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Service Delivery Innovation Profile

Use of Spiritual Healers Reduces Cultural Misunderstandings and Conflicts and Increases Satisfaction Among Hospitalized Hmong Patients


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Snapshot

Summary

As part of a community-hospital partnership known as the “Partners in Healing” program, Mercy Medical Center Merced allows Hmong spiritual healers (known as shamans) to conduct healing ceremonies when requested by Hmong patients or family members to meet their spiritual needs, provide support, and promote optimal healing. Shamans also periodically educate physicians and hospital staff about their beliefs and practices. Anecdotal reports suggest the program has reduced cultural conflicts and miscommunications between Hmong patients and physicians, and increased Hmong support of Western medicine, physician acceptance of traditional medicine, and satisfaction among Hmong patients.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation anecdotal reports from patients, shamans, and physicians.
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Developing Organizations

Healthy House Within a MATCH (Multidisciplinary Approach to Cross-Cultural Health) Coalition; Mercy Medical Center Merced
Healthy House Within a MATCH Coalition and Mercy Medical Center Merced are located in Merced, CA.end do

Date First Implemented

2000
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Patient Population

Race and Ethnicity > Asian; Vulnerable Populations > Immigrantsend pp

Problem Addressed

Lack of cross-cultural awareness leads to misunderstandings, mistrust, and less effective patient care for certain patient populations. Beliefs in traditional medicine and the absence of programs that integrate traditional and Western medicine further exacerbate health care disparities.
  • Disparities caused by lack of cross-cultural awareness, linguistic barriers: People of color frequently receive a lower standard of care than do whites, even when income, insurance status, age, and severity of conditions are comparable. Key factors contributing to these disparities include cultural and linguistic barriers within the health care system; greater clinical uncertainty among providers when interacting with minority patients; and beliefs or stereotypes held by providers about the health or behavior of minorities.1 For example, the Hmong language lacks terms that adequately translate medical care needs, medical terms, body anatomy, and diagnoses.2
  • Preference for traditional medicine, leading to further disparities and poor outcomes: In some patient populations, preference for and comfort with traditional medicine causes further disparities. Focus groups of Hmong people found that differences between their traditional beliefs (including shamanism) and Western biomedical beliefs create a lack of understanding between patients and Western providers, and that negative experiences with the Western health care system have caused mistrust and fear of medicine in the Hmong community.2 At Mercy Medical Center Merced, a number of cross-cultural conflicts related to medical care contributed to a growing distrust between the Hmong community and Western providers, leading to suboptimal medical care and poor patient outcomes.3
  • Lack of programs that integrate traditional and Western medicine: Traditional healers can serve as a valuable link between ethnic populations and Western practitioners, but few hospitals offer access to such resources. For example, Hmong shamans are natural gatekeepers, because most Hmong go to a shaman before seeing a physician; in Merced, for example, roughly three-fourths of Hmong first approach a shaman to determine the nature of a physical or spiritual problem.3

What They Did

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Description of the Innovative Activity

As part of the “Partners in Care” program, Mercy Medical Center Merced allows Hmong shamans who have been oriented to Western medicine to conduct healing ceremonies when requested by Hmong patients to meet their spiritual needs, provide support, and promote optimal healing. Shamans also periodically educate physicians and hospital staff about their beliefs and practices. Key program elements include the following:
  • Initial orientation on Western medicine: Hmong shamans receive a 40-hour intensive orientation on Western medicine where they learn about Western biomedical practices, germ theory, and disease symptomatology; they also tour the hospital, including the operating room, emergency department, labor and delivery room, and laboratory and radiology departments. Mental health topics (including conditions, symptoms, and services) have recently been incorporated into this orientation (updated May 2012). Once shamans complete the program, they can be called upon to visit Hmong patients at Mercy Medical Center Merced. Shamans are treated as clergy and have hospital badges. They also wear traditional embroidered Hmong jackets to distinguish them from hospital staff and volunteers. As of May 2012, 112 shamans have completed the program, one-third of whom are women.
  • Coordination of shaman visit: When a Hmong patient or family member requests a visit from a Hmong shaman, the chaplain or bedside nurse works with a qualified interpreter to enumerate for the patient/family the list of ceremonies approved by the hospital (see below), and then contacts staff from the Healthy House program (which conducts the shaman orientation and oversees the "Partners in Healing" program; see Context section for more details) to schedule the visit.
  • Ceremonies: Hmong healing ceremonies, which typically last 10 or 15 minutes, involve traditional chants, “soul calling,” “soul tying,” and blessings that promote protection and healing. Ceremonies are conducted by the shaman in a low voice so as not to disrupt others.
    • Approved ceremonies: The medical center has preapproved nine ceremonies that can be conducted in the patient’s hospital room, emergency department, or preoperative unit. The ceremonies are brief, quiet, and do not require a private environment.
    • Nonapproved ceremonies: If a shaman recommends a more extensive ceremony, the chaplain or nurse will contact Healthy House representatives, who then seek approval from physicians, nursing administrators, the hospital’s director of mission integration (who oversees the chaplaincy program), and/or other administrators as necessary.
    • Respect for other patients: If the Hmong patient is sharing a room, the chaplain or nurse will describe the ceremony and its approximate length to the roommate and request his/her consent. If the roommate does not provide consent, the nurse will make arrangements to transport the Hmong patient to a private area for the ceremony.
    • Documentation: The request for and provision of the ceremony is documented in the patient’s chart.
  • Education of Western providers: During the orientation sessions and in periodic meetings with physicians, shamans, with the help of an interpreter, teach Western providers about Hmong medicine and health beliefs. In addition, a shaman serves on the Mercy Hospital Advisory Board, providing periodic input on policy issues from the perspective of the Hmong community.

Context of the Innovation

Merced County experienced a significant influx of Hmong residents in the mid-1970s, when refugees from Laos relocated to the county after fleeing in fear of persecution at the end of the Vietnam War. By the early 1990s, approximately 20 percent of the county population was Hmong, although today they represent just over 12 percent (8,500 Hmong live in Merced County out of a total population of approximately 70,000). The “Partners in Healing” program operates out of the nonprofit "Healthy House Within a MATCH" coalition, which seeks to facilitate community–provider partnerships to improve health care for minority populations. Mercy Medical Center Merced—a 196-bed institution that is part of the Catholic Healthcare West system—is the Healthy House program’s largest health partner, treating approximately four Hmong patients daily. The Healthy House program has also developed strategic partnerships with other providers, including the Merced County Department of Mental Health, the local ambulance company, Merced Pathology Associates, the Merced Family Practice Residency Program, and other local health services, including dialysis and diabetes centers. These partnerships allow Hmong patients to receive traditional care from shamans in a variety of settings.

The concept for the shaman program stemmed from an incident in 1996, when a prominent 55-year-old Hmong businessman with gastrointestinal problems refused surgery because of cultural and linguistic communication difficulties between his extended family and his physicians. This patient postponed medical care until all of his body systems failed; many Hmong gathered outside of the patient's room and requested that a shaman perform traditional healing ceremonies and blessings. These community members ultimately succeeded and the ceremonies were performed. Although physicians had no hope that this man would survive, he did, which had a powerful impact on hospital administrators and providers regarding the potency of traditional medicine. Moving forward, the hospital continued to allow Hmong shaman ceremonies on an ad hoc basis when requested.

Did It Work?

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Results

Anecdotal reports suggest the program has reduced cultural conflicts and miscommunications between Hmong patients and physicians, and increased Hmong support of Western medicine, physician acceptance of traditional medicine, and satisfaction among Hmong patients.
  • Significantly fewer cultural misunderstandings and conflicts: Since program inception, relatively few cultural conflicts have occurred (particularly with regard to recommended surgeries), leading to better, more timely care and fewer frustrations for patients and physicians.
  • Increased Hmong support of Western medicine: Fears about what occurs “behind closed doors” at the hospital have declined among Hmong patients and their families. Hmong shamans now refer more quickly to physicians because they better understand Western views of disease and treatment.
  • Increased physician support of traditional care: Some physicians now refer Hmong patients to shamans to provide services that complement their medical care.
  • Higher patient satisfaction: Anecdotal reports suggest that Hmong patients are more satisfied and comfortable with Western providers.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation anecdotal reports from patients, shamans, and physicians.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Hospital and physician approval: Healthy House representatives talked to hospital administrators about formalizing the Hmong shaman program and providing them with training on Western medicine. Physicians and administrators were willing to do so because Healthy House representatives had a history of negotiating these inhospital ceremonies with administrators and selected physicians.
  • Training: The program initially trained six shamans on Western medicine. Over time, the training program has been expanded to include 106 additional shamans and more than 300 health care providers; at present, 40 hours of training occurs over a 6-week period and quarterly continuing education programs are provided.
  • Policy development: The hospital and Healthy House developed a policy on what ceremonies could be performed, along with processes for accessing a shaman, requesting roommate approval, and arranging a nonapproved ceremony.

Resources Used and Skills Needed

  • Staffing: The Healthy House program has four Hmong staff who provide support to the "Partners in Healing" program and other initiatives.
  • Costs: The program costs relatively little to operate, as shaman services are paid by the patient/family.
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Funding Sources

Mercy Medical Center Merced; Healthy House Within a MATCH (Multidisciplinary Approach to Cross-Cultural Health) Coalition; The California Endowment
As noted, Hmong patients/families pay the shaman for his or her services.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Support sharing of health beliefs: Support mutual understanding by allowing each group to teach the other about health practices pertinent to its culture.
  • Develop relationships with community: This type of program is much easier to implement if hospital administrators and physicians already have a working relationship with leaders of community-based organizations serving ethnic populations. It is important to identify and support champions of the program within the hospital setting.
  • Start small: Start with only a few providers and traditional healers to enable them to build relationships with each other. They will then share their positive experiences with others.

Sustaining This Innovation

  • Emphasize cultural humility: To promote ongoing provider support, emphasize the role of cultural humility in improving patient outcomes and satisfaction.

More Information

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Contact the Innovator

Candice Adam-Medefind
Executive Director, Healthy House Within a MATCH Coalition
1729 Canal Street
Merced, CA 95340
(209) 724-0102
E-mail: candice@healthyhousemerced.org

Innovator Disclosures

Ms. Adam-Medefind reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Brown, PL. A Doctor for Disease, a Shaman for the Soul. The New York Times. September 19, 2009. Available at: http://www.nytimes.com/2009/09/20/us/20shaman.html?_r=1.

Udesky L. A Matter of Respect: Training Hmong shaman in the ways of Western medicine is saving lives in Merced. San Francisco Chronicle. June 4, 2006. Available at:
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/06/04/CMGPOIP5CV1.DTL.

Footnotes

1 Institute of Medicine. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. March 2002. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care
/Disparitieshcproviders8pgFINAL.ashx
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2 Johnson SK. Hmong health beliefs and experiences in the western health care system. J Transcult Nurs. 2002;13(2):126-32. [PubMed]
3 Interview with Marilyn Mochel, November 13, 2009.
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Original publication: March 17, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 31, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.