Journal of Immigrant and Minority Health

, Volume 9, Issue 3, pp 179–190 | Cite as

We are out of balance here”: a Hmong Cultural Model of Diabetes

  • Kathleen A. Culhane-Pera
  • Cheng Her
  • Bee Her
Original paper


A Hmong cultural model of type 2 diabetes has not been described. We analyzed 20 group discussions during 21 group visits over 1 year with 39 Hmong adults with type 2 diabetes in order to describe a model that underlines their discussions. These Hmong adults attribute their diabetes to their refugee experience. They do not fit with the food, activity, weather, or community in the United States. Consuming sugar, salt, fat, and chemicals and then not sweating them out of the body, combined with emotional losses of being refugees, the participants feel they are out of balance. And being out of balance, they develop diabetes. The participants interpret biomedical information, community experiences, and personal sensations of diabetes in terms of a traditional health model of balance and in the context of refugee loss of place. Throughout their discussions, the shared suffering of their personal experiences of diabetes was evident. This cultural model may help providers implement diabetes treatment and prevention programs.


Culture Hmong Diabetes mellitus 



Many thanks to 39 group visit participants, and to the professionals who helped with group visits: Kang Xiaaj M.D., Mary Yee, M.D., Tely Xiong R.N., Hli Lo Xiong B.S.W., Xee Vang, LPN Mai Thao Vang, Bao Thao Vangsoua. And thanks to our funders, HealthPartners Research Foundation and American Academy of Family Physicians’ Advanced Research Training Grant.


  1. 1.
    Her C, Mundt M. Risk prevalence for type 2 diabetes mellitus in adult Hmong in Wisconsin: a pilot study. WMJ 2005;104(5):70–7PubMedGoogle Scholar
  2. 2.
    Kunstadter P. Health implications of globalization at the village level: the good, the bad, and the ugly: some results of comparative research in Thailand and the US. Presentation at Woodrow Wilson School of International Studies. Princeton, New Jersey: Princeton University; 2001 March 12Google Scholar
  3. 3.
    National Diabetes Information Clearinghouse: Diabetes Statistics 2002. National Institute for Diabetes and Diseases of the Kidney. National Institutes of Health. Washington, D.C: NIH; 2005. Available at Scholar
  4. 4.
    Culhane-Pera KA, Peterson KA, Crain AL, Center BA, Lee M, Her B, et al. Group visits for Hmong adults with type 2 diabetes mellitus: a pre-post analysis. J Health Care Poor Underserved 2005;16(2):315–27PubMedCrossRefGoogle Scholar
  5. 5.
    Johnson SK. Diabetes in the Hmong refugee population. Unpublished PhD dissertation. San Francisco: University of California, San Francisco; 1995Google Scholar
  6. 6.
    American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2004;27:S15–35Google Scholar
  7. 7.
    Peterson KA, Vang ML, Xiong YM. Type 2 diabetes mellitus in the Hmong community. In: Culhane-Pera KA, Vawter DE, Xiong P, Babbitt B, Solberg M, editors. Healing by heart: clinical and ethical case stories of Hmong families and Western providers. Nashville TN: Vanderbilt University Press; 2003. pp. 173–182Google Scholar
  8. 8.
    Brown SA, Harris CL. Culturally competent diabetes education for Mexican Americans: the Starr County study. Diabetes Educ 1999;2592:226–36Google Scholar
  9. 9.
    Steckler A, Ethelba B, Martin CJ, Stewart D, Pardilla M, Gittelsohn J, et al. Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students. Prev Med 2003;37(6 Pt 2):S80–90PubMedCrossRefGoogle Scholar
  10. 10.
    Wang CY, Abbott LJ. Development of a community-based diabetes and hypertension preventive program. Public Health Nursing 1998;15(6):406–14PubMedGoogle Scholar
  11. 11.
    Glasser B, Strauss AL. The discovery of grounded theory. New York: Aldine; 1967Google Scholar
  12. 12.
    Gittelsohn J, Harris SB, Burris KL, Kakegamic L, Landman LT, Sharma A, et al. Use of ethnographic methods for applied research on diabetes among the Ojibway-Cree in Northern Ontario. Health Educ Q 1996;23(3):365–82PubMedGoogle Scholar
  13. 13.
    Gregory D, Whalley W, Olson J, Bain M, Garper GG, Roberts L, et al. Exploring the experience of type 2 diabetes in urban Aboriginal people. Can J Nurs Res 1999;31(1):101–15PubMedGoogle Scholar
  14. 14.
    Hunt LM, Valenzuela MA, Pugh JA. Porque me toco a mi? Mexican American diabetes patients’ causal stories and their relationship to treatment behaviors. Soc Sci Med 1998;46(8):959–69PubMedCrossRefGoogle Scholar
  15. 15.
    Lang GC. “Making sense” about diabetes: Dakota narratives of illness. Med Anthropol 1989;11:305–27PubMedCrossRefGoogle Scholar
  16. 16.
    Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press; 1980Google Scholar
  17. 17.
    Cohen MA, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: patient practitioner variation. Soc Sci Med 1994;38(1):S59–66CrossRefGoogle Scholar
  18. 18.
    Daniulaityte R. Making sense of diabetes: cultural models, gender, and individual adjustment to type 2 diabetes mellitus in Mexican community. Soc Sci Med 2005;59:1899–1912CrossRefGoogle Scholar
  19. 19.
    Garro LC. Intracultural variation in causal accounts of diabetes: a comparison of three Canadian Anishinaabe (Ojibway) communities. Cult Med Psychiatry 1996;20:381–420PubMedCrossRefGoogle Scholar
  20. 20.
    Poss J, Jezewski MA. The role and meaning of susto in Mexican Americans’ explanatory model of type 2 diabetes. MAQ (new series) 2003;16(3):360–77Google Scholar
  21. 21.
    Savoca MR, Miller CK, Quandt SA. Profiles of people with type 2 diabetes mellitus: the extremes of glycemic control. Soc Sci Med 2004;59:2655–66CrossRefGoogle Scholar
  22. 22.
    Helsel D, Mochel M, Bauer R. Chronic illness and Hmong shamans. J Transcult Nurs 2005;16(2):150–4PubMedCrossRefGoogle Scholar
  23. 23.
    Henry RR. Sweet blood, dry liver: diabetes and Hmong embodiment in a foreign land. Unpublished PhD Dissertation. Chapel Hill: University of North Carolina at Chapel Hill; 1996Google Scholar
  24. 24.
    Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. J Comm J Qual Saf 2003;29(11):563–74Google Scholar
  25. 25.
    Faderman L, Xiong G. I begin my life all over: the Hmong and the American immigrant experience. Boston: Beacon Press; 1998Google Scholar
  26. 26.
    Mattison W, Lo L, Scarseth T. Hmong lives: from Laos to LaCrosse: stories of eight Hmong elders. LaCrosse, WI: The Pump House; 1994Google Scholar
  27. 27.
    Lee SC. Stress, social support systems, and psychosocial well-being of Hmong refugee adults. Unpublished Ph.D. thesis. Seattle: University of Washington; 1994Google Scholar
  28. 28.
    Lo F. The promised land: socioeconomic reality of the Hmong people in urban American (1976–2000). Lima, OH: Wyndham Hall Press; 2001Google Scholar
  29. 29.
    Westermeyer J, Neider J, Callies A. Psychosocial adjustment of Hmong refugees during their first decade in the United States: a longitudinal study. J Nerv Ment Dis 1989;177:132–39PubMedCrossRefGoogle Scholar
  30. 30.
    Culhane-Pera KA, Xiong P. Hmong culture: tradition and change. In: Culhane-Pera KA, Vawter DE, Xiong P, Babbitt B, Solberg M, editors. Healing by heart: clinical and ethical case stories of Hmong families and western providers. Nashville, TN: Vanderbilt University Press; 2003Google Scholar
  31. 31.
    Cha D. Hmong American concepts of health, healing, and conventional medicine. New York: Routledge; 2003Google Scholar
  32. 32.
    Thao X. Hmong perception of illness and traditional ways of healing. In: Hendrick G, Downing BT, Deinard AS, editors. The Hmong in transition. New York: Center for Migration Studies of New York and Southeast Asian Refugee Studies Center; 1986. pp. 365–378Google Scholar
  33. 33.
    Capps LL. Concepts of health and illness of the Protestant Hmong. Unpublished PhD Dissertation. Kansas City: University of Kansas; 1991Google Scholar
  34. 34.
    Capps LL. Change and continuity in the medical culture of the Hmong in Kansas City. MAQ (new series) 1999;8(2):161–77Google Scholar
  35. 35.
    Topley M. Chinese traditional etiology and methods of cure in Hong Kong. In: Leslie C, editors.Asian medical systems: a comparative study. Berkeley: University of California Press; 1985. pp. 243–265Google Scholar
  36. 36.
    Unschuld P. Medicine in China: a history of ideas. Berkeley: University of California Press; 1976. pp. 243–65Google Scholar
  37. 37.
    Tapp N. The Hmong of China: context, agency, and the imaginary. Boston: Brill Academic Publishers; 2003Google Scholar
  38. 38.
    Rice PL. Nyo dua hli–30 days’ confinement: traditions and changing childbearing beliefs and practices among Hmong women in Australia. Midwifery 2000;16(1):22–34PubMedCrossRefGoogle Scholar
  39. 39.
    Symonds PV. Calling in the soul: gender and the cycle of life in a Hmong village. Seattle: University of Washington Press; 2004Google Scholar
  40. 40.
    Buchwald D, Caralis PV, Gany F, Hardt EJ, Johnson TM, Muecke MA, et al. Caring for patients in a multicultural society. Patient Care 1994; 28;105–23Google Scholar
  41. 41.
    Muecke M. Caring for Southeast Asian refugee patients in the USA. Am J Public Health 1983;73(4):431–38PubMedCrossRefGoogle Scholar
  42. 42.
    Pachter LM, Weller SC, Baer RD, de Garcia JE, Trotter RT, Glazer M, et al. Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans. J Asthma 2002;39(2):119–34PubMedCrossRefGoogle Scholar
  43. 43.
    Farmer P. AIDS-talk and the constitution of cultural models. Soc Sci Med 1994;38(6):801–9PubMedCrossRefGoogle Scholar
  44. 44.
    Centers for Disease Control and Prevention. Serious psychological distress among persons with diabetes. MMWR 2003;53(46):1089–92Google Scholar
  45. 45.
    Institute of Medicine Report: Does the built environment influence physical activity? Examining the evidence – special report 282; 2005. Retrieved January 17, 2005 at Scholar
  46. 46.
    Kleinman A, Das V, Lock M, editors. Social suffering. Berkeley: University of California Press, 1997Google Scholar
  47. 47.
    Garro LC. Lay understandings about the gravity of diabetes in three Canadian Anishinaabe communities. Circumpolar Health 1993;53:S183–7Google Scholar
  48. 48.
    Garro LC. Individual or societal responsibility? Explanations of diabetes in an Anishinaabe (Ojibway) community. Soc Sci Med 1993;40(1):37–46CrossRefGoogle Scholar
  49. 49.
    Devlin H, Roberts M, Okaya A, Xiong, YM. Our lives were healthier before: Focus groups with African-American, American-Indian, Hispanic/Latino and Hmong people with diabetes. Health Promot Pract 2006;7(1):47–55PubMedCrossRefGoogle Scholar
  50. 50.
    Romney AK, Weller XC, Batchelder WH. Culture as consensus: a theory of culture and informant accuracy. Am Anthropol 1986;88:313–38CrossRefGoogle Scholar
  51. 51.
    Weller SC, Baer RD, Pachter LM, Trotter RT, Glazer M, de Garcia JE, et al. Latino beliefs about diabetes. Diabetes Care 1999;22:722–8PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Kathleen A. Culhane-Pera
    • 1
    • 2
    • 3
  • Cheng Her
    • 4
    • 5
  • Bee Her
    • 6
  1. 1.West Side Community Health ServicesSt. PaulUSA
  2. 2.Department of Family Medicine and Community HealthUniversity of MinnesotaMinneapolisUSA
  3. 3.St. PaulUSA
  4. 4.Gundersen Lutheran Clinic in La CrosseLa CrosseUSA
  5. 5.University of Wisconsin Medical SchoolMadisonUSA
  6. 6.College of PharmacyUniversity of Southern NevadaLas VegasUSA

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