1986). Khmer refugees in Dallas: Medical decisions in the context of pluralism. Unpublished doctoral dissertation, Southern Methodist University, Dallas. Martin, M. (1983, June). Elements de medecine traditionnelle Khmere [Elements of traditional Khmer medicine]. Seksa Khmer, pp. 135-17 1. Meinhardt, K., Tom, S., Tse, P., & Yu, C. (1984). Santa Clara County Health Department Asian health assessment project. San Jose: Santa Clara County Health Department, Division of Mental Health Services. Messer, M., & Rasmussen, N. (1986). Southeast Asian children in America: The impact of change. Pe-
diatrics, 78, 323-329. Mollica, R., & Wyshak, G., & Lavelle, J. (1987). The psychological impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572. Montero, D. (1979). VietnameseAmericans: Patterns of resettlement and socio-economic adaptation in the United States. Boulder, CO: Westview Press. Muecke, M. (1983a). Caring for Southeast Asian refugee patients in the USA. American Journal of
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Office of Refugee Resettlement. (1985). Refugee Reports, 5, 23-24. Rosenberg, J., & Givens, S. (1986). Teaching child health care to Khmer mothers. Journal of Commu-
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World Health Organization Technical Report, Series 690. (1983). New Approaches to health education in primary health care. Geneva: Author. Young, J. (1981). Medical choices in a Mexican town. New Brunswick, NJ: Rutgers University Press. Young, J., & Garro, L. (1982). Variations in the choice of treatment in two Mexican communities. Social Science and Medicine, 16, 1453-1465.
