Stress in Cambodian Refugee Families

Stress in Cambodian Refugee Families Carolyn Erickson D’Avanzo, Barbara Frye, Robin Froman

Southeast Asians are a rapidly growing, culturally varied group needing physical and mental health services. The sources, manifestations, and coping strategies associated with stress experienced by this group are not well documented. Interviews were conducted with 7 20 Cambodian women in this comparative descriptive study to identify their perceptions of stress-related factors confronting families. Memories of the war, financial concerns, and family problems were frequently cited. Somatic manifestations were the most common symptoms. A general sense of inability to cope with stress suggests the need for health care providers to be sensitive to undeclared problems.

[Keywords: stress, psychological; Cambodian; refugee; Southeast Asian]

*

ver a million Southeast Asians from Cambodia, Laos, and Vietnam live in the United States (U.S. Bureau of the Census, 1990). The majority have resettled as refugees since 1975 and the close of the Vietnam War.

Based on the psychosocial stressor severity classi- fication for mental disorders of the American Psychiatric Association, the Khmer people of Cambodia are the most traumatized of all Southeast Asians (Kinzie & Fleck, 1987). Their experience under the Khmer Rouge has been equated to the Jewish holocaust, with survivors having witnessed sexual abuse, ridicule, murder punishment, exhaustion, starvation, and unremitting insecurity and uncertainty (Yeung, 1988).

As of 1990, more than 147,000 Cambodians lived in the United States (U.S. Bureau of the Census, 1993). California has the greatest number of Cambodian refugees, with a large concentration in the Long Beach area. Another large group lives in Massachusetts, in the Lowell region. Since their arrival, it has been evident that Cambodians are at a particularly high risk for stress-related disorders, the majority of which are attributed to the events of the war and Khmer Rouge, when more than one-third of the people died or were murdered (Boehnlein, 1987; Duncan, 1987; Mollica, Wyshak, & Lavelle, 1987). Cambodians call reflection on past traumatic events “Koucharang,” or thinking too much.

The Cambodian genocide has had serious and long-lasting consequences for survivors. One epidemiologic profile of 378 Cambodian refugees in California showed them to be the most

* *

mentally depressed when compared to other Southeast Asians (Meinhardt, Tom, Tse, & Yu, 1984). Somatization, clinical depression, post-traumatic stress syndrome, suicide, and sudden unexpected death syndrome are common knowledge among Cambodian refugees (Mollica et al., 1987; Nicassio & Pate, 1984; Nolan, Elarth, & Barr, 1988). If acts of violence among Cambodians occur in the United States, they usually are not reported to avoid further conflict (Thayer, 1990).

Few Cambodian immigrants receive mental health services, even when available, because of their lack of knowledge about the treatment for mental illness. In California, where it is estimated that close to half of all Cambodian refugees need mental health services, only one percent has actually sought them (Yeung, 1988).

As a minimally studied minority, Cambodians are frequently an enigma to American health care providers (Falvo & Achalu,

Volume26, Number 2, Summer 1994

Carolyn Erickson D’Avanzo, RN, DNSc, Mu, is Associate Professor, Health Promotion Unit, University of Connecticut. Barbara Frye, RN, DrPR, is Associate Professor, Loma Linda University School of Public Health, Loma Linda, California. Robin Froman, RN, PhD, FAAN, Mu, i s Associate Professor of Nursing, Health Promotion Unit, University of Connecticut. Data collection for the east coast comparison group was partially funded through a grant to Olga Church, RN, PhD, 5T15SP07525-03 from the Department of Health and Human Services Center for Substance Abuse Prevention. Correspondence to Dr. D’Avanzo at the University of Connecticut, School of Nursing, 231 Glenbrook Road, Storrs, CT 06269.

Accepted for publication March 29, 1993

101

Stress in Cambodian Refugee Families

1983; Rosenberg & Givens, 1986). It would be erroneous to assume that the world view and conceptual framework of a Cambodian patient matches that of the American health care provider. Nurses who work with these people often know little about their cultural backgrounds or ways of coping with the stressors that face them after resettlement (Bernal & Froman, 1987). But such knowledge is vital to link Cambodian refugees with the most appropriate psychosocial services. Although there is a substantial body of knowledge about the psychological consequences of organized violence and victimization of Cambodians, there are few descriptive studies that examine beliefs, and the cultural management of stress in Cambodian families. Understanding the perceptions of Cambodian women, in particular, is crucial. These women often serve as the heads of their households. Even when they do not, they are by tradition the family "stress-bearers,'' assuming the role of maintaining the family's emotional equilibrium.

The purpose of this study was to improve understanding of the beliefs of Cambodian refugee women about stressors that affect their families, and how the resulting stress is handled.

Six research questions were used in this comparative descriptive study: 1.

2. 3.

4. 5 .

. 6.

what behaviors are culturally recognized as indicating a stressful state? What are the perceived causes of stress? What taboos are imposed by the culture when a person is in a stressful state? What coping strategies for stress does the culture dictate? What can a family do to help a person who is experiencing stress? What is the role of women in the management and prevention of stress?

Methodology

Two samples of 60 Cambodian women were interviewed in their homes in two communities containing large enclaves of Cambodian refugees. A west coast location, Long Beach, and an east coast location, Lowell, provided the comparative groups; 60 from each site, for a total of 120 cases were interviewed in their homes. Interview rapport was enhanced by using a female Cambodian known to each community as a trusted, informal community leader to provide entry and translation. The structured interview format was practiced with the translators prior to data collection.

To gain access to a potentially resistent subject pool, the informants were identified by snowball or network sampling (Burns & Grove, 1987). The investigators and translators at each site had substantial linkages within the targeted communities. Participants were told that the investigation had nothing to do with the government and that they were free to refhe. Participants invited the investigator and translator into their homes, and signed a consent form written in the Cambodian language.

One trained translator at each site was used to enhance reliability. Validity was reinforced through triangulation across

verbal reports given by subjects and behavioral cues given by the women during the interview (Bums & Grove, 1987). Data were collected using a structured interview with questions asked in the Cambodian language with alternate translation and clarification. Those items used to elicit responses necessary to answer the research questions are provided in Table 1. Interviews lasted two hours. Asking structured questions with an open-ended response format is the recommended strategy in cross-cultural studies attempting exploration and description (Eyton & Neuwith, 1984; Kirk & Miller, 1986; Miles & Huberman, 1984).

Data were analyzed in three tiers. First, demographic variables on the total sample and the two subgroups were summarized using descriptive statistics and tests of differences. Next, the responses to the major questions of interest were analyzed by determining the most frequently occurring responses and the rank order of response by

Table 1 : Stimulus Questions that Address Each Research Question.

Research Question 1 :

Stimulus Question:

Research Question 2 :

Stimulu5 Question:

What behaviors arc culturally recognized as indicating a stresstill \Me?

When a Khmer person is thinking too much, how i s she most likely to hehave? What is another way d i e might hehave? How else might she behave!

What dr r the iicrctived causes of stress?

What is the most important reason why Khmer people "think too much?" What i s the next most important reason? What is another reason!

Research Question 3:

Stimulus Question:


Stimulus Question:


Stimulus Question:


Stimulus Question:

What taboos are imposed by the ( ulture when J p w o n 15 in stressful state)

When a Khmer perwn is "thinkinq too much," what should she do)

What coping strategies tor stress does the culture dictate?

When a Khmer person is "thinking tom much," what is themost important things/heshoulddo to help herAiimself?

What can a family do to help a person who i s experiencing stress?

What is the most important thing that the family should do to help herhim? What is the next niost important thing! What else should the tamilv do!

What i s the role ot w'omen in the management of stress and prevention of stress?

What is the most important thing that the woman should do to help herhim! What is the next most important thing! What else should the family do!

102 IMAGE: Journal of Nursing Scholarship

Stress in Cambodian Refugeo Families

Table 2: Demographic Characteristics of the Sample and Subgroups.

Variable Total Group (N=l20)

sd ~~

M ..- - -

Size of household 4 95 3 20

Underage dependents in household 2.42 1.71"

Elderly dependents in household 0.50 0 . 2 5

Years in US. 6.83 2.7?

Years Cambodian education 1.26 1.18'

Years US. education 0.90 1.05

Age of informant 40.21 13.36

Household income $12,823. 6,242.

f-test differences at ~ . 0 5 * * !-test differences at w.01

west coast East Coast (N=60) (N=60)

M s d M sd 4.83 388 5 0 7 2 37

0.02 0.1 3 0.08 0. 1 1

7.33 3 . 3 2 6 . 3 2 1.85

0.87 0.93 0.9 1 1 . I b

42.07 13.75 38.12 12.t10

12.999 6,050 1 1 , 1 1 1 0, 1bC)

frequency. Finally, the two subgroups were compared for similarities of ranking of responses.

Inspection of data showed a normal distribution. Thus, parametric t-tests were justified even though the samples were non-random (Burns & Grove, 1987). The two subgroups differed significantly on some of the demographic variables as shown in Table 2. The east coast group had fewer years in the United States, less education before emigration, and a greater number of young children living at home; 67% of the households had three or more dependent children at home, as compared to 38% in the west coast sample. Almost 60% of the east coast sample had been in the United States for 6 years or less. By contrast, 55% of the west coast sample had been residents for 8 years or more. In the east coast sample, only 38% reported 2 years or more of education in Cambodia before emigration, as compared to 67% in the west coast sample. In summary, while the subsamples were similar in size, income, and the age of the woman being interviewed, the east coast women reported more recent emigration and had considerably less education, as well as a greater number and proportion of young dependents. A Chi Square of 18.35 (p<.Ol) revealed the east coast group was more likely to have a woman as the head of house than was the west coast group. Specifically, 18 of the east coast homes were headed by the man identified as "father," while 36 of the west coast homes were headed by fathers; 34 of the east coast homes were headed by mothers, as compared to 17 on the west coast. Other female family members such as grandmother, sister, or daughter acted as household head in the remaining eight east coast homes.

Table 3: Most Common* Responses to Research Questions About Behaviors, Causes and Taboos Associated with Stress.

Frequency.. Rank Frequency

I . Bohavior?, indicating stressful litate.

He,iclar he 8 9 1

"Other things" 66 >

Sleeping J lot 55 3

Quiet 1 7 4

Being sick 18 >

2 Perceived c auses ot stress

Ll"i r n: I

h.1onc.b 68 >

"Other t hings" hl 1

Fa ni i I b c on 1 I ict 4h 4

L.inguage ditttculty 19 i

( ultiiral dittitulty 25 h

i T ~ l ~ o o < awxia ted n i th stress

Exc e w \ e alcohol Ll5e 96 1

Street drugs 51 7

5atl thoughts LO 3

\leeping too much 1 5 4

Prescription drugs 9 5

Being alone 8 b

( ited a3 tirst to sizth most coninion. *' Not all subjects ranhed al l possibilities

~

Total Group west coast (N=120) (N=60)

I

5 1

35

2 5

20

27

5h

2 2

44

% 5

1

I 3

55

2

18

1

1

8

Rank

1

2

4

5

3

1

4

2

3

-

5

I

-

7 .. -

-

3

East C d (N=60)

Frequency Rank

$6

11

10

27

1 1

$1

4h

17

I I

36

I 2

41

19

2

14

8

0

Frequency of citation of behaviors associated with stress, or "thinking too much," and the ranking by frequency were calculated for the total group to answer research question one. The most commonly cited response to stress was headaches. This was followed by other responses such as shouting. Most of the other responses such as chest pain, pressure or palpitations, and shortness of breath. Sleeping a lot and being quiet were also commonly reported behaviors. Other behaviors cited with less frequency included being sick (often described as dizziness or an ability to think or concentrate), loss of appetite, and neglecting religious or spiritual needs. Behaviors asked about during interviews but generally denied as being associated with stress were use of alcohol and prescription or street drugs, hitting or perpetrating violence on others, and neglecting family or friends. Frequencies of the most commonly cited behaviors for each of the research questions are in Table 3.

The most commonly perceived causes of stress were thoughts about the war in Cambodia, concerns about money,

Volume26, Number2,Summer 1994 103


and other concerns including infidelity, loneliness, grief about family left behind, cultural losses, and health status. There were many east to west coast differences in response to this question. The east coast group was more characterized by stress related to money and language problems than thoughts of the war. The west coast group experienced stress related primarily to recalling the war, “other” individual concerns, and family conflicts.

When asked what behavioral responses to “thinking too much” are taboo in the Cambodian culture, there were wide differences in the two groups. A common proscription against excessive use of alcohol in response to stress was shared by all subjects. The east coast group, however, more frequently reported taboos against street or prescription drugs or sleeping too much. The west coast sample showed more frequently cited taboos against thinking sad thoughts or being alone when under stress.

Research question four asked what coping strategies are appropriate when Cambodians experience stress. There was general agreement that two things were to be avoided when under stress: sad thoughts and being alone. Attending to one’s spirituifl or religious needs, and avoiding medications to induce sleep were also cited. Use of street or prescription drugs was not cited, and use of alcohol to help cope with stress was cited only once in the total group. Other behaviors were also mentioned such as going to movies, shopping, or keeping

Table 4: Most Common* Responses to Research Questions About Strategies to Cope with Stress.

Total Group (N=120)

Frequency.. Rank ~~ ~

4 Accepted coping strategies

Avoid sad thoughts 38 1

Avoid being alone 29 2

Attend to religious or 12 3 spiritual needs

Don’t use sleeping pills 11 4

5 What should the family do to help,

Provide encouraging words7 % 1

“O t her things” 72 2

Discourage sad thoughts 67 1

Don’t let person be alone 47 4

6 What should J woman do to help!

Use encouraging words 62 1

Divzourage sad thoughts 52 2

Don’t let person be alone 19 1

~ ~~ ~

west coast (N=60)

Frequency Rank

East coast (N=60)

Frequency Rank

24 1

17 7

3 4

&

10 3

14 1

12 ‘. 3

9 3

1

46 2

38 3

47 1

28 4 ... .. ..

54 1

48 2

36 3

27 - 7

34 1

20 3

19 4 ~~

8 1

4 >

3 3 _ _ _ - -

Cited as first to fourth most conimon ’* Not all subjects ranked al l possibilities

busy that might be characterized as engaging in public behavior. Even though encouraged to report their own individual coping strategies, many subjects, especially those on the east coast, could not cite ways to reduce stress. Instead, they responded with nonhelpful comments such as “forget stress,” “do nothing” or “I can’t help at all.”

The last two research questions pertained to what could be done to help people suffering from stress. One focused on help provided by family members in general and the other on help from women in the family. This question, like the next, was difficult for subjects to answer. A variety of concerns were cited. These were disparate and included such things as “The family or woman can’t help,” “It’s best to keep quiet,” “It’s best for the family not to know” and “I don’t know; accept Karma.” There was general agreement in the groups that it was important for the family to provide encouraging words, discourage sad thoughts, and not leave people alone who are stressed. These activities seemed particularly important to the woman’s role, in that subjects stated that while women were “most responsible” for decreasing intrafamilial stress, they were often powerless to do so.

Table 4 shows the responses to the last three research questions. There were fewer responses to these last three questions than the first three in both groups. Responses indicated that while the traditional role of the Cambodian woman is to be the “stress bearer,” she often feels unable to bear it and is resigned to a stressful state for herself and others.

Discussion

This was a comparative descriptive study of stress-related behaviors and responses in Cambodian refugee women. Overall, the reported behaviors were primarily somatic including headaches, sickness or sleeping a lot, chest pain and shortness of breath. These descriptions are consistent with reports of somatization in this group (Lin, Carter, & Kleinman, 1985). Cambodians are reluctant to seek mental health services (Yeung, 1988), and when they do they describe symptoms that personnel who are unfamiliar with Cambodian culture may not recognize as stress-related.

Past events such as the war in Cambodia, and present events such as money and language problems, were seen as causes of the stressful state Cambodians call “thinking too much.” Both subgroups recognized that women and families should help stressed family members by providing company and encouragement. However, women who headed their households and had the responsibility of several dependent children, such as the east coast subsample, were more likely to respond that they felt unable to take constructive action to reduce the stress the family might be experiencing. This is especially problematic and is consistent with what is known about Cambodian refugees high risk for stress-related mental and physical illness. These women saw themselves as responsible for the emotional equilibrium of their families, yet ineffectual in understanding stress. To feel responsible, yet powerless, is a predicament

IMAGE: Journal of Nursing Scholarship

regardless of cultural background. This state, accompanied by the process of acculturation, limited social supports, and low income may produce a cycle of stress than cannot be managed without culturally-sensitive health care.

Secondary analyses were performed which created five comparison groups based on years in the United States, (<3,3- 5, 6-7, 8-9, lo+). When indicators of stressful behaviors were ranked within the groups, headaches consistently ranked first. Feeling sick was most prevalent in under three years group, while either shouting or being quiet or sleeping was more prevalent in the other groups.

When causes of stressful behaviors were ranked by number of years in the United States, memories of the war in Cambodia were clearly the most frequent cause, again being ranked first consistently across groups. Financial concerns were ranked second for all except the less than 10 group which ranked family concerns as second most important. Other frequent stressors were infidelity, loneliness, loss of culture or changing health status, followed by poor English language skills. For those who had been in the United States 7 years or more, however, lack of English language skills was notably absent from the list of perceived stressors.

The most prevalent cultural taboos when stressed were use of alcohol, street drugs, or other antisocial behavior such as hitting children or committing suicide. The frequency pattern of citing taboos was interesting. Those new to the United States (up to 3 years) cited the fewest cultural taboos. Refugees in the United States between 4 to 7 years cited taboos with twice the frequency of new immigrants. As the following data indicates, this group also cited the largest number of coping strategies.

Coping strategies were very limited in the less than 3 year group, and the 4 to 5 and 6 to 7 year groups cited a greater number of coping strategies. At 8 to 9 years and beyond there was a slight reduction in the number of coping strategies cited. This coincides with the emergence of problems with teenaged children and health concerns concomitant with increasing age.

When asked what family members could do to help people suffering stress, confidence in the family’s ability to help was clearly low in the most recent immigrants, and remarkably high in the 10 year and over group. Confidence in the woman’s ability to help followed an almost identical pattern as to family strategies. Providing kind words, not allowing the stressed person to be alone, and helping to reduce sadness were important family or women interventions across all groups.

The subgroups differed on some demographic variables and were interviewed by two different investigators. Given the absence of census data describing Cambodian refugees in the United States it is impossible to identify whether the sample differences reflect real geographically-linked differences in the refugee groups, or an outcome of the community network approach to sampling. Adequate sample size and use of the home setting for interviews were used to decrease bias (Miles & Huberman, 1984).

Steps were taken to limit interviewer differences. The use of a standard interview format, rehearsed extensively with translators, and efforts to confirm any vague responses through

Volurne26, Number2,Surnrner 1994


repeated questioning were used. However, responses may have been biased by translation error. This study emphasizes the need for nurses and other health care providers to be aware of undeclared problems. g q

References

Bernal, H., & Froman, R. (1987). The confidence of community health nurses in caring for ethnically diverse populations. IMAGE: Journal of Nursing Scholarship, 19, 201-203.

Boehnlein, J. (1987). Clinical relevance of grief and mourning among Cambodian refugees. Social Science in Medicine, 25, 765-772.

Burns, N., & Grove, S. (1987). The practice of nursing research. Philadelphia: Saunders.

Duncan, J. (1987). Cambodian refugee use of indigenous and Western healers to prevent or alleviate mental illness. Unpublished doctoral dissertation, University of Washington.

Eyton, J., & Neuwirth, G. (1984). Cross-cultural validity: Ethnocentrism in health studies with special reference to the Vietnamese. Social Science & Medicine, 18, 447-453.

Falvo, D., & Achalu, D. (1983) Differences in perceptions of health status and health needs between refugees and physicians providing care. Health Values, 7(5), 20-24.

Kinzie, J., & Fleck, J. (1987). Psychotherapy with severely traumatized refugees. American Journal of Psychotherapy, 41, 82-94.

Kirk, J., & Miller, M. (1986). Reliability and validity in qualitative research. Beverly Hills, CA: Sage Publications.

Lin, W., Carter, W., & Kleinman, A. (1985). An exploration of somatization among Asian refugees and immigrants in primary care. American Journal of Public Health, 75, 1080-1084.

Meinhardt, K., Tom, S., Tse, P., & Yu, C. (1984). Santa Clara County Health Department Asian health assessment project. San Jose: Santa Clara County Health Department, Division of Mental Health Services, 1-45.

Miles, M., & Huberman, A. (1984). Qualitative data analysis. Beverly Hills: Sage Publications.

Mollica, R., Wyshak, G., & Lavelle, J. (1987) The psychosocial impact of war trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572.

Nicassio, P., & Pate, J. (1984). An analysis of problems of resettlement of the Indochinese refugees in the United States. Social Psychiatry, 19(3), 135- 141.

Nolan, C., Elarth, A., & Barr, H. (1988). Intentional Isoniazid overdose in young Southeast Asian refugee women. Chest, 93, 803-806.

Rosenberg J., & Givens, S. (1986). Teaching child health care concepts to Khmer mothers. Journal of Community Health Nursing, 3, 157-168.

Thayer, R.P. (1990). Who killed Heng Lim?: The Southeast Asian experience of racial harassment and violence in Philadelphia. Philadelphia: Southeast Asian Mutual Assistance Coalition.

U.S. Bureau of the Census. (1993). Statistical Abstract of the United States: 1993 (1 13th edition). Washington, DC.

Yeung, R.M. (1 988). Help-seeking behavior of Cambodian refugees experiencing posttraumatic stress disorder. Unpublished master’s thesis, California State University, Long Beach, CA.

105

Today! The Online Journal of

Knowledge Synthesis for Nursing

The Online Journal of Knowledge Synthesis for Nursing: Offers timely, synthesized knowledge to guide nursing practice and research. It provides a critical review of research pertinent to clinical practice and research situations that nurses can access and use immediately. The journal helps the nursing community stay abreast of the vast amount of published scientific information.

Technical Information: Two interfaces are available for viewing, displaying and printing The Online Journal of Knowledge Synthesis for Nursing:

MICROSOFT WINDOWS full-feature, graphical user interface. It

Guidon is recommended and offers a

runs in the Microsoft Windows environment and provides typeset-quality displays and graphics.

Accessibility: Hardware PC with an 80386 processor, 4MB RAM

journal subscribers can search articles online - virtually 24 hours a day - and review, download, and print relevant information in whole or in part.

Requirements: (required), VCA or SVCA monitor, 9600- bps modem, high-quality laser printer with 1.5MB memory (minimum), Microsoft Windows 3.1 (required).

Access Method: Dial access-OCLC or ComDuServe

Searching Flexibility: Optimal searching capabilities - including every word in every article - allow the reader to electronically search by subject, title, author, keyword, date, phrase or combination of words. In a single search, the reader can cover the entire collection of Knowledge Synthesis for Nursing articles.

Sophisticated navigation tools allow users to: Jump to references, figures and tables: Move from one section of an article to another; and, Link to external bibliographic databases on the Online Computer Library Center (OCLC) reference systems such as Medline.

Articles include: Statements of practice situations Research summaries Annotated critical references Practice implications Research needed Search strategies References used

network internet* - Networked machines or dial access via SLIP.

OCLC EJO/ASCII is a command-oriented interface and has fewer features than Guidon.

ASCII terminal or PC with

VTlOO terminal emulation (e.g. ProCommTM) + dial access via modem or other telecommunications method, e.g., Ethernet board.

Access Method: Dial access-OCLC or CompuServe network Internet OCLC multidrop line (for those already using other OCLC online services).

DOS

Hardware Requirements: communications software providing

Support Services: Each subscription includes:

Users' Guide and Password. Three software diskettes (3 1/2" diskettes for Guidon software, Internet Access and Knowledge Synthesis for Nursing).

OCLC User & Network Support. Phone: 800-848-5800 (National), 614-793- 3682 (International). Hours: Monday - Friday, 7:OO a.m. - 9:OO p.m. (Eastern Time) and Saturday 8:00 a.m. - 8:OO p.m, Manuscripts, written by clinicianhesearcher

teams, are peer-reviewed. Subscription Rates:

Individual - $60/yr. Institution - $250/yr.

*To access The Online Journal of Knowledge Synthesis for Nursing via the Internet using Guidon 2.0, the work station must have a direct TCP/IP connection to the Internet, either via an installed Ethernet or Token Ring board, or via dial access to a host computer supporting the Serial-Line Interface protocol (SLIP)

For subscriptions or information call: (317) 634-8171

106 IMAGE: Journal of Nursing Scholarship

Documents

Stress in Cambodian Refugee Families