Cultural competency | Working with interpreters | Important note

There have been many years of political conflict in Laos, and particularly since the French colonial rule ended in 1954. The communist party under Pathet Lao eventually took power in 1975 and formed the Lao People's Democratic Republic, beginning a 20 year rule of terror. This government was backed by the Soviet Union and the Northern Vietnamese Army which was given considerable influence in the country. To escape the atrocities perpetuated by the communist regime (in what became known as the Killing Fields of Laos) Laotians began fleeing to Thailand to refugee camps. Many of these refugees spent over 10 years in camps before resettling elsewhere. Most arrived in New Zealand in the late 1970’s and early 1980’s under the NZ quota system, totaling 239 displaced Laotians at that time. Although dissidents (largely Hmong people) have been in conflict with the communist regime since they took power, media reports suggest that this is waning. However, since all dissent in Laos is repressed, this picture is not necessarily reliable. In New Zealand less people arrive as refugees, more recent arrivals have been through family re-unification schemes.

There have been many years of political conflict in Laos, and particularly since the French colonial rule ended in 1954. The communist party under Pathet Lao eventually took power in 1975 and formed the Lao People's Democratic Republic, beginning a 20 year rule of terror. This government was backed by the Soviet Union and the Northern Vietnamese Army which was given considerable influence in the country. To escape the atrocities perpetuated by the communist regime (in what became known as the Killing Fields of Laos) Laotians began fleeing to Thailand to refugee camps. Many of these refugees spent over 10 years in camps before resettling elsewhere. Most arrived in New Zealand in the late 1970’s and early 1980’s under the NZ quota system, totaling 239 displaced Laotians at that time. Although dissidents (largely Hmong people) have been in conflict with the communist regime since they took power, media reports suggest that this is waning. However, since all dissent in Laos is repressed, this picture is not necessarily reliable. In New Zealand less people arrive as refugees, more recent arrivals have been through family re-unification schemes.

Although the Laotian community has integrated well into new Zealand, many of those who came as refugees suffered extensive trauma during the Killing Field era, and subsequently during flight and in refugee camps. Some of the older generation may live with unresolved trauma which can sometimes be passed on to the next generation. Although the Laotians are known as an industrious and resilient people, health providers need to be aware of heritage of our settlers. 

The population consists of three main ethnic groups: Lao Lum (lowlanders), about half the population; Lao Theung (highlanders), including the Khmu; and Lao Sung (mountain people), including the Hmong and Mien. There are more than 30 tribes all speaking different languages. The information below is generalized except when stated.

Laotian greetings

Speech bubble

Hello

Speech buble

Sah-bye-dee

Speech bubble

Goodbye

Speech buble

Lagorn

Lao or Laotian (some also speak Thai)

Lao or Laotian is the country's official language. The Lao alphabet and many words were derived from Pali and Sanskrit, languages of ancient India. The Hmong have their own written language, but only a few are literate. Some people will also speak Thai as a second language.

Gestures and interaction

  • The traditional means of salutation (coming or going) is called wai, which involves placing one's hands together as if praying and inclining the head. The height at which the hands are held designates status of the person being greeted
  • Respect and politeness is critical for Laotions
  • Respect also involves explaining about procedures and treatments, practitioners being on time for appointments, addressing elders first
  • Since there is a very strong emphasis on personal privacy it is important to ensure confidentiality

Gestures and interaction

  • Wai, the traditional salutation (for coming or going) involves placing one's hands together as if praying and inclining the head
  • Respect and politeness is critical
  • Explain about procedures and treatments, be on time for appointments, address elders first
  • Show an interest in the culture and practices
  • Ensure confidentiality (there is a very strong emphasis on personal privacy)
  • Women do not shake hands
  • Using hand gestures to summon someone is considered insulting
  • It is disrespectful to touch another’s head (except for medical examination)
  • It is important that children should NOT be used as interpreters as this puts the family in a difficult position of the child having superior status over the adult/s
  • ‘Yes’ can be an ambiguous response sometimes indicating paying attention and not necessarily indicating agreement (ask open-ended questions)
  • Invite the family to ask questions as they may be reticent out of respect for authority
  • Migrated Laotians have tended to live in more closely knit communities than most other refugees from Southeast Asia
  • Families are patrilineal with extended households
  • Reverence to ancestors is practiced
  • Clan obligations were important in the homeland but for many refugees they may be the only member of their clan in the new country
  • Laotians have a lot of pride and will usually be reticent in asking for help or in using local charity and services
  • Migrant Laotians tend to live in closely knit communities
  • Families are patrilineal and extended
  • Elders of both genders are given great respect
  • Some health decisions may be made by the elder even if the client is an adult
  • Filial respect and reverence to ancestors is important
  • Clan obligations are important in the homeland but for many refugees they may be the only member of their clan in New Zealand
  • Role reversals and small communities have altered many traditional social structures
  • Laotians have a lot of pride and will usually be reticent in asking for help or in using services
  • Supernatural
  • Spiritual
  • Humoral imbalances
  • Western concept of disease causation

Practices around health are related largely to Phram beliefs (Brahmanistic and animanistic) rather than Buddhism. However some of these will occur in the context of Buddhist beliefs and practices. The views on health and illness are complex and multidimensional and strongly spiritually based:

  1. The first could be considered supernatural, where illness can be brought on by hostile spirits, spells or curses, or violation of taboos.
  2. Secondly, a spiritual belief is that illness may be caused by loss of soul (or more specifically to the loss of one of 32 spirits responsible for maintaining health). The loss may occur when being startled whilst alone, being unconscious (including from anesthesia), feeling sad or lonely, having an accident and many other causes. An acharn or teacher/healer (not to be confused with a monk) is called on to perform a ceremony to call the soul/spirit back to the body. A visit to the temple where prayer and lustral water are used is also sought to relieve the problem.
  3. Thirdly, as with other Southeast Asians, an imbalance in "winds", and hot and cold forces also play a role in health and illness, and restoring balance restores health or well-being.
  4. There is also some acceptance of the western concept that illness can be the result of external factors such as accidents and infectious diseases. As with many resettled peoples, the degree to which traditional practices are modified varies enormously.
  • Coining (Khout lom)
  • Cupping
  • Pinching
  • Traditional Lao medicines
  • Massage and manipulation
  • Chinese medicines
  • Monks can be involved in health care
  • Wearing a sacred talisman (get permission in a culturally sensitive manner before removing these)
  • Coining (Khout lom)
  • Cupping
  • Pinching
  • Traditional Lao medicines (imported or ingredients grown and gathered locally)
  • Massage and manipulation (performed by healers and elders with knowledge of healing techniques)
  • Chinese medicines
  • Monks and acharns are involved in health care and illness
  • Wearing a sacred talisman:
    • one that has been spiritually prepared by monks and holy men
    • Buddha images around the neck
    • a katha, which is a metal string inscribed with Pali prayers around the wrists (similar to Cambodians)
    • a haksa, which is a small bag given by grandparents or parents as protection and worn around the neck
    • adorning a Yarn (a protective tattoo) on the chest, back and arms for men (similar to Cambodians)

Permission needs to be gained (in a culturally sensitive manner) from clients before these articles are removed for healthcare interventions 

Important factors for Health Practitioners to know when treating Laotian clients:
  1. Health histories may be incomplete for several reasons, the most basic of which is a reluctance to volunteer information. Privacy in personal matters, especially related to family, sexual and illness (vulnerability) issues is highly valued, and this as well as trust or its lack, are major issues when it comes to divulging information. With trust based on relationships, one might assume that the history will evolve over time, rather than be complete in one or two interviews
  2. Language barriers are often an issue for older Laotians, especially those from a rural background. Because health care situations present unique challenges in understanding, particularly given the diversely different practices between traditional and New Zealand health systems, and also the cultural gradations in decision-making, even the presence of a bilingual family member may not be sufficient for some circumstances
  3. Cultural issues present are sometimes difficult to identify and increase problems in understanding. Laotians may feel alienated and isolated when confronted with the extensive and foreign western health systems
  4. Most Laotians focus on acute illness and otherwise do not place high value on disease prevention and health promotion
  5. Seeking health care from clinics or hospitals is usually deferred until family, community, and spiritual resources are exhausted. Using clinics or hospitals as a last resort, coupled with reticence in complaining, results in some clients presenting with advanced illness
  6. Note that traditional practices are often continued while utilizing western medicine
  7. It is useful to provide treatment instructions in varying forms such as spoken word, written and pictorial (see http://spiral.tufts.edu/laotian.shtml for Patient Information in Laotian on a wide range of illnesses for adults and children. However, dialect issues may be a problem and an interpreter may still be needed)
  8. Some traditional techniques (e.g. coining, cupping, pinching) may leave marks on the body and providers need to investigate these before assuming abuse
  9. The values and practices of some 2nd and 3rd generation Laotians may be quite similar to the host New Zealand culture
  10. 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
  • If the father/head of household is required for the interview/family session this will need to be arranged in advance as traditionally this would not be seen as part of his role
Important factors for Health Practitioners to know when treating Laotian clients:
  1. Health histories may be incomplete for several reasons, the most basic of which is a reluctance to volunteer information. Privacy in personal matters, especially related to family, sexual, and illness (vulnerability) issues is highly valued, and this as well as trust or its lack, are major issues when it comes to divulging information. With trust based on relationships, one might assume that the history will evolve over time, rather than be complete in one or two interviews
  2. Language barriers are often an issue for older Laotians, especially those from a rural background. Because health care situations present unique challenges in understanding, particularly given the diversely different practices between traditional and New Zealand health systems, and also the cultural gradations in decision-making, even the presence of a bilingual family member may not be sufficient for some circumstances
  3. Cultural issues present are sometimes difficult to identify and increase problems in understanding. Laotians may feel alienated and isolated when confronted with the extensive and foreign western health systems
  4. Most Laotians focus on acute illness and otherwise do not place high value on disease prevention and health promotion
  5. Seeking health care from clinics or hospitals is usually deferred until family, community, and spiritual resources are exhausted. Using clinics or hospitals as a last resort, coupled with reticence in complaining, results in some clients presenting with advanced illness
  6. Note that traditional practices are often continued while utilizing western medicine
  7. It is useful to provide treatment instructions in varying forms such as spoken word, written and pictorial (see http://spiral.tufts.edu/laotian_index.html for Patient Information in Laotian on a wide range of illnesses for adults and children. However, dialect issues may be a problem and an interpreter may still be needed)
  8. Some traditional techniques (e.g. coining, cupping, pinching) may leave marks on the body and providers need to investigate these before assuming abuse
  9. The values and practices of some 2nd and 3rd generation Laotians may be little different from the host New Zealand culture
  10. 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
  • Dress modestly

Sue to add

Rice, meat (traditionally a preference for beef over fish and chicken) is the staple diet. Since the culture also considers hot/cold body states as factors in health, diet will play an important part in treatment and the client’s preferences may need to be encorporated in interventions

Sue to add

  • When there is a terminal illness, it is best to consult the client about how much s/he wants to know about the diagnosis and prognosis, and who else in the family s/he wants to be involved in decision making. The process of Informed Consent may be new to many families and this process will need to be explained. If the client does not want to make any decisions for themselves, they will need to have a Durable Power of Attorney
  • Families prefer terminally ill members to return home to die as it is believed that the soul of a person who does not die at home may wander and not be reincarnated
  • The entire family will want to be present for the member’s last days. If the client is hospitalized and is Buddhist, they should be told directly that a monk will be welcomed by the institution. The presence of a monk is helpful to the client and the family
  • Nutritional deficits
  • Hepatitis B
  • Tuberculosis
  • Parasites (roundworm, hookworm, filaria, flukes, amoebae, giardia)
  • Malaria HIV
  • Hansen's disease
  • Cardiovascular ailments
  • Diabetes
  • PTSD

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 Laos:

  • 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

[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.

Sue to add

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
  • 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)

Sue to add

  • Early menopause is common
  • Contraceptives are avoided as having many children is highly valued However, oral contraceptive and barrier methods are preferred when used
  • Menstrual blood is considered a pollutant and so missing a period is a worry to women
  • Amongst Laotians modesty is highly valued, especially in women from waist to knees - and most especially in younger women. Women may refuse vaginal examinations, especially by male doctors. This may be a reason for late presentations for antenatal care and non-attendance at post-partum checks. Pelvic examinations of unmarried women should therefore not be a routine practice, especially by male providers. Same gender practitioners should be used whenever possible
  • In part because of issues of modesty, there is often resistance to breast self examinations among Laotian women
  • It is recommended that double gowning of hospitalized clients should be practiced as much as possible
  • In Hmong culture, mothers and mothers-in-law assist with the birth (traditionally squatting position) and the husband cuts the cord and helps wash the infant. Women are reported to prefer natural tearing and healing to episiotomies
  • Traditionally the placenta is required for reincarnation and so is usually buried at the place of birth. It is reported that in Australia some Laotian women prefer the hospital to bury the placenta. This needs to be discussed with women resettled in New Zealand
  • It is customary to keep warm for 3 days post-partum and touching cold water is prohibited. Special foods are required to restore and maintain appropriate body states
  • A necklace is traditionally placed on the newborn’s neck. Praising the baby is not encouraged as it could cause harm from the spirits if there is no protection from the ‘evil eye’
  • Breast feeding is common although resettled mothers who work and might adopt bottle feeding for convenience

Sue to add

  • According to Metha’s (2012) report on health needs for Asians living in the Auckland region:
    • Alcohol consumption is less prevalent amongst Asian students as compared to NZ European students
    • Almost all Asian youth reported good health
    • Most Asian youth reported positive relationships and friendships
    • Most Asian youth reported positive family, home and school environments
    • 40% of Asian youth identified spiritual beliefs as important in their lives
    • 75% of Asian students do not meet current national guidelines on fruit and vegetable intake
    • 91% of Asian students do not meet current national guidelines on having one or more hours of physical activity daily
    • Mental health is of concern amongst all Asian students, particularly depression amongst secondary student population
  • In addition, adolescents who migrate without family may encounter the following difficulties:
    • Loneliness
    • Homesickness
    • Communication challenges
    • Prejudice from others
    • Finance challenges
    • Academic performance pressures from family back home
    • Cultural shock
  • Others who live with migrated family can face: 
    • Status challenges in the family with role-reversals
    • Family conflict over values as the younger ones acculturate
    • Health risks due to changes in diet and lifestyle
    • Engaging in unsafe sex (there is limited or no sexual education amongst new immigrants from Laos)
    • Barriers to healthcare because of lack of knowledge of the NZ health system, as well as associated costs and transport difficulties

Sue to add

According to Metha’s (2012) report on health needs for Asians living in the Auckland region: 

  • There are no significant differences in mortality rates of Asian babies compared to European/Other children
  • There were no significant differences in potentially avoidable hospitalizations (PAH) as compared to other children studied
  • The main 3 causes of PAH amongst all Asian children studied were ENT infections, dental conditions or asthma
  • The rate of low birth weights were similar amongst ‘Other Asian’ babies and their European/Other counterparts
  • 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
  • A lower proportion of Asian five-year olds had caries-free teeth compared to the other ethnic groups studied

Sue to add

  • Breastfeeding may be lacking due to:
    • misinformation about breastfeeding and infant feeding practices
    • the belief that bottle-feeding is modern and superior
    • concerns about privacy and modesty
    • communication difficulties with health professionals
    • 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
  • Traditionally girls have lower status than boys. They gain status with producing children. No circumcision is practiced in Laos.

The Lao New Year is celebrated from 13-16 April and is also known as the water festival. It has its origins in the Hindu tradition.

The Lao New Year is celebrated from 13-16 April and is also known as the water festival. It has its origins in the Hindu tradition.

For Laotians, the beliefs and symbolism of the different traditions are combined and adapted to one another quite readily in practice. Overall, Buddhism has been a strong force in Laos and the basic tenets of Buddhism guide most traditional Laotians

  • Buddhism
  • Phram
  • Animism
  • A small number practice Christianity

For Laotians, the beliefs and symbolism of the different traditions are combined and adapted to one another quite readily in practice. Overall, Buddhism has been a strong force in Laos and the basic tenets of Buddhism guide most traditional Laotians

  • The main Buddhist practice is Theravada. There are however, regional variations in Laotian Buddhism, with the northern region influenced by Burmese Buddhism, while central and southern regions are influenced by Khmer Buddhism. The easy combining of practices can be seen in the relatively common approach to shrines where the shrine inside the home is dedicated to Buddhist faith, and the shrine outside the home is reserved for the spirits in the form of a Phi (a small ‘house’ on top of a pole or column)
  • Many Laotians also practice a mix of Buddhism and Brahmanism (this predated Hinduism) or Phram
  • Most mountain people practice animism, again in conjunction with other faiths

View references and resources in the Comprehensive Guide section.

  1. Chao, P.C. (1996). Voices of the South Asian Communities - Mien. Retrieved  July 2006 at: http://ethnomed.org. Link no longer current at 2015.
  2. Kemp, C., Rasbridge, L. (2004). Refugee and Immigrant Health. A handbook for Health Professionals. Cambridge: University Press.
  3. Keovilay, L. Kemp, C. Laotians. Retrieved November 2006 from  www3.balor.ed/~Charles­_Kemp/Iraqi­_refugees.htm. Link no longer current in February 2015.
  4. Lim, S. (2004). Cultural Perspectives in Asian Patient Care (handout). Asian Support services. Waitemata District Health Board.
  5. Man Hau Liev and Rosa Chhun. 'Laotians', Te Ara - the Encyclopedia of New Zealand. Retrieved August 2006 at: http://www.teara.govt.nz/en/laotians
  6. Mehta S. Health needs assessment of Asian people living in the Auckland region. Auckland: Northern DHB Support Agency, 2012.
  7. No author. Laos. On-line. Retreived August 2006 at: http://en.wikipedia.org/wiki/Laos
  8. No author. (2014). Laos Major Infections Diseases. Retrieved February 2015 from: http://www.indexmundi.com/laos/major_infectious_diseases.html
  9. 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
  10. Sompasong Keohavong. (1996). Voices of the South Asian Communities. Updated February 2015 from: http://www.austincc.edu/health/rnsg/culturalcompetence/Community%2520Profile%2520-%2520Lao.pdf

Resources

  1. A wide range of Patient Information in Laotian on health issues for adults and children and can be downloaded from:  http://spiral.tufts.edu/laotian.shtml
  2. 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.ARCC can provide information on resettlement issues and contacts for community leaders. Contact +64 9 629 3505. 
  3. Refugee Services can be contacted on +64 9 621 0013 for assistance with refugee issues.
  4. The http://www.ecald.com website has patient information by language and information about Asian health and social services.
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