hmong americans and healthcare inequalities and solutions. b.a

Hmong Americans and Healthcare Inequalities and Solutions

By

Aurea A. Berger

Senior Thesis in Asian American Studies

San Francisco State University

Professor Jonathan H.X. Lee

May 2011

3

ABSTRACT

The Hmong Americans are the newly added component of United States society. Due to

lack of written language, exposure to harsh living conditions in refugee camps, and war, Hmong

Americans’ adjustment to life in the United States has not been an easy process. As refugees,

most of them have to rely on welfare for cash assistance and healthcare, especially the first

generation immigrants. However, due to the existence of inequities in the US healthcare system

as well as cutbacks on welfare budgets ─ many Hmong Americans ─ are without health

insurance and are poorly served in the US healthcare system. The purpose of this research paper

is to bring awareness to the existing problem that harms the health of the Hmong American

community. Oral interviews, in-depth research, and questionnaires are used to investigate the

problem regarding the ongoing healthcare issues that affect the Hmong American community.

The findings of this research indicate that the Hmong Americans are indeed being served poorly

in the US healthcare system because of lack of interpreter service (i.e. translator), conflict

between the Hmong traditional healing methods and the Western health practices, and the lack of

understanding by the Western health providers of Hmong American culture.

HMONG AMERICANS AND HEALTHCARE 4

Hmong Americans and Healthcare: Inequalities and Solutions

This research paper explores the Hmong American community and the inequities in

healthcare in the United States. The Hmong American community is poorly served in the United

States healthcare system. Although this group is given the opportunity to be part of American

society, health disparities and inequality continue to burden their everyday lives. This research

paper will be divided in five sections. First, the racial and social positions of the Hmong

Americans will be discussed. Second, the social inequalities that exist in the Hmong American

community will be examined. Third, the chronic diseases that afflict this group will be closely

inspected, emphasizing the plight of the elderly, low income, and newly arrived immigrants.

Fourth, the quality and utilization of healthcare services will be analyzed, which would also

include access to primary and preventive care. Lastly, the health disparities and health

inequalities that impact the Hmong Americans will be summarized and recommendations will be

offered to address these problems.

Review of Literature

Who are the Hmong Americans?

After the end of the Second Indochina War in 1975, tens of thousands of Hmong refugees

immigrated to the United States. The Hmong are mountain-dwelling of people of Laos; while

most of the world’s Hmong live in China, two southern groups live in Laos, the White and the

Blue (Vang, 2011). In July 23, 1962, United States, North Vietnam, and other fourteen nations

signed the 1962 Geneva Agreement, guaranteeing the neutrality of Laos. However, the US

Central Intelligence Agency (CIA) believed it could intervene in the post-independence politics

of Laos to promote conservative, anti-Communist influences. In order to keep Laos as an asset

HMONG AMERICANS AND HEALTHCARE 5 in the war against North Vietnam, the CIA waged a secret war in Laos. Hmong soldiers in

General Pao’s “Secret Army” helped the CIA restrict the usage of the Ho Chi Minh trail as

passage to attack South Vietnam (Ely, 1990). After the US-backed regime in South Vietnam

ended in 1975, Vietnamese military allies were airlifted to the United States along with their

family.

The Hmong who came to the US lived in the mountainous regions of Laos and their

livelihood was slash-and-burn agriculture. Hmong do not have a written language. The Hmong

language is only in the form of oral communications (Vang, 2011). Being refugees, transition to

a new life caused massive anxiety, which led to stress and trauma (Ostergen, 1991; Lee, 1993).

The Hmong Americans transition to Western living is not easy. As newly arrived members of the

American society, they have to start building their new lives. As a result, the Hmong Americans

are underrepresented in the socioeconomic and racial hierarchy of the US society.

Racial and Social Positions of Hmong Americans in the US Society

As refugees, the Hmong Americans’ adjustment to life in United States has been very

harsh. There have been many barriers that led them to suffer high level of stress and cultural

shock. Upon arrival in the United States, they became concentrated in Fresno, Minneapolis,

Rhode Island, and Texas. Huping Ling presents evidence that Hmong are underrepresented in

politics, health, and business (Ling, 2008). Hmong Americans often report feeling that their lives

are empty and meaningless. Language barriers and traditional religious beliefs and rituals are

only a few of the reasons for their anxiety. Difficulty adjusting to a new culture by Hmong adult

refugees caused isolation from the main society and reluctance to take advantage of the

healthcare system (Lee, 1993). McInnis, et al (1990) argue that the Hmong are the most

HMONG AMERICANS AND HEALTHCARE 6 disadvantaged among the Southeast Asian refugees because they have large families that were

unemployable and had little education. Since their arrival in the United States, the government

has tried to disperse them to several states in order to reduce the burden to each state’s welfare

resource and to avoid conflicts with the rest of the members of the host society (Trueba, 1990).

The Refugee Act of 1980 offered welfare support to the Hmong Americans which helped them

start a new life. However, due to the country’s fluctuating economic conditions, refugees and

welfare dependents are getting negative pressure from the changing welfare policies. “With

respect to Hmong refugees, Wisconsin is an important state to examine for many reasons. It is

home to the largest Hmong refugee population in the United States. Over the past few decades,

the rapid growth of this refugee population and their unique and multiple needs have brought

challenges to the state’s welfare system” (Kretsemadas and Aparicio, 2004). In a research article

entitled, Community-Based Participatory Action research: Offering Hmong Welfare Recipients’

Voices for Dialogue and Change, Kalyani Rai presents evidence that poverty and welfare

dependency continue to plague the Hmong Americans in Wisconsin; thus, a program was

developed to increase their active participation in dialogues to mobilize their social and

economic status (Rai, 2004). Despite the studies on ways of eliminating welfare dependency, one

question remains to be answered: How will the Hmong Americans rise up from poverty if

language barriers and isolation continue to plague them as adults? For this reason, the Hmong

Americans socioeconomic inequalities remain remarkably high at present times.

Social Economic Inequalities in the US Society

In 1982, President Reagan issued a new policy initiative regarding welfare called the

New Federalism wherein the states were responsible for Aid to Families with Dependent

HMONG AMERICANS AND HEALTHCARE 7 Children (AFDC), one of the welfare programs impacting the Hmong American households.

Hmong Americans were heavily harmed by the welfare reforms. According to Mark E. Pfiefer,

“34.8% of U.S. Hmong families lived below the poverty level in 1999 compared to 12% of all

U.S. families (2005). In 2006, the poverty rate of Hmong American was 26.4% and 44.9% for

families with female as head of household and no husbands (Pfeifer, 2008). Some oral histories

were documented witnessing the serious impact of welfare reform to the Hmong American

community (Fujiwara, 2008), along with some research and studies of the Hmong American

family (Koltyk, 1998). Several Hmong American soldiers were denied benefits by Department of

Veterans Affairs, despite the fact that the US government used them in their “Secret Army” (Ely,

1990), for intelligence and combat support during the second part of the American War with

Indochina.

As with the Japanese Americans, Filipino Americans and Chinese Americans, Hmong

Americans also experienced discrimination and racism by the US Department of Housing and

Urban development. “In contrast, the large Southeast Asian population was generally reluctant to

leave public housing; Hmong residents, in particular, strongly opposed relocation. The Hmong

had only recently immigrated to the United States. Living in a tightly knit community with other

Hmong is an integral part of their cultural identity; separating clans and family through

relocation disrupts this strong connection” (Popkin, Galster, Temkin, et al, 2003, p. 189-190).

The housing, where these minorities reside, is characterized by violence and high crime rates,

poorly maintained property, and social ills. Overall, the surroundings are poor and toxic, which

contributes to the poor health and chronic diseases of the Hmong American residents in that area.

HMONG AMERICANS AND HEALTHCARE 8 Chronic Diseases that Impacts Hmong Americans

Moving to an unfamiliar place and experiencing events like war causes trauma and stress

to refugees. To be a refugee is a very sad experience for anyone. It could mean losing your

culture, identity, and physical security. The Hmong Americans suffered from the exposure to war

and refugee camp living conditions. One of the chronic diseases that plague the Hmong

Americans, especially adult male is Sudden Unexpected Nocturnal Death Syndrome (SUNDS),

wherein the cause of their death is unknown (Adler, 1991). Many of the Hmong refugees also

suffered mental health issues like Post Traumatic Stress Disorder (PTSD) and depression, due to

their exposure to combat (Choi, 2001; McInnis, Petracchi, and Morgenbesser, 1990; Prior 1994,

Lee 1993). Hypertension, obesity, tuberculosis, death due to violence, and a rare form of cancer

on nasal cavities, are some of the chronic diseases that impact the Hmong Americans (Ling,

2008; California Newsreel, 2008). If Hmong Americans are not immune to disease brought by

psychosocial adjustment, how will US society response to their demands of care? How do they

access healthcare?

Access to Healthcare and Utilization of Health

Since the Hmong arrived in the United States, their health coverage is automatically

covered by the US government. At present, in California, Hmong Americans experience limited

access to MediCal due to language barriers and computer errors in inputting Hmong information

to the database (Health Rights Hotline, 2006). There is limited access to language information

provided by MediCal; thus problems on billing and denial of care are a common issue. Also, due

to the strong beliefs of many Hmong Americans in traditional healing, misunderstanding and

contradictions between the Hmong American patient’s family and clan on the one hand, and the

HMONG AMERICANS AND HEALTHCARE 9 health provider on the other, becomes a continuing issue in accessing conventional health in the

US health care system (Cha, 2001; Mote, 2004; Koltyk, 1998; Lee, 1993). The Hmong

American’s isolation prevents them from accessing health benefits. “There were no instances in

which American friends were used for support, and only a handful of people stated that they

sought help from health and mental health services”(Lee, 1993). Training and education about

Hmong American social and cultural perception is necessary for health care providers and health

advocates; while educating Hmong Americans about Western health system and health

prevention will help make the Hmong Americans live longer and better.

In response to the continuing problem in the United States regarding the uninsured, the

federal government created the Patient Protection and Affordable Care Act. The Patient

Protection and Affordable Care Act, is part of President Obama’s Health Care Reform of 2010.

Hence, the Southeast Asia Resource Center (SEARAC), a non-profit organization whose aim is

to empower the Cambodian, Laos, and Vietnamese American community, partnered with their

community advocates in creating a program to make sure that the Southeast Asians voices are

heard and represented in the decision-making in carrying out the goal of the Affordable Care

Act. This effort is being collaborated from five states such as: California, Minnesota, Louisiana,

Maryland, and Pennsylvania, in response to the first year anniversary of the signing of the

Patient Protection and Affordable Act (SEARAC, 2010). In addition to this, Hmong American’s

advocates and community center organized the Hmong Health Collaborative ─ a program whose

aim is to harmonize Hmong traditional healings with Western health methods. For example,

Western health providers and hospitals allow the Hmong American patients to be visited and

treated by a shaman while being treated at a Western medical institution (Lee’s interview, 2011).

HMONG AMERICANS AND HEALTHCARE 10 These efforts on both parts of the government, the Hmong American advocates and communities

have improved the health prospects for Hmong Americans, but they are offset by the general

decline in social services everywhere in the US.

Health Disparities and Health Inequalities in the US Healthcare System

There are many reasons for disparities in the US healthcare system. One is that medical

research tends to lump different Asian groups together, so that health risks that affect one group,

such as ─ Hmong Americans ─ are averaged out with other groups with very different risks

(American Heart Association Scientific Statement, 2010). Similarly, social disparities in cancer

results from the lack of research regarding the impact of cancer on specific ethnic minorities.

Lack of insurance health coverage prohibit the less privileged ethnic minorities from accessing

prescreening for cancer and increases their risks of death from cancer. Researchers argue that:

The issue of heterogeneity applies equally to the underlying causes of disparities. The application of the research grid made clear that research in this area is far from one-dimensional in its findings, and can sometimes lead to surprises. For example, it is commonly thought that disparities are the result of differences in screening rates, but public health success stories in breast cancer and cervical cancer screening have all but eliminated the screening differentials - yet differences in outcome remain. Thus, researchers need to examine health status prior to diagnosis as well as the intermediate steps - diagnosis and treatment - to understand why these disparities persist (Weissman and Schneider, 2005, p.73).

Researchers need to differentiate among the challenging issues facing ethnic Chinese,

Hmong, Cambodian, and other Southeast Asian ethnicities. Furthermore, financial difficulties

put a burden in the health and life of adult people. “Nevertheless, disparities in life chances

persist within the population, with health surveys clearly showing that rates of mortality,

morbidity, and functional limitation continue to be higher for persons with limited social and

HMONG AMERICANS AND HEALTHCARE 11 economic resources as well as for racial and ethnic minorities” (Kahn and Pearlin, 2006, p. 17).

Due to poverty, low income minorities are forced to reside in an unhealthy area, with high

number of crimes and drug dealings, which causes stress that leads to serious health problems.

Likewise, Alameda County, the subject of study tracing the influence of poverty on people’s

psychological well-being,(Kahn and Pearlin, 2006), and a Hmong American family who are

residents of Richmond, a county in Alameda, California, show evidences of poverty’s impact on

health (California Newsreel, 2008).

Methods and Data

In doing this research, various sources were employed. I primarily used textbooks,

journal articles, and internet sources. As support for data gathered during research,

questionnaires and interview were also employed. The subjects for the questionnaires consisted

of five elderly Hmong Americans from Merced, California; a highly educated Program Director

of a non-profit organization that serves the Hmong Americans in Merced and one middle-age

Hmong American woman from Stockton, California. The surveys consisted of the following

eleven questions:

1. Do you have access to health insurance?

2. If you, how often do you see your health care provider/doctor/

3. How often do you see a dentist?

4. What kind of health insurance do you have?

5. If ever you have to change health insurance coverage and health care provider, do you

know whom to ask for help?


6. Do you encounter difficulty in accessing the customer service hotline? If so, what are

those problems you encounter?

7. How do you rate your health at present? Please use the scale 1-5, as in: 1 =worst, 2=good,

3=better, 4= best, and 5- excellent?

8. When you get prescription for medications, do you encounter problems purchasing using

your health insurance card? If so what kind of problems?

9. How often do you visit your health care provider for check-ups?

10. Any problems that deal with accessing the health care provider network?

11. Please list any recommendations that can help improve the healthcare service provided to

Hmong Americans.

The questionnaires also requested which health insurance coverage is mostly utilized by

the Hmong Americans community, especially in the Central Valley area. The results and

findings for these questionnaires interview will be discussed in the next section. The survey was

done on a two- day visit because of the number of Hmong Americans who visit the Merced Lao

Family Community Center varies from day to day. On the last day of the researcher’s visit, Miss

Juoa Lee, Program Director of the Merced Lao Family Community Center, answered all the

questions presented to her. The interview was conducted with the goal of gathering more valid

evidences regarding the utilization of the health care system by the elderly Hmong American

community in Merced, California. Furthermore, to conduct a more factual research, one middle-

aged Hmong American woman, who is a second generation Hmong American, was also asked

to answer the health care questionnaire. Although, the human subjects for the research and

HMONG AMERICANS AND HEALTHCARE 13 interview are limited, all of the methods used in this research successfully provided factual and

good evidence for the validity of the research argument.

Analysis and Findings

The Hmong American communities are a new additional component to the Americans

society. Many studies have been done by various non-profit organizations, scholars, and medical

organizations to ease their transition. Due to lack of written language in their homeland,

acculturation and assimilation became one of the major problems encountered by the Hmong

Americans since their arrival. The objective of this research paper is to find solutions to the

problems to help Hmong Americans get better access to healthcare and maximized its benefit.

There were several questions during this research. These questions are as follows:

• What are the barriers that hinder Hmong Americans from accessing health care

benefits?

• Is being poor a hindrance to good health among Hmong Americans?

• How could the government help ease the Hmong Americans access to health care?

• Should Hmong Americans traditional beliefs be abandoned in order for them to

maximized benefit offered by Western health care medicine?

• What is the impact of health disparities and health inequalities to Hmong Americans’

health? If so, how could these problems is eliminated?

The migration of the Hmong Americans to the United States is the result of CIA’s secret war in

Laos. After the Second Indochina War ended in a communist victory, the US government was

obligated to help its Hmong allies and their dependents move to US to avoid potential reprisals

by the new Lao regime. Hence, most Hmong arrived as refugees; some relied on welfare and

HMONG AMERICANS AND HEALTHCARE 14 Refugee Act grants. Because of the extreme cultural differences between rural Laos and urban

America, Hmong refugees had a hard time adjusting to life in America. The Hmong American

adults became socially isolated from the rest of the American society because of their lack of

English proficiency. Some have found jobs but these jobs offer inadequate pay and no health

insurance coverage.

Studies found out that there were several reasons for the reluctance of the Hmong

Americans to access Western healthcare services. These are:

1. the language barrier,

2. errors inputting Hmong American data in computer databases

3. the cultural aspects of the Hmong Americans such as traditional beliefs

4. and the cultural insensitivities on the part of health care providers.

One of the reasons why Hmong Americans are hesitant to seek the help of Western healthcare

provider is the language barrier. Although, they only come to see a provider when they are

already very sick, Hmong Americans find it hard to communicate their symptoms to the provider

without a Hmong interpreter; consequently, they often do not return for follow-up appointments

or they misunderstand the instruction of the doctor. Cultural differences make it hard for the

older patients to ask questions to the doctor regarding their diagnosis or prescription. Also, if

there is an interpreter available, there is no guarantee that the interpreter is fully effective

because of the interpreter may lack the knowledge regarding the Hmong American patients’

background. Studies had been found this to be the weak point in using the interpreter method

among the Hmong Americans.


To be in the bottom of the ladder of the society is also a hindrance for accessing the

healthcare system. Since they do not make enough money and work menial jobs, healthcare

insurance is hard for them to obtain; thus, access to see medical specialists is sometimes

impossible. This makes it hard for them to notice and respond promptly to cancer when it

appears. Lack of knowledge of the health field itself is another issue. Since they are poor, they do

not get the proper education to understand more about the advantage of the Western healthcare

instead on traditional beliefs in healing the illness. The Hmong traditional belief of healing is

limited to shamanic rituals, herb usage, and massages. The Hmong Americans believed that a

man’s body is composed of twelve souls. They say that a person is sick physically if he cannot

do what a normal active person does like playing, singing, working, smiling, jumping and

anything a physically active person can do. Sometimes, when a person is already too sick and all

the traditional healing were exhausted, then that’s the only time the Hmong Americans seek help

from a Western health provider for treatment.

Every time a non-profit organization or a US government department do a census or

survey, there is a problem with grouping the Asian Americans as one homogenous group. When

research are done using Asian Americans as one big group alone; then, the impact of diseases on

each subgroup are not carefully being studied and evaluated. Hence, the health disparities

become health inequalities. Health inequalities is the result of not being able to fully analyze and

seeing the results of the difference on health between socially advantage and the socially

disadvantage group or from one ethnicity to the other; thus, the socially disadvantage groups

diseases is not fully studies and causes them to suffer more due to lack of information for

treating their disease. If the different ethnicities in the US are surveyed as subgroups, then,

HMONG AMERICANS AND HEALTHCARE 16 understanding the problems and causes of their diseases will help find a better way to treat their

illnesses better. Not until the government finds a systematic way to understand and study how

each disease impact each different ethnicity; ethnic minority’s access to Western healthcare is

not really maximized.

As a result of the budget cuts in 1984, the California state government terminated the

Hmong interpretation services at various medical center and welfare services office. The

interpreter services are available on a seasonal basis and on casual occasions only. The Hmong’s

only choice is to use their children as interpreters. Since the children are less exposed to Hmong

traditional healing methods, they are often embarrassed by their elder’s preferences; often they

are reluctant to admit to accredited medical personnel that their elders use traditional methods.

At the same instance, the doctor presumed that the information provided by children is correct;

thus, they do not question the children any further at all.

Furthermore, when the University of Wisconsin partnered with the W.K.Kellogg

Foundation to study the Hmong Americans welfare recipient to self-sufficiency, they found out

that Hmong Americans, who suffered psychological problems, complained that their efforts on

behalf of the US government during the Vietnam War had been ignored. For example, they do

not receive access to counseling services. “The Hmong population in Wisconsin includes a high

proportion of adults with barriers to learning. There are Hmong welfare recipients who need

mental health counseling and training to facilitate their transition through and off welfare. They

are not provided with these essential services to meet their needs” (Kretsemadas and Aparicio,

2004).


Aside from the poor communication between the Hmong American children interpreters,

the cultural differences also contribute to the difficulty in accessing healthcare by Hmong

American adults. The filial piety is a big issue among Hmong Americans. Children often do not

question the Western medical provider because of the respect for authority; thus, poor

communication is always the result, making it a problem of language barrier and lack of

interpreter services. In addition to this, the lack of medical brochures and pamphlets written in

Hmong language pertaining to diseases like hypertension and cancer impede the Hmong

Americans in accessing Western Medical treatment resulting in a more serious health condition.

When surveys are done by the United States government the minority are lumped

together as groups; thus the differences between different subgroups’ diseases are overlooked.

For example, the misclassification of ethnicity when inputting data on death certificates causes

errors in determining risk factors. When Asian Americans are surveyed, they are often lumped

together as a single “race”; as a result, differences in the incidence of illnesses that affect these

Asian American subgroups are often overlooked and not studied. It should be remembered that

different illnesses has different impact on each ethnicity.

The lack of transportation and information for accessing health coverage such as

changing the healthcare providers, are two major problems found among Hmong Americans.

Some Hmong Americans do not know whom to ask about issues of changing primary health

providers and primary dentists. The difficult experiences of Hmong Americans in dealing with

the customer service issue of Medical, a California state medical program, remains a problem for

the Hmong Americans. Sometimes, due to errors of the data entered on the computer database

often lead to termination of coverage for the Hmong Americans. Also, erroneous bills are sent by

HMONG AMERICANS AND HEALTHCARE 18 healthcare providers to Hmong Americans, not screening if they are eligible for charity and

financial assistance offered by county programs. Another added issue is the access to customer

service. The Hmong Americans have difficulty accessing healthcare benefits because of the lack

of interpreter services or customer service representatives who speak Hmong language. Due to

this issue, Hmong Americans call is left unanswered.

Based from the oral interview with Miss Juoa Lee, the Program Director of Merced Lao

Family, the Hmong American advocates in the Merced County launched a program called the

Hmong Health Collaborative. The mission of the Health Hmong Collaborative is to incorporate

the Hmong traditional healing method with the western health method in order to better serve the

Hmong Americans in the Merced and Sacramento area. Although this program was approved,

Miss Juoa Lee, still hopes that this method will be used to serve the entire Hmong American

population in the United States. In addition to this, the questionnaires results showed evidence

that Hmong Americans lack the support of the government in providing dental health insurance.

Five out of the six Hmong Americans, who filled up the questionnaires for this specific research,

do not have any dental health coverage. The reason for their lack of dental health insurance is the

elimination of the dental services by Medical of California. Dental hygiene is very essential in

maintaining our physical well-being. How could we promote a well-develop and healthy

communities if the elderly, the underrepresented, and the children are poorly serve in the United

States healthcare system? The following section shows the result of the questionnaires gathered

from among the six Hmong Americans from Merced County, California.

HMONG AMERICANS AND HEALTHCARE 19 Results from the questionnaires taken from Hmong Americans in Merced, California on March 31, 2011:

Tabulated Results for the Questionnaire

Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6

Have access with health insurance Yes Yes Yes Yes Yes Yes

Number of visit to the doctor

once in every 2-3 months

about 4-5 times per year


About 4-5 times per year

once every other month as needed

Number of visit to a dentist None None None None None None

Knowledge in getting help to change providers Yes No Yes No Yes Yes

Difficulties accessing customer service hotline Yes Yes Yes Yes Yes No

Problems in accessing prescription medicine No No No No No No

Number of visit for check-ups

Only when sick


only when sick


Only when sick

only when sick

Problems with accessing health network No Yes No Yes No No

Recommendations

Subject 1

Subject 2 Subject 3 Subject 4 Subject

5 Subject 6


None Interpreters None

Speakers Customer Service

Representatives

Need Hmong

translators

Hence, it is for the advantage of everyone else in the United States that the government

should not cut back on healthcare system financially. If possible funding the research for health-

care should be maximized as well as education. By educating the researchers and the people of

the society about diseases and health, it is a reassurance of a healthy, happy society. As a

research, I recommend the following theory to help the easy access of Hmong Americans to US

healthcare system: The Worked-based Learning and Conventional Learning Model.

Work-based Learning Model

1. Offering health educational program and clinical training to Hmong American young

adults and Hmong American adults should be implemented such as: registered nurse,

doctors, dentist, nurse’s aide, pharmacy technicians, medical receptionist, and

medical transcriptionists; so, as they can help educate the elders.

2. Training and hiring more Hmong American adults and students as interpreters in the

health field industry is an option.

3. Offering scholarships for other Southeast Asian Americans to become interpreters

help serve underrepresented minorities will help ease the burden of minorities who

lack the English language proficiency.

4. Requiring units on continuing education to Western healthcare providers and holding

annual conferences about different ethnicities culture will help Western health


providers gain knowledge and understanding of the Hmong Americans culture and

the importance of the traditional healing beliefs and practices to the ethnic minorities.

Conventional Learning Model

1. Improving the system of data entry in the government bureau’s computer database.

2. Organizing healthcare fairs in the Hmong American communities that include free

lunch and games for kids during the fair will encourage attendance to this educational

event.

3. Improving the interpreter service by hiring more Hmong American teenagers or

anyone who have knowledge of Hmong American culture.

4. Medical schools should adopt a curriculum about ethnic studies in order to help

students to be culturally-sensitive to diverse people.

This research hopes that all the above recommendations could contribute to easing the

problems of the Hmong Americans and any other underserved communities in preserving and

promoting their good health.

CONCLUSION

In the course of this research, I found out that although there are few developed programs

that help ease the problems of Hmong Americans in utilizing the healthcare system of the United

States, the Hmong Americans are overall still poorly served in the United States healthcare

system. Data gathered from interviews and questionnaires confirmed that Hmong Americans

need translators in accessing healthcare and in utilizing the western health methods. At the end of

the research, several issues were identified that continue to plague the Hmong Americans in the

United States healthcare system. First, language barrier is found to be the number one issue.

HMONG AMERICANS AND HEALTHCARE 22 Since, the first generation Hmong Americans do not speak and understand the English language,

they need translators to utilize the western health system. However, when welfare funds were cut

and California Medical cut health services, Hmong translation services were cut, making the

situation hard especially for the elderly Hmong Americans. Dental coverage was eliminated and

access to customer service hotline became a problem to the Hmong American community.

Although, several organizations like Southeast Asian Resource Center, Health Hmong

Collaborative, scholars, and other community advocates found ways to ease some of the

problems of the Hmong Americans in finding social just and equality, the Hmong Americans are

still poorly served in terms of healthcare. Not until the government will stop cutting the funds for

healthcare and education, the Hmong Americans, together with other ethnic minorities, and the

underrepresented will continue to suffer the plagued health disparities and health inequalities.

Hopefully, this research will be an eye opener to the government and to the entire American

society, to work together in finding ways in advocating and empowering the Hmong Americans

because they are Americans who possess the right to happiness, equal rights, and justice.

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Kretsedemas, P., & Aparico, A. (Eds.). (2004). Immigrants, Welfare Reform, and the Poverty of

Policy. Connecticut: Praeger Publishers. Koltyk, J. (1998). New Pioneers in the Heartland: Hmong Life in Wisconsin. Massachusetts:

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HMONG AMERICANS AND HEALTHCARE 24 McInnis, K., Morgenbensen, M., & Petracchi, H. (1990). The Hmong in America: Providing

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Carolina: McFarland and Company, Inc. Publishers. Ostergen, J. (1991). Relationship Among English Performance, Self-efficacy, Anxiety and

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Hmong National Conference in Fresno, California. April 9, 2005. Popkin, S., Laster, G., Temkin, K., Herbig, C., Levy, D., & Richer, E. (2003). Obstacles to

Desegrating Public Housing: Lessons Learned From Implementing Eight Consent Decrees. Journal of Policy Analysis and Management, Vol. 22, No. 2 (Spring, 2003), pp. 179-199. Retrieved on March 2, 2011 from Stable URL: http://www.jstor.org/stable/3325820.

Prior, S. (1984). The Significance of Gardening on the Psychosocial Adjustment of the Hmong

Elderly. California: San Diego State University. The American Community survey publishes the annual Hmong profile with detailed demographic data for the U.S. Hmong population. This data is not available at the state or smaller geographic level with the exception of the state of California. The most recent ACS profile (2006) has been posted at the Hmong Studies Internet resource Center website: http://hmongstudies.org/HmongACs2006.pdf.

Rai, K. (2004). Community-Based Participatory Action research: Offering Hmong Welfare

Recipients’ Voices for Dialogue and Change. In P. Kretsemadas & A. Aparicio (Eds.), Immigration, Welfare Reform, and the Poverty of Policy, (pp. 187-203). Connecticut: Praeger Publishers

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Hmong Children in American Society. Philadelphia: The Filmer Press. Vang, X. The Hmong Language. Retrived on March 23, 2011 from URL:

http://www.uwex.edu/ces/hmong/resources/documents/HmongLanguage.pdf Weismann, J. & Schneider, E. Social Disparities in Cancer: Lessons from a Multidisciplinary

Workshop. Source: Cancer Causes & Control, Vol. 16, No.1 (Feb. 2005), pp. 71-74. Retrieved on March 3, 2011 from a Stable URL: http://0-www.jstor.org.opac.sfsu.edu/stable/pdfplus/20069442.pdf?acceptTC=true

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Appendix A: Sample Informed Consent Form to Participate in a Research Project/ Survey

San Francisco State University

Informed Consent to Participate in a Research Project/Survey US Healthcare System and Hmong Americans

A. Purpose and Background The purpose of this research project/survey is to do interviews with key stakeholders in the California Central Valley who can influence key decision makers on this issue. The Investigator, Aurea Berger, is an undergraduate student at San Francisco University, conducting this study for a research project. You are being asked to participate in this research/survey because you are 1) a Hmong American 2.) a key leader in the Hmong American community and/or 3. A key leader/official who is/will be serving Asian or Hmong Americans in your community. Procedures: If you agree to participate in this research/survey, the following will occur:

• You will be interviewed for approximately 20-30 minutes about your first hand experiences in utilizing the US healthcare system. We want to hear your recommendations regarding this issue.

• The interview will be audiotape to ensure accuracy in reporting your statements. • The interview will take place at a time and location convenient to you. • This information will be used to assist me in completing a research paper regarding the

Hmong Americans and their utilization of US healthcare system. PARTICIPATION IN THIS PROJECT IS VOLUNTARY. You are free to decline to participate in this project, or to withdraw your participation at any point, without penalty. If you have questions regarding this project, you may contact Professor Jonathan Lee at (415) 338-2279 or [email protected]. Signature_________________________ Date_____________ Research/Survey Participant Signature_________________________ Date_____________ Student Investigator

Appendix B: Questionnaires for Hmong American Participants

mailto:[email protected]


Questionnaires for Hmong Americans participants:

Name: _______________________ Age: _____

1. Do you have access to health insurance?

2. If you, how often do you see your health care provider/doctor/

3. How often do you see a dentist?

4. What kind of health insurance do you have?

5. If ever you have to change health insurance coverage and health care provider, do you

know whom to ask for help?

6. Do you encounter difficulty in accessing the customer service hotline? If so, what are

those problems you encounter?

7. How do you rate your health at present? Please use the scale 1-5, as in: 1 =worst, 2=good,

3=better, 4= best, and 5- excellent?

8. When you get prescription for medications, do you encounter problems purchasing using

your health insurance card? If so what kind of problems?

9. How often do you visit your health care provider for check-ups?

10. Any problems that deal with accessing the health care provider network?

11. Please list any recommendations that can help improve the healthcare service provided to

Hmong Americans.


Appendix C: Signed Informed Consent Forms to Participate in Research Project/Survey


Appendix D: Answers to Research Project Questionnaires/ Survey


Appendix E: Transcript for Juoa Lee’s Interview Interviewer: Aurea Berger Location: Merced Lao Family Community Center, Merced, California Date of Interview: March 31, 2011 Interviewer: This interview is regarding the Hmong Americans dealing with the Hmong Americans and the healthcare society; wherein it talks about the issue of Hmong Americans being poorly served in the US healthcare system. I’m interviewing Miss Juoa Lee, the Program Director of the Merced Lao Family Community Center in Merced, California and today’s date is March 31, 2011. Interviewer: How are you Miss Lee? Interviewee: I’m good. Interviewer: That’s Fine! Can I ask you the first question now? Interviewee: Yes. Interviewer: My first question is: what are the common problems that the Hmong Americans encounter when they utilized their US health insurance like Medical? Interviewee: I think the biggest thing is that they do not speak the English language; so, they always need an interpreter. But, then the provider does not always provide an interpreter; so, they always have an issue, when they go see a doctor. That is why most of time they don’t go when the provider is not Hmong. So they don’t feel like going because they do not understand their medical issues. I think right now, because ………a lot of the Hmong Americans, who are our community members, are under Medical; but end up cutting a lot of services that is available under Medical; so they cannot get the service anymore. Interviewer: Like for example, the biggest hospital in this area……..even one interpreter they cannot even provide it? Interviewee: Yah!!!!They had one. Like…….I believed before they had two: one on day shift and the other on graveyard shift…… rotating. But now, since one of my partners is interpreting in the hospital and said that they cut services on Hmong interpreters. That they can just use the phone system to call and it does not help. Still, they need a person beside them to provide the interpretation. I think there is only one hospital that provides the interpretation service. Interviewer: As far as I know……from the book that I read, they had more Hmong interpretations before; but because of the fund….the big cut of the funding in welfare….

HMONG AMERICANS AND HEALTHCARE 49 Interviewee: I think…the hospital is ….like a private hospital. I don’t think it has something to do with the federal or the state funding, the main thing is that this hospital have less funds ……it’s only last week or so….that they cut the Hmong interpretation service to help them. Interviewer: How does this community center able to help Hmong Americans in safeguarding their health? Do you offer …like….education programs? Interviewee: Yes, we usually provide workshops for the Hmong Americans and we always come up with information that they can’t always get. We provide workshops. The Merced County just recently came, under the Merced Managed Care, so we invited some Managed Care group to come here and do workshops to show: what services are available, what the changes at Medical, what are the rules to advance medical care. We always have obesity workshop, nutrition workshops. We even had a toxic specialists come out, even pharmacists come out. So we have a connection so we can treat the community members who do not speak English at all. So we are like providers. Interviewers: So what age range do clients come here? Are they mostly elderly? Interviewee: Most of them are the first generations Hmong Americans. Interviewer: Oh!!!The first generations!!! Interviewee: Yah! The young folks don’t come here, the reason why the older generation come is because they believe of this office services. The young ones speak English and they do their own thing, so they don’t usually come here. Interviewer: So, (laughs), just like those four gentlemen outside, every time they come here, like…… they play game cards and watched TV? Interviewee: Yes!!!(Laughs) Interviewer: I see computers out there too. Do they use the computers also? Interviewer: Yes, we just recently bought these computers under our program and its for the elders so that they can work hard and use emails; so that they will learn how to send emails. We provide basically that they need because they don’t understand English; so that we can help them. Interviewer: Oh!!!Same thing with the Southeast Asian Community center in San Francisco, they have computers. The director told me during my interview with him last semester, that they are teaching those Southeast Asian elderly how to send emails. Interviewer: My fourth question is: Do you think that the State provides good health services to the Hmong Americans?

HMONG AMERICANS AND HEALTHCARE 50 Interviewee: The state…….just like what I am saying, the Hmong Americans here are on Medical and they cut mostly of the health services. I think that it is hard for the Hmong Americans considering that most of them are low income; because of the Hmong here are on welfare and are on Medical and cutting those services affected our community members. Yah! Interviewer: What are some issues that burden the elderly Hmong Americans utilizing the US healthcare system? Interviewee: I would say the language because ……..especially the elders who first came here, it, they don’t speak the language, and they always need somebody to go with them Even going to appointment, they don’t drive. That is always a problem to them, that’s why they always need somebody to go with them. They don’t have the transportation and they don’t know how to drive. Interviewer: I have a question with this transportation. Just like in San Mateo County, in Daly City, where I live, the San Mateo County transit has the paratransit that provides transportation for the elderly to take them to their doctor’s appointment; wherein they just pay one dollar. Don’t they have it here? Interviewee: They do but the thing is: our people don’t know how to use it. Because they don’t know how to use the system because they don’t speak the language and they are isolated. They don’t speak the language; that’s why they are always home all the time Interviewer: You mean to say they are still isolated till now? Interviewer: Yes. Interviewer: How about those elderly with kids who went to school here. Do they still feel isolated you think? Interviewer: No, but the first generation Hmong Americans who first came here and those who are not able to provide for themselves, are poor and cannot find jobs. The elderly Hmong population, who do not know how to drive and do not know the language, are still isolated. That’s why we always advocate for the Hmong community……… at least to help them come, participate and socialize with other Hmong elders. Interviewer: Do they still use the Hmong traditional healing method? Interviewer: I am going to tell you about that Interviewee: Yah! One thing that we did…because we are part of this groups the Hmong Health Collaborative, we added to the health system, for the healthcare system of the Hmong American

HMONG AMERICANS AND HEALTHCARE 51 community. What actually propose like a document to the hospital here in Merced and also in Sacramento because of the large Hmong population in this area, we could bring a shaman to the hospital to see a Hmong patient and perform those rituals. They approved it; and if the Hmong patient’s family requests the shaman’s presence, then we could bring one to the hospital to perform the ritual. Interviewer: That is good. At least they are able to adapt to it because that what the Hmong Americans believe. Interviewee: So they adapted that policy and when there is a Hmong patient there and the family request it, they will call and let the shaman perform the ritual. Interviewer: So, do they ask the patient if they need it? Interviewee: They don’t ask the patient; but only if the patient request it. Interviewer: My last question: Do you have any recommendations that could help both the Hmong Americans and the healthcare provider to better the service to Hmong Americans in the US health care system? Interviewee: Yah!!! I guess just believe in Hmong and not actually just use the western healthcare system always but incorporate the Hmong traditional healing method because Hmong Americans community in this area is big. So, just incorporate the Hmong traditional healing method also with the western health method. Interviewer: and probably more interpreters too right? Interviewee: Oh!!!! Yah!!! and more transportation for the elderly to use. Interviewer: Okay. I will end up my interview then and I really appreciate your help, Thank you for your time! Interviewee: No problem.

hmong americans and healthcare inequalities and solutions. b.a

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