As the cultural diversity of older adults in the United States grows, clinicians are very likely to encounter older patients from a wide range of ethnic groups. The purpose of the Geriatrics Cultural Navigator is to provide cross-cultural assistance to clinicians with older patients from minority groups. The Geriatrics Cultural Navigator outlines factors for the practitioner to reflect upon before interacting with a patient.
Doorway Thoughts
- Refugee immigrants
- High poverty/illiteracy rates
- Little to no English skill, high probability needs for interpreter.
- High risk of traumatic history due to Khmer Rouge genocide conflict (PTSD)
- Suspicion of government; suboptimal access to benefits
- Difficulties accessing transportation for medical visits
Preferred Cultural Terms
- Cambodian American; Khmer American
- Mostly Khmer; Subgroups: Sino Khmer (Khmer with Chinese heritage), Cham (Muslim), Khmer Loeu (highlands)
Formality of Address
- Title: Oum/Pu (uncle), Ming (auntie), Yeay (grandma), Ta (grandpa), Bong (refer to someone who is elder or unfamiliar), Oun (refer to someone younger or unfamiliar) – plus first name
- Impolite: calling by first name without using any of the titles above. Note: calling someone by their last name considered rude in Khmer culture.
- Use formal name until patient suggests informality
Effective Communication
- Welcome greeting: palms together, slight bow while saying “Chum Reap Sur (Hello)”
- Farewell greeting: palms together, slight bow while saying “Chum Reap Leah (Goodbye)”
- Avoid steady eye contact
- Avoid touching head (location of persons spirit)
- Interpreter services often essential to establish rapport with Cambodian patients and their family members.
Tradition and Health Beliefs
- Disease caused by spirits, spells, imbalances
- No tradition of consulting physicians
- Herbal remedies, dermal coining/pinching, special foods
- Healing rituals, traditional healers
- Emotional/mental illnesses caused by spirits, are shameful/hidden
- Commonly report “wind” illness (feeling ill, feverish)
- Expect to receive medications from Western physicians
- Communication facilitated by interpreter improves detection of possible side effects of any prescribed medications, interaction with foods and/or herb
Culture-Specific Health Risks
- Limited medical and health literacy
- Inadequate medical screening or care due to poverty
- High smoking rates
- Unhealthy diets lack of availability and affordability (fewer fresh fruits, vegetables)
- Fresh seafood preferred, but lack of availability and affordability
- Subsistence fishing from polluted water precautions
- Illnesses underreported
- High rates of diabetes, CAD, stroke, hepatitis B, liver cancer
- Cancers of the mouth from betel nut chewing and tobacco smoking
- Trauma sequelae of war, starvation, brutality:
- Organ-system insufficiency (cardiac muscle damage, mitral prolapse, bone effects, neurologic damage, vision/hearing impairments)
- Heart palpitations, high risk for sudden cardiac arrest
- Mental health problems: PTSD, depression, obsessive thoughts, conversion reactions (dizziness, headaches, blindness)
- Alcohol abuse, assault, homicide
Practices and Health
- Traditional healer (Kru Khmer), herbal remedies (tnam Khmer)
- Cupping, pinching, or rubbing (coining) to release excess air is still common
- Buddhist monk blessings
- Possible iatrogenic interactions in use of both Western and traditional medicines or herbal remedies
Approaches to Health Decision-Making
- Older adults usually live within extended family, prefer group decisions
- Ask patient if decisions will be made by family, patient, or both
- Buddhist outlook: selflessness, cooperation, family honor
- Assessment of cognitive, physical, mental health is enhanced by medical Khmer language interpretation. When possible, collect detailed patient history from English speaking family members.
- Formal neuropsychological assessment may not be possible with Cambodian older adults due to lack of validated tools.
Informed Consent
- Family may wish to shield patient from bad news
- Prefer to keep discussion within family
- Resistance to withholding any treatment
- Tradition of stoicism requires sensitive inquiry about pain
- Ask patient in advance about who will make decisions, to whom to give information
Gender and Social Issues
- Increasing gender equality, but males still hold authority
- Issues of modesty may impede care (e.g., screening mammography)
- Loss of social, financial rank through war may cause family tensions
- If issues arise, consider respectful inquiry into gender, social roles
End-of-Life Care
- Buddhist/Christian: belief in reincarnation, karma, ancestral spirits
- Home death preferred; hospital care avoided due to harmful spirits
- Heroic interventions, surrounding strangers, considered “bad death”
- Rituals after death: body washing, candles, incense
- Cremation customary
- Discuss DNR orders in advance of health crises, once relationship established