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Cambodian Cultural Profile

Reviewed and updated October 2008, by Jeniffer Huong and James Heng.
Updates are indicated at the end of sections throughout this article.

Contents

Cambodia

Geography

Cambodia borders Thailand, Laos, and Vietnam in the southeastern part of Asia. Before 1970 Cambodia was fairly rich in natural and agricultural resources. Cambodia, unlike most Southeast Asian countries, enjoyed a stable export business and shipped rice, rubber, coal, and cotton worldwide. Many people lived in small villages near waterways, the majority working in agriculture.

History and Politics

In contrast to this solid economic foundation, the political framework was unstable. The government was dominated by unpredictable leadership and erratic government policies. Some struggles ended when France established its protectorate over Cambodia in 1863. When Cambodia gained its independence from France in 1953, Prince Norodom Sihanouk ruled the country as an autocracy and continued to rule until 1970. In 1970 his prime minister, General Lon Nol, overthrew him and established a military government. The Khmer Rouge (Red or Communist Cambodians), a small movement of revolutionaries, began as a reaction to the military rule of Lon Nol and waged a war with the army until 1975 (Mattson, 1993).

Khmer Rouge

In 1975, the Khmer Rouge overthrew the Lon Nol government and abolished the monarchy. This new regime was headed by Pol Pot and they began to systematically eliminate the Cambodian population in a reign of terror lasting from 1975 to 1979. An estimated 1.5 million to 3.0 million Cambodians, or 20% to 40% of the total population, died between 1975 and 1979 under the Khmer Rouge regime (Mollica et al., 1993). Hundreds of thousands were executed. Others died of disease and starvation during forced urban evacuation and brutal labor camps. The first to be killed were Buddhist monks, urban dwellers, government officials, and people with Western educations.

The purpose of this revolutionary movement was to make a new society in which all past influences were destroyed. Not only were millions of people killed, the Cambodian culture was largely destroyed. The term "autogenocide" was coined to characterize the savage acts committed by fellow Cambodians. The Vietnamese ousted the Khmer Rouge in 1979, ending the reign of terror that has been likened to the Nazi holocaust (Kinzie et al., 1984).

Refugees

Government upheaval, destruction, and indiscriminate killings throughout Cambodia became a way of life for those who remained. Hundreds of thousands of Cambodians tried escaping across the Thai border. Some succeeded, however, many never reached their destination. The refugees who made it to camps in Thailand and Malaysia found starvation, disease, overcrowding, and violence. Within the camps, guards frequently robbed, raped, and even killed refugees.

Once in the refugee camps, the Cambodians were at the mercy of the international community. Government and voluntary agencies responded by donating food, medical supplies, money, and volunteers to help them. Many Cambodians remained in these camps for years until they were able to resettle in receiving countries around the world. Australia, France, Canada, and the United States were the countries receiving the largest number of Cambodian refugees (U.S. Committee for Refugees, 1989). Over 180,000 Cambodians sought refuge in the United States (Pike, 1990). Many of the refugees who resettled in Seattle spent 6 months in the Philippines in programs designed to facilitate acculturation. Their classes included English, Western etiquette and hygiene, and other basics common to life in the U.S.

Cambodians in the U.S.

Most of the Cambodians in the U.S. are from rural Cambodia and are predominantly illiterate or semiliterate in their own language. This is because schools were located in the few cities and were often inaccessible to the rural dwellers. There are three groups of Cambodians who have been resettled in the U.S. since 1975:

the few government officials, military officers, business and professional people who arrived in 1975 immediately after the fall of Phnom Penh;

rural and uneducated Cambodians who crossed the border and fled to Thailand in 1975. They were detained in Thai camps until 1979, when the U.S. Congress called for their admission as a special group;

the remainder admitted into the U.S. since 1980. This group consists of a mix of urban and rural, educated and illiterate refugees (Song, 1986).

Update 2008:

In the decade or so leading up to 2008, Cambodian immigrants have continued to arrive in the United States. Some are sponsored by family members who already settled in the U.S. Some are being brought as new wives of Cambodian American men. Many of these more recently arrived Cambodian immigrants were born after the war and do not have the same experience of hardship as the earlier wave of refugees. People who have grown up in cities have more experience with Western cultural norms, through exposure to education, tourism and economic development. The rural life in Cambodia is very poor and many people migrate to the cities to earn money by laboring in sweatshops owned by Chinese and Korean businesses. People coming to the U.S. from the countryside are still very traditional and may have more difficulty adapting to the culture in the U.S.

Language

Khmer (also known as Cambodian) is the official language of Cambodia. The Khmer language has the oldest written records of any Southeast Asian language in stone inscriptions dating back to the seventh century (Vickery, 1990). Because of the historical ties of the Khmer people to the culture of India, the language has many words similar to Sanskrit, especially words relating to administrative, political, military and literary subjects. The written language is complex, including 66 consonant symbols, 35 vowel symbols, 33 superscripts, and 33 subscripts (Center for Applied Linguistics, 1981). See: Khmer Language: Non-standard Romanization

While Cambodia was a colony of France (1853-1953), French instruction was begun in primary school and all higher education was in French. This education was limited to the elite, and was essential for a successful administrative career because most official documents were in French. Those individuals who were poor or from rural areas (where there were no schools) spoke Khmer. Since 1979 and the end of Pol Pot's rule, which completely halted education of any kind, Khmer language and literature have been revived both within schools and in the press (Vickery, 1990).

Most of Seattle's Cambodians are from rural Cambodia where they worked as farmers. In Cambodia, especially in rural areas, few people attended school. Many of these individuals never learned to read or write in Khmer (Cambodian language). Schools were located in the cities, and were unavailable for those without money for tuition, books, supplies and transportation. As a result, many Cambodian refugees arrived in the U.S. unable to read or write their language. Some have now learned these skills in small groups once resettled. Some people who did attend formal education in Cambodia and worked in teaching or other professional fields before coming here may also have learned some English through private instruction.

In Seattle, Cambodians mainly speak their language while at home, and as stated previously many can not read or write Khmer. Most elders continue to speak Khmer only, while many middle-age individuals are learning English through ESL (English as a second language) classes. Children learn English through the public school system and often are the most fluent English speaking and writing members of the household. When interpreters are required for communication, nationality is not of concern to most Cambodians, however, most prefer same sex interpreters.

Update 2008:

A language barrier exists across generations. Many younger Cambodians, children of refugees, have ‘lost’ their Khmer language, never having learned it at home. Some community organizations in Seattle have offered Khmer culture and language classes for youth, providing opportunity for younger members of the community to learn their traditional language. The more-recently arrived immigrants from Cambodia most often do speak and write in Khmer.

People often prefer to have the same interpreter used for each healthcare visit. When different interpreters are used a patient may feel lack of trust or embarrassment and may therefore not readily share information that is personal or about family problems.

Addendum: 2008: Additional information contributed by Wanna Net, Graduate Student, Information School, Univ of WashingtonIn addition to the complexity of the written language, there is no standardized set of computer fonts for representing the characters which makes it difficult to easily share computer based documents. Also, the Romanization of the characters is not standardized. For more details see Khmer Language: Fonts and Romanization.

Interpersonal Relationships

Naming

This section has been written by Paularita Seng, Harborview Medical Center, Seattle, WA. Also see Naming in Cambodian Culture for a longer article.

One feature of Cambodian names that often confuse Westerners is the origin of family names and the order in which they are used. This can present confusion in schools and in clinics as filing systems and roll calls are developed. The Cambodian name is always spoken and written in the order of last name then first name. For example: if my last name were Soth, and my first name were Sopheap, my full name would be written and spoken as Soth Sopheap. Notice, there is no comma used to separate the last name from the first name. My family and friends will call me Sopheap, or by a nick name. In Cambodia my records would be categorized with Soth as my last name. This can cause substantial confusion in the American record keeping system because someone may think my last name is Sopheap and use this as the filing name because it is called last. I could easily end up with two files, one Soth, Sopheap, and another Sopheap, Soth.

Status, Role, Prestige

Traditionally, high status was given only to Buddhist monks and important government officials. Traditional values included a strong family identity, respect for ancestors and the past and a desire for smooth interpersonal relationships, i.e., non confrontational in disagreement, tolerance for ambiguity, and willingness to accept things the way they were (Kinzie, Fredrickson, Ben, Fleck and Karls, 1984).

Update 2008:

Reportedly there is competition within the Seattle-area community to have status in terms of owning a nice house. In order to keep up, some people work more than one job.

Greetings

When Cambodians greet each other, they will place their hands, palms together, near their faces and often state the greeting /chum reap sur/. They appreciate such a greeting from individuals other than Cambodians as well.

Update 2008:

Many young Cambodian Americans who grew up in the United States do not greet older people in the traditional way. This is perceived in the community as a loss of respect.

This language learning tool features videos of native speakers saying phrases of courtesy in nine languages, including Khmer. Phrases of greeting, introduction, acknowledgment, departure and for emergency situations in a clinical setting can be played at a normal speed and at a learning speed. The goal of this tool is to provide a jumping-off point for developing rapport in the interpreted health encounter. Read more about the tool... | View Khmer videos...

Displays of Respect

Some of the customs of Cambodians differ from American ones; many of the Seattle Cambodians use a combination of Cambodian and American ways.

The following are some customs that differ from American ones. It is very insulting to touch an individual's head. This is considered the most important part of the body and the place where the spirit is found. Feet are considered the lowest in value of body parts and thus it is insulting to point them at someone. While someone is lying down, it is impolite to step over their feet and legs. And when walking in front of someone other than children, Cambodians are expected to bow slightly from the waist as a sign of respect. Finally, in Cambodia, it is not polite to have eye contact with someone who is older or someone who is considered a superior, but Cambodians in Seattle tend to use this custom but with modification.

General Etiquette

Cambodians traditionally greet each other with palms together, in a manner of prayer. They lift up their hands to the chest level and bow slightly. This is called Som Pas. In general, the higher the hands and lower the bow, the more respect is being shown. When meeting, Cambodians will Som Pas and say Choum Reap Sur (Hello). When departing, again they will Som Pas and say Choum Reap Lir (Goodbye). Cambodians use Som Pas for greeting and to display respect. When used for greeting, it would be impolite not to return a Som Pas; it is tantamount to rejecting an offered handshake in Western culture.

In Cambodia today, Western cultural influence is being accepted. Cambodian men often shake hands. Women, however, often adhere to the traditional greeting and are reluctant to shake hands, as Cambodians are not accustomed to touching, especially those of the opposite sex. In the U.S., many Cambodian women still are reluctant to shake hands, especially the older generation or new immigrants.

In formal situation, Cambodians address people with Lok (Mr.) or Lok Srey (Mrs.) followed by his/her given name or both given and family name. Rarely is the family name used by itself as Westerners do. For example, my name is Keo Mony. Keo is my family name and Mony my given name. I will be addressed Mr. Mony. In the U.S., I am often addressed Mr. Keo. Some Cambodians consider using only the family name impolite as that was the name of the individual's father, grandfather or ancestor.

In an informal situation, Cambodians will refer to an older man as Ta (grandfather), Po (uncle) or Bang (brother) and to an older woman as Yeay (grandmother), Ming (aunt) or Bang Srey (sister). They are also widely used in a situation where one is not sure the age of other parties, in deference to one who may be the senior. In Cambodia, for a younger person to address an older individual without using a title would be considered rude or a form of misbehavior. For instance, a fifteen year-old boy will call his thirty year-old neighbor Sokha Po Sokha or Bang Sokha. People of the same age or younger can be called by their given name without the use of a title.

The tradition has changed so that today, when people greet others in public they might use these titles to reflect differences in the social or professional class, and not only seniority or age. For example, older patients will often use one of these terms to greet their younger caseworker who is a professional at the hospital.

Marriage, Family and Kinship Structure

Marriage

Traditionally, marriages are arranged by the woman's family and dating is not a common practice. In Seattle, young Cambodians date as a means for finding a spouse, and arranged marriages are on the decline, with few occurring in the last decade. More often people are marrying for love and are respecting the woman’s right to choose her husband. The arranged marriages occurring before, happened mostly among the refugees who arrived in the U.S. as teenagers, and many of those marriages did not last. In Cambodia, when divorce happened, the woman was perceived as having been a “bad wife”. In the Seattle Cambodian community, reportedly there is still less respect for single mothers, and elders especially might look down on those who are not properly married. There is some loss of status in such situations, though it can depend on the circumstances.

Many middle aged married men in their 50s and 60s are making visits to Cambodia. Some men go for the purpose of marrying and may visit a brothel to marry a girl. Some men decide not to return to the U.S., and others return home having left a pregnant woman behind in Cambodia. Human trafficking, through some of these marriages or by other means, has become a major problem in Cambodia.

Young women who are brought to the U.S. for marriage or as new wives may strongly feel the impact of social isolation and/or domestic violence. In some cases, the age difference between husband and new wife is great, with the woman being as much as 40 years younger than the man. The husband may struggle with psychological problems. He may already have another family in the U.S. The young wife may experience abuse upon arriving.

The new Cambodian wife may be reluctant to talk about an abusive situation with a health care provider or others who might be able to help. A traditional Cambodian woman would not want to tell on her husband. Additionally, she may worry about immigration or green card status, threat of deportation or increased violence. Sometimes, a man will sponsor a fiancé to come to the U.S. and during the initial trial period before they marry, she may feel pressure to stay with him, worrying that separating may lead her to have illegal immigration status.

In Cambodia, if a family is wealthy, cousins may marry to keep the wealth in the family. Some Cambodian American men in the U.S. have married cousins back home to bring here. Especially now, with email and phone calls, there is increasing communication and re-connection with family and friends back home.

Gender, Status and Age Relationships

The roles of males and females are given a large amount of respect in traditional Cambodian culture. The traditional role of Khmer women goes back at least to the Angkor era (802 - 1431 A.D.), when the "apsara" or “goddess” was accepted as the embodiment of a virtuous, ideal woman and described in proverbs, folktales and novels as the example of how women should behave. Traditionally, a girl is expected to obey her parents and elders, to be gentle and softly spoken, to behave according to social norms and to avoid any transgression that could be branded as ‘dirty’. She is expected not to date or mingle freely with men or to have premarital sex. A girl is taught that virtuous behavior includes not complaining. The tradition of holding girls to strict, sometimes harsh standards creates many problems between Khmer-American youth and their parents.

Women typically take care of things within the home: cooking, cleaning, laundry, and care of the children. Men typically work outside the home and bring home the income. Boys are expected to be involved in religion and the community. Girls represent the family by marrying someone who deserves her family's respect (Center for Applied Linguistics, 1981). The wife who fulfills her traditional role in a family has a highly respected position and in some ways she is the leader of the family. She will generally handle the financial matters and is mainly responsible for the education of the children in social and moral issues. In general, the role of wife is given great respect both within the family and by the community at large.

Traditionally a man experiences less social and family pressure to conform. In the case of marriage, he has more freedom in seeking and choosing a spouse. For a man, any transgression can be corrected, whereas a woman cannot regain purity once her virtue is compromised.

In Seattle, the roles of men and women are quite variable as well as the level of respect for each. Some couples must both work outside the home to support the family. Grandparents, or more frequently other Cambodian families, take care of the children. Some married couples who speak minimal English must rely on welfare for income and remain fairly isolated while their children learn English in school and the ways of life in the U.S. Additionally, there are a large number of single parents who must raise their children alone with limited outside support. Because of their English skills, Cambodian children often take on roles that usually are performed by parents, such as paying bills and shopping. This is often thought to diminish respect for their parents as the children consider them "stupid" because they do not know English. The difficult process of acculturation, limited social support, and low income are issues that many Cambodians struggle with daily. These issues cause strain within the family and role changes which act together to diminish family cohesiveness and respect for one another.

Older women, residents of low-income housing, and single-mothers may be disrespected by some people in the community who perceive them to be lower status or uneducated, or lonely and easy to take advantage of.

Update 2008:

Some elder parents are mistreated or belittled by their adult children. There are cases in which older people are victims of credit card fraud and identity theft by their children. Community organizations deal with a lot of this kind of heartache and legal issue.

Family and Kinship Structure

In Cambodia the nuclear family is more common than the extended families found in other Southeast Asian cultures. In rural areas, extended families, including grandparents, aunts, uncles and cousins often live together for financial reasons. The family is likely to be economically independent, owning enough land and a home to be self-sufficient (Center for Applied Linguistics, 1981). In Seattle, the families fortunate enough to own their home often live together in extended families. Married children may continue to live in their parents home for one to two years after marriage. For those living in Seattle Public Housing, regulations limit the number of family members in each dwelling or apartment. This often results in parents, aunts and other relatives being located in housing separate from the rest of the family, possibly in another section of the city. Where there are clusters of Cambodian residents the atmosphere in the public housing is sometimes described as friendly and open with neighbors visiting and relying on each other. Otherwise people describe feeling a lack of safety because of much criminal and gang activity in the housing project and surrounding area.

Update 2008:

Throughout the 1980s and 1990s, the Cambodian community in Seattle was particularly concerned about their children because many became involved in gangs. After the 1990s, the community has seen Cambodian gangs slowly disappear and become less of an issue, as the younger generation has grown up and begun to have their own families.

Children sometimes remain living at home while working and attending college, then move out when they begin to have their own families and careers. It is common in Seattle that when children grow up and move out and have their own spouse and kids, they may bring their parents to live with them to care for young grandchildren. Some young married couples without kids do prefer to live alone.

Typically, the older child is responsible for taking care of his/her aging parents, or if that is not a good fit, another child may take care. In some cases, older parents may favor one child more in a will, which can cause conflict in families. Lots of older Cambodians in Seattle live alone in public or senior housing, with children visiting once (more or less) each week.

In Seattle, many older Cambodians and their families are faced with decisions about housing and senior care. There is a statewide caregiver program through which some seniors in the community have received assistance at home, usually from a family member, sometimes an outsider. Many elders do not mind senior housing but do not want to live n nursing homes. Those who are ill in a hospital, at discharge will desire to go home or remain in the hospital, rather than go to a nursing home. There is fear about nursing homes from news stories and from concern about the language barrier. Elders become worried about how they will communicate their needs.

Reproduction

Pregnancy

Family planning is uncommon in Cambodia and women will often have many children. In the cities, some women use birth control pills and rarely condoms. Some herbal medicines are thought to be effective for abortion by increasing excess heat in the body. The medicine needs to be ingested daily for effectiveness and may include Chinese herbs with hot water or cho plag which is made from tree root, water and wine (Kulig, 1988). In Seattle, it is reported that when Cambodian women use birth control, they mainly use Depo-provera injections or birth control pills.

In Cambodia, women sought assistance from the midwife and elders about diet, herbal medicines, and activities during pregnancy (Kulig, 1989). In Seattle, women use both formal and informal prenatal care. Prenatal visits are often avoided by women as they require many physical examinations, however, local Cambodians are gradually participating in more prenatal care as they become aware of the importance. A variety of foods and activities are thought to be good for the unborn baby. Pregnant mothers may drink homemade rice wine, herbal medicines (herbs unknown), coconut water, or beer which are all thought to make the baby healthy. Some things to avoid include showering at night and drinking milk as these will make the baby fat and difficult to deliver.

Update 2008:

Younger Cambodian women in the U.S. are more educated about health and tend to access prenatal care. Younger women who grew up in the U.S. are not taking the traditional remedies even as their mothers persist in wanting their pregnant daughters to follow their advice - “eat this, do that” – and complain when they don’t.

Child Birth and Post Partum Practices

Few babies are delivered in a hospital by a physician in Cambodia, most are delivered at home by midwives. The postpartum period is considered to be the most important time in life for a woman, called “Sor Sai Kjey” or “Saw Sai Kachai” (SSK). For one month after the birth, she will lie on a bamboo bed with a constant fire underneath. There is no bathing during this time. The woman will drink only hot water, homemade wine, or herbal tea and eat hot fish and pork. This is believed to help repair tendons and will allow the woman to regain her strength. During the first three days, others will breastfeed the baby; they will care for the baby for the full month. The majority of babies born in Seattle are born in hospitals. Women are unable to have an entire month for resting as they must often return immediately to work, school, or taking care of the home and family. Some women do not have sexual intercourse for six months to one year following birth as they believe it is best to avoid this and allow their bodies to recover and heal from pregnancy.

Cambodians believe that the woman's body becomes cold after giving birth. Cold ice water offered post delivery in the hospital may be seen as unhealthy.

Infancy, Childhood and Socialization

Infant Feeding and Care

In Cambodia, most women breastfeed their babies and breastfeeding in public is common with older mothers. Breastfeeding is thought by some to make their baby strong, smart, and obedient to his parents. In Seattle many women feel that breastfeeding is very difficult because of competing school, job, and household responsibilities. Bottlefeeding is more practical. Several reported that they used Simulac, some breastfeed in private, and some start feeding their baby rice soup as early as six weeks.

Cambodian women frequently place tiger balm on their baby's soft spot and stomache as they believe this protects their baby. Others make a paste from an herb similar to ginger and place this on their soft spot.

Update 2008:

Nowadays, young women have adopted American practices of pumping breast milk and storing it for bottle feeding.

Child Rearing Practices

In Seattle, children are encouraged and expected to attend school as this is perceived as the best route to obtaining a well paying job. In Cambodia, their time would have been spent working to help support the family. Traditionally, marriages are arranged by the woman's family and dating is not a common practice. Arranged marriages reportedly occur frequently in Seattle, however, some young Cambodians date as a means for finding a spouse.

Refugee children are a special group. They live in a society with rules and customs quite different from those that controlled life in Cambodia and are particularly susceptible to breaking away from the old ways. Additionally, the old ways are without power or perceived validity and the new ones seem infallible. Discipline traditionally includes respect for elders, verbal correction of mistakes and occasional spanking. Parents who, in the past, would have controlled their children's behavior may be so caught up in their own struggles and grief that unacceptable behavior is ignored. Others who try to discipline their children are afraid of Child Protective Services (CPS) involvement and are not quite sure what methods to employ.

Toilet training is begun at a wide variety of age ranges; most use a regular toilet as they can not afford a special one for the baby. Similarly, high chairs and baby play cribs are not used either. Most women report that they use baby car seats.

Nutrition and Food

Each small family group in Cambodia typically owns its own rice paddy lot and vegetable garden and raises livestock. Meal patterns consist of breakfast, lunch, dinner, and occasional snacks. Rice is typically the base of each meal and is accompanied by a clear or a vegetable soup, fish, or meat and vegetables (fresh and dried). Most families eat all three meals together in Southeast Asia (Story and Harris, 1989).

Local Cambodians usually do not have a place to grow vegetables or raise livestock and rely on shops in their neighborhood run by other Southeast Asians. The bulk of their food is bought at these stores with only an occasional visit to chain stores such as Safeway. White rice continues as a main staple with accompanying soup. Brown rice is not typically eaten with some local Cambodians stating that it is for birds and prisoners. Some additional favorites include: fish, shrimp, stir fried vegetables and the following vegetables: eggplant, cauliflower, broccoli, string beans, sweet potatoes, pumpkin, Thai okra, and watercress. Fruit is often included in a meal and may include: coconut, mango, pineapple, pomegranate, tamarind, mangostein, watermelon, orange, rambutan, durian, jackfruit or guava. Sweets are a rare addition and may include imported cupcakes, cookies, or candies. Family meals are still valued, however, daily life takes family members away from home at all hours (working, ESL, and school) making communal mealtime often difficult.

Update 2008:

Cambodian families in Seattle shop for food at a mix of stores. Nowadays, the larger chain grocery stores tend to have more Asian foods available to be purchased. The older generation may still shop primarily at local Asian groceries, while families with children who grew up in the U.S. may shop more at grocery stores like Safeway and also at Asian groceries. Young Cambodians who grew up in the United States may not like to eat traditional foods cooked by parents.

Cambodian Americans now live in a culture with easy access to unhealthy foods. The American culture of a sedentary lifestyle and a surplus of convenient high fat, high calorie, low-cost foods may contribute to weight gain and disease. In 2002, a report by the Lowell Community Center (Lowell, Massachusetts) suggested that an estimated 26% of approximately 10,000 Cambodians in Lowell ate American meals at least once a day (Cambodian Community Health 2010, 2002). Adjusting to a Western lifestyle may result in increased risk for diabetes and adverse health outcomes for many Cambodian Americans.

Many of the issues that Cambodian Americans face when trying to eat healthily in the U.S. are similar to those faced by many other Americans but with higher incidence. Rising food costs, unfamiliar foods, busy schedules and lack of nutrition education are some of the challenges Cambodians face when trying to improve dietary habits.

Vegetables that are familiar to Cambodians because of their common use and availability in Cambodia may be unavailable in the U.S. When they are imported, they may not be fresh or affordable. There is lack of knowledge about how to prepare vegetables that are available in the U.S. but which were not eaten in Cambodia. Consequently, people consume a reduced number of vegetables.

Busy schedules constrain the time people can spend on food preparation and meal planning. Many people choose less healthy alternatives that are ready to eat or quicker to prepare, such as Vietnamese sandwiches and Ramen noodles. Traditionally, at least one meal a day would be prepared to be eaten as a family meal. Nowadays this may not occur as regularly.

Drinks, Drugs and Indulgences

In Cambodia

This section has been written by Keo Mony, Seattle, WA, Community Contributor to EthnoMed

In Cambodia may people drink locally brewed rice wine that is relatively inexpensive. It often has herbs, tree bark and/or wild animal parts added and it believed to have medicinal properties. Because of the demand for higher alcohol content, recently some brewers started to spike the wine with insecticides which caused death, blindness and other illnesses. Consequently the Cambodian Ministry of Health appealed to the people to quit drinking the locally brewed rice wine.

Traditionally Cambodians smoked and gave cigarettes as offerings and gifts. Most men and some women smoke. Multinational cigarette companies have successfully encouraged Cambodians to smoke more.

Drug abuse problems are new in Cambodia. Currently methamphetamine use has the most severe impact on the culture, but marijuana is smoked throughout the country. Various pharmaceuticals, opium and heroin are occasionally abused.

In the US Cambodians most commonly used alcohol and tobacco; some use crack cocaine. Low income Cambodians are at greatest risk for substance abuse.

Alcohol

Most Cambodians consume locally brewed rice wine. Foreign beers and liquors are abundant but tend to be expensive.

The rice wine is usually consumed after herbs, tree bark and/or wild animal parts have been added to it. The concoction is believed to help sustain good health, have medicinal properties and improve energy levels. It is popular with laborers and the poor. Women also use it after giving birth.

Rice wine is becoming very dangerous because brewers, responding to the strong demand for higher alcohol content, spike their product with insecticide. In 1996, for example, more than 50 people, and in 1998 more than 44 people, died from consuming the poisonous wine. The Cambodian Health Ministry appealed to the population to stop consuming the potentially poisonous rice wine because which was causing death, blindness and other serious ailments.

Smoking

Smoking is not a new phenomenon to Cambodians. It is part of the culture. Cigarettes, among other items, are usually included with the offerings made to a monk, given to guests at wedding receptions and provided to houseguests. In the rural areas, smoking is even used to keep away insects.

The recent influx of multinational cigarette companies into Cambodia and the success of their aggressive advertising campaigns have increased smoking drastically. According to figures from Indochina Research, a private research firm, 69 percent of men and 10 percent of women in Cambodia smoke. The numbers are even higher in rural areas, where it is reported that 85 percent of men smoke. (Phnom Penh Post, Jan. 18-31, 2002, Vol.11, No.2)

Drugs

Cambodia had been spared from drug abuse problems for many years. However, in the past few years drug abuse, especially related to methamphetamine use, has become a major national concern.

Known as yaba (crazy medicine), methamphetamine is smuggled in from neighboring Thailand. It is widely used by diverse groups such as garment factory workers, soldiers, manual laborers, sex workers, street children and middle class teenagers. According to a program officer for the UN Office for Drug Control and Crime Prevention, the abuse "has reached levels which are quite horrific, especially amongst young people." (The Cambodia Daily, Aug. 21-22, 2002) Because of the heavy use of methamphetamine by many young Cambodians from various socioeconomic classes, there is great concern that drug abuse will grow to become as even bigger problem in the future and will be associated with increasing crime and a greater variety of substances of abuse.

According to a DEA Drug Intelligence Brief for Dec. 2001, marijuana is used throughout Cambodia. Other drugs that are abused to a much lesser extent are various pharmaceuticals, opium, and heroin.

There are currently no estimates available on the number of Cambodian drug addicts.

In the United States

In the US, according to U.S. Department of Health and Human Services, Cambodians most commonly use alcohol and tobacco. Crack cocaine is used to a lesser extent. The Cambodians most at risk of substance abuse are low-income individuals of all ages and of either gender.

Khmer weddings in the U.S. always "require" that some form of hard liquor, such as whiskey, be served. It is considered offensive not to provide alcohol to wedding guests.

Recent studies in California among three Asian American immigrant groups found the highest cigarette smoking rate is among Cambodian men at 71% (compared to 65% for Vietnamese and 55% for Chinese-Vietnamese). The rate is far higher than the state or national average for males. (Facts on Asians and Pacific Islanders and Tobacco [website] www.corpwatch.org)

A survey conducted by the Washington State Health Department in 1989 found that 32.8% of Cambodian men smoke. (Washington state, 1989 - MMWR 41(45); 854-855,861) This statistic seems to be very low when compared to other data from Cambodia and California. The editor notes that the actual smoking prevalence may be underestimated because of family advice to deny smoking because of possible penalties and unreliable recording of smoking habits by interviewers.

Update 2008:

Alcohol and Gambling

Over the last decades in the United States, people have worked so hard that there is a sense now among some Cambodians that it is finally time after so much hardship, to enjoy life. Overall, consumption of alcohol is increasing in the Cambodian community in Seattle. Many people drink every week. People will drink at every social and community gathering whereas in the past that was not always the case. Stress relief, especially for single or divorced women, may be a factor leading to more drinking. Tolls are taken on marriages and families, with some families splitting up, and some experiencing domestic violence.

Gambling is part of the New Year tradition for Cambodians, Chinese, and Vietnamese. Some casinos around Seattle have ‘Cambodian Nights’ and often there is a big New Years show in April with as many as 1000-2000 people from the community attending. Some middle-aged and older Cambodians spend more time and money gambling in casinos and consuming alcohol.

Those whose behavior becomes problematic often feel embarrassed to seek help, and so problems can intensify.

Smoking Cessation

Some people in the community have been successful quitting smoking, and there may be willingness to try the nicotine patches and enlist a doctor’s help in quitting cigarettes. Reportedly, it is common that newer immigrants arriving more recently from Cambodia smoke.

Religious Life

Theravada Buddhism has been the official religion in Cambodia, although Christianity and animism are also found. For many centuries monks had lived in wats (temple monasteries) in every community in Cambodia. They practiced and taught that the suffering we all experience can be traced to desire or passion. The way to escape constant suffering is to diminish one's desire of lust, aggression, avariciousness, and deceit.

During the war between 1970 and 1975 more than one-third of the 3,369 wats were destroyed; many of the 65,000 monks and novices were killed or became refugees. Between 1975-1979, Pol Pot and the Khmer Rouge sought to systematically completely obliterate Buddhism from Cambodian society. It was not until after the invasion of Cambodia by the Vietnamese in 1979 that Buddhism was permitted to be restored in Cambodia. An official report in 1982 stated that 2,311 monks had returned to the Buddhist order (Keyes, 1990).

Most of Seattle's Cambodian population are Buddhist, however, some are Christians. Two temples are found within Seattle, one in the Beacon Hill area and the other in the White Center area; many individuals report going regularly to the temples. In Cambodia, one must move out of the way of monks, and only men are allowed to touch them. In contrast, many report less strict rules here. Some families invite the monks to their homes for ceremonial events. Friends are often included in these events with the atmosphere described as formal but friendly.

Death

Note: The following section focuses on Cambodian Buddhist perspectives and practices concerning death. It was written by: Keo Mony, 2004; Last Review 2008 by: Jeniffer Huong. The following was summarized from a longer article:Death in Cambodian Buddhist Culture.

Death is grief as much to Cambodians as to Westerners. Many Cambodians are Buddhists who believe that life does not end with death, but evolves in a successive cycle of birth, sickness, old age, death and rebirth/reincarnation. Traditional Buddhist rituals are performed to help the deceased move onto the next stage of the cycle, rebirth. A monk is often invited to recite sermon at the bedside of a dying patient in order to prepare him/her for the next life. The soul is believed to be in a state of confusion and fright after exiting the body and, if possible, the monk will be present when death happens in order to calm the departing soul.

In Cambodia, the care of the body is undertaken by family. The body is brought home, washed, dressed, and placed into a coffin. Traditionally, the body is kept in the house for seven days or longer before cremation. Nowadays it is common that the body is kept for only three days. Traditional practice and belief does not allow autopsy, organ removal or embalming. In the United States, Cambodian Buddhists try to adhere to the traditional funeral ritual, including keeping the body for three days, although some families try to keep it up to seven. How long the body is kept may depend on factors like the family's financial circumstances (the longer the body is kept, the more expensive it can be) or the lack of family living in the area where the death happens (when there are few or no family members around, the funeral practices may happen sooner; or, on the other hand, more time may be given for the arrival of family traveling from elsewhere). Since the law in the United States does not permit the body to be kept at home, some rituals are skipped while many others are either done at the temple or at home while the body is at the funeral home. Sometimes, monks are invited to the funeral home to recite a sermon by the body in the evenings and also right before the body is moved to the crematorium or burial site.

Traditionally, a funeral procession consisting of an achar (priest) , Buddhist monks, members of the family, and other mourners accompany the coffin to the cremation. The immediate family, including spouse and children, mourn their loved ones by shaving their heads and by wearing white clothing. White is the traditional color of mourning. However, in the United States, guests and extended family usually wear black. It is believed that cremation allows the soul to part from the body and to go to hell or heaven in order to wait for reincarnation. After cremation, the ashes (bones) are collected, cleaned and usually kept in a stupa in the temple compound. Some families keep the ashes at home while others have a piece of their beloved one's bone or tooth gilded as amulets, worn around their necks. This is done in love for the person, or in belief that the parting ancestor will protect them. A funeral/remembrance ceremony is held on the seventh or one-hundredth day after death.

Prachum Bend (gathering together to make offerings) is another ceremony celebrated by Cambodians (in the United States and elsewhere) for fifteen days in September or October. There is recognition that some souls, because of bad karma, are not able to be reincarnated. During Prachum Bend , those souls are released to search for their living relatives, to meditate and/or repent. People go to the temple and make offerings of food to their ancestors and other trapped souls who have no living relatives. It is also an opportunity for the living to meditate and pray for their ancestor's soul to be repentant for bad karma that enables the ancestor's soul to reborn.

Update 2008:

Many elders want to return to Cambodia near the end of their life, feeling that they should be honored at death in the traditional ways done there. That is not a financially feasible option for most people.

Traditional Medical Practices

Cambodians have traditionally dealt with illness through self-care and self-medication. This is related to their having access to most drugs over-the-counter at low cost, having few hospitals and physicians, and to the high cost of Western medical care. In rural Cambodian communities, herbal remedies, dermal techniques, maintenance of hot-cold balance, and rituals are the principal forms of medical treatment. More than one treatment will frequently be used for the same illness. The assistance of a health practitioner is sought if their own remedies don't work.

In Cambodia, herbs are often grown in a home garden. A Khru Khmer (traditional healer) may be sought who will often travel into the jungle for herbs, roots and plants for healing. The presence of spirits is reality to many Cambodians, and often take an active role in an individual's life. Spirit possession or sickness may be the result of evil spells cast by another, mistakes made in various rituals through the life cycle or neglect of rituals. Traditional healers or spiritual healers will be sought for illnesses thought to be caused by spirits (Kemp, 1985). The dermal techniques are perceived as ways to relieve headaches, muscle pains, sinusitis, colds, sore throat, coughs, difficulty breathing, diarrhea, or fever.

Cupping, pinching, or rubbing (also known as coining) are the most commonly used and are thought to restore balance by releasing excessive "air". In cupping, a cup is heated and then placed on the skin usually on the forehead or abdomen; as it cools, it contracts, drawing the skin and what is believed to be excess energy or "air" into the cup; a circular ecchymosis is left on the skin. Pinching uses the same principle, but pressure is applied by pinching the skin between the thumb and index finger to the point of producing a contusion. This usually is done at the base of the nose, between the eyes, on the neck, chest or back. Rubbing is usually in the same areas as pinching and involves firmly rubbing of lubricated skin with a spoon or a coin in order to bring toxic "air" to the body surface. In the hot-cold theory, illness is caused by an alteration in the natural balance between hot and cold elements in the universe. To restore balance and harmony, intake of drugs, herbs and foods is adjusted. Western medicines are generally considered hot, and herbal remedies have cooling properties. Foods are considered to have varying properties with for example, fruits and vegetables being "cold" (Muecke, 1983).

Any of the previously mentioned concepts of illness may pertain to emotional as well as to physical illness. Unmistakable emotional disturbance is usually attributed to possession by malicious spirits; to bad karma accumulated by misdeeds in past lives; or to the bad luck of familial inheritance. Partially due to its attribution to immoral causes, mental illness is commonly denied and feared. The disturbed individuals are protected by their family and if outsiders become aware of the mental illness, great shame is brought to the family. In consequence, Cambodians who are having emotional problems tend to present themselves for care with physical problems (Muecke, 1983).

In Seattle, Cambodians utilize both traditional and Western medicine. Herbs are often difficult to obtain, as many of them must be cut fresh from the jungle for benefit and most of the herbs can not be grown locally. Some of the medicinal herbs can be bought in Chinatown (Seattle) and some are hand carried back from Cambodia. Chinese physicians provide care for some individuals; the use of herbs being familiar as a treatment. Spiritual healers are found in Seattle and are utilized by some individuals, however, they are often very expensive. Some individuals go to the Buddhist temple to "get rid of the bad spirit". Cupping, pinching and rubbing are practiced by many local Cambodians. Caution should be taken not to mistake the resulting skin alterations and scarring for the results of abuse. Some local Cambodians adhere to the hot-cold theory and will adjust their drugs, food and herbs accordingly. Vietnamese physicians are often visited by Cambodians. They claim that these practitioners require few tests and minimal physical examination but will dispense medications freely, something very important to these individuals. As in Cambodia, many of the local individuals will use more than one treatment for the same illness, either simultaneously or in succession. Many are hesitant to share the fact that they are using other forms of health care because they believe the person providing Western medical care will think it's wrong to use these alternatives.

Update 2008:

People in the community seek out traditional healers among the more recently arrived Cambodian immigrants. Buddhist temples have sponsored monks to come from Cambodia, some of whom are experienced fortune tellers and spiritual healers. People in the community seek their advice.

Experience with Western Medicine

Experience with Western Medicine in Home Country

If available, Western medicine may be tried only when all known remedies have failed. Cambodians living in an urban setting in Cambodia having greater availability of practitioners of Western medicine, however, will usually try traditional treatments first (Buchwald, Panwala, Hooton, 1992).

Experience with Western Medicine in the United States

Western health care is confusing and overwhelming for many Cambodians. Language and cultural barriers, crowded waiting areas, multiple interviews, mysterious procedures, and the somewhat abrupt behavior of personnel combine to make obtaining health care an unpleasant experience. Medical practices and procedures such as blood drawing, genital exams, x-rays, and surgery often make the individual very nervous and may contribute to their not seeking care. Blood draws are thought to be very painful and will make them weaker because the blood is "taken away" and not replaced. Genital exams are foreign to many and are preferred to be performed by the same sex provider. X-rays are thought by many to destroy red blood cells (which never are replaced) and to decrease general life expectancy. Some believe radiation from x-rays can cause cancer. Surgery has traditionally been a frightening "last resort", so Cambodians hospitalized for this purpose are extremely frightened. Elective surgery is almost unthinkable to many.

Practices common to Western medicine such as appointments and preventive health care are not familiar to most Cambodians. As many have lived in the U.S. for a while, they are aware of the expectations of appointments and are becoming more adherent. Preventive health care is a new concept to most Cambodians, with visits to a provider only when ill. Written material about this topic is generally thrown away, as the individual may not be able to read it or does not believe it applies to him.

Cambodian women are particularly concerned about Western medicine practices for women's health care. Most women are very modest and will avoid annual exams because they know pelvic and breast exams will be included. They will present for care only when a problem arises. Some are taught SBE (self breast exam), however, very few perform this monthly. Cambodian women in general prefer women providers for women's health care and related issues.

Cambodians expect to receive medications for every illness because it makes them feel like something is being done. If medication is not dispensed, they will find another provider who will provide medications. Medications are often shared among friends and family. They are frequently taken only for as long as the individual "feels sick" and if side effects occur the dose is adjusted down as it is obviously "too much". Compliance with medications for a chronic disease such as hypertension is a major problem, as individuals expect drugs to relieve the problem fairly quickly.

According to several studies, the Cambodians as a group arrived in the U.S. in poorer health than most other refugees. This is related to the extreme deprivation of food, shelter, and medical care by many. The most common diseases found in this group were tuberculosis, hepatitis B, and intestinal parasites (hookworm, Giardia, and Strongyloides). Hemoglobin E and thalassemia minor have also been observed in Cambodians (Catanzaro and Moser, 1982).

Update 2008:

Cambodian refugees who came to live in the United States many years ago have become accustomed to Western medical care. For the most part, they no longer experience the shock or confusion about the US health care system that they felt when they were first resettled here. However, beliefs about blood and x-rays as described above may still hold true among the older generations. Newer immigrants tend to be open to receiving Western medical care and are taught about what to expect by their relatives who have sponsored them to be in the U.S.

Reportedly, the younger generation of Cambodian women in the U.S. has become more receptive of women’s health care and exams. Older women who have been educated by their daughters are becoming more accepting of these practices as well.

Older people in Seattle’s Cambodian community who still expect to receive quick diagnosis and immediate treatment at doctor visits may have preferred to go to Western-trained Vietnamese doctors in the community. Reportedly, some of these physicians more readily prescribed medications. Children growing up in the U.S. have educated their parents about the dangers of that type of care, and some notably bad experiences in the late 1990s have curbed the number of Cambodians seeing those doctors.

Mental Health

Cambodians within the U.S. are identified as being at very high risk for psychiatric symptoms because of their collective traumatic experiences. These experiences include witnessing war, separation from and death of family members, cultural destruction, torture, and starvation. These initial experiences have been compounded by terrifying escape and refugee camp experiences, and cultural adjustment to American life, primarily within the inner-city environment. Common stress related problems among this group include somatization, posttraumatic stress disorder, and suicide (Frye and D'Avanzo, 1994).

Related to their political persecution, many suffer from posttraumatic stress disorder (PTSD). Symptoms found consistently in individuals with PTSD include 1) reexperience of the trauma, 2) recurrent intrusive recollections, 3) recurrent dreams and nightmares, 4) acting out or feeling as if the traumatic event were recurring, 5) social numbness or withdrawal, 6) hyperalertness or hyperactive startle reaction, 7) sleep disorders, 8) guilt, 9) memory impairment, 10) avoidance of activities that arouse recollection of the event, and 11) intensification of the symptoms by exposure to similar events (Kinzie et al., 1984).

In Seattle, many Cambodians are depressed and suffer with PTSD. Many are not able to understand what they are suffering from as there are no directly translatable terms in Khmer. Many are afraid to take prescribed anti-depressants as they are afraid they may become addicted. Anti-depressants are often described to patients as "something to help you sleep" and many are afraid they may never awaken if they take them. Some local Cambodians go to the temple to be blessed; this often reportedly helps. Others go to the Asian Counseling Center for counseling and support. Some gather for support in groups such as women's groups or quilting groups. Many however remain isolated and hopeless, unaware that help is available.

Update April 2014:Khmer Health Advocates (KHA) in W. Hartford, CT have announced the first available data on co-morbid chronic disease in survivors of the Cambodian American genocide living in Connecticut and Western Mass. This study by KHA reveals that even when Cambodian American genocide survivors with complex mental and physical health conditions have access to medical care, their health outcomes are very poor. The research, which appears in the April issue of the Journal of Community Health, surveyed 136 Cambodian American refugees living in Connecticut and Western Massachusetts, who reported having nearly twice as many physical health problems (i.e. diabetes, cardiovascular disease, stroke) when diagnosed with depression and post-traumatic stress disorder (PTSD). You can access the abstract at the Journal of Community Health.

Community Structure

Community Organization

Organizations such as the World Relief Refugee Services, International Rescue Committee, and the Refugee Federation Service Center attempt to help refugees integrate into U.S. society. Some of the services offered include: English as a second language classes, assistance in locating housing, career counseling and job placement with local companies.

The Khmer Community of Seattle-King County (KCSKC) is a community agency located in the White Center neighborhood of Seattle committed to providing social services to SE Asian refugees/immigrants, mainly serving Cambodian clients. KCSKC has offered the following services: information and referral, case management, advocacy, tutoring, parenting classes, resettlement assistance, counseling, housing assistance, domestic violence education and support, legal referrals and assistance, youth services, senior services, interpretation and translation, family support, group orientations, culture and language classes and seminars. Currently, fees may be charged for some services, and there is a focus on employment assistance and assistance with immigration/U.S. citizenship classes and paperwork. KCSKC is a naturalization services contractor of DSHS, WA. KCSKC is located at 10025 16th Avenue Southwest Seattle, WA 98146; 206-762-3922.

Asian Counseling and Referral Services (ACRS)ACRS helps clients attain the highest levels of self-sufficiency in Western society, while maintaining their cultural identity. In most cases, clients are served by professional staff who speak the same language and come from the same culture. ACRS provides the following programs in a culturally appropriate setting in order to improve the lives of Asian Pacific Americans:

Aging and Adult Services

Chemical Dependency Treatment

Children, Youth, and Families

Citizenship Services

Comprehensive Mental Health Services

Congregate Meals and Emergency Feeding

Consultation and Education

Domestic Violence Batterers Treatment

Employment and Training Services

Food Bank

Information and Referral Services

Legal Clinic

Problem Gambling Treatment

ACRS provides high quality and affordable services. For mental health services, ACRS accepts Medicaid, Medicare and most private insurance plans. Other programs and classes are offered on a sliding-fee scale based on household income.

ACRS offers the largest Citizenship Services Program in Washington State. The program helps immigrants and refugees become active U.S. citizens by providing high quality classes at convenient locations within King County. ACRS provides:

Neighborhoods

Washington State is the home for 12,933 Cambodians according to information compiled from DSHS health screening for new arrivals. Most of these refugees live in King County (5637) and Pierce County (4260) (WA State, DSHS, 1994). Most of Seattle's Cambodian population live in south Seattle (White Center, Holly Park, High Point, Rainier Vista, Rainier Valley, Mt. Baker and Park Lake) although some families are found in other sections of the city. A few have been able to purchase their own homes, but most live in Seattle Public Housing.

In the past, the majority of Cambodian families lived in Seattle Public Housing, however many have since been able to purchase homes; decreased numbers remain on public assistance. As families earned more money, some moved to other neighborhoods such as Kirkland on the eastside. Community members estimate the population of Cambodians in Washington State is higher than the census figure - closer to 30,000 people living just in the greater Seattle area (including Everett and the eastside).

Common Acculturation Issues

In Cambodia, especially in rural areas, few people attended school. Many of these individuals never learned to read or write in Cambodian. Schools were located in the cities, and were unavailable for those without money for tuition, books, supplies and transportation. Most of Seattle's Cambodians are from rural Cambodia where they worked as farmers. Many arrived unable to read or write their language; some are now learning these skills in small groups. Some more fortunate individuals attended formal education in Cambodia, and worked in teaching or other professional fields before coming here. These few individuals also learned some English through private instruction and have been able to find employment in well paying jobs. A few Cambodians have been able to establish their own businesses including restaurants, grocery stores and jewelry stores. However, because of language barriers and lack of education many Cambodians are unemployed and are receiving public assistance. Those who are employed often work as janitors, restaurant workers, or other low paying jobs. They frequently need to work two or even three jobs to make enough money to support themselves.

The Cambodian community is particularly concerned about their children because many become involved in gangs. Parents hope they will be able to encourage their children to attend school and to become productive members of society. They believe higher education will provide a way for them to attain a higher standard of living than they have been able to provide. The community remains hopeful as they continue to struggle with these issues and with rebuilding their lives in the U.S. while maintaining elements of their own culture.

Update 2008:

After the 1990s, the community has seen Cambodian gangs slowly disappear and become less of an issue, as the younger generation has grown up and begun to have their own families.

Individuals who arrived in the U.S. with more language skills and formal education were able to find employment in more well paying jobs. Overtime, more Cambodians have established their own businesses including restaurants, grocery stores and jewelry stores. Some have become self-employed in the janitorial business in Seattle, finding success and bidding competitively for jobs. Others have become free-lance landscapers. It is still true that language barriers and lack of education have led many Cambodians, especially middle to older age people, to remain unemployed or working in lower-paying jobs. Still, fewer people are on public assistance than in the past. Many younger to middle age people have gained language skills and education, and become professionals in various fields.

In families today it is common that both parents work. Reportedly there is competition within the community to have status in terms of owning a nice house. In order to keep up, some people work more than one job. In some families, older parents are now retiring from their jobs as taxi drivers, janitors, landscapers, self-employed occupations, etc.

Cambodian immigrants arriving more recently are less likely to be on public assistance and are among those who have more education. Some are trained as doctors or work in business. They may experience difficulty getting jobs because they can appear overqualified from experience back home.

Issues troubling some families today include immigration concerns, alcohol and gambling problems, domestic violence, debt among young people, language barriers between adult children and older parents, fraud or mistreatment of elder parents, sentiment among older parents that “kids are useless” and the resulting burden on the children, and senior care needs. There is embarrassment and lack of trust to talk about family problems with a health care provider.