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Page CONTENTS 2 Communications 2 Traditional Family Values 2 Health Care Beliefs and Practices 6 Health Risks 6 Women’s Health 7 Youth Health 9 Special Events 9 Spiritual Practices 10 References and Resources

CAMBODIAN CULTURE

BACKGROUND INFORMATION Cambodians, like most Southeast Asian peoples have experienced political domination and instability for the last couple of hundred years. However the reign of terror of the extremist Maoist regime, the Khmer Rouge (from the 1960’s), and the ensuing struggles that continued after they were ousted in 1979 (by the Vietnamese) devastated the country and the people. Cambodians suffered severe brutality, starvation, virtual obliteration of their culture and desperate poverty during this reign. As a result there have been enormous numbers of refugees fleeing Cambodia whilst the Khmer Rouge was in power, and since, to escape the continued struggle and poverty. Most Cambodians who came to New Zealand as refugees arrived with high health needs. However many issues including access difficulties, poor mental health and culture differences made it difficult for them to make use of the new resources. As a result, many Cambodians suffer with less than satisfactory physical and mental health, and for many there is still significant pain related to past trauma and difficulties. It is therefore, particularly important to be aware of the cultural factors that could assist their access to much needed care. Photos by kind permission of Refugees International www.refugeesinternational.org.

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COMMUNICATION Greetings Hello Choum Reap Sur Goodbye Choum Reap Lir Main language The main language spoken is Khmer (also known as Cambodian). Some speak French, and a little English may be spoken although the latter is mostly understood by the young people who have learned it at school since migrating. Gestures and interaction • When Cambodians greet each other they place their hands, palms together at

chest level and bow slightly. This is called a Som Pas. It is considered impolite not to return this gesture when greeting. It is tantamount to refusing to do a handshake in Western culture. It is appropriate to make the gesture and then greet them in your own language

• The second name is traditionally a Cambodian’s given name, and they place the family name first. This can be confusing for records. It is useful to check whether they have adopted the New Zealand system or retained their own name order

• Use Mr. or Mrs. and the given name, or both names. It is not usual to address someone using the second name only as westerners do (it is considered impolite as this would be the name of the father or ancestor)

• Elders are treated with the utmost respect • It is considered bad luck if a baby is praised too much (without the protection

from the ‘evil eye’)

TRADITIONAL FAMILY VALUES • The nuclear family is more common in Cambodia than in the other Southeast

Asian countries although extended families also live together or in close proximity • The roles of both men and women are well respected within Cambodian culture • The wife in a family is leader in some ways and responsible for handling financial

matters, seeing to the education of the children and doing housework. Men bring in the income

• Families value having meals together.

HEALTH CARE BELIEFS AND PRACTICES Factors seen to influence health: (the focus is on Khmer from rural backgrounds) In general, the Khmer are comfortable with western medicine and with traditional or indigenous healing practices, both spiritual and medicinal. Often both factors will be seen to be equally influential.

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Illness is understood: 1. To be an imbalance in natural forces. However, this concept is often not directly

expressed and the influence of “wind” or kchall on blood circulation (and hence on illness) will be noted instead

2. To be an imbalance of “cold” or “hot” conditions (similar to the other Asian cultures presented in this resource, this does not necessarily imply body temperatures, but rather body states)

3. To have spiritual/supernatural causes where illness can be brought on by a curse or sorcery, or from non-observance of a religious ethic

Traditional healing and indigenous practices Some of the procedures below are carried out by family members and some by traditional healers or kruu Khmer. Some kruu Khmer specialize in medicinal practice with a spiritual component, while others specialize in magic with a medicinal component. Irrespective of whether the procedures are carried out by kruu Khmer or lay people, they are often accompanied by prayer and other spiritual activities: • Coining (Dermabrasion) (Kooí’kchall) • Pinching (Jup) • Cupping (Jup kchall) • Moxibustion (Oyt pleung) • Massage or manipulation is practiced by kruu Khmer and others • Traditional or natural medicines • Magico-religious articles • Yuan are magical pictures/words placed over doors or sometimes kept in pockets • Tattoos with magical designs and religious words can be found on the chest,

back and arms of men • Blowing on the sick person’s body in a prescribed manner and showering or

rubbing with blessed water is another spiritual treatment Western medicine is also accepted and used, especially by resettled Vietnamese. 2nd and 3rd generation resettled Vietnamese may not adhere to traditional practices or some may combine these with Western medicine. (See Chapter 2, Introduction to Asian Cultures, ‘Traditional treatments/practices’ pg 6, for additional information on some of the above practices). Important factors for Health Practitioners to know when treating Cambodian clients: 1. Cambodians have traditionally dealt with illness through self-care and self-

medications. This may have been due to lack of resources, and also to the ready availability of drugs over-the-counter at low cost. As a result Many Khmer are slow to seek healthcare from western practitioners and self-care or traditional measures may be tried first. Clients may therefore present only when the condition is serious.

2. Traditional treatment may be used simultaneously with western medicine 3. Communication is a major issue in assessment and all other phases of care. This

might be due to language or cultural issues. A cultural problem might involve using an interpreter who for gender, age, social status, or past relationship

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incompatibilities, may be rejected or not listened to by the client 4. Communication can often be indirect with questions couched in vague terms, or

no response being given if the answer is negative. It is best to ask open ended questions which avoid responses where the negative is masked

5. Accurate and complete assessments are major issues in providing quality care. There is a reluctance to complain or express negative feelings and it is common for patients to not report or even to deny symptoms or problems. Answers such as ‘it’s OK’, or ‘no problem’ are common when there is actually a problem. In other cases, symptoms or problems may be reported to several sources or to one source and not another.

6. Non-compliance with medications and treatment is another problem and may be due to several factors: • The patient may not believe that he or she has communicated the problem

successfully and so have little faith in the solution. Careful questioning is therefore crucial

• A common Khmer orientation to symptoms (vs. cause) of illness may result in discontinuation of treatment as soon as symptoms have resolved

• Treatment through dietary measures is very difficult because of difficulty in food substitutions, differences in perceptions of foods, and in some cases, financial issues

• Difficulty in independently obtaining refills or new appointments. This might be due to access and language difficulties, or sometimes to financial ones. The business aspects of the health care system can be challenging and upon receiving a large bill, some will react by simply not returning to the practitioner

• Rather than report that the treatment has been unsuccessful, some Cambodians may report “no problem” or “its okay”. This may be due to lack of faith in the medicine, or to lack of motivation, or to access difficulties

7. Most Khmer are oriented more to illness than prevention of illness. Childhood immunizations are accepted, but adult immunizations (influenza, pneumonia) are usually not sought until illness is evident. Most Khmer do not value early detection or disease screening. This has implications for breast and uterus cancer check-ups amongst other things. (See http://ethnomed.org for tutorials and information in Cambodian on various types of cancer)

8. Some traditional techniques (e.g. coining, cupping, moxibustion, pinching) may leave marks on the body and providers need to investigate these before assuming abuse

9. Mental health problems are more likely to present somatically 10. There are some culture-bound presentations, e.g. ‘sore-neck’ syndrome presents

with symptoms similar to panic attacks, ‘thinking too much illness’ with some depressive and anxiety symptoms

11. When doing HOME VISITS: • Give a clear introduction of roles and purpose of visit • Check whether it is appropriate to remove shoes before entering the home

(notice whether there is a collection of shoes at the front door) • If food or drink is offered, it is acceptable to decline politely even though the

offer may be made a few times Diet and Nutrition White rice with accompanying vegetable soup is the staple diet with fish and meat when available.

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Death and dying • Dying, for resettled Cambodians, is often accompanied by more “baggage” than

in other cultures. Besides the usual physical, personal, interpersonal, and spiritual issues, many may have been left with unresolved issues around survivor guilt, guilt over decisions made during the Holocaust, grief, lack of cultural support, lack of family support, and others. Most often they will only display acceptance or resignation

• It is preferable to discuss end-of-life issues with the family rather than the client.

There is a tendency to “protect” the client from knowledge of a poor prognosis. In some families there is an almost mystical faith in Western medicine and so there is an eagerness to accept even the most futile of treatments. Withdrawal of treatment usually requires extended discussion with all family members and in many cases, repeated explanations

• Pain and other symptoms are often endured with stoicism so it is important to

ask very direct and specific questions about each symptom. General or passing questions are meaningless and will likely gain little useful clinical information. The strong Buddhist heritage makes equanimity in the face of death highly valued. It is believed that one should go into death calmly and mindfully, so maintaining a state of awareness is valued over pain control. It may need to be explained that alertness can be experienced with some pain control

• Dying at home is preferred as this allows more cultural/community support than

a hospital death and ceremonies and visitations are very helpful to the family • Family expressions of grief vary significantly. In literature on Cambodians

resettled in the US it has been noted that persons in acute mourning are often extensively coined – as if to say, without words, “see my terrible pain” as this is otherwise difficult to express

• Ideally, the family prefers to wash and prepare the body of the deceased. The

hands are placed in a prayerful position holding candles and incense. Some families place a coin in the mouth of the deceased. Usually after the death, neighbours and friends visit in large numbers and are expected to contribute to expenses and related ceremonies by making financial offerings to the family

• Cremation is preferred, though some resettled Cambodians may be buried.

Ceremonies are usually held the weekend after the death and again at 100 days after the death. Offerings commemorating the deceased are also made at the Khmer New Year in April

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HEALTH RISKS AND CONCERNS According to Metha’s (2012) report on health needs for Asian people living in the Auckland region, the following were noted as significant 1: • Stroke • Overall Cardiovascular (CVD) hospitalizations • Diabetes (including during pregnancy) • Child oral health • Child asthma • Cervical screening coverage • Cataract extractions • Terminations of pregnancy In addition, Unexmundi, August 2014 lists the following as major infectious diseases for Cambodians: • Hepatitis A and E • Typhoid fever • Malaria • Dengue Fever • Yellow Fever • Japanese Encephalitis • African Trypanosomiasis • Cutaneous Leishmaniasis • Plague • Crimean-Congo hemorrhagic fever • Rift Valley fever • Chikungunya • Leptospirosis • Schistosomiasis • Lassa fever • Meningococcal meningitis • Rabies

WOMEN’S HEALTH

According to Metha’s (2012) report on health needs for Asian people living in the Auckland region: • Asian women have lower total fertility rates (TFR) in the Auckland region as

compared with European/Other ethnicities

1 The Metha 2012 report refers to three ethnic groups stratified in the Auckland region: Chinese, Indian, ‘Other Asian’ (includes Southeast Asian). Ethnicities include Korean, Afghani, Sri Lankan, Sinhalese, Bangladeshi, Nepalese, Pakistani, Tibetan, Eurasian, Filipino, Cambodian, Vietnamese, Burmese, Indonesian, Laotian, Malay, Thai, Other Asians and Southeast Asians not elsewhere classified (NEC) or further defined (NFD) Unless otherwise specified, the term ‘Asian’ used in this CALD resource refers to Asians in general and does not imply a specific ethnicity or stratified group.

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• All Asian groups had lower rates of live births than their European/Other counterparts

• Teenage deliveries occurred at significantly lower rates among the Asian groups as compared to European/Other teenagers

• Asian women have more complications in live deliveries because of diabetes compared with European/other ethnicities

• Asian women had lower rates of hospitalizations due to sexually transmitted diseases than European/other ethnicities (but across all ethnic groups studied, women had a much higher hospitalization rates compared to men)

Traditional health care: Family planning in Cambodia is uncommon and women will often have a number of children. Herbal medicines, Depro-provera injections and birth control pills are used rather than condoms. In Cambodia the midwife is consulted for pre-natal care. In resettled places women will often use herbal medicines and a variety of foods and activities which are thought to be good for the baby. Although there is more acceptance of pre-natal care after migration, it may be avoided because of pelvic examinations. Same gender practitioners are preferred. The post-partum period is considered to be the most important time in a woman’s life. It is called “Sor Si Kjey” or “Saw Sai Kachai”. Recovery lasts for a month during which time traditionally there is no bathing, the woman rests, special foods are eaten and people assist with care of the baby. However, in resettled countries it is often not possible to have a month to rest and many babies are delivered in hospitals and traditional breastfeeding is replaced with bottle feed if the mother has to return to work. The whole process can be quite foreign for an immigrant woman and it would be helpful if some of the traditional practices could be included in her care. It is best to consult each client about her preferences. YOUTH HEALTH Adolescent Health • According to Metha’s (2012) report on health needs for Asians living in the

Auckland region:

o Alcohol consumption is less prevalent amongst Asian students as compared to NZ European students

o Almost all Asian youth reported good health o Most Asian youth reported positive relationships and friendships o Most Asian youth reported positive family, home and school environments o 40% of Asian youth identified spiritual beliefs as important in their lives o 75% of Asian students do not meet current national guidelines on fruit and

vegetable intake o 91% of Asian students do not meet current national guidelines on having one

or more hours of physical activity daily o Mental health is of concern amongst all Asian students, particularly

depression amongst secondary student population

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• In addition, adolescents who migrate without family may encounter the following difficulties:

o Loneliness o Homesickness o Communication challenges o Prejudice from others o Finance challenges o Academic performance pressures from family back home o Cultural shock

• Others who live with migrated family can face:

o Status challenges in the family with role-reversals o Family conflict over values as the younger ones acculturate o Health risks due to changes in diet and lifestyle o Engaging in unsafe sex o Barriers to healthcare because of lack of knowledge of the NZ health system,

as well as associated costs and transport difficulties Child Health • According to Metha’s (2012) report on health needs for Asians living in the

Auckland region:

o There are no significant differences in mortality rates of Asian babies compared to European/Other children

o There were no significant differences in potentially avoidable hospitalizations (PAH) as compared to other children studied

o The main 3 causes of PAH amongst all Asian children studied were ENT infections, dental conditions or asthma

o The rate of low birth weights were similar amongst ‘Other Asian’ babies and their European/Other counterparts

o Asian children had similar or higher rates of being fully immunized at two and five years of age as compared with European/Other children studied

o A lower proportion of Asian five-year olds had caries-free teeth compared to the other ethnic groups studied

Traditional issues in child health • Breastfeeding may be lacking due to:

o misinformation about breastfeeding and infant feeding practices o the belief that bottle-feeding is modern and superior o concerns about privacy and modesty o communication difficulties with health professionals o lack of family support

• Newborns tend to be kept warm at all times, even in summer • Babies are kept close to stop excessive crying, and may share a room with

parents until at least a year old • Children are usually highly valued and seen as an asset to the family, so

childhood illness causes immediate anxiety

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• Children are expected to be respectful to their elders, well disciplined and to help around the home. They are encouraged to attend school and do well as this is perceived as the best route to a good job

• Changes in roles, different cultural norms around parenting styles and acculturation of the youth make some of the traditions difficult to follow

• Parents who are still struggling with their own grief and traumas may have been unable to attend to what would normally be considered unacceptable behaviour resulting in problematic social patterns

SPECIAL EVENTS • The Lunar New Year is celebrated from 13 – 15 April with the Water Festival • The Khmer New Year, is celebrated on 14, 15, and 16 April and has great cultural

significance when all business stops and families come together

SPIRITUAL PRACTICES • Buddhism – this is practiced by most Cambodians and has a strong influence on

the way of life, even for those who follow other practices • Evangelical Christianity, particularly the Church of Jesus Christ of Latter Day

Saints (Mormon) • Various forms of Animism • Some Cambodians, mostly the Cham-Malays (about 500,000) who live around

Phnom Penh are Muslim Many Khmer would be comfortable with attending or combining Christian and Buddhist practices and worship (See Chapter 2, Introduction to Asian Cultures, pgs 12-16 for more information related to religions and spiritual practices). DISCLAIMER Every effort has been made to ensure that the information in this resource is correct at the time of publication. The WDHB and the author do not accept any responsibility for information which is incorrect and where action has been taken as a result of the information in this resource.

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REFERENCES AND RESOURCES

1. Kemp, C., Rasbridge, L. (2004). Refugee and Immigrant Health. A handbook for Health Professionals. Cambridge: University Press.

2. Lim, S. (2004). Cultural Perspectives in Asian Patient Care (handout). Asian

Support services. Waitemata District Health Board.

3. Mehta S. Health needs assessment of Asian people living in the Auckland region. Auckland: Northern DHB Support Agency, 2012.

4. Mony, K. (1994). Post-partum practices. Retrieved July 2006 at

http://ethnomed.org/cultures/cambodian/camb_birth.htm. Link no longer current.

5. No author. (2014). China Major Infections Diseases. Retrieved February 2015

from: http://www.indexmundi.com/cambodia/major_infectious_diseases.html

6. No author, or date. Cambodian Culture. On-line (downloaded August 2006). Available at: http://www.world66.com/asia/southeastasia/cambodia/culture

7. Rasanathan, K. et al (2006). A health profile of Asian New Zealanders who

attend secondary school: findings from Youth2000. Auckland: The University of Auckland. Available at: www.youth2000.ac.nz, www.asianhealth.govt.nz, www.arphs.govt.nz

8. Rasbridge, L.A., Kemp, C. Cambodians. Retrieved July 2006 from:

http://www3.baylor.edu/~Charles_Kemp/cambodian_health.htm. Link no longer current. Information moved to journal article. Link no longer current in February 2015

9. Wetzel, L. Huong, J. 1996. Voices of the South Asian Communities. Retrieved

July 2006. In 2015 available at: http://sntc.medicine.ufl.edu/Files/Products/Cambodia_final.pdf

10. Wetzel, LRN, Author, Huong, J. Community Reader. 02.01.95. Cultural Profile. On-line. (downloaded July 2006). http://ethnomed.org/culture/cambodian

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Additional Resources:

1. The http://ethnomed.org/patient-education site has patient education materials in Cambodian.

2. The http://spiral.tufts.edu website has Patient Information by Language with

many resources in Cambodian.

3. RAS NZ (Refugees As Survivors New Zealand) can provide assistance to mental health practitioners on clinical issues related to refugee and cultural needs, and contacts for community leaders/facilitators. They can be contacted at +64 9 270 0870.

4. ARCC can provide information on resettlement issues and contacts for community leaders. Contact +64 9 629 3505.

5. Refugee Services can be contacted on +64 9 621 0013 for assistance with refugee issues.

6. The http://www.ecald.com website has patient information by language and information about Asian health and social services.