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Little has been written about Laotian health care beliefs and practices in the Western world. What has been written focuses almost exclusively on the Hmong, an ethnic group from the highlands of Laos and other areas of Southeast Asia. Although this work focuses on lowland Lao (Lao Lum), readers should note that there are other ethnic and cultural groups from Laos living in America, including the Hmong, Mien, Tai Dam, and ethnic Chinese from Laos. It is our sincere hope that readers of this material will send additional information, corrections, and any other material of interest to health care providers involved with first or second generation Laotians in the Western world.

Laos is a landlocked country surrounded by China, Vietnam, Cambodia, and Thailand. From its beginnings in the sixth century A.D., Laos has been ruled by competing kings and foreign powers (Thailand, Japan, France). Full independence was achieved in 1954 with the end of France's colonial rule of Indochina. Years of conflict ensued and in 1975, the communist Pathet Lao emerged in control of the country. Both lowland Lao and Hmong refugees began fleeing to Thailand. Most of the resettlement in the U.S. occurred between 1975 and 1985, primarily in California, Iowa, Minnesota, Texas, and Washington.

Laotians have tended to live in tightly knit communities to a greater extent than most other refugees from Southeast Asia. In several states there are now rural or semi-rural communities in which Laotians live in a traditional mutually assisting social structure. Many of the adults work in nearby towns or cities, while elders live more or less traditional lives. As with other first generation refugees or immigrants, assimilation has been difficult for many older Laotians.

Most Laotians practice Theravada Buddhism. There are regional variations in Laotian Buddhism, generally according to the area of Laos from which a person originated. Northern Laotian Buddhism is influenced by Burmese Buddhism, while central and southern Laotian Buddhism is influenced by Khmer Buddhism. Many Laotians also practice a mix of Buddhism and Brahmanism or Phram. The practice of both, as well as belief in spirits is seen in the relatively common approach to shrines: Inside the home is reserved for the Buddhist shrine; while outside may be found what appears to be a spirit (Phi) house (small house or shrine on top of a pole or column). Offerings of food are to spirits, while offerings of flowers are to Phram. In any case, what a person does in life rather than his or her beliefs is the central canon. There are also strong elements of animism found among many Laotians. It is of little use to try to determine exactly what beliefs or combination of beliefs a Laotian might hold. The beliefs and symbolism of the traditions and faiths are combined and adapted to one another with no conflict whatsoever. Overall, however, the basic tenets of Buddhism guide at least most traditional Laotians. These tenets include the Four Noble Truths:

• To live is to suffer (dukkha) - all sentient beings suffer.
• The cause of suffering is desire, e.g., for happiness, for life, for permanence, for cessation of suffering, and so on.
• To cease to suffer, one must cease to desire.
• Cessation of desire (enlightenment or nirvana) may occur by following the Eightfold Path of right thought, right resolve, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration.

To follow this path to enlightenment, it is necessary to become and remain a member of the sangha, i.e., a monk. Realistically, few (at least in this life) are able to effectively follow this path, hence there is a focus on rebirth to a better state based on merit or karma (kamma) - especially related to fulfilling responsibilities to society. The ethic of Buddhism is centered around the four "Palaces of Brahma" or virtuous attitudes: Loving-kindness, compassion, sympathetic joy, and equanimity.

Please note that although Buddhist temples or Wats have statues of the Buddha, according to the teachings of the Buddha, these are not to be worshipped. Rather, the teachings are to be followed. The same holds true for images of the Buddha worn around people's neck or displayed in their homes.

Laotian (and other Southeast Asian) views of physical and mental wellness are also tied to a person's ability to sleep and eat without difficulty. Moreover, in Asia, only poor people or strict vegetarians eat large amounts of vegetables. Those who can afford meat are inclined to eat beef more than fish or chicken. Some traditional or popular commercial medicines are intended to increase both appetite and sleep. With respect to types and amounts of foods consumed there are often important educational issues to address with Laotian patients - especially as life-span is extended among Laotians living in the Western world.

Access to care remains a significant problem for many Laotians. Barriers to obtaining and effectively utilizing health and other services include:

• Language barriers are often an issue for older Laotians, especially those from a rural background. Because health care situations present unique challenges in understanding and often fine points or gradations in decision-making, even the presence of a family member who speaks English and Laotian may not be sufficient for some circumstances.
• Cultural issues present a sometimes difficult to identify and understand problems in understanding. Laotians may not understand a Western health care system (a culture in itself) and Westerners may not understand Laotian culture. Once in the health care system, Laotians may experience deep feelings of isolation and a kind of cultural depersonalization.
• Transportation is often a problem when either all adults in a family are working or the family is poor.

Health histories may be incomplete for several reasons, the most basic of which is a reluctance to volunteer information. Such reluctance has its origin in a cultural value of privacy in personal matters, especially related to family, sexual, and illness (vulnerability) issues. Trust or its lack is a major issue. With trust based on relationships, one might assume that the history will evolve over time, rather be complete in one or two interviews.

In general, persons who are sick will look first to the family and/or community for understanding of the problem and treatment. Traditional treatments may be tried first; or, if the loss of spirit is thought to be the problem, a ceremony performed by a family member, elder, or, if possible, an acharn or teacher/healer. The purpose of the ceremony is to call the spirit back to the body. Another route of treatment is to go to the temple, where prayer and lustral water will be used to address the problem. The last resource is to seek treatment at a clinic or hospital. Note that traditional practices are often continued while utilizing western medicine.

Travel seems to bring increased vulnerability, hence spirits are called to the body before and after traveling. A family member may perform the ceremony before travel, but an acharn is preferred for the ceremony after travel as there is thought to be a high likelihood of spirits staying behind.

Most Laotians focus on acute illness and otherwise do not place high value on disease prevention and health promotion. Seeking health care from clinics or hospitals is usually deferred until family, community, and spiritual resources are exhausted. Using clinic or hospital as a last source of care, coupled with reticence in complaining results in some patients presenting with advanced illness.

Mental illness will in many cases be ascribed to spirit loss. To seek care from a Western source indicates the likelihood of an ongoing and very difficult problem. The issues that affect most other health problems are magnified in the case of mental illness. One can assume deep individual and family distress among Laotians seeking care for mental illness.

Traditional treatments or indigenous practices: The following treatments for illness include procedures similar to those used by other Southeast Asians:

• Khout lom or coining is the use of a coin and mentholated medicine to rub the chest, back, upper arms, or neck in one direction with resulting ecchymosis. This releases the "wind" that may be causing the illness.
• Pinching in a prescribed manner (rubbing the temples, pulling forward to the eyebrow and nose, and pinching the nose) is used to relieve headache.
• Cupping is performed by fixing a piece of cotton in the bottom of a glass, lighting the cotton on fire, and placing the open mouth of the glass on the sick person's back. This creates a vacuum (and contusion) and thus draws the wind from the body. In one session, the procedure is carried out three to four times bilaterally down the back on either side of the spine with six to eight circular contusions resulting.
• Massage and manipulation is performed by elders and others with knowledge of healing techniques.
• Traditional Lao medicines are available in America, with some of these found or grown locally. Most are classified as "cool" as opposed to western medicines which are usually classified as "hot." Gathering such substances includes prayer and other prescribed means of respectfully taking them from the earth or elsewhere. Most such medicines are imported from Thailand, Laos, or elsewhere in Southeast Asia.
• Chinese medicine is widely available from both stores and individuals. In some cases, the medicine or combinations of medicines are soaked or dissolved in vodka (called "wine") and thence consumed in small quantities. Commercial preparations from Asia and elsewhere are also used by many Laotians.

Spiritual healing practices: It will by now be obvious to readers that Laotian views of health, illness, and healing are complex and multidimensional, and encompass to a very strong degree, spiritual components. Spiritual or spirit-based practices are related to Phram beliefs rather than Buddhism, but many of these practices will occur in the context of Buddhism. Evidence of the spiritual or spirit components is seen in several phenomena:

• The involvement of monks and acharn, as well as family in spirit-based practices is seen throughout illness and health-related aspects of life such as birth and death.
• Some Laotians wear katha (or katout), which is a string passed through a small cylinder or cylinders of gold or brass. The metal is inscribed with Pali prayers called To Dham. These are not viewed as decorative jewelry, but as potent and sacred talismans which are made by monks or holy men. Yarn refers to the magical protective tattoos found on the chest, back, and arms of some men; or to pictures and words on fabric which may be carried or put over a door. Buddha or boddhisatva images are worn on a chain around the neck by some Laotians.
• One will sometimes encounter Laotians with one or more pieces of string tied around the wrist. This also has spiritual and protective meaning and derives from a practice in Laos of wearing around the wrist twisted palm leaf on which is written To Dham. These are thought to prevent loss of spirits.
• A small bag worn on a string around the neck is called haksa. The haksa is given by parents or grandparents and affords protection to the wearer.

In general - as is so with people of any culture - health care providers should be aware that traditional practices and beliefs of Laotians are dynamic and changing. In some cases, there may be little or no reliance on traditional practices. In other cases, illness will result in a turning back to more traditional practices, especially as it becomes apparent that Western medicine does not have all the answers.

Interacting with Laotians

Healthcare issues: Respect for individuals, families, and the culture is critical. Respect includes being polite as most people might define politeness. Respect also encompasses respecting the privacy of individuals, families, and the culture. Thus health care providers might avoid asking questions that are not germane to the problem at hand - especially in early stages of the relationship. Except when vital, personal questions are best deferred until there is a working relationship. When a personal question is necessary, it might be prefaced with assurance that the question and answer are not for public discussion. If the information will not be charted, one might say, "This is between you and me. I will not talk about this with anyone else."

Respect also includes explaining procedures and medicines to patients. Traditional medicines are mixed, dosed, and prepared according to individual patient needs. That same model may be expected of Western medicines. It is thus a good idea to explain medications and dosing on an individual basis. Even for patients with limited English skill, it is wise to write (print or type) instructions for medications or treatments. The patient may not read the information, but he or she will find someone in the community who will read and explain what is written.

Some Laotians value the relating of symptoms more than the health history. Explaining links between questions or problems will help in eliciting information. Falling back on the relationship may also help. One might say, "Remember as much as possible. Help me." Regardless of what techniques are used, remember that the history will evolve over time as the relationship (hopefully) evolves.

When there is a terminal illness, it is usually a good idea to ask the patient how much he or she wants to know about the diagnosis and prognosis. The entire family will want to be present for the patient's last days. If the patient 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 patient and the family.

A Laotian proverb: Nobody can control when a woman delivers a baby. Nobody can control when a monk disrobes (leaves the sangha). And nobody can control when a person dies. There may thus be an acceptance of fate with the perspective that what happens now is all related to the past (including past life) and whatever one is born to is what one is born to.

Social issues: As noted earlier, significant numbers of Laotians have created more or less traditional communities in the U.S. The extended family is the central social unit within the community. Home and family are headed by the husband or oldest man, with elders of both sexes given great respect. Some health care decisions will be made by an elder rather than the patient - even when the patient is an adult. Physicians have great status, and health care providers may note that older patients will listen to a physician to a greater extent than a younger family member.

When visiting a Laotian home one should note the shoes lined up just outside or inside the front door and despite being told "never mind" go ahead and remove the shoes before going into the home. Many homes will have both a mat on the floor and chairs, a couch, etc. It is well to sit on or below the level of the oldest person there. In other words, if an older person is sitting on the floor it is impolite for the visitor to sit in a chair.

Laotians tend to be reserved in most interactions (and all health care interactions). Effusiveness and expression of strong feelings - including strong positive feelings - is not valued. Fussing over and complementing children and infants is not good form. In the case of infants, praise and complements may bring ill fortune; and with children, result in self-centeredness. Children should remain quiet and respectful in interactions with elders, including visitors. As much as possible do not use children to translate for adults. Doing so puts both parties in an untenable social situation of the child showing superiority to the adult.

The head is the highest (literally and figuratively) and thus one should not touch another's head, and preferably not his or her shoulder either. It is also impolite to point one's foot at another or sit with one leg crossed over the other so that the bottom of the foot or toe is pointed toward another. It is generally understood that it is necessary to touch other people's head during the course of some physical examinations.

Modesty is highly valued, especially in women from waist to knees - and most especially in younger women. Double gowning of hospitalized patients should be practiced as much as possible. Pelvic examinations of unmarried women should not be a routine practice, especially by male providers. In part because of issues of modesty, we find resistance to breast self exams among Laotian women. Please see our work on cancer screening for other barriers to BSEs.

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 depends on the social or spiritual status of the person being greeted, with the hands held higher for persons of greater status. Western greetings are well accepted, except that many women are not comfortable shaking hands with men.

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As noted at the beginning of this work, we present this information with the sincere hope that it will be helpful to nurses, physicians, social workers, and others seeking to provide quality services to Laotians. We ask that readers contact us if they see a need for additional information or wish a correction made. We are thankful for the presence of the Laotian people in the United States and we pray for peace and freedom in Laos.

Health Risks in Refugees from Asia (See Infectious Diseases section for updated information)

• Nutritional deficits
• Hepatitis B
• Tuberculosis
• Parasites (roundworm, hookworm, filaria, flukes, amoebae, giardia)
• Malaria
• HIV
• Hansen's disease
• PTSD

Recommended Laboratory and Other Tests for Refugees from Asia

• Nutritional assessment
• Stool for ova and parasites
• Hemoglobin or hematocrit
• PPD
• VDRL should be considered

References

World Health Organization (2000). Healthy life expectancy rankings. Accessed on the World Wide Web on October 14, 2000 at http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english

Authors: Leck Keovilay and Charles Kemp