Like previous research, we found knowledge and use of traditional medicine to be more prevalent within the Cambodian American community than in the general U.S. population18, 24 and lower than in Cambodia.25 For Cambodian refugees, a blend of traditional and Western beliefs and strategies have been used to address health and healing, including during postpartum care.26–27 Knowledge of traditional medicine and cultural health practices within these communities is strongly informed by migration history27 and guides management of illness as well as utilization of the U.S. health care system.26, 28 The almost universal knowledge and high prevalence of ever consuming sra thnam, a Cambodian traditional postpartum remedy, in our study is corroborated by previous research in the U.S.18, 27 Further, our findings were in the higher end of the 25–45% range of Americans reporting use of natural medicines for health concerns.29
We confirmed that Cambodians perceive illness as being caused by an imbalance of hot and cold elements within the body, a belief shared by other Asian groups.27,30 In particular, the concept of ‘hot’ and ‘cold’ foods to aid with maintaining balance within the body, especially during the postpartum period, is prevalent in Asia.17, 27, 31 Illnesses or health conditions which are believed to be ‘cold’ require medicines (or foods) that will warm up the body in order to heal and restore balance.27, 30 Pregnancy is considered a ‘hot’ state and delivery of a child places a woman in a ‘cold’ state,17 resulting in an imbalance that may place a woman at risk for adverse health outcomes.30 ‘Hot’ foods or beverages, such as sra thnam, are believed to stimulate blood circulation and healing during the postpartum period.17, 27, 31
The continued use of sra thnam we observed in this population confirms previous reports of maintenance of cultural knowledge and practices among Cambodians in the U.S.27 who perceive traditional medicine as essential for maternal and infant health.25,32 After childbirth, Cambodian women are considered to be at risk of natural and spiritual factors, such as tos,24, 25 resulting in humoral imbalance.30, 32 Hence, adherence to traditional health practices is seen as protective of maternal health and a strategy to regain balance.27Tos, described as a conflict within the body or an adverse reaction to food,24 is a culture-bound syndrome within Cambodian culture.24,25 The consistent use of traditional medicines in postpartum care contrasts with the trend towards greater use of biomedicine or Western medicine for general health in Cambodia.25,24 Deur (2015) reported that ‘strong’ postpartum care using Cambodian traditional medicine was considered central for optimal health and while Cambodian women accepted biomedicine from clinics they consumed traditional medicine to balance hot and cold energy within their bodies.33
As in Cambodia25 and in an earlier U.S. study,18 some participants in our study reported purchasing prepared sra thnam or someone else preparing it for them. Traditionally prepared with rice wine, an alcohol made from fermented rice grains, sra thnam undergoes a secondary fermentation process which contributes to its potential pharmacological properties.25,34 Cultural understanding of the solvent choice is an important factor of traditional medicine, where healers in Cambodia tailor their medicinal preparations of tonics based on the daily strength needed for recovery.25 Healers noted that the use of dried plants and honey fermented in rice wine “makes the body hot, so the medicine works better”.25 Like Pung (2003), we found that preparation of sra thnam in the U.S. differed from methods in Cambodia, particularly by switching the solvent from a low ethanol content rice wine to high ethanol content liquors such as vodka or cognac.18 Use of vodka as a solvent may explain one participant’s belief that sra thnam was a drink for alcoholics with no health benefits. Use of vodka and other spirits may pose a health risk for excessive alcohol use due to elevated alcohol content and exacerbated by the high level of alcohol consumption reported among Cambodians.17, 35
In contrast to a small study in Rhode Island,18 none of our participants reported consuming sra thnam during pregnancy. The difference could be explained by reporting bias, a greater concentration of cultural knowledge among the larger Cambodian population in Massachusetts, and the availability of female kin who support new mothers in adhering to traditional health practices.36 Furthermore, our community partnership, CBPR approach, and careful attention to building rapport may have led to more accurate reporting from participants.
Although acculturation scores were not associated with ever using sra thnam, being born in the U.S. (proxy of higher acculturation) was a salient and statistically significant predictor of sra thnam use. Barimah and van Teijlingen (2008) found that 73% of immigrants from Ghana in a Canadian study had positive perspectives of Ghanaian traditional medicines, and place of birth (Canada or Ghana) was not associated with attitudes toward traditional medicines.37 However, Jenkins (1996) found Vietnamese participants in a Californian study who had lived fewer years in the U.S. and had limited English proficiency (proxies of lower acculturation) scored higher on the traditional health belief scale (p < .05).38
The lack of association between perceived discrimination in health care and sra thnam use in our study might be explained by only 9% of the sample perceiving being discriminated in the health care system. Another explanation may be that health care professionals in Lowell, MA, have been responsive to supporting Cambodian health,9 evidenced by over 1000 healthcare professionals trained on cultural competence and specifically on Cambodian health beliefs; a high percentage of attendees demonstrated cultural competence in the evaluation of this training.9 Cultural competence likely reduced bias in health care delivery and could explain the low levels of perceived discrimination in health care among this sample.
Consistent with our findings, age was positively associated with use of herbal medicine among women in a U.S. study.39 However, given that our sample included young women less likely to report having a child, the association observed in our study could be an artefact of age. Likewise, the lack of association between education and sra thnam use could be explained by the fact that most participants with ≤ high school education were also younger than 18 years and nulliparous. In contrast, Vietnamese community members in California with lower educational attainment scored higher on the traditional health belief scale (p < .05) (38) and among predominantly White women, higher educational attainment was predictive of herbal medicine use.39
Refugee and immigrant women face many challenges in their host countries, particularly in regards to maternal and child health.6, 12, 18 These women experience pregnancy and childbirth in a Western model of health care which can isolate them from larger social networks and traditional health practices,36 as well as engage them in cultural norms that may conflict with their cultural practices. As such, pregnancy, childbirth, and postpartum experiences shift at a critical and vulnerable time in a refugee or immigrant woman’s life. As reported elsewhere and in our study, women may adhere to some traditional practices due to historically and culturally understood health benefits16 and the concern about potential negative health consequences that would arise if they did not continue to practice these traditions.31
More importantly, use of traditional health practices may serve a protective role for preservation of cultural and familial ties within Cambodian refugee families, especially given the crucial role of traditional medicine in survival during war under the Khmer Rouge regime25 and new health challenges experienced upon resettlement.19 As noted in our FGD results, traditional beliefs and practices regarding pregnancy and childbirth are typically passed down across generations.15–17, 31 As such, refugee families may benefit from intergenerational sharing of such practices, thus placing a premium on elderly and ancestral wisdom.16