The following is a guide for healthcare providers to learn about the Hmong culture with emphasis on Hmong healthcare beliefs.  This site should serve only as a general reference in relevant cases.  It is the belief of the authors of this site that every Hmong patient is an individual with individual ideas that may or may not reflect these generalizations on traditional Hmong culture.  Furthermore, even very westernized Hmong patients may wish to combine their physician's care with traditional practices.  More information about this page can be found under the Sources and References links.

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Advanced Directive: Advanced directives can be a difficult process, as many people have not considered the various technological options that sustain life and their significance for quality of life.  Also, the meaning of "brain death" is a new concept, as opposed to death that occurs with the cessation of breath.  Finally, some people are reluctant to make advanced directives for fear that the predictions will cause dire events to occur prematurely.  See Decision Making and Brain Death links for more information.
Amulet: Amulets are bracelets, anklets or necklaces made from twisted cloth, metal, plants, or herbal medications that ward off spirits that cause illnesses.  Healthcare workers should respect this religious and traditional healing rite and should avoid removal of these items unless absolutely necessary and after talking with the patient or the family.  If they have been removed without permission, patients or patients' family members could blame adverse medical or surgical outcomes on the amulet's removal.
Anatomy: The traditional Hmong perception of the body is different from Western culture.  The Hmong view the body as a whole, with each body part having a soul that interconnects with the souls of the other body parts.  If one part of the body is sick, this sickness will spread throughout the body to affect the whole body.
Autopsy: Many Hmong tend to dislike and refuse autopsies while some accept autopsies as a way to determine the cause of death.  For many people, burying the whole body is important for 1) respect of the dead person; 2) successful reincarnation of a healthy body; or 3) ensuring the happiness of the soul that stays with the body until it disintegrates.  Furthermore, burying the body with missing parts may cause one of the dead person's souls to be unsettled, which may lead the soul to haunt living ancestors and cast bad luck upon them.
Birth Control: Some believe that birth control pills or injections are unsafe for Hmong women.  This belief stems from the idea that Western medications are designed for Western women and are too strong for a Hmong woman's body.  In addition, the hormones alter the woman's natural menstrual cycle which is thought to be important for the woman's overall health.  See individual listed birth control methods below for more information.
Blood Draw: This procedure can cause much concern for the some Hmong patients.  Many feel that physicians draw too much blood and that blood is nonrenewable.  Some believe that taking too much blood will cause the person to die, and they relate the lightheadedness and weakness associated with blood draws to interrupted blood flow.  To help alleviate these concerns, physicians may chose to use finger-sticks, give iron supplements to help people replace their blood, and only order blood draws when critically necessary.  Other patients are eager to have providers check their blood when they are sick, as they want physicians to diagnose their illness and prescribe treatments.
Brain Death: Hmong believe that life continues within a person until either respiratory or cardiac arrest, and may not interpret brain death as death.  However, as the Hmong population becomes more acquainted with Western medicine, more people understand the idea that technology can prolong physical life and postpone cardiac death.
Breast Exam: Asymptomatic patients may refuse cancer screening of the breasts, genitals, and colon, seeing these exams as invasive and unnecessary.  However, clinical breast exams are more accepted than pelvic or rectal exams.
Bone Marrow: Some Hmong may view bone marrow draws as they do other invasive procedures, as painful and potentially harmful.  Deciding to have a bone marrow biopsy will require careful consideration of the costs and benefits.  Also, people may believe that marrow is a nonrenewable source and that drawing too much can interfere with one's own health.
Chest Pain: Pain described as "mob huav siab" can indicate pain located in either the chest cavity or in the region next to the liver.  Due to problems in translation, a careful history and physical exam as well as a skilled interpreter are important in determining the distinction between chest pain and right upper quadrant pain.
Childhood Illness: Parents may interpret childhood febrile illnesses as due to a variety of causes, including: 1) frightening or startling the child (ceeb); 2) bad spirits; 3) a build-up of pressure within the body from excess wind exposure; or 4) germs.  Some parents or grandparents may treat the child by wrapping the child in warm blankets, rubbing a coin or boiled egg on the child, calling the soul, or giving the child medications, including herbal or over-the-counter Western medications.  A soul-calling ceremony is done to restore the child's soul back into his/her body if illness is thought to be due to soul-loss.  NOTE: Parents may resist cooling a febrile child too quickly from fear that 1) wind will enter the child's body and make the child more sick; or 2) abrupt transitions in temperature will harm the child further. Clans: A clan is a group of patriarchal families with common ancestral ties.  When a woman marries, she switches from her parents' clan to her husband's.  Marrying within one's own clan is taboo.  18 patriarchal clans are recognized; however, 15-22 clans may actually exist depending on people's interpretations.  Large clans have been subdivided further into lineages that share a common ancestor.  Social, political, financial, and health issues are traditionally decided by the men in the family with extended families offering much assistance in the decision-making process.  There are also societal distinctions based upon the style of clothing, language and rituals that divide the Hmong into White (Hmoob Dawb) and Green/Blue divisions (Moob Leeg or Moob Ntsuab).

Coin Rubbing: (Kav) A Hmong healing method in which the skin is vigorously rubbed in specific areas with medicated oil and silver coins or a spoon.  Rubbing creates pressure on the skin to draw the wind or excess pressure, that is believed to be causing the ailment, out of the body.  This is a harmless procedure; however, the red marks can be mistaken as abuse. 
Contraception: See Birth Control Link
Cupping: (Nqus) A piece of paper is lit inside a cup and placed on top of the skin to create a vacuum.  When the fire burns out, suction is created, drawing out the "wind" or "bad blood" causing the ailment.  This is a painful procedure that is done for its curative powers.  Unfortunately, sometimes American officials have mistaken the bruises for abuse, with dire social consequences. 

For more information about Hmong healing see Coin Rubbing Link.
Dab/Spirit: Dab is the general term for spirits in the world and can cause a wide variety of illnesses through various mechanisms.  Some dab spirits are malevolent while some dab spirits are tame and benign or even benevolent.  The malevolent dab may steal the souls of living people and, in particular, the souls of the weak or ill, for these souls are easier for the dab to steal.  Telling Hmong patients directly that they are dying is taboo, for a dab may overhear the conversation, realize the patient is weak, and steal the weak patient's soul.  Other dab are not evil, but if their homes are disturbed, they may cause people harm.  Some dab are believed to live in certain places, in particular around certain bodies of water, or rocks, or mountains.  Some Hmong take caution to avoid walking past such areas and those affected with illnesses may blame themselves for having wandered past an area believed to have an evil dab lurking.
Death Discussions: It is important when working with most Hmong not to directly tell the patient or their loved ones that the person may die.  For some people, telling them directly that they will die is viewed as cursing them to death.  Words have power, and so may bring death.  Some believe that a dab or evil spirit may overhear the conversation, recognize the person as weak, and steal the weak person's spirit, causing death.  For others, speaking directly about death may take away the patient's hope for a cure.  Rather, speaking indirectly, or metaphorically, is more acceptable.  For example, phrases such as "we cannot help you anymore," and "I fear the sky is getting darker and darker for you," are more accepted ways of conveying the patient's prognosis.  For animists, it is important for people to die in their own house, or the house of their family or clan members, where the ancestral spirits reside, rather than in other people's houses where other people's ancestral spirits reside.  Failure to do so may result in angering the ancestral spirits, causing the spirits to lash out on familial lineage or punish the deceased to a lower level of reincarnation.  See End-of-Life Link Issues for more information.
Decision Making: Many Hmong regard "the family group" as more important than "the individual," for making health care decisions.  Extended male family members and clan leaders are often involved in difficult decision making processes.  Usually, the husband's or father's side of the family is responsible for medical decision making, however the wife's or mother's side of the family may participate in discussions about health matters.  In some families, younger and educated patients may play a larger role in decision making and, oftentimes, serve as interpreters to others that do not speak English.  See Family Decision Making Link for more specific information.
Devil: Ntxwv Nyoog is an evil god who guards the gates of hell.  Christian Hmong consider Htxwv Nyoog to be the devil.
Diagnostic Procedures: Individual patients and families usually evaluate the pros and cons before accepting diagnostic procedures.  Generally, as with most patients, the more invasive the procedure, the more likely it is to draw resistance from the patient.  Blood draws and pelvic exams may be met with some resistance (see Blood Draw Link and Pelvic Exam Link for more information) while CT, MRIs, nuclear scans, and X-rays are generally accepted. 
Digestive System: See Anatomy Link
Divorce: Historically, divorce was an uncommon occurrence, while now it is more accepted.  Marital couples with conflicts often seek help from their family members, including sage male elders, who often counsel the couple to patch up their differences and love one another.  Oftentimes, couples are given many chances to learn from their mistakes, make-up, and continue trying to be a loving couple and effective parents.  Divorce is often considered a last option. 
Disrobing: Some Hmong women are reluctant to expose their bodies to anyone, even their husbands, and may perceive the request as being for the physician's pleasure rather than for diagnostic purposes. 
Elders: The elders of the Hmong community are treated with respect and serve a vital part in Hmong decision-making processes.  The word "elders" does not always refer to advanced age; successful and middle-aged men and women can be considered elders whose advise and counsel are worthy.  Elders are included many important decisions made concerning family members, with the older men in the family playing the dominant role in culture, religious, health, finance, and political decisions.  In today's society, there is a struggle within the Hmong community to keep this tradition as the younger generation continues to gain power in the family hierarchy due to their education, English-skills, literacy, and experience. 
End-of-Life Issues: Making decisions for patients at the end of the patient's life varies from patient to patient and from family to family.  Most Hmong adults have not created living wills, as it has been taboo to make plans for future adverse events.  Some families will want everything done for their loved ones, while others will carefully accept some interventions while rejecting others.  Some families embrace hospice and palliative care while others continue to pursue multiple therapies in the hopes of a cure.  See Decision Making and Death Discussion links for more information.
Family Decision Making: In family decision-making, decisions are generally made as a concerted effort between members of the family.  Often, the men in the family and the members of the husband/father's side of the family carry more weight in their opinions then do the women in the family, or the people on the wife/mother's side.  Usually, no one person makes a decision; rather, the group discusses the options with certain members holding more respect or weight in the conversation.  The group then comes to an agreement such that the group is then responsible for the outcome of the decision.  Some people believe that it is better to do nothing then to interfere with fate and be responsible for the result of interfering.  It is important for physicians to realize that decision-making in the traditional Hmong community can be a timely process, but the time is important for in creating a trusting and therapeutic relationship.  See Decision Making Link for more information.
Fevers: See Childhood Illness Link
Fontanel (anterior): See Anatomy Link
Funerals: Following death, the entire family will gather to see the deceased, and some will dress the body in either traditional Hmong clothing or in formal Western clothing of 3 to 4 layers to ensure better preparation for the body's return to heaven or to the land of the ancestors.  Funerals for animists and Christians are different. 

Gender Roles: Traditionally, Hmong men are more powerful than Hmong women.  Men were able to perform ancestral and spirit rituals, arrange marriage contracts, conduct funerals, and settle disputes between clans or within one's family.  Middle-aged men held the most power with their power decreasing as they got older.  Women tended to hold more power within the household and gained power with age.  A newly married bride often faced much criticism from elders of her husband's family and worked hard to please her new family.  Middle-aged women were able to make or contribute to decisions about money, household chores, animals, family relations, and the health of a family member.  As couples entered old age, they depended on their sons for financial support. 
Gods: See Religion Link.  The Hmong believe that Huab Tais Ntuj is the creator and supreme ruler of the world and heaven.  Saub is a lesser god who created the original 12 Hmong clans that originated after the great flood on Earth.  The Hmong also believe in a number of lesser gods and in spirits that reside in the spiritual world.
Herbalist: See Medicine Doctor Link for more information.
History: The Hmong were a migratory people who, due to their physical characteristics, are thought to have originated in Europe and moved to Asia around 5000 years ago.  Scarce resources, a growing population, and confrontations with the Chinese drove most of the Hmong clans to new locations in Southeast Asia, including areas in Thailand, Burma, Vietnam, and Laos, sometime in the 1800's.  In 1893, the French began to colonize Laos.  Failure to profit from the land drove the French to raise revenue through taxation and forced labor, with the Hmong population in Laos suffering from the heaviest taxation.  This led to the "Madman's War" from 1918-1921.  Following the war, relations improved between the French and Hmong, with the Hmong gaining much autonomy and self government.  The Hmong learned to raise opium for a cash crop and sold some of the opium to the French.  After WWII, the confrontation between the French and Laotians renewed, eventually arriving at the Paris Peace Accords, which required the French to stop assisting the Royalist government against the communist Laotians.  In the 1960's, the United State's CIA employed many of the Hmong men and boys, some as young as 10 years old, to help fight the communist Northern Vietnamese and Pathet Laos soldiers in Laos.  The Hmong leader General Vang Pao was instrumental in the recruitment and leadership of Hmong fighters.  In 1973, the US withdrew from the war and in 1975, the communists took over Vietnam and Laos.  When the Americans pulled out of the Vietnam War, many Hmong were left behind without supplies and protection against the victorious communist leader Pathet Lao.  Fearing persecution, thousands of Hmong fled Laos to Thailand, where refugee camps were created.  This refugee flight was dangerous as the communist soldiers continued to fight, killing many Hmong who left Laos for Thailand.  In 1976, the US, as well as France, Germany, Australia, Argentina, French Guyana, and Canada agreed to accept these refugees into their countries.  Today, California, Wisconsin, and Minnesota have the highest Hmong populations in the U.S.  In 2004-2006, the U.S. received approximately 15,000 refugee Hmong from the forced closing of the illegal sanctuary at the Thai Buddhist temple of Wat Tham Krabok.  The current U.S. population of Hmong is estimated at 280,000 according to the Hmong National Development Inc. 
Hmong Medicine Doctor: See Medicine Doctor Link for more information.
Hospice: Many patients and patients' family members have taken advantage of hospice services and have been receptive to the comfort care they have received, although the patients' and families' philosophy of end of life care has not always fit exactly with the hospice philosophy.  It is imperative that the hospice staff understand that the Hmong may agree to supportive care while also hoping for a cure, and that saying a person will die may not be acceptable to the family.  See Religion Link for more information.
Illness: The Hmong view the body as a whole, with each body part having a soul that interconnects with the souls of the other body parts.  If one part of the body is sick, this sickness may spread throughout the body to affect the whole body.  Illnesses may be caused by natural phenomena (such as germs, changes in weather, accidents, or emotions) or supernatural forces (such as fate, soul loss, tame spirits, ancestral spirits, or evil spirits).
Immunizations: Some Hmong adults accept immunizations for their children to keep them healthy or to allow them to attend school, while others reject vaccinating young children because they believe that immunizations can make their children sick.
Interpreters: The Hmong language is complex, leading to problems with interpretation.  Certified interpreters have also been noted to be inaccurate and may not be fluent in English or may not be fluent in the some Hmong of the patient.  Problems may also arise when parents use their children as interpreters--parents may have a distorted perception of their children's knowledge of English, and parents may be providing more medical information to the child interpreter than they wish. 
Jewelry: Necklaces, bracelets, or anklets made of metal, copper, and/or silver that may be worn for beauty or after a healing ritual.  A Shaman may make and place these items to fend off bad spirits and alleviate symptoms. 
Khi hluas tes: Tying strings around one's wrist to keep the soul in the body. 
Labor & Delivery:  See Pregnancy Link for more information.
Language: The Hmong language is a tonal language.  Each word has a beginning consonant, a middle vowel, and a final tone, with eight tones imparting as much meaning as the consonant and vowel.  So, two words with the same consonant and the same vowel but different tones have different meanings.  Common phrases include:
Literacy: Traditionally, Hmong is an illiterate language, although they may have developed a written language years ago when they lived in China.  Since then, many have developed writing using Chinese, Laotian, Thai, and Roman systems.  Today, the younger generation is more literate in English than in Hmong.
Life Circle: Traditional Hmong believe that the physical world (World of Light) co-exists with and is connected to the spiritual world (World of Dark).  Life and death are joined in a circle in which the person rotates with reincarnation bringing the soul back to life.  The person fate, whether born as an animal or person, and how much one suffers, depends on the type of life they lead in a previous life, as energy (kharma or dharma in Buddhism) is carried further into future lives.  See Religion Link for more information.
Lumbar Puncture: As with other invasive procedures, many have concerns about this procedure, perhaps, because it was associated with paralysis and death from stories originating back in the Thailand refugee camps.
Magical Healer: A magical healer, or ritual healer, is a person who performs healing rituals to cure various illnesses.  The healer, usually a man, learns his gift and receives his connection with healing spirits from other healers.  The healer calls spirits with incense and then directs spirits to help the patient by using a bowl of water and silver coins, a metal knife, or his own breath.  Healers are consulted for specific problems and are thought to solve physical problems (particularly burns, eye problems, broken bones, and childhood fevers with rashes), emotional problems (such as fright or startle), and spiritual problems (frightened by spirits). 
Marriage: Historically, marriages occurred through multiple ways: 1) through parental arrangement; 2) individual choice with parental approval; 3) elopement; 4) force (i.e., the woman is pregnant); and 5) bride capture (the woman is captured by the husband and his relatives and forced to physically sleep with him in his house.)  Currently, most marriages occur by the man and woman's mutual desire and decision, with or without family approval.  In traditional Hmong marriage ceremonies, the male family members take vows to support the marriage and take good care of the bride as one of their beloved family members, in contrast to American weddings where both the bride and groom make committments to each other.  A bride price is often paid to the bride's family, and the bride brings money with her into the marriage.  The bride becomes a part of the groom's family, clan, spiritual lineage, and cultural practices.  See Divorce Link, Polygyny Link, Wedding Link, and Widow Link for more information.
Medications, Hmong: Most Hmong medicines are natural products of the Earth, including fresh plants, dried insects, and powdered rocks.  In the U.S., herbalists either grow their own herbs indoors and outdoors, obtain them from other herbalists in the U.S. and Southeast Asia, or gather them in local woods and meadows.  Medicines are drunk as teas or placed on the skin as poultices.  Most medicines are used for short periods of time or used preventively rather than chronically.  See Medicine Doctor Link for more information.
Medications, Western: Many Hmong seek medical attention in order to obtain efficacious Western medicines, and often prefer medicines to procedures or operations, although people also fear side effects of short-term and long-term medications.  Some view Western medicine as too potent or fast for Hmong bodies to handle.  Some people also express concern that the medications they receive are inferior, with the best medication being saved for non-Hmong patients.
Medicine Doctor: The medicine doctor is usually a woman who, like a physician, examines the patient's body, makes a diagnosis, and offers an herbal medical treatment.  They may also charge fees for their medicines, although in some situations (such as infertility) people don't pay if the medicines don't work.  All herbalists have learned from other more experienced herbalists.  Herbalists also have spirits who help them diagnose and treat efficiently.
Menstruation: Menstruation is believed to clean out a woman's uterus and many Hmong view a menstrual cycle as being required for a woman to be healthy.  This belief may interfere with the acceptance or compliance of certain contraceptive measures.
Natural Remedies: Natural treatments may include herbal medications, acupuncture, massage, coining, cupping, incense, drawing blood and examining its color, and ritual healing.  Treatments are often determined by the help of elders, herbalists, or ritual healers, who use traditional Hmong techniques to heal the ill and wounded.  Treatment may be decided by a Hmong family member in common illnesses such as colds or pains.
New Year's Celebration: This is a holiday of rest, religion, and celebration.  In the past, it has been associated as a time for picking a mate, with the couple's marriage following in a month or two.  Dietary changes associated with this holiday involve only eating meat and rice and forbidding rice soup during the first 3 days of the year.  Breaking dietary rules is believed to curse the person into not being able to find enough meat to eat during the rest of the year.
Ntxwv Nyoog: Ntxwv Nyoog is an evil god who guards the gates of hell.  Christian Hmong consider Ntxwv Nyoog to be the devil.
Nudity: Some Hmong women are reluctant to expose their bodies to anyone, even their husbands, and may perceive the request as being for the physician's pleasure rather than for diagnostic purposes. 
Obstetrics: See Pregnancy Link or Labor and Delivery Link
Opium: Historically, Hmong grew opium as a cash crop in the mountains of China and Southeast Asia.  Opium was used as an effective medicine for pain, and some people became addicts.  Opium addicts in refugee camps were not allowed to immigrate to the U.S. until they had not kicked their habit.  Despite this measure, opium addiction has continued in the U.S., although not at as high a rate given the difficulty of obtaining opium. 
Organ Donation: The option of donating organs to others is often refused by some Hmong who believe that losing one's organs can damage the patient's future reincarnations.
Organ Transplantation: The Hmong believe that the body is a whole that functions in harmony when all of its parts are together.  Organ transplantation is hard for some to accept; however, with exposure to Western healing options, this procedure is increasing in acceptance.
Pelvic Exam: Hmong women may refuse routine pelvic exams as they feel that such procedures are both intrusive and unnecessary.  When done without the woman's consent, many view this procedure as a form of rape.  The physician should respect the patient's right to refuse pelvic exams.  Failure of physicians to respect this right has led to a decrease in Hmong people seeking prenatal care.  See Birth Control Link for more information.
Placenta: Hmong parents may choose to bury the placenta at their home so that the spirit of the person can find it, once deceased, to aide in the spirits journey back into the spirit world where the ancestors reside.  See Pregnancy link for more information.
Polygyny: Polygyny is still practiced by some Hmong men, although these men only have one legal wife, so the other "wives" are mistresses.  Some people may not tell their physician about multiple wifes due to its illegality in this country, but may admit to multiple relationships.
Post Traumatic Stress Disorder (PTSD): Elders in the Hmong community, who were children in Laos during the war years, are susceptible to PTSD. Many lived through the Secret War in Laos, the Vietnam War, the life-and-death risk of finding one's way to Thailand refugee camps, and assimilation into the American culture.  When working with the middle aged and elderly patients, one must be sensitive to the likelihood that these individuals may suffer from this disorder, and the healthcare worker should adjust their care accordingly--from referring patients for psychiatric and psychological care to being aware that loud noises or physical exams can trigger intrusive memories. 
Pregnancy: Pregnancy is understood as resulting from sexual intercourse between a man and a woman, when they bring their body fluids together, specifically semen and blood.  Special considerations should be considered regarding Hmong women's beliefs about pelvic examinations and blood draws (see Blood Draw Link and  Pelvic Exam Link for more information).
Prenatal Care: See Pregnancy Link.
Qeej: The qeej is a traditional musical bamboo flute used in funerals and entertainment.  The notes are actually words, so that the people who know the language can hear the words in the music. 
Reincarnation: The Hmong believe in reincarnation.  As with other religions that believe in reincarnation, actions throughout life (such as the way one person treats another or one's ancestors) will influence the person's fate in the next life, and actions in their previous life influence their fate in this life.  Burying a person with missing organs, body parts, or with the inclusion of mechanical devices, may cause the person to be unable to find one's ancestral spirits after death, leading to the person being formed into a lesser being in his/her next life.
Religion: Traditional Hmong religion is animistic, with belief in multiple souls in the body, reincarnation, presence of multiple spirits and gods, and connections between supernatural spirits and human souls that cause illnesses and influence health.  Animists believe in a Life Circle which connects the physical world (World of Light) with the spiritual world (World of Dark).  Humans are a part of both worlds, cycling between life and death via reincarnation.  Each human is believed to have more than one soul (with discussions of 3, 5, 7, 9, or 31 souls per person, although some people assert there is only one soul), which function in harmony for life and health.  If part of the unit leaves or is disrupted, the person's spiritual, mental, and physical health will be affected and the person becomes ill.  Souls may leave the body because they are frightened, caught in a dream world, fallen down, stolen by spirits, or gone to be reincarnated.  Soul-calling is a ritual that returns the soul back to the patient.  (See Soul Loss Link for more information.)  In addition, if an organ or body part is removed, the body is no longer considered whole; this can cause harm to both the person and their family.  If the body's parts are not in order, or if artificial parts are still in the body when one dies, some sources state that the soul that guards the grave will be upset and will not find its ancestors in the spiritual world.  The soul may haunt living ancestors on Earth, and the deceased may be demoted to a lower reincarnation life.  Others believe that there are two different souls, with one guarding over the body and another that seeks out its ancestors in the spirit world.  And yet another group of people believes that after the body disintegrates, the soul that guards the body of the deceased will join the soul that finds the ancestors in the spirit world.  See Life Circle Link, Spiritual Sources of Illness Link, Dab/Spirits Link for more information.
Ritual Healer: Also known as a magical healer.  See Magical Healer Link for more information.
Sacrifices: Animals are sacrificed for different reasons for various healing and religious purposes.  If a sick patient's soul was stolen and taken to the spirit world, a shaman might exchange the animal's soul for the human soul.  If an evil spirit is threatening a sick person, the shaman can command the animal's soul to stand guard and protect the vulnerable patient's soul.  Or, when a person dies, the animal's soul will accompany the person's soul on the long and dangerous journey to the ancestral world.  Chickens and pigs are usually sacrificed.  However, for more serious illness and funerals, cows are used.  Despite reports of sacrificing dogs, legal and social issues have made this historically rare practice an obsolete practice in the United States.
Saub: The kind of god who resides in the sky and created mankind.  Christian Hmong believe Saub to be God.
Shaman: (Tus ua neeb) There are varying levels of healers who perform healing rituals.  Shamans are revered as healers and many are considered family and community leaders.  Shaman can be men or women who have been chosen by the shaman's helping spirits (dab neeb).  The choice is recognized by another shaman who arrives to divine and cure the patient's serious illness.  The patient who is recognized to be a shaman may be either an adult or a child. 
Social Structure: Hmong society is traditionally a patrilineal, patriarchal, and patrilocal society.  Eighteen clans are recognized.  Intra-clan marriages are considered incestual and therefore taboo, so marriages only occur between clans.  Men hold the most power in decision making in matters concerning money, politics, or health (see Decision Making Link for more information).  The family is obligated first to the husband's side, before the wife's, as the wife becomes part of her husband's clan through marriage.  There are also societal distinctions based on the style of clothing, dialect, and rituals that divide Hmong into White and Green/Blue divisions (Hmoob Dawb and Moob Leeg or Moob Ntsuab).
Soul Loss: Soul loss can occur in several ways: 1) ancestral spirits or evil spirits may steal the ill person's soul; 2) the soul may be frightened, perhaps by surgery; 3) the soul may be caught in the dream world, perhaps during anesthesia; or 4) the soul may not have gotten up after the person fell.  Soul loss or "poob plig" can be remedied by a Soul Caller calling the spirit back to the person's body in a special ceremony lasting up to three days.  Soul-calling ceremonies start at the location of the soul loss (i.e., the operating room) and continue back to the doorway of the sick person's house.  The soul-caller calls the soul, enticing it with incense, rice, spirit money, and chicken.  Other situations that may result in soul calling include the birth of a newborn child, prevention of illness, and promotion of health such as at New Year's.
Spirit Money: Paper designed as spirit money is often burned as an offering or payment to spirits and souls in religious and healing ceremonies. 
Spirits: See Dab/Spirit Link and Religion Link for more information.
Spiritual Sources of Illness: There are several types of supernatural illnesses.  Soul loss is caused by a person's soul leaving the body (see Soul Loss Link).  Tame household spirits can make people sick when they haven't received the attention they need, or when a social taboo has occurred.  Ancestral spirits can cause illnesses when they need something, usually spirit money or an animal sacrifice.  Wild evil spirits generally make people sick by their very nature, while wild benign spirits only bother people if they are disturbed.  Shaman -helping-spirits can communicate their choice of someone to become shaman by making that person sick. 
Surgery: Certain surgeries are more easily accepted than others.  Operations on the gallbladder and appendix, for instance, are accepted more rapidly than those on the heart or brain.  Surgeries of special concern involve the liver, due to its importance in the Hmong tradition of anatomy and its belief in shaping a person's personality, as well as surgeries involving blood loss (see Blood Link for more information).  Also, the Hmong believe that the body is a whole that functions best and in harmony when all of its pieces are together.  As familiarity with Westernized medicine spreads, the variability in individual beliefs about operations increases as well.  See Anatomy Link for more information.
Transfusions: While many people accept blood transfusions, there are some concerns about donating blood, as some people feel giving blood makes them more vulnerable to weakness and illness.  Also, some people's reluctance may be related to the belief that blood cannot be regenerated.  In addition, some Hmong people share the same Westernized concerns of contracting disease or illness from donated blood. 
Transplantations: See Organ Transplantation Link.
Tshuaj noj: Oral Medication believed to dissolve blood clots.  See Traditional Healing Link for more information about techniques used to heal within the Hmong medical community.
Vaginal Exam: See Pelvic Exam Link
Vasectomy: See Birth Control Link
Visitors in Hospital Settings: Many Hmong patients want to have immediate family as well as clan members present when a family member is sick in the hospital.  Families tend to be large, and it is culturally important that the extended family show their respect by being present for a family member's serious health problems.  While many hospitals have policies surrounding how many people can visit patients, bending this rule can both show respect for the patient's culture as well as facilitate the Hmong family decision-making process.  Having all members present may speed this process when time is of the essence and decisions need to be made quickly.  See Decision Making and Family Decision Making for more information.
Weddings: Historically, many couples met during the New Year celebration; today, younger generations meet in a variety of ways, including the internet.  Weddings were traditionally arranged by the husband's family and clan.  Marriage is seen as a step from childhood into adulthood.  Traditionally, the bride leaves her family behind to become a part of her husband's family and clan, and she adapts to his customs, traditions, religion, and language, if they differ from her own.  Historically, married woman do not wear wedding rings;  rather they wore a turban with black and white stripe removed to signal that she is married.  See Marriage Link for more information. 
White Fabric Cross: Two sections of white fabric sewn in a cross may be placed on a person's shirt during a shaman's ceremony to extend the life of the person whose fate has expired. 
Widow: A widow can either stay to live with her husband's family, remain single, or marry her deceased husband's younger brother, or marry someone else.  If she marries a man from another clan, her children may stay with her deceased husband's family due to the social perspective that the children will be better taken care of by the father's family than by the new husband's family and by religious belief that the children's souls belong to the father's ancestral lineage. 
Zaj: Dragon spirits that hide in the water and steal souls of those who play in or around it.  Pregnant women are careful to avoid water for fear that these spirits will cause miscarriages. 
Zaws hno: A massage followed by a finger prick believed to release built-up pressure within the body.
                                                                                                                                                                                                                                                                                  

Sources:
This website was completed with the help of the following people who reviewed the website and offered suggestions for its improvement.  The following people were chosen to review the website due to their extensive knowledge about Hmong culture, health care, and beliefs.

Website Reviewed By:
1) Dr. Kathleen Culhane-Pera, University of Minnesota Medical School, Twin Cities, Assistant Professor of Family Medicine/Community Health and co-editor of Healing By Heart.
2) Bea Larson, Hmong-English Language Instructor, Hmong Family Advocate, author of Hmong Roots and the later volume Hmong Roots with Paper Dolls and Story Cloths, Community Cultural Competence Educator.
3) Tria Lor, University of Minnesota Medical School, Duluth, MSI
4) Dr. Glen Nordehn, University of Minnesota Medical School, Duluth, Assistant Professor of Family Medicine

Faculty Advisor:
Dr. Jim Boulger, University of Minnesota Medical School, Duluth, Professor of Behavioral Sciences and Family Medicine

IT Support:
1) Brad Ingersoll, University of Minnesota Medical School, Duluth
2) Toni Winslow, University of Minnesota Medical School, Duluth

Website Research & Design:
Autumn Erwin, University of Minnesota Medical School, Duluth, MSII
*For comments or suggestions please contact erwi0010@d.umn.edu
                                                                                                                                                                                                                                                                                  
References:
1. Cha, D. (2004).  Field Guide to Hmong Culuture.  Madison's Children's Museum.  Madison, Wisconsin.
2. Culhane-Pera, KA, Vawter DE, Xiong P, Babbitt B, Solberg M, eds.  Healing By Heart: Clinical and Ethical Case Stories of Hmong Families and Western Providers.  Nashville TN: Vanderbilt University Press.  2003.
3. Fadiman, A. (1998).  The Spirit Catches You and You Fall Down (1st ed.).  New York: Farrar, Straus, and Giroux.
4. Larson, B. (1998).  Hmong Roots (4th ed.).  Duluth, MN
5. Hennepin County Website "Hmong Culture".  http://www.co.hennepin.mn.us/
6. Hmong Cultural Center, Inc., St. Paul, MN.  http://www.hmongcenter.org
7. Hmong Nationality Archive.  http://www.hmongarchives.org/index.php
8. Lao Family Community of Minnesota.  http://www.laofamily.org/
9. The Hmong: An Introduction to their History and Culture.  http://www.culturalorientation.net/hmong/hhist.html
10. This is Home: The Hmong in Minnesota.  Minnesota Public Radio program.  http://news.minnesota.publicradio.org/fatures/199903/08_nyman1_home/index.shtml
11. WWW Hmong Homepage.  http://www.hmongstudies.org/
12. MMA Publications Website.  "Laying the Body to Rest."  http://www.mmaonline.net/publications/MNMed2004/January/Maas.html