Gambling problems, risk factors, community knowledge, and impact in a US Lao immigrant and refugee community sample.

OBJECTIVES: The objectives of this study were to examine gambling-related problems, risk factors, help-seeking attitudes, community perceptions, and correlates of problem gambling in a Lao sample of Southeast Asian refugees and immigrants and to discuss cultural implications for the treatment and prevention of gambling problems in Southeast Asian refugee and immigrant populations. STUDY DESIGN: This was a cross-sectional, community-based interview study. METHODS: Participants (N = 200, males = 51%, females = 49%) were recruited from a Lao community center in a major US metropolitan area (convenience sample; community center recruitment and peer nomination). Structured interviews on gambling and substance use were conducted by Lao center staff members in both English and Lao languages. RESULTS: Gambling-related problems were measured using the South Oaks Gambling Screen (SOGS), gambling frequency, and quantity measures. In a previous study, we reported a substantial number of participants from the sample endorsed gambling-related harms and problems (SOGS score of five or more = 24%) and common methods of play were slots, house betting, cards at a casino, and sports betting. Among those endorsing five or more gambling problems, reasons for gambling included making money (68%), social life (31.3%), entertainment (58.3%), and reducing boredom (35.4%). Less commonly endorsed reasons were depression or stress (14.6%) and escape (10.4%). Many participants reported a family history of gambling problems. Those with problem gambling had twice the level of sibling problem gambling histories relative to those without problem gambling (35.4% vs. 11.1%). There were substantially more participants in the problem gambling group who had started gambling before the age of 13 years than in non-problem gamblers (P < .05). Many recognized gambling as a significant issue in the community and reported knowing several individuals affected by gambling-related problems. CONCLUSIONS: Many participants recognized gambling as a significant issue in the Lao community. We include insights gleaned from a research partnership with a community organization. Although data cannot be generalized to the Lao community because of limitations in sampling methodology, participants viewed gambling as a culturally common social practice. Cultural norms affected where community members gamble, types of games, and betting practices. In this context, community members may view gambling-related harms as both a community-level and individual-level concern. These data suggest a significant need for rigorous research to inform policies and a culturally sensitive approach to public health prevention, intervention, and education. We discuss the challenges and cultural barriers to research and community engagement and offer suggestions for prevention and intervention ideas efforts.

Perceptions and management of postpartum haemorrhage among remote communities in Lao PDR.

INTRODUCTION: In Lao People's Democratic Republic, despite a policy to provide free maternal health services in healthcare facilities, many rural women continue to deliver at home, without a skilled birth attendant. These women are at high risk of postpartum haemorrhage, the leading cause of maternal mortality in the country. While women in remote areas continue to be unable to access facility-based birthing, interventions to reduce postpartum haemorrhage are a priority. This requires an understanding of how women and their families recognise and manage postpartum haemorrhage in home births. The purpose of this study was to understand community perceptions and management of postpartum bleeding during home births in remote Lao communities. METHODS: Five focus group discussions with a total of 34 women and their support networks were conducted in five remote communities in Oudomxay, a province with high rates of maternal mortality. Villages were selected with district health officials based on (1) known cases of postpartum haemorrhage, (2) travel time from the provincial capital (2-4 hours), (3) distance to the district health service (>4 km), and (4) population (50-150 people), with the five selected villages being the farthest from the district health service. The focus group discussions were complemented by qualitative, community-based key informant interviews (n=9). All interviews were conducted in Lao, English or the ethnic language most suitable for the sample and simultaneously translated by native speakers. All transcripts were translated into English, back translated and checked against interview recordings. The qualitative data were coded into key themes while moving between the data and the coded extracts. Interpretation of the data themes and coding was an ongoing process with codes and themes checked by the research team. RESULTS: Women described postpartum bleeding as a normal, necessary cleansing process. Some women felt it was critical in order to expel 'bad blood' and restore the mother to good health. Participants were able to describe late symptoms of postpartum haemorrhage but did not describe any methods to accurately estimate the amount of blood loss that required intervention. Traditional remedies were the first courses of action, potentially delaying treatment at a healthcare facility. When asked about the acceptability of taking oral medication immediately following home births to prevent postpartum haemorrhage, most women felt it would be acceptable provided it would not stop normal bleeding, and its usage, benefits and side-effects were clearly explained. CONCLUSION: While women continue to home birth in remote communities without skilled birth attendants, an informed understanding of traditional management of postpartum haemorrhage can assist in designing culturally responsive interventions. To support a reduction in morbidity and mortality from postpartum haemorrhage, tailored interventions are needed to raise awareness among women and their families to reduce delays in seeking health care. Women felt it would be acceptable to take oral medication to prevent postpartum haemorrhage. As such, community-based distribution of misoprostol that can be administered by lay people would provide an effective and acceptable prevention strategy. Other strategies should include promoting birthing plans, delivery by skilled birth attendants and early initiation of breastfeeding.

Factors Associated with Reported Colorectal Cancer Screening Among Lao-American Immigrants in Minnesota.

Colorectal Cancer (CRC) is common in Lao Americans, but screening is suboptimal. To investigate CRC screening rates of Lao Americans in Minnesota, and how predisposing characteristics, enabling resources, and perceived need are associated with screening. We conducted a convenience-sample cross-sectional survey of 50-75-year-old Lao Americans, using step-wise multivariate logistic regression to identify factors associated with ever being screened. Of the 118 survey participants, 45% ever received CRC screening. In univariate regression, some enabling resources (having a primary care provider, higher self-efficacy in pursuing screening) and perceived needs (knowledge of who should be screened, higher number of chronic illnesses) were associated with screening. In multivariate logistic regression, the odds of ever being screened was 12.4 times higher for those with a primary care provider than for those without (p = 0.045). The findings reinforce a need for developing culturally tailored interventions focused on Lao-American immigrants to promote CRC screening.

Differences in knowledge about epilepsy and antiepileptic drugs among pharmacy-dispensing workers in Cambodia and in Lao PDR.

Epilepsy is the most common neurological disorder encountered in primary care in Southeast Asia. People with epilepsy require long-term therapy management. Nonadherence to antiepileptic drugs (AEDs) has been identified as a major factor in suboptimal control of epilepsy. Pharmacies offer patients a first-line point of contact with the healthcare system. Many pharmacies operate with limited or nonqualified human resources that can lead to insufficient knowledge, inappropriate supply of medicines, and insufficient counseling. OBJECTIVE: The aim of this study was to evaluate the qualification and knowledge concerning epilepsy and AEDs among pharmacy-dispensing workers who sell drugs to people with epilepsy. METHOD: A cross-sectional qualitative study was conducted in public and private pharmacies, in both urban and rural areas of Cambodia and Lao People's Democratic Republic (Lao PDR). The knowledge was collected through a questionnaire. RESULTS: A total of 180 respondents from 123 outlets in the two countries were included in this study. A proportion of 40.8% (31) of respondents in Cambodia and 38.5% (40) in Lao PDR were pharmacists, followed by sellers who did not received any healthcare training with a proportion of 18.4% (14) in Cambodia compared to 20.2% (21) in Lao PDR. Head trauma was cited as the main cause of epilepsy by 72.4% (55) in Cambodia and 27.2% (28) in Lao PDR (p < 0.001). Epilepsy was considered as a contagious disease by 6.6% (5) of respondents in Cambodia compared to 18.4% (19) in Lao PDR (p = 0.03). Eighty-seven percent (66) of respondents in Cambodia knew at least one long-term AED versus 67.3% (70) in Lao PDR (p = 0.003). Phenobarbital was mentioned in more than 90.0% of cases in both countries. In overall, 15.4% (21) thought that if seizures are controlled for some months, people with epilepsy could stop taking their AEDs. Only one respondent from Lao PDR was aware of drug-drug interaction between AEDs and oral contraception. CONCLUSION: An educational intervention should be implemented to improve the knowledge of epilepsy and AEDs for pharmacy-dispensing workers. This could include advice for all pharmacy-dispensing workers in order to improve AED management and follow-up of therapeutic adherence.

An exploration of healthy eating and physical activity habits of Hmong high-school students by disability status: A pilot study.

BACKGROUND: Immigrants are at risk of being obese from obesogenic environments and face factors which limit physical activity and healthy eating. While Hmong immigrants acknowledge the importance of healthy eating and physical activity, to our knowledge no studies have looked at health promoting behaviors among Hmong adolescents with and without disabilities. OBJECTIVE: In this paper, we seek to provide baseline data about physical activity and healthy eating among Hmong high school students with disabilities in Minnesota. METHODS: We used data from the 2016 Minnesota Student Survey. The study included responses from 1,824 Hmong high school students. We compared physical activity and healthy eating of Hmong high school students by disability status. RESULTS: Approximately 13% of Hmong had a disability (n = 239). A greater percentage of Hmong high school students with disabilities reported zero days of 60 min of physical activity (20.5% vs 14.8%, p < 0.10) and zero days participation in sports teams outside of school (69.0% vs. 64.3%, p < 0.10). Compared to Hmong students without disabilities, a significantly lower percentage of Hmong students with disabilities reported not receiving free/reduced lunch (66.5% vs 73.1%, p < 0.05) and significantly more likely to skip meals because their family did not have enough money (14.2% vs 9.7%, p < 0.05). CONCLUSION: Adolescent Hmong with disabilities encounter both cultural and disability specific factors which could contribute to poorer health promoting behaviors. This study shines light on the need for social policy that promotes disability inclusive, culturally specific health promotion information and advocacy for immigrant youth with disabilities and their families in schools and communities.

Seeking Help for Harm from Others' Drinking in Five Asian Countries: Variation Between Societies, by Type of Harm and by Source of Help.

AIMS: This study aims to measure the prevalence rates and patterns of help-seeking behavior as a consequence of being harmed by drinkers in five Asian countries (India, Sri Lanka, Vietnam, Lao PDR and Thailand). METHODS: A total of 9832 respondents aged 18-65 years from the WHO/ThaiHealth Collaborative Project were surveyed between 2012 and 2014 about their experiences of being negatively affected due to another's drinking, and whether and where they sought help, focusing on four adverse aspects of harms from others' drinking. RESULTS: The prevalence of seeking help from any source in the past year due to harm from others' drinking ranged from 7% to 20%. The most common service used by those who were affected by other people's drinking was asking for help from friends, followed by calling the police and using health-related services. The largest proportion of help-seeking was among those reporting property harm, followed by those being harmed physically and sexually by drinkers. CONCLUSION: Given a wide range of harms from others' drinking in the general population and different needs of those affected, prevalence rates for help-seeking behavior due to others' drinking in South and South East Asian countries were low and the help sought was often informal. There is a large knowledge gap in our understanding of the mechanisms of help-seeking behavior and the pathways for access to help among those affected. Further studies are important for enhancing the social response services available and making these more accessible to those who need help.

Seroprevalence of Histoplasmosis in Somali, Burmese, and Hmong Refugees Residing in Thailand and Kenya.

Histoplasmosis is known to be endemic to the Midwestern United States, but cases have been reported throughout much of the world. Somali, Hmong, and Burmese (ethnically Karen) persons make up some of the largest refugee populations coming the United States in recent years. Yet, information about risk of Histoplasma capsulatum infection amongst these populations is limited. This study used the CDC Migrant Serum Bank to test ~100 samples from each of Somali, Burmese, and Hmong U.S.-bound refugees. Samples were tested by enzyme immunoassay for Histoplasma capsulatum IgG. Overall 1% (2/299) of refugee serum samples were positive for H. capsulatum IgG. One of 99 samples obtained from Hmong refugees was positive, and the other positive sample came from among 100 Burmese refugee samples. H capsulatum IgG positivity was detected at low levels in Hmong and Burmese refugees. No IgG positivity was detected among 100 Somali refugees.

Barriers to Health Care among Laotian Americans in Middle Tennessee.

We examined barriers to health care among Laotian Americans in a Middle Tennessee community that included a Laotian-speaking practitioner. A Laotian American primary care clinic nurse practitioner surveyed 312 adult Laotian Americans. The dependent variable was whether respondents visited (n = 214, 77.8%) or did not visit (n = 61,22.2%) primary care providers (PCP) in the last year. Chi-square analysis found visiting less likely if respondents were age 18-34 (p < .001), born in U.S. (p < .001), spent less time in U.S. (p = .010), never married (p = .001), lacked health insurance (p < .001), or lacked a PCP (p < .001). Chi-square analysis segmented by age found neither lack of English fluency nor preference for Laotian-speaking providers significantly reduced access, possibly because of the Laotian practitioner. Logistic regression found individuals with insurance five times more likely to visit and individuals with PCP 8.5 times more likely. Results support the value of training minority providers.

Violating Clan and Kinship Roles as Risk Factors for Suicide and Stigma among Lao Refugees: An Application of the Cultural Model of Suicide and "What Matters Most" Frameworks.

BACKGROUND: While Asian groups have immigrated worldwide, suicide risk models have neglected to integrate cultural components. This study incorporates how stigma associated with failure to uphold clan/kinship roles can increase suicide risk in highly-marginalized Lao-Americans. METHODS: One focus group with five Lao participants and 21 individual semi-structured interviews with community family members were conducted. Transcripts were coded via directed content analysis using the "What Matters Most" and Cultural Theory of Suicide frameworks. RESULTS: Violating role-expectations associated with youth, adults and older adults appears to be associated with risk for suicide. This suggests that the failure of adults to fulfill their roles might potentially threaten loss of "full personhood" and trigger stigma, thus potentially evoking greater suicide risk. CONCLUSION: Interventions would benefit from cultural considerations of fulfilling role-expectations and "personhood" to combat suicide and stigma within cultural communities.

Recurring Vivid Dreams in an Older Hmong Man With Complex Trauma Experience and Cognitive Impairment.

INTRODUCTION: Health care workers need to consider the culture and ethnic preferences prevalent in the Hmong community in order to provide optimal care. We describe an older Hmong man to illustrate the challenges faced and competencies needed by primary care. CASE PRESENTATION: An 80-year-old non-English speaking Hmong man with diabetes, nerve sheath tumor, and hypertension presented to the outpatient clinic with his grandson complaining of sleep problems. He had had 2 vivid recurring dreams during the previous few months. Memory assessment was significant for dementia. DISCUSSION: This case addresses the complexity in taking care of a non-English speaking Hmong older man who has memory loss, trauma in adulthood, multiple caregivers, and sleep problems. CONCLUSIONS: A careful history from patient and family to get to know their cultural preferences and attitudes was helpful. Identification of the primary caregiver was critical in providing care.

The Impact of Gender Differences in Attitudes and Beliefs Concerning HBV Vaccination and Screening in the Lao Community.

Liver cancer incidence is increasing among Asian Americans. Laotians in the US have greater risk of liver cancer death compared to other Asian American groups. However, ethnicity is not the only disparity; Laotian men are at increased risk of liver cancer compared to Laotian women. Use of hepatitis B virus (HBV) vaccination and screening is low among Laotians. The impact of gender differences in attitudes and beliefs concerning HBV vaccination and screening is unknown. This secondary analysis of a cross-sectional community-based participatory research study. Although men were more likely to believe that infection with HBV is preventable, and treatable, causes liver cancer, and that healthy persons should be vaccinated, of those who thought people should get vaccinated, women were four times more likely to receive vaccine than men (adj. OR 4.0, CI 1.2-19). Understanding and addressing gender differences may increase HBV screening and vaccination uptake, thus reducing disparities within the Laotian community.

Preterm birth among the Hmong, other Asian subgroups and non-Hispanic whites in California.

BACKGROUND: We investigated very preterm (VPTB) and preterm birth (PTB) risk among Hmong women relative to non-Hispanic whites and other Asian subgroups. We also examined the maternal education health gradient across subgroups. METHODS: California birth record data (2002-2004) were used to analyze 568,652 singleton births to white and Asian women. Pearson Chi-square and logistic regression were used to assess variation in maternal characteristics and VPTB/PTB risk by subgroup. RESULTS: White, Chinese, Japanese, Korean, Asian Indian, and Vietnamese women had 36-59% lower odds of VPTB and 30-56% lower odds of PTB than Hmong women. Controls for covariates did not substantially diminish these disparities. Cambodian, Filipino and Lao/Thai women's odds of VPTB were similar to that of Hmong women. But they had higher adjusted odds of PTB compared to the Hmong. There was heterogeneity in the educational gradient of PTB, with significant differences between the least and most educated women among whites, Chinese, Japanese, Asian Indians, Cambodians, and Laoians/Thais. Maternal education was not associated with PTB for Hmong, Vietnamese and Korean women, however. CONCLUSIONS: Studies of Hmong infant health from the 1980s, the decade immediately following the group's mass migration to the US, found no significant differences in adverse birth outcomes between Hmong and white women. By the early 2000s, however, the disparities in VPTB and PTB between Hmong and white women, as well as between Hmong and other Asian women had become substantial. Moreover, despite gains in post-secondary education among childbearing-age Hmong women, the returns to education for the Hmong are negligible. Higher educational attainment does not confer the same health benefits for Hmong women as it does for whites and other Asian subgroups.

Towards a Spatial Understanding of Trade-Offs in Sustainable Development: A Meso-Scale Analysis of the Nexus between Land Use, Poverty, and Environment in the Lao PDR.

In land systems, equitably managing trade-offs between planetary boundaries and human development needs represents a grand challenge in sustainability oriented initiatives. Informing such initiatives requires knowledge about the nexus between land use, poverty, and environment. This paper presents results from Lao PDR, where we combined nationwide spatial data on land use types and the environmental state of landscapes with village-level poverty indicators. Our analysis reveals two general but contrasting trends. First, landscapes with paddy or permanent agriculture allow a greater number of people to live in less poverty but come at the price of a decrease in natural vegetation cover. Second, people practising extensive swidden agriculture and living in intact environments are often better off than people in degraded paddy or permanent agriculture. As poverty rates within different landscape types vary more than between landscape types, we cannot stipulate a land use-poverty-environment nexus. However, the distinct spatial patterns or configurations of these rates point to other important factors at play. Drawing on ethnicity as a proximate factor for endogenous development potentials and accessibility as a proximate factor for external influences, we further explore these linkages. Ethnicity is strongly related to poverty in all land use types almost independently of accessibility, implying that social distance outweighs geographic or physical distance. In turn, accessibility, almost a precondition for poverty alleviation, is mainly beneficial to ethnic majority groups and people living in paddy or permanent agriculture. These groups are able to translate improved accessibility into poverty alleviation. Our results show that the concurrence of external influences with local-highly contextual-development potentials is key to shaping outcomes of the land use-poverty-environment nexus. By addressing such leverage points, these findings help guide more effective development interventions. At the same time, they point to the need in land change science to better integrate the understanding of place-based land indicators with process-based drivers of land use change.

Help Seeking Attitudes Among Cambodian and Laotian Refugees: Implications for Public Mental Health Approaches.

This is a pilot study of demographic and acculturation factors in relation to attitudes toward seeking psychological help among Lao and Cambodian refugees and immigrants in the United States of America. Cambodian and Laotian American adults in the United States of America were approached to complete help-seeking attitudes and acculturation scales. T test and hierarchical multiple regression analyses were used to analyze the relationships between the demographic and acculturation variables, and attitudes toward seeking psychological help. Out of 270 target subjects approached there were 108 respondents. Of the demographic variables, gender was associated with favorable attitudes towards psychological help-seeking. As expected, women were significantly more likely than men to recognize the need for help, to seek psychological help, to be more open to discussing mental health problems, and have more confidence in professional services. Acculturation was more powerfully associated with help- seeking attitudes than any of the demographic variables. In hierarchical multiple regression, acculturation contributed significant unique variance over and beyond the entire set of demographic variables to openness to discussing problems and having confidence in professional help. The findings of this pilot study suggest that there are significant barriers to seeking psychological help among Lao and Cambodian Americans. Attention to the issues of gender and levels of acculturation may improve access.

Research challenges and lessons learned from conducting community-based research with the Hmong community.

BACKGROUND: Conducting research with underserved communities with little exposure to research presents a number of challenges and opportunities. Our study used a community-based approach to better understand factors that influence breast and cervical cancer screening among Hmong women. OBJECTIVE: This article shares lessons learned during the process of developing and conducting qualitative research with a Hmong community with limited experience with research. METHOD: We conducted 17 key informant and 84 in-depth interviews with Hmong women and men. Research team discussions, insights from Hmong research team members, input from our Community Advisory Committee, and project documents were sources of information about the process of conducting research in this community. RESULTS: Lessons learned concern including a cultural insider as an investigator; building community partnerships and support; establishing and working with a community advisory committee; hiring and training bilingual, bicultural staff; and using culturally appropriate materials and methods in a small, kinship-based community. We used multiple strategies to ensure that this study was conducted in a culturally appropriate manner. CONCLUSION: The lessons learned from our experiences can provide guidance to researchers on methodological and practical issues in conducting research with the Hmong and can inform future research with the Hmong and other similar underserved populations.

Cross-border mobility and social networks: Laotians seeking medical treatment along the Thai border.

Drawing upon research conducted on cross-border patients living in Laos and seeking care in Thailand, this paper examines the important role played by social networks in patients' decision-making and on the itineraries they choose to seek treatment on the Thai side of the border. Due to the vastly contrasting situations between the two countries in terms of healthcare supply, and considering Laotians' increasing demand for high quality healthcare, a number of them have managed to satisfy their needs by combining cross-border treatment with the use of the healthcare facilities provided by their own country. This study consisted first of household surveys conducted in five border areas (2006-2007) in Laos in order to quantify and map out cross-border healthcare-related travel patterns. Afterwards, interviews were conducted with cross-border patients (55), Laotian and Thai medical doctors (6), Thai social workers (5), and officials working in public institutions (12). While socioeconomic and spatial factors partly explain cross-border mobility, patients' social networks significantly influence treatment itineraries throughout the decision-making process, including logistical and financial considerations. The social networks existing at different geographical levels (neighbourhood, regional and global) are therefore a powerful analytical tool not only for understanding the emergence of these cross-border movements but also for justifying them in an authoritarian political environment such as Lao PDR's.

Obstacles to parent-adolescent communication in Hmong American families: exploring pathways to adolescent mental health promotion.

OBJECTIVE: Mental health challenges disproportionately affect children in refugee families, with Hmong American adolescents being an extreme case (Thao, Leite, and Atella 2010). Limited understanding about the processes associated with this enhanced risk for children of refugees exists. Obstacles to parent-adolescent communication may contribute to this increased risk (Laursen and Collins 2004). This study's objective is to explore our limited understanding of parent-adolescent communication in refugee families by examining communication obstacles among Hmong Americans. DESIGN: Thirty Hmong American young adults (18 to 25 years; mean = 21.2, 50% female or n =15) participated in interviews that focused retrospectively on the parent-adolescent relationship. RESULTS: Results revealed obstacles that were initiated by the adolescent, parent, and community. Two adolescent-focused sub-themes (emotional discomfort and psychosocial immaturity), five parent-focused sub-themes (parental judgment, parental intimidation, no benefits of communication with parents, generational/cultural differences, and lack of parent-adolescent bond), and two culture/community-focused sub-themes (traditions/values and vocabulary) emerged. CONCLUSIONS: The findings provide a foundation for future qualitative and quantitative studies to promote Hmong American family communication, and encourage an ecological approach to promote parent-adolescent communication conducive to supporting adolescent mental health outcomes.

Environmental, personal, and behavioral influences on BMI and acculturation of second generation Hmong children.

This project investigated influences (environmental, personal, and behavioral) on body mass index (BMI) and acculturation of Hmong children born in the United States (US) using the social cognitive theory as the theoretical framework. Using formative information from 12 child focus groups (n = 68) and a review of the literature, a quantitative survey was developed and administered to Hmong children (n = 300) ≥ 9 ≤ 18 years-old. Heights, weights, and acculturation level were measured. B-US(1) were raised in the US and 9-13 years-old (n = 144) and B-US(2) were raised in the US and 14-18 years-old (n = 156). Approximately 50 % of children were classified as overweight/obese (BMI ≥ 85th percentile). Across age and gender sub-groups, questions from the environmental construct appeared to be the most predictive of variances in BMI percentiles (50-60 %). In contrast, acculturation scores were equally predicted by environmental, behavioral, and personal constructs for age and gender sub-groups. Sum acculturation score was significantly higher for B-US(2) compared to B-US(1), with B-US(2) being more acculturated in language use and thought, overall dietary acculturation, and foods eaten at lunch. The high prevalence of obesity in Hmong children suggests that future studies investigate factors influencing obesity to identify the most effective method to reduce/prevent this problem. In particular, acculturation level of the child should be assessed to determine changed dietary behavior and possible risk for obesity.