Peer Review Article on Cambodian Population in Usa
Prog Community Health Partnersh. Author manuscript; available in PMC 2017 April 1.
Published in last edited class as:
PMCID: PMC4810451
NIHMSID: NIHMS721298
Improving the Health of Cambodian Americans: Grassroots Approaches and Root Causes
Juliet P. Lee
onePacific Constitute for Inquiry and Evaluation, Prevention Research Center, 180 Thousand Artery, Suite 1200, Oakland, CA 94612 USA
Sean Kirkpatrick
twoCommunity Health for Asian Americans, 268 Thousand Avenue, Oakland, CA 94610 USA
Ann Rojas-Cheatham
2Community Wellness for Asian Americans, 268 Grand Avenue, Oakland, CA 94610 U.s.
Talaya Sin
1Pacific Institute for Research and Evaluation, Prevention Research Center, 180 G Avenue, Suite 1200, Oakland, CA 94612 USA
3Association of Asian Pacific Community Wellness Organizations, 300 Frank H. Ogawa Plaza, Suite 620, Oakland, CA 94612
Roland S. Moore
anePacific Institute for Research and Evaluation, Prevention Inquiry Center, 180 Grand Artery, Suite 1200, Oakland, CA 94612 USA
Sotheavy Tan
iiCommunity Wellness for Asian Americans, 268 Thousand Avenue, Oakland, CA 94610 USA
Shadia Godoy
2Community Health for Asian Americans, 268 Thousand Avenue, Oakland, CA 94610 United states of america
Angelo Ercia
twoCommunity Health for Asian Americans, 268 Thousand Avenue, Oakland, CA 94610 USA
4The Academy of Edinburgh, Schoolhouse of Social & Political Science, Chrystal Macmillan Building, 15a George Square, Edinburgh EH8 9LD, Great britain
Abstract
Groundwork
Cambodian Americans experience groovy disparities in health compared to other Americans, yet may be underserved by conventional healthcare systems. CBPR is a means to engage underserved communities in health research and programming. Nosotros depict results of our efforts to engage the Cambodian grassroots members every bit well as formal leaders in Oakland, CA.
Objectives
In addition to a customs advisory group, nosotros convened a Community Work Grouping (CWG), composed of ten grassroots community women of varying ages and backgrounds. The project aimed to leverage the lived experiences of these women and their understandings of health and wellness in identifying specific health bug and developing culturally resonant strategies.
Methods
The CWG met weekly with staff facilitators using methods for collective analysis including theater, body mapping, and other expressive arts.
Results
The arroyo proved logistically challenging, but resulted in novel analyses and strategies. The group identified trauma, along with poor access to instruction, united nations- and under-employment, social isolation, and generation gap, together with community violence, as root causes of cardinal behavioral health problems, i.eastward. alcohol abuse, gambling, prescription drug misuse, and domestic violence. Strategies proposed and implemented by the group and project staff were a customs garden, Cambodian New year'due south celebrations, and a museum exhibit on the Cambodian refugee experiences.
Conclusions
Grassroots community engagement tin support projects in identifying social determinants of health and developing the capacities of community members to conduct inquiry and actions to amend health.
Background
Many years after the genocidal Khmer Rouge menstruation, Cambodian Americans and their children continue to experience poor health (1–4), evidenced past high rates of post-traumatic stress disorder (PTSD), depression, feet, and substance misuse (5–xi). Community-Based Participatory Research (CBPR) may help in identifying new ways to address such persistent health atmospheric condition (12–14). Our project utilized CBPR to better the behavioral health of Cambodian Americans in Oakland, CA. We focused on building the capacities of grassroots Cambodian American women to identify behavioral wellness problems and disparities, and develop ideas for interventions addressing those problems.
Objectives
Partnerships
The project was a collaboration between the Pacific Establish for Research and Evaluation (PIRE), a public health inquiry agency, and Community Health for Asian Americans (CHAA), a community-based behavioral wellness and wellness provider, together with Cambodian Community Development, Inc. (CCDI), and Center for Empowering Refugees and Immigrants (CERI), two customs-based organizations serving Oakland Cambodian Americans. These partners had worked together in various configurations for ten years prior to the project, including federally-funded research and intervention projects on the etiology of problematic substance use among U.South. Southeast Asians (15–17), and had a mutual interest in improving the health of Cambodian Americans through enquiry and customs engagement. Post-obit these projects we conducted focus groups with key community leaders to assess unmet community behavioral wellness needs and consider new approaches to address these needs. During the project period a 3rd community-based organization, Peralta Hacienda Historical Park (PHHP), was recruited as an issue site and somewhen came to act equally a full collaborator. Nosotros obtained funding for a two-year airplane pilot CBPR project in which the collaborators were to assemble a community advisory board and carry main research to place a key health result in a 6-month Stage 1, and then pattern, field, and evaluate a pilot intervention to accost this wellness issue for a 18-month Phase 2.
"Customs engagement" operationalized
In the U.South. in that location has been increasing involvement in customs-engaged research approaches (xviii, 19); nevertheless, it oftentimes unclear how "the customs" should be represented (20). We chose to engage the Oakland Cambodian American community at the "formal leadership" level, i.eastward., Cambodians representing the community in a professional capacity, and at the the grassroots level, i.e., Cambodians who may non (still) be in formal leadership roles. This decision derived from our agreement of CBPR as an arroyo to addressing persistent behavioral health issues for Cambodian Americans.
Although many Cambodians seek treatment, in that location is a express behavioral health workforce with acceptable training to address the unique needs of this population. Of equal importance, many Cambodians present behavioral health problems somatically (x, 21) and bring these issues to principal intendance rather than a behavioral health service. Nosotros speculated that engaging the community simply at the level of formal leadership—people already working within conventional behavioral wellness settings—might go along the projection interventions inside pre-established service modalities. In order to identify new and innovative approaches, nosotros focused on utilizing CBPR to support grassroots customs members to bring new data to calorie-free based in their own lived experiences of behavioral wellness issues, and to use this research to design a pilot intervention, at the aforementioned time developing the leadership capacity of grassroots community member. We focused on women since our community assessment had identified the key roles women play in family unit wellness and health.
Methods
Community representation
For this projection CHAA hired a full-fourth dimension Community Health Worker (CHW), a Cambodian American woman with deep ties to local Cambodian American residents too every bit feel working with key organizations serving Cambodian Americans. The CHW's role was to support the work of the Customs Work Group (the core grouping of grassroots co-researchers) by providing interpretation and translation in meetings, supporting CWG members to attend project activities, and too outreach to key community resources (e.grand., Buddhist temples; community leaders). PIRE as well hired a Cambodian American Research Banana (RA), an Oakland native with a wide range of research skills, to support community enquiry activities and assist in documenting the process. Nosotros organized a volunteer Community Informational Committee (CAC), composed of sixteen people who represented a variety of Cambodian-serving social service, educational and health organizations. The CAC's role was to support the projection activities in all phases of the project with resource and guidance. In Phase ane, the CAC established the criteria for the CHW and for CWG membership and recruited candidates for these roles. In Stage 2, the CAC linked the projection activities to on-going customs initiatives and resources. CCDI and CERI were contracted to serve equally "Customs Hosts" to provide the project with culturally-advisable resources including meeting spaces, translation of documents, outreach and back up of inquiry activities, and their executive staff served on the CAC. The authors of this commodity include staff from all four of the key collaborating agencies, including the project's CHW and RA.
Community Work Group/Cambodian Women's Group
At the cadre of the project was a Community Piece of work Group (CWG), also referred to as the Cambodian Women's Group by our project team. Typically when community members are engaged in community-based inquiry this involvement is express to focus groups and fundamental informant interviews conducted by a research expert who extracts information from participants on preselected topics. The results of this enquiry may be analyzed and interpreted by the professional researchers, perchance with consultation from other professionals within the community, and utilized to better outreach for wellness education, prevention programs, and other interventions. Dutta (22) refers to this type of approach equally a cultural sensitivity approach, too referred to as cultural tailoring by Peterson (20) in dissimilarity to a culturally-centered approach in which "alternative theories of wellness are generated past engaging in meaning-making with cultural participants." Our project aimed for a culturally-centered approach. The CWG participants were engaged as co-researchers, and the "data" upon which our collaborative enquiry was based would be derived from expertise based on their lived experiences and means of understanding health and health (23).
Following the advice of the CAC that the CWG correspond the diversity of the experiences of Cambodian Americans in Oakland, nosotros recruited 10 women who ranged in age from 21 to 65 and included Cambodian-built-in refugees, American-built-in children of refugees, and contempo immigrants from Cambodia. Additionally, the CWG included LGBTQ members every bit another characteristic of diverseness. While all members were able to speak and understand some Khmer and some English, younger members were much more skilful in English, while older members and contempo immigrants were much more skilful in Khmer. Some participants were able to read and write in English but not Khmer, some were skillful in written Khmer but had express proficiency in written English, and some could not read or write in either linguistic communication.
The CWG met once a week for two-hours per session. Each session was facilitated by project staff, which included two non-Cambodians with expertise in CBPR as well as the Cambodian American CHW, and recorded in detailed notes past the bilingual/bicultural Research Assistant. These staff members met weekly to plan each session, led by the CBPR expert in Popular Education methods. All project protocols were reviewed and approved by PIRE'southward Institutional Review Board. CWG participants received stipends of $50 per session. Over the course of the project, iii CWG members dropped out due to personal reasons.
Collective analysis methods
The high validity of analyses conducted in a grassroots approach to CBPR derives from the iterative cycles of activity and reflection within which community members comport research and/or intervention activities and and so connect this work to their ain lived experiences to contextualize the work and deepen their understandings of it (24). Working with the facilitation team, the CWG conducted collective analyses start with the domains of health, health, and community, and so expanding to include emergent topics such as family and generation gap, and on to specific issues that helped shape the components of a pilot intervention. These collective analyses formed the cadre of Stage i activities but continued throughout Phase 2. We utilized methods from Freirian Pop Education that use concrete, typically non-verbal, foci to generate reflection and dialogue by enabling participants "to 'see' their reality with new eyes and develop new ways of thinking and acting," (25–27). The methods we used were:
Popular theater
This technique involved office playing, sometimes called applied theater, likewise equally Theater of the Oppressed (28). Working in pairs or small groups, the participants developed cursory dramatic improvisations based on their lived experiences of focal bug. These pieces were presented to and discussed within the group. This method—combining theater with participatory learning (29–31)—was specially effective for exploring and articulating complex relationships associated with community health issues such as alcohol use and misuse, domestic violence, and the generation gap within families.
Trunk mapping
In our project the method of trunk mapping (32–35) was used to establish a foundation of co-learning equally well equally place recurring and/or complementary themes across the experiences of the diverse group of CWG participants. This method facilitated discussions of life experiences and how they are continued to the concrete and socio-cultural environment and historical context. By the end of the practise, the CWG members were able to articulate these connections in their own lives.
Interpretive fine art making
At various stages in the collective analysis the participants sculpted items and images from play-dough as ways to depict and contextualize themes that emerged, such as food or self-epitome. The group collaboratively generated murals to conceptualize possible futures for Cambodian Americans, including detailed depictions of their proposed intervention components described below (Figure 1, drafted for the CWG by co-writer TS, illustrates linkages between root crusade analyses and the community garden component of the intervention design).
Analysis and interpretation
The analytic procedure consisted of small group discussions, supported by the facilitation team. These conversations were summarized and presented to the larger group. Analyses and interpretation across small groups were summarized equally bullet points on large pieces of paper posted at the end of the session. When decisions were made within the group—notably, selection of a focal wellness issue and pilot intervention components—the controlling process was by vote.
All discussions were conducted with interpretation in English and Khmer. Notes were generally summarized in English. The small and whole grouping discussions were recorded in English past the projection Research Assistant and combined as session notes. These weekly session notes were uploaded to a database attainable to all staff members. The facilitation team likewise met weekly to debrief on the sessions, consider the results, and program for the following sessions. These debrief and planning meetings were likewise documented in written notes.
Weekly session summaries prepared past the projection Research Assistant were sent to all CAC members. In quarterly meetings, the results of the CWG sessions were presented to the CAC for review, consideration, and feedback.
Results
Health issues and root causes
The CWG identified a constellation of interrelated behavioral wellness problems that shared common roots. Four issues they identified are familiar within the dictionary of behavioral health issues addressed in handling and prevention programs: alcohol misuse; problem gambling; prescription drug misuse; and domestic violence. Other issues are less direct recognizable as "wellness issues" per se although some are increasingly recognized equally social determinants of health. These were: generation gap; lack of teaching; un/underemployment; customs violence; social isolation; and trauma. Trauma included both the Khmer Rouge and refugee experiences as well every bit new traumas and re-traumatization due to community- and gang-related violence, poverty, and discrimination in the U.Southward.
Applied solutions: Centering the customs
The practical solutions that the CWG proposed aimed to address root causes of behavioral health issues for Cambodian Americans living in Oakland. The group's original proposal was to develop a Cambodian community heart: a infinite where Cambodians could socialize in positive means, providing alternatives to parties that featured or included gambling and drinking, which the CWG identified as the main ways Cambodians socialize. A center could be a place where people could find visitor and condolement while reducing their social and cultural isolation. A community center could provide services such equally tutoring and mentoring to support educational aspirations and cultural preservation goals. Finally, such a eye could provide a infinite for both older and younger Oakland Cambodians to meet within activities and programs (east.thou., Khmer language or music classes; all-ages social events) that could help span the generation gap.
Given that our federal funding and two-year timeline precluded establishing such a facility, the grouping instead considered what might be key features of a Cambodian community centre that could constitute doable projects. The group came up with a list of possible and doable projects and voted on these. This process resulted in the identification of 3 core components of our pilot intervention: Cambodian Customs Gardens, with an initial demonstration garden followed by two more gardens; Cambodian Community New Twelvemonth'due south Celebrations, organized in 2011 and 2012 by the project and in 2013, 2014, and 2015 by community leaders; and a Cambodian Cultural Exhibit, featuring the life stories of CWG and other community members and Cambodian cultural practices (e.g., music, dance) and social modify. The intervention components, the root causes they aimed to accost, and their community impacts are summarized in Tabular array 1.
Tabular array i
Pilot Intervention Components
| Intervention Component | Actualization | Roots Causes Addressed | Activities Included | Community Impacts |
|---|---|---|---|---|
| Cambodian Community Gardens |
|
|
|
|
| Cambodian New Yr Celebrations |
|
|
|
|
| Cambodian Cultural Showroom |
|
|
|
|
The project timeline did not allow us to evaluate intervention outcomes. Withal, process evaluation indicated that the CWG accurately assessed and addressed areas of unmet need. Procedure evaluation for the intervention consisted of surveys or attendance rolls to record participation in and responses to the intervention activities by the broader Oakland Cambodian American community. Of attendees at the 2011 New Year'due south event, 171 took a survey addressing key Cambodian American community concerns including the root causes identified by the CWG as well every bit health and social issues. The survey was conducted in both English language and Khmer. Respondents ranged in age from eighteen to 84, with the median age of 32 (standard deviation xvi). Of these participants, many reported a good deal of social isolation: merely 26% reported ever going to Buddhist temples, and there was a lack of activity exterior the domicile for older adults. The bulk (55%) reported that the best thing about the upshot was seeing other Cambodian Americans. Since the terminate of our project, Cambodian American community activists working with Peralta Hacienda Historical Park have taken on leadership of this upshot and have continued to host information technology with the same essential structure (36). The customs garden intervention, in which 129 Cambodian American community members participated, has as well been adopted by two of the collaborating organizations (CHAA and CERI).
Of the 108 people who took the community survey at the 2012 Cambodian New Year celebration, 54% (58 people) reported that they saw the cultural exhibit. Most of these who saw the showroom reported that the best affair about it was "pride in my culture." Peralta Hacienda Historical Park and collaborating community leaders, including one of our project staff and two CAC members, have obtained funds from local traditional arts councils to develop and expand the cultural exhibit (37, 38) past developing the supplemental audios into a larger oral history projection.
Such efforts to institutionalize these project components reverberate the success of these intervention activities in meeting the customs's goals and needs. The CWG members have continued to show leadership in these and other related activities. Additionally, these activities have provided opportunities for new leaders, both older people of the refugee generation and younger Cambodian Americans, to step up, have buying and responsibility for these activities, and develop their leadership capacities.
Conclusions
Research shows that personal choices and behaviors influence only part of what determines an individual's wellness condition, but that social determinants of health—economic and social conditions—influence the health of people and communities every bit a whole (39–41). Many of the unfavorable conditions that arise in communities—specially in low-income and communities of colour—are due to the circumstances in which people live, work, age, socialize, and form relationships, and the gaps in the systems aiming to regulate and amend negative impacts of these social circumstances. Our research methods supported our interest in better agreement and addressing the underlying social determinants of health in the Cambodian American customs from the community'south direct, lived experiences. This project may be also seen as contributing to the emerging "Trauma-Informed Care" discourse which places individuals' and communities' feel at the center and pulls the frame of health bug out to a larger and more holistic organisation of interconnected, recursive and cocky-amplifying issues (42). Accordingly, the Cambodian Women's Group members did not focus on 1 isolated health problem but developed an in-depth examination of inter-related contexts and root causes of multiple interconnected health and social problems in their community. The grassroots approach allowed united states of america to not only place root causes but also propose novel and community-centered responses to address social determinants of poor health.
Our process challenges underscore why culturally-tailored approaches to customs engagement may exist more common than culturally-centered approaches. Peterson notes that community members may exist limited in their ability to participate in community engagement processes because of material and opportunity costs (43). For our group, younger community participants, and sometimes staff, were already stretched thin across work (multiple part-time jobs for some) and school also as taking care of children, older parents, and other family members. Childcare needs prevented some members from participating in project events scheduled outside of sessions—as yet, federal grant funds do not allow for childcare reimbursement.
Language proved to be a core challenge. Fifty-fifty as the variety within the grouping proved to exist a keen strength and asset for the project and participants, working simultaneously in two languages was difficult. Staff and participants had to larn to pause frequently during speeches and conversations to allow for interpretation. When interpretation was delayed or shortened, participants and staff members expressed frustration at feeling they were missing vital ideas, or concerned that their own words were non being communicated adequately. Still, this bilingual work procedure was critical to the projection's ability to comprehend the lived experiences of a wide range of Cambodian Americans. The pauses needed for interpretation besides provided opportunities for reflection that may have been missed if the group proceeded at total speed.
While our research methods were well-suited to a group which included members with limited literacy, these methods required skills in facilitation and implementation that might evidence challenging to mainstream researchers and wellness and social service settings. Nonverbal methods besides helped to bridge historic period and experiential gaps that could make it the manner of sharing and communications, as well as to provide movement-based therapeutic outlets for those suffering from the effects of trauma and PTSD (due east.g., 44). However, the intensive staff construction entailed substantial investments in labor and time for the partner agencies.
Finally, in refugee and immigrant communities, bridging generational gaps may be challenging for program design, simply ultimately rewarding both for results and community capacity building. Similar many societies, Cambodian diasporic society places a loftier value on children and on the well-being of hereafter generations. This feeling may be particularly poignant for survivors of genocide. At the same time, youth are taught to laurels and show respect by non challenging or contradicting elders, and may feel inhibited speaking at all in the presence of elders. Our program bridged the tension between these positions by deliberately constructing a setting within which elders and youth were encouraged to participate equally equals with valid experiences and perspectives. The facilitators and bilingual bicultural staff (the RA and CHW, who themselves represented the younger and older generation) "held" this space in key means. The staff helped the group found guidelines and agreements that supported mutual respect; for example, an understanding to take turns in talking circles and yield the floor to whoever was holding a toy donut—symbolizing both equality and the donut-making small businesses by which many U.S. Cambodian families make a living. The staff planned group discussions and activities with sensitivity to generation gap bug; for example, soliciting opinions from both youth and elders in group discussions and ensuring that pause-out discussion groups included members of both generations. The staff also invited the CWG members to straight address the generation gap by scripting and enacting cursory performances about information technology, as a manner to have fun, safely raise hard and sensitive generation gap issues, and clarify these issues as a group. As a outcome, the participants gained valuable experiences in bridging the generation gap and developed a greater sensation of both the challenges faced by each generation also as the avails each brings to the piece of work of community building. Moreover, the resulting interventions do good from reflecting the perspectives and serving interests of both younger and older community members.
In conclusion, we encourage researchers to consider engaging grassroots community members directly in community-partnered research. Grassroots engagement has great potential to deepen the investigation of the social determinants of health and move intervention strategies into innovative modalities and structures, perhaps with high risks merely besides with potential for high rewards, to address seemingly-intractable health issues. Grassroots engagement may back up community ownership and institutionalization of intervention strategies, and develop new leadership capacities to improve community well-existence.
Supplementary Material
Community/Policy brief
Acknowledgments
Enquiry and preparation of this report were supported by grant R24MD004902 from the National Plant on Minority Health and Health Disparities (J.P. Lee, PI). The authors admit the invaluable work of the members of the Cambodian Women's Group: Thavery Hov; Sarouen Im; Phannara Khun; Kong Lap; Choun Norn; Maria San; Poly Yat Tep; and Monica Then. We also thank members of our Customs Advisory Committee; Center for Empowering Refugees and Immigrants; Banteay Srei of Oakland; Peralta Hacienda Historical Park; Harbor Firm Ministries of Oakland; Cambodian Customs Development, Inc.; and Oakland Cambodian Americans for supporting the project.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810451/
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