Table 1.

Qualitative Studies

Authors	Study Purpose	Sample	Setting	Design	Analysis	Results
Baisch, Vang, & Peterman, 2008	Explored the perspectives of Hmong women on cancer, using focus groups as the research method.	10	WI	Qualitative study	Inductive content analysis	There is no Hmong word for ‘cancer.’ Hmong participants have ‘fatalistic’ beliefs about cancer. Misunderstandings occur because of misunderstandings due to inadequate translations. Women are embarrassed to discuss about their body parts and male leaders controlled women’s health care decisions.
Barrett, Shadick, Schilling, Spencer, del Rosario, Moua, & Vang, 1998	Examined interaction between Hmong patients and their health care providers and identified specific factors that either enable or obstruct health care delivery	47	WI	Complementary qualitative method including participant observation, focus groups, and literature review	Transcripts were analyzed by a multidisciplinary team	Hmong patients and their health care providers have different health beliefs systems. Translation was reported as a challenge, specifically for linguistic and cultural translation. The majority of Hmong patients identified kindness, caring, and a positive attitude as important provider characteristics. Providers reported that Hmong patients lack understanding of the following concepts: acute versus chronic diseases, illness prevention, and pain, both physical and psychological.
Burgess et al., 2008	Explored beliefs and experiences related to smoking and cessation among the Hmong population in the United States	18	MN	Qualitative using focus groups	Used Patton (2002)’s qualitative analysis methods	Barriers to smoking cessation were different based on gender and acculturation. For example, women were concerned about having their smoking status revealed if they were to seek help, because of cultural prohibitions against female smokers. Less acculturated Hmong believed U.S. commercial tobacco to be more addictive than the homegrown tobacco they were used to. Participants were strongly influenced by smokers in their social networks. A powerful obstacle to quitting was addiction or “cravings”.
Burgess et al., 2014	Examined how tobacco use patterns in Minnesota’s Southeast Asian communities (Minnesota’s Hmong, Khmer (Cambodian), Lao, and Vietnamese) have been shaped by culture, immigration, and adjustment to life in America.	60	MN	Qualitative	Used a standardized framework for ethnographic analysis called a face sheet comparison to look at each interview as a whole and to compare interviews to find similarities and differences	Among the Hmong participants, regular consumption of tobacco was unacceptable. Consumption of tobacco was rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. Social norms of smoking have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, they reported that smoking reduced their stress of social isolation, economic hardship, prior trauma, and the loss of power and status.
Culhane-Pera & Lee, 2006	Explored Hmong patients and family members’ explanatory models, decision-making processes, and experiences with the health care system.	34	Not specify	Qualitative study	Analyzed major themes related to ideas of etiology, patho-physiology, signs/symptoms, course, and preferred treatment; reaction to health care system and medical decision	Hmong people’s concepts of kidney function and explanatory models of kidney stones are both from traditional and biomedical concepts. Hmong understood kidney stones as acute health problems caused by hard substances in water and food that stick to the kidney, which weak kidneys cannot excrete. People who had kidney stone did not know they had stones until they passed a stone or they saw stones on X-rays. They preferred medications, including herbal medicines, to invasive urological procedures.
Culhane-Pera, Her, & Her, 2007	Increased understanding about Hmong cultural model of type 2 diabetes	39	MN	Qualitative		Hmong adults attribute their diabetes to their refugee experience. They also reported that feeling out of balance, defined as not fitting with the food, activity, weather, or community in the U.S., combined with emotional losses of being refugees, resulted in the development of diabetes. Hmong adults’ interpretation of diabetes was related to their traditional health model of balance and in the context of their loss place as refugees.
Devlin, Roberts, Okaya & Xiong, 2006	Explored health-related beliefs and experiences of African American, Hispanic/Latino, American Indian, and Hmong people with diabetes and engage community members in improving diabetes care.	80	MN	phenomenological approach using focus groups	Data were organized into similar or contrasting groups of themes using Krueger (1998) team-based analysis strategy approach	People reported a loss of health, healthy habits, and traditions through the exposure of American lifestyle, particularly with the lack of physical activity and poor diet resulted in the development of diabetes. Participants also reported a lack of confidence in the medical system. Participants also expressed the importance of spirituality, which shaped their experiences and self-care practices.
Fang & Baker, 2013	Explored barriers and facilitators of cancer screening among women of Hmong origin	44	CA	Qualitative study using community-based participatory research approach	Krippendorff guidelines : used for reliability & reliability Social determinant of health framework used to guide probe and discussion during focus group and to capture key themes (analysis)	Sociocultural barriers to screening included a lack of accurate knowledge about the causes of cervical cancer, language barriers, stigma, fear, lack of time and embarrassment. Structural barriers to screening included attitudes and practices of health care providers, lack of insurance (for college & professional women), and quality of service provision at clinics for the uninsured
Fu et al., 2007	Explored minority smokers including Hmong’s experiences and beliefs about guideline-recommended smoking cessation treatments	95	MN	Qualitative using focus groups	Used Patton (2002)’s qualitative analysis method	Hmong participants reported that it was unlikely for the older Hmong generation to seek smoking cessation help from doctors due to the lack of awareness of the services.
Helsel, Mochel, & Bauer, 2004	Examined Hmong Shaman respondents’ understanding and management of their illnesses.	11	CA	Exploratory qualitative	Grounded theory	Hmong shamans are influential individuals within the Hmong community and are often the resource persons to whom patients turn to for information on health. Hmong participants do not understand the concept of chronic illness, as a result, Hmong participants have sporadic medication and dietary regimens. They also lack awareness of potential complications, and persistently believed that chronic diseases could be cured rather than managed.
Johnson, 2002	Determined Hmong perspectives and beliefs that influence the Hmong experience in Western medical situations.	19	CA	Ethnography study	No information on analysis	Hmong language lacked terminology of biomedical body physiology and anatomy. Medical terms and diagnoses lack direct translation and require extensive nondirect terms to approximate meaning.
Lor et al., 2013	Described the beliefs, feelings, norms, and external conditions regarding breast and cervical cancer screening in a sample of Hmong women.	16	WI	Descriptive study, guided by the Theory of Care Seeking Behavior	Directed content analysis	Hmong women’s beliefs about breast and cervical cancer screening were based on their earlier experiences with breast and cervical symptoms. Many Hmong women felt embarrassed about breast and cervical cancer screening. They also fear about dealing with the results. Hmong women’s cultural norms about undressing for an exam and listening to authority figures were different from Western norms. Hmong women reported that difficulties in communicating with interpreters and clinicians were external conditions that influenced their screening behaviors.
De Castro, Krenz, & Neitzel, 2014	Investigated agricultural-related safety and health issues among Hmong refugees working on family-operated farms.	11	WA	Photovoice methodology	Used a group analysis using Wang & Burris, 1997’s coding method	Hmong participants shared that their farm work put them at risk for musculoskeletal problems (e.g. chronic pain). Participants reported that handling and operating heavy machinery resulted in physical injuries. Participants also reported problems related to heat and cold stress and respiratory exposures. Pest management was reported as a challenge for Hmong farmers. Due to Hmong farmers’ socioeconomic status and language barriers, they reported difficulty in affording crops and communicating with supply stories and companies.
Nguyen & Seal, 2014	Elicited the definitions of successful aging according to Chinese and Hmong elders living in Milwaukee, WI.	44	WI	Exploratory qualitative	Used Grounded Theory principles for analysis (Corbin & Strauss, 2990; Strauss & Corbin, 1994)	Hmong elders reported concerns about having good physical health, strength, and energy. They also reported having harmonious family relationships were important to them and feeling love is an important part of healthy aging. Hmong elders’ source of happiness included having children and having loving relationships with siblings and extended relatives. Elders expect to live with their children and for their children to provide tangible forms of support such as buying groceries, paying bills, and household chores.
Perez & Cha, 2007	Investigated knowledge, beliefs, and treatment of diabetes in the Hmong community in Fresno County	33	No specificity	Qualitative using focus groups	Used Miles and Huberman (1984) and Patton (1990) for dealing with qualitative data	Findings from this survey revealed that the majority of study participants had no knowledge of the disease. Results from the survey also revealed misconceptions about the disease (e.g., believing a person can catch the disease by eating too many sweet foods). The study also revealed that the majority of study participants utilize traditional Hmong remedies such as herbs, including plants and tree roots for diabetes treatments
Perez & Thao, 2009	Documented barriers to addressing diabetes in the Hmong community.	10	CA	Photovoice, a qualitative	Code for issues, themes, and theories in the documented stories	Barriers to diabetes prevention included 1) the environment, 2) personal choices, habits, and life style and, 3) lack of a safe environment to access physical activity as factors contributing to the potential for developing diabetes.
Perez, Moua, & Pinzon-Perez, 2006	Identified risk factors for food-borne illness, knowledge of safe food handling practices, and understanding that transmission of food-borne diseases among Hmong.	25	CA	Qualitative	Data were coded into themes	Participants did not understand the direct relationship between bacteria and food borne illnesses. Participants were more likely to report reliance on traditional medicine to address foodborne illnesses.
Pham, Harrison, & Kagawa-Singer, 2007	Explored Hmong parents’ and youths’ knowledge, attitudes, opinions, and behavior about health and healthy lifestyles.	84	CA	Qualitative	Data analyzed using inductive approach	Hmong valued physically active lifestyles and dietary patterns as well as fresh foods. Barriers to a healthy lifestyle included limited access to safe spaces, time for adequate physical activity, access to land to grow fresh produce, and time for home preparation of food.
Plotnikoff et al., 2002	Increased understanding of the process and meanings of shamanic care from patient complaint through diagnosis, treatment, and outcome.	36	CA	Descriptive qualitative study	Grounded theory	Hmong patients sought shamanic help for different types of care including physical, emotional, and psychological complaints.
Thorburn, Kue, Keon, & Zukoski, 2013	Explored family and clan influences on Hmong women’s breast and cervical cancer screening attitudes and behavior.	83	Oregon	Exploratory study	Content analysis	Hmong women make their own independent decisions about breast and cervical cancer screening. Half the women shared that their family encouraged/supported them in getting screened. However, some shared that elders discouraged screening. Hmong families do not discuss about breast and cervical cancer screening because they see it as a way for their family and clan to influence their attitudes.
Thorburn, Kue, Keon, & Lo, 2012	Explored medical mistrust and trust of Western medicine and the health care system among Hmong women and men as well their experiences with discrimination in health care, and how these factors may influence Hmong women’s breast and cervical cancer screening behavior.	83	Oregon	Exploratory study	Did not specify type of data analysis method	Hmong distrust their doctors. Sources of mistrust included lack of understanding and negative impressions of Western medicine and the health care system. In addition, having a positive experience with providers created trust with some Hmong participants. However, participants reported that mistrust/trust did not have any effect on their decisions to get breast and cervical cancer screenings. A few Hmong participants reported being treated differently when they obtained their screening. This experience of discrimination affect Hmong participants’ behavior in willing to seek care.
Thorburn, Keon, et al., 2013	Explored sources of information about breast and cervical cancer, including screening, and identify barriers to seeking such information fir Hmong women & men	83	Oregon	Qualitative descriptive study	Content analysis	Health care providers and the Internet were the most frequently cited sources for obtaining information about breast and cervical cancer for Hmong. Barriers to seeking information included fear of knowing they had the disease or of inviting it
Van Duyn et al., 2007	Examined how best to adapt proven, evidence-based strategies to increase physical activity for use with underserved racial or ethnic groups.	292	CA	Qualitative study using focus groups	Did not specify	Media messages in the Hmong native language were important. Hmong families reported that community campaigns to increase physical activity could be done at Asian grocery stores, community organizations, churches, and festivals. Hmong gatekeepers reported they had little ability to change their environments (e.g. workplace, schools). Hmong reported safety concerns as a barrier to access their resources because they live in communities with high crime rates.
Vang, 2009	Explored factors that influence Hmong women‘s willingness to be screened for breast cancer	15	WI	Qualitative	Used grounded theory to guide analysis	Breast health messages influenced Hmong women’s decisions about obtaining a mammogram. Hmong women only sought care when they were symptomatic (e.g. there is a visible sign or symptoms of illness). Instrumental barriers were reported to influence screening including lack of tangible aid and services, language barriers, and lack of insurance and transportation. Sociocultural influence such as family influences (e.g. husbands’ approval) on decisions to seek screening.
Vue, Wolff, & Goto, 2011	Examined perspectives on food habits, acculturation, and health among Hmong women with young children in northern California.	15	CA	Qualitative	Data analysis done using principles of Grounded Theory	Participants reported that Hmong food culture is a healthful lifestyle and helps them maintain their self-identity. Hmong mothers encountered enormous challenges in bridging two extreme generations; the less acculturated immigrant adults and the highly acculturated, US-born children in their households.
Xiong & Westberg, 2012	Determined perceptions of the Hmong population about Type 2 Diabetes	9	MN	Qualitative using focus group	Looked for common themes	Participants lacked knowledge about diabetes including different types of diabetes, risks of diabetes, causes, and treatment for diabetes. As a result, many participants were upset about taking the medication for the rest of their life and were reluctant to take their medications as prescribed.
Yang, Xiong, Vang, & Pharris, 2009	Explored how to better care for Hmong women with diabetes using nursing theory praxis.	5	MN	Qualitative phenomenologic design	Data were analyzed using Newman’s (1994) hermeneutic-dialectic method	Hmong participants viewed causes of diabetes from culture change and hardships. Further, also described a direct connection between their loss, depression, deep grief, worry, stress, and diabetes.