CulturallV Smsi&e. Prenatal Care for. ]oc;a\ CLINICAL STUDIES

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1 ]oc;a\ CLINICAL STUDIES SUSAN MATTSON, LILLIAN LEW, RD, RNC, CTN, PHD MED CulturallV Smsi&e J Prenatal Care for Southeast Asians Objective: To evaluate the success of the Southeast Asian Health Project in terms of client satisfaction with the prenatal care and other services. To obtain additional data about Southeast Asian women s health practices regarding childbearing. Design: Survey through questionnaires administered as interviews. Setting: In clients homes or via telephone. Particlpants: 119 women from SEAHP s case files of recently delivered clients. Measurements and Main Results: Interviews were conducted by four community workers fluent in Cambodian or Lao. The majority of women were satisfied with SEAHP, particularly the interpretation and education in native languages. Women were also satisfied with SEAHP, encouraging others to seek care. Conclusions: SEAHP appears to meet prenatal care needs of Southeast Asian women in Long Beach, California. More objective outcome data await analyses, but the program s approach may ensure access to and use of health services. Accepted: June 1991 I nfant mortality in the United States remains alarmingly high. Twenty other industrialized nations have lower infant mortality. Many infant deaths are believed to be related to low birth weight, often the result of the expectant mother having received little or no prenatal care (Cable, 1987; US. Department of Health and Human Services [HHS], 1988). Among the goals established by the surgeon general s office for 1990 were two that addressed this issue: (a) to reduce the number of low-birth-weight infants to 5% of all live births, with no county, racial, or ethnic subgroup exceeding 9% in the number of low-birthweight infants; and (b) to ensure that at least 90% of all pregnant women begin prenatal care during the first 3 months of pregnancy (HHS, 1988). Unfortunately, analysts who have studied the situation believe that these goals were not met; indeed, some states and population groups have reported a trend toward even more low-birth-weight infants and fewer women who receive early prenatal care (Hughes et al., 1986). The cost of such prenatal neglect can be high, financially and emotionally. In its final report, Death before Life: The Tragedy of Infant Mortality, the National Commission to Prevent Infant Mortality (1988) recommended an overall plan of action that would provide universal access to early maternity and pediatric care for all mothers and infants through private and public means. Early and regular Providing prenatal care to and improving use of available services by Southeast Asians can be dificult. prenatal care is the first step in preventing low birth weights of infants. Prenatal care aids in determining which pregnant women and fetuses may be at risk. Threatening medical conditions can be monitored and treated safely: weight gain can be watched carefully with an eye toward determining whether the fetus is receiving adequate nutrition; and a large number of cases of preterm labor may be detected early enough for intervention to be effective in preventing the delivery of a low-birth-weight infant (March of Dimes Birth Defects Foundation, 1986). Initiating prenatal care, however, becomes difficult when the target population is an ethnic minority. Providing services and improving the use of available care to such a population are in doubt. Of the 400,000 Southeast Asian refugees in California, an estimated 50,000 ended their journey in Long Beach and have made a major impact on the city. About 40,000 of the Long Beach refugees are from Cambodia, giving the city the largest concentration of Cambodians outside their home 48 J O C N N Volume 21 Number 1

2 Culturally Sensitive Prenatal Care country. The other 10,000 are primarily Laotian and Vietnamese, with a few Mien and Hmong (Lew, 1988). Southeast Asians The majority of the Southeast Asian refugees arrived after 1980 in a second wave of immigration. These people had suffered years of deprivation and seen the loss of loved ones under the repressive communist regimes and in the consequent holocaust. They who had suffered the indignity and deprivation of refugee camps were from the rural countryside and had little or no formal education. Many of them came to the United States suffering from anxiety and depression, poor health, and malnutrition (Lew, 1990; Muecke, 1983; Van Esterik, 1980). Ninety percent are younger than 45 years; thus, their first contacts with the U.S. health-care system are usually through obstetrics, pediatrics, and emergency rooms (Muecke, 1983). Many of these new arrivals entered the United States with health problems such as parasites, anemia, malnutrition, a positive test result for the hepatitis B antigen, tuberculosis, mental health problems, growth retardation in children, and certain genetic blood disorders-for example, hemoglobin E, alpha thalassemia 1, and beta thalassemia (Lew, 1990). All of these problems place pregnant women at risk. Several factors in the refugees life-style contribute to continued health problems. First, childbearing begins early and ends late in the reproductive years, and their fertility rate is considerably higher than the U.S. average (an estimated 28 births per 1,000 women of childbearing age compared with 15.5 per 1,000, respectively). In addition, their large family size often leads to overcrowded living conditions. Finally, their education level remains low, and a high unemployment rate contributes to a low economic level of existence (Lew, 1990). Despite the availability of health care, many barriers to accessing this care exist for Southeast Asian refugees. Language may be the biggest barrier. Besides the national languages of Vietnam, Cambodia, and Laos, many tribal languages are spoken within each country. In addition, most of these refugees have little or no knowledge of anatomy, physiology, germ theory and hygiene, prenatal care, or family planning. In particular, childbearing is not considered an illness, so the concept of seeking health-related advice during this period is strange to the refugees, except for asking for assistance from elders and family members. Furthermore, Cambodian women are extremely modest, and many of them (or their family members) were raped during the Khmer Rouge rule and in the refugee camps. For these reasons, the com- monly accepted U.S. practice of pelvic examinations can be psychologically distressful to them. A lack of surgical tradition further contributes to their attitudes toward prenatal care. Surgery is seen as a violation-a mutilation of the body that releases the soul. If surgery is recommended, it is imperative that a bilingual, bicultural medical translator be available to discuss the implications with both the family and the health-care practitioner. Southeast Asians have a traditional healing culture, which they use whenever possible. They recognize three categories of illnesses: physical, caused by accidents, spoiled food, and some recognized diseases such as leprosy, tuberculosis, malaria, and cholera; metaphysical, based on the principle of yin and yang and caused by bad winds, an imbalance of hot and cold energy, an incorrect diet, or excessive emotions; and supernatural, caused by evil spirits or the loss of one s soul. Folk remedies and practices to alleviate pain and illness abound, including the use of herbs and other ingredients available in the home, in the countryside, or in the local ethnic store. For more complicated problems, the Southeast Asian may turn to an herbalist, Buddhist monk, or pharmacist. Pharmacists will diagnose illnesses and dispense medications, or the patient can perform the diagnosis and purchase whatever medicine he or she wishes. Another health-care practice commonly used is dermabrasion, the rubbing or irritation of the skin in some form to relieve discomfort. The most popular form is coining, in which the affected area is covered with a mentholated ointment such as tiger balm, and then the edge of a coin is rubbed over the area. All dermabrasion methods leave marks resembling bruises or burns on the skin and are frequently mistaken for signs of child abuse. Lack of maternity care for Southeast Asians is reflected in the fact that the small numbers of those who seek prenatal care do so late in the pregnancy. Lack of care is reflected in the birth of low-birth-weight infants to this population. The overall belief of Southeast Asians is the unity of mind and body, so monks and other spiritual healers are often sought to assist in alleviating physical symptoms that may be mental in origin. Western health practices often seem frightening and intrusive, partly because of the dichotomous practices seen with Western medicine and the lack of understanding of Januury/February 1992 J O G N N 49

3 C L I N I C A L S T U D I E S diagnostic procedures. The belief that blood is not replaceable further impedes the diagnostic process. The aversion to needles may stem from the fact that some of the patients and their families were tortured with needles before escaping from Cambodia. Southeast Asians have a strong belief in fate or Karma. The religious beliefs (mostly Buddhist, with some animism) of Southeast Asians encourage tolerance and suffering. Thus, many do not seek medical treatment because they perceive their pain as something that must be endured, rather than something that can be alleviated. Often the women will choose to have the baby at home to save money, or because Cambodians believe it is important that the woman in labor have someone with her at all times. Birth attendants stay with the woman constantly and provide supportive care. Southeast Asians believe women are vulnerable to evil spirits during childbirth, and the protective rites they believe necessary to ward off the evil spirit often cannot be performed in the hospital. After the birth, they believe it important that the woman be kept warm, because blood, which is characteristically hot, has been lost; therefore, the woman is at risk of becoming cold. The women often refuse to take baths, wash their heads, or drink cold liquids in the postpartum period for this reason and for fear of upsetting the necessary balance of hot and cold. The insensitivity of health-care providers may cause these refugees to feel ridiculed because of their adherence to their beliefs and may cause the refugees to avoid prenatal care. Health-care providers must educate themselves to the culture and make an effort not to deter the refugee from returning for care in the future (Kulig, 1989; Lew, 1990). Concrete evidence of the lack of maternal and child health care for the Southeast Asian refugee population is reflected in (a) the low numbers of pregnant women seeking any prenatal care, (b) the fact that those who seek care do so quite late in their pregnancy, (c) the high incidence of poor nutrition among pregnant women, (d) the delivery of neonates with low birth weights, and (e) inadvertent child abuse and neglect (Lew, 1989). The Southeast Asian Health Project: A Response In the case of Southeast Asians, culturally sensitive health care is required. According to Jezewski (1990), most Westerners who perceive themselves to be ill elect to enter the established health-care system, having confidence that their symptoms will be understood and treated effectively and that they will be accepted as persons in need of medical care. They usually have the economic means to pay for services. Recent immigrants to the United States, however, such as Southeast Asians-and particularly those with a different approach to illness and healing-may require efforts on the part of health-care providers to assist them in receiving care. In such a circumstance, a culture broker can be useful. Culture brokering is an anthropologic concept that involves a go-between to link diverse groups. This mediating between groups reduces conflict and produces change. In health care, it oeten involves brokering between health-care providers and potential consumers. The culture broker uses strategies such as negotiating, mediating, innovating, and sensitizing to achieve the desired linkage (Jezewski, 1990). The Southeast Asian Health Project (SEAHP) was initiated to act as a culture broker and respond to the need for maternal and child care among Southeast Asian refugees. The utility of the culture broker approach is documented in the literature by Rimmer (1975), who described how nonprofessional neighborhood workers functioned as brokers between medicine and the clients of a local neighborhood clinic. Jezewski (1990) reported that culture brokering was effective in increasing health-care use by migrant farm workers. SEAHP acted as a culture broker to provide culturally sensitive maternal and child care to Southeast Asian refugees. As an initial step toward assuring access to health services for Southeast Asian mothers, infants, and children, SEAHP began as a prenatal and maternal health support services program. Funding was obtained from several private foundations, St. Mary Medical Center Foundation, and the United Cambodian Community (a service agency). SEAHP is now a demonstration project funded by the Office of Maternal Child Health, in the U.S. Department of Health and Human Services. Actual prenatal care and delivery services are provided at St. Mary Medical Center, which accepts California Medicaid payment, for which most of the clients qualify. When genetic counseling is recommended, clients are referred to another hospital, with the project providing transportation and translation services. Genetic counseling is not done at St. Mary Medical Center, a Catholic institution, because of abortion being a possible option. Outreach to Southeast Asian refugees was the first service offered, and it remains an important one. Bilingual, bicultural outreach workers go into the South- 50 JOGNN Volume 21 Number 1

4 Culturally Sensitive Prenatal Care east Asian community and provide education about the importance of preventive health care in general and prenatal care in particular. These workers explain the scope of available medical services and help allay the fears of the community. Initial contacts with the families are made in many ways: door-to-door canvassing of neighborhoods known to contain large numbers of refugees, posters and brochures placed in local markets, ads in refugee papers, meetings at Buddhist temples and other gathering places, and referrals by other clients. Once the refugees become clients in the system, the workers function as interpreters in the clinic, and if any referrals are needed, they accompany the women. A second, educational, thrust of the project was the development of resource materials. Information about prenatal care and nutrition, child development, and infant feeding was printed in three Southeast Asian languages. Because of the high illiteracy rate in this population, many pictures are used to illustrate the text. Oral classes are offered in Cambodian and Lao by the outreach workers. The rare Vietnamese client is put into the Cambodian-speaking class, and a Cambodian worker who speaks Vietnamese will translate for her. Classes are offered on labor and delivery orientation, prenatal nutrition, infant feeding, child development, parenting skills, and health and hygiene. Classes on breastfeeding and infant car seat safety have just begun, and a class on hepatitis B is being developed. The classes are offered on a rotating basis every other month. For each class, transportation, baby-sitting, and a nutritious snack are provided. New clients often receive a phone call from the outreach worker explaining the classes and inviting them to attend; a follow-up call is made the morning of the class as a reminder. Before the inception of SEAHP, no Southeast Asian obstetric patients attended health education classes at St. Mary Medical Center; by now, more than 300 women have attended those offered by the project. SEAHP has provided education for the professional staff (nurses, physicians, aides) and ancillary workers of the St. Mary Medical Center clinic and hospital, as well as for neighboring health centers. Education was conducted in the form of large conferences and small in-service classes on the health-care practices and beliefs of Southeast Asians and, in particular, childbearing women. Written information is also available. These efforts have improved client-practitioner relationships and encouraged the continuation of care. Since June 1987, when the project began, more than 600 patients have been seen in the prenatal clinic. The current active caseload is about 240. Their ethnic composition is consistent with that of the community: 63% Cambodian; 30% Laotian; 5% Vietnamese; 2% Hmong; and a very small number of Mien. Because of these numbers, two full-time Cambodian outreach workers, one full-time Laotian worker, and two other Cambodians work with the project in various capacities. These workers make visits to the clients homes for one-on-one education about home hygiene, safety, and nutrition. Project Evaluation Health-care programs need to be evaluated periodically to determine their effectiveness and to provide for future planning; evaluation also is necessary for continued financial and institutional support. Therefore, a two-phase evaluation program was designed. The first phase, that described in this article, was to evaluate retrospectively SEAHP s success from the clients perspective. The second phase is a review of patients charts for objective data regarding birth outcomes. Out of the total of 598 women seen, 119 were interviewed over 6 months. These interviews were conducted by four women fluent in Cambodian and Lao. One was an outreach worker for the project, and the other three were active in the Southeast Asian community and were known to the project director and staff. A structured questionnaire was developed by the author and validated by the outreach workers for appropriateness of content. The questionnaire was translated into Cambodian and Lao, but because of the known high rate of illiteracy in these women, the researchers decided to have the questionnaire read to the clients. The interviewers were instructed in use of the questionnaire and in ways to modify the phrasing of questions to facilitate understanding by the clients if necessary. Approval for the interviews was obtained from the Institutional Review Board of St. Mary Medical Center and from the Institutional Review Board for Protection of Human Subjects at California State University, Long Beach, which provided partial funding for the evaluation through grants to the author. The primary outreach workers pulled clients names from their caseloads and gave them to the interviewers. The latter contacted everyone on the list who could be reached (some had moved or were otherwise no longer able to be contacted), explained the purpose of the contact, and conducted the interview, either in the client s home or by phone if the client preferred. The questionnaire informed the clients of their option to participate and assured anonymity. Ac- January/February 1.92 J O G N N 51

5 C L I N I C A L S T U D I E S tual consent was implied by their agreement to answer the questions. The interviews yielded the following information about the Southeast Asian women attending the clinic. Of 119 women, 28 (24%) had no education; the range was 0 to 9 years of education, with a mean of 2.3 years. Once in the United States, the women acquired a mean of 1.1 additional years of education (range, 0 to 7 years); interestingly, 41 (34%) of them acquired no further education. Overall, 60 (50%) reported having no knowledge of English at the time of the interview. Only 31 (26%) could speak English, and 21 (18%) could read and write English; the remainder could perhaps pronounce or write their names only. Fewer than half of the women were literate in their native language. These women had been in the United States an average of 5 years, but 60% had spent from 3 to 5 years in refugee camps, mainly in Thailand, before arriving here. While in their native lands, an average of 6 people lived in each household, with a range of 2 to 14, mostly family members. The sample of women thus exemplifies typical characteristics found in Southeast Asian refugees with regard to education, deprivations endured in refugee camps, and crowded house holds. After enrolling in the clinic and attending some of the numerous classes o$ered, clients reported changes in behavior, including encouraging others to seek earlier prenatal care. Before going to refugee camps, 58 (49%) of the women had delivered their children at home, attended primarily by midwives, family, or neighbors; rarelyrwas a physician in attendance. They usually consulted with their husbands, family, and friends about care during the pregnancy. Of the 119 women, 10 knew someone who had died in childbirth. While in the refugee camps, 46 (39%) of the women became pregnant and delivered a child. The majority of them sought assistance at the camp hospital or clinic and were delivered by a physician or midwife there. Six were delivered by friends or family. In many cases, this care in the refugee camp was their first contact with any form of Western health care. Presented in Table 1 is a summary of actions these women take when they or someone in their family is ill. While the majority of them use the Western healthcare system now, they usually enter through emergency rooms, emergency centers, and clinics not re- Table 1. Wbat Do You Do Wben You or Your Family Are Ill? In Southeast Asia Perform coining Consult a herbalist consult a spiritual leader Use over-the-counter drugs Consult a monk In refugee camp Visit the camp infirmary Perform coining or other self-treatment Consult a healer (spiritualist, herbalist) In United States Consult a medical doctor Visit an emergency room Visit a children s clinic Visit a clinic not requiring appointment Consult a monk/spiritual healedother Use over-the-counter drugs 95 (80%) 63 (53%) 20 (17%) 16 (13%) 12 (10%) 105 (88%) 70 (59%) 7 (6%) 74 (62%) 72 (60%) 29 (24%) 24 (20%) 8 (7%) 7 (6%) quiring an appointment. Except for some of those attending the clinic for their current pregnancy, they stated that they do not see a physician regularly. This behavior is consistent with that reported in other documentation of Southeast Asian health behaviors: they seek assistance when ill, not in a preventive fashion (Lew, 1989; Muecke, 1983). Most of the women sought prenatal care when they were sick (meaning when the effects of the pregnancy were making themselves known) and mainly for the reason of checking on the baby. This behavior supports behaviors reported by Kulig (1989) in her study of Cambodian childbearing beliefs. Most of the women learned about SEAHP from friends and family, but 50 (42%) heard about it from outreach workers; some clients attributed their knowledge to both sources. Data about class attendance and changes in behavior are summarized in Table 2. The classes were offered on an equal basis and were most likely to be attended on the basis of the perceived needs of the clients. It is encouraging to note the increase in intake of milk and milk products or appropriate substitutes after the emphasis on the need for calcium during the classes. Ninety-four (79%) of the women have talked to others about the project, with care at the clinic, the classes, and nutrition (especially milk) being the topics most frequently discussed. They all indicated that they urged other pregnant women to attend the clinic. 52 J O G N N Volume 21 Number 1

6 Culturally Sensitive Prenatal Care Table 2. Class Attendance and Behavior Changes How did you learn about SEAHP? Friends/family 79 (66%) Outreach workers 50 (42%) Which classes did you attend? Nutrition 94 (79%) Parenting skills 80 (67%) Labor and delivery 68 (57%) Child development 60 (50%) Hygiene 53 (45%) Breastfeeding 12 (10%) All of the above 2 (2%) What behaviors are different since you attended the classes? Use of milk products 70 (59%) Use of food substitutes 63 (53%) Food preparation 47 (39%) Regular medical care 45 (38%) Care of children 35 (29%) Bathing 23 (19%) Almost 100% enjoyed the classes and found them helpful Ninety-six (81%) needed the community workers to serve as interpreters while at the clinic, and 76 (64%) indicated that it was those workers who would draw them back to the clinic again. The next most important reasons for returning were the classes and information in their own languages (71, or GO%), treatment by the clinic and hospital staff (37, or 31%), and convenience (35, or 29%). They disliked the long wait at the clinic and did not want their blood drawn. The women s feelings when they first came to the clinic and again at the time of the interviews are described in Table 3. At the time of the interviews, most of the women were very pleased with the services offered, the attitudes of the nursing and medical staff, and the concern and availability of the outreach workers. The few who gave a reason why their feelings changed in a positive manner after participating in the project indicated that it was because of the helpfulness of nurses and physicians, the presence of the interpreters, and the other efforts of the community outreach workers. Nursing Implications Lew (1990) delineated several approaches to bridging the gap between Western health care and recently arrived immigrants that were used successfully in this project, enabling it to be a culture broker between Southeast Asian refugees and medical care in Long Beach. The foremost approach appears to be the use of bilingual, bicultural community workers, with knowledge of or training in medical terminology in their indigenous languages and in English, as well as in Western or modern health practices. These workers are aware of the indigenous traditional health concepts or beliefs and practices and are the initial link between the health-care delivery system and potential clients. In addition, cultural sensitivity training for health professionals, along with education in indigenous beliefs and practices, is essential. Finally, the use of community bilingual media is effective, as is the development of culturally sensitive and language-specific educational materials. While this article describes the project as the culture broker, a nurse could ideally function in this capacity in a health-care setting (Tripp-Reimer & Brink, 1984), especially in the prenatal area. Jezewski (1990) identified several characteristics of nurses and nursing that would support this contention, including that nursing emphasizes care and caring within a holistic framework and that nursing has a history of advocacy, with nurses considering themselves patients advocates. Nurses have consistent and frequent contact Table 3. Emotional Responses to SEAHP What best describes your emotions when you first went to the SEAHP? Happy 45 (38%) Nervous 35 (29%) No feelings one way or another 20 (17%) Afraid 18 (15%) Waste of time 1(1%) What best describes your emotions now? Happy 92 (77%) No feelings one way or another 20 (17%) Nervous 4 (3%) Afraid 2 (2%) Waste of time 1(1%) If your feelings changed, what is the most important reason?* Staff/physician was helpful Interpreter Outreach workers *TOO few responses to report. January/February 1992 J O G N N 53

7 C L I N I C A L S T U D I E S with patients and can be acutely aware of the refugees social and cultural needs. Nurses can function as culture brokers to bridge the gap between Western health care and recently arrived immigrants. Nurses frequently provide the link between physicians and patients and between health-care delivery settings and clients. The concept of culture brokering may assist nurses in facilitating access to health care for those persons for whom the system presents barriers that are difficult to overcome. Through advocacy, negotiation, mediation, innovations, and sensitization, nurses can assist new immigrants, in particular, in overcoming some of the traditional barriers to care. Summary Although SEAHP focuses on the situation in Long Beach, the problem of lack of access to health care for immigrants is not limited to that geographic area. The Asian Pacific minority is the fastest growing segment of the American population, according to the Asian Advisory Committee to the Task Force on Black and Minority Health. The problem of inaccessibility to health care for minority groups, particularly new immigrants, is reflected across the country. Nor is the problem limited to immigrant populations; it can be seen with other ethnic groups whose values, customs, and languages are not addressed by existing healthcare systems. SEAHP provides a model that can be adapted for use with many minority groups. Acknowledgment We would like to acknowledge the assistance and support of Steve Robertson, Director of Personnel and Education, St. Mary Medical Center, Long Beach, California. References Cable, C. (1987). Access to prenatal care and prevention of low birth weight. Maternal Child Nursing Journal, 12, Hughes, D., et al. (1986). Maternal and child health data book: The health ofamerica s children. Washington, DC: Children s Defense Fund. Jezewski, M. (1990). Culture brokering in migrant farmworker health care. Western Journal of Nursing Research, 12, Kulig, J. (1989). Childbearing beliefs among Cambodian refugee women. Western Journal of Nursing Research, 12, Lew, L. (1988). Southeast Asian Health ProjectJinal report. Manuscript submitted for publication. Lew, L. (1989). Southeast Asian Health Project: Application for mother, children and infants demonstration grant. Manuscript submitted for publication. Lew, L. (1990). Understanding the Southeast Asian health care consumer: Bridges and barriers. Genetic Services for Underserved Populations, 26, March of Dimes Birth Defects Foundation. (1986). Low birth weight. White Plains, Ny: Author. Muecke, M. (1983). Caring for Southeast Asian refugee patients in the U.S.A. American Journal of Public Health, 73, National Commission to Prevent Infant Mortality. (1988). Death before life: The tragedy of infant mortality. Washington, DC: Author. Rimmer, L. (1975). Brokerage in an experimental neighborhood health project. Dissertation Abstracts International. (University Microfilms No , 770) Tripp-Reimer, T., & Brink, P. (1984). Culture brokerage. In G. Bullechek & J. McCloskey (Eds.), Nursing interventions: Treatments for nursing diagnoses (pp ). Philadelphia: W. B. Saunders. US. Department of Health and Human Services. (1988). Morbidity and Mortality Weekly Report (Vol. 37, No. 26). Washington, DC: Author. Van Esterik, P. (1980). Cultural factors affecting the adjustment of Southeast Asian refugees. In E. Tepper (Ed.), Southeast Asian exodus: From tradition to resettlement (pp ). Ottawa: The Canadian Asian Studies Association. Address for correspondence: Susan Mattson, RNC, CTN, PhD, 535 W. Valencia Mesa Drive, Fullerton, CA Susan Mattson is an associate professor at CaliJornia State University in Long Beach. She is a member of NAACOG. Lillian Lew is project director of the Southeast Asian Health Project in Long Beach, CaliJornia. 54 J O G N N Volume 21 Number 1