The malevolent dab may steal the souls of living people and, in particular, the souls of the weak or ill, for these souls are easier for the dab to steal. Telling Hmong patients directly that they are dying is taboo, for a dab may overhear the conversation, realize the patient is weak, and steal the weak patient's soul. Other dab are not evil, but if their homes are disturbed, they may cause people harm.
Some dab are believed to live in certain places, in particular around certain bodies of water, or rocks, or mountains. Some Hmong take caution to avoid walking past such areas and those affected with illnesses may blame themselves for having wandered past an area believed to have an evil dab lurking.
Death Discussions : It is important when working with most Hmong not to directly tell the patient or their loved ones that the person may die. For some people, telling them directly that they will die is viewed as cursing them to death. Words have power, and so may bring death. Some believe that a dab or evil spirit may overhear the conversation, recognize the person as weak, and steal the weak person's spirit, causing death. For others, speaking directly about death may take away the patient's hope for a cure.
Rather, speaking indirectly, or metaphorically, is more acceptable. For example, phrases such as "we cannot help you anymore," and "I fear the sky is getting darker and darker for you," are more accepted ways of conveying the patient's prognosis. For animists, it is important for people to die in their own house, or the house of their family or clan members, where the ancestral spirits reside, rather than in other people's houses where other people's ancestral spirits reside.
Failure to do so may result in angering the ancestral spirits, causing the spirits to lash out on familial lineage or punish the deceased to a lower level of reincarnation. See End-of-Life Link Issues for more information. Decision Making : Many Hmong regard "the family group" as more important than "the individual," for making health care decisions.
Extended male family members and clan leaders are often involved in difficult decision making processes. Usually, the husband's or father's side of the family is responsible for medical decision making, however the wife's or mother's side of the family may participate in discussions about health matters. In some families, younger and educated patients may play a larger role in decision making and, oftentimes, serve as interpreters to others that do not speak English.
See Family Decision Making Link for more specific information. Devil : Ntxwv Nyoog is an evil god who guards the gates of hell. Christian Hmong consider Htxwv Nyoog to be the devil. Diagnostic Procedures : Individual patients and families usually evaluate the pros and cons before accepting diagnostic procedures.
Generally, as with most patients, the more invasive the procedure, the more likely it is to draw resistance from the patient. Digestive System : See Anatomy Link Divorce : Historically, divorce was an uncommon occurrence, while now it is more accepted. Marital couples with conflicts often seek help from their family members, including sage male elders, who often counsel the couple to patch up their differences and love one another. Oftentimes, couples are given many chances to learn from their mistakes, make-up, and continue trying to be a loving couple and effective parents.
Divorce is often considered a last option. Disrobing : Some Hmong women are reluctant to expose their bodies to anyone, even their husbands, and may perceive the request as being for the physician's pleasure rather than for diagnostic purposes. Elders : The elders of the Hmong community are treated with respect and serve a vital part in Hmong decision-making processes. The word "elders" does not always refer to advanced age; successful and middle-aged men and women can be considered elders whose advise and counsel are worthy.
Elders are included many important decisions made concerning family members, with the older men in the family playing the dominant role in culture, religious, health, finance, and political decisions.
In today's society, there is a struggle within the Hmong community to keep this tradition as the younger generation continues to gain power in the family hierarchy due to their education, English-skills, literacy, and experience.
End-of-Life Issues : Making decisions for patients at the end of the patient's life varies from patient to patient and from family to family. Most Hmong adults have not created living wills, as it has been taboo to make plans for future adverse events.
Some families will want everything done for their loved ones, while others will carefully accept some interventions while rejecting others. Some families embrace hospice and palliative care while others continue to pursue multiple therapies in the hopes of a cure.
See Decision Making and Death Discussion links for more information. Family Decision Making : In family decision-making, decisions are generally made as a concerted effort between members of the family. Usually, no one person makes a decision; rather, the group discusses the options with certain members holding more respect or weight in the conversation. The group then comes to an agreement such that the group is then responsible for the outcome of the decision.
Some people believe that it is better to do nothing then to interfere with fate and be responsible for the result of interfering. It is important for physicians to realize that decision-making in the traditional Hmong community can be a timely process, but the time is important for in creating a trusting and therapeutic relationship.
See Decision Making Link for more information. Fevers : See Childhood Illness Link Fontanel anterior : See Anatomy Link Funerals : Following death, the entire family will gather to see the deceased, and some will dress the body in either traditional Hmong clothing or in formal Western clothing of 3 to 4 layers to ensure better preparation for the body's return to heaven or to the land of the ancestors.
Funerals for animists and Christians are different. The following is a guide for healthcare providers to learn about the Hmong culture with emphasis on Hmong healthcare beliefs. This site should serve only as a general reference in relevant cases. It is the belief of the authors of this site that every Hmong patient is an individual with individual ideas that may or may not reflect these generalizations on traditional Hmong culture.
Furthermore, even very westernized Hmong patients may wish to combine their physician's care with traditional practices. More information about this page can be found under the Sources and References links. Advanced Directive : Advanced directives can be a difficult process, as many people have not considered the various technological options that sustain life and their significance for quality of life.
Also, the meaning of "brain death" is a new concept, as opposed to death that occurs with the cessation of breath. Increasingly, elders are placed in nursing homes as families are not able to take care of them and meet the demands of society.
This is an on-line learning module, but you can download the module as a PDF and print the cultural profile by filling out a short survey.
Additional cultures and geriatric information also available on their site. Rice is a staple in Hmong cuisine. Distinctions among various kinds of rice are found in Hmong language — new rice, sweet rice, purple rice, sticky rice, rice in field, harvested rice. Rice is usually eaten at every meal, along with everyday dishes of meats, fish and vegetables, grilled, fried boiled and spiced.
Families eat together around the table, using utensils both in Laos and in the US. No chopsticks are used in Laos.
Feasting on special occasions usually includes a menu of roast pig or boiled pork soup, fruit, boiled eggs, egg rolls, seasoned meats, vegetables, rice, and salad. Hmong will commonly grow vegetables and herbs in their gardens or yards here in the US. Traditionally, during family feasts, males ate first. This is a dish common for many adults and elder people, even in the US today.
In the US, having drinks during family meals is similar to American meals. In the US, wine and beer are used during special occasions. Excessive alcohol is consumed during traditional Hmong wedding ceremonies, both in the homeland and in the US.
In Laos, opium is used as a treatment drug to cure muscle aches after a hard day of farm work or severe injury to the body. Abusive use of opium leads to family poverty and causes a bad family name. This negative image continues to taint families in the US. Indulgence cannot be defined in the Hmong culture or Hmong people. In Hmong society, there is no such food as ice cream or other edible things that someone could indulge oneself in. If there is a strong interest to explore indulgence in Hmong, the word needs to be defined carefully in order to guide discussion.
Hmong animist tradition believes in multiple supreme beings, called Gods, responsible for high-level creation and functions of nature.
These Gods along with other spirits are believed to dwell in the spiritual world — the realm of the dead, the invisible, and the supernatural. The Hmong believe that the spiritual world coexists with the physical world and is inhabited by a wide variety of spirits, many of which can influence the course of human life.
The Hmong believe spirit types include ancestral spirits, house spirits, spirits in nature, as well as evil spirits. Ancestral spirits include any deceased member of the family. House spirits are believed to inhabit each corner of a Hmong house. Each part of the house is also believed to have its own spirit, including the stove, and the doors.
The altar is assumed to be the place in the house to which ancestors return. Spirits of nature include mountains, trees, streams, valleys, caves, ponds, and winds. It is said people have 12 souls — the three major ones are the reincarnation soul, the residing soul and the wandering soul.
The residing soul stays with the body as it breaks down and becomes the ancestral spirit that descendants revere and pay homage to. The wandering soul leaves the body during dreams or to play with other souls or spirits.
If frightened, the wandering soul may be lost in the spirit world. At death, the wandering soul returns to the spirit world and continues to live life there much as it did in the physical world. A traditional animist practices shamanism. Shamans are people who mediate between the visible and spirit worlds through ritual practices conducted for purposes of healing, divination, and control over natural events.
For a shaman, the altar is the sacred place where the shaman spirits dwell. Shamanism is viewed as a way to maintain communication between the Hmong and the spiritual world. Spirits of nature can cause physical and psychological harm to Hmong in the guise of illness, nightmares, and even death. Hmong shamans perform ritual trances in order to figure out the causes of illnesses for the purpose of treating the effects. Shamans communicate messages from spirits to the persons affected, and vice versa.
Almost all aspects of traditional Hmong life are affected by contact with supernatural beings. A person is thought to have been allotted time on earth by God and to have been given several souls.
The Hmong perform many ritual ceremonies for the purpose of fulfilling the will of the ancestors and natural spirits. Hmong rituals usually revolve around the practices that their ancestors passed onto them. Variations in rituals are found in the practices among different clans and lineages and are passed down from generation to generation through oral tradition. Fathers pass animist ritual traditions to their sons. Cha, Persons of Hmong origin traditionally believe in life after death.
With proper guidance from Hmong musical performers during the funeral rituals, Hmong believe that the souls of the deceased will come back to their ancestors for reincarnation, and that the new bodies of their relatives will come back as new members of Hmong families.
Many Hmong in the United States continue to practice some form of the Hmong animist tradition. Some practices have undergone changes due to restrictive factors of the new environment.
Missionaries in China in the s and in Laos in the s first introduced Christianity to the Hmong. However the majority of Hmong Christians converted in the United States. People converted for various reasons — to please their Christian resettlement sponsors, to qualify for private school scholarships or in response to the difficulty of performing traditional rituals. Within some families, divisions have resulted when some members have converted to Christianity and others have not.
Some Christian Hmong label traditional animist practices as sinful. On the other hand, some Hmong believe it is dangerous for everyone when Christian members of the household disrespect the spirits by not performing the traditional rituals. In general, Hmong Catholics are more likely than Hmong Protestants to accommodate some forms of traditional animist practices within their new faith framework.
Traditional animists may be more willing to attend Christian rituals than their Christian counterparts are willing to attend animist rituals. Wrist usually occurs during wedding, celebration of a new birth of a child, and feast to honor parents or relatives. Neck stringing is generally done to promote good health. When an old person dies, the body is usually kept inside the house for five to ten days.
A funeral consists of 5 days of ceremony including speeches, drumming, hours-long chants to guide spirits home to Heaven, and ritualized crying — a way of declaring love for the person. Traditionally, Hmong graves can be a mound of earth on which tree branches are piled to protect disruption by animals, a mound of earth surrounded by a wooden fence, or a mound protected by boulders, the type depending on sub-clan funeral tradition.
In the United States, it still may be important for terminally ill patients to return home to die, as the soul of a person who does not die at home may wander and not be reincarnated.
Family members of the deceased may refuse autopsies, and reasons for this include belief that intact body parts and organs are needed for smooth reincarnation and response to rumors that organs are taken out for eating and for sale.
Hmong recognize that illness can be a result of external natural forces, such as accidents and infectious diseases. The concept of contagion is not new to the Hmong in understanding diseases like TB and Chickenpox. Hostile spirits, spells, curses and a violation of taboos are other factors believed to cause illness.
A traditional Hmong belief is that ill health may be the result of the soul wandering from the body unable to find its way home. The soul may be lost due to injury, wounds, a fall, a loud noise, being unconscious including from anesthesia , fear, or feeling sad and lonely.
In the United States, environmental toxins are also seen as causing illness. Hmong believe the liver is the center and regulator of human emotions, playing a role in mental health and personality. Traditionally, Hmong use home therapies for common aliments. For more unusual or serious problems people seek help from folk medicine doctors, ritual healers, and shamans. Throughout life, people learn about home therapies for common conditions like colds and aches, and sometimes for other issues as varied as arthritis and fertility.
Many homes have a family member specializing in healing herbs. Medicinal plants are grown in home gardens or imported from Thailand, and are administered in teas and ointments. Other healing techniques include massage, coining or spooning rubbing an area vigorously with a silver coin or spoon , and cupping applying negative suctioning pressure on the skin with a cup. Physical marks like bruises and redness might be found on the body of a Hmong person, the results of these treatments.
Hmong also may wear accessories such as red necklaces made from silver and brass, white cloths around their wrists, and red or white strings on their wrists, necks, or ankles. These accessories may be worn for health and religious purposes. The medicine doctor gains knowledge of diagnosis and treatment by apprenticing with another healer and from the guidance of her helping spirits.
She specializes in healing with herbs and may be a generalist or may be dedicated to healing certain conditions. He calls on healing spirits with Laotian and Chinese words and incense. The symptoms of soul loss include weakness, tiredness, fever and headache, loss of appetite with extra thirst, insomnia or dreams of being in a strange place with a stranger. A soul calling ceremony is required to cure the sick person. Some family members may learn to call a soul home.
If no one in the household is able to call the soul, a revered soul caller is consulted. The soul caller observes the chicken killed and boiled to divine whether the soul has returned and in what condition. If the healing is not successful, a shaman is consulted. A shaman is the supreme spiritual healer whose primary means of patient care is to travel to the spirit world. Shamans are usually well known, well respected, and mostly male though some are female, and are key figures in traditional culture.
It is said that shamans do not seek the calling but that the spirits call them to the spiritual healing practice. They learn from other shaman. Shaman ceremonial tools include a gong and a wooden bench, and rituals involve going into trance, long chanting, and sacrificing animals, usually chickens or pigs.
Animals are killed so their souls can be asked to guard the patient. Shamans are able to speak the language of the spirits, negotiate and fight with the spirits for the health of the patient. Shamans perform divination procedures for diagnosis, and trance rituals for curing and further protection. Hmong families rely mainly on traditional healers and shamans for prevention and treatment of mild to life-threatening illnesses.
In Laos, there is minimal contact with Western Medicine due to isolation from big cities and medical facilities. The biggest barrier is the cost of conventional health services. Those who are able to seek modern health care services for life-threatening conditions are those with the knowledge of the health care services and the money to pay for them.
Anyone without money is denied conventional medical services even for life-threatening but preventable health conditions, such as diarrhea in young children.
Modern health care is believed to be beneficial, but traditional diagnosis and treatment either herbal or spiritual may be used first. Some biomedical treatments may conflict with Hmong belief. After a general anesthetic, it may be necessary to perform a soul calling ceremony in the operating room. People may consider the amount of blood in the body to be finite and not rejuvenating, and they may resist blood draws.
There may be resistance to vaccines and problems of adherence to treatments that require long-term sustained use of medicine. In most cases, Hmong will willingly use medicine that brings observable results.
Hmong women may refuse vaginal examinations, especially by male doctors. Medical examinations of the breast or private parts are sensitive issues in the Hmong community as well as other ethnicities not used to Western medical practices. Mammogram, Pap smear or rectal exams were not available back in the homeland. When the patient is Hmong, knowledge of the medical services must be assessed first before introducing the medical exams.
To foster understanding of the medical exams or diagnosis, visual aids of the human body part related to health condition must be used to accompany the information. Issues of trust between a care provider and the patient and family are critical. The reputations of care providers, those trusted and those not trusted, are shared in the community. When dealing with a Hmong family, confidentiality is considered to be a very important issue. However, within the family itself, confidentiality may not be thought of as all that important and families may make care-giving decisions together.
The men in the family may consult traditional healers for advice about health care decisions. Family members share their experiences and seek support from one another. When talking to less assimilated Hmong persons it may be necessary to repeat questions and allow extra time for responses. In the United States, less-assimilated Hmong may have a limited English vocabulary; it is helpful to use simple terminology whether by telephone, in person, or through an interpreter.
Traumatic experiences of war and its aftermath leave an impact on health. Hmong were victims or witnesses to terror — bombings, murder, rape, drowning, starvation, displacement and discrimination. Post-traumatic stress disorder may be prevalent among Hmong in the United States. US studies have shown high rates of depression, often related to the life situation difficulties of the Hmong refugee — especially difficulties of adjusting to life in the US.
See a May 25, New York Times article about a program in which construction and maintenance of community gardens and adjoining meeting spaces for Hmong and other immigrant communities are made possible by the California Mental Health Services Act of Immigrant families often struggle to meet insurance co-payments, and culturally attuned therapists are in short supply.
Warner and M. Mochel discussing the linguistic and cultural barriers the Hmong encounter when they attempt to access the health care delivery system in Merced County, CA.
The Hmong society remains one of the most structured social groupings in the world. Several levels of community are identifiable in the Hmong social structure worldwide: clan, sub-clan, ceremonial households, extended families, and nuclear families. At all levels, the Hmong are communitarian in nature, surviving on relationships. Due to the various influences of acculturation, the Hmong community has become less cohesive in the United States compared to life in Laos or other homelands.
In traditional Hmong culture, the son and his wife are to live with the parents and care for them in old age. In the modern day, specifically in the US, as many children and parents become independent, there is tendency to live in separate houses. A decrease in extended families living together has led to loss of social support for elderly parents.
In the homeland, people farmed for their own crops and food. People had similar lives and there was no large income gap causing people to look down on each other. In the US, the social structure has changed. People work to earn a living. Those who are unable to work rely on public welfare. In the US, the gap between household incomes has resulted in decreased community coherence.
The events are organized independently by different Hmong organizations established by different clans. People travel from afar, even across the country, to join different New Years events. The U. A community estimate puts the total number of Hmong living in the U.
It is rare that Hmong families in the U. Minnesota appears to have attracted the strongest percentages of Hmong from various regions throughout the country between According to the Census, the largest population of Hmong in the U.
Census data indicate that Refugee arrivals peaked at 27, in Of the current population, about According to the census, the Hmong are the only ethnically based population with a median age under Fifty-six percent of Hmong are under the age of 18 compared to twenty-five percent of the entire US population. The median age for Hmong in the US is Fifty-one percent are males, forty-nine percent females. Hmong families in the US average 6. Per average Hmong household there are 6. Clan leaders will typically settle any dispute between two Hmong persons or between different clans.
Clan leaders may be involved in such matters as reconciling a quarreling couple, and ensuring that individuals fulfill ritual obligations. In Laos, there was no single Hmong government or ruler. The leader at the family level can be a powerful and influential person in the community.
He may not necessarily be the most educated but is someone who holds the respect of others because he cares for the people and is just and fair. He is someone who knows all the rules and norms of the culture. Incidents of stress, sickness, and death indicate that while the Hmong retain their animist concerns, they have lost or abandoned their animist leaders and ritual responses. This leaves the Hmong with serious anxieties but no way to resolve those tensions.
Thus Hmong refugees come to Christian ministers pleading for animist advice. One minister performing a funeral service described the Hmong as desperate for "ritualistic" and "God-appeasing" suggestions: which were the clothes, prayers, and corpse orientations that would best help the soul of the dead child? Hmong seem most attracted to the rituals of certain ministers who emphasize candles, colors, and ceremony. The religious disorientation exhibited by the refugees is in strong contrast to centuries-old Hmong behavior in China and Laos.
There, a strong sense of ethnic identity, a reluctance to assimilate, a high mobility, and the isolation of the hill communities insulated and guarded the identity of the Hmong religion. In the US, however, the sponsoring system of resettlement has consistently stressed adaptation and adjustment rather than enforcing ethnic identity. The dependence of the refugees on sponsors, social agencies, and public aid has drastically reduced their mobility and rendered isolation from Americans virtually impossible.
The Hmong resettled before were scattered throughout the country to avoid burdening particular communities. Though the policy was soon abandoned, these Hmong were isolated from each other rather than from Americans. Plunged into a society which is either secular or Christian but far from animist, the Hmong assume the exteriors of the Americans around them - either religiously ambivalent or Christian. The Hmong in Philadelphia frequent five churches. According to the pastors' own estimates, a total of refugees are associated with the churches.
Their involvement ranges from picking up clothes and furniture donations to attending bible classes and services, becoming baptized members of the congregation, and acting as interpreters, readers, and ministers. The ministers recall that the Hmong joined the churches in two groups. The majority of the first wave of refugees had been Christian in Laos.
Although most Hmong recall only "the missionary" and not his denomination, American ministers suggest that the proselytizing had been most often Protestant, carried out largely by the Christian and Missionary Alliance. Such exposure undoubtedly influences Hmong affiliation in Philadelphia, where the majority choose Protestant rather than Catholic Christianity. While three churches were sought out by the Hmong independently, many refugees sponsored by religious organizations have accepted the denomination of their hosts.
Here again the Protestant choice predominates, for most Protestant sponsors are individual churches. Catholic sponsorship tends to be less personal because it is often executed by a larger voluntary agency. Lastly, even Catholic Hmong avoid those Catholic churches frequented by ethnic Vietnamese, preferring to walk considerable distances to attend other parishes. Turnover in the original Hmong congregation has been high. One minister estimates that Hmong came to his church initially.
About 50 of that group maintain contact with the church, with some thirty attending services regularly. Some Hmong have moved out of Philadelphia while others have quietly dropped out, often about a month after baptism. The churches have responded by beginning bible study groups, which now draw higher attendances than the services. Although most of the clergy depend on Christian Hmong to translate and interpret, the language barrier continues to be significant.
But the obstacles to understanding are not only linguistic. American Christianity assumes a Western orientation and a store of cultural knowledge alien to the Hmong. Theologies rendered in Hmong remain hard to convey across such a barrier. This is an issue to which the Christian churches have responded variously. One pastor interviews those ready for baptism through an interpreter for up to six hours, to confirm the candidates' comprehension of their new creed.
Other ministers are less thorough. Still others may be less scrupulous: widespread rumors suggest that at least one church pressures refugees into attendance, baptisms, and financial contributions, apparently by implying that it can influence welfare payments.
Several pastors agree that the Hmong's comprehension of Christian ideology varies as widely as the responses of the churches. Some Hmong, especially those with a long exposure to Christianity, have not only a devout attitude but a detailed knowledge of the faith.
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