Western or Traditional Healers? Understanding Decision Making in the Hmong Population

Barriers to Type 2 Diabetes Mellitus Management for Older Hmong Patients with Minimal English Language Skills: Accounts from Caregivers, Case Managers, and Clinicians

Type 2 diabetes mellitus prevalence rates for Hmong Americans in Wisconsin are more than double that of non-Hispanic Whites. The Hmong's history, lifestyle (dietary and behavioral patterns), and reliance on traditional medicine contribute to their increased risk of diabetes. This qualitative study aimed to better understand the barriers challenging older Hmong patients' ability to manage diabetes. Asian Americans have long been overlooked in health-related research, but recent disaggregated data of specific ethnic groups reveal significant health inequities. Among the different ethnic groups, there is a significant lack of research on the Hmong Americans. Three participant groups (Hmong American family caregivers, Hmong American case managers, and clinicians from different racial backgrounds who provide care for Hmong patients) were recruited from the community and interviewed to understand the barriers experienced by older Hmong patients with minimal English language skills in managing their diabetes. Directed content analysis of the data resulted in three major themes: adherence to culture, health inequity, and managing diabetes. Subthemes included Hmong herbs and shamans, lack of trust in Western medicine, the significance of rice, language barriers, lack of cultural sensitivity, health literacy, monitoring glucose, medicine compliance, and nutrition. Minimal English language skills and low literacy rates (health and education) contribute to their strong adherence to cultural practices which challenges Western medicine, creating difficulty for older Hmong patients to manage their diabetes. Recognizing cultural differences and barriers will enable healthcare providers to improve and cater the treatment options, bridging the gap between older Hmong patients and Western medicine.

Post-immigration factors affecting retention in HIV care and viral suppression in Latin American and Caribbean immigrant populations in the United States: a systematic review

OBJECTIVES

To reduce disparities in HIV care outcomes among Latin American and Caribbean (LAC) immigrants living with HIV in the U.S., it is necessary to identify factors influencing HIV care in this population. A systematic review that provides a comprehensive understanding of factors influencing retention in HIV care and viral suppression among LAC immigrants living with HIV in the U.S. is lacking. This systematic review used the Immigrant Health Services Utilization theoretical framework to provide an understanding of these factors.

DESIGN

We searched for peer-reviewed publications in MEDLINE, EMBASE, CINAHL, PsycINFO, and ASSIA, from January 1996 to June 2020.

RESULTS

A total of 17 qualitative (n = 10) and quantitative (n = 7) studies were included in the review. The most commonly reported general and immigrant-specific factors appearing in studies were undocumented immigration status, HIV stigma, homophobia, cultural norms, values and beliefs, family and social support, language barriers, structure, complexity and quality of the U.S. healthcare delivery system, and patient-provider relationship.

CONCLUSION

These findings highlight the importance of considering immigrant-specific factors along with general factors to improve the provision of HIV care services and HIV care outcomes among LAC immigrant populations.

Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin

INTRODUCTION

We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients.

METHODS

We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models.

RESULTS

The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09).

CONCLUSION

Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.

Do Limited English Proficiency and Language Moderate the Relationship Between Mental Health and Pain?

AIM

To explore whether the relationship between mental health diagnosis (i.e., mood or neurotic, stress-related, or somatoform disorder) and pain is moderated by language in patients with limited English proficiency (LEP). Southeast Asian languages (i.e., Hmong, Lao, Khmer) and Spanish were compared with English.

METHOD

A retrospective data mining study was conducted (n = 79,109 visits). Pain scores, language, mental health diagnoses, age, sex, race, ethnicity, and pain diagnosis were obtained from electronic medical records. Cragg two-equation hurdle regression explored: (1) the effect of patient language and mental health diagnosis on pain and (2) the interaction between language and mental health diagnosis on pain.

RESULTS

Visits were primarily for female (62.45%), White (80.10%), not Hispanic/Latino (96.06%), and English-speaking (97.85%) patients. Spanish or Southeast Asian language increased chances of reporting any pain (i.e., pain score of 0 versus ≥1) and pain severity in visits with pain scores ≥1, whereas mental health diagnosis decreased chances of reporting any pain and pain severity. The combination of Southeast Asian language and mood disorder contributed to higher chances of reporting any pain (odds ratio [OR] = 1.78, p<.001) but no difference in severity. A similar trend was observed for Southeast Asian language and neurotic disorder (OR = 1.29, p=.143). In contrast, the combination of Spanish language and mood (p = .066) or neurotic (p = .289) disorder contributed to lower pain severity but did not change the chances of reporting any pain.

CONCLUSIONS

LEP and patient language should be considered during pain assessment within the context of mental health.

Sex differences in health status, healthcare utilization, and costs among individuals with elevated blood pressure: the LARK study from Western Kenya

BACKGROUND

Elevated blood pressure is the leading risk factor for global mortality. While it is known that there exist differences between men and women with respect to socioeconomic status, self-reported health, and healthcare utilization, there are few published studies from Africa. This study therefore aims to characterize differences in self-reported health status, healthcare utilization, and costs between men and women with elevated blood pressure in Kenya.

METHODS

Data from 1447 participants enrolled in the LARK Hypertension study in western Kenya were analyzed. Latent class analysis based on five dependent variables was performed to describe patterns of healthcare utilization and costs in the study population. Regression analysis was then performed to describe the relationship between different demographics and each outcome.

RESULTS

Women in our study had higher rates of unemployment (28% vs 12%), were more likely to report lower monthly earnings (72% vs 51%), and had more outpatient visits (39% vs 28%) and pharmacy prescriptions (42% vs 30%). Women were also more likely to report lower quality-of-life and functional health status, including pain, mobility, self-care, and ability to perform usual activities. Three patterns of healthcare utilization were described: (1) individuals with low healthcare utilization, (2) individuals who utilized care and paid high out-of-pocket costs, and (3) individuals who utilized care but had lower out-of-pocket costs. Women and those with health insurance were more likely to be in the high-cost utilizer group.

CONCLUSIONS

Men and women with elevated blood pressure in Kenya have different health care utilization behaviors, cost and economic burdens, and self-perceived health status. Awareness of these sex differences can help inform targeted interventions in these populations.

Gout prevalence in the Hmong: a prime example of health disparity and the role of community-based genetic research

Individuals of distinct Asian backgrounds are commonly aggregated as Asian, which could mask the differences in the etiology and prevalence of health conditions in the different Asian subgroups. The Hmong are a growing Asian subgroup in the United States with a higher prevalence of gout and gout-related comorbidities than non-Hmong. Genetic explorations in the Hmong suggest a higher prevalence of genetic polymorphisms associated with an increased risk of hyperuricemia and gout. History of immigration, acculturation, lifestyle factors, including dietary and social behavioral patterns, and the use of traditional medicines in the Hmong community may also increase the risk of developing gout and lead to poor gout management outcomes. Engaging minorities such as the Hmong population in biomedical research is a needed step to reduce the burden of health disparities within their respective communities, increase diversity in genomic studies, and accelerate the adoption of precision medicine to clinical practice.

Fish soup for the falling sickness: Tracing epilepsy through Hmong and Western beliefs

Hmong communities originated in China but today are located across the globe. Salvation, health, and well-being in Hmong tradition are contingent upon pleasing spirits and ancestors. While most diseases are believed to reflect the displeasure of spirits and ancestors, epilepsy is unique in that it portends a heightened capacity for achieving an elevated level of spirituality, which has led it to be deemed honorable by Hmong society members. This stands in stark contrast to some contexts within which epilepsy has been historically understood in the West in which the disease was believed to originate from sin and evil. If and how societal response toward persons with epilepsy (PWE) in Hmong communities differ from that in other Western communities in a way that parallels these differences in beliefs regarding the etiology and significance of the seizures is unknown. Understanding this may have implications that guide efforts in combatting stigma affecting PWE.

Healthcare Disparities Identified Between Hmong and Other Asian Origin Groups Living with Chronic Hepatitis B Infection in Sacramento County 2014-2017

Chronic hepatitis B (CHB) disproportionately affects non-US born Asians. The Hmong have been shown to have the highest rates of CHB and mortality from liver cancer compared to other Asian groups. From September 2014 to September 2017, testing for CHB within Sacramento County was conducted through community-based testing events and an electronic health record alert that identified Asian patients by surname. Demographic and laboratory data were collected for analysis and patients were followed through the study period to assess linkage to care and treatment to compare differences between Asian origin groups. Of 4350 patients tested for CHB, 318 (7.3%) were HBsAg positive, including 90 Chinese, 47 Hmong, and 101 Vietnamese. Hmong were more likely to have Medicaid insurance compared to other Asian origin groups (15%, p < 0.001). Hmong had significantly lower rates of hepatitis B DNA testing (p < 0.001), referral to hepatology (p < 0.001), attendance of first (p < 0.001) and second medical visit (p = 0.0003), and lower rates of antiviral treatment compared to other Asian origin groups. Hmong also had the highest proportion of non-English speakers (p < 0.001). Hmong patients in the Sacramento CHB testing and linkage to care program experience socioeconomic disadvantages compared to Vietnamese and Chinese patients. These factors may contribute to decreased linkage of care and decreased anti-viral treatment rates for CHB.

Hmong Older Adults' Perceptions of Insider and Outsider Researchers: Does It Matter for Research Participation?

BACKGROUND

Recruiting racial/ethnic minorities into health research is challenging. Although researchers affiliated with members of the study population (seen as insiders) may increase research participation of racial/ethnic minorities, little is known about who participants see as insiders and how they respond to insider versus outsider researchers.

OBJECTIVES

The aim of the study was to examine perceptions of Hmong older adults toward insider versus outsider researchers and the influence of these perceptions on their willingness to participate in research.

METHODS

Participants in a study evaluating use of a culturally and linguistically adapted audio computer-assisted self-interviewing system with helper assistance (ACASI-H) provided information about what they thought would encourage others in their community to participate in research. ACASI-H was used for collection of health data with 30 Hmong older adults. Participants rated the likelihood of participation if the researcher was Hmong and answered open-ended questions about participation when the researcher was not Hmong. Conventional content analysis was used to analyze open-ended questions.

RESULTS

Sixteen (53%) participants reported that they would be "likely" to participate in the research if the researcher was Hmong. Fourteen (47%) participants reported that they would participate in research if the researcher was not Hmong. In addition to ethnic affiliation, trust in the researcher could shift the perception of the researcher toward insider status, thereby increasing willingness of Hmong adults to participate in research. Trust in the researcher and movement toward insider status could be increased by calling out a connection between the researcher and the participant or creating reciprocity.

DISCUSSION

Findings suggest that increasing research participation of Hmong (and possibly other) participants, particularly when researchers do not share ethnic membership, can be achieved by building trust. This study also suggests a more nuanced perception of insider status, as a continuum, rather than a dichotomy, may be a more accurate reflection of the relationship between participants and researchers.

Systematic Review: Health Promotion and Disease Prevention Among Hmong Adults in the USA

Although disparities in the burden of disease and illness experienced across major racial and ethnic groups in the USA is well known, little is known about subgroups, including the Hmong population. This review sought to determine the current state of health disparities related to health promotion and disease prevention among Hmong adults from 1975 to 2015. Seventy-one descriptive (qualitative, mixed methods, and quantitative) studies were reviewed. Most focused on two areas: (1) health status (mainly breast and cervical cancers) and (2) health-related behaviors. This literature review confirms the existence of health disparities related to health promotion and disease prevention in the Hmong adult population. Effective intervention relies on identifying these disparities. A possible explanation for these disparities is the lack of health data collected on subgroup populations, which include the Hmong adult population. More research and more comprehensive health policies at the organizational level are needed to allow data to be collected on subgroup populations in order to better understand the social determinants that place the Hmong people at risk.

Paper Spirits and Flower Sacrifices: Hmong Shamans in the 21st Century

INTRODUCTION

Fresno, California, is home to more than 30,000 Hmong. The purpose of this research was to explore the utilization of Hmong shamans 40 years after the first Hmong immigrants arrived in the United States. Hmong shamanism is examined to identify and analyze changes to shamans' practices or patients.

METHODS

Using grounded theory, semistructured interviews were conducted with a convenience sample of 20 shamans in their homes. Transcribed data were qualitatively analyzed.

RESULTS

Shamans continue to train and practice in this community; utilization by older patients persists while young adult patients have become the fastest-growing group of users. Healing rituals have changed in response to the legalities of animal sacrifice in urban areas and the time demands of work schedules.

DISCUSSION

Nurses' awareness that the availability of biomedicine does not preclude the continuing or recurring utilization of traditional healers can facilitate understanding of culturally defined health care needs.