(Note that generalizations about Cambodians (Khmer) are about as accurate as generalizations about any other large group. Nevertheless, it is necessary to deal in generalizations to some extent.)
Understanding Cambodians (or Khmer) requires knowledge of the culture itself and also of Khmer experiences during the communist Khmer Rouge holocaust and subsequent refugee experiences. From 1975-78 when the Khmer Rouge were in power, all schools were closed, everyone was forced to work beyond human capacity, non-communist Cambodian leaders were killed, many people were starved or let die from disease, and a deliberate attempt made to destroy Khmer culture. Virtually all Khmer over age 25 have memories of concentration camp experiences, starvation, and stunning brutality. By 1979, 1.5 - 2 million out of a population of 7 million were dead. From 1981-1985, about 150,000 Khmer were resettled in the U.S. Although many Khmer enjoy success in the U.S., many others are a hidden part of inner-city urban life. And most carry great pain related to past traumas.
Religion: Most adult Khmer in America are Buddhist. Buddhism is based on the teaching of Siddhartha Gautama, The Buddha. Central to Buddhism is belief in the Four Noble Truths. These are: (1) All sentient beings suffer. Birth, death, and other separations are inescapably part of life. (2) The cause of suffering is desire. Desire is manifested by attachment to life, to being, to security, to others, etc. (3) The way to end suffering is to cease to desire. (4) To way to cease to desire is to follow the Eightfold Path of right belief,right intent, right speech, right conduct, right endeavor, right effort, right mindfulness, and right meditation. Following the path leads to cessation of desire and to nirvana or emancipation from rebirth. Evangelical Christian churches and Mormons are active in most Khmer communities. Readers should note that many Khmer are comfortable with attending both Christian and Buddhist worship.
Background: In general, the Khmer are comfortable with cosmopolitan or western medicine and with traditional or indigenous healing practices. Illness may be attributed to imbalance in natural forces, i.e., a humoural theory of causation. However, many Khmer will not directly express this concept. A common expression of the concept(s) is for people to note the influence of "wind" or kchall on blood circulation and thus on illness. There may also be discussion of body conditions called "cold" or "hot." These are not necessarily temperatures, but rather are body states leading to or caused by illness or other changes such as childbirth.
For a variety of reasons, many Khmer are slow to seek care from western practitioners and often traditional measures are tried first. Reasons for delaying healthcare include: (1) acceptance of illness or discomfort, (2) difficulty accessing public or private health providers, (3) difficulty traversing the healthcare system (e.g., business/eligibility aspects, appointments, prescription refills, etc.), and (4) other factors related to culture, language, poverty, and the healthcare system itself.
Traditional healing or indigenous practices: Some of the following procedures are carried out by family members and some by traditional healers or kruu Khmer. Some kruu Khmer specialize in medicinal practice with a spiritual component, while others specialize in magic with a medicinal component. Regardless of who carries out the below or other procedures, they are often accompanied by prayer and other spiritual activities.
Spiritual healing practices: There often are both spiritual and medicinal elements in healing practices. Magico-religious articles such as amulets, strings, and Buddha images are commonly part of treatment or prevention of illness. Other spiritual or magical means of treating illness include blowing on the sick person's body in a prescribed manner and showering or rubbing with lustral water. As noted earlier, many Khmer see no conflict in practicing or using traditional or magic means of treating illness simultaneously with western medicine. Many would further see no conflict in adding Christian prayer to the mix.
Response to western or cosmopolitan medicine: Often traditional measures are tried in the home before seeking health care outside the home and/or be used simultaneously with western medicine. Major issues in providing quality care are difficulty obtaining accurate and complete assessment, lack of compliance with medications and treatment, and a reluctance to be involved in preventive measures.
Communication is a major issue in assessment and all other phases of care. Communication barriers may be due to language or to cultural issues. The latter include attempting to use a translator who, for gender, age, social status, or past relationship incompatibilities, may be rejected or not listened to.
Assessment is complicated first by a reluctance to complain or express negative feelings. It is common for patients to not report or even to deny symptoms or problems. This may be a cultural issue or may be due to past difficulties in obtaining health care.
Non-compliance may be due to several factors. The patient may not believe that he or she has communicated the problem and thus have little faith in the solution. A common Khmer orientation to symptoms (vs. cause) of illness may result in discontinuation of treatment as soon as symptoms are resolved. Treatment through dietary measures is very difficult because of difficulty in food substitutions, differences in perceptions of foods, and in some cases, financial issues. Often there is an erroneous assumption on the part of health providers that the patient will be able to independently obtain refills or reappointments. Difficulty negotiating the business aspects of the health care system may result in failure to complete therapy. Some patients, rather than report a less than efficacious response to treatment, will report "no problem" or "its okay."
Most Khmer are oriented more to illness than prevention of illness. Childhood immunizations are accepted, but adult immunizations (influenza, pneumonia) are of little interest until illness strikes. Most Khmer do not value early detection or disease screening.
As with most other cultures, respect is essential. Communication is often indirect and requests or questions may be couched in seemingly vague terms. It is unusual for older people to make a direct "no" response to a question or request. Effusive, loud, or over-familiar behavior toward Khmer (including children) is seldom in good form; nor is showing anger or involvement in confrontation.
It is difficult if not impossible to learn and follow all the proper cultural patterns of a culture not oneís own. It is possible, however to (1) maintain both an inner and outer respect for others (2) pay attention to what others are doing and how they are reacting to a situation, and (3) learn about the culture and attempt to implement that knowledge.