Health disparities prevent people from receiving high quality care and the ability to achieve good health. Coupled with low health literacy, healthcare barriers and cultural differences, Hmong individuals are challenged with major health risk factors and increased morbidity and mortality. In an analysis of the literature on Hmong Americans, cultural and linguistic barriers, health literacy, and mistrust of the Western healthcare system are identified as barriers to healthcare that increase health disparities for the Hmong in the United States.
Background
The Hmong are a nomadic group of pre-literate farmers without a country, living in mountainous areas of Southeast Asia, such as China, Thailand, Laos and Vietnam. Having helped the United States (U.S.) during the Vietnam War, the Hmong immigrated to the U.S. in the 1970s as refugees, settling throughout various parts of the U.S. as part of the scattering policy. Although over 45 years have passed since the Hmong’s migration, many continue to struggle with acclimating to the U.S. mainstream and continue to hold onto their traditional beliefs and practices. Health beliefs and practices in particular are among the Hmong’s strongest cultural values. The Hmong’s unique traditional beliefs in healing practices and alternative medicine have resulted in poor health outcomes, high mortality rates and poor provider patient relationships.
Review of the Literature
Hmong in the United States
Making up only 2% of all Asian Americans, there are approximately 281,000 Hmong living in various areas of the U.S. (Center for American Progress, 2015). However due to language barriers, literacy and mistrust of the U.S. government, the number of Hmong residing in the U.S. was likely under reported in the 2010 U.S. Census Bureau (Hmong National Development, 2013).
Generalized and categorized as Asian Americans, many overlook the socioeconomic disadvantages the Hmong encounter in the U.S. The Center for American Progress (2015) reports that 36% of the Hmong have less than a high school education and 27% are living in poverty. The per capita income of the Hmong is $10,949 a year, which falls below any racial group nationwide and remains one of the poorest ethnic groups in the U.S. (Asian Pacific American Legal Center & Asian American Justice Center, 2011). With income as a major indicator of stability, the Hmong face multiple socioeconomic adversities. The Hmong are more likely than other racial groups to access cash public assistance (13%) and receive some form of public assistance (41%) (Hmong National Development, 2013). Furthermore, the Hmong struggle with job stability, resulting in 11% of the Hmong being without work and 32% living in overcrowded housing (Asian Pacific American Legal Center & Asian American Justice Center, 2011). Low educational attainment and financial disparities have resulted in 14.9% of the Hmong being without any health insurance and only 48.9% having some form of private health insurance compared to 71.9% of other Asian Americans and 67.7% of the total population (United States Census Bureau, 2010).
Cultural Perceptions of Health and Illness
The literature on the Hmong suggests that illnesses are perceived to be caused by losing one’s soul (Hendricks, 1986). The Hmong believe that spirits dominate all aspects of human life, including an individual’s health. The Hmong’s religious and traditional views are rooted in animistic beliefs that all objects, places and creatures have distinct spiritual ties. The concept of illness as the loss of an individual’s soul encourages the Hmong to use shamanistic rituals to restore one’s health. The Hmong believe that shamans have the capability to travel into the spirit world and search for wondering souls to restore health (Helsel, Mochel, & Bauer, 2004). Although many Hmong engage in shamanistic rituals to help maintain and restore health, not all Hmong participate in such activities. Some Hmong have diverted away from shamanistic rituals but may still retain the belief that health problems may have spiritual causes and will pray for healing in place of shamanistic rituals (Gerdner, 2012).
Disease Prevalence
The Hmong are a young population. The median age of the Hmong is 20.4 years old compared to 37 years in the U. S. population and 33.1 years in the Asian American population (Hmong National Development, 2013). Life expectancy of the Hmong is higher for those born in the U.S. compared to those of Hmong immigrants. However, median life expectancy of the Hmong in the U.S. is 57 years compared to 77 years among Non-Hispanic Whites (NHW) (Yang, Mills, & Nasseri, 2010).
The lack of preventative screenings has made it difficult to determine the disease prevalence rate in the Hmong. Common health complications seen in the Hmong include diabetes, hypertension, kidney disease, cancer and hepatitis B (Fang & Stewart, 2018; Lee & Vang, 2010; Schroepfer, Waltz, Noh, Matloub, & Kue, 2010). The perception of not “feeling sick” has prevented the Hmong from seeking preventative screening measures and/or adhering to medications prescribed by physicians. As a result, the Hmong are experiencing 1.3-1.9 times higher mortality rates compared to NHW and have mortality rates for stomach cancer that are 8.9 times higher than Asian Americans overall (Schroepfer et al., 2010; Yang et al., 2010).
Health Literacy
In a culture with no written language and limited vocabulary, the Hmong lack the ability to understand concepts of the human body. Illnesses are hard to comprehend especially when they have never encountered them before. Studying health literacy in the Hmong, Khuu et al. (2018) found that more than half of the Hmong did not understand the health information that was being provided to them, resulting in 18.3% of the participants not taking their medications appropriately. Likewise, Lor et al. (2017) found that in addition to cultural beliefs and values, one of the major factors leading to the delay of seeking early healthcare services was the lack of knowledge about illnesses and diseases. Sparks (2014) on the other hand, found that seeking healthcare services in the absence of symptoms made no sense to the Hmong, therefore, the context of preventative healthcare does not exist in the Hmong world view.
Linguistic Discordance
Ninety-two percent of Hmong Americans speak another language other than English at home, with the majority speaking Hmong (Lor, Xiong, Schwei, Bowers, & Jacobs, 2016). The literature identifies linguistic discordance as a major barrier to preventing adequate access to healthcare services. The Hmong come from an oral culture where many do not know how to read and write. The lack of vocabulary to describe diseases such as cancer and hepatitis, makes medical information difficult to interpret. In an interview with Hmong medical interpreters, Krieger et al. (2018) found that even with professional interpreters, it is challenging to interpret medical concepts when the Hmong have no vocabulary or descriptions for the biomedical model of health.
Mistrust of a Western System
The literature suggests that mistrust of the Western system is a barrier for the Hmong to seek healthcare services and achieving health equity. Lee and Vang (2010) found that the Hmong felt betrayed after the Vietnam War, resulting in skepticism of the Western system and contributing to difficulty acclimating to mainstream American culture. Studying Hmong experiences with the Western healthcare system, Johnson (2002) found that many Hmong fear that they are being experimented on and that the treatments they receive are for the benefit of the doctor.
Conclusion
While the literature reveals significant barriers to healthcare access and utilization among Hmong Americans, it is crucial to understand that not all healthcare providers are aware of these issues. The findings of these studies illustrate how cultural beliefs, linguistic discordance and low health literacy may impact disparities in healthcare and health outcomes among the Hmong. In addition to demonstrating the need for further research on Hmong health and disease prevalence in the United States, cultural competency and sensitivity training appears warranted when caring for diverse patient populations such as the Hmong.
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